Changes Coming to the U.S. Health System as the Covid Emergency Ends

End of Covid Emergency Will Usher in Changes Across the US Health System

Rachana Pradhan March 22, 2023

The Biden administration’s decision to end the covid-19 public health emergency in May will institute sweeping changes across the healthcare system that go far beyond many people having to pay more for covid tests.

In response to the pandemic, the federal government in 2020 suspended many of its rules on how care is delivered. That transformed essentially every corner of American health care — from hospitals and nursing homes to public health and treatment for people recovering from addiction.

Now, as the government prepares to reverse some of those steps, here’s a glimpse at ways patients will be affected:

Training Rules for Nursing Home Staff Get Stricter

The end of the emergency means nursing homes will have to meet higher standards for training workers.

Advocates for nursing home residents are eager to see the old, tougher training requirements reinstated, but the industry says that move could worsen staffing shortages plaguing facilities nationwide.

In the early days of the pandemic, to help nursing homes function under the virus’s onslaught, the federal government relaxed training requirements. The Centers for Medicare & Medicaid Services instituted a national policy saying nursing homes needn’t follow regulations requiring nurse aides to undergo at least 75 hours of state-approved training. Normally, a nursing home couldn’t employ aides for more than four months unless they met those requirements.

Last year, CMS decided the relaxed training rules would no longer apply nationwide, but states and facilities could ask for permission to be held to the lower standards. As of March, 17 states had such exemptions, according to CMS — Georgia, Indiana, Louisiana, Maryland, Massachusetts, Minnesota, Mississippi, New Jersey, New York, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Vermont, and Washington — as did 356 individual nursing homes in Arizona, California, Delaware, Florida, Illinois, Iowa, Kansas, Kentucky, Michigan, Nebraska, New Hampshire, North Carolina, Ohio, Oregon, Virginia, Wisconsin, and Washington, D.C.

Nurse aides often provide the most direct and labor-intensive care for residents, including bathing and other hygiene-related tasks, feeding, monitoring vital signs, and keeping rooms clean. Research has shown that nursing homes with staffing instability maintain a lower quality of care.

Advocates for nursing home residents are pleased the training exceptions will end but fear that the quality of care could nevertheless deteriorate. That’s because CMS has signaled that, after the looser standards expire, some of the hours that nurse aides logged during the pandemic could count toward their 75 hours of required training. On-the-job experience, however, is not necessarily a sound substitute for the training workers missed, advocates argue.

Adequate training of aides is crucial so “they know what they’re doing before they provide care, for their own good as well as for the residents,” said Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy.

The American Health Care Association, the largest nursing home lobbying group, released a December survey finding that roughly 4 in 5 facilities were dealing with moderate to high levels of staff shortages.

Treatment Threatened for People Recovering From Addiction

A looming rollback of broader access to buprenorphine, an important medication for people in recovery from opioid addiction, is alarming patients and doctors.

During the public health emergency, the Drug Enforcement Administration said providers could prescribe certain controlled substances virtually or over the phone without first conducting an in-person medical evaluation. One of those drugs, buprenorphine, is an opioid that can prevent debilitating withdrawal symptoms for people trying to recover from addiction to other opioids. Research has shown using it more than halves the risk of overdose.

Amid a national epidemic of opioid addiction, if the expanded policy for buprenorphine ends, “thousands of people are going to die,” said Ryan Hampton, an activist who is in recovery.

The DEA in late February proposed regulations that would partly roll back the prescribing of controlled substances through telemedicine. A clinician could use telemedicine to order an initial 30-day supply of medications such as buprenorphine, Ambien, Valium, and Xanax, but patients would need an in-person evaluation to get a refill.

For another group of drugs, including Adderall, Ritalin, and oxycodone, the DEA proposal would institute tighter controls. Patients seeking those medications would need to see a doctor in person for an initial prescription.

David Herzberg, a historian of drugs at the University at Buffalo, said the DEA’s approach reflects a fundamental challenge in developing drug policy: meeting the needs of people who rely on a drug that can be abused without making that drug too readily available to others.

The DEA, he added, is “clearly seriously wrestling with this problem.”

Hospitals Return to Normal, Somewhat

During the pandemic, CMS has tried to limit problems that could arise if there weren’t enough health care workers to treat patients — especially before there were covid vaccines when workers were at greater risk of getting sick.

For example, CMS allowed hospitals to make broader use of nurse practitioners and physician assistants when caring for Medicare patients. And new physicians not yet credentialed to work at a particular hospital — for example, because governing bodies lacked time to conduct their reviews — could nonetheless practice there.

Other changes during the public health emergency were meant to shore up hospital capacity. Critical access hospitals, small hospitals located in rural areas, didn’t have to comply with federal rules for Medicare stating they were limited to 25 inpatient beds and patients’ stays could not exceed 96 hours, on average.

Once the emergency ends, those exceptions will disappear.

Hospitals are trying to persuade federal officials to maintain multiple covid-era policies beyond the emergency or work with Congress to change the law.

Surveillance of Infectious Diseases Splinters

The way state and local public health departments monitor the spread of disease will change after the emergency ends, because the Department of Health and Human Services won’t be able to require labs to report covid testing data.

Without a uniform, federal requirement, how states and counties track the spread of the coronavirus will vary. In addition, though hospitals will still provide covid data to the federal government, they may do so less frequently.

Public health departments are still getting their arms around the scope of the changes, said Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.

In some ways, the end of the emergency provides public health officials an opportunity to rethink covid surveillance. Compared with the pandemic’s early days, when at-home tests were unavailable and people relied heavily on labs to determine whether they were infected, testing data from labs now reveals less about how the virus is spreading.

Public health officials don’t think “getting all test results from all lab tests is potentially the right strategy anymore,” Hamilton said. Flu surveillance provides a potential alternative model: For influenza, public health departments seek test results from a sampling of labs.

“We’re still trying to work out what’s the best, consistent strategy. And I don’t think we have that yet,” Hamilton said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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To Save Money, More Big Employers Shifting Retiree Health Costs to Taxpayers

Seeking to Shift Costs to Medicare, More Employers Move Retirees to Advantage Plans

Susan Jaffe March 3, 2022

As a parting gesture to a pandemic-ravaged city, former New York Mayor Bill de Blasio hoped to provide the city with a gift that would keep on giving: new health insurance for 250,000 city retirees partly funded by the federal government. Although he promised better benefits and no change in health care providers, he said the city would save $600 million a year.

Over the past decade, an increasing number of employers have taken a similar deal, using the government’s Medicare Advantage program as an alternative to their existing retiree health plan and traditional Medicare coverage. Employers and insurers negotiate behind closed doors to design a private Medicare Advantage plan available only to retirees from that employer. Then, just as it does for private individuals choosing a Medicare Advantage plan, the federal government pays the insurer a set amount for each person in the plan.

Experts say this arrangement often saves the employer money because the federal payment reduces the employer’s share of the cost of coverage. But retirees’ health care may be disrupted if the plan no longer includes their doctors and hospitals or the insurer has new requirements or charges new fees to access benefits.

Scores of private and public employers offer Medicare Advantage plans to their retirees. Yet the details — and the costs to taxpayers — are largely hidden. Because the federal Centers for Medicare & Medicaid Services is not a party to the negotiations among insurers and employers, the agency said it does not have details about how many or which employers are using this strategy or the cost to the government for each retiree group.

Employer-sponsored plans receive billions of dollars in federal payments, but they also get something other Medicare Advantage insurers don’t: automatic exemptions to some requirements that apply to the policies available to individual beneficiaries. Plans can set their own enrollment deadlines, send members information without prior CMS approval for accuracy, and follow weaker requirements for provider networks, among other things.

“There are as many plans as there are stars in the sky because employers and insurers can design their health benefits any way they want to,” said Tatiana Fassieux, a training specialist for California Health Advocates, a consumer group. She switched her health coverage to try a new employer-sponsored Medicare Advantage plan AT&T introduced this year for retirees to see whether it would save her money for better benefits. She qualifies for it because her late husband was an employee of the company.

These group retiree plans are similar to the public Medicare Advantage plans that insurance companies advertise on TV and in the mail. Run by private insurance companies, they must offer the benefits of the government’s traditional Medicare and often add extras like dental and vision coverage. However, they can restrict members to a network of medical providers.

In traditional Medicare, the government pays doctors, hospitals, and other health care providers directly for beneficiaries’ care. But Medicare Advantage is different. The government pays the insurance companies that sell Medicare Advantage policies a fixed amount every month for each member they sign up.

In most of the employer-sponsored retiree plans, the federal government is paying the “overwhelming majority” of medical costs, said Barry Carleton, senior director for health and benefits at Willis Towers Watson, which advises dozens of large companies and state retirement systems. “And in some cases, it pays the entirety of the cost.” Under a separate arrangement for employer-sponsored Part D drug coverage, the federal contribution and manufacturer discounts “can account for a majority of the cost of the pharmacy plan,” he said.

“Employers find Medicare Advantage [plans] appealing because they can drive significant savings,” said Chris Maikels, a senior principal and the U.S. marketplace growth leader for retiree solutions at Mercer Marketplace, another benefits consulting firm. His clients have saved up to 50% by moving retirees into employer-sponsored Medicare Advantage and drug plans. Under some plans, retirees can go to any Medicare provider, he said, so “there is typically little retiree disruption.”

CareFirst BlueCross BlueShield — an insurer that serves Maryland, Washington, D.C., and Northern Virginia — began offering Medicare Advantage plans to four new retiree groups this year, said Dave Corkum, executive vice president and chief growth officer. “Most employer groups could achieve double-digit percent savings on annual retiree health costs,” he said.

The number of beneficiaries in employer-sponsored Medicare Advantage plans has soared from about 1.6 million in 2008 to more than 5 million last year, according to CMS. UnitedHealthcare, the nation’s largest health insurance company, has “seen tremendous growth” in the employer-sponsored plans during the past decade, said national vice president Joe Altman. “We’ve had new groups coming on to our group Medicare Advantage [plans] every year,” Altman said. He would not divulge their names.

In a typical employer retiree plan, beneficiaries are often covered by traditional Medicare, which picks up part of their medical costs, and the employer and retiree are responsible for the rest. The government’s payments to Medicare Advantage plans are supposed to be equal to what it would cost if beneficiaries stayed in the government-run Medicare. But it doesn’t always work out that way.

With each Advantage member, the government spends 4% more than it does for someone in the traditional fee-for-service program, according to the Medicare Payment Advisory Commission, which advises Congress. In 2019, CMS paid the plans $7 billion more than the cost of caring for those beneficiaries in traditional Medicare, a study by KFF found. Much of that difference comes when the insurers’ reimbursements are increased by Medicare to account for services for sicker patients that are either not provided or not necessary. A recent investigation by the inspector general for the U.S. Department of Health and Human Services found that the practice resulted in overpayments of $6.7 billion in 2017.

The exemptions to Medicare Advantage rules granted to these retiree plans are intended to make it easy for employers to make the switch. A provision of federal law allows Medicare officials to “waive or modify requirements that hinder” employer-sponsored Advantage plans.

For example, provider network requirements are watered down for the employer plans, which means finding a doctor who participates in the plan may be more difficult for members, explained David Lipschutz, associate director of the Center for Medicare Advocacy.

Details about plan benefits and costs don’t have to be approved by Medicare for accuracy or posted on the insurer’s website, as they do for Medicare Advantage plans sold to the public. Medicare’s plan finder website also omits this information, since employer-sponsored plans are only for retirees from the same company. So retirees must rely on their former employer, their union, or the health insurer for assistance, instead of impartial sources such as the State Health Insurance Assistance Program.

“We know that these employer Medicare Advantage plans receive a great deal of federal subsidies, with the cost paid by CMS and the taxpayers,” Lipschutz said. “But what are the strings attached to this money? And what kind of oversight do these plans get?”

In New York City, some retirees sued to stop the new plan. They claimed they didn’t have essential details, including which doctors and hospitals would accept it. About 47,000 retirees have opted out of the new plan, according to a spokesperson for Mayor Eric Adams.

“We were told that everything that this plan is doing has been approved by Medicare and that they have to follow all the Medicare rules,” said Marianne Pizzitola, a Fire Department retiree and president of the New York City Organization of Public Service Retirees, which filed the lawsuit.

State Supreme Court Justice Lyle Frank has twice delayed implementation of the plan and has ordered city officials to correct mistakes in the enrollment guide, contact medical providers about accepting the new coverage, and take other steps to address retirees’ concerns. City officials have assured the judge they will follow his instructions but declined to provide KHN with details, including how much the federal government is paying for the plan.

If Frank is satisfied, the change can take effect April 1. A decision in the lawsuit is expected this week.

Some New York officials are still skeptical. “I sure hope this plan is better for cheaper,” Eric Dinowitz, a city council member from the Bronx, said during a hearing on the plan. “It sounds like magic,” he quipped sarcastically.

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Patients Face High Prices in the "Wild West" Service Dog Market

Demand for Service Dogs Unleashes a ‘Wild West’ Market

Markian Hawryluk February 16, 2022

Jenni Mahnaz admits she’s not much of a dog person. She’s mildly allergic and the only pet she had as a child was a hermit crab. But once she learned that specially trained dogs could help her daughters with their medical needs, she was willing to do anything to make it happen.

Her oldest daughter, Suraiya, 6, was diagnosed with autism and sensory processing challenges. Soon after, 4-year-old Phoenix was diagnosed with epilepsy.

“Our family is very likely to end up with two service dogs,” Mahnaz said. “I think we’re probably looking at $10,000 per dog.”

That’s a serious hurdle for the Troy, New York, family of five whose income is below the federal poverty line, even though they’ll save money by buying pups from a breeder and then paying a local trainer to train them as service dogs.

 Organizations charge from $15,000 to $40,000 for a fully trained service dog, which they have bred, raised, and trained for a year and a half. None of that cost is covered by health insurance. Other trainers have long waiting lists or won’t place dogs with young children.

“This is very expensive for us, but I am my girls’ parent, and it is my job to do whatever I can to make their standard of living as good as I can,” Mahnaz said. “It is a need for them and it will make a big difference in their lives.”

Demand for service dogs has exploded in recent years as dogs have proved adept at helping children and adults with an increasing range of disabilities. While dogs once served primarily people with vision or mobility impairments, they now help people with autism, diabetes, seizures, and psychiatric disorders. That has overwhelmed nonprofit service dog trainers, who generally donate dogs to patients for at most a small application fee. But unmet needs have helped launch a for-profit service dog industry with hefty price tags.

Rapid growth, however, has come with little oversight, potentially subjecting people who have complex medical issues to huge financial barriers, poorly trained dogs, and outright fraud. Those pitfalls are only exacerbated by social media, including fundraising sites like GoFundMe that allow families to meet pricing thresholds they wouldn’t be able to afford on their own. The flourishing market emboldens trainers to charge more for their services, confident that the funds will be donated.

Some, like the Mahnaz family, gamble by training their own dogs to lower the cost. But trainers say that the success rate for self-trained dogs is lower than their own — and that families could be out thousands of dollars.

“The dog could absolutely fail. We could end up with an adult dog who cannot be a service animal,” Mahnaz said. “The reality is we don’t have a choice.”

The lack of regulations for service dog trainers has opened the door for scores of backyard trainers who may or may not be qualified to train service dogs, said Lynette Hart, a professor of veterinary medicine at the University of California-Davis. There is no certification process for service dogs, either.

“There’s a big opportunity for people who are dog trainers to say, ‘Oh, I will sell you one for tens of thousands of dollars,” she said. “It’s a kind of a wild West issue.”

But that also leaves families open to getting burned with little recourse.

“Sometimes they’re sold a bill of goods,” said Sheila O’Brien, chairperson of the North American board of Assistance Dogs International. The group accredits service dog trainers, but the accreditation is voluntary and only nonprofit organizations are eligible. The group has 80 accredited members and 25 candidate programs in North America. But nobody knows how many unaccredited dog trainers are operating in the U.S.

“It’s so easy to defraud people over the internet. There’s a lot of money to be made here,” said David Favre, a Michigan State University law professor specializing in animal law. “It’s never been controlled, and it’s gotten worse.”

In 2018, for example, Virginia’s attorney general filed a lawsuit alleging a company named Service Dogs by Warren Retrievers charged families up to $27,000 per dog but often delivered “poorly-trained puppies with significant behavioral issues and inadequate skills or training.” The trainer settled the lawsuit last year for $3 million.

In 2020, North Carolina’s attorney general filed a similar suit against the owner of Ry-Con, a nonprofit service dog trainer. The suit alleged that Ry-Con charged families up to $16,710 per dog despite knowing the dogs were not adequately trained.

Both training companies are now out of business and the former owners could not be reached for comment.

O’Brien estimates the average training cost in the U.S. is $30,000 per dog. But trainers must also account for the costs of the 60% of dogs who won’t make it through the training.

Sometimes dogs wash out because of health or temperament issues. “Some are just lovers and not workers,” O’Brien said.

Jennifer Arnold, founder of Canine Assistants, a Milton, Georgia, nonprofit training organization, said much work remains after a dog graduates, but many for-profit trainers end their involvement when they sell the dog. Many people need help troubleshooting issues such as housebreaking or leash-walking difficulties.

“Clients can get dogs that aren’t prepared, and sometimes, when dogs are prepared, they end up with families who don’t follow through,” Arnold said. “It’s difficult on both sides, but families get taken advantage of a lot more than the other way around.”

Canine Assistants has the ability to train and place a maximum of 100 dogs per year but receives about 1,400 applications.

“The need is overwhelming,” Arnold said. “It made the industry perfect for folks who want to make a little money.”

In most cases, that money isn’t coming directly out of patients’ pockets.

Kelly Camm, development director with the Xenia, Ohio-based nonprofit 4 Paws for Ability, said only about 5% of families can write the $17,000 check required for a service dog. The rest rely on their community, family, friends, or sometimes complete strangers for donations.

Medical Mutts Service Dogs in Indianapolis trains about 30 service dogs a year, about a third of which are dogs that board with them for training.

“There is no guarantee for any of those dogs to go through,” said Eva Rudisile, Medical Mutts’ director of client services. “As you start training and you take them out in public places, you start practicing certain behaviors, it’s quite stressful. And some dogs, they just can’t handle that.”

Medical Mutts charges $15,000 to $17,000 for a program dog depending on what type of disability is involved. It’s $11,000 to board and train a dog. If that dog washes out, the family is out that money. Families that opt for a program dog, on the other hand, are guaranteed to get a dog that completes the training.

“That’s the biggest plus for a program dog,” Rudisile said. “They don’t have the risk of, ‘OK, I got a dog and now I’m stuck with it and it’s not working.’”

For the Mahnaz family, that’s a gamble worth taking. A friend has set up a GoFundMe page to raise the initial $4,000 to get their first dog, a goldendoodle, from a breeder. They’ll start with basic obedience training and, when the dog is old enough, begin its service dog training.

An autism service dog, they hope, will help Suraiya deal with uncomfortable social situations and settle her down when she is on the verge of a meltdown. Eventually, they’ll get a second dog trained to alert them when Phoenix experiences a seizure.

Suraiya, who cannot write yet, has nonetheless created a list of potential dog names that only she can read: Blueberry, Alex, Stardust, Jelly-Jam. Phoenix has settled on Pancake.

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Millions Could Lose Health Insurance Coverage in Coming Months

Why Millions on Medicaid Are at Risk of Losing Coverage in the Months Ahead

Rachana Pradhan February 14, 2022

The Biden administration and state officials are bracing for a great unwinding: millions of people losing their Medicaid benefits when the pandemic health emergency ends. Some might sign up for different insurance. Many others are bound to get lost in the transition.

State Medicaid agencies for months have been preparing for the end of a federal mandate that anyone enrolled in Medicaid cannot lose coverage during the pandemic.

Before the public health crisis, states regularly reviewed whether people still qualified for the safety-net program, based on their income or perhaps their age or disability status. While those routines have been suspended for the past two years, enrollment climbed to record highs. As of July, 76.7 million people, or nearly 1 in 4 Americans, were enrolled, according to the Centers for Medicare & Medicaid Services.

When the public health emergency ends, state Medicaid officials face a huge job of reevaluating each person’s eligibility and connecting with people whose jobs, income, and housing might have been upended in the pandemic. People could lose their coverage if they earn too much or don’t provide the information their state needs to verify their income or residency.

Medicaid provides coverage to a vast population, including seniors, the disabled, pregnant women, children, and adults who are not disabled. However, income limits vary by state and eligibility group. For example, in 2021 a single adult without children in Virginia, a state that expanded Medicaid under the Affordable Care Act, had to earn less than $1,482 a month to qualify. In Texas, which has not expanded its program, adults without children don’t qualify for Medicaid.

State Medicaid agencies often send renewal documents by mail, and in the best of times letters go unreturned or end up at the wrong address. As this tsunami of work approaches, many state and local offices are short-staffed.

The Biden administration is giving states a year to go through the process, but officials say financial pressures will push them to go faster. Congress gave states billions of dollars to support the coverage requirement. But the money will dry up soon after the end of the public emergency — and much faster than officials can review the eligibility of millions of people, state Medicaid officials say.

In Colorado, officials expect they’ll need to review the eligibility of more than 500,000 people, with 30% of them at risk of losing benefits because they haven’t responded to requests for information and 40% not qualifying based on income.

In Medicaid, “typically, there’s always been some amount of folks who lose coverage for administrative reasons for some period of time,” said Daniel Tsai, director of the CMS Center for Medicaid and CHIP Services. “We want to do everything possible to minimize that.”

In January the eligibility of roughly 120,000 people in Utah, including 60,000 children, was in question, according to Jeff Nelson, who oversees eligibility at the Utah Department of Health. He said that 80% to 90% of those people were at risk because of incomplete renewals. “More often than not, it’s those that just simply have not returned information to us,” he said. “Whether they didn’t receive a renewal or they’ve moved, we don’t know what those reasons are.”

Arizona Medicaid director Jami Snyder said 500,000 people are at risk of losing Medicaid for the same reasons. She said that processing all the eligibility redeterminations takes at least nine months and that the end of the federal funding bump will add pressure to move faster. However, she said, “we’re not going to compromise people’s access to care for that reason.”

Still, officials and groups who work with people living in poverty worry that many low-income adults and children — typically at higher risk for health problems — will fall through the cracks and become uninsured.

Most might qualify for insurance through government programs, the ACA insurance marketplaces, or their employers — but the transition into other coverage isn’t automatic.

“Even short-term disruptions can really upend a family,” said Jessie Mandle, deputy director of Voices for Utah Children, an advocacy group.

‘More Marginalized People’

Low-income people could still be in crisis when the public health emergency ends, said Stephanie Burdick, a Medicaid enrollee in Utah who advocates on behalf of patients with traumatic brain injuries.

In general, being uninsured can limit access to medical care. Covid vaccination rates among Medicaid enrollees are lower than those of the general population in multiple states. That puts them at higher risk for severe disease if they get infected and for exorbitant medical bills if they lose their insurance.

“They’re more marginalized people,” Burdick said. She said she worries “that they’re going to fall off and that they’re going to be more excluded from the health care system in general and just be less likely to get care.”

Burdick knows this firsthand as someone who experienced traumatic brain injury. Before covid-19, she would periodically lose her Medicaid benefits because of byzantine rules requiring her to requalify every month. The gaps in coverage kept her from seeing certain specialists and obtaining necessary medicines. “I really do remember being at the pharmacy not being able to afford my medication and just sobbing because I didn’t know what to do about it,” she said. “It was horrible.”

The covid Medicaid continuous coverage requirement was enacted under the Families First Coronavirus Response Act, which gave states an increase of 6.2 percentage points in federal funds if they agreed to maintain eligibility levels in place at the time.

The boost meant tens of billions of additional dollars would flow to states, estimates from KFF show. The U.S. Department of Health and Human Services can extend the public health emergency in 90-day increments; it is currently set to end April 16.

Groups that advocate for the needs of low-income Americans say the renewal tidal wave will require outreach rivaling that of almost a decade ago, when the ACA expanded Medicaid and created new private insurance options for millions of people.

Independent research published in September by the Urban Institute, a left-leaning think tank based in Washington, D.C., estimated that 15 million people younger than 65 could lose their Medicaid benefits once the public health emergency ends. Nearly all of them would be eligible for other insurance options, including heavily subsidized plans on the ACA marketplaces.

Tsai said the 15 million estimate provides a “helpful grounding point to motivate everybody” but declined to say whether the Biden administration has its own estimates of how many people could lose benefits. “I don’t think anyone knows exactly what will happen,” he said.

Tsai and state officials said they have worked hand in hand for months to prevent unnecessary coverage loss. They’ve tried to ensure enrollees’ contact information is up to date, monitored rates of unreturned mail, worked with insurers covering Medicaid enrollees, and conducted “shadow checks” to get a sense of who doesn’t qualify, even if they can’t disenroll people.

Some enrollees could be renewed automatically if states verify they qualify by using data from other sources, such as the Internal Revenue Service and the Supplemental Nutrition Assistance Program.

For others, though, the first step entails finding those at risk of losing their coverage so they can enroll in other health benefits.

“It’s a big question mark how many of those would actually be enrolled,” said Matthew Buettgens, a senior fellow in Urban’s Health Policy Center and author of the September report. One factor is cost; ACA or job-based insurance could bring higher out-of-pocket expenses for the former Medicaid enrollees.

“I am particularly worried about non-English speakers,” said Sara Cariano, a policy specialist with the Virginia Poverty Law Center. “Those vulnerable populations I think are at even higher risk of falling out improperly.” The law center is planning enrollment events once the unwinding begins, said Deepak Madala, its director of the Center for Healthy Communities and Enroll Virginia.

Missouri, already sluggish in enrolling eligible people into the state’s newly expanded Medicaid program, had 72,697 pending Medicaid applications as of Jan. 28. Enrollment groups worry the state won’t be able to efficiently handle renewals for nearly all its enrollees when the time comes.

By December, the Medicaid rolls in the state had swelled to almost 1.2 million people, the highest level since at least 2004. The state — one of several with histories of removing from the program people who were still eligible — did not say how many people could lose their benefits.

“I want to make sure that everybody that is entitled to and is eligible for MO HealthNet is getting the coverage that they need — all the way from babies to older individuals to individuals on disability,” said Iva Eggert-Shepherd of the Missouri Primary Care Association, which represents community health centers.

‘No End in Sight’

Some people argue the current protections have been in place long enough.

“There’s no end in sight. For two years, it’s still a quote-unquote ‘emergency,’” said Stewart Whitson, a senior fellow with the Foundation for Government Accountability. The conservative think tank has argued that states can legally begin trimming people from Medicaid rolls without jeopardizing their funding.

“This is the kind of problem that just grows worse every day,” he said of not removing ineligible people. “At the beginning of the pandemic, people were in a different position than they are now. And so responsible legislators and government officials in each state have to look at the facts as they are now.”

Tsai said “it’s quite clear to us” that for states to be eligible for the covid relief bill’s enhanced Medicaid funding, they must keep people enrolled through the emergency. “Those two things are interlinked,” he said.

Meanwhile, states still have no idea when the renewal process will begin. HHS has said that it would give states 60 days’ notice before ending the emergency period. The additional Medicaid funds would last until the end of the quarter when the emergency expires — if it ended in April, for example, the money would last until June 30.

“It’s hard to do a communication plan when you say, ‘You’ve got 60 days, here you go,’” Nelson of Utah’s Department of Health said.

Colorado officials had debated sending letters to enrollees when the public health emergency was nearing its scheduled end on Jan. 16 but held off, expecting that it would be extended. HHS announced a 90-day extension only two days before it was set to expire.

“Those kinds of things are really confusing to members,” Medicaid Director Tracy Johnson said. “OK, your coverage is going to end. Oh, just kidding. No, it’s not.”

KHN senior Colorado correspondent Markian Hawryluk and Midwest correspondent Bram Sable-Smith contributed to this report.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Hiring Bonuses Pose More Staffing Challenges to Small U.S. Hospitals

Bounties and Bonuses Leave Small Hospitals Behind in Staffing Wars

Bram Sable-Smith February 7, 2022

A recent lawsuit filed by one Wisconsin health system that temporarily prevented seven workers from starting new jobs at a different health network raised eyebrows, including those of Brock Slabach, chief operations officer of the National Rural Health Association.

“To me, that signifies the desperation that hospital leaders are facing in trying to staff their hospitals,” said Slabach.

His concern is for the smaller facilities that lack the resources to compete.

Already strained by the covid-19 pandemic, hospitals around the country are desperate to staff their facilities as the highly transmissible omicron variant spreads. Governors in states such as Massachusetts and Wisconsin deployed the National Guard to help hospitals combat the surge. Six hospitals in Cleveland took out a full-page ad in the Sunday Plain Dealer with a singular plea to the community, “Help.” CoxHealth is among the medical systems in Missouri to ask its office staff to help out on the front lines.

With no end to the crisis in sight, hospitals have taken to enticing workers from other facilities to fulfill needs. In South Dakota, Monument Health offered signing bonuses up to $40,000 for experienced nurses who would make a two-year commitment to the health system. Job listings for nurses in Maine and Virginia include $20,000 signing bonuses. Montana is offering health care workers up to $12,500 in moving expenses to relocate to the state.

The labor market squeeze is affecting more than just health care. People are being lured into teaching jobs and the military with $20,000 signing bonuses, while construction and trucking companies are looking everywhere for workers, even within their competitors’ ranks.

But in the life-or-death field of medical care, these sorts of bounties have turned an already stressful situation into one that Slabach called “almost combustible.” Smaller facilities — particularly rural ones that have struggled for years to stay afloat — are finding it difficult, if not impossible, to compete for health care workers in this labor market. If a hospital is unable to maintain safe staffing levels, it could be forced to curtail services or possibly close, a devastating blow for both the patients and economies of those communities. Nineteen rural hospitals closed in 2020 alone.

In Pilot Knob, Missouri, Iron County Medical Center CEO Joshua Gilmore said staffing costs for his 15-bed rural hospital have jumped 15% to 20% during the pandemic after he gave raises across the board to nurses and nursing assistants. He’s also offering $10,000 signing bonuses to fill three nursing positions.

Those are big expenses for such a small facility, particularly during a pandemic when spending on supplies like masks and other personal protective equipment has also increased. The hospital has received just under $5 million in federal covid relief, without which it likely would have closed, Gilmore said.

Gilmore said he has lost nurses to travel nursing jobs that can pay $10,000 per week. Typical pay for a nurse at Gilmore’s facility is about $70,000 per year, he said. The hospital’s staffing costs could have risen even higher if he had hired more travel nurses. Not only is their pay rate too expensive, he said, but his hospital lacks an intensive care unit — the area most commonly staffed by temporary nurses.

Two hundred miles to the west in Springfield, Missouri, CoxHealth has invested in training and retaining health care workers for years, according to Andy Hedgpeth, its vice president of human resources. Those efforts included increasing the class size at the affiliated nursing school from 250 to 400 students per year. Even so, the health system spent $25.5 million last year to give raises to 6,500 employees in an effort to retain workers.

“What we are seeing right now is the magnification of a critical shortage across the nation,” Hedgpeth said. “The way out of that is through workforce development and showing individuals they can have stable careers in their community.”

When hospitals do spend the money to hire travel nurses, it often ruffles the feathers of staff nurses, many of whom are already fighting for better working conditions. Hospitals are also losing workers to the very agencies they depend on for help.

In La Crosse, Wisconsin, the travel nursing agency Dedicated Nursing Associates placed a billboard near a Gundersen Health System facility advertising the agency’s pay: $91 an hour for registered nurses, $69 for licensed practical nurses, and $41 for certified nursing assistants. Neither Gundersen nor Dedicated Nursing Associates responded to requests for comment.

Shane Johnson took to travel nursing after he was laid off from MU Health Care in Columbia, Missouri, as part of pandemic cutbacks in May 2020. He said it’s hard to see himself going back to being on staff at a hospital given the better pay and flexibility that the temporary assignments afford him. A six-week contract in Chicago allowed him to earn as much in two days as he would have in two weeks at his previous job. A 15-week contract in Louisville, Kentucky, allowed him to be closer to family. His current work with the staffing platform CareRev allows him to choose his assignments on a shift-by-shift basis while still getting health insurance and retirement benefits.

“The question all these nurses are asking is: If they can pay these crisis wages right now, why couldn’t they pay us more to do the work we were doing?” Johnson said.

The travel nursing industry has caught the eye of lawmakers. Some states are considering legislation that would cap travel nurses’ pay. Federally, more than 200 members of Congress asked the White House Coronavirus Response Team coordinator to investigate possible “anticompetitive activity.”

Even in a hiring environment this competitive, the Wisconsin lawsuit filed on Jan. 20 is a new frontier in the staffing battles. ThedaCare, a regional health system in Wisconsin’s Fox Valley, filed a temporary injunction attempting to prevent three of its nurses and four of its technicians — all at-will employees — from leaving and joining competitor Ascension Wisconsin until ThedaCare could find replacement workers. A judge temporarily blocked those health care workers from starting their new jobs before deciding ThedaCare couldn’t force the employees to stay.

The spat is just a small piece of “a much bigger issue,” according to Tim Size, executive director of Rural Wisconsin Health Cooperative. Without intervention, he said, the staffing shortages currently attributed to the pandemic could become the new normal.

Case in point, Size said, is a 2021 report by the Wisconsin Council on Medical Education and Workforce that projects the state could be short almost 16,000 nurses by 2035. Even if the reality is only half as bad as the projection, Size said, a shortage of 8,000 nurses in Wisconsin dwarfs the shortages now experienced in the pandemic.

“We have to make a much more substantive investment in our schools of nursing,” Size said.

According to Slabach, one missed opportunity was the National Health Care Workforce Commission created in 2010 by the Affordable Care Act but never funded by Congress. The commission would have been tasked with measuring the scope of the health care workforce challenges and proposing solutions, but it has never convened.

“We need to mobilize all of the resources that we have to figure out how we’re going to solve this problem, and it starts with a systemic approach,” Slabach said. “We can’t just pay our way out of this through bonuses and bounties.”

In the shorter term, Gilmore said, small hospitals like his could use more federal support. The $5 million that Iron County Medical Center received was critical, Gilmore said, but has already been spent. Now his facility is dealing with the omicron surge and is still reeling from the delta wave over the summer.

“I’m calling my congressman and letting him know that we need help,” Gilmore said. “We can’t do this on our own.”

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Home Health Care Patients Suffer Amid Acute Staffing Shortages

Pandemic-Fueled Shortages of Home Health Workers Strand Patients Without Necessary Care

Judith Graham February 3, 2022

Frail older adults are finding it harder than ever to get paid help amid acute staff shortages at home health agencies.

Several trends are fueling the shortages: Hospitals and other employers are hiring away home health workers with better pay and benefits. Many aides have fallen ill or been exposed to covid-19 during the recent surge of omicron cases and must quarantine for a time. And staffers are burned out after working during the pandemic in difficult, anxiety-provoking circumstances.

The implications for older adults are dire. Some seniors who are ready for discharge are waiting in hospitals or rehabilitation centers for several days before home care services can be arranged. Some are returning home with less help than would be optimal. Some are experiencing cutbacks in services. And some simply can’t find care.

Janine Hunt-Jackson, 68, of Lockport, New York, falls into this last category. She has post-polio syndrome, which causes severe fatigue, muscle weakness, and, often, cognitive difficulties. Through New York’s Medicaid program, she’s authorized to receive 35 hours of care each week. But when an aide left in June, Hunt-Jackson contacted agencies, asked friends for referrals, and posted job notices on social media, with little response.

“A couple of people showed up and then disappeared. One man was more than willing to work, but he didn’t have transportation. I couldn’t find anybody reliable,” she said. Desperate, Hunt-Jackson arranged for her 24-year-old grandson, who has autism and oppositional defiant disorder, to move into her double-wide trailer and serve as her caregiver.

“It’s scary: I’m not ready to be in a nursing home, but without home care there’s no other options,” she said.

Because comprehensive data isn’t available, the scope and impact of current shortages can’t be documented with precision. But anecdotal reports suggest the situation is severe.

“Everyone is experiencing shortages, particularly around nursing and home health aides, and reporting that they’re unable to admit patients,” said William Dombi, president of the National Association for Home Care & Hospice. Some agencies are rejecting as many as 40% of new referrals, according to reports he’s received.

“We’re seeing increasing demand on adult protective services as a result of people with dementia not being able to get services,” said Ken Albert, president of Androscoggin Home Healthcare and Hospice in Maine and chair of the national home care association’s board. “The stress on families trying to navigate care for their loved ones is just incredible.”

In mid-January, the Pennsylvania Homecare Association surveyed its members: Medicare-certified home health agencies, which provide assistance from aides and skilled nursing and therapy services, and state-licensed home care agencies, which provide nonmedical services such as bathing, toileting, cooking, and housekeeping, often to people with disabilities covered by Medicaid. Ninety-three percent of Medicare-certified home health and hospice agencies and 98% of licensed agencies said they had refused referrals during the past year, according to Teri Henning, the association’s chief executive officer.

“Our members say they’ve never seen anything like this in terms of the number of openings and the difficulty hiring, recruiting, and retaining staff,” she told me.

Lori Pavic is a regional manager in Pennsylvania for CareGivers America, an agency that provides nonmedical services, mostly to Medicaid enrollees who are disabled. “Our waiting list is over 200 folks at this time and grows daily,” she wrote in an email. “We could hire 500 [direct care workers] tomorrow and still need more.”

Another Pennsylvania agency that provides nonmedical services, Angels on Call, is giving priority for care to people who are seriously compromised and live alone. People who can turn to family or friends are often getting fewer services, said C.J. Weaber, regional director of business development for Honor Health Network, which owns Angels on Call.

“Most clients don’t have backup,” she said.

This is especially true of older adults with serious chronic illnesses and paltry financial resources who are socially isolated — a group that’s “disproportionately affected” by the difficulties in accessing home health care, said Jason Falvey, an assistant professor of physical therapy and rehabilitation science at the University of Maryland School of Medicine.

Many agencies are focusing on patients being discharged from hospitals and rehab facilities. These patients, many of whom are recovering from covid, have acute needs, and agencies are paid more for serving this population under complicated Medicare reimbursement formulas.

“People who have long-term needs and a high chronic disease burden, [agencies] just aren’t taking those referrals,” Falvey said.

Instead, families are filling gaps in home care as best they can.

Anne Tumlinson, founder of ATI Advisory, a consulting firm that specializes in long-term care, was shocked when a home health nurse failed to show up for two weeks in December after her father, Jim, had a peripherally inserted central catheter put in for blood cell transfusions. This type of catheter, known as a PICC line, requires careful attention to prevent infections and blood clots and needs to be flushed with saline several times a day.

“No show from nurse on Friday, no call from agency,” Tumlinson wrote on LinkedIn. “Today, when I call, this 5 star home health agency informed me that a nurse would be out SOMETIME THIS WEEK. Meanwhile, my 81 year old mother and I watched youtube videos this weekend to learn how to flush the picc line and adjust the oxygen levels.”

Tumlinson’s father was admitted to the hospital a few days before Christmas with a dangerously high level of fluid in his lungs. He has myelodysplastic syndrome, a serious blood disorder, and Parkinson’s disease. No one from the home health agency had shown up by the time he was admitted.

Because her parents live in a somewhat rural area about 30 minutes outside Gainesville, Florida, it wasn’t easy to find help when her father was discharged. Only two home health agencies serve the area, including the one that had failed to provide assistance.

“The burden on my mother is huge: She’s vigilantly monitoring him every second of the day, flushing the PICC line, and checking his wounds,” Tumlinson said. “She’s doing everything.”

Despite growing needs for home care services, the vast majority of pandemic-related federal financial aid for health care has gone to hospitals and nursing homes, which are also having severe staffing problems. Yet all the parts of the health system that care for older adults are interconnected, with home care playing an essential role.

Abraham Brody, associate professor of nursing and medicine at New York University, explained these complex interconnections: When frail older patients can’t get adequate care at home, they can deteriorate and end up in the hospital. The hospital may have to keep older patients for several extra days if home care can’t be arranged upon discharge, putting people at risk of deteriorating physically or getting infections and making new admissions more difficult.

When paid home care or help from family or friends isn’t available, vulnerable older patients may be forced to go to nursing homes, even if they don’t want to. But many nursing homes don’t have enough staffers and can’t take new patients, so people are simply going without care.

Patients with terminal illnesses seeking hospice care are being caught up in these difficulties as well. Brody is running a research study with 25 hospices, and “every single one is having staffing challenges,” he said. Without enough nurses and aides to meet the demand for care, hospices are not admitting some patients or providing fewer visits, he noted.

Before the pandemic, hospice agencies could usually guarantee a certain number of hours of help after evaluating a patient. “Now, they really are not able to guarantee anything on discharge,” said Jennifer DiBiase, palliative care social work manager at Mount Sinai Health System in New York City. “We really have to rely on the family for almost all hands-on care.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

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American Workers Have No Assurances of Time Off After a Miscarriage

After Miscarriages, Workers Have Few Guarantees for Time Off or Job-Based Help

Bryce Covert January 26, 2022

For three years, Rachel Makkar said, she thrived in her job as a broker and asset manager at J&B Building Co. in Colorado. She excelled at her work — she said her performance reviews noted that — and she thought it was “the best place I’ve ever worked.”

That changed in August. After trying for “a really long time” to conceive a second child, she suffered an early miscarriage at home one weekend. She couldn’t go to work that Monday. “I was really traumatized,” she said. “That entire first week was like a heightened level of emotion that I hadn’t really been through before.” She also had a doctor’s appointment to ensure she wasn’t experiencing an ectopic pregnancy, which would have required immediate surgery.

She had emailed her bosses, informing them of the miscarriage and her need to take Monday off, which she had enough paid leave to cover. Because of the pandemic, she had been working from home several days a week and opted to do that again Tuesday because she was still bleeding and her face was “so puffy from crying,” she said. She returned to the office, as scheduled, on Wednesday, she said, and then, given that her managers were out of the office, worked from home the rest of the week.

The following week, 10 days after her miscarriage, one of the company owners called her and fired her, allegedly for working from home repeatedly, even though others at the firm had similar hybrid schedules, according to Makkar. She was “shocked.”

When Makkar reminded him that she had worked from home because of her miscarriage, she said he responded, “When my wife had a miscarriage in the beginning of our marriage, she only took a half a day off work.”

Getting fired right after her miscarriage “was really, really awful,” she said through tears. “You’re already so devastated, and it’s just another blow.”

Makker filed a complaint based on her allegations against J&B with the Colorado Civil Rights Division, accusing the company of gender and pregnancy discrimination for her firing, in violation of Colorado state laws. “This shouldn’t have to happen to other women,” she said.

Makkar’s lawyer, David E. Gottlieb, said they “intend to file a lawsuit in the coming months in Colorado state court.”

A lawyer for J&B said its policy is not to comment on ongoing litigation and declined to provide any responses the company may have filed with the state. “We’re just confident that once the facts are reviewed the company will be vindicated,” he said.

Miscarriage, which occurs in about a quarter of all pregnancies, is the most common form of loss of a pregnancy. And yet there are no national laws that protect people when they need time off from work to deal with the loss.

The physical needs of someone who experiences a miscarriage vary greatly. Within the first week or two, symptoms may resemble a heavy menstrual period with cramping and some pain. The later in the pregnancy that a miscarriage occurs, the more likely there will be significant bleeding, “to the point where it leads to anemia in some cases,” said Dr. Wael Salem, a reproductive endocrinologist and fertility specialist with CCRM San Francisco. Some people have such heavy contractions that they need pain management, he added. Miscarriages in the second trimester or later may require procedures needing hospital admission. The aftereffects are often unpredictable and can last for weeks or months.

“Miscarriage is not a one-and-done thing at all,” Salem said. “It drags on physically, mentally, and emotionally.”

The emotional aspect “can be a very traumatic experience,” noted Maria Brann, a professor of communications studies at Indiana University who has studied miscarriage for a decade. Some people blame themselves even though the vast majority of early miscarriages are due to chromosomal abnormalities beyond people’s control. Compounding the grief is the lack of established rituals that accompany other losses, as well as a stigma some people attach to miscarriage.

In the wake of such trauma, “it’s very difficult to focus,” Brann said. “An individual is probably not going to be as productive.”

“It is really important that we encourage women to take care of themselves,” Brann said. Otherwise, the grief won’t be processed and it can “cause even greater mental anguish later on.”

More people are speaking out about the experience of miscarriage, including high-profile women like Michelle Obama, Meghan Markle, and actress Gabrielle Union.

But many workers find it difficult to get time off from work. The federal Pregnancy Discrimination Act prohibits employers from treating workers who are pregnant, give birth, or have related medical conditions — including miscarriage — worse than comparable co-workers. Courts, however, have interpreted that law differently, even after a 2015 Supreme Court decision decided in favor of a plaintiff who claimed pregnancy discrimination. Judges have dismissed two-thirds of cases in the aftermath, according to a review by A Better Balance, a national legal nonprofit promoting workplace rights.

Thirty states and five localities — including Colorado — have enacted laws that require employers to offer workers accommodations related to pregnancy, which can include time off to recover from a miscarriage. But outside those states, workers are protected only by the pregnancy act or the Americans with Disabilities Act, if a miscarriage is severe enough to substantially limit a “life activity.”

Currently, 13 states, 20 cities, and four counties, also including Colorado, have enacted laws requiring some employers to provide paid sick leave to workers for medical needs, such as for the physical and mental health impacts of miscarriage. They don’t require employees to say why they need the time off, other than perhaps producing a doctor’s note.

“It’s not putting the onus on the worker to have to reveal something that might be very personal and very sensitive,” said Sarah Brafman, a senior policy counsel at A Better Balance.

Nine states and the District of Columbia have paid family leave programs, which can be used for more serious complications resulting from miscarriage. Elsewhere workers can take unpaid leave through the Family and Medical Leave Act if they qualify.

To fill the gaps, Sen. Tammy Duckworth (D-Ill.) and Rep. Ayanna Pressley (D-Mass.) introduced legislation that would ensure three days of paid leave for miscarriage and other fertility challenges. Democrats have also put forward federal legislation to guarantee paid sick leave, and they’ve included paid family leave in President Joe Biden’s social spending plan, although that provision is meeting stiff opposition from some lawmakers and the bill is languishing in Congress.

Makkar is living with the repercussions of her miscarriage. “It’s all so traumatizing still,” she said. She’s trying to find a new job, but the search is complicated. She’s “terrified of getting myself in this situation again,” she said, because she wants to have more children. “I don’t want to be somewhere that that’s not going to be supported.”

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California's Brewing Vaccine War

Vaccine Wars Ignite in California as Lawmakers Seek Stronger Laws

Angela Hart January 24, 2022

SACRAMENTO — California is poised to become the front line of America’s vaccination wars.

State lawmakers are drafting the toughest covid-19 vaccine legislation in the country, backed by a new pro-vaccine lobbying force promising to counter anti-vaccine activists who have threatened government officials and shut down public meetings across the state. Legislators want to require most Californians to get the shots — not just schoolchildren and health care workers — and eliminate the exemptions that would allow many people to get out of them.

But vaccine opponents say Democratic-led efforts to adopt stricter vaccine requirements are only helping propel their movement, handing them unparalleled momentum to build their ranks both in California and nationally.

Vaccine opponents are focusing their ire on Democratic state Sen. Richard Pan of Sacramento, a pediatrician and the driving force behind three state vaccination laws passed since 2012. Prompted by outbreaks of pertussis and measles, the laws make it harder for schoolchildren to get out of childhood vaccinations.

“We have to be willing to take a stand,” said Pan, who is developing legislation to crack down on covid vaccine exemptions. “We need to be able to respond to this pandemic and future pandemics, but there is this asymmetrical warfare going on right now, and we’re seeing the anti-vaccine movement trafficking in misinformation, threats, and violence.”

The coming fight in California foreshadows looming vaccine battles across the country. President Joe Biden and Democratic governors are pressing vaccination as the most crucial public health measure for combating the coronavirus pandemic — while some prominent Republican governors cast doubt on the safety and value of vaccines, inciting anti-vaccination activists.

In California, the ultimate decision on toughening state vaccination laws will fall to Democratic Gov. Gavin Newsom, who is facing reelection in November after defeating a recall attempt last year.

Newsom has played to both sides recently. He has pushed tough vaccine mandates for groups such as health care workers, children, and teachers. But in nearly every pandemic-related press conference since October and on national TV, he has also reassured the public that they can receive medical, religious, and personal belief exemptions from his mandates.

“He’s trying to be comforting and non-confrontational, but it sends a message that if you don’t want to get the vaccine, don’t get it,” said Catherine Flores Martin, executive director of the California Immunization Coalition. “Gov. Newsom struggles with this — he’s trying to have it both ways.”

Pushing Mandates ‘Aggressively’

Anti-vaccine demonstrations dominated Sacramento during California’s last big vaccination fight, in 2019. In weekly rallies outside the Capitol, hundreds of activists railed against lawmakers, toting a portrait of Pan’s face splattered in red. They shouted down lawmakers in legislative hearings and at one point hurled menstrual blood at state senators.

The fight that year was over Pan’s bill to crack down on bogus medical exemptions for common childhood vaccinations against measles, polio, and other infectious diseases, which are required to attend in-person public and private school in California. Four years earlier, he spearheaded a law to ban personal belief exemptions for childhood vaccines.

But under state law, personal belief exemptions must be allowed for any newly required childhood vaccine unless the legislature passes a new law banning them.

Newsom issued a directive in October 2021 adding covid vaccines to the list of required childhood immunizations — once federal officials fully authorize them for children. But because the legislature has not yet acted, Californians will be able to opt out by claiming the vaccines violate personal beliefs.

Pan and other Democratic lawmakers want to close that loophole this year, and potentially eliminate religious exemptions that health care workers can claim. They’re also considering requiring a broad swath of Californians to get covid vaccines to participate in much of daily life.

Lawmakers are still hashing out details but are expected to propose legislation requiring covid vaccines for people to be in workplaces, schools, and public venues like malls, museums, and restaurants — without allowing them to avoid the shots through exemptions. Pan, who is leaving the legislature after this year because of term limits, may also push legislation to hold tech companies more accountable for spreading misinformation on social media platforms.

“Do you have the right to be safe at school? Do people deserve to be safe at work? Are businesses responsible for creating an environment that won’t injure or harm you? This has to be part of the conversation,” said Pan, who was shoved by a protester near the Capitol in 2019.

Last year, Buffy Wicks, a Democratic Assembly member from Oakland, and Evan Low, a Democratic Assembly member from Campbell, tried but failed to muscle through legislation establishing covid vaccine mandates for workers and businesses. But the ongoing challenges of the pandemic have “reenergized” Democratic lawmakers this year, said state Sen. Scott Wiener (D-San Francisco), who is carrying legislation to lower the age at which someone can consent to a vaccine without parental permission from 18 to 12.

“It’s important that we continue to push for vaccine mandates the most aggressively we possibly can,” said Wicks, who faced death threats over her vaccine legislation last year. “We can’t let ourselves be held hostage by these right-wing conspiracy theorists who are perpetrating hate and violence.”

‘The Firestorm Is Here’

Anti-vaccine activists acknowledge they may not succeed at defeating new legislation but welcome state lawmakers’ attempts to impose stricter rules — they argue it helps them build a larger movement in California, on social media, and in other states.

“What they don’t realize is the point of these rallies and protests is to bring more people into the fold, from all around the country,” said Stefanie Fetzer, a chief organizer of the 2019 anti-vaccination demonstrations at the state Capitol. “Senator Pan galvanized a larger anti-vax movement that wouldn’t have happened without him.”

Scientists and health officials blame California’s stagnating covid vaccination rate largely on the anti-vaccine movement, which is peddling misinformation and lies. The share of Californians who are considered fully vaccinated is 69%, and booster shots are lagging — even though the state and local governments have plowed tens of millions of dollars into vaccination campaigns.

“What you see now is this movement being taken over by Republicans and this libertarian right-wing notion of individual rights and ‘get government off my back.’ They’re believing and spreading this misinformation even though it’s disproven,” said Dr. Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia. “Trying to stop it is like trying to stop Niagara Falls.”

Vaccine opponents have also shut down government meetings and lobbed violent threats at officials backing mandates.

The Los Angeles Unified School District delayed its student vaccine mandate after anti-vaccine demonstrations, in an effort to keep unvaccinated students from dropping out. In Stockton and elsewhere, vaccine opponents have shouted down proposed school vaccine mandates.

Joshua Coleman, who organized hundreds of protesters in 2019 under his group V Is for Vaccine, has held rallies in Sacramento this year, again targeting Pan with a 10-foot poster and his image smeared in red.

“There will be constant pressure,” Coleman said. “This is happening more and more all over the country, but we are building a movement out of California. Being forced to take a vaccine in order to participate in society is absolutely totalitarian.”

Vaccine supporters realize they must fight back and are launching a lobbying campaign, led by political heavyweights from Sacramento and Washington, D.C., to combat vaccine opponents with some of their own tactics.

“The firestorm is here. This is ground warfare that the anti-vax extremists are bringing, and I think we need to be able to match it,” said Crystal Strait, the former president and CEO of Planned Parenthood Affiliates of California who is leading the campaign under the group ProtectUS.

Campaign leaders are organizing students, parents, and pro-vaccine activists to counter anti-vaccination demonstrators in cities and counties across California and to debunk misinformation while giving state lawmakers political cover to enact tougher laws.

“We need to draw a really bold, bright line and let these extremists know that we will not be silent,” Strait said.

The campaign emerged quietly last year, sponsoring a new law to limit protests outside vaccination clinics — which has since been blocked in court — and will launch ground-game political efforts this year.

“The science is on our side, and there’s a silent majority on our side, but we’re being drowned out in public forums where these decisions are being made,” said Rose Kapolczynski, a longtime political consultant to former U.S. Sen. Barbara Boxer, who is working on the campaign. “We’re going to activate the pro-vaccine majority when policies are being considered at the state and local levels.”

Whither Newsom?

Newsom is also wading into the fray.

His administration has plowed $145 million into a campaign to increase covid vaccinations and fight misinformation, in part by monitoring social media posts and flagging vaccine myths to social media companies. The administration is also developing a pro-vaccine counternarrative based on the misinformation.

“We want to be proactive about what the truth is and put it out there while debunking misinformation,” said Dr. Mark Ghaly, secretary of the state’s Health and Human Services Agency.

More than half a dozen public health experts interviewed for this story said that vaccine mandates work and that Newsom can boost the state’s faltering vaccination rates by eliminating exemptions.

But since Newsom announced the covid vaccine mandate for schoolchildren, he has publicly promoted exemptions.

“The mandate we put in place for the state of California includes personal exemptions,” Newsom said during an appearance on “Good Morning America” in December. “There’s plenty of latitude for families to make decisions.”

Newsom has declined to say whether he would support legislation banning exemptions but said he’d work with lawmakers. “We can discuss the merits and demerits” of allowing exemptions, Newsom said this month. “We did what we felt was appropriate.”

Barbara Ferrer, the public health director for Los Angeles County, which has recorded nearly 28,000 covid deaths, more than a third of the state’s total, called on Newsom and state lawmakers to adopt mandates without exemptions.

“If you allow that, you may as well not have a vaccine mandate,” she said. “If you don’t want your child to get vaccinated, then your child doesn’t have to go to school. And you don’t have to go to a restaurant. I’m not trying to be mean to people. I’m just saying there are some things you shouldn’t be able to do if you’re not vaccinated.”

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Covid Antibody Treatments Ineffective Against Omicron Still Being Used

Patient, Beware: Some States Still Pushing Ineffective Covid Antibody Treatments

JoNel Aleccia, Kaiser Health News January 21, 2022

As the omicron variant completes its sweep across the U.S., states with scarce supplies of monoclonal antibody therapies continue to use two treatments that federal health officials warn no longer work against the highly contagious version of the virus that causes covid-19. The antibody treatment now most recommended is sotrovimab from GlaxoSmithKline and Vir Biotechnology, and it’s in short supply.

Use of the newly ineffective treatments produced by Regeneron Pharmaceuticals and Eli Lilly and Co. is highest in a dozen states. They include several Southern states with some of the nation’s lowest vaccination rates, but also California, which ranks in the nation’s top 20 for fully vaccinated residents, a KHN analysis of federal data shows. Many hospitals and clinics are still infusing the costly treatments — often charging hundreds of dollars a session — that public health officials now say are almost certainly useless.

That’s because of the near-total dominance of omicron, which accounted for 99.5% of new covid infections in the U.S. during the week that ended Jan. 15, according to the Centers for Disease Control and Prevention.

That point was underscored this week by updated guidelines from the National Institutes of Health that now recommend sotrovimab as the primary monoclonal treatment for the disease.

Unless providers are certain they are still treating patients infected with the delta variant, they shouldn’t use the others, said Dr. Mark McClellan, director of the Duke-Margolis Center for Health Policy, who is also a former commissioner of the FDA and former administrator of CMS. And the delta variant is increasingly rare, accounting for 3% of cases in Louisiana, 7% in California, and 10% in Ohio, as examples.

“There’s not a medical justification based on the evidence on the Regeneron and Lilly products,” McClellan said.

Determining which patients are infected with the delta vs. omicron variant is complicated, said Dr. Christian Ramers, chief of population health and an infectious disease specialist at Family Health Centers of San Diego.

His clinic is one of the few sites in the nation using laboratory screening of positive PCR covid tests that can tell whether patients are infected with delta vs. omicron — and then treating them accordingly. “Otherwise, you’re giving this false sense of security to a patient that they’re getting treatment,” Ramers said. “I don’t think it is ethical, and it goes against the principle of doing no harm.”

Overall, U.S. hospitals used about 72,000 doses of the Regeneron and Lilly monoclonal antibody therapies from Jan. 5 through Jan. 18, according to the latest figures from the Department of Health and Human Services. Data regarding hospital-level use of sotrovimab, which became available more recently than the other products, is not yet available on the HHS site.

By comparison, hospitals used about 153,000 courses of the Regeneron and Lilly treatments from Dec. 22 through Jan. 4. They used about 169,000 courses from Aug. 26 through Sept. 8, near the height of the delta surge.

On Jan. 19, hospitals still had about 295,000 doses of the Regeneron and Lilly treatments on hand.

Nationwide, the federal government is distributing more than 50,000 courses of sotrovimab per week, though it remains in short supply. The Biden administration has agreed to buy about 1 million doses, including about 600,000 promised by March, GSK officials said.

Respectively, Michigan, Florida, Indiana, Missouri, Louisiana, California, Oklahoma, Kansas, Georgia, Ohio, New York, and Mississippi used the most courses of the Regeneron and Lilly treatments from Jan. 5 through Jan. 18, KHN’s analysis showed.

In Florida, which used more than 5,200 courses of the outdated treatments during that two-week period, Republican Gov. Ron DeSantis has said he is not convinced that the Regeneron and Lilly products don’t work against omicron. In Florida, omicron accounted for 97% of cases as of Jan. 20; delta accounted for 3%.

“We have had practitioners give both of those to people with omicron who said the symptoms got resolved,” he said in a Jan. 5 speech provided by his spokesperson, Christina Pushaw.

Federal health officials managing allocation of the monoclonal antibody therapies paused shipments of the Regeneron and Lilly treatments on Dec. 23, after laboratory tests showed they were less effective against the surging omicron variant than the delta variant. But the Biden administration resumed shipments on Dec. 31, after complaints from DeSantis and some doctors that those therapies could still help people in places where the delta variant persisted.

Regeneron itself has said its antibody treatments are ineffective against the omicron variant. It contains more than 30 mutations in the virus’s spike protein, which makes the variant better at dodging the monoclonal antibody treatments.

“It’s really not justified at this point unless there’s some other underlying secondary gain, political pressure, or perhaps the providers are truly not in touch with the reality of the variant proportions,” Ramers said.

Earlier this month, HHS officials indicated that shipments of the three monoclonal antibody treatments would continue through Jan. 31, despite the growing proportion of omicron cases. A department spokesperson on background said the agency would continue to assess “any impacts to covid-19’s therapeutic allocations.”

Monoclonal antibody treatments are lab-based molecules that mimic the body’s immune response to infection. They are most often given through IV infusion, though some can be delivered with an injection. The federal government has agreed to purchase millions of doses of the Regeneron and Lilly products at a cost of about $2,100 per dose. The medicines are free to consumers, though hospitals and clinics do charge fees for administering the drugs and monitoring patients during the process.

Other treatments expected to be effective against omicron in high-risk, non-hospitalized patients include AstraZeneca’s Evusheld, a long-acting injectable monoclonal antibody for immunocompromised people, and a three-day infusion of Gilead Sciences’ remdesivir, which is approved by the FDA. New oral antiviral pills also are expected to be effective, although they, too, remain in short supply.

Providers in several states that have continued to use the Regeneron and Lilly products have offered varied reasons. Some said they believed delta infections continued to circulate locally; others said they felt desperate to try something.

Officials in Michigan, which used more than 5,800 doses of the Regeneron and Lilly products during the most recent two weeks, and California, which used more than 3,400, have allowed health care providers to use their clinical judgment about which treatment to prescribe.

But in Mississippi, where omicron is rampant and fewer than half of residents have been fully vaccinated, state health officer Dr. Thomas Dobbs called for an end to the use of the treatments.

“We will be recommending that clinicians and physicians do not use these products right now based on the distribution of omicron vs. delta,” he said during a recent press conference.

At Ramers’ clinic in San Diego, care providers have been dispensing scarce doses of the monoclonal antibody treatments only when they’re confident they’ll help. That has meant sending batches of positive PCR tests to a laboratory in nearby Irvine, where they are screened to see whether one of three target genes is not detected, a known marker for an omicron infection.

Patients infected with the delta variant were able to be treated with REGEN-COV, the Regeneron product, preserving sotrovimab for the growing number of omicron cases, said Pauline Lucatero, the clinic’s director of nursing.

“Looking into my patients’ eyes and seeing fear, just fear, all I could tell them is we believe this treatment works and we’re going to do everything we can to save as many people as we can,” she said.

Phillip Reese, an assistant professor of journalism at California State University-Sacramento, contributed to this report.

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