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KAISER HEALTH NEWS | By Markian Hawryluk | AUGUST 28, 2020

In the 2014 elections, Republicans rode a wave of anti-Affordable Care Act sentiment to pick up nine Senate seats, the largest gain for either party since 1980. Newly elected Republicans such as Cory Gardner in Colorado and Steve Daines in Montana had hammered their Democratic opponents over the health care law during the campaign and promised to repeal it.

Six years later, those senators are up for reelection. Not only is the law still around, but it’s gaining in popularity. What was once a winning strategy has become a political liability.

Public sentiment about the ACA, also known as Obamacare, has shifted considerably during the Trump administration after Republicans tried but failed to repeal it. Now, in the midst of the COVID-19 pandemic and the ensuing economic crisis, which has led to the loss of jobs and health insurance for millions of people, health care again looks poised to be a key issue for voters this election.

With competitive races in Colorado, Montana, Arizona, North Carolina and Iowa pitting Republican incumbents who voted to repeal the ACA against Democratic challengers promising to protect it, attitudes surrounding the health law could help determine control of the Senate. Republicans hold a slim three-vote majority in the Senate but are defending 23 seats in the Nov. 3 election. Only one Democratic Senate seat — in Alabama, where incumbent Doug Jones is up against former Auburn University football coach Tommy Tuberville — is considered in play for Republicans.

“The fall election will significantly revolve around people’s belief about what [candidates] will do for their health coverage,” said Dr. Daniel Derksen, a professor of public health at the University of Arizona.

The Affordable Care Act has been a wedge issue since it was signed into law in 2010. Because it then took four years to enact, its opponents talked for years about how bad the not-yet-created marketplace for insurance would be, said Joe Hanel, spokesperson for the Colorado Health Institute, a nonpartisan nonprofit focused on health policy analysis. And they continued to attack the law as it took full effect in 2014.

Gardner, for example, ran numerous campaign ads that year criticizing the ACA and, in particular, President Barack Obama’s assertion that “if you like your health care plan, you’ll be able to keep your health care plan.”

But now, Hanel said, the ACA’s policies have become much more popular in Colorado as the costs of health exchange plans have dropped. Thus, political messaging has changed, too.

“This time it’s the opposite,” Hanel said. “The people bringing up the Affordable Care Act are the Democrats.”

Despite Gardner’s multiple votes to repeal the ACA, he has largely avoided talking about the measure during the 2020 campaign. He even removed his pro-repeal position from his campaign website.

Democratic attack ads in July blasted Gardner for repeatedly dodging questions in an interview with Colorado Public Radio about his stance on a lawsuit challenging the ACA.

His opponent, Democrat John Hickenlooper, fully embraced the law when he was Colorado governor, using the measure to expand Medicaid eligibility to more low-income people and to create a state health insurance exchange. Now, he’s campaigning on that record, with promises to expand health care access even further.

Polling Data

Polling conducted by KFF for the past 10 years shows a shift in public opinion has occurred nationwide. (KHN is an editorially independent program of KFF, the Kaiser Family Foundation.)

“Since Trump won the election in 2016, we now have consistently found that a larger share of the public holds favorable views” of the health law, said Ashley Kirzinger, associate director of public opinion and survey research for the foundation. “This really solidified in 2017 after the failed repeal in the Senate.”

The foundation’s polling found that, in July 2014, 55% of voters opposed the law, while 36% favored it. By July 2020, that had flipped, with 51% favoring the law and 38% opposing it. A shift was seen across all political groups, though 74% of Republicans still viewed it unfavorably in the latest poll.

Public support for individual provisions of the ACA — such as protections for people with preexisting conditions or allowing young adults to stay on their parents’ health plans until age 26 — have proved even more popular than the law as a whole. And the provision that consistently polled unfavorably — the mandate that those without insurance must pay a fine — was eliminated in 2017.

“We’re 10 years along and the sky hasn’t caved in,” said Sabrina Corlette, a health policy professor at Georgetown University.

Political Messaging

Following the passage of the ACA, Democrats didn’t reference the law in their campaigns, said Erika Franklin Fowler, a government professor at Wesleyan University and the director of the Wesleyan Media Project, which tracks political advertising.

“They ran on any other issue they could find,” Fowler said.

Republicans, she said, kept promising to “repeal and replace” but weren’t able to do so.

Then, in the 2018 election, Democrats seized on the shift in public opinion, touting the effects of the law and criticizing Republicans for their attempts to overturn it.

“In the decade I have been tracking political advertising, there wasn’t a single-issue topic that was as prominent as health care was in 2018,” she said.

As the global health crisis rages, health care concerns again dominate political ads in the 2020 races, Fowler said, although most ads haven’t explicitly focused on the ACA. Many highlight Republicans’ support for the lawsuit challenging preexisting condition protections or specific provisions of the ACA that their votes would have overturned. Republicans say they, too, will protect people with preexisting conditions but otherwise have largely avoided talking about the ACA.

“Cory Gardner has been running a lot on his environmental bills and conservation funding,” Fowler said. “It’s not difficult to figure out why he’s doing that. It’s easier for him to tout that in a state like Colorado than it is to talk about health care.”

Similar dynamics are playing out in other key Senate races. In Arizona, Republican Sen. Martha McSally was one of the more vocal advocates of repealing the ACA while she served in the House of Representatives. She publicly acknowledged those votes may have hurt her 2018 Senate bid.

“I did vote to repeal and replace Obamacare,” McSally said on conservative pundit Sean Hannity’s radio show during the 2018 campaign. “I’m getting my ass kicked for it right now.”

She indeed lost but was appointed to fill the seat of Sen. Jon Kyl after he resigned at the end of 2018. Now McSally is in a tight race with Democratic challenger Mark Kelly, an astronaut and the husband of former Rep. Gabby Giffords.

“Kelly doesn’t have a track record of voting one way or another, but certainly in his campaign this is one of his top speaking points: what he would do to expand coverage and reassure people that coverage won’t be taken away,” said Derksen, the University of Arizona professor.

The ACA has proved a stumbling block for Republican Sens. Thom Tillis of North Carolina and Joni Ernst of Iowa. In Maine, GOP Sen. Susan Collins cast a key vote that prevented the repeal of the law but cast other votes that weakened it. She now also appears vulnerable — but more for her vote to confirm Brett Kavanaugh’s nomination to the Supreme Court and for not doing more to oppose President Donald Trump.

In Montana, Daines, who voted to repeal the ACA, is trying to hold on to his seat against Democratic Gov. Steve Bullock, who used the law to expand the state’s Medicaid enrollment in 2015. At its peak, nearly 1 in 10 Montananswere covered through the expansion.

As more Montanans now face the high cost of paying for health care on their own amid pandemic-related job losses, Montana State University political science professor David Parker said he expects Democrats to talk about Daines’ votes to repeal cost-saving provisions of the ACA.

“People are losing jobs, and their jobs bring health care with them,” Parker said. “I don’t think it’s a good space for Daines to be right now.”

KOLD NEWS 13 | By Megan McNeil | August 17, 2020 at 5:23 PM MST | 3min:27sec

TUCSON, Ariz. (KOLD News 13) - Dan Derksen, M.D. with the University of Arizona’s Center for Rural Health, said two of the most common factors for COVID-19 impacts, are socio-economic status and living in a rural area, among other risk factors. “COVID-19 has disproportionately affected certain populations,” said Derksen.

Drive times to get care can often be much longer than urban areas and smaller hospitals serve large geographic regions. It’s a problem many in rural areas have faced before the pandemic.  
The Robert Graham Center estimates by 2030, Arizona will need nearly two-thousand more physicians to keep up with demand. Derksen said the Arizona surge line and telehealth have helped ease some of the burden on healthcare systems, but rural areas still face challenges—especially as we enter the fall and winter. 

“We’ve never really emerged from the first wave,” he said. 

Flu and other respiratory illnesses could pile on with COVID-19 infections. 

“(It) could add stress to the systems that are always borderline stretched, especially in these rural areas,” said Derksen. 

Right now, trends are looking more positive, with hospitalizations, daily cases and other daily statistics trending down. Santa Cruz county has almost double the amount of deaths per 100,000 people than Pima County. Federal dollars have helped, sending about $71,000 to 16 rural and critical access hospitals for COVID-19 support, most of those also got another $8,500. Derksen said testing and contact tracing will help these communities continue to see better stats. 

“For these very small communities, it’s very important because we have these people spreading the virus and never having a symptom,” he said. 

According to the Center for Rural Health, about 18 percent of COVID-19 deaths in Arizona have been indigenous people, who make up less than 5 percent of the population.

NBC NEWS | By Kenzi Abou-Sabe, Cynthia McFadden and Didi Martinez | Aug. 3 2020

When the largest Indian reservation in the U.S. was hit by a surge of COVID-19 cases in April and May, it took weeks for federal aid to arrive. By the time it did, Navajo Nation had already begun to flatten its curve, but the virus had exacted a heavy toll. 

“It hit our relatives. It hit people that we knew and love and respected,” area resident Crystal Kee said. “And it has hit us at our core.”

With more deaths per capita than any U.S. state, community members say virtually everyone on the reservation knows someone who has been personally affected by the virus. 

The coronavirus was so devastating on Navajo Nation in part, experts say, because of severely lacking infrastructure on the reservation. An estimated 30 percent of homes don’t have running water, and over half of Navajo communities lack broadband access. Compounding the problem, a lack of healthy food options — there are just 13 grocery stores on land the size of West Virginia — overcrowded housing and high rates of heart disease, diabetes and obesity created a perfect storm for calamity in a pandemic. 

Now, officials and community members want to use some of the $714 million in federal aid they received to prevent a public health crisis of this scale from ever happening again, but two major obstacles stand in their way: onerous regulation that makes construction on tribal land near impossible and a looming deadline that mandates the money be spent by Dec. 30. If the money tribal governments received from the CARES Act isn’t spent by the end of the year, tribes risk having to send it back.

“Don't get me wrong, we are going to get PPEs, but if $714 million is there, we should be able to improve our economy and our communities with that money for the long term,” said Navajo Nation President Jonathan Nez.

Nez wants to spend the money on expanding access to running water and electricity and providing broadband access and more affordable housing on the reservation — in effect addressing the infrastructure gaps that experts said contributed to COVID-19’s deadliness there.

“This money is to combat, yes, the immediate needs of COVID-19, but also for the future. We have no cure. There's no vaccine. So how do we prepare for the future?” Nez said. “If we can get running water to our citizens, it will help push COVID-19 off our nation, and any future virus.”

The stakes are particularly high, experts say, because even though Navajo Nation has had success in containing its COVID-19 outbreak, the states that surround the reservation have experienced surges of coronavirus cases in recent weeks. At one point, Arizona’s infection rate — when adjusted for population size — was the highest in the world.

Cases on Navajo Nation peaked in May, with an average of 104 new cases per day. By July, that number dropped by half to about 48 new cases reported each day. In all, about 9,000 of the roughly 172,000 Navajo members living on and around the reservation have tested positive and more than 450 have died from the virus. 

Local officials say Navajo Nation’s success in flattening the curve has been largely due to three things: widespread adherence to mask-wearing and social distancing, one of the strictest stay-at-home curfews in the country and an aggressive testing regime. 

But even the most stringent measures could prove ineffective amid spiking cases in Navajo Nation’s neighbors: Utah, New Mexico and Arizona. Cross-border travel is frequent, and it’s not uncommon for people to live on the reservation but work in a border town.

“I watch the Arizona predictive models and New Mexico predictive models, including Texas and Colorado, every day, several times a day, because of the big effect it has on us,” said Dr. Loretta Christensen, chief medical officer for the Navajo Nation at the federal government's Indian Health Service.

Of particular concern is the nation’s intensive care capacity. According to Christensen, Navajo Nation health facilities currently have roughly 40 ICU beds. 

During the first surge of cases in April and May, Navajo health centers were able to transfer the most critical patients to ICUs in neighboring cities like Phoenix, Flagstaff and Albuquerque. That ability was critical to their success in managing hospital capacity and caring for patients, Christensen said. Now, as those cities deal with their own surges, that may no longer be an option. 

“I will be totally honest: It will be a huge challenge to manage that volume of patients in our facilities,” Christensen said. “Do I believe our staff can do it? Yes, they've risen way above all levels of performance, and they've been innovative and adaptive and strong.”

Complicating the risk is the fact that thus far, COVID-19 has proven particularly deadly for Native Americans. They have the highest rates of hospitalization from the virus of any racial group in the U.S., according to Centers for Disease Control and Prevention data.

“This isn't a matter of race, but a matter of institutional racism that has made people at higher susceptibility for infectious diseases and kept them at higher susceptibility for many, many years,” said Dr. Laura Hammitt, director of infectious disease programs at the Johns Hopkins Center for American Indian Health at the Bloomberg School of Public Health.

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Trailing Democratic challenger Mark Kelly in one of the country’s most hotly contested Senate races, Arizona Sen. Martha McSally is seeking to tie herself to an issue with across-the-aisle appeal: insurance protections for people with preexisting health conditions.

"Of course I will always protect those with preexisting conditions. Always," the Republican said in a TV ad released June 22.

The ad comes in response to criticisms by Kelly, who has highlighted McSally’s votes to undo the Affordable Care Act. That, he argued, would leave Americans with medical conditions vulnerable to higher-priced insurance.

The Arizona Senate race has attracted national attention and is considered a toss-up, though Kelly is leading in many polls. McSally’s attempt to present herself as a supporter of protecting people with preexisting conditions — a major component of the 2010 health law — is part of a larger pattern in which vulnerableRepublican incumbents stake out positions advocating for this protection while also maintaining the GOP’s strong stance against the ACA.

McSally, who was appointed by the governor to take over John McCain’s Senate seat in 2019, used similar messaging in her failed 2018 bid for the state’s other Senate position. And President Donald Trump echoed the declaration at a June 23 rally in Phoenix, saying McSally — along with the rest of the Republican Party — "will always protect people with preexisting conditions."

With that in mind, we decided to take a closer look. We contacted McSally’s campaign, which cited her support of a different piece of legislation, the Protect Act. But independent experts told us that legislation doesn’t satisfy the standard she sets out.

Past and present

Only one national law makes sure people with preexisting medical conditions don’t face discrimination or higher prices from insurers. It’s the Affordable Care Act.

Both as a member of the House of Representatives and as a senator, McSally has supported efforts to undo the health law — voting in 2015 to repeal it and in 2017 to replace it with the Republican-backed American Health Care Act, which would have permitted insurers to charge higher premiums for people with complicated medical histories.

"Anyone who voted for that bill was voting to take away the ACA’s preexisting condition protections," said Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill. "Sen. McSally is trying to erase history for electoral purposes."

Especially as COVID-19 cases climb, health care— and, in particular, the ACA — has emerged as a flashpoint in the Arizona election, said Dr. Daniel Derksen, a professor of public health, medicine and nursing at the University of Arizona.

"Martha McSally has in her actions, in her votes, been pretty consistent about cutting back benefits and trying to repeal the ACA without any clear plan in mind that would protect people who gained insurance through the ACA," Derksen added. "Her words on preexisting condition protections don’t align with any votes I’ve seen."

AzHHA Conection Newsletter | June 17, 2020

In a joint letter sent yesterday morning, AzHHA along with other healthcare leaders encouraged Governor Ducey to implement a requirement that would require Arizonans to wear face masks in public to reduce the spread of COIVD-19. In addition, the letter also encouraged the governor to implement a comprehensive contact tracing program for all of Arizona. 

Governor Doug Ducey yesterday signed executive order 2020-40 which allows a county, city and town to implement policies which would require residents to wear face masks in public spaces in order to mitigate the spread of COVID-19. In addition, the executive order requires the Arizona Department of Health Services to implement a consistent statewide system for case investigation and contact tracing which all local health departments will follow.

AzHHA encourages Arizonans to continue social distancing practices, wear masks, and wash your hands to stop the spread to protect ourselves, our community members and healthcare heroes who are in the frontline of the COVID-19 response.

CRONKITE NEWS | By Ellie Borst, Lisa Diethelm and  Farah Eltohamy | June 9, 2020

Surging numbers of COVID-19 cases in Arizona have pushed some hospital intensive-care units to their limits in recent weeks, but health experts around the state said hospitals still have room to adapt – for now.

The Arizona Department of Health Services has recorded 8,360 new cases of the coronavirus so far this month, almost 30% of the total 28,296 cases since the disease was first reported in the state in January.

Those new patients are putting a strain on hospital beds, with 76% of ICU beds occupied as of Monday. Hospital administrators said they are coping, but one nurse said seeing the constant stream of COVID-19 patients is “soul-crushing.”

“I didn’t use to dread going to work but when I know I am going to be in the COVID unit, I dread it. I have the best job in the world but it’s just – soul crushing is just the best way to describe it,” said Austin Kopas, an ICU nurse in Phoenix.

Experts say the pinch is being felt around the state, from hospitals in Phoenix to those in rural areas. At Yuma Regional Medical Center, officials said close to half of the ICU beds in use Tuesday were occupied by COVID-19 patients.

“So right now we’re able to manage everything we’ve got coming in,” said Dr. Robert Trenschel, the Yuma hospital’s CEO. “The issue comes in when we get quite a few of COVID patients coming in at the same time. Sometimes it’s a family of five or six that comes in.”

Hospitals are coping with the surge by shifting patients from maxed-out hospitals to those that still have space, a practice known as “load balancing.” Becky Armendariz, a spokeswoman for Banner Health, described it in an email as “when you transfer patients or resources from one hospital to another so that no one hospital is stressed or overwhelmed with cases.”

Banner is also “upskilling,” training health care workers who do not normally work in an ICU to assist there.

The state health department reported Monday that 76% of the state’s supply of ICU beds were occupied, leaving 24% available. Dr. Daniel Derksen said that state hospitals should be able to handle the patient load for the time being with the measures they are currently using.

“Once we start getting in the single digits (for percentage of available beds), then we really have to employ other interventions to make sure you have the capacity to deal with what’s going on,” said Derksen, a University of Arizona professor.

Gov. Doug Ducey in March gave hospitals a month to develop plans for increasing ICU bed capacity by 50%, but Derksen said it is not clear how many hospitals met that goal. State health officials reminded hospitals over the weekend that they need to have those plans ready.

Derksen said the extra beds – and the workers needed to staff them – come from different areas of a hospital, which may be called on to contribute equipment, beds, staff and space.

Will Humble, the executive director of the Arizona Public Health Association said there’s no single way for hospitals to make room for inpatient beds, calling it a “multipronged approach.”

One way hospitals can make the most of their space is by repurposing, turning a recovery room into an infectious disease ward, for example, or dedicating entire floors to COVID-19 patients.

The problem with that, Humble said, is that it requires staff to work overtime. That means someone who normally does surgeries would also have to work longer hours to see COVID-19 patients as well.

Humble said hospitals’ hardest decisions will come down to patients: They may have to begin delaying or canceling elective procedures, or start looking into discharge planning. That means discharging patients to a rehabilitation hospital or sending them home instead of recuperating in the hospital, “even though under normal circumstances, you wouldn’t do that,” he said.

Derksen said the increase in COVID-19 cases is “almost certainly” the result of Ducey relaxing social-distancing and stay-at-home orders on May 15, when the spread of the disease appeared to be waning.

That allowed for packed public spaces during the Memorial Day weekend, followed by protests last week over the death of George Floyd that health officials worry could also end up spreading the virus.

Kopas said he expects another spike in cases. Since the virus has an incubation period of two weeks, he said he expects things will continue to get worse.

“It seems like because the state is opening up, people think it is going away,” Kopas said. “It is getting much worse, extremely quickly.”

Mark Coleman is a registered nurse who has gone part-time after deciding to go back to graduate school to become a family nurse practitioner. He has adjusted from working full time to one shift every two weeks, but Coleman said he has lost trust with government officials and hospital administrators because of the “abusive” treatment he said nurses have endured during the pandemic.

That treatment will hurt health care in the long run by discouraging nurses, he said.
“I’d say it definitely hurts the community because less nurses wanting to go to work or be involved in their job is not a good sign,” he said.

Kopas said the safety protocols involved with COVID-19 can add work to even the simplest tasks, noting the case of one patient who called him back right after he had left the room. Unit rules require that gowns, goggles, and masks be wiped down with bleach and hung up to dry after every patient visit.

But when the patient called, Kopas “put on a mask that was still wet with bleach and put on everything just to go into the room” for what turned out to be an itch. The patient had been in bed so long that he lost the ability to do anything but move his fingers, so Kopas scratched the patient’s leg “for him because he is not strong enough to move.”

Kopas said he has been treating COVID-19 patients since “the whole thing started,” and while he loves his job, recent months have been draining. He said one of his main fears now is that the virus “is something that will never go away,” that there’s no guarantee of a vaccine and that society will have to adjust to a new norm of social distancing.

He does not want to be the guy who says, “The sky is falling!,” but Kopas said it can be hard to be upbeat.

“It’s hard not to be pessimistic when you go and see it all of the time,” he said.

Denelle Confair | News 4 Tucson KVOA | May 18, 2020 | Watch (2min:2sec)

TUCSON - The University of Arizona is ramping up antibody testing for Arizona health care workers and first responders. On Monday, dozens of testing sites throughout Arizona were offering the blood-drawn antibody test for free. The state used $3.5 million to fund the antibody tests. This will test about 250,000 health care workers and first responders. 

“We started the statewide testing of the antibody tests this week,” said Dr. Daniel Derksen with the University of Arizona. 

“We’re in over 30 sites and in all over 15 Arizona counties,” said Derksen. “The plan is to do 250,000 tests over the next two to three months, prioritizing first responders and licensed health care professionals.” 

The goal is to give state health officials a better grip on how wide the virus has spread. Tests are by appointment only. Once the test is done, the blood is taken by a courier service to the labs at the University of Arizona. It may take two to three days to get test results back. 

How accurate is the test? “The specificity is very high. So, if you have a positive result, it’s a true positive,” Derksen said. “It’s designed in such a way that if you have the antibodies, they are very specific to the COVID-19 antibodies that form,” he said. “So that means that you’ve had the COVID-19 infection, you’ve developed an immune response and you developed the antibodies to fight the infection.” 

» For more information on antibody testing, click here.