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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.

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.

Divya Singh, a student at Hofstra University in Hempstead, New York, sought counseling help after feeling panicked when she had trouble paying a big tuition bill. A weeklong stay in a psychiatric hospital followedalong with a $3,413 bill. (Jackie Molloy for KHN)

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.”


Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills.
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.

COVID Slams Ethnic Minorities

As the COVID-19 vaccination program rolls out erratically across the US, research increasingly shows that health inequities underlying who gets infected will also affect who gets vaccinated.

In telling statistics reported by the CDC and KFF, people of color are more likely to be infected or hospitalized, and more likely to die from the coronavirus.

The numbers are stark.

Compared to whites, American Indians are 1.9 times more likely to be infected, African Americans nearly 3 times more likely to be hospitalized, and Latinx people 2.4 times more likely to die.

Asian Americans are the highest risk for hospitalization and death among any ethnic group. In San Francisco, it’s reported that  Asian Americans consistently account for nearly half of COVID-19 deaths.

It’s impossible to ignore the disproportionate toll of the pandemic on racial and ethnic minorities. Even though all communities are at risk for COVID-19, the socioeconomic status of people of color, and their occupations in frontline, essential and infrastructure jobs puts them at greater risk of exposure to the coronavirus.

For minority communities, it means that where you live and where you work shapes how the virus impacts your health, while inadequate access to healthcare makes you more vulnerable to its consequences.

“The pandemic has exposed the “underlying health disparities, social determinants of health, systemic inequalities and discrimination contribute to the disproportionate impact the virus has had on all communities of color,” said Adam Carbullido of AAPCHO, at an EMS press briefing on February 12, about health inequities in the pandemic.

Health advocates predicted that an inequitable distribution of vaccines was inevitable, given the high rates at which Blacks, Latinos and other ethnic groups were being infected and dying in each wave of the pandemic.

This is borne out by data from the Kaiser Family Foundation (KFF) which is tracking vaccine distribution. For example, fewer black people are getting vaccines despite a higher rate of COVID 19 cases. In Delaware only 6% of Blacks were vaccinated though 24% were infected, and in Louisiana, only 13% of Blacks received vaccines though 34% were infected, while in Mississippi, 38% of Blacks were infected but only 17% got the vaccine.

However, the lack of disaggregated racial data at the state and national level is hobbling equitable distribution of the COVID-19 vaccine, noted Dr. Daniel Turner-Lloveras of the Latino Coalition Against COVID-19. Currently only 20 US states are reporting racial data.

Given that it’s primarily Black and Latino workers in essential jobs,  it’s imperative to consider who’s at high risk when making decisions about reopening the economy, he added.

If we cannot quantify racial disparity in vaccine distribution, warned Lloveras, it will be difficult to develop interventions to ensure vaccines are given to those who need it most.

Health disparities between whites and people of color that are impacting vaccine distribution, are “gaps that have become chasms,” said Lloveras. The vaccine roll out “inherently prioritizes a population that is not reflective of the people who are disproportionately affected by the coronavirus”, added Virginia Hedrick, of the California Consortium for Urban Indian Health.

In American Indian country, inequitable vaccine distribution is merely a reflection of the historical trauma inflicted on indigenous communities that has negatively impacted their health and wellbeing over the long term, said Hedric resulting in the highest rates of diabetes, heart disease and substance use disorders. Its only because of advocacy that the Indian Health Service has a separate vaccine reserve allocated to urban and tribal Indian American communities.

Barriers to Better Health  & Vaccines

Several other factors create barriers to better health and getting a vaccine among people of color.

Ethnic minorities tend to live in densely populated areas which makes social distancing difficult, and often in multi generation family homes which put elders at risk. They may use public transportation which could expose them the virus, and lack health insurance or healthcare access.

Farmworkers and the elderly face similar barriers in the form of digital literacy, language barriers and internet access, said Lloveras.  With stay at home orders in place, telehealth depends on who has access to technology. He suggested providing Internet access hotspots and community classes on computer literacy to expand digital access for underserved minorities.

The lack of a robust public healthcare system requires that we provide the technology to help people see a doctor and register for vaccines.

In Asian communities, added Carbullido, patients of Asian descent report fear in getting help they need because of emotional trauma caused by racism and xenophobic attacks associated with the virus.

Yet, many ethnic minorities are reluctant to get their shot because they mistrust the government. Kaiser Family Foundation’s vaccine tracker data reports ‘fear of side effects” prevents people from obtaining the vaccine.

Lloveras proposed ‘a gigantic digital patient engagement project’ to address vaccine hesitancy to set the path to herd immunity and a semblance of normal life .

Missteps in California

Each state’s scramble to acquire and distribute vaccines signaled an unpreparedness for a public health crisis like the coronavirus, said Dr.David Carlyle, President and CEO of the Charles R. Drew University of Science and Medicine, calling California’s missteps in the pandemic a “failure of public policy.”

When MLK Community Hospital, a 130-bed facility at the epicenter of the pandemic in Los Angeles County tried to transfer its sickest patients to nearby tertiary hospitals for oxygenation, they were repeatedly refused because because their patients did not have health insurance. When the vaccine roll out flatlined mid-February, high volume vaccine centers (LA Forum, Dodgers Stadium) in LA county closed mid -February, because supplies of vaccine doses ran out. Commercial pharmacies placed vaccination sites in smaller, less diverse towns like Huntington Beach, Irvine and Newport Beach, while Los Angeles, a city of 8 million was allotted just one site.

“In my estimation we weren’t prepared for COVID 19.” Carlyle concluded.

A Robust Rescue Package

Given the lack of a robust public health system, panelists urged Congress to bolster the public health infrastructure with a bold COVID 19 rescue package for testing, treatment, vaccine distribution.

They called for increased investment in public health and community-based organizations (CBOs) that serve marginalized communities which have more chronic medical issues and higher risk factors for complications of COVID19.  CBOs are vital in reaching communities of color and other hard hit communities, by providing culturally and linguistically appropriate services where government and private institutions have fallen short. Supporting CBOs could mitigate the health inequities of the COVID19 crisis, said Carbullido.

The pandemic overwhelmed most healthcare systems which were not prepared or adequately funded creating crises like the MLKCH that Carlyle called “a  perfect example of the inhumanity of equities in healthcare.”

But “the pandemic has not created these inequities,” concluded Hedrick, “it’s simply highlighting them.”

More information is available at:
https://bit.ly/vaccines-race-data
https://ccuih.org/


Meera Kymal is the Contributing Editor at India Currents
Photo by Ivan Diaz on Unsplash

Online Classes Divide Haves & Have Nots

It’s Tuesday morning, and teacher Tamya Daly has her online class playing an alphabet game. The students are writing quickly and intently, with occasional whoops of excitement, on the little whiteboards she dropped off at their homes the day before along with coloring books, markers, Silly Putty and other learning props — all of which she created or paid for with her own money.

Two of the seven children in her combined third and fifth grade class weren’t home when Daly came by with the gift bags. One of the two managed to find her own writing tablet, thanks to an older brother, but the other can’t find a piece of paper in her dad’s house. She sits quietly watching her classmates on Zoom for half an hour while Daly tries futilely to get the father’s attention. Maybe the student is wearing earphones; maybe the father is out of the room.

As children head back to school online across California and much of the nation, some of the disparities that plague education are growing wider. Instead of attending the same school with similar access to supplies and teacher time, children are directly dependent on their home resources, from Wi-Fi and computers to study space and parental guidance. Parents who work, are poor or have less education are at a disadvantage, as are their kids.

Daly teaches elementary students with special needs. The children in her class, who have a variety of diagnoses and intellectual disabilities, are at even higher risk — they can’t work independently and need more hands-on instruction. “The more they’re not getting those kinds of accommodations, the further they’re going to fall behind,” said Allison Gandhi, a managing director in special education at the nonprofit American Institutes for Research.

Educators and families fear devastating long-term consequences from COVID-19 for the nearly 800,000 California children who received special education services. So, in early August, the state announced it was developing a waiver application process for schools, even in COVID-plagued counties, that want to bring small groups of these students back for in-person education.

“There are simply kids that will never, ever have that quality learning that we all desire to advance online, no matter what kind of support we provide, even if we individualize it,” Gov. Gavin Newsom said at an Aug. 14 news conference.

Online learning is interfering with the students’ individualized education programs, or IEPs — legal agreements among families, school districts and specialists that set academic and behavioral goals for students and the services they’re entitled to.

The gap in online learning experience is sharply visible in Daly’s class, and the parents’ role is crucial. For parents who don’t have to work, distance learning may be tense and time-consuming, but it becomes part of a daily routine to be endured until the pandemic ebbs. For others, schooling is an unworkable nightmare burdening parents already stretched to their limits.

School started Aug. 12. By day five, Daly knew which children had the luxury of a stay-at-home parent and which were being supervised by older siblings. She knew which students struggled to get online on time every day — a new state requirement for all virtual learners — and which ones needed reminding to eat breakfast before class started.

She also knew, from last spring, that most of the parents couldn’t print the worksheets she had uploaded to Google Classroom. Their printers were broken, or printer ink cost too much, or they didn’t have printers. For this semester, she set up a time every Thursday for parents to drive by the school and pick up packets for the following week.

Daly works at Emery Park Elementary School in Alhambra, east of downtown Los Angeles, where two-thirds of the students qualified last year for free or reduced-price school meals. The school has loaned about 80% of the 434 students Chromebooks because they didn’t have computers at home, said principal Jeremy Infranca.

Like most schools in California, Emery Park started the school year in virtual classrooms — the safest option for a state with a stubbornly persistent infection rate. The Alhambra school district has yet to decide whether to apply for a waiver to bring students with special needs back on campus. Infranca and Daly would like to — if they can secure COVID-19 protective gear for themselves and their students, and if families feel comfortable with it.

In the meantime, Daly is doing her best to accommodate her families, which isn’t easy. Parents have told her to limit live group instruction to an hour a day, so as not to interfere with child care schedules or the laptop needs of other children in the household. To make up for the reduced time, Daly records several 15- to 30-minute videos explaining the work to be done and plans to schedule an individual session with each child once a week.

“I choose to be positive about this experience, and I choose to communicate and do my best to reach out to the students and connect with parents and family members,” said Daly. “We just need to be proactive, and also a little patient.”

Families have different opinions about whether to return their kids to the schoolhouse. It often depends more on a family’s desperation over child care than consideration of COVID-19 risks.

Cat Lee, 44, was nervous at first when she realized she had to take on the bulk of hands-on teaching for her son, Jacob, a fifth grader in Daly’s class.

“I wondered, would I be able to teach him as well, and would he be able to learn it?” she said.

Lee is a stay-at-home mom, and so far she has been able to stick to the schedule Daly lays out. She’s there with Jacob at every Zoom session and logs onto the Seesaw app to go through all the assignments. She praised Daly for her curriculum, which she felt was better and easier to teach than what the family received back in March. But she had reservations about her son’s new normal.

“It’s really slowing down his learning; plus, he doesn’t interact with kids anymore,” said Lee.

Still, if she had the chance to send Jacob for in-person learning now, Lee wouldn’t take it. She has concerns about their immune systems — Lee had a kidney transplant five years ago, and Jacob was born at just 27 weeks’ gestation — and is holding out for a COVID vaccine before allowing Jacob to resume his normal activities.

Not that she doesn’t have doubts.

“My fear is that he’s going to be home for so long, he’ll be so used to it and he won’t want to go back to school,” she said.

Danielle Musquiz, a 32-year-old mother with five elementary school-aged boys — four adopted from a relative — would favor a return to school. She gets three or four hours of sleep each night because of her 90-hour workweek with two jobs, as a home aide and a cashier at a regional park.

Four of her sons receive special education services, including an adopted middle child who is in Daly’s class and has cognitive delays linked to fetal alcohol spectrum disorder. The children, crowded together at the dining room table or in the living room, listen to their classes with earphones to keep from disturbing one another, which means she can’t hear a teacher calling out to her from the screen.

The four kids have individual education programs, but it’s hard for Musquiz to oversee them “with the minimal amount of time I have at home,” she said. She’s feeling overwhelmed by having to coordinate, supervise and respond to teachers, counselors and therapists for each child.

Musquiz is working longer hours than before the pandemic, and she picks up shifts at the park when the boys’ former stepfather takes them for the weekend.

“I’m slowly starting to say — and I know that this sounds bad — I don’t care anymore about the kids’ schooling,” Musquiz laughed nervously. “I feel like it’s chaos, and I’m drowning.”

To help with child care, her mother lives with the family Monday through Thursday, and her sons spend Thursday nights at her sister’s house. On Fridays, nine kids are all streaming their classes online from that house. On a recent Friday, the Wi-Fi broke, prompting a call from the school of one of her sons asking why he had left class early.

If she had the opportunity, Musquiz would send her children back to in-person learning in a heartbeat.

“None of my kids are really going to learn what they need to,” said Musquiz. “They need hands-on, they need interaction, they need motivation, and these classes are not doing that for them.”


This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

The New Digital World Can Give Seniors A Hard Time

Family gatherings on Zoom and FaceTime. Online orders from grocery stores and pharmacies. Telehealth appointments with physicians.

These have been lifesavers for many older adults staying at home during the coronavirus pandemic. But an unprecedented shift to virtual interactions has a downside: Large numbers of seniors are unable to participate.

Among them are older adults with dementia (14% of those 71 and older), hearing loss (nearly two-thirds of those 70 and older) and impaired vision (13.5% of those 65 and older), who can have a hard time using digital devices and programs designed without their needs in mind. (Think small icons, difficult-to-read typefaces, inadequate captioning among the hurdles.)

Many older adults with limited financial resources also may not be able to afford devices or the associated internet service fees. (Half of seniors living alone and 23% of those in two-person households are unable to afford basic necessities.) Others are not adept at using technology and lack the assistance to learn.

During the pandemic, which has hit older adults especially hard, this divide between technology “haves” and “have-nots” has serious consequences.

Older adults in the “haves” group have more access to virtual social interactions and telehealth services, and more opportunities to secure essential supplies online. Meanwhile, the “have-nots” are at greater risk of social isolation, forgoing medical care and being without food or other necessary items.

Dr. Charlotte Yeh, chief medical officer for AARP Services, observed difficulties associated with technology this year when trying to remotely teach her 92-year-old father how to use an iPhone. She lives in Boston; her father lives in Pittsburgh.

Yeh’s mother had always handled communication for the couple, but she was in a nursing home after being hospitalized for pneumonia. Because of the pandemic, the home had closed to visitors. To talk to her and other family members, Yeh’s father had to resort to technology.

But various impairments got in the way: Yeh’s father is blind in one eye, with severe hearing loss and a cochlear implant, and he had trouble hearing conversations over the iPhone. And it was more difficult than Yeh expected to find an easy-to-use iPhone app that accurately translates speech into captions.

Often, family members would try to arrange Zoom meetings. For these, Yeh’s father used a computer but still had problems because he could not read the very small captions on Zoom. A tech-savvy granddaughter solved that problem by connecting a tablet with a separate transcription program.

When Yeh’s mother, who was 90, came home in early April, physicians treating her for metastatic lung cancer wanted to arrange telehealth visits. But this could not occur via cellphone (the screen was too small) or her computer (too hard to move it around). Physicians could examine lesions around the older woman’s mouth only when a tablet was held at just the right angle, with a phone’s flashlight aimed at it for extra light.

“It was like a three-ring circus,” Yeh said. Her family had the resources needed to solve these problems; many do not, she noted. Yeh’s mother passed away in July; her father is now living alone, making him more dependent on technology than ever.

When SCAN Health Plan, a Medicare Advantage plan with 215,000 members in California, surveyed its most vulnerable members after the pandemic hit, it discovered that about one-third did not have access to the technology needed for a telehealth appointment. The Centers for Medicare & Medicaid Services had expanded the use of telehealth in March.

Other barriers also stood in the way of serving SCAN’s members remotely. Many people needed translation services, which are difficult to arrange for telehealth visits. “We realized language barriers are a big thing,” said Eve Gelb, SCAN’s senior vice president of health care services.

Nearly 40% of the plan’s members have vision issues that interfere with their ability to use digital devices; 28% have a clinically significant hearing impairment.

“We need to target interventions to help these people,” Gelb said. SCAN is considering sending community health workers into the homes of vulnerable members to help them conduct telehealth visits. Also, it may give members easy-to-use devices, with essential functions already set up, to keep at home, Gelb said.

Landmark Health serves a highly vulnerable group of 42,000 people in 14 states, bringing services into patients’ homes. Its average patient is nearly 80 years old, with eight medical conditions. After the first few weeks of the pandemic, Landmark halted in-person visits to homes because personal protective equipment, or PPE, was in short supply.

Instead, Landmark tried to deliver care remotely. It soon discovered that fewer than 25% of patients had appropriate technology and knew how to use it, according to Nick Loporcaro, the chief executive officer. “Telehealth is not the panacea, especially for this population,” he said.

Landmark plans to experiment with what he calls “facilitated telehealth”: nonmedical staff members bringing devices to patients’ homes and managing telehealth visits. (It now has enough PPE to make this possible.) And it, too, is looking at technology that it can give to members.

One alternative gaining attention is GrandPad, a tablet loaded with senior-friendly apps designed for adults 75 and older. In July, the National PACE Association, whose members run programs providing comprehensive services to frail seniors who live at home, announced a partnership with GrandPad to encourage adoption of this technology.

“Everyone is scrambling to move to this new remote care model and looking for options,” said Scott Lien, co-founder and chief executive officer of the company, which is headquartered in Orange County, California.

PACE Southeast Michigan purchased 125 GrandPads for highly vulnerable members after closing five centers in March where seniors receive services. The devices have been “remarkably successful” in facilitating video-streamed social and telehealth interactions and allowing nurses and social workers to address emerging needs, said Roger Anderson, senior director of operational support and innovation.

Another alternative is technology from iN2L (an acronym for It’s Never Too Late), a company that specializes in serving people with dementia. In Florida, under a new program sponsored by the state’s Department of Elder Affairs, iN2L tablets loaded with dementia-specific content have been distributed to 300 nursing homes and assisted living centers.

The goal is to help seniors with cognitive impairment connect virtually with friends and family and engage in online activities that ease social isolation, said Sam Fazio, senior director of quality care and psychosocial research at the Alzheimer’s Association, a partner in the effort. But because of budget constraints, only two tablets are being sent to each long-term care community.

Families report it can be difficult to schedule adequate time with loved ones when only a few devices are available. This happened to Maitely Weismann’s 77-year-old mother after she moved into a short-staffed Los Angeles memory care facility in March. After seeing how hard it was to connect, Weismann, who lives in Los Angeles, gave her mother an iPad and hired an aide to ensure that mother and daughter were able to talk each night.

Without the aide’s assistance, Weismann’s mother would end up accidentally pausing the video or turning off the device. “She probably wanted to reach out and touch me, and when she touched the screen it would go blank and she’d panic,” Weismann said.

What’s needed going forward? Laurie Orlov, founder of the blog Aging in Place Technology Watch, said nursing homes, assisted living centers and senior communities need to install communitywide Wi-Fi services — something that many lack.

“We need to enable Zoom get-togethers. We need the ability to put voice technology in individual rooms, so people can access Amazon Alexa or Google products,” she said. “We need more group activities that enable multiple residents to communicate with each other virtually. And we need vendors to bundle connectivity, devices, training and service in packages designed for older adults.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

The New Normal For Seniors In A Post-Vaccine World

Imagine this scenario, perhaps a year or two in the future: An effective COVID-19 vaccine is routinely available and the world is moving forward. Life, however, will likely never be the same — particularly for people over 60.

That is the conclusion of geriatric medical doctors, aging experts, futurists and industry specialists. Experts say that in the aftermath of the pandemic, everything will change, from the way older folks receive health care to how they travel and shop. Also overturned: their work life and relationships with one another.

“In the past few months, the entire world has had a near-death experience,” said Ken Dychtwald, CEO of Age Wave, a think tank on aging around the world. “We’ve been forced to stop and think: I could die or someone I love could die. When those events happen, people think about what matters and what they will do differently.”

Older adults are uniquely vulnerable because their immune systems tend to deteriorate with age, making it so much harder for them to battle not just COVID-19 but all infectious diseases. They are also more likely to suffer other health conditions, like heart and respiratory diseases, that make it tougher to fight or recover from illness. So it’s no surprise that even in the future, when a COVID-19 vaccine is widely available — and widely used — most seniors will be taking additional precautions.

“Before COVID-19, baby boomers” — those born after 1945 but before 1965 — “felt reassured that with all the benefits of modern medicine, they could live for years and years,” said Dr. Mehrdad Ayati, who teaches geriatric medicine at Stanford University School of Medicine and advises the U.S. Senate Special Committee on Aging. “What we never calculated was that a pandemic could totally change the dialogue.”

It has. Here’s a preview of post-vaccine life for older Americans:

Medical Care

  • Time to learn telemed. Only 62% of people over 75 use the internet — and fewer than 28% are comfortable with social media, according to data from the Pew Research Center. “That’s lethal in the modern age of health care,” Dychtwald said, so there will be a drumbeat to make them fluent users of online health care.
  • 1 in 3 visits will be telemed. Dr. Ronan Factora, a geriatrician at Cleveland Clinic, said he saw no patients age 60 and up via telemedicine before the pandemic. He predicted that by the time a COVID-19 vaccine is available, at least a third of those visits will be virtual. “It will become a significant part of my practice,” he said. Older patients likely will see their doctors more often than once a year for a checkup and benefit from improved overall health care, he said.
  • Many doctors instead of just one. More regular remote care will be bolstered by a team of doctors, said Greg Poland, professor of medicine and infectious diseases at the Mayo Clinic. The team model “allows me to see more patients more efficiently,” he said. “If everyone has to come to the office and wait for the nurse to bring them in from the waiting room, well, that’s an inherent drag on my productivity.”
  • Drugstores will do more vaccinations. To avoid the germs in doctors’ offices, older patients will prefer to go to drugstores for regular vaccinations such as flu shots, Factora said.
  • Your plumbing will be your doctor. In the not-too-distant future — perhaps just a few years from now — older Americans will have special devices at home to regularly analyze urine and fecal samples, Dychtwald said, letting them avoid the doctor’s office.

Travel

  • Punch up the Google Maps. Many trips of 800 miles or less will likely become road trips instead of flights, said Ed Perkins, a syndicated travel columnist for the Chicago Tribune. Perkins, who is 90, said that’s certainly what he plans to do — even after there’s a vaccine.
  • Regional and local travel will replace foreign travel. Dychtwald, who is 70, said he will be much less inclined to travel abroad. For example, he said, onetime plans with his wife to visit India are now unlikely, even if a good vaccine is available, because they want to avoid large concentrations of people. That said, each year only 25% of people 65 and up travel outside the U.S. annually, vs. 45% of the general population, according to a survey by Visa. The most popular trip for seniors: visiting grandchildren.
  • Demand for business class will grow. When older travelers (who are financially able) choose to fly, they will more frequently book roomy business-class seats because they won’t want to sit too close to other passengers, Factora said.
  • Buying three seats for two. Older couples who fly together — and have the money — will pay for all three seats so no one is between them, Perkins said.
  • Hotels will market medical care. Medical capability will be built into more travel options, Dychtwald said. For example, some hotels will advertise a doctor on-site — or one close by. “The era is over of being removed from health care and feeling comfortable,” he said.
  • Disinfecting will be a sales pitch. Expect a rich combination of health and safety “theater” — particularly on cruises that host many older travelers, Perkins said: “Employees will be wandering around with disinfecting fogs and wiping everything 10 times.”
  • Cruises will require proof of vaccination. Passengers — as well as cruise employees — will likely have to prove they’ve been vaccinated before traveling, Factora said.

Eating/Shopping

  • Local eateries will gain trust. Neighborhood and small-market restaurants will draw loyal customers — mainly because they know and trust the owners, said Christopher Muller, a hospitality professor at Boston University.
  • Safety will be a bragging point. To appeal to older diners in particular, restaurants will prominently display safety-inspection signage and visibly signal their cleanliness standards, Muller said. They will even hire employees exclusively to wipe down tables, chairs and all high-touch points — and these employees will be easy to identify and very visible

Home Life

  • The homecoming. Because of so many COVID-19 deaths in nursing homes, more seniors will leave assisted living facilities and nursing homes to move in with their families, Factora said. “Families will generally move closer together,” he said.
  • The fortress. Home delivery of almost everything will become the norm for older Americans, and in-person shopping will become much less common, Factora said.
  • Older workers will stay home. The 60-and-up workforce increasingly will be reluctant to work anywhere but from home and will be very slow to re-embrace grocery shopping. “Instacart delivery will become the new normal for them,” Dychtwald said.

Gatherings

  • Forced social distancing. Whenever or wherever large families gather, people exhibiting COVID-like symptoms may not be welcomed under any circumstances, Ayati said.
  • Older folks will disengage, at a cost. Depression will skyrocket among older people who isolate from family get-togethers and large gatherings, Ayati said. “As the older population pulls back from engaging in society, this is a very bad thing.”
  • Public restrooms will be revamped. For germ avoidance, they’ll increasingly get no-touch toilets, urinals, sinks and entrances/exits. “One of the most disastrous places you can go into is a public restroom,” Poland said. “That’s about the riskiest place.”
  • This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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Why Does COVID-19 Testing Take So Long?

After a slow start, testing for COVID-19 has ramped up in recent weeks, with giant commercial labs jumping into the effort, drive-up testing sites established in some places and new products approved under emergency rules set by the Food and Drug Administration.

But even for people who are able to get tested (and there’s still a big lag in testing ability in hot spots across the U.S.), there can be a frustratingly long wait for results — not just hours, but often days. Sen. Rand Paul (R-Ky.) didn’t get his positive test results for six days and is now being criticized for not self-quarantining during that time.

We asked experts to help explain why the turn-around time for results can vary widely — from hours to days or even a week — and how that might be changing.

It’s A Multistep Process

First, a sample is taken from a patient’s nose or throat, using a special swab. That swab goes into a tube and is sent to a lab. Some large hospitals have on-site molecular labs, but most samples are sent to outside labs for processing. More on that later.

That transit time usually runs about 24 hours, but it could be longer, depending on how far the hospital is from the processing lab.

Once at the lab, the specimen is processed, which means lab workers extract the virus’s RNA, the molecule that helps regulate genes.

“That step of cleaning, the RNA extraction step, is one limiting factor,” said Cathie Klapperich, vice chair of the department of biomedical engineering at Boston University. “Only the very biggest labs have automated ways of extracting RNA from a sample and doing it quickly.”

After the RNA is extracted, technicians also must carefully mix special chemicals with each sample and run those combinations in a machine for analysis, a process called polymerase chain reaction (PCR), which can detect whether the sample is positive or negative for COVID.

“Typically, a PCR test takes six hours from start to finish to complete,” said Kelly Wroblewski, director of infectious disease programs at the Association of Public Health Laboratories.

Some labs have larger staffs and more machines, so they can process more tests at a time than others. But even for those labs, as demand grows, so does the backlog.

Capacity Is Expanding, But Not Enough

Initially, only a few public health labs and the federal Centers for Disease Control and Prevention processed COVID-19 tests. Problems with the first CDC test kits also led to delays.

Now the CDC has a better kit, and 94 public health labs across the country do COVID-19 testing, said Wroblewski.

But those labs can’t possibly do all that’s needed. In normal times, their main function is regular public health surveillance — detecting more common threats such as outbreaks of measles or monitoring seasonal influenza — “but not to do diagnostic testing of the magnitude that is required in this response,” she said.

Large commercial labs like those run by companies such as Quest Diagnostics and LabCorp were given the go-ahead late last month by the FDA to start testing, too.

The FDA has said it won’t stop certain private labs — those that are already certified to perform complex testing — and diagnostic companies from developing their own test kits. Labs at some big-name hospital systems, such as Advent Health, the Cleveland Clinic and the University of Washington, are among those doing this.

In addition, the FDA has approved more than a dozen testing kits by various manufacturers or labs under special emergency rules designed to speed the process. Those include tests by Quest Diagnostics, LabCorp, Roche, Quidel Corp. and others. The kits are used in PCR machines, either in hospital labs or large commercial labs.

“Our chief medical officer on the East Coast said that, up until two days ago, on average it was taking 72 hours to get results,” said Susan Van Meter, executive director of AdvaMedDx, a division of the Advanced Medical Technology Association, a device and diagnostics industry trade group. “That will get better as our member companies come on the market.”

Even so, supply is not keeping up with demand, Roche CEO Severin Schwan told CNBC on Monday. Roche won the first approval from the FDA for a test kit under emergency rules, and it has delivered more than 400,000 kits so far.

“Demand continues to be much higher than supply,” Schwan told CNBC. “So we are glad that overall capacity is increasing, but the reality is that broad-based testing is not yet possible.”

How Many Tests Can Be Done At A Time?

That varies. Large commercial labs can do a lot. LabCorp, for example, said it is processing 20,000 tests a day — and hopes to do more soon. Other test kit makers and labs are also ramping up capacity.

Smaller labs — such as molecular labs at some hospitals — can do far fewer per day but get results to patients faster because they save on transit time.

Still, it’s usually only large academic medical centers and some health systems that have their own molecular labs, which require complex equipment.

One of those is Medstar Georgetown University Hospital in Washington, D.C.

“From beginning to results can take five to six hours,” said Joeffrey Chahine, technical director for the molecular pathology division there.

Even at such hospitals, the tests are often prioritized for patients who have been admitted and staff who might have been exposed to COVID-19, said Chahine. His lab can process 93 samples at a time and run a few cycles a day, up to about 280, he said. Last week, it did 186 a day, three days in a row.

But hospitals with this ability are generally “not testing from their outpatient centers or the ER,” he said. In other words, the in-house labs aren’t running tests from walk-in patients.

Those tests are sent to large outside labs “so as not to overwhelm the hospital lab.” While those outside labs have large staffs, “the demand is so high that these outpatient clinics and ERs say the turnaround time can be four to seven business days,” he said.

Supply Shortages Are Slowing Test Production

As the worldwide demand for testing has grown, so, too, have shortages of the chemical agents used in the test kits, the swabs used to get the samples, and the protective masks and gear used by health workers taking the samples.

“There is an inadequate supply of so many things associated with testing,” said Wroblewski, which is why her group, along with officials in states including New York and cities including Los Angeles, recommend prioritizing who should be tested for COVID-19.

At the front of the line, she said, should be health care workers and first responders; older adults who have symptoms, especially those living in nursing homes or assisted living residences; and people who may have other illnesses that would be treated differently if they were infected. Bottom line: prioritizing who is tested will help speed the turnaround time for getting results to people in these circumstances and reduce their risk of spreading the illness.

Still, urgent shortages of some of the chemicals needed to process the tests are hampering efforts to test health care workers, including at hospitals such as SUNY Downstate medical center in hard-hit New York.

Looking forward, companies are working on quicker tests. Indeed, the FDA in recent days has approved tests from two companies that promise results in 45 minutes or less. Those will be available only in hospitals that have special equipment to run them. One of those companies, Cepheid of Sunnyvale, California, says about 5,000 U.S. hospitals already have the equipment needed to process these tests. Both firms say they will ship to the hospitals soon but have given few specifics on quantity or timing.

But many public health officials say doctors and clinics need a truly rapid test they can use in their offices, one like the tests already in use for influenza or strep throat.

A number of companies are moving in that direction. Late Friday, for instance, Abbott Laboratories announced that the FDA has given emergency-use authorization for the company’s rapid, point-of-care test, which can deliver positive results in as little as five minutes and negative results in 13.

The tests are processed on a small device already installed in thousands of medical offices, ERs, urgent care clinics and other settings. Abbott said it will begin this week to make 50,000 tests available per day.

“That’s going to make a meaningful difference,” said Van Meter at AdvaMedDx, who believes the rapid tests are a critical piece in the continuum of available testing.

Even though lab-based PCR tests, which are done at large labs and academic medical centers, can take several hours to produce a result, the machines used can test high numbers of cases all at once. The rapid test by Abbott — and other, similar tests now under development — do far fewer at a time but deliver results much faster.

“This can be provided in a doctor’s office or an ER, helping to triage patients who are waiting to get in,” said Van Meter. “It’s a very fine complement to the testing that exists.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.</>