“I’m somebody who struggles with my mental health quite a bit,” said the 17-year-old, who attends school in this suburb of about 77,000 people northwest of Chicago. “When you’re in school and not fully mentally there, it’s like you’re not really grasping anything anyway.”

Now Illinois is giving Linnea and students like her a new option for dealing with mental health lows. The state allows K-12 students in public schools to have five excused absences per school year for mental health reasons, another example of the growing acknowledgment among lawmakers that emotional and physical health are intertwined. The , which went into effect at the beginning of 2022, passed both chambers of the state legislature unanimously.

But such novel policies are, in many ways, a half-step toward addressing the crisis of teenage mental health that has been highlighted and exacerbated by the educational interruptions caused by the pandemic. Many parts of the country are woefully short of therapists who can work with students to address mental health problems.

that responded to a federal survey in April said more students had sought mental health services since the pandemic started. The National Center for Education Statistics’ polling also showed that only 56% of schools said they effectively provide mental health services to all students in need and just 41% reported hiring new staff members to help address students’ mental health needs.

Nearly half the nation lives in a designated mental health worker shortage area, according to , and an estimated 7,550 new professionals are needed to fill that void nationwide. Even in places where mental health professionals are more plentiful, they often do not accept public insurance, making them inaccessible to many kids.

In other states where lawmakers have implemented policies that allow students to take mental health days — including Arizona, California, Colorado, Connecticut, Maine, Nevada, Oregon, Utah, and Virginia — a lack of services for young people remains a concern.

Schools in , , , , and , have tried to narrow the gap through less costly solutions, such as in-class meditation, mindfulness rooms, and social-emotional learning. The latter became a of conservative lawmakers in recent months.

In a 2020 of young people’s greatest mental health needs, the top responses from 14- to 18-year-olds were access to mental health professionals and mental health absences or breaks as part of school or work.

“The more we can shift to a prevention mindset and integrate mental health promotion into schools from a young age, I see that as very key to helping reduce the needs for treatment that we see in young people,” said , director of the Center for Adolescent Health at the Johns Hopkins Bloomberg School of Public Health.

Education officials and mental health experts in Illinois say the mental health day policy is a good start toward tamping down a that had been growing during an era of school shootings and cyberbullying and then exploded during the pandemic. The move is another indication that schools are increasingly being relied upon to meet students’ social needs, from feeding, clothing, and vaccinating them to spotting abuse and neglect.

“I’ve been a teacher for 19 years, and this is as bad as I’ve seen it,” Ben Lobo said of the mental health of his students at Schaumburg High School.

, president and CEO of the Josselyn Center, a community mental health center north of Chicago, said the pandemic was “like putting a match to fuel.”

Before March 2020, the nonprofit received about 50 new clients a month, Resko said. That number is now 250, and two-thirds are children or young adults. The organization hired 70 therapists in the past year and has received an influx of requests for mental health counseling services from local schools.

Some critics of the new Illinois law note that it without ready access to child care. And a lack of data from some schools means officials don’t know whether the policy is being used.

The Illinois State Board of Education does not require schools to report how many students are taking mental health absences. KHN contacted the 10 in Illinois seeking that data. Six didn’t respond (the districts based in Elgin, Aurora, Algonquin, Oswego, Romeoville, and Schaumburg), and three said they either aren’t tracking that number (Chicago) or couldn’t release it (Rockford and Naperville).

School officials in Plainfield, Illinois — a town about 35 miles southwest of Chicago whose district has an enrollment of more than 25,000 — said 3,703 students took a combined 6,237 mental health days from early January through the end of the school year. That means nearly 15% of the student body used an average of 1.7 days per student. Officials also noted that 123 of those days were used on the last day of school before summer break.

The community had been seeking to provide more services to students even before the pandemic hit. In 2019, Plainfield Community Consolidated School District 202 added 20 social workers after data showed that overnight hospitalizations of any kind among students had more than doubled in the previous five years. That type of staff expansion just “doesn’t happen in education,” said , the district’s director of student services.

Under the state’s new policy, after students have a second mental health-related absence, district officials are required to refer them to the “appropriate school support personnel.” But many schools can’t afford the types of services Plainfield is offering, education officials say, and in rural areas they sometimes have trouble finding people to fill those jobs.

Chicago isn’t scheduled to have a social worker in each of its more than 600 schools until 2024. School social workers there often devote most of their time to students who receive special education services dictated by an individualized education program, or IEP.

“My door gets knocked on all day long. And I have to choose — am I going to reschedule my IEP services, or am I going to help a student who’s experiencing a crisis like right now?” said Mary Difino, a social worker at Brian Piccolo Elementary Specialty School on Chicago’s West Side. “The neighborhood I work in, there’s a lot of trauma, there’s a lot of community violence, there’s a lot of death and hardship.”

Fourteen-year-old Heaven Draper, an eighth grader at Brian Piccolo, said she had used two mental health days: one to take a break from a chaotic classroom environment — she said she sometimes feels more like a teacher than a student — and another to de-stress from the pressures of applying and testing for high schools in the city. “This is our first year back in person from quarantine,” she said. “It’s gotten overwhelming at times.”

Her classmate Ariyonnah Brown, 14, said she took a day to help defuse a situation with another student. She said she’d like to see more awareness of mental health among adults, especially in communities of color like hers.

“Parents need to be educated,” said Sheila Blanco, 57, a food distribution purchaser from Chicago whose , Carli, died by suicide in 2017. “So many parents, they don’t know what resources are, and even if there are resources, to help out the child or help them to help the child.”

Anna Sanderson, a Schaumburg High School junior, said she believes the policy is a good idea, just not for her. “If I miss a day because I’m overwhelmed or not feeling well mentally, I feel like when I go back, I’ll only be worse,” the 17-year-old said. “I’ll have to make up assignments and tests and be behind in my classes.”

But she said she hopes it’s a sign of greater support for students’ mental health. She said schools sometimes fail to acknowledge student suicides or to provide counseling that goes much beyond education.

“I feel like we get dismissed a lot of the times,” she said.

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They converted an old farmhouse into a seven-bed medical center. They treated their first patient for a broken leg amid carpenters hammering nails. Surgeons laid their patients on a kitchen table for operations.

The hospital — then named after St. Margaret, known for her service to the poor — eventually became one of the largest in the area. Hundreds of thousands of Indiana and Illinois residents took their first, or last, breaths there.

A hundred twenty-four years later, the hospital has, in a sense, come full circle. This spring, , the nonprofit owner — still affiliated with the same Catholic order of sisters — plans to demolish most of the 226-bed Franciscan Health Hammond complex, leaving only eight beds, an emergency department, and outpatient services. The move cost 83 jobs at the hospital and 110 more at a long-term acute-care center that rented space there.

The news stung many in this Rust Belt city of nearly 80,000 people, who have watched businesses — and neighbors — flee Hammond for decades. It’s especially painful, they say, because the hospital system has dedicated more than half a billion dollars in recent years to new facilities in wealthier, less-diverse communities.

“It’s deplorable that a Catholic institution like the Franciscans would make a financially motivated decision and leave thousands of people potentially at risk,” said Mayor Thomas McDermott Jr., who complained that he was informed of the downsizing barely two hours before it was announced publicly. “I’m not trying to be alarmist, but people are gonna die because of this decision. And they know it.”

But the larger question is whether Hammond needs a hospital with hundreds of beds, given the shifts in medical practice and transportation in the 21^st century. Only 50 to 60 of its beds are full on most days, said hospital CEO Patrick Maloney. Another Franciscan Alliance hospital is only 6 miles away. Much more care today is being delivered on an outpatient or virtual basis than even five years ago.

And the Hammond site has had quality concerns. It rates only one out of five stars on , the lowest possible score and worst of any of the nine rated hospitals in its county.

“Stewardship of our resources is one of the components of our Catholic mission,” Maloney stated in an email. “Key to that is efficient delivery of care.”

He noted that Franciscan is investing $45 million to transform the campus and will continue to operate a medical clinic there for uninsured or underinsured patients, as well as services like imaging, a medical lab, and prenatal care.

While rural hospital closures often get more attention, cities like Hammond have also been prone to losing medical services, as health systems adjust to changes in care, and opt to invest in places where more people have private insurance. But the shutdowns raise questions about the changing mission of nonprofit hospitals — and whom they help.

Since the 1930s, the urban hospitals most likely to close are those serving low-income, minority populations, according to research by , professor at the Boston University School of Public Health. He calls large swaths of Detroit and New York City “medical wastelands.”

When the city hospital in Hartford, Connecticut, contracted in the 1970s, it kept its emergency room running — until that got too expensive, Sager said. “I predict, within a decade, despite the best intentions of everyone involved, it will prove financially unsustainable to support an eight-bed hospital plus ER in Hammond,” he said.

Hammond’s population is down about a third from its peak in the mid-20th century. Like other former manufacturing hubs in the Midwest and Northeast, the city has been hollowed out by deindustrialization and white flight to suburban areas. It is in the part of Indiana, affectionately known as “the Region,” that’s essentially an extension of south Chicago, crisscrossed with freight train tracks, dissected by interstates, littered with factories in various states of decay.

On a recent overcast morning, Franciscan Health Hammond’s parking garage and surrounding lots were mostly empty. A sprinkling of people trickled out of the hospital. A sign advised that birthing services had moved to the suburbs.

The that covers the hospital and its surrounding neighborhood has a poverty rate of 36%, with a median household income of $30,400. Its population is 82% Black and/or Latino. The hospital treats a large share of patients on Medicaid, the government insurance program for low-income people, which typically pays health care providers a lower rate than Medicare or private insurance.

For Franciscan Alliance, the driving factors in shrinking Franciscan Health Hammond were the costs required to maintain the aging infrastructure, and less demand for care expected in that part of “the Region,” Maloney said.

He said Hammond residents are welcome at Franciscan Alliance’s hospital 6 miles away in Munster, Indiana. The organization has spent at least $133 million in recent years on that facility, located in a wealthier suburb only a few blocks from a larger, competing hospital.

But for Carlotta Blake-King, a Hammond school board trustee, that’s not close enough, especially since the area doesn’t have much mass transit. “I’m a senior citizen. I don’t like to drive,” she said. “Everybody can’t afford a car.”

Free transportation to medical appointments, though, is offered through the and .

Franciscan Alliance has replaced older hospitals in other communities, albeit a few miles from their original locations, spending $333 million on a new medical center in Crown Point, Indiana, and $243 million in Michigan City, Indiana. In 2018, however, it shuttered a century-old hospital in Chicago Heights, Illinois, a working-class Chicago suburb demographically similar to Hammond.

The missions of many nonprofit hospital chains like Franciscan Alliance have evolved. Around the turn of the 20th century, hospitals often deliberately set up shop in less-fortunate neighborhoods, with community members providing time, money, and supplies. When St. Margaret opened, for example, local farmers donated food. The Internal Revenue Service exempted so-called charity hospitals from paying taxes.

Today, “hospitals are operating as corporations, as moneymaking business entities, and their decisions are largely driven by financial concerns,” said , a professor of accounting and health policy at Johns Hopkins University. “The line between the current nonprofit hospitals and for-profit hospitals is very, very murky.”

In 2018, nonprofit hospitals provided less unreimbursed Medicaid and charity care than their for-profit counterparts, Bai’s . However, she noted, Franciscan Alliance spent more than the average nonprofit on both fronts.

Pat Vosti, a retired nurse from Hammond, worked in the cardiology unit, so she knows how time is of the essence in health care. She’s concerned about patients who have to be diverted to other hospitals. “It’s a matter of minutes, but minutes count in some instances, you know?” she said.

However, people have been bypassing the Hammond hospital for years. Along with its sister campus in Dyer, Indiana, it has only a 15% market share, according to a 2016 bond filing, compared with 45% for Franciscan’s Michigan City facility and 38% for Crown Point.

“Now, why they haven’t been using it could be a function of management choices made 15, 20 years ago: ‘Don’t build that new ER, don’t recruit those young doctors, don’t open a service for substance abuse,’” said , an adjunct professor at the Harvard T.H. Chan School of Public Health. “This is usually a gradual death. These places don’t suddenly go bad.”

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So does Gene Cox, 48. He hasn’t been homeless in more than seven years. That’s the point of this little development.

“This is the longest time I’ve stayed in one place,” said Cox, nursing coffee and a cigarette outside his tiny home after working second shift as a benefits administrator. “I’m very nomadic. I’ve moved around Wisconsin a lot over the last 22 years.”

After Cox got divorced in 2009, he bounced around rentals before living in his van for a year. He tried a local men’s shelter. He lasted only two nights.

Then in 2014, he heard about this community being planned by , a spinoff of the national movement against income inequality. Cox started helping with gardening, one of his passions. A few months later, he moved into one of its 99-square-foot houses (echoing the “99%” of the population that Occupy aimed to represent).

With housing costs rising, tiny homes are spreading as a solution to homelessness in California, Indiana, Missouri, Oregon, and beyond. Arnold Schwarzenegger garnered considerable publicity in December when he for homeless veterans in Los Angeles. It reflects a growing interest in outside-the-box ideas to get unhoused people off the streets, especially during winter in cold climates and amid the covid-19 pandemic.

“Anything that increases the supply of affordable housing is a good thing,” said , CEO of the National Alliance to End Homelessness. “We have a huge shortage of housing — around 7 million than there are households that need them.”

Housing and health are inextricably linked. In a of 64,000 homeless people, individuals living on the streets were more likely to report chronic health conditions, trauma, substance misuse, and mental health issues than those who were temporarily sheltered.

But not all tiny homes are created equal. They range from cabins with a cot and a heater to miniature houses with kitchens and bathrooms.

The communities themselves differ, too. Some are just “agency-managed shelters that use pods instead of the traditional gymnasium full of bunk beds,” said Victory LaFara, a program specialist with , a tiny-home encampment since 2000, in Portland, Oregon. Some are self-governing, like Dignity Village and Occupy Madison, and a few offer a .

Many are in remote parts of town, though — far from jobs, grocery stores, and social services. “There’s a balance between the benefits you get from the improved structure and the bad factors you could get from being in a worse location,” said , a housing researcher at the Johns Hopkins Carey Business School.

, executive director of the National Coalition for the Homeless, said he thinks tiny homes are a good emergency option, to protect people from the elements and violence, but are not long-term solutions, like increasing the number of living-wage jobs, the housing stock, and funding for housing vouchers.

“There’s been this theme since the ’70s that there are some people in society that are less deserving,” he said. “And the tiny home kind of fits within that mindset.”

Zoning regulations and building codes have prevented tiny homes from being built in some cities, as have . That opposition often fades once the communities are up and running, according to village organizers. “Since we moved into six years ago, there have been no documented crimes from anyone on this property in any of the adjacent neighborhoods,” said , president of Mobile Loaves & Fishes, a homeless outreach group in Austin, Texas, that operates the nation’s largest tiny-home project.

Madison, which has about 270,000 residents and is home to Wisconsin’s Capitol and flagship university, has three different types of tiny homes showcased in three locations.

Occupy Madison’s newest village opened in late 2020 about a mile north of its original site. Next to a shuttered bar, 26 Conestoga huts, resembling covered wagons from the old West, line a fenced parking lot. The 60-square-foot temporary structures will eventually be replaced by tiny houses, which occupants are expected to help build.

On the outskirts of town, in an industrial development near an interstate, the city’s new tiny-home project features parallel rows of 8-by-8-foot white prefabricated shelters that look like ice fishing shanties. Unlike the two Occupy settlements, this one has a full-time staff, including a social worker and an addiction counselor; on a recent day, residents streamed in and out of its cramped office, either to use the phone or grab a muffin or some cookies. People walked their dogs outside.

The 30 residents had previously been living in tents in Madison’s busy Reindahl Park.

“The city was solving a political problem, first and foremost,” said Brenda Konkel, president of Occupy Madison and executive director of . The so-called sheltered encampment cost about $1 million to set up and will run about $800,000 to $900,000 a year to operate.

City Community Development Director said housing people in a traditional shelter would be significantly cheaper in the short term. But tiny-home villages can often serve those who are either unwilling or unable to stay in a congregate setting, because they have pets or partners, have severe emotional or psychological issues, or are banned from the shelter system.

“Anybody that spent any time at Reindahl understood how unsafe and untenable it was for people who were staying there,” O’Keefe said.

, clinical director of Kabba Recovery Services, said residents’ substance use had increased since they arrived at the city-run site, perhaps because they finally had warmth and didn’t have to worry about keeping their belongings safe. She hopes their newfound quietude will also give them the space to recover when they’re ready.

For Jay Gonstead, a lifelong Madisonian who moved into the camp after it opened in November, the place has been a godsend. After a divorce, he lived in the tent city for seven months.

“Toward the end, it got really bad. I never thought in my lifetime I’d have to shoot Narcan into somebody, but I did,” he said, referring to the treatment that reverses opioid overdoses. “I witnessed a man be shot. I witnessed stabbings. That was not a good place.”

The 54-year-old sets out on his bike regularly to look for work. “I have a criminal history. I’m an alcoholic,” he said. “It makes it tough.”

But he’s noticed smiles on his neighbors’ faces for the first time he can remember. Electricity and hot showers — along with a sense of community — tend to have that effect, he said.

“When you’ve got a roof and a door that locks, that’s home,” he said, fighting back tears. “We’re not homeless.”

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“It’s not going to hurt, OK? I’ll hold your hand, I’ll hold your hand,” said her older sister, Alondra, 8. “Deep breath, deep breath.”

The medical assistant, Rachel Blancas, poked Victoria’s left arm for about a second. Victoria opened her eyes. And with that, the Macias sisters were among the first 5- to 11-year-olds to get the covid-19 vaccine in the Midwest’s largest city.

Their mom, Maria Lopez, took them out of school early last Thursday to stop by the mass immunization site on Chicago’s southwest side. “They have gotten every other vaccine available, so why not this one?” said Lopez, 43, a real-estate broker.

, a nonprofit health provider that is operating the site, has been the top pediatric covid vaccine provider in Chicago, according to the city’s Department of Public Health, administering about 10,000 immunizations to 12- to 17-year-olds. Now that the Food and Drug Administration has authorized the Pfizer-BioNTech shot for kids ages 5-11, the organization’s efforts may provide lessons for other places in the U.S. that have struggled to vaccinate children.

“People in the community trust us,” said Veronica Flores, manager of covid response for Esperanza, which has five medical clinics that see patients regardless of insurance or immigration status. “When the pandemic started, we were one of the first ones doing testing.”

At one point, she noted, Esperanza was responsible for more than half of all covid tests done in the city. The federally qualified health center’s patient population, which is about 90% Hispanic, has doubled in the wake of covid.

Everyone who works with patients at Esperanza is bilingual. The immunization site and is open five days a week, including to people without appointments. The clinic will even pay for patients’ Uber rides to get vaccinated.

If parents or guardians have questions or concerns about the pediatric vaccine, Esperanza connects them to one of its doctors.

Dr. , pediatric medical director, seeks to reassure patients, telling them the shot, which is given at a lower dose than for teens and adults, has been found to be both for 5- to 11-year-olds. The relatively mild side effects may include pain at the injection site, headaches and fatigue that could last a day or two. In addition, he reminds them that children are at risk from the virus.

“Around 2 million kids between 5 and 11 years old have been diagnosed with covid, and there’s been about 170 deaths,” Minier said. “That’s still too many. If we have something that can help prevent death or any sort of morbidity for kids for covid, then we should do it.”

Cynthia Galvan, a medical assistant at Esperanza who lives nearby, brought her 10-year-old son, Andres, to get the shot Thursday. She hopes it will ensure her family has a better Thanksgiving than last year, when several of her relatives were sick with covid-19.

“Everyone at home was already vaccinated, except him,” said Cynthia, 34. “There’s 10 of us.”

of 58.2% for 12- to 17-year-olds is higher than the of about 50%, largely because of the work of community health centers like Esperanza, said city Health Commissioner Dr. . Not only are they familiar with the local languages and cultures, but they’re also the type of places where the whole family is likely to get immunizations, starting with grandparents last winter.

“We know the biggest predictor of whether a child gets a vaccine is whether the parent or guardian is vaccinated,” Arwady said.

She still worries about the estimated 750,000 residents of the city without immunity to covid. Young Black Chicagoans have lagged behind other groups in getting the shot, and she’s concerned outbreaks could occur this winter among those unvaccinated networks.

“One way or another, your immune system is likely to learn its covid lesson and probably over the next few months,” Arwady said. “So either that’s through the safer way of getting vaccinated or taking your chance of getting infected.”

The city is working to increase vaccine uptake by offering $100 gift cards, administering free shots at home to anyone who wants them, and giving all public school kids the day off this Friday to get immunized.

Last week, Esperanza Health Centers texted the families of each of its roughly 8,000 patients ages 5 to 11 to let their parents know the vaccine was available. The organization started distributing the shots to younger kids Wednesday morning, just hours after the Centers for Disease Control and Prevention . They will start giving out second doses in three weeks.

“I hate shots,” said Benicio Decker, 7, as he played a game on an iPad in the clinic’s waiting area Thursday. “The only time I like shots is when we get ice cream after.”

But the Chicago second grader said he was willing to withstand a little discomfort “because I want to protect my family, me, my friends, my teacher.”

On the brisk fall afternoon, families with young kids streamed in and out of the site, a 23,000-square-foot former gym with exposed ventilation, hanging fluorescent lights and a blue-speckled rubber floor. As Disney songs played over the loudspeakers, the children stopped to take pictures in front of astronaut-themed, balloon-covered photo backdrops the health center had set up.

“They do a great job of making information available where people are,” said Benicio’s mom, Esmie De Maria, 39. “They have flyers up at restaurants, laundromats, the grocery store. They’re not expecting people to come to them.”

Esperanza has also done pop-up vaccine clinics at local schools and parks.

De Maria said she didn’t run into waitlists as she had at other places in the city. She even enlisted the health center to teach vaccine workshops to her colleagues at a local neighborhood organization.

Esperanza is a trusted institution in a largely Hispanic part of the city, De Maria said — the health center’s name means “hope” in Spanish. and , Latinos have been less likely than whites and Asians to be immunized against the coronavirus, though that gap has been closing.

“People of color have every right, historically, to be wary of vaccinations,” said De Maria, noting that many women in her ancestral home of Puerto Rico were coerced into being . “It’s embedded in our DNA to be skeptical.”

But she said she hopes everyone will consider getting immunized, for the good of the community. “This isn’t just for him,” she said, gesturing to Benicio.

Over at the vaccine station, Blancas, the medical assistant, told Benicio the shot would feel like a mosquito bite. “You’re being really brave. You’re earning that ice cream,” his mom said.

When Blancas stuck Benicio’s arm with the needle, the boy, holding tight to his Batman teddy bear, let out a quiet “Ow.” Afterward, he said he’d just felt a little pinch.

“You are officially vaccinated,” his mother told him, as he sat playing with her phone in the observation area for 15 minutes to make sure he didn’t have any dangerous allergic reactions. “He’s going to be one of the first kids at his school to get vaccinated. He’s a little superhero.”

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But when the Illinois State Dental Society met with key lawmakers virtually for its annual lobbying day in the spring, the proposals to allow dental hygienists to clean the teeth of certain underprivileged patients without a dentist seemed doomed.

State Sen. , a Republican legislative leader, warned against the bills even if they sounded minor. “It’s just getting the camel’s nose under the tent,” he said in an audio recording of the meeting obtained by KHN. “We’ll have, before long, hygienists doing the work that, if they wanted to do, they should have gone to dental school for.”

The senator added that he missed “the reception and the dinners that you guys host” and the “nice softball questions that I usually get” from the dental society’s past president, who happens to be his first cousin.

The bills never made it out of committee.

The situation in Illinois is indicative of the types of legislative dynamics that play out when lower-level health care providers such as dental hygienists, and try to gain greater autonomy and access to patients. And the fate of those Illinois bills illustrates the power that lobbying groups such as the Illinois dental society have in shaping policies on where health professionals can practice and who keeps the profits.

“There’s always a struggle,” said , a researcher for the Center for Health Workforce Studies at the University of Albany in New York. “We have orthopedists fighting podiatrists over who can take care of the ankle. We have psychiatrists fighting with clinical psychologists about who can prescribe and what they can prescribe. We have nurses fighting pharmacists over injections and vaccinations. It’s the turf battles.”

In 2015, the was revised to let hygienists treat low-income patients on Medicaid or without insurance in “public health settings” — such as schools, safety-net clinics and programs for mothers and children — without a dentist examining them or being on-site. Besides doing cleanings, the hygienists can take X-rays, place sealants and apply fluoride.

This year, lawmakers proposed bills that would have expanded those settings to include , and .

The state dental society, in a , wrote that the fact it took years for hygienists to develop their public health training program shows “they have no real interest in providing access to care to needy patients.”

As it is, Illinois trails many in allowing dental hygienists unsupervised contact with patients. In Colorado, on the extreme end, hygienists can own practices.

“It’s just the nature of the beast politically in Illinois. The dental lobby isn’t as strong in those other states,” noted Margaret Vaughn, executive director of the . “The Illinois State Dental Society is much more powerful, and they’re much more organized than the hygienists are politically.”

From 2015 to 2019, the dental society spent more than $55,000 on lobbying, for its annual gathering and meals for lawmakers, typically hosted at a swanky Italian spot near the state Capitol in Springfield, according to . In the same period, the Illinois Dental Hygienists Association reported spending nothing in its lobbying reports. (Neither group has listed any expenditures since the beginning of 2020.)

The dental society has two exclusive lobbyists and four lobbying firms on contract, state records show. The hygienist group, meanwhile, employs no lobbyists and contracts with just one firm.

The dental society donates generously to both Republicans and Democrats. Its had nearly $742,000 in cash on hand as of June 30, according to Reform for Illinois’ Sunshine Database. While the PAC has given $4,050 since 2014 to support the campaigns of state Sen. , a Democrat who sponsored the nursing home bill, the database shows it has contributed far more to help elect Syverson, the senator who spoke at the conference. It has given to his campaigns since 1999, with bigger annual gifts than to Bush.

“I receive contributions from many groups on both sides of issues,” Syverson emailed KHN. “They are not contributing to influence my vote on a particular bill. In fact, if a PAC sent a check while we were negotiating or voting on an issue they are involved with, I would not accept it.”

The hygienists’ PAC gave $1,100 to the campaign committee of Bush, , but nothing to Syverson. Bush did not respond to requests for comment.

“The bottom line is, if you don’t have a healthy mouth, you don’t have a healthy body,” said Ann Lynch, director of advocacy and education for the . “It only makes sense that we would remove any barriers that do not allow a licensed health care provider to practice at the top of their scope.”

But Dave Marsh, a lobbyist for the , said it would be dangerous for hygienists to treat nursing home residents, who are often elderly and sick.

“I just don’t feel anybody with a two-year associate’s degree is medically qualified to correct your health,” Marsh added. “They’re trained to clean teeth. They take a sharp little instrument and scrape your teeth. That’s what they do. That’s all they do.”

He said the problem is not a shortage of dental professionals but, rather, a lack of dentists who can afford to accept Medicaid patients — and “nobody wants to raise taxes to actually be able to reimburse” dentists at higher rates.

He also pointed to the scarcity of research on the benefits of dental hygienists having more professional freedom.

Langelier acknowledged that little academic literature exists on this topic, in part because of inadequate data collection on oral health. But in 2016, a found that, as dental hygienists gained more autonomy, fewer people had teeth removed because of decay or disease. And she said Medicaid data shows more children had dental visits as hygienists expanded .

“I don’t want this to be acrimonious,” said Laura Scully, chair of the access-to-care committee of the . “I would like it to be more of a collaboration, because truly that’s what this is about: getting together so we can help more people.”

Karen Webster works as a dental hygienist for the , a free clinic in St. Charles, Illinois, about 40 miles west of Chicago. In the past, she could only briefly screen patients before scheduling them with one of the center’s volunteer dentists, often months out.

“Imagine if you had a toothache and the doctor couldn’t see you that day,” she said, noting that her patients have low incomes. “They can’t afford the services. They wait till something hurts.”

But since becoming a public health dental hygienist, Webster now does immediate cleanings, takes X-rays she sends to teledentists for exams, and applies a solution called silver diamine fluoride that can halt tooth decay.

“The whole thing, start to finish, it’s just a lot more efficient,” she said.

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One day in December, they set out with cards and candy canes and dropped by the homes of every eighth grader at in Terre Haute, a city of more than 60,000 near the Illinois border where both Indiana State University and the federal death row are located. They saw firsthand how these kids, many living in poverty and dysfunctional families, were coping with the pandemic’s disruptions to their academic and social routines.

“You just have a better concept of where they’re coming from and the challenges they really do have,” Goulding said. “When you’re looking at that electronic grade book and Sally Lou hasn’t turned in something, you remember back in your mind: ‘Oh, yeah, Sally Lou was home by herself, taking care of three younger siblings when I stopped by, and I spotted her helping Johnny with his math and she was helping this one with something else.’”

The school’s experience provides a window into the hardships millions of families across the country have endured since last March, and exemplifies why education isn’t the only reason many Americans want schools to fully reopen. Schools like Sarah Scott help hold their communities together by providing households with wide-ranging support, which has become much tougher during the pandemic.

“A lot of our students are struggling emotionally,” said Sarah Scott’s principal, . “They’re stressed because they’re falling behind in their work. Or they’re stressed because of the conditions they’re living with at home.”

Even before the coronavirus struck, kids at Sarah Scott faced significant obstacles that compounded the normal social challenges and surging hormones of middle school. They live in Vigo County, which has the state’s and . Nearly 90% of students qualified for free or reduced-fee lunches. Some showed up needing to shower and change at the school, which has a food pantry that also offers clothes and hygiene products.

Things got more difficult for students when covid threw Sarah Scott’s normal schedule into disarray. Initially, the school went totally remote, then moved to partially in-person for the start of the 2020-21 school year. When covid spiked in October, Sarah Scott went remote again because not enough substitute teachers could fill in for quarantining staff. Since January, students have been spending part of each week in the school building, with no plans as of early March to open fully.

Kids were given laptops to use at home. But internet access can be problematic.

“Internet has been the worst,” said Samantha Riley, mother of seventh grader Mariah Pointer. “So many people are on it, it shuts down all the time.”

When that happens, she uses the Wi-Fi emitting from the school bus that sits in front of her apartment complex, one of several parked around the community to fill the gaps.

Even when the internet works, though, keeping kids on task at home isn’t easy. Heather Raley said she often cries from the stress of trying to make her seventh grade daughter engage online. “It just seems like we’re always butting heads over this,” Raley said. “It’s just a bigger battle getting the work done.”

As in many other communities, students are falling behind academically. Some don’t do any of their e-learning activities. Sarah Scott’s reports to child protective services for educational neglect — when caregivers aren’t getting their children to either in-person or remote classes — have more than tripled this school year.

Brown said she also worries about physical neglect and abuse, which is harder to detect when interacting with students remotely. “If you’re in an abusive home and you have to be there five days out of the week because you’re doing remote learning, you’re in that environment even more,” she said.

More time at home can also mean doing without necessities, including food.

The school helps by offering free breakfasts and lunches for in-person students and to-go lunches on remote days. Sometimes, the principal . The school recently secured a microwave for one family and an inflatable mattress for a student who’d been sharing a bed with his grandmother.

For some kids, the stress of the pandemic has worsened emotional problems and mental illness. Recently, a former Sarah Scott student who had moved out of state logged into her former teacher’s virtual class to say she planned to kill herself. The school contacted police, who checked on her. Referrals for suicidal students are up fourfold, Brown said.

School social worker said it’s been tough counseling kids online or through text messages.

“I am all about building relationships and being in person and being able to dap you up or give you a hug and be like, ‘Hey, what’s up?’” she said, using a term for various greetings like fist bumps or elaborate handshakes. “So being online is extremely difficult for me, because you can’t really tell the tone of your student. When I’m talking to you in person, I can read your body language and I can gauge where you’re at.”

Right now, she said, the psychological well-being of her middle schoolers is even more important than education.

Many students, such as eighth grader Trea Johnson, come up against challenges on both fronts. Trea transferred to Sarah Scott two days before covid ended in-person learning.

“We struggle with school anyway,” said his mom, Kathy Poff. “Then when this pandemic came along, it just knocked our feet out from under us.”

His grades plunged. He began to hate school, Poff said. He didn’t attend his daily video meetings with his teachers. His mother fought with him to complete his online assignments.

“I usually get pretty bored,” said Trea, whose long, straight hair sometimes falls over his eyes.

Poff found him a therapist he meets with once a week. She said his mood and academic productivity have improved. He wants to be a computer programmer and has been coding in his spare time lately. She also moved his computer into her bedroom so she could better monitor him and has started paying him to do his schoolwork.

“I can’t even imagine what it would be like to be a 13-year-old going through this pandemic,” said Poff, 51, a single mother. “They’re going through changes anyway, adjusting to adolescence and figuring out who they are, and they don’t even have a social group to figure that out.”

Goulding, the math teacher, said she’s glad she and her co-workers can help provide stability and continuity during this trying period. One recent night, for example, she got a call from a truant boy’s grandmother, who said she was in poor health and raising him alone. The next day, the principal and social worker picked him up and drove him to school.

Still, Goulding lamented not seeing her most vulnerable students on the days when they are remote.

“How do I check on my kids? How do I make sure they’re eating? How do I make sure,” she paused to compose herself, her voice quavering, “they’re safe?

“You’re no longer thinking about, ‘How are they doing on their polynomials?’ You’re thinking about, you know, the reality of life.”

[Correction: This article was updated at 12:30 p.m. ET on March 25, 2021, to correct the grade level of Heather Raley’s daughter.]

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“We’re in a bad dream all the time,” she said during a recent day treating coronavirus patients at , which was founded in the early 20th century to care for the city’s poorest immigrants. “I can’t wait to wake up from this.”

Prendkowski believes some of the death and suffering could have been avoided if more of these people had regular treatment for the types of chronic conditions — asthma, diabetes, heart disease — that can worsen covid. She now sees a new reason for hope.

Amid a deadly virus outbreak that has , Illinois recently became the first state to provide public health insurance to all low-income noncitizen seniors, even if they’re in the country illegally. Advocates for immigrants expect it will inspire other states to do the same, building on efforts to cover undocumented children and young adults. Currently, Democratic legislators in California to expand coverage to all low-income undocumented immigrants there.

“The fact that we’re going to do this during the pandemic really shows our commitment to expansion and broadening health care access. It’s an amazing first step in the door,” said Graciela Guzmán, campaign director for , a group that advocates for universal coverage.

Undocumented immigrants without health insurance often skip care. That was the case for Victoria Hernandez, 68, a house cleaner who lives in West Chicago, a suburb. The Mexico City native said she had avoided going to the doctor because she didn’t have coverage. Eventually, she found a charity program to help her get treatment, including for her prediabetes. She said she intends to enroll in the new state plan.

“I’m very thankful for the new program,” she said through a translator who works for the , a nonprofit that coordinates charity care for the uninsured in DuPage County, the state’s second-most populous. “I know it will help a lot of people like me.”

Healthy Illinois pushed state lawmakers to offer health benefits to all low-income immigrants. But the legislature opted instead for a smaller program that covers people 65 and older who are undocumented or have been legal permanent residents, also known as green card holders, for less than five years. (These groups don’t typically qualify for government health insurance.) Participants must have an income at or below the federal poverty level, which is $12,670 for an individual or $17,240 for a couple. It like hospital and doctor visits, prescription drugs, and dental and vision care ( stays in nursing facilities), at no cost to the patient.

The new policy continues a trend of expanding government health coverage to undocumented immigrants.

Illinois was the first state to cover children’s care — a handful of states and the District of Columbia — and for unauthorized immigrants. In 2019, California to offer public coverage to adults in the country illegally when it opened eligibility for its Medi-Cal program to all low-income residents under age 26.

Under federal law, undocumented people are generally not eligible for Medicare, nonemergency Medicaid and the Affordable Care Act’s health insurance marketplace. The states that do cover this population get around that by using only state funds.

An estimated 3,986 undocumented seniors live in Illinois, according to a by Rush University Medical Center and the Chicago demographer group — but that number is expected to grow to 55,144 by 2030. The report also found that 16% of Illinois immigrants 55 or older live in poverty, compared with 11% of the native-born population.

Given the outgoing Trump administration’s , some advocates worry that people will be afraid to enroll in the insurance because it could affect their ability to obtain residency or citizenship. , senior attorney for health care justice at the Shriver Center on Poverty Law in Chicago, said she and others are working to assure immigrants they don’t need to worry. Because the new program is state-funded, federal guidance suggests it is not subject to the designed to keep out immigrants who might end up on public assistance.

“Illinois has a legacy of being a very welcoming state and protecting immigrants’ privacy,” Kovach said.

The Illinois policy is initially expected to cover 4,200 to 4,600 immigrant seniors, at an approximate cost of $46 million to $50 million a year, according to John Hoffman, a spokesperson for the . Most of them would likely be undocumented.

Some Republicans the coverage expansion, saying it was reckless at a time when Illinois’ finances are being shredded by the pandemic. The Illinois Republican Party “free healthcare for illegal immigrants.”

But proponents contend that many unauthorized immigrants pay taxes without being eligible for programs like Medicare and Medicaid, and that spending on preventive care saves money in the long run by cutting down on more expensive treatment for emergencies.

State Rep. , a Chicago Democrat who helped shepherd the , advocated for a more expansive plan. She was inspired by her uncle, a 64-year-old immigrant who has asthma, diabetes and high blood pressure but no insurance. He has been working in the country for four decades.

She wanted the policy to apply to people 55 and older, since the vast majority of those who are undocumented are not seniors (she noted that a lot of older immigrants — 2.7 million, according to — obtained legal status under the 1986 federal amnesty law).

The real impact of this plan will likely be felt in years to come. At Esperanza Health Centers, one of Chicago’s largest providers of health care to immigrants, 31% of patients 65 and older lack coverage, compared with 47% of those 60 to 64, according to , who oversees patient access there.

Ramirez said her uncle called her after seeing news of the legislation on Spanish-language TV.

“And I said to him, ‘Tío, not yet. But when you turn 65, you’ll finally have health care, if we still can’t help you legalize,’” Ramirez recalled, choking up during a recent phone interview.

“So it is a reminder to me that, one, it was a major victory for us and it has meant life or a second chance at life for many people,” she said. “But it is also a reminder to me that we still have a long way to go in making health care truly a human right in the state and, furthermore, the nation.”

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“I’ve always considered myself homeless because I don’t have a home,” he said on a recent crisp, fall day in the shelter’s sun-splashed courtyard. But he’s fortunate, said Barnes, 44. He’s never had to sleep outside when it was below zero or snowy. He always found a friend’s place, building or shelter to crash in. He knows others aren’t so lucky.

As winter approaches, — perhaps thousands — of people in this city of nearly 3 million are living on the streets: some in encampments, others hopping from corner to corner. And the numbers could grow without more federal aid and protections amid economic pressures from the pandemic.

This year, the coronavirus has forced homeless shelters to limit the number of beds they can offer. , for instance, is operating at roughly half its normal capacity of 740. And COVID-19 cases are rising as temperatures drop.

“What happens if we’re in the midst of a pandemic and a polar vortex happens?” said Doug Schenkelberg, executive director of the . “We’re trying to keep the contagion from spreading and keep people from dealing with hypothermia. Is there the infrastructure in place that can handle that type of dual crisis?”

Cold-weather cities across the nation are seeking creative ways to cautiously shelter homeless people this winter. Exposure to the elements kills individuals staying outside every year, so indoor refuges can be lifesaving. But fewer options exist nowadays, as coronavirus concerns limit access to libraries, public recreation facilities and restaurants. And in official shelters, safety precautions — spacing out beds and chairs, emphasizing masks and hand-washing, testing — are critical.

“The homeless check off most boxes in terms of being the most susceptible and most vulnerable to the COVID-19 pandemic, and most likely to spread and most likely to die from it,” said Neli Vazquez Rowland, founder of , a Chicago nonprofit that has been operating a “medical respite” isolation facility for homeless individuals with the coronavirus.

Demand for shelter could grow. Stimulus checks helped stave off some of the pandemic’s initial economic pain, but Congress has stalled on additional relief packages. And though the Trump administration has ordered a moratorium on evictions for tenants who meet certain conditions through the end of the year, . Some states have their own prohibitions on evictions, but only Illinois, Minnesota and Kansas do in the Midwest.

At the , a publicly funded homeless shelter in Wisconsin, the pandemic complicates an already challenging situation.

“We’re like many communities. We never really have completely enough space for everybody who is in need of shelter,” said Cindy Krahenbuhl, its executive director. “The fact that we’ve had to reduce capacity, and all shelters have, has created even more of a burden on the system.”

She said outreach teams plan to connect individuals living outside with an open bed — whether at a shelter, a hotel or an emergency facility for homeless people at risk for COVID — and get them started with case management.

“The reality is we’ve got to make it happen. We’ve got to have space for folks because it’s a matter of life and death. You cannot be outside unsheltered in this environment too long,” said Rob Swiers, executive director of the in Fargo, North Dakota, where the average high in January is 18 degrees.

His shelter, Fargo’s largest, plans to use an insulated, heated warehouse to provide roomy sanctuary for clients.

In Minnesota’s Ramsey County, home to St. Paul, an estimated 311 people are living on the streets, compared with “dozens” at this time in 2019, according to Max Holdhusen, the county’s interim manager of housing stability. The area just had a .

The county has been using hotel rooms to make up for the reduction in shelter beds, and recently agreed to lease an old hospital to shelter an additional 100 homeless people.

The city of Chicago has set up emergency shelters in two unused public school buildings to replace beds lost to social distancing. As it does every winter, the city will also operate warming centers across Chicago, although this year with precautions such as spacing and masking.

In September, the city — mostly from the federal CARES Act for coronavirus relief — to an “expedited housing” program aiming to get more than 2,500 people housed in the next few years. The initiative plans to financially incentivize landlords to take risks on renters they might normally avoid, such as those with criminal histories or poor credit. The nonprofit in charge, , is also hosting “accelerated moving events,” in which its staffers descend on a shelter, encampment or drop-in center and work to house everyone in that facility.

“In the ideal world, we would have permanent housing for them,” said Dr. , senior vice president of community health equity at Chicago’s Rush University Medical Center. “That is the only way we can protect people’s health. That’s the fundamental health issue. It’s a fundamental racial justice issue. It’s a fundamental social justice issue.”

Even though Black people make up only a third of Chicago’s population, they account for roughly three-fourths of those who are homeless, .

Dr. , a family physician with Lawndale Christian Health Center on the city’s largely impoverished West Side, also called safely sheltering and housing people this winter a racial equity issue.

“We know that people who are African American have a higher prevalence of hypertension, of diabetes, of obesity, of smoking, of lung issues,” he said. “So they are hit harder with those predisposing conditions that make it more likely that if you get coronavirus, you’re going to have a serious case of it.”

Then add the cold. Dr. , an infectious disease specialist from the University of Illinois Hospital in Chicago, said hypothermia doesn’t increase the chances of contracting the virus but could aggravate symptoms.

As of Sept. 30, according to All Chicago, 778 people were unsheltered in the city. However, that number includes only people who are enrolled in homelessness services, and are even higher.

Some homeless people who plan to live outside this winter said they worry about staying warm, dry and healthy in the age of COVID-19. Efren Parderes, 48, has been on the streets of Chicago since he lost his restaurant job and rented room early in the pandemic. But he doesn’t want to go to a shelter. He’s concerned about catching the coronavirus and bedbugs, and doesn’t want to have to obey curfews.

He recently asked other unsheltered people what they do to keep warm during the winter. Their advice: Locate a spot that blocks the wind or snow, bundle up with many layers of clothing, sleep in a sleeping bag and use hand warmers.

“This is going to be the first time I’ll be out when it’s really cold,” he said after spending a largely sleepless night in the chilly October rain.

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Corrections officers stood watch as Porter held her daughter, Gianna, to her chest for the first time. Back at a , Gianna slept in a crib in her mother’s cell, about 2 feet from her pillow.

The prison program allowed Porter to keep her baby with her — including when she went out into the yard — until her discharge nearly a year later. She didn’t recall ever bonding so closely with her previous 11 kids. She finally felt her life moving in a positive direction.

“I didn’t want to be a messed-up person,” she said. “I didn’t want to be a messed-up mom once I realized what a real mom is.”

When Porter was released in 2012, however, she didn’t know how to stay on that path and resorted to what she knew: drugs and crime. She never returned to prison, but her struggles eventually led to a new mission of supporting incarcerated moms as they adjust to life on the outside.

This month, a program Porter developed called Mothers on the Rise is set to launch in the same unit where the 46-year-old raised her daughter. The project, among the first of its kind, aims to help formerly incarcerated mothers maneuver a post-prison world that can often be unwelcoming.

Research shows that recently incarcerated moms are a variety of mental and physical health problems and .

“They’re released with maybe no place to stay and go to. And if they do have a place, it may be transient. They don’t have money, might not have a cellphone — and they have to take care of a baby,” said , an Indiana University public health professor who is advising Porter on her project. “How does one navigate all of that?”

The number of incarcerated women in the United States exploded from about to , with African American women imprisoned at twice the rate of white women.

But incarcerated women often lack programs that help them transition back into society, even though they expressed more of a need for them than have men or juveniles. There are also few reentry resources outside of prison, especially those designed for the of imprisoned women who have children.

The group “at the greatest disadvantage coming out of prison is going to be women,” said , a leading expert on prison reentry and researcher for the nonprofit research organization . “Family support for women is — we found pretty consistently across our data — much less than what was available for men.”

give birth while incarcerated, but Indiana is that allows new mothers to raise their babies in prison. The nursery — where moms and infants have private rooms and get help from inmates who are trained to be nannies — assists the women in planning for reentry with a checklist of needs and services. But until now, there’s been no peer support or mentoring for new moms or moms-to-be from anyone who’s been through it.

A Chance Encounter

Until recently, Porter lived such a chaotic, difficult life that she contemplated suicide. Her early years were filled with abuse and neglect. She’d spent much of her adulthood behind bars, mostly for fraud and forgery.

She thought the last time she left prison would be different. But when she and Gianna got out, they bounced around from place to place for a few years. Porter tried to survive the only way she knew how.

“My scum of the pond was I took advantage of anything — however I had to get money. I was just a con artist,” she said. “I’ve been charged with prostitution. I was actually charged with it, not doing it, but … when you’re a crack addict, you’re going to do anything you need to do to get that dope.”

So, in March 2019, she planned to take her life. She had a gun at the ready.

Then there was an unexpected visitor at her apartment. It was Ashley Phillips, project manager for a program Porter was involved in, .

Turman, the IU professor, had started that program in 2018 to help lower the infant death rate in a — and — with one of the highest in the nation. The project trains women who have overcome personal struggles to develop initiatives and policies that support other vulnerable moms.

Porter had begun attending the training that same year, but only because it offered $300 in gift cards. She never considered herself a community leader and didn’t think she had any business telling women how to be mothers.

When Phillips stopped by that day, she handed Porter a flower, comparing it to the women in the project: You plant a seed, watch it grow, and it eventually blossoms into something beautiful.

“She actually saved my life,” Porter said. “I had sent the kids to their dad’s. I was overwhelmed, and I wasn’t sad about taking my life. I was just so tired and ready. … Then Ashley came.”

From that day until she graduated last December, Porter stuck with the leadership training. She’d been hoping to help other moms since she was in prison, and the training gave her the tools to start her own program.

Mothers on the Rise was born.

Program Offers Support and Savings

Porter’s idea drew the interest of the , which is providing nearly $60,000 in one-time funding for the project. Agency spokesperson Jeni O’Malley said it “aligns with our priorities of reducing preventable deaths among women and children, reducing health disparities and inequities, and strengthening mental, social and emotional well-being.” The program will be evaluated after the first year for possible future funds and expansion.

The state is allowing women in the prison nursery to join the initiative, albeit virtually for now, because of coronavirus. Indiana stands to save money if the women stay out of prison; it to keep them locked up.

Mothers on the Rise will initially assist 10 women, helping them secure housing, child care and, if needed, addiction and mental health treatment. Porter will advise them 90 days before their release and another 90 days afterward on tasks such as connecting with doctors, finding employment and opening bank accounts.

The program will also pay for three months of child care and bus fare for the women and provide infant supplies such as strollers, baby wipes and clothing.

Porter will operate in tandem with the nursery’s social worker.

“My advantage is I know the street mentality, if you will,” Porter said. “I can cut the crap with the women from the beginning.”

She will act as a trusted guide in returning to a society that isn’t always so forgiving to ex-offenders, particularly mothers of young children.

“We like to ostracize those in the justice system and then we’re surprised when they fail — fail at reentering the community they’re not welcome in,” said Maranda Sparks, transitional health care manager for the Indiana DOC.

After she last got out of prison in 2012, Porter visited , a historical, 126-acre green space on Indianapolis’ south side. She snapped a picture of Gianna sitting on the ground next to a fountain. From time to time, she still looks at it, reminding her of a hopeful yet precarious moment in their lives.

Porter went back to the park on a recent late-summer day, the sky powder-blue. Gianna, now almost 9, was there too. So were Porter’s younger kids, 6-year-old Kevin and nearly 2-year-old Kamiah. The children raced one another and scrambled up trees. Flowers bloomed all around.

Watching her children play, Porter pondered how her life might have been different had someone helped her navigate the post-prison experience.

“I think I would have gotten here, but with more healing,” she said. “Because I didn’t even realize a lot of the stuff I was doing was wrong, that life didn’t have to be like that.”

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The 20-year-old wasn’t in jail. He wasn’t on the streets chasing drugs. Methadone to treat his opioid addiction was delivered to his door.

Hayes was staying at the hotel because of a coronavirus outbreak at the 270-bed Kirkbride Center addiction treatment center in Philadelphia, where he had been seeking help.

From early April to early May, 46 patients at Kirkbride tested positive for the virus and were isolated. The facility is now operating at about half-capacity because of the pandemic.

Drug rehabs around the country — including in Pennsylvania, Illinois, Indiana, Minnesota and Florida — have experienced flare-ups of the coronavirus or COVID-related financial difficulties that have forced them or limit operations. Centers that serve the poor have been hit particularly hard.

And that has left people who have another potentially deadly disease — addiction — with fewer opportunities for treatment, while threatening to reverse their recovery gains.

“It’s hard to underestimate the effects of the pandemic on the community with opioid use disorder,” said Dr., a professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health. “The pandemic . Normally that would drive more people to treatment. Yet treatment is harder to come by.”

Keeping Clients Safe

Drug rehabs aren’t as much of a COVID “tinderbox” as nursing homes, Alexander said, but both are communal settings where social distancing can be difficult.

Shared spaces, double-occupancy bedrooms and group therapy are common in rehabs. People struggling with addiction are generally younger than nursing home residents, but both populations are vulnerable because they’re more likely to suffer from other health conditions, such as diabetes or cardiovascular disease, that leave them at risk of succumbing to COVID-19.

To keep clients safe, some addiction treatment centers employ safety precautions similar to hospitals, like testing all incoming patients for COVID-19, noted Dr. , a senior scholar at the Johns Hopkins University Center for Health Security. But drug rehabs must avoid some strategies, such as keeping potentially intoxicating hand sanitizer on the premises.

Adalja said he hopes safety measures make people feel more comfortable about seeking addiction help.

“There’s not going to be anything that’s zero risk, in the absence of a vaccine,” he said. “But this is in a different category than going to a birthday party. You don’t want to postpone needed medical care.”

Still, some people requiring drug or alcohol rehab have stayed away for fear of contracting COVID-19. , CEO of the National Association of Addiction Treatment Providers, said many of its roughly 1,000 members saw their patient numbers down by much as 40% to 50% in March and April before bouncing back to 80%.

Unlike many other centers, Recovery Works, a 42-bed treatment center in Merrillville, Indiana, has seen more clients than normal during the pandemic. The facility had to close for a few days early on after a suspected COVID-19 case, but reopened after the person tested negative. It has since split its therapy sessions into three groups, staggered mealtimes and banned visitors, CEO Thomas Delegatto said. It then had an influx of patients.

“I think there are a variety of reasons why,” Delegatto said. “A person who was struggling with a substance use disorder, and who was laid off and a nonessential worker, might have seen this as an opportunity to go to treatment without having to explain to their employer why they’re taking two, three, four weeks off.”

He also noted that at the beginning of the pandemic as anxiety and isolation rose, and sheltering in place may have made some families realize that a loved one needed help for an addiction.

Centers Serving The Poor Hit Hard

Homeless and poor Americans, because they often live in close quarters, have been to catching COVID-19 — leaving drug rehabs dedicated to this population especially vulnerable.

Haymarket Center, a 380-bed treatment and sober living facility in Chicago’s West Loop that serves many people who are homeless, recently had an outbreak of 55 coronavirus cases among clients and staff members.

Two employees there tested positive for COVID-19 in late February, but testing was available then only for people showing symptoms, said Haymarket president and CEO Dan Lustig.

Haymarket worked with nearby Rush University Medical Center to test its clients. Twenty-six men, though asymptomatic, were found to be positive for COVID-19.

The center isolated those patients and eventually went from double- to single-occupancy rooms, improved its air filtration system and changed the way it served food. It now tests all new admissions.

“What we found was by doing serial testing we could tamp down the epidemic, not just at Haymarket but the whole city,” said Dr. , senior vice president for community health equity at Rush, which partnered with the city and other health systems on a COVID-19 .

The pandemic’s economic fallout has also forced some facilities to scale back. The Salvation Army is shuttering a handful of its roughly 100 adult rehabilitation centers nationwide due to COVID-related revenue losses. Those rehabs were funded by the organization’s resale shops, which were forced to close during stay-at-home orders.

“A lot of what we do relies on donations or items that were donated and then sold in our stores,” said Alberto Rapley, who oversees business development for the Salvation Army’s rehab facilities in the Midwest. “When financially we struggle, that is then felt on the other side.”

For instance, the Salvation Army drug rehab in Gary, Indiana, which is set to close in September, treated as many as 80 men at a time in its free, abstinence-based program. The next closest facility will be in Chicago, more than 30 miles away.

Outbreak Contained, But Beds Still Limited

Philadelphia’s Kirkbride Center also serves a mostly homeless and low-income population. Dr. Fred Baurer, the facility’s medical director, said Kirkbride was “flying blind” early in the pandemic, with little testing capacity and personal protective equipment.

On April 8, the first COVID-19 case appeared on Kirkbride’s long-term men’s wing. Over the next week, six more men on the unit showed symptoms and tested positive, as did 12 of the remaining 22. All quarantined at a .

Kirkbride started requiring face masks, testing all new clients for COVID-19 and prohibiting people in its various units from mingling.

The rehab has been about half-full lately — it’s usually closer to 90% occupied — partly because it stopped taking walk-in clients and confined new admissions to single rooms.

“I’m starting to feel more confident we’re past the worst of this, at least for now,” Baurer said.

Hayes, who has recovered from COVID-19 without experiencing any symptoms, was discharged from the facility June 15 to a sober living house. He plans to attend 12-step meetings regularly. He hopes to get his GED and eventually enter the mental health field.

He recognizes the need to stay vigilant about his recovery now, at a time of increased anxiety and despair.

“Regardless of the coronavirus or not, the addiction crisis ,” Hayes said. “It’s bad. It’s really bad.”

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“I’m somebody who struggles with my mental health quite a bit,” said the 17-year-old, who attends school in this suburb of about 77,000 people northwest of Chicago. “When you’re in school and not fully mentally there, it’s like you’re not really grasping anything anyway.”

Now Illinois is giving Linnea and students like her a new option for dealing with mental health lows. The state allows K-12 students in public schools to have five excused absences per school year for mental health reasons, another example of the growing acknowledgment among lawmakers that emotional and physical health are intertwined. The , which went into effect at the beginning of 2022, passed both chambers of the state legislature unanimously.

But such novel policies are, in many ways, a half-step toward addressing the crisis of teenage mental health that has been highlighted and exacerbated by the educational interruptions caused by the pandemic. Many parts of the country are woefully short of therapists who can work with students to address mental health problems.

that responded to a federal survey in April said more students had sought mental health services since the pandemic started. The National Center for Education Statistics’ polling also showed that only 56% of schools said they effectively provide mental health services to all students in need and just 41% reported hiring new staff members to help address students’ mental health needs.

Nearly half the nation lives in a designated mental health worker shortage area, according to , and an estimated 7,550 new professionals are needed to fill that void nationwide. Even in places where mental health professionals are more plentiful, they often do not accept public insurance, making them inaccessible to many kids.

In other states where lawmakers have implemented policies that allow students to take mental health days — including Arizona, California, Colorado, Connecticut, Maine, Nevada, Oregon, Utah, and Virginia — a lack of services for young people remains a concern.

Schools in , , , , and , have tried to narrow the gap through less costly solutions, such as in-class meditation, mindfulness rooms, and social-emotional learning. The latter became a of conservative lawmakers in recent months.

In a 2020 of young people’s greatest mental health needs, the top responses from 14- to 18-year-olds were access to mental health professionals and mental health absences or breaks as part of school or work.

“The more we can shift to a prevention mindset and integrate mental health promotion into schools from a young age, I see that as very key to helping reduce the needs for treatment that we see in young people,” said , director of the Center for Adolescent Health at the Johns Hopkins Bloomberg School of Public Health.

Education officials and mental health experts in Illinois say the mental health day policy is a good start toward tamping down a that had been growing during an era of school shootings and cyberbullying and then exploded during the pandemic. The move is another indication that schools are increasingly being relied upon to meet students’ social needs, from feeding, clothing, and vaccinating them to spotting abuse and neglect.

“I’ve been a teacher for 19 years, and this is as bad as I’ve seen it,” Ben Lobo said of the mental health of his students at Schaumburg High School.

, president and CEO of the Josselyn Center, a community mental health center north of Chicago, said the pandemic was “like putting a match to fuel.”

Before March 2020, the nonprofit received about 50 new clients a month, Resko said. That number is now 250, and two-thirds are children or young adults. The organization hired 70 therapists in the past year and has received an influx of requests for mental health counseling services from local schools.

Some critics of the new Illinois law note that it without ready access to child care. And a lack of data from some schools means officials don’t know whether the policy is being used.

The Illinois State Board of Education does not require schools to report how many students are taking mental health absences. KHN contacted the 10 in Illinois seeking that data. Six didn’t respond (the districts based in Elgin, Aurora, Algonquin, Oswego, Romeoville, and Schaumburg), and three said they either aren’t tracking that number (Chicago) or couldn’t release it (Rockford and Naperville).

School officials in Plainfield, Illinois — a town about 35 miles southwest of Chicago whose district has an enrollment of more than 25,000 — said 3,703 students took a combined 6,237 mental health days from early January through the end of the school year. That means nearly 15% of the student body used an average of 1.7 days per student. Officials also noted that 123 of those days were used on the last day of school before summer break.

The community had been seeking to provide more services to students even before the pandemic hit. In 2019, Plainfield Community Consolidated School District 202 added 20 social workers after data showed that overnight hospitalizations of any kind among students had more than doubled in the previous five years. That type of staff expansion just “doesn’t happen in education,” said , the district’s director of student services.

Under the state’s new policy, after students have a second mental health-related absence, district officials are required to refer them to the “appropriate school support personnel.” But many schools can’t afford the types of services Plainfield is offering, education officials say, and in rural areas they sometimes have trouble finding people to fill those jobs.

Chicago isn’t scheduled to have a social worker in each of its more than 600 schools until 2024. School social workers there often devote most of their time to students who receive special education services dictated by an individualized education program, or IEP.

“My door gets knocked on all day long. And I have to choose — am I going to reschedule my IEP services, or am I going to help a student who’s experiencing a crisis like right now?” said Mary Difino, a social worker at Brian Piccolo Elementary Specialty School on Chicago’s West Side. “The neighborhood I work in, there’s a lot of trauma, there’s a lot of community violence, there’s a lot of death and hardship.”

Fourteen-year-old Heaven Draper, an eighth grader at Brian Piccolo, said she had used two mental health days: one to take a break from a chaotic classroom environment — she said she sometimes feels more like a teacher than a student — and another to de-stress from the pressures of applying and testing for high schools in the city. “This is our first year back in person from quarantine,” she said. “It’s gotten overwhelming at times.”

Her classmate Ariyonnah Brown, 14, said she took a day to help defuse a situation with another student. She said she’d like to see more awareness of mental health among adults, especially in communities of color like hers.

“Parents need to be educated,” said Sheila Blanco, 57, a food distribution purchaser from Chicago whose , Carli, died by suicide in 2017. “So many parents, they don’t know what resources are, and even if there are resources, to help out the child or help them to help the child.”

Anna Sanderson, a Schaumburg High School junior, said she believes the policy is a good idea, just not for her. “If I miss a day because I’m overwhelmed or not feeling well mentally, I feel like when I go back, I’ll only be worse,” the 17-year-old said. “I’ll have to make up assignments and tests and be behind in my classes.”

But she said she hopes it’s a sign of greater support for students’ mental health. She said schools sometimes fail to acknowledge student suicides or to provide counseling that goes much beyond education.

“I feel like we get dismissed a lot of the times,” she said.

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They converted an old farmhouse into a seven-bed medical center. They treated their first patient for a broken leg amid carpenters hammering nails. Surgeons laid their patients on a kitchen table for operations.

The hospital — then named after St. Margaret, known for her service to the poor — eventually became one of the largest in the area. Hundreds of thousands of Indiana and Illinois residents took their first, or last, breaths there.

A hundred twenty-four years later, the hospital has, in a sense, come full circle. This spring, , the nonprofit owner — still affiliated with the same Catholic order of sisters — plans to demolish most of the 226-bed Franciscan Health Hammond complex, leaving only eight beds, an emergency department, and outpatient services. The move cost 83 jobs at the hospital and 110 more at a long-term acute-care center that rented space there.

The news stung many in this Rust Belt city of nearly 80,000 people, who have watched businesses — and neighbors — flee Hammond for decades. It’s especially painful, they say, because the hospital system has dedicated more than half a billion dollars in recent years to new facilities in wealthier, less-diverse communities.

“It’s deplorable that a Catholic institution like the Franciscans would make a financially motivated decision and leave thousands of people potentially at risk,” said Mayor Thomas McDermott Jr., who complained that he was informed of the downsizing barely two hours before it was announced publicly. “I’m not trying to be alarmist, but people are gonna die because of this decision. And they know it.”

But the larger question is whether Hammond needs a hospital with hundreds of beds, given the shifts in medical practice and transportation in the 21^st century. Only 50 to 60 of its beds are full on most days, said hospital CEO Patrick Maloney. Another Franciscan Alliance hospital is only 6 miles away. Much more care today is being delivered on an outpatient or virtual basis than even five years ago.

And the Hammond site has had quality concerns. It rates only one out of five stars on , the lowest possible score and worst of any of the nine rated hospitals in its county.

“Stewardship of our resources is one of the components of our Catholic mission,” Maloney stated in an email. “Key to that is efficient delivery of care.”

He noted that Franciscan is investing $45 million to transform the campus and will continue to operate a medical clinic there for uninsured or underinsured patients, as well as services like imaging, a medical lab, and prenatal care.

While rural hospital closures often get more attention, cities like Hammond have also been prone to losing medical services, as health systems adjust to changes in care, and opt to invest in places where more people have private insurance. But the shutdowns raise questions about the changing mission of nonprofit hospitals — and whom they help.

Since the 1930s, the urban hospitals most likely to close are those serving low-income, minority populations, according to research by , professor at the Boston University School of Public Health. He calls large swaths of Detroit and New York City “medical wastelands.”

When the city hospital in Hartford, Connecticut, contracted in the 1970s, it kept its emergency room running — until that got too expensive, Sager said. “I predict, within a decade, despite the best intentions of everyone involved, it will prove financially unsustainable to support an eight-bed hospital plus ER in Hammond,” he said.

Hammond’s population is down about a third from its peak in the mid-20th century. Like other former manufacturing hubs in the Midwest and Northeast, the city has been hollowed out by deindustrialization and white flight to suburban areas. It is in the part of Indiana, affectionately known as “the Region,” that’s essentially an extension of south Chicago, crisscrossed with freight train tracks, dissected by interstates, littered with factories in various states of decay.

On a recent overcast morning, Franciscan Health Hammond’s parking garage and surrounding lots were mostly empty. A sprinkling of people trickled out of the hospital. A sign advised that birthing services had moved to the suburbs.

The that covers the hospital and its surrounding neighborhood has a poverty rate of 36%, with a median household income of $30,400. Its population is 82% Black and/or Latino. The hospital treats a large share of patients on Medicaid, the government insurance program for low-income people, which typically pays health care providers a lower rate than Medicare or private insurance.

For Franciscan Alliance, the driving factors in shrinking Franciscan Health Hammond were the costs required to maintain the aging infrastructure, and less demand for care expected in that part of “the Region,” Maloney said.

He said Hammond residents are welcome at Franciscan Alliance’s hospital 6 miles away in Munster, Indiana. The organization has spent at least $133 million in recent years on that facility, located in a wealthier suburb only a few blocks from a larger, competing hospital.

But for Carlotta Blake-King, a Hammond school board trustee, that’s not close enough, especially since the area doesn’t have much mass transit. “I’m a senior citizen. I don’t like to drive,” she said. “Everybody can’t afford a car.”

Free transportation to medical appointments, though, is offered through the and .

Franciscan Alliance has replaced older hospitals in other communities, albeit a few miles from their original locations, spending $333 million on a new medical center in Crown Point, Indiana, and $243 million in Michigan City, Indiana. In 2018, however, it shuttered a century-old hospital in Chicago Heights, Illinois, a working-class Chicago suburb demographically similar to Hammond.

The missions of many nonprofit hospital chains like Franciscan Alliance have evolved. Around the turn of the 20th century, hospitals often deliberately set up shop in less-fortunate neighborhoods, with community members providing time, money, and supplies. When St. Margaret opened, for example, local farmers donated food. The Internal Revenue Service exempted so-called charity hospitals from paying taxes.

Today, “hospitals are operating as corporations, as moneymaking business entities, and their decisions are largely driven by financial concerns,” said , a professor of accounting and health policy at Johns Hopkins University. “The line between the current nonprofit hospitals and for-profit hospitals is very, very murky.”

In 2018, nonprofit hospitals provided less unreimbursed Medicaid and charity care than their for-profit counterparts, Bai’s . However, she noted, Franciscan Alliance spent more than the average nonprofit on both fronts.

Pat Vosti, a retired nurse from Hammond, worked in the cardiology unit, so she knows how time is of the essence in health care. She’s concerned about patients who have to be diverted to other hospitals. “It’s a matter of minutes, but minutes count in some instances, you know?” she said.

However, people have been bypassing the Hammond hospital for years. Along with its sister campus in Dyer, Indiana, it has only a 15% market share, according to a 2016 bond filing, compared with 45% for Franciscan’s Michigan City facility and 38% for Crown Point.

“Now, why they haven’t been using it could be a function of management choices made 15, 20 years ago: ‘Don’t build that new ER, don’t recruit those young doctors, don’t open a service for substance abuse,’” said , an adjunct professor at the Harvard T.H. Chan School of Public Health. “This is usually a gradual death. These places don’t suddenly go bad.”

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So does Gene Cox, 48. He hasn’t been homeless in more than seven years. That’s the point of this little development.

“This is the longest time I’ve stayed in one place,” said Cox, nursing coffee and a cigarette outside his tiny home after working second shift as a benefits administrator. “I’m very nomadic. I’ve moved around Wisconsin a lot over the last 22 years.”

After Cox got divorced in 2009, he bounced around rentals before living in his van for a year. He tried a local men’s shelter. He lasted only two nights.

Then in 2014, he heard about this community being planned by , a spinoff of the national movement against income inequality. Cox started helping with gardening, one of his passions. A few months later, he moved into one of its 99-square-foot houses (echoing the “99%” of the population that Occupy aimed to represent).

With housing costs rising, tiny homes are spreading as a solution to homelessness in California, Indiana, Missouri, Oregon, and beyond. Arnold Schwarzenegger garnered considerable publicity in December when he for homeless veterans in Los Angeles. It reflects a growing interest in outside-the-box ideas to get unhoused people off the streets, especially during winter in cold climates and amid the covid-19 pandemic.

“Anything that increases the supply of affordable housing is a good thing,” said , CEO of the National Alliance to End Homelessness. “We have a huge shortage of housing — around 7 million than there are households that need them.”

Housing and health are inextricably linked. In a of 64,000 homeless people, individuals living on the streets were more likely to report chronic health conditions, trauma, substance misuse, and mental health issues than those who were temporarily sheltered.

But not all tiny homes are created equal. They range from cabins with a cot and a heater to miniature houses with kitchens and bathrooms.

The communities themselves differ, too. Some are just “agency-managed shelters that use pods instead of the traditional gymnasium full of bunk beds,” said Victory LaFara, a program specialist with , a tiny-home encampment since 2000, in Portland, Oregon. Some are self-governing, like Dignity Village and Occupy Madison, and a few offer a .

Many are in remote parts of town, though — far from jobs, grocery stores, and social services. “There’s a balance between the benefits you get from the improved structure and the bad factors you could get from being in a worse location,” said , a housing researcher at the Johns Hopkins Carey Business School.

, executive director of the National Coalition for the Homeless, said he thinks tiny homes are a good emergency option, to protect people from the elements and violence, but are not long-term solutions, like increasing the number of living-wage jobs, the housing stock, and funding for housing vouchers.

“There’s been this theme since the ’70s that there are some people in society that are less deserving,” he said. “And the tiny home kind of fits within that mindset.”

Zoning regulations and building codes have prevented tiny homes from being built in some cities, as have . That opposition often fades once the communities are up and running, according to village organizers. “Since we moved into six years ago, there have been no documented crimes from anyone on this property in any of the adjacent neighborhoods,” said , president of Mobile Loaves & Fishes, a homeless outreach group in Austin, Texas, that operates the nation’s largest tiny-home project.

Madison, which has about 270,000 residents and is home to Wisconsin’s Capitol and flagship university, has three different types of tiny homes showcased in three locations.

Occupy Madison’s newest village opened in late 2020 about a mile north of its original site. Next to a shuttered bar, 26 Conestoga huts, resembling covered wagons from the old West, line a fenced parking lot. The 60-square-foot temporary structures will eventually be replaced by tiny houses, which occupants are expected to help build.

On the outskirts of town, in an industrial development near an interstate, the city’s new tiny-home project features parallel rows of 8-by-8-foot white prefabricated shelters that look like ice fishing shanties. Unlike the two Occupy settlements, this one has a full-time staff, including a social worker and an addiction counselor; on a recent day, residents streamed in and out of its cramped office, either to use the phone or grab a muffin or some cookies. People walked their dogs outside.

The 30 residents had previously been living in tents in Madison’s busy Reindahl Park.

“The city was solving a political problem, first and foremost,” said Brenda Konkel, president of Occupy Madison and executive director of . The so-called sheltered encampment cost about $1 million to set up and will run about $800,000 to $900,000 a year to operate.

City Community Development Director said housing people in a traditional shelter would be significantly cheaper in the short term. But tiny-home villages can often serve those who are either unwilling or unable to stay in a congregate setting, because they have pets or partners, have severe emotional or psychological issues, or are banned from the shelter system.

“Anybody that spent any time at Reindahl understood how unsafe and untenable it was for people who were staying there,” O’Keefe said.

, clinical director of Kabba Recovery Services, said residents’ substance use had increased since they arrived at the city-run site, perhaps because they finally had warmth and didn’t have to worry about keeping their belongings safe. She hopes their newfound quietude will also give them the space to recover when they’re ready.

For Jay Gonstead, a lifelong Madisonian who moved into the camp after it opened in November, the place has been a godsend. After a divorce, he lived in the tent city for seven months.

“Toward the end, it got really bad. I never thought in my lifetime I’d have to shoot Narcan into somebody, but I did,” he said, referring to the treatment that reverses opioid overdoses. “I witnessed a man be shot. I witnessed stabbings. That was not a good place.”

The 54-year-old sets out on his bike regularly to look for work. “I have a criminal history. I’m an alcoholic,” he said. “It makes it tough.”

But he’s noticed smiles on his neighbors’ faces for the first time he can remember. Electricity and hot showers — along with a sense of community — tend to have that effect, he said.

“When you’ve got a roof and a door that locks, that’s home,” he said, fighting back tears. “We’re not homeless.”

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“It’s not going to hurt, OK? I’ll hold your hand, I’ll hold your hand,” said her older sister, Alondra, 8. “Deep breath, deep breath.”

The medical assistant, Rachel Blancas, poked Victoria’s left arm for about a second. Victoria opened her eyes. And with that, the Macias sisters were among the first 5- to 11-year-olds to get the covid-19 vaccine in the Midwest’s largest city.

Their mom, Maria Lopez, took them out of school early last Thursday to stop by the mass immunization site on Chicago’s southwest side. “They have gotten every other vaccine available, so why not this one?” said Lopez, 43, a real-estate broker.

, a nonprofit health provider that is operating the site, has been the top pediatric covid vaccine provider in Chicago, according to the city’s Department of Public Health, administering about 10,000 immunizations to 12- to 17-year-olds. Now that the Food and Drug Administration has authorized the Pfizer-BioNTech shot for kids ages 5-11, the organization’s efforts may provide lessons for other places in the U.S. that have struggled to vaccinate children.

“People in the community trust us,” said Veronica Flores, manager of covid response for Esperanza, which has five medical clinics that see patients regardless of insurance or immigration status. “When the pandemic started, we were one of the first ones doing testing.”

At one point, she noted, Esperanza was responsible for more than half of all covid tests done in the city. The federally qualified health center’s patient population, which is about 90% Hispanic, has doubled in the wake of covid.

Everyone who works with patients at Esperanza is bilingual. The immunization site and is open five days a week, including to people without appointments. The clinic will even pay for patients’ Uber rides to get vaccinated.

If parents or guardians have questions or concerns about the pediatric vaccine, Esperanza connects them to one of its doctors.

Dr. , pediatric medical director, seeks to reassure patients, telling them the shot, which is given at a lower dose than for teens and adults, has been found to be both for 5- to 11-year-olds. The relatively mild side effects may include pain at the injection site, headaches and fatigue that could last a day or two. In addition, he reminds them that children are at risk from the virus.

“Around 2 million kids between 5 and 11 years old have been diagnosed with covid, and there’s been about 170 deaths,” Minier said. “That’s still too many. If we have something that can help prevent death or any sort of morbidity for kids for covid, then we should do it.”

Cynthia Galvan, a medical assistant at Esperanza who lives nearby, brought her 10-year-old son, Andres, to get the shot Thursday. She hopes it will ensure her family has a better Thanksgiving than last year, when several of her relatives were sick with covid-19.

“Everyone at home was already vaccinated, except him,” said Cynthia, 34. “There’s 10 of us.”

of 58.2% for 12- to 17-year-olds is higher than the of about 50%, largely because of the work of community health centers like Esperanza, said city Health Commissioner Dr. . Not only are they familiar with the local languages and cultures, but they’re also the type of places where the whole family is likely to get immunizations, starting with grandparents last winter.

“We know the biggest predictor of whether a child gets a vaccine is whether the parent or guardian is vaccinated,” Arwady said.

She still worries about the estimated 750,000 residents of the city without immunity to covid. Young Black Chicagoans have lagged behind other groups in getting the shot, and she’s concerned outbreaks could occur this winter among those unvaccinated networks.

“One way or another, your immune system is likely to learn its covid lesson and probably over the next few months,” Arwady said. “So either that’s through the safer way of getting vaccinated or taking your chance of getting infected.”

The city is working to increase vaccine uptake by offering $100 gift cards, administering free shots at home to anyone who wants them, and giving all public school kids the day off this Friday to get immunized.

Last week, Esperanza Health Centers texted the families of each of its roughly 8,000 patients ages 5 to 11 to let their parents know the vaccine was available. The organization started distributing the shots to younger kids Wednesday morning, just hours after the Centers for Disease Control and Prevention . They will start giving out second doses in three weeks.

“I hate shots,” said Benicio Decker, 7, as he played a game on an iPad in the clinic’s waiting area Thursday. “The only time I like shots is when we get ice cream after.”

But the Chicago second grader said he was willing to withstand a little discomfort “because I want to protect my family, me, my friends, my teacher.”

On the brisk fall afternoon, families with young kids streamed in and out of the site, a 23,000-square-foot former gym with exposed ventilation, hanging fluorescent lights and a blue-speckled rubber floor. As Disney songs played over the loudspeakers, the children stopped to take pictures in front of astronaut-themed, balloon-covered photo backdrops the health center had set up.

“They do a great job of making information available where people are,” said Benicio’s mom, Esmie De Maria, 39. “They have flyers up at restaurants, laundromats, the grocery store. They’re not expecting people to come to them.”

Esperanza has also done pop-up vaccine clinics at local schools and parks.

De Maria said she didn’t run into waitlists as she had at other places in the city. She even enlisted the health center to teach vaccine workshops to her colleagues at a local neighborhood organization.

Esperanza is a trusted institution in a largely Hispanic part of the city, De Maria said — the health center’s name means “hope” in Spanish. and , Latinos have been less likely than whites and Asians to be immunized against the coronavirus, though that gap has been closing.

“People of color have every right, historically, to be wary of vaccinations,” said De Maria, noting that many women in her ancestral home of Puerto Rico were coerced into being . “It’s embedded in our DNA to be skeptical.”

But she said she hopes everyone will consider getting immunized, for the good of the community. “This isn’t just for him,” she said, gesturing to Benicio.

Over at the vaccine station, Blancas, the medical assistant, told Benicio the shot would feel like a mosquito bite. “You’re being really brave. You’re earning that ice cream,” his mom said.

When Blancas stuck Benicio’s arm with the needle, the boy, holding tight to his Batman teddy bear, let out a quiet “Ow.” Afterward, he said he’d just felt a little pinch.

“You are officially vaccinated,” his mother told him, as he sat playing with her phone in the observation area for 15 minutes to make sure he didn’t have any dangerous allergic reactions. “He’s going to be one of the first kids at his school to get vaccinated. He’s a little superhero.”

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But when the Illinois State Dental Society met with key lawmakers virtually for its annual lobbying day in the spring, the proposals to allow dental hygienists to clean the teeth of certain underprivileged patients without a dentist seemed doomed.

State Sen. , a Republican legislative leader, warned against the bills even if they sounded minor. “It’s just getting the camel’s nose under the tent,” he said in an audio recording of the meeting obtained by KHN. “We’ll have, before long, hygienists doing the work that, if they wanted to do, they should have gone to dental school for.”

The senator added that he missed “the reception and the dinners that you guys host” and the “nice softball questions that I usually get” from the dental society’s past president, who happens to be his first cousin.

The bills never made it out of committee.

The situation in Illinois is indicative of the types of legislative dynamics that play out when lower-level health care providers such as dental hygienists, and try to gain greater autonomy and access to patients. And the fate of those Illinois bills illustrates the power that lobbying groups such as the Illinois dental society have in shaping policies on where health professionals can practice and who keeps the profits.

“There’s always a struggle,” said , a researcher for the Center for Health Workforce Studies at the University of Albany in New York. “We have orthopedists fighting podiatrists over who can take care of the ankle. We have psychiatrists fighting with clinical psychologists about who can prescribe and what they can prescribe. We have nurses fighting pharmacists over injections and vaccinations. It’s the turf battles.”

In 2015, the was revised to let hygienists treat low-income patients on Medicaid or without insurance in “public health settings” — such as schools, safety-net clinics and programs for mothers and children — without a dentist examining them or being on-site. Besides doing cleanings, the hygienists can take X-rays, place sealants and apply fluoride.

This year, lawmakers proposed bills that would have expanded those settings to include , and .

The state dental society, in a , wrote that the fact it took years for hygienists to develop their public health training program shows “they have no real interest in providing access to care to needy patients.”

As it is, Illinois trails many in allowing dental hygienists unsupervised contact with patients. In Colorado, on the extreme end, hygienists can own practices.

“It’s just the nature of the beast politically in Illinois. The dental lobby isn’t as strong in those other states,” noted Margaret Vaughn, executive director of the . “The Illinois State Dental Society is much more powerful, and they’re much more organized than the hygienists are politically.”

From 2015 to 2019, the dental society spent more than $55,000 on lobbying, for its annual gathering and meals for lawmakers, typically hosted at a swanky Italian spot near the state Capitol in Springfield, according to . In the same period, the Illinois Dental Hygienists Association reported spending nothing in its lobbying reports. (Neither group has listed any expenditures since the beginning of 2020.)

The dental society has two exclusive lobbyists and four lobbying firms on contract, state records show. The hygienist group, meanwhile, employs no lobbyists and contracts with just one firm.

The dental society donates generously to both Republicans and Democrats. Its had nearly $742,000 in cash on hand as of June 30, according to Reform for Illinois’ Sunshine Database. While the PAC has given $4,050 since 2014 to support the campaigns of state Sen. , a Democrat who sponsored the nursing home bill, the database shows it has contributed far more to help elect Syverson, the senator who spoke at the conference. It has given to his campaigns since 1999, with bigger annual gifts than to Bush.

“I receive contributions from many groups on both sides of issues,” Syverson emailed KHN. “They are not contributing to influence my vote on a particular bill. In fact, if a PAC sent a check while we were negotiating or voting on an issue they are involved with, I would not accept it.”

The hygienists’ PAC gave $1,100 to the campaign committee of Bush, , but nothing to Syverson. Bush did not respond to requests for comment.

“The bottom line is, if you don’t have a healthy mouth, you don’t have a healthy body,” said Ann Lynch, director of advocacy and education for the . “It only makes sense that we would remove any barriers that do not allow a licensed health care provider to practice at the top of their scope.”

But Dave Marsh, a lobbyist for the , said it would be dangerous for hygienists to treat nursing home residents, who are often elderly and sick.

“I just don’t feel anybody with a two-year associate’s degree is medically qualified to correct your health,” Marsh added. “They’re trained to clean teeth. They take a sharp little instrument and scrape your teeth. That’s what they do. That’s all they do.”

He said the problem is not a shortage of dental professionals but, rather, a lack of dentists who can afford to accept Medicaid patients — and “nobody wants to raise taxes to actually be able to reimburse” dentists at higher rates.

He also pointed to the scarcity of research on the benefits of dental hygienists having more professional freedom.

Langelier acknowledged that little academic literature exists on this topic, in part because of inadequate data collection on oral health. But in 2016, a found that, as dental hygienists gained more autonomy, fewer people had teeth removed because of decay or disease. And she said Medicaid data shows more children had dental visits as hygienists expanded .

“I don’t want this to be acrimonious,” said Laura Scully, chair of the access-to-care committee of the . “I would like it to be more of a collaboration, because truly that’s what this is about: getting together so we can help more people.”

Karen Webster works as a dental hygienist for the , a free clinic in St. Charles, Illinois, about 40 miles west of Chicago. In the past, she could only briefly screen patients before scheduling them with one of the center’s volunteer dentists, often months out.

“Imagine if you had a toothache and the doctor couldn’t see you that day,” she said, noting that her patients have low incomes. “They can’t afford the services. They wait till something hurts.”

But since becoming a public health dental hygienist, Webster now does immediate cleanings, takes X-rays she sends to teledentists for exams, and applies a solution called silver diamine fluoride that can halt tooth decay.

“The whole thing, start to finish, it’s just a lot more efficient,” she said.

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One day in December, they set out with cards and candy canes and dropped by the homes of every eighth grader at in Terre Haute, a city of more than 60,000 near the Illinois border where both Indiana State University and the federal death row are located. They saw firsthand how these kids, many living in poverty and dysfunctional families, were coping with the pandemic’s disruptions to their academic and social routines.

“You just have a better concept of where they’re coming from and the challenges they really do have,” Goulding said. “When you’re looking at that electronic grade book and Sally Lou hasn’t turned in something, you remember back in your mind: ‘Oh, yeah, Sally Lou was home by herself, taking care of three younger siblings when I stopped by, and I spotted her helping Johnny with his math and she was helping this one with something else.’”

The school’s experience provides a window into the hardships millions of families across the country have endured since last March, and exemplifies why education isn’t the only reason many Americans want schools to fully reopen. Schools like Sarah Scott help hold their communities together by providing households with wide-ranging support, which has become much tougher during the pandemic.

“A lot of our students are struggling emotionally,” said Sarah Scott’s principal, . “They’re stressed because they’re falling behind in their work. Or they’re stressed because of the conditions they’re living with at home.”

Even before the coronavirus struck, kids at Sarah Scott faced significant obstacles that compounded the normal social challenges and surging hormones of middle school. They live in Vigo County, which has the state’s and . Nearly 90% of students qualified for free or reduced-fee lunches. Some showed up needing to shower and change at the school, which has a food pantry that also offers clothes and hygiene products.

Things got more difficult for students when covid threw Sarah Scott’s normal schedule into disarray. Initially, the school went totally remote, then moved to partially in-person for the start of the 2020-21 school year. When covid spiked in October, Sarah Scott went remote again because not enough substitute teachers could fill in for quarantining staff. Since January, students have been spending part of each week in the school building, with no plans as of early March to open fully.

Kids were given laptops to use at home. But internet access can be problematic.

“Internet has been the worst,” said Samantha Riley, mother of seventh grader Mariah Pointer. “So many people are on it, it shuts down all the time.”

When that happens, she uses the Wi-Fi emitting from the school bus that sits in front of her apartment complex, one of several parked around the community to fill the gaps.

Even when the internet works, though, keeping kids on task at home isn’t easy. Heather Raley said she often cries from the stress of trying to make her seventh grade daughter engage online. “It just seems like we’re always butting heads over this,” Raley said. “It’s just a bigger battle getting the work done.”

As in many other communities, students are falling behind academically. Some don’t do any of their e-learning activities. Sarah Scott’s reports to child protective services for educational neglect — when caregivers aren’t getting their children to either in-person or remote classes — have more than tripled this school year.

Brown said she also worries about physical neglect and abuse, which is harder to detect when interacting with students remotely. “If you’re in an abusive home and you have to be there five days out of the week because you’re doing remote learning, you’re in that environment even more,” she said.

More time at home can also mean doing without necessities, including food.

The school helps by offering free breakfasts and lunches for in-person students and to-go lunches on remote days. Sometimes, the principal . The school recently secured a microwave for one family and an inflatable mattress for a student who’d been sharing a bed with his grandmother.

For some kids, the stress of the pandemic has worsened emotional problems and mental illness. Recently, a former Sarah Scott student who had moved out of state logged into her former teacher’s virtual class to say she planned to kill herself. The school contacted police, who checked on her. Referrals for suicidal students are up fourfold, Brown said.

School social worker said it’s been tough counseling kids online or through text messages.

“I am all about building relationships and being in person and being able to dap you up or give you a hug and be like, ‘Hey, what’s up?’” she said, using a term for various greetings like fist bumps or elaborate handshakes. “So being online is extremely difficult for me, because you can’t really tell the tone of your student. When I’m talking to you in person, I can read your body language and I can gauge where you’re at.”

Right now, she said, the psychological well-being of her middle schoolers is even more important than education.

Many students, such as eighth grader Trea Johnson, come up against challenges on both fronts. Trea transferred to Sarah Scott two days before covid ended in-person learning.

“We struggle with school anyway,” said his mom, Kathy Poff. “Then when this pandemic came along, it just knocked our feet out from under us.”

His grades plunged. He began to hate school, Poff said. He didn’t attend his daily video meetings with his teachers. His mother fought with him to complete his online assignments.

“I usually get pretty bored,” said Trea, whose long, straight hair sometimes falls over his eyes.

Poff found him a therapist he meets with once a week. She said his mood and academic productivity have improved. He wants to be a computer programmer and has been coding in his spare time lately. She also moved his computer into her bedroom so she could better monitor him and has started paying him to do his schoolwork.

“I can’t even imagine what it would be like to be a 13-year-old going through this pandemic,” said Poff, 51, a single mother. “They’re going through changes anyway, adjusting to adolescence and figuring out who they are, and they don’t even have a social group to figure that out.”

Goulding, the math teacher, said she’s glad she and her co-workers can help provide stability and continuity during this trying period. One recent night, for example, she got a call from a truant boy’s grandmother, who said she was in poor health and raising him alone. The next day, the principal and social worker picked him up and drove him to school.

Still, Goulding lamented not seeing her most vulnerable students on the days when they are remote.

“How do I check on my kids? How do I make sure they’re eating? How do I make sure,” she paused to compose herself, her voice quavering, “they’re safe?

“You’re no longer thinking about, ‘How are they doing on their polynomials?’ You’re thinking about, you know, the reality of life.”

[Correction: This article was updated at 12:30 p.m. ET on March 25, 2021, to correct the grade level of Heather Raley’s daughter.]

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“We’re in a bad dream all the time,” she said during a recent day treating coronavirus patients at , which was founded in the early 20th century to care for the city’s poorest immigrants. “I can’t wait to wake up from this.”

Prendkowski believes some of the death and suffering could have been avoided if more of these people had regular treatment for the types of chronic conditions — asthma, diabetes, heart disease — that can worsen covid. She now sees a new reason for hope.

Amid a deadly virus outbreak that has , Illinois recently became the first state to provide public health insurance to all low-income noncitizen seniors, even if they’re in the country illegally. Advocates for immigrants expect it will inspire other states to do the same, building on efforts to cover undocumented children and young adults. Currently, Democratic legislators in California to expand coverage to all low-income undocumented immigrants there.

“The fact that we’re going to do this during the pandemic really shows our commitment to expansion and broadening health care access. It’s an amazing first step in the door,” said Graciela Guzmán, campaign director for , a group that advocates for universal coverage.

Undocumented immigrants without health insurance often skip care. That was the case for Victoria Hernandez, 68, a house cleaner who lives in West Chicago, a suburb. The Mexico City native said she had avoided going to the doctor because she didn’t have coverage. Eventually, she found a charity program to help her get treatment, including for her prediabetes. She said she intends to enroll in the new state plan.

“I’m very thankful for the new program,” she said through a translator who works for the , a nonprofit that coordinates charity care for the uninsured in DuPage County, the state’s second-most populous. “I know it will help a lot of people like me.”

Healthy Illinois pushed state lawmakers to offer health benefits to all low-income immigrants. But the legislature opted instead for a smaller program that covers people 65 and older who are undocumented or have been legal permanent residents, also known as green card holders, for less than five years. (These groups don’t typically qualify for government health insurance.) Participants must have an income at or below the federal poverty level, which is $12,670 for an individual or $17,240 for a couple. It like hospital and doctor visits, prescription drugs, and dental and vision care ( stays in nursing facilities), at no cost to the patient.

The new policy continues a trend of expanding government health coverage to undocumented immigrants.

Illinois was the first state to cover children’s care — a handful of states and the District of Columbia — and for unauthorized immigrants. In 2019, California to offer public coverage to adults in the country illegally when it opened eligibility for its Medi-Cal program to all low-income residents under age 26.

Under federal law, undocumented people are generally not eligible for Medicare, nonemergency Medicaid and the Affordable Care Act’s health insurance marketplace. The states that do cover this population get around that by using only state funds.

An estimated 3,986 undocumented seniors live in Illinois, according to a by Rush University Medical Center and the Chicago demographer group — but that number is expected to grow to 55,144 by 2030. The report also found that 16% of Illinois immigrants 55 or older live in poverty, compared with 11% of the native-born population.

Given the outgoing Trump administration’s , some advocates worry that people will be afraid to enroll in the insurance because it could affect their ability to obtain residency or citizenship. , senior attorney for health care justice at the Shriver Center on Poverty Law in Chicago, said she and others are working to assure immigrants they don’t need to worry. Because the new program is state-funded, federal guidance suggests it is not subject to the designed to keep out immigrants who might end up on public assistance.

“Illinois has a legacy of being a very welcoming state and protecting immigrants’ privacy,” Kovach said.

The Illinois policy is initially expected to cover 4,200 to 4,600 immigrant seniors, at an approximate cost of $46 million to $50 million a year, according to John Hoffman, a spokesperson for the . Most of them would likely be undocumented.

Some Republicans the coverage expansion, saying it was reckless at a time when Illinois’ finances are being shredded by the pandemic. The Illinois Republican Party “free healthcare for illegal immigrants.”

But proponents contend that many unauthorized immigrants pay taxes without being eligible for programs like Medicare and Medicaid, and that spending on preventive care saves money in the long run by cutting down on more expensive treatment for emergencies.

State Rep. , a Chicago Democrat who helped shepherd the , advocated for a more expansive plan. She was inspired by her uncle, a 64-year-old immigrant who has asthma, diabetes and high blood pressure but no insurance. He has been working in the country for four decades.

She wanted the policy to apply to people 55 and older, since the vast majority of those who are undocumented are not seniors (she noted that a lot of older immigrants — 2.7 million, according to — obtained legal status under the 1986 federal amnesty law).

The real impact of this plan will likely be felt in years to come. At Esperanza Health Centers, one of Chicago’s largest providers of health care to immigrants, 31% of patients 65 and older lack coverage, compared with 47% of those 60 to 64, according to , who oversees patient access there.

Ramirez said her uncle called her after seeing news of the legislation on Spanish-language TV.

“And I said to him, ‘Tío, not yet. But when you turn 65, you’ll finally have health care, if we still can’t help you legalize,’” Ramirez recalled, choking up during a recent phone interview.

“So it is a reminder to me that, one, it was a major victory for us and it has meant life or a second chance at life for many people,” she said. “But it is also a reminder to me that we still have a long way to go in making health care truly a human right in the state and, furthermore, the nation.”

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“I’ve always considered myself homeless because I don’t have a home,” he said on a recent crisp, fall day in the shelter’s sun-splashed courtyard. But he’s fortunate, said Barnes, 44. He’s never had to sleep outside when it was below zero or snowy. He always found a friend’s place, building or shelter to crash in. He knows others aren’t so lucky.

As winter approaches, — perhaps thousands — of people in this city of nearly 3 million are living on the streets: some in encampments, others hopping from corner to corner. And the numbers could grow without more federal aid and protections amid economic pressures from the pandemic.

This year, the coronavirus has forced homeless shelters to limit the number of beds they can offer. , for instance, is operating at roughly half its normal capacity of 740. And COVID-19 cases are rising as temperatures drop.

“What happens if we’re in the midst of a pandemic and a polar vortex happens?” said Doug Schenkelberg, executive director of the . “We’re trying to keep the contagion from spreading and keep people from dealing with hypothermia. Is there the infrastructure in place that can handle that type of dual crisis?”

Cold-weather cities across the nation are seeking creative ways to cautiously shelter homeless people this winter. Exposure to the elements kills individuals staying outside every year, so indoor refuges can be lifesaving. But fewer options exist nowadays, as coronavirus concerns limit access to libraries, public recreation facilities and restaurants. And in official shelters, safety precautions — spacing out beds and chairs, emphasizing masks and hand-washing, testing — are critical.

“The homeless check off most boxes in terms of being the most susceptible and most vulnerable to the COVID-19 pandemic, and most likely to spread and most likely to die from it,” said Neli Vazquez Rowland, founder of , a Chicago nonprofit that has been operating a “medical respite” isolation facility for homeless individuals with the coronavirus.

Demand for shelter could grow. Stimulus checks helped stave off some of the pandemic’s initial economic pain, but Congress has stalled on additional relief packages. And though the Trump administration has ordered a moratorium on evictions for tenants who meet certain conditions through the end of the year, . Some states have their own prohibitions on evictions, but only Illinois, Minnesota and Kansas do in the Midwest.

At the , a publicly funded homeless shelter in Wisconsin, the pandemic complicates an already challenging situation.

“We’re like many communities. We never really have completely enough space for everybody who is in need of shelter,” said Cindy Krahenbuhl, its executive director. “The fact that we’ve had to reduce capacity, and all shelters have, has created even more of a burden on the system.”

She said outreach teams plan to connect individuals living outside with an open bed — whether at a shelter, a hotel or an emergency facility for homeless people at risk for COVID — and get them started with case management.

“The reality is we’ve got to make it happen. We’ve got to have space for folks because it’s a matter of life and death. You cannot be outside unsheltered in this environment too long,” said Rob Swiers, executive director of the in Fargo, North Dakota, where the average high in January is 18 degrees.

His shelter, Fargo’s largest, plans to use an insulated, heated warehouse to provide roomy sanctuary for clients.

In Minnesota’s Ramsey County, home to St. Paul, an estimated 311 people are living on the streets, compared with “dozens” at this time in 2019, according to Max Holdhusen, the county’s interim manager of housing stability. The area just had a .

The county has been using hotel rooms to make up for the reduction in shelter beds, and recently agreed to lease an old hospital to shelter an additional 100 homeless people.

The city of Chicago has set up emergency shelters in two unused public school buildings to replace beds lost to social distancing. As it does every winter, the city will also operate warming centers across Chicago, although this year with precautions such as spacing and masking.

In September, the city — mostly from the federal CARES Act for coronavirus relief — to an “expedited housing” program aiming to get more than 2,500 people housed in the next few years. The initiative plans to financially incentivize landlords to take risks on renters they might normally avoid, such as those with criminal histories or poor credit. The nonprofit in charge, , is also hosting “accelerated moving events,” in which its staffers descend on a shelter, encampment or drop-in center and work to house everyone in that facility.

“In the ideal world, we would have permanent housing for them,” said Dr. , senior vice president of community health equity at Chicago’s Rush University Medical Center. “That is the only way we can protect people’s health. That’s the fundamental health issue. It’s a fundamental racial justice issue. It’s a fundamental social justice issue.”

Even though Black people make up only a third of Chicago’s population, they account for roughly three-fourths of those who are homeless, .

Dr. , a family physician with Lawndale Christian Health Center on the city’s largely impoverished West Side, also called safely sheltering and housing people this winter a racial equity issue.

“We know that people who are African American have a higher prevalence of hypertension, of diabetes, of obesity, of smoking, of lung issues,” he said. “So they are hit harder with those predisposing conditions that make it more likely that if you get coronavirus, you’re going to have a serious case of it.”

Then add the cold. Dr. , an infectious disease specialist from the University of Illinois Hospital in Chicago, said hypothermia doesn’t increase the chances of contracting the virus but could aggravate symptoms.

As of Sept. 30, according to All Chicago, 778 people were unsheltered in the city. However, that number includes only people who are enrolled in homelessness services, and are even higher.

Some homeless people who plan to live outside this winter said they worry about staying warm, dry and healthy in the age of COVID-19. Efren Parderes, 48, has been on the streets of Chicago since he lost his restaurant job and rented room early in the pandemic. But he doesn’t want to go to a shelter. He’s concerned about catching the coronavirus and bedbugs, and doesn’t want to have to obey curfews.

He recently asked other unsheltered people what they do to keep warm during the winter. Their advice: Locate a spot that blocks the wind or snow, bundle up with many layers of clothing, sleep in a sleeping bag and use hand warmers.

“This is going to be the first time I’ll be out when it’s really cold,” he said after spending a largely sleepless night in the chilly October rain.

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Corrections officers stood watch as Porter held her daughter, Gianna, to her chest for the first time. Back at a , Gianna slept in a crib in her mother’s cell, about 2 feet from her pillow.

The prison program allowed Porter to keep her baby with her — including when she went out into the yard — until her discharge nearly a year later. She didn’t recall ever bonding so closely with her previous 11 kids. She finally felt her life moving in a positive direction.

“I didn’t want to be a messed-up person,” she said. “I didn’t want to be a messed-up mom once I realized what a real mom is.”

When Porter was released in 2012, however, she didn’t know how to stay on that path and resorted to what she knew: drugs and crime. She never returned to prison, but her struggles eventually led to a new mission of supporting incarcerated moms as they adjust to life on the outside.

This month, a program Porter developed called Mothers on the Rise is set to launch in the same unit where the 46-year-old raised her daughter. The project, among the first of its kind, aims to help formerly incarcerated mothers maneuver a post-prison world that can often be unwelcoming.

Research shows that recently incarcerated moms are a variety of mental and physical health problems and .

“They’re released with maybe no place to stay and go to. And if they do have a place, it may be transient. They don’t have money, might not have a cellphone — and they have to take care of a baby,” said , an Indiana University public health professor who is advising Porter on her project. “How does one navigate all of that?”

The number of incarcerated women in the United States exploded from about to , with African American women imprisoned at twice the rate of white women.

But incarcerated women often lack programs that help them transition back into society, even though they expressed more of a need for them than have men or juveniles. There are also few reentry resources outside of prison, especially those designed for the of imprisoned women who have children.

The group “at the greatest disadvantage coming out of prison is going to be women,” said , a leading expert on prison reentry and researcher for the nonprofit research organization . “Family support for women is — we found pretty consistently across our data — much less than what was available for men.”

give birth while incarcerated, but Indiana is that allows new mothers to raise their babies in prison. The nursery — where moms and infants have private rooms and get help from inmates who are trained to be nannies — assists the women in planning for reentry with a checklist of needs and services. But until now, there’s been no peer support or mentoring for new moms or moms-to-be from anyone who’s been through it.

A Chance Encounter

Until recently, Porter lived such a chaotic, difficult life that she contemplated suicide. Her early years were filled with abuse and neglect. She’d spent much of her adulthood behind bars, mostly for fraud and forgery.

She thought the last time she left prison would be different. But when she and Gianna got out, they bounced around from place to place for a few years. Porter tried to survive the only way she knew how.

“My scum of the pond was I took advantage of anything — however I had to get money. I was just a con artist,” she said. “I’ve been charged with prostitution. I was actually charged with it, not doing it, but … when you’re a crack addict, you’re going to do anything you need to do to get that dope.”

So, in March 2019, she planned to take her life. She had a gun at the ready.

Then there was an unexpected visitor at her apartment. It was Ashley Phillips, project manager for a program Porter was involved in, .

Turman, the IU professor, had started that program in 2018 to help lower the infant death rate in a — and — with one of the highest in the nation. The project trains women who have overcome personal struggles to develop initiatives and policies that support other vulnerable moms.

Porter had begun attending the training that same year, but only because it offered $300 in gift cards. She never considered herself a community leader and didn’t think she had any business telling women how to be mothers.

When Phillips stopped by that day, she handed Porter a flower, comparing it to the women in the project: You plant a seed, watch it grow, and it eventually blossoms into something beautiful.

“She actually saved my life,” Porter said. “I had sent the kids to their dad’s. I was overwhelmed, and I wasn’t sad about taking my life. I was just so tired and ready. … Then Ashley came.”

From that day until she graduated last December, Porter stuck with the leadership training. She’d been hoping to help other moms since she was in prison, and the training gave her the tools to start her own program.

Mothers on the Rise was born.

Program Offers Support and Savings

Porter’s idea drew the interest of the , which is providing nearly $60,000 in one-time funding for the project. Agency spokesperson Jeni O’Malley said it “aligns with our priorities of reducing preventable deaths among women and children, reducing health disparities and inequities, and strengthening mental, social and emotional well-being.” The program will be evaluated after the first year for possible future funds and expansion.

The state is allowing women in the prison nursery to join the initiative, albeit virtually for now, because of coronavirus. Indiana stands to save money if the women stay out of prison; it to keep them locked up.

Mothers on the Rise will initially assist 10 women, helping them secure housing, child care and, if needed, addiction and mental health treatment. Porter will advise them 90 days before their release and another 90 days afterward on tasks such as connecting with doctors, finding employment and opening bank accounts.

The program will also pay for three months of child care and bus fare for the women and provide infant supplies such as strollers, baby wipes and clothing.

Porter will operate in tandem with the nursery’s social worker.

“My advantage is I know the street mentality, if you will,” Porter said. “I can cut the crap with the women from the beginning.”

She will act as a trusted guide in returning to a society that isn’t always so forgiving to ex-offenders, particularly mothers of young children.

“We like to ostracize those in the justice system and then we’re surprised when they fail — fail at reentering the community they’re not welcome in,” said Maranda Sparks, transitional health care manager for the Indiana DOC.

After she last got out of prison in 2012, Porter visited , a historical, 126-acre green space on Indianapolis’ south side. She snapped a picture of Gianna sitting on the ground next to a fountain. From time to time, she still looks at it, reminding her of a hopeful yet precarious moment in their lives.

Porter went back to the park on a recent late-summer day, the sky powder-blue. Gianna, now almost 9, was there too. So were Porter’s younger kids, 6-year-old Kevin and nearly 2-year-old Kamiah. The children raced one another and scrambled up trees. Flowers bloomed all around.

Watching her children play, Porter pondered how her life might have been different had someone helped her navigate the post-prison experience.

“I think I would have gotten here, but with more healing,” she said. “Because I didn’t even realize a lot of the stuff I was doing was wrong, that life didn’t have to be like that.”

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The 20-year-old wasn’t in jail. He wasn’t on the streets chasing drugs. Methadone to treat his opioid addiction was delivered to his door.

Hayes was staying at the hotel because of a coronavirus outbreak at the 270-bed Kirkbride Center addiction treatment center in Philadelphia, where he had been seeking help.

From early April to early May, 46 patients at Kirkbride tested positive for the virus and were isolated. The facility is now operating at about half-capacity because of the pandemic.

Drug rehabs around the country — including in Pennsylvania, Illinois, Indiana, Minnesota and Florida — have experienced flare-ups of the coronavirus or COVID-related financial difficulties that have forced them or limit operations. Centers that serve the poor have been hit particularly hard.

And that has left people who have another potentially deadly disease — addiction — with fewer opportunities for treatment, while threatening to reverse their recovery gains.

“It’s hard to underestimate the effects of the pandemic on the community with opioid use disorder,” said Dr., a professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health. “The pandemic . Normally that would drive more people to treatment. Yet treatment is harder to come by.”

Keeping Clients Safe

Drug rehabs aren’t as much of a COVID “tinderbox” as nursing homes, Alexander said, but both are communal settings where social distancing can be difficult.

Shared spaces, double-occupancy bedrooms and group therapy are common in rehabs. People struggling with addiction are generally younger than nursing home residents, but both populations are vulnerable because they’re more likely to suffer from other health conditions, such as diabetes or cardiovascular disease, that leave them at risk of succumbing to COVID-19.

To keep clients safe, some addiction treatment centers employ safety precautions similar to hospitals, like testing all incoming patients for COVID-19, noted Dr. , a senior scholar at the Johns Hopkins University Center for Health Security. But drug rehabs must avoid some strategies, such as keeping potentially intoxicating hand sanitizer on the premises.

Adalja said he hopes safety measures make people feel more comfortable about seeking addiction help.

“There’s not going to be anything that’s zero risk, in the absence of a vaccine,” he said. “But this is in a different category than going to a birthday party. You don’t want to postpone needed medical care.”

Still, some people requiring drug or alcohol rehab have stayed away for fear of contracting COVID-19. , CEO of the National Association of Addiction Treatment Providers, said many of its roughly 1,000 members saw their patient numbers down by much as 40% to 50% in March and April before bouncing back to 80%.

Unlike many other centers, Recovery Works, a 42-bed treatment center in Merrillville, Indiana, has seen more clients than normal during the pandemic. The facility had to close for a few days early on after a suspected COVID-19 case, but reopened after the person tested negative. It has since split its therapy sessions into three groups, staggered mealtimes and banned visitors, CEO Thomas Delegatto said. It then had an influx of patients.

“I think there are a variety of reasons why,” Delegatto said. “A person who was struggling with a substance use disorder, and who was laid off and a nonessential worker, might have seen this as an opportunity to go to treatment without having to explain to their employer why they’re taking two, three, four weeks off.”

He also noted that at the beginning of the pandemic as anxiety and isolation rose, and sheltering in place may have made some families realize that a loved one needed help for an addiction.

Centers Serving The Poor Hit Hard

Homeless and poor Americans, because they often live in close quarters, have been to catching COVID-19 — leaving drug rehabs dedicated to this population especially vulnerable.

Haymarket Center, a 380-bed treatment and sober living facility in Chicago’s West Loop that serves many people who are homeless, recently had an outbreak of 55 coronavirus cases among clients and staff members.

Two employees there tested positive for COVID-19 in late February, but testing was available then only for people showing symptoms, said Haymarket president and CEO Dan Lustig.

Haymarket worked with nearby Rush University Medical Center to test its clients. Twenty-six men, though asymptomatic, were found to be positive for COVID-19.

The center isolated those patients and eventually went from double- to single-occupancy rooms, improved its air filtration system and changed the way it served food. It now tests all new admissions.

“What we found was by doing serial testing we could tamp down the epidemic, not just at Haymarket but the whole city,” said Dr. , senior vice president for community health equity at Rush, which partnered with the city and other health systems on a COVID-19 .

The pandemic’s economic fallout has also forced some facilities to scale back. The Salvation Army is shuttering a handful of its roughly 100 adult rehabilitation centers nationwide due to COVID-related revenue losses. Those rehabs were funded by the organization’s resale shops, which were forced to close during stay-at-home orders.

“A lot of what we do relies on donations or items that were donated and then sold in our stores,” said Alberto Rapley, who oversees business development for the Salvation Army’s rehab facilities in the Midwest. “When financially we struggle, that is then felt on the other side.”

For instance, the Salvation Army drug rehab in Gary, Indiana, which is set to close in September, treated as many as 80 men at a time in its free, abstinence-based program. The next closest facility will be in Chicago, more than 30 miles away.

Outbreak Contained, But Beds Still Limited

Philadelphia’s Kirkbride Center also serves a mostly homeless and low-income population. Dr. Fred Baurer, the facility’s medical director, said Kirkbride was “flying blind” early in the pandemic, with little testing capacity and personal protective equipment.

On April 8, the first COVID-19 case appeared on Kirkbride’s long-term men’s wing. Over the next week, six more men on the unit showed symptoms and tested positive, as did 12 of the remaining 22. All quarantined at a .

Kirkbride started requiring face masks, testing all new clients for COVID-19 and prohibiting people in its various units from mingling.

The rehab has been about half-full lately — it’s usually closer to 90% occupied — partly because it stopped taking walk-in clients and confined new admissions to single rooms.

“I’m starting to feel more confident we’re past the worst of this, at least for now,” Baurer said.

Hayes, who has recovered from COVID-19 without experiencing any symptoms, was discharged from the facility June 15 to a sober living house. He plans to attend 12-step meetings regularly. He hopes to get his GED and eventually enter the mental health field.

He recognizes the need to stay vigilant about his recovery now, at a time of increased anxiety and despair.

“Regardless of the coronavirus or not, the addiction crisis ,” Hayes said. “It’s bad. It’s really bad.”

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