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As Congress debates cutting prescription drug costs, a poll released Tuesday found the vast majority of adults — regardless of their political party or age — support letting the federal government negotiate drug prices for Medicare beneficiaries and those in private health insurance plans.

The argument that pharmaceutical companies need to charge high prices to invest in research and develop new drugs does little to change that sentiment, according to the new KFF poll. Most respondents agreed the negotiation strategy is needed because Americans pay more than people in other countries and because companies’ profits are too high.

Various polls, in addition to KFF’s, have found the plan to allow Medicare to negotiate prescription drug prices to be very popular. (KHN is an editorially independent program of KFF.) The policy has polled favorably for at least the past six years, according to Ashley Kirzinger, associate director of public opinion and survey research at KFF.

Still, congressional lawmakers have yet to reach a consensus on whether to include such a provision in the major reconciliation bill aimed at funding President Joe Biden’s domestic policy agenda and enhancing social programs. Republican lawmakers generally oppose efforts to impose price restraints on prescription drugs. Democrats in the House are pushing a bill that would allow changes in Medicare drug policies, including negotiations of prices for some medications. The bill passed the House last year but has run into opposition this fall. A few moderate Democrats have introduced a narrower approach.

The KFF poll found 83% of the public — including 91% of Democrats, 85% of Independents, 76% of Republicans and 84% of seniors — initially favored the federal government negotiating lower drug prices for both Medicare and private insurance. These opinions were relatively unchanged by the arguments in favor or against the policy, the poll found. Even Republican support remained relatively steady, at 71%, after hearing concerns about how negotiations could upend the pharmaceutical industry. However, the share of Republicans who “strongly” favored the plan dipped from 44% to 28%.

For example, large majorities regardless of party identification and age found the following argument convincing: “Those in favor say negotiation is needed because Americans pay higher prices than people in other countries, many can’t afford their prescriptions, and drug company profits are too high.”

A third, including a slight majority of Republicans 65 or older, found the following argument convincing: “Those opposed say it would have the government too involved and will lead to fewer new drugs being available in the future.”

In addition, 93% — including 90% of Republicans — said that even if prescription prices were lower “drug companies would still make enough money to invest in the research needed to develop new drugs,” while just 6% said “drug companies need to charge high prices in order to fund the innovative research necessary for developing new drugs.”

These findings represent a change from a June KFF poll, which found attitudes changed after hearing assertions that allowing the federal government to negotiate Medicare prescription drug prices could lead to less research and development or limited access to newer prescriptions.

“This [latest] poll did a better job of representing what’s happening in the debate,” said Kirzinger. “The public is hearing both sides of the argument.”

Pharmaceutical companies have spent a lot of money on messaging. PhRMA, the industry’s trade group, launched a seven-figure ad campaign against legislation to lower drug prices through negotiation. Pharmaceutical companies have spent the most of any single industry on federal lobbying this year and donated sizable sums to House Democrats opposed to the plan, according to Open Secrets.

But the Medicare drug-pricing negotiation plan outlined in H.R. 3 (or the “Elijah E. Cummings Lower Drug Costs Now Act”) is estimated to save roughly $500 billion in federal spending for Medicare drugs over 10 years, according to a Congressional Budget Office estimate. Many Democrats hope to use the savings to expand coverage in Medicare and Medicaid as they piece together their larger spending plan.

The KFF poll also found most people have little or no confidence that Biden or Congress will “recommend the right thing” for the country on prescription drug prices. The vast majority expressed the same about drug companies. A slight majority reported confidence in what AARP recommends — and the advocacy group backs the negotiated Medicare prices.

The KFF Health Tracking Poll was conducted from Sept. 23 to Oct. 4 among a nationally representative sample of 1,146 adults, including an oversample of adults 65 and older. The margin of sampling error is plus or minus 4 percentage points for the full sample.

Amanda Michelle Gomez:
amandag@kff.org,
@amanduhgomez

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The night before Brian Gorzney planned to check into rehab for alcohol use, he began vomiting blood. First at 2 a.m. Then 5. And again at 11.

When he arrived at the rehab facility in North Kansas City, Missouri, they sent him directly to the adjoining hospital. There, Gorzney, then 50, and his family learned he had severe alcoholic hepatitis, an inflammation of the liver typically associated with excessive alcohol use.

Gorzney had been drinking heavily on and off for years and, by February 2020, was having as many as a dozen drinks a day. His only chance of survival was a liver transplant, doctors said.

“So let’s do that,” his daughter Cameron Gorzney, now 22, told them. She was ready for anything that would save her dad, the man who had coached her softball team until high school and later cheered from the stands at every game.

But Gorzney wasn’t eligible for a transplant, the doctors said. He hadn’t been six months sober.

In the U.S., a widespread practice requires patients with alcoholic liver disease to complete a period of sobriety before they can get on the waiting list for a liver.

This informal policy, often called “the 6-month rule,” can be traced to the 1980s. The thinking then — and among proponents of the practice today — was that six months of abstinence gave a patient’s liver time to heal and, thus, avoid a transplant. If that didn’t work, the patient would have proven they can stay sober and would not return to drinking after a transplant.

However, a landmark European study published in 2011 and several American studies in the decade since have exposed flaws in that premise. Six months of abstinence is not a good predictor of long-term sobriety, and for people with conditions like Gorzney’s, more than half die within that time. Now, as the understanding of addiction evolves — viewing it as a disease rather than a personal failing — many surgeons and families say the six-month hold unfairly penalizes those with substance use disorder. And with alcoholic liver disease rising among young adults and pandemic-related drinking exacerbating those numbers, it has become a pressing concern.

“We have to move beyond denying people lifesaving therapy because we think they don’t deserve it,” said Dr. Andrew Cameron, head of the liver transplant program at Johns Hopkins Medicine in Baltimore. Doctors don’t withhold treatment from people with diabetes who are obese or people with sexually transmitted infections who had unprotected sex, he said.

Cameron and his colleagues published a study this August, which found that among patients with alcoholic liver disease who were made to wait six months and those who were not, about 20% in each group returned to drinking one year after their transplants. That means about 80% stayed sober, regardless of how long they abstained from alcohol before the surgery.

“There was nothing at all helpful or predictive about a six-month waiting period,” Cameron said.

No national regulation determines how long a patient needs to be abstinent before being added to the waitlist; each transplant center sets its own policies. As of 2019, only about one-third of liver transplant hospitals in the U.S. had performed a transplant without one. Patients who don’t live near those hospitals — or don’t have the knowledge and resources to get to them — can die without ever making it onto the waitlist, Cameron said.

On the other hand, some physicians worry abandoning the six-month rule could overwhelm the limited supply of donor organs. With nearly 12,000 people on the waiting list for a liver, it’s crucial to ensure patients who receive transplants are ready to care for themselves and the “gift of the donated organ,” said Dr. Kenneth Andreoni, a transplant surgeon and past president of the United Network for Organ Sharing, which manages the nation’s transplant system. (UNOS determines who ultimately receives a donor organ, but it does not determine who can or cannot be put on the waitlist.)

Since 2016, alcoholic liver disease has been the most commonly identified justification for a liver transplant, and since these patients often have dire prognoses with little time to live, they can quickly jump to the top of the waiting list, surpassing those with liver cancer or other diseases. When one patient receives a liver, “someone else is not getting that organ,” Andreoni said. “It’s just math.”

He said more long-term research is needed. “If all these people [who receive transplants without the waiting period] are doing great and living 15 years, then that’s the right answer.” Only time and statistics will tell.

Dr. Josh Levitsky, treasurer of the American Society of Transplantation, said some hospitals may worry that transplanting organs into patients with a higher risk of relapse could result in poor outcomes and threaten their accreditation or insurance contracts.

In fact, some insurance companies require patients to provide documentation of a sobriety period before agreeing to cover the cost of surgery. A study examining Medicaid policies in 2017 found 24 states had such policies, while 14 did not. (Twelve states didn’t perform any liver transplants that year.)

In Brian Gorzney’s case, insurance wasn’t the issue. Finding a hospital to say yes was.

When the team at North Kansas City Hospital, which is not a transplant center, suggested Gorzney look into hospice options, his family refused. They took him across state lines to the University of Kansas Health System for a second opinion.

There, Gorzney’s daughter Cameron, his ex-wife (Cameron’s mom), his then-girlfriend and his sister teamed up to explain why they knew Gorzney would stay sober and care for a new liver responsibly. He had held steady jobs throughout his life, they said. He had never had a DUI. He coached his daughters’ softball teams and was like a father figure to his sister, who is 10 years younger. He was headed to rehab before this crisis started, and he had a supportive family to help him sustain sobriety after surgery.

But, ultimately, the hospital’s transplant committee said no.

Brian Gorzney developed severe alcoholic hepatitis in February 2020. His liver was inflamed after years of alcohol abuse. His only chance of survival was a liver transplant. (Jennifer Evans-Page)

In May 2021, more than a year after his liver transplant, Brian Gorzney attended his daughter Cameron’s college graduation. (Jennifer Evans-Page)

In a statement about the general transplant process, Dr. Ryan Taylor, medical director of liver transplantation at the hospital, said each candidate is reviewed by a committee of more than 30 members. “High risk transplant patients may be required to complete 6 months of counseling to demonstrate an ongoing commitment to sobriety,” he wrote, but there is an “expedited pathway” for people with alcoholic hepatitis who also have a “low risk for recidivism.”

Gorzney was considered for this pathway, but the committee didn’t approve him, his daughter Cameron said.

She was devastated by the no. But she’s stubborn, she said, just like her dad. So, she and the rest of the family frantically scoured news articles and academic studies and called transplant hospitals across the country for another option.

“My dad was really deteriorating each day,” she said.

They finally settled on the University of Iowa, where Cameron Gorzney had attended her first year of college and heard of its renowned medical system. The family made their case on Gorzney’s behalf again. This time, they got a yes. The family’s group text exploded, Cameron recalled.

Dr. Alan Gunderson, medical director of liver transplantation at the University of Iowa Hospitals and Clinics, said most hospitals that allow transplants without the six-month wait look at similar factors: the patient’s medical need, financial stability, social support, understanding of their addiction and desire to recover. But the subjectivity of these measures means different transplant committees can come to different decisions.

In a letter to Gorzney, the Iowa transplant team explained they’d typically recommend a six-month waiting period but were approving him for the waiting list immediately because he wouldn’t survive otherwise. In return, Gorzney agreed to attend counseling and treatment programs after the transplant.

Within 24 hours of being put on the waitlist, Gorzney received a new liver.

Today, more than a year and a half later, Gorzney, 52, is still sober and embracing the “opportunity to be somebody that I haven’t been in a while,” he said.

He and his girlfriend are engaged, and he’s grateful to see his daughters, Cameron and Carson, grow into young adults. A lifelong Illinois Fighting Illini football fan, he even considers rooting for the Iowa Hawkeyes now.

But it worries him that the six-month rule, which led his family to travel to three hospitals in three states, still stymies others.

“People are, unfortunately, passing away … not knowing that there may be other options for them because they don’t have a support group that I had that was aggressive enough and strong enough to reach out and not accept no on the first response they got.”

Aneri Pattani:
apattani@kff.org,
@aneripattani

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I hadn’t expected the tears.

My primary care doctor and I were saying goodbye after nearly 30 years together.

“You are a kind and a good person,” he told me after the physical exam, as we wished each other good luck and good health.

“I trust you completely — and always have,” I told him, my eyes overflowing.

“That means so much to me,” he responded, bowing his head.

Will I ever have another relationship like the one with this physician, who took time to ask me how I was doing each time he saw me? Who knew me from my first months as a young mother, when my thyroid went haywire, and who since oversaw all my medical concerns, both large and small?

It feels like an essential lifeline is being severed. I’ll miss him dearly.

This isn’t my story alone; many people in their 50s, 60s and 70s are similarly undergoing this kind of wrenching transition. A decade from now, at least 40% of the physician workforce will be 65 or older, according to data from the Association of American Medical Colleges. If significant numbers of doctors retire, as expected, physician shortages will swell. Earlier this year, the AAMC projected an unmet need for up to 55,200 primary care physicians and 86,700 specialists by 2033, amid the rapid growth of the elderly population.

Stress from the covid pandemic has made the outlook even worse, at least in the near term. When the Physicians Foundation, a nonprofit research organization, surveyed 2,504 doctors in May and June, 61% reported “often experiencing” burnout associated with financial and emotional strain. Two percent said they had retired because of the pandemic; another 2% had closed their practices.

Twenty-three percent of the doctors surveyed said they’d like to retire during the next year.

Baby boomers, like me, whose medical needs are intensifying even as their longtime doctors bow out of practice, are most likely to be affected.

“There’s a lot of benefit to having someone who’s known your medical history for a long time,” especially for older adults, said Dr. Janis Orlowski, AAMC’s chief health care officer. When relationships with physicians are disrupted, medical issues that need attention can be overlooked and people can become less engaged in their care, said Dr. Gary Price, president of the Physicians Foundation.

My doctor, who’s survived two bouts of cancer, didn’t mention the pandemic during our recent visit. Instead, he told me he’s turning 75 a week before he closes the practice at the end of October. Having practiced medicine for 52 years, 40 as a solo practitioner, “it’s time for me to spend more time with family,” he explained.

An intensely private man who’s averse to publicity, he didn’t want his name used for this article. I know I’m lucky to have had a doctor I could rely on with complete confidence for so long. Many people don’t have this privilege because of where they live, their insurance coverage, differences in professional competence, and other factors.

With a skeletal staff — his wife is the office manager — my doctor has been responsible for 3,000 patients, many of them for decades. One woman sobbed miserably during a recent visit, saying she couldn’t imagine starting over with another physician, he told me.

At one point, when my thyroid levels were out of control, I saw my physician monthly. After my second pregnancy, when this problem recurred, I brought the baby and her toddler brother in a double stroller into the exam room. One or the other would often cry sympathetically when he drew my blood.

I remember once asking when a medical issue I was having — the flu? a sore throat? — would resolve. He pointed upward and said, “Only Hashem knows.” A deeply religious man, he wasn’t afraid to acknowledge the body’s mysteries or the limits of medical knowledge.

“Give it a few days and see if you get better,” he frequently advised me. “Call if you get worse.”

At each visit, my doctor would open a large folder and scribble notes by hand. My file is more than 4 inches thick. He never signed up for electronic medical records. He’s not monetizing his practice by selling it. For him, medicine was never about money.

“Do you know the profit margins this hospital makes?” he asked at our last visit, knowing my interest in health care policy and finance. “And how do you think they do it? They cut costs wherever they can and keep the nursing staff as small as possible.”

Before a physical exam, he’d tell a joke — a way to defuse tension and connect with a smile. “Do you know the one about …” he’d begin before placing his fingers on my throat (where the thyroid gland is located) and squeezing hard.

Which isn’t to say that my doctor was easygoing. He wasn’t. Once, he insisted I go to the emergency room after I returned from a long trip to South Asia with a very sore leg and strange pulsing sensations in my chest. An ultrasound was done and a blood clot discovered.

The young doctors in the ER wanted to give me intravenous blood thinner and send me home with a prescription. My doctor would have nothing of it. I was to stay in the hospital overnight and be monitored every few hours, efficiency and financial considerations be damned. He was formidable and intransigent, and the younger physicians backed down.

At that last meeting, my doctor scribbled the names of two physicians on a small sheet of paper before we said our goodbyes. Both would take good care of me, he said. When I called, neither was accepting new patients. Often, I hear this from older friends: They can’t find physician practices that are taking new patients.

Price, who’s 68, went through this when his family physician announced she was retiring and met with him in January to work out who might take over his care. Price was admitted into the practice of a younger physician with a good reputation only because he asked a medical colleague to intervene on his behalf. Even then, the first available appointment was in June.

Orlowski had a similar experience two years ago when searching for a new primary care doctor for her elderly parents. “Most of the practices I contacted weren’t accepting new patients,” she told me. It took six months to find a physician willing to see her parents — again, with the help of medical colleagues.

I’m lucky. A friend of mine has a physician daughter, part of an all-women medical practice at a nearby university hospital. One of her colleagues had openings and I got on her schedule in December. My friend’s daughter recommends her highly.

Still, it will mean starting over, with all the dislocation that entails. And these transitions are hard, for patients and doctors alike.

Several weeks ago, I received a letter from my doctor, likely his last communication, which I read with a lump in my throat.

“To my beloved patients,” he wrote. “I feel so grateful for the opportunity to treat you and develop relationships with you and your families that I will always treasure. … I bid you all adieu. I hope and pray for your good health. I will miss each and every one of you and express to you my appreciation for so many wonderful years of doing what I love, caring for and helping people.”

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.

Judith Graham:
khn.navigatingaging@gmail.com,
@judith_graham

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El departamento de emergencias del Hospital San Leandro, en California, donde trabaja la enfermera Mawata Kamara, se cerró de urgencia cuando un visitante, preocupado por no poder ver a un paciente por las restricciones de covid-19, amenazó con volver con un arma.

No fue la primera vez que el departamento se enfrentó a una amenaza de arma de fuego durante la pandemia. A principios de año, un paciente psiquiátrico al que todos conocían se volvió cada vez más violento, gritando insultos raciales, escupiendo a los empleados y lanzando puñetazos antes de amenazar con dispararle a Kamara en la cara.

“La violencia siempre ha sido un problema”, dijo Kamara. “Esta pandemia realmente solo le puso una lupa”.

En los primeros días de la pandemia, las celebraciones nocturnas elogiaban la valentía de los trabajadores sanitarios de primera línea. Un año y medio después, esos mismos trabajadores dicen que están experimentando un aumento alarmante de la violencia en sus lugares de trabajo.

Una enfermera testificó ante un comité del Senado de Georgia en septiembre que un paciente la atacó tan severamente la primavera pasada que terminó en la sala de emergencias de su propio hospital.

En el Research Medical Center en Kansas City, en Missouri, la unidad de covid llamó a seguridad, contó la enfermera Jenn Caldwell, cuando un visitante gritó agresivamente al personal de enfermería sobre la condición de su esposa, que era una paciente.

En Missouri, las agresiones físicas contra las enfermeras se han triplicado, y llevó a Cox Medical Center Branson a colocar botones de pánico en las tarjetas de identificación de los empleados.

Los ejecutivos de los hospitales ya estaban en alerta por este fenómeno desde antes que estallara la pandemia. Pero dicen que las tensiones de covid han exacerbado el problema, lo que ha provocado un refuerzo de la seguridad, entrenamientos para lidiar con situaciones de violencia y pedidos de civilidad.

Y mientras muchos hospitales trabajan para abordar el problema por sí mismos, las enfermeras y otros trabajadores están impulsando una legislación federal para crear estándares aplicables en todo el país.

Paul Sarnese, ejecutivo de Virtua Health en Nueva Jersey y presidente de la Asociación Internacional para la Seguridad y Protección de la Atención Médica, dijo que muchos estudios muestran que los trabajadores de salud tienen muchas más probabilidades de ser víctimas de agresión agravada que los trabajadores de cualquier otra industria.

Datos federales muestran que los trabajadores de salud enfrentaron el 73% de todas las lesiones no fatales por violencia en el lugar de trabajo en los Estados Unidos en 2018. Es demasiado pronto para tener estadísticas completas de la pandemia.

Aun así, Michelle Wallace, directora de enfermería de Grady Health System en Georgia, dijo que la violencia probablemente sea aún mayor porque muchas víctimas de agresiones de pacientes no los denuncian.

“Nos decimos que esto es parte de nuestro trabajo”, dijo Wallace, quien aboga por más denuncias.

Caldwell dijo que había sido enfermera por menos de tres meses la primera vez que fue agredida en el trabajo: un paciente la escupió. En los cuatro años que pasaron desde entonces, estima que no han pasado más de tres meses sin que haya sido agredida verbal o físicamente.

“No diría que se espera, pero se acepta”, dijo Caldwell. “Tenemos muchas personas con problemas de salud mental que entran por nuestras puertas”.

Jackie Gatz, vicepresidente de seguridad y preparación de la Missouri Hospital Association, dijo que la falta de recursos de salud conductual puede estimular la violencia cuando los pacientes buscan tratamiento para problemas de salud mental y trastornos por uso de sustancias en las salas de emergencia.

La vida también puede derramarse dentro del hospital, con episodios violentos que comenzaron afuera y continuar adentro, o la presencia de agentes del orden aumentando las tensiones.

Un informe de febrero de 2021 de National Nurses United, el sindicato en el que tanto Kamara como Caldwell son representantes, ofrece otro factor posible: niveles de personal que no permiten a los trabajadores el tiempo suficiente para reconocer y aliviar situaciones posiblemente volátiles.

Las enfermeras de la unidad de covid también han asumido responsabilidades adicionales durante la pandemia. Otros miembros del personal del hospital suelen realizar tareas como alimentar a los pacientes, extraer sangre y limpiar las salas, pero las enfermeras han colaborado en esos trabajos para minimizar la cantidad de trabajadores que visitan las salas de presión negativa donde se tratan a los pacientes con covid.

Si bien la carga de trabajo ha aumentado, la cantidad de pacientes que supervisa cada enfermera no ha cambiado, lo que deja poco tiempo para escuchar las preocupaciones de los visitantes que temen por el bienestar de sus seres queridos, como el hombre que gritó agresivamente a las enfermeras en la unidad de Caldwell.

En septiembre, el 31% de las enfermeras hospitalarias encuestadas por ese sindicato dijeron que habían enfrentado violencia en el lugar de trabajo, frente al 22% de marzo.

El doctor Bryce Gartland, presidente del grupo de hospitales de Emory Healthcare, con sede en Atlanta, dijo que la violencia se intensificó a medida que avanzaba la pandemia, particularmente durante la última ola de infecciones, hospitalizaciones y muertes.

“Los trabajadores de atención médica de primera línea y los socorristas han estado en el campo de batalla durante 18 meses”, dijo Garland. “Están agotados”.

Al igual que el aumento de la violencia en los aviones, en los estadios deportivos y en las reuniones de la junta escolar, las crecientes tensiones dentro de los hospitales podrían ser un reflejo de las crecientes tensiones fuera.

William Mahoney, presidente del Cox Medical Center Branson, dijo que la ira política nacional se manifiesta a nivel local, especialmente cuando el personal pide a las personas que entran al hospital que se pongan una máscara.

Caldwell, la enfermera de Kansas City, dijo que la naturaleza física de las infecciones por covid puede contribuir a un aumento de la violencia. Los pacientes de la unidad de covid a menudo tienen niveles de oxígeno peligrosamente bajos.

“La gente tiene diferentes puntos de vista políticos, ya sea CNN o Fox News, y comienzan a gritarte”, dijo Mahoney.

“Cuando eso sucede, se vuelven confusos y también extremadamente combativos”, dijo Caldwell.

Sarnese dijo que la pandemia ha dado a los hospitales la oportunidad de revisar sus protocolos de seguridad. Limitar los puntos de entrada para permitir la detección de covid, por ejemplo, permite a los hospitales canalizar a los visitantes más allá de las cámaras de seguridad.

Research Medical Center recientemente contrató oficiales de seguridad adicionales y brindó capacitación para reducir la tensión para complementar su videovigilancia, dijo su vocera Christine Hamele.

En Branson, el hospital de Mahoney ha reforzado su personal de seguridad, ha montado cámaras alrededor de la instalación, ha traído perros (“la gente realmente no quiere golpearte cuando hay un pastor alemán en la entrada”) y ha llevado a cabo un entrenamiento de desescalamiento, además a los botones de pánico.

Algunos de esos esfuerzos son anteriores a la pandemia, pero la crisis de covid ha agregado urgencia en una industria que ya lucha por contratar empleados y mantener niveles adecuados de personal. “La pregunta número uno que nos empezaron a hacer es: ‘¿Me vas a mantener a salvo?’”, dijo Mahoney.

Si bien varios estados, incluido California, tienen reglas para abordar la violencia en los hospitales, National Nurses United está pidiendo que el Senado nacional apruebe la Ley de Prevención de la Violencia en el Lugar de Trabajo para los Trabajadores de Servicios Sociales y de Salud que requeriría que los hospitales adopten planes para prevenir la violencia.

“Con cualquier estándar, al final del día es necesario que se cumpla”, dijo la higienista industrial del sindicato, Rocelyn de Leon-Minch.

Las enfermeras en los estados con leyes vigentes aún enfrentan violencia, pero tienen un estándar al que pueden señalar cuando piden que se aborde esa violencia. De Leon-Minch dijo que el proyecto de ley federal, que fue aprobado por la Cámara en abril, tiene como objetivo extender esa protección a los trabajadores de la salud en todo el país.

Destiny, la enfermera que testificó en Georgia usando solo su nombre de pila, está presentando cargos contra la paciente que la atacó. El comité del Senado estatal ahora está considerando la legislación para el próximo año.

Kamara dijo que la violencia reciente ayudó a que su hospital brindara capacitación para reducirla, aunque no estuvo satisfecha con eso. La vocera del Hospital San Leandro, Victoria Balladares, dijo que el hospital no experimentó un aumento en la violencia en el lugar de trabajo durante la pandemia.

Para los trabajadores de la salud como Kamara, todo este antagonismo está muy lejos de los primeros días de la pandemia, cuando los trabajadores de los hospitales eran aclamados como héroes.

“No quiero ser una heroína”, dijo Kamara. “Quiero ser mamá y enfermera. Quiero que me consideren una persona que eligió una carrera que ama, y merece ir a trabajar y hacerlo en paz. Y no sentir que va a resultar lastimada”.

Bram Sable-Smith:
brams@kff.org,
@besables

Andy Miller:
amiller@kff.org,
@gahealthnews

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JoNel Aleccia, Kaiser Health News

Un candidato a trasplante de riñón de Colorado que fue puesto en estado inactivo por no vacunarse contra covid-19 se ha convertido en el ejemplo más público de un debate que afecta a los más de 250 centros de trasplante de órganos alrededor del país. (El estado inactivo es cuando la persona ya fue aceptada y evaluada para un transplante pero no puede recibirlo por alguna razón)

En todo el país, un número creciente de programas de trasplantes ha optado por excluir a los pacientes que se niegan a recibir las ampliamente disponibles vacunas contra covid, o darles una prioridad menor en las abarrotadas listas de espera de órganos. Sin embargo, otros dicen que por ahora no implementarán estas restricciones.

En el centro del debate: si los pacientes de trasplantes que rechazan las vacunas no solo se ponen ellos mismos en mayor riesgo de sufrir una enfermedad grave y la muerte por una infección por covid, sino también desperdician órganos escasos que podrían beneficiar a otros.

El argumento semeja a las demandas de que los fumadores dejen de fumar seis meses antes de recibir un trasplante de pulmón o que los adictos se abstengan de consumir alcohol y drogas antes de recibir nuevos hígados.

“Es un debate en curso”, dijo el doctor Deepali Kumar, experto en enfermedades infecciosas y trasplantes de la Universidad de Toronto y presidente electo de la Sociedad Estadounidense de Trasplantes. “Es realmente una decisión individual del programa. En muchos programas, está cambiando”.

Leilani Lutali, de 56 años, una paciente con enfermedad renal en etapa avanzada de Colorado Springs, Colorado, se enteró en una carta del 28 de septiembre de UCHealth en Denver que si no comenzaba con la serie de vacunas contra covid en 30 días, perdería su lugar en la lista de espera de trasplantes. Tanto ella como su donante vivo, Jaimee Fougner, de 45 años, de Peyton, Colorado, se negaron a vacunarse, citando objeciones religiosas e incertidumbre sobre la seguridad y eficacia de las vacunas.

“Tengo demasiadas preguntas sin respuesta en este momento. Siento que me están obligando a no poder esperar y ver, y a vacunarme si quiero este trasplante que salvará mi vida”, dijo Lutali.

Agregó que ofreció a hacerse la prueba de covid antes de la cirugía o firmar una exención que absolviera al hospital del riesgo legal por su negativa a la vacuna. “¿En qué momento ya no eres partícipe de las decisiones sobre tu propia atención?”, se preguntó Lutali.

Lutali ahora espera buscar un trasplante en Texas, donde varios hospitales, incluidos Houston Methodist y Baylor University Medical Center, en Dallas, dijeron que no requieren vacunas contra covid para aprobar a candidatos activos en la lista de espera nacional.

La diferencia entre las normas en Denver y Dallas, y en otros lugares, remarca una tensa división nacional. A fines de abril, menos del 7% de los programas de trasplantes en todo el país informaron que iban a cambiar el estatus de pacientes que no estaban vacunados contra covid, según una investigación de la doctora Krista Lentine, nefróloga de la Escuela de Medicina de la Universidad de Saint Louis.

Pero eso fue solo una instantánea a fines de la primavera y, como todas las prácticas relacionadas con covid, está “cambiando rápidamente”, agregó Lentine.

UCHealth en Denver comenzó a requerir vacunas contra covid para pacientes de transplantes a fines de agosto, citando la recomendación de ese mismo mes de la Sociedad Estadounidense de Trasplantes de que “todos los receptores de trasplantes de órganos sólidos deberían estar vacunados contra el SARS-CoV-2”.

Los pacientes que se someten a un trasplante tienen su sistema inmunológico artificialmente suprimido durante la recuperación, para evitar que sus cuerpos rechacen el nuevo órgano. Eso deja a los pacientes no vacunados en “riesgo extremo” de enfermedad grave por covid si se infectan, con tasas de mortalidad estimadas en 20% a 30%, según el estudio, dijo Dan Weaver, vocero de UCHealth.

Por la misma razón, los pacientes trasplantados que reciben vacunas contra covid después de la cirugía pueden no desarrollar una respuesta inmune fuerte, muestra una investigación.

UW Medicine en Seattle comenzó a exigir vacunas contra covid este verano, dijo el doctor Ajit Limaye, director del programa de enfermedades infecciosas de trasplante de órganos sólidos. Los pacientes ya debían cumplir con otros criterios estrictos para ser considerados para un trasplante, incluido recibir vacunas contra varias enfermedades, como la hepatitis B y la influenza.

“Básicamente, la estamos requiriendo para cualquiera que no tenga una contraindicación médica”, dijo. “Hay una idea fuerte para convertirlo en un requisito, como todos los demás”.

Por el contrario, Northwestern Medicine en Chicago, donde los médicos realizaron el primer trasplante doble de pulmón en un paciente con covid en junio de 2020, está alentando la vacunación contra la enfermedad pandémica, pero no es un requisito.

“No rechazamos la atención del trasplante en base al estatus de vacunación”, dijo Jenny Nowatzke, gerenta de relaciones con los medios nacionales de Northwestern. “El paciente tampoco obtiene puntuaciones más bajas”.

La falta de una norma única para todos los programas envía un mensaje contradictorio al público, opinó el doctor Kapilkumar Patel, director del programa de trasplante de pulmón en el Hospital General de Tampa, en Florida, donde no se requieren las vacunas.

“Exigimos vacunas contra la hepatitis y la influenza, y nadie tiene problemas con eso”, dijo. “Y ahora tenemos esta vacuna que puede salvar vidas y tener un impacto en la fase de recuperación posterior al trasplante. Y tenemos este gran alboroto del público”.

Casi 107,000 candidatos esperan órganos en los Estados Unidos; decenas mueren cada día durante la espera. Los centros de trasplantes evalúan qué pacientes pueden ser incluidos en la lista nacional, teniendo en cuenta los criterios médicos, y otros factores como los medios económicos y el apoyo social para garantizar que los órganos de donantes no fallen.

“Realmente hacemos todo tipo de juicios de valor selectivos”, dijo el doctor David Weill, ex director del programa de trasplante de pulmón y corazón-pulmón del Centro Médico de la Universidad de Stanford que ahora trabaja como consultor. “Cuando el comité selecciona, escucho los juicios más subjetivos, basados ​​en valores sobre la vida de las personas. Esto es solo una cosa más”.

Los centros pueden optar por colocar a los candidatos en estado inactivo por una variedad de razones, incluido el incumplimiento médico, según datos de United Network for Organ Sharing (UNOS), que supervisa los trasplantes. Al 30 de septiembre, esa categoría contaba con 738 de los más de 47,000 solicitantes que esperaban en estado inactivo, aunque no está claro cuántos están vinculados al estatus de vacunación.

Una pregunta particularmente espinosa involucra a personas no vacunadas que necesitan trasplantes específicamente porque las infecciones por covid destruyeron sus órganos. A fines de septiembre, más de 200 pulmones, así como al menos seis corazones y dos combinaciones de corazón y pulmón, habían sido trasplantados por razones relacionadas con covid, según datos de UNOS.

Muchos de esos órganos fueron trasplantados al comienzo de la pandemia, antes de que cualquier vacuna estuviera disponible. Ese ya no es el caso, dijo Weill. “Si recién te acabas de vacunarte, en realidad lo has hecho a punta de pistola”, dijo. “No es solo una elección personal; están mostrando su punto de vista”.

Estos pacientes suelen ser más jóvenes y más sanos que otros candidatos a trasplantes, más allá del daño relacionado con covid, y a menudo están lo suficientemente enfermos como para llegar a lo más alto de cualquier lista de trasplantes. “El paciente enfermo con covid podría estar adelante del paciente estable con fibrosis quística”, dijo Weill.

Patel, de Tampa, dijo que realizó un trasplante de pulmón a un paciente que fue trasladado a Florida después de ser excluido de la lista en otro centro porque no estaba vacunado contra covid. “Básicamente le ordené con un apretón de manos que recibiera su vacuna después del trasplante”, dijo Patel. “¿Pero su familia? No han estado de acuerdo”.

Patel piensa que, con el tiempo, todos los programas de trasplantes exigirán la vacunación contra covid, en gran parte porque los centros se evalúan en función de la supervivencia a largo plazo de sus pacientes.

“Creo que se extenderá en todo el país”, dijo. “Si comienzas a perder pacientes en un año por covid, será obligatorio más temprano que tarde.

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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Rachana Pradhan and Rachel Bluth, Kaiser Health News

Community clinics in California say they haven’t been paid for at least 1 million covid-19 vaccine doses given since January, creating a “massive cash flow problem” for some and complicating efforts to retain staff. Clinics in other states, including Michigan and Mississippi, are also awaiting payment.

The delays stem from the distinct way federally qualified health centers are reimbursed for care under Medicaid, the joint federal-state program providing health coverage for low-income people. Some centers are not even billing for the shots because they say it’s too complicated.

Clinics are owed tens of millions of dollars, at minimum, for shots they’ve given since the vaccines received emergency authorization.

Of the roughly 70,000 doses administered by La Clínica de la Raza, an organization with more than 30 Bay Area locations, almost none of those costs have been reimbursed, chief financial officer Susan Moore said. And the clinics don’t expect to receive reimbursement for around half of those shots because they were administered to the community without collecting insurance information. The extra staff time and supplies were covered with grant money.

“We were monitoring our cash very closely,” Moore said. “Early in the pandemic I was very concerned, but by the time the vaccine came out, it was clear to me that we were going to have enough cash in the short term.”

The Biden administration has relied on the clinics to boost vaccination rates among racial and ethnic minorities and people living in poverty. Health centers have administered nearly 15 million vaccine doses, federal data shows, although it is unclear how many of those were given during a patient visit.

Under federal law, the government pays health centers a set rate for patient visits, each potentially costing hundreds of dollars. Many state Medicaid agencies have said that if a patient receives a covid shot along with other care, the clinic’s cost to give the vaccine is covered as part of its normal payment rate.

Troubles getting paid occur when the covid vaccination is the only service provided, officials say, such as during a mass immunization clinic.

During large-scale vaccine events, “we’re usually administering vaccines without that broader service,” said Phillip Bergquist, chief operating officer of the Michigan Primary Care Association, which lobbies for health centers.

Some states have told health centers they can bill Medicaid separately for each dose administered in that situation, such as at the Medicare payment level of approximately $40 per shot. But others, like Michigan and California, have endured a months-long process with the Centers for Medicare & Medicaid Services to devise a payment formula for how much it costs a clinic to give a shot.

CMS said it is reviewing proposals from 13 states to pay clinics for the vaccinations. “We are continuing to work with states on their proposals,” a CMS spokesperson said. If they are approved, the clinics would be paid retroactively.

Michigan has been working with CMS to figure out reimbursement “when those vaccines are administered as a stand-alone service,” said Bob Wheaton, spokesperson for the state’s health department. Bergquist said the calculated cost in Michigan was just shy of $40 a dose.

California devised a plan that “meets federal requirements that reimbursement to these clinics be based on cost to provide services,” said Carol Sloan, spokesperson for the California Department of Health Care Services.

California’s average cost to provide each dose is about $67, based on data clinics provided.

Because of the short shelf life of an open vial of vaccine, health centers opted for dedicated vaccination clinics instead of individual appointments, to avoid wasting doses, said Andie Martinez Patterson, a senior vice president at the California Primary Care Association, which lobbies for the state’s health centers.

Lack of payment is “untenable given these providers’ financial restraints and tremendous outlay of resources during this historic pandemic response,” Barbara Ferrer, director of the Los Angeles County Department of Public Health, wrote in a Sept. 22 letter to CMS Administrator Chiquita Brooks-LaSure. In interviews, clinics cited high expenses related to vaccination, including running community-based clinics and targeted social media campaigns.

“There’s a tremendous amount of misinformation and disinformation out there,” said Jim Mangia, CEO of the St. John’s Well Child & Family Center in Los Angeles, which opened 26 vaccination sites and operates three mobile units. “You kind of have to do double the work to counter it.”

Angel Greer, CEO of Coastal Family Health Center on Mississippi’s Gulf Coast, said not receiving payment to help cover the clinic’s staffing costs is detrimental. More than 50% of the health center’s patients are uninsured — and 14% each are on Medicare or Medicaid. The federal Health Resources and Services Administration separately reimburses clinics for vaccines administered to uninsured people.

In Mississippi, state officials initially proposed a plan that would have reimbursed health centers at the Medicare rate for stand-alone vaccinations. CMS has not approved it.

“I’m sure, across the nation is no different than Mississippi in our struggles to maintain adequate workforce. It’s extremely difficult to be competitive with these workforce constraints when we’re not being reimbursed for these services,” Greer said. The health center administered 1,000 covid vaccine doses in September, with the “overwhelming majority” occurring outside a regular medical visit, Greer said.

In winter 2020, it became clear California clinics were going to have to eat the costs of vaccination for a while, Martinez Patterson said. They were “hoping on a prayer that most of their costs would be reimbursed” but went ahead and vaccinated patients anyway.

Scott McFarland, CEO of MCHC Health Centers, said his staff at four clinics in rural Lake and Mendocino counties have administered 3,500 shots without reimbursement.

“I’m fairly confident that we will eventually get paid, but this is one of the downsides to being a community health center,” McFarland said, a sentiment others expressed. The clinic is still giving shots, and he thinks the money will come eventually. “It’s just a timing issue, I guess.”

Health centers are pulling from different pots to stay afloat: The American Rescue Plan Act provided $7.6 billion to clinics to support covid vaccination, testing and treatment. Clinics relied on small-business loans from the Paycheck Protection Program, as well as state money, for vaccination efforts. “I do think because of the federal relief, there is not a fire,” Martinez Patterson said.

Health centers in other states echoed that.

“We do not have an issue with reimbursement,” said Dr. Andrea Caracostis, CEO of the Hope Clinic in Houston. She noted that the federal government paid for vaccines and that some health centers’ payment rates cover vaccines.

Fifty-one federally qualified health centers in California earlier this year reported unpaid claims for 1 million doses. The actual total is probably higher; California has 188 health centers.

“We don’t view this small subset, nor the data provided, as sufficiently representative” to accurately estimate the extent of unpaid vaccination claims, Sloan said.

Health centers in California have administered 4.8 million doses, according to federal data.

“We’re just whittling away at it,” said Mangia, of St. John’s.

St. John’s anticipates getting reimbursed for doses under Medicaid in November or December, the clinic said through a spokesperson.

“We know they’re good for it. We know it’s coming,” Louise McCarthy, CEO of the Community Clinic Association of Los Angeles County, said of the Medicaid payments. “But it’s really hard to hire people when you don’t have cash flow.”

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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Bram Sable-Smith and Andy Miller

The San Leandro Hospital emergency department, where nurse Mawata Kamara works, went into lockdown recently when a visitor, agitated about being barred from seeing a patient due to covid-19 restrictions, threatened to bring a gun to the California facility.

It wasn’t the first time the department faced a gun threat during the pandemic. Earlier in the year, a psychiatric patient well known at the department became increasingly violent, spewing racial slurs, spitting toward staffers and lobbing punches before eventually threatening to shoot Kamara in the face.

“Violence has always been a problem,” Kamara said. “This pandemic really just added a magnifying glass.”

In the earliest days of the pandemic, nightly celebrations lauded the bravery of front-line health care workers. Eighteen months later, those same workers say they are experiencing an alarming rise in violence in their workplaces.

A nurse testified before a Georgia Senate study committee in September that she was attacked by a patient so severely last spring she landed in the ER of her own hospital.

At Research Medical Center in Kansas City, Missouri, security was called to the covid unit, said nurse Jenn Caldwell, when a visitor aggressively yelled at the nursing staff about the condition of his wife, who was a patient.

In Missouri, a tripling of physical assaults against nurses prompted Cox Medical Center Branson to issue panic buttons that can be worn on employees’ identification badges.

Hospital executives were already attuned to workplace violence before the pandemic struck. But stresses from covid have exacerbated the problem, they say, prompting increased security, de-escalation training and pleas for civility. And while many hospitals work to address the issue on their own, nurses and other workers are pushing federal legislation to create enforceable standards nationwide.

Paul Sarnese, an executive at Virtua Health in New Jersey and president of the International Association for Healthcare Security and Safety, said many studies show health care workers are much more likely to be victims of aggravated assault than workers in any other industry.

Federal data shows health care workers faced 73% of all nonfatal injuries from workplace violence in the U.S. in 2018. It’s too early to have comprehensive stats from the pandemic.

Even so, Michelle Wallace, chief nursing officer at Grady Health System in Georgia, said the violence is likely even higher because many victims of patient assaults don’t report them.

“We say, ‘This is part of our job,’” said Wallace, who advocates for more reporting.

Caldwell said she had been a nurse for less than three months the first time she was assaulted at work — a patient spit at her. In the four years since, she estimated, she hasn’t gone more than three months without being verbally or physically assaulted.

“I wouldn’t say that it’s expected, but it is accepted,” Caldwell said. “We have a lot of people with mental health issues that come through our doors.”

Jackie Gatz, vice president of safety and preparedness for the Missouri Hospital Association, said a lack of behavioral health resources can spur violence as patients seek treatment for mental health issues and substance use disorders in ERs. Life can also spill inside to the hospital, with violent episodes that began outside continuing inside or the presence of law enforcement officers escalating tensions.

A February 2021 report from National Nurses United — a union in which both Kamara and Caldwell are representatives — offers another possible factor: staffing levels that don’t allow workers sufficient time to recognize and de-escalate possibly volatile situations.

Covid unit nurses also have shouldered extra responsibilities during the pandemic. Duties such as feeding patients, drawing blood and cleaning rooms would typically be conducted by other hospital staffers, but nurses have pitched in on those jobs to minimize the number of workers visiting the negative-pressure rooms where covid patients are treated. While the workload has increased, the number of patients each nurse oversees is unchanged, leaving little time to hear the concerns of visitors scared for the well-being of their loved ones — like the man who aggressively yelled at the nurses in Caldwell’s unit.

In September, 31% of hospital nurses surveyed by that union said they had faced workplace violence, up from 22% in March.

Dr. Bryce Gartland, hospital group president of Atlanta-based Emory Healthcare, said violence has escalated as the pandemic has worn on, particularly during the latest wave of infections, hospitalization and deaths.

“Front-line health care workers and first responders have been on the battlefield for 18 months,” Garland said. “They’re exhausted.”

Like the increase in violence on airplanes, at sports arenas and school board meetings, the rising tensions inside hospitals could be a reflection of the mounting tensions outside them.

William Mahoney, president of Cox Medical Center Branson, said national political anger is acted out locally, especially when staffers ask people who come into the hospital to put on a mask.

Caldwell, the nurse in Kansas City, said the physical nature of covid infections can contribute to an increase in violence. Patients in the covid unit often have dangerously low oxygen levels.

“People have different political views — they’re either CNN or Fox News — and they start yelling at you, screaming at you,” Mahoney said.

“When that happens, they become confused and also extremely combative,” Caldwell said.

Sarnese said the pandemic has given hospitals an opportunity to revisit their safety protocols. Limiting entry points to enable covid screening, for example, allows hospitals to funnel visitors past security cameras.

Research Medical Center recently hired additional security officers and provided de-escalation training to supplement its video surveillance, spokesperson Christine Hamele said.

In Branson, Mahoney’s hospital has bolstered its security staff, mounted cameras around the facility, brought in dogs (“people don’t really want to swing at you when there’s a German shepherd sitting there”) and conducted de-escalation training — in addition to the panic buttons.

Some of those efforts pre-date the pandemic but the covid crisis has added urgency in an industry already struggling to recruit employees and maintain adequate staffing levels. “The No. 1 question we started getting asked is, ‘Are you going to keep me safe?’” Mahoney said.

While several states, including California, have rules to address violence in hospitals, National Nurses United is calling for the U.S. Senate to pass the Workplace Violence Prevention for Health Care and Social Service Workers Act that would require hospitals to adopt plans to prevent violence.

“With any standard, at the end of the day you need that to be enforced,” said the union’s industrial hygienist, Rocelyn de Leon-Minch.

Nurses in states with laws on the books still face violence, but they have an enforceable standard they can point to when asking for that violence to be addressed. De Leon-Minch said the federal bill, which passed the House in April, aims to extend that protection to health care workers nationwide.

Destiny, the nurse who testified in Georgia using only her first name, is pressing charges against the patient who attacked her. The state Senate committee is now eyeing legislation for next year.

Kamara said the recent violence helped lead her hospital to provide de-escalation training, although she was dissatisfied with it. San Leandro Hospital spokesperson Victoria Balladares said the hospital had not experienced an increase in workplace violence during the pandemic.

For health care workers such as Kamara, all this antagonism toward them is a far cry from the early days of the pandemic when hospital workers were widely hailed as heroes.

“I don’t want to be a hero,” Kamara said. “I want to be a mom and a nurse. I want to be considered a person who chose a career that they love, and they deserve to go to work and do it in peace. And not feel like they’re going to get harmed.”

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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Contributing writer and former KHN correspondent Michelle Andrews discussed difficulties in providing clinical training to student nurses who refuse to get vaccinated on CBS News on Thursday.

• Click here to watch Andrews on CBS News
• Read Andrews’ “Student Nurses Who Refuse Vaccination Struggle to Complete Degrees“

KHN Colorado correspondent Rae Ellen Bichell discussed San Juan County, Colorado, one of the most vaccinated places in the U.S. on KUNC’s “Colorado Edition” on Tuesday and Colorado Public Radio’s “Colorado Matters” on Wednesday.

• Click here to hear Bichell on “Colorado Edition”
• Click here to hear Bichell on “Colorado Matters”
• Read Bichell’s “A Colorado Town Is About as Vaccinated as It Can Get. Covid Still Isn’t Over There.“

KHN Midwest correspondent Lauren Weber discussed covid-19 deaths in rural America on “NBC Now” on Oct. 1.

• Click here to watch Weber on “NBC Now”
• Read Weber’s “Covid Is Killing Rural Americans at Twice the Rate of Urbanites“

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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This story can be republished for free (details).

Journalists Examine Vaccination Rates Among Student Nurses and in Covid Hot Spots https://khn.org/news/article/journalists-examine-vaccination-rates-among-student-nurses-and-in-covid-hot-spots/

SACRAMENTO, Calif. — It’s now illegal in California to harass people on their way into a vaccination clinic, under a law signed Friday by Gov. Gavin Newsom.

But First Amendment experts continue to raise legal questions about the law’s constitutionality, including its definition of harassment.

The new law, which takes effect immediately, makes it a misdemeanor to harass, intimidate, injure or obstruct people on their way to get a covid-19 or any other kind of vaccine, punishable by a maximum $1,000 fine and/or up to six months in jail.

Even though the measure, SB 742, was amended to remove a phrase that free speech experts said made it unconstitutional, they maintain that the new version still violates the First Amendment.

“It sweeps up broad activities that are protected by the First Amendment and defines them as harassing,” said David Snyder, executive director of the First Amendment Coalition, which advocates for free speech and government transparency. “That problem hasn’t changed at all.”

But the law is more necessary than ever, said Catherine Flores Martin, executive director of the California Immunization Coalition, which promotes vaccines. Martin said she has advocated for pro-vaccine legislation for years, and that the atmosphere surrounding vaccination, especially covid vaccines, has grown threatening and toxic.

“Our biggest concern is when children are getting vaccinated,” she said. “Some of these people feel like they need to protest, and that’s scary and extremely inappropriate.”

The bill was introduced by state Sen. Richard Pan (D-Sacramento), who chairs the Senate health committee and was inspired to write this new measure after protesters briefly shut down a mass covid vaccination site at Dodger Stadium in January. Pan is a practicing pediatrician who still administers vaccines, and has been threatened, assaulted and called out by name at protests.

Pan has been at the center of California’s vaccine wars since long before the covid pandemic, and has been targeted by anti-vaccine groups for introducing laws that made it harder for parents to refuse routine vaccinations for their kids, including a 2015 law that eliminated personal belief exemptions and another approved in 2019 that made it harder to get medical ones.

“While, as a public official, I must live being threatened and stalked at my work, my home, and in my community by extremists, there is no place in the Constitution that says ordinary people and health care workers have to be subjected to that behavior,” Pan said in a written statement.

When the anti-harassment bill was introduced in February, it drew criticism from First Amendment scholars who said it violated Californians’ right to free speech.

The original bill restricted speech only “in connection with vaccination services,” which they said is problematic because it singled out a certain topic.

According to Eugene Volokh, a First Amendment professor at the UCLA law school, the government is allowed to restrict speech, but only if it’s “content-neutral” and applies equally to all protests, no matter the subject or message.

To make the bill content-neutral, the phrase singling out vaccination services was removed in early September, according to a state Senate analysis of the measure.

At the same time, lawmakers added wording to exempt “lawful picketing arising out of a labor dispute.”

That “creates another unconstitutional form of content discrimination” that has been outlawed by the U.S. Supreme Court, Volokh said

The court has twice struck down laws that restricted protesting but exempted labor disputes. In 1972, it overturned a Chicago ordinance that outlawed picketing within 150 feet of a school, other than picketing arising from labor disputes at those schools. In 1980, the court found an Illinois law unconstitutional because it prohibited protests in front of homes, except in cases of labor disputes.

“I think that raises the specter that this law favors one type of message,” said Snyder, with the First Amendment Coalition. “The government doesn’t get to decide what protest message is allowed.”

Snyder said he’s also concerned by the bill’s definition of harassment and the size of the “buffer zone” in which protesters are not allowed to engage with people getting vaccinated.

The measure defines harassment as getting within 30 feet of a patient who is within 100 feet of an entrance to a vaccine site or waiting in their car to get a vaccine, in order to hand out a leaflet, display a sign, protest or engage in any education or sidewalk counseling.

Although Pan said the provision is modeled after buffer zones that protect patients entering abortion clinics, the 30-foot zone in his vaccine protest law goes further than what the U.S. Supreme Court has allowed. In 2000, the high court upheld a Colorado law that created an 8-foot “bubble zone” around a person entering or exiting an abortion clinic, but in 2014 it struck down a Massachusetts law that created a 35-foot “buffer zone” around clinics.

Because the 30-foot zone is so big, it prohibits even having a conversation with someone or asking them what they know about vaccines, which is lawfully protected speech, Snyder said.

According to the language of the law, the 30-foot zone serves as a suitable distance to prevent the spread of covid and other illnesses.

But that may not be sufficient justification to limit free speech, said Erwin Chemerinsky, dean of the University of California-Berkeley School of Law and a First Amendment expert.

And while he’s sympathetic to the idea of stopping people from being harassed on their way to get inoculated, he said he’s concerned about the constitutionality of the labor exemption and the size of the buffer zone.

“I would expect if this gets adopted, it will get challenged,” Chemerinsky said.

For Crystal Strait, the board chair of ProtectUS, an advocacy organization that promotes public health, the law strikes a balance between protecting free speech and protecting the community from covid. Pan is an honorary chair of her organization, and she has witnessed the kind of yelling and harassment he’s trying to prevent.

“I’ve seen people yell into a bullhorn literal lies about the vaccine and how these young people were going to die,” Strait said of a recent clinic where teenagers were getting shots. “They’re just there to spread misinformation.”

Joshua Coleman, co-founder of the group V is for Vaccine, which argues vaccines carry risk, often protests at vaccine clinics in parks with his bullhorn, including one Pan attended in July. He says he plans to sue once he or one of his members gets arrested under the new law.

“This bill is a violation to our constitutional rights to peacefully assemble,” Coleman said. “It just takes somebody actually enforcing it.”

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

Rachel Bluth:
rbluth@kff.org,
@RachelHBluth

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El doctor Aaron Kheriaty, profesor de psiquiatría en la Universidad de California-Irvine, pensó que no necesitaba vacunarse contra covid porque había sufrido la enfermedad en julio de 2020.

Por eso, en agosto, presentó una demanda para frenar el mandato de vacunación del sistema universitario, alegando que la inmunidad “natural” le había dado a él y a millones de personas una mejor protección que la que podría ofrecer cualquier vacuna.

El 28 de septiembre, un juez desestimó la solicitud de Kheriaty de un requerimiento judicial contra la universidad por el mandato, que entró en vigencia el 3 de septiembre. Aunque Kheriaty tiene la intención de seguir adelante con el caso, los expertos legales dudan de que su demanda y otras similares presentadas en todo el país tengan éxito.

Dicho esto, cada vez hay más pruebas de que contraer SARS-CoV-2, el virus que causa covid-19, es, en general, tan eficaz como la vacunación para estimular el sistema inmunitario y prevenir la enfermedad.

Sin embargo, los funcionarios federales se han mostrado reacios a reconocer cualquier equivalencia, alegando la amplia variación en la respuesta inmunitaria de los pacientes de covid a la infección.

Al igual que muchos debates durante la pandemia de covid, el valor incierto de una infección previa ha dado lugar a desafíos legales, ofertas de marketing y exabruptos políticos; mientras los científicos trabajan, silenciosa y discretamente, para aclarar los datos.

Durante décadas, los médicos han utilizado análisis de sangre para determinar si las personas están protegidas contra enfermedades infecciosas. Las embarazadas se someten a pruebas de anticuerpos contra la rubéola para asegurarse de que sus fetos no se infecten con el virus que la provoca, que causa defectos de nacimiento devastadores. Trabajadores en hospitales se someten a pruebas de detección de anticuerpos, contra el sarampión y la varicela, para evitar la propagación de esas enfermedades.

Pero la inmunidad a covid parece más difícil de discernir que esas infecciones.

La Administración de Alimentos y Medicamentos (FDA) ha autorizado el uso de pruebas de anticuerpos contra covid, que pueden costar unos $70, para detectar una infección pasada. Algunas pruebas pueden distinguir si los anticuerpos proceden de una infección o de una vacuna.

Pero ni la FDA, ni los Centros para el Control y la Prevención de Enfermedades (CDC), recomiendan utilizar las pruebas para evaluar si se es, de hecho, inmune a covid. Para eso, las pruebas resultan inútiles porque no hay acuerdo sobre la cantidad, o los tipos de anticuerpos, que indicarían una protección contra la enfermedad.

“Todavía no tenemos un conocimiento claro de lo que la presencia de anticuerpos nos dice sobre la inmunidad”, afirmó Kelly Wroblewski, directora de enfermedades infecciosas de la Asociación de Laboratorios de Salud Pública.

Del mismo modo, los expertos no se ponen de acuerdo sobre el grado de protección que ofrece una infección.

Ante la falta de certeza, y a medida que se imponen los mandatos de vacunación en todo el país, las demandas legales ponen presión sobre el tema.

Los individuos que afirman que los mandatos de vacunación violan sus libertades civiles, argumentan que la inmunidad adquirida por la infección les protege. En Los Angeles, seis policías han demandado a la ciudad, alegando que tienen inmunidad natural.

En agosto, el profesor de derecho Todd Zywicki alegó que el mandato de vacunación de la Universidad George Mason violaba sus derechos constitucionales, dado que tiene inmunidad natural. Citó una serie de pruebas de anticuerpos y la opinión médica de un inmunólogo de que era “médicamente innecesario” que se vacunara. Zywicki retiró la demanda después de que la universidad le concediera una exención médica que, según la institución académica, no está relacionada con el pleito.

Los legisladores republicanos se han unido a la cruzada. El GOP Doctors Caucus, formado por médicos republicanos en el Congreso, ha instado a las personas que desconfían de la vacunación a que se sometan a una prueba de anticuerpos, contradiciendo las recomendaciones de los CDC y la FDA.

En Kentucky, el Senado del estado aprobó una resolución que concede el mismo estatus de inmunidad a aquellos que muestren una prueba de vacunación o una prueba de anticuerpos positiva.

Los hospitales fueron de las primeras instituciones en imponer la obligación de vacunarse a sus trabajadores de primera línea, ante el peligro de que contagiaran la enfermedad a pacientes vulnerables. Pocos han ofrecido exenciones de vacunación a los previamente infectados. Pero hay excepciones.

Dos sistemas hospitalarios de Pennsylvania permiten a los miembros del personal clínico aplazar la vacunación, durante un año, después de dar positivo en la prueba de covid. Otro, en Michigan, permite a los empleados elegir no vacunarse si presentan pruebas de una infección previa, y una prueba de anticuerpos positiva en los tres meses anteriores. En estos casos, los sistemas indicaron que querían evitar la escasez de personal que podría conllevar la renuncia de enfermeras que rechazan vacunarse.

Para Kheriaty, la cuestión es sencilla. “La investigación sobre la inmunidad natural ya es bastante definitiva”, declaró a KHN. “Es mejor que la inmunidad otorgada por las vacunas”. Pero está claro que la mayoría de la comunidad científica no comparte afirmaciones tan categóricas.

El doctor Arthur Reingold, epidemiólogo de la UC-Berkeley, y Shane Crotty, virólogo del  Instituto de Inmunología de La Jolla, en San Diego, declararon como testigos expertos en la demanda de Kheriaty, afirmando que se desconoce el alcance de la inmunidad proporcionada por la reinfección, especialmente contra las nuevas variantes de covid. Señalaron que la vacunación da un enorme refuerzo de inmunidad a las personas que han estado enfermas anteriormente.

Sin embargo, no todos los que presionan para que se reconozca el valor de pasar una infección son críticos de las vacunas o abanderados del movimiento antivacunas.

El doctor Jeffrey Klausner, profesor clínico de ciencias de la población y salud pública de la Universidad del Sur de California, es coautor de un análisis, publicado el 30 de septiembre, que demuestra que la infección suele proteger durante 10 meses o más. “Desde el punto de vista de la salud pública, negar el trabajo y el acceso y los viajes a personas que se han recuperado de la infección no tiene sentido”, señaló.

En su testimonio contra los argumentos de Kheriaty a favor de la inmunidad “natural”, Crotty citó estudios sobre el brote masivo de covid que asoló Manaos, en Brasil, a principios de este año y que incluyó la variante gamma del virus. Uno de los estudios estimó, basándose en los análisis de las donaciones de sangre, que tres cuartas partes de la población de la ciudad ya estaban infectadas antes de la llegada de gamma. Eso sugirió que la infección pasada podría no proteger contra las nuevas variantes. Pero Klausner y otros sospechan que la tasa de infección previa, presentada en el estudio, había sido sobrevalorada.

Un amplio estudio realizado en agosto en Israel, que demostró una mejor protección como resultado de la infección que de la vacunación, podría ayudar a cambiar la tendencia a aceptar la infección previa, apuntó Klausner. “Todo el mundo está esperando que Fauci diga: ‘La infección previa proporciona protección’”, añadió.

Cuando se le preguntó al doctor Anthony Fauci, máximo experto federal en enfermedades infecciosas, durante una entrevista en CNN el mes pasado, si las personas infectadas estaban tan protegidas como las que han sido vacunadas, dudó. “Podría haber un argumento de que lo están”, dijo. Fauci no respondió a una solicitud de KHN para ofrecer más comentarios.

Kristen Nordlund, vocera de los CDC, dijo en un correo electrónico que la “evidencia actual” muestra una amplia variación en las respuestas de los anticuerpos después de la infección por covid. “En las próximas semanas, esperamos contar con información adicional sobre la protección de la inmunidad de la vacuna en comparación con la inmunidad natural”, agregó.

Se está realizando un “esfuerzo monumental” para determinar qué nivel de anticuerpos es protector, expresó el doctor Robert Seder, jefe de la sección de inmunología celular del Instituto Nacional de Alergia y Enfermedades Infecciosas. Algunos estudios recientes han intentado establecer una cifra.

Las pruebas de anticuerpos nunca proporcionarán una respuesta afirmativa o negativa sobre la protección contra covid, señaló el doctor George Siber, consultor de la industria de las vacunas y coautor de uno de los trabajos. “Pero hay personas que no se van a vacunar. Vale la pena tratar de predecir quiénes tienen un riesgo más bajo”.

Esta historia fue producida por KHN, que publica California Healthline, un programa editorialmente independiente de la California Health Care Foundation.

Arthur Allen:
ArthurA@kff.org,
@ArthurAllen202

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