Darius Tahir

Most people have at least a vague sense that someone somewhere is doing mischief with the data footprints created by their online activities: Maybe their use of an app is allowing that company to build a profile of their habits, or maybe they keep getting followed by creepy ads.

It’s more than a feeling. Many companies in the health tech sector — which provides services that range from mental health counseling to shipping attention-deficit/hyperactivity disorder pills through the mail — have shockingly leaky privacy practices.

A guide released this month by the Mozilla Foundation found that 26 of 32 mental health apps had lax safeguards. Analysts from the foundation documented numerous weaknesses in their privacy practices.

Jen Caltrider, the leader of Mozilla’s project, said the privacy policies of apps she used to practice drumming were scarcely different from the policies of the mental health apps the foundation reviewed — despite the far greater sensitivity of what the latter records.

“I don’t care if someone knows I practice drums twice a week, but I do care if someone knows I visit the therapist twice a week,” she said. “This personal data is just another pot of gold to them, to their investors.”

The stakes have become increasingly urgent in the public mind. Apps used by women, such as period trackers and other types of fertility-management technology, are now a focus of concern with the potential overturning of Roe v. Wade. Fueled by social media, users are exhorting one another to delete data stored by those apps — a right not always granted to users of health apps — for fear that the information could be used against them.

“I think these big data outfits are looking at a day of reckoning,” said U.S. Sen. Ron Wyden (D-Ore.). “They gotta decide — are they going to protect the privacy of women who do business with them? Or are they basically going to sell out to the highest bidder?”

Countering those fears is a movement to better control information use through legislation and regulation. While nurses, hospitals, and other health care providers abide by privacy protections put in place by the Health Insurance Portability and Accountability Act, or HIPAA, the burgeoning sector of health care apps has skimpier shields for users.

Although some privacy advocates hope the federal government might step in after years of work, time is running out for a congressional solution as the midterm elections in November approach.

Enter the private sector. This year, a group of nonprofits and corporations released a report calling for a self-regulatory project to guard patients’ data when it’s outside the health care system, an approach that critics compare with the proverbial fox guarding the henhouse.

The project’s backers tell a different story. The initiative was developed over two years with two groups: the Center for Democracy and Technology and Executives for Health Innovation. Ultimately, such an effort would be administered by BBB National Programs, a nonprofit once associated with the Better Business Bureau.

Participating companies might hold a range of data, from genomic to other information, and work with apps, wearables, or other products. Those companies would agree to audits, spot checks, and other compliance activities in exchange for a sort of certification or seal of approval. That activity, the drafters maintained, would help patch up the privacy leaks in the current system.

“It’s a real mixed bag — for ordinary folks, for health privacy,” acknowledged Andy Crawford, senior counsel for privacy and data at the Center for Democracy and Technology. “HIPAA has decent privacy protections,” he said. The rest of the ecosystem, however, has gaps.

Still, there is considerable doubt that the private sector proposal will create a viable regulatory system for health data. Many participants — including some of the initiative’s most powerful companies and constituents, such as Apple, Google, and 23andMe — dropped out during the gestation process. (A 23andMe spokesperson cited “bandwidth issues” and noted the company’s participation in the publication of genetic privacy principles. The other two companies didn’t respond to requests for comment.)

Other participants felt the project’s ambitions were slanted toward corporate interests. But that opinion wasn’t necessarily universal — one participant, Laura Hoffman, formerly of the American Medical Association, said the for-profit companies were frustrated by “constraints it would put on profitable business practices that exploit both individuals and communities.”

Broadly, self-regulatory plans work as a combination of carrot and stick. Membership in the self-regulatory framework “could be a marketing advantage, a competitive advantage,” said Mary Engle, executive vice president for BBB National Programs. Consumers might prefer to use apps or products that promise to protect patient privacy.

But if those corporations go astray — touting their privacy practices while not truly protecting users — they can get rapped by the Federal Trade Commission. The agency can go after companies that don’t live up to their promises under its authority to police unfair or deceptive trade practices.

But there are a few key problems, said Lucia Savage, a privacy expert with Omada Health, a startup offering digital care for prediabetes and other chronic conditions. Savage previously was chief privacy officer for the U.S. Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology. “It is not required that one self-regulate,” she said. Companies might opt not to join. And consumers might not know to look for a certification of good practices.

“Companies aren’t going to self-regulate. They’re just not. It’s up to policymakers,” said Mozilla’s Caltrider. She cited her own experience — emailing the privacy contacts listed by companies in their policies, only to be met by silence, even after three or four emails. One company later claimed the person responsible for monitoring the email address had left and had yet to be replaced. “I think that’s telling,” she said.

Then there’s enforcement: The FTC covers businesses, not nonprofits, Savage said. And nonprofits can behave just as poorly as any rapacious robber baron. This year, a suicide hotline was embroiled in scandal after Politico reported that it had shared with an artificial intelligence company online text conversations between users considering self-harm and an AI-driven chat service. FTC action can be ponderous, and Savage wonders whether consumers are truly better off afterward.

Difficulties can be seen within the proposed self-regulatory framework itself. Some key terms — like “health information” — aren’t fully defined.

It’s easy to say some data — like genomic data — is health data. It’s thornier for other types of information. Researchers are repurposing seemingly ordinary data — like the tone of one’s voice — as an indicator of one’s health. So setting the right definition is likely to be a tricky task for any regulator.

For now, discussions — whether in the private sector or in government — are just that. Some companies are signaling their optimism that Congress might enact comprehensive privacy legislation. “Americans want a national privacy law,” Kent Walker, chief legal officer for Google, said at a recent event held by the R Street Institute, a pro-free-market think tank. “We’ve got Congress very close to passing something.”

That could be just the tonic for critics of a self-regulatory approach — depending on the details. But several specifics, such as who should enforce the potential law’s provisions, remain unresolved.

The self-regulatory initiative is seeking startup funding, potentially from philanthropies, beyond whatever dues or fees would sustain it. Still, Engle of BBB National Programs said action is urgent: “No one knows when legislation will pass. We can’t wait for that. There’s so much of this data that’s being collected and not being protected.”

KHN reporter Victoria Knight contributed to this article.

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

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For two years, you beat the odds. You masked, kept your distance, got your shots.

Now, despite those efforts, you, your child, or someone else in your home has come down with covid-19. And the last thing you want is for the virus to spread to everyone in the family or household. But how do you prevent it from circulating when you live in close quarters?

The Centers for Disease Control and Prevention recommends isolating covid patients for at least five days, preferably in a separate room with access to their own bathroom, as well as diligent mask-wearing for both patient and caregiver. But for many families, those aren’t easy options. Not everyone has an extra bedroom to spare, let alone a free bathroom. Young children should not be left alone, and the youngest can’t tolerate masks.

“For parents of a young child, it’s pretty difficult not to be exposed,” said Dr. Preeti Malani, chief health officer at the University of Michigan. “You have to work back from the perfect to the possible and manage your risk the best you can.”

But take heart. Scientists say there is still a lot people can do to protect their families, chief among them improving ventilation and filtration of the air.

“Ventilation matters a lot,” said Dr. Amy Barczak, an assistant professor of medicine at Harvard Medical School. “If you’re taking care of someone at home, it’s really important to maximize all the interventions that work.”

To understand why good ventilation can make a difference, it helps to understand how the novel coronavirus spreads. Scientists have learned a lot in two years about its infectious mechanisms.

Viral particles float through the air like invisible secondhand smoke, diffusing as they travel. Outside the home, viruses are quickly dispersed by the wind. Inside, germs can build up, like clouds of thick cigarette smoke, increasing the risk of inhaling the virus.

The best strategy for avoiding the virus is to make your indoor environment as much like the outdoors as possible.

Start by opening as many windows as the weather allows, said Joseph Fox, a heating, ventilation, and air conditioning engineer for a large school district in Ontario, Canada. If possible, open windows on opposite sides of the home to create a cross breeze, which can help sweep viruses outside and bring fresh air inside.

For extra protection, place a box fan in the patient’s window, facing outward, to draw germy air outside. Seal any openings around the sides of the fan, said Jim Rosenthal, CEO of Tex-Air Filters, a company that manufactures air filtration products in Fort Worth, Texas.

“It’s real simple, and it’s cheap,” Rosenthal said.

To prevent infected air from seeping out of the sickroom, Fox suggests wedging towels in the gap under the bedroom door. People should also cover return air grills with plastic. These grills cover vents that suck air out of the room and recycle it through the heating or cooling system.

Fox also suggests turning on bathroom or kitchen exhaust fans, which can shuttle germy air outside. Although running exhaust fans while taking a shower is relatively safe, Fox said, it’s important to open windows when running the fans for more than 10 minutes. That’s to avoid depressurizing the house, a circumstance that could result in carbon monoxide being pulled into the home from the furnace or water heater.

Coronaviruses thrive in dry air, and increasing the amount of moisture in the air can help deactivate them, said Linsey Marr, a professor of civil and environmental engineering at Virginia Tech. Marr suggests increasing humidity levels to somewhere between 40% and 60%.

Using portable air cleaners can provide additional protection. Research shows that high-efficiency particulate air filters, or HEPA filters, can remove coronaviruses from the air. If people have only one HEPA filter, it’s best to place it in the sickroom, to trap any virus the patient exhales.

“You want to put the filter as close to the source [of the virus] as possible,” Fox said.

If affordable for families, additional air cleaners can be used in other rooms.

Store-bought air purifiers can be expensive, with some models costing hundreds of dollars. Yet for about $100, people can build their own portable air cleaners using a box fan, four high-efficiency air filters, and duct tape. These do-it-yourself devices have been dubbed Corsi-Rosenthal boxes, after their co-inventors, Rosenthal and Richard Corsi, dean of the college of engineering at the University of California-Davis. The low-cost boxes have been shown to work just as well as commercial air purifiers.

Rosenthal said the pandemic motivated him to help design the air purifiers. “We’re not helpless,” Rosenthal said. “We need to provide tools that people can use right now to make things better.”

Although nursing a loved one through covid puts the caregiver at risk, the danger is much smaller today than in the first year of the pandemic. An estimated 95% of the population has some immunity to the coronavirus, due to vaccines, prior infections, or both, said Dr. Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia.

Nonetheless, a recent study found that half of the people living in an infected patient’s household also contracted the virus.

Given that older people and those who are immunocompromised are at higher risk from covid, they might consider staying with a friend or neighbor, if possible, until the sick family member has recovered, said Priya Duggal, a professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health.

Patients can be considered covid-free after a negative PCR test, Barczak said. Because patients with even tiny amounts of residual virus can continue to test positive on PCR tests for weeks, long after symptoms disappear, patients can also use rapid antigen tests to assess their progress. If antigen tests are negative two days in a row, a person is considered less likely to be contagious.

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Bernard J. Wolfson

When she was Pennsylvania’s insurance commissioner, Jessica Altman, the appointee of a Democratic governor, often bumped against the political limits of health care policy in a state where Republicans controlled the legislature.

Despite the constraints of a divided government, Altman played a key role in persuading lawmakers in 2019 to join Gov. Tom Wolf in passing legislation that established Pennsylvania’s state-run Affordable Care Act marketplace, known as Pennie. And she had a big hand in its launch in November 2020, as the first chairperson of its board.

In March, Altman took the reins of Covered California, the Golden State’s ACA insurance marketplace, following the departure of its first executive director, Peter Lee. Altman will earn $450,000 annually.

In taking on the new role, the 33-year-old Altman returned to her home state, whose Democratic leadership has supported extending health coverage to as many residents as possible. Covered California, established shortly after the ACA passed in 2010, was the first state-operated insurance exchange created under the new law. And the state was an enthusiastic endorser of the ACA’s Medicaid expansion.

However, Covered California relies on federal tax credits to make coverage more affordable for most of its enrollees. The American Rescue Plan Act, passed by Congress last year, helped boost enrollment in plans offered on the exchange by increasing the size of the credits, which sharply lowered premiums for enrollees, and extended financial assistance to many middle-class families. People can take the credits in the form of reduced monthly premiums or wait until they file their taxes.

The extra dollars reduced the average monthly premium cost to Covered California enrollees by 20% this year compared with 2021, according to estimates from the exchange. And the lower cost helped push enrollment to a record 1.8 million this year. Nationally, the average premium cost for marketplace enrollees dropped 23%, and enrollment rose to 14.5 million, also a record.

But the financial boost is set to expire at the end of this year, and Congress so far has not renewed it. California Gov. Gavin Newsom has proposed that the state use $304 million of its budget surplus on subsidies if the federal government doesn’t act, but that amount would replace only a fraction of the federal enhancements.

Altman fears that without the continued support, the cost to consumers will rise sharply, and many people will forgo coverage. It’s why she says one of her first tasks is to push Congress for an extension of the American Rescue Plan subsidies.

Altman arrives just as Covered California is pushing commercial health plans to upgrade the quality of their care and tackle inequities to improve the health of low-income and disadvantaged people.

The marketplace’s board in February approved a new multiyear initiative that will require Covered California health plans to submit data on the quality of care broken down by race and ethnicity. Covered California will require plans to pay into a fund if they fail to meet benchmarks of care for childhood immunizations and certain health conditions — diabetes, hypertension, and colorectal cancer — that disproportionately affect underserved people.

In a recent interview, Altman discussed this new policy, as well as her push to extend the federal premium subsidies. The interview has been edited for length and clarity.

Q: What are the biggest differences between California and Pennsylvania in terms of health care politics and policy?

What you can accomplish is really about understanding the art of the possible. Your political constraints, your system constraints, will show you what is possible. In Pennsylvania, you dream big, and you try hard. I think that accomplishing a transition to a state-based exchange, given the political environment — with unanimous support from a Republican legislature and a Democratic governor — is a big accomplishment.

In California, we have a marketplace that is advanced in so many ways. So, here, the art of what’s possible is a broader set.

Q: What’s the message you want to deliver about extending the American Rescue Plan Act’s increased subsidies?

I come into this role after a record-breaking enrollment in California, which is true in so many states because of the enhanced subsidies. So, really an unbelievable impact when you look at the affordability that is available for Californians — and Americans.

The flip side of that is what it would mean if they were not to continue. Prior to the American Rescue Plan, [federal] subsidies went away at 400% of the federal poverty level [currently slightly over $54,000 a year for an individual and $111,000 for a family of four]. In California, folks above that income level would see an average $272 increase in their premium each month. And then there’s the lowest-income enrollees in Covered California, who would see premiums, on average, double, to $131 a month. These are impacts that are going to change the minds of people about whether they stay covered or not or become covered or not.

Q: What’s the cutoff date for a decision on the enhanced subsidies to be reflected in 2023 premiums?

The premiums are generally locked down in July. We will always try to move mountains when there’s uncertainty. Fundamentally, for me, the date that we should be thinking about is in October, when we send letters to the Covered California enrollees telling them, “This is what your premium will be next year.”

Q: The way I read the quality and equity initiative approved by your board in February is that the overall quality of care and health equity are wrapped up together. Is that correct?

Yes. It starts with a pretty fundamental principle that quality is equity — that if we improve quality, we are improving equity.

Q: How will all the components of this initiative fit together over time to improve equity in health care?

It’s really about accurately capturing what the people we cover are experiencing each and every day in their care, understanding it, and striving to do better for everyone.

When we look at these poor health care areas where we know the outcomes vary by your race and ethnicity and we work to raise the floor, we are going to help populations that experience worse health outcomes on these key measures to a greater degree.

And I don’t want to lose sight of the robust data collection associated with the measures, because fundamentally it starts with understanding on a really granular level what the disparities are within our covered population.

Q: What’s your definition of success in addressing health equity problems with the measures that Covered California’s board has approved?

One of the things you and I didn’t talk about in great detail are the financial incentives underlying what we are doing. And that includes a shared responsibility model, where there’s money on the table from insurers if they aren’t meeting the 66th percentile of quality.

I would say the best definition of success is if our insurers don’t have to pay anything. Do I think that will happen right away? I hope so, but maybe not. But that’s OK. It’s all about moving forward.

Q: If no health plan is paying anything because they’re all meeting the targets, what does that mean for consumers?

It means more children are getting immunized. It means more people are getting their colorectal cancer screenings, which means more colorectal cancers are being identified early and lives are being saved. It really translates into better health and better outcomes for people.

Jessica Altman is the daughter of Drew Altman, who is president and CEO of KFF. KHN is an editorially independent program of KFF.

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

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

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Nearly 18 months after getting covid-19 and spending weeks in the hospital, Terry Bell struggles with hanging up his shirts and pants after doing the laundry.

Lifting his clothes, raising his arms, arranging items in his closet leave Bell short of breath and often trigger severe fatigue. He walks with a cane, only short distances. He’s 50 pounds lighter than when the virus struck.

Bell, 70, is among millions of older adults who have grappled with long covid — a population that has received little attention even though research suggests seniors are more likely to develop the poorly understood condition than younger or middle-aged adults.

Long covid refers to ongoing or new health problems that occur at least four weeks after a covid infection, according to the Centers for Disease Control and Prevention. Much about the condition is baffling: There is no diagnostic test to confirm it, no standard definition of the ailment, and no way to predict who will be affected. Common symptoms, which can last months or years, include fatigue, shortness of breath, an elevated heart rate, muscle and joint pain, sleep disruptions, and problems with attention, concentration, language, and memory — a set of difficulties known as brain fog.

Ongoing inflammation or a dysfunctional immune response may be responsible, along with reservoirs of the virus that remain in the body, small blood clots, or residual damage to the heart, lungs, vascular system, brain, kidneys, or other organs.

Only now is the impact on older adults beginning to be documented. In the largest study of its kind, published recently in the journal BMJ, researchers estimated that 32% of older adults in the U.S. who survived covid infections had symptoms of long covid up to four months after infection — more than double the 14% rate an earlier study found in adults ages 18 to 64. (Other studies suggest symptoms can last much longer, for a year or more.)

The BMJ study examined more than 87,000 adults 65 and older who had covid infections in 2020, drawing on claims data from UnitedHealth Group’s Medicare Advantage plans. It included symptoms that lasted 21 days or more after an infection, a shorter period than the CDC uses in its long covid definition. The data encompasses both older adults who were hospitalized because of covid (27%) and those who were not (73%).

The higher rate of post-covid symptoms in older adults is likely due to a higher incidence of chronic disease and physical vulnerability in this population — traits that have led to a greater burden of serious illness, hospitalization, and death among seniors throughout the pandemic.

“On average, older adults are less resilient. They don’t have the same ability to bounce back from serious illness,” said Dr. Ken Cohen, a co-author of the study and executive director of translational research for Optum Care. Optum Care is a network of physician practices owned by UnitedHealth Group.

Applying the study’s findings to the latest data from the CDC suggests that up to 2.5 million older adults may have been affected by long covid. For those individuals, the consequences can be devastating: the onset of disability, the inability to work, reduced ability to carry out activities of daily life, and a lower quality of life.

But in many seniors, long covid is difficult to recognize.

“The challenge is that nonspecific symptoms such as fatigue, weakness, pain, confusion, and increased frailty are things we often see in seriously ill older adults. Or people may think, ‘That’s just part of aging,’” said Dr. Charles Thomas Alexander Semelka, a postdoctoral fellow in geriatric medicine at Wake Forest University.

Ann Morse, 72, of Nashville, Tennessee, was diagnosed with covid in November 2020 and recovered at home after a trip to the emergency room and follow-up home visits from nurses every few days. She soon began having trouble with her memory, attention, and speech, as well as sleep problems and severe fatigue. Though she’s improved somewhat, several cognitive issues and fatigue persist to this day.

“What was frustrating was I would tell people my symptoms and they’d say, ‘Oh, we’re like that too,’ as if this was about getting older,” she told me. “And I’m like, but this happened to me suddenly, almost overnight.”

Bell, a singer-songwriter in Nashville, had a hard time getting adequate follow-up attention after spending two weeks in intensive care and an additional five weeks in a nursing home receiving rehabilitation therapy.

“I wasn’t getting answers from my regular doctors about my breathing and other issues. They said take some over-the-counter medications for your sinus and things like that,” he said. Bell said his real recovery began after he was recommended to specialists at Vanderbilt University Medical Center.

James Jackson, director of long-term outcomes at Vanderbilt’s Critical Illness, Brain Dysfunction, and Survivorship Center, runs several long covid support groups that Morse and Bell attend and has worked with hundreds of similar patients. He estimates that about a third of those who are older have some degree of cognitive impairment.

“We know there are significant differences between younger and older brains. Younger brains are more plastic and effective at reconstituting, and our younger patients seem able to regain their cognitive functioning more quickly,” he said.

In extreme cases, covid infections can lead to dementia. That may be because older adults who are severely ill with covid are at high risk of developing delirium — an acute and sudden change in mental status — which is associated with the subsequent development of dementia, said Dr. Liron Sinvani, a geriatrician and an assistant professor at Northwell Health’s Feinstein Institutes for Medical Research in Manhasset, New York.

Older patients’ brains also may have been injured from oxygen deprivation or inflammation. Or disease processes that underlie dementia may already have been underway, and a covid infection may serve as a tipping point, hastening the emergence of symptoms.

Research conducted by Sinvani and colleagues, published in March, found that 13% of covid patients who were 65 and older and hospitalized at Northwell Health in March 2020 or April 2020 had evidence of dementia a year later.

Dr. Thomas Gut, associate chair of medicine at Staten Island University Hospital, which opened one of the first long covid clinics in the U.S., observed that becoming ill with covid can push older adults with preexisting conditions such as heart failure or lung disease “over the edge” to a more severe impairment.

In older adults especially, he said, “it’s hard to attribute what’s directly related to covid and what’s a progression of conditions they already have.”

That wasn’t true for Richard Gard, 67, who lives just outside New Haven, Connecticut, a self-described “very healthy and fit” sailor, scuba diver, and music teacher at Yale University who contracted covid in March 2020. He was the first covid patient treated at Yale New Haven Hospital, where he was critically ill for 2½ weeks, including five days in intensive care and three days on a ventilator.

In the two years since, Gard has spent more than two months in the hospital, usually for symptoms that resemble a heart attack. “If I tried to walk up the stairs or 10 feet, I would almost pass out with exhaustion, and the symptoms would start — extreme chest pain radiating up my arm into my neck, trouble breathing, sweating,” he said.

Dr. Erica Spatz, director of the preventive cardiovascular health program at Yale, is one of Gard’s physicians. “The more severe the covid infection and the older you are, the more likely it is you’ll have a cardiovascular complication after,” she said. Complications include weakening of the heart muscle, blood clots, abnormal heart rhythms, vascular system damage, and high blood pressure.

Gard’s life has changed in ways he never imagined. Unable to work, he takes 22 medications and can still walk only 10 minutes on level ground. Post-traumatic stress disorder is a frequent, unwanted companion.

“A lot of times it’s been difficult to go on, but I tell myself I just have to get up and try one more time,” he told me. “Every day that I get a little bit better, I tell myself I’m adding another day or week to my life.”

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

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Durante dos años, las personas usaron máscaras, mantuvieron la distancia física, recibieron sus vacunas.

Y ahora, a pesar de todo el esfuerzo, alguien de la familia, o toda, terminó teniendo COVID-19. ¿Cómo evitar que el virus circule cuando vives en espacios reducidos?

Los Centros para el Control y la Prevención de Enfermedades (CDC) recomiendan aislar a los pacientes con COVID durante al menos cinco días, preferiblemente en una habitación separada con acceso a un baño individual, y usar máscaras dentro del hogar.

Pero, para muchas familias, esas no son opciones fáciles. No todo el mundo tiene una habitación adicional, y mucho menos un baño extra. No se debe dejar solos a los niños pequeños, que suelen no tolerar los cubrebocas.

“Para los padres de un niño pequeño, es bastante difícil no exponerse”, dijo la doctora Preeti Malani, directora de salud de la Universidad de Michigan. “Tienes que ir de lo perfecto a lo posible y gestionar tu riesgo lo mejor que puedas”.

Pero, ánimo. Los científicos dicen que todavía la gente puede hacer mucho para proteger a sus familias, por ejemplo, mejorar la ventilación y la filtración del aire.

“La ventilación es muy importante”, dijo la doctora Amy Barczak, profesora asistente de medicina en la Escuela de Medicina de Harvard. “Si estás cuidando a alguien en casa, es esencial maximizar todas las intervenciones que funcionan”.

Para comprender por qué una buena ventilación puede marcar la diferencia, es útil entender cómo se propaga el nuevo coronavirus. Los científicos han aprendido mucho en dos años sobre su forma de infectar.

Las partículas virales flotan en el aire como humo de segunda mano invisible, diseminándose a medida que viajan. Fuera de casa, el viento dispersa rápidamente los virus. En interiores, los gérmenes pueden acumularse, como nubes de humo espeso de cigarrillo, lo que aumenta el riesgo de inhalarlo.

La mejor estrategia para evitar el virus es hacer que el ambiente interior sea lo más parecido posible al exterior.

Comienza abriendo tantas ventanas como permita el clima, dijo Joseph Fox, ingeniero de calefacción, ventilación y aire acondicionado de un gran distrito escolar en Ontario, Canadá. Si es posible, abre ventanas en lados opuestos de la casa para que haya brisa, que puede ayudar a expulsar los virus fuera y traer aire fresco.

Para protección adicional, coloca un ventilador de caja en la ventana del paciente, mirando hacia afuera, para sacar el aire lleno de gérmenes hacia el exterior. Sella todas las aberturas alrededor de los lados del ventilador, dijo Jim Rosenthal, director ejecutivo de Tex-Air Filters, una empresa que fabrica productos de filtración de aire en Fort Worth, Texas.

“Es muy simple y es barato”, explicó Rosenthal.

Para evitar que el aire infectado se filtre fuera de la habitación del enfermo, Fox sugiere colocar toallas en el espacio debajo de la puerta del dormitorio. Las personas también deben cubrir las rejillas de aire de retorno con plástico. Estas rejillas cubren las rejillas de ventilación que extraen el aire de la habitación y lo reciclan a través del sistema de calefacción o refrigeración.

Fox también sugiere encender los extractores de aire del baño o la cocina, que pueden expulsar el aire lleno de gérmenes al exterior. Aunque hacer funcionar los ventiladores de escape mientras se ducha es relativamente seguro, dijo Fox, es importante abrir las ventanas cuando los ventiladores estén funcionando durante más de 10 minutos.

Eso es para evitar despresurizar la casa, una circunstancia que podría provocar que el monóxido de carbono ingrese a la casa desde el horno o el calentador de agua.

Los coronavirus prosperan en el aire seco y aumentar la cantidad de humedad en el aire puede ayudar a desactivarlos, dijo Linsey Marr, profesora de ingeniería civil y ambiental en Virginia Tech. Marr sugiere aumentar los niveles de humedad entre un 40% y 60%.

El uso de purificadores de aire portátiles puede brindar protección adicional. Las investigaciones muestran que los filtros de aire de partículas de alta eficiencia, o filtros HEPA, pueden eliminar los coronavirus del aire. Si las personas tienen solo un filtro HEPA, es mejor colocarlo en la habitación del enfermo para atrapar cualquier virus que el paciente exhale.

“Se debe colocar el filtro lo más cerca posible de la fuente del virus”, dijo Fox.

Si las familias pueden solventarlos, se pueden usar filtros de aire adicionales en otras habitaciones.

Comprar los purificadores de aire en tiendas es caro: algunos modelos cuestan cientos de dólares. Sin embargo, por alrededor de $100, las personas pueden construir sus propios purificadores portátiles usando un ventilador de caja, cuatro filtros de aire de alta eficiencia y cinta adhesiva.

Estos dispositivos de bricolaje han sido denominados cajas de Corsi-Rosenthal, en honor a sus co-inventores, Rosenthal y Richard Corsi, decano de la Escuela de Ingeniería de la Universidad de California-Davis. Se ha demostrado que las cajas de bajo costo funcionan tan bien como los purificadores de aire comerciales.

Rosenthal dijo que la pandemia lo motivó a ayudar a diseñar estos purificadores. “No estamos indefensos”, dijo Rosenthal. “Necesitamos proporcionar herramientas que las personas puedan usar ahora mismo para mejorar las cosas”.

Aunque cuidar a un ser querido por covid pone en riesgo al cuidador, el peligro es mucho menor hoy que en el primer año de la pandemia. Se estima que el 95 % de la población tiene algo de inmunidad al coronavirus, por las vacunas, infecciones previas o ambas, explicó el doctor Paul Offit, director del Centro de Educación sobre Vacunas del Hospital Infantil de Philadelfia.

No obstante, un estudio reciente halló que la mitad de las personas que viven en el hogar de un paciente infectado también contrajeron el virus.

Dado que los adultos mayores y las personas inmunocomprometidas corren un mayor riesgo de desarrollar covid, podrían considerar quedarse con un amigo o vecino, si es posible, hasta que el familiar enfermo se haya recuperado, dijo Priya Duggal, profesora de epidemiología la Escuela Bloomberg de Salud Pública de Johns Hopkins.

Los pacientes pueden considerarse libres de covid después de una prueba de PCR negativa, dijo Barczak. Debido a que los pacientes con incluso pequeñas cantidades de virus residual pueden continuar dando positivo en las pruebas de PCR durante semanas, mucho después de que desaparezcan los síntomas, los pacientes también pueden usar pruebas rápidas de antígenos para evaluar su progreso.

Si las pruebas de antígeno son negativas dos días seguidos, se considera que es menos probable que una persona sea contagiosa.

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Julie Appleby, Kaiser Health News

Americans generally don’t spend much time thinking about the nation’s blood supply.

That’s mainly because the collection and distribution system is safe and efficient. But there’s a new behind-the-scenes challenge, according to some hospital officials, who fear a change in how blood platelets are handled will sharply increase the cost — and, in some cases, the number of transfusions needed — to treat cancer patients, trauma victims, and those undergoing surgery.

The concern revolves around the American Red Cross, the nation’s single-largest provider of blood products, which will exclusively use an expensive technology to reduce the risk of dangerous bacteria tainting platelets. But the move limits hospitals’ choice of less expensive testing options, which are also effective. “We are very concerned the blood collection centers have decided what is best for our patients when we are on the front line,” said Dr. Aaron Tobian, director of the transfusion medicine division at Johns Hopkins Hospital.

His concerns are echoed by some in Congress, including Rep. Earl “Buddy” Carter (R-Ga.), who in February joined 12 other congressional Republicans in signing a letter to the Department of Health and Human Services asking whether something could be done to boost hospital choices for complying with blood safety guidelines.

“This has impacted rural hospitals in particular,” which have tight budgets, he told KHN.

The switch by the Red Cross, which it expects to be fully implemented by next year, stems from a recommendation by the FDA in late 2020 to use any of three methods to reduce the risk of bacterial contamination in the blood platelets.

Under those recommendations, hospitals can buy platelets specially processed to reduce pathogens, which is the method the Red Cross and some other, smaller suppliers are moving toward. Or blood centers can test samples of each unit of platelets, looking for bacterial contamination, at least 36 hours after the blood is collected. The other option is to use a rapid test for bacteria shortly before the platelets are transfused, which occurs in addition to a primary screening for bacteria after collection.

The FDA did not rank the options. And many hospitals and blood centers already employ one or more of them. No test or process is 100% effective.

“Each of those methods has pluses and minuses,” said Dr. Claudia Cohn, chief medical officer for the nonprofit Association for the Advancement of Blood and Biotherapies, which represents health care providers involved with transfusion medicine. She is also a professor of laboratory medicine and pathology at the University of Minnesota.

The FDA offered the guidance because platelet transfusions are associated with a higher risk of sepsis and fatality than any other blood component, with some research estimating the chance of a serious infection at 1 in 10,000. Platelet transfusions are important to prevent or treat bleeding in some patients, such as those who have certain types of cancer, are trauma accident victims, or are undergoing surgical procedures that can result in a large loss of blood.

The Red Cross, which collects about 1 million units of platelets annually, chose the processing method that reduces pathogens, the most expensive option, adding about $150 more per unit to hospitals’ costs for platelets. It precludes the use of the lowest-cost alternative, a $25 rapid test made by Verax Biomedical, because that test is not approved by the FDA for use on those processed platelets. The other testing method adds about $83 per unit.

The Red Cross, which collects and distributes about 40% of the nation’s overall blood supply, signed a five-year deal in April with California-based Cerus Corp., which provides the synthetic compound and ultraviolet illuminator used to process the platelets. Approved in 2014, it remains the only such system sold in the U.S.

Platelets are already one of the most expensive blood products with an average per-unit price of $500.

Pathogen reduction could translate into six-digit additional costs to small hospitals’ annual expenses, and “$1.5 million to $3 million” to what large academic medical centers spend each year on platelets, said Tobian, based on a research paper he co-authored.

Some of that might be passed along to patients — if they pay a percentage of their treatment costs, for instance, or in higher insurance premiums.

But hospitals may also have to eat some of the additional expense.

The financial effect on the Red Cross and other blood suppliers is unclear. Organizations that supply blood are seeing declining donations, and operate on thin margins, although platelets tend to be one of their most profitable products. Pathogen reduction allows the Red Cross to charge more for platelets, but it must also buy the processing system from Cerus.

In its most recent IRS filings, covering the financial year that ended June 30, 2021, the Red Cross said its “biomedical services” brought in $1.89 billion in revenue, but cost $1.83 billion, a $49 million difference.

Red Cross spokesperson Jenelle Eli said in an email that is “not a revenue number” but would not give more specifics. In some years, Red Cross’ costs exceed revenue, she wrote, and in others, the opposite is true.

She also would not provide details on the cost of purchasing the system from Cerus, whose chief medical officer joined the company after holding a similar position at the Red Cross.

Pathogen-reduced platelets, while requiring a higher upfront cost, are a better value for hospitals because they reduce bacterial risk “while also mitigating other pathogen threats, like parasites, viruses and even pathogens we may not know about yet,” wrote Jessa Merrill, American Red Cross Biomedical Services communications director, in a separate email. It’s a “ready-to-use product that doesn’t require any testing or further manipulation.”

Hospitals say the other testing methods outlined by the FDA have advantages, also, including a longer shelf life for platelets. Platelets that are tested for bacteria can be used for up to seven days, as compared with the five-day life of the processed platelets.

“We have to be very efficient,” said Kazem Shirazi, a technical specialist in transfusion services at George Washington Hospital in Washington D.C., who spends part of his days juggling requests from surgeons for a supply in the operating rooms with the need to have a supply on hand in the emergency room.

The reduced time frame for the platelets his hospital buys from the Red Cross means “we end up wasting more,” Shirazi said.

Patients probably won’t know what method is used on the platelets they receive, although research indicates the more expensive option can sometimes increase the amount of product needed.

The process is useful to kill pathogens, but also “makes for a platelet that doesn’t do its job as well,” said Cohn.

A meta-analysis of 12 studies of cancer patients who received pathogen-reduced platelets found no increased risk of death or bleeding. However, it did show an increase in the “number of transfusions required.”

And that’s an issue. Tobian at Johns Hopkins said physicians like to keep the number of transfusions to a minimum: “The safest transfusion is the one that can be avoided.”

Safety was another concern raised by Rep. Carter during an April 27 House Energy and Commerce Committee hearing. He mentioned three cases of platelet-linked sepsis since 2019. Those platelets had been processed with the pathogen-reduction method, the FDA said in a December memorandum.

But Red Cross spokesperson Merrill dismissed Carter’s example, saying that those cases “were not due to a failure of the pathogen reduction/inactivation, but instead due to a post-manufacturing issue.”

Some platelet contamination cases — in both processed or tested platelets — might involve tiny leaks or other damage in storage containers, suggested a paper published last year in the journal Transfusion. Two Cerus employees were among the authors.

The view of the processing method may depend on the size of the hospital. Smaller hospitals, which don’t have trauma centers or large cancer programs, use far fewer platelets each year than large academic centers, which might need 10,000 or more units annually. “Smaller centers love the pathogen-reduced platelets because they don’t have to mess with it and it’s easy and safe to use,” said Cohn.

But academic hospitals, which do a lot of transfusions, “are really frustrated,” she said. “If their blood suppliers are only willing to offer one kind, they are constrained.”

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

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Andrew Bade, who was diagnosed with Type 1 diabetes nearly two decades ago, is accustomed to all the medical gear he needs to keep his blood sugar under control. His insulin pump contains a disposable insulin cartridge, and a plastic tubing system with an adhesive patch keeps in place the cannula that delivers insulin under his skin. He wears a continuous glucose monitor on his arm.

Bade, 24, has used the same equipment for years, but every three months when he needs new supplies, his health insurance plan requires him to go through an approval process called prior authorization.

Getting that approval can take as many as three weeks, and Bade sometimes runs out of insulin before it comes through. When that happens, the resident of Fenton, Michigan, makes do with leftover preloaded insulin pens. They’re less precise than the pump, and he feels tired when he uses them. But they get him through.

“I don’t understand why they’re taking all this time to make these decisions and then they always say ‘yes’ anyway,” Bade said.

Michigan legislators in April sought to help patients like Bade by approving a law that sets standards meant to hasten that process. Beginning in June 2023, health plans will have to act on non-urgent prior authorization requests in nine calendar days and on urgent requests in 72 hours. In 2024, the time frame for non-urgent requests will shrink to seven days.

“We are ecstatic that it passed,” said Dr. Nita Kulkarni, an obstetrician-gynecologist in Flint and a member of the board of directors for the Michigan State Medical Society, which has pushed for the law for years. “It’s a step in the right direction in decreasing the wait time for therapy.”

Michigan’s law is the most recent example of efforts by states, insurers, and doctors to un-gum a process that is notoriously sticky. Yet most of the initiatives have had limited success.

At least a dozen states have passed broad reforms, according to tracking by the American Medical Association. Others have passed narrower laws that target the process or certain types of medical care or drugs. However, state laws don’t protect most patients because they are in so-called self-funded plans, in which the employer pays claims directly rather than buying insurance for that purpose. Self-funded plans are generally regulated by the federal government, not states. There’s no broad protection at the federal level for people with commercial coverage.

A 2018 consensus statement issued by key health plan and medical provider groups to improve the process has been slow to make inroads.

Prior authorization requirements are intended to reduce wasteful and inappropriate health care spending. Few would disagree with that goal. Studies have found that about a quarter of health care spending is wasteful, whether because of overtreatment, overpricing, fraud and abuse, or problems with health care coordination and delivery.

Health plans say that prior authorization requirements help them protect patients’ safety and improve the quality of care, in addition to rooting out waste and error. Doctors disagree. They say that the process too often leads to delays in patient care and that those delays can sometimes cause consumers to abandon treatment.

The complaints aren’t confined to regular commercial coverage. A report released in April by the U.S. Department of Health and Human Services’ inspector general examined a random sample of 250 prior authorization denials at 15 large Medicare Advantage plans in June 2019. It found that 13% of prior authorization denials by Medicare Advantage plans were for services that met Medicare coverage rules.

Health plans’ use of such requirements continues to rise, according to medical groups. In a March poll, 79% of medical practices said that prior authorization requirements had increased in the previous year, according to the Medical Group Management Association.

Even though insurers and providers may fundamentally disagree on the usefulness of prior authorization, many agree that the process needs to be improved. The consensus statement listed several areas that the groups agreed need fixing. For example, they said doctors and other health care providers who follow evidence-based treatment guidelines and have historically had high prior authorization approval rates may sidestep the process.

The groups also agreed that regular review of these requirements is a good idea, with an eye toward eliminating therapies from the list that no longer warrant it. Improved transparency and automation also made the list.

But doctors say that insurers have made little progress in the four years since the document was released.

“It’s been abysmal,” said Dr. Jack Resneck Jr., a dermatologist who is president-elect of the American Medical Association. “We see the problem getting worse, and we don’t see health plans taking any action to honor the commitments they made.”

Insurers say they’re working through the items on the list.

“We believe that a number of the concerns can be solved by innovations in technology,” said Kris Haltmeyer, vice president of policy analysis at the Blue Cross Blue Shield Association, one of the six organizations that partnered on the statement. He pointed to an electronic prior authorization pilot project undertaken by the insurers’ trade group, AHIP, that resulted in a 69% reduction in the decision time on requests, to just under six hours.

That sort of speedy turnaround would have made a big difference to Jodi Burk, 63, who has rheumatoid arthritis. Burk, who lives in Bellaire, Michigan, takes pricey biologic medications to control her pain and other symptoms. A few years ago, her medication stopped working, and the pain became so bad that she could no longer even take her dog for walks.

Her doctor prescribed a different biologic that she thought would treat her symptoms. But the insurer wouldn’t approve the prescribed drug until she had tried — and failed — four other medications, a prior authorization process called step therapy.

It was five months before Burk was approved and began taking a drug that effectively treated her symptoms. “With these time frames, you’re not getting any better,” Burk said. “You hurt more, and your life is put on hold. There were lots of things that I used to be able to do and couldn’t during those times.”

In addition to establishing time frames for acting on prior authorization requests, the new Michigan law sets standards for notifying doctors and other health care providers about changes or additions to existing requirements. And it requires insurers to implement standardized electronic transaction processes for prior authorization requests.

That standard web-based process was a key element of the law for insurers, said Dominick Pallone, executive director of the Michigan Association of Health Plans.

“Many times [providers] submit incomplete or incorrect information,” Pallone said. “We’re trying to make it easier for the provider to go through and complete it quickly.”

“At the end of the day, we do feel we reached a good compromise,” he said.

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La administración Biden anunció en marzo de 2021 que invertiría $2,250 millones para hacer frente a las disparidades de salud por covid, la mayor iniciativa de financiación federal diseñada específicamente para ayudar a las comunidades desatendidas más afectadas por el virus.

Dos meses después, los Centros para el Control y la Prevención de Enfermedades (CDC) concedieron subvenciones a los departamentos de salud estatales y a unas 60 agencias de salud de ciudades y condados. Debían destinar el dinero a controlar la propagación de covid entre personas de grupos raciales y étnicos minoritarios en mayor riesgo, y personas que viven en zonas rurales.

Un año después, cuando covid ya ha matado a un millón de personas y hospitalizado a millones más, los funcionarios de salud pública han gastado muy poco o nada del dinero, según un sondeo de KHN realizado entre una docena de organismos estatales y de condado.

Missouri no ha gastado nada de sus $35,6 millones. Wisconsin, Illinois y Idaho, que recibieron entre $27 millones y $31 millones cada uno, utilizaron menos del 5% de sus subvenciones.

Pennsylvania ha utilizado alrededor del 6% de sus casi $28 millones.

California ha gastado algo más del 10% de sus $32 millones de financiación.

Las agencias de salud pública ofrecen una variedad de razones para el retraso. Aseguran necesitar tiempo para contratar personal. Culpan al largo proceso presupuestario de su estado. Dicen que toma tiempo trabajar con organizaciones sin fines de lucro para establecer nuevos programas. Y que ya utilizan otros fondos federales para luchar contra covid.

La lentitud de los desembolsos pone de manifiesto el perjuicio que han sufrido los sistemas de salud pública por los años de abandono y el ciclo de altas y bajas en la financiación legislativa. “Son inversiones que desbordan un sistema que ha estado hambriento durante mucho tiempo”, dijo el doctor Usama Bilal, profesor de epidemiología y bioestadística en la Universidad Drexel de Philadelphia.

La doctora Kirsten Bibbins-Domingo, experta en equidad sanitaria y nueva redactora jefe de JAMA, añadió que es difícil que los sistemas de salud pública, que carecen de recursos y luchan contra una pandemia, establezcan vínculos con organizaciones locales sin fines de lucro tan rápidamente.

“La pandemia puso de manifiesto estas grandes disparidades sanitarias, pero también el hecho de que [los sistemas de salud pública] no tienen las estructuras necesarias para asociarse directamente con las comunidades”, señaló Bibbins-Domingo.

La financiación fue la respuesta al efecto desproporcionado de la pandemia entre las minorías. Las comunidades de afroamericanos, hispanos y nativos americanos experimentaron tasas más altas de infecciones y muertes por covid-19 en comparación con los blancos no hispanos, especialmente si se tienen en cuenta las diferencias de edad entre los grupos raciales y étnicos.

A pesar de la necesidad de abordar estas cuestiones, los funcionarios de salud de los condados afirman que han tenido problemas para gastar el dinero.

En California, el Departamento de Salud Pública del condado de Riverside ha gastado unos $700,000 de una subvención de $23 millones.

“La salud pública ha estado históricamente subfinanciada, y de repente contamos con más dinero del que nunca habíamos recibido”, indicó Wendy Hetherington, jefa del programa de salud pública de la agencia. “Es estupendo que hayamos conseguido esta financiación porque es necesaria, pero se nos hace complicado gastarla”.

Parte del problema fue que los funcionarios de salud del condado tuvieron que esperar seis meses para obtener la aprobación del gobierno local para gastar el dinero. Luego, explicó, se enfrentó a retrasos en la negociación de contratos con organizaciones sin fines de lucro locales para llevar a cabo el trabajo.

Stan Veuger, investigador en el conservador American Enterprise Institute, dijo que la lentitud en la distribución de los fondos, y la capacidad de los estados para gastar otros dólares federales en cuestiones de disparidad, demuestran que el Congreso envió demasiado dinero a los gobiernos estatales y locales en respuesta a la pandemia, un argumento esgrimido en el Capitolio por los republicanos mientras sopesan las peticiones de la administración Biden para obtener más fondos en la lucha contra el virus.

“Plantea dudas sobre el motivo por el que se creó este programa de subvenciones por separado”, añadió.

Según Veuger, los gobiernos estatales y locales recibieron unos $900,000 millones en ayuda contra covid, lo que terminó siendo más de lo que necesitaban, ya que sus ingresos fiscales se recuperaron mucho más rápido de lo que la mayoría esperaba tras la recesión causada por la pandemia.

Rachel Greszler, investigadora de la Heritage Foundation, que se opuso a que el Congreso financiara nuevas ayudas contra covid debido a los dólares que aún quedaban de iniciativas anteriores, apuntó que la lentitud del gasto también muestra cómo los estados necesitan tiempo para absorber la inyección de ingresos y desarrollar nuevos programas, especialmente cuando los gobiernos se enfrentan a la escasez de mano de obra y a problemas en la cadena de suministro.

Los CDC comunicaron que el dinero podría utilizarse para ayudar a mitigar los efectos de covid, mejorar la recopilación de datos de quienes se vieron afectados desproporcionadamente por el virus y desarrollar colaboraciones para “avanzar en la equidad sanitaria.” En un principio, los CDC dijeron que la subvención debía gastarse antes de mayo de 2023, pero a principios de este año comunicaron a los estados que podían solicitar una ampliación de ese plazo.

Las subvenciones están diseñadas para ayudar a prevenir la propagación del virus, mejorar la recopilación de datos, ampliar la infraestructura de los servicios de atención sanitaria relacionados y abordar los problemas sociales y económicos que impiden a muchas comunidades minoritarias recibir una atención adecuada durante la pandemia.

Los CDC trabajan con varias organizaciones en la implementación de la subvención, dijo la vocera Jade Fulce.

Dado que el término disparidades sanitarias engloba los retos a los que se enfrentan todo tipo de grupos de población, los condados y las ciudades tienen flexibilidad para gastar el dinero en casi cualquier cosa que repercuta en la salud.

El Departamento de Salud Pública de Illinois recibió $28,9 millones y ha gastado $138,000, según el vocero Mike Claffey. La financiación se destinará a programas que incluyen la traducción al lenguaje de signos estadounidense de los materiales sobre covid, programas de divulgación en las cárceles, unidades sanitarias móviles para las zonas rurales y trabajadores comunitarios de la salud.

“El objetivo era diseñar programas que construyeran la infraestructura sanitaria y abordaran estas desigualdades históricas de forma significativa y con sentido”, añadió Claffey.

El Departamento de Salud de Florida está utilizando $236,000 de su subvención de $35 millones en las pruebas de audición para recién nacidos. El vocero Jeremy Redfern dijo que los cierres relacionados con covid provocaron un gran descenso en la detección y el diagnóstico de la pérdida de audición, y que el equipo ayudaría a ampliar las pruebas de audición en todo el estado.

El Departamento de Salud del condado de Miami-Dade, que gastó $4 millones de su subvención de $28 millones, concedió dinero a grupos locales para hacer frente a la inseguridad alimentaria y de vivienda. El departamento concedió $100,000 a Saradjine Batrony, una investigadora sanitaria haitiana, para ayudar a mejorar la alfabetización en inglés entre la numerosa comunidad haitiana del condado. Recibió el dinero en enero y espera ayudar a un máximo de 100 personas a partir de mayo. 

“La barrera del idioma es lo que impide que la gente se vacune”, señaló Batrony, que fue investigadora en la Universidad de Miami antes de crear su propia empresa el año pasado, centrada en la traducción de documentos sobre salud al criollo haitiano.

Alrededor de $4,5 millones de la subvención de los CDC de Pennsylvania se destinaron a la Oficina de Salud Rural del estado, que el pasado otoño planeaba dar dinero a 20 condados. Hasta mayo, no ha financiado ninguno de ellos.

“En los últimos dos meses, hemos encontrado problemas con los líderes de los condados que han perdido el impulso y el interés en el trabajo contra covid-19”, aseguró Rachel Foster, gerente del programa rural de covid-19 para la agencia con sede en la Universidad de Penn State. “En las zonas rurales de Pennsylvania, los casos son bajos, el interés por las vacunas ha disminuido y la mayoría de los residentes consideran que la pandemia ha terminado”.

La Facultad de Medicina de Penn State ha estado utilizando su subvención de casi $3 millones para formar a trabajadores comunitarios de la salud que ayuden a los pacientes con sus necesidades sociales y a acceder a recursos para sus problemas de salud. Más de 45 personas ya han recibido formación en línea gracias a la subvención, según el doctor Benjamin Fredrick, que supervisa la subvención.

En algunas ocasiones ya se abordan los problemas de diversidad.  La subvención de $8 millones de Philadelphia “llegó tras otras subvenciones de los CDC que incluyen actividades para abordar las disparidades o financian puestos de personal que se encargan de planificar e implementar el trabajo para promover la equidad”, según dijo el vocero Matthew Rankin. Philadelphia ha gastado unos $147,000 de la subvención.

El sistema de salud de la Universidad de Florida, en Jacksonville, recibió el pasado mes de julio $1,25 millones del condado de Duval para ampliar los servicios a las comunidades desproporcionadamente afectadas por covid. Pero a principios de mayo, la universidad aún no había recibido el dinero, según el portavoz Dan Leveton. “No estamos preocupados porque tenemos otros fondos para covid, que estamos utilizando por ahora, y utilizaremos los fondos de los CDC cuando lleguen”, dijo Leveton.

El Departamento de Salud de Mississippi recibió $48 millones, la mayor dotación concedida a una agencia de salud estatal. Hasta ahora, la agencia ha gastado $8 millones, dijo la vocera Liz Sharlot, aunque ya ha utilizado otros dólares de ayuda federal para hacer frente a las disparidades sanitarias por covid.

Mientras los estados averiguan cómo gastar el dinero, a los expertos en salud les preocupan las consecuencias.

“El dinero es muy necesario, pero hay que tener en cuenta que estos departamentos de salud llevan mucho tiempo sobrecargados y no tienen suficiente personal para ocuparse de ello”, señaló Bilal, de Drexel.

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Samantha Young

SACRAMENTO, Calif. — When Johanna Trenerry found a nursing home for her husband after his stroke, she expected his stay would be temporary.

He never came home.

Arthur Trenerry died at Windsor Redding Care Center in Northern California in October 2020. The 82-year-old great-grandfather is among more than 9,900 California nursing home residents who have died of covid-19.

The nursing home where Trenerry died is licensed by the state, but not under its current owner, Shlomo Rechnitz. The state denied Rechnitz a license, citing at least one death and multiple cases of “serious harm” at other nursing homes he owns or operates. To get around that, Rechnitz formed a business partnership with one of the home’s former owners, who continues to hold the facility’s license.

Some California lawmakers want to put an end to those types of business arrangements and ban people or entities from buying or operating nursing homes unless they have a license — which is the situation in most states. They’re also proposing an overhaul of the licensing process to reject applicants with poor performance and those without adequate experience or financial resources.

The ambitious effort, which the industry considers an overreach, could make California’s oversight the gold standard and a model for other states trying to improve nursing home care. Nationwide, more than 152,000 residents of nursing homes have died of covid during the pandemic, according to federal data.

“The public health emergency that we’ve experienced could be something that becomes a catalyst for making real change,” said Dr. Debra Saliba, a UCLA professor of medicine who served on a National Academies of Sciences, Engineering, and Medicine committee that released a comprehensive report on nursing homes in April. “One of the things that we have right now is the determination, the resources to make things happen.”

In his State of the Union address in March, President Joe Biden said the quality of care had declined in nursing homes taken over by investors — and vowed to set higher federal standards. In anticipation of the speech, the White House released a proposal calling on Congress to boost funding for nursing home inspections and to give federal regulators the authority to deny Medicare funds to underperforming facilities. The administration also directed the Centers for Medicare & Medicaid Services to propose minimum staffing standards within a year.

States are also taking steps to improve quality. New Jersey, for example, this year adopted a law that toughens penalties for health violations and requires nursing homes to disclose financial records.

In California, lawmakers are considering several proposals, including the changes to nursing home licensing rules.

Companies and individuals can buy or run nursing homes in California before they get a license, a process that even an industry lobbyist described at a legislative hearing this year as “backward” and unique to the state.

“In California, nursing home owners and operators can operate without a license even after they’ve been denied a license,” said state Assembly member Al Muratsuchi (D-Torrance), author of AB 1502. “Many of these owners and operators have, unfortunately, an extensive history of neglect and abuse.”

Muratsuchi’s bill would require an owner or company to apply for a license 120 days before buying or operating a nursing home and include financial records that contain the names of all owners and investors. The state would reject applicants who fail to meet standards for character, performance in other homes, and the financial ability to run the home. Homes operating without a license would lose Medicaid funding and couldn’t admit new residents.

The powerful California Association of Health Facilities, which represents more than 800 nursing homes, has blocked previous licensing legislation and has set its sights on Muratsuchi’s bill. The group is led by Craig Cornett, a veteran of the state Capitol who has worked for four Assembly speakers and two Senate leaders.

The organization has made just over $2 million in political contributions and spent $5.9 million lobbying lawmakers from Jan. 1, 2011, through March 31, 2022, according to records filed with the California secretary of state’s office.

The bill fails to consider the state’s “complex regulatory environments” and would create “extensive” disclosure requirements on ownership applications that “in many cases would fill an entire room with boxes and boxes of paper,” Jennifer Snyder, a lobbyist for the association, told lawmakers in January. 

The measure would “eliminate the ability for most current owners in California to actually apply or even apply for a change of ownership,” she added.

But this year, the industry faces an altered political landscape.

Covid has pushed lawmakers to act — and Muratsuchi has gained a valuable co-sponsor for his bill, Democratic state Assembly member Jim Wood, head of the Assembly Health Committee. Wood has condemned nursing homes for not doing enough during the pandemic and has directed state regulators to conduct stricter oversight.

Muratsuchi’s measure has cleared the state Assembly and awaits a hearing in the Senate.

Investigations by news organizations CalMatters and LAist last year found that at least two California nursing home operators without licenses were running dozens of facilities even though officials at the state Department of Public Health had declared them unfit to do so.

The homes remain open, in large part because finding another nursing home for residents is incredibly difficult.

In July 2016, state regulators denied a license to Rechnitz — who had purchased the Windsor Redding Care Center, where Arthur Trenerry died — citing 265 health and safety code violations at his other facilities in the previous three years. Nevertheless, Rechnitz continues to operate the home in partnership with a former owner, Lee Samson, who is listed as a license holder in state records.

Mark Johnson, a lawyer who represents Rechnitz and his company, Brius Healthcare, said that Windsor Redding Care Center’s “license is in good standing” and that Rechnitz is managing the facility under an agreement “that is customary in the skilled nursing facility industry.” Rechnitz has filed a new and updated license application with the state, Johnson said.

Johanna Trenerry said she had no idea Rechnitz had been denied a license. Had she known, she said, she would never have placed her husband of 60 years at Windsor Redding.

Even before her husband caught covid, Trenerry and her children were trying to transfer him to another home because he seemed overly medicated, could no longer hold up his head, and fell numerous times trying to get out of bed, she said. Once, she recalled, the nursing home brought out the wrong person when the family visited.

They kept him “so drugged up,” said Nancy Hearden, one of the Trenerrys’ eight children. “And I think it was just because it was easier for them. He wasn’t getting to go to his rehab. I felt, ‘We’ve got to get him out of this place.’”

Then he got covid.

Sixty of the 84 residents at the facility came down with the disease in September 2020 — and at least two dozen of them died. According to a lawsuit filed by family members of 15 residents who died, including the Trenerrys, employees of the home were forced to work despite having covid symptoms. The lawsuit refers to state citations that found the home didn’t supply enough personal protective equipment to staffers, didn’t test staff, and placed covid patients and untested patients in the same rooms with residents who weren’t infected.

Johnson denied the allegations.

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

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

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The Biden administration in March 2021 announced it was investing $2.25 billion to address covid health disparities, the largest federal funding initiative designed specifically to help underserved communities hardest hit by the virus.

Two months later, the Centers for Disease Control and Prevention awarded grants to every state health department and 58 large city and county health agencies. The money is intended to help limit the spread of covid-19 among those most at risk in rural areas and within racial and ethnic minority groups, as well as improve their health. The CDC initially said the grant had to be spent by May 2023 but earlier this year told states they could apply to extend that time.

A year later — with covid having killed 1 million people in the U.S. since the start of the pandemic and hospitalizing millions more — little of the money has been used, according to a KHN review of about a dozen state and county agencies’ grants. While some states and localities have allocated large portions of the CDC money for projects, they still have spent only a small proportion.

Missouri’s health department has not spent any of its $35.6 million. Wisconsin, Illinois, and Idaho — whose state health departments each received between $27 million and $31 million — have used less than 5% of their grant money.

Pennsylvania’s health department has used about 6% of its nearly $27.7 million grant.

California’s health department has spent just over 10% of its $32.5 million funding.

The public health agencies give a litany of reasons for that: They need time to hire people. They blame their state’s long budget process. They say it takes time to work with nonprofit organizations to set up programs or for them to put the money to use. They’re already tapping other federal dollars to fight covid disparities.

Mounting unspent covid relief dollars is one of the key reasons Republicans in Congress oppose Democrats’ efforts to appropriate billions more federal dollars for managing the pandemic.

The slow disbursement also highlights the ripple effects of years of neglect for public health systems and the boom-bust cycle of legislative funding. “They are investments that overwhelm a system that has been starved for so long,” said Dr. Usama Bilal, an assistant professor of epidemiology and biostatistics at Drexel University in Philadelphia.

Dr. Kirsten Bibbins-Domingo, chair of the Department of Epidemiology and Biostatistics at the University of California-San Francisco, added that it is difficult for public health systems lacking resources and fighting a pandemic to establish ties to local nonprofits so quickly.

“The pandemic shone a light on these big health disparities, but they also shone a light on the fact that [public health systems] don’t have the structures in place to partner directly with communities,” she said.

The funding is meant to reduce the pandemic’s disproportionate effect on minorities. When adjusting for the age differences across racial and ethnic groups, Black, Hispanic, and Native American communities experienced higher rates of covid hospitalizations and deaths compared with white people. Such adjustments are necessary, researchers say, as communities of color tend to be younger.

Despite the need to address these issues, the Riverside County health department in California has spent about $700,000 of its $23.4 million grant, which is separate from the state health department’s funds.

“Public health has been historically underfunded, and all of a sudden this is way more money than we ever get,” said Wendy Hetherington, public health program chief with the agency. “It’s great that we got this funding because it’s necessary, but we are struggling in trying to spend it.”

Part of the problem was that county health officials had to wait six months for local government approval to spend it. Then, she said, she faced delays negotiating contracts with area nonprofits.

Stan Veuger, a senior fellow at the conservative American Enterprise Institute, echoed Republican lawmakers’ concerns, saying the slow rollout of these grants shows that Congress sent more pandemic relief than state and local governments needed since their tax revenue rebounded much quicker than many expected.

“It raises questions about why this separate grant program was set up,” he said.

Rachel Greszler, a senior research fellow at the Heritage Foundation who has argued against Congress funding new covid relief, said the slow spending also shows how states need time to absorb an influx in revenue and develop programs, especially when governments are facing labor shortages and supply chain issues.

The CDC has said the money could be used to aid in preventing the spread of the covid virus, improve data collection, expand health services related to covid, and address social and economic issues that have hampered many minority communities from receiving appropriate care during the pandemic.

CDC officials are working with groups on the implementation of the grant, said spokesperson Jade Fulce.

Because the term “health disparities” encompasses challenges facing all types of population groups, the money can be applied to almost anything that affects health.

The Illinois Department of Public Health received $28.9 million and has spent $138,000, according to spokesperson Mike Claffey. The state plans to spend some of the money on American Sign Language translation for covid materials, outreach to those in jail, mobile health units for rural areas, and the hiring of community health workers.

“The goal was to design programs that build up the health care infrastructure and address these historic inequities in a significant way and meaningful way,” Claffey said.

Florida’s Health Department plans to use $236,000 of its nearly $35 million grant on newborn hearing screenings after covid-related closures led to a decline in timely checks, said spokesperson Jeremy Redfern.

The Miami-Dade County Health Department has spent $4 million of its $28 million CDC grant. It’s giving money to local nonprofit groups to deal with food insecurity and language barriers. Like other jurisdictions, the county noted it has awarded funding that groups haven’t spent yet, including $100,000 to improve literacy among its large Haitian community. Saradjine Batrony said she hopes to help between 60 and 100 people starting in May with that grant.

“The language barrier is what prevented people from getting vaccinated,” said Batrony, who was a researcher at the University of Miami before starting her own company last year focused on translating health documents into Haitian Creole.

Almost $4.6 million of Pennsylvania’s CDC grant went to the state Office of Rural Health, which last fall was planning to give money to 20 counties. As of May 5, it hadn’t funded any of them.

“In the last couple months, we have encountered issues with county leaders losing momentum and interest in covid-19 work,” said Rachel Foster, rural covid-19 program manager for the agency based at Penn State University. “In rural Pennsylvania, cases are low, interest in vaccines has waned, and rural residents largely feel the pandemic is over.”

Some counties and states say they were addressing health inequity issues before the CDC disparity money.

Philadelphia’s $8.3 million grant followed several CDC awards that also dealt with issues affecting underserved communities, said spokesperson Matthew Rankin. Philadelphia has spent about $147,000 of the disparities grant.

The University of Florida health system in Jacksonville was awarded $1.25 million last July from Duval County to expand services to communities disproportionately affected by covid. But as of early May, the university had not yet received the money, said spokesperson Dan Leveton. “We’re not concerned because we have other covid funding we’re using for now and will use the CDC’s funding when it comes through,” he said.

Mississippi received $48.4 million, the single-largest award to any state health agency from the grant. So far, the agency has spent $8.2 million, said spokesperson Liz Sharlot, although it has already used other federal relief dollars to address covid health disparities.

While states figure out how to spend the money, health experts worry about the consequences politically and to the communities that need help.

“The money is terribly needed, but we need to consider that these health departments have long been overburdened and they don’t really have enough people to handle it,” said Drexel’s Bilal.

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