People were so eager to see Pence at the rally in Canton, Georgia, that parking spots were scarce and a long line of cars snaked through the parking lot of a community college. Some drivers jumped the curb and parked in the grass.

Hundreds of people, many unmasked, were given temperature checks before boarding large coach buses for a short ride to the rally site. The venue was a large, open space outside the conference center, but few attendees maintained physical distance

The runoff in Georgia was triggered when no candidate in either Senate race won more than 50% of the vote in the general election on Nov. 3.

In the midst of the coronavirus pandemic and with the fate of the Affordable Care Act in question, Republicans hope the two incumbents will win reelection, thus preserving their party’s 50-48 control of the Senate.

But if the two challengers, Raphael Warnock and Jon Ossoff, win their runoffs, Democrats will gain narrow control of the Senate, with Vice President-elect Kamala Harris serving as the designated tie-breaker.

Yana De Moraes came to the rally from another Atlanta suburb, Buford. She is uninsured and, after a recent hospital stay, said the high cost of medical care was weighing on her mind.

“We would like our health care costs lowered, so it could be more affordable,” she said, with a rueful laugh. “So you don’t get another heart attack while you’re getting a bill!”

De Moraes added she’d also like to see better price controls on prescription drugs to stop pharmaceutical companies from “robbing American people.”

Others on their way to the rally said they were looking for any kind of change, ideally one that minimizes government involvement in health care.

Barry Brown made the 40-mile drive from his home in Atlanta for the rally. He’s retired but too young to qualify for Medicare, so he has ACA insurance, which he affords with the help of a federal subsidy.

“It sort of works. It’s better than nothing,” Brown said. “I would like to see an improved health care situation. I don’t know what that will be, so maybe they’ll mention that today. I’m hoping so.”

But at the rally, Loeffler only briefly mentioned her , which focuses on reducing drug prices and giving people access to insurance options that cost less but offer fewer benefits.

When it was his turn to speak, Perdue didn’t talk much about health care either, though he did take a shot at Obamacare, which he’s voted multiple times to overturn.

“Remember a little thing called the Affordable Care Act? You think that was done bipartisan?” Perdue asked the crowd. “No! It was done with a supermajority! Can you imagine what they’re gonna do if they get control of the Senate?”

As the two Republicans have campaigned throughout the state, they have consistently stoked fears about what Democrats will do, and health care policy has not led their messaging.

Their Democratic challengers, however, have been all over health care in their own speeches.

Warnock opened his runoff campaign to unseat Loeffler with a modestly attended Nov. 12 event to health care. That’s also been a focus for Ossoff in his bid to win Perdue’s seat.

“This is why these Senate runoffs are so vital,” Ossoff explained at a small, physically distanced event in the shadow of the Georgia Capitol building in Atlanta on Nov. 10.

and support adding a to the Affordable Care Act. They also have emphasized the role Democrats will play in resurrecting key parts of the law if the U.S. Supreme Court decides to overturn it. The justices are set to make a ruling next year.

“If the Supreme Court strikes down the Affordable Care Act, it will be up to Congress to decide how to legislate such that preexisting conditions remain covered,” Ossoff said.

Voters like Janel Green, a Democrat, connect with that message. She’s from the nearby suburb of Decatur and is fighting breast cancer — for the second time. Green wondered whether her private health insurance might try to deny her coverage if the protections in the ACA disappear.

“I have to worry about whether or not next year in open enrollment that I won’t be discriminated against, that I won’t have limits that would then potentially end my life,” she said.

More than one-quarter of Georgians have preexisting conditions that could make it hard to get coverage if the ACA is struck down, according to an by KFF. (KHN is an editorially independent program of KFF.)

That possibility also drove Atlanta resident Herschel Jones to support the runoff. On a recent weekday morning, he dropped by an Ossoff campaign office to pick up a yard sign.

Jones, who has diabetes, is insured through the Veterans Health Administration. He said everyone deserves access to health care.

“It’s a main issue, because the Affordable Care Act benefits all those individuals who might have preexisting conditions,” Jones said.

One likely reason Ossoff and Warnock are running so much harder on health care than Perdue and Loeffler is because that strategy paid off for Democrats in the general election, said a health policy professor at Emory University.

President-elect Joe Biden can thank independent voters for his win in Georgia, Thorpe said, and they were drawn to him because of

“The threat of potentially losing health insurance in the midst of this pandemic turned out to be probably the major defining issue in the election,” Thorpe said.

Polling in the days leading up to the Nov. 3 election Democrats were motivated on the issues of health care and the coronavirus pandemic.

For Democrats to win Georgia’s Senate seats, Thorpe said, they’ll need to stay focused on those issues. That emphasis could help them attract additional moderate voters, as well as entice those in the party base to cast ballots a second time.

“The health care issue is the probably main motivating factor that’s gonna get Democrats and independents to the polls,” he said.

Still, no Democrat has ever won a statewide runoff race in Georgia. That means that even with a strong health care message, it’ll be tough for Ossoff and Warnock to break that trend and unseat the Republicans, Thorpe said.

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The pain is from , a group of genetic conditions that affect  many of them of African or Hispanic descent.

Sitting in the afternoon heat on her mom’s porch in Athens, Georgia, Hardy recollected how a recent “crisis” derailed her normal morning routine.

“It was time for my daughter to get on the bus, and she’s too young to go on her own,” Hardy recalled. “I was in so much pain I couldn’t walk. So, she missed school that day.”

Sickle cell disease affects red blood cells, which travel throughout the body carrying oxygen to tissues. Healthy red blood cells are shaped like plump and flexible doughnuts, but in people with sickle cell disease, the red blood cells are deformed, forming C-shaped “sickles” that are rigid and sticky.

These sickle-shaped cells can cause blockages in the blood vessels, slowing or even stopping normal blood flow. An episode of blockage is known as a sickle cell “crisis” — tissues and organs can be damaged because of lack of oxygen, and the patient experiences severe spells of pain.

‘It’s Like Torture’

Hardy tries to manage these crises on her own. She’ll take a hot bath or apply heating pads to try to increase her blood flow. Hardy also has a variety of pain medications she can take at home.

When she has exhausted those options, she needs more medical help. Hardy would prefer to go to a specialized clinic for sickle cell patients, but the closest is almost two hours away, and she doesn’t have a car.

So, Hardy often goes to the emergency room at nearby  for relief. Until recently, the doctors there would give her injections of the opioid hydromorphone, which she says would stop her pain.

Then, some months ago, the emergency room changed its process: “Now they will actually put that shot in a bag which is full of fluids, so it’s like you’re getting small drips of pain medicine,” Hardy said. “It’s like torture.”

It’s the same for her brother, Rico, who also has sickle cell disease and has sought treatment at St. Mary’s. The diluted medicine doesn’t give the same pain relief as a direct injection, they say.

Striking A Balance

St. Mary’s staffers explain that they’re trying to strike a balance with their new treatment protocol between adequate pain treatment and the risk that opioid use can lead to drug dependence.

It’s a local change that reflects a national concern. The U.S. is in the midst of an addiction and overdose crisis, fueled by powerful opioids like hydromorphone. That crisis has made medical providers more aware of the risks of administering these drugs. More than 47,000 Americans  from an overdose involving an opioid, according to the Centers for Disease Control and Prevention.

That has prompted some emergency room leaders to rethink how they administer opioid medications, including how they treat people, such as Hardy, who suffer from episodes of severe pain.

“We have given sickle cell patients a pass [with the notion that] they don’t get addicted — which is completely false,” said Dr. Troy Johnson, who works in the emergency room at St. Mary’s. “For us to not address that addiction is doing them a disservice.”

Johnson proposed the ER’s shift to intravenous “drip delivery” of opioids for chronic pain patients because of personal experience. His son has sickle cell disease, and Johnson said he has seen firsthand how people with the disease are exposed to opioids when very young.

“We start creating people with addiction problems at a very early age in sickle cell disease,” Johnson said.

He brought his concerns to the director of the ER,Ìý, and found support for the change. Hospital officials say they also consulted  for treating sickle cell crises.

“We’re trying to alleviate suffering, but we’re also trying not to create addiction, and so we’re trying to find that balance,” Earnest said. “Some times it’s harder than others.”

St. Mary’s says the new IV-drip protocol is for all patients who come to the emergency room frequently for pain, and most of their sickle cell patients are fine with the change.

Caught In The Crossfire

The national guidelines cited by St. Mary’s also say doctors should reassess patient pain frequently and adjust levels of opioids as needed “until pain is under control per patient report.”

Some people who work closely with sickle cell patients, upon hearing about the new approach to pain management at St. Mary’s, called it “unusual.”

“When individuals living with sickle cell disease go to emergency departments, they are living in extreme amounts of pain,” said , chief medical officer of the .

It’s more common for ERs to give those patients direct “pushes” of pain medication via injection, she noted, not slower IV drips.

People with sickle cell disease aren’t fueling the opioid problem, Andemariam said. published in 2018 found that opioid use has remained stable among sickle cell patients over time, even as opioid use has risen in the U.S. generally.

“If anything, individuals with sickle cell disease in our country have really been caught in the crossfire when it comes to this opioid epidemic,” Andemariam said.

She suggested that ER doctors and nurses need more education on how to care for people with sickle cell, especially during the painful crisis episodes, .

A study of some 16,000 deaths from 1979 to 2005 related to sickle cell found that men in the group lived to be only 33, on average. Women didn’t fare much better, living to an average age of 37. The same study suggested that a lack of access to quality care is a factor in the short life spans of people with sickle cell disease.

Researchers who study sickle cell say the opioid epidemic has  for patients with the condition to get the pain medication they need. The American College of Emergency Physicians is  on the problem, asking federal health officials to speak out about sickle cell pain and fund research on how to treat it without opioids.

“We in the physician community are looking for ways to make sure they get adequate pain relief,” said , vice president of the group. “We recognize that the process is not perfect, but this is what we’re striving for — to make a difference.”

Considering A Move To Find Relief

In the meantime, India Hardy said she feels those imperfections in the process every time she suffers a pain crisis, and she’s not alone.

In addition to her brother, Hardy said she has another friend in Athens with sickle cell disease, and that friend has also reported difficulty in finding pain relief at the St. Mary’s emergency room.

“It’s just really frustrating, because you go to the hospital for help — expecting to get equal help, and you don’t,” Hardy said, her voice breaking. “They treat us like we’re not wanted there or that we’re holding their time up or taking up a bed that someone else could be using.”

Hardy filed a complaint with the hospital but said nothing has changed, at least not yet. She still gets pain medication through an IV drip when she goes to the St. Mary’s emergency room.

At this point, she’s considering leaving her relatives and friends behind in Athens to move closer to a sickle cell clinic. She hopes doctors there will do a better job of helping to control her pain.

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The van and Ware’s flu shot are part of a “street medicine” program designed to bring health care to people who haven’t been able to pay much attention to their medical needs. For those who struggle to find a hot meal or a place to sleep, health care can take a back seat.

As he anticipated the needle, Ware recalled previous shots and said, “It might sting.” He grimaced slightly as the nurse injected his upper arm.

After filling out paperwork, he climbed down the van’s steps and walked back to a small cluster of tents. Ware lives in the nearby homeless encampment tucked below an interstate overpass, next to a busy rail line.

, a health care nonprofit in Atlanta, operates brick-and-mortar clinics throughout the city that mainly treat poor residents. Since 2013, Mercy has also sent out teams of health care providers to treat homeless people.

It’s a public health strategy that can be found in dozens of cities in the United States and around the world, according to the , which works to spread the practice.

Relationship Leads To Care

Getting homeless patients to accept help, whether it’s a vaccination or something simpler — like a bottle of water — can be challenging. And giving shots and conducting exams outside the walls of a health clinic often requires a different approach to health care.

“When we’re coming out here to talk to people, we’re on their turf,” said nurse practitioner Joy Fernandez de Narayan, who runs

“We’ll sit down next to someone, like, ‘Hey, how’s the weather treating you?'” she said.

“And then kind of work our way into, like, ‘Oh, you mentioned you had a history of high blood pressure. Do you mind if we check your blood pressure?'”

It can take several encounters to gain someone’s trust and get them to accept medical care, so the outreach workers spend a lot of time forging relationships with homeless clients.

Their persistent encouragement was helpful for Sopain Lawson, who caught a debilitating foot fungus while living in the encampment.

“I couldn’t walk,” Lawson said. “I had to stay off my feet. And the crew, they took good care of my foot. They got me back.”

“This is what street medicine is about — going out into these areas where people are not going to seek attention until it’s an emergency,” said Matthew Reed, who’s been doing social work with the team for two years.

“We’re trying to avoid emergencies, but we’re also trying to build relationships.”

‘Go To The People’

The street medicine team members use the trust they’ve built with patients to eventually connect them to other services, such as mental health counseling or housing.

Access to those services may not be readily available for many reasons, said , who studies health care and homelessness at St. Michael’s Hospital in Toronto.

Sometimes the obstacle — not having money for a bus ticket, for example — seems small, but is formidable.

“It may be difficult to get to a health care facility, and often there are challenges, especially in the U.S., where people [may not] have health insurance,” Hwang said.

Georgia is among a handful of states that have not expanded Medicaid to all low-income adults, which means many of its poorest residents don’t have access to the government-sponsored health care program.

But even when homeless people are able to get health coverage and make it to a hospital or clinic, they can run into other problems.

“There’s a lot of stigmatization of people who are experiencing homelessness,” Hwang said, “and so often these individuals will feel unwelcome when they do present to health care facilities.”

Street medicine programs are designed to break down those barriers, said .

He’s the medical director of the Street Medicine Institute and started making outreach visits to the homeless in 1992, when he worked at a clinic in Pittsburgh.

“Health care likes people to come to it on its terms,” Withers said, while the central tenet of street medicine is, “Go to the people.”

Help And Respect

Mercy Care in Atlanta spends about $900,000 a year on its street medicine program. In 2018, that sum paid for direct treatment for some 300 people, many of whom got services multiple times. Street clinics can help relieve the care burden of nearby hospitals, which Withers said don’t have a great track record in treating the homeless.

“We’re not dealing with them well,” Withers said, speaking about American health care in general. In traditional health settings, homeless patients do worse compared with other patients, he said.

Those extra days and clinical complications mean additional costs for hospitals. cited in a 2017 legislative report on homelessness suggested that more than $60 million in medical costs for Atlanta’s homeless population were passed on to taxpayers.

Mercy Care said its program makes homeless people less likely to show up in local emergency rooms and healthier when they do — which saves money.

It’s past sundown when the street medicine team rolls up to the day’s final stop: outside a church in Atlanta where the homeless often gather. A handful of people have settled down for the night on the sidewalk. Among them is Johnny Dunson, a frequent patient of the Street Medicine program.

Dunson said the Mercy Care staffers have a compassionate style that makes it easy to talk to them and ask for help.

“You gotta let someone know how you’re feeling,” Dunson said. “Understand me?

Sometimes it can be like behavior, mental health. It’s not just me. It’s a lot of people that need some kind of assistance to do what you’re supposed to be doing, and they do a wonderful job.”

Along with medical assistance, the staff at Mercy Care give patients doses of respect and dignity.

This story is part of a partnership that includes , and Kaiser Health News.

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