A review of state distribution plans reveals that officials don’t know how they'll deal with the difficult storage and transport requirements of Pfizer's vaccine, especially in the rural areas currently seeing a spike in infections.
This article was published on Tuesday, November 10, 2020 in ProPublica.
As the first coronavirus vaccine takes a major stride toward approval, state governments’ distribution plans show many are not ready to deliver the shots.
The challenge is especially steep in rural areas, many of which are contending with a surge of infections, meaning that access to the first batch of COVID-19 vaccines may be limited by geography.
Pfizer announced Monday that its vaccine demonstrated more than 90% effectiveness and no serious bad reactions in early trial results — an impressive outcome that will pave the way for the company to seek an emergency authorization once it collects more safety data for another week or two. But establishing that the vaccine is safe and effective is just the first step.
The Pfizer vaccine is unusually difficult to ship and store: It is administered in two doses given 28 days apart, has to be stored at temperatures of about minus 100 degrees Fahrenheit and will be delivered in dry ice-packed boxes holding 1,000 to 5,000 doses. These cartons can stay cold enough to keep the doses viable for up to 10 days, according to details provided by the company. The ice can be replenished up to three times. Once opened, the packages can keep the vaccine for five days but can’t be opened more than twice a day. The vaccine can also survive in a refrigerator for five days but can’t be refrozen if unused.
Health officials haven’t figured out how to get the ultracold doses to critical populations living far from cities, according to a ProPublica review of distribution plans obtained through open records laws in every state. Needing to use 1,000 doses within a few days may be fine for large hospital systems or mass vaccination centers. But it could rule out sending the vaccine to providers who don’t treat that many people, even doctors’ offices in cities. It’s especially challenging in smaller towns, rural areas and Native communities on reservations that are likely to struggle to administer that many doses quickly or to maintain them at ultracold temperatures.
The government’s vaccine program, Operation Warp Speed, has projected optimism about its readiness to distribute the vaccine. On Monday, Gen. Gustave Perna told NPR, “I think we’re in a good place,” saying that “with the right planning, we can execute it with zero loss of vaccine.” But the federal program is only going to be responsible for delivering vaccines to the states, which must then figure out on their own how to get the shots to the people who need them most. The Centers for Disease Control and Prevention asked each state to turn in distribution plans on Nov. 2, imagining a scenario in which a vaccine with Pfizer’s specifications came first.
ProPublica obtained full preliminary plans for 47 states (Hawaii, Pennsylvania and Minnesota say they’re still working on theirs). Many struggled with how to handle a Pfizer-like vaccine. Washington state’s Health Department does not have its own warehouse that can store the Pfizer vaccine at a cold enough temperature. Arizona expects the Pfizer vaccine cannot be handled by the state’s rural communities and tribal lands. North Dakota and Oregon aren’t sure how to take care of migrant workers. Kansas’ plan appears to mistakenly assume shipments will be far smaller than 1,000 doses. Georgia’s Public Health Department is relying on local districts and counties to work out their own details.
“Early, when we don’t have lots of doses, I frankly do not anticipate that vaccine will be widely available in every rural community,” Dr. Amanda Cohn, chief medical officer for the CDC’s Vaccine Task Force, said during a call on vaccine implementation planning with rural stakeholders on Nov. 3. “The first couple months will be not ideal, but we really want to listen to our rural partners and understand what we can do to make it better,” she added.
The concern is most pronounced in places like Mt. Vernon Countryside Manor, a nursing home in southern Illinois more than 100 miles from the nearest major city, where the staff is working to contain the facility’s first COVID-19 outbreak. Glenda Lee Young, a nurse at the home, said four residents and an employee tested positive for COVID-19 in recent weeks. The sick have been isolated from the other 70 elderly residents, and are recovering.
The surrounding county has a fatality rate of 4.5%, more than double that of Illinois as a whole, according to data from the Johns Hopkins University COVID-19 dashboard. The staff at Mt. Vernon is eager for a vaccine to help them and their residents. Illinois’ distribution plan includes health care workers and people 65 years and older among the first groups to be immunized.
“Our people would not travel,” Young said. “If a vaccine becomes available, it would have to come to us.”
However, Illinois’ plan does not specify how shots will be provided to rural parts of the state that may not have enough people or ultracold storage. The state’s Department of Public Health didn’t immediately respond to a request for comment.
Young said she was not surprised by the state’s silence on rural vaccine access. “We get the shaft on a lot of stuff.”
Officials Are Trying to Hit “a Moving Target”
Health officials stressed that the plans are still evolving as they receive changing information. Even though Pfizer’s vaccine has long been seen as the likely front-runner, details from the trial, including the vaccine’s efficacy in specific populations like the elderly, have yet to be published. Shipping and storage logistics are also expected to continue to be fine-tuned with each passing week.
“It’s a moving target,” Dr. Philip Huang, director of the Dallas County Health and Human Services Department, said. “There’s new info every day.”
The changing details make it harder to plan, and some officials acknowledged they haven’t gotten very far.
“There are too many variables still to be worked out at the federal level,” a spokeswoman for the Georgia Department of Public Health said by way of declining an interview request for this article. “Much of what happens going forward will depend on the vaccine itself, when we receive it and what the protocols will be for prioritizing distribution among various populations.”
The problem with waiting for details on the vaccine to be revealed is that mass immunization is a multilayered process, involving public communication campaigns, ordering of equipment, hiring of staff, training of vaccine providers and the added complexity, in this pandemic, of making sure all vaccine sites are safe and won’t contribute to the spread. Operation Warp Speed has said its goal is to begin shipping the day that a vaccine is given the green light by the FDA, so states need to be ready at any moment.
For the initial months after the Food and Drug Administration signs off on a vaccine, the CDC advised state and local health authorities to prioritize health care workers, then move on to other essential workers and at-risk populations such as nursing home residents. Access would expand to the general public as manufacturing ramps up to make more doses available.
But there are a lot of details left to determine within those broad categories. Some health care workers have more exposure than others; North Dakota wants hospitals to document how they decided whom to vaccinate first. Maryland is prioritizing people in jails and prisons (where sharing close quarters has led to severe outbreaks), but states like Idaho and Mississippi have scheduled them for later. Arkansas, which has a large chicken industry, considers meatpacking workers to be essential. Oklahoma is prioritizing its long-term care population. Some states stressed communities of color, which have been disproportionately sickened and killed by the virus. “We are currently in the midst of a social justice movement across the county,” Kentucky’s plan notes.
Rural Communities Are “the Greatest Challenge”
Across the country, authorities are grappling with how to accommodate the Pfizer vaccine’s finicky specifications. So far, state plans show few have come up with clear solutions. Oregon, for instance, said it still needs to “develop [a] plan” for how to handle 1,000-dose orders in “remote Oregon locations, while maintaining the ultracold chain and avoiding wastage.”
Perna, the general leading logistics for Operation Warp Speed, told NPR that it’s up to states to buy more freezers. That contradicts the CDC’s instruction to not invest in more equipment. But many states said they’re doing so anyway, or at least looking into it. They’re also taking stock of what facilities already exist in their states at hospitals and universities, or where they can get dry ice.
North Dakota, where the virus has killed roughly 1 out of every 1,200 people, is considering whether to break down the 1,000-dose packages and, on its own, distribute smaller quantities to individual hospitals and clinics.
“The greatest challenge will be to moving small amounts of vaccine to widely scattered locations during Phase 1 since only a small percentage of the small population will be eligible for the vaccine,” the state’s plan said. It describes one health district that has three hospitals, two of which are more than an hour’s drive away from the nearest city via a two-lane road, and eight long-term care facilities that are even more remote. “Reaching small populations without redistribution may not [be] possible.”
Even in the case where prioritized health care workers were physically capable of driving themselves to the city to get a vaccine, relying on doctors and nurses to get themselves to a vaccine “doesn’t compute,” said Tim Size, executive director of the Rural Wisconsin Health Cooperative, which represents 43 rural acute hospitals. Wisconsin is battling its worst outbreak of the pandemic, and every hospital is stretched thin on staff, he said. Requiring everyone to take time off, twice, to get the Pfizer vaccine “means two days of lost staff time at a time we’re desperately short of staff.”
Size urged Pfizer to figure out a way to package its vaccine in smaller shipments so it could be delivered directly to rural hospitals. A spokeswoman for Pfizer declined to comment on whether the company is working on that.
Later vaccines will likely have less onerous storage requirements, and at least one, made by Johnson & Johnson, only requires one dose instead of two, so many states are hoping to have multiple options to work with that may make it easier to reach remote populations.
Some states appeared to be avoiding the issue of Pfizer’s packaging for now. The Kansas Department of Health and Environment’s plan assumes any approved vaccine will be “available in minimal quantities such as 100 doses per order.” Kansas’ department did not respond to requests for comment.
“If Pfizer comes out and says they’re going to provide doses of 25 instead of 1,000, that’s a game changer,” said Imelda Garcia, associate commissioner for the Texas Department of State Health Services’ Division for Laboratory and Infectious Disease Services. “The manufacturers were imagining mass vaccination efforts and not really thinking about rural areas. We’ve been pushing pretty hard at the federal level for them to provide smaller packages. We don’t know if that will occur or not.”
As Texas and other states consider the need to break down the 1,000-dose packages into smaller shipments, that’s an additional cost that they’d have to shoulder, since the federal government will only pay to move the vaccines once. Several states identified funding as a major problem.
Virginia’s plan included a “preparedness gap analysis” that estimates that it will need $71 million to establish and operate mass vaccination clinics, which would include hiring temporary staff and covering facility rental costs, translation services, signage and other operating costs.
The plan also calls for a further $2.5 million in equipment such as refrigerators and thermometers and $3 million for public education, including TV, radio and social media ads, as well as “targeted outreach to clinicians, vulnerable populations and other key groups.”
CDC Director Robert Redfield has said Congress will need to provide up to $6 billion for vaccine distribution, but funding negotiations stalled ahead of the election. To date, the federal government has allocated 3% of that amount, $200 million, to the states to immunize the nation.
Much of the implementation will spill into the next administration. President-elect Joe Biden on Monday named a team of public health experts to advise him on the COVID-19 response. But so far the Trump administration is refusing to cooperate with the transition.
Experts who study the way we think and make decisions say that it can be more than politics driving our decision-making this year. The unprecedented nature of the pandemic undermines how we process information and assess risk. Need proof? Look around.
This article was published on Monday, November 2, 2020 in ProPublica.
It was mid-February and Maria Konnikova — a psychologist, writer and champion poker player — was on a multicity trip. From her hotel room in New Orleans, she called her sister, a doctor, to discuss the emerging COVID-19 pandemic. Konnikova saw there were early cases in Los Angeles, where she was headed for a poker tournament.
The odds of Konnikova getting infected or spreading the virus by participating in a large indoor event were unknown. But as a poker player she had a lot of experience thinking through the probable risks associated with different decisions. So she played it conservatively. She cut short her trip and went home to quarantine in New York.
Konnikova’s psychology expertise tells her that most people have a hard time thinking through the uncertainty and probabilities posed by the pandemic. People tend to learn through experience, and we’ve never lived through anything like COVID-19. Every day, people face unpleasant and uncertain risks associated with their behavior, and that ambiguity goes against how we tend to think. “The brain likes certainty,” she said. “The brain likes black and white. It wants clear answers and wants clear cause and effect. It doesn’t like living in a world of ambiguities and gray zones.”
Many months into the pandemic, even as the nation faces its highest average daily case counts to date, people still don’t agree on how to live in the era of COVID-19. We know how to protect ourselves — washing our hands, wearing masks and staying socially distant — but many people still take unnecessary risks, even at the highest levels of government.
In late September, the White House hosted an indoor party celebrating the nomination of Judge Amy Coney Barrett to the Supreme Court. It became a possible superspreader event because attendees did not wear masks and ignored social distancing recommendations. Former New Jersey Gov. Chris Christie didn’t wear a mask at the event. He also went without one when he helped President Donald Trump prepare for his first debate. Christie later spent a week in intensive care with COVID-19 and then wrote an opinion article in The Wall Street Journal titled “I Should Have Worn a Mask.” “I let my guard down,” he wrote.
The U.S. Centers for Disease Control and Prevention called on Americans to wear masks in July. So why is it so hard for people to mask up and practice other established behaviors to prevent the spread of COVID-19? The problem, experts who study the way we think say, is that the unprecedented nature of the pandemic makes us vulnerable to subtle biases that undermine how we process information and assess risk. Our brains can play tricks on us. That causes some people to underestimate their risk, the experts said.
When Las Vegas reopened, crowds showed up without masks. An estimated 365,000 people attended the annual Sturgis Motorcycle Rally in South Dakota. Many didn’t wear helmets or masks. The festivities included a non-socially distanced concert by Smashmouth. And even though masks were distributed and required at a recent Trump campaign rally in Erie, Pennsylvania, some attendees did not wear them, and the campaign packed people into crowded buses.
It may not always seem like it, but people are rational and weigh the costs and benefits when they make decisions, said Eve Wittenberg, a decision scientist at the Center for Health Decision Science at the Harvard T.H. Chan School of Public Health. “People are not stupid here,” she said. But they have no experience thinking through a pandemic and are also getting mixed and conflicted messages from leaders, she said. That creates uncertainty and can lead people to rely on patterns of risk perception that may not be accurate.
The Power of Social Norms and Personal Experience
People may be more likely to participate in riskier activities because they tend to behave according to the norms that surround them, said Lisa Robinson, a senior research scientist at the Center for Health Decision Science. If we’re surrounded by people who behave a certain way, she said, we are more likely to behave the same way.
At this point the facts about COVID-19 are well established. It’s extremely contagious and transmitted via droplets that come from an infected person’s mouth or nose. This can happen during speech, coughing, sneezing or breathing — whether a person is experiencing symptoms or not. Older and sicker people are at higher risk of serious illness or death. But young, healthy people can still become infected and sick, and they can also put others at risk by spreading the virus.
A well-known historical example of people being directed by social norms is smoking, Robinson said. For decades the societal norm said smoking was cool, even after it was known to kill people. That contributed to a lot of people smoking, willing to take the risk. Then the norm flipped and smoking became uncool, and fewer people smoked. “We take a lot of cues from our environment,” Robinson said. “If I see a lot of people wearing a mask, I wear a mask.”
Betsy Paluck, a professor of psychology and public policy at Princeton University and MacArthur “Genius” Fellow, studies how these social norms are formed and how they shift over time.
“There’s a lot of competing information out there,” Paluck said. “Your individual decisions are very real to you, of course, but they need to be validated by other people in your neighborhood, your organization.”
Paluck said everyone is influenced by social norms, including her. She has a newborn and elderly parents, so she’s been cautious during the pandemic. But it’s getting harder to be careful as people broaden their social lives.
She talked recently to a friend who is holding her kids out of school, opting for all virtual instruction. The friend’s decision felt like a huge relief because it affirmed Paluck’s own feelings. It showed her how much we all rely on our shared reality. “Holding the line on your own is just not tenable,” she said.
Personal experience also has an outsized role in decision-making. People who were in the hot zones of New York City and New Jersey during the initial spread of COVID-19 witnessed the effects of the virus. They may have become infected themselves or known others who became sick or even died. They might have known health care workers who cared for the sick, potentially exposing themselves in the process. Meanwhile, people in parts of the country that have not been hit hard by the virus might not have had that experience and therefore fail to appreciate the risk.
Poker players, along with folks like meteorologists, horse race handicappers and lawyers who work on a contingency basis are routinely rewarded or punished based on the odds. This gives them a rare visceral, experiential understanding of percentages and lets them short-circuit a cognitive effect called the “description-experience gap,” which leads people to underestimate risk based on their own personal experiences.
Even Nobel Prize-winning economists are susceptible to it. The pandemic is beyond the limits of human intuition, said the psychologist and economist Daniel Kahneman on Konnikova’s podcast.
Wittenberg pointed to the work of Kahneman and Amos Tversky, who coined the term “availability” to describe how we base our thinking on what we’ve seen or experienced. We see it show up when a person assesses his or her risk of a heart attack by recalling instances among acquaintances, the two researchers wrote in their 1974 paper, “Judgment Under Uncertainty.”
The researchers also noted how some instances might come to mind more easily than others and thus get more heavily weighted in decision-making. Other instances might be more salient or may have happened more frequently, so they come to mind faster. Relying on “availability” to make decisions introduces biases, according to Kahneman and Tversky. “It is a common experience that the subjective probability of traffic accidents rises temporarily when one sees a car overturned by the side of the road,” the researchers wrote.
The Need for Leaders and Institutions to Guide Us
The confusion surrounding COVID-19 was magnified by a lack of testing in the early days of the pandemic and then delays in test results, Wittenberg said. That meant people didn’t have clear data to anchor their risk assessment.
The confusion called for leaders to guide the public with clear public health messages, but instead they have exacerbated the problems. It was well known relatively early in the pandemic that wearing a mask could help prevent the spread of the virus, but it took until July before Trump wore one in public for the first time. Some governors have downplayed the risk posed by the virus, others have emphasized it. That’s left the public “grappling with mixed and conflicted messages,” Wittenberg said.
Baruch Fischhoff, a psychologist who studies risk and decision-making at Carnegie Mellon University, said people are good at perceiving risk if they are getting information from a trustworthy source. But the risks associated with the coronavirus, which is invisible, are not intuitive, he said. It’s hard for people to project the exponential spread of the virus, he said. Our minds don’t easily extrapolate it, so we need leaders to help protect us from ourselves, he said.
The situation could be compared to how the government protects people at train crossings, Fischhoff said. Drivers are good at estimating the speed of other cars. But research from accidents at train crossings has shown that drivers are not good at estimating the speed of oncoming trains, which are much bigger. “Our brains are calibrated to treat a train like a car,” he said, “but it’s going faster than it looks.”
To stay safe from an oncoming train, drivers either need to go against their intuition, have someone warn them in a way they will remember or have something block the crossing when a train approaches. “Somebody needs to protect you,” he said.
Good public health communication requires testing messages to make sure they are interpreted correctly by a wide range of people, Fischhoff said. “Our official communicators have dropped the ball, and they have been undermined by people who don’t have the public’s interest at heart,” he said.
Paluck, the social psychologist, said certain leaders and influencers stick out like bright colors. They’re charismatic and we look to them when we check our own behavior. “What they say and do becomes the anchor we use,” she said.
People also put faith in trustworthy institutions, she said, even when they may not agree with what the institution is saying. She and a colleague found something suprising when they studied the effect of the Supreme Court legalizing same-sex marriage. A greater number of people supported same-sex marriage because of the Supreme Court’s decision, even if they had not changed their personal views. “They thought that there was a bigger consensus in the United States that same-sex marriage was a good thing,” Paluck said. “So that’s the power of an institution.”
Optimism Bias and Why Institutions Failed to Act
Optimism bias is a pattern of thinking that causes our brains to see future outcomes as rosier than they really are. It transcends gender, culture and age. It turns out to be incredibly helpful in most situations. There’s only one subset of the population that doesn’t experience optimism bias, Konnikova said — people suffering from depression.
“This is actually something that’s very psychologically protective,” she said. “It ends up that seeing the world as it is makes you clinically depressed.”
When it comes to institutional behavior, however, optimism bias can lead to poor planning and risky decision-making.
Dr. Eric Toner is a senior scholar at the Johns Hopkins Center for Health Security and says that the pandemic has taught him about the power of denial. The global public health community learned in mid-January about the extent of community transmission of the novel coronavirus in Wuhan, China, Toner said. The most obvious sign of concern, he said, came when China took the dramatic step of locking down Wuhan, one of its largest cities. Something really bad is happening, he thought to himself.
And yet, public health officials in the United States were slow to sound an alarm. “People have trouble recognizing when they’re facing a catastrophic threat and on the other hand they exaggerate minor threats,” Toner said. “We needed messaging from the top of the government that says this is a serious threat.”
“Until you hear the message from somebody who is in a position of authority, I think there is a tendency to really want to not believe it. People don’t want to believe really bad news.”
Toner said the Center for Health Security heard over and over again that hospital CEOs would not be convinced of the dire threat posed by the pandemic until the federal government decided to say something. But by then much time had been lost.
When public health officials did sound an early alarm, their voices were squelched. Dr. Nancy Messonnier, one of the senior leaders at the CDC, warned on Feb. 25 that there would be community spread of the virus, and that protective measures might include school closures and working from home. As ProPublica previously reported, her comments caused the stock market to drop, which infuriated Trump. Vice President Mike Pence was installed as communicator-in-chief, and the CDC officials were sidelined. “When it mattered most, they shut us up,” a senior CDC official told ProPublica.
Toner’s group is in charge of designing pandemic preparedness exercises. Some of them are eerily similar to our current situation. He said he’s often asked how it’s possible that we did all these exercises and still had such a bad response to the COVID-19 pandemic. His answer: The exercises advanced the field, but they had their limits. “They didn’t inoculate us against really bad decision-making,” he said.
Dr. Mark Zucker was put on administrative leave after ProPublica showed he told staff to keep a heart transplant patient on life support because of concerns about survival stats. Now Newark Beth Israel will seek a new leader for the program.
This article was published on Friday, October 30, 2020 in ProPublica.
Dr. Mark Zucker, director of Newark Beth Israel Medical Center’s heart transplant center, is departing after a yearlong administrative leave, the New Jersey hospital said Friday.
“Dr. Zucker and the leadership of NBIMC and RWJBarnabas Health have mutually agreed that this is an appropriate time for a formal leadership transition in the Medical Center’s transplant program,” Newark Beth Israel said in a statement. RWJBarnabas Health is the parent health system of the hospital.
Zucker went on administrative leave last year following an Oct. 3, 2019, report by ProPublica that revealed he instructed his staff to keep a patient named Darryl Young on life support and not to discuss options such as hospice care with his family until the one-year anniversary of his surgery. Young suffered brain damage during heart transplant surgery in September 2018 and never woke up.
According to current and former employees, as well as audio recordings of transplant team meetings, Zucker was concerned about the program’s one-year survival rate — the proportion of people undergoing transplants who are still alive a year after their operations. Newark Beth Israel’s one-year rate for heart transplants had dipped below the national average, and Zucker was concerned that the program might attract scrutiny from federal regulators.
Spurred by ProPublica’s articles, a subsequent investigation by the Centers for Medicare and Medicaid Services in December 2019 found that the transplant program placed patients in “immediate jeopardy,” the regulator’s most serious level of violation.
CMS investigators uncovered a series of incidents in which the hospital identified areas for improvement following botched surgeries but didn’t carry out its own recommendations, allowing “subsequent adverse events to occur.” The investigators required corrective measures, which the hospital has carried out.
Newark Beth Israel also hired outside counsel to conduct its own investigation.
“Based on the available evidence, the ongoing investigation by outside counsel — with the assistance of expert transplant consultants including physicians — has determined that Dr. Zucker and the transplant team’s post-transplant care of the patient was not affected or compromised by concerns about survival rates or concerns about the interests of the program; was not unethical; and did not deviate from the standard of care expected of medical professionals,” the hospital said in its statement.
In response to a request for comment, Zucker's lawyer sent a press release, which includes the following statement from Zucker: "Newark Beth Israel Medical Center has always had a reputation for providing high quality care, state-of-the-art care and I am truly proud to have worked there for more than three decades, served the community with honor, and contributed substantially to that reputation.”
In the past year, two other cardiologists have left the hospital to work at other programs. Newark Beth Israel said it will now start a search for a new director for its heart transplant program.
Given that we are in the midst of an unprecedented pandemic and billions of dollars in federal aid are being thrown at response and recovery efforts in Illinois, we thought you should know more about how your taxpayer dollars are being spent. Plus, we figured there’d probably be a few interesting needles in the haystack.
To accomplish this, ProPublica reporter Jodi Cohen, Chicago Tribune reporter Jennifer Smith Richards and I combed through more than 20,000 expense items from the state comptroller. We found that while the vast majority of expenses were indeed obviously linked to the pandemic — items like face masks, school meals, business grants and COVID-19 testing services — some spending included unusual purchases like crowd control grenades and firearms training simulators.
Our analysis also showed a broader pattern in the state’s response to the pandemic. In the spring, the largest contracts went to vendors for ventilators and millions of pieces of protective equipment amid a severe global supply shortage. By the summer, payments had shifted toward helping schools, businesses, and child care and health care providers. Spending continues as the state faces another wave of the virus.
There were also a number of expenses that made us pause and think: “Huh! That’s interesting.” The Department of Corrections spent nearly $1 million on bread. In seeking an explanation, we learned that the inmate-staffed central bakery was shut down for safety reasons, prompting the state to purchase bread as an alternative. Then there were payments to lease out entire hotels for people who needed somewhere to temporarily quarantine. We found that some of these facilities sat empty for almost two months.
The most questionable line items we came across were a series of purchases made by the Illinois State Police. The agency had submitted tear gas grenades, flash-bangs and other crowd control weapons as COVID-19 expenses, telling us they needed to stock up in case hospitals were overrun by people seeking COVID-19 treatment.
After we asked the governor’s Office of Management and Budget about these expenses, a spokeswoman informed us that the office had rejected the state police’s purchases, concluding that the spending might not be directly related to COVID-19.
Our story also includes a look-up tool that lets readers like you put on an investigative hat and see how your money has been spent. We’ve already gotten some interesting responses: Geoff Hing, a reporter with APM Reports, noticed millions spent on postage and printing related to increased unemployment claims. Another reader pointed out that the Department of Revenue paid $6.75 per gallon for 100 gallons of distilled water, when those regularly go for $1 at a supermarket.
Cuomo's new book on leadership, published as the pandemic continues to ravage America, touts his willingness to speak hard truths about the pandemic. Why then has he still not said how many nursing home residents perished on his watch?
This article was published on Friday, October 23, 2020 in ProPublica.
New York Gov. Andrew Cuomo’s latest book, “American Crisis: Leadership Lessons From the COVID-19 Pandemic,” went on sale this month. Its publisher has hailed the governor’s courageous honesty.
“Real leadership, he shows, requires clear communication, compassion for others, and a commitment to truth-telling — no matter how frightening the facts may be,” one bit of advertising for the book reads.
Nine months into the pandemic, and three months after his health commissioner testified that he was hard at work counting nursing home deaths, Cuomo has not announced the grim total.
“The governor has time, in the middle of a pandemic, to write a book on the COVID-19 crisis, but after months of delay he has not delivered on his word to provide the legislature with the accurate numbers of nursing home deaths,” said Ron Kim, a Democratic state legislator from Queens. “As a result, we are squandering away an opportunity to demonstrate how his government can be there to respond to this crisis.”
To date, Cuomo has only publicly acknowledged nursing home residents who died of COVID-19 inside their residences, some 6,500 people. While other states have all along combined those deaths with those of nursing home residents who died at hospitals, and made those totals public, New York has not.
Cuomo’s health commissioner, Howard Zucker, testified before state lawmakers in early August that the administration would not announce the total until it had done a careful review. He has so far declined to say why counting deaths in the state’s hospitals is taking so long.
“You know me,” Zucker told lawmakers during sworn testimony in August. “I will not provide information unless I know that it is absolutely accurate.”
The Cuomo administration did not respond to a request for an update and comment on criticism.
This fall, the Empire Center for Public Policy, an independent think tank in Albany, sued the State Department of Health to release full data on nursing home COVID-19 deaths. Bill Hammond, a senior fellow at the center, reported recently that the department had responded to the suit by saying it could not comply because “a diligent search for relevant documents is still being conducted.”
“It’s unfortunate that Gov. Cuomo continues using skewed facts and disingenuous arguments in a book that purports to draw lessons from the pandemic,” Hammond told ProPublica. “If we’re going to improve our public health defenses against future viruses, we need honest analysis of what happened, not self-justifying spin.”
The question of nursing home deaths has dogged Cuomo virtually since the outbreak of the pandemic. He announced that protecting the state’s roughly 600 facilities was his top priority. But under a policy he enacted in late March, more than 6,400 patients sick with COVID-19 were sent from hospitals to nursing homes without being tested to see if they were still contagious.
The policy was adopted out of a fear that hospitals would become overwhelmed during the initial surge of infections and deaths. As a result, the policy allowed patients deemed “medically stable” to be sent to nursing home facilities.
The policy enraged families, home administrators, epidemiologists and politicians of both major parties. Historically, nursing homes have struggled to limit outbreaks of infectious disease, in part because they have large staffs that come and go and often work at other facilities. Admitting sick COVID-19 patients, to many, seemed a needless added risk.
Cuomo declared an end to the practice six weeks after its implementation, but he insists to this day that COVID-19 patients sent to the homes were not a significant driver of subsequent infection and death.
In an effort to defend the policy that sent COVID-19 patients to nursing homes, Cuomo’s Health Department produced what it said was a peer-reviewed report showing it was infected staff members who drove nursing home infections and deaths. The report cited a variety of data to support its conclusions — how many homes had been infected before hospital patients arrived, the median number of days that had elapsed from the time the patients tested positive to when they were sent to the homes and more.
Yet state officials have maintained that accurately tabulating total deaths nine months into the pandemic is up to now beyond them.
In his book, Cuomo cites the report in support of his claim that the policy was not responsible for large numbers of infections and deaths. He maintains that the rules governing sending patients to homes was not, in fact, a formal policy, but merely guidance, and that no home should have accepted a person sick with COVID if it couldn’t safely care for him or her.
He writes that the state’s efforts to better protect the homes were undermined by how widely the virus had spread even early on and how limited the state was in its ability to conduct aggressive testing of staff and residents. He writes that criticism of his performance on nursing homes was the organized and cynical work of Republicans looking to avoid accountability for their own failures in the face of the crisis.
In October, ProPublica asked the Health Department to account for the time the count was taking.
“We are carefully reviewing all previous data, as the commissioner committed to, and we’re also requiring confirmatory and post mortem testing for anybody who may have had COVID-19 or flu symptoms, or exposure to someone who did, to ensure data integrity,” Jonah Bruno, a department spokesman, said.
Cuomo, in his book, was as he has been in public — withering in his criticism of President Donald Trump and his administration. He portrays the administration as ignornant, incompetent, dishonest and more concerned with public relations spin than saving lives.
His administration was different.
“Donald Trump did not have the only microphone,” Cuomo wrote. “I had one, too. And I had something else — credibility.”
So far, Cuomo has not used that microphone to deliver the hard truth of the state’s tragic loss of life.
Fighting—and adapting to—the coronavirus in Illinois has been costly. So far, state agencies have spent more than $1.6 billion in federal and state COVID-19 funding since late March, buying everything from face masks to Subway sandwiches.
This article was published on Thursday, October 22, 2020 in ProPublica.
This story is a collaboration between ProPublica Illinois and the Chicago Tribune.
As of Oct. 1, state agencies reported spending more than $1.6 billion in federal and state funds on COVID-19, with purchases that range from predictable items like face masks to more unexpected expenditures, such as sliced bread and sporks.
In the first comprehensive analysis of the state’s COVID-19 spending, ProPublica Illinois and the Chicago Tribune found that the vast majority of purchases were linked to the pandemic, but that some spending has been questionable. The Illinois State Police, for example, submitted tear gas grenades and other crowd-control equipment as COVID-19 expenses.
Many of the purchases show how costly it has been for state agencies to execute their “pandemic pivot.” Employees needed computers and security software to work remotely and protective equipment to work in person. Temporary meal sites had to be set up throughout Illinois to provide food for children who weren’t getting fed at school. Agencies spent at least $287 million on cleaning supplies and protective gear.
Some significant purchases went largely unused: The state leased out entire hotels that sat empty and erected a field hospital that treated only a few dozen patients.
The ProPublica/Tribune analysis covers every state agency expenditure that was submitted to the comptroller’s office as a pandemic-related expense from March through the end of September. Millions of dollars continue to be spent every day.
The expenditures are self-reported and, for the most part, aren’t scrutinized by state government officials in real time; the spending won’t be audited until at least next year.
“We might send it back or question it and ask for some backup. But most likely, where you’ll catch that kind of spending is when the auditors go in and say that it is 100% not COVID spending; then depending on what fund it’s out of, the agency/state of Illinois may have to pay it back,” Illinois Assistant Comptroller Ellen Andres said.
Much of the spending will be covered by federal funds from the Coronavirus Aid, Relief, and Economic Security Act, also known as CARES. Illinois expects to receive up to $5.5 billion in CARES funding this year.
States have wide latitude in how to spend that money, but purchases must be directly related to the pandemic. Federal relief money also can’t go toward purchases already planned and approved before late March — prior to the virus’s spread. And funds must be spent on costs incurred this year.
State agencies seek approval from the governor’s Office of Management and Budget to use CARES funding. Spokeswoman Carol Knowles declined to detail purchases that had been rejected but did confirm, after questions from the Tribune and ProPublica, that federal coronavirus relief money would not be used to reimburse several purchases by the state police, including crowd-control weapons.
Knowles said agencies were told to think broadly about what would qualify as a COVID-19-related expense but said budget officials are being “conservative” in deciding what can be funded with CARES money.
Ralph Martire, executive director of the nonprofit Center for Tax and Budget Accountability in Illinois, said that with little guidance from the federal government and few reporting requirements, some misspending is likely.
“Some agencies and individuals are going to try to game the system to cover purchases they want to make but can’t afford,” he said. While Martire expects the “vast majority” of funds to be spent appropriately, he said: “Will some things slip through the cracks? I imagine they will.”
To date, the Illinois Emergency Management Agency has spent the most of any agency on the pandemic, accounting for a third of the state’s COVID-19-related spending. That includes millions of pieces of personal protective equipment and hundreds of ventilators it acquired after the governor issued a disaster declaration in March.
Big-ticket PPE purchases have waned since spring. By August and September, the majority of the state’s spending went to grant programs that supported businesses, schools, and child care and health care providers, as well as continued COVID-19 testing and local contact tracing programs.
Here are some of the other expenditures found in the state’s records:
Grenades and Gun Simulators
The Illinois State Police asked for COVID-19 funds to cover $75,000 it had spent on 2,240 tear gas or other “nonlethal” grenades, 100 flash-bang grenades and 1,400 projectiles used for crowd control, plus $30,000 in hotel rooms and dinners for troopers deployed to Chicago in late May and again in August amid civil unrest related to police violence.
The police also tried to submit as a COVID-19 expense $572,000 worth of firearms simulators that the agency said were intended to help train troopers and new cadets on the use of force.
State police officials told reporters that they looked for a “nexus” between their purchases and the pandemic in case agency spending could be reimbursed with federal money.
For example, the police were stockpiling “less-lethal” weapons like tear gas grenades in case hospitals were overrun by people seeking COVID-19 treatment, according to First Deputy Matthew Davis. He also said the state police wanted to replenish supplies that had expired or were used during the wave of protests that followed the May killing of George Floyd by a Minneapolis police officer.
And when troopers were deployed to Chicago amid widespread unrest in late May and again in August, the department booked 102 rooms at a Chicago Hyatt — twice as many as would be typical — to give each trooper his or her own room and avoid spreading the virus.
Agency officials also argued to state budget officials that the firearms simulators they were already planning to buy had a COVID-19 purpose because they allowed for social distancing among cadets and eliminated the need for additional people to role-play, Davis said.
But the governor’s Office of Management and Budget recently rejected all of those purchases, concluding that the spending might not be directly related to COVID-19. Knowles did not say when officials made their decision, but reporters had sought information about the police purchases for several weeks.
Empty Hotel Rooms
For two months beginning in early April, the Illinois Emergency Management Agency spent about $7.5 million to lease five hotels across the state to provide temporary housing for people who needed to be quarantined. In all, about 250 people stayed at the hotels, and almost all of them were housed in Schaumburg. The average length of stay was 24 days.
The vast majority — 210 people — were housed at the Embassy Suites in Schaumburg between April 3 and June 4. The state paid $2.1 million to lease the hotel. Most of the people who stayed there were transferred from Hesed House in Aurora, the state’s second-largest homeless shelter, after an outbreak there in April.
An additional 31 people stayed at the Hyatt Regency in Schaumburg, rented at a cost of $2.93 million.
The state rented the entire 180-room Drury Inn in Mount Vernon for 62 days for $727,175 but housed only six people there during that time. In Springfield, the state paid nearly $660,000 to reserve the Holiday Inn Express and nearly $1.1 million for the Crowne Plaza, but neither hotel was used.
State health officials said the idea was to give people a place near their homes where they could “safely isolate or quarantine in order to not expose others in their home.” People referred by local health departments included those who tested positive or who had been exposed to the virus but did not require hospitalization, or those who needed to isolate themselves as a precautionary measure, including health care workers.
The state hired a hotel broker, at a cost of $200,000, to identify available hotels throughout Illinois. Other expenses included more than $100,000 in mattress covers and at least $130,000 paid to a company to decontaminate the rooms.
An Illinois Emergency Management Agency spokeswoman said the hotel rooms were intended to supplement local alternative housing efforts if needed. “The fact that these rooms were largely unused is a testament to the planning and resiliency of our local jurisdictions and the success of the administration’s mitigation measures,” spokeswoman Rebecca Clark said.
Millions of Masks
Before the pandemic, N95 masks cost about $1 each. But prices have fluctuated over the course of the pandemic, given the short supply and high demand for personal protective equipment.
The average cost for the millions of N95 masks bought by the Illinois Emergency Management Agency was $3.11 per mask.
But in one of its first purchases, on March 24, the agency paid nearly $10 each for 325,000 masks from a Dallas-based business called Sada MXC.
An agency spokesperson said the purchase was made at a time of great need, when Illinois was forced to compete against other states and countries because of a “broken supply chain and lack of supplies from the Strategic National Stockpile,” a federal source of supplies and equipment for state and local governments during emergencies.
Bread, Snacks and Sporks
he Illinois Department of Corrections, unable to operate its inmate-staffed central bakery at a men’s prison near Peoria for safety reasons, spent more than $956,000 on bread, more than $152,000 on cookies and at least $66,000 on commissary snacks from outside vendors.
A spokeswoman for the department said it paid for extra snacks to “help alleviate the stressors of the COVID-19 pandemic.”
To reduce the risk of infection, many prisons have been serving meals in smaller living units instead of in dining halls. That accounts for the $53,000 the department spent on disposable sporks.
Body Bags
Agencies feared that local coroners’ offices might be overwhelmed if deaths from COVID-19 surged. The Illinois Emergency Management Agency spent more than $44,000 on renting refrigerated trailers. to store bodies and purchased $54,000 worth of body bags.
The corrections department bought 500 body bags for $23,000 with the understanding that two bags would be needed for each body. More than 2,100 people in custody have contracted the novel coronavirus in the state’s correctional facilities, state data shows, and 27 have died. There were about 32,000 incarcerated individuals in Illinois as of June.
Catered Meals, Boxed Lunches
When the state deployed 60 members of the Illinois National Guard for nine days to work at a medical supply warehouse in Springfield, $15,862.96 in COVID-19 funds was used to cater their meals. Other agencies subsidized food costs with COVID-19 money, too, including the Illinois Department of Public Health, which spent tens of thousands on boxed lunches for dozens of employees.
And during the civil unrest in Chicago in May, the Illinois State Police bought hundreds of meals — pizzas, boxed lunches, Jimmy John’s sandwiches — so troopers wouldn’t have to leave the areas of the city where they were posted.
Census Masks
One Illinois agency used grant money earmarked to promote the U.S. census to also fight COVID-19. The Illinois Department of Commerce & Economic Opportunity reported paying $850,000 to the Chicago advertising agency O’Keefe Reinhard and Paul to design and produce face masks branded with the logo for the 2020 census. More than 474,000 masks with the words “Make it Count” and the census website were distributed, according to an agency spokeswoman.
Remote Work: The Pandemic Pivot
Agencies purchased hundreds of computers, monitors, webcams and other supplies so their employees could work from home. Buying laptops and other hardware alone had cost agencies at least $890,000 by the start of October.
The Teachers’ Retirement System, for example, spent more than $50,000 on equipment and office supplies as employees shifted to a remote work plan and then a hybrid option in which workers split time between the office and home.
The state’s Department of Innovation & Technology has spent more than $19 million on COVID-19-related purchases, including software licenses, online security monitoring, cloud data storage and wireless network equipment. The agency also spent at least $90,000 on consultants to provide technical assistance to employees working remotely, records show.
Private Flights to China
In mid-April, Illinois officials spent nearly $1.8 million to charter two FedEx flights to Shanghai to pick up supplies of personal protective equipment.
A spokeswoman for Gov. J.B. Pritzker, Jordan Abudayyeh, said at the time that the administration was working “around the clock” to purchase PPE for health care workers and first responders.
“The supply chain has been likened to the Wild West, and once you have purchased supplies, ensuring they get to the state is another herculean feat,” she said in a statement. “These flights are carrying millions of masks and gloves our workers need.”
An Empty Hospital
The state and city of Chicago together spent about $107 million to build and then operate a little-used field hospital at McCormick Place.
It closed in early May after receiving only 38 patients over four weeks. The average cost of treating a patient there was at least $2.81 million.
The field hospital cost $65.9 million to construct; most of that will be reimbursed through Federal Emergency Management Agency funds as well as CARES Act funds. But it also was expensive to operate. The Illinois Emergency Management Agency spent $15.1 million, mostly to hire temporary medical staff and IT consultants.
Favorite Healthcare Staffing received about $11 million to provide medical care at McCormick Place, records show. The Kansas-based company has been the state’s top COVID-19 vendor in 2020, accounting for nearly $50 million in spending on nurses and other health care providers at prisons and state-run developmental centers in addition to McCormick.
Electioneering by a cabinet secretary is unusual by historical standards, but Trump administration officials continue to show no reluctance to play politics.
This article was published on Wednesday, October 21, 2020 in ProPublica.
Veterans Affairs Secretary Robert Wilkie headlined a fundraiser for the North Carolina Republican Party last week, taking time away from his job leading the government’s second-largest agency at a moment when COVID-19 cases are surging in VA hospitals.
Though legal, campaigning by cabinet secretaries is a departure from historical norms. Nevertheless, it’s become standard practice in the administration of President Donald Trump. Secretary of State Mike Pompeo has hit the campaign trail for Trump, and several other cabinet members recently visited Iowa. Seema Verma, the administrator of the Centers for Medicare & Medicaid Services, is also campaigning in North Carolina. Trump himself has routinely blurred politics with official functions, most prominently by hosting the Republican convention on the White House lawn, and he’s brushed off more than a dozen staff violations of the federal Hatch Act, which limits political activity by government employees.
Wilkie, in particular, was already under fire for frequent trips that appear to have partisan agendas. In a letter last week, the top Democrats on the House and Senate veterans committees accused Wilkie of using taxpayer-funded travel to boost Trump and other Republican candidates.
“Leaders at VA have historically risen above partisan politics,” Senate veterans committee ranking member Jon Tester of Montana and House committee chairman Mark Takano of California said in their letter to Wilkie. “Furthermore, efforts to engage in overtly political activity may have come at the expense of legitimate functions of the department’s mission.”
The letter highlighted Wilkie’s previous official trips to North Carolina, Maine and Montana for appearances with GOP senators in tough reelection races. The partisan tilt of the Montana trip was especially pronounced because it included no events with Tester despite his key post on the Senate panel that oversees the VA.
Wilkie’s latest visit to North Carolina, his home state, was not part of an official trip, according to the VA’s response to a Freedom of Information Act request. That indicates his fundraiser appearance wasn’t paid for by taxpayers. Wilkie’s spokeswoman declined to say who footed the bill for his travel or why he was in North Carolina on a weekday instead of at his job.
“He attended this event as a private citizen,” spokeswoman Christina Noel said.
The party’s financial disclosures, which might show donations and expenditures connected to the event, are not yet available for that time period. The North Carolina GOP’s finance director, Amanda Parrish, didn’t respond to messages seeking comment.
The event took steps to comply with the Hatch Act. The invitation, obtained by ProPublica, omitted Wilkie’s official titles, referring to him as “honorable” (a general signifier for people who have been Senate confirmed). The invitation also said “his participation is not a solicitation for funds,” but it listed suggested donations ranging from $250 to $2,500.
The email accompanying the fundraiser invitation said the organizers wanted “this event jam-packed (within CDC guidelines).” But a photo posted on Facebook by the state party chairman showed people indoors less than 6 feet apart and not wearing masks.
Noel declined to comment on what public health measures Wilkie observed to participate in the event.
Other political figures who attended, including state Rep. Holly Grange and Trump campaign organizer Matt Dula, didn’t respond to requests for comment.
From North Carolina, Wilkie traveled to Arizona, Utah and Colorado for what appeared to be official functions, according to posts on his Twitter account.
A former aide to North Carolina’s endangered incumbent senator, Thom Tillis, and former Sen. Jesse Helms, Wilkie is widely viewed as aspiring to elected office in the state. North Carolina’s other senator, Richard Burr, is not seeking reelection in 2022. Noel didn’t respond to a question about Wilkie’s political ambitions.
Wilkie has faced criticism for appearing disengaged from the VA’s critical programs. He’s also under investigation by the department’s inspector general for allegations, which Wilkie has denied, that he attempted to collect dirt on a congressional staffer who said she was sexually assaulted in a VA hospital. The results of the probe are expected soon.
The VA hospital system currently has almost 4,500 active cases of COVID-19 (including veterans and employees), a 70% increase from a month ago. More than 3,700 VA patients have died of the virus.
Veterans are a key constituency for Trump, a favorite topic in his tweets and at rallies. The VA is accommodating more political events this year by relaxing a long-standing policy that discourages site visits by political candidates close to an election. Noel didn’t respond to a question about the change.
Particulate matter kills people. That was true before the pandemic, and new research has tied it to coronavirus deaths. But the EPA is ignoring scientists who say stricter particulate matter limits could prevent tens of thousands of early deaths.
This article was published on Wednesday, October 21, 2020 in ProPublica.
In April, as coronavirus cases multiplied across the country, the head of the U.S. Environmental Protection Agency rejected scientists’ advice to tighten air pollution standards for particulate matter, or soot.
In the next few weeks, EPA Administrator Andrew Wheeler likely will reaffirm that decision with a final ruling, despite emerging evidence that links particulate pollution to COVID-19 deaths.
There was enough evidence to support a stricter standard before the pandemic, said Christopher Frey, an environmental engineering professor at North Carolina State University who studies air pollution. The added threat from the coronavirus is like “icing on the cake,” he said, and should compel Wheeler to adopt an even more stringent limit.
Particulate matter kills people. “It is responsible for more deaths and sickness than any other air pollutant in the world,” said Gretchen Goldman, a research director at the Union of Concerned Scientists.
Wheeler’s decision was specifically about fine particulate matter, or PM2.5, microscopic solid and liquid droplets less than one-thirtieth the width of a human hair. The pollution comes from cars, power plants, wildfires and anything that burns fossil fuels. When people take a breath, the particles can lodge deep into their lungs and even enter the bloodstream. The pollutant causes health complications that can lead people to die earlier than they would have, and it is linked to conditions such as COPD, asthma and diabetes.
Frey was part of a 26-member scientific panel that advised the EPA on particulate pollution until Wheeler disbanded the group in 2018. Twenty of the former members continued to review the science and provided unofficial advice to Wheeler as part of the public comment process. Their letter told Wheeler— a former coal lobbyist — that tightening the standard would avoid tens of thousands of premature deaths per year.
Firing the advisory panel and opting not to pursue a more stringent particulate standard were in keeping with the administration of President Donald Trump’s dim view of environmental regulation. By one tally compiled by The New York Times, 72 regulations on air, water and soil pollution, climate change and ecosystems have been canceled or weakened, with an additional 27 in progress. EPA leadership has sidelined or ignored research by agency scientists, and career staff are censoring their reports to avoid terms like “climate change” out of fear of repercussions from political staff. Many of the changes involve narrowing the scope of science, and scientists, that contribute to policy, experts said.
The EPA has an “apparatus of particulate matter science denial” that rivals its attacks on climate science, Frey said. “If I wanted to get rid of [regulations on] particulate matter, I would do all the things Wheeler is doing.”
Wheeler made his decision “after carefully reviewing [the] scientific evidence and consulting with the agency’s independent science advisors,” an EPA spokesperson said in a statement. “The U.S. now has some of the lowest fine particulate matter levels in the world, five times below the global average, seven times below Chinese levels, and 20 percent lower than France, Germany and Great Britain.”
These standards are set “based on protection of human health,” not how the levels compare to elsewhere, Michael Brauer, a public health professor at the University of British Columbia, said in an email. There are “ample studies” demonstrating health effects when particulate pollution is at levels “well below” the current standard, he said.
The National Association of Manufacturers did not return requests for comment. Jim Harris, a spokesman who represents many petrochemical facilities in Louisiana, pointed to written comments from a coalition of industry groups including the National Mining Association, American Petroleum Institute and the U.S. Chamber of Commerce.
“The evidence indicates that the current suite of [particulate matter standards] protects public health, including the health of at-risk populations, with an adequate margin of safety,” they wrote to the EPA after Wheeler proposed keeping the regulation unchanged in April. More stringent standards “cannot be justified, given the substantial uncertainties in, and limitations of, the scientific evidence.”
Complying with a new standard could cost the manufacturing sector nearly $20 billion and complicate the permitting process for business expansions, they wrote, citing an analysis from the American Forest & Paper Association (ProPublica asked for the report but didn’t get a response before deadline). These proposed projects “create jobs and bring much needed tax revenue to local communities now in critical need of economic development,” they wrote.
Wheeler’s decision could delay stronger regulation for years. The Clean Air Act dictates a meticulous process for considering a new standard; each review usually takes at least five years, Goldman said. Once the EPA adopts a new rule, states have several years to adjust. If Trump loses the election and a Joe Biden administration restarts the particulate review process right away, “we’re really looking at a decade before people are incentivized to reduce particulate pollution,” she said.
Ignoring Evidence, Pausing Enforcement Amid a Pandemic
While scientists have yet to prove that exposure to air pollution increases the risks of dying from COVID-19, a mounting body of research suggests a link. Researchers in the U.K. and Italy have found correlations between high COVID-19 mortality rates and elevated pollution levels. A study conducted by the State University of New York and ProPublica found an association between COVID-19 mortality, particulate pollution from diesel engines and hazardous air pollutants — a class of chemicals that can cause cancer. Hazardous air pollutants are often found attached to particulate matter.
The comments from the industry coalition against strengthening the regulation emphasized the “preliminary” and “evolving” nature of research on air pollution and the coronavirus. If relevant peer-reviewed science becomes available, they said, “EPA could consider them during the next PM [standards] review.”
Emerging evidence should be enough, said Mychal Johnson, co-founder of South Bronx Unite, a community organizing group in the Mott Haven neighborhood. Of all of the roughly 3,100 counties in the country, the Bronx had the highest combination of COVID-19 mortality rates and air pollution levels, according to the SUNY-ProPublica study. Johnson said the pandemic has “pulled back the scab” on the environmental harm in his neighborhood, which has high rates of asthma.
Mott Haven is flanked by two interstate highways. Asphalt playgrounds sit next to those highways, close to the pollution coming out of tailpipes. For decades, policymakers have permitted industrial sites in the area, including waste transfer stations, a FreshDirect warehouse and two natural gas “peaker” plants that generate electricity when there’s high energy demand.
Sometimes the pollution is “so thick you feel it in your lungs and your throat,” Johnson said. “You can’t really describe the smell, it just stinks.”
The community was disproportionately vulnerable when the pandemic hit, both because of the number of people who had preexisting health conditions and the number who worked front-line jobs that put their lives at risk, he said. If the EPA isn’t “moving forward to make sure our policies are strong, to save lives, then we’re definitely moving back[ward].”
It’s too early for conclusive evidence on the coronavirus and particulate matter, said Brauer, the University of British Columbia professor. Even the official death count from COVID-19 remains preliminary, he said. There is, however, plenty of evidence from other respiratory illnesses showing that “if you’re exposed to an infection and at the same time exposed to pollution, that infection is more likely to become severe.”
There is also growing consensus that factors like air pollution contribute to health disparities in poor and minority communities, and those who are disproportionately affected are more vulnerable to COVID-19, he said.
Wheeler doesn’t need definitive proof, said Bernard Goldstein, a professor emeritus of environmental and occupational health at the University of Pittsburgh. The law allows Wheeler to consider a “margin of safety” that acknowledges ongoing research, Goldstein said. “You have two different things that violently attack the same organs” in the respiratory and cardiovascular systems, he added. From a margin of safety perspective, it’s enough to say “I’ve got data showing the dam is about to break.”
Far from acknowledging the pandemic as an added threat, Wheeler has used it to loosen reporting requirements for coal plants and other polluters. The temporary policy, announced on March 26, said the EPA would not penalize businesses that failed to monitor or report pollution, as long as they were “making good faith efforts to comply with their obligations during this difficult time.”
Nine state attorneys general sued the EPA in response. They dropped the lawsuit after the EPA ended the practice Aug. 31.
The policy has already had deadly consequences, said Claudia Persico, an assistant professor with American University’s Department of Public Administration and Policy in Washington, D.C. An analysis by Persico and Kathryn Johnson, a doctoral student, found that the EPA’s coronavirus policy led to a 14% increase in particulate matter emissions in roughly 700 counties with major polluters, and that change is “associated with” more than 7,300 additional deaths from COVID-19 from March 26 to July 11. The paper is undergoing peer review. Two other experts who read the study told the news publication Grist that the paper’s methodology is sound.
Persico and Johnson’s research controlled for the effects of pandemic shutdowns that temporarily drove down emissions in many counties. Their estimate of 7,300 deaths only accounts for the counties where the first COVID-19 deaths occurred after March 26, leaving out major metropolitan areas like New York City and Chicago, Persico said.
“Because we allowed this rollback, more people died,” she said. “And that’s a pretty serious thing.”
The EPA says the practice did not permit any additional release of pollutants. “There is no support in the [Persico and Johnson] paper for their allegation that ‘policy-induced increases in pollution’ occurred,” the agency said in a statement.
The spokesperson pointed to a peer-reviewed study led by the University of Minnesota that “reported declines in air pollution during the COVID-19 pandemic.” But that paper only captured what happened in the initial shutdowns, from March 13 through April 21, when many nonessential businesses closed and commuter traffic plummeted; particulate pollution dropped 11% in 63 counties that adopted early business shutdowns.
There was also a marginal increase in particulate matter in 59 other counties without early shutdowns, but the findings were not conclusive. The study didn’t include data from after April, when pollution may have rebounded as businesses reopened, said one of its authors, Jesse Berman, an assistant professor at the University of Minnesota’s School of Public Health. The study doesn’t prove or disprove whether the EPA’s lack of enforcement increased pollution. “It just wasn’t designed to do that,” Berman said.
Cementing a “Full-Frontal Assault” on Science
The particulate pollution decision shows how the Trump administration has rewritten the rules on how independent science affects regulation, Goldman said.
The latest particulate pollution review kicked off during President Barack Obama’s second term. In 2018, EPA staff scientists published an exhaustive, 1,881-page summary of the science. The report found strong evidence that particulate matter can kill people through its effects on the cardiovascular system. Even short-term exposure may be deadly, it said. Additional evidence showed how it can damage children’s lungs and exacerbate asthma.
Under normal circumstances, that report would have gone to a review panel of more than 20 outside scientists, including Frey. The panel included epidemiologists, physicians, biostatisticians and other experts who specialize in particulate pollution. The members work with the Clean Air Scientific Advisory Committee, or CASAC, a seven-member team that helps Wheeler determine the final standard.
But Wheeler dismissed the review panel a few days before it could weigh in on the EPA report. He and his predecessor, Scott Pruitt, also replaced most of the independent scientists on CASAC. It once had a plurality of doctors, biostatisticians and epidemiologists, and it is now dominated by state regulators from Republican states and led by a consultant with close ties to industry. None of them are experts in epidemiology — the study of how diseases affect populations, a linchpin of particulate matter research.
“All of the current members hold Ph.D.s in fields that include health sciences, toxicology, ecology, chemical engineering and risk analysis,” and the majority of CASAC members recommended maintaining the current standard, the EPA spokesperson said. Wheeler has considered the committee’s advice “but is also reviewing additional input provided during the public comment period,” the statement added.
The EPA has turned the entire process into “a sham,” said Lianne Sheppard, a professor of biostatistics and environmental health at the University of Washington. Sheppard served on CASAC from 2015 to 2018 and was a member of the now-dismantled particulate panel. The large panel existed because the science is so vast and complex that “no seven people, no matter how expert they are,” can review the information on their own, Sheppard said.
Goldman said the EPA under Trump has always sought to undermine the science, as particulate matter involves “super inconvenient” math that complicates deregulation efforts.
Many environmental rules involve a cost-benefit analysis. On one side of the ledger is the price of forcing industry to comply with a new rule; on the other, money saved from avoiding pollution-related deaths and illnesses. A good cost-benefit ratio can do wonders for selling the rule to the public. Often, the strategies used to reduce one air pollutant also cut down on other pollutants like particulate matter. Those ancillary gains count as a “co-benefits.”
Since particulate pollution kills so many people, even a small reduction can tip the scales in favor of regulation, Goldman said.
When the Obama administration moved to regulate mercury from power plants, for instance, the savings from reducing mercury, a poison that damages children’s brains, came to just $6 million. The co-benefits from slashing particulates — a byproduct of those efforts — added up to billions.
Wheeler’s EPA watered down the mercury regulation in April by disregarding the co-benefits from reducing particulate matter. Frey and other experts feared it would set a precedent. Indeed, within weeks, the EPA introduced a new regulation to codify the practice. It proposed that key air pollution rules would report co-benefits separately. Frey said it opens the door for “cherry-picking” what goes into the economic analysis.
“As soon as you start saying, ‘We’re going to look at this thing but not these things,’ that’s not benefit-cost anymore. That’s just a game,” he said.
The agency is now reviewing public comments on the rule.
In another move, the EPA plans to finalize a “Transparency Rule” that could force agency scientists to prioritize studies where researchers have made all of the raw data publicly available. That’s simply not possible for many health studies, where doing so would reveal private medical data, Goldman said, and it ignores how these studies have already been vetted through the peer-review process. Scientists “cannot legally, ethically provide” such data, she added. “Everyone in the scientific community and their brother [has] said this is a terrible idea.”
The rule could dismiss key epidemiology studies on the dangers of particulate matter, especially those that show why the current standard is inadequate, Goldman said.
Epidemiology is a complicated discipline that requires careful analysis and statistics. When researching air pollution, epidemiologists might study whether residents in neighborhoods with high levels of particulate matter are in worse health than those in areas with less pollution. They would need to control for other factors, such as income, to make sure the health effects they’re seeing truly come from particulate matter.
Over decades, epidemiology has provided “this giant statistical power” that shows how harmful particulate matter can be, and the findings have been repeated in different cities, on different groups of people, with varying levels of pollution, Goldman said.
EPA’s attempt to disqualify these studies is a “full-frontal assault on epidemiology,” Frey said. “This administration is just taking tools out of the toolbox and scooping things out.”
Three weeks ago, the agency finalized another rule allowing certain polluters to follow weaker air emissions standards. Wheeler has said the environmental rollbacks will continue if Trump is reelected.
The thousands of "Trumpcare" ads Facebook and Google have published show that the shadowy "lead generation" economy has a happy home on the platforms — and even big names like UnitedHealthcare take part.
This article was published on Tuesday, October 20, 2020 in ProPublica.
"Trumpcare" insurance will "finally fix healthcare," said an advertisement on Facebook.
A Google ad urged people to "Enroll in Trumpcare plans. Healthcare changes are coming."
The problem is, there's no such thing as "Trumpcare."
Facebook and Google have promised to crack down on lies and misinformation about politics in the run-up to next month's presidential election, but they have run tens of thousands of ads in the past year containing false claims about health insurance reform and plans.
The "Trumpcare" ads don't appear to have a political aim and don't advocate for the reelection of President Donald Trump over former Vice President Joe Biden. Nonetheless, the Facebook ads touting these nonexistent products have been viewed some 22 million times in the past year, disproportionately in battleground states like Texas, Florida, Georgia, North Carolina, Ohio and Pennsylvania, according to Facebook data.
The ads are placed by marketers targeting consumers — politically conservative ones in some cases — who become sales leads if they respond. Then the consumers get deluged with phone calls from brokers hawking health insurance plans that are not the comprehensive solution that's often promised, but instead are less conventional products that have traditionally been used as supplemental coverage or for when people transition between jobs.
Identifying deceptive tactics related to healthcare plans is as easy as going online and looking.
Southern California marketer Stuart Millar said he's placed "Trumpcare" advertisements to join in "the gold rush of online entrepreneurship."
Millar has spent at least $350,000 on 12,500 "Trumpcare" ads from four Facebook pages with "Trumpcare"-themed names since last October. "Thanks to our President," one of them said, "U.S. health insurance companies have had to drastically drop their rates." (ProPublica can see how much Millar spent because he had proactively marked his ads as political, triggering Facebook to disclose this information.)
Millar isn't an insurance broker — one of the people who sell insurance and are regulated by the states. He's a "traffic broker," a marketer in charge of running ads to drive visitors to his clients' websites. There's little regulation of his activities. His ads have focused so much on the term "Trumpcare," he said, because it's clickbait. He called it far more attention-getting than the "left-wing one," his term for "Obamacare."
"I've got to find a fun way to make healthcare interesting," Millar said. "'Trumpcare' is interesting but healthcare in general isn't."
"Traffic brokers," like any Facebook advertiser, can select the specific demographics of the Facebook users who will see their ads.
Millar declined to get into details about how he targeted his ads, but said he mostly relied on Facebook's algorithm to find him the people who'd click. He said he tested thousands of iterations of the ad to make sure it found an audience. "What I went with was what converted," Millar said, a reference to people responding to the ads.
Some "Trumpcare" ads — not apparently linked to Millar — have been targeted at people Facebook labels as "interested in Donald Trump," according to targeting data provided by Facebook to users along with ads that are shared with the Ad Observer project.
Millar says he didn't come up with the idea of using "Trumpcare." That came from his clients, whom he wouldn't name. Many of Millar's ads led to a page featuring a red, white and blue "Trumpcare" logo on HealthPlansAmerica.org, which is owned by a company called Apollo Interactive. (The company is not a nonprofit, but anyone can buy a .org website address.)
Apollo Interactive isn't an insurance broker either. It's what's called a lead broker, yet another cog in the lightly regulated machinery of insurance "lead generation" marketing. That means it gathers profiles of people who are looking for health insurance. Those who input their information on these sites become "leads." And then they're put up for auction.
Officials from Apollo Interactive wouldn't say how the company sells leads. But Colin Sholes, an activist and former online health insurance marketer, said lead generators extract an anonymized sample of each person's data: ZIP code, age, gender. This profile, without any contact information, gets shared with potential buyers, who bid for it in an instant, automated auction. The winning bidder or bidders get the person's name and their contact information.
Leads are often sold as "shared leads" — meaning they're sold to more than one buyer at the same time. Some of the buyers are insurance brokers. Some are other lead brokers who bid so they can resell data that originated elsewhere. "It's a big web and everybody's interconnected," Sholes said. "A lot of data just floats around."
So how much is each "lead" worth? Sholes estimated that a lead for a person under 55 would cost as much as $20.
The lead might be even more valuable if it was sold as what the industry calls a "warm lead," he explained. Some companies exist just to buy leads, then have a call center agent call and, if a human picks up, the agent "warms you up," Sholes said. That means they check to make sure the consumer is interested in buying insurance. At that point the company sells the call to an insurance broker as a "warm" transfer. "A connected call," he said, might sell for up to $80.
Millar confirmed he got paid by the lead, but he refused to say how much. He did say that he made a profit on what he paid Facebook to run the ads. He was not aware of what happens to consumers who click on his ads, then purchase the health plans. "I didn't ever call in myself. I am not exactly sure how any of that works."
Facebook and Google Profit From the Misinformation
This fall, someone Googling for affordable health insurance might have come across an ad that said: "Healthcare changes are coming. Check out the new pricing tiers under the American Healthcare Act."
The American Healthcare Act — the bill most commonly called "Trumpcare" — failed to pass the Senate in 2017 when the terminally ill Sen. John McCain dramatically walked across the chamber's floor and gave a thumbs down, leading to the bill's defeat. So there were no new "pricing tiers" on offer, as the ad claimed, in 2020.
Those ads led to Apollo's HealthPlansAmerica.org site. Apollo Interactive attorney Chris Deatherage said in a written statement that the Google ads "appear to be old ads" from when AHCA "was actively being discussed in the legislature."
Deatherage said "Trumpcare" is an "abstract" term used to "tie together" various pieces of intended or existing legislation and policies and that Apollo's "Trumpcare" website said the term refers to Trump's "collective policy updates." He compared it to "Obamacare" — which specifically refers to the Affordable Care Act — and proposals for "Medicare for All," which are not law. He added that Apollo Interactive's website lets visitors connect with brokers who can explain the term.
Google's rulessay it does not allow ads that "deceive users by excluding relevant product information or providing misleading information." Facebook says it bans ads with "deceptive, false, or misleading claims." But both accepted the "Trumpcare" promotions. Google even gave the misinformation prime real estate, with the ads as the top-listed results when people search for affordable health insurance.
Christa Muldoon, a spokeswoman for Google said, "Healthcare ads cannot make misleading claims about the advertiser's identity or the services they offer." She said Google removed the ads referencing AHCA under that policy after ProPublica contacted Google about them. She wouldn't explain why the company apparently let the ads run for years, despite violating Google's rules.
Until last year, Google also soldads that lured in consumers with the phrase Healthcare.gov — the federal government site where you can purchase plans that comply with the Affordable Care Act — even though they were for private, lead-generation websites.
It's not clear how much Google earned from selling "Trumpcare" ads. Unlike Facebook, Google doesn't consider ads about "Trumpcare" political, so it doesn't publish any data about them. Muldoon would not say how much Google made from the ads.
But, she said, citing Trump's executive orders on healthcare, "We do not consider the phrase 'Trumpcare' alone to be misleading," so it's allowed in Google ads.
A reporta year ago from Sen. Bob Casey, a Pennsylvania Democrat, criticized Google and other search engines for showing ads for for-profit lead-generation sites listed above the official Healthcare.gov site when a person searched for "Obamacare" or even "Healthcare.gov." Casey called for search engines to put an "answer box" above all content, even ads, with a link to Healthcare.gov on searches for health insurance.
Muldoon hinted at a coming change to what kinds of health insurance-related ads the company will allow. She said that Google is "evaluating the health insurance space to strengthen our protections for users and prevent misleading ads."
After Newsweek flagged the Facebook ads in a blog post in August, the Lead Stories news organization published a fact-check saying that "there is no such thing as Trumpcare." That prompted Facebook to stop accepting the ads, under a policy that bans ads with content that fact-checkers have found to not be true.
Devon Kearns, a Facebook spokesperson, told ProPublica that some of the ads were removed for violating a Facebook policy that bans "scammy tactics."
But then in mid-September, more "Trumpcare" ads appeared on Facebook, from something called "National Center for Medical Records," which didn't return a request for comment. These ads led to another company's website, not Apollo's. One of them featured a smiling Trump with his arm around the shoulder of a doctor and the slogan: "Trumpcare from $1/Day."
Omissions and High-Pressure Sales
ProPublica wanted to learn more about the sales tactics involving "Trumpcare" ads, so we checked for ourselves. One of the reporters on this story, Jeremy, had been laid off in May. So he clicked on an ad in Facebook's ad transparency portal, featuring photos of a health insurance card and a tuxedoed Donald Trump with Melania Trump in a ballgown. It took him to HealthPlansAmerica.org, which prompted him to input his contact details, as well as his age, gender, address, income range and whether he had any "major medical conditions."
Jeremy is young and healthy, and he answered the questions honestly, so his information made him a hot prospect.
Jeremy entered a burner phone number that he acquired for this project — a good choice, because he got 67 phone calls the day he submitted the form; the day after, he got 46 more. The plans the brokers offered were legal, to the extent that they gave enough information to check. But to be informed, a consumer would want to know each plan's limits and exceptions and be provided with detailed information about what's covered, or not. The brokers often withheld crucial information.
Alex, from "the Enrollment Center," said his plan offered free preventive care and would let Jeremy pick his own doctor. Using the lingo of the Affordable Care Act he described the insurance as a "minimum essential coverage plan." But that's exactly what it was not. Jeremy, who is married with no children, had to ask if the plan covered maternity costs, something that might be relevant to a childless couple. Alex said that would require something else, a "major medical plan."
When Jeremy asked Alex to email the plan documents, so he could read what the plan covered or excluded, the line disconnected. Alex never called back.
When we called back several weeks later to ask for comment, the line was apparently disconnected.
Another company, "Modern Health," would not even provide a brochure about its health plans. A supervisor named Louis said he was "in charge of the company" and that it would be a violation of patient privacy laws to send information in writing about the plan. (It isn't.) Those details would supposedly have to come from the insurance company, and only after Jeremy signed up.
Anthony, who said he worked for the "National Health Enrollment Agency," also wouldn't send anything in writing. But his reason made it sound like he needed to lock in a fare on a flight that was rapidly running out of seats. "Once we disconnect the line, the companies aren't going to let me hold onto the plan," he said.
When Jeremy said he wanted to talk it over with his wife, Anthony countered: "Is she a licensed broker?" He offered to add her to the call rather than have the couple discuss it alone.
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None of the salespeople volunteered the details a consumer would need to make an informed choice. Brandon, the salesman from Modern Health, for example, offered a plan from a company called "HealthShield." It's for "things like emergency surgeries, hospitalization, ambulances and prescriptions," he said. He went into painstaking detail about the amount it paid for certain items. But when asked if he'd shared everything Jeremy needed to know, he said, "It does have your essential package that a lot of people sign up for, especially at this time." Only later, when asked what category of insurance the plan fell under, did he say that "they do remove certain things, which include substance abuse, mental health and maternity benefits."
Reached for comment for this article, a man who said that his name was Brandon Greer and that he was now in charge of Modern Health said "I'm not sure" when asked if these omissions might confuse consumers. He said that the company instructs its salespeople to note the exclusions "upfront." He then ended the call.
When we tried to reach the National Health Enrollment Agency minutes later, to get a comment for this story, the phone rang at the offices of Modern Health. The person who picked up denied knowing what the National Health Enrollment Agency was and hung up when asked his name.
Omitting the details of health insurance plans can harm consumers. In August, the Government Accountability Office, the auditing and investigative unit of Congress, published a secret shopper investigation of the sales tactics for the plans. GAO investigators tested 31 brokers by using a fake persona, a person who had a preexisting condition. Eight of the 31 brokers made misstatements, the reportsays. One was selling the GAO investigator — who claimed to have diabetes — a health insurance plan that the broker said would cover the investigator's diabetes, but it really didn't. In a different case, the investigator told the broker that they had diabetes, but the application completed by the sales representative said there was no treatment or diagnosis for diabetes in the past five years. "This indicates that the broker may have intentionally falsified information," the report said.
The GAO didn't disclose the names of any of the brokers in its report, but it said it referred them to the Federal Trade Commission and state insurance regulators.
"Garbage" Insurance Generates Profit for Brokers and Insurance Companies
USHEALTH Advisors, one of the companies whose broker contacted Jeremy, posts videos online to show off how much money its brokers are making selling limited insurance plans.
"How much can you earn monthly at US Health Advisors?" asks one of the videos, posted by US Health Advisors Coral Springs.
"$16,000," says a bearded man in a black shirt and tie.
"$18,000," says a woman in a sleeveless top.
"$34,000," says a man in a dress shirt and tie, a family photo in the background behind him.
Then, the closer: "$42,000 — in one month," a man says.
Justin Brain, the USHEALTH benefits specialist whose number is on the US Health Advisors Coral Springs Facebook page, said commissions vary depending on a broker's "production," or sales totals. He declined to say how much the commissions were per sale, but he said the video is used for bringing in new sales recruits to "give them what's possible."
An April study by the Urban Institute found brokers making commissions of around 25% for the type of plans offered by the company. Other insurance brokers told ProPublica the commissions on some plans could be as much as 50%.
The video closes with a USHEALTH Advisors logo that adds, "A UnitedHealthcare Company." UnitedHealthcare is a massive company that provides health insurance and benefits. It's part of UnitedHealth Group, one of the largest companies in the country, with $242 billion in annual revenue in 2019. UnitedHealthcare declined to say how much the brokers made in commissions.
A USHEALTH broker pitched Jeremy a plan sponsored by Freedom Life Insurance Company of America, which is also a UnitedHealthcare company. The broker characterized the coverage as similar to Affordable Care Act plans and sent a 36-page brochure that laid out the details of the offer.
The document he sent made it clear that the Freedom Life plan would provide limited coverage that could leave a person with hefty bills. But it would take an exceptionally savvy consumer to sort through dozens of pages of insurance jargon to understand that. At ProPublica's request, Jeffrey Hogan, the Northeast regional manager for Rogers Benefit Group, a national benefits marketing firm, examined the document.
Hogan pointed out that it disclosed on Page 3 that the plans would "supplement" any "essential health benefit plan," meaning one of the more comprehensive plans sold under the Affordable Care Act. If this plan was meant as a supplement, then it would not be ideal for an uninsured couple. This was not mentioned in Jeremy's sales presentation from the Freedom Life broker.
One portion of the plan listed its "maximum" benefit for various "defined" sicknesses. It did not say what its "minimum" payment might be. The daily maximum paid under the plan for an X-ray would be $50. For a CAT scan it would be $200. For an outpatient lab it would be $30. Each of those procedures could cost many hundreds of dollars more than the maximum benefit.
Hogan called the plan a "cascading mess" of coverage for specific conditions. "I wouldn't sell this stuff if it was the last piece of garbage on earth," Hogan said.
The limited benefit, accident or defined benefit plans like the ones offered by Freedom Life are highly profitable for the companies that operate them, Hogan said. "They pay very little out on the dollar," he said.
In 2019, Freedom Life took in $171 million for Accident and Health policies covering about 291,000 people, according to a report by the National Association of Insurance Commissioners. Its "loss ratio" was 46%, the report said, which means Freedom Life spent less than half of what it brought in from premiums on medical claims and funding its reserves. That leaves plenty of revenue for profit and to pay commissions and fees to brokers and lead generators.
By comparison, the plans sold under the Affordable Care Act have a minimum loss ratio of 80% to 85%, meaning 80 to 85 cents of every dollar must be spent on medical care for the people paying premiums. If companies spend less, they are required to refund the difference to consumers or employers.
Hogan said that he's been selling insurance for 35 years and that it wasn't easy for him to sift through all the jargon and limits and caveats about coverage in the Freedom Life document. One of the most insidious details was "buried" on Page 22, Hogan said. That's where the company disclosed that any cost incurred as a result of a preexisting health condition would not be covered under the short-term plan included in the package. "This just makes my blood boil," Hogan said. "This hurts people."
Maria Gordon-Shydlo, a spokeswoman for UnitedHealthcare, said in an email the plans provided by USHEALTH provide "valuable health coverage options to meet people's individual financial and care needs." Its brokers present various options, including Affordable Care Act plans, to help people find the plan that's best for them, she said.
Jorie Jacobi, a 31-year-old from St. Louis, signed up for a plan through Freedom Life Insurance in 2018 when she was working as a freelance writer. She searched for affordable health insurance on Google and put in her phone number on a website that promised she'd receive quotes. She got inundated with phone calls that went on for more than a year.
Jacobi is relatively healthy, so she figured she didn't need to pay for the more comprehensive, higher-priced plans offered under the Affordable Care Act. She spoke to a USHEALTH agent selling Freedom Life and said she was under the impression at the time that the package of limited health plans provided by Freedom Life would make sense for her. Her monthly premium came to $224 — not cheap, she said.
Jacobi admits that she didn't do her due diligence when she signed up for the coverage. "I feel silly about this now, but I just trusted them," Jacobi said. She doesn't remember her exact conversations with the agent, and UnitedHealthcare said that there are no recordings of the sales calls, and that it would not provide a recording or transcript of a follow-up call. Jacobi insisted that she would have made sure she had coverage for routine visits to her internist and obstetrician-gynecologist, but after she went to the doctors she received bills for lab work that came to $311 and $710.
After about a dozen hours on the phone with Freedom Life's customer service representatives, Jacobi said the bills still hadn't been paid. So she wrote a negative review on Yelp. That led to a phone call from a company vice president who helped make sure the insurer paid the bills.
In another case, the Freedom Life plan did not cover a drug Jacobi needed. And when she needed a minor surgical procedure she learned it would not be covered by the plan, so she paid cash.
Gordon-Shydlo, the UnitedHealthcare spokeswoman, said Jacobi had selected coverage that had a lower premium but only covered specific diseases, accidents and other items. The insurer complied with its "stringent application process" and addressed Jacobi's questions and correctly paid her claims, Gordon-Shydlo said.
Jacobi is now covered by a health plan sponsored by her employer. She regrets getting caught up with Freedom Life. "It makes you feel really stupid that you fell for it," she said.
Regulators Play "Whack-a-Mole"
Frank Pyle has been chasing junk insurance companies for years as the director of market conduct enforcement for the Delaware Department of Insurance. "As soon as you take one down another one pops up in its place."
Pyle said regulators across the country are aware of misrepresentations by insurers selling limited, short term, accident and defined sickness plans.
Pyle and his team in Delaware have to get throwaway phones when they play secret shopper on the lead generating websites, because the lines get inundated with so many calls from brokers.
In one investigation, Pyle said his team listened to a random sample of 87 recorded sales calls from a particular company. At least half of them contained some form of deception, he said. The level of misrepresentation seemed to depend on the savviness of the consumer, he said. A consumer would ask if the limited plan was the same as an Obamacare plan and the broker would tell them it's just as good. If the consumer asked if the plan covered diabetes, the broker would tell them it did when it didn't, he said. The case resulted in a fine against the company, he said.
When some states identify violations, they impose weighty penalties, like fines or revoking the license of a broker. But in others the penalties are light or sometimes limited to warnings.
Numerousstateinsurance commissioners have warned consumers to "be wary of telemarketers from the 'national enrollment center,' 'national healthcare center,' or other official-sounding names."
Physicians Premier ER charged Dr. Zachary Sussman's insurance $10,984 for his COVID-19 antibody test even though Sussman worked for the chain and knows the testing materials only cost about $8. Even more surprising: The insurer paid in full.
The Virginia State Corporation Commission settled a case for $6,300 with Freedom Life that alleged the company misrepresented benefits or terms of a policy with advertising that was "untrue, deceptive or misleading" and failed to give applicants a summary of their rights. The company agreed to a corrective action plan that addressed the alleged violations, documents show. Gordon-Shydlo, the spokeswoman for UnitedHealthcare, which owns Freedom Life, said in an email that the company's brochures included notices about the limitations of the products and that the company did not admit to any violation of the law.
It was hard to find state regulatory agencies that had taken action against lead generating companies. One state insurance regulator, who spoke anonymously because he didn't want his colleagues to be criticized, said his agency "probably" has the authority to regulate the lead generators, because they are engaged in selling or soliciting the sale of insurance. "But it's something we haven't done in the past," the regulator said. "It's something that hasn't been the best use of our time."
New Mexico's superintendent of insurance issued an official warning, saying it intended to hold insurance brokers and companies responsible for "abusive marketing practices by lead generators." It also said the kinds of sales tactics used by brokers — such as referring to limited plans with terms associated with "Obamacare" plans — were misleading and deceptive, and banned them.
Corlette, the Georgetown insurance expert, said the Federal Trade Commission could take a "more aggressive" look at deceptive advertising and lead generating. An FTC spokeswoman said in an email that the agency is "concerned with illegal lead generation across the board," but could point to only five enforcement actions that related to the deceptive marketing of healthcare plans. Only one of the cases took place within the past five years. None involved Millar or Apollo Interactive.
The FTC's jurisdiction includes almost any sales claim that is "unfair" or is misleading and would affect a consumer's decision to buy, says Aaron Rieke, a former FTC staff attorney. Because the agency is "super understaffed for their jurisdiction," he said, its attorneys aim to take enforcement actions that yield real systemic improvement for consumers. But the fact that the lead-generation ecosystem includes many small players who buy ads on Google, Facebook and elsewhere presents a "structural challenge" — because "swatting [them] down doesn't feel like a very effective way to go."
Pyle said the state regulators should hold the insurance companies responsible for their advertising tactics, including the actions of lead generators. In 2016, the Delaware Department of Insurance fined Companion Life Insurance Company $487,000 for violations that included "deceptive acts," documents show. Many of the problems in the case came from the lead generators the insurer was paying to do the outreach to consumers, Pyle said.
A person in the Companion Life compliance department referred ProPublica to its parent organization, BlueCross BlueShield of South Carolina. But no one returned requests for comment.
Pyle said he's troubled that legitimate insurance giants own some of what he calls the "bad companies." "I'll be honest with you," he said. "I am surprised UnitedHealthcare is involved as much as it is."
Pyle said regulators from various states have regular meetings and are considering pursuing criminal action against insurance company executives. "If the insurance company is paying someone to work on their behalf, they are responsible for their actions," Pyle said. "You can fine these companies and they consider it the cost of doing business. But if you lock up their CEO in federal prison, they'll think twice about harming our consumers."
Informed by a ProPublica article investigating why Black Americans were three times more likely to undergo diabetic amputations, five members of congress are working to fund screening and enhance diagnostics in an effort to save limbs.
This article was published on Monday, October 19, 2020 in ProPublica.
On Friday, Congressman Donald M. Payne Jr., a Democrat from New Jersey, introduced a sweeping bill to reduce unnecessary amputations and address racial disparities that were the subject of a ProPublica story investigating why Black Americans were three times more likely to undergo diabetic amputations than others. The Amputation Reduction and Compassion Act of 2020 was introduced five months after the ProPublica investigation showed how government and hospital policies obstruct equitable care for at-risk patients.
The bill proposes major reforms that seek to address policy gaps explored in the article. Today, about half of patients with peripheral artery disease — a condition in which clogged arteries limit the flow of blood — are asymptomatic, and primary care physicians are not always reimbursed for screening. But catching and treating the disease, which is often caused by diabetes, is critical to preventing unnecessary amputations. The bill seeks to ensure that all at-risk patients can obtain a screening at no cost. It requires that Medicare and Medicaid cover the tests, as well as private insurers.
The ProPublica article also focused on how patients often undergo diabetic amputations without arterial testing beforehand. That testing, either with duplex scans or angiography, can show where blood flow is blocked and can indicate whether an intervention can restore blood flow before surgeons resort to amputation. But nationwide, more than 30% of patients don’t get arterial testing before amputation. One doctor likened this to removing a woman’s breast after she felt a lump, without first ordering a mammogram. The bill proposes that Medicare only pay for an amputation caused by vascular disease or diabetes if the patient has received arterial testing within three months of the surgery.
“The greatest problem with peripheral artery disease is that it can go undetected for years and lead to limb amputations that could be avoided with early detection,” said Congressman Payne, who launched the bi-partisan Congressional Peripheral Artery Disease Caucus with Congressman Gus Bilirakis, a Republican from Florida, in 2019. Payne said the bill provides resources to screen-at risk patients and educate doctors, which in turn will reduce racial disparities in amputations. Five co-sponsors, all Democrats, have signed onto the bill, including Congressman Bobby Rush, from Illinois, Congressman Ruben Gallego, from Arizona, Congressman Bennie Thompson, from Mississippi, Congresswoman Eddie Bernice Johnson, from Texas, and Congresswoman Lisa Blunt Rochester, from Delaware.
Rush and Gallego joined the effort after reading the ProPublica article on the work of Dr. Fakorede, a cardiologist who is reducing amputation rates in Mississippi and advocating nationally for safeguards for patients. “I was shocked and disturbed by the investigative article published earlier this year in ProPublica,” Rush said by email. “The article succinctly highlighted the financial incentives to amputate diabetic patients’ limbs rather than invest earlier in preventive screenings, particularly for poor Black and Brown patients who are disproportionately and discriminatorily overlooked until it is too late.”
After reading the ProPublica article, Gallego was also galvanized to craft legislation to reduce unnecessary amputations. His office reached out to medical experts, including Dr. Fakorede, and other key stakeholders, like the American Diabetes Association. “It is truly disturbing that race and economic status are the two biggest indicators of whether someone with peripheral artery disease will have their limb amputated,” he said.
The American Diabetes Association is one of the most influential lobbies on issues related to diabetes in the United States, and prompted by the ProPublica article, it introduced an initiative to reduce unnecessary amputations earlier this year. The organization supports this legislative effort. Tracey D. Brown, their CEO, is particularly shocked by how many of these amputations are preventable. “Policies that make screening and treatment for conditions that cause amputations are urgently needed,” she said, after reading the bill.
Dr. Ronald Dalman, President of the Society for Vascular Surgery, said he would have to review the bill before commenting on its specific proposals. He said that while many factors lead to amputations, and preventing them involves more than just testing, “to the extent to which vascular disease does contribute to the risk for limb loss, we support all efforts to ensure that patients get the testing and care they need.”
The bill also attempts to better align Medicare payments with the American Heart Association and the American College of Cardiology guidelines on peripheral artery disease; the groups recommend arterial testing before amputation. Dr. Marie Gerhard-Herman, who co-chaired the committee on these guidelines, called the bill “a crucial start in the crusade to save legs.” Dr. Michelle A. Albert, president of the Association of Black Cardiologists, added, “Similar to COVID-19, peripheral artery disease care and outcomes can no longer be dictated by racism and zip code.”
