With the Covid-19 surge straining America’s health care system, the 911 emergency call system has been stretched to “the breaking point,” the American Ambulance Association says.
“It has never been this bad and we are looking for a tonic, something that can help us to alleviate this surge, so that that does not happen, so that someone doesn’t call 911 and a unit doesn’t arrive within the appropriate amount of time to help that person,” she said.
Telehealth has taken off.
Spurred by the pandemic, many doctors in the U.S. now offer online appointments, and many patients are familiar with getting live medical advice over the internet. Given the obvious benefits, many experts have concluded that telehealth is here to stay. “It’s taken this crisis to push us to a new frontier,” said Seema Verma, administrator of the Center for Medicare and Medicaid Services. “But there’s absolutely no going back.”
Now the question is, where are we going? Telehealth has played an essential role during the pandemic, and it could do even more good in the years to come. But we are still in the very early days of its development. And if we are to realize telehealth’s full potential, then we must first reckon with the fact that there are serious flaws in the predominant way it is delivered today– flaws that endanger patients themselves.
Legacy telehealth services like Teladoc and others were built for a time when telehealth was a fringe phenomenon, mostly used to support acute needs like a bad cold or a troubling rash. They largely offer, in effect, randomized triage care. Patients go online, wait in a queue and see the first doctor who happens to be available. These companies market this as a virtual house call, but for patients, the experience may feel more like being stuck on a conveyer belt. Too often, they get funneled through they system with little to no choice along the way.
Insurance companies love this model because it is cheap to operate. But patients bear the cost. Doctors, in this arrangement, get paid to work the assembly line. Every minute they spend listening to patients– learning about their lives, building a personal relationship– is a minute they’re not moving them down the line, seeing the next patient and earning their next fee. The system doesn’t reward doctors for providing care; it rewards them for churning through patients.
As we build telehealth’s future, doubling down on this model would be a worrisome mistake since it is antithetical to how our healthcare system should operate. Healthcare has long been premised on the idea that you should have an ongoing relationship with your local care provider– someone with a holistic, longitudinal view of your health, who you trust to help navigate difficult or sensitive medical issues.
The randomized triage model breaks this bond and replaces it with a series of impersonal interactions that feel more like the ones you have with an Uber driver– polite but transactional, brief and ephemeral. Healthcare, however, should not be treated in the same way as the gig economy.
As a physician, I am troubled by the prospect of what happens when you scale this model up. Every time a patient gets passed from one doctor to the next, there is a chance that critical information is lost. They won’t understand your baseline mood, your family context or living situation– all critical “intangibles” for informed treatment. That lack of longitudinal data leads to worse outcomes. This is why the healthcare system has long been designed to minimize patient handoffs– and why it would be a mistake for us to choose a telehealth infrastructure that increases them.
What, then, does a better approach look like?
We are at the very dawn of telehealth’s integration into our country’s healthcare system, and I won’t claim to know the full answer. But I do know that patients are far better stewards of their own health than a random doctor generator. A more effective approach to telehealth puts the power in the patients’ hands. Because when we give them choices and then listen to them, patients tell us what they prefer.
Data gathered by my company makes it clear that by a substantial margin, people want to make this decision themselves: 9 out of 10 telehealth patients prefer to schedule an appointment with a provider of their choosing rather than seeing a randomly assigned doctor after waiting in a digital queue.
Not only that: when given this choice, most patients– about 7 out of 10– make an appointment with a nearby doctor when booking a virtual visit. Patients instinctively know that at some point, they’ll want or need to physically be in the same room with their doctor. And they know that choosing a local provider makes it possible to pick up the conversation in-person right where they left it off online. They don’t want to be forced to choose between telehealth and an ongoing relationship with a trusted provider. And they’re right– they shouldn’t have to.
None of the legacy telehealth companies focus on this imperative. Instead, while the pandemic rages on, they are rushing to scale while their randomized triage model is still viable. And the markets may reward them in the near term for being in the right place at the right time. But long-term value will be derived from listening to, responding to and iterating on what patients want.
Experience suggests patients will reward whoever can give them the most control over their healthcare. That’s where I’m placing my bet, too.
Hospitals will be allowed to care for Medicare patients in their own homes during the pandemic under a new program announced Wednesday to help hospitals deal with the latest surge.
Some hospitals already offered patients with private insurance the choice of getting care at home instead of in the hospital. The pandemic dramatically boosted use of such programs.
The Centers for Medicare and Medicaid Services said it will let hospitals quickly launch home programs, which will offer around-the-clock electronic monitoring for Medicare and Medicare Advantage patients who are sick enough to be hospitalized, but don’t need intensive care.
COVID-19 patients are eligible. Six health systems already offering “hospital-at-home” care were approved to participate in the Medicare program immediately.
“We’re at a new level of crisis response with COVID-19” and this option will help hospitals increase their capacity to help more patients, CMS Administrator Seema Verma said in a statement.
Hospitals would need to meet certain standards to participate. Those include providing twice-daily visits by medical workers and equipment such as blood pressure and oxygen-level monitors, and keeping patients connected via an iPad or other device to a command center should they need help. Medicare would pay hospitals the same rate as for in-hospital care.
Earlier in the pandemic, CMS expanded coverage for telemedicine appointments and launched a program paying for care in field hospitals and hotels.
“This will help health systems create capacity to care for patients during the surge,” said Dr. Bruce Leff, a geriatrics professor at Johns Hopkins School of Medicine and a home hospital pioneer.
He said hospital-at-home programs have proven benefits for patients and can prevent complications they might experience in a hospital.
Leff helped CMS plan the program, along with experts at major hospitals already running such programs and three companies that contract with hospitals to run programs for them: Medically Home, Contessa Health and Dispatch Health.
Since the pandemic began, all three companies have reported a surge of new, privately insured patients choosing to stay at home, where they can be more comfortable and have family around.
Medically Home Chief Executive Rami Karjian said he hopes elderly patients who might defer care during the pandemic “will now get the care they need.”
What do you think about receiving at-home care instead of checking in for care at a hospital? Are you for or against this program? Would you try it?
A company has started selling the first blood test to help diagnose Alzheimer’s disease, a leap for the field that could make it easier for people to learn whether they have dementia. It also raises concerns about the accuracy and impact of such life-altering news.
Independent experts are leery because key test results have not been published and the test has not been approved by the U.S. Food and Drug Administration– it’s being sold under more general rules for commercial labs. But they agree that a simple test that can be done in a doctor’s office has been long needed.
It might have spared Tammy Maida a decade of futile trips to doctors who chalked up her symptoms to depression, anxiety, or menopause before a $5,000 brain scan last year finally showed she had Alzheimer’s.
“I now have an answer,” said the 63-year-old former nurse from San Jose, California.
If a blood test had been available, “I might have been afraid of the results” but would have “jumped on that” to find out, she said.
More than 5 million people in the United States and millions more around the world have Alzheimer’s, the most common form of dementia. To be diagnosed with it, people must have symptoms such as memory loss plus evidence of a buildup of a protein called beta-amyloid in the brain.
The best way now to measure the protein is a costly PET brain scan that usually is not covered by insurance. That means most people don’t get one and are left wondering if their problems are due to normal aging, Alzheimer’s or something else.
The blood test from C2N Diagnostics of St. Louis aims to fill that gap. The company’s founders include Drs. David Holtzman and Randall Bateman of Washington University School of Medicine, who headed research that led to the test and are included on a patent that the St. Louis university licensed to C2N.
The test is not intended for general screening or for people without symptoms– it’s aimed at people 60 and older who are having thinking problems and are being evaluated for Alzheimer’s. It’s not covered by insurance or Medicare; the company charges $1,250 and offers discounts based on income. Only doctors can order the test and results come within 10 days. It’s sold in all but a few states in the U.S. and just was cleared for sale in Europe.
It measures two types of amyloid particles plus various forms of a protein that reveal whether someone has a gene that raises risk for the disease. These factors are combined in a formula that includes age, and patients are given a score suggesting low, medium, or high likelihood of having amyloid buildup in the brain.
If the test puts them in the low category, “it’s a strong reason to look for other things,” besides Alzheimer’s, Bateman said.
“There are a thousand things that can cause someone to be cognitively impaired,” from vitamin deficiencies to medications, Holtzman said.
“I don’t think this is any different that the testing we do now” except it’s from a blood test rather than a brain scan, he said. “And those are not 100% accurate either.”
The company has not published any data on the test’s accuracy, although the doctors have published on the amyloid research leading to the test. Company promotional materials cite results comparing the test to PET brain scans— the current gold standard– in 686 people, ages 60-91, with cognitive impairment or dementia.
If a PET scan showed amyloid buildup, the blood test also gave a high probability of that in 92% of cases and missed 8% of them, said the company’s chief executive, Dr. Joel Braunstein.
If the PET scan negative, the blood test ruled out amyloid buildup 77% of the time. The other 23% got a positive test result, but that doesn’t necessarily mean the blood test was incorrect, Braunstein said. The published research suggests it may detect amyloid buildup before it’s evident on scans.
Braunstein said the company wills eek FDA approval and the agency has given it a designation that can speed review. He said study results would be published, and he defended the decision to start selling the test now. “Should we be holding that technology back when it could have a big impact on patient care?” he asked.
Dr. Eliezer Masliah, neuroscience chief at the U.S. National Institute on Aging, said the government funded some of the work leading to the test as well as other kinds of blood tests.
“I would be cautious about interpreting any of these things,” he said of the company’s claims. “We’re encouraged, we’re interested, we’re funding this work but we want to see results.”
Heather Snyder of the Alzheimer’s Association said it won’t endorse a test without FDA approval. The test also needs to be studied in larger and diverse populations.
“It’s not quite clear how accurate or generalizable the results are,” she said.
Vaccines like to be kept cool, none more so than the Pfizer candidate for Covid-19, which has to be deep-frozen. And that’s going to be an issue for developing countries — and for rural areas in the developed world.
The “cold rain” is just one of the challenges in distributing vaccines worldwide.
There are plenty of others: decisions about priority populations and databases to keep track of who’s received what vaccine, where and when. Additionally, different vaccines may have more or less efficacy with different population groups; and governments will need PR campaigns to persuade people that vaccines are safe.
But the logistics of transporting and storing vaccines– getting them from the factory gate to the patient’s arm– are critical. And as most vaccines are likely to require two doses, the whole chain needs must be repeated within weeks.
The Pfizer-BioNTech vaccine needs to be kept at around -70 degrees Celsius (-94 degrees Fahrenheit) while it’s transported. That’s 50 degrees Celsius colder than any other vaccine currently used.
Moderna says its vaccine can be kept in freezers typically available in pharmacies, and in a refrigerator for up to 30 days. But there are likely to be fewer doses of the Moderna vaccine than of the Pfizer’s available over the next year.
Phase 3 trials have shown both vaccines to be around 95% effective but the results haven’t yet been reviewed by regulators.
On Wednesday, the CEO of BioNTech, the German biotech company partnering with Pfizer, acknowledged the issue of temperature control.
Employees fill a clinical and pharmaceutical product shipping box with dry ice at the Va-Q-Tec AG factory in Wurzburg, Germany, on Wednesday, Nov. 18, 2020.
“We are working on formulation which could allow us to ship the vaccine even maybe at room temperature,” Ugur Sahin told CNN. “We believe that in the second half of 2021 we will have come up with a formulation which is comparable to any other type of vaccine.”
But in the meantime US Health and Human Services Secretary Alex Azar believes the Moderna candidate is “more flexible” for settings like a local pharmacist. Pfiszer’s, he said Monday, would be better suited to “big institutional vaccination, say a while hospital setting, several nursing homes at once.”
Pfizer plans to ship up to 1.3 billion doses next year, requiring a lot of dry ice (carbon dioxide in solic form at around -78 degrees Celsius), and a lot of isothermic boxes. The boxes will hold up to 95 vials (4,875 doses) and be refilled with dry ice for up to 15 days of storage.
Pfizer is testing the supply chain in four US states. Its CEO, Albert Bourla, said Wednesday he has “zero concerns” about the cold chain requirements.
But shipping such a vaccine can pose big challenges. Dr. Jarbas Barbosa, assistant director of the Pan American Health Organization, told CNN that “the rural and the urban areas in any country in the world are not ready to manage this vaccine today.”
“So, who is prepared in the world? No one.”
One issuee is the availability of dry ice.
The Compressed Gas Association says carbon dioxide production capacity in the US and Canada is about 30,000 tons a day and is confident its members can meet demand for dry ice. It says that vaccine supply-chain officials believe less than 5% of dry ice production will be needed to support ultra-cold storage of Covid-19 vaccines in the United States and Canada.
Others in the industry expect bottlenecks. Several dry ice producers in the US told CNN they’ve already had offers for their entire output. Buddy Collen at Reliant and Pacific Dry Ice told online publication GasWorld: “We are in scramble mode trying to manipulate our production plants.”
Sam Rushing, president of Florida-based Advanced Cryogenics, told CNN there are already regional shortages in the US.
The main problem, Rushing says, is fewer vehicles on the road during the pandemic, meaning lower production of ethanol, from which carbon dioxide is a byproduct. European ethanol production has also fallen sharply this year.
US officials are confident enough dry ice will be available. Paul Ostrowski, director of supply, production, and distribution of Operation Warp Speed, told CNN last week that courier UPS had pledged to “provide dry ice replenishments throughout all of America upon demand.”
But Rushing cautions that dry ice is not very user-friendly and can be hazardous if stored improperly, especially in a confined space. The Federal Aviation Administration classifies it as hazardous cargo.
Peter Gerber, CEO of Lufthansa Cargo, told CNN that the need for dry ice “clearly reduces also the transport capacity because if you have to load more ice you can’t load so much vaccine. And of course the procedures have to be very special in order to ensure that it always has this degree of coldness.”
US courier DHL is adapting distribution plans according to each vaccine’s specifications. David Goldberg, CEO of Global Forwarding US for the company, says “there is a restriction on the amount of dry ice used on an aircraft– typically 500-1,000 kilos depending on a number of factors.”
Once they arrive, Pfizer vials can be stored at between 2 and 8 degrees Celsius for up to five days before deteriorating. Pfizer says it has developed a “just-in-time system which will ship the frozen vials direct to the point of vaccination.” It will also monitor the temperature of every box being shipped.
Julie Swann, an expert in supply chains at North Carolina State University, says that large hospital systems, which often have ultra-cool freezers, may have a role as distribution hubs. But not all US states have them; Hawaii said last week none of its hospitals has such freezers.
Breaking down shipments of a frozen vaccine for rural areas or small groups of essential workers– without compromising their temperature– will be another headache, Swann said.
When a vaccine needs to be used with a few days, providers will need to ensure they are ready. “You can’t just wait to see who shows up,” Swann told CNN. “And we don’t really have good data yet defining where and who the priority populations are.”
The more links in the supply chain, the more risk that the vaccine’s temperature will be compromised. Last month the US Centers for Disease Control and Prevention advised states they should “limit transport of frozen of ultra-cold vaccine products.”
Prashant Yadav, a supply chain expert and senior fellow at the Center for Global Development said: “It’s a question of how soon can we start thinking about multiple packaging formats.”
If getting a frozen vaccine to tens of millions of people is a challenge in the US, it’s a far greater problem for poorer countries.
Transport links are slower and medical facilities less equipped in the developing world. CO2 production is scarce, and the cost and hazards of shipping huge amounts of dry ice are also a hurdle, Yadav says.
David Gitlin, the CEO of refrigeration specialists Carrier, told CNN last week: “When you look at places like Africa and India, they just don’t have the cold chain infrastructure. The Untied State spends 300 times more per capita on cold chain than India.”
Peru is one of many countries that have order the Pfizer vaccine. In the capital, Lime, where large volumes can be administered quickly, it should be effective, says Dr. German Malaga, one of a team working on Peru’s vaccine options. But while there are probably 30 ultra-cold freezers in Lima “for the other 20 million Peruvians including in the Andes and the rainforest there are none.”
“For the rest of the country we could use vaccines like the Chinese one that requires from 2 to 8 degrees is more manageable,” Malaga said.
“It’s about cost-effectiveness, which is not just about the vaccine but the whole process of vaccinating,” said Yadav. But if Pfizer’s candidates proves to be the most effective, demand for ultra-cold freezers would be overwhelming.
Barbosa says the Pan American Health Organization is urging member states not to spend huge sums on preparing for one vaccine but join a multilateral facility called COVAX– essentially a clearing house for buying vaccines run by the World Health Organization.
Beyond the cold chain, there are other logistical hurdles.
A massive airlift will be required to get vaccines where they need to go. Pfizer, which has production lines in Europe and the US, says it expects an average of 20 daily cargo flights worldwide.
DHL expects that 15 million cooling boxes will need to be delivered on 15,000 flights over the next two years. David Goldberg told CNN the company has established a high quality cold-chain network and is adding flights between China, Europe and the US.
Many countries can call on existing programs as models. Peru’s national vaccination program reaches about 75% of its population, Malaga said.
India’s polo vaccination program is ubiquitous– covering more than 90% of children by this year, according to Gagandeep Kang of the Wellcome Trust Research Laboratory at the Christian Medical College in Vellore.
“For polio programs, we have used boats and mules and enterprising health staff,” said Kang. But such programs are designed for less than a tenth of the population, and Covid-19 vaccines will need to focus on different groups, she said.
India will need “a series of waves each addressing a different group as vaccines become available,” she told CNN.
“We will need to see performance characteristics of other vaccines, and their delivery requirements before making a call on what to go with,” said Kang, who is also a member of the World Health Organization’s Global Advisory Committee on Vaccine Safety.
In such a dynamic situation, record-keeping becomes critical. Dr. Anna Blakney, who is working on a vaccine being developed by Imperial College London, said there is no centralized infrastructure in the US for monitoring who is getting what and when, which she describes as a “really critical issue.”
Yadav says that even when the vaccine reaches its destination there will need to be some flexibility to allow people to get their second dose in a different location if desired. And that demands reliable databases.
Barbosa said that beyond the supply chain, governments “must have a good communications strategy to overcome public skepticism and conspiracy theories about vaccines.”
Blakney agrees. “The process [of vaccine development] has been so fast that it’s not surprising people are skeptical as they read about safety and possible side-effects,” she said. Blakney is part of an international effort launched by research scientists to reassure people via social media about the safety and efficacy of Covid-19 vaccines.
Finding enough dry ice is just one in a sequence of challenges to get the world vaccinated against Covid-19.
Medicare’s ‘Part B’ monthly premium for outpatient care will go up by $3.90 next year to $148.50, officials announced late Friday afternoon.
For most retirees, the health care cost increase will claim a significant slice of their Social Security cost-of-living adjustment, or COLA. It works out to nearly 20% of the average retired worker’s COLA of $20 a month next year.
The bite could have been deeper. It was feared that emergency actions the government took to stabilize the health care system in the coronavirus pandemic could have triggered lare premium increases. That prompted Congress to pass bipartisan legislation that limited the increase for 2021 but would gradually collect the full amount later under a repayment mechanism.
The Part B premium is set by law to cover about 25% of the cost of Medicare’s supplemental insurance for outpatient services. Inpatient care is covered by Medicare’s ‘Part A,’ which is financed with payroll taxes from workers and employers.
Medicare also announced that the Part B deductible next year will be $203, an increase of $5. The deductible is the amount patients pay each year before their insurance kicks in.
The inpatient deductible will be $1,484, an increase of $76.
Most Medicare recipients rely on supplemental insurance or a Medicare Advantage plan to cover their annual deductibles.
Federal officials have recommended that nursing home staff and residents avoid contact with relatives during the holidays.
As coronavirus rates surge across the nation, the Trump administration issued new recommendations this week urging residents and staff of nursing homes to avoid contact with relatives during the upcoming holiday season– a dark reminder of the threat now bearing down on seniors in congregate settings.
The guidance comes as nursing homes grapple with the renewed challenge of infected staff members. One of the nation’s largest providers, ProMedica Senior Care, which operates 222 nursing homes around the country, has seen the virus’s dramatic onset. Since the beginning of the pandemic, the company’s 30,000 senior care staffers have recorded 2,000 positive tests. But 600 of those have come in the past two weeks.
“We’re all afraid as employees to be “patient zero,” said Katy Tenner, a dietician at a ProMedica nursing home in Sacramento, California. “Knowing what we know about what it can do if it gets into a nursing home. None of us wants to be that person.”
Nursing facilities are home to some of the populations’ most vulnerable to COVID-19– the elderly and sick. Since the start of the pandemic through Nov. 18, nearly 94,000 people have died in those facilities, according to an ABC News analysis of state data– representing about 37% of all deaths nationwide. Approximately 1.4 million people living in nursing care in the U.S.
The COVID Tracking Project, run by The Atlantic, reported this week that nursing homes infections rose 17% during the week ending Nov. 17, the sharpest national increase they had seen since May.
And state-by-state data reviewed by ABC News shows the virus is consistently finding its way into nursing facilities. In at least 16 states, nursing homes currently account for more than half of all COVID deaths. Senior care settings now accounting for 70% of fatalities in New Hampshire and Rhode Island.
There is another dimension to the pandemic that may not be as visible– the pain of months of isolation that residents have experienced with visitors forbidden in many cases, making the new federal recommendations all the more daunting.
“We understand the emotional impact that separation from loved ones has cased,” wrote Seema Verma, the federal administrator who regulates nursing homes. “With the potential for a safe and effective vaccine on the immediate horizon, extra precautions now are essential to protect nursing home residents until a vaccine becomes available.”
At the John Knox Village Care Center, an independent 430-bed nursing facility located in a Kansas City suburb, evidence coronavirus cases were spiking started surfacing six weeks ago. Rodney McBride, the facility’s vice president of health service, said he believes that a patient who was traveling for daily dialysis treatments may have caught the virus and carried it back inside.
The home now has 30 active cases, and 20 residents have died of the virus since early October. McBride told ABC News that after an initial fatal outbreak in March, the facility installed an air scrubber and ultraviolet lights and used grant money to buy special equipment to disinfect rooms.
“We have done everything we can,” McBride said. “But the virus is quick and it made its way into our facility.”
Dr. Mark Gloth, the chief medical officer for ProMedica Senior Care, said he believes nursing facilities are far better prepared to weather a second wave of the virus than they were in February and March.
“Back then, we were just learning that this could be spread from asymptomatic individuals. We were strictly going on symptoms,” Gloth said.
Now, the company says it is testing all residents and staff as frequently as twice each week.
“Testing of our employees is the critical piece,” he said. “When we identify an index case, we can go and test the entire facility. That gives us the ability to very quickly make the determination on how we are isolating individuals.”
Gloth said he is encouraged that he has not seen death rates going up as fast as they did earlier in the year– even though the caseload is clearly rising quickly. At the peak, 36% of those who became infected were dying. Now, he said, the number is holding level at about 5%.
Richard Mollot, executive director of the Long Term Care Community Coalition, which advocates for nursing home residents, told ABC News he remains deeply concerned that many nursing homes are still not taking needed steps to protect residents. Specifically, he is concerned about low staffing levels might leave facilities unprepared for this wave of new cases. The sad reality, he said, is that “the death rate and the case rate in [these] facilities is still many, many times higher than the general population.”
Mollot said the new guidelines from the Centers for Medicare and Medicaid Services, urging nursing home residents to pass up on family gatherings during the holidays has been a tough message to accept, we even though he knows there are “no easy answers or decisions.”
“It’s been eight months since some people have had any visitors, any human contact,” Mollot said. “People dying of loneliness is actually happening.”
At the John Knox Village Care Center, McBride, the facility’s vice president, said residents feel the sting of isolation and the yearning to “go back to the way that it used to be.”
“It’s getting old for them. Not being able to see their family is really hard on them,” he said. “But our group, they understand. They have been really good during this time.”
Coronavirus infections among nursing home residents are ticking higher in New Jersey as the second wave has taken effect, per a report.
State health records show cases at the Dellridge Health & Rehabilitation Center in North Jersey spiked from two infections in October to seven this week, a local outlet, NorthJersey.com, reported.
The incidence of cases among nursing homes in the Garden State represent just one example of the scene across the country, with one virus-laden nursing home in Kansas even recently losing its federal Medicare funding.
This state’s coronavirus mitigation tactics “likely” dropped cases, serious outcomes
In late September, Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases (NIAID), told Gov. Phil Murphy the state was well-positioned for the colder months ahead given its low baseline of community spread. Figures from the state health department show new daily cases have gradually been on the rise since then, but are nowhere near the surge seen in April when nearly 4,400 cases were reported on several occasions.
By Nov. 2, the state had a positivity rate of 6%, which is just above the World Health Organization’s threshold of a 5% positivity rate for two weeks as a guide for reopening.
The outlet reported that facilities in northern New Jersey counties are reporting some of the largest spikes in cases statewide, citing state records. As of Thursday, there were reportedly ongoing outbreaks across 191 nursing facilities, which is a jump from 156 on Oct. 19.
“We remain hyper-vigilant in our efforts to eradicate COVID-19,” said Family of Care, the health system owning Dellridge, per the outlet. “We have increased our staff testing to twice weekly based on the county positivity rate. We are in daily contact with our Local and State Health Departments of Health.”
However, there was a mistake: Dellridge officials were reportedly removing case numbers off of totals as residents recovered, though a state spokeswoman reportedly said the facility would correct the issue. So far, New Jersey has reported a total of 249,380 coronavirus cases and 14,616 related deaths.
Missourians mobilized by the thousands to get Medicaid expansion on the ballot this year, a move that will impact 230,000 low-income residents in the “coverage gap.”
For almost a decade, advocates in Missouri have been lobbying their legislators to expand Medicaid coverage in the red state.
Since the Supreme Court ruled in 2012 that the Medicaid expansion under the Affordable Care Act was optional, 36 states plus Washington, D.C., have adopted and implemented the expansion. In those states where coverage has not been expanded, the decision has come at a devastating cost to Americans who fall into the “coverage gap,” advocates said.
“When the Affordable Care Act was originally passed, folks who were making up to 138% of the federal poverty level were supposed to be on Medicaid. And folks making more than 138% of the federal poverty level would be given subsidies to buy coverage through the exchange or healthcare.gov,” Kelly Hall, director of health policy for the Fairness Project, told ABC News.
“Because some states haven’t expanded their Medicaid program, they are creating a problem for people who don’t make enough money to get the subsidies on the exchange, but they make too much money to be on their state’s Medicaid program.”
In the states that chose not to expand Medicaid coverage, the maximum income for Medicaid eligibility varies. In Missouri– which for now has one of the lowest Medicaid income eligibility limits in the U.S.– this meant that a family of three had to earn at most 21% of the federal poverty level, or $4,479 in 2019, annually to be eligible for Medicaid. Subsidies for the Affordable Care Act marketplace aren’t accessible until earning 100% to 400% of the federal poverty level.
After their conservative state legislature did not address the issue for years, Missourians mobilized by the thousands to get Medicaid expansion on the ballot. This year, Missouri became one of two states–along with Oklahoma– that voted to implement that expansion next year.
ABC News is examining the coverage gap and expansion of Medicaid as part of its “My America” video series, which highlights issues that are key to the electorate in the run-up to the 2020 election and spoke to voters and experts about the issue.
The personal cost
Fair Grove, Missouri resident Amber Ledbetter, a single mother of two, is one of thousands of Americans without healthcare because their income falls into the “coverage gap.”
“It’s stressful, especially with the kids,” Ledbetter told ABC News. “I don’t want to end up in a position where I’m having to bankrupt my family just to get the health care that I need immediately.”
Ledbetter has Crohn’s disease, a chronic illness that causes her fatigue and pain and impacts her ability to work as a house cleaner. Last year, she was so sick she had to go to the emergency department.
“I kept putting it off and putting it off and was working through the pain and probably causing myself more harm,” she said. “I was more concerned about what the bill would be than the treatment I was going to get.”
Ledbetter said she makes too much money to qualify for Medicaid in Missouri, but not enough to qualify for Affordable Care Act subsidies.
“I was just caught in this gap that I didn’t know existed,” said Ledbetter, who has to take into consideration what she could get covered through charity when she discusses treatment options with her gastroenterologist.
Single mom Victoria Altic fell into the coverage gap last year. The Missouri resident racked up thousands of dollars in medical debt, she told ABC News, after several episodes of seizures a couple of years ago. She delayed seeking medical care for an ear infection, and the resulting visits caused her to go further into debt, she said.
“One of the worst parts about all of that, besides the actual health effects of not having health insurance, is the financial aspect, where you’re falling into debt,” said Altic, who was laid off from her restaurant job at the start of the coronavirus pandemic.
Erich Arvidson’s parents were in the coverage gap– both retired but not yet eligible for Medicare– when his father fell ill last year, he told ABC News.
“My sister and I were forced to make decisions for him based on what he could afford and not necessarily what was the best course of action for him,” the Boonville, Missouri resident said.
His father died last February. Then, a few months later, his mother fell ill. “We had to make those same decisions just right away,” Arvidson said.
In Missouri, citizens can petition to put constitutional amendments on the ballot. Arvidson was one of thousands of volunteers who worked to get the Medicaid expansion on the ballot as on amendment in August.
“Ballot measures are a team sport,” said Hall, of the Fairness Project, which focuses on ballot initiative efforts to promote economic and social justice. “It takes a lot of different folks putting money into the effort, putting sweat equity in the effort, standing on street corners with clipboards and talking to their neighbors.”
In Missouri, volunteers collected over 350,000 signatures from all over the state to get Medicaid expansion on the ballot, Hall said.
“We went everywhere,” Arvidson said. “We went to county fairs. We went to cotton carnivals and apple festivals and stood on town squares and just talked to people about it and gathered the signatures that we needed.”
On August 4, Missourians voted 53% to 47% to pass the amendment to expand Medicaid coverage. The move came two months after Oklahoma also passed its expansion through a ballot measure.
That signaled to Hall and other experts that Medicaid expansion is “not a partisan issue anymore.”
“The same voters in Missouri and Oklahoma who are going to the polls to vote for President [Donald] Trump are also saying we want Medicaid expansion,” she said.
“Nobody really asked, well, is this a Democratic thing or is this a Republican thing?” Richard Von Glahn, policy director of the coalition Missouri Jobs with Justice, told ABC News. “Voters don’t actually think that way. They think, well, what is this actually going to mean for the state?”
Beyond Oklahoma and Missouri, other states, including Idaho, Maine, Nebraska and Utah, have voted to expand Medicaid through a ballot measure, as opposed to a bill.
“What we learned is that if we’re going to be successful in moving and shifting power in a state like Missouri, which is so adverse to providing equity for the poor and people of color, what we must do if organize and mobilize,” Dr. Rev. Vernon Howard, president of the Southern Christian Leadership Conference of Greater Kansas City and a community organizer for Missouri’s Medicaid expansion, told ABC News.
Medicaid expansion coverage is set to begin in Missouri on July 1, 2021. The constitutional amendment, protected from changes by the state legislature, will impact about 230,000 low-income Missourians, according to Von Glahn– Missourians like Ledbetter and Altic.
“I know it’s still gonna take some time before I can take advantage of those health care options for Medicaid,” Ledbetter said. “But it’s a step in the right direction.”
The move will make a “huge difference” for Altic.
“I wouldn’t have to worry about whether I can go to the doctor if I have a small earache and wonder if it’s going to become something way worse,” she said.
For Howard, the passage was a sign of “hope to bring equal access to voting to the ballot.”
“There is hope to bring living wages for the working poor,” he said. “There is hope to bring healthcare as a right and not a privilege. And when we mobilize and organize together around these issues, we can see good things happen.”
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