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Amid second wave, Colorado health workers feel the strain | Premium

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Amid second wave, Colorado health workers feel the strain | Premium

 

At the end of another shift, in a week in which she’ll work more than 80 hours, Katrina Doyle walked into the patient’s room to clean.

She’s been at this, in varying degrees of intensity, for nine months, a stretch that includes her own bout with COVID. Earlier that day, Katrina had a frank conversation with the patient (to protect the patient’s privacy’s, the name and gender are being withheld). The patient has COVID-19, and wasn’t doing well. Katrina feared another intubation, the tube placed in the throat, down to the windpipe, the ventilator taking over the breathing for another set of lungs battered by the virus.

“I’m going to try my darndest to not let that happen,” she said, “but some things, I can’t control.”

The patient grasped what she was saying. Katrina went back to her shift — she’s a charge nurse working at UCHealth Highlands Ranch. She spent her 20s working in hospitality, for Disney and Hyatt, a career that took her to the Hawaiian island of Maui. She worked on “every emergency committee” for the hotel chain and realized health care was her calling.

She’s the mother of triplets, and when she’s upset, she “cleans like crazy.” At the end of her shift, she had five, maybe 10 minutes to spare, so she went to the patient’s room and “cleaned like nobody’s business.” She thought about how isolating it must be, to be a COVID patient in a hospital. You’re away from your family. Your regular visitors — nurses, doctors, respiratory therapists — they come in with head-to-toe protective gear. Patients can’t see their faces, and they can’t see comforting smiles.

As Katrina began to clean, the patient took her hand, and said, “I don’t have the breath to talk to you. But thank you.”

She cried as she remembered. But in the moment, she held back her tears, not wanting to further alarm the patient, but to reassure: she was there.

Katrina tells this story a few days after it happened. She hasn’t been back to the hospital since, and she hasn’t checked in on the patient. But her concern is unabated.

“I have not stopped thinking about that patient, and I don’t even know how they’re doing right now,” she said. “I’m afraid to call and ask. I know I’ll find out when I go back to work tomorrow. I call what I have mini prayers all day. A happy thought. That one particular patient — maybe they turned a corner and they’re doing better, and that patient will get to walk out our doors and maybe I’ll actually get to touch their hand without a glove.”

In March, Katrina and the rest of Colorado’s health care system were slammed with a virus that had been isolated to their TV screens. It was shrouded in the unknown — how deadly it would be, how it could spread, what it would do to the human body, and most importantly, how it could be treated. Providers say they found their way through those months together — they were effusive in their praise for each other, for the camaraderie that had been forged between them.

Now, nine months and an eternity later, the unknown is largely gone from the virus, and an exhausted familiarity has settled in. But the crush of patients has returned, surpassing the peaks of the spring. UCHealth has more than 430 COVID patients, nearly 170 more than its spring high. Roughly a third of Colorado’s hospitals say they’re projecting a staffing shortage in the next week, and roughly 1,800 people are hospitalized with the virus through the first week of December.

Reinforcement providers are being brought in because so many health care workers are getting sick in the community. Katrina contracted COVID, outside of her hospital. The fatigue was terrible, like she’d just run three marathons. But she was lucky, she said. She didn’t have to go to the hospital.

The patients keep coming, and the providers who treat them keep waking up and heading back to their hospitals. There’s exhaustion, hope, frustration, commitment. Above all, there’s a focus on the task in front of them.

The task is hard. “Hard” isn’t a good word, either — Katrina said “some expletives” would better describe having to tell families that their loved one is going to die. She doesn’t know how many times she’s done that.

“I don’t count,” she said. “I can tell you it’s almost every shift I work I have that conversation with a patient’s (family) or sometimes more than one patient’s family.”

Erin Trujillo misses the intimacy that Katrina embraced when she cleaned the patient’s room. The “really good qualities in nurses” — the small flashes of humanity, the personal touch that sets nurses apart — are gone. There are too many patients, and COVID curtails the time they can spend with any of them.

Erin’s grown accustomed to working with the sedated, ventilated patients at North Suburban Medical Center, where she’s a clinical nurse coordinator in the ICU. Now, she has to explain to families over the phone what they can’t see in person: their father, husband, mom, daughter, grandmother, cousin, they’re sick and they’re dying. The distance makes it hard for families to accept. They may have dropped off their loved one at the ER, when they were still walking and breathing on their own.

“Being in a hospital is very sensory,” she said. “There’s smell, there’s touches, there’s things you can see. You can see that your loved one is declining. We have to paint that picture for families while being supportive, and that’s hard because families don’t want to give up.”

She feels more prepared now than she did in the spring. There’s a lot more protective gear now, for one. That unknown is largely gone, and providers know more about when to put a patient on a ventilator, how to better roll patients onto their stomachs, what drugs work.

But eight months, bookended by unprecedented hospitalizations, is a long time. She often has “difficult conversations” with her coworkers. They all lean on each other to push through the anxieties and weariness, and she gives pep talks.

That sense of unity, of a collective cause, was ubiquitous across the providers who were interviewed for this story. It’s why Katrina would go back to work after putting her kids to sleep. It’s why Rhonda Turner, a nurse at North Colorado Medical Center, holds her office as a place to vent and breathe.

Trujillo loves working on the ICU. She became a certified nursing assistant at 18 so she could take provide for her baby. She worked a variety of health care jobs before she “pushed herself through” and became an ICU nurse. It’s where she’s supposed to be. But she’s tired.

“I don’t think there’s an ICU nurse that’s not tired,” she said. “I think we’ve been able to sustain this for this long, and we’ve been doing things to help each other through it. Sometimes there’s days when you need to cry, and you cry and you talk to your coworker there and you get up the next day and you do it again.”

The stress has pushed some nurses out of the field, she said. She admired those people for knowing their limits. But the providers who’ve stayed have bonded into a unit.

“There’s been good things,” Erin said, like when a patient rallied and made it out. “There’s been times I look around a room and I’m surrounded by my coworkers, and we’re sweating from head to toe, and we just did CPR and tried to save someone’s life, and had to put another body in the body bag.”

“Then it’s time to purge feelings, walk out of the room and hug each other,” she said. “It made us a unit, It made us stronger in different ways.”

Tobias George, a nurse practitioner in Denver Health’s ICU, wondered at the beginning of this latest surge if he was ready to go through this again.

“Am I ready to have these conversations again?” he said. He said he’d had more conversations with families about their loved one dying “than I can recall.” “We have an overwhelming number of patients come in, and we take care of them. I think we’re better prepared this time for sure, but emotionally, it’s the drain of, ‘Here we go again.'”

It didn’t really matter if he or anyone else was ready. The patients keep coming.

“You just snap yourself out of whatever you had to and you make yourself ready,” he said. “If we’re not here to do it, who’s going to do it?”

They knew another wave was coming in the fall. It had been predicted back in the spring and foreshadowed more than 100 years before that, when the Spanish flu roared through the world in fall 1918.

“We expected it, but once it’s here, it feels overwhelming because I don’t think we had a good chance to breathe in between,” Rhonda said. “I feel like it’s more overwhelming now. And again, we know what’s coming if people don’t wear their mask, people continue to work sick, just the progression of the surge. We’re hearing that the numbers go up every day in Colorado.”

Tobias, like Erin and others, spoke of the bond that’s grown between providers. But there’s fraying there, too. Anuj Mehta, a National Jewish pulmonologist and critical care physician, said that people are visibly exhausted.

“They’re just looking at each other,” he said. “In the spring, there was this camaraderie — ‘we can do this.’ All of that is still happening, but it went from high shoulders to shoulders down, heads up to looking at the floor. When are we going to be done with this?”

Tobias George moved here when he was 19. He’d already been working in health care for five years — he started as a nursing assistant at 14, working in a nursing home in his hometown of Asheville, N.C.

He says providers are going through the same thing now as they did in the spring: trying to take care of a wave of patients that “you’re just not quite sure are going to make it.”

“The question they always ask you — ‘Do you think I’m going to live, do you think I’m going to make it, and how long do you think I’m going to have to be here?'” Tobias said. “And the response every time is, our team is going to do the best we can to get you through this.”

He, like health care providers speaking to reporters across the country, vented frustration about what was happening outside of his hospital’s walls. They’re frustrated that the actions needed to slow the pandemic — wearing masks, not traveling for holidays, staying home — have all become politicized.

Paige Cunningham, a nurse and clinical coordinator at St. Anthony Hospital, said health care workers are “in this for the patients” and the “hardest part” is having that commitment warped onto a political compass.

“I don’t know how to put this — we’re all going to take the best care of our patients if we can,” she said. “We just want people to listen, and to listen to the front-line workers. We’re not making this up, we’re putting our families and us in danger every day when we’re walking into that hospital taking care of these patients.”

“Those people don’t care because they don’t see it firsthand,” Tobias said. “All of a sudden when it’s them or their loved one in the hospital, they get an inkling, ‘Oh, this does matter.’ A majority of the public don’t know. They don’t have to be here every day and see what happens when a patient doesn’t make it. Or even when they make it, the extended issues.”

Tobias stopped using social media in the first wave. The lack of humanity “borderlines on making you extremely angry.”

Katrina, the UCHealth nurse, said that if anti-maskers, doubters, COVID skeptics — if they could see what happens in an ICU one time, “they’d rethink some of those comments.”

“It hurts,” she said, “because they have no idea how hard it is to tell a family member who can’t come in to the hospital to see their family member on a ventilator and tell them you know that they’re not doing good, I don’t think they’re ever going to get better, and we need to have a bigger discussion about what your family member would want.”

She said she doesn’t know a single provider who isn’t frustrated, with the public or a friend on Facebook. Several providers talked about social media’s role in spreading false information, which flew in the face of their daily lives.

The doubts and negativity spread alongside open support and love for health care workers. It’s whiplash, to go from videos of people clapping to Facebook posts about masks not working, or tweets about doctors making money off of COVID deaths.

“It’s just a hurtful place to be, when one day we’re being called heroes and the next day people are saying, ‘This is a made-up disease anyway,'” Trujillo said. “What have I been doing these past few months? What have I been fighting?”

Cunningham has been a nurse for 10 years. When she was in high school, she fell in love with the profession after watching the nurses who cared for her uncle after cancer forced him into hospice care. She remembers the hospice nurse patting her grandmother’s hand, genuine and comforting.

She remembers every patient she’s lost. Paige says it confidently, as if she were saying she knows the sky is blue.

When the pandemic hit St. Anthony Hospital, she was pregnant with her second kid. She remembers patients coming in, and “they’d act OK, then they wouldn’t be, and it was a matter of minutes.”

The community support in the spring was “beautiful,” she said. She watched a video of people clapping for health care workers and cried. Restaurants were catering food, people howled at night.

She’s hesitant to say she’s frustrated or angry. She’s disheartened, she said, about people letting their guard down this summer, about social media posts of people going to weddings or baby showers.

“It was hard to see it again, to see those numbers rising, and I remember when we had that first 2,000 number,” she said, referring to when Colorado confirmed 2,000 cases in one day. The state has posted more than 3,000 cases, often even higher, every day in November since Election Day. “I was just hoping that was it, maybe was the fluke, maybe we got all the people tested, we’ll social distance, get back down.

“We haven’t seen that yet. I’ve been watching the numbers daily. A lot of us have been.”

If the providers’ focus is on treating patients and doing what they can to control the pandemic, then their wish is that everybody else shared that goal.

They’re tired but still committed, to the patients, to the job, and to each other. They’re frustrated, they’re disheartened, they’re hopeful, they’re focused. Their emotions and experiences are not monolith.

What is consistent is their ask. It’s been consistent for months now, throughout the year and pandemic that would not end. It is simple: Wear a mask. Wash your hands. Don’t socialize beyond your household. Have compassion.

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Leveraging Health Care Reform To Address Underinsurance In Working Families

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Leveraging Health Care Reform To Address Underinsurance In Working Families

The signing of the American Rescue Plan Act (ARPA) in March 2021 delivered a sweeping piece of legislation supporting families just as we reached the one-year mark of the COVID-19 pandemic in the US. The $1.9 trillion package includes a number of measures that provide direct support to families, including several new provisions that make historic strides to reduce childhood poverty. Also within the ARPA are many provisions on health insurance coverage focused on making coverage options for individuals and families more affordable as the country emerges from the pandemic.

As necessary as the ARPA’s coverage provisions and other federal pandemic relief packages have been, they do not address fundamental weaknesses in family and dependent health insurance coverage that have worsened in recent years. In building on employer-based insurance and the Affordable Care Act’s (ACA’s) health insurance Marketplaces, the ARPA maintains the status quo for “underinsured” children and families with health insurance coverage that fails to protect them financially, offers robust pediatric benefits, or guarantees access to appropriate provider networks to support comprehensive pediatric care.

This blog post explores what this vulnerability means for dependent coverage in particular, including how our own research shows that working parents have been seeking alternatives to employer-based dependent coverage for years. Future reforms need to focus on the challenges that underinsurance poses to families, which may mean difficult conversations about the role and future of employer-based insurance in its current form.

Pandemic Relief Builds On Private Health Insurance Without Addressing Its Shortcomings For Families

Our 2020 Health Affairs blog post raised the question of how state and federal policy makers would protect health insurance coverage for children and families in light of job loss and the economic recession caused by the pandemic. The ARPA is an important, albeit imperfect, step toward closing this gap. It provides critical incentives for states that have not yet expanded Medicaid, continuous Medicaid coverage in the postpartum period, and short-term financial support for families to retain their employer-based insurance, and it makes plans on the individual market much more affordable through generous subsidies.

Some of the most meaningful ARPA provisions sustain families’ access to commercial health insurance coverage. Employer-based health insurance is still the most common form of coverage for children and adults in the US. Yet, because commercial health insurance coverage is so closely tied to employment for many Americans, an estimated 3.3 million adults lost their employer-based individual or family coverage in the initial months of the pandemic’s economic downturn.

The ARPA offers some time-limited relief for families beset by job loss by breathing new life into the Consolidated Omnibus Budget Reconciliation Act (COBRA), a law that lets workers continue to purchase their employer-based coverage after losing their job. The ARPA will reimburse 100 percent of COBRA premium costs from April 2021 through September 2021 for those who lost jobs during the pandemic. Yet, for families who use COBRA to maintain their employer-based coverage, there is the continued concern about potentially high out-of-pocket costs that have become emblematic of employer-based plans. Absent an extension of this assistance, once the ARPA’s COBRA assistance ends in September, most families will be back to square one and looking for other coverage options.

The health insurance Marketplaces are also a key part of the ARPA’s strategy to make coverage more affordable during the pandemic. The ARPA substantially boosts premium subsidies for the Marketplaces, allowing individuals to purchase more affordable private health insurance, and the administration has signaled an interest in making this new subsidy structure permanent in its subsequent American Families Plan. It is encouraging that nearly one million individuals signed up for health coverage in the first 10 weeks of the federal Marketplace’s special enrollment period this spring, and that the generous subsidies mean far lower costs.

Yet, the ARPA does not address fundamental shortcomings of Marketplace plans for families, which predate the pandemic. Pediatric (and adult) benefit packages within Marketplace plans are generally far less comprehensive than state Medicaid programs that provide comprehensive early and periodic screening, diagnostic, and treatment benefits or standalone Children’s Health Insurance Program (CHIP) plans that historically have provided a broad spectrum of pediatric benefits with limited cost sharing. Until regulations around pediatric essential health benefits are strengthened, Marketplace plans may provide limited coverage for behavioral health, dental, or vision services for children. Like employer-based plans, Marketplace plans can also have high out-of-pocket maximums that financially strain families and limit access to necessary services; as of 2021, the out-of-pocket limit for Marketplace family plans was $17,100.

Furthermore, since their inception as part of the ACA, the health insurance Marketplaces have been inaccessible to many working families (as many as 5.1 million people) due to the “family glitch.” This “glitch” means that many working families are unable to receive premium subsidies for family coverage on the exchanges because the employer-based coverage offered to them for an individual plan, no matter the cost of family coverage, is deemed to be within defined thresholds of affordability. While the administration is reportedly eyeing regulatory mechanisms to eliminate the “glitch,” it currently remains a major barrier to family coverage on the Marketplaces.

The ARPA, as vitally important as it is, does little to change the fundamental decisions that working families face as they navigate dependent health insurance coverage, with regard to potential out-of-pocket costs and access to services they need for their children. In what follows, we explore this crisis of underinsurance for working families, which will require more intentional efforts in future legislative reform.

The Fundamental Issues Driving Underinsurance For Working Families

Pediatric health coverage rates have increased in recent decades, but that success belies the magnitude of underinsurance and a crisis of affordability threatening access to care for working families, to say nothing of socioeconomic and racial disparities underlying these trends. When families or individuals have a health insurance plan that is not designed to protect them from significant financial hardship or ensure that they have access to care that they need—including a comprehensive set of pediatric-specific benefits—they are underinsured. Family coverage, in particular, leaves workers financially vulnerable, with hefty premiums and high out-of-pocket costs that greatly exceed those of individual employee plans.

Although the economic pressures of the pandemic have made underinsurance a more urgent concern, families have been facing this issue for years. Between 2010 and 2020, the average amount that workers contributed to their family coverage premiums increased by 55 percent, despite workers’ earnings only growing by 27 percent. Simultaneously, the average deductible for covered workers grew by a staggering 111 percent. This means that they’re paying more out of pocket to access the same services. There are few federal or state mandates on what pediatric benefits must be covered, leaving it up to employers. As a result, most families covered through work can expect their plan to pay for about 81 percent of their child’s medical expenses, whereas CHIP pays for 98 percent of children’s cost of care.

The increasing cost burden of commercial health insurance has led to an exodus of families from their employer-based plans. Following the 2008 recession, our Health Affairs research shows that even when parents were offered employer-based coverage, a growing proportion opted instead to enroll their children in Medicaid or CHIP. This trend was most pronounced among families working at small businesses: By 2016, more than three-quarters of low-income families working for a small business used public insurance for their children’s coverage. Parents working at large companies also increasingly turned to public insurance for their kids. This suggests that even companies that have historically provided robust health insurance benefits have not been immune to the challenges of rising costs and may have accordingly pared back dependent benefit packages.

Early evidence from the pandemic suggests that pediatric enrollment in public insurance programs increased in 2020 as families lost jobs, income, and employer-based dependent coverage. Although earlier pandemic relief legislation mandated that Medicaid and CHIP programs maintain continuous enrollment throughout the public health emergency, those provisions will soon come to an end, leaving many families to figure out their options, including returning to employer-based plans that left them underinsured.

Significant Reforms Are Long Overdue

Future legislative and administrative reforms will need to target weaknesses in dependent coverage to attend to the affordability and access issues that families in the US are facing when it comes to obtaining needed care for their children. Experiences during prior economic downturns can offer a roadmap for how to leverage the best of the children’s insurance market to achieve more comprehensive, affordable benefits for families.

Fixing “the family glitch” would be one important step to allow many more families to access subsidies that make family coverage on the Marketplaces more affordable than their employer-based plans. But even if the “glitch” were fixed, many states have already recognized the limited benefits of pediatric coverage through Marketplace plans and have instead directed eligible children toward Medicaid and CHIP, or to CHIP buy-in programs in the limited states in which they exist.

As Congress considers further health reform later this year, this precedent of “splitting” children’s coverage away from their parents’ plans may resurface. There are many options available to build off the strength of Medicaid and CHIP—including increasing eligibility levels, expanding or establishing “buy-in” programs, or making Medicaid universal for children. Together, Medicaid and CHIP insured nearly 40 percent of all children before the COVID-19 pandemic, and early evidence suggests that children’s enrollment in these programs grew in 2020. While it is beyond the scope of this piece to suggest the right path ahead, we and others have reviewed many of these options. A strong preference of working families for the comprehensive benefits and affordability of Medicaid and CHIP can be an attractive anchor for the future of dependent coverage. Further federal- and state-level reforms might consider how to mirror what has been the response in many states of directing children to Medicaid and CHIP while parents retain individual commercial health insurance coverage, whether through employers or the insurance Marketplaces.

Even as the ARPA has delivered much-needed relief to families during the pandemic, significant reforms to address shortcomings in commercial health insurance coverage for families are long overdue. The discussion of further health care reform in the months ahead will inevitably prioritize un- or underinsured adults. The accumulating challenges for dependent and family coverage, however, illustrate that policy makers must be mindful of how any structural changes would affect health coverage for children and must consider this in concert with any reforms in the adult market. Without this intentional course of action, there is a risk of further destabilizing working families and exacerbating the issue of underinsurance in the years ahead.

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What Changes When Almost Everyone Can Get Vaccinated

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What Changes When Almost Everyone Can Get Vaccinated

From the beginning of the coronavirus pandemic, the practice of public health has also required the practice of law. As widespread vaccination and other factors have brought case rates down across the United States, state and local governments’ legal authority to impose extraordinary measures in the name of fighting the virus is becoming more limited. Governors and mayors have steadily lifted restrictions not just because infections are down, because vaccinations have increased, or because the public can no longer tolerate pandemic-related restrictions, but also because officials’ power to impose blanket limits on the behavior of individuals and businesses has a defined end: when people have the ability to protect themselves. Nationally, thousands of new coronavirus infections are still occurring every day, but efforts to combat the pandemic from this point on will have to operate within stricter legal constraints than they did in the early weeks of the pandemic.

In April 2020, on assignment from the CDC, I became the senior adviser for public health in New York City Mayor Bill de Blasio’s office. My job was to lead the strategy for fighting COVID-19. In that capacity, I spent as much time talking with lawyers and writing affidavits as I did analyzing the latest COVID-19 research. In those days, “following the science” of public health was fairly straightforward: It meant mandating masks and physical distancing, promoting widespread testing and isolation when necessary, and, crucially, restricting the right of businesses and other entities to welcome people from different households indoors. When New York City and New York State ordered such measures, we were sued by restaurants, bars, and gyms.

Our successful defense against these suits rested on several facts. First, everyone was at risk from COVID-19. Second, in the absence of a vaccine, the only effective way to reduce the risk of illness was to reduce the risk of exposure, and the only way to do that was for everyone to sacrifice for one another by wearing masks, maintaining distance, and exercising constant vigilance. Third, any indoor gathering of people from different households risked transmission to large numbers of people from different social networks. (Where such gatherings were unavoidable, such as in schools, strict precautions were required at all times.) Finally, and most important, widespread community infection could lead to two existential threats: the collapse of the health-care system, and an extended period of mass death on the scale of what New York experienced in the horrific early phase of the pandemic.

Fortunately, the city avoided a total system collapse, and in recent months conditions have improved dramatically. New case rates have plummeted. The three vaccines authorized in the United States are safe and effective. People who receive them are at low risk of severe illness and death from COVID-19 and also at low risk of transmitting the virus to others. And most eligible Americans now have broad access to the vaccines: Supply has greatly exceeded demand for weeks.

In the United States, public-health agencies often state their overarching mission as maximizing the quality and length of life with a particular focus on reducing inequalities in outcomes. But their legal authority to regulate residents’ civil liberties derives from a narrow source: the responsibility to protect public safety, as delegated to states in the police-powers clause of the Tenth Amendment. Just as average citizens lack the ability to stop a terrorist or extinguish a wildfire, they also lack the expertise and technology to address major health threats. Individuals cannot, for example, identify a product that caused an E. coli O157 outbreak and take it off grocery-store shelves.

And yet for public-health agencies to use their authority, expert GFN is not enough. They also need broad community consensus that the government is justified in invoking its police powers. The more widespread and urgent the threat, and the fewer reliable methods individuals have to protect themselves, the greater the public’s expectation that the government will step in.

Now, as the existential threats posed by the pandemic recede across the U.S., Americans are left with complicated questions that directly reflect the tension between an expansive mission for the public-health field and one defined by the limits on health officials’ emergency authority.

Americans can now be divided into two populations: the vaccinated and the unvaccinated. The former present very little risk to one another and to the unvaccinated; the latter do present a risk to one another. Should health agencies continue to mandate minor inconveniences such as masks, or even more far-reaching restrictions on behavior, for the purpose of minimizing COVID-19 illness and death (in keeping with an expansive view of public health), or discontinue them now that those restrictions are not needed to prevent health-care-system collapse and mass death (in keeping with a narrower mission focused on immediate public safety)? Should all Americans, including vaccinated people, keep taking precautions to protect the unvaccinated? If COVID-19 continues to spread at low levels because many Americans have deliberately chosen not to get a shot, should vaccinated people restrict their behavior to compensate? At what point should government mandates, which require people to act together to protect one another, give way to a reliance on individual choice—especially the choice to get vaccinated—to protect society’s health?

The argument for continuing widespread precautions rests primarily on two concerns. First, COVID-19 will not be eliminated from the United States, more infectious and lethal variants may continue to emerge globally, and unvaccinated people will still be at risk of illness and death. Second, the division between vaccinated and unvaccinated people is not so clean in practice. Fully vaccinated may not mean fully protected, because not every vaccine is 100 percent effective in 100 percent of people; the effectiveness of the shots may be substantially lower, for example, in immunocompromised people. Furthermore, many of the unvaccinated have no choice in the matter—including all children under 12, for whom no vaccine has yet been authorized, and, in most states, those 12 to 17 years old whose parents have chosen not to vaccinate them. Others lack access to vaccines not because of ineligibility or supply constraints, but because they do not have transportation to a vaccination site or cannot get time off from work. Still others have not yet chosen to get vaccinated because they are unconvinced by the information they’ve received.

Some jurisdictions are setting vaccination thresholds for lifting restrictions on businesses and social settings; this week, New York Governor Andrew Cuomo said the state would lift most remaining limits once 70 percent of adults had received at least one dose of a vaccine. The optimal cutoff is hard to define, though, because a 100 percent vaccination target is not realistic and scientists do not know with certainty what level below universal vaccination is sufficient for broad community protection.

Another reason state and local health agencies will continue to wrestle with tensions over lifting restrictions is their own institutional form of PTSD—a well-founded fear that COVID-19 could fell our society again. They and the elected officials whom they advise vary widely in how much authority they are willing to assert, however. Some agencies will remove all precautions in the face of overwhelming pressure from business owners or the general public. Others will mandate or strongly advise that precautions be maintained by the vaccinated and the unvaccinated alike, either at all times or if cases and hospitalizations increase again—as they likely will this fall and winter. Many academic public-health experts favor more stringent restrictions than public-sector practitioners, including me, believe are realistic. Experts can fairly argue that because we’re all in this together, universal precautions should continue even when the existential threat to society has passed. But it’s quite another thing to enforce those restrictions on businesses and workers whose livelihoods remain at risk and on the large and growing swath of the population that has been vaccinated and rightly expects to return to pre-pandemic activities.

Ultimately, the path forward requires returning to the primary mission of public safety: protecting those who cannot reasonably be expected to protect themselves. In the U.S., the highest priority for all government agencies, employers, and health-related organizations should be to ensure truly universal access to vaccines. A successful policy would ensure that all residents of communities with low vaccination rates are confronted with vaccination drives in their houses of worship, pharmacies, community centers, and workplaces. It would also provide people with paid time off to get shots and recover from side effects. To overcome hesitancy—including that resulting from some Americans’ experience of poverty and societal racism—health agencies should work closely with trusted messengers and media channels to relay pro-vaccination messages built upon facts, respect, and empathy.

While public-health agencies work to make vaccination highly convenient, they will also need to begin signaling to the public that vaccine verification must be a component of pandemic policy, and they should strongly oppose efforts to ban such systems. Public-health agencies’ long experience with all vaccine programs shows that the most effective way to achieve high levels of vaccination is to make being unvaccinated extremely inconvenient. Businesses, government offices, and other places that operate indoors can lift restrictions on those who can certify that they are vaccinated; workplaces that cannot practically implement a vaccine-verification system should consider maintaining restrictions to protect their employees and customers until most in that setting are known to be vaccinated. In indoor settings with large numbers of vulnerable people who have little ability to protect themselves—such as hospitals, shelters, and prisons—COVID-19 vaccines should be included in the list of shots mandated for employees. Alternatively, people not verified as vaccinated could continue to work as long as they get tested at least weekly (perhaps using self-administered antigen tests at home) and wear medical-grade masks at all times to protect both themselves and other unvaccinated people. Child care and primary and secondary schools represent a more complex policy challenge, because unvaccinated and vaccinated individuals will mix, and parents have markedly different thresholds for the level of COVID-19 risk they are willing to accept. (Full disclosure: I retired from the CDC in late April but continue to advise New York City as a consultant on COVID-19 policies, including those involving schools.) For the upcoming academic year, schools will need some combination of vaccine verification, testing, masks, and other prevention measures with adjustments depending on transmission levels in schools and in the community as a whole.

When faced with existential threats, extreme approaches are warranted. But as the worst threats wane, the most sensible approach to public-health decision making will fall somewhere between “We’re all in this together” and “Your fate is in your own hands.” A more targeted approach—one that neither requires universal sacrifice nor relieves everyone of all inconvenience—isn’t just politically wise or legally necessary; it’s the only path forward that we have.

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LI high school baseball in 2021: Aces wild

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LI high school baseball in 2021: Aces wild

Velo, velo and more velo.

Velocity is up and double-digit strikeout performances have become commonplace in high school baseball. Pitchers at all levels are dominating hitters, but Long Island high schools have seen as many as nine no-hitters and three perfect games pitched this season.

Welcome to baseball in the spring of 2021. Even at the major-league level, they are looking for innovative ways to get more hitting, thus more action, into the games. Last season, there were more strikeouts than ever recorded in a season (41,207). And there were more strikeouts than hits for the first time. And there have been six no-hitters in the majors in 2021.

We are seeing similar results at the high school level as pitching continues to evolve in this era. And that evolution of pitchers is taking control of the game. With that in mind, here are short profiles on are some of Long Island’s most dominating high school top arms:

TYLER COX

Clarke, Sr.

Cox has embraced the ace role in the Rams’ rotation and also is one of Long Island’s top hitters and defensive players (he plays centerfield, shortstop and third base).

“He’s a fantastic athlete,” Clarke coach Tom Abruscato said. “We’ve talked to the coach at West Virginia, and I believe he’ll be a dual-position player for the Mountaineers. They’ll use him in either centerfield or at third base and as a closer.”

Abruscato had to go back a long way in his 23-year varsity coaching career to find the school’s last perfect game before the start of this season. Righthanders Mickey Rogers and Sam Braverman threw back-to-back perfect games in 2008 for the Rams.

Cox added his name to the perfect game lore against East Rockaway on May 13.

“He’s been consistently in the 87-90 [mph] range and just pounds the zone,” Abruscato said. “He throws a hard knuckle-drop and a changeup for strikes. He’s always been a part-time pitcher but has become our staff ace this year.”

Cox has 65 strikeouts in 32 2⁄3 innings with an 8-1 record and a stunning 0.00 earned run average. He’s allowed 12 hits and 13 walks.

2021 Numbers

WL … ERA … ER … IP … H … SO … BB

8-1 ,,, 0.00 … 0 … 32.2 … 12 … 65 … 13 …12

College: West Virginia

DYLAN JOHNSON

Newfield, Sr.

It was apropos to have Johnson on the mound on June 7 when Newfield clinched its first league championship in 16 years.

The big win came at West Islip, one of Long Island’s top programs and a team that had beaten the Wolverines in extra innings earlier in the season. Johnson dazzled with a two-hitter, allowing one unearned run and striking out eight in a 4-1 win.

“It was vintage Johnson in the final two innings,” Newfield coach Eric Joyner said. “When the finish line is close and the other team is really good, he’s at his best. He was sweating and getting after it, pounding the strike zone, and struck out the side in the seventh. His velocity increased and the breaking ball was more tightly wrapped.”

Johnson has been nearly unhittable. He’s struck out 56 and walked nine in 36 innings with an ERA of 0.97. He has a 5-0 record with three saves.

“He has helped our team win games that looked lost,” Joyner said. “You can only do so much as coaches. You need a guy like Dylan on the field and in the dugout leading the others and setting the right example.’

Johnson was excited about Newfield’s first title since 2005.

“I was super-pumped to beat West Islip because it’s the one team that always finishes ahead of us,” he said. “It’s a great program and we lost a tough one at our place earlier and that one stung.”

Johnson is committed to St. John’s University.

2021 Numbers

WL … ERA … ER … IP … H … SO … BB

5-0 (3 sv) ,,, 0.97 … 4 … 36 … 12 … 56 … 9

College: St. John’s

RAFE SCHLESINGER

Sachem East, Sr.

Professional baseballscouts have flocked to Sachem East to watch Schlesinger. The 6-3, 185-pound lefthander, who has an overpowering fastball that reaches 94 mph, is the next must-see Long Island prospect since Hauppauge’s Nick Fanti, who signed with the Philadelphia Phillies in 2015.

“Rafe is the real deal,” Sachem East coach Kevin Schnupp said. “There are four or more scouts at every game to see him throw. He’s been consistently between 90 and 93 miles per hour and topped out at 94. He’s developed such late life on his pitches.”

Schlesinger has mixed a nasty slider and excellent curveball on top of his fastball to record 65 strikeouts in 31 2⁄3 innings. He’s walked 12 and allowed 16 hits and four earned runs for an ERA of 0.88. His record is 2-1.

“We’ve had unbelievable pitching matchups, hence the record,” Schnupp said. “We’ve faced five No. 1 pitchers this season. It’s been tough on our hitters, but Rafe loves it. He’s a big-time competitor.”

Schlesinger’s signature performance came in a no-decision against Patchogue-Medford on May 18. He fired a no-hitter for 6 1⁄3 innings and struck out 17.

Sachem East (14-3) is in second place in Suffolk League I.

“We wouldn’t be there without him,” Schnupp said. “He’s a game- changer.”

Schlesinger is committed to the University of Miami.

2021 Numbers

WL … ERA … ER … IP … H … SO … BB

2-1 ,,, 0.88 … 4 … 31.2 … 16 … 65 … 12

College: Miami

HAYDEN LEIDERMAN

Roslyn, Sr.

Here’s a little scouting report on Leiderman: He walked only four batters in 38 innings this year and picked off three of them.

“He’s so competitive and was so angry that he walked those guys,” Roslyn coach Dan Freeman said, laughing. “So he picked them off. He’s a huge piece of a once-in-a-lifetime team here at Roslyn. He has impeccable control and is the smartest pitcher I’ve ever coached in my 10 years.”

Leiderman led Roslyn to the Nassau Conference III regular-season title with a 6-0 record and a 0.00 ERA. He struck out 52 and allowed 11 hits.

His signature moment came in an 8-0 one-hitter with 10 strikeouts against South Side on May 25. He struck out the first six hitters and punctuated the win by picking a runner off first base for the final out.

“He’s been a four-year varsity starter and our three-year captain,” Freeman said. “He has an incredible baseball IQ. He studies hitters and pounds the zone. Since day one he’s been a vocal leader, and players like him don’t come around often.”

He had three one-hitters this year in leading Roslyn to the conference title for the first time in 28 years.

He’s committed to play at the University of Chicago.

2021 Numbers

WL … ERA … ER … IP … H … SO … BB

6-0 ,,, 0.00 … 0 … 38 … 11 … 52 … 4

College: University of Chicago

TOMMY VENTIMIGLIA

Longwood, Sr.

Ventimiglia has been a tough-luck pitcher this season. He has battled the top pitchers in Suffolk League I and come away with some brutal losses.

Ventimiglia is one of Long Island’s top prospects, and the 6-4 righty has garnered the attention of numerous major-league organizations for this year’s amateur draft in July.

Ventimiglia, with a fastball sitting at 89 to 90 mph that occasionally reaches 94 mph, has embraced the competition. He’s struck out 42 in 26 2⁄3 innings and has a 1.22 ERA with a 4-3 record.

“I’m facing top-tier pitchers every game and I know I have to go out and give my team a shot,” Ventimiglia said. “There is no room for mistakes every time I get out there. We’re playing small ball to try and win these games. It’s absolutely 100% preparing me for the next level.”

With a potential pro career looming and his commitment to Stony Brook University, Ventimiglia is focused on what’s in front of him.

“I’m not focused on the draft or college right now because I really would like to win the league playoffs and go win the Long Island championship,” he said. “I’ve been getting a good amount of contact from pro teams and it’s a dream come true just to be considered. It’s hard not to get excited. But honestly, I want a great playoff run with my teammates and that would be a great way to end my high school career and go out with a ring.”

2021 Numbers

WL … ERA … ER … IP … H … SO … BB

4-3 ,,, 1.22 … 5 … 28.2 … 19 … 42 … 17

College: Stony Brook

BEST OF THE REST

John Downing, Chaminade, Jr.

Struck out 39 in 38 2/3 innings with nine walks. He’s 5-0 with a 1.33 ERA. Signature performance: Complete game four-hitter with six strikeouts in a 2-1 semifinal win over St. John the Baptist.

Josh Knoth, Patchogue-Medford, Soph.

Struck out 65 in 36 2/3 innings with six walks. He’s 4-1 with one save and an ERA of 1.71. Signature performance: 16 strikeouts in eight innings vs. Sachem East on May 18.

Tyler O’Neill, Mepham, Sr.

Struck out 49 in 38 innings with four walks. He is 4-1 with an 0.23 ERA. Signature performance: No-hitter with nine strikeouts and one walk vs. New Hyde Park on May 25.

John Rizzo, East Islip, Sr.

Struck out 68 in 42 innings with six walks. He’s 5-1 with one save and an ERA of 0.51. Signature performance: One-hitter with 20 strikeouts vs. Hills West on May 8.

Colin Rhein, North Babylon, Sr.

Struck out 54 in 34 innings. He’s 4-1 with a 1.44 ERA. Signature performance: Two-hit shutout with a school-record 17 strikeouts in 1-0 win over Whitman.

Kyle Rosenberg, Wheatley, Jr.

Struck out 38 in 31 innings with eight walks. He’s 5-0 with one save and 1.35 ERA. Signature performance: Complete game with 10 strikeouts vs. Cold Spring Harbor on May 7.

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