Americans’ health has long been unequal, but shows that the disparity between the life expectancies of different populations has nearly doubled since 2000. “This is like comparing very different countries,” said Tom Bollyky, director of the global health program at the Council on Foreign Relations and an author of the study.

Called “Ten Americas,” the analysis published late last year in The Lancet found that “one’s life expectancy varies dramatically depending on where one lives, the economic conditions in that location, and one’s racial and ethnic identity.” The worsening health of specific populations is a key reason the country’s — at 75 years for men and 80 for women — is the shortest among wealthy nations.

To deliver on pledges from the new Trump administration to make America healthy again, policymakers will need to fix problems undermining life expectancy across all populations.

“As long as we have these really severe disparities, we’re going to have this very low life expectancy,” said Kathleen Harris, a sociologist at the University of North Carolina. “It should not be that way for a country as rich as the U.S.”

Since 2000, the average life expectancy of many American Indians and Alaska Natives has been steadily shrinking. The same has been true since 2014 for Black people in low-income counties in the southeastern U.S.

“Some groups in the United States are facing a health crisis,” Bollyky said, “and we need to respond to that because it’s worsening.”

Heart disease, car fatalities, diabetes, covid-19, and other common causes of death are directly to blame. But research shows that the , their behaviors, and their environments heavily influence why some populations are at higher risk than others.

Native Americans in the West — defined in the “Ten Americas” study as more than a dozen states excluding California, Washington, and Oregon — were among the poorest in the analysis, living in counties where a person’s annual income averages below about $20,000. Economists have shown that people with low incomes generally .

Studies have also linked the stress of poverty, to detrimental coping behaviors like and And reservations often lack grocery stores and , which makes it hard to buy and cook healthy food.

About 1 in 5 Native Americans in the Southwest don’t have health insurance, according to a . Although the Indian Health Service provides coverage, the report says the program is weak due to chronic underfunding. This means people may delay or skip treatments for chronic illnesses. Postponed medical care contributed to the outsize toll of covid among Native Americans: About 1 of every died of the disease at the peak of the pandemic.

“The combination of limited access to health care and higher health risks has been devastating,” Bollyky said.

At the other end of the spectrum, the study’s category of Asian Americans maintained the longest life expectancies since 2000. As of 2021, it was 84 years.

Education may partly underlie the reasons certain groups live longer. “People with more education are more likely to seek out and adhere to health advice,” said Ali Mokdad, an epidemiologist at the Institute for Health Metrics and Evaluation at the University of Washington, and an author of the paper. Education also offers more opportunities for full-time jobs with health benefits. “Money allows you to take steps to take care of yourself,” Mokdad said.

The group with the highest incomes in most years of the analysis was predominantly composed of white people, followed by the mainly Asian group. The latter, however, maintained the highest rates of college graduation, by far. About half finished college, compared with fewer than a third of other populations.

The study suggests that education partly accounts for differences among white people living in low-income counties, where the individual income averaged less than $32,363. Since 2000, white people in low-income counties in southeastern states — defined as those in Appalachia and the Lower Mississippi Valley — had far lower life expectancies than those in upper midwestern states including Montana, Nebraska, and Iowa. (The authors provide details on how the groups were defined and delineated in .)

Opioid use and HIV rates didn’t account for the disparity between these white, low-income groups, Bollyky said. But since 2010, more than 90% of white people in the northern group were high school graduates, compared with around 80% in the southeastern U.S.

The education effect didn’t hold true for Latino groups compared with others. Latinos saw lower rates of high school graduation than white people but lived longer on average. This long-standing trend recently changed among Latinos in the Southwest because of covid. Hispanic or Latino and Black people were as likely to die from the disease.

On average, Black people in the U.S. have long experienced worse health than other races and ethnicities in the United States, except for Native Americans. But this analysis reveals a steady improvement in Black people’s life expectancy from 2000 to about 2012. During this period, the gap between Black and white life expectancies shrank.

This is true for all three groups of Black people in the analysis: Those in low-income counties in southeastern states like Mississippi, Louisiana, and Alabama; those in highly segregated and metropolitan counties, such as Queens, New York, and Wayne, Michigan, where many neighborhoods are almost entirely Black or entirely white; and Black people everywhere else.

Better drugs to treat high blood pressure and HIV help account for the improvements for many Americans between 2000 to 2010. And Black people, in particular, saw steep rises in high school graduation and gains in college education in that period.

However, progress stagnated for Black populations by 2016. Disparities in wealth grew. By 2021, Asian and many white Americans had the highest incomes in the study, living in counties with per capita incomes around $50,000. All three groups of Black people in the analysis remained below $30,000.

A wealth gap between Black and white people has historical roots, stretching back to the days of slavery, Jim Crow laws, and policies that prevented Black people from owning property in neighborhoods that are better served by public schools and other services. For Native Americans, a historical wealth gap can be traced to a near annihilation of the population and mass displacement in the 19th and 20th centuries.

Inequality has continued to rise for several reasons, such as a between predominantly white corporate leaders and low-wage workers, who are disproportionately people of color. And reporting from ºÚÁϳԹÏÍø News shows that decisions not to expand Medicaid have jeopardized the health of hundreds of thousands of people living in poverty.

Researchers have studied the potential health benefits of reparation payments to address historical injustices that led to racial wealth gaps. One estimates that such payments could reduce premature death among Black Americans by 29%.

Less controversial are interventions tailored to communities. Obesity often begins in childhood, for example, so policymakers could invest in after-school programs that give children a place to socialize, be active, and eat healthy food, Harris said. Such programs would need to be free for children whose parents can’t afford them and provide transportation.

But without policy changes that boost low wages, decrease medical costs, put safe housing and strong public education within reach, and ensure access to reproductive health care including abortion, Harris said, the country’s overall life expectancy may grow worse.

“If the federal government is really interested in America’s health,” she said, “they could grade states on their health metrics and give them incentives to improve.”

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It was the latest in a drumbeat of health issues that she traces to the first months of 2020, when dozens of veterans died at the Soldiers’ Home in Holyoke, in one of the country’s at a long-term nursing facility. Ragoonanan has worked at the home for nearly 30 years. Now, she said, the sights, sounds, and smells there trigger her trauma. Among her ailments, she lists panic attacks, brain fog, and other symptoms of post-traumatic stress disorder, .

Scrutiny of the outbreak prompted the state to change the facility’s name to the , replace its leadership, sponsor a of the premises, and agree to a $56 million settlement for veterans and families. But the front-line caregivers have received little relief as they grapple with the outbreak’s toll.

“I am retraumatized all the time,” Ragoonanan said, sitting on her back porch before her evening shift. “How am I supposed to move forward?”

Covid killed more than 3,600 U.S. health care workers in the first year of the pandemic. It left many more with physical and mental illnesses — and a gutting sense of abandonment.

What workers experienced has been detailed in state investigations, surveys of nurses, and published studies. These found that many health care workers weren’t given masks in 2020. Many got covid and worked while sick. More than a dozen lawsuits filed on behalf of residents or workers at nursing facilities detail such experiences. And others allege that accommodations weren’t made for workers facing depression and PTSD triggered by their pandemic duties. Some of the lawsuits have been dismissed, and others are pending.

Health care workers and unions reported risky conditions to state and federal agencies. But the federal Occupational Safety and Health Administration had fewer inspectors in 2020 to investigate complaints than at any point in a half-century. It investigated only about that were filed officially, and just 4% of more than 16,000 informal reports made by phone or email.

Nursing assistants, health aides, and other lower-wage health care workers were particularly vulnerable during outbreaks, and many remain burdened now. About 80% of lower-wage workers who provide are women, and these workers are more likely to be immigrants, to be people of color, and to live in poverty than doctors or nurses.

Some of these a person’s covid risk. They also help explain why these workers had limited power to avoid or protest hazardous conditions, said Eric Frumin, formerly the safety and health director for the Strategic Organizing Center, a coalition of labor unions.

He also cited decreasing membership in unions, which negotiate for higher wages and safer workplaces. One-third of the U.S. labor force was , but the level has fallen to 10% in recent years.

Like essential workers in meatpacking plants and warehouses, nursing assistants were at risk because of their status, Frumin said: “The powerlessness of workers in this country condemns them to be treated as disposable.”

In interviews, essential workers in various industries told ºÚÁϳԹÏÍø News they felt duped by a system that asked them to risk their lives in the nation’s moment of need but that now offers little assistance for harm incurred in the line of duty.

“The state doesn’t care. The justice system doesn’t care. Nobody cares,” Ragoonanan said. “All of us have to go right back to work where this started, so that’s a double whammy.”

‘A War Zone’

The plight of health care workers is a problem for the United States as the population ages and the threat of future pandemics looms. called their burnout “an urgent public health issue” leading to diminished care for patients. That’s on top of a predicted shortage of more than 3.2 million lower-wage health care workers by 2026, according to the .

The veterans home in Holyoke illustrates how labor conditions can jeopardize the health of employees. The facility is not unique, but its situation has been vividly described in a state investigative report and in a report from a joint oversight committee of the Massachusetts Legislature.

The Soldiers’ Home made headlines in March 2020 when got a tip about refrigerator trucks packed with the bodies of dead veterans outside the facility. About 80 residents died within a few months.

The placed blame on the home’s leadership, starting with Superintendent Bennett Walsh. “Mr. Walsh and his team created close to an optimal environment for the spread of COVID-19,” the report said. He resigned under pressure at the end of 2020.

Investigators said that “at least 80 staff members” tested positive for covid, citing “at least in part” the management’s “failure to provide and require the use of proper protective equipment,” even restricting the use of masks. They included a disciplinary letter sent to one nursing assistant who had donned a mask as he cared for a sick veteran overnight in March. “Your actions are disruptive, extremely inappropriate,” it said.

To avoid hiring more caretakers, the home’s leadership combined infected and uninfected veterans in the same unit, fueling the spread of the virus, the report found. It said veterans didn’t receive sufficient hydration or pain-relief drugs as they approached death, and it included testimonies from employees who described the situation as “total pandemonium,” “a nightmare,” and “a war zone.”

Because his wife was immunocompromised, Walsh didn’t enter the care units during this period, according to his lawyer’s statement in a deposition obtained by ºÚÁϳԹÏÍø News. “He never observed the merged unit,” it said.

In contrast, nursing assistants told ºÚÁϳԹÏÍø News that they worked overtime, even with covid, because they were afraid of being fired if they stayed home. “I kept telling my supervisor, ‘I am very, very sick,’” said Sophia Darkowaa, a nursing assistant who said she now suffers from PTSD and symptoms of long covid. “I had like four people die in my arms while I was sick.”

Nursing assistants recounted how overwhelmed and devastated they felt by the pace of death among veterans whom they had known for years — years of helping them dress, shave, and shower, and of listening to their memories of war.

“They were in pain. They were hollering. They were calling on God for help,” Ragoonanan said. “They were vomiting, their teeth showing. They’re pooping on themselves, pooping on your shoes.”

Nursing assistant Kwesi Ablordeppey said the veterans were like family to him. “One night I put five of them in body bags,” he said. “That will never leave my mind.”

Four years have passed, but he said he still has trouble sleeping and sometimes cries in his bedroom after work. “I wipe the tears away so that my kids don’t know.”

High Demands, Low Autonomy

A third of health care workers reported symptoms of PTSD related to the pandemic, according to covering 24,000 workers worldwide. The disorder predisposes people to dementia and Alzheimer’s. It can lead to substance use and self-harm.

Since covid began, Laura van Dernoot Lipsky, director of the Trauma Stewardship Institute, has been inundated by emails from health care workers considering suicide. “More than I have ever received in my career,” she said. Their cries for help have not diminished, she said, because trauma often creeps up long after the acute emergency has quieted.

Another factor contributing to these workers’ trauma is “moral injury,” a term first applied to soldiers who experienced intense guilt after carrying out orders that betrayed their values. It became common among in the pandemic who weren’t given ample resources to provide care.

“Folks who don’t make as much money in health care deal with high job demands and low autonomy at work, both of which make their positions even more stressful,” said Rachel Hoopsick, a public health researcher at the University of Illinois at Urbana-Champaign. “They also have fewer resources to cope with that stress,” she added.

People in lower income brackets have to mental health treatment. And health care workers with less education and financial security are less able to take extended time off, to relocate for jobs elsewhere, or to shift careers to avoid retriggering their traumas.

Such memories can feel as intense as the original event. “If there’s not a change in circumstances, it can be really, really, really hard for the brain and nervous system to recalibrate,” van Dernoot Lipsky said. Rather than focusing on self-care alone, she pushes for policies to ensure adequate staffing at health facilities and accommodations for mental health issues.

In 2021, Massachusetts legislators acknowledged the plight of the Soldiers’ Home residents and staff in a joint saying the events would “impact their well-being for many years.”

But only veterans have received compensation. “Their sacrifices for our freedom should never be forgotten or taken for granted,” the state’s veterans services director, Jon Santiago, said at an event announcing a memorial for veterans who died in the Soldiers’ Home outbreak. The state’s $56 million settlement followed a class-action lawsuit brought by about 80 veterans who were sickened by covid and a roughly equal number of families of veterans who died.

The state’s attorney general also brought criminal charges against Walsh and the home’s former medical director, David Clinton, in connection with their handling of the crisis. The two averted a trial and possible jail time this March by changing their not-guilty pleas, instead acknowledging that the facts of the case were sufficient to warrant a guilty finding.

An attorney representing Walsh and Clinton, Michael Jennings, declined to comment on queries from ºÚÁϳԹÏÍø News. He instead referred to legal proceedings in March, in which Jennings argued that “many nursing homes proved inadequate in the nascent days of the pandemic” and that “criminalizing blame will do nothing to prevent further tragedy.”

Nursing assistants sued the home’s leadership, too. The lawsuit alleged that, in addition to their symptoms of long covid, what the aides witnessed “left them emotionally traumatized, and they continue to suffer from post-traumatic stress disorder.”

The case was dismissed before trial, with courts ruling that the caretakers could have simply left their jobs. “Plaintiff could have resigned his employment at any time,” Judge Mark Mastroianni wrote, referring to Ablordeppey, the nursing assistants’ named representative in the case.

But the choice was never that simple, said Erica Brody, a lawyer who represented the nursing assistants. “What makes this so heartbreaking is that they couldn’t have quit, because they needed this job to provide for their families.”

‘Help Us To Retire’

Brody didn’t know of any cases in which staff at long-term nursing facilities successfully held their employers accountable for labor conditions in covid outbreaks that left them with mental and physical ailments. ºÚÁϳԹÏÍø News pored through lawsuits and called about a dozen lawyers but could not identify any such cases in which workers prevailed.

A Massachusetts chapter of the Service Employees International Union, SEIU Local 888, is looking outside the justice system for help. It has pushed for a bill — proposed last year by Judith García, a Democratic state representative — to allow workers at the state veterans home in Holyoke, along with its sister facility in Chelsea, to receive their retirement benefits five to 10 years earlier than usual. The bill’s fate will be decided in December.

Retirement benefits for Massachusetts state employees amount to 80% of a person’s salary. Workers qualify at different times, depending on the job. Police officers get theirs at age 55. Nursing assistants qualify once the sum of their time working at a government facility and their age comes to around 100 years. The state stalls the clock if these workers take off more than their allotted days for sickness or vacation.

Several nursing assistants at the Holyoke veterans home exceeded their allotments because of long-lasting covid symptoms, post-traumatic stress, and, in Ragoonanan’s case, a brain aneurysm. Even five years would make a difference, Ragoonanan said, because, at age 56, she fears her life is being shortened. “Help us to retire,” she said, staring at the slippers covering her swollen feet. “We have bad PTSD. We’re crying, contemplating suicide.”

I got my funeral dress out because the way everybody was dying, I knew I was going to die.

Debra Ragoonanan

Certain careers are linked with shorter life spans. Similarly, economists have shown that, on average, people with lower incomes in the United States than those with more. Nearly 60% of long-term care workers are among the bottom earners in the country, paid less than $30,000 — or about $15 per hour — in 2018, according to analyses by the Department of and , a health policy research, polling, and news organization that includes ºÚÁϳԹÏÍø News.

Fair pay was among the solutions listed in the surgeon general’s report on burnout. Another was “hazard compensation during public health emergencies.”

If employers offer disability benefits, that generally entails a pay cut. Nursing assistants at the Holyoke veterans home said it would halve their wages, a loss they couldn’t afford.

“Low-wage workers are in an impossible position, because they’re scraping by with their full salaries,” said John Magner, SEIU Local 888’s legal director.

Despite some public displays of gratitude for health care workers early in the pandemic, essential workers haven’t received the financial support given to veterans or to emergency personnel who risked their lives to save others in the aftermath of 9/11. Talk show host Jon Stewart, for example, has lobbied for this group for over a decade, successfully pushing Congress to compensate them for their sacrifices.

“People need to understand how high the stakes are,” van Dernoot Lipsky said. “It’s so important that society doesn’t put this on individual workers and then walk away.”

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The 2010 reauthorization of the Indian Health Care Improvement Act gave tribal epidemiology centers and requires the federal Department of Health and Human Services to grant them access to and use of data and other protected health information that’s regularly distributed to state and local officials. But tribal epidemiology center workers have told government investigators that’s not often the case.

By July 2020, American Indians and Alaskan Natives had a covid-19 that of non-Hispanic whites. Problems accessing data predated the pandemic, but the alarming infection and death rates in Native American communities underscored the importance of making data-sharing easier so tribal health leaders and epidemiologists have the information they need to make lifesaving decisions.

Tribal health officials have repeatedly said data denials impeded their responses to disease outbreaks, including slowing and an in the Midwest and Southwest.

“We’re being blinded,” said Meghan Curry O’Connell, the chief public health officer for the Great Plains Tribal Leaders’ Health Board and a citizen of the Cherokee Nation. The sharing of data has improved somewhat in recent years, she said, but not enough.

Federal investigators and tribal epidemiologists have documented a litany of obstacles keeping state and federal public health information from tribes, including confusion about data-sharing policies, inconsistent processes for requesting information, data that’s of poor quality or outdated, and strict privacy rules for sensitive data on health issues like HIV and substance misuse.

Limiting the ability of tribes and tribal epidemiology centers to monitor and respond to public health issues makes historical health disparities difficult to address. Life expectancy among American Indians and Alaskan Natives is at least 5½ years shorter than the national average.

Sarah Shewbrooks and her colleagues at the Great Plains Tribal Epidemiology Center are among those who’ve found themselves blinded by bureaucratic walls. Shewbrooks said the data dearth was particularly evident during the covid pandemic, when her team couldn’t access public health data available to other public health workers in state and local agencies. Her team was forced to manually record positive cases and deaths in the 311 counties of North Dakota, South Dakota, Nebraska, and Iowa — the region the center serves.

Shewbrooks, director of the center’s data-coordinating unit and its lead epidemiologist, estimates staffers spent more than a year’s worth of their time during the pandemic scraping together their own datasets to steer information to tribal leaders making decisions about closing down reservations and asking residents to isolate at home.

She said the process was frustrating and stressful, especially since it robbed her team of hours they could’ve spent trying to save lives in the communities they serve. The tribes in their region were doing “incredible things,” she said, by providing food and shelter for people who needed to quarantine.

“But they were having to do it all without being given real-time understanding of what’s going on around them,” Shewbrooks said.

Contact tracers who work for state governments cover Native American populations, but it’s important to have people from within the community take the lead, Shewbrooks said. Tribal workers are better equipped to move around within their communities and meet people where they are.

Shewbrooks said state contact tracers relied on calling and texting patients, which is often not the most effective method. Tribal members can be a hard-to-reach community for state workers whose protocol is to move on to the next case if they don’t get a response.

“So many cases were just getting closed,” Shewbrooks said.

In 2022, the Government Accountability Office that confirmed concerns raised by tribal health officials, including at the Great Plains tribal epidemiology center. Federal investigators found that health officials working to address public health issues in Native American communities dealt with federal agencies lacking clear processes, policies, and guidelines for sharing data with tribal officials.

In one example, officials said that as of November 2021, 10 of the 12 tribal epidemiology centers in the U.S. had access to Centers for Disease Control and Prevention covid data, but not all had full data. Some centers had access to case surveillance data that included information on positive cases, hospitalizations, and deaths. Only half said they also had access to covid vaccination data from HHS.

The GAO report also found that staffers responding to data requests at HHS, the CDC, and the Indian Health Service did not consistently recognize tribal epidemiology centers as public health authorities. Center officials told federal investigators that they’d sometimes been asked to request data they needed as outside researchers or through the Freedom of Information Act.

The report recommended agencies make several corrections, including responding to tribal epidemiology centers as required by law and clarifying how agency staffers should handle requests from epidemiology centers.

HHS officials agreed with all the recommendations. The agency consulted with tribal leaders in fall 2022 and, this year, that clarifies what data centers can access.

Some tribal leaders say the proposal is a step in the right direction but is incomplete. Jim Roberts, senior executive liaison in intergovernmental affairs at the Alaska Native Tribal Health Consortium, a nonprofit organization that provides care and advocacy for Alaskan tribes, said the GAO report focused on tribal epidemiology centers, which operate separately from tribal governments, each serving dozens of tribes divided into regions. The report left out tribes, which he said have a right to their data as sovereign nations.

HHS officials declined an interview request, but Samira Burns, principal deputy assistant secretary for public affairs, said the agency is reviewing feedback and recommendations it received from tribal leaders during consultation on the draft policy and will continue to consult with tribes before it’s finalized.

Stronger federal policy on tribal data sharing would help with relationships with states, too, Roberts said. Tribal officials say problems they’ve experienced at the federal level are often worse in states, where laws might not recognize tribes or tribal epidemiology centers as authorities that can receive data.

At the Northwest Tribal Epidemiology Center, which works on behalf of tribes in Washington, Oregon, and Idaho, forging a data-use agreement with state governments in Washington and Oregon before the pandemic helped their response by providing immediate access to near real-time data on emergency room and other health care facility visits. The center’s staff used this data to monitor for suspected covid-related visits that could be shared with tribal leaders.

It took seven months for the center to get access to covid surveillance data from the CDC, said Sujata Joshi, director of the Northwest center’s Improving Data and Enhancing Access project, and about nine months for HHS vaccination data after vaccinations became available. Even after getting the information, she said, there were concerns about its quality.

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A doctor confirmed that Hyatt had covid-19 and sent him to CVS with a prescription for the antiviral drug Paxlovid, the generally recommended medicine to fight covid. Hyatt handed the pharmacist the script, but then, he said, “She kept avoiding me.”

She finally looked up from her computer and said, “It’s $1,600.”

The generally healthy 76-year-old went out to the car to consult his wife about their credit card limits. “I don’t think I’ve ever spent more than $20 on a prescription,” the astonished Hyatt recalled.

That kind of sticker shock has stunned thousands of sick Americans since late December, as Pfizer shifted to commercial sales of Paxlovid. Before then, the federal government covered the cost of the drug.

The price is one reason Paxlovid is not reaching those who need it most. And patients who qualify for free doses, which Pfizer offers with the federal government, often don’t realize it or know how to get them.

“If you want to create a barrier to people getting a treatment, making it cost a lot is the way to do it,” said William Schaffner, a professor at Vanderbilt University School of Medicine and spokesperson for the National Foundation for Infectious Diseases.

Public and medical is low, and putting people through an application process to get the drug when they’re sick is a non-starter, Schaffner said. Pfizer says it takes only five minutes online.

It’s not an easy drug to use. Doctors are wary about prescribing it because of dangerous interactions with common drugs that treat cholesterol, blood clots, and other conditions. It must be taken within five days of the first symptoms. It leaves a foul taste in the mouth. In one study, 1 in 5 patients a few days after finishing the medicine — though rebound without Paxlovid.

A recent JAMA Network study found that sick people 85 and older than younger Medicare patients to get covid therapies like Paxlovid. The drug might have prevented up to 27,000 deaths in 2022 if it had been allocated based on which patients were at highest risk from covid. Nursing home patients, who account for U.S. covid deaths, were about two-thirds as likely as other older adults to get the drug.

Shrunken confidence in government health programs is one reason the drug isn’t reaching those who need it. In senior living facilities, “a lack of clear information and misinformation” are “causing residents and their families to be reluctant to take the necessary steps to reduce covid risks,” said David Gifford, chief medical officer for an association representing 14,000 health care providers, many in senior care.

The anti-vaxxers spreading falsehoods about vaccines have targeted Paxlovid as well. Some call themselves .

“Proactive and health-literate people get the drug. Those who are receiving information more passively have no idea whether it’s important or harmful,” said Michael Barnett, a primary care physician at Brigham and Women’s Hospital and an associate professor at Harvard, who led the JAMA Network study.

In fact, the drug is still free for those who are uninsured or enrolled in Medicare, Medicaid, or other federal health programs, including those for veterans.

That’s what rescued Hyatt, whose Department of Veterans Affairs health plan doesn’t normally cover outpatient drugs. While he searched on his phone for a solution, the pharmacist’s assistant suddenly appeared from the store. “It won’t cost you anything!” she said.

As Hyatt’s case suggests, it helps to know to ask for free Paxlovid, although federal officials say they’ve educated clinicians and pharmacists — like the one who helped Hyatt — about the program.

“There is still a heaven!” Hyatt replied. After he had been on Paxlovid for a few days his symptoms were gone and his surgery was rescheduled.

About That $1,390 List Price

Pfizer sold the U.S. government 23.7 million five-day courses of Paxlovid, produced under an FDA emergency authorization, in 2021 and 2022, at a price of around $530 each.

, Pfizer commits to provide the drug for the beneficiaries of the government insurance programs. Meanwhile, Pfizer bills insurers for some portion of the $1,390 list price. Some patients say pharmacies have quoted them prices of $1,600 or more.

How exactly Pfizer arrived at that price isn’t clear. Pfizer won’t say. A Harvard estimated the cost of producing generic Paxlovid at about $15 per treatment course, including manufacturing expenses, a 10% profit markup, and 27% in taxes.

in Paxlovid and covid vaccine sales in 2023, after a $57 billion peak in 2022. The company’s 2024 Super Bowl ad, which cost to place, focused on Pfizer’s cancer drug pipeline, newly reinforced with its $43 billion purchase of biotech company Seagen. Unlike some other recent oft-aired Pfizer ads (“”), it didn’t mention covid products.

Connecting With Patients

The other problem is getting the drug where it is needed. “We negotiated really hard with Pfizer to make sure that Paxlovid would be available to Americans the way they were accustomed to,” Department of Health and Human Services Secretary Xavier Becerra told reporters in February. “If you have private insurance, it should not cost you much money, certainly not more than $100.”

Yet in nursing homes, getting Paxlovid is particularly cumbersome, said Chad Worz, CEO of the American Society of Consultant Pharmacists, specialists who provide medicines to care homes.

If someone in long-term care tests positive for covid, the nurse tells the physician, who orders the drug from a pharmacist, who may report back that the patient is on several drugs that interact with Paxlovid, Worz said. Figuring out which drugs to stop temporarily requires further consultations while the time for efficacious use of Paxlovid dwindles, he said.

His group tried to get the FDA to approve a shortcut similar to the standing orders that enable pharmacists to deliver anti-influenza medications when there are flu outbreaks in nursing homes, Worz said. “We were close,” he said, but “it just never came to fruition.” “The FDA is unable to comment,” spokesperson Chanapa Tantibanchachai said.

Los Angeles County requires nursing homes to offer any covid-positive patient an antiviral, but the Centers for Medicare & Medicaid Services, which oversees nursing homes nationwide, has not issued similar guidance. “And this is a mistake,” said Karl Steinberg, chief medical officer for two nursing home chains with facilities in San Diego County, which also has no such mandate. A requirement would ensure the patient “isn’t going to fall through the cracks,” he said.

While it hasn’t ordered doctors to prescribe Paxlovid, CMS on Jan. 4 issued detailed instructions to health insurers urging swift approval of Paxlovid prescriptions, given the five-day window for the drug’s efficacy. It also “encourages” plans to make sure pharmacists know about the free Paxlovid arrangement.

Current covid strains appear less virulent than those that circulated earlier in the pandemic, and years of vaccination and covid infection have left fewer people at risk of grave outcomes. But risk remains, particularly among older seniors, who account for most , which number more than 13,500 so far this year in the U.S.

Steinberg, who sees patients in 15 residences, said he orders Paxlovid even for covid-positive patients without symptoms. None of the 30 to 40 patients whom he prescribed the drug in the past year needed hospitalization, he said; two stopped taking it because of nausea or the foul taste, a pertinent concern in older people whose appetites already have ebbed.

Steinberg said he knew of two patients who died of covid in his companies’ facilities this year. Neither was on Paxlovid. He can’t be sure the drug would have made a difference, but he’s not taking any chances. The benefits, he said, outweigh the risks.

Reporter Colleen DeGuzman contributed to this report.

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Garfield County’s public health nurse, one of few public health officials serving the town and nearly 5,000 square miles that surround it, had quit because she had given birth to her second child and couldn’t find day care.

“My primary goal was to give families a safe place to take their children so they could work if they needed to,” said Murnion, 63. She started in 2015 with eight slots, the maximum she could cover herself, and slowly grew. Then, during the covid-19 pandemic, a surge in federal aid to child care programs helped her raise wages for her workers and expand to a second facility.

Today, her day care programs, the only ones in Jordan, can serve up to 30 children, ranging from 6 weeks old to school age. But after that pandemic-era funding support ended in September, Murnion began to wonder how long she could sustain her expanded capacity, or whether she’d need to raise prices or lower enrollment.

And she isn’t alone.

Data collected prior to the pandemic shows that of Americans lived in neighborhoods classified as child care deserts, areas that have no child care providers or where there are more than three children in the community for every available licensed care slot. parents and child care providers in rural areas face unique barriers. Access to quality child care programs and early education is linked to for kids and can also help link families and children to immunizations, health screenings, and greater food security by providing meals and snacks.

Policymakers and researchers now fear that inequitable child care access threatens the sustainability and longevity of rural communities.

“If we want to keep rural parts of this country alive and thriving, we need to address this,” said Linda Smith, director of the Early Childhood Initiative at the Bipartisan Policy Center, a Washington, D.C.-based think tank.

According to an that Smith co-authored, there is a 35% gap between the need for and availability of child care programs in rural areas, compared with 29% in urban areas, based on data from 35 states.

The report echoed concerns local, state, and national experts have raised for a number of years.

A report published last year by the National Advisory Committee on Rural Health and Human Services found that, per capita, more parents rely on family members or friends for child care in rural areas than in urban areas. This isn’t sustainable for parents, said Cara James, CEO and president of Grantmakers in Health, a nonprofit that helps guide health philanthropy.

“Right now, we have a system that’s very expensive for people who can afford it and for people who can access it, not necessarily available to all those who need it,” James said. “That’s leading us to rely on other workarounds that are not ideal or ones that are giving the children the best support that they need to grow into healthy adults.”

For example, according to a state report, Montana’s total child care capacity in 2021 and infant care capacity met only 34% of estimated demand. Garfield County had only 23% of potential demand for children under six. Nationally, the rural health advisory committee has found, child care deserts are most likely to be located in “low-income rural census tracts.”

The dearth of child care in many rural communities exacerbates workforce shortages by forcing parents, including those who work in health care locally, to stay home as full-time caregivers, and by preventing younger workers and families from putting down roots there.

Eighty-six percent of parents in rural areas who are not working or whose partner is not working said in a that child care responsibilities were a reason why, while 45% said they or their spouse cared for at least their youngest child. Staying home to care for children is a responsibility that disproportionately falls on women, affecting their ability to and make an independent living.

A report from the rural health advisory committee shows that when center-based care is readily available in a community, the percentage of mothers who use that type of care and are employed doubles from 11% to 22%.

According to the Biden administration, pandemic emergency funding increased maternal labor workforce participation, stabilized employment and increased wages for child care workers, tempered costs for families, and helped providers afford their facilities.

That funding included allocated by Congress for child care program owners and low-income families. Murnion’s day care was one of an estimated 30,000 in rural counties that received federal grants.

She said the roughly $100,000 she received in federal aid allowed her to raise wages for her workers to $13 an hour and expand her facility space. She said she doesn’t take a paycheck from the business and instead relies on income from a family ranch and trucking business.

Now that the federal aid programs have expired, Murnion and other child care operators nationwide are wrestling with how to sustain those wages without hiking the cost of care for parents.

The Biden administration of $16 billion to extend the pandemic-era child care stabilization program but doesn’t have enough support to continue the funding, despite increasing federal funding for states to expand their child care programs.

According to the administration, the funding would support more than 220,000 child care providers in the U.S. that collectively serve more than 10 million kids. Montana would receive an estimated additional $46 million if Congress approved the request.

Although federal aid helped Murnion get through the pandemic, she said she doesn’t want to rely on the government forever. She charges parents $30 a day for one child and $22 a day each for siblings. And she doesn’t charge parents for days their children don’t attend. If she does need to raise prices, Murnion said, she’ll increase the per-sibling cost.

The pandemic provided some meaningful lessons, said Smith of the Bipartisan Policy Center. “Those stabilization grants were, I think, a key to what we actually need to do with child care down the road.”

The number of child care programs has in most states, but the employee count per facility has decreased. The federal cash infusion helped child care employment rebound after a 35% dip at the beginning of the pandemic. By November 2022, the number of workers in child care jobs had climbed to 92% of the pre-pandemic level.

In the best circumstances, Smith said, parents would pay more for child care, and the corresponding supply or availability of programs would increase. But because parents are struggling to keep up with the rising costs, which in some places can be more than in-state college tuition, supply is stagnant.

Smith said the end of federal aid programs kicked the issue back to state and local governments. “I think most people would agree that what we need is some type of funding that goes to the programs to keep it so that they can do what they need to do and not charge the parents for it,” she said.

Some state and local governments are doing so. In Alabama, lawmakers last year in the state budget for child care. The Missouri state legislature for child care. Voters in rural Warren, Minnesota, a half-percent sales tax to support a child care center that was struggling to stay open.

During last year’s legislative session, Montana lawmakers and Republican Gov. Greg Gianforte to improve child care access, including removing state licensing requirements for small in-home day cares and expanding a program that helps lower-income families pay for child care.

“You can’t sit here in Washington, D.C., and figure out how you’re going to get child care out in eastern Montana,” Smith said. “It just doesn’t work.”

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“Urging people to get boosters has really only worked for Democrats, college graduates, and people making over $90,000 a year,” said Gregg Gonsalves, an epidemiologist at Yale University. “Those are the same people who will get this booster because it’s not like we’re doing anything differently to confront the inequities in place.”

As the effects of vaccines offered in 2021 have diminished over time, boosters have been shown to strongly protect people against , and more modestly . They can have a dramatic impact on those most likely to die from covid, such as older adults and immunocompromised people. Public health experts say re-upping vaccination is also important for those in group housing, like prisons and nursing homes, where the virus can move swiftly between people in close quarters. A boost in protection is also needed to offset the persistent disparities in the toll of covid between racial and ethnic groups.

However, the intensive outreach efforts that successfully led to decent vaccination rates in 2021 have largely ended, along with mandates and the urgency of the moment. Data now suggests that the people getting booster doses are often not those most at risk, which means the toll of covid in the U.S. may not be dramatically reduced by this round of vaccines. Hospitalizations and deaths due to covid have risen in recent weeks, and a leading cause of death, with roughly 7,300 people dying of the disease in the past three months.

Tyler Winkelman, a health services researcher at Hennepin Healthcare in Minneapolis, said outreach of the intensity of 2021 is needed again. Back then, throngs of people were hired to tailor communication and education to various communities, and to administer vaccines in churches, homeless encampments, and stadiums. “We can still save lives if we are thoughtful about how we roll out the vaccines.”

Complicating matters, this is the first round of covid vaccines not fully covered by the federal government. Private and public health insurers will get them to members at no cost, but the situation for some uninsured adults — predominantly — is in flux. On Sept. 14, the CDC announced a kickoff of plans to temporarily , at least partly through $1.1 billion left over in pandemic emergency funds through the Bridge Access Program.

Costs are probably an issue, said Peter Maybarduk, at Washington-based advocacy organization Public Citizen. Moderna and Pfizer have the price of the vaccines to about $130 a dose, compared with about $20 for the first vaccines and $30 for the last boosters, raising overall health care costs. Maybarduk pointed out that the U.S. government funded research involved in developing mRNA vaccines, and said the government missed an opportunity to request price caps in return for that investment. Both companies earned billions from vaccine sales in 2021 and 2022. Moderna’s predicts another $6 billion to $8 billion in covid vaccine sales this year and Pfizer expects $14 billion. Maybarduk suggests the government would have more funds for equity initiatives if so much weren’t being spent on the boosters through Medicare, Medicaid, and its access program. “If these vaccines had been kept at the same price, what decisions would be made to expand the response?”

People age 75 and up have accounted for of the country’s pandemic deaths. But whereas the first vaccines were quickly taken up in nursing homes, boosters have been less popular, with of residents in Arizona, Florida, Nevada, and Texas getting the bivalent booster released last year. At nationwide, rates are below 10%.

Jails and prisons have seen some of the largest U.S. outbreaks — yet booster uptake there often appears to be poor. In Minnesota, just 8% of incarcerated people in jails and 11% in prisons have gotten last year’s booster, according to analyses of electronic health records by the Minnesota EHR Consortium. About in prisons in California are up to date on boosters. Boosters make a difference. A study of California prisons found that among incarcerated people, the effectiveness of the first two doses was about 20% against infection, compared with 40% for three doses. (Prison staff saw larger benefits from three doses, an effectiveness of 72%, presumably because the chance of infection is lower when not living within the facilities.)

Low-income groups are also at heightened risk, for reasons including a lack of paid sick leave and medical care. In surveys of homeless people in California, about 60% reported chronic health conditions, said Tiana Moore, the policy director at the Benioff Homelessness and Housing Initiative at the University of California-San Francisco. Studies have found that members of this community , with people in their 50s experiencing strokes, falls, and urinary incontinence at rates typical of people in their late 70s and 80s.

Booster rates among people who lack housing are largely unknown, but Moore is concerned, saying they face high barriers to vaccination since many also lack medical providers, knowledge about where to go for vaccines, and the means to get there. “Many of our participants talked about concerns about leaving their belongings when unsheltered since they don’t have a door to lock,” she said. “That underscores the need to meet people where they are in an effective booster campaign.”

Black and Hispanic people have faced than white people throughout the pandemic. And these groups are significantly with the covid drug Paxlovid than white patients. (Hispanic people can be of any race or combination of races.)

Uneven rates of booster uptake may exacerbate these inequalities. An analysis of Medicare claims across the U.S. found that 53% of Hispanic people and 57% of Black people age 66 and older had by May 2022, compared with about 68% of their white and Asian counterparts. Disparities were most dramatic in cities where booster uptake among white people was above average. In Boston, for example, 73% of white people were boosted compared with 58% of Black people.

People opt out of vaccination for many reasons. Those living farther from vaccine sites, on average, have . Misinformation spread by politicians may account for disparities seen along political lines, with having gotten a bivalent booster compared with 11% of Republicans. Lower vaccine coverage among Black communities has been from discrimination by the medical system, along with worse health care access. However, many Black people who hesitated at first eventually when given information and easy access to them, suggesting it could happen again.

But Georges Benjamin, executive director of the American Public Health Association, said the downturn of reporting on vaccination and covid rates makes it harder to tailor outreach.

“If we had the data, we could pivot quickly,” he said, adding that this was once possible but that reporting lapsed after the end of the public health emergency this spring. “We’ve gone back to the old way, re-creating the conditions in which inequities are possible.”

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She was taking care of her father, now 86, who has been in and out of hospitals and rehabs after a worsening series of strokes in recent years.

Working from home for a rental property company, she could handle it. In fact, like most family caregivers during the early days of covid-19, she had to handle it. Community programs for the elderly had shut down.

Even when Beltré switched to a hybrid work role — meaning some days in the office, others at home — caring for her father was manageable, though never easy.

Then she was ordered back to the office full time in 2022. By then, Medicaid was covering 17 hours of home care a week, up from five. But that was not close to enough. Beltré, now 61, was always rushing, always worrying. There was no way she could leave her father alone so long.

She quit. “I needed to see my dad,” she said.

In theory, the national debate about remote or hybrid work is one great big teachable moment about the demands on the 53 million Americans taking care of an elderly or disabled relative.

But the “return to office” debate has centered on commuting, convenience, and child care. That fourth C, caregiving, is seldom mentioned.

That’s a missed opportunity, caregivers and their advocates say.

Employers and co-workers understand the need to take time off to care for a baby. But there’s a lot less understanding about time to care for anyone else. “We need to destigmatize it and create a culture where it’s normalized, like birth or adoption,” said Karen Kavanaugh, chief of strategic initiatives at the Rosalynn Carter Institute for Caregivers. For all the talk of cradle to grave, she said, “mostly, it’s cradle.”

After her stepmother died, Beltré moved her father into her home in Fort Myers, Florida, in 2016. His needs have multiplied, and she’s been juggling, juggling, juggling. She’s exhausted and, now, unemployed.

She’s also not alone. About , and nearly a third have quit a job because of their caregiving responsibilities, according to a report from the Rosalynn Carter Institute. Others cut back their hours. The Rand Corp. has estimated that caregivers in family income each year — an amount that’s almost certainly gone up since the report was released nearly a decade ago.

Beltré briefly had a remote job but left it. The position required sales pitches to people struggling with elder care, which she found uncomfortable. She rarely gets out — only to the grocery store and church, and even then she’s constantly checking on her dad.

“This is the story of my life,” she said.

Workplace flexibility, however desirable, is no substitute for a national long-term care policy, a viable long-term care insurance market, or paid family leave, none of which are on Washington’s radar.

President Joe Biden gave family caregivers a shoutout in his State of the Union address in February and followed up in April with an executive order aimed at supporting caregivers and incorporating their needs in planning federal programs, including Medicare and Medicaid. Last year, his Department of Health and Human Services released a outlining how federal agencies can help and offering road maps for the private sector.

Although Biden checked off priorities and potential innovations, he didn’t offer any money. That would have to come from Congress. And Congress right now is locked in a battle over cutting spending, not increasing it.

So that leaves it up to families.

Remote work can’t fill all the caregiving gaps, particularly when the patient has advanced disease or dementia and needs intense round-the-clock care from a relative who is also trying to do a full-time job from the kitchen table.

But there are countless scenarios in which the option to work remotely is an enormous help.

When a disease flares up. When someone is recuperating from an injury, an operation, or a rough round of chemo. When a paid caregiver is off, or sick, or AWOL. When another family caregiver, the person who usually does the heavy lift literally or metaphorically, needs respite.

“Being able to respond to time-sensitive needs for my dad at the end of his life, and to be present with my stepmother, who was the 24/7 caregiver, was an incredible blessing,” said Gretchen Alkema, a well-known expert in aging policy who now runs a consulting firm and was able to work from her dad’s home as needed.

That flexibility is what Rose Garcia has come to appreciate, as a small-business owner and a caregiver for her husband.

Garcia’s husband and business partner, Alex Sajkovic, has Lou Gehrig’s disease. Because of his escalating needs and the damage the pandemic wrought on their San Francisco stone and porcelain design company, she downsized and redesigned the business. They cashed in his retirement fund to hire part-time caregivers. She goes to work in person sometimes, particularly to meet architects and clients, which she enjoys. The rest of the time she works from home.

As it happened, two of her employees also had caregiving obligations. Her experience, she said, made her open to doing things differently.

For one employee, a hybrid work schedule didn’t work out. She had many demands on her, plus her own serious illness, and couldn’t make her schedule mesh with Garcia’s. For the other staff member, who has a young child and an older mother, hybrid work let her keep the job.

A third worker comes in full time, Garcia said. Since he’s often alone, his dogs come too.

In Lincoln, Nebraska, Sarah Rasby was running the yoga studio she co-owned, teaching classes, and taking care of her young children. Then, at 35, her twin sister, Erin Lewis, had a sudden cardiac event that triggered an irreversible and ultimately fatal brain injury. For three heartbreaking years, her sister’s needs were intense, even when she was in a rehab center or nursing home. Rasby, their mother, and other family members spent hour after hour at her side.

Rasby, who also took on all the legal and paperwork tasks for her twin, sold the studio.

“I’m still playing catch-up from all those years of not having income,” said Rasby, now working on a graduate degree in family caregiving.

Economic stress is not unusual. Caregivers are disproportionately women. If caregivers quit or go part time, they lose pay, benefits, Social Security, and retirement savings.

“It’s really important to keep someone attached to the labor market,” the Rosalynn Carter Institute’s Kavanaugh said. Caregivers “prefer to keep working. Their financial security is diminished when they don’t — and they may lose health insurance and other benefits.”

But given the high cost of home care, the sparse insurance coverage for it, and the persistent workforce shortages in home health and adult day programs, caregivers often feel they have no choice but to leave their jobs.

At the same time, though, more employers, facing a competitive labor market, are realizing that flexibility regarding remote or hybrid work helps attract and retain workers. Big consultant companies like BCG offer advice on “.”

Successful remote work during the pandemic has undercut bosses’ abilities to claim, “You can’t do your job like that,” observed Rita Choula, director of caregiving for the AARP Public Policy Institute. It’s been more common in recent years for employers to offer policies that help workers with child care. Choula wants to see them expanded “so that they represent a broad range of caregiving that occurs across life.”

Yet, even with covid’s reframing of in-person work, telecommuting is still not the norm. A March report from the Bureau of Labor Statistics private businesses had some or all of their workforce remote last summer — a dropoff from 40% in 2021, the second pandemic summer. Only about 1 in 10 workplaces are fully remote.

And remote and hybrid work is mostly for people whose jobs are largely computer-based. A restaurant server can’t refill a coffee cup via Zoom. An assembly line worker can’t weld a car part from her father-in-law’s bedside.

But even in the service and manufacturing sectors, willing employers can explore creative solutions, like modified shift schedules or job shares, said Kavanaugh, who is running pilot programs with businesses in Michigan. Cross-training so workers can fill in for one another when one has to step into caregiving is another strategy.

New approaches can’t come soon enough for Aida Beltré, who finds joy in caregiving along with the burden. She’s looking for work, hybrid this time. “I am a people person,” she said. “I need to get out.”

She also needs to be in. “Every night, he says, ‘Thank you for all you do,’” she said of her father. “I tell him, ‘I do this because I love you.’”

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According to new data from the U.S. Census Bureau, working from home for some portion of the week has become the new normal for a large segment of Californians. The data shows high-income employees with college degrees are more likely to have access to this hybrid work model, while lower-income employees stay the course with on-site responsibilities and daily commutes.

At a basic level, that means low-wage workers will continue to shoulder greater risks of infection and serious illness as new covid variants sweep through job sites, alongside seasonal waves of flu and other respiratory viruses. Multiple studies have found that covid took its greatest toll in low-income neighborhoods, whose workers were deemed essential during early pandemic lockdowns — the farmworkers, grocery clerks, warehouse packers, and other service employees who continued to report to work in person.

In addition, researchers say the shift will ripple across the broader economy in ways big and small, as more employees have the flexibility to live farther from a job site and as workplace traditions like lunch outings and bar nights fade or evolve.

The U.S. Census Bureau interviewed roughly 260,000 Americans from June through October, including about 20,000 Californians, as part of a wide-ranging questionnaire called the . Surveyors asked dozens of questions about pandemic-era lifestyle changes, including some about working from home.

The survey found that nearly 20% of California adults lived in households in which at least one person had telecommuted or worked from home five days or more in the previous week. About 33% of California adults lived in households in which someone had worked from home at least one day the previous week.

Nationwide, the survey found that almost 30% of adults lived in households in which at least one person worked from home for some portion of the previous week. About 16% lived in households in which someone worked from home at least five days the previous week.

The results mark a notable shift from previous Census Bureau surveys that asked about working from home, though in different terms. In 2019, before the pandemic, about 6.3% of employed Californians and 5.7% of employed Americans said they “usually worked from home.”

Researchers who specialize in workforce issues said the findings mirror their own and are indicative of a cultural upheaval that will outlive the pandemic.

is an academic economist and a co-founder of , which is documenting the shift toward working from home. Before the pandemic, about 5% of workdays in the U.S. were conducted from home, according to his group’s analyses. In contrast, its surveys this year show that about 30% of working days in the U.S. are now work-from-home days.

The 2022 survey by the Census Bureau revealed disparities in the kinds of families that are adapting to hybrid work, mostly centered around income.

About 64% of California adults in households with annual incomes of $150,000 or higher said at least one household member had worked from home some portion of the week. Nearly 40% of adults in those high-earning households said a household member had worked from home five days a week or more.

By comparison, just 15% of California adults in households with annual incomes of less than $50,000 said a household member had worked from home at least part of the week.

“It’s very hard for you to work remotely if you are a barista in a coffee shop or you’re working in a manufacturing plant,” Barrero said. “The sorts of jobs that people with low education tend to do are jobs that require them to be physically present.”

Racial disparities also exist. Nearly 45% of California adults who identify as Asian and 40% who identify as white lived in households in which someone worked from home some portion of the week, compared with 26% of Black adults and 21% of Latino adults.

The connection between income and hybrid work played out nationally, as well. States with greater portions of high-income residents tended to have more workers who reported telecommuting.

For example, fewer than 20% of adults in Alabama, Arkansas, Kentucky, Louisiana, Mississippi, and West Virginia lived in households in which at least one member had worked from home the prior week. The median household income in each of those states last year was between $48,000 and $56,000.

By comparison, 35% or more of adults in Colorado, Maryland, Massachusetts, Minnesota, New Jersey, Oregon, Utah, Virginia, and Washington lived in households in which at least one member had worked from home. The median household income in each of those states last year was between $71,000 and $91,000.

The disparities also clustered along educational lines. About 56% of California adults with a bachelor’s degree lived in households in which someone worked from home at least one day during the prior week, compared with 17% of California adults with only a high school degree.

The gaps will have consequences.

, an economist at the University of Utah who studies work-from-home patterns, said tens of millions of Americans are settling into “hybrid” arrangements, in which they work from home a few days a week and occasionally go into the office. Before the home-work option, she said, many didn’t want to live too far from the urban core, concerned that commutes would become unmanageable. But with routine daily commutes out of the picture, many will move to the suburbs or exurbs, where they will have more space, she said.

On the one hand, commuting less, particularly by car, is often good for the health of the environment, Ghent noted. “But if people move to places where the usual mode of transit is cars instead of something that’s more pedestrian- or cyclist-friendly or more likely to use public transit, that’s not such a good thing,” Ghent said. “It sort of increases our urban sprawl, which we know is not good for sustainability.”

When higher-income people move away, cities lose a valuable source of tax revenue. That could exacerbate challenges in urban areas, as resources for social programs and infrastructure shrink. To avoid that fate, cities will need to make themselves attractive places to live, not just work, Barrero said.

“What you don’t want to be is a city of basically office towers, and everybody at the end of the day leaves, and there’s nothing to do in evenings and on weekends,” he said. “Because that means that basically all of the people can be remote or hybrid.”

The migration to telecommuting also allows employers to look to other states or even other countries for hires. , an associate economist at the Rand Corp., recently authored detailing how U.S. companies may increasingly “offshore” remote work to employees abroad.

In addition, higher-income workers could see their wages rise or fall, depending on where they live, Sytsma said. High-paid workers in San Francisco will compete for remote jobs with lower-paid workers in places like Fresno, California, or Boise, Idaho.

“So we should start to see these wages fall in cities like San Francisco and New York and Seattle, where they’re already really high,” Sytsma said, “and we’ll probably start to see them rise in more rural areas.”

Barrero said employers recognize that many people have found they prefer working from home — and that it gives companies leverage to ask workers to accept less money in exchange.

He said his research also indicates that today’s work models — for both at-home and on-site employees — are likely to endure for months and years.

“We’ve had in our survey a question asking people, ‘Is this the long-term plan that your employer has, or are you still waiting to implement part of the plan?’” Barrero said. “And consistently we get more than 80% of people saying that they’re already following the long-term plan.”

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

This story was produced by , which publishes , an editorially independent service of the .

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“It’s when things go really, really fast and they seem overwhelmingly disastrous. That’s when it happens,” said Myrick, who was diagnosed with schizophrenia 25 years ago. “The attacking voices were calling me stupid. … I literally had a meltdown right here in my house. Just lost it.”

She was able to calm herself and quiet the voices, and as the pandemic wore on, she kept them at bay by keeping busy: continuing her work for a foundation, hosting a podcast, and writing a children’s book. She managed, but she worried about other people like her.

“People with schizophrenia were not actually deemed as ‘the priority vulnerable population’ to be served or to be addressed in the same way as people who had other chronic health conditions and who were over a certain age,” said Myrick, who lives in Los Angeles. “So we kind of got left out.”

This omission occurred even as new data published in JAMA Psychiatry showed that people with schizophrenia were as likely to die from covid-19 as the general population. Their risk of death from the virus is greater than it is for people with diabetes, heart disease, or any other factor aside from older age.

“People’s initial reaction to this was one of disbelief,” said Katlyn Nemani, a New York University school of medicine neuropsychiatrist and the study’s lead author.

Some researchers initially questioned whether the disparate death rates could be explained by the often poor physical health of people with schizophrenia or their difficulty accessing health care. But Nemani’s study controlled for those factors: All the patients in the study were tested and treated for covid, and they got care from the same doctors in the same health care system.

Then studies started rolling in from countries with universal health care systems — the U.K., Denmark, Israel, South Korea — : a nearly three times higher risk of death for people with schizophrenia. A from the U.K., published in December 2021, found the risk was nearly five times as great.

“You have to wonder, is there something inherent to the disorder itself that’s contributing to this?” Nemani asked.

The immune dysfunction that causes severe covid in people with schizophrenia could be what drives their psychotic symptoms, Nemani said. This suggests schizophrenia is not just a disorder of the brain, but a disease of the immune system, she said.

Although researchers had already been , the data from the pandemic has shed light on it in a new way, opening doors for discoveries.

“This is a really rare opportunity to study the potential relationship between the immune system and psychiatric illness, by looking at the effects of a single virus at a single point in time,” Nemani said. “It could potentially lead to interventions that improve medical conditions that are associated with the disease, but also our understanding of the illness itself and what we should be doing to treat it.”

In the long term, it could lead to new immunological treatments that might work better than current antipsychotic drugs.

For now, advocates want the data about risk to be shared more widely and taken more seriously. They want people with schizophrenia and their caretakers to know they should take extra precautions. Earlier in the pandemic, they had hoped people with schizophrenia would get vaccine priority.

“It’s been a challenge,” said Brandon Staglin, who has schizophrenia and is the president of , a mental health advocacy group based in Napa Valley.

When he and other advocates first saw Nemani’s data in early 2021, they started lobbying public health officials for priority access to the vaccines. They wanted the Centers for Disease Control and Prevention to add schizophrenia to its list of high-risk conditions for covid, as it had done for cancer and diabetes.

But they heard crickets.

“It doesn’t make any sense,” Staglin said. “Clearly, schizophrenia is a higher risk.”

In several other countries, including the U.K. and Germany,  for vaccines from the beginning of the rollout in February 2021. In the U.S., though, it wasn’t until people were getting  2021 that the CDC added schizophrenia to the priority list.

“We were happy when that happened, but we wish there had been faster action,” Staglin said.

It’s always like this with mental illness, said Myrick.

“It’s like we have to remind people,” she said. “It’s just sort of, ‘Oh yeah, oh right, I forgot about that.'”

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Young spoke with Ghaly, Gov. Gavin Newsom’s top health adviser, about the administration’s plans for moving forward as covid case rates and hospitalizations ebb. Vaccines, testing, and masking are all part of the governor’s strategy, Ghaly said, as covid becomes endemic and Californians learn to live with the virus.

A pediatrician and father of four, Ghaly said the covid vaccine should be required for schoolchildren, similar to other mandatory childhood vaccines. “Our schools are better off because we have these requirements” for preventing diseases, Ghaly said.

California will allow children to be in classrooms without a mask after March 11, but Ghaly said he hasn’t yet talked with his kids about what they’ll do.

Click to listen to the full conversation.

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ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).