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ATLANTA — Sometimes, Pamela Winn isn’t sure how to connect with people, even those she loves, like her 9-month-old granddaughter. When the baby is in her arms, “I sit there quietly, and I don’t know what to say. What to do,” she said, her eyes filling with tears. “My socializing skills are just not there anymore.”

On days like these, Winn, who lives south of Atlanta, is haunted by the memory of her 6-by-9-foot prison cell, where she spent eight months in solitary confinement more than 10 years ago. She said she now feels “safest when I’m by myself.”

It’s a common paradox of solitary confinement, said Craig Haney, a professor of social psychology at the University of California-Santa Cruz. Instead of craving the company of others after release from social isolation, many former prisoners want just the opposite.

“Solitary forces prisoners to live in a world without people,” he said. “And they adapt to it.”

Research has long shown that solitary confinement — isolating prisoners for weeks, months, years and sometimes decades — has devastating effects on their physical and mental health. Once released, either to the general prison population or to the outside world, they can face a suite of problems, like heart damage and depression. They’re often hypersensitive to light, sound, smell or touch. Like Winn, they may struggle to read social cues. People, Haney said, “become a source of anxiety rather than support.”

And the coronavirus pandemic may have made the situation worse.

Before the pandemic, the estimated number of people in solitary confinement in the U.S. ranged from 50,000 to 80,000 on any given day, though many advocacy organizations believe counts are underestimated. The Centers for Disease Control and Prevention states that medical isolation — the separation of people with a contagious disease from the rest of the population — should not hinge on solitary confinement. Yet, at the height of the pandemic last year, up to 300,000 incarcerated individuals were in solitary, according to estimates from Solitary Watch and The Marshall Project, non-profits focused on criminal justice.

“Jails and prisons, like many organizations, acted in fear,” said Tammie Gregg, deputy director of the American Civil Liberties Union’s National Prison Project. “They thought the way to keep people from infecting each other was to simply put them in solitary.”

Solitary confinement can serve many goals, from punishment to protection. And it is called many things — protective custody, restrictive or secure housing, administrative or disciplinary segregation, or simply “the Hole.”

“The conditions are essentially the same: It’s the extreme deprivation of any meaningful social contact,” Haney said.

In the so-called Mandela Rules, named for South African leader Nelson Mandela, who was imprisoned for 27 years, the United Nations associates solitary confinement lasting longer than 15 consecutive days with a form of torture. More than half of all U.S. states have introduced or passed some type of legislation restricting or regulating the use of solitary confinement — like limiting the practice for juveniles, for example. But it is still widely used in American jails and prisons.

Inmates in solitary typically live in a small cell for up to 23 hours a day. They have little sensory stimulation, like sunlight. Access to reading materials, educational programming and personal property is limited or nonexistent. Prisoners may get one hour in a recreational yard, an equally isolated area typically enclosed or surrounded by concrete walls, with a secured high window that opens for fresh air.

An analysis by researchers with the University of Colorado and Human Rights Watch suggests that more than half of all prison suicides occur in solitary confinement. A study conducted by the New York City Department of Health and Mental Hygiene found that the rate of self-harm among those in solitary is 10 times that of the general prison population.

The isolation can be particularly destabilizing for people with preexisting mental health conditions, often exacerbating underlying issues that cause people to end up behind bars in the first place. “It’s a downward spiral,” said Haney.

A Florida State University study published earlier this year found that prisoners with mental illness, especially bipolar disorder, severe depression and schizophrenia, were up to 170% more likely to be placed in solitary for extended periods. In many prisons, experts worry, mental health treatment is nonexistent, making matters worse.

But even among people without a history of mental health problems, it may be impossible to predict who is susceptible to the harmful effects of solitary confinement, including suicide.

Pamela Winn, a registered nurse by training, was incarcerated in 2008 and later convicted to a 6½-year federal prison sentence for health care fraud. As the now-53-year-old African American woman with red-colored curls sits in her ranch home, her mind goes back to what she said was the darkest time of her life.

When she entered a federal holding facility south of Atlanta, she said, she was a healthy woman. She was also six weeks pregnant. One day, she fell as she was trying to step into a van while shackled. Three months later, she miscarried and was put into solitary confinement for what she was told was medical observation.

After a few months, she was transferred to a municipal prison, where she was placed into solitary again, this time for protection. For a total of eight months, at two facilities, she lived in tiny cells, with iron beds, thin foam mattresses, and metal sinks with toilets attached.

“No window. No mirror. No clock. No concept of time,” she said. She was allowed to leave her cell for one hour a day. She could shower three times a week if staffers were available.

In the beginning, she replayed the traumatic memory of the night she lost her baby. Eventually, she joined in when other inmates screamed in their cells.

“I acted out. I threw stuff against the wall. I was angry,” she said. Before she went to sleep, she prayed for God to take her. “But I kept waking up.”

In Haney’s experience, prisoners who develop a strategy to withstand the excruciating loop of idleness have a better chance of surviving. Some individuals force themselves to maintain a routine, to act as if there is a coherence in their life, “even though there isn’t,” he said.

Winn said she developed a strategy: She would start the day by praying. She would picture what her two teenage sons were doing. She would do sit-ups and mental exercises, like remembering street names. After solitary, she served most of her sentence in a federal prison in Florida and was released in 2013.

Her time in solitary scarred her for life, she said. To this day, she has high blood pressure. Paranoia is a constant companion; her house is surrounded by a solid wooden fence with a security gate, and she has two Rottweilers. Small spaces make her anxious, and she can’t tolerate strangers getting too close, such as in a coffee shop line.

While she struggles to connect with her granddaughter, Winn keeps a journal, hoping that one day, when her granddaughter is old enough, she’ll understand.

“She can read it and learn about everything that’s in my heart and on my mind … if I’m still here, if I’m not here, wherever I am.”

Both Haney and Gregg said jails and prisons have alternatives to long-term, extreme isolation. Mentally ill prisoners who engage in disciplinary infractions should be put into a treatment-oriented unit, said Haney.

For someone who acts violently, solitary confinement should be only a short-term solution aimed at acutely de-escalating the outburst, said Gregg. Afterward, those individuals should go to units that provide programming to address the root cause of their behavior. This may mean separation from the general prison population, but less time in total isolation.

A similar model could also apply to prisoners in solitary for their own safety, such as former Minneapolis police officer Derek Chauvin, who is serving a 22½-year-prison sentence for the murder of George Floyd. They could be placed in smaller units with individuals who have undergone a thorough risk assessment, and with access to education and training, Haney said.

Prisoner advocates are hopeful that solitary confinement in the U.S. will eventually be a concept of the past. In April, New York became the first state to codify the U.N.’s Mandela Rules that ban solitary after 15 consecutive days, when the Halt Solitary Confinement Act was signed into law. The legislation will take effect next April.

After Winn’s release from prison, she founded RestoreHER, a nonprofit that advocates to end the mass incarceration of women of color, and pregnant people, in particular. She also helped enact laws in Georgia and North Carolina that bar the shackling of pregnant women.

“What I’m doing now gives me some redemption,” she said.

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When Billy Lemon was trying to kick his methamphetamine addiction, he went to a drug treatment program at the San Francisco AIDS Foundation three times a week and peed in a cup. If it tested negative for meth, he got paid about $7.

As the pandemic has raged, so has the country’s drug epidemic. Health officials have been struggling with methamphetamine and cocaine abuse, in particular, because of a lack of effective treatment for those stimulants.

Listen to Lemon’s story and to understand how California’s unconventional treatment works.

“For somebody who had not had any legitimate money ― without committing felonies ― that seemed like a cool thing,” said Lemon, who was arrested three times for selling meth before starting recovery.

The payments were part of an addiction treatment called contingency management, which gives drug users incentives ― money or gift cards ― to stay off drugs. At the end of 12 weeks, after all his drug tests came back negative for meth, Lemon received $330. For him, it was about more than just the money. It was being told: Good job.

Read the full story here.

This story is from a partnership that includes KQED, NPR and KHN.

April Dembosky, KQED:

@adembosky

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Kaitlyn Hevner expects to complete a 15-month accelerated nursing program at the University of North Florida in Jacksonville in December. For her clinical training this fall, she’s working 12-hour shifts on weekends with medical-surgical patients at a hospital.

But Hevner and nursing students like her who refuse to get vaccinated against covid-19 are in an increasingly precarious position. Their stance may put their required clinical training and, eventually, their nursing careers at risk.

In early September, the Biden administration announced that workers at health care facilities, including hospitals and ambulatory surgery centers, would be required to receive covid vaccines. Although details of the federal rule won’t be released until October, some experts predict that student nurses doing clinical training at such sites will have to be vaccinated, too.

Groups representing the nursing profession say “students should be vaccinated when clinical facilities require it” to complete their clinical training. In a policy brief released Monday, the National Council of State Boards of Nursing and eight other nurse organizations suggested that students who refuse to be vaccinated and who don’t qualify for an exception because of their religious beliefs or medical issues may be disenrolled from their nursing program or be unable to graduate because they cannot fulfill the clinical requirements.

“We can’t have students in the workplace that can expose patients to a serious illness,” said Maryann Alexander, chief officer for nursing regulation at the national council. “Students can refuse the vaccine, but those who are not exempt maybe should be told that this is not the time to be in a nursing program.”

“You’re going to go into practice and you’re going to be very limited in your jobs if you’re not going to get that vaccine,” Alexander said.

Kaitlyn Hevner, a nursing student at the University of North Florida, has opted not to get vaccinated against covid even though many medical facilities require it. She questions whether “we give up our own religious rights and our own self-determination just because we work in a health care setting.” (Robert Working)

Hevner, 35, set to finish her clinical training in early October, said she doesn’t feel it’s acceptable to benefit from a vaccine that was developed using fetal cells obtained through abortion, which she opposes. (Development of the Johnson & Johnson covid vaccine involved a cell line from an abortion; the Pfizer-BioNTech and Moderna mRNA vaccines were not developed with fetal cell lines, but some testing of the vaccines reportedly involved fetal cells, researchers say. Many religious leaders, however, support vaccination against covid.)

With vaccines for nursing students still optional in many health care settings, nursing educators are scrambling to place unvaccinated students in health care facilities that will accept them.

Down the coast from Jacksonville in Fort Pierce, Florida, 329 students are in the two-year associate degree nursing program at Indian River State College, said Roseann Maresca, an assistant professor who teaches third-semester students and coordinates their clinical training. Only 150 of them are vaccinated against covid, she said.

Not all of the eight medical facilities that have contracts with the school require student nurses to be vaccinated.

“It’s been a nightmare trying to move students around this semester” to match them with facilities depending on their vaccination status, Maresca said.

Commonly, health care facilities have long required employees to be vaccinated against various illnesses such as influenza and hepatitis B. The pandemic has added new urgency to these requirements. According to a September tally by FierceHealthcare, more than 170 health systems mandate covid vaccines for their workforces.

In May, the federal Equal Employment Opportunity Commission made it clear that under federal law employers can mandate covid vaccinations as long as they allow workers to claim religious and medical exemptions.

Under the Biden administration’s covid plan, roughly 50,000 health care facilities that receive Medicare or Medicaid payments must require workers to be vaccinated. Until the administration releases its draft rule in October, it is unclear how nursing students assigned to health care sites for clinical training will be treated.

But the federal rule published in August that lays out regulations for government hospital payments in 2022 offers clues. It defined health care personnel that should be vaccinated as employees, licensed independent contractors and adult students/trainees and volunteers, said Colin Milligan, director of media relations at the American Hospital Association.

In addition to staff members, the Biden plan says mandates will apply to “individuals providing services under arrangements” at health care sites.

A spokesperson for the Centers for Medicare & Medicaid Services declined to clarify who would be covered by the Biden plan, noting the agency is still writing the rules.

Nonetheless, vaccination mandates threaten to derail the training of a relatively small proportion of nursing students. A recent survey by the National Student Nurses’ Association reported that 86% of nursing students and 85% of new nursing graduates who responded to an online survey said they had been or planned to be vaccinated against covid.

But the results varied widely by state, from 100% in New Hampshire and Vermont on the high end to 63% in Oklahoma, 74% in Kentucky and 76% in Florida on the low end. The survey had 7,501 respondents.

Students who don’t want to be vaccinated are asking schools to offer them alternatives to on-site clinical training. They suggest using life-size computer-controlled mannequins or computer-based simulations using avatars, said Marcia Gardner, dean of the nursing school at Molloy College in Rockville Centre, New York.

Last year, when the pandemic led hospitals to close their doors to students, many nursing programs increased simulated clinical training to give nursing students some sort of clinical experience.

But that’s no substitute for working with real patients in a health care setting, educators say. State nursing boards permit simulated clinical study to varying degrees, but none allow such instruction to exceed 50% of clinical training, said Alexander. A multisite study found that nursing students could do up to half their clinical training using simulation with no negative impact on competency.

The policy brief by the council of state nursing boards states that nursing education programs “are not obligated to provide substitute or alternate clinical experiences based on a student’s request or vaccine preference.”

As more nursing students become vaccinated, the issue will grow less acute. And if the Biden plan requires nursing students to be vaccinated to work in hospitals, the number of holdouts is likely to further shrink.

Hevner, the University of North Florida student, said she’s not opposed to vaccines in general and would consider getting a covid vaccine in the future if she could be assured it wasn’t created using aborted fetal cells. She filed paperwork with the college to get a religious exemption from vaccine requirements. It turned out she didn’t need one because Orange Park Medical Center, where she is doing her clinical training, doesn’t require staffers or nursing students to be vaccinated against covid “at this time,” said Carrie Turansky, director of public relations and communications for the medical center, in Orange Park, Florida.

Although Hevner opposes getting the vaccine, “I take protecting my patients and protecting myself very seriously,” she said. She gets tested weekly for covid and always wears an N95 mask in a clinical setting, among other precautions, she said. “But I would ask: Do we give up our own religious rights and our own self-determination just because we work in a health care setting?”

She hopes the profession can accommodate people like her.

“I’m concerned because we’re in such a divisive place,” she said. But she is eager to find a middle ground because, she said, “I think I would make a really great nurse.”

Michelle Andrews:
andrews.khn@gmail.com,
@mandrews110

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Phebe Cox grew up in what might seem an unlikely mental health danger zone for a kid: tony Palo Alto, California, in the heart of Silicon Valley. But behind its façade of family success and wealth, she said, is an environment of crushing pressure on students to perform. By 2016, when Cox was in middle school, Palo Alto had a teen suicide rate four times the national average.

Cox’s family lived by the railroad tracks where many of the suicides occurred. She got counseling. But that option, she told KHN, is not always easily available to teens in crisis — and she and her peers regarded school mental health services as their last choice because of concerns about either confidentiality or anonymity.

A new program, designed largely by the people who use it, provides an alternative. Called Allcove, it offers standalone health and wellness sites to those ages 12 to 25, often on a walk-in basis, at minimal or no cost. Although Allcove is built to support a wide range of physical, emotional and social needs, its overarching goal is to deal with mental health challenges before they develop into deeper problems.

Allcove is yet in its infancy, with two sites just opened in the Bay Area and five more in the pipeline around California. It’s modeled on a 15-year-old program in Australia, Headspace, which has 130 such clinics. Headspace has inspired programs in other countries as well, including Jigsaw in Ireland and Foundry in Canada. All of them, including Allcove, also offer online and phone services.

Allcove’s core values resonate with Cox, now 19 and a student at Pitzer College in Claremont, California, and one of dozens of young people who have offered advice on the program’s structure and services.

“Right away, I knew it was going to be a big thing,” Cox said. “I felt pretty helpless as a young teenager, but Allcove is all about the students and the students’ needs.”

About half of all lifetime mental illness begins by age 14, and 75% before age 25, according to researchers. Yet access to mental health care in the U.S. is lacking. According to the National Alliance on Mental Illness, some 30 million adults and children with mental health conditions go without treatment, and 129 million people live in areas with shortages of mental health professionals. A 2017 survey found that Californians were five times more likely to go outside their private insurance network for mental health office visits than for medical or surgical needs.

Allcove meets some of that head-on by providing fully staffed safe spaces for teens and young adults to discuss and deal with their health, both mental and physical, along with substance misuse issues and educational support. California law allows those 12 and older to get outpatient mental health or counseling services without a guardian’s consent.

Allcove’s sites in Palo Alto and San Jose are filled with vibrant colors and plenty of open space, the result of input by a youth advisory group that numbers a dozen or more members and changes out about once a year. Inside Allcove, clients can access group or individual care, ask a doctor about a problem, and even get help preparing for college.

Unlike the Australian program, Allcove has no ongoing funding source yet. Allcove is “a really big lift, and we [at the state level] want to say, ‘How can we help you?’” said Toby Ewing, executive director of the California Mental Health Services Oversight and Accountability Commission, which administers the fund that seeded the first two sites with $15 million.

Funding eventually may come from a combination of state, private and nonprofit sources, as well as Medi-Cal reimbursements, said Dr. Steven Adelsheim, a psychiatrist who directs Stanford University’s Center for Youth Mental Health and Wellbeing.

Adelsheim previously spent nearly 30 years in New Mexico, helping that state build a network of school-based health centers. His experience convinced him that many students were likely to avoid mental health services at school. They were reluctant, he said, to discuss such issues with their own counselors, who might be the same people writing the students’ letters of recommendation for college and might unwittingly breach privacy.

That realization led Adelsheim in 2014 to get exploratory funding from the Robert Wood Johnson Foundation to create Allcove. (KHN, which produces California Healthline, also receives funding support from the foundation.) “There is a crying need in the U.S. to reach kids with early intervention and help,” Adelsheim said.

The idea struck a chord with Santa Clara County officials, who’d seen Palo Alto lashed by teen suicide clusters during the 2009-10 and 2014-15 school years. “The saddest part of the story is that a teen didn’t reach out earlier, didn’t have the opportunity to get help when and where they needed it,” County Supervisor Joe Simitian said in announcing Allcove’s opening in June. “The appeal of the Allcove model is it’s designed to engage young people who are struggling, long before they hit a crisis point.”

When Cox moved from middle school to Palo Alto’s Henry M. Gunn High School, her therapist told her about Adelsheim’s project and suggested Cox apply to be part of Allcove’s youth council. One of Cox’s contributions was to suggest weekday hours extending at least to 7 p.m., “because young adults are doing things and on the move all day. It’s the evenings — and even the weekends — when we’re dealing with things or feeling more helpless. For a lot of my friends, at night is when things can get overwhelming.”

Both Foundry, the Canadian program, and Allcove address physical health as well. Steve Mathias, CEO of Foundry, said his program’s emphasis is “on health and wellness, not just mental health, which is a part of wellness.” Said Adelsheim, “Sometimes a kid may come in with a physical complaint, and only after a few visits is the mental suffering brought out into the open.” When that happens, Allcove can make a “warm handoff” to a mental health specialist on-site.

The most significant difference between Headspace and Allcove may be funding. Headspace is part of the Australian government’s mental health initiative, and thus budgeted. Allcove is essentially building on the fly, and its long-term ability to grow will depend on money.

California’s Proposition 63, written in 2004 by then-Assembly member Darrell Steinberg (now the mayor of Sacramento), levies a 1% tax on personal incomes over $1 million to fund community mental health services. This year, the tax may yield $2.4 billion, Ewing said. Most of that goes to existing programs, but about 5% each year — more than $100 million in 2021 — feeds an innovation fund to encourage new approaches to mental health.

Santa Clara County got $15 million from that fund to launch Allcove. The state also has helped fund Allcove sites, in Sacramento, San Mateo and Orange counties, and two in Los Angeles County.

“We’ve made a $30 million-plus investment in this model,” Ewing said. “We are assuming that it’s going to be successful.”

Success, say Adelsheim and Cox, would mean the establishment of hundreds of Allcove centers up and down the state, readily available to young people. The hope is that, if it catches on, Allcove could become a well-known brand for young Californians — and, eventually, others around the country.

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

Mark Kreidler:

@MarkKreidler

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KHN Midwest correspondent Lauren Weber discussed how hospitals are dealing with covid-19 on WOSU’s “All Sides With Ann Fisher” on Tuesday. Weber also discussed the Food and Drug Administration’s approval of a covid vaccine booster on WAMU’s “1A” on Sept. 24.

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

• Click here to hear Weber on WAMU
• Read Weber’s “Over Half of States Have Rolled Back Public Health Powers in Pandemic”

KHN reporter Victoria Knight discussed doctors who spread covid misinformation on social media on Newsy’s “Morning Rush” on Tuesday.

• Click here to watch Knight on Newsy
• Read Knight’s “Will ‘Dr. Disinformation’ Ever Face the Music?”

KHN correspondent Rachana Pradhan discussed why President Joe Biden hasn’t yet nominated a permanent leader for the FDA on NPR’s “All Things Considered” on Monday.

• Click here to hear Pradhan on NPR
• Read Pradhan’s “Public Health Experts ‘Flabbergasted’ That Biden Still Hasn’t Picked an FDA Chief”

California Healthline correspondent Angela Hart discussed health care unions pushing for a single-payer system in the wake of California’s failed governor recall on Peacock TV’s “Reported With Sam Seder” on Sept. 23. (Note: To access the clip, you’ll be required to register for a free account and log in.)

• Click here to watch Hart on “Reported With Sam Seder”
• Read Hart’s “Health Care Unions Defending Newsom From Recall Will Want Single-Payer Payback”

KHN chief Washington correspondent Julie Rovner discussed the Centers for Disease Control and Prevention’s recommendation of covid vaccine boosters on KNX News Radio’s “KNX In Depth” on Sept. 23.

• Click here to hear Rovner on KNX News Radio

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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Journalists Drill Down on Covid Vaccine Boosters, Misinformation Online https://khn.org/news/article/khn-on-aircovid-vaccine-boosters-misinformation-online/

Anna Maria Barry-Jester

Two California public health officials who pressed forward with aggressive measures to contain covid-19 even while enduring death threats and harassment will be honored with the 2021 PEN/Benenson Courage Award from PEN America, the group announced Friday.

Mimi Hall and Dr. Gail Newel, health director and health officer, respectively, for Santa Cruz County, California, will be honored Tuesday at the PEN America Literary Gala in New York City. Newel was one of the first officials in the nation to institute a shelter-in-place order at the beginning of the pandemic, and under Hall and Newel, Santa Cruz has experienced some of the lowest covid case rates in the country, as well as one of the smallest gaps in vaccination by race or ethnicity.

“In a sea of denialism and pushback against credible science, Mimi Hall and Gail Newel are standard bearers for everyone who’s on the side of responsible public health messaging,” Suzanne Nossel, chief executive officer of PEN America, a nonprofit that advocates for freedom of expression, said in a statement.

Over the course of the pandemic, public health officers across the nation have become the face of local government authority. In turn, they have confronted rage and resentment from members of the public and become targets of loose-knit militia and white nationalist groups. Hall and Newel lived through such a scenario in Santa Cruz County, where legitimate debate over their covid-related public health orders devolved into vitriol and sinister intimidation.

Earlier this year, KHN profiled the women and their experiences in an online story, as well as an audio episode with “This American Life.” Both women soldiered on with their public health duties, even as their homes and families became targets of protest and violent threats and their daily routines morphed to incorporate security patrols and surveillance cameras.

“It’s not okay what’s happening now. I don’t think there’s any time other than now that I’ve actually been afraid for American democracy, and it’s highlighted and exacerbated by this assault on science and service,” Hall said in a statement. Both women said they are accepting the award on behalf of health officials across the country, many of whom risked losing their jobs if they spoke out.

In September, Hall tendered her resignation, joining more than 300 top public health officials who have resigned, retired or been fired during the pandemic, according to an ongoing KHN-AP analysis.

The PEN/Benenson Courage Award was created in 2015 to honor “exceptional acts of courage in the exercise of freedom of expression.” Previous winners include Darnella Frazier, the Minneapolis teenager who filmed the murder of George Floyd by a police officer; law professor and equal rights advocate Anita Hill; and Dr. Mona Hanna-Attisha and LeeAnne Walters, two women who helped expose the water crisis in Flint, Michigan.

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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Democrats on Capitol Hill missed their deadline to finish two huge bills that constitute the bulk of President Joe Biden’s domestic agenda, but negotiations continue over expansions to major health programs, as well as ways to rein in prescription drug costs.

Meanwhile, the Biden administration issued regulations to implement last year’s law to limit “surprise” medical bills to patients who get care outside their insurance networks. Health providers — doctors and hospitals — are already complaining that they will be asked to pick up too much of the bill to protect patients.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Tami Luhby of CNN and Kimberly Leonard of Insider.

Among the takeaways from this week’s episode:

• Progressive Democratic lawmakers successfully used their leverage to thwart passage of a bill funding traditional infrastructure projects before they secure a deal on spending for new and enhanced domestic policy initiatives. Negotiations might not move any faster, though, and it appears an ugly fight still looms over what could get cut from those domestic plans.
• One major debate seems to revolve around expanding Medicare benefits versus providing coverage to low-income people in the 12 states that refused to expand Medicaid under the Affordable Care Act. Medicare benefits might be a more popular lure with older voters, an important voting bloc, and Republicans would be less likely to come back later and overturn that initiative. Medicaid expansion, however, is an issue dear to many Democrats who see it as important to finishing the ACA legacy. They also say it may give Democrats in those 12 conservative states a good campaign hook.
• The rift between progressives and moderates over “social infrastructure” spending in the reconciliation bill has shed light on the difficult task of brokering major legislation. Clinching a spending bill for even $1.5 trillion would be an enormous accomplishment for the Democrats. But their infighting projects failure to the public. And that can have repercussions at the ballot box.
• New rules on protecting consumers from surprise medical bills — announced this week by the Biden administration — put limits on the arbitration process set up by the law passed by Congress last year. And those limits appear to favor the insurance industry over hospitals and other health care providers.
• A poll from KFF shows the big divide over vaccinations between Democrats and Republicans. Even former President Donald Trump, who was booed at a recent rally when suggesting that the audience get vaccinated, may not be able to bridge the gulf.
• One group that has been reluctant to get vaccinated are rural residents —a population also hit hard by the opioid epidemic. That crisis led many rural Americans to grow wary of the health care industry, which may influence their views on getting vaccinated against covid-19.
• The House last week passed a bill to codify a woman’s right to an abortion. It’s a landmark bill but likely to die in the Senate. Part of the problem for groups seeking to buttress the right to abortion is that states handle the issue so differently. In those conservative states where lawmakers are seeking to limit or deny access to abortion, the issue may be front and center. But many states have not restricted abortion facilities and people in those areas may not see the issue as imperative.

Also this week, Rovner interviews Anna Flagg, a data journalist for the Marshall Project, about a story she wrote on how a major medical education report from 1910 inadvertently contributed to racial inequities in health care that persist today.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Science’s “Top Secret: U.S. National Academy of Medicine Keeps Expulsions Quiet,” by Meredith Wadman

Alice Miranda Ollstein: The New York Times’ “‘Mandates Are Working’: Employer Ultimatums Lift Vaccination Rates, So Far,” by Shawn Hubler

Tami Luhby: The Wall Street Journal’s “Vaccination Status Is the New Must-Have on Your Resume,” by Patrick Thomas

Kimberly Leonard: Insider’s “Walmart’s Health Clinics Are Struggling With Basic Functions Like Billing, Imperiling the Company’s Push to Upend Care,” by Shelby Livingston

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And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

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Sarah Jane Tribble, Kaiser Health News

As President Joe Biden’s government overhaul stalls in Congress, tensions are mounting over what changes ― if any ― could come for Americans at the pharmacy counter.

The proposals in flux range from tinkering with tax credits to far-reaching changes in federal payments systems.

Pressure is building to contain costs that have skyrocketed over the past decade. In a recent Gallup poll, an estimated 18 million Americans said that within the previous three months they had been unable to pay for at least one doctor-prescribed medication.

The Biden administration has called for a plan that would allow Medicare to negotiate drug prices, cap out-of-pocket drug costs for beneficiaries while restricting price increases by drugmakers and ending their practice of paying rivals to delay the introduction of cheaper generic products.

Still, despite 2020 campaign promises to cut prices, Democrats have not coalesced around a plan as they seek to push through Congress a massive spending bill that would fund domestic policy initiatives, including new and enhanced health care programs. Party progressives focused on Medicare drug spending have supported a plan passed by the House last year that allows Medicare to negotiate prices. The Congressional Budget Office estimates it would save the government around $500 billion over 10 years.

Pharmaceutical executives have said lower drug prices would limit their industry’s ability to research and develop important new drugs.

“We cannot and will not support the very dangerous idea of allowing the government to simply set prices,” said Ken Frazier, executive chairman of Merck & Co., at a recent industry briefing. “That is not negotiation. It is not good for the future health of the American people or the economy.”

Given their razor-thin majority in Congress, Democrats cannot lose a single senator or more than three House members on a vote. Three House members ― Reps. Kurt Schrader (D-Ore.), Scott Peters (D-Calif.) and Kathleen Rice (D-N.Y.) ― last week voted against the drug pricing measure in committee, threatening to jettison it, although they have offered more restrained options. The Senate has yet to offer a proposal.

Paul Ginsburg, an economist and professor of health policy at the University of Southern California, said of the effort: “You can’t really do much to alleviate patients’ out-of-pocket burdens for prescription drugs without also addressing prices.”

The House Democrats’ proposals for the reconciliation package ― which would rein in drug pricing and provide money for use on other federal programs ― can be lumped into three buckets:

• Enabling Medicare to negotiate or limit drug prices.
• Putting caps on what people would pay out-of-pocket for drugs under Medicare’s Part D.
• Forcing pharmaceutical companies to pay rebates.

Rachel Sachs, a health policy and drug law expert at Washington University in St. Louis, summarized the package’s intent: “Companies should not be able to increase their prices more quickly than inflation or however much they want.”

In the rebate bucket, the legislation would require manufacturers to pay the government based on any increase in a drug’s price beyond standard inflation costs ― in simple terms, if the price is raised 10% and inflation is 3%, the manufacturer would be required to rebate the government 7%.

The proposal takes aim at drugs like AbbVie’s Humira, which reportedly has increased 470% since it entered the market in 2003. If approved, the rebate could send dollars back to enrollees through lower cost sharing and, in time, reduced Medicare Part D premiums, said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy.

“Even moderate Democrats seem to be on board with price cuts to the drugs that still have market exclusivity,” Adler said. “Largely because they’ve been playing games that sort of keep new biosimilars or competitors off the market.”

Another bucket would cap how much Medicare enrollees spend on drug coverage. Experts said it should have broad appeal. Currently, Medicare beneficiaries must pay out-of-pocket for the first $6,550 in drug costs each year, and then are responsible for 5% of any additional drug spending. There is no limit to how much they could pay.

In 2019, nearly 1.5 million Medicare Part D beneficiaries spent above the catastrophic coverage threshold. Patients taking expensive cancer drugs or rheumatoid arthritis medications quickly fall into this category.

“That portion of patients that hit the catastrophic coverage has been increasing every year, basically just because there are more drugs to market and there are more high-cost drugs,” said Lovisa Gustafsson, vice president of the controlling health care costs program at the Commonwealth Fund.

The final bucket calls for federal regulators to negotiate what Medicare pays for drugs. It sets a maximum price and a floor that the federal government is willing to pay for select high-cost drugs ― initially, Democrats had included a penalty for companies not willing to participate.

USC’s Ginsburg, a longtime Washington health policy expert, said putting negotiations ― or price ceilings, as he sees them ― on the table at all is “amazing.”

“The political boundaries on this policy area have really moved a lot in recent years,” Ginsburg said.

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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Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

This made me cry. I don’t think we understand yet the devastating impact this is having on our nurses, doctors, and other members of the healthcare workforce. At an Overrun ICU, ‘the Problem Is We Are Running Out of Hallways’ – Kaiser Health News https://t.co/ObOSEIHuvt

— Martha Carter (@mcarterwv) September 22, 2021

— Martha Carter, Culloden, West Virginia

Fractured Communication — Compounded

I wanted to thank and praise Nick Ehli for his touching, poignant, well-written and necessary article homing in on covid through the lens of a Billings, Montana, hospital (“Postcard From Montana: At an Overrun ICU, ‘the Problem Is We Are Running Out of Hallways,’” Sept. 22). Sadly, American’s moral compass has been smashed by the pressure of divisive and narcissistic propaganda. We are now splintered into tribes filled with anger, hate and distrust toward those who don’t share or respect our values.

The time when Democrats and Republicans once could laugh and talk about their differences and similarities is gone. It is as if we cannot love.

— David Miller, Normandy Park, Washington

So heartbreaking.Vaccine refusal is traumatizing a generation of health care workers right now. My heart aches for every HCW trapped in this terrible situation in Billings, MT. It didn’t need to be like this. https://t.co/1VTDXcsCws

— Jennifer Boeder (@jenniferboeder) September 22, 2021

— Jennifer Boeder, Los Angeles

Examining the US Health Care System

I just wanted to chime in on the article on covid tests in the U.S. (“Bill of the Month: A Covid Test Costing More Than a Tesla? It Happened in Texas,” Sept. 30). I am an expat living in Germany. When I read about these stories about the exploitation of the health care industry in the U.S., it does make me boil. It doesn’t have to be this way, really.

In Germany everyone pays into a “bucket,” then the costs are distributed. It is true that doctors here don’t make Hollywood salaries, but they make enough to own a Mercedes and a house in Tuscany.

“Me, me for myself, and I” culture in the U.S. is making lives harder for everyone. The media and policymakers should study the German health care model. It works and works well.

The covid test here? The PCR tests are free, and I can find them pretty much in every corner of the neighborhood. The rapid tests you find in every supermarket or drugstore. They cost less than 1 euro (about $1.16) per box.

The result? A healthy and happy society. Everyone benefits.

— Helen Antebi, Bonn, Germany

Can’t believe we have to say this – a #COVID19 test should never cost $54,000. It’s time to rethink our system.https://t.co/6LHdScFZC7

— We The Patients NY (@WeThePatientsNY) September 30, 2021

‘Bill of the Month’: Don’t Add to Billing Confusion

I would avoid calling an EOB (“explanation of benefits” notice) a bill. It’s not and says as much on the document. The public is already confused when it comes to managing their health care/insurance and your reporting inaccurately is not helping. We all expect more from NPR and KHN.

— Rory R. Stark, Garrison, New York

This reporter’s “mild” breakthrough infection was worse than the flu I had in 2012 that felt like I was on my deathbed.https://t.co/27470F2uPT

— Kori is Fully Vaccinated (but still masking 😷) (@koritiche) September 21, 2021

— Kori Tichenor, Scottsdale, Arizona

Time to Think of Covid as We Do Herpes

I’d like to comment on Will Stone’s great article about his breakthrough case of covid (“I Got a ‘Mild’ Breakthrough Case. Here’s What I Wish I’d Known,” Sept. 20). He said how after he got the vaccine he relaxed his protective standards and that is most likely the reason that he ended up getting covid. I’d like to say that what is not being communicated properly to the public is the difference between infection and disease. Infection is when a type of bacteria or a virus enters your system and starts to multiply, creating an immune response. Disease is when this causes cell breakdown or bodily damage leading to sickness. The covid vaccines are effective against disease, not infection.

Most people have been infected with the herpes virus. But not everybody gets the disease. The virus is dormant in your nervous system unless it’s stimulated to come out and cause a disease like a cold sore or other types of lesions. Similarly, with covid, you can get the infection and not know it, but the vaccine will protect you, for the most part, against severe disease and possibly death. That is why protective precautions such as masking and avoiding crowds, etc., are still required, especially because the delta variant is so much more contagious than previous iterations of the virus. You can become infected with the covid virus and remain asymptomatic and still be very contagious. So it’s great that you will likely not end up in the hospital, but someone you spread it to may not be so lucky.

And the more spread there is, the more likely that the virus will mutate and become even worse. There’s no way to stop this right now, but vaccination and social precautions are still needed in the near future.

It must be stressed that the vaccine can protect you against disease, not infection. And although the covid virus is expected to be cleared from your system like most respiratory viruses, possible latency and long-term effects are still being researched.

— Len Baskin, Montreal

– https://t.co/m2fZkWO1z7 Vaccines are saving lives and preventing serious illness. But they don’t prevent all transmission. Rapid tests give the best fast answers but false negatives will send far too many “test-to-stay” students back to school. Thoroughly exposed? Quarantine

— Jay Gordon, MD, FAAP (@JayGordonMDFAAP) September 20, 2021

— Dr. Jay Gordon, Santa Monica, California

Careful Not to Add Fuel to the Anti-Vaccine Fire

The article “Federal Vaccine Program Hasn’t Helped Those Whose Lives Were Altered by Covid Shot” (Aug. 18) is going to be front and center of my talk at the huge anti-vax rally in Orange County. Thank you for taking some of the wind out of the sails of those vaccine zombie makers. You couldn’t have run this at a better time. The lies about the delta and lambda variants were gaining traction. More people were getting vaccinated — can you believe that?! Thank you for being a beacon of truth against the so-called Scientific Community.

Seriously, this is an important topic, but do you really think that, during this new surge and the incredible importance of getting the population vaccinated, this was the proper time to publish this article? Do you ever consider the influence of your stories and your responsibility to the broader public? Or is it all about filling up content and the byline?

— Michael Dalali, Los Angeles

This article from a very pro vax site would indicate otherwise…complete denial of these cases is worse for govt credibility than CDC’s initial stance on masks. State the facts, even when they require explaining. https://t.co/uh9d56vKtw

— Joel Suiter (@suiterman88) August 25, 2021

— Joel Suiter, Minneapolis

Will Covid-19 Usher in a Single-Payer System?

I wanted to weigh in on last month’s opinion piece “Analysis: Don’t Want a Vaccine? Be Prepared to Pay More for Insurance” (Aug. 4).

The current utilization of emergency rooms, hospitalizations and intensive care units for covid-19 cases has been largely dedicated to unvaccinated individuals who prioritize personal freedoms above government mandates related to vaccination. Unfortunately, what anti-vaxxers seemingly don’t realize is that their refusal to get vaccinated is only supporting the political agenda to push for a single-payer health care system in the U.S.

As long as variants of covid are rampant, hospitals will continue to financially suffer due to limited utilization of elective profitable service lines, while our aging communities simultaneously suffer as covid drives down needed interventions for the burgeoning amount of new and existing chronic illnesses.

Clinicians’ lack of revenue coupled with America’s aging population, the worsening state of chronic illness and lack of personal accountability creates a perfect storm where employers will no longer be able to afford to offer insurance benefits to their employees.

Employers are already paying for health care in at least three ways: employee health care benefits, Medicare tax and now the cost of lost business due to the pandemic. The cost of commercial health insurance will continue to rise as employer-sponsored health insurance is typically used to cover a clinician’s financial losses from government-funded insurance. And those rising costs are correlated with the imbalanced growth of the government-funded patient population compared with those on employer plans. None of this is mathematically sustainable, and there will be only one option to choose when the system nears implosion — single-payer.

Unvaccinated individuals who demand less government involvement in today’s health care sector are ultimately supporting a political and mathematical agenda that will lead to more government involvement in the future of health care.

— Jeb Dunkelberger, CEO of Sutter Health-Aetna, Sacramento, California

The willfully unvaccinated should be shunned.They should be treated like lepers.They should lose their jobs.Consequences.https://t.co/k91VsxwSSt

— The Hand That Feeds You (@HandFeeds) September 21, 2021

— Grey Parker, Evanston, Illinois

Seeing Clear to Loosen Prior Authorization Policies

Even before hospitals had to delay surgeries due to covid-19 (“Covid-Overwhelmed Hospitals Postpone Cancer Care and Other Treatment,” Sept. 17), many patients were already experiencing care disruptions due to restrictive insurance prior-authorization policies.

On July 1, Aetna hastily rolled out a new policy requiring insurance preapproval on all cataract surgeries. The policy wreaked immediate havoc, causing as many as 20,000 cataract operations to be delayed in July alone. For Aetna to delay these sight-restoring surgeries at any time, but especially during a pandemic that has upended surgical operations in hospitals across the country, is dangerous and irresponsible.

With hospitals’ surgical backlog growing, Aetna must reverse its prior-authorization policy immediately. Further, Congress must put reasonable guidelines on the prior-authorization process to hold insurers accountable. I urge all our lawmakers in Washington to support the bipartisan Improving Seniors’ Timely Access to Care Act of 2021.

— Dr. Kevin M. Miller, chair of the American Society of Cataract and Refractive Surgery (ASCRS) Cataract Clinical Committee, Los Angeles

How everything is interconnected. More so in a pandemic. When hospitals are overwhelmed with COVID care of other disorders for people in that community is affected. @ErikMNeumann @JPRnews @KHNews https://t.co/qasfQhTee0

— Vincent Rajkumar (@VincentRK) September 17, 2021

— Dr. Vincent Rajkumar, Rochester, Minnesota

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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Readers and Tweeters Feel Americans’ Pain https://khn.org/news/article/letters-to-editor-readers-feel-pain-of-fellow-americans-september-2021/

Miranda Green

When triple-digit temperatures hit the Pacific Northwest this summer, the emergency room at Seattle’s Harborview Medical Center was ill prepared. Doctors raced to treat heat-aggravated illness in homeless people, elderly patients with chronic ailments, and overdosing narcotics users.

“The magnitude of the exposure, this was so far off the charts in terms of our historical experience,” said Dr. Jeremy Hess, an emergency medicine physician and professor of environmental and occupational health sciences at the University of Washington.

Doctors, nurses and hospitals increasingly are seeing patients sickened by climate-related problems, from overheating to smoke inhalation from wildfires and even infectious diseases. One recent assessment predicts annual U.S. heat deaths could reach nearly 60,000 by 2050.

For some medical professionals, this growing toll has stimulated a reckoning with the health care industry’s role in global warming. U.S. hospitals and medical centers consume more energy than any industry except for food service, according to the U.S. Energy Information Administration. Hospitals consume 2.5 times as much energy per square foot as typical office buildings, on average. They also contribute mountains of medical waste and emit atmosphere-damaging gases used in surgery and other procedures.

But the health care sector is beginning to respond. The Health and Human Services Department’s newly created Office of Climate Change and Health Equity, in addition to focusing on climate-related illness, says it will work “to reduce greenhouse gas emissions and criteria air pollution throughout the health care sector.” The office could help change regulations that restrict sustainability efforts, climate activists say.

Already, many U.S. hospitals have begun installing solar panels, while others are trying to cut surgical waste and phase out ozone-damaging chemicals. Activists are pressing for the industry to cut back on energy-intensive protocols, such as ventilation requirements that mandate a high level of air circulation, measured as air changes per hour. They say they could be reduced without harming patients.

“I think there is recognition among physicians that climate change is likely to continue and worsen over time,” said Hess. “We don’t necessarily do as much as we could otherwise to reduce our footprint and advance sustainability, and that’s where I’d like to see our health systems go.”

But the industry is moving cautiously to avoid harm to patients — and legal liability. They “don’t want to make any mistakes. And part of not making mistakes is a resistance to change,” said Dr. Matthew Meyer, co-chair of University of Virginia Health’s sustainability committee.

The University of Vermont Medical Center was one of the first U.S. hospital systems to focus on sustainability initiatives. It has succeeded in reducing emissions by roughly 9% since 2015 by renovating and building structures to be more energy-efficient and converting off-site medical centers to run 50% on renewable natural gas. One of its hospitals cut waste by more than 60% through reuse and recycling.

Managed-care nonprofit Kaiser Permanente, meanwhile, has focused on greening its energy consumption. By September 2020, all of its 39 hospitals and 727 medical offices had achieved carbon neutrality. At most Kaiser Permanente hospitals, solar panels provide one-quarter to one-third of energy needs.

Kaiser Permanente aims eventually to generate enough electricity through solar technology to eliminate the need for diesel-powered backup generators at its hospitals, which are heavily used in areas with stressed power grids. In 2017 and 2019, power company shut-offs in California forced the health network to evacuate its Santa Rosa Medical Center, and electricity was cut to its Vallejo Medical Center.

“To have those facilities be out for a week or more is just not tolerable,” said Seth Baruch, Kaiser Permanente’s national director for energy and utilities.

Increased energy sustainability has brought a small financial windfall. Kaiser Permanente saves roughly $500,000 a year in electricity costs through its grids and solar panels, Baruch said. (KHN is not affiliated with Kaiser Permanente.)

Reaching consensus on emission-lowering steps can be difficult. It took seven months for UVA’s Meyer, an anesthesiologist, to persuade his hospital to phase out most uses of desflurane, a common anesthetic that damages the ozone layer and is a potent greenhouse gas.

Meyer argued other drugs could replace desflurane. But critics warned that the most common alternatives slowed patients’ postoperative recovery, when compared with desflurane. They said there were ways to neutralize excess desflurane in operating room air without discontinuing it entirely.

The “first do no harm” ethos of medicine can also be an obstacle to the reduction of medical waste. The Joint Commission, which accredits more than 22,000 U.S. health care organizations, has in recent years pushed for hospitals to use more disposable devices instead of sanitizing reusable devices.

The commission’s primary objective is to cut hospital infections, but more disposable items means less sustainability. About 80% of U.S. health care sector emissions arise from the manufacturers, and their suppliers and distributors, including the production of single-use disposable medical equipment, according to a study.

Complicating the issue, ethylene oxide — a chemical the Food and Drug Administration requires for sterilization of many devices — has been categorized as a carcinogen by the Environmental Protection Agency. In 2019, health concerns led communities to push for the closure of facilities that use the gas, which threatened to create a shortage of clean medical devices.

Maureen Lyons, a spokesperson for the Joint Commission, said the private accreditor lacks the authority to change regulations. The procurement of disposable versus reusable devices is a supply chain issue, “not one that the Joint Commission is able to evaluate for compliance.”

For this reason, health care activists are lobbying for sustainability through policy changes. Health Care Without Harm, an environmental advocacy group, seeks to undo state rules that impose what it sees as excessively energy-intensive ventilation, humidification and sterilization requirements.

In California, the group has sought to change a medical building code adopted statewide in July that will require a higher ventilation standard at health care facilities. The group says the new standard is unnecessary. While high rates of circulation are needed in intensive care units, operating rooms and isolation chambers, there is no evidence for maintaining such standards throughout a hospital, said Robyn Rothman, associate director of state policy programs at Health Care Without Harm. She cited a 2020 study from the American Society for Health Care Engineering.

Hospital groups have resisted sustainability commitments on the grounds they will bring more red tape and costs to their hospitals, Rothman said.

The American Society for Health Care Engineering, a professional group allied with the American Hospital Association, has developed sustainability goals for reducing emissions. But existing regulations make it difficult to achieve many of them, said Kara Brooks, the group’s sustainability program manager.

For example, the Centers for Medicare & Medicaid Services requires hospitals that treat Medicaid and Medicare patients to have backup diesel generators.

“Hospitals will not be able to eliminate their use of fossil fuels based on the current regulations,” Brooks said, but “we encourage hospitals to work toward their goals within the parameters given.”

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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