Months after hundreds of students were met by SWAT teams, the Catholic Diocese of Pittsburgh began forming its own armed police force.

Wendell Hissrich, a former safety director for the city and career FBI unit chief, was hired that year to form a department to safeguard 39 Catholic schools as well as dozens of churches in the region. Hissrich has since added 15 officers and four supervisors, including many formerly retired officers and state troopers, who now oversee school campuses fitted with Stop the Bleed kits, cameras, and defibrillators.

When religious leaders first asked for advice after what are known as “swatting” incidents, the veteran lawman said he didn’t hesitate to deliver blunt advice: “You need to put armed officers in the schools.”

But he added that the officers had to view schools as a special assignment: “I want them to be role models. I want them to be good fits within the school. I’m looking for someone to know how to deal with kids and with parents — and, most importantly, knows how to de-escalate a situation.”

Gun violence is a leading cause of death for young people in America, and the possibility of shootings has influenced costly decision-making in school systems as administrators juggle fear, duty, and dizzying statistics in efforts to keep schools safe from gun harm. In the first week of September, the risks were made tragically clear again, this time in Georgia, as a teenager stands accused of shooting his way through his high school and killing two students and two teachers.

Still, scant research supports the creation of school police forces to deter gun violence — and what data exists can raise as many questions as answers. are, in fact, suicides — a sobering statistic from the federal Centers for Disease Control and Prevention that reflects a range of ills. and studies found that as white children to experience firearm assaults. Research on racial bias in policing overall in the U.S. as well as studies on have prompted calls for caution. And an oft-cited U.S. Secret Service review of 67 thwarted plots at schools supports reasons to examine parental responsibility as well as police intervention as effective ways to stop firearm harm.

The Secret Service threat assessment, published in 2021, analyzed plots from 2006 to 2018 and found students who planned school violence had guns readily at home. It also found that school districts that contracted sworn law officers, who work as full- or part-time school resource officers, had some advantage. The officers proved pivotal in about a third of the 67 foiled plots by current or former students.

“Most schools are not going to face a mass shooting. Even though there are more of them — and that’s horrible — it is still a small number,” said Mo Canady, executive director of the National Association of School Resource Officers. “But administrators can’t really allow themselves to think that way.

“They have to think, ‘It could happen here, and how do I prevent it?’”

About a 20-minute drive north of Pittsburgh, a top public school system in the region decided the risk was too great. North Allegheny Superintendent Brendan Hyland last year recommended retooling what had been a two-person school resource officer team — staffed since 2018 by local police — into a 13-person internal department with officers stationed at each of the district’s 12 buildings.

Several school district board members voiced unease about armed officers in the hallways. “I wish we were not in the position in our country where we have to even consider an armed police department,” board member Leslie Britton Dozier, a lawyer and a mother, said during a public planning meeting.

Within weeks, all voted for Hyland’s request, estimated to cost $1 million a year.

Hyland said the aim is to help 1,200 staff members and 8,500 students “with the right people who are the right fit to go into those buildings.” He oversaw the launch of a police unit in a smaller school district, just east of Pittsburgh, in 2018.

Hyland said North Allegheny had not focused on any single news report or threat in its decision, but he and others had thought through how to set a standard of vigilance. North Allegheny does not have or want metal detectors, devices that some districts have seen as necessary. But a trained police unit willing to learn every entrance, stairway, and cafeteria and who could develop trust among students and staffers seemed reasonable, he said.

“I’m not Edison. I’m not inventing something,” Hyland said. “We don’t want to be the district that has to be reactive. I don’t want to be that guy who is asked: ‘Why did you allow this to happen?’”

Since 2020, the role of police in educational settings has been hotly debated. The video-recorded death of George Floyd, a Black man in Minneapolis who was murdered by a white police officer during an arrest, prompted national outrage and demonstrations against police brutality and racial bias.

Some school districts, notably in large cities such as Los Angeles and Washington, D.C., reacted to concerns by reducing or removing their school resource officers. Examples of unfair or biased treatment by school resource officers drove some of the decisions. This year, however, there has been apparent rethinking of the risks in and near school property and, in California, Colorado, and Virginia, parents are .

The 1999 bombing plot and shooting attack of Columbine High School and a massacre in 2012 at Sandy Hook Elementary School are often raised by school and police officials as reasons to prepare for the worst. But the value of having police in schools also came under sharp review after a blistering federal review of the mass shooting in 2022 at Robb Elementary School in Uvalde, Texas.

The federal Department of Justice this year produced a 600-page report that laid out multiple failures by the school police chief, including his attempt to try to negotiate with the killer, who had already shot into a classroom, and waiting for his officers to search for keys to unlock the rooms. Besides the teenage shooter, 19 children and two teachers died. Seventeen other people were injured.

The DOJ report was based on hundreds of interviews and a review of 14,000 pieces of data and documentation. This summer, the former chief was indicted by a grand jury for his role in “abandoning and endangering” survivors and for failing to identify an active shooter attack. Another school police officer was charged for his role in placing the murdered students in “imminent danger” of death.

There have also been increased judicial efforts to pursue enforcement of firearm storage laws and to hold accountable adults who own firearms used by their children in shootings. For the first time this year, the who fatally shot four students in 2021 were convicted of involuntary manslaughter for not securing a newly purchased gun at home.

In recent days, Colin Gray, the father of the teenage shooting suspect at Apalachee High School in Georgia, was charged with second-degree murder — the most severe charges yet against a parent whose child had access to firearms at home. The 14-year-old, Colt Gray, who was apprehended by school resource officers on the scene, according to initial media reports, also faces murder charges.

Hissrich, the Pittsburgh diocese’s safety and security director, said he and his city have a hard-earned appreciation for the practice and preparation needed to contain, if not thwart, gun violence. In January 2018, Hissrich, then the city’s safety officer, met with Jewish groups to consider a deliberate approach to safeguarding facilities. Officers cooperated and were trained on lockdown and rescue exercises, he said.

Ten months later, on Oct. 27, 2018, a lone gunman entered the Tree of Life synagogue and, within minutes, killed 11 people who had been preparing for morning study and prayer. Law enforcement deployed quickly, trapping and capturing the shooter and rescuing others caught inside. The coordinated response was praised by witnesses at the trial where the killer was convicted in 2023 on federal charges and sentenced to die for the worst antisemitic attack in U.S. history.

“I knew what had been done for the Jewish community as far as safety training and what the officers knew. Officers practiced months before,” Hissrich said. He believes schools need the same kind of plans and precautions. “To put officers in the school without training,” he said, “would be a mistake.”

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In a storage unit, Lomax has a thousand canvasses, she estimates, mostly of young people who died from gunfire, and others of the mothers, sisters, friends, and mourners left to ask why.

“The purpose is not to make people cry,” said Lomax, a Philadelphia native who has traveled to New York, Atlanta, and Miami to collaborate on similar exhibitions on trauma. “It is for families and for people who have gone through this to know that they are not forgotten.”

Each person “is not a number. This is somebody’s child. Somebody’s son, somebody’s daughter who was working toward something,” she said. “The portraits are not just portraits. They are telling us what the consequences are for what’s happening in our cities.”

Firearms in 2020 became the for children and teens under 18 — from both suicides and assaults — and fresh research on the public health crisis from Harvard Medical School’s Blavatnik Institute show how those losses with significant economic and psychological costs.

On June 25, U.S. Surgeon General Vivek Murthy declared gun violence a public health crisis, noting: “Every day that passes we lose more kids to gun violence. The more children who are witnessing episodes of gun violence, the more children who are shot and survive that are dealing with a lifetime of physical and mental health impacts.”

Philadelphia has recorded more than 9,000 fatal and nonfatal shootings since 2020, with about 80% of the victims identified as Black, according to . Among those injured or dead, about 60% were age 30 or younger.

Lomax has been a singular, and perhaps unlikely, force in making the statistics unforgettable. Since 2018, when a young friend poised to graduate from Penn State University was on a Sunday afternoon in Philadelphia, Lomax has set out to support healing among those who experience violence.

She launched a show on PhillyCAM, a community access media channel, to encourage people to talk about guns and opioids and grief. She organized fashion shows with local artists and families that focused on bearing witness to distress. She seized on portraiture, reaching out to local artists to memorialize the lives, not the deaths, of Philadelphia’s young. She began tracking shootings on social media, in news accounts, and sometimes by word of mouth. In 2022, City Hall to a remarkable exhibition of lost lives, organized by Lomax and created by .

She recently shared the portraits at a summit sponsored by the nonprofit and . The meeting offered guidance on enforcing regulations to prevent straw gun purchases that propel crime and provided data on weapon trafficking across state lines. Lomax knew the art, displayed along the stage, brought home the stakes.

Look at these faces, she said. These people had promise. What happened? What can be done?

Lomax, now 40, said the conversations she starts have purpose. Some paintings she gives to families. Others she stores for future exhibits.

“This is not what I set out to do in life,” she said. “When I was growing up, I thought I’d be a nurse. But I guess I am kind of nursing people this way.”

So far this year, Philadelphia has seen a drop in the number of murders, according to an online database by AH Datalytics, but ranks among the top five cities in murder count. Last year, the Harvard researchers established that communities and families are left vulnerable by gun injuries.

The 2023 study led by Zirui Song, an associate professor of health care policy at Harvard Medical School, examined data related to newborns through age 19. The research documented a “massive” economic toll, with health care spending increasing by an average of $35,000 for survivors in the year after a shooting, and life-altering mental health challenges.

Survivors of shootings and their caregivers, whether dealing with physical injuries or generalized fear, often struggle with “long-lasting, invisible injuries, including psychological and substance-use disorders,” according to Song, who is also a general internist at Massachusetts General Hospital. His study found that parents of injured children experienced a 30% increase in psychiatric disorders compared with parents whose children did not sustain gunshot injuries.

, who paints with acrylics, has been helping Lomax since 2021. Like all the artists, she’s paid by Lomax. She has , always after sitting down with the subject’s family. “I get a backstory so I can incorporate that in the portrait,” she said. “Sometimes we cry. Sometimes we pray. Sometimes we try to uplift each other. It is hard to do.”

“I hope one day I would not have to paint another portrait,” said Norwood, a mother of five children. “The idea that Zarinah has had so many exhibits, with numerous people who have died, is scary and heartbreaking.”

, a self-taught digital artist, was among those who wanted to help to “honor and to offer a better look at who these people were.” Doughty, a city employee who works at a courthouse, may be best known within Philadelphia for a series of fanciful murals in which he has grouped famous natives such as Will Smith, Grace Kelly, and Kevin Hart.

He has produced about 150 portraits on his iPad and laptop, working with Lomax’s nonprofit group, The Apologues, to best match a face with a phrase, embedded in the scene, that telegraphs the lost potential of youth.

“At the beginning it was hard to do,” said Doughty, who works from family photographs. “I look and I think: They are kids. Just kids.”

One time, he received a text from Lomax seeking a portrait of a rapper he recognized from art and music shows. Another day, he opened an email to find a photo of a man he knew from high school. In May, Doughty his work process for a portrait of Derrick Gant, a rapper with the stage name Phat Geez, who was . The killing happened a few weeks after the rapper a music video referring to an Instagram account that promotes anti-violence efforts in the city.

Doughty, 33, who grew up in the Nicetown section of north Philadelphia, wryly noted: “It wasn’t so nice.” Lomax’s exhibitions, he said, allow families, even neighborhoods, to sort through sorrow and pain.

“I went to the last one and a mother came up and said, ‘Did you draw my child’s portrait?’ She just fell into my arms, crying. It was such a moment,” he said. “And a reminder on why we do what we do.”

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Nearly every day of 2024 so far has brought more violence. On Feb. 14, gunfire broke out at the Super Bowl parade in Kansas City, killing one woman and injuring 22 others. Most events draw little attention — while the injuries and toll pile up.

Gun violence is among America’s most deadly and costly public health crises. But unlike other big killers — diseases like cancer and HIV or dangers like automobile crashes and cigarettes — sparse federal money goes to studying gun violence or preventing it.

That’s because of a one-sentence amendment tucked into the 1996 congressional budget bill: “None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”

Its author was Jay Dickey, an Arkansas Republican who called himself the on Capitol Hill. And for nearly 25 years the amendment was perceived as a threat and all but paralyzed the CDC’s support and study of gun violence.

Even so, a small group of academics have toiled to document how gun violence courses through American communities with vast and tragic outcomes. Their research provides some light as officials and communities develop policies mostly in the dark. It has also inspired a fresh generation of researchers to enter the field — people who grew up with mass shootings and are now determined to investigate harm from firearms. There is momentum now, in a time of rising gun injury and death, to know more.

The reality is stark:

Gun sales reached record levels in 2019 and 2020. Shootings soared. In 2021, , more people — than in any year on record, according to a Johns Hopkins University analysis of CDC data. Guns became the leading cause of death for children and teens. Suicides accounted for more than half of those deaths, and homicides were linked to 4 in 10.

Black people are nearly 14 times as likely to die from firearm violence as white people — and guns were responsible for ages 15 to 19 in 2021, the data showed.

Harvard research published in JAMA in 2022 estimated gun injuries translate into economic losses of , or 2.6% of the U.S. gross domestic product.

With gun violence touching nearly every corner of the country, surveys show that Americans — whatever their political affiliation or whether they own guns or not — .

What Could Have Been

It is no secret that many strategies proposed today — from school metal detectors to enhanced policing, to the optimal timing and manner of safely storing guns, to restrictions on gun sales — have limited scientific ballast because of a lack of data.

It could have been otherwise.

U.S. firearm production , flooding communities with . In that era, Mark Rosenberg was the founding director of the CDC’s National Center for Injury Prevention and Control and his agency, over time, was pivotal in helping to fund research on gun violence and public health.

Rosenberg thought then that gun violence could go the way of car crashes. The federal government spent $200 million a year on research to redesign roadways and cars beginning in the 1970s, he said, and had seen death rates plummeted.

“We said, ‘Why can’t we do this with gun violence?’” Rosenberg said. “They figured out how to get rid of car crashes — but not cars. Why can’t we do the same thing when it comes to guns?”

The Dickey Amendment sidelined that dream.

concluded that “guns kept in the home are associated with an increase in the risk of homicide,” a finding on risk factors that prompted an uproar in conservative political circles. To newly elected representatives in the midterm “Republican Revolution” of 1994, the research was a swipe at gun rights. The NRA stepped up lobbying, and Congress passed what’s known as the Dickey Amendment in 1996.

Some Democrats, such as the influential John Dingell of Michigan (a onetime NRA board member who received the group’s “”), would join the cause. Dingell proposed his own bills, detailed last summer by .

Under heavy political pressure, the CDC ousted Rosenberg in 1999. Soon after, some CDC administrators began alerting the NRA to research before publication.

“It was clearly related to the work we were doing on gun violence prevention,” Rosenberg, now 78, said of his job loss. “It was a shock.”

Those Who Persevered

The quarter-century spending gap has left a paucity of data about the scope of gun violence’s health effects: Who is shot and why? What motivates the violence? With what guns? What are the injuries? Can suicides, on the rise from gunfire, be reduced or prevented with safeguards? Does drug and alcohol use increase the chances of harm? Could gun safeguards reduce domestic violence? Ultimately, what works and what does not to prevent shootings?

If researchers say they “lost a generation” of knowledge about gun violence, then American families lost even more, with millions of lives cut short and a legacy of trauma passed down through generations.

Imagine if cancer research had been halted in 1996 — many tumors that are now eminently treatable might still be lethal. “It’s like cancer,” said Rebecca Cunningham, vice president for research at the University of Michigan, an academic who has kept the thread of gun research going all these years. “There may be 50 kinds of cancer, and there are preventions for all of them. Firearm violence has many different routes, and it will require different kinds of science and approaches.”

Cunningham is one of a small group of like-minded researchers, from universities across the United States, who refused to let go of investigating a growing public health risk, and they pushed ahead without government funds.

has spent about to support seminal research at the University of California-Davis. With state and private funding, he created a violence prevention program in California, a leader in firearm studies. He has documented an unprecedented increase in gun sales since 2020 — about 15 million transactions more than expected based on previous sales data.

at Johns Hopkins University focused on teenagers and guns — particularly access and suicides — and found that local police who coped with gun risks daily were willing to collaborate. He secured grants, even from the CDC, with carefully phrased proposals that avoided the word “guns,” to study community violence.

At Duke University, explored the underground gun market, interviewing people incarcerated in Chicago jails and compiling pivotal social science research on how guns are bought, sold, and traded.

, an economist and public policy professor at Harvard, worked on the national pilot to document violent deaths — knowing most gun deaths would be recorded that way — because, he said, “if you don’t have good data, you don’t have nothin’.”

Hemenway, writing in the journal Nature in 2017, found a 30% rise in gun suicides over the preceding decade and nearly a 20% rise in gun murders from 2014 to 2015. The data was alarming and so was the lack of preventive know-how, he wrote. “The US government, at the behest of the gun lobby, limits the collection of data, prevents researchers from obtaining much of the data that are collected and severely restricts the funds available for research on guns,” he wrote. “Policymakers are essentially flying blind.”

His work helped create the most ambitious database of U.S. gun deaths today — the . Funded in 1999 by private foundations, researchers were able to start understanding gun deaths by compiling data on all violent deaths from health department, police, and crime records in several states. The CDC took over the system and eventually rolled in data from all 50 states.

Still, no federal database of nonfatal gun injuries exists. So the government would record one death from the Super Bowl parade shooting, and the 22 people with injuries remain uncounted — along with many thousands of others over decades.

Philanthropy has supported research that Congress would not. The funded the bulk of the grants, with more than $33 million since the 1990s. ’ philanthropy and the Robert Wood Johnson Foundation have added millions more, as has Michael Bloomberg, the politician and media company owner. , which keeps a tab of ongoing research, finds states increasingly are stepping up.

Timothy Daly, a Joyce Foundation program director, said he remembers when the field of gun harm was described by some as a “desert.” “There was no federal funding. There was slim private funding,” he said. “Young people would ask themselves: ‘Why would I go into that?’”

in 2017 found gun violence “was the least-researched” among leading causes of death. Looking at mortality rates over a decade, gun violence killed about as many people as sepsis, the data showed. If funded at the same rate, gun violence would have been expected to receive $1.4 billion in research funds. Instead, it received $22 million from across all U.S. government agencies.

There is no way to know what the firearm mortality or injury rate would be today had there been more federal support for strategies to contain it.

A Reckoning

As gun violence escalated to once unthinkable levels, Rep. Dickey came to regret his role in stanching research and became friends with Rosenberg. They wrote a about the need for gun injury prevention studies. In 2016, they delivered a letter supporting the creation of the California Firearm Violence Research Center.

Both men, they emphasized, were NRA members and agreed on two principles: “One goal must be to protect the Second-Amendment rights of law-abiding gun owners; the other goal, to reduce gun violence.”

Dickey died in 2017, and Rosenberg has only kind words for him. “I did not blame Jay at all for what happened,” he said. The CDC was “under pressure from Congress to get rid of our gun research.”

As alarm over gun fatality statistics from diverse sectors of the nation — scientists, politicians, and law enforcement — has grown, research in the field is finally gaining a foothold.

Even Congress, noting the Dickey Amendment was not an all-out ban, appropriated $25 million for gun research in late 2019, split between the CDC — whose imperative is to research public health issues — and the National Institutes of Health. It’s a drop in the bucket compared with what was spent on car crashes, and it’s not assured. House Republicans this winter have pushed an amendment to once again cut federal funding for CDC gun research.

Still, it’s a start. With growing interest in the field, the torch has passed to the next generation of researchers.

In November, Cunningham helped organize a on the prevention of firearm-related harm. More than 750 academics and professionals in public health, law, and criminal justice met in Chicago for hundreds of presentations. A similar event in 2019, the first in 20 years, drew just a few dozen presentations.

“You can feel momentum,” Cunningham said at the conference, reflecting on the research underway. “There’s a momentum to propel a whole series of evidence-based change — in the same way we have addressed other health problems.”

During , Yale University School of Public Health Dean Megan L. Ranney bluntly described the rising number of gun deaths — noting the overwhelming number of suicides — as an alarm for lawmakers. “We are turning into a nation of traumatized survivors,” she said, urging their support for better data and research on risk factors.

Cassandra Crifasi, 41, was a high school sophomore when the Columbine massacre outside Littleton, Colorado, shook the country. She recently succeeded Webster, her , as co-director of the Johns Hopkins Center for Gun Violence Solutions.

Crifasi has spent much of her career evaluating risk factors in gun use, including collaborative studies with Baltimore police and the city to reduce violence.

Raised in Washington state, Crifasi said she never considered required training in firearms an affront to the Second Amendment. She owns guns. In her family, which hunted, it was a matter of responsibility.

“We all learned to hunt. There are rules to follow. Maybe we should have everybody who wants to have a gun to do that,” she said.

Crifasi pointed to the 2018 shooting at in Parkland, Florida — which left 17 dead and 17 injured — as a turning point. Students and their parents took “a page out of Mothers Against Drunk Driving — showing up, testifying, being in the gallery where laws are made,” she said.

“People started to shift and started to think: This is not a third rail in politics. This is not a third rail in research,” Crifasi said.

worked in corporate management before she arrived at Johns Hopkins to pursue a master’s in public health. It was summer 2012, and a gunman killed 12 moviegoers at a midnight showing of “The Dark Knight Rises” in Aurora, Colorado. The town’s pain led the national news, and “rightfully so,” Buggs said. “But I was in Baltimore, in East Baltimore, where there were shootings happening that weren’t even consistently making the local news.”

Now violence “that once was considered out of bounds, out of balance — it is more and more common,” said Buggs who recently joined the as a lead investigator.

Buggs’ research has examined anxiety and depression among youths who live in neighborhoods with gun violence — and notes that firearm suicide rates too have drastically increased among Black children and adolescents.

There is a trauma from hearing gunshots and seeing gun injuries, and daily life can be a thrum of risk in vulnerable communities, notably those largely populated by Black and Hispanic people, Buggs said. Last year, Buggs organized with a core group of about two dozen scientists committed to contextualizing studies on gun violence.

“The people most impacted by the gun violence we usually hear about in America look like our families,” she said of the collective.

“They are not resilient. People are just surviving,” Buggs said. “We need way more money to research and to understand and address the complexity of the problem.”

Illustration credit: Oona Tempest/ºÚÁϳԹÏÍø News. (Reference photos of Buggs, Cook, Crifasi, Cunningham, Daly, Hemenway, Webster: Christine Spolar for ºÚÁϳԹÏÍø News; Rosenberg: Getty Images; Wintemute: University of California-Davis.)

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A Centene subsidiary, Operose Health, took over nearly three dozen medical practices in London — gateways for NHS care — in a deal worth tens of millions of dollars. The subsidiary became the largest private supplier of general practice services in the United Kingdom, with 67 practices accounting for 570,000 patients.

A local health commission, records show, signed off after a nine-minute review in a virtual hearing held the week before Christmas. Centene was not mentioned. Not a question was asked. It was the time of year — amid pandemic restraints — when official business in London gave way to fizzy cocktails and quiet glad tidings.

Within weeks, the acquisition set off alarms for Louise Irvine, an NHS doctor, who called it “privatization of the NHS by stealth.” Irvine, other practitioners, and residents supported a crowdfunded legal challenge to the takeover of AT Medics Holdings, the U.K. primary care company under contract to the NHS.

Centene is the largest privately managed care provider in the U.S. that offers government-sponsored insurance, such as Medicaid and Affordable Care Act plans, as well as health care to seniors, prisoners, military members, and veterans. Britons who protested its expansion saw a for-profit outsider with ambitions that could weaken the NHS. They worried Centene would decide on staffing to suit its bottom line. NHS contracts with doctors at set rates, and assistants are paid less; critics questioned whether the Centene deal would reduce more highly trained staff.

Then there was this: The corporation since 2013, over noncompliance with state or federal Medicaid contracts or rules. By mid-2021, as its legal battle intensified in London, Centene was grappling with allegations of overbilling Medicaid for pharmacy services. It has since paid about $657 million . It faces investor lawsuits as well as overbilling allegations from several more states. Centene, based in Missouri, has denied wrongdoing.

Centene’s “suitability” for doing business with the NHS was not discussed in the virtual hearing. And because of technical limitations, members of the public could review the decision only through an audio recording, released online a day later.

“It was covid time,” Irvine, now retired, said with some frustration about the public meeting. “We believe NHS should be a public service, and it is being gradually eroded.”

Centene did not respond to requests to discuss its U.K. strategy. By July 2021, Centene’s interests also acquired Circle Health Group, a private health care group based in London with 50 hospitals.

Earlier this year, a judge ruled that the 2020 public meeting was conducted lawfully. The judge questioned the relevance of raising Centene’s liabilities; she noted the American company’s counsel had documented that its “financial position was strong” and that the insurer “continues to operate successfully in the U.S. health care market.”

Advocates for market-based efficiencies, including former NHS chiefs who were hired by Centene-related businesses, portray the managed-care titan as a change agent that can innovate and trim costs.

In October, an NHS care commission declined to renew a Centene contract for Hanley Primary Care Center in north London, which . The clinic was left with too few doctors, , and patient appointments had dropped by 270 a week, representing a “huge hole” in care since the acquisition. The NHS’ decision , in which clinic employees said the practice was short eight doctors and that less qualified workers, called physician associates, filled the gaps.

Operose spokesperson Stephen Webb, in an email, said the Hanley practice “is currently rated as ‘Good’ by the national regulator” and the contract would be reviewed next year. On its website, Operose calls the BBC report “sensational.” It adds that “we have a strong track record of performance, recruitment and investment in our staff and services.”

The Hanley decision is a small validation for Irvine and others who warned that efficiencies would degrade the quality of care.

“The whole ethos of the American system, well, it is fundamentally different than how we view care in the U.K.,” Irvine said. “Our values are free and accessible health care for all.”

Cultivating Ties in Government

Centene was eyeing the British health system in winter 2011, when it hosted health advisers from across Europe to tour its facilities in Spain’s seaside region of Valencia.

In March 2011, and again in 2015, representatives from Centene’s subsidiary Ribera Salud promoted its “pioneering approach” to caregiving at hospitals and treatment centers through a public-private partnership, according to.

Like Britain, Spain faces an aging population. The subsidiary promised a model for “efficient and effective healthcare” for patients who are government-supported or pay out-of-pocket. The government paid the provider a flat rate per patient each year, and Ribera Salud operated the sites and managed staff.

The approach intrigued British politicians and advisers, conservatives as well as liberals, eager to manage health care costs by encouraging competition.

Centene cultivated its image and relationships, launching the subsidiary Centene UK in 2016. Within months, it was hiring NHS administrators for its executive ranks. Among the highest-profile recruits: Samantha Jones, a nurse and the NHS England director of “new care models,” who had championed Centene’s work in Spain.

By 2019, Jones was named CEO of Centene UK. In 2021, she left to work for Prime Minister Boris Johnson as “an expert adviser for NHS transformation and social care.”

As Johnson’s premiership came under pressure, Jones was named chief of operations at No. 10 Downing St. She left when he resigned in July.

By then, Centene had a substantial U.K. foothold and other former NHS administrators had joined its top ranks. Contacted through LinkedIn, Jones said she was “not available to do any interviews.”

For consumers intent on preserving Britain’s national health care — or just understanding who owns what and where — Centene is difficult to track. It’s the same in the U.S., where the company has more than 300 subsidiaries. Names there typically lean into local iconography such as Peach State Health Plan of Georgia and Buckeye Community Health Plan of Ohio — with no mention of Centene.

In England, Jenny Shepherd, 72, has written about Centene and its subsidiaries for years. She set up a hyperlocal news site in 2012 to track public services amid government budget restraints. She soon focused on NHS. When Centene’s operations in Spain were being floated as a model for reform, Shepherd saw little coverage of it. “Journalism was lacking,” she said.

Shepherd scours regulatory filings for her posts, published under “.” Over years, she has documented a flowchart of sorts of Centene’s businesses. She said the company routinely recasts its corporate profile. From 2016 to 2018 alone, subsidiary names, addresses, and company directors changed often, she noted.

In 2018, Centene UK was listed as controlled by a Centene subsidiary, MH Services International Holdings. In November 2019, according to regulatory filings, Centene UK formally changed its name to Operose Health.

The practices acquired in 2020, however, were still identified in March 2021 as part of AT Medics Holdings. That filing, in U.K. government records, lists Operose Health as a board member.

Centene’s stake in Circle Health was laid out in December 2021 regulatory filings. Circle Health’s parent company in the U.K. is MH Services International (UK) Ltd., “with the ultimate parent being Centene Corporation,” records show.

Centene aims to wring profit from government-guaranteed payments, Shepherd said: “The English NHS is as big as the Chinese army, and it was clear that the Americans wanted to get their hands on it.”

Such guarantees have diminished, however, as health care costs have increased. The pandemic has propelled a two-year backlog for some treatments. For the first time in history, NHS nurses in England, Wales, and Northern Ireland went on strike in December, largely over pay. Ambulance drivers and paramedics in England and Wales followed suit. Military personnel were readied to take over some services.

‘Closer to the American Model’

The rise of for-profit providers within the British NHS has sparked incendiary debates, with brute questions about costs and motives. How much is spent on patients? How much is spent on services? And could market forces plow the national health landscape into a tiered system of care?

“We are seeing a shift in care access and waiting times, and a big rise in the number of people moving toward a private system,” said Chris Thomas, principal health fellow at the Institute for Public Policy Research think tank in London. “Britain already has the largest number of private patients in the G-7, and that brings us closer to the American model.”

Centene has been welcomed by some as a way “to ease burdens within a chronically overworked NHS,” Thomas said. “But it doesn’t seem optimal to have a corporation — a for-profit organization — coming in.”

Centene has seen limits to government guarantees, particularly in Spain.

Even as British health advisers visited Ribera Salud in 2011, the Spanish press was documenting financial missteps in the venture. Fees per patient, meant to cover access to universal care, had to be renegotiated. Directors and administrators moved between public-sector jobs and Ribera through what appeared to be an unchecked .

Anne Stafford, a finance professor at University of Manchester, behind the Ribera model. The rhetoric of savings never matched reality, she said, with no clear comparison offered of labor costs, financing, wage demand, and patient ratios between Spain and Britain.

Debates over how best to deliver care often lack rigor and consistency, she added. “People say they love their NHS, but they have no concept of how it is funded or how it operates,” she said. “That allows people with an agenda to get into the market.”

British politicians have seen health care as ripe for privatization since the late 1990s, she said, but “there is very little proper accountability” for whether “the private sector, in fact, is delivering value for money.”

NHS advisers also have questioned whether the two systems could be effectively compared: Invented after World War II, the NHS was so celebrated that in 2012 doctors and nurses marched in the opening ceremony of the London Olympics. Spain’s national health care emerged in the 1980s, after the death of dictator Gen. Francisco Franco, and it struggled with costs within its first decade. The Centene model in Valencia, reliant on bank financing, was implemented in 1999.

The report found differences in size and staffing of facilities as well as how care systems were integrated. Measuring possible cost savings was difficult and, the report said,

By December 2021, it was clear that Centene no longer regarded its Ribera operations as a moneymaker. It announced it would divest “non-core assets” to improve its profit margin.

Centene executives to two international assets: Circle Health and Ribera.

Within months, the Spanish subsidiary was sold for an undisclosed figure, bundled with other health and diagnostic groups, to Vivalto Santé, the third-largest private hospital company in France. The acquisition was completed in November.

Centene, in a statement, described its excising of Ribera, with 10 hospitals, 1,650 beds, and 71 primary care and outpatient clinics, as a “significant milestone in our value creation plan.”

For now, with its Circle Health venture. Its 1,900 beds delivered two-thirds of more than $2 billion in annual revenue, according to investor guidance in December 2021. It’s now the largest private hospital care provider in England.

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Within weeks, the Four Seasons brand may be finished.

Christie & Co., a commercial real estate broker, splashed a summer sale across its website that signaled the demise: The last 111 Four Seasons facilities in England, Scotland, and Jersey were on the market. Already sold were its 29 homes in Northern Ireland.

Four Seasons collapsed after years of private equity investors rolling in one after another to buy its business, sell its real estate, and at times wrest multimillion-dollar profits through complex debt schemes — until the last big equity fund, Terra Firma, which in 2012 paid about $1.3 billion for the company, was caught short.

In a country where government health care is a right, the Four Seasons story exemplifies the high-stakes rise — and, ultimately, fall — of private equity investment in health and social services. Hanging over society’s most vulnerable patients, these heavily leveraged deals failed to account for the cost of their care. Private equity firms are known for making a profit on quick-turnaround investments.

“People often say, ‘Why have American investors, as well as professional investors here and in other countries, poured so much into this sector?’ I think they were dazzled by the potential of the demographics,” said Nick Hood, an analyst at Opus Restructuring & Insolvency in London, which advises care homes — the British equivalent of U.S. nursing homes or assisted living facilities. They “saw the baby boomers aging and thought there would be infinite demands.”

What they missed, Hood said, “was that about half of all the residents in U.K. homes are funded by the government in one way or another. They aren’t private-pay — and they’ve got no money.”

Residents as ‘Revenue Streams’

As in the United States, long-term care homes in Britain serve a mixed market of public- and private-pay residents, and those whose balance sheets rest heavily on government payments are stressed even in better economic times. Andrew Dobbie, a community officer for Unison, a union that represents care home workers, said private equity investors often see homes like Four Seasons as having “two revenue streams, the properties themselves and the residents,” with efficiencies to exploit.

But investors don’t always understand what caregivers do, he said, or that older residents require more time than spreadsheets have calculated. “That’s a problem when you are looking at operating care homes,” Dobbie said. “Care workers need to have soft skills to work with a vulnerable group of people. It’s not the same skills as stocking shelves in a supermarket.”

, funded in part by Unison and conducted by University of Surrey researchers, found big changes in the quality of care after private equity investments. More than a dozen staff members, who weren’t identified by name or facility, said companies were “cutting corners” to curb costs because their priority was profit. Staffers said “these changes meant residents sometimes went without the appropriate care, timely medication or sufficient sanitary supplies.”

In August, the House of Commons received : The number of adults 65 and older who will need care is speedily rising, estimated to go from 3.5 million in 2018 to 5.2 million in 2038. Yet workers at care homes are among the lowest paid in health care.

“The covid-19 pandemic shone a light on the adult social care sector,” according to , which noted that “many frustrated and burnt out care workers left” for better-paying jobs. The report’s advice in a year of soaring inflation and energy costs? The government should add “at least £7 billion a year” — more than $8 billion — or risk deterioration of care.

Britain’s care homes are separate from the much-lauded National Health Service, funded by the government. Care homes rely on support from local authorities, akin to counties in the United States. But they have seen a sharp drop in funding from the British government, which cut a third of its payments in the past decade. When the pandemic hit, the differences were apparent: Care home workers were not afforded masks, gloves, or gowns to shield them from the deadly virus.

Years ago, care homes were largely run by families or local entities. In the 1990s, the government promoted privatization, triggering investments and consolidations. Today, private equity firms own three of the country’s five biggest care home providers.

Chris Thomas, a research fellow at the Institute for Public Policy Research, said investors benefited from scant financial oversight. “The accounting practices are horrendously complicated and meant to be complicated,” he said. Local authorities try “to regulate more, but they don’t have the expertise.”

The Financial Shuffle

At Four Seasons, the speed of change was dizzying. From 2004 to 2017, big money came and went, with revenue at times threaded through multiple offshore vehicles. Among the groups that owned Four Seasons, in part or in its entirety: British private equity firm Alchemy Partners; Allianz Capital Partners, a German private equity firm; Three Delta LLP, an investment fund backed by Qatar; the American hedge fund Monarch Alternative Capital; and Terra Firma, the British private equity group that wallowed in debt demands. H/2 Capital Partners, a hedge fund in Connecticut, was Four Seasons’ main creditor and took over. By 2019, Four Seasons was managed by insolvency experts.

Pressed on whether Four Seasons would exist in any form after the current sale of its property and businesses, MHP Communications, representing the company, said in an email: “It is too early in the process to speculate about the future of the brand.”

Vivek Kotecha, an accountant who has examined the Four Seasons financial shuffle and co-authored the Unison report, said private equity investment — in homes for older residents and, increasingly, in facilities for troubled children — is now part of the financial mainstream. The consulting firm McKinsey this year estimated that , making them a dominant force in global markets.

“What you find in America with private equity is much the same here,” said Kotecha, the founder of Trinava Consulting in London. “They are often the same firms, doing the same things.” What was remarkable about Four Seasons was the enormous liability from high-yield bonds that underpinned the deal — one equaling $514 million at 8.75% interest and another for $277 million at 12.75% interest.

Guy Hands, the high-flying British founder of Terra Firma, bought Four Seasons in 2012, soon after losing an epic court battle with Citigroup over the purchase price of the music company EMI Group. Terra Firma acquired the care homes and then a gardening business with more than 100 stores. Neither proved easy, or good, bets. Hands, a Londoner who moved offshore to Guernsey, declined through a representative to discuss Four Seasons.

Kotecha, however, try to make sense of Four Seasons’ holdings by tracking financial filings. It was “the most complicated spreadsheet I’ve ever seen,” Kotecha said. “I think there were more subsidiaries involved in Four Seasons’ care homes than there were with General Motors in Europe.”

As Britain’s small homes were swept up in consolidations, some financial practices were dubious. At times, businesses sold the buildings as lease-back deals — not a problem at first — that, after multiple purchases, left operators paying rent with heavy interest that sapped operating budgets. By 2020, some care homes were estimated to be spending as much as 16% of their bed fees on debt payments, .

How could that happen? In part, for-profit providers — backed by private equity groups and other corporations — had subsidiaries of their parent companies act as lender, setting the rates.

Britain’s elder care was unrecognizable within a generation. By 2022, private equity companies alone accounted for 55,000 beds, or about 12.6% of the total for-profit care beds for older people in the United Kingdom, according to LaingBuisson, a health care consultancy. LaingBuisson calculated that the average residential care home fee as of February 2022 was about $44,700 a year; the average nursing home fee was $62,275 a year.

From 1980 to 2018, the number of residential care beds provided by local authorities fell 88% — from 141,719 to 17,100, . Independent operators — nonprofits and for-profits — moved in, it said, controlling 243,000 beds by 2018. Nursing homes saw a similar shift: Private providers accounted for 194,100 beds in 2018, compared with 25,500 decades earlier.

Beyond Government Control

British lawmakers last winter tried — and failed — to bolster financial reporting rules for care homes, including banning the use of government funds to pay off debt.

“I don’t have a problem with offshore companies that make profits if they offer good services. I don’t have a problem with private equity and hedge funds who deliver good returns to their shareholders,” Ros Altmann, a Conservative Party member in the House of Lords and a pension expert, said in a February debate. “I do have a problem if those companies are taking advantage of some of the most vulnerable people in our society without oversight, without controls.”

She cited Four Seasons as an example of how regulators “have no control over the financial models that are used.” Altmann warned that economic headwinds could worsen matters: “We now have very heavily debt-laden [homes] in an environment where interest rates are heading upward.”

In August, the Bank of England raised borrowing rates. It now forecasts double-digit inflation — as much as 11% — through 2023.

And that leaves care home owner Robert Kilgour pensive about whether government grasps the risks and possibilities that the sector is facing. “It’s a struggle, and it’s becoming more of a struggle,” he said. A global energy crisis is the latest unexpected emergency. Kilgour said he recently signed electricity contracts, for April 2023, at rates that will rise by 200%. That means an extra $2,400 a day in utility costs for his homes.

Kilgour founded Four Seasons, opening its first home, in Fife, Scotland, in 1989. His ambition for its growth was modest: “Ten by 2000.” That changed in 1999 when Alchemy swooped in to expand nationally. Kilgour had left Four Seasons by 2004, turning to other ventures.

Still, he saw opportunity in elder care and opened Renaissance Care, which now operates 16 homes with 750 beds in Scotland. “I missed it,” he said in an interview in London. “It’s people and it’s property, and I like that.”

“People asked me if I had any regrets about selling to private equity. Well, no, the people I dealt with were very fair, very straight. There were no shenanigans,” Kilgour said, noting that Alchemy made money but invested as well.

Kilgour said the pandemic motivated him to improve his business. He is spending millions on new LED lighting and boilers, as well as training staffers on digital record-keeping, all to winnow costs. He increased hourly wages by 5%, but employees have suggested other ways to retain staff: shorter shifts and workdays that fit school schedules or allow them to care for their own older relatives.

Debates over whether the government should move back into elder care make little sense to Kilgour. Britain has had private care for decades, and he doesn’t see that changing. Instead, operators need help balancing private and publicly funded beds “so you have a blended rate for care and some certainty in the business.”

Consolidations are slowing, he said, which might be part of a long-overdue reckoning. “The idea of 200, 300, 400 care homes — that big is good and big is best — those days are gone,” Kilgour said.

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A surge of covid infections spurred wide demand for over-the-counter antigen tests during the holidays: Clinics were overwhelmed with people seeking tests and the few off-the-shelf brands were nearly impossible to find at pharmacies or even online via Amazon. Prices for some test . And the government vowed that its purchase could provide the tests faster and cheaper so people, by simply swabbing at home, could quell the spread of covid.

The Defense Department organized the bidding and announced , after a limited competitive process, that three companies were awarded contracts totaling nearly $2 billion for 380 million over-the-counter antigen tests, all to be delivered by March 14.

The much-touted purchase was the latest tranche in trillions of dollars in public spending in response to the pandemic. How much is the government paying for each test? And what were the terms of the agreements? The government won’t yet say, even though, by law, this information should be available.

The cost — and, more importantly, the rate per test — would help demonstrate who is getting the best deal for protection in these covid times: the consumer or the corporation.

The reluctance to share pricing details flies against basic notions of cost control and accountability — and that’s just quoting from a . “The prices in government contracts should not be secret,” according to its website. “Government contracts are ‘public contracts,’ and the taxpayers have a right to know — with very few exceptions —what the government has agreed to buy and at what prices.”

Americans often pay far more than people in other developed countries for tests, drugs, and medical devices, and the pandemic has accentuated those differences. Governments abroad had been buying rapid tests in bulk for over a year, and many national health services distributed free or low-cost tests, for less than $1, to their residents. In the U.S., retailers, companies, schools, hospitals, and everyday shoppers were competing months later to buy swabs in hopes of returning to normalcy. The retail price climbed as high as $25 for a single test in some pharmacies; tales abounded of corporate and wealthy customers hoarding tests for work or holiday use.

or more are required to be routinely posted to or . But none of the three new rapid-test contracts — awarded to iHealth Labs of California, Roche Diagnostics Corp. of Indiana, and Abbott Rapid Dx North America of Florida — could be found in the online databases.

“We don’t know why that data isn’t showing up in the FPDS database, as it should be visible and searchable. Army Contracting Command is looking into the issue and working to remedy it as quickly as possible,” spokesperson Jessica R. Maxwell said in an email in January. This month, she declined to provide more information about the contracts and referred all questions about the pricing to the Department of Health and Human Services.

Only vague information is available in DOD press releases, dated Jan. 13 and Jan. 14, that note the overall awards in the fixed-price contracts: iHealth Labs for $1.275 billion, Roche Diagnostics for $340 million, and Abbott Rapid Dx North America for $306 million. There were no specifics regarding contract standards or terms of completion — including how many test kits would be provided by each company.

Without knowing the price or how many tests each company agreed to supply, it is impossible to determine whether the U.S. government overpaid or to calculate if more tests could have been provided faster. As variants of the deadly virus continue to emerge, it is unclear if the government will re-up these contracts and under what terms.

To put forth a bid to fill an “urgent” national need, to the Defense Department by Dec. 24 about their capacity to scale up manufacturing to produce 500,000 or more tests a week in three months. Among the questions: Had a company already been granted “emergency use authorization” for the test kits, and did a company have “fully manufactured unallocated stock on hand to ship within two weeks of a contract award?”

Based on responses from about 60 companies, the Defense Department said it sent “requests for proposals” directly to the manufacturers. Twenty companies bid. Defense would not release the names of interested companies.

Emails to the three chosen companies to query the terms of the contracts went unanswered by iHealth and Abbott. Roche spokesperson Michelle A. Johnson responded in an email that she was “unable to provide that information to you. We do not share customer contract information.” The customers — listed as the Defense Department and the Army command — did not provide answers about the contract terms.

The Army’s Contracting Command, based in Alabama, initially could not be reached to answer questions. An email address on the command’s website for media bounced back as out-of-date. Six phone numbers listed on the command’s website for public information were unmanned in late January. At the command’s protocol office, the person who answered a phone in late January referred all queries to the Aberdeen Proving Ground offices in Maryland.

“Unfortunately, there is an issue with voicemail,” said Ralph Williams, a representative of the protocol office. “Voicemail is down. I mean, voicemail has been down for months.”

Asked about the bounced email traffic, Williams said he was surprised the address — acc.pao@us.army.mil — was listed on the . “I’m not sure when that email was last used,” he said. “The army stopped using the email address about eight years ago.”

Williams provided a direct phone number for Aberdeen and apologized for the confusion. “People should have their phone forwarded,” he said. “But I can only do what I can do.”

Joyce Cobb, an Army Contracting Command-Aberdeen Proving Ground spokesperson, reached via phone and email, referred all questions to Defense personnel. Maxwell referred more detailed questions about the contracts to HHS, and emails to HHS went unanswered.

Both the Defense and Army spokespeople, after several emails, said the contracts would have to be reviewed, citing the Freedom of Information Act that protects privacy, before release. Neither explained how knowing the price per test could be a privacy or proprietary concern.

A Defense spokesperson added that the contracts had been fast-tracked “due to the urgent and compelling need” for antigen tests. Defense obtained “approval from the Assistant Secretary of the Army for Acquisition, Logistics, & Technology to contract without providing for full and open competition.”

KHN separately searched for the contracts on the sam.gov website during a phone call with a government representative who assisted with the search. During an extended phone session, the representative called in a supervisor. Neither could locate the contracts, which are updated twice a week. The representative wondered whether the numbers listed in the Defense press release were wrong and offered: “You might want to double-check that.”

On Jan. 25, Defense spokesperson Maxwell, in an email, said that the Army Contracting Command “is working to prepare these contracts for public release and part of that includes proactively readying the contracts for the FOIA redaction.” Three days later, she sent an email stating that “under the limited competition authority … DOD was not required to make the Request for Proposal (RFP) available to the public.”

Maxwell did not respond when KHN pointed out that the contracting provision she cited does not prohibit the release of such information. In a Feb. 2 email, Maxwell said “we have nothing further to provide at this time.”

On sam.gov, the covid spreadsheets include a disclaimer that “due to the tempo of operations” in the pandemic response, the database shows only “a portion of the work that has been awarded to date.”

In other words, it could not vouch for the timeliness or accuracy of its own database.

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In California, which has a strong union tradition, Kaiser Permanente management misjudged workplace tensions during the covid-19 crisis and risked a walkout of thousands when union nurses balked at signing a four-year contract that would have slashed pay for new hires. In Colorado, Pennsylvania, North Carolina and Massachusetts, nurses have been embroiled in union battles over staffing and work conditions.

As deadly coronavirus cases spiked this year, daily pressures intensified on hospital floors. Some nurses retired; some became travel nurses, hired by agencies that advertised more than double, even triple, the day rates for intensive care unit, telemetry and emergency room nurses. Others gave up their jobs to avoid possibly carrying the covid virus home to their families.

“Things had gotten particularly stark for nurses,” said Rebecca Kolins Givan, an associate professor of labor studies at Rutgers University.

‘They Can Make More at McDonald’s’

It was so grim in Pittsburgh that registered nurses at West Penn Hospital, part of the Allegheny Health Network, voted this year to authorize a strike — less than a year after they unionized with SEIU Healthcare Pennsylvania. Chief among their complaints: The hospital system had balked at improving staff ratios even as it offered bonuses, up to $15,000 for some, to hire registered nurses to fill vacancies.

Kathleen Jae, a member of the bargaining team that reached a pact without a work stoppage, said nurses wanted management to work harder to retain veteran staff members: “We had to face the fact that nurses are retiring, nurses are leaving the bedside out of frustration, and, in certain instances this year, nurses had more patients than they felt comfortable taking care of.”

Allegheny Health Network said the first-ever pact with RNs at West Penn provides “competitive wages and benefits” to help it “recruit and retain talented, experienced nurses.”

Liz Soriano-Clark, a teacher-turned-nurse on the bargaining team, said the pandemic had made workers across the health sector more careful and choosier about what jobs they’ll take.

“There’s a nursing shortage and a shortage of nursing instructors, nationwide. They’ve seen aides leave. They’ve seen cleaners leave,” Soriano-Clark said. “Why is that? Because they can make more at McDonald’s and not have to clean up vomit.”

In September, the alerted the Biden administration to an “unsustainable nurse staffing shortage facing our country” in a . The ANA said a “crisis-level human resource shortage” was evident: Mississippi had 2,000 fewer nurses than it did at the beginning of 2021. Tennessee called on its National Guard to reinforce hospital staffs. Texas was recruiting 2,500 nurses from outside the state.

Union membership among U.S. nurses has inched up over the past 15 years and held steady, , for five years, according to , an academic website. But 2021, a year of union organizing and holdouts in such disparate workplaces as Starbucks cafes and John Deere tractor plants, might well be a turning point for essential workers in health care.

“If you ask nurses what they want,” said Givan, who interviewed dozens of nurses on health care workers, “they want working conditions where they can provide a high level of care. They don’t want appreciation that is lip service. They don’t want marketing campaigns. They don’t want shiny new buildings.”

Still, Givan noted, the health care sector has spent handsomely to fight unions.

After years of staff retention issues at Longmont United Hospital in Colorado, nurses are awaiting the results of a vote on whether to join National Nurses United, the largest union of registered nurses in the U.S.

Stephanie Chrisley, a registered nurse in the hospital’s ICU, said nurses are regularly caring for double the number of patients — often three to four “ventilated, sedated, critically ill patients.”

She and others protested outside the hospital in early December. They said the company that runs the hospital, Centura Health, this year had employed aggressive union-busting tactics, including disputing a handful of votes, which dragged out the union election for about five months. In another instance, her colleague Kris Kloster said, Centura, , issued company-wide emails announcing raises and retention bonuses for everyone except nurses at her hospital.

“Where there should have been newly hired nurses, there were anti-union consultants roaming around the hospital,” Chrisley said. Since July, she added, the hospital has lost nearly 80 RNs, “nearly a third of our nursing staff.” Longmont United Hospital Interim CEO Kristi Olson said in a statement that the hospital “will remain open and fully operational” and that “we are committed to making sure that all voices were heard” in the union election.

Organizing can take a long time, Givan said, pointing to tense labor negotiations in Massachusetts, North Carolina and Pennsylvania. “But when there is a crisis — what we call a hot shop — you can get workers to organize quite quickly.” Nurses represented by the Massachusetts Nurses Association walked off the job March 8 in Worcester. A chance to break the bitter impasse collapsed when management, Tenet Healthcare, refused to allow some nurses to return to their original jobs. In North Carolina, registered nurses at Mission Hospital in Asheville ratified a contract with the HCA management that locked in 17% raises over three years and set up a committee to review patient care conditions.

A recent poll by Gallup, the global analytics firm, found that the share of Americans who say they approved of unions was at 68%, its since 1965.

Sal Rosselli, president of the National Union of Healthcare Workers, said that in the past year “there has just been an explosion of leads,” queries from health workers exploring how to unionize.

Rosselli, whose organization represents about 15,000 health workers, said the pandemic exposed practices that had long antagonized employees. Too many hospitals scrambled for masks, gloves and gowns, he said, and front-line workers were on round-the-clock schedules and facing ghastly daily deaths. “They weren’t keeping their employees and their patients safe,” Rosselli said, “and all because these systems were focused on profit over anything else. That has been coming on for a long, long time.”

Registered nursing is among the U.S. occupations expected to experience the greatest levels of job growth in the next decade, according to the Bureau of Labor Statistics’ . Also among the are nurse practitioners, home health care aides and assistants. Shortages of RNs and other health care workers are expected to be the most intense in the South and West.

Some of the most powerful nursing unions in the nation operate out of California, representing employees in Western states. “The nurses in California have the hours they have, the care they have, the protections they have because of the union,” said Soriano-Clark, who has worked at hospitals in California and Pennsylvania.

Ready to Picket in a Pandemic

Douglas Wong, a physician assistant, never imagined hoisting a “strike” sign outside Riverside Medical Center. But that nearly happened after a sobering breakdown in talks between Kaiser Permanente and a top nurses union at the facility, part of the KP system. Nurses, pharmacists and operations staffers are among the insurers’ 160,000-plus unionized employees, according to KP spokesperson Marc Brown.

The California-based health system giant tried to force a two-tier pay schedule that would have cut wages for new nurses by 26%. Wong and thousands of allies — many who dryly noted they had been heralded as “heroes” in the covid crisis — prepared to picket in the middle of a pandemic. Kaiser Permanente’s demands crumbled when dozens of affiliated unions threatened one-day sympathy strikes.

The tiered-pay demand and an attempt to lower wages in some markets were dropped. Staffing ratios were adjusted to ease safety concerns. Wong said that, despite the pact, the bruising negotiations “felt like a betrayal.”

“Make no mistake: This was an enormous win for labor, especially pushing back on the two-tier. At the end of the day, they pulled back. And we made huge strides toward improvement in our staffing,” said Wong, a six-year KP employee and an official with the United Nurses Associations of California/Union of Health Care Professionals.

The negotiations were a marked shift for Kaiser Permanente, which for most of three decades has relied on a labor-management partnership with its unions, emphasizing cooperative decision-making and robust discussions. Talks were held with teams, set around circular tables, hashing out concerns. KP was known for much of the past decade as a market leader in wages and quality of care, and the labor-management partnership was received by academics and labor experts as an innovative, successful approach to managing a workforce.

The health system recently hired new top executives, and, to the surprise of the unions, Kaiser Permanente used negotiations this year to offer the two-tier pay regimen, a tactic used by auto- and steel-makers during economic downturns in the 1980s. The union negotiators noted this: The health care giant’s management wanted to scale back wages after notching $6.8 billion in net revenue from 2018 to 2020.

On Thursday, workers voted to ratify a four-year contract with KP. The company declined to comment for this article. , Christian Meisner, KP’s chief human resources officer, said: “This contract reflects our deep appreciation for the extraordinary commitment and dedication of our employees” during the pandemic. “We look forward to working together with our labor partners,” he said, to “further our mission of providing high-quality, affordable care.”

that nurses’ pay was sweetened in 2021 by thousands of dollars in raises — handed out without union wrangling — as hospitals competed for workers. Premier, a health care consultancy hired by the Journal, analyzed 60,000 registered nurses’ salaries and found that average annual pay, not including overtime or bonuses, grew about 4% in the first nine months of the year, to more than $81,000. That compares with a 2.6% rise in 2019, according to federal data.

Raises don’t necessarily mean retention.

“There always seems to be a shortage of nurses,” said professor Paul Clark, who is a former director of Penn State University’s School of Labor and Employment Relations and has studied nursing and labor organizing. “But it’s important to realize there’s not a shortage of RNs. There’s a shortage of RNs willing to work under the conditions they’ve been asked to work.”

Aya Healthcare, a national travel nurse provider, has found that the pandemic aggravated historical understaffing at hospitals, spokesperson Lisa Park said in an email. “There were over 100,000 vacancies at the start of the pandemic. And now, that number has increased to over 195,000,” Park said. Travel nurses account for fewer than 2% of the nursing workforce, she added, but “with the increase in permanent vacancies due to burnout/resignations, the demand for temporary healthcare workers has increased.”

David Zonderman, a professor of labor history at North Carolina State University, noted that nurses unions have grown more political and more outspoken — in Washington, D.C., and their home states. Nurses on the hospital floor lived through a crisis — fearing for their lives amid shortages of protective equipment — much like the trials of American workers in the mining and manufacturing industries in decades past.

“This may sound weird,” Zonderman said, “but nurses are a little like coal miners. They tend to help each other. They are watching each other’s back. They have solidarity.”

“And,” he said, “if you treat people badly long enough, they finally say, ‘I’m done.’”

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Black researchers, medical professionals and allies knew that people of color, even before covid, experienced bias in public health policy. As the deadly virus emerged, data analysts from Carnegie Mellon and the University of Pittsburgh, foundation directors, epidemiologists and others pooled their talents to configure databases from unwieldy state data to chart covid cases.

Their work documented yet another life-threatening disparity between white and Black Pittsburgh: People of color were at higher risk of catching the deadly virus and at higher risk of severe disease and death from that infection.

More than 100 weeks after advocates began pinging and ringing one another to warn of the virus’ spread, these volunteers are the backbone of the , a grassroots collaboration that scrapes government data and shares community health intel.

About a dozen members of its data team of 60 meet twice weekly to study hospitalization rates and employment statistics. Social media advisers turned health equity into a buzzy online effort, with videos and weekly Facebook town halls, to encourage vaccinations. Local ministries are consulted, and volunteers take surveys at pop-up clinics, sponsored by other groups, at barbershops and hair salons. Elected lawmakers seek its counsel.

“We came together because we were concerned about saving lives,” said Tiffany Gary-Webb, associate dean for diversity and inclusion at the University of Pittsburgh, who oversees the data effort. “It evolved, with us realizing we can do more than address covid.”

Covid ravaged communities across the United States — , including Colin Powell, the first Black secretary of state and a decorated Army general — and laid bare how marginalized populations lose out in the scrum for public health dollars and specific populations were left vulnerable.

Months before the pandemic began, the Rev. Ricky Burgess led the Pittsburgh City Council to declare racism a public health crisis.

“Institutional racism is for real,” the councilman said in a recent interview. “You are talking about generational disproportional investment and generational disproportional treatment. And it impacts all that you see.”

The covid pandemic proved how structural inequities have been missed or ignored, Burgess said.

“I’ve lost friends, family and a lot of church members. My son had covid. For me it’s personal,” he said. “I knew immediately it would have a disproportionate effect.”

In 2020, covid , according to the National Center for Health Statistics. Black and Hispanic people fared the worst, losing more than three years in life expectancy. White people saw a 1.2-year drop.

Using county data, the Black Equity researchers found a sobering racial gap in the Pittsburgh area: Black residents of Allegheny County saw disproportionate hospitalization rates — and were more likely to land in the ICU or on a — in the pandemic. Weekly hospitalization rates were higher during surges of infection in April, July and December 2020 and again in March and October 2021. Deaths, too, were disproportionate but fluctuated after December 2020.

For much of the pandemic, death rates were higher for African Americans than for other racial groups, the coalition said.

‘It’s All a Shade of Bad’

Kellie Ware has long considered health inequity a deadly problem. She graduated from Pittsburgh public schools, left for law school in Boston, and months before covid began its global assault she was working in her hometown mayor’s office as an equity and diversity policy analyst.

Ware was at her desk in late 2019 when her phone started ringing. A damning report, compiled by university sociologists and the city’s gender commission, had yet again detailed glaring disparities.

The blandly titled report, “Pittsburgh’s Inequality Across Gender and Race,” jolted emotions in the city of 303,000 people — and underscored how health disparities track with income.

Among the findings: Black people in Pittsburgh earned far less than their white neighbors and suffered far worse from disease. For every dollar white men earned, , Black women earned 54 cents, making them five times as likely to live in poverty as white men.

With notably higher cardiovascular disease and cancer rates, Black residents’ life expectancy was about eight years less than white Pittsburghers’.

The report sparked a furor, which Ware met with perspective shaped over years away from the former steel town. “The report was factual,” Ware said, “but I know this: There’s not a ton of places where it’s great to be a Black woman. Those earnings? It’s 54 cents to a dollar for women in Pittsburgh. It’s 68 cents nationally. It’s all a shade of bad.”

The first signs of the pandemic supercharged Ware and others. As covid devastated New York in March 2020, Karen Abrams, a program officer at the Heinz Endowments, a foundation in Pittsburgh that spends $70 million a year on community programs, began connecting the dots in texts and calls with nonprofits, business owners and university researchers.

Covid spread quickly in dense multi-generational households and in Black neighborhoods in Chicago, Washington, New Orleans and Detroit. Abrams was among the advocates in Pennsylvania who watched county and state health systems race to prepare and who feared that Black residents would be underserved.

In Philadelphia, early on in the pandemic, volunteer doctors in mobile units began distributing protective equipment and covid tests in Black neighborhoods. In Pittsburgh, Abrams asked tech-minded allies to document the reality of covid infection in Pittsburgh. “We intuitively knew what was happening,” she said. “But without that data, we couldn’t target our attention and know who needed the help most.”

Within days, volunteers were on daylong rounds of video calls and appealing to county and state bureaucrats for more race-based statistics to bolster their research.

Fred Brown, president of the nonprofit Forbes Funds, and Mark Lewis, who heads the Poise Foundation, were stalwarts of a “huddle,” a core of longtime advocates who eventually founded the coalition.

Brown emphasized pulling labor statistics to show that the essential workers keeping the city running — among them nursing homes aides and home care staff — were overwhelmingly Black or Latino.

Mapping covid testing centers and analyzing data proved sobering, he said. It turned out that the people most likely to be tested lived in Pittsburgh’s predominately white neighborhoods. Largely employed in tech, academia and finance, they could easily adapt to lockdowns. They had round-the-clock internet at home and could afford food deliveries to limit the chance of infection. Later, they could access vaccines quicker.

“The communities that had the most tests were the affluent ones,” Brown said. And those with the fewest “were the most resilient, the people who had to go out there and work.”

Lewis, a certified public accountant who spent years as a corporate auditor, focused on standards. County and state health professionals worked mightily to control the spread of covid but didn’t always gather data to ensure fairness in distribution, he said. “We realized that, as testing was done, it was not being recorded by race,” Lewis said. “Why? A lot of the issue was — at the state and the local level — there was no requirement to collect it.”

Gary-Webb said researchers had a sense of where the inequities would be found because they knew the neighborhoods. They first layered in percentages of Black families in poverty as well as data on the locations of federally qualified health centers to advise health authorities on where and when to increase testing.

University and nonprofit researchers found anomalies as they worked. For instance, race was noted on some testing data, with patients designated as Black, white or, inexplicably, unknown. The “unknowns” were a significant percentage. So researchers began layering additional census, labor and ZIP code data, to identify neighborhoods, even streets, at risk.

The ZIP code data took months to shake loose from state databases, largely because government software was slow in the fast-moving pandemic and government data was not updated regularly or formatted in ways that could be easily shared.

Their efforts paid off: The group was able to winnow down Allegheny County records that omit race to 12% of positive covid cases; 37% of statewide records are missing race details, .

Robert Gradeck, who runs the Western Pennsylvania Regional Data Center, a data collaborative managed by the University of Pittsburgh, said covid should play a lasting role in improving public health reporting. “We kept thinking: What can we learn from this?” Gradeck said. “It’s not that you can’t answer questions. But you can answer only part of them.”

Among the top recommendations to health authorities: adopt software practices to ensure that race and other demographic data must be entered into electronic records. And then refine how to share data among counties, states, research institutions and the public.

The coalition attracted support in monthly calls with state Health Secretary Rachel Levine, recently sworn in as a four-star admiral in charge of the U.S. Public Health Service Commissioned Corps, which responds to health crises on behalf of the federal government.

“I thought what they did was critically important,” Levine said, noting that officials recognized the coalition’s research as revelatory. With “a diverse group of professionals, they were able to use and collect data in a very effective way.”

Their early research found the covid rate among Black people in Allegheny County, which encompasses Pittsburgh, was three times the rate of white people. Hospitalizations among Black people have been as high as seven times the rate of whites, according to ,” the coalition’s 2021 report.

A Vaccine Clinic Campaign Stop

Ed Gainey, a state legislator from Pittsburgh, was among the first politicians to say African Americans in his hometown were missing out on covid protections. Last month, Gainey was elected the city’s first Black mayor, after winning a primary, within months of the murder of George Floyd, that pointed to inequities in health care and policing.

A Democrat who worked for two Pittsburgh mayors, Gainey admits he and other Black elected officials were somewhat ill-equipped in the first weeks of the pandemic.

“I fought hard to get the vaccine into the community last year, but I really didn’t know the language — the health language — to be able to get it,” Gainey said during an interview at a pop-up vaccine clinic in the city.

Vaccinations have risen because of community efforts, he said, but children are still a source of worry. Gainey, who grew up in a low-income housing complex, said he understands when some youngsters shrug when asked about covid risks. “But I will tell you I know this: If you can make a kid believe in Santa Claus, you can make them believe in the vaccine. And you know, I understand some of the young kids’ reluctance. I didn’t grow up going to the doctor regularly either,” he said. “I came from the same kind of environment.”

As the 2019 report made clear, many of the benefits of Pittsburgh’s tech-based economy — a vaunted “ed-and-meds” renewal against the industrial decline of the 1980s — still was largely bypassing African Americans.

The first year of covid was an iterative process of trying to stay ahead of the virus. Gary-Webb, who earned a doctorate from Johns Hopkins’ public health school, said it was also a time for Black residents to be heard about what they knew and saw in their neighborhoods.

The coalition, sustained by thousands of volunteer hours, attracted some funding earlier this year, notably for outreach and to pay for running datasets. Last month, the Poise Foundation was approved for a three-year, $6.99 million grant, federal money to be administered by the state health department to support an array of health partnerships in the region and, notably, to improve covid vaccine uptake in ZIP code areas the Black Equity Coalition identified as vulnerable. Among its goals: demographic messaging, data analysis on covid testing and education outreach in dozens of counties.

Gary-Webb counts herself among a group of “boomerang” Pittsburghers who have lived other places — in her case, Baltimore, New York and Philadelphia — and covid has helped them recalibrate how Black residents can participate in public health.

As she put it: “The health planners were saying, ‘Help us get out the message.’ We said, ‘No, we are not just getting out the message. We want to be talking about equity at the same time.’”

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Although residents were eager for the shots this year, he’s counted only about 3 in 4 workers vaccinated at any one time. The excuses, among its staff of roughly 100, had a familiar ring: Because covid vaccines were authorized only for emergency use, some staffers worried about safety. Convenience mattered. In winter, shots were administered at work through a federal rollout. By spring, though, workers had to sign up online through a state program — a time-sucking task.

ManorCare urges every worker to be immunized against covid but turnover has vexed that effort. Managers at ProMedica, a nonprofit health system that operates ManorCare and senior care facilities in 26 states, faced a workforce conundrum familiar to all manner of providers during the pandemic: how to persuade essential workers to get vaccinated — and in a way that didn’t drive them away. Raises and bonuses, costing millions of dollars, did not move the needle to 100%.

Animus toward the vaccine created turmoil for some providers. Dr. Eric Berger, a pediatrician in Philadelphia who opened his practice more than a dozen years ago, enforced mandatory shots in May and saw six of his 47 staff members walk out. Berger said he worked for months to educate resistant workers. In April, he learned that several, women in their 20s and 30s, had attended a private karaoke party. Within days, four staffers were infected with covid.

Berger, who had seen in-office costs for protective equipment soar, then set a deadline for shots. He looks back with steely resolve over the last-minute “I quit” texts he received — and the hassle of finding a new receptionist and billing and medical assistants.

“Fortunately, we had some wonderful people who put in extra time,” he said. “It’s been stressful, but I think we did the right thing.”

Brittany Kissling, 33 and a mother of four, was one of the hesitant workers at Berger’s practice who decided — largely for financial reasons — to get vaccinated. The clinic manager couldn’t afford to lose her job. But she said she was nervous and that most of the workers who left recoiled at being told vaccinations were not negotiable. “I was a no-show my first time,” Kissling said about her first vaccine appointment. “I was scared. There were a lot of unknowns.”

But Kissling said Berger’s practice has spent “thousands and thousands and thousands of dollars” on masks and even paid workers for five days a week when they worked only two during the pandemic’s worst months. She said she understood how and why the karaoke episode prompted a mandate. “I get it from the business side,” said Kissling, about the requirement. “I do think it’s fair. I do think it is tough.”

Berger saw no other choice. “Vaccines are fundamental to our practices. That’s what we do,” he said. “Some got it in their heads that it could cause infertility; some had other reasons. It’s frustrating … [and] I don’t think it was political. If anything, most of these people are apolitical.”

At ManorCare, managers decided money could make a difference. Bonuses — up to $200 per employee — were added as an incentive, which in Pennsylvania alone cost ProMedica $3 million, said Luke Pile, vice president and general manager for ProMedica Senior Care skilled nursing centers.

Richmond, at ManorCare, said the resident council has been pivotal in keeping the focus on the risks of covid to the elderly — and no one there needs a reminder about the stress of the past year. According to Medicare records, the facility had 107 cases of covid among staffers and residents — and 14 deaths among residents beginning in March 2020.

“I constantly wear a mask. Not out of fear, but I don’t want to spread it by being asymptomatic,” Richmond said. “I tell people here: Whatever is happening in the community, that is what is happening in the community. But we are a health care institution and caring for the elderly. We need to be constantly vigilant.”

Richmond and other administrators admit it can be a struggle to understand why some health workers are unmoved by the science.

“Everything has been so polarized this past year. I don’t know that there is a single reason that individuals don’t get the vaccine,” Pile said. “In trying to educate people, personally and professionally, we talk about the history and science. Unfortunately, individual opinions don’t always align with that.”

Mandating vaccines is a step that ProMedica has yet to take, even as more businesses, universities and health care providers do so. A few long-term care operators, such as Atria Senior Living, operating in the United and Canada, and Juniper Communities, Some have been met with lawsuits from workers aligned with conservative groups. filed suit to dispute and derail the hospital system’s compulsory vaccination. A judge dismissed the challenge this month on the grounds that the hospital’s requirement or public policy.

Last week, the U.S. Labor Department issued a temporary emergency standard for health care workers, saying they face “grave danger” in the workplace when “less than 100 percent of the workforce is fully vaccinated.”

In Pennsylvania, whose population ranks among the oldest according to 2019 census data, statistical snapshots published in April underscored the need for vigilance. Two state agencies overseeing skilled nursing care and personal care homes reported that only half of their workers were vaccinated. Covid was notably devastating to long-term care facilities nationwide in 2020; some of Pennsylvania’s deadliest outbreaks were reported by local media in places shown later to have low staff vaccination rates.

A survey by the , begun in March 2020 with over 700,000 Facebook respondents ages 18 to 64, recently was analyzed by researchers from Carnegie Mellon and the University of Pittsburgh, who found that health care workers were largely leading the vaccine uptake. But there were notable differences over the winter among people working, side by side, in health care settings.

Pharmacists, physicians and registered nurses were the least hesitant to get vaccinated. Home health care aides, EMTs and nursing assistants showed the highest hesitancy among front-line health workers. Overall hesitancy across professions decreased from January to March 2021, as much as 5 percentage points, as vaccinations expanded,

University of Pittsburgh researcher Wendy King said people indicated they were receptive to the vaccine if they were familiar with its science. Educators, overall, displayed the least hesitancy; workers in construction, mining and oil/gas extraction showed the greatest. Half of those who were hesitant cited possible side effects — a fear that could be eased by education, King said. A third among the hesitant gave other reasons: They didn’t believe they needed the vaccine. They didn’t trust the government. Or they didn’t trust the covid-19 vaccines.

“We expected hesitancy to vary by group, but how much they varied was surprising,” King said. “These were not people who were anti-vaccine, but they were worried about the effect of the vaccine.”

Still, King said the percentage who didn’t trust the government was alarming. “If somebody doesn’t understand the vaccine, that’s one thing. If you don’t trust that government, that is a much more difficult issue to address.”

That may change as two prominent vaccine makers approach full approval by the Food and Drug Administration. Pfizer and BioNTech applied for approval in May; Moderna applied in early June. A recent nearly a third of unvaccinated adults said they would be more likely to get a vaccine once it was fully approved by the FDA.

At ProMedica, Pile described a multipronged approach in such states as Florida and Pennsylvania, home to large elderly populations. On-site counseling in groups, with familiar doctors and staff, helped persuade some who were reluctant, he said. Short videos on why and how the vaccine worked were readied. ProMedica senior medical staff flew to Florida to advise as the National Guard arrived at its facility in Pinellas County, the health system’s first to receive the vaccine.

Falon Blessing, a nurse, manages other practitioners at ManorCare Health Services Center throughout the Tampa region. She recounted how employees had wondered aloud how such newly created vaccines could be safe.

“I think people at first just wanted to know: I’m not going to grow a tail in five years,” she said. “But then there was a momentum. It wasn’t so much ‘Are you going to get vaccinated?’ but rather ‘Of course, I’m going to get vaccinated.’”

During three vaccinations sessions ended in January, though, the facility reached about the same rate as Pennsylvania overall — about 76% of its workers were vaccinated. That rate has fallen to 62% this month because of attrition. An education effort continues, a ProMedica spokesperson said.

“My takeaway was it mattered to have one-on-one discussions,” Pile said. “If you talk to 10 people, why they wouldn’t get the vaccine, you’d get 10 different reasons.”

“And there were political opinions — what they heard on Facebook — and then they’d say: I want to see how it goes,” he said.

The questions and qualms about vaccines came at the end of a deeply distressing pandemic year for health care workers, and facilities are now finding fewer applicants for essential care.

By spring, ProMedica had 1,500 job postings in Pennsylvania alone, compared with a typical 400 openings. Pile said ProMedica raised wages in dozens of locations, though he declined to provide wage ranges or rates. It spent $4.5 million in Pennsylvania from March through last week — and still supplemented its workforce across the U.S. by hiring through staffing agencies.

“In 2020, we spent over $32 million on staffing agencies,” he said. Through this spring, ProMedica was on course to spend $66 million on staffing agencies for 2021, said Pile, who has worked in the care sector for 18 years.

“I have less employees than ever before,” he said. “I have never seen anything like it.”

The Pennsylvania Health Care Association, an advocacy group, surveyed members in April to better understand vaccine reluctance. Zachary Shamberg, the group’s president, said it found that defining “hesitancy is not that simple.”

Shamberg said PHCA focused on why people had yet to be immunized and the characteristics of the workforce were telling: About 92% of all its workers are women; 65% are between ages 16 and 44. Among them, some worried early on about possible infertility from the new vaccine, he said, and some wanted to wait for the single-shot Johnson & Johnson vaccine. Others were sick with covid and were advised, once recovered, not to get a vaccine for 90 days.

Shamberg was also critical of the state data. Those surveys, taken in March and released in April, reflected a time when the vaccine was new to many people.

Pennsylvania, a battleground state in recent presidential elections, remains politically charged, and Shamberg noted that politics likely plays a role among holdouts. In recent months, PHCA enlisted churches and doctors’ consortiums to change minds. Keeping residents and workers safe should be a priority in a state that, in a few years, will face a “silver tsunami” of residents in their 80s, Shamberg said.

In recent weeks, there has been clear momentum among the general population for shots in Pennsylvania. The state now ranks among the top 10 states in the nation to administer first doses of vaccines, according to data from the Centers for Disease Control and Prevention.

“Pennsylvania is a big and diverse state,” Shamberg said. “And it’s interesting why some of our staff in western Pennsylvania were hesitant versus workers in the city of Philadelphia.”

“The vast majority of workers in Philadelphia are female and, among them, minority populations that have some inherent distrust based on historical experience. Then you go out west and you have a more conservative viewpoint — and a distrust of government today and a distrust of government vaccine.”

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But Baylor not only weathered the crisis, it thrived. By the end of 2020, Baylor had accumulated an $815 million surplus, $20 million more than it had in 2019, creating a 7.5% operating margin that would be the envy of most other hospitals in the flushest of eras, a KHN examination of financial statements shows.

Like Baylor, some of the nation’s richest hospitals and health systems recorded hundreds of millions of dollars in surpluses after accepting the lion’s share of the federal health care bailout grants, their records show. Those included the Mayo Clinic, Pittsburgh’s UPMC and NYU Langone Health. But poorer hospitals — many serving rural and minority populations — got a tinier slice of the pie and limped through the year with deficits, downgrades of their bond ratings and bleak fiscal futures.

“A lot of the funding helped the wealthy hospitals at a time, especially in New York, when safety-net hospitals were hemorrhaging,” said Colleen Grogan, a health policy professor at the University of Chicago. “We could have tailored it to hospitals we knew were really suffering and taking on a disproportionate amount of the burden.”

In Baylor’s case, the system, which runs Baylor University Medical Center in Dallas and 51 other hospitals, said it spent $257 million last year on pandemic-related costs, including protective clothing for employees and patients and creating isolation rooms. Baylor has $197 million in unspent federal relief funds to use this year to cover costs of battling the virus and refrigerating vaccines, it said.

“Our covid-19-related expenses and lost revenue continue to exceed the funding we have received to date,” Baylor said in a statement to KHN.

Other well-heeled hospitals or large systems faced bigger problems. Both NewYork-Presbyterian Hospital and CommonSpirit Health, a 140-hospital Catholic system that operates in 21 states, lost money despite federal grants in the vicinity of a billion dollars each. A few systems, including the for-profit chain HCA Healthcare, returned federal funds when they saw they had skirted their worst-case scenarios. But most spent the aid and held onto any leftover money and new grants to cover anticipated pandemic costs this year because hospital executives fear more case spikes.

Much of the lopsided distribution was caused by the way the Department of Health and Human Services based the allotment of the initial bailout funds on hospitals’ past revenue. That with well-off patients who have private health plans over those that rely on lower-paying government insurance, which is what many poor people use.

HHS distribution formulas did not take into account which hospitals had enough assets to survive.

Baylor, for instance, began 2020 with $5.4 billion in cash and investments, enough to keep it running for 238 days, the financial disclosures show.

Hospitals that ended the year with profits were entitled to federal aid because of the Congress and HHS set in how hospitals could classify their pandemic costs.

Last fall, when HHS attempted to limit how much aid hospitals could keep based on their profits — so the money could be redirected to struggling hospitals — the effort was swiftly beaten back by the industry and Congress. HHS officials declined requests for an interview but noted in a statement that Congress had ordered it to revert to its “broader definition of permissible use of PRF funds.”

“The Biden Administration continues to review programs and policies including considerations for the unallocated funding under the PRF program and the $8.5 billion recently appropriated under the recently signed American Rescue Plan Act,” the statement said.

Avoiding a Drawdown of Reserves

The were initiated last spring to help health care providers ride out a once-in-a-century public health calamity. The money designated to hospitals and other health care providers from the Coronavirus Aid, Relief, and Economic Security (CARES) Act and subsequent legislation totaled .

It was intended to offset all costs of treating infected patients, including purchasing ventilators, masks, gowns and other personal protective equipment. Congress further authorized hospitals to use the money to compensate for a drop in revenue when they shut down elective surgeries and non-emergency treatments to prepare for the anticipated deluge of covid-19 patients.

The money, referred to as the Provider Relief Fund, helped many poorer hospitals avert cash crunches, layoffs and bond rating downgrades. A  found that the median hospital gain during 2020 would have been 0.3% without the federal support. With it, half of hospitals posted gains of 2.7% or more, below the 2019 median margin of 3.1%, according to the firm, which also produces for the American Hospital Association.

In February, the association to replenish the nearly empty relief fund, saying, “hospitals have never experienced such a widespread, national health crisis.”

Some hospitals’ finances deteriorated significantly during the pandemic. From the end of March through December, the rating agency Moody’s downgraded 28 hospitals, primarily because of weaknesses such as higher debt or more competition, said Lisa Goldstein, associate managing director at Moody’s.

Others suffered worse fates, like Williamson Memorial Hospital, which shut down last April. The hospital, in West Virginia’s coal country, had been out of bankruptcy protection, but “unfortunately, the decline in volumes experienced from the current pandemic were to[o] sudden and severe for us to sustain operations,” its on Facebook.

Conversely, many prosperous health systems emerged unscathed from the moratoriums of last spring, often due to the federal aid. “It gave them an ability to not have to draw down on their reserves to make up for the loss in revenue,” said Suzie Desai, a senior director at S&P Global Ratings.

Systems saw patient visits return to near normal as the year wore on. In some cases, business in the latter half of 2020 was even higher than in the same period in 2019 because of pent-up demand for treatments postponed from the spring, financial records show.

“We saw volumes spring back” in every area except emergency room visits, said Kevin Holloran, a senior director at Fitch Ratings. Major hospital systems also reported that cases tended to be more complex than normal, leading to higher insurance payments.

UPMC in bailout funds while collecting $2.5 billion more in revenue in 2020 than in 2019. The nonprofit system ended the year with an $836 million operating surplus — providing a 3.6% margin that was triple the prior year’s — in part due to the growth of the health insurance plan the system owns.

Other hospitals that sold insurance, including Baylor, persevered because the cause of their financial troubles — fewer surgeries and doctors’ visits — meant the health plans paid fewer claims.

UPMC’s strong finances went unmentioned in a recent fundraising pitch announcing the launch of its “Health Care Heroes” campaign. “During the past year, health care workers have carried the weight of the world on their shoulders, risking their own health and safety to ensure ours as we navigated the covid-19 pandemic,” the email said. “Now it’s our turn to recognize their hard work. … By making a donation, you will help provide training, recognition, and support for our staff initiatives.”

Donald Yealy, a senior vice president of UPMC and the chief medical officer of UPMC Health Services, said the fundraising appeal was a way to allow people in the community to show their appreciation.

“The intent of the request and the letter were clear. People are free to ignore or to have an opinion. I don’t begrudge that at all. I respect people having a different opinion,” he said.

Hospitals can hold on to unspent relief funds until the end of July to defray any further pandemic-related costs. After that, any unspent money must be returned to the U.S. Treasury. UPMC retains $80 million in unspent relief funds, which the health system said it expects to use. “We’re still in the process of incurring significant costs related to covid,” said Edward Karlovich, UPMC executive vice president and chief financial officer.

‘A Shot in the Arm’ Sometimes Unneeded

In April 2020, the Mayo Clinic in Rochester, Minnesota, in lost revenue because of the pandemic. Instead, Mayo, which received $338 million in federal relief funds, with revenue that was $202 million higher than in 2019. Mayo recorded a $728 million surplus, which equaled a 5.2% margin.

“It gave us a shot in the arm when we needed it,” said Dennis Dahlen, Mayo’s chief financial officer. Later, when it seemed likely Mayo would run a surplus, executives debated what to do with the federal funds.

“Honestly, we considered dropping the margin,” Dahlen said. After weighing their options, Mayo “landed in a middle-of-the-road decision” by returning $156 million to the federal government.

“We considered it with what everyone else was doing … and we thought about what was good for society,” Dahlen said. “’Nonprofit’ doesn’t really mean no profit. It means tax-exempt. We still have to create earnings so we can reinvest in ourselves.”

Mayo $14 billion in investments, $3 billion more than it had in 2019, a 29% increase.

The funds were, indeed, a lifesaver for some. Marvin O’Quinn, president and chief operating officer of CommonSpirit Health, said “there was never a thought of turning back the money.”

Despite receiving $1.3 billion in relief funds, CommonSpirit, based in Chicago, ended last year with a $75 million deficit, which translated to a 0.2% loss.

“We have been set back by a year,” O’Quinn said. “All the things we wanted to do — to renovate, to building new facilities, to expand our service — we’ve had to slow up to get through the crisis.”

Scattershot Relief

The in relief funds “was sent out indiscriminately as a life support,” said Ge Bai, an associate professor at Johns Hopkins Bloomberg School of Public Health. HHS tried . It sent $22 billion to 1,090 hospitals with large numbers of covid patients. It sprinkled an additional $16 billion among hospitals that serve poor populations, Native American tribes, people in rural areas and children.

But even with the targeted aid, recipients included well-endowed academic medical centers and major urban hospitals. Only $14 billion took profitability into consideration, HHS documents show. HHS restricted those payments to hospitals with 3% or lower profit margins.

Wealthy hospitals also benefited because HHS used a broad definition of lost revenue. If a hospital earned less than in the year before, or simply less revenue than it had budgeted for, it could chalk up that difference to the pandemic and apply the relief funds to it. The implications garnered little attention at the time as they were overshadowed by the concerns about how HHS was doling out the money rather than how it could be used.

In September, HHS to tighten its overall limits on how much money the hospitals could keep by basing it on the difference from the previous year’s net income rather than overall revenue — a number that in many cases would be much lower. The goal, , was to “prohibit most providers from using PRF [Provider Relief Fund] payments to become more profitable than they were pre-pandemic, to conserve resources to allocate to providers who were less profitable.”

The American Hospital Association that would punish hospitals that had behaved responsibly by cutting costs and be an “administrative and accounting disaster,” as many hospitals had already spent the grant money.

HHS a month later, citing “significant attention and opposition from many stakeholders and Members of Congress.” Not fully satisfied, Congress the rollback in a December law.

Some hospital executives attributed their surpluses to their aggressive cost-cutting measures.

NYU Langone Health, for instance, received $461 million in relief funds, which covered about a third of its pandemic-related losses, said Daniel Widawsky, chief financial officer. Another third of Langone’s losses was absorbed by the record-high financial performance in the months before the pandemic, he said, and prompt cost control addressed the rest.

Widawsky said that at the beginning of March Langone canceled travel, froze hiring, paused construction and stopped discretionary purchases. “The first three days in March, we locked down spending,” he said. “If they wanted to buy a pencil, they had to call me.” Langone ended its fiscal year in August with $208 million in net income, and recorded a $136 million surplus in the final quarter of 2020, or 5.5%. Earlier this year, two credit agencies on Langone from stable to positive.

Despite accepting $942 million in bailout funds, NewYork-Presbyterian Hospital had a $457 million operating deficit, a 7% loss, at the end of September. It was a sharp turn from September 2019, when the system recorded a $166 million surplus, a 2.5% gain.

The system, which declined to comment, has not yet released its financial metrics for the final three months of 2020, but Fitch it would remain in the red. Still, NewYork-Presbyterian remains fiscally solid: Its most disclosure reported $3.8 billion in cash and short-term investments, enough to keep operating for more than a year.

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Months after hundreds of students were met by SWAT teams, the Catholic Diocese of Pittsburgh began forming its own armed police force.

Wendell Hissrich, a former safety director for the city and career FBI unit chief, was hired that year to form a department to safeguard 39 Catholic schools as well as dozens of churches in the region. Hissrich has since added 15 officers and four supervisors, including many formerly retired officers and state troopers, who now oversee school campuses fitted with Stop the Bleed kits, cameras, and defibrillators.

When religious leaders first asked for advice after what are known as “swatting” incidents, the veteran lawman said he didn’t hesitate to deliver blunt advice: “You need to put armed officers in the schools.”

But he added that the officers had to view schools as a special assignment: “I want them to be role models. I want them to be good fits within the school. I’m looking for someone to know how to deal with kids and with parents — and, most importantly, knows how to de-escalate a situation.”

Gun violence is a leading cause of death for young people in America, and the possibility of shootings has influenced costly decision-making in school systems as administrators juggle fear, duty, and dizzying statistics in efforts to keep schools safe from gun harm. In the first week of September, the risks were made tragically clear again, this time in Georgia, as a teenager stands accused of shooting his way through his high school and killing two students and two teachers.

Still, scant research supports the creation of school police forces to deter gun violence — and what data exists can raise as many questions as answers. are, in fact, suicides — a sobering statistic from the federal Centers for Disease Control and Prevention that reflects a range of ills. and studies found that as white children to experience firearm assaults. Research on racial bias in policing overall in the U.S. as well as studies on have prompted calls for caution. And an oft-cited U.S. Secret Service review of 67 thwarted plots at schools supports reasons to examine parental responsibility as well as police intervention as effective ways to stop firearm harm.

The Secret Service threat assessment, published in 2021, analyzed plots from 2006 to 2018 and found students who planned school violence had guns readily at home. It also found that school districts that contracted sworn law officers, who work as full- or part-time school resource officers, had some advantage. The officers proved pivotal in about a third of the 67 foiled plots by current or former students.

“Most schools are not going to face a mass shooting. Even though there are more of them — and that’s horrible — it is still a small number,” said Mo Canady, executive director of the National Association of School Resource Officers. “But administrators can’t really allow themselves to think that way.

“They have to think, ‘It could happen here, and how do I prevent it?’”

About a 20-minute drive north of Pittsburgh, a top public school system in the region decided the risk was too great. North Allegheny Superintendent Brendan Hyland last year recommended retooling what had been a two-person school resource officer team — staffed since 2018 by local police — into a 13-person internal department with officers stationed at each of the district’s 12 buildings.

Several school district board members voiced unease about armed officers in the hallways. “I wish we were not in the position in our country where we have to even consider an armed police department,” board member Leslie Britton Dozier, a lawyer and a mother, said during a public planning meeting.

Within weeks, all voted for Hyland’s request, estimated to cost $1 million a year.

Hyland said the aim is to help 1,200 staff members and 8,500 students “with the right people who are the right fit to go into those buildings.” He oversaw the launch of a police unit in a smaller school district, just east of Pittsburgh, in 2018.

Hyland said North Allegheny had not focused on any single news report or threat in its decision, but he and others had thought through how to set a standard of vigilance. North Allegheny does not have or want metal detectors, devices that some districts have seen as necessary. But a trained police unit willing to learn every entrance, stairway, and cafeteria and who could develop trust among students and staffers seemed reasonable, he said.

“I’m not Edison. I’m not inventing something,” Hyland said. “We don’t want to be the district that has to be reactive. I don’t want to be that guy who is asked: ‘Why did you allow this to happen?’”

Since 2020, the role of police in educational settings has been hotly debated. The video-recorded death of George Floyd, a Black man in Minneapolis who was murdered by a white police officer during an arrest, prompted national outrage and demonstrations against police brutality and racial bias.

Some school districts, notably in large cities such as Los Angeles and Washington, D.C., reacted to concerns by reducing or removing their school resource officers. Examples of unfair or biased treatment by school resource officers drove some of the decisions. This year, however, there has been apparent rethinking of the risks in and near school property and, in California, Colorado, and Virginia, parents are .

The 1999 bombing plot and shooting attack of Columbine High School and a massacre in 2012 at Sandy Hook Elementary School are often raised by school and police officials as reasons to prepare for the worst. But the value of having police in schools also came under sharp review after a blistering federal review of the mass shooting in 2022 at Robb Elementary School in Uvalde, Texas.

The federal Department of Justice this year produced a 600-page report that laid out multiple failures by the school police chief, including his attempt to try to negotiate with the killer, who had already shot into a classroom, and waiting for his officers to search for keys to unlock the rooms. Besides the teenage shooter, 19 children and two teachers died. Seventeen other people were injured.

The DOJ report was based on hundreds of interviews and a review of 14,000 pieces of data and documentation. This summer, the former chief was indicted by a grand jury for his role in “abandoning and endangering” survivors and for failing to identify an active shooter attack. Another school police officer was charged for his role in placing the murdered students in “imminent danger” of death.

There have also been increased judicial efforts to pursue enforcement of firearm storage laws and to hold accountable adults who own firearms used by their children in shootings. For the first time this year, the who fatally shot four students in 2021 were convicted of involuntary manslaughter for not securing a newly purchased gun at home.

In recent days, Colin Gray, the father of the teenage shooting suspect at Apalachee High School in Georgia, was charged with second-degree murder — the most severe charges yet against a parent whose child had access to firearms at home. The 14-year-old, Colt Gray, who was apprehended by school resource officers on the scene, according to initial media reports, also faces murder charges.

Hissrich, the Pittsburgh diocese’s safety and security director, said he and his city have a hard-earned appreciation for the practice and preparation needed to contain, if not thwart, gun violence. In January 2018, Hissrich, then the city’s safety officer, met with Jewish groups to consider a deliberate approach to safeguarding facilities. Officers cooperated and were trained on lockdown and rescue exercises, he said.

Ten months later, on Oct. 27, 2018, a lone gunman entered the Tree of Life synagogue and, within minutes, killed 11 people who had been preparing for morning study and prayer. Law enforcement deployed quickly, trapping and capturing the shooter and rescuing others caught inside. The coordinated response was praised by witnesses at the trial where the killer was convicted in 2023 on federal charges and sentenced to die for the worst antisemitic attack in U.S. history.

“I knew what had been done for the Jewish community as far as safety training and what the officers knew. Officers practiced months before,” Hissrich said. He believes schools need the same kind of plans and precautions. “To put officers in the school without training,” he said, “would be a mistake.”

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In a storage unit, Lomax has a thousand canvasses, she estimates, mostly of young people who died from gunfire, and others of the mothers, sisters, friends, and mourners left to ask why.

“The purpose is not to make people cry,” said Lomax, a Philadelphia native who has traveled to New York, Atlanta, and Miami to collaborate on similar exhibitions on trauma. “It is for families and for people who have gone through this to know that they are not forgotten.”

Each person “is not a number. This is somebody’s child. Somebody’s son, somebody’s daughter who was working toward something,” she said. “The portraits are not just portraits. They are telling us what the consequences are for what’s happening in our cities.”

Firearms in 2020 became the for children and teens under 18 — from both suicides and assaults — and fresh research on the public health crisis from Harvard Medical School’s Blavatnik Institute show how those losses with significant economic and psychological costs.

On June 25, U.S. Surgeon General Vivek Murthy declared gun violence a public health crisis, noting: “Every day that passes we lose more kids to gun violence. The more children who are witnessing episodes of gun violence, the more children who are shot and survive that are dealing with a lifetime of physical and mental health impacts.”

Philadelphia has recorded more than 9,000 fatal and nonfatal shootings since 2020, with about 80% of the victims identified as Black, according to . Among those injured or dead, about 60% were age 30 or younger.

Lomax has been a singular, and perhaps unlikely, force in making the statistics unforgettable. Since 2018, when a young friend poised to graduate from Penn State University was on a Sunday afternoon in Philadelphia, Lomax has set out to support healing among those who experience violence.

She launched a show on PhillyCAM, a community access media channel, to encourage people to talk about guns and opioids and grief. She organized fashion shows with local artists and families that focused on bearing witness to distress. She seized on portraiture, reaching out to local artists to memorialize the lives, not the deaths, of Philadelphia’s young. She began tracking shootings on social media, in news accounts, and sometimes by word of mouth. In 2022, City Hall to a remarkable exhibition of lost lives, organized by Lomax and created by .

She recently shared the portraits at a summit sponsored by the nonprofit and . The meeting offered guidance on enforcing regulations to prevent straw gun purchases that propel crime and provided data on weapon trafficking across state lines. Lomax knew the art, displayed along the stage, brought home the stakes.

Look at these faces, she said. These people had promise. What happened? What can be done?

Lomax, now 40, said the conversations she starts have purpose. Some paintings she gives to families. Others she stores for future exhibits.

“This is not what I set out to do in life,” she said. “When I was growing up, I thought I’d be a nurse. But I guess I am kind of nursing people this way.”

So far this year, Philadelphia has seen a drop in the number of murders, according to an online database by AH Datalytics, but ranks among the top five cities in murder count. Last year, the Harvard researchers established that communities and families are left vulnerable by gun injuries.

The 2023 study led by Zirui Song, an associate professor of health care policy at Harvard Medical School, examined data related to newborns through age 19. The research documented a “massive” economic toll, with health care spending increasing by an average of $35,000 for survivors in the year after a shooting, and life-altering mental health challenges.

Survivors of shootings and their caregivers, whether dealing with physical injuries or generalized fear, often struggle with “long-lasting, invisible injuries, including psychological and substance-use disorders,” according to Song, who is also a general internist at Massachusetts General Hospital. His study found that parents of injured children experienced a 30% increase in psychiatric disorders compared with parents whose children did not sustain gunshot injuries.

, who paints with acrylics, has been helping Lomax since 2021. Like all the artists, she’s paid by Lomax. She has , always after sitting down with the subject’s family. “I get a backstory so I can incorporate that in the portrait,” she said. “Sometimes we cry. Sometimes we pray. Sometimes we try to uplift each other. It is hard to do.”

“I hope one day I would not have to paint another portrait,” said Norwood, a mother of five children. “The idea that Zarinah has had so many exhibits, with numerous people who have died, is scary and heartbreaking.”

, a self-taught digital artist, was among those who wanted to help to “honor and to offer a better look at who these people were.” Doughty, a city employee who works at a courthouse, may be best known within Philadelphia for a series of fanciful murals in which he has grouped famous natives such as Will Smith, Grace Kelly, and Kevin Hart.

He has produced about 150 portraits on his iPad and laptop, working with Lomax’s nonprofit group, The Apologues, to best match a face with a phrase, embedded in the scene, that telegraphs the lost potential of youth.

“At the beginning it was hard to do,” said Doughty, who works from family photographs. “I look and I think: They are kids. Just kids.”

One time, he received a text from Lomax seeking a portrait of a rapper he recognized from art and music shows. Another day, he opened an email to find a photo of a man he knew from high school. In May, Doughty his work process for a portrait of Derrick Gant, a rapper with the stage name Phat Geez, who was . The killing happened a few weeks after the rapper a music video referring to an Instagram account that promotes anti-violence efforts in the city.

Doughty, 33, who grew up in the Nicetown section of north Philadelphia, wryly noted: “It wasn’t so nice.” Lomax’s exhibitions, he said, allow families, even neighborhoods, to sort through sorrow and pain.

“I went to the last one and a mother came up and said, ‘Did you draw my child’s portrait?’ She just fell into my arms, crying. It was such a moment,” he said. “And a reminder on why we do what we do.”

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Nearly every day of 2024 so far has brought more violence. On Feb. 14, gunfire broke out at the Super Bowl parade in Kansas City, killing one woman and injuring 22 others. Most events draw little attention — while the injuries and toll pile up.

Gun violence is among America’s most deadly and costly public health crises. But unlike other big killers — diseases like cancer and HIV or dangers like automobile crashes and cigarettes — sparse federal money goes to studying gun violence or preventing it.

That’s because of a one-sentence amendment tucked into the 1996 congressional budget bill: “None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.”

Its author was Jay Dickey, an Arkansas Republican who called himself the on Capitol Hill. And for nearly 25 years the amendment was perceived as a threat and all but paralyzed the CDC’s support and study of gun violence.

Even so, a small group of academics have toiled to document how gun violence courses through American communities with vast and tragic outcomes. Their research provides some light as officials and communities develop policies mostly in the dark. It has also inspired a fresh generation of researchers to enter the field — people who grew up with mass shootings and are now determined to investigate harm from firearms. There is momentum now, in a time of rising gun injury and death, to know more.

The reality is stark:

Gun sales reached record levels in 2019 and 2020. Shootings soared. In 2021, , more people — than in any year on record, according to a Johns Hopkins University analysis of CDC data. Guns became the leading cause of death for children and teens. Suicides accounted for more than half of those deaths, and homicides were linked to 4 in 10.

Black people are nearly 14 times as likely to die from firearm violence as white people — and guns were responsible for ages 15 to 19 in 2021, the data showed.

Harvard research published in JAMA in 2022 estimated gun injuries translate into economic losses of , or 2.6% of the U.S. gross domestic product.

With gun violence touching nearly every corner of the country, surveys show that Americans — whatever their political affiliation or whether they own guns or not — .

What Could Have Been

It is no secret that many strategies proposed today — from school metal detectors to enhanced policing, to the optimal timing and manner of safely storing guns, to restrictions on gun sales — have limited scientific ballast because of a lack of data.

It could have been otherwise.

U.S. firearm production , flooding communities with . In that era, Mark Rosenberg was the founding director of the CDC’s National Center for Injury Prevention and Control and his agency, over time, was pivotal in helping to fund research on gun violence and public health.

Rosenberg thought then that gun violence could go the way of car crashes. The federal government spent $200 million a year on research to redesign roadways and cars beginning in the 1970s, he said, and had seen death rates plummeted.

“We said, ‘Why can’t we do this with gun violence?’” Rosenberg said. “They figured out how to get rid of car crashes — but not cars. Why can’t we do the same thing when it comes to guns?”

The Dickey Amendment sidelined that dream.

concluded that “guns kept in the home are associated with an increase in the risk of homicide,” a finding on risk factors that prompted an uproar in conservative political circles. To newly elected representatives in the midterm “Republican Revolution” of 1994, the research was a swipe at gun rights. The NRA stepped up lobbying, and Congress passed what’s known as the Dickey Amendment in 1996.

Some Democrats, such as the influential John Dingell of Michigan (a onetime NRA board member who received the group’s “”), would join the cause. Dingell proposed his own bills, detailed last summer by .

Under heavy political pressure, the CDC ousted Rosenberg in 1999. Soon after, some CDC administrators began alerting the NRA to research before publication.

“It was clearly related to the work we were doing on gun violence prevention,” Rosenberg, now 78, said of his job loss. “It was a shock.”

Those Who Persevered

The quarter-century spending gap has left a paucity of data about the scope of gun violence’s health effects: Who is shot and why? What motivates the violence? With what guns? What are the injuries? Can suicides, on the rise from gunfire, be reduced or prevented with safeguards? Does drug and alcohol use increase the chances of harm? Could gun safeguards reduce domestic violence? Ultimately, what works and what does not to prevent shootings?

If researchers say they “lost a generation” of knowledge about gun violence, then American families lost even more, with millions of lives cut short and a legacy of trauma passed down through generations.

Imagine if cancer research had been halted in 1996 — many tumors that are now eminently treatable might still be lethal. “It’s like cancer,” said Rebecca Cunningham, vice president for research at the University of Michigan, an academic who has kept the thread of gun research going all these years. “There may be 50 kinds of cancer, and there are preventions for all of them. Firearm violence has many different routes, and it will require different kinds of science and approaches.”

Cunningham is one of a small group of like-minded researchers, from universities across the United States, who refused to let go of investigating a growing public health risk, and they pushed ahead without government funds.

has spent about to support seminal research at the University of California-Davis. With state and private funding, he created a violence prevention program in California, a leader in firearm studies. He has documented an unprecedented increase in gun sales since 2020 — about 15 million transactions more than expected based on previous sales data.

at Johns Hopkins University focused on teenagers and guns — particularly access and suicides — and found that local police who coped with gun risks daily were willing to collaborate. He secured grants, even from the CDC, with carefully phrased proposals that avoided the word “guns,” to study community violence.

At Duke University, explored the underground gun market, interviewing people incarcerated in Chicago jails and compiling pivotal social science research on how guns are bought, sold, and traded.

, an economist and public policy professor at Harvard, worked on the national pilot to document violent deaths — knowing most gun deaths would be recorded that way — because, he said, “if you don’t have good data, you don’t have nothin’.”

Hemenway, writing in the journal Nature in 2017, found a 30% rise in gun suicides over the preceding decade and nearly a 20% rise in gun murders from 2014 to 2015. The data was alarming and so was the lack of preventive know-how, he wrote. “The US government, at the behest of the gun lobby, limits the collection of data, prevents researchers from obtaining much of the data that are collected and severely restricts the funds available for research on guns,” he wrote. “Policymakers are essentially flying blind.”

His work helped create the most ambitious database of U.S. gun deaths today — the . Funded in 1999 by private foundations, researchers were able to start understanding gun deaths by compiling data on all violent deaths from health department, police, and crime records in several states. The CDC took over the system and eventually rolled in data from all 50 states.

Still, no federal database of nonfatal gun injuries exists. So the government would record one death from the Super Bowl parade shooting, and the 22 people with injuries remain uncounted — along with many thousands of others over decades.

Philanthropy has supported research that Congress would not. The funded the bulk of the grants, with more than $33 million since the 1990s. ’ philanthropy and the Robert Wood Johnson Foundation have added millions more, as has Michael Bloomberg, the politician and media company owner. , which keeps a tab of ongoing research, finds states increasingly are stepping up.

Timothy Daly, a Joyce Foundation program director, said he remembers when the field of gun harm was described by some as a “desert.” “There was no federal funding. There was slim private funding,” he said. “Young people would ask themselves: ‘Why would I go into that?’”

in 2017 found gun violence “was the least-researched” among leading causes of death. Looking at mortality rates over a decade, gun violence killed about as many people as sepsis, the data showed. If funded at the same rate, gun violence would have been expected to receive $1.4 billion in research funds. Instead, it received $22 million from across all U.S. government agencies.

There is no way to know what the firearm mortality or injury rate would be today had there been more federal support for strategies to contain it.

A Reckoning

As gun violence escalated to once unthinkable levels, Rep. Dickey came to regret his role in stanching research and became friends with Rosenberg. They wrote a about the need for gun injury prevention studies. In 2016, they delivered a letter supporting the creation of the California Firearm Violence Research Center.

Both men, they emphasized, were NRA members and agreed on two principles: “One goal must be to protect the Second-Amendment rights of law-abiding gun owners; the other goal, to reduce gun violence.”

Dickey died in 2017, and Rosenberg has only kind words for him. “I did not blame Jay at all for what happened,” he said. The CDC was “under pressure from Congress to get rid of our gun research.”

As alarm over gun fatality statistics from diverse sectors of the nation — scientists, politicians, and law enforcement — has grown, research in the field is finally gaining a foothold.

Even Congress, noting the Dickey Amendment was not an all-out ban, appropriated $25 million for gun research in late 2019, split between the CDC — whose imperative is to research public health issues — and the National Institutes of Health. It’s a drop in the bucket compared with what was spent on car crashes, and it’s not assured. House Republicans this winter have pushed an amendment to once again cut federal funding for CDC gun research.

Still, it’s a start. With growing interest in the field, the torch has passed to the next generation of researchers.

In November, Cunningham helped organize a on the prevention of firearm-related harm. More than 750 academics and professionals in public health, law, and criminal justice met in Chicago for hundreds of presentations. A similar event in 2019, the first in 20 years, drew just a few dozen presentations.

“You can feel momentum,” Cunningham said at the conference, reflecting on the research underway. “There’s a momentum to propel a whole series of evidence-based change — in the same way we have addressed other health problems.”

During , Yale University School of Public Health Dean Megan L. Ranney bluntly described the rising number of gun deaths — noting the overwhelming number of suicides — as an alarm for lawmakers. “We are turning into a nation of traumatized survivors,” she said, urging their support for better data and research on risk factors.

Cassandra Crifasi, 41, was a high school sophomore when the Columbine massacre outside Littleton, Colorado, shook the country. She recently succeeded Webster, her , as co-director of the Johns Hopkins Center for Gun Violence Solutions.

Crifasi has spent much of her career evaluating risk factors in gun use, including collaborative studies with Baltimore police and the city to reduce violence.

Raised in Washington state, Crifasi said she never considered required training in firearms an affront to the Second Amendment. She owns guns. In her family, which hunted, it was a matter of responsibility.

“We all learned to hunt. There are rules to follow. Maybe we should have everybody who wants to have a gun to do that,” she said.

Crifasi pointed to the 2018 shooting at in Parkland, Florida — which left 17 dead and 17 injured — as a turning point. Students and their parents took “a page out of Mothers Against Drunk Driving — showing up, testifying, being in the gallery where laws are made,” she said.

“People started to shift and started to think: This is not a third rail in politics. This is not a third rail in research,” Crifasi said.

worked in corporate management before she arrived at Johns Hopkins to pursue a master’s in public health. It was summer 2012, and a gunman killed 12 moviegoers at a midnight showing of “The Dark Knight Rises” in Aurora, Colorado. The town’s pain led the national news, and “rightfully so,” Buggs said. “But I was in Baltimore, in East Baltimore, where there were shootings happening that weren’t even consistently making the local news.”

Now violence “that once was considered out of bounds, out of balance — it is more and more common,” said Buggs who recently joined the as a lead investigator.

Buggs’ research has examined anxiety and depression among youths who live in neighborhoods with gun violence — and notes that firearm suicide rates too have drastically increased among Black children and adolescents.

There is a trauma from hearing gunshots and seeing gun injuries, and daily life can be a thrum of risk in vulnerable communities, notably those largely populated by Black and Hispanic people, Buggs said. Last year, Buggs organized with a core group of about two dozen scientists committed to contextualizing studies on gun violence.

“The people most impacted by the gun violence we usually hear about in America look like our families,” she said of the collective.

“They are not resilient. People are just surviving,” Buggs said. “We need way more money to research and to understand and address the complexity of the problem.”

Illustration credit: Oona Tempest/ºÚÁϳԹÏÍø News. (Reference photos of Buggs, Cook, Crifasi, Cunningham, Daly, Hemenway, Webster: Christine Spolar for ºÚÁϳԹÏÍø News; Rosenberg: Getty Images; Wintemute: University of California-Davis.)

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A Centene subsidiary, Operose Health, took over nearly three dozen medical practices in London — gateways for NHS care — in a deal worth tens of millions of dollars. The subsidiary became the largest private supplier of general practice services in the United Kingdom, with 67 practices accounting for 570,000 patients.

A local health commission, records show, signed off after a nine-minute review in a virtual hearing held the week before Christmas. Centene was not mentioned. Not a question was asked. It was the time of year — amid pandemic restraints — when official business in London gave way to fizzy cocktails and quiet glad tidings.

Within weeks, the acquisition set off alarms for Louise Irvine, an NHS doctor, who called it “privatization of the NHS by stealth.” Irvine, other practitioners, and residents supported a crowdfunded legal challenge to the takeover of AT Medics Holdings, the U.K. primary care company under contract to the NHS.

Centene is the largest privately managed care provider in the U.S. that offers government-sponsored insurance, such as Medicaid and Affordable Care Act plans, as well as health care to seniors, prisoners, military members, and veterans. Britons who protested its expansion saw a for-profit outsider with ambitions that could weaken the NHS. They worried Centene would decide on staffing to suit its bottom line. NHS contracts with doctors at set rates, and assistants are paid less; critics questioned whether the Centene deal would reduce more highly trained staff.

Then there was this: The corporation since 2013, over noncompliance with state or federal Medicaid contracts or rules. By mid-2021, as its legal battle intensified in London, Centene was grappling with allegations of overbilling Medicaid for pharmacy services. It has since paid about $657 million . It faces investor lawsuits as well as overbilling allegations from several more states. Centene, based in Missouri, has denied wrongdoing.

Centene’s “suitability” for doing business with the NHS was not discussed in the virtual hearing. And because of technical limitations, members of the public could review the decision only through an audio recording, released online a day later.

“It was covid time,” Irvine, now retired, said with some frustration about the public meeting. “We believe NHS should be a public service, and it is being gradually eroded.”

Centene did not respond to requests to discuss its U.K. strategy. By July 2021, Centene’s interests also acquired Circle Health Group, a private health care group based in London with 50 hospitals.

Earlier this year, a judge ruled that the 2020 public meeting was conducted lawfully. The judge questioned the relevance of raising Centene’s liabilities; she noted the American company’s counsel had documented that its “financial position was strong” and that the insurer “continues to operate successfully in the U.S. health care market.”

Advocates for market-based efficiencies, including former NHS chiefs who were hired by Centene-related businesses, portray the managed-care titan as a change agent that can innovate and trim costs.

In October, an NHS care commission declined to renew a Centene contract for Hanley Primary Care Center in north London, which . The clinic was left with too few doctors, , and patient appointments had dropped by 270 a week, representing a “huge hole” in care since the acquisition. The NHS’ decision , in which clinic employees said the practice was short eight doctors and that less qualified workers, called physician associates, filled the gaps.

Operose spokesperson Stephen Webb, in an email, said the Hanley practice “is currently rated as ‘Good’ by the national regulator” and the contract would be reviewed next year. On its website, Operose calls the BBC report “sensational.” It adds that “we have a strong track record of performance, recruitment and investment in our staff and services.”

The Hanley decision is a small validation for Irvine and others who warned that efficiencies would degrade the quality of care.

“The whole ethos of the American system, well, it is fundamentally different than how we view care in the U.K.,” Irvine said. “Our values are free and accessible health care for all.”

Cultivating Ties in Government

Centene was eyeing the British health system in winter 2011, when it hosted health advisers from across Europe to tour its facilities in Spain’s seaside region of Valencia.

In March 2011, and again in 2015, representatives from Centene’s subsidiary Ribera Salud promoted its “pioneering approach” to caregiving at hospitals and treatment centers through a public-private partnership, according to.

Like Britain, Spain faces an aging population. The subsidiary promised a model for “efficient and effective healthcare” for patients who are government-supported or pay out-of-pocket. The government paid the provider a flat rate per patient each year, and Ribera Salud operated the sites and managed staff.

The approach intrigued British politicians and advisers, conservatives as well as liberals, eager to manage health care costs by encouraging competition.

Centene cultivated its image and relationships, launching the subsidiary Centene UK in 2016. Within months, it was hiring NHS administrators for its executive ranks. Among the highest-profile recruits: Samantha Jones, a nurse and the NHS England director of “new care models,” who had championed Centene’s work in Spain.

By 2019, Jones was named CEO of Centene UK. In 2021, she left to work for Prime Minister Boris Johnson as “an expert adviser for NHS transformation and social care.”

As Johnson’s premiership came under pressure, Jones was named chief of operations at No. 10 Downing St. She left when he resigned in July.

By then, Centene had a substantial U.K. foothold and other former NHS administrators had joined its top ranks. Contacted through LinkedIn, Jones said she was “not available to do any interviews.”

For consumers intent on preserving Britain’s national health care — or just understanding who owns what and where — Centene is difficult to track. It’s the same in the U.S., where the company has more than 300 subsidiaries. Names there typically lean into local iconography such as Peach State Health Plan of Georgia and Buckeye Community Health Plan of Ohio — with no mention of Centene.

In England, Jenny Shepherd, 72, has written about Centene and its subsidiaries for years. She set up a hyperlocal news site in 2012 to track public services amid government budget restraints. She soon focused on NHS. When Centene’s operations in Spain were being floated as a model for reform, Shepherd saw little coverage of it. “Journalism was lacking,” she said.

Shepherd scours regulatory filings for her posts, published under “.” Over years, she has documented a flowchart of sorts of Centene’s businesses. She said the company routinely recasts its corporate profile. From 2016 to 2018 alone, subsidiary names, addresses, and company directors changed often, she noted.

In 2018, Centene UK was listed as controlled by a Centene subsidiary, MH Services International Holdings. In November 2019, according to regulatory filings, Centene UK formally changed its name to Operose Health.

The practices acquired in 2020, however, were still identified in March 2021 as part of AT Medics Holdings. That filing, in U.K. government records, lists Operose Health as a board member.

Centene’s stake in Circle Health was laid out in December 2021 regulatory filings. Circle Health’s parent company in the U.K. is MH Services International (UK) Ltd., “with the ultimate parent being Centene Corporation,” records show.

Centene aims to wring profit from government-guaranteed payments, Shepherd said: “The English NHS is as big as the Chinese army, and it was clear that the Americans wanted to get their hands on it.”

Such guarantees have diminished, however, as health care costs have increased. The pandemic has propelled a two-year backlog for some treatments. For the first time in history, NHS nurses in England, Wales, and Northern Ireland went on strike in December, largely over pay. Ambulance drivers and paramedics in England and Wales followed suit. Military personnel were readied to take over some services.

‘Closer to the American Model’

The rise of for-profit providers within the British NHS has sparked incendiary debates, with brute questions about costs and motives. How much is spent on patients? How much is spent on services? And could market forces plow the national health landscape into a tiered system of care?

“We are seeing a shift in care access and waiting times, and a big rise in the number of people moving toward a private system,” said Chris Thomas, principal health fellow at the Institute for Public Policy Research think tank in London. “Britain already has the largest number of private patients in the G-7, and that brings us closer to the American model.”

Centene has been welcomed by some as a way “to ease burdens within a chronically overworked NHS,” Thomas said. “But it doesn’t seem optimal to have a corporation — a for-profit organization — coming in.”

Centene has seen limits to government guarantees, particularly in Spain.

Even as British health advisers visited Ribera Salud in 2011, the Spanish press was documenting financial missteps in the venture. Fees per patient, meant to cover access to universal care, had to be renegotiated. Directors and administrators moved between public-sector jobs and Ribera through what appeared to be an unchecked .

Anne Stafford, a finance professor at University of Manchester, behind the Ribera model. The rhetoric of savings never matched reality, she said, with no clear comparison offered of labor costs, financing, wage demand, and patient ratios between Spain and Britain.

Debates over how best to deliver care often lack rigor and consistency, she added. “People say they love their NHS, but they have no concept of how it is funded or how it operates,” she said. “That allows people with an agenda to get into the market.”

British politicians have seen health care as ripe for privatization since the late 1990s, she said, but “there is very little proper accountability” for whether “the private sector, in fact, is delivering value for money.”

NHS advisers also have questioned whether the two systems could be effectively compared: Invented after World War II, the NHS was so celebrated that in 2012 doctors and nurses marched in the opening ceremony of the London Olympics. Spain’s national health care emerged in the 1980s, after the death of dictator Gen. Francisco Franco, and it struggled with costs within its first decade. The Centene model in Valencia, reliant on bank financing, was implemented in 1999.

The report found differences in size and staffing of facilities as well as how care systems were integrated. Measuring possible cost savings was difficult and, the report said,

By December 2021, it was clear that Centene no longer regarded its Ribera operations as a moneymaker. It announced it would divest “non-core assets” to improve its profit margin.

Centene executives to two international assets: Circle Health and Ribera.

Within months, the Spanish subsidiary was sold for an undisclosed figure, bundled with other health and diagnostic groups, to Vivalto Santé, the third-largest private hospital company in France. The acquisition was completed in November.

Centene, in a statement, described its excising of Ribera, with 10 hospitals, 1,650 beds, and 71 primary care and outpatient clinics, as a “significant milestone in our value creation plan.”

For now, with its Circle Health venture. Its 1,900 beds delivered two-thirds of more than $2 billion in annual revenue, according to investor guidance in December 2021. It’s now the largest private hospital care provider in England.

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Within weeks, the Four Seasons brand may be finished.

Christie & Co., a commercial real estate broker, splashed a summer sale across its website that signaled the demise: The last 111 Four Seasons facilities in England, Scotland, and Jersey were on the market. Already sold were its 29 homes in Northern Ireland.

Four Seasons collapsed after years of private equity investors rolling in one after another to buy its business, sell its real estate, and at times wrest multimillion-dollar profits through complex debt schemes — until the last big equity fund, Terra Firma, which in 2012 paid about $1.3 billion for the company, was caught short.

In a country where government health care is a right, the Four Seasons story exemplifies the high-stakes rise — and, ultimately, fall — of private equity investment in health and social services. Hanging over society’s most vulnerable patients, these heavily leveraged deals failed to account for the cost of their care. Private equity firms are known for making a profit on quick-turnaround investments.

“People often say, ‘Why have American investors, as well as professional investors here and in other countries, poured so much into this sector?’ I think they were dazzled by the potential of the demographics,” said Nick Hood, an analyst at Opus Restructuring & Insolvency in London, which advises care homes — the British equivalent of U.S. nursing homes or assisted living facilities. They “saw the baby boomers aging and thought there would be infinite demands.”

What they missed, Hood said, “was that about half of all the residents in U.K. homes are funded by the government in one way or another. They aren’t private-pay — and they’ve got no money.”

Residents as ‘Revenue Streams’

As in the United States, long-term care homes in Britain serve a mixed market of public- and private-pay residents, and those whose balance sheets rest heavily on government payments are stressed even in better economic times. Andrew Dobbie, a community officer for Unison, a union that represents care home workers, said private equity investors often see homes like Four Seasons as having “two revenue streams, the properties themselves and the residents,” with efficiencies to exploit.

But investors don’t always understand what caregivers do, he said, or that older residents require more time than spreadsheets have calculated. “That’s a problem when you are looking at operating care homes,” Dobbie said. “Care workers need to have soft skills to work with a vulnerable group of people. It’s not the same skills as stocking shelves in a supermarket.”

, funded in part by Unison and conducted by University of Surrey researchers, found big changes in the quality of care after private equity investments. More than a dozen staff members, who weren’t identified by name or facility, said companies were “cutting corners” to curb costs because their priority was profit. Staffers said “these changes meant residents sometimes went without the appropriate care, timely medication or sufficient sanitary supplies.”

In August, the House of Commons received : The number of adults 65 and older who will need care is speedily rising, estimated to go from 3.5 million in 2018 to 5.2 million in 2038. Yet workers at care homes are among the lowest paid in health care.

“The covid-19 pandemic shone a light on the adult social care sector,” according to , which noted that “many frustrated and burnt out care workers left” for better-paying jobs. The report’s advice in a year of soaring inflation and energy costs? The government should add “at least £7 billion a year” — more than $8 billion — or risk deterioration of care.

Britain’s care homes are separate from the much-lauded National Health Service, funded by the government. Care homes rely on support from local authorities, akin to counties in the United States. But they have seen a sharp drop in funding from the British government, which cut a third of its payments in the past decade. When the pandemic hit, the differences were apparent: Care home workers were not afforded masks, gloves, or gowns to shield them from the deadly virus.

Years ago, care homes were largely run by families or local entities. In the 1990s, the government promoted privatization, triggering investments and consolidations. Today, private equity firms own three of the country’s five biggest care home providers.

Chris Thomas, a research fellow at the Institute for Public Policy Research, said investors benefited from scant financial oversight. “The accounting practices are horrendously complicated and meant to be complicated,” he said. Local authorities try “to regulate more, but they don’t have the expertise.”

The Financial Shuffle

At Four Seasons, the speed of change was dizzying. From 2004 to 2017, big money came and went, with revenue at times threaded through multiple offshore vehicles. Among the groups that owned Four Seasons, in part or in its entirety: British private equity firm Alchemy Partners; Allianz Capital Partners, a German private equity firm; Three Delta LLP, an investment fund backed by Qatar; the American hedge fund Monarch Alternative Capital; and Terra Firma, the British private equity group that wallowed in debt demands. H/2 Capital Partners, a hedge fund in Connecticut, was Four Seasons’ main creditor and took over. By 2019, Four Seasons was managed by insolvency experts.

Pressed on whether Four Seasons would exist in any form after the current sale of its property and businesses, MHP Communications, representing the company, said in an email: “It is too early in the process to speculate about the future of the brand.”

Vivek Kotecha, an accountant who has examined the Four Seasons financial shuffle and co-authored the Unison report, said private equity investment — in homes for older residents and, increasingly, in facilities for troubled children — is now part of the financial mainstream. The consulting firm McKinsey this year estimated that , making them a dominant force in global markets.

“What you find in America with private equity is much the same here,” said Kotecha, the founder of Trinava Consulting in London. “They are often the same firms, doing the same things.” What was remarkable about Four Seasons was the enormous liability from high-yield bonds that underpinned the deal — one equaling $514 million at 8.75% interest and another for $277 million at 12.75% interest.

Guy Hands, the high-flying British founder of Terra Firma, bought Four Seasons in 2012, soon after losing an epic court battle with Citigroup over the purchase price of the music company EMI Group. Terra Firma acquired the care homes and then a gardening business with more than 100 stores. Neither proved easy, or good, bets. Hands, a Londoner who moved offshore to Guernsey, declined through a representative to discuss Four Seasons.

Kotecha, however, try to make sense of Four Seasons’ holdings by tracking financial filings. It was “the most complicated spreadsheet I’ve ever seen,” Kotecha said. “I think there were more subsidiaries involved in Four Seasons’ care homes than there were with General Motors in Europe.”

As Britain’s small homes were swept up in consolidations, some financial practices were dubious. At times, businesses sold the buildings as lease-back deals — not a problem at first — that, after multiple purchases, left operators paying rent with heavy interest that sapped operating budgets. By 2020, some care homes were estimated to be spending as much as 16% of their bed fees on debt payments, .

How could that happen? In part, for-profit providers — backed by private equity groups and other corporations — had subsidiaries of their parent companies act as lender, setting the rates.

Britain’s elder care was unrecognizable within a generation. By 2022, private equity companies alone accounted for 55,000 beds, or about 12.6% of the total for-profit care beds for older people in the United Kingdom, according to LaingBuisson, a health care consultancy. LaingBuisson calculated that the average residential care home fee as of February 2022 was about $44,700 a year; the average nursing home fee was $62,275 a year.

From 1980 to 2018, the number of residential care beds provided by local authorities fell 88% — from 141,719 to 17,100, . Independent operators — nonprofits and for-profits — moved in, it said, controlling 243,000 beds by 2018. Nursing homes saw a similar shift: Private providers accounted for 194,100 beds in 2018, compared with 25,500 decades earlier.

Beyond Government Control

British lawmakers last winter tried — and failed — to bolster financial reporting rules for care homes, including banning the use of government funds to pay off debt.

“I don’t have a problem with offshore companies that make profits if they offer good services. I don’t have a problem with private equity and hedge funds who deliver good returns to their shareholders,” Ros Altmann, a Conservative Party member in the House of Lords and a pension expert, said in a February debate. “I do have a problem if those companies are taking advantage of some of the most vulnerable people in our society without oversight, without controls.”

She cited Four Seasons as an example of how regulators “have no control over the financial models that are used.” Altmann warned that economic headwinds could worsen matters: “We now have very heavily debt-laden [homes] in an environment where interest rates are heading upward.”

In August, the Bank of England raised borrowing rates. It now forecasts double-digit inflation — as much as 11% — through 2023.

And that leaves care home owner Robert Kilgour pensive about whether government grasps the risks and possibilities that the sector is facing. “It’s a struggle, and it’s becoming more of a struggle,” he said. A global energy crisis is the latest unexpected emergency. Kilgour said he recently signed electricity contracts, for April 2023, at rates that will rise by 200%. That means an extra $2,400 a day in utility costs for his homes.

Kilgour founded Four Seasons, opening its first home, in Fife, Scotland, in 1989. His ambition for its growth was modest: “Ten by 2000.” That changed in 1999 when Alchemy swooped in to expand nationally. Kilgour had left Four Seasons by 2004, turning to other ventures.

Still, he saw opportunity in elder care and opened Renaissance Care, which now operates 16 homes with 750 beds in Scotland. “I missed it,” he said in an interview in London. “It’s people and it’s property, and I like that.”

“People asked me if I had any regrets about selling to private equity. Well, no, the people I dealt with were very fair, very straight. There were no shenanigans,” Kilgour said, noting that Alchemy made money but invested as well.

Kilgour said the pandemic motivated him to improve his business. He is spending millions on new LED lighting and boilers, as well as training staffers on digital record-keeping, all to winnow costs. He increased hourly wages by 5%, but employees have suggested other ways to retain staff: shorter shifts and workdays that fit school schedules or allow them to care for their own older relatives.

Debates over whether the government should move back into elder care make little sense to Kilgour. Britain has had private care for decades, and he doesn’t see that changing. Instead, operators need help balancing private and publicly funded beds “so you have a blended rate for care and some certainty in the business.”

Consolidations are slowing, he said, which might be part of a long-overdue reckoning. “The idea of 200, 300, 400 care homes — that big is good and big is best — those days are gone,” Kilgour said.

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A surge of covid infections spurred wide demand for over-the-counter antigen tests during the holidays: Clinics were overwhelmed with people seeking tests and the few off-the-shelf brands were nearly impossible to find at pharmacies or even online via Amazon. Prices for some test . And the government vowed that its purchase could provide the tests faster and cheaper so people, by simply swabbing at home, could quell the spread of covid.

The Defense Department organized the bidding and announced , after a limited competitive process, that three companies were awarded contracts totaling nearly $2 billion for 380 million over-the-counter antigen tests, all to be delivered by March 14.

The much-touted purchase was the latest tranche in trillions of dollars in public spending in response to the pandemic. How much is the government paying for each test? And what were the terms of the agreements? The government won’t yet say, even though, by law, this information should be available.

The cost — and, more importantly, the rate per test — would help demonstrate who is getting the best deal for protection in these covid times: the consumer or the corporation.

The reluctance to share pricing details flies against basic notions of cost control and accountability — and that’s just quoting from a . “The prices in government contracts should not be secret,” according to its website. “Government contracts are ‘public contracts,’ and the taxpayers have a right to know — with very few exceptions —what the government has agreed to buy and at what prices.”

Americans often pay far more than people in other developed countries for tests, drugs, and medical devices, and the pandemic has accentuated those differences. Governments abroad had been buying rapid tests in bulk for over a year, and many national health services distributed free or low-cost tests, for less than $1, to their residents. In the U.S., retailers, companies, schools, hospitals, and everyday shoppers were competing months later to buy swabs in hopes of returning to normalcy. The retail price climbed as high as $25 for a single test in some pharmacies; tales abounded of corporate and wealthy customers hoarding tests for work or holiday use.

or more are required to be routinely posted to or . But none of the three new rapid-test contracts — awarded to iHealth Labs of California, Roche Diagnostics Corp. of Indiana, and Abbott Rapid Dx North America of Florida — could be found in the online databases.

“We don’t know why that data isn’t showing up in the FPDS database, as it should be visible and searchable. Army Contracting Command is looking into the issue and working to remedy it as quickly as possible,” spokesperson Jessica R. Maxwell said in an email in January. This month, she declined to provide more information about the contracts and referred all questions about the pricing to the Department of Health and Human Services.

Only vague information is available in DOD press releases, dated Jan. 13 and Jan. 14, that note the overall awards in the fixed-price contracts: iHealth Labs for $1.275 billion, Roche Diagnostics for $340 million, and Abbott Rapid Dx North America for $306 million. There were no specifics regarding contract standards or terms of completion — including how many test kits would be provided by each company.

Without knowing the price or how many tests each company agreed to supply, it is impossible to determine whether the U.S. government overpaid or to calculate if more tests could have been provided faster. As variants of the deadly virus continue to emerge, it is unclear if the government will re-up these contracts and under what terms.

To put forth a bid to fill an “urgent” national need, to the Defense Department by Dec. 24 about their capacity to scale up manufacturing to produce 500,000 or more tests a week in three months. Among the questions: Had a company already been granted “emergency use authorization” for the test kits, and did a company have “fully manufactured unallocated stock on hand to ship within two weeks of a contract award?”

Based on responses from about 60 companies, the Defense Department said it sent “requests for proposals” directly to the manufacturers. Twenty companies bid. Defense would not release the names of interested companies.

Emails to the three chosen companies to query the terms of the contracts went unanswered by iHealth and Abbott. Roche spokesperson Michelle A. Johnson responded in an email that she was “unable to provide that information to you. We do not share customer contract information.” The customers — listed as the Defense Department and the Army command — did not provide answers about the contract terms.

The Army’s Contracting Command, based in Alabama, initially could not be reached to answer questions. An email address on the command’s website for media bounced back as out-of-date. Six phone numbers listed on the command’s website for public information were unmanned in late January. At the command’s protocol office, the person who answered a phone in late January referred all queries to the Aberdeen Proving Ground offices in Maryland.

“Unfortunately, there is an issue with voicemail,” said Ralph Williams, a representative of the protocol office. “Voicemail is down. I mean, voicemail has been down for months.”

Asked about the bounced email traffic, Williams said he was surprised the address — acc.pao@us.army.mil — was listed on the . “I’m not sure when that email was last used,” he said. “The army stopped using the email address about eight years ago.”

Williams provided a direct phone number for Aberdeen and apologized for the confusion. “People should have their phone forwarded,” he said. “But I can only do what I can do.”

Joyce Cobb, an Army Contracting Command-Aberdeen Proving Ground spokesperson, reached via phone and email, referred all questions to Defense personnel. Maxwell referred more detailed questions about the contracts to HHS, and emails to HHS went unanswered.

Both the Defense and Army spokespeople, after several emails, said the contracts would have to be reviewed, citing the Freedom of Information Act that protects privacy, before release. Neither explained how knowing the price per test could be a privacy or proprietary concern.

A Defense spokesperson added that the contracts had been fast-tracked “due to the urgent and compelling need” for antigen tests. Defense obtained “approval from the Assistant Secretary of the Army for Acquisition, Logistics, & Technology to contract without providing for full and open competition.”

KHN separately searched for the contracts on the sam.gov website during a phone call with a government representative who assisted with the search. During an extended phone session, the representative called in a supervisor. Neither could locate the contracts, which are updated twice a week. The representative wondered whether the numbers listed in the Defense press release were wrong and offered: “You might want to double-check that.”

On Jan. 25, Defense spokesperson Maxwell, in an email, said that the Army Contracting Command “is working to prepare these contracts for public release and part of that includes proactively readying the contracts for the FOIA redaction.” Three days later, she sent an email stating that “under the limited competition authority … DOD was not required to make the Request for Proposal (RFP) available to the public.”

Maxwell did not respond when KHN pointed out that the contracting provision she cited does not prohibit the release of such information. In a Feb. 2 email, Maxwell said “we have nothing further to provide at this time.”

On sam.gov, the covid spreadsheets include a disclaimer that “due to the tempo of operations” in the pandemic response, the database shows only “a portion of the work that has been awarded to date.”

In other words, it could not vouch for the timeliness or accuracy of its own database.

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In California, which has a strong union tradition, Kaiser Permanente management misjudged workplace tensions during the covid-19 crisis and risked a walkout of thousands when union nurses balked at signing a four-year contract that would have slashed pay for new hires. In Colorado, Pennsylvania, North Carolina and Massachusetts, nurses have been embroiled in union battles over staffing and work conditions.

As deadly coronavirus cases spiked this year, daily pressures intensified on hospital floors. Some nurses retired; some became travel nurses, hired by agencies that advertised more than double, even triple, the day rates for intensive care unit, telemetry and emergency room nurses. Others gave up their jobs to avoid possibly carrying the covid virus home to their families.

“Things had gotten particularly stark for nurses,” said Rebecca Kolins Givan, an associate professor of labor studies at Rutgers University.

‘They Can Make More at McDonald’s’

It was so grim in Pittsburgh that registered nurses at West Penn Hospital, part of the Allegheny Health Network, voted this year to authorize a strike — less than a year after they unionized with SEIU Healthcare Pennsylvania. Chief among their complaints: The hospital system had balked at improving staff ratios even as it offered bonuses, up to $15,000 for some, to hire registered nurses to fill vacancies.

Kathleen Jae, a member of the bargaining team that reached a pact without a work stoppage, said nurses wanted management to work harder to retain veteran staff members: “We had to face the fact that nurses are retiring, nurses are leaving the bedside out of frustration, and, in certain instances this year, nurses had more patients than they felt comfortable taking care of.”

Allegheny Health Network said the first-ever pact with RNs at West Penn provides “competitive wages and benefits” to help it “recruit and retain talented, experienced nurses.”

Liz Soriano-Clark, a teacher-turned-nurse on the bargaining team, said the pandemic had made workers across the health sector more careful and choosier about what jobs they’ll take.

“There’s a nursing shortage and a shortage of nursing instructors, nationwide. They’ve seen aides leave. They’ve seen cleaners leave,” Soriano-Clark said. “Why is that? Because they can make more at McDonald’s and not have to clean up vomit.”

In September, the alerted the Biden administration to an “unsustainable nurse staffing shortage facing our country” in a . The ANA said a “crisis-level human resource shortage” was evident: Mississippi had 2,000 fewer nurses than it did at the beginning of 2021. Tennessee called on its National Guard to reinforce hospital staffs. Texas was recruiting 2,500 nurses from outside the state.

Union membership among U.S. nurses has inched up over the past 15 years and held steady, , for five years, according to , an academic website. But 2021, a year of union organizing and holdouts in such disparate workplaces as Starbucks cafes and John Deere tractor plants, might well be a turning point for essential workers in health care.

“If you ask nurses what they want,” said Givan, who interviewed dozens of nurses on health care workers, “they want working conditions where they can provide a high level of care. They don’t want appreciation that is lip service. They don’t want marketing campaigns. They don’t want shiny new buildings.”

Still, Givan noted, the health care sector has spent handsomely to fight unions.

After years of staff retention issues at Longmont United Hospital in Colorado, nurses are awaiting the results of a vote on whether to join National Nurses United, the largest union of registered nurses in the U.S.

Stephanie Chrisley, a registered nurse in the hospital’s ICU, said nurses are regularly caring for double the number of patients — often three to four “ventilated, sedated, critically ill patients.”

She and others protested outside the hospital in early December. They said the company that runs the hospital, Centura Health, this year had employed aggressive union-busting tactics, including disputing a handful of votes, which dragged out the union election for about five months. In another instance, her colleague Kris Kloster said, Centura, , issued company-wide emails announcing raises and retention bonuses for everyone except nurses at her hospital.

“Where there should have been newly hired nurses, there were anti-union consultants roaming around the hospital,” Chrisley said. Since July, she added, the hospital has lost nearly 80 RNs, “nearly a third of our nursing staff.” Longmont United Hospital Interim CEO Kristi Olson said in a statement that the hospital “will remain open and fully operational” and that “we are committed to making sure that all voices were heard” in the union election.

Organizing can take a long time, Givan said, pointing to tense labor negotiations in Massachusetts, North Carolina and Pennsylvania. “But when there is a crisis — what we call a hot shop — you can get workers to organize quite quickly.” Nurses represented by the Massachusetts Nurses Association walked off the job March 8 in Worcester. A chance to break the bitter impasse collapsed when management, Tenet Healthcare, refused to allow some nurses to return to their original jobs. In North Carolina, registered nurses at Mission Hospital in Asheville ratified a contract with the HCA management that locked in 17% raises over three years and set up a committee to review patient care conditions.

A recent poll by Gallup, the global analytics firm, found that the share of Americans who say they approved of unions was at 68%, its since 1965.

Sal Rosselli, president of the National Union of Healthcare Workers, said that in the past year “there has just been an explosion of leads,” queries from health workers exploring how to unionize.

Rosselli, whose organization represents about 15,000 health workers, said the pandemic exposed practices that had long antagonized employees. Too many hospitals scrambled for masks, gloves and gowns, he said, and front-line workers were on round-the-clock schedules and facing ghastly daily deaths. “They weren’t keeping their employees and their patients safe,” Rosselli said, “and all because these systems were focused on profit over anything else. That has been coming on for a long, long time.”

Registered nursing is among the U.S. occupations expected to experience the greatest levels of job growth in the next decade, according to the Bureau of Labor Statistics’ . Also among the are nurse practitioners, home health care aides and assistants. Shortages of RNs and other health care workers are expected to be the most intense in the South and West.

Some of the most powerful nursing unions in the nation operate out of California, representing employees in Western states. “The nurses in California have the hours they have, the care they have, the protections they have because of the union,” said Soriano-Clark, who has worked at hospitals in California and Pennsylvania.

Ready to Picket in a Pandemic

Douglas Wong, a physician assistant, never imagined hoisting a “strike” sign outside Riverside Medical Center. But that nearly happened after a sobering breakdown in talks between Kaiser Permanente and a top nurses union at the facility, part of the KP system. Nurses, pharmacists and operations staffers are among the insurers’ 160,000-plus unionized employees, according to KP spokesperson Marc Brown.

The California-based health system giant tried to force a two-tier pay schedule that would have cut wages for new nurses by 26%. Wong and thousands of allies — many who dryly noted they had been heralded as “heroes” in the covid crisis — prepared to picket in the middle of a pandemic. Kaiser Permanente’s demands crumbled when dozens of affiliated unions threatened one-day sympathy strikes.

The tiered-pay demand and an attempt to lower wages in some markets were dropped. Staffing ratios were adjusted to ease safety concerns. Wong said that, despite the pact, the bruising negotiations “felt like a betrayal.”

“Make no mistake: This was an enormous win for labor, especially pushing back on the two-tier. At the end of the day, they pulled back. And we made huge strides toward improvement in our staffing,” said Wong, a six-year KP employee and an official with the United Nurses Associations of California/Union of Health Care Professionals.

The negotiations were a marked shift for Kaiser Permanente, which for most of three decades has relied on a labor-management partnership with its unions, emphasizing cooperative decision-making and robust discussions. Talks were held with teams, set around circular tables, hashing out concerns. KP was known for much of the past decade as a market leader in wages and quality of care, and the labor-management partnership was received by academics and labor experts as an innovative, successful approach to managing a workforce.

The health system recently hired new top executives, and, to the surprise of the unions, Kaiser Permanente used negotiations this year to offer the two-tier pay regimen, a tactic used by auto- and steel-makers during economic downturns in the 1980s. The union negotiators noted this: The health care giant’s management wanted to scale back wages after notching $6.8 billion in net revenue from 2018 to 2020.

On Thursday, workers voted to ratify a four-year contract with KP. The company declined to comment for this article. , Christian Meisner, KP’s chief human resources officer, said: “This contract reflects our deep appreciation for the extraordinary commitment and dedication of our employees” during the pandemic. “We look forward to working together with our labor partners,” he said, to “further our mission of providing high-quality, affordable care.”

that nurses’ pay was sweetened in 2021 by thousands of dollars in raises — handed out without union wrangling — as hospitals competed for workers. Premier, a health care consultancy hired by the Journal, analyzed 60,000 registered nurses’ salaries and found that average annual pay, not including overtime or bonuses, grew about 4% in the first nine months of the year, to more than $81,000. That compares with a 2.6% rise in 2019, according to federal data.

Raises don’t necessarily mean retention.

“There always seems to be a shortage of nurses,” said professor Paul Clark, who is a former director of Penn State University’s School of Labor and Employment Relations and has studied nursing and labor organizing. “But it’s important to realize there’s not a shortage of RNs. There’s a shortage of RNs willing to work under the conditions they’ve been asked to work.”

Aya Healthcare, a national travel nurse provider, has found that the pandemic aggravated historical understaffing at hospitals, spokesperson Lisa Park said in an email. “There were over 100,000 vacancies at the start of the pandemic. And now, that number has increased to over 195,000,” Park said. Travel nurses account for fewer than 2% of the nursing workforce, she added, but “with the increase in permanent vacancies due to burnout/resignations, the demand for temporary healthcare workers has increased.”

David Zonderman, a professor of labor history at North Carolina State University, noted that nurses unions have grown more political and more outspoken — in Washington, D.C., and their home states. Nurses on the hospital floor lived through a crisis — fearing for their lives amid shortages of protective equipment — much like the trials of American workers in the mining and manufacturing industries in decades past.

“This may sound weird,” Zonderman said, “but nurses are a little like coal miners. They tend to help each other. They are watching each other’s back. They have solidarity.”

“And,” he said, “if you treat people badly long enough, they finally say, ‘I’m done.’”

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Black researchers, medical professionals and allies knew that people of color, even before covid, experienced bias in public health policy. As the deadly virus emerged, data analysts from Carnegie Mellon and the University of Pittsburgh, foundation directors, epidemiologists and others pooled their talents to configure databases from unwieldy state data to chart covid cases.

Their work documented yet another life-threatening disparity between white and Black Pittsburgh: People of color were at higher risk of catching the deadly virus and at higher risk of severe disease and death from that infection.

More than 100 weeks after advocates began pinging and ringing one another to warn of the virus’ spread, these volunteers are the backbone of the , a grassroots collaboration that scrapes government data and shares community health intel.

About a dozen members of its data team of 60 meet twice weekly to study hospitalization rates and employment statistics. Social media advisers turned health equity into a buzzy online effort, with videos and weekly Facebook town halls, to encourage vaccinations. Local ministries are consulted, and volunteers take surveys at pop-up clinics, sponsored by other groups, at barbershops and hair salons. Elected lawmakers seek its counsel.

“We came together because we were concerned about saving lives,” said Tiffany Gary-Webb, associate dean for diversity and inclusion at the University of Pittsburgh, who oversees the data effort. “It evolved, with us realizing we can do more than address covid.”

Covid ravaged communities across the United States — , including Colin Powell, the first Black secretary of state and a decorated Army general — and laid bare how marginalized populations lose out in the scrum for public health dollars and specific populations were left vulnerable.

Months before the pandemic began, the Rev. Ricky Burgess led the Pittsburgh City Council to declare racism a public health crisis.

“Institutional racism is for real,” the councilman said in a recent interview. “You are talking about generational disproportional investment and generational disproportional treatment. And it impacts all that you see.”

The covid pandemic proved how structural inequities have been missed or ignored, Burgess said.

“I’ve lost friends, family and a lot of church members. My son had covid. For me it’s personal,” he said. “I knew immediately it would have a disproportionate effect.”

In 2020, covid , according to the National Center for Health Statistics. Black and Hispanic people fared the worst, losing more than three years in life expectancy. White people saw a 1.2-year drop.

Using county data, the Black Equity researchers found a sobering racial gap in the Pittsburgh area: Black residents of Allegheny County saw disproportionate hospitalization rates — and were more likely to land in the ICU or on a — in the pandemic. Weekly hospitalization rates were higher during surges of infection in April, July and December 2020 and again in March and October 2021. Deaths, too, were disproportionate but fluctuated after December 2020.

For much of the pandemic, death rates were higher for African Americans than for other racial groups, the coalition said.

‘It’s All a Shade of Bad’

Kellie Ware has long considered health inequity a deadly problem. She graduated from Pittsburgh public schools, left for law school in Boston, and months before covid began its global assault she was working in her hometown mayor’s office as an equity and diversity policy analyst.

Ware was at her desk in late 2019 when her phone started ringing. A damning report, compiled by university sociologists and the city’s gender commission, had yet again detailed glaring disparities.

The blandly titled report, “Pittsburgh’s Inequality Across Gender and Race,” jolted emotions in the city of 303,000 people — and underscored how health disparities track with income.

Among the findings: Black people in Pittsburgh earned far less than their white neighbors and suffered far worse from disease. For every dollar white men earned, , Black women earned 54 cents, making them five times as likely to live in poverty as white men.

With notably higher cardiovascular disease and cancer rates, Black residents’ life expectancy was about eight years less than white Pittsburghers’.

The report sparked a furor, which Ware met with perspective shaped over years away from the former steel town. “The report was factual,” Ware said, “but I know this: There’s not a ton of places where it’s great to be a Black woman. Those earnings? It’s 54 cents to a dollar for women in Pittsburgh. It’s 68 cents nationally. It’s all a shade of bad.”

The first signs of the pandemic supercharged Ware and others. As covid devastated New York in March 2020, Karen Abrams, a program officer at the Heinz Endowments, a foundation in Pittsburgh that spends $70 million a year on community programs, began connecting the dots in texts and calls with nonprofits, business owners and university researchers.

Covid spread quickly in dense multi-generational households and in Black neighborhoods in Chicago, Washington, New Orleans and Detroit. Abrams was among the advocates in Pennsylvania who watched county and state health systems race to prepare and who feared that Black residents would be underserved.

In Philadelphia, early on in the pandemic, volunteer doctors in mobile units began distributing protective equipment and covid tests in Black neighborhoods. In Pittsburgh, Abrams asked tech-minded allies to document the reality of covid infection in Pittsburgh. “We intuitively knew what was happening,” she said. “But without that data, we couldn’t target our attention and know who needed the help most.”

Within days, volunteers were on daylong rounds of video calls and appealing to county and state bureaucrats for more race-based statistics to bolster their research.

Fred Brown, president of the nonprofit Forbes Funds, and Mark Lewis, who heads the Poise Foundation, were stalwarts of a “huddle,” a core of longtime advocates who eventually founded the coalition.

Brown emphasized pulling labor statistics to show that the essential workers keeping the city running — among them nursing homes aides and home care staff — were overwhelmingly Black or Latino.

Mapping covid testing centers and analyzing data proved sobering, he said. It turned out that the people most likely to be tested lived in Pittsburgh’s predominately white neighborhoods. Largely employed in tech, academia and finance, they could easily adapt to lockdowns. They had round-the-clock internet at home and could afford food deliveries to limit the chance of infection. Later, they could access vaccines quicker.

“The communities that had the most tests were the affluent ones,” Brown said. And those with the fewest “were the most resilient, the people who had to go out there and work.”

Lewis, a certified public accountant who spent years as a corporate auditor, focused on standards. County and state health professionals worked mightily to control the spread of covid but didn’t always gather data to ensure fairness in distribution, he said. “We realized that, as testing was done, it was not being recorded by race,” Lewis said. “Why? A lot of the issue was — at the state and the local level — there was no requirement to collect it.”

Gary-Webb said researchers had a sense of where the inequities would be found because they knew the neighborhoods. They first layered in percentages of Black families in poverty as well as data on the locations of federally qualified health centers to advise health authorities on where and when to increase testing.

University and nonprofit researchers found anomalies as they worked. For instance, race was noted on some testing data, with patients designated as Black, white or, inexplicably, unknown. The “unknowns” were a significant percentage. So researchers began layering additional census, labor and ZIP code data, to identify neighborhoods, even streets, at risk.

The ZIP code data took months to shake loose from state databases, largely because government software was slow in the fast-moving pandemic and government data was not updated regularly or formatted in ways that could be easily shared.

Their efforts paid off: The group was able to winnow down Allegheny County records that omit race to 12% of positive covid cases; 37% of statewide records are missing race details, .

Robert Gradeck, who runs the Western Pennsylvania Regional Data Center, a data collaborative managed by the University of Pittsburgh, said covid should play a lasting role in improving public health reporting. “We kept thinking: What can we learn from this?” Gradeck said. “It’s not that you can’t answer questions. But you can answer only part of them.”

Among the top recommendations to health authorities: adopt software practices to ensure that race and other demographic data must be entered into electronic records. And then refine how to share data among counties, states, research institutions and the public.

The coalition attracted support in monthly calls with state Health Secretary Rachel Levine, recently sworn in as a four-star admiral in charge of the U.S. Public Health Service Commissioned Corps, which responds to health crises on behalf of the federal government.

“I thought what they did was critically important,” Levine said, noting that officials recognized the coalition’s research as revelatory. With “a diverse group of professionals, they were able to use and collect data in a very effective way.”

Their early research found the covid rate among Black people in Allegheny County, which encompasses Pittsburgh, was three times the rate of white people. Hospitalizations among Black people have been as high as seven times the rate of whites, according to ,” the coalition’s 2021 report.

A Vaccine Clinic Campaign Stop

Ed Gainey, a state legislator from Pittsburgh, was among the first politicians to say African Americans in his hometown were missing out on covid protections. Last month, Gainey was elected the city’s first Black mayor, after winning a primary, within months of the murder of George Floyd, that pointed to inequities in health care and policing.

A Democrat who worked for two Pittsburgh mayors, Gainey admits he and other Black elected officials were somewhat ill-equipped in the first weeks of the pandemic.

“I fought hard to get the vaccine into the community last year, but I really didn’t know the language — the health language — to be able to get it,” Gainey said during an interview at a pop-up vaccine clinic in the city.

Vaccinations have risen because of community efforts, he said, but children are still a source of worry. Gainey, who grew up in a low-income housing complex, said he understands when some youngsters shrug when asked about covid risks. “But I will tell you I know this: If you can make a kid believe in Santa Claus, you can make them believe in the vaccine. And you know, I understand some of the young kids’ reluctance. I didn’t grow up going to the doctor regularly either,” he said. “I came from the same kind of environment.”

As the 2019 report made clear, many of the benefits of Pittsburgh’s tech-based economy — a vaunted “ed-and-meds” renewal against the industrial decline of the 1980s — still was largely bypassing African Americans.

The first year of covid was an iterative process of trying to stay ahead of the virus. Gary-Webb, who earned a doctorate from Johns Hopkins’ public health school, said it was also a time for Black residents to be heard about what they knew and saw in their neighborhoods.

The coalition, sustained by thousands of volunteer hours, attracted some funding earlier this year, notably for outreach and to pay for running datasets. Last month, the Poise Foundation was approved for a three-year, $6.99 million grant, federal money to be administered by the state health department to support an array of health partnerships in the region and, notably, to improve covid vaccine uptake in ZIP code areas the Black Equity Coalition identified as vulnerable. Among its goals: demographic messaging, data analysis on covid testing and education outreach in dozens of counties.

Gary-Webb counts herself among a group of “boomerang” Pittsburghers who have lived other places — in her case, Baltimore, New York and Philadelphia — and covid has helped them recalibrate how Black residents can participate in public health.

As she put it: “The health planners were saying, ‘Help us get out the message.’ We said, ‘No, we are not just getting out the message. We want to be talking about equity at the same time.’”

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Although residents were eager for the shots this year, he’s counted only about 3 in 4 workers vaccinated at any one time. The excuses, among its staff of roughly 100, had a familiar ring: Because covid vaccines were authorized only for emergency use, some staffers worried about safety. Convenience mattered. In winter, shots were administered at work through a federal rollout. By spring, though, workers had to sign up online through a state program — a time-sucking task.

ManorCare urges every worker to be immunized against covid but turnover has vexed that effort. Managers at ProMedica, a nonprofit health system that operates ManorCare and senior care facilities in 26 states, faced a workforce conundrum familiar to all manner of providers during the pandemic: how to persuade essential workers to get vaccinated — and in a way that didn’t drive them away. Raises and bonuses, costing millions of dollars, did not move the needle to 100%.

Animus toward the vaccine created turmoil for some providers. Dr. Eric Berger, a pediatrician in Philadelphia who opened his practice more than a dozen years ago, enforced mandatory shots in May and saw six of his 47 staff members walk out. Berger said he worked for months to educate resistant workers. In April, he learned that several, women in their 20s and 30s, had attended a private karaoke party. Within days, four staffers were infected with covid.

Berger, who had seen in-office costs for protective equipment soar, then set a deadline for shots. He looks back with steely resolve over the last-minute “I quit” texts he received — and the hassle of finding a new receptionist and billing and medical assistants.

“Fortunately, we had some wonderful people who put in extra time,” he said. “It’s been stressful, but I think we did the right thing.”

Brittany Kissling, 33 and a mother of four, was one of the hesitant workers at Berger’s practice who decided — largely for financial reasons — to get vaccinated. The clinic manager couldn’t afford to lose her job. But she said she was nervous and that most of the workers who left recoiled at being told vaccinations were not negotiable. “I was a no-show my first time,” Kissling said about her first vaccine appointment. “I was scared. There were a lot of unknowns.”

But Kissling said Berger’s practice has spent “thousands and thousands and thousands of dollars” on masks and even paid workers for five days a week when they worked only two during the pandemic’s worst months. She said she understood how and why the karaoke episode prompted a mandate. “I get it from the business side,” said Kissling, about the requirement. “I do think it’s fair. I do think it is tough.”

Berger saw no other choice. “Vaccines are fundamental to our practices. That’s what we do,” he said. “Some got it in their heads that it could cause infertility; some had other reasons. It’s frustrating … [and] I don’t think it was political. If anything, most of these people are apolitical.”

At ManorCare, managers decided money could make a difference. Bonuses — up to $200 per employee — were added as an incentive, which in Pennsylvania alone cost ProMedica $3 million, said Luke Pile, vice president and general manager for ProMedica Senior Care skilled nursing centers.

Richmond, at ManorCare, said the resident council has been pivotal in keeping the focus on the risks of covid to the elderly — and no one there needs a reminder about the stress of the past year. According to Medicare records, the facility had 107 cases of covid among staffers and residents — and 14 deaths among residents beginning in March 2020.

“I constantly wear a mask. Not out of fear, but I don’t want to spread it by being asymptomatic,” Richmond said. “I tell people here: Whatever is happening in the community, that is what is happening in the community. But we are a health care institution and caring for the elderly. We need to be constantly vigilant.”

Richmond and other administrators admit it can be a struggle to understand why some health workers are unmoved by the science.

“Everything has been so polarized this past year. I don’t know that there is a single reason that individuals don’t get the vaccine,” Pile said. “In trying to educate people, personally and professionally, we talk about the history and science. Unfortunately, individual opinions don’t always align with that.”

Mandating vaccines is a step that ProMedica has yet to take, even as more businesses, universities and health care providers do so. A few long-term care operators, such as Atria Senior Living, operating in the United and Canada, and Juniper Communities, Some have been met with lawsuits from workers aligned with conservative groups. filed suit to dispute and derail the hospital system’s compulsory vaccination. A judge dismissed the challenge this month on the grounds that the hospital’s requirement or public policy.

Last week, the U.S. Labor Department issued a temporary emergency standard for health care workers, saying they face “grave danger” in the workplace when “less than 100 percent of the workforce is fully vaccinated.”

In Pennsylvania, whose population ranks among the oldest according to 2019 census data, statistical snapshots published in April underscored the need for vigilance. Two state agencies overseeing skilled nursing care and personal care homes reported that only half of their workers were vaccinated. Covid was notably devastating to long-term care facilities nationwide in 2020; some of Pennsylvania’s deadliest outbreaks were reported by local media in places shown later to have low staff vaccination rates.

A survey by the , begun in March 2020 with over 700,000 Facebook respondents ages 18 to 64, recently was analyzed by researchers from Carnegie Mellon and the University of Pittsburgh, who found that health care workers were largely leading the vaccine uptake. But there were notable differences over the winter among people working, side by side, in health care settings.

Pharmacists, physicians and registered nurses were the least hesitant to get vaccinated. Home health care aides, EMTs and nursing assistants showed the highest hesitancy among front-line health workers. Overall hesitancy across professions decreased from January to March 2021, as much as 5 percentage points, as vaccinations expanded,

University of Pittsburgh researcher Wendy King said people indicated they were receptive to the vaccine if they were familiar with its science. Educators, overall, displayed the least hesitancy; workers in construction, mining and oil/gas extraction showed the greatest. Half of those who were hesitant cited possible side effects — a fear that could be eased by education, King said. A third among the hesitant gave other reasons: They didn’t believe they needed the vaccine. They didn’t trust the government. Or they didn’t trust the covid-19 vaccines.

“We expected hesitancy to vary by group, but how much they varied was surprising,” King said. “These were not people who were anti-vaccine, but they were worried about the effect of the vaccine.”

Still, King said the percentage who didn’t trust the government was alarming. “If somebody doesn’t understand the vaccine, that’s one thing. If you don’t trust that government, that is a much more difficult issue to address.”

That may change as two prominent vaccine makers approach full approval by the Food and Drug Administration. Pfizer and BioNTech applied for approval in May; Moderna applied in early June. A recent nearly a third of unvaccinated adults said they would be more likely to get a vaccine once it was fully approved by the FDA.

At ProMedica, Pile described a multipronged approach in such states as Florida and Pennsylvania, home to large elderly populations. On-site counseling in groups, with familiar doctors and staff, helped persuade some who were reluctant, he said. Short videos on why and how the vaccine worked were readied. ProMedica senior medical staff flew to Florida to advise as the National Guard arrived at its facility in Pinellas County, the health system’s first to receive the vaccine.

Falon Blessing, a nurse, manages other practitioners at ManorCare Health Services Center throughout the Tampa region. She recounted how employees had wondered aloud how such newly created vaccines could be safe.

“I think people at first just wanted to know: I’m not going to grow a tail in five years,” she said. “But then there was a momentum. It wasn’t so much ‘Are you going to get vaccinated?’ but rather ‘Of course, I’m going to get vaccinated.’”

During three vaccinations sessions ended in January, though, the facility reached about the same rate as Pennsylvania overall — about 76% of its workers were vaccinated. That rate has fallen to 62% this month because of attrition. An education effort continues, a ProMedica spokesperson said.

“My takeaway was it mattered to have one-on-one discussions,” Pile said. “If you talk to 10 people, why they wouldn’t get the vaccine, you’d get 10 different reasons.”

“And there were political opinions — what they heard on Facebook — and then they’d say: I want to see how it goes,” he said.

The questions and qualms about vaccines came at the end of a deeply distressing pandemic year for health care workers, and facilities are now finding fewer applicants for essential care.

By spring, ProMedica had 1,500 job postings in Pennsylvania alone, compared with a typical 400 openings. Pile said ProMedica raised wages in dozens of locations, though he declined to provide wage ranges or rates. It spent $4.5 million in Pennsylvania from March through last week — and still supplemented its workforce across the U.S. by hiring through staffing agencies.

“In 2020, we spent over $32 million on staffing agencies,” he said. Through this spring, ProMedica was on course to spend $66 million on staffing agencies for 2021, said Pile, who has worked in the care sector for 18 years.

“I have less employees than ever before,” he said. “I have never seen anything like it.”

The Pennsylvania Health Care Association, an advocacy group, surveyed members in April to better understand vaccine reluctance. Zachary Shamberg, the group’s president, said it found that defining “hesitancy is not that simple.”

Shamberg said PHCA focused on why people had yet to be immunized and the characteristics of the workforce were telling: About 92% of all its workers are women; 65% are between ages 16 and 44. Among them, some worried early on about possible infertility from the new vaccine, he said, and some wanted to wait for the single-shot Johnson & Johnson vaccine. Others were sick with covid and were advised, once recovered, not to get a vaccine for 90 days.

Shamberg was also critical of the state data. Those surveys, taken in March and released in April, reflected a time when the vaccine was new to many people.

Pennsylvania, a battleground state in recent presidential elections, remains politically charged, and Shamberg noted that politics likely plays a role among holdouts. In recent months, PHCA enlisted churches and doctors’ consortiums to change minds. Keeping residents and workers safe should be a priority in a state that, in a few years, will face a “silver tsunami” of residents in their 80s, Shamberg said.

In recent weeks, there has been clear momentum among the general population for shots in Pennsylvania. The state now ranks among the top 10 states in the nation to administer first doses of vaccines, according to data from the Centers for Disease Control and Prevention.

“Pennsylvania is a big and diverse state,” Shamberg said. “And it’s interesting why some of our staff in western Pennsylvania were hesitant versus workers in the city of Philadelphia.”

“The vast majority of workers in Philadelphia are female and, among them, minority populations that have some inherent distrust based on historical experience. Then you go out west and you have a more conservative viewpoint — and a distrust of government today and a distrust of government vaccine.”

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But Baylor not only weathered the crisis, it thrived. By the end of 2020, Baylor had accumulated an $815 million surplus, $20 million more than it had in 2019, creating a 7.5% operating margin that would be the envy of most other hospitals in the flushest of eras, a KHN examination of financial statements shows.

Like Baylor, some of the nation’s richest hospitals and health systems recorded hundreds of millions of dollars in surpluses after accepting the lion’s share of the federal health care bailout grants, their records show. Those included the Mayo Clinic, Pittsburgh’s UPMC and NYU Langone Health. But poorer hospitals — many serving rural and minority populations — got a tinier slice of the pie and limped through the year with deficits, downgrades of their bond ratings and bleak fiscal futures.

“A lot of the funding helped the wealthy hospitals at a time, especially in New York, when safety-net hospitals were hemorrhaging,” said Colleen Grogan, a health policy professor at the University of Chicago. “We could have tailored it to hospitals we knew were really suffering and taking on a disproportionate amount of the burden.”

In Baylor’s case, the system, which runs Baylor University Medical Center in Dallas and 51 other hospitals, said it spent $257 million last year on pandemic-related costs, including protective clothing for employees and patients and creating isolation rooms. Baylor has $197 million in unspent federal relief funds to use this year to cover costs of battling the virus and refrigerating vaccines, it said.

“Our covid-19-related expenses and lost revenue continue to exceed the funding we have received to date,” Baylor said in a statement to KHN.

Other well-heeled hospitals or large systems faced bigger problems. Both NewYork-Presbyterian Hospital and CommonSpirit Health, a 140-hospital Catholic system that operates in 21 states, lost money despite federal grants in the vicinity of a billion dollars each. A few systems, including the for-profit chain HCA Healthcare, returned federal funds when they saw they had skirted their worst-case scenarios. But most spent the aid and held onto any leftover money and new grants to cover anticipated pandemic costs this year because hospital executives fear more case spikes.

Much of the lopsided distribution was caused by the way the Department of Health and Human Services based the allotment of the initial bailout funds on hospitals’ past revenue. That with well-off patients who have private health plans over those that rely on lower-paying government insurance, which is what many poor people use.

HHS distribution formulas did not take into account which hospitals had enough assets to survive.

Baylor, for instance, began 2020 with $5.4 billion in cash and investments, enough to keep it running for 238 days, the financial disclosures show.

Hospitals that ended the year with profits were entitled to federal aid because of the Congress and HHS set in how hospitals could classify their pandemic costs.

Last fall, when HHS attempted to limit how much aid hospitals could keep based on their profits — so the money could be redirected to struggling hospitals — the effort was swiftly beaten back by the industry and Congress. HHS officials declined requests for an interview but noted in a statement that Congress had ordered it to revert to its “broader definition of permissible use of PRF funds.”

“The Biden Administration continues to review programs and policies including considerations for the unallocated funding under the PRF program and the $8.5 billion recently appropriated under the recently signed American Rescue Plan Act,” the statement said.

Avoiding a Drawdown of Reserves

The were initiated last spring to help health care providers ride out a once-in-a-century public health calamity. The money designated to hospitals and other health care providers from the Coronavirus Aid, Relief, and Economic Security (CARES) Act and subsequent legislation totaled .

It was intended to offset all costs of treating infected patients, including purchasing ventilators, masks, gowns and other personal protective equipment. Congress further authorized hospitals to use the money to compensate for a drop in revenue when they shut down elective surgeries and non-emergency treatments to prepare for the anticipated deluge of covid-19 patients.

The money, referred to as the Provider Relief Fund, helped many poorer hospitals avert cash crunches, layoffs and bond rating downgrades. A  found that the median hospital gain during 2020 would have been 0.3% without the federal support. With it, half of hospitals posted gains of 2.7% or more, below the 2019 median margin of 3.1%, according to the firm, which also produces for the American Hospital Association.

In February, the association to replenish the nearly empty relief fund, saying, “hospitals have never experienced such a widespread, national health crisis.”

Some hospitals’ finances deteriorated significantly during the pandemic. From the end of March through December, the rating agency Moody’s downgraded 28 hospitals, primarily because of weaknesses such as higher debt or more competition, said Lisa Goldstein, associate managing director at Moody’s.

Others suffered worse fates, like Williamson Memorial Hospital, which shut down last April. The hospital, in West Virginia’s coal country, had been out of bankruptcy protection, but “unfortunately, the decline in volumes experienced from the current pandemic were to[o] sudden and severe for us to sustain operations,” its on Facebook.

Conversely, many prosperous health systems emerged unscathed from the moratoriums of last spring, often due to the federal aid. “It gave them an ability to not have to draw down on their reserves to make up for the loss in revenue,” said Suzie Desai, a senior director at S&P Global Ratings.

Systems saw patient visits return to near normal as the year wore on. In some cases, business in the latter half of 2020 was even higher than in the same period in 2019 because of pent-up demand for treatments postponed from the spring, financial records show.

“We saw volumes spring back” in every area except emergency room visits, said Kevin Holloran, a senior director at Fitch Ratings. Major hospital systems also reported that cases tended to be more complex than normal, leading to higher insurance payments.

UPMC in bailout funds while collecting $2.5 billion more in revenue in 2020 than in 2019. The nonprofit system ended the year with an $836 million operating surplus — providing a 3.6% margin that was triple the prior year’s — in part due to the growth of the health insurance plan the system owns.

Other hospitals that sold insurance, including Baylor, persevered because the cause of their financial troubles — fewer surgeries and doctors’ visits — meant the health plans paid fewer claims.

UPMC’s strong finances went unmentioned in a recent fundraising pitch announcing the launch of its “Health Care Heroes” campaign. “During the past year, health care workers have carried the weight of the world on their shoulders, risking their own health and safety to ensure ours as we navigated the covid-19 pandemic,” the email said. “Now it’s our turn to recognize their hard work. … By making a donation, you will help provide training, recognition, and support for our staff initiatives.”

Donald Yealy, a senior vice president of UPMC and the chief medical officer of UPMC Health Services, said the fundraising appeal was a way to allow people in the community to show their appreciation.

“The intent of the request and the letter were clear. People are free to ignore or to have an opinion. I don’t begrudge that at all. I respect people having a different opinion,” he said.

Hospitals can hold on to unspent relief funds until the end of July to defray any further pandemic-related costs. After that, any unspent money must be returned to the U.S. Treasury. UPMC retains $80 million in unspent relief funds, which the health system said it expects to use. “We’re still in the process of incurring significant costs related to covid,” said Edward Karlovich, UPMC executive vice president and chief financial officer.

‘A Shot in the Arm’ Sometimes Unneeded

In April 2020, the Mayo Clinic in Rochester, Minnesota, in lost revenue because of the pandemic. Instead, Mayo, which received $338 million in federal relief funds, with revenue that was $202 million higher than in 2019. Mayo recorded a $728 million surplus, which equaled a 5.2% margin.

“It gave us a shot in the arm when we needed it,” said Dennis Dahlen, Mayo’s chief financial officer. Later, when it seemed likely Mayo would run a surplus, executives debated what to do with the federal funds.

“Honestly, we considered dropping the margin,” Dahlen said. After weighing their options, Mayo “landed in a middle-of-the-road decision” by returning $156 million to the federal government.

“We considered it with what everyone else was doing … and we thought about what was good for society,” Dahlen said. “’Nonprofit’ doesn’t really mean no profit. It means tax-exempt. We still have to create earnings so we can reinvest in ourselves.”

Mayo $14 billion in investments, $3 billion more than it had in 2019, a 29% increase.

The funds were, indeed, a lifesaver for some. Marvin O’Quinn, president and chief operating officer of CommonSpirit Health, said “there was never a thought of turning back the money.”

Despite receiving $1.3 billion in relief funds, CommonSpirit, based in Chicago, ended last year with a $75 million deficit, which translated to a 0.2% loss.

“We have been set back by a year,” O’Quinn said. “All the things we wanted to do — to renovate, to building new facilities, to expand our service — we’ve had to slow up to get through the crisis.”

Scattershot Relief

The in relief funds “was sent out indiscriminately as a life support,” said Ge Bai, an associate professor at Johns Hopkins Bloomberg School of Public Health. HHS tried . It sent $22 billion to 1,090 hospitals with large numbers of covid patients. It sprinkled an additional $16 billion among hospitals that serve poor populations, Native American tribes, people in rural areas and children.

But even with the targeted aid, recipients included well-endowed academic medical centers and major urban hospitals. Only $14 billion took profitability into consideration, HHS documents show. HHS restricted those payments to hospitals with 3% or lower profit margins.

Wealthy hospitals also benefited because HHS used a broad definition of lost revenue. If a hospital earned less than in the year before, or simply less revenue than it had budgeted for, it could chalk up that difference to the pandemic and apply the relief funds to it. The implications garnered little attention at the time as they were overshadowed by the concerns about how HHS was doling out the money rather than how it could be used.

In September, HHS to tighten its overall limits on how much money the hospitals could keep by basing it on the difference from the previous year’s net income rather than overall revenue — a number that in many cases would be much lower. The goal, , was to “prohibit most providers from using PRF [Provider Relief Fund] payments to become more profitable than they were pre-pandemic, to conserve resources to allocate to providers who were less profitable.”

The American Hospital Association that would punish hospitals that had behaved responsibly by cutting costs and be an “administrative and accounting disaster,” as many hospitals had already spent the grant money.

HHS a month later, citing “significant attention and opposition from many stakeholders and Members of Congress.” Not fully satisfied, Congress the rollback in a December law.

Some hospital executives attributed their surpluses to their aggressive cost-cutting measures.

NYU Langone Health, for instance, received $461 million in relief funds, which covered about a third of its pandemic-related losses, said Daniel Widawsky, chief financial officer. Another third of Langone’s losses was absorbed by the record-high financial performance in the months before the pandemic, he said, and prompt cost control addressed the rest.

Widawsky said that at the beginning of March Langone canceled travel, froze hiring, paused construction and stopped discretionary purchases. “The first three days in March, we locked down spending,” he said. “If they wanted to buy a pencil, they had to call me.” Langone ended its fiscal year in August with $208 million in net income, and recorded a $136 million surplus in the final quarter of 2020, or 5.5%. Earlier this year, two credit agencies on Langone from stable to positive.

Despite accepting $942 million in bailout funds, NewYork-Presbyterian Hospital had a $457 million operating deficit, a 7% loss, at the end of September. It was a sharp turn from September 2019, when the system recorded a $166 million surplus, a 2.5% gain.

The system, which declined to comment, has not yet released its financial metrics for the final three months of 2020, but Fitch it would remain in the red. Still, NewYork-Presbyterian remains fiscally solid: Its most disclosure reported $3.8 billion in cash and short-term investments, enough to keep operating for more than a year.

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