California leads the nation in COVID deaths, now nearing 52,000. And while hospitalizations and infections are down, some health workers on the frontlines of the COVID crisis are now confronting a mental health crisis.
As vaccinations ramp up and COVID cases plummet, there's reason for optimism in America's COVID-19 disaster, but still, not all is well.
After being asked how she was, intensive care unit nurse Mariana Roman said, "That's a loaded question. I am exhausted."
Fighting COVID has taken a heavy toll on healthcare workers, especially those in the ICU. New studies show that nearly half may have mental health issues including anxiety, depression, insomnia and PTSD.
Rebecca Sandoval, the clinical nursing director for the ICU at the largest hospital in Los Angeles, said "This has been a really long road and we're not at the end. We're going to need to make sure that our staff is OK again."
Frontline workers experience mental health struggles amid pandemic
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Every surge brings increased workloads, personal risk of infection and the loss of many patients.
Roman said she's seen too much death. "Sometimes I went home and cried," she said. "It's hard to just go home and turn it off."
Healthcare workers' stress is compounded as they watch beds fill up with members of their community. In California, infection rates among Latinos are double those of White residents.
"So many have been ill and, in the hospital, its underserved population, really, just the access to care," Sandoval said. "I think all the comorbidities that as Hispanic people we have — the diabetes, hypertension, all those things."
Help has arrived, including at County USC Medical Center. The Biden administration has deployed troops to speed up shots and help in the intensive care unit.
U.S. Army Lieutenant General Laura Richardson said "Our providers were able to go into those hospitals and decompress those hospitals and wrap their arms around the staff there, just tremendous."
Respiratory therapist Derick Sherwood serves in the Air Force. He's been at this ICU for months.
"I really resort to FaceTime with my family. It's how I keep myself balanced," Sherwood said when asked how he is coping.
Checking in with loved ones, eating right and exercising helps avoid burnout, but there is the danger of PTSD — similar to being in combat.
Captain Hughes Choy, a military psychologist, said that "for our medical providers, you're seeing repeated loss of life each and every day. That's going to wear on you."
But with fewer deaths and infections, things appear to be getting better.
"It's a new day. It'll be a better day. That's what I keep telling myself. Today is going to be a better day," Roman said.
A surge in child mental health cases is expected to emerge as schools reopen next week, amid warnings of a “crisis on top of a crisis” hitting vulnerable children during the pandemic.
Paediatricians, psychologists and charitable groups providing mental health support all told the Observer they were seeing increasing demand and warned of another surge as lockdown is lifted. Several reported longer waiting lists for young people in need of help.
Some charitable mental health services said they had seen a 70% rise in demand over the past three months, compared with the previous year. The number experiencing eating disorders, self-harm and even psychosis is causing serious concern. There are also warnings that the crisis is having a disproportionate impact on children living in poverty.
Karen Street, officer for mental health at the Royal College of Paediatrics and Child Health, told the Observer: “We are all really worried about what we’re already seeing, and really worried about what might be coming. We’re seeing an increased presentation to acute hospitals of children in crisis. What we found in the first lockdown is that things seem to go quite quiet on all fronts right at the beginning, but later there was a really steady and very big surge of young people presenting with eating disorders.
“That surge peaked in September and October, when they were back in school and the teachers had that opportunity to see them for the first time in months.
“What we’ve seen from members on eating disorders is that they’ve dropped slightly again in this lockdown. We’re all thinking, gosh, what’s going to happen now when they all go back to school? We’re all just feeling we’re going to see lots of slightly lost, sad, confused, anxious, disorientated kids coming back into school.”
Bernadka Dubicka, chair of the child and adolescent faculty at the Royal College of Psychiatrists, said the Covid pandemic had highlighted and intensified an existing problem in child mental health. “We’ve got a crisis on top of a crisis,” she said. “We had a pre-existing crisis in child and adolescent mental health before the pandemic. The indications are things just got much more difficult for many children and families, and also for the staff trying to provide services.
“We already have evidence of an increase in mental health problems among families living in poverty. We know the pandemic has hit many of those families the hardest. It’s extremely worrying.
“I think our prediction would be that [an increase in demand for services] is the direction things are likely to go in because of all the existing data that we have, and trends that we can already see. I’ve seen a lot of children that hit crisis on going back to school in September last year and are terrified about going back again.”
Julia Britton, director of charity Open Door, a community service for young people in north London, said in the last three months, she had seen “an increase of around 70-75%” compared to last year. “We’re aiming to see them for an initial assessment within four weeks, but they might then sit on a waiting list for anything from two to nine months, which we don’t want to see at all,” she said.
“We are seeing a big increase in suicidal thinking and self-harm, eating disorders, anxiety and of course, isolation.”
It follows a series of warnings that the funding for child mental health was failing to match the increased need even before the pandemic hit. Many local clinical commissioning groups are still spending less than 1% of their budget on providing children’s mental health services. Recent research suggests one in six children now has a mental health issue, while the 61,000 referrals to children and young people’s mental health services in England last November was a record high. It represented a 66% increase on the same month in 2019 and 139% higher than the same period in 2017.
NHS sees surge in referrals for eating disorders among under-18s during Covid
A Department of Health and Social Care spokesperson said: “We know this year has been exceptionally difficult, especially for our children and young people, and that for many it is having a real impact on their mental health.
“Early intervention and treatment is vital, and we are providing an extra £2.3bn to help an additional 345,000 children and young people access NHS-funded services or school and college-based support.
“We are also training a new dedicated mental health workforce to provide targeted support, and investing £8m to help upskill education staff so they can better respond to children’s emotional and mental health needs as a result of the pandemic.”
Health insurance companies are set for a windfall in the next coronavirus relief package, even though Joe Biden had vowed during his campaign to take on the industry for its high prices.
The stimulus bill that just passed the Democratic-controlled House includes a provision that would send insurers almost $48 billion through federal subsidies that would temporarily pay for private plans offered in the Affordable Care Act marketplaces. The money would also pay for subsidies for COBRA, a program that laid-off workers can buy into after losing their employer-provided insurance.
Should those provisions pass as part of the $1.9 trillion package headed next before the Senate, health insurance companies — the subject of much criticism by Democrats — would check off major items on their wishlist to Congress.
About 29 million people in the US are uninsured and the subsidies would only make a small dent in reducing that number. Instead, they'd shift how people get coverage and lower premiums for people who already have insurance.
"It's no secret that it's not the approach I would have chosen if I were queen of the world," Democratic Rep. Pramila Jayapal of Washington, who chairs the Congressional Progressive Caucus, told reporters recently.
The $47.8 billion projections come from the nonpartisan Congressional Budget Office, which is tasked with evaluating how policies will affect businesses, consumers, and federal spending. It found that under the latest relief plan called the American Rescue Plan Act, insurers would get $35.5 billion for ACA subsidies and $7.8 billion for COBRA subsidies. Another $4.5 billion would pay the full cost of ACA premiums for people who are on unemployment insurance.
The provisions would cut the number of uninsured by less than 2.5 million overall and lower premiums for about 11 million people who already have coverage, according to an Insider tally of numbers from the CBO report. Critics of the plans say there are better alternatives, such as enrolling people in government health insurance.
"It is saddling taxpayers with unnecessary expense," Wendell Potter, president of the Center for Health and Democracy, which supports expanding government health plans, told Insider. "This is not the right way or the most cost-effective way to try to bring relief to people who are uninsured or under-insured."
The expected boon for insurers would come after a mostly good year for the industry's bottom lines in a troubled economy.
Health insurers had record profits during the second and third quarters of 2020 while the coronavirus started spreading in the US. Even in the midst of a pandemic, people used healthcare services less overall by delaying surgeries and doctor checkups.
That meant insurers didn't have to pay out as much money for medical care. By the fourth quarter of 2020, though, people started getting care again and insurance profits dipped.
The policies in the stimulus bill indicate Democrats are working with the industry, at least for now, rather than cracking down on prices or cutting into its profits.
A Biden administration official told Insider in an interview Tuesday that right now it was important to focus on how the stimulus plan would quickly make premiums far less expensive for people. The aid package is on track to pass by March 14, which would give Biden a major legislative victory early in his presidency.
"In addition to bringing new people into coverage, this is a massive premium savings for struggling families as they fight to keep health insurance during the pandemic," the official said.Renay Grace holds a poster calling on California to switch the state to a ``Medicare for All'' healthcare system on Friday, Jan. 1, 2021 in Pasadena, CA. Irfan Khan / Los Angeles Times via Getty Images 'More moderate approach'
The subsidies for ACA plans and COBRA have backing from the powerful health insurance industry as well as many healthcare providers and businesses. The subsidies address the problem of high premiums by having the government pick up a greater share of the costs.
Democrats say the subsidies in the bill provide the best way to move quickly in the midst of an international emergency and to fulfill their promises to strengthen the Affordable Care Act.
Millions of people find ACA premiums to be too expensive, and Biden promised if elected that he'd make subsidies for those plans more generous just like he's doing in the stimulus.
But he also promised he'd pair such help with a public option which would increase competition in the ACA marketplaces and lower prices. A public option would allow people to buy into a government plan similar to Medicare or keep their private insurance if they so choose.
Hospital groups oppose the idea of a public option because they'd get paid less to deliver medical services. And a public option would lure customers away from private insurers.
Despite industry opposition, several Democrats in Congress have said they hope a public option would be next on Congress' agenda, even as soon as this year.
But the task will be difficult given the entrenched industry opposition and Democrat's slim Senate majority.
They aren't united on how to create a public option and Republicans oppose expanding government insurance or additional funding to the Affordable Care Act. Some have said they'd be open to COBRA subsidies.
One healthcare industry consultant and lobbyist predicted Congress wouldn't pass a public option this year.
"The first step you're seeing played out is: What is the smaller, low-hanging fruit we can do to make healthcare more affordable and more accessible? It's more of a moderate approach," said the lobbyist and consultant, who requested anonymity to speak candidly.
"This bill was about a quick recovery solution," the person added. "No one is ready to talk about a public option right now."Anthem Health Insurance facility in Indianapolis, Indiana. Aaron P. Bernstein/Getty Images 'Enriching an industry that doesn't need it'
Potter, who was a health insurance executive before becoming a whistleblower, said that Congress should start planning for a public option to reduce healthcare costs in the long-run. Potter said he was particularly worried about the high out-of-pocket costs people will still face under private plans for prescription drugs and doctor and emergency room visits.
"This is not a good, sound economic policy for the country," he said of the temporary subsidies in the stimulus. "It is enriching an industry that doesn't need it and there are other ways to do this."
The healthcare industry supported Biden over his predecessor Donald Trump during the 2020 election. Though Trump cut taxes for corporations, he also tried unsuccessfully to kill the Affordable Care Act through Congress and the courts. The industry opposed his actions because they would have caused massive disruption.
The Biden campaign raised almost $57 million in personal donations from healthcare executives over the course of the 2020 cycle, while Trump's campaign brought in $28 million, according to the Center for Responsive Politics, which runs the money-in-politics website Open Secrets.
Health insurers such as Centene and Molina stand to profit from the changes in the relief package, analyst Scott Fidel of Stephens predicted in a research note.
Asked about the legislation, a Centene spokesperson said the company supported "all efforts to facilitate access to comprehensive, high quality, and affordable health insurance for more Americans."
Insurers support not only more funding for the ACA marketplaces but other plans they administer alongside the government, such as Medicaid. In addition to the subsidies, the coronavirus aid package has a provision to try to entice states to enroll more low-income people in Medicaid. Insurers stand to benefit from that move as well.
Organizations like the Partnership for America's Health Care Future support these kinds of measures, within the existing system, rather than trying to create a new plan.
"The best way to expand access to quality, affordable health care is to build on the strength of our current system, where private coverage works together with public programs like Medicare and Medicaid to get Americans covered," said Lauren Crawford Shaver, executive director for the organization, which is a coalition of healthcare and business groups.Protesters supporting “Medicare for All” hold a rally outside PhRMA headquarters April 29, 2019 in Washington, DC. The rally was held by the group Progressive Democrats of America. Photo by Win McNamee/Getty Images Eyes on the next relief package
Potter said the health insurance approaches Congress and the administration were taking was "politically expedient" because they would "satisfy the desires of big campaign contributors and entities with a lot of lobbyists."
He warned that, in contrast, moving toward a public option would be "a heavy lift because what you're trying to do is really attacking healthcare costs in ways that the Affordable Care Act did not and you've got entrenched opposition to it."
Some Democrats still want to try. Sens. Tim Kaine of Virginia and Michael Bennet of Colorado have a public option plan that they hope can be passed under a reconciliation bill. The process fast-tracks legislation and only requires 51 votes in the Senate, but there are also complicated restrictions tied to it that have to be interpreted by a referee called the parliamentarian.
Jayapal, too, said she told the Biden administration and House Speaker Nancy Pelosi that she wanted to see a public option in the next legislative package Congress tackles.
She added that Congress hasn't done enough to make sure uninsured people are covered as part of the stimulus package, but that progressives wouldn't stand in the way of the current plan.
"We are where we are," Jayapal said. "And so the question is: How quickly can we get people covered? A public option would take legislation from Congress and we need to get this rescue package done quickly."
Progressives want to make sure a public option that Congress creates would be administered by the government rather than a plan like Medicare Advantage that's run by private insurers and is lucrative to the industry. Many centrists support the latter arrangement, while others prefer lowering Medicare's eligibility from 65 to 60. All of this division threatens consensus.
Jayapal and other progressives would ultimately prefer to go further in the form of the Medicare for All Act. It would virtually eliminate all private health insurance in favor of placing everyone living in the US into a single, government-funded health plan.
This is the kind of snowball effect the health insurance industry's lobbying arm, America's Health Insurance Plans, warns about, pointing out that 183 million people in the US now have coverage through their employers.
"The American people want healthcare that works — not a one-size-fits-all health care system. They want to improve what's working and fix what's broken," David Allen, AHIP spokesman, told Insider. He added, "a government-run insurance system will fail, and tens of millions of Americans will pay more to wait longer, for worse care."
The health insurance industry is almost certain to lobby for the ACA subsidies to become permanent, given that it has pushed for them for years.
The Biden administration hasn't publicly disclosed a timeline for its other healthcare policies including a public option.
"We are 32 days in and are working to deliver on as much as we can as quickly as we can," the Biden administration official said. "But there's a lot of legislative work to do over the rest of the administration."
This story originally ran on February 24 and has been updated to reflect the latest developments.