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Unfair Medi-Cal Test Removed!

No more asset test for Medi-Cal. Seniors and people with disabilities can get and keep free health coverage!

A provision in California’s newly approved state budget will eliminate the asset test for the 2 million Californians enrolled in both Medi-Cal and Medicare, the federal health insurance program for people 65 and older and people under 65 with certain disabilities. Instead, their financial eligibility will be based solely on income, as it is for the millions of other people in Medi-Cal.

The elimination of the test will be a game changer for aging or impaired Californians who need long-term care but are caught in a common conundrum: They don’t earn enough to cover the high costs of ongoing nursing home care and can’t rely on Medicare, which does not cover extended nursing home stays. They can get that care through Medi-Cal, but they would have to wipe out their savings first.

The 2021-22 state budget deal includes several provisions that will make it easier to get on and stay on Medi-Cal, including the elimination of the asset test. Everyone 50 and over will be eligible, regardless of immigration status. And new mothers will be allowed to remain on Medi-Cal for one year after giving birth, up from 60 days.

The budget also includes $15 million over the next three years, starting this year, to develop online enrollment forms and translate them into multiple languages, and $8 million for counties to help some people who get in-home care stay enrolled.

California has a strong Medi-Cal takeup rate, with 95% of eligible people enrolled, said Laurel Lucia, director of the health care program at the Center for Labor Research and Education at the University of California-Berkeley. But of the remaining uninsured people, about 610,000 qualify for Medi-Cal, she said.

“We are doing well, but so many people are eligible and not enrolled,” Lucia said. “The barriers to Medi-Cal enrollment and retention are really multifaceted, so the solutions have to be as well.”

This is an especially volatile moment for the program, which covers 13.6 million Californians. The state is trying to improve the quality of care by renegotiating its contracts with managed-care insurance companies. At the same time, Gov. Gavin Newsom and the state Department of Health Care Services are proposing a massive overhaul that would provide more services to homeless people and incarcerated people and boost mental health care.

Meanwhile, Medi-Cal enrollment continues to grow: State officials estimate enrollment will balloon to 14.5 million this fiscal year, which began July 1.

The changes to Medi-Cal that were approved in the budget include an expansion that Democratic lawmakers have been seeking for years: California already allows eligible unauthorized immigrants up to age 26 to receive full Medi-Cal benefits. Starting next spring, that will expand to people 50 and up.

State officials estimate about 175,000 people will enroll in the first year, with an additional 3,600 people signing up every year thereafter, eventually costing the state $1.3 billion annually.

And, starting next July, new mothers will be able to stay on Medi-Cal for up to one year after giving birth. By 2027, the additional coverage is expected to cost the state about $200 million a year.

Assembly Republican Leader Marie Waldron (R-Escondido), who said she supports expanding eligibility for the program in limited circumstances, was the author of a bill to allow incarcerated people to enroll before they’re released that was ultimately folded into the budget and will take effect in 2023.

But she said the changes in this year’s budget go too far.

“Expensive government-run health care doesn’t really work, and most voters don’t want to pay for it,” Waldron said. “But California Democrats seem to think everyone will love it once they are on it, which is not true. It’s creeping socialism.”

The elimination of the Medi-Cal asset test for older Californians and those with certain disabilities, which takes effect July 1, 2022, marks a dramatic change to the program. Officials estimate it will cost the state roughly $200 million a year once fully implemented because of the increased enrollment.

Right now, these people can’t qualify for Medi-Cal if they have saved more than $2,000. For couples, it’s $3,000. Complicated rules dictate what counts as an “asset” and what doesn’t: A house doesn’t count and neither does one car, but a second car does. Engagement rings and heirlooms are fine, but other jewelry counts toward the limit.

Ultimately, the test favors individuals and families who can navigate the rules and find ways to hide money in exempt accounts, said Claire Ramsey, a senior attorney with Justice in Aging.

“You create administrative hurdles, which keeps people artificially off the program,” Ramsey said. “If it’s hard for the lawyers to understand all the rules, what does that mean for the average person who’s just trying to have health insurance?”

The federal Affordable Care Act eliminated the asset test for most Medicaid enrollees, basing financial eligibility exclusively on income, but left out people who qualify for both Medicaid and Medicare.

This is especially important when it comes to expensive long-term care, like nursing homes, which can cost $10,000 a month, said Patricia McGinnis, executive director of California Advocates for Nursing Home Reform.

Medicare covers nursing home care only in limited circumstances and for up to 100 days. After that, patients must find another way to pay, either out-of-pocket or through Medi-Cal. Because many people don’t qualify for Medi-Cal if they have too much money or other assets, they have to spend through their savings and shed their belongings before they can get on the program.

“Thousands and thousands of people have become impoverished to afford nursing home care,” McGinnis said. “You want free medical care? You’re going to have to spend every penny you have to get it.”

A state Assembly analysis estimated that 17,802 additional Californians would have become eligible in 2018 if the asset test hadn’t been required. Of those, 435 were in long-term care, and over the course of the year, 263 spent their money or gave away their assets to qualify for Medi-Cal.

Assembly member Wendy Carrillo (D-Los Angeles), the author of the asset test bill that was folded into the budget, sees eliminating the requirement as part of a larger movement toward universal coverage, in line with efforts to expand Medi-Cal to older unauthorized immigrants or establish a single-payer system.

“We need to aggressively and proactively work on legislation that gives more people coverage,” Carrillo said. “And until we have universal health care, these are the steps necessary to ensure that.”

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

Photo by Pranav Kumar Jain on Unsplash

 

For Toddlers, Pandemic Shapes Development During Formative Years

Lucretia Wilks, who runs a small day care out of her home in north St. Louis County, is used to watching young children embrace, hold hands and play together in close quarters.

But the covid-19 pandemic made such normal toddler behavior potentially unsafe.

“It’s weird that they now live in a time where they’re expected to not hug and touch,” said Wilks, founder of Their Future’s Bright Child Development Center, which cares for about a dozen children ranging from infants to 7 years old. “They’re making bonds, friendships, and that’s how they show affection.”

Day care and other child care providers said they are relieved to see covid cases drop as vaccines roll out across the United States. But even as the nation reopens, mental health and child development experts wonder about what, if any, long-term mental health and development consequences young children may face.

In the short term, medical and child development experts said the pandemic has harmed even young children’s mental health and caused them to miss important parts of typical social and emotional development. Besides not being able to get as close to other people as usual, many young children have seen their routines interrupted or experienced family stress when parents have lost jobs or gotten sick. The pandemic and its economic fallout have also forced many families to change caregiving arrangements.

“Coronavirus is impacting children and families in many ways mentally. The biggest and most obvious way is in the children’s structure and routine,” said Dr. Mini Tandon, an associate professor of psychiatry at the Washington University School of Medicine in St. Louis. “Young kids thrive in structure and routine, so when you disrupt that, things go awry pretty quickly in their day-to-day lives.”

Tandon, who has spoken frequently with parents and caregivers since the pandemic began, said she and her peers have seen more severe anxiety and high levels of stress in young children than in the past.

Child behavior experts pointed to a number of problems exacerbated by the pandemic in a National Center on Early Childhood Health and Wellness webinar last year, including separation anxiety and clinginess, sleep issues and challenges learning new information. Children have also shown regressive behaviors — wetting the bed even though they’ve been potty-trained, for example.

For young children, changes in caregiving arrangements can be a huge source of stress. And the financial strain of the pandemic forced many families to rethink how they cared for their youngest children.

The average monthly child care cost in Missouri, for example, is $584 for 4-year-olds and $837 for infants, according to Procare Solutions, which works with over 30,000 programs for children. That has been too high for some parents who lost their jobs in the pandemic. President Joe Biden’s covid relief plan signed into law in March gives monthly payments of up to $300 per child this year and his latest proposal would help reduce child care costs and increase access to preschool, if approved.

But in the many months when day care has been out of reach, some parents have had to rearrange their work schedules to care for infants or toddlers while also helping school-age children with virtual learning. Others have relied on grandparents for help, although that option was potentially dangerous before vaccines were available. Keeping children apart from grandparents has been tough for both kids and seniors.

Even when parents could afford day care, fear of getting or spreading covid affected their choices about whether and when to send them. And some facilities closed temporarily during the pandemic.

Aimee Witzl, 34, of St. Louis, an accountant and new mom, said she and her husband were hesitant to send their daughter, Riley Witzl, to day care early in the pandemic. Riley was born prematurely in November 2019 and had to spend nine weeks in the neonatal intensive care unit before coming home. So, the couple waited until August to send her to day care part time, then until January to send her full time.

“We were already high-risk,” Witzl said. “Then covid happened, so we kept her home even longer than planned.”

Fortunately, she said, no one in her family has contracted the virus.

In March 2020, the Early Childhood Development Action Network, a global collection of agencies and institutions promoting child health and safety, put out a “call to action” shared by the World Health Organization saying they were concerned about the pandemic putting “children at great risk of not reaching their full potential” because the early years are a “critical window of rapid brain development that lays the foundation for health, wellbeing and productivity throughout life.”

Tandon, the Washington University psychiatrist, said she’s especially worried about young children who may have been isolated in unsafe homes where they were mistreated. Maltreatment is more likely to go unnoticed, she said, when children are outside of the day cares and schools where adults are required to report child abuse and neglect.

But Tandon said the stresses of the pandemic can affect the mental health of any child, which motivated her to write a children’s book about a girl dealing with anxiety during the pandemic.

Now, though covid vaccinations still remain months away for the youngest children, a shift is occurring that may cause a new round of disruptions for them. Nancy Rotter, a child psychologist and assistant professor at Harvard University, said young children may be experiencing separation anxiety as they fully transition back into their schools and day cares after being at home with their parents.

To help kids heal, the Centers for Disease Control and Prevention suggests families make sure kids stay connected to relatives and friends. The agency also advises that parents do their best to recognize and address fear and stress in themselves and their kids and seek professional help if needed. CDC experts suggest parents talk about emotions and provide opportunities for children to express their fears in a safe place.

Yet as children and toddlers return to a new normal, it may not be as strange to them as it is for adults. Though the pandemic has presented stressors, Rotter said, children can be very resilient.

“Supportive caregivers and supportive emotional environments help with resilience in the child,” she said. “Resilience is not just what’s in the child, but what’s within the child’s environment. It’s the home, religious community, school and day care environment that aid in the child’s development and how they cope with changes.”

And the pandemic may leave behind one benefit for children: the emphasis on washing hands. Child care experts said good hygiene habits are an important life lesson that will likely last beyond this health crisis.

This story was produced by KHN (Kaiser Health News), 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.

 

Racism is a Public Health Crisis Say CA Lawmakers

After the killing last year of George Floyd, a Black man, by a white Minneapolis police officer, Wisconsin Gov. Tony Evers declared racism a public health crisis. The governors of Michigan and Nevada quickly followed, as have legislative bodies in Minnesota, Virginia and Washington, D.C.

Yet California Gov. Gavin Newsom, who governs one of the most racially and ethnically diverse populations in the U.S., has not.

State Democratic lawmakers are not waiting for Newsom to make a declaration and are pressuring the first-term Democrat to dedicate $100 million per year from the state budget, beginning July 1, to fund new health equity programs and social justice experiments that might help break down systemic racism. Possibilities for the funding include transforming parking lots in low-income neighborhoods into green spaces and giving community clinics money to distribute fresh fruit and vegetables to their patients.

Lawmakers say covid’s disproportionate impact on California’s Black and Latino residents, who experienced higher rates of sickness and death, makes their request even more pressing.

“Covid uncovered the disparities of the segregated California of the past that still has an effect today, and that we can correct if we focus on equity,” said Assembly member Mike Gipson (D-Carson), who is spearheading the funding push. “We need to build a healthier society that works for everyone.”

Lawmakers are lobbying for the money in their negotiations with the governor over the 2021-22 state budget. The legislature must pass a budget bill by June 15 for the fiscal year beginning July 1. Once Newsom receives the bill, he has 12 days to sign it into law.

The $100 million proposal to address the health effects of racism is part of the Democratic-controlled legislature’s broader public health agenda that includes a request for $235 million annually to help rebuild gutted local public health departments, $15 million per year for transgender health care and $10 million to establish an independent “Office of Racial Equity,” which would attempt to identify and address racism in state spending and policies.

Health care advocacy groups say the investments are critical to address inequality in society and the health care system that has contributed not only to higher rates of covid within disadvantaged communities, but also chronic diseases like diabetes and heart disease.

“Those who got sick and lost jobs were mostly communities of color, so seeing no new investment from the governor to really tackle racial equity is unconscionable,” said Ronald Coleman, managing director of policy for the California Pan-Ethnic Health Network, which sent Newsom a letter last July asking him to declare racism a public health crisis.

Newsom hasn’t committed to supporting the funding but said he’d be “very mindful” in negotiations with lawmakers. One proposal Newsom and state lawmakers agree on is funding for a chief equity officer to address racial disparities within state government.

Newsom pointed to other budget proposals he has made, including $600 economic stimulus payments to households earning less than $75,000, rent and utility bill assistance, and an expansion of the state’s Medicaid program for low-income residents, called Medi-Cal, to unauthorized immigrants age 60 and older.

Dr. Georges Benjamin, executive director of the American Public Health Association, said George Floyd’s killing in May 2020 motivated state and local lawmakers to look at racism through the lens of public health — which could have helped save lives during the covid pandemic. “We’re at a tipping point,” Benjamin said. “It’s important to first acknowledge that racism is real, but then it requires you to do something about it. We’re now seeing other states beginning to put money and resources behind the words.”

Some cities and counties in California have declared racism a public health crisis, including Los Angeles and San Bernardino County. But those declarations would be more meaningful backed by an infusion of state resources, health care advocates say.

“We need to be willing to put dollars into innovative approaches to addressing racism in the same way we invest in stem cells, and we need to be willing to accept that some of the things we try will work and some won’t,” said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network.

Should Newsom sign off on the funding, grants would be available to health clinics, Native American tribes and community-based organizations to develop programs aimed at combating racism and health disparities.

The Community Coalition in South Los Angeles, a nonprofit that originally set out decades ago to address the crack epidemic, expressed interest in applying.

“There are so many vacant lots in South Los Angeles that could be turned into mini-parks. That helps not only with physical health but mental health,” said Marsha Mitchell, the organization’s communications director. “We have very few grocery stores, and if you live in Compton or South Los Angeles, your life expectancy is almost seven years lower than if you lived in Santa Monica, Beverly Hills or Malibu.”

Directing more resources to address racism could backfire, in part because voters, including some Democrats, have displayed skepticism over some of the liberal and expensive policies sought by Democrats who control Sacramento, said Mike Madrid, a Sacramento-based Republican political consultant who has also worked for Democrats.

He pointed to Proposition 16, the November 2020 ballot initiative that would have repealed California’s 1996 law banning affirmative action, which was defeated 57% to 43%.

“Racism is very much a public health problem — just look at the chronic diseases and lower life expectancies of Black and brown people, and most people believe that racism is systemic in our governance,” Madrid said. “But voters are becoming more discerning about how racism is being used by politicians to advance an agenda.”

Focusing too heavily on racism could prompt a backlash, he said, “whereas if you focused on poverty and inequality, that would solve many of the racial problems.”

But state Sen. Richard Pan (D-Sacramento), who is leading the drive to establish an Office of Racial Equity, said funding and state leadership focused intensely on structural racism are essential to ending it. Should the office not be funded in the budget, Pan said he’d press forward with a bill.

The office would work with the state’s new chief equity officer to examine the California government, including state hiring practices, proposed legislation and budget spending decisions, for evidence of racism or inequality.

It’s a priority for the legislature’s Asian & Pacific Islander Legislative Caucus, given the rise in hate crimes perpetrated against people of Asian descent, Pan said.

“We need to invest more in prevention,” Pan said. “The state needs to step up and support communities of color.”

This story was produced by KHN (Kaiser Health News), 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.

 

Did It Feel Like A Truck Hit You After Your Covid Vaccination?

If you think vaccination is an ordeal now, consider the 18th-century version. After having pus from a smallpox boil scratched into your arm, you would be subject to three weeks of fever, sweats, chills, bleeding and purging with dangerous medicines, accompanied by hymns, prayers and hell-fire sermons by dour preachers.

That was smallpox vaccination, back then. The process generally worked and was preferred to enduring “natural” smallpox, which killed around a third of those who got it. Patients were often grateful for trial-by-immunization — once it was over, anyway.

“Thus through the Mercy of God, I have been preserved through the Distemper of the Small Pox,” wrote one Peter Thatcher in 1764, after undergoing the process in a Boston inoculation hospital. “Many and heinous have been my sins, but I hope they will be washed away.”

Today, Americans are once again surprisingly willing, even eager, to suffer a little for the reward of immunity from a virus that has turned the world upside down.

Roughly half of those vaccinated with the Moderna or Pfizer-BioNTech vaccines, and in particular women, experience unpleasantness, from hot, sore arms to chills, headache, fever and exhaustion. Sometimes they boast about the symptoms. They often welcome them.

Suspicion about what was in the shots grew in the mind of Patricia Mandatori, an Argentine immigrant in Los Angeles, when she hardly felt the needle going in after her first dose of the Moderna vaccine at a March appointment.

A day later, though, with satisfaction, she “felt like a truck hit me,” Mandatori said. “When I started to feel rotten I said, ‘Yay, I got the vaccination.’ I was happy. I felt relieved.”

While the symptoms show your immune system is responding to the vaccine in a way that will protect against disease, evidence from clinical trials showed that people with few or no symptoms were also protected. Don’t feel bad if you don’t feel bad, the experts say.

“This is the first vaccine in history where anyone has ever complained about not having symptoms,” said immunologist Dr. Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia.

To be sure, there is some evidence of stronger immune response in younger people — and in those who get sick when vaccinated. A small study at the University of Pennsylvania showed that people who reported systemic side effects such as fever, chills and headache may have had somewhat higher levels of antibodies. The large trial for Pfizer’s vaccine showed the same trend in younger patients.

But that doesn’t mean people who don’t react to the vaccine severely are less protected, said Dr. Joanna Schaenman, an expert on infectious diseases and the immunology of aging at the David Geffen School of Medicine at UCLA. While the symptoms of illness are undoubtedly part of the immune response, the immune response that counts is protection, she said. “That is preserved across age groups and likely to be independent of whether you had local or systemic side effects or not.”

The immune system responses that produce post-vaccination symptoms are thought to be triggered by proteins called toll-like receptors, which reside on certain immune cells. These receptors are less functional in older people, who are also likely to have chronic, low-grade activation of their immune systems that paradoxically mutes the more rapid response to a vaccine.

But other parts of their immune systems are responding more gradually to the vaccine by creating the specific types of cells needed to protect against the coronavirus. These are the so-called memory B cells, which make antibodies to attack the virus, and “killer T cells” that track and destroy virus-infected cells.

Many other vaccines, including those that prevent hepatitis B and bacterial pneumonia, are highly effective while having relatively mild side effect profiles, Schaenman noted.

Whether you have a strong reaction to the vaccine “is an interesting but, in a sense, not vital question,” said Dr. William Schaffner, a professor of infectious disease at Vanderbilt University Medical Center. The bottom line, he said: “Don’t worry about it.”

There was a time when doctors prescribed cod-liver oil and people thought medicine had to taste bad to be effective. People who get sick after covid vaccination “feel like we’ve had a tiny bit of suffering, we’ve girded our loins against the real thing,” said Schaenman (who had a slight fever). “When people don’t have the side effects, they feel they’ve been robbed” of the experience.

Still, side effects can be a hopeful sign, especially when they end, says McCarty Memorial Christian Church leader Eddie Anderson, who has led efforts to vaccinate Black churchgoers in Los Angeles. He helps them through the rocky period by reminding them of the joyful reunions with children and grandchildren that will be possible post-vaccination.

“I’m a Christian pastor,’’ he said. “I tell them, ‘If you make it through the pain and discomfort, healing is on the other side. You can be fully human again.”

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

image credit: getty images at KHN

In Santa Clara County, Nearly 67% Of Residents 16 + Have Had A Vaccine Shot

The Number of Californians With at Least One Covid Vaccine Dose Continues to Rise.

More than 75% of California’s seniors have had at least one dose, which makes epidemiologists hopeful that other age groups will follow suit

Demand for covid vaccines is slowing across most of California, but as traffic at vaccination sites eases, the vaccination rates across the state are showing wide disparities.

In Santa Clara County, home to Silicon Valley, nearly 67% of residents 16 and older have had at least one dose as of Wednesday, compared with about 43% in San Bernardino County, east of Los Angeles. Statewide, about 58% of eligible residents have received at least one dose.

The differences reflect regional trends in vaccine hesitancy and resistance that researchers have been tracking for months, said Dean Bonner, associate survey director at the Public Policy Institute of California, a nonpartisan think tank.

In a PPIC survey released Wednesday, only 5% of respondents in the San Francisco Bay Area and 6% of those in Los Angeles said they wouldn’t be getting vaccinated. But that share is 19% in the Inland Empire and 20% in the Central Valley.

“More urban areas might be hitting a wall, but their number of shots given is higher,” said Bonner. “The rural areas might be hitting a wall maybe even before, but their shots given isn’t quite as high.”

Infectious disease experts estimate that anywhere from 50% to 85% of the populationwould need to get vaccinated to put a damper on the spread of the virus. But overall state numbers may mask pockets of unvaccinated Californians, concentrated inland, that will prevent these regions from achieving “herd immunity,” the point at which the unvaccinated are protected by the vaccinated. Epidemiologists worry that the virus may continue to circulate in these communities, threatening everyone.

The regional differences could be attributed, at least in part, to political opposition to the vaccine, said Bonner, as about 22% of Republicans and 17% of independents in the survey said they wouldn’t be getting the vaccine, compared with 3% of Democrats.

But officials and epidemiologists see some encouraging signs that the state has yet to hit a wall of vaccine refusal. “As a strongly blue state, one would expect that California is less likely than red states to hit a relatively low ceiling of vaccination, assuming that the access is good and the messaging is strong,” said Dr. Robert Wachter, chair of the department of medicine at the University of California-San Francisco School of Medicine.

As of Wednesday, 77% of seniors in California, and 68% of those ages 50 to 64, had received at least one dose of covid vaccine, according to a KHN analysis. These large percentages reflect the early vaccine eligibility of these age groups and are a hopeful sign considering how difficult it was to get a shot in the beginning of the year, said Rebecca Fielding-Miller, an assistant professor at the University of California-San Diego specializing in infectious diseases and public health.

“I’m very hopeful that addressing access would pick up at least another 10-15% before we need to really start addressing myths and hesitancy issues,” she said.

The state could see a new jump in vaccinations as workplaces, schools and event organizers begin to require the shots, Wachter said. For example, the University of California and California State University systems announced April 22 that their 1 million-plus students and staff members will be required to get vaccinated against covid once the shots are formally licensed by the Food and Drug Administration, likely to occur this summer.

Still, the red-blue political distinction on vaccination is meaningful within California as well as nationally. Despite depressed vaccine demand across the board, counties that lean conservative have lower rates of vaccinations.

In true-blue Los Angeles, 4.5 million first covid vaccine doses have been administered, meaning that about 55% of eligible Angelenos have gotten at least one shot.

But first-dose appointments at county-run sites were down at least 50% last week, said public health director Barbara Ferrer on Thursday. The county has opened several sites where people can walk in and get vaccinated without an appointment, but these walk-ins don’t make up for all of the unfilled spots.

Last week probably marked the first time the county did not administer 95% of the doses distributed to it, she said.

In San Diego and Orange counties, meanwhile, vaccination appointments are going unfilled or taking days to get booked up.

About 20% of appointments in Orange County started going unclaimed on April 25 and the slack has persisted, said Dr. Regina Chinsio-Kwong, deputy health officer.

However, based on survey data from last winter indicating that about 58% of Orange County residents plan to get vaccinated against the coronavirus, the county is still expecting more residents to seek out appointments. As of Sunday, about 49% of residents had received at least one dose.

In San Diego, officials expect all appointments to be filled despite the slowdown, said county spokesperson Michael Workman. About 54% of eligible residents had received at least one dose as of Wednesday.

In San Bernardino, the slowdown started in late March, said county spokesperson David Wert. Only 42% of county residents had gotten at least one dose as of Monday.

Across the state, officials are unclear on the extent to which hesitancy or lack of access to a vaccine are responsible for the slowdown.

Campaigns to educate, convince and reach out to people have started to pick up throughout the country, including targeted messaging for conservatives. Ten GOP doctors in Congress recently issued an ad urging their constituents to get vaccinated.

Santa Clara is shifting most county-run sites to enable walk-ins and expanding evening and weekend hours to make it easier for working people to get a shot. San Diego and San Bernardino are also allowing walk-ins.

Other counties are returning unused doses to the state to be redistributed, a bounty from which Los Angeles County has benefited, according to Barbara Ferrer, director of the county public health department. Representatives from Blue Shield and the California Department of Public Health would not say which counties are sending doses back.

California’s good pandemic news, which has enabled counties to reopen many businesses, is one of the challenges to getting less-than-enthusiastic people in for their shots right now, said Wachter of UCSF.

As of Thursday, California has one of the lowest case rates in the U.S. at 31.3 cases per 100,000 and a covid-test positivity rate of 1.3%.

“My hope is that a strong communication campaign, perhaps coupled with some degree of vaccine requirements, will get some people to jump off the fence,” Wachter said.

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

Image: County of Santa Clara Public Health Department

To book your appointment go to https://covid19.sccgov.org/covid-19-vaccine-information

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.

Seniors! Get Advice On Medicare Open Enrollment

If you’ve been watching TV lately, you may have seen actor Danny Glover or Joe Namath, the 77-year-old NFL legend, urging you to call an 800 number to get fabulous extra benefits from Medicare.

There are plenty of other Medicare ads, too, many set against a red-white-and-blue background meant to suggest officialdom — though if you stand about a foot from the television screen, you might see the fine print saying they are not endorsed by any government agency.

Rather, they are health insurance agents aggressively vying for a piece of a lucrative market.

This is what Medicare’s annual enrollment period has come to. Beneficiaries — people who are 65 or older, or with long-term disabilities — have until Dec. 7 to join, switch or drop health or drug plans, which take effect Jan. 1. By switching plans, they can potentially save money or get benefits not ordinarily provided by the federal insurance program.

For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.

The right choice for you depends on your financial wherewithal and current health status, and on future health scenarios that are often difficult to foresee and unpleasant to contemplate.

Costs and benefits among the multitude of competing Medicare plans vary widely, and the maze of rules and other details can be overwhelming. Indeed, information overload is part of the reason a majority of the more than 60 million people on Medicare, including over 6 million in California, do not comparison-shop or switch to more suitable plans.

“I’ve been doing it for 33 years and my head still spins,” says Jill Selby, corporate vice president of strategic initiatives and product development at SCAN, a Long Beach nonprofit that is one of California’s largest purveyors of Medicare managed care, known as Medicare Advantage. “It’s definitely a college course.”

Which explains why airwaves and mailboxes are jammed with all that promotional material from people offering to help you pass the course.

Many are touting Medicare Advantage, which is administered by private health insurers. It might save you money, but not necessarily, and research suggests that, in some cases, it costs the government more than administering traditional Medicare.

But the hard marketing is not necessarily a sign of bad faith. Licensed insurance agents want the nice commission they get when they sign somebody up, but they can also provide valuable information on the bewildering nuances of Medicare.

Industry insiders and outside experts agree most people should not navigate Medicare alone. “It’s just too complicated for the average individual,” says Mark Diel, chief executive officer of California Coverage and Health Initiatives, a statewide association of local outreach and health care enrollment organizations.

However, if you decide to consult with an insurance agent, keep your antenna up. Ask people you trust to recommend agents, or try eHealth or another established online brokerage. Vet any agent you choose by asking questions on the phone.

“Be careful if you feel like the insurance agent is pushing you to make a decision,” says Andrew Shea, senior vice president of marketing at eHealth. And if in doubt, don’t hesitate to get a second opinion, Shea counsels.

You can also talk to a Medicare counselor through one of the State Health Insurance Assistance Programs, which are present in every state. Find your state’s SHIP at www.shiptacenter.org.

Medicare & You, a comprehensive handbook, is worth reading. Download it at the official Medicare website, www.medicare.gov.

The website offers a deep dive into all aspects of Medicare. If you type in your ZIP code, you can see and compare all the Medicare Advantage plans, supplemental insurance plans, known as Medigap, and stand-alone drug (Part D) plans.

The site also shows you quality ratings of the plans, on a five-star scale. And it will display your drug costs under each plan if you type in all your prescriptions. Explore the website before you talk to an insurance agent.

California Coverage and Health Initiatives can refer you to licensed insurance agents who will provide local advice and enrollment assistance. Call 833-720-2244. Its members specialize in helping people who are eligible for both Medicare and Medicaid, the health insurance program for low-income people.

These so-called dual eligibles — nearly 1.5 million in California and about 12 million nationwide — get additional benefits, and in some cases they don’t have to pay Medicare’s monthly medical (Part B) premium, which will be $148.50 in 2021 for most beneficiaries, but higher for people above certain income thresholds.

If you choose traditional Medicare, consider a Medigap supplement if you can afford it. Without it, you’re liable for 20% of your physician and outpatient costs and a hefty hospital deductible, with no cap on how much you pay out of your own pocket. If you need prescription drugs, you’ll probably want a Part D plan.

Medicare Advantage, by contrast, is a one-stop shop. It usually includes a drug benefit in addition to other Medicare benefits, with cost sharing for services and prescriptions that varies from plan to plan. Medicare Advantage plans typically have low to no premiums — aside from the Part B premium that most people pay in either version of Medicare. And they increasingly offer additional benefits, including vision, dental, transportation, meal deliveries and even coverage while traveling abroad.

Beware of the risks, however.

Yes, the traditional Medicare route is generally more expensive upfront if you want to be fully covered. That’s because you pay a monthly premium for a Medigap policy, which can cost $200 or more. Add to that the premium for Part D, estimated to average $41 a month in 2021, according to KFF. (KHN is an editorially independent program of KFF.)

However, Medigap policies will often protect you against large medical bills if you need lots of care.

In some cases, Medicare Advantage could end up being more expensive if you get seriously ill or injured, because copays can quickly add up. They are typically capped each year, but can still cost you thousands of dollars. Advantage plans also typically have more limited provider networks, and the extra benefits they offer can be subject to restrictions.

Over one-third of Medicare beneficiaries nationally are enrolled in Advantage plans. In California, about 40% are.

The main appeal of traditional Medicare is that it doesn’t have the rules and restrictions of managed care.

Dr. Mark Kalish, a retired psychiatrist in San Diego, says he opted for traditional fee-for-service with Medigap and Part D because he didn’t want a “mother may I” plan.

“I’m 69 years old, so heart attacks happen; cancer happens. I want to be able to pick my own doctor and go where I want,” Kalish says. “I’ve done well, so the money isn’t an issue for me.”

Be aware that if you don’t join a Medigap plan during a six-month open enrollment period that begins when you enroll in Medicare Part B, you could be denied coverage for a preexisting condition if you try to buy one later.

There are a few exceptions to that in federal law, and four states — New York, Massachusetts, Maine, Connecticut — require continuous or yearly access to Medigap coverage regardless of health status.

Make sure you understand the rules and exceptions that apply to you.

Indeed, that is an excellent rule of thumb for all Medicare beneficiaries. Read up and talk to insurance agents and Medicare counselors. Talk to friends, family members, your doctor, your health plan — and other health plans.

When it comes to Medicare, says Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, “it takes a village.”

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

Califiornia’s Deadliest Spring In 20 Years

The first five months of the COVID-19 pandemic in California rank among the deadliest in state history, deadlier than any other consecutive five-month period in at least 20 years.

And the grim milestone encompasses thousands of “excess” deaths not accounted for in the state’s official COVID death tally: a loss of life concentrated among Blacks, Asians and Latinos, afflicting people who experts say likely didn’t get preventive medical care amid the far-reaching shutdowns or who were wrongly excluded from the coronavirus death count.

About 125,000 Californians died from March through July, up by 14,200, or 13%, from the average for the same five months during the prior three years, according to a review of data from the state Department of Public Health.

By the end of July, California had logged about 9,200 deaths officially attributed to COVID-19 in county death records. That left about 5,000 “excess” deaths for those months — meaning deaths above the norm not attributed to COVID-19. Deaths tend to increase from year to year as the population grows, but typically not by that much.

A closer look at California’s excess deaths during the period reveal a disturbing racial and ethnic variance: All the excess deaths not officially linked to COVID infection were concentrated in minority communities. Latinos make up the vast majority, accounting for 3,350 of those excess deaths, followed by Asians (1,150), Blacks (860) and other Californians of color (350).

Map by Phillip Reese for California Healthline Source: California Department of Public Health

The overall number of excess deaths across all races and ethnicities was ultimately tempered because, compared with the three prior years, there were actually 383 fewer deaths among white Californians than would be expected in the absence of COVID-19. In addition, California Healthline adjusted the overall numbers to reflect more than 320 COVID deaths that could not be categorized by race or ethnicity because that information was missing from state records.

Several epidemiologists interviewed said they believe a sizable portion of the excess deaths among people of color did, in fact, stem from COVID infections but went undetected for a variety of reasons. Among them: a shortage of coronavirus tests in the early months of the pandemic; an uneven strategy for how and when to administer those tests, which persists; and inadequate access to health care providers in many low-income and immigrant communities.

Dr. Kirsten Bibbins-Domingo, chair of the Department of Epidemiology and Biostatistics at the University of California-San Francisco, is among those who suspect the excess deaths reflect a COVID undercount in minority communities. She noted that several chronic health conditions that disproportionately affect Blacks and Latinos — including diabetes, high blood pressure and heart disease — also place them at higher risk for severe complications from COVID-19.

In addition, Bibbins-Domingo said, the prolonged shutdown of medical offices in the early months of the pandemic — and with them non-urgent surgeries and routine medical care — likely accelerated death among people with those chronic conditions.

“Shutdowns always come at a cost,” she said. “It is our most marginalized communities that experience the cost of a shutdown.”

According to state Department of Public Health data, deaths in California attributed to diabetes rose 12% from March through July when compared with the average for the same period over the past three years. In addition, deaths attributed to Alzheimer’s disease rose 11%.

“Dementia is also a disease where we have racial, ethnic minorities already at greater risk,” said Andrea Polonijo, a medical sociologist at the University of California-Riverside. “Now that we have the pandemic, they’re more socially isolated. Social isolation we know can cause deeper cognitive decline.”

It’s hard to determine whether a death is due to COVID-19 if the victim never sought medical care, said Jeffrey Reynoso, executive director of the nonprofit Latino Coalition for a Healthy California. Latinos in California are less likely to have health insurance, he said. They may face language barriers if their medical provider — or contact tracer — does not speak Spanish. Latino immigrants working in the U.S. without authorization may hesitate to visit the doctor.

“Immigration is definitely a driver in creating a fear and a mistrust of systems, and that includes our health care system,” Reynoso said.

Polonijo said the fact that Latinos make up the bulk of the excess deaths correlates with their dominant role in farming, meat processing, manufacturing and food service, jobs all deemed essential during the pandemic.

“This population is also more likely to live in more crowded conditions,” she said. “So not only are they exposed at work, but they are bringing disease home and with it the possibility of spreading it to their family, bringing it to the community.”

Bibbins-Domingo noted that, while a major portion of COVID deaths overall have occurred among seniors and nursing home residents, a disproportionate number of the state’s excess deaths are of working-age adults.

“The excess deaths that we’re seeing in communities of color and in low-income communities are deaths that are occurring at younger ages,” she said. “These are deaths that are occurring in these ages from 20 to 60, generally speaking — the ages when people would be out working.”

Kathy Ko Chin, president of the Oakland-based Asian & Pacific Islander American Health Forum, said Asian Americans also tend to be overrepresented in essential worker occupations, noting that a large proportion of the state’s nurses are Filipino. In addition, she said, government officials have not done enough to translate COVID educational materials into the many languages spoken by California’s Asian Americans. The Trump administration’s rhetoric on immigration during the past four years, she added, has had a “chilling effect” that has kept many foreign-born Asian Americans from visiting a doctor.

“People were really, really scared,” Chin said.

Counties in Southern California and the largely rural Central Valley — places with a high proportion of Latino residents — tended to have high rates of excess deaths from March to July. Among counties with at least 100,000 people, Kings County, an arid expanse north of Los Angeles that is home to industrial-scale agriculture, had the highest rate of excess deaths per capita.

Officials at the Kings County Department of Public Health did not return a message seeking comment.

Bibbins-Domingo and others said it is important for state and county health officials to take a hard look at their excess death numbers. Excess deaths matter, she said, because they expose shortcomings in health care delivery. In addition, local and state responses to COVID-19 are grounded in data; if that data is inaccurate, the responses may be misguided.

“Deaths are important because they also help us to understand how much severe COVID is there in the community that we have to worry about,” Bibbins-Domingo said. “I think when we undercount that, we both fly blind for the overall pandemic management, and we might fly particularly blind in understanding the impact of the pandemic in particular communities.”

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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

Photo by engin akyurt 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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Can COVID Tracing Apps Help Fight The Pandemic?

My 18-year-old daughter, Caroline, responded quickly when I told her that she’d soon be able to download an app to alert her when she had been in risky proximity to someone with COVID-19, and that public health officials hoped to fight the pandemic with such apps.

“Yeah, but nobody will use them,” she replied.

My young smartphone addict’s dismissal sums up a burning question facing technologists around the country as they seek to develop and roll out apps to track the newly resurgent pandemic.

The app developers, and the public health experts who are watching closely, worry that if they do not engage enough people, the apps will fail to catch a significant number of infections and people at risk of infection. Their success relies on levels of compliance and public health competence that have been sorely lacking in the U.S. during the COVID crisis.

“We can’t even get people to wear masks in this country,” said Dr. Eric Topol, director of the Scripps Research Translational Institute in San Diego. “How are we going to get them to be diligent about using their phones to help with contact tracing?”

The tracking apps, a handful of which have already been launched in the U.S., enable cellphones to send signals to one another when they are nearby — and if they are equipped with the same app, or a compatible one. The devices keep a record of all their digital encounters, and later on, they alert users when someone with whom they were in physical proximity tests positive for the virus.

For an app to stop an outbreak in a given community, 60% of the population would have to use it, although a lower rate of participation could still reduce the number of cases and deaths, according to one recent study. Some say an adoption rate as low as 10% could provide benefits.

In many places where apps have been implemented so far, adoption has failed to reach even that lower threshold. In France, less than 3% of the population had activated the government-endorsed app, StopCovid, as of late June. Italy’s app had attracted about 6% of the population. The percentage of residents who have downloaded the app endorsed by North and South Dakota, Care19, is in the low single digits.

One exception is Germany, where more than 14% of the population downloaded the new Corona Warn App in the first week after its launch.

COVID-19 apps are generally intended to supplement the work of human contact tracers, who follow up with people who’ve tested positive for the virus, asking them where they’ve been and with whom they’ve been in contact. The tracers then contact those potentially exposed individuals and advise them on the next steps, such as testing or self-quarantine.

Human contact tracing, slow and laborious in the best of times, has been a notable failure in the United States so far: An insufficient number of sometimes inadequately trained people have been deployed, and the infected people they’ve contacted often won’t cooperate.

The prospects for digital tracing appear no better. “Ideally, we’d have a digital way to supplement the human contact tracing,” said Topol. But “there hasn’t been any place yet globally where there’s proof that it goes from a clever idea to really helping people.”

Close to 20 tracing apps are in use or under development in the U.S.

A growing number of U.S. app developers are targeting state health agencies because Google, the maker of Android cellphone software, and iPhone maker Apple won’t enable an app to use their joint platform without a state’s endorsement. The Google-Apple technology, despite very limited use so far, is considered by many the most promising platform.

However, many states are lukewarm to the Google-Apple technology — and to digital contact tracing more broadly. In a Business Insider survey published in June, only three states said they had committed to the Google-Apple model, while 19 — including California — were noncommittal. Seventeen states had no plans for a smartphone-based tracking system. The remaining 11 didn’t respond or gave unclear plans.

In April, California Gov. Gavin Newsom said his office was working with Apple and Google to make their technology a part of the state’s plan for easing out of the stay-at-home order. Two months later, the Golden State seems to have backed off the idea.

Instead, it is training 20,000 human contact tracers with the hope they will hit the ground running this month. The state’s Department of Public Health told California Healthline in an email that most contact tracing “can be done by phone, text, email and chat.”

Trust Is Important

The multiple obstacles to successful use of digital tracing apps include indifference or outright hostility to anti-COVID measures. Some people won’t even wear masks or are leery of other public health efforts.

Moreover, to the extent that people do adopt phone-based tracing, it might miss potential outbreaks among the hardest-hit populations — seniors and low-income people, who are less likely than others to engage with smartphones.

“If adoption is high among 20-year-olds and low among seniors and in nursing homes, we probably don’t want the result to be that seniors and nursing homes don’t get the attention they should get through contact-tracing efforts,” said Greg Nojeim, director of the Freedom, Security and Technology Project at the Center for Technology and Democracy in Washington, D.C.

Unresolved technical challenges could also hamper the effectiveness of the apps.

To capture risky close encounters between users, some apps employ GPS to track their location. Others use Bluetooth, which gauges the proximity of two cellphones to each other without revealing their whereabouts.

Neither approach is perfect at measuring distance, and either might incorrectly assess a COVID threat to users. GPS can tell if two people are at the same address, but not if they are on different floors of a building. Bluetooth determines distance based on the strength of a phone’s signal. But signal strength can be distorted if a phone is in somebody’s purse or pocket, and metal objects can also interfere with it.

The biggest barrier to public buy-in is the privacy question. Advocates of the Google-Apple system, which uses Bluetooth, say the two companies enhanced the prospects for wide adoption by addressing fundamental privacy concerns

Google-Apple won’t allow apps to track the locations of smartphone users, and it ensures that all contacts traced are stored on the phones of individuals, not on a centralized database that would give public health authorities greater access to the information.

That means every decision based on the tracking data is up to the smartphone users. They decide whether to notify other app users if they contract the virus or whether to follow the advice — to self-quarantine and contact public health authorities — that would accompany an alert of possible exposure.

The Google-Apple system makes it easy for apps that use it to communicate with one another, which could be particularly important in multistate regions — the Washington metropolitan area, for example — where each state might have a different app and people frequently travel back and forth across state lines.

But developers of apps that don’t use the Google-Apple platform will struggle to sync with it, especially if their apps track locations or use a centralized server. Those include the Care19 app in the Dakotas and Healthy Together, Utah’s app, which both use GPS and Wi-Fi to track locations. Healthy Together also allows public health officials to see people’s names, phone numbers and location history.

These models are anathema to privacy-first app proponents, which might limit their uptake. In fact, North Dakota has announced it is planning a second app based on the Google-Apple technology.

Some public health experts, however, warn that the strong privacy focus of Google-Apple, to the exclusion of other important factors, may limit the value of the apps in tackling the pandemic.

“Apple-Google in their partnership have pretty narrowly defined what is acceptable,” said Jeffrey Kahn, director of Johns Hopkins University’s Berman Institute of Bioethics. “If these things are going to work as everyone hopes, we have to have a fuller and more soup-to-nuts discussion about all the parts that matter.”

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