Methodology

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UPDATE: Â鶹ŮÓÅ Health News has removed contributions from Abbott Laboratories after 2013, when the company spun off its pharmaceutical business as Abbvie Inc. Abbott Laboratories is a medical device and health care company.

Kaiser Health News uses campaign finance reports from the Federal Election Commission (FEC) to track donations from political action committees (PACs) registered with the FEC by pharmaceutical companies. Totals include donations to the principal campaign committees and leadership PACs for current members of Congress. We include only donations to members for election cycles in which they hold office (even if they weren’t in office for the full cycle, in the case of special elections). Donations are assigned to the quarter in which they were given, regardless of when they are reported by the receiving committee or PAC. Exact amounts can change as amendments and refunds are reported; Â鶹ŮÓÅ Health News will update the analysis quarterly. Occasionally, refunds are reported in a different cycle from the original contribution, resulting in a negative total for the cycle.

There is a legal limit to how much each PAC can give to a member of the Senate or House of Representatives: $5,000 per election (including primaries and general elections) and per committee, or $10,000 per cycle. Each cycle is two calendar years, e.g. Jan. 1, 2017-Dec. 31, 2018.

When calculating changes in contributions from one cycle to another, we compare the latest quarter in the current cycle to the same point in the previous cycle for all drugmakers and for members of the House, who run for re-election every two years. For senators, who run for re-election every six years, we compare the current cycle to the cycle six years prior. We use the to gather some information about past and present members. We use both and to collect additional information about PACs and verify our work.

Â鶹ŮÓÅ Health News' coverage of prescription drug development, costs and pricing is supported in part by the .

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The siren call to contain rising drug costs helped catapult Democrats to power, and the idea is popular among voters regardless of their politics. Yet granting Medicare broad authority to intervene in setting prices has nonetheless divided the party.

And so, as it normally does, the drug industry gave generously to members of Congress, according to new data from KHN’s Pharma Cash to Congress database. Contributions covering the first half of this year show that some of its biggest donations were delivered with surgical-strike precision to sympathetic or moderate Democratic lawmakers the industry needs to remain in its corner.

Campaign donations to members of Congress — which must be reported to the Federal Election Commission — are the tip of the iceberg, signaling far greater activity in influence peddling that includes spending millions on lobbying activities and advertising campaigns.

Unusually, in the first half of this year Republicans and Democrats in Congress were virtually neck and neck in pulling in drug industry money, according to a KHN analysis of campaign contributions. In prior years, Republicans dominated giving from that sector, often by huge margins.

Pharmaceutical companies and their lobbying groups gave roughly $1.6 million to lawmakers during the first six months of 2021, with Republicans accepting $785,000 and Democrats $776,200, the Pharma Cash to Congress database shows. Since the 2008 cycle, the industry has generally favored Republicans. The exception was 2009-10, the last time Democrats controlled both chambers of Congress and the White House.

Democrats again narrowly hold both the House and Senate, and political scientists and other money-in-politics experts said the contributions likely reflect who is in power, which lawmakers face tougher reelection bids next year, and who has outsize sway over legislation affecting the industry’s bottom line.

Several pharmaceutical companies paused contributions to Republican lawmakers who voted against certifying the results of the 2020 election, blunting the GOP’s total fundraising haul and overall industry giving compared with other years.

The drug industry’s campaign contributions are markedly strategic, said , an associate professor at the Graduate School of Political Management at George Washington University.

“This is a really well-organized commercial sector,” Billet said. “If I’m one of these PACs, I’ve surveyed the landscape at the front end of the process, decided on our agenda and budget, and figured out who I may be able to get to and who I wouldn’t be able to get to.”

Of the top 10 recipients of funding, Republican lawmakers accounted for six; Democrats, four. (D-Calif.) received the most money of any member of Congress, with $63,900 in contributions in the first half of the year. Peters, whose San Diego-area district includes multiple drug companies, has consistently accepted money from drugmakers since he took office in 2013, according to KHN’s database. Right behind Peters was Rep. Cathy McMorris Rodgers (R-Wash.), who received $50,000 from the industry in the first six months of 2021. McMorris Rodgers was chosen this year to be the most senior Republican on the House Energy and Commerce Committee, which has significant influence on pharmaceutical issues. Peters sits on the same committee.

“They’re typically going to saturate the committees that are relevant to their industry,” said Nick Penniman, CEO of Issue One, a nonprofit that advocates reforming money’s influence in politics.

Next in line was Sen. Robert Menendez (D-N.J.), who accepted $49,300, the most of any senator this year despite not facing reelection until 2024. The vote of Menendez, a longtime ally of the industry, would be crucial for Democrats to pass any proposal giving the government greater control over drug prices. The pharmaceutical industry is a major employer in New Jersey, home to headquarters of behemoths like Johnson & Johnson, Merck, Novo Nordisk and Sanofi.

Menendez said he’s waiting to see the proposal, “which I expect will include language to allow Medicare to negotiate drug prices.”

“The focus of any proposal must be lowering patient costs,” he said, “and that will drive my analysis.”

Among other moderate Democrats is Sen. Kyrsten Sinema (D-Ariz.), whose vote also is critical to passage. She received $108,500 in pharma contributions in 2019-20, according to the KHN database. However, in the first half of this year, she received only $8,000. She has not said publicly where she stands on the current pricing proposal.

As Billet sees it, the pharmaceutical industry knew allowing Medicare to negotiate drug prices would likely be on the table, and drug companies shored up members, such as Peters and Menendez, who have sided with them in the past. Plus, “right now, the Democrats are driving the train, and because of that they’re going to get a few more contributions,” Billet added.

Peters received funds from nearly two dozen companies or industry groups, including Eli Lilly, Takeda Pharmaceutical, Pfizer, Merck, GlaxoSmithKline, EMD Serono and Amgen. Menendez’s donors included Boehringer Ingelheim, Sanofi, Pfizer, Merck, Gilead Sciences, Eli Lilly, Teva and Novo Nordisk. A spokesperson for Peters did not respond to request for comment.

Controlling drug prices has broad support among adults regardless of political party, according to from Â鶹ŮÓÅ (KHN is an editorially independent program of Â鶹ŮÓÅ). But facing industry opposition, Democrats have yet to agree on a plan as lawmakers weigh which policies make it into a massive domestic spending bill to expand the social safety net and address climate change. Central to the industry’s argument is that greater government intervention in setting prices would harm new drug development; however, drug pricing experts generally say this argument is overblown. Republicans remain unanimously opposed, which means Senate Democrats can’t afford any defections to advance legislation.

Fourth in industry contributions was (D-Nev.), a freshman lawmaker on the powerful Senate Finance Committee, which oversees legislation pertaining to federal health programs like Medicare. Cortez Masto received $46,000, with cash flowing in from companies like Eli Lilly, Merck, Pfizer, Johnson & Johnson and Mallinckrodt Pharmaceuticals, the latter of which filed for bankruptcy in 2020 after being swamped with litigation over its alleged role in the opioid crisis. One of her recent aides, Eben DuRoss, was hired as a lobbyist this year by the Pharmaceutical Research and Manufacturers of America, or PhRMA, federal disclosures show.

Cortez Masto is up for reelection next year in a battleground state that’s been competitive between Republicans and Democrats in recent elections. She was narrowly elected in 2016, and recent showed she held a small lead against her expected Republican challenger in 2022, former Nevada attorney general Adam Laxalt.

But her contributions dwarf those of other Senate Democrats in close races. For example, in the first half of this year, (D-N.H.), who also sits on the Senate Finance Committee, reported having accepted $6,000.

Two other lawmakers in competitive seats, (D-Ga.) and (D-Ariz.), didn’t receive funding from the pharmaceutical sector.

, research director of OpenSecrets, a nonprofit that tracks money in politics, noted several reasons Cortez Masto would pull in more money. In addition to her committee seat and competitive race, politically she’s more moderate than progressive lawmakers who have been bigger agitators against the drug industry.

“She’s not seen as an extremist, which is the kind of person who would typically take in more money” from political action committees, Bryner said.

Cortez Masto was also a recent past chair of the Democratic Senatorial Campaign Committee and therefore heavily involved in the party’s national fundraising efforts to preserve Democrats’ Senate majority. Those relationships with corporate and other donors could be leveraged for her own race, Bryner said. “Once you’ve made all the relationships, it’s not like they just disappear,” she said.

Still, the freshman Democrat allowing Medicare to negotiate prescription drug prices, in contrast to Menendez, who voted against the idea in 2019. The Nevada senator recently told KHN that she “absolutely” backs the policy and that the pharma cash flowing into her campaign coffers doesn’t influence her decisions.

“I’ve already supported it in Finance and actually voted to pass legislation to do just that,” Cortez Masto said. “We need to reduce the health care costs for so many in this country, and that’s what I’m focused on doing, including reducing prescription drug costs.”

Peters — who unseated a Republican in 2012 — was one of four moderate House Democrats who in September voted against a plan to give Medicare broad authority to negotiate prescription drug prices. They backed a narrower alternative that includes caps on out-of-pocket spending and limits the scope of Medicare’s negotiating authority to a smaller set of medications.

The money Peters and McMorris Rodgers got from drugmakers ($63,900 and $50,000, respectively) significantly jumped from the same periods in past cycles. In the first half of 2019, Peters received $19,500, and during those same quarters in 2017 he got $36,000. McMorris Rodgers’ haul for the first six months of 2019 was $2,500, and two years earlier it was $3,000. However, Menendez received more funding in the first half of 2019 ($52,000) than this year.

That some drugmakers — including Pfizer, Johnson & Johnson, Gilead and Eli Lilly — as well as PhRMA and the Biotechnology Innovation Organization, another lobbying group for the industry, paused contributions to Republicans after the events of seems at least in part to account for overall pharma contributions dropping in comparison with other years. In the first half of 2019 drugmakers gave $3.7 million, and in the first half of 2017 they gave about $4.4 million, versus 2021’s $1.6 million.

However, other drug company PACs and their industry groups kept up contributions or failed to void checks they’d issued to those who refused to certify the election results, according to a KHN analysis of the FEC data.

They include Merck, Novo Nordisk, GlaxoSmithKline, AstraZeneca, Genentech, Boehringer Ingelheim, Amgen, Teva, EMD Serono and the Association for Accessible Medicines, which all gave $1,000 or more to at least one of the who voted to overturn the election results.

Direct contributions to lawmakers’ political accounts are only one way for the industry to channel cash to Congress. Companies also give money to trade associations and 501(C)(4)s, which are nonprofits that often function as “dark money” groups because they are not required to disclose their donors.

“We know that they’re giving; they didn’t stop giving. Their giving went underground,” said , research director for the Center for Political Accountability, a nonprofit that tracks money in politics.

Groups also funnel money into advertising — in September, a seven-figure ad campaign opposing Democrats’ drug pricing plan — or into from which it may eventually trickle down to political candidates.

Another factor? Hail Mary covid-19 vaccines, developed and distributed in record time, that may have shored up goodwill with lawmakers. Or that, despite everything lawmakers have said about lowering drug costs, the industry suspects drug pricing legislation will stall once again and don’t want to spend their political capital on the issue.

“I think, frankly, drugmakers know they’ve won the match when it comes to drug pricing. This whole question of the cost of pharmaceuticals, it has come up for literally decades now and they have successfully shut it down, year after year,” Penniman said. “At a certain point, they know they have driven the nail far enough in the wood and they don’t need to do much more.”

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He was known for buying his students shoes and bow ties for their band concerts, his effortlessly positive demeanor and a suave personal style — “he looked like he stepped out of a different era, the 1950s,” said his niece Ruby Montana.

While Valles was singular in life, his death at age 60 in February was part of a devastating statistic: He was one of thousands of deaths in Texas border counties — where coronavirus mortality rates far outpaced state and national averages.

In the state’s border communities, including El Paso, not only did people die of covid-19 at significantly higher rates than elsewhere, but people under age 65 were also more likely to die, according to a KHN-El Paso Matters analysis of covid death data through January. More than 7,700 people died of covid in the border area during that period.

In Texas, covid death rates for border residents younger than 65 were nearly three times the national average for that age group and more than twice the state average. And those ages 18-49 were nearly four times more likely to die than those in the same age range across the U.S.

“This was like a perfect storm,” said Heide Castañeda, an anthropology professor at the University of South Florida who studies the health of border residents. She said a higher-than-normal prevalence of underlying health issues combined with high uninsurance rates and flagging access to care likely made the pandemic even more lethal for those living along the border than elsewhere.

That pattern was not as stark in neighboring New Mexico. Border counties there recorded covid death rates 41% lower than those in Texas, although the New Mexico areas were well above the national average as of January, the KHN-El Paso Matters analysis found. Texas border counties tallied 282 deaths per 100,000, compared with 166 per 100,000 in New Mexico.

That stark divide could be seen even when looking at neighboring El Paso County, Texas, and Doña Ana County, New Mexico. The death rate for residents under 65 was 70% higher in El Paso County.

Health experts said Texas’ refusal to expand Medicaid under the Affordable Care Act, a shortage of health care options and the state’s lax strategy toward the pandemic also contributed to a higher death rate at the border. Texas GOP leaders have opposed Medicaid expansion for a litany of economic and political reasons, though largely because they object to expanding the role or size of government.

“Having no Medicaid expansion and an area that is already underserved by primary care and preventive care set the stage for a serious situation,” Castañeda said. “A lot of this is caused by state politics.”

Texas was following the nationwide coronavirus shutdown in March and April last year. Last June — even as cases were rising — Gov. Greg Abbott allowed all businesses, including restaurants, to operate at up to 50% capacity, with limited exceptions. And he refused to put any on churches and other religious facilities or let local governments impose mask requirements.

In November, Texas Attorney General Ken Paxton filed an injunction to stop a lockdown order implemented by the El Paso county judge, the top administrative officer, at a time when El Paso hospitals were so overwhelmed with covid patients that had to be set up at an area hospital to accommodate the dead.

Unlike Texas, New Mexico expanded Medicaid under the ACA and, as a result, has a much lower uninsured rate than Texas for people under age 65 — 12% compared with Texas’ 21%, according to Census figures. And New Mexico had aggressive rules for face masks and public gatherings. Still, that didn’t spare New Mexico from the crisis. Outbreaks in and around the Navajo reservation hit hard. Overall, its state death rate exceeded the state rate for Texas, but along the border New Mexico’s rates were lower in all age groups.

For some border families, the immense toll of the pandemic meant multiple deaths among loved ones. Ruby Montana lost not only her uncle to covid in recent months, but also her cousin Julieta “Julie” Apodaca, a former elementary school teacher and speech therapist.

Montana said Valles’ death surprised the family. He had been teaching remotely at Guillen Middle School in El Paso’s Segundo Barrio neighborhood, an area known as because of its adjacency to the border and its history as an enclave for Mexican immigrant families.

When Valles first got sick with covid in December, Montana and the family were not worried, not only because he had no preexisting health conditions, but also because they knew his lungs were strong from practicing his trumpet daily over the course of decades.

In early January, he went to an urgent care center after his condition deteriorated. He had pneumonia and was told to go straight to the emergency room.

“When I took him to the [hospital], I dropped him off and went to go park,” said his wife, Elvira. But when she returned, she was not allowed inside. “I never saw him again,” she said.

Valles, a father of three, had been teaching one of his three grandchildren, 5-year-old Aliq Valles, to play the trumpet.

They “were joined at the hip,” Montana said. “That part has been really hard to deal with too. [Aliq] should have a whole lifetime with his grandpa.”

Hispanic adults are more than twice as likely to die of covid as white adults, according to the . In Texas, Hispanic residents died of covid at a rate four times as high as that of non-Hispanic white people, according to a December analysis by .

Ninety percent of residents under 65 in Texas border counties are Hispanic, compared with 37% in the rest of the state. Latinos have high rates of chronic conditions like diabetes and obesity, which increases their risks of covid complications, health experts say.

Because they were more likely to die of covid at earlier ages, Latinos are among all racial and ethnic groups, said Coda Rayo-Garza, an advocate for policies to aid Hispanic populations and a professor of political science at the University of Texas-San Antonio.

Expanding Medicaid, she said, would have aided the border communities in their fight against covid, as they have some of the highest rates of residents without health coverage in the state.

“There has been a disinvestment in border areas long before that led to this outcome that you’re finding,” she said. “The legislature did not end up passing Medicaid expansion, which would have largely benefited border towns.”

The higher death rates among border communities are “unfortunately not surprising,” said Democratic U.S. Rep. Veronica Escobar, who represents El Paso.

“It’s exactly what we warned about,” Escobar said. “People in Texas died at disproportionate rates because of a dereliction on behalf of the governor. He chose not to govern … and the results are deadly.”

Abbott spokesperson Renae Eze said the governor mourns every life lost to covid.

“Throughout the entire pandemic, the state of Texas has worked diligently with local officials to quickly provide the resources needed to combat covid and keep Texans safe,” she said.

Ernesto Castañeda, a sociology professor at American University in Washington, D.C., who is not related to Heide Castañeda, said structural racism is integrally linked to poor health outcomes in border communities. Generations of institutional discrimination — through policing, educational and job opportunities, and health care — worsens the severity of crisis events for people of color, he explained.

“We knew it was going to be bad in El Paso,” Ernesto Castañeda said. “El Paso has relatively low socioeconomic status, relatively low education levels, high levels of diabetes and overweight [population].”

In some Texas counties along the border more than a third of workers are uninsured, according to by Georgetown University’s Center for Children and Families.

“The border is a very troubled area in terms of high uninsured rates, and we see all of those are folks put at increased risk by the pandemic,” said Joan Alker, director of the center.

In addition, because of a shortage of health workers along much of the border, the pandemic surge was all the deadlier, said Dr. Ogechika Alozie, an El Paso specialist in infectious diseases.

“When you layer on top not having enough medical personnel with a sicker-on-average population, this is really what you find happens, unfortunately,” he said.

The federal government has designated the entire Texas border region as both a health professional shortage area and a medically underserved area.

Jagdish Khubchandani, a professor of public health at New Mexico State University in Las Cruces, about 40 miles northwest of El Paso, said the two cities were like night and day in their response to the crisis.

“Restrictions were far more rigid in New Mexico,” he said. “It almost felt like two different countries.”

Manny Sanchez, a commissioner in Doña Ana County, credits the lower death rates in New Mexico to state and local officials’ united message to residents about covid and the need to wear masks and maintain physical distance. “I would like to think we made a difference in saving lives,” Sanchez said.

But, because containing a virus requires community buy-in, even El Paso residents who understood the risks were susceptible to covid. Julie Apodaca, who had recently retired, had been especially careful, in part because her asthma and diabetes put her at increased risk. As the primary caregiver for her elderly mother, she was likely exposed to the virus through one of the nurse caretakers who came to her mother’s home and later tested positive, said her sister Ana Apodaca.

Julie Apodaca had registered for a covid vaccine in December as soon as it was available but had not been able to get an appointment for a shot by the time she fell ill.

Montana found out that Apodaca had been hospitalized the day after her uncle died. One month later, and after 16 days on a ventilator, she too died on March 13.

She was 56.

This story was done in partnership with , a member-supported, nonpartisan media organization that focuses on in-depth and investigative reporting about El Paso, Texas, Ciudad Juárez across the border in Mexico, and neighboring communities.

Methodology

To analyze covid deaths rates along the border with Mexico, KHN and El Paso Matters requested covid-related death counts by age group and county from Texas, New Mexico, California and Arizona. California and Arizona were unable to fulfill the requests. The Texas Department of State Health Services and the New Mexico Department of Health provided death counts as of Jan. 31, 2021.

Texas’ data included totals by age group for border counties as a group and for the state with no suppression of data. New Mexico provided data for individual counties, and small numbers were suppressed, totaling 1.6% of all deaths in the state. (Data on deaths is commonly suppressed when it involves very small numbers to protect individual identities.)

National death counts by age group were calculated using from the Centers for Disease Control and Prevention, and included deaths as of Jan. 31, 2021.

Rates were calculated per 100,000 people using the 2019 American Community Survey.

The ethnic breakdown in Texas’ border counties comes from the Census Bureau’s .

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

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This story can be republished for free (details).

Chin has patented more than 40 pieces of such hardware, including doughnut-shaped plastic cages, titanium screws and other products used to repair spines — generating $100 million for his company SpineFrontier, according to government officials.

Yet SpineFrontier’s success arose not from the quality of its goods, these officials say, but because it paid kickbacks to surgeons who agreed to implant the highly profitable devices in hundreds of patients.

In March 2020, the Department of Justice accused Chin and SpineFrontier of illegally funneling more than $8 million to nearly three dozen spine surgeons through “sham consulting fees” that paid them handsomely for doing little or no work. Chin had no comment on the civil suit, one of more than a dozen he has faced as a spine surgeon and businessman. Chin and SpineFrontier have yet to file a response in court.

Medical industry payments to orthopedists and neurosurgeons who operate on the spine have risen sharply, despite government accusations that some of these transactions may violate federal anti-kickback laws, drive up health care spending and put patients at risk of serious harm, a KHN investigation has found. These payments come in various forms, from royalties for helping to design implants to speakers’ fees for promoting devices at medical meetings to stock holdings in exchange for consulting work, according to government data.

Health policy experts and regulators have focused for decades on pharmaceutical companies’ payments to doctors — which research has shown can influence which drugs they prescribe. But far less is known about the impact of similar payments from device companies to surgeons. A drug can readily be stopped if deemed harmful, while surgical devices are permanently implanted in the body and often replace native bone that has been removed.

Every year, a torrent of cash and other compensation flows to these surgeons from manufacturers of hardware for spinal implants, artificial knees and hip joints — totaling more than $3.1 billion from August 2013 through the end of 2019, a KHN analysis of government data found. These bone specialists make up a quarter of U.S. doctors who have accepted at least $100,000 or more, and two-thirds of those who raked in $1 million or more, from the medical device and drug industries last year, the data shows.

“It is simply so much money that it is staggering,” said Dr. Eugene Carragee, a professor of orthopedic surgery at the Stanford University Medical Center and of the medical device industry’s influence. Much of the money is deemed to be compensation for consulting duties or medical research, or royalties for inventing, or fine-tuning, new surgical tools and techniques. In some cases, it pays for trips or splashy junkets or rewards surgeons for promoting products to their peers.

Device makers say the long-established practice leads to higher-quality, safer products. “Doctors help develop and refine medical devices, and they even create new devices themselves, sharing their intellectual property with companies to help save and improve patients’ lives,” said Scott Whitaker, president and CEO of AdvaMed, the medical technology industry’s trade group.

But industry whistleblowers and government investigators say all that money changing hands can corrupt medical judgment and tempt surgeons to perform unnecessary and wasteful operations. In ongoing lawsuits, patients say they have suffered life-altering injuries from screws or other spinal hardware that snapped apart or live with disabilities they blame on defective knee or hip implants. Patients alleging injuries range from seniors on Medicare to celebrities such as Olympic gold medalist Mary Lou Retton, who had surgery to replace both her hips. The gymnast sued device maker Biomet in January 2018, alleging the hip implants were defective. The suit has since been settled under confidential terms.

The case of Chin’s company, SpineFrontier, is among more than 100 federal fraud and whistleblower actions, filed or settled mostly in the past decade, that accuse implant surgeons of taking illegal compensation from device makers — from surgeon entrepreneurs like Chin to marquee names like Medtronic and Johnson & Johnson. In some cases, device makers have paid hundreds of millions of dollars in fines to wrangle out of trouble for their involvement, often without admitting any wrongdoing.

Court pleadings examined by KHN identified more than 700 surgeons who have taken money, including dozens who pocketed millions in royalties, fees or other compensation from 2013 through 2019.

The names of hundreds more surgeons were redacted in court filings or sealed by judges.

Court filings 35 spine surgeons who used SpineFrontier’s surgical gear, some for years. At least six of those surgeons have admitted wrongdoing and paid a total of $3.3 million in penalties. Another has to criminal charges. It’s illegal under federal law to accept anything of value from a device maker for using its wares, though most offenders don’t face criminal prosecution.

Chin, 57, who lives in Fort Lauderdale, Florida, and owns SpineFrontier through his investment company, declined comment about the DOJ lawsuit or the consulting agreements.

“There is a court date [for the DOJ case] as ordered by a judge,” Chin said via email. “If we get to that point the facts of the case will be litigated.”

Back Surgeries Under Scrutiny

The nation’s outlay for spine surgery to treat back pain, or to replace worn-out knees and hips, tops $20 billion a year, according to one industry .

Taxpayers shoulder much of that cost through Medicare, the federal program for those 65 and older, and Medicaid, which caters to low-income people.

In one common spinal procedure, surgeons may replace damaged discs with an implant and screws and metal rods that hold it in place. The demand for surgery to replace worn-out knees and hips also has mushroomed as aging boomers and others seek relief from joint pain that restricts their movement.

Perhaps not surprisingly, the competition for sales of orthopedic devices is fierce: Some 250 companies proffer a dizzying array of products. Industry critics blame the Food and Drug Administration, which allows manufacturers to roll out new hardware that is substantially equivalent to what already is sold — though it often is marketed as more durable, or otherwise better for patients.

“The money is just phenomenal for this medical hardware,” said Dr. James Rickert, a spine surgeon and head of the Society for Patient Centered Orthopedics, an advocacy group. He said most of the products are “essentially the same,” adding: “These are not technical instruments; [it’s often] just a screw.”

Hospitals can end up charging patients $20,000 or more for the materials, though they pay much less for them. Spine surgeons — who make upward of $500,000 a year — bill separately and may charge $8,000 to $20,000 for major procedures.

Which equipment hospitals choose may fall to the preference of surgeons, who are wooed by manufacturing sales reps possibly present in the operating room.

And it doesn’t stop there. Whistleblower cases filed under the federal False Claims Act allege a startling array of schemes to influence surgeons, including compensating them for joining a medical society created and financed by a device company. In other cases, companies bought billboard space or other advertising to promote medical practitioners, hired surgeons’ relatives, paid for hunting trips — even mailed checks to their homes.

Orthopedic and neurosurgeons collected more than half a billion dollars in industry consulting fees from 2013 through 2019, federal payment records show.

These gigs are legal so long as they involve professional work done at fair market value. But they have drawn fire as far back as 2007, when four manufacturers that dominated the hip and knee implant market, including a J&J division, to pay $311 million to settle charges of violating anti-kickback laws through their consulting deals.

KHN found at least 20 whistleblower suits, some settled, others pending, that have since accused device makers of camouflaging kickbacks as consulting work, including paying doctors to sit on suspect “advisory boards” or other activities that entailed little work to justify the fees.

In November 2019, device maker Life Spine and two of its executives admitted to paying consulting fees to induce dozens of surgeons to use Life Spine’s implants in the operating room. In all, 21 of the top 30 Life Spine adopters were paid and they accounted for about half its total device sales, according to the Justice Department. Life Spine and the executives a total of $6 million in penalties. The company did not respond to requests for comment.

Similarly, SpineFrontier received “the vast majority” of its sales, more than $100 million worth, from surgeons who were compensated, the Justice Department alleges. Often, they were paid by way of a “sham” company run by Chin’s wife, Vanessa, from a mail drop in Fort Lauderdale, according to the Justice Department. Vanessa Dudley Chin, a defendant in the DOJ civil case, had no comment.

Kingsley Chin told KHN via email that he takes no salary from SpineFrontier, based in Malden, Massachusetts. In 2013, Chin received $4.3 million in income from the company, according to court filings in a divorce case in Philadelphia from an earlier marriage. In 2018, SpineFrontier valued Chin’s interest in the company at $75 million, according to government records, though its current worth is unclear.

SpineFrontier’s management thought paying doctors was “the only reliable way to steadily increase its market share and stave off competition,” Charles Birchall, a former business associate of Chin’s, alleged in a whistleblower complaint. The case is one of two whistleblower suits filed against SpineFrontier that the DOJ has joined and consolidated. Chin has yet to file a response in court.

From March 2013 through December 2018, the company offered some surgeons $500 or more an hour for “consulting,” which could include the time they spent operating on patients — even though they already were being paid by Medicare or other health insurers. Other surgeons were paid repeatedly to “evaluate” the same products, though their feedback was “often minimal or nonexistent,” according to the DOJ complaint.

Patient Injuries Pile Up

While the payments have piled up for doctors, so have injuries for patients, according to lawsuits against device makers and whistleblower testimony.

Orthopedic surgeon-turned-whistleblower Dr. Manuel Fuentes is suing his former employer, Florida device maker Exactech, alleging it offered “phony” consulting deals to surgeons who had complained about alarming defects in one of its knee implants.

Their findings should have been forwarded to the FDA to protect the public, Fuentes and two former Exactech sales reps alleged in their suit. Instead, the company paid the surgeons “to retain their business and secure their silence” about patients needlessly undergoing a second operation to address the defects implanted in the first, according to the suit. Lawyer Thomas Beimers, who represents Exactech in the case, said the company “emphatically denies the allegations and looks forward to presenting the real facts to the court.” In a court filing, the company said the suit was “full of conclusory, vague and immaterial facts” and said it should be dismissed.

In Maryland, spine surgeon Dr. Randy F. Davis faces a lawsuit filed in early 2020 by 14 former patients who claim he implanted counterfeit hardware from a device distributor that had paid him hundreds of thousands of dollars in consulting fees and other compensation.

Davis used the hardware, which had not been FDA-approved, on about 250 patients at the University of Maryland Baltimore Washington Medical Center in Glen Burnie, Maryland, according to the suit. Several patients say screws or other implants failed and they sustained permanent injuries as a result. One woman said she was left with little feeling in her right foot and needs a cane or walker to get around. Others claim “extreme mental anguish” for fear the hardware inside them will fail, according to the suit.

The patients allege that Davis improperly disposed of defective screws and other hardware he removed rather than send the items for analysis or report the failures to authorities. Instead, the University of Maryland hospital sent “hush” letters to patients that falsely told them that no defects had been found, according to the suit. A spokesperson for the hospital, which also is a defendant in the suit, denied the allegations, noting: “We will vigorously defend this lawsuit and at its conclusion are quite confident we will prevail.” Davis and his lawyer didn’t respond to repeated requests for comment. The lawsuit is pending in Anne Arundel County state court.

Surgeons are free to implant devices they helped bring to market or promoted, though doing so can prompt criticism when injuries or defects occur.

That happened when three patients filed lawsuits in 2018 against Arthrex, a Florida device company. The patients argued they were forced to undergo repeat operations to replace defective Arthrex knee devices implanted by Pennsylvania orthopedic surgeon Dr. Thomas Meade.

Meade was not a defendant in the cases. But the patients accused him of misleading them about the product’s safety and a recall. One noted that Meade had served as a prominent consultant to Arthrex and had “participated in the design, testing, marketing, promotion and sales” of the knee implant. The patient alleged that Arthrex had paid Meade more than $250,000 for work that included “promotional speaking, travel, lodging, and consulting.”

In court filings, Arthrex admitted making payments to Meade for “consulting and royalties” but denied wrongdoing. The cases were settled in 2020. Meade did not respond to requests for comment.

Chin’s dual roles as SpineFrontier’s CEO and user of its hardware was called a “huge” conflict of interest by a judge in a pending malpractice case filed against him and the company in South Florida.

In that case, Miami resident Patrick Chapoteau alleges Chin performed back surgery in 2014 using SpineFrontier hardware even though it had little chance of success. According to the suit, a Chin-designed screw implanted to stabilize Chapoteau’s spine broke in half, causing him pain and disabling injuries.

In a legal brief, Chin’s lawyers argued that he regularly operates on people with disabling back problems, noting: “The surgery is sophisticated and challenging. On a few rare occasions, his patients have not obtained the relief they expected or experienced unanticipated complications that required additional care.”

Joseph Wooten, a former Chin patient and Florida power company employee, alleged in a 2014 lawsuit in Broward County Circuit Court that Chin had 15 previous malpractice claims that had ended in more than $8 million in settlements, an assertion Chin’s lawyers disputed.

“He never told me of his bad record injuring people,” Wooten, 64, wrote in a court filing. He and his wife, Kim, said the surgery caused “debilitating and life-altering injuries.” The case has since been settled. Chin acknowledged no wrongdoing and the terms are confidential.

KHN reviewed court pleadings in nine settled malpractice cases in Philadelphia, where Chin served on the faculty of the University of Pennsylvania Medical School from 2003 to 2007, and six in South Florida filed since 2012. Details of the settlements are confidential. Five of the six South Florida cases are pending, including one filed in December by the widow of a man who died shortly after spine surgery. In all the cases and settlements, Chin has denied negligence.

In her lawsuit pending against Chin in South Florida, Nancy Lazo of Hialeah Gardens, Florida, said she slipped and tumbled down the stairs outside her Miami office, landing on her back and arm. When the pain would not go away, she turned to Chin and had two operations, in 2014 and 2015. Her lawyers allege that a SpineFrontier screw Chin implanted in her spine in the second procedure caused nerve damage. Lazo, 51, a former billing clerk with two adult sons, said she can no longer work and remains in “constant” pain. “Based on what my doctors have told me,” she said, “I will never get back to normal.” Chin denied any negligence and the case is pending.

“Based on what my doctors have told me, I will never get back to normal.”

— Nancy Lazo

Government Struggles to Keep Pace

Concerns that industry payments can corrupt medical practice have been aired repeatedly at congressional , in media and in federal . The recurring scandals led Congress to require that device makers and pharmaceutical companies report the payments, starting in August 2013, to a government-run website called . That website shows that payments to all doctors have risen from $8.6 billion in 2014 to just over $10 billion last year. A recent found payments by device makers exceeded those of pharmaceutical companies by a wide margin.

Both the North American Spine Society and the American Academy of Orthopaedic Surgeons told KHN that close ties with the industry, while seeming to generate huge payouts to some surgeons, lead to the design of safer and better implants. “These interactions are really essential for good outcomes in patient care and that needs to be preserved,” said Dr. Joshua J. Jacobs, who chairs the orthopedic surgery department at Rush University Medical Center in Chicago and the AAOS’ ethics committee.

Although more than 600,000 American doctors lap up industry largesse, most do so through small payments that cover the cost of food, drinks and travel to industry-sponsored events. When it comes to big money, however, orthopedists and neurosurgeons dominate, collecting 25% of the total — even though they represent only 5% of the doctors accepting payments, according to the KHN analysis of Open Payments data.

Dr. Charles Rosen, a spine surgeon and co-founder of the advocacy group Association for Medical Ethics, said he was once offered $2,000 just to show up and watch an industry-sponsored panel. “It was quite unbelievable,” he said.

Rosen said while he believes a “relatively small number” of surgeons cash whopping industry checks, many who do so are influential figures who can “help direct medical care.”

Government data confirms that even as several orthopedic and neurosurgeons received tens of millions of dollars in 2019, 81% of them got less than $5,000 from industry.

Federal officials recently signaled their displeasure with the hefty fees paid to doctors who promote their products to peers, especially at restaurants, entertainment or sports venues that feature free food and booze but little educational content. In November, the inspector general at the Department of Health and Human Services issued a that such gestures could violate anti-kickback laws.

Companies that ignore the reporting law can be fined up to $1 million, though no fines were levied from 2014 through spring 2020, according to a CMS . That changed in October, when device giant Medtronic to pay the government $9.2 million to settle allegations that it paid kickbacks to Sioux Falls, South Dakota, neurosurgeon Dr. Wilson Asfora to promote its goods. Officials said the company sponsored more than 100 events at a Brazilian restaurant owned by the surgeon to clinch the sales. Just over $1 million of the fine was assessed for failing to report the transactions. A Medtronic spokesperson said the company fired or took other disciplinary action against the sales employees involved and “remains committed to maintaining the highest standards of ethical conduct.”

KHN identified four spinal device makers — including SpineFrontier — that have been accused in whistleblower cases of scheming to hide consulting payments from the government.

Responding to written questions, a CMS spokesperson said the agency “has multiple formal compliance actions pending which it is unable to discuss further at this time.”

But penalties for paying, or accepting, kickbacks often are small compared with the profits they can generate.

“Some people would say if you penalize companies enough, they won’t be making these offers,” said Genevieve Kanter, an assistant professor at the University of Pennsylvania Perelman School of Medicine. She said small fines may be chalked up to the “cost of doing business.”

The Federation of State Medical Boards does not keep data on how often its members discipline doctors for civil kickback offenses, according to spokesperson Joe Knickrehm. The federation has “long advocated for stronger reporting requirements,” Knickrehm said.

Justice Department officials would not discuss whether they are seeking fines from more surgeons. But in a in April 2020, then-U.S. Attorney for the District of Massachusetts Andrew E. Lelling noted that the government will investigate any doctor “who accepts money from a device manufacturer simply for using that company’s products.”

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Amgen gave $5,000. So did Genentech and Merck. Sanofi, Pfizer and Eli Lilly all gave $2,500. Each of those companies has invested heavily in personalized medicine, which promises individually tailored drugs that can cost a patient hundreds of thousands of dollars.

Sinema is a first-term Democrat from Arizona but has nonetheless emerged as a pharma favorite in Congress as the industry steers through a new political and economic landscape formed by the coronavirus.

She is a leading recipient of pharma campaign cash even though she’s not up for reelection until 2024 and lacks major committee or subcommittee leadership posts. For the 2019-20 election cycle through March, political action committees run by employees of drug companies and their trade groups gave her $98,500 in campaign funds, Kaiser Health News’ Pharma Cash to Congress database shows.

That stands out in a Congress in which a third of the members got no pharma cash for the period and half of those who did got $10,000 or less. The contributions give companies a chance to cultivate Sinema as she restocks from a brutal 2018 election victory that cost nearly $25 million. Altogether, pharma PACs have so far given $9.2 million to congressional campaign chests in this cycle, compared with $9.4 million at this point in the 2017-18 period, a sustained surge as the industry has responded to complaints about soaring prices.

Sinema’s pharma haul was twice that of Sen. Susan Collins of Maine, considered one of the most vulnerable Republicans in November, and approached that of fellow Democrat Steny Hoyer, the powerful House majority leader from Maryland.

It all adds up to a bet by drug companies that the 43-year-old Sinema, first elected to the Senate in 2018, will gain influence in coming years and serve as an industry ally in a party that also includes many lawmakers harshly critical of high drug prices and the companies that set them.

“This is a long-term play,” said Steven Billet, a former AT&T lobbyist who teaches PAC management at George Washington University. “She’s more of a moderate than people are giving her credit for. If I’m a pharmaceutical guy, I’m saying, ‘You know what? Maybe this is somebody we can work with down the road.’”

The industry’s pivot to Sinema comes as powerful favorites such as former Sen. Orrin Hatch of Utah and retiring Rep. Greg Walden of Oregon, both Republicans, fade from the scene.

Bisexual, an LGBTQ rights advocate and a former member of the Arizona Green Party, Sinema said in 2006 that she was the most liberal member of the Arizona State Legislature, These days, representing traditionally conservative Arizona statewide, she portrays herself as a moderate. She favors better medical coverage by improving the insurance company-friendly Affordable Care Act, for example, not by scrapping it in exchange for “Medicare for All.”

“Sinema is a talented politician who knows where she needs to be politically and will get there,” said Nathan Gonzales, editor of Inside Elections, a nonpartisan newsletter.

Sinema’s spokesperson did not respond to queries from KHN.

First elected to the U.S. House in 2012, she has a history of supporting pharmaceutical and biotech firms, dozens of which have operations in Arizona. Her acceptance of drug industry campaign contributions sets her apart from Democrats such as Sen. Cory Booker of New Jersey who have pledged to reject pharma money, not to mention those who spurn all corporate cash.

“The Republican Party tends to be more receptive to pharma cash,” said Paul Jorgensen, a political science professor at the University of Texas Rio Grande Valley, who analyzes campaign finance. “You’re going to see divisions within the party on pharma on the Democratic side.”

In 2017 Sinema , strongly supported by the Biotechnology Innovation Organization trade group, that would have eased financial regulation on publicly traded biotech firms with little revenue. The measure has not become law, but two weeks later BIO named Sinema calling her a “stalwart advocate” for life sciences jobs.

“We welcome the opportunity to work with any policymaker who understands the value of science, the risks, costs and challenges of developing new medicines, and the need to ensure patients have access to medicines with out-of-pocket costs they can afford,” BIO spokesperson Brian Newell said.

Sinema portrayed her backing of a 2016 measure to accelerate the introduction of scarce generic drugs as A version became law the next year. But support for the bill by the Pharmaceutical Research and Manufacturers of America, the main brand-drug lobby, prompted some to question its potential to bring down overall drug prices.

Sinema was a strong advocate of the biggest overhaul of over-the-counter drug regulation in almost half a century. The measure became law in March with little public notice as part of the CARES Act to rescue the economy and fight the coronavirus. It gives the Food and Drug Administration new leeway to move against possibly dangerous drugs, sets up industry fees to pay for accelerated reviews and creates incentives to bring new medicines to market.

The changes drew widespread, bipartisan support. The old OTC regulation “wasn’t good for anyone,” said Joshua Sharfstein, who was deputy FDA commissioner in the Obama administration. “It wasn’t good for consumers. It wasn’t good for industry.”

The new system resembles the user-fee financing of regulation for prescription drugs. But making the FDA dependent on drug company money for OTC oversight — subject to periodic negotiation with industry — makes the agency beholden to the companies it oversees, said David Hilzenrath, chief investigative reporter for the Project on Government Oversight, a watchdog nonprofit.

Accelerating review of OTC medicines “may be a double-edged sword,” he said. “It could speed decisions that benefit the public and it could speed decisions that put the public at risk.”

Personalized medicine — also known as precision medicine — promises to use genetic characteristics and other traits to identify which treatments are best for a particular patient.

Sinema c along with Republican Sen. Tim Scott of South Carolina and two House members. The lawmakers introduced the group , the Personalized Medicine Coalition.

“Raising awareness of the benefits of personalized medicine helps detect and prevent diseases, while making health care more affordable and accessible for Arizona families” was Sinema’s quote in the press release.

But affordability has not been a hallmark of personalized medicine so far. Like other recent pharma products, genetically targeted medicines and tests can come with extremely high prices while sometimes delivering mediocre benefits, health policy analysts say.

One of the best-known precision medicines is Merck’s Keytruda, used against a variety of cancer tumors with certain genetic profiles. It costs more than $100,000 a year.

“It’s a good drug,” said Vinay Prasad, an associate professor at the University of California-San Francisco who studies health policy and cancer drugs. “But behind it is a marketing machine that is trying to maximize its use.”

In any case, personalized medicine generally “has been a mixed bag,” with prices for cancer drugs that are “universally horrendous,” he said. Industry enthusiasm may be “motivated by the fact that when something is called precision or personalized, the regulatory bar needed to approve it is lower,” he added. “And that is often good for profits.”

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In many of those homes, people can’t even turn on a faucet. There’s no running water.

In 470,000 dwellings in the United States — spread across every state and in most counties — inadequate plumbing is a problem, the starkest of several challenges that make it tougher for people to avoid infection.

That’s according to a Kaiser Health News analysis of data from the Census Bureau and the in Washington, D.C. The analysis reveals other ways that inadequate housing in the United States puts people at risk during this pandemic. Nearly a million homes scattered across almost all counties don’t have complete kitchens, raising the risk of hunger and vulnerability to illness, even as people have been expected to eat all meals there amid stay-at-home orders. And over 4 million homes are overcrowded, with more than a person per room, making it nearly impossible to isolate the sick.

In fact, about 828,000 people have to deal with more than one of these housing problems.

“We assume this is happening in Third World places,” said Greg Carter, an assistant professor at the Indiana University School of Nursing. “But it’s happening here.”

Carter’s work takes him to southern Indiana’s Orange County, a community of just under 20,000 that, as of Sunday, had 113 confirmed COVID-19 cases and 18 deaths. It’s also one of 322 U.S. counties with rates of inadequate plumbing at least three times the national average of four homes in every 1,000.

Phil Mininger, construction manager for Habitat for Humanity there, said he knows a man in his early 70s who lives in a dilapidated house without running water or electricity. The man walks to a Walmart about a half a mile away to use the bathroom and wash his hands.

Conditions like these also occur in states such as Colorado, Alaska and New York wherever plumbing is absent or in disrepair or water has been shut off.

Percentages are twice as high in rural areas overall, but similar conditions can be found in urban centers, too. Just under half a percent of dwellings in New York City have inadequate plumbing, for example, but that’s still about 14,000 homes.

Public health experts say substandard housing reflects vast socioeconomic inequities that make America a breeding ground for the coronavirus. Poverty, and the poor health that goes with it, fuel the spread and raise the likelihood of dying from COVID-19, both in places the disease already has hit hard and those it’s just reaching.

“The discrepancies between those with privilege and those without, they existed before our pandemic. What happens after?” asked , an assistant professor of community and behavioral health at the University of Minnesota-Duluth. “I hope when this is done, we as a community and as a society recognize there are people who don’t have access to what they need. And that has to be addressed.”

Facing The Virus Without Running Water

The federal government made huge public health gains in the early- to mid-20th century by spending heavily on water infrastructure. The result was healthier people who lived significantly longer. But that changed in the 1980s, according to a 2019 by the , and Michigan State University researchers. From 1977 to 2014, said, federal spending on water infrastructure dropped from $76 to $11 per person in inflation-adjusted dollars. Local and state spending rose, but didn’t come close to meeting the need.

Then the COVID pandemic struck.

Nick Slim, tribal council administrator in the remote Yup’ik Eskimo village of Kipnuk, about 500 miles west of Anchorage, said people there have been “doing the best we can” to follow hand-washing advice, but it can be a struggle. They have no piped water; he and the other 650 residents depend on hauling ice and collecting rain.

“We’re all concerned about the virus,” Slim said.

Just over a third of homes in the Bethel Census Area of Alaska have inadequate plumbing, the nation’s second-highest rate behind the adjacent Yukon-Koyukuk Census Area.

According to state officials, most Alaska homes without running water and flush toilets are in Native Alaskan villages either not served by water utilities, or in places where water must be hauled or that have aging and deteriorating piped systems. Compared with the overall U.S. population, KHN found, Native Americans are eight times more likely to lack sufficient plumbing in their homes.

In the absence of running water, respiratory illness festers. Rates of invasive pneumococcal disease in southwestern Alaska are among the highest in the world.

Still, Alaska has had fewer confirmed cases of COVID-19 than many other states, with 381 through Sunday. But a study said that if a county has just one case of COVID-19, there is a 51% chance that an outbreak is underway.

Gunnison County, Colorado, has already been hit hard by the coronavirus, with 173 confirmed cases through Sunday and six deaths among just over 17,000 people. That gives the county, known for the Crested Butte ski resort, one of the highest case rates in its state. It also has one of Colorado’s highest rates of inadequate plumbing — about 1 in 45 homes. It’s a place of housing extremes, with the median owner-occupied home costing $339,000, and some mobile homes going for a tenth of that.

Loren Ahonen, a program administrator with the , recalled a mobile home with an unrepaired frozen water line. Water was restored about a week after county residents were told to stay home amid the pandemic, he said. But until then, he said, tenants relied on 5-gallon jugs of water from the grocery store, neighbors and good Samaritans.

As in many other communities, Ahonen said, all utilities in Gunnison County have suspended shut-offs for nonpayment during the pandemic. But emergency water shut-offs are still happening when leaks arise, as he noticed recently when he drove through a mobile home park prone to water problems.

Raising The Risk Of Disease

Such issues compound another perennial issue in mobile homes: overcrowding. Ahonen said he’s seen up to six people squeeze into a small home. A created by the Colorado Health Institute found that 1 in 20 homes in a Gunnison County census tract were overcrowded.

Crowded housing is also a big issue in urban areas, and has been linked to higher rates of COVID-19. An of New York City cases by the New York University Furman Center found that the ZIP codes with the highest rates of positive cases had more than twice the rate of renters living in overcrowded conditions as those with the lowest rates.

Pascual Peña, 33, an aide to a New York City council member, said he and seven family members are packed into a small, four-bedroom apartment in the Manhattan neighborhood of Washington Heights.

Recently, his parents and sister developed COVID-19 symptoms, he said, and “it was difficult with so many people to separate each other.” Peña said he spent most of his time in the kitchen, while his father stayed in a bedroom, his mother in the living room and his sister in her room. Everyone shares the bathroom, cleans constantly and hopes the virus won’t spread further.

Indiana University’s Carter said people living in unhealthy housing conditions are often older or suffer from chronic disease, further raising their risk of becoming seriously ill with COVID-19. Carter recalled a woman with diabetes who lived in an Orange County home buzzing with fruit flies, where meat rotted in a dilapidated refrigerator.

While Carter and his team were able to help her, aid is harder to come by these days, with many outreach programs on pause. Arranging repairs has been complicated by social distancing rules.

As the pandemic and its accompanying economic crisis continue, public health experts worry that people living in substandard housing may spiral further downward — especially since housing is usually just one of their challenges. They may have lost low-wage jobs to COVID-19. Or they may lack medical care, steady food or other ingredients of a healthy life.

“We’re going to see them experience a greater lack of access to these things.” Carter said. “People were already dying of poverty.”

Carter and other experts said policymakers, and society as a whole, must focus more on housing and health disparities. Pandemic or not, no one in America should live without the basics of indoor plumbing, said Lance George, research director for the nonprofit Housing Assistance Council, which helps build homes across rural America.

“This is 2020,” George said. “These are problems that should’ve been solved.”

KHN data reporter Hannah Recht contributed to this report.

METHODOLOGY

For estimates of households in the United States that do not have adequate plumbing or adequate kitchens or are overcrowded, KHN analyzed data from the American Community Survey (ACS) five-year estimates (2014-18), specifically the Integrated Public Use Microdata Series () provided by the University of Minnesota. This data provides demographic data on individual members in each household. KHN excluded those living in group quarters.

For race/ethnicity categories, whites, American Indians, blacks and Asians include non-Hispanics only; Asians include Pacific Islanders and American Indians include Alaska Natives; and Hispanics are of any race or combination of races. Non-Hispanics who responded as representing more than one race are included in the “other” category.

Plumbing is considered inadequate if it lacks one or more of the following: piped hot and cold water; a bathtub or shower; or a toilet. A kitchen is considered inadequate if it lacks a refrigerator, a stove or range, or a sink with a faucet. A household is considered overcrowded if it has more than one person per room.

To compare rural and non-rural areas, KHN used data from the , which coded census tracts as rural, urban, or exurban/suburban and provided household estimates by census tract for inadequate plumbing and kitchens, based on ACS five-year estimates (2013-17).

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Probably few hospital systems need the emergency federal grants announced this week to handle the coronavirus crisis as badly as Florida’s Jackson Health does.

Miami, its base of operations, is the worst COVID-19 hot spot in one of the most severely hit states. Even in normal years, the system sometimes barely makes money. At least two of its staff members have died of the virus.

But in a scathing letter to policymakers, system CEO Carlos Migoya said the way Washington has handled the bailout “could jeopardize the very existence” of Jackson, one of the nation’s largest public health systems, and similar hospital groups.

“We are here for you right now,” Migoya, who has tested positive for COVID-19 himself, said in a Thursday letter to Alex Azar, secretary of Health and Human Services. “Please, be here for us right now.”

Migoya and executives at other beleaguered systems are blasting the government’s decision to take a one-size-fits-all approach to distributing the first $30 billion in emergency grants. HHS confirmed Friday it would give hospitals and doctors money according to their historical share of revenue from the Medicare program for seniors — not according to their coronavirus burden.

That method is “woefully insufficient to address the financial challenges facing hospitals at this time, especially those located in ‘hot spot’ areas such as the New York City region,” Kenneth Raske, CEO of the Greater New York Hospital Association, said in members.

States such as Minnesota, Nebraska and Montana, which the pandemic has touched relatively lightly, are getting more than $300,000 per reported COVID-19 case in the $30 billion, according to a Kaiser Health News analysis.

On the other hand, New York, the worst-hit state, would receive only $12,000 per case. Florida is getting $132,000 per case. KHN relied on a state breakdown provided to the House Ways and Means Committee by HHS along with COVID-19 cases tabulated by The New York Times.

The CARES Act, the emergency law passed last month to address the pandemic, gives HHS wide latitude to administer $100 billion in grants to hospitals and doctors.

But the decision to allocate the first $30 billion according to past Medicare business surprised many observers.

The law says the $100 billion is intended “to prevent, prepare for and respond to coronavirus,” including paying for protective equipment, testing supplies, extra employees and temporary shelters and other measures ahead of an expected surge of cases. It says hospitals must apply for the money.

“It seems weird that they wouldn’t just target areas geographically based on where the surge has been,” said Chas Roades, CEO of Gist Healthcare, a consulting firm.

Issuing the funds based on Medicare revenue “allowed us to make initial payments to providers as quickly as possible,” an HHS spokesperson said Friday. Some of the money was expected to go out as soon as Friday in electronic deposits.

HHS “has failed to consider congressional intent” in distributing the $30 billion by not accounting for “the number of COVID-19 cases hospitals are treating,” New Jersey Sens. Bob Menendez and Cory Booker and Rep. Bill Pascrell said in a Friday letter to Azar.

All three are Democrats. Behind New York, New Jersey has the second-highest number of recorded coronavirus cases, as of Friday afternoon.

The administration is struggling to balance the need to help systems slammed by the coronavirus with the need to provide immediate relief, said Bill Horton, a health care lawyer with Jones Walker in Birmingham, Alabama.

“Providers have to appreciate that there is a focus on trying to respond to their cries of pain and coming up with ways to get some money out there,” he said. On the other hand, he said, HHS sets itself up for criticism by paying “a chunk of money without particular regard for who has been hardest hit.”

Medicare revenue can vary sharply by hospital, depending on who their patients are and what part of the country they are in.

HHS’ method “could tilt the playing field” against hospitals whose patients are largely uninsured or covered by the Medicaid program for low-income patients, said Bruce Siegel, CEO of America’s Essential Hospitals, a group of systems serving the poor and vulnerable.

HHS said the next slice of the $100 billion to go out “will focus on providers in areas particularly impacted by the COVID-19 outbreak” as well as rural hospitals and those with lower shares of Medicare revenue.

Jackson Health’s budget depends heavily on reimbursement for the kind of elective procedures that it has canceled to ensure it has the capacity to handle COVID-19 patients, Migoya said. Lost revenue is $25 million per month, it estimates.

“We cut off our own funding sources in order to sustain our mission,” he wrote in the letter to Azar.

Hospitals in relatively COVID-19-free areas, on the other hand, could continue elective procedures but still receive a big chunk of the $30 billion, said Gerard Anderson, a health economist at Johns Hopkins University.

“If I’m in rural Kansas and I don’t have any COVID patients in my area, I’m not going to ― I should not — stop doing elective surgeries,” he said.

Even the type of Medicare payments hospitals typically receive will give some systems a much bigger share of the $30 billion than others of the same size.

HHS is basing the payments on traditional “fee for service” Medicare revenue. But hospitals with a big chunk of managed care Medicare business, called Medicare Advantage, won’t be credited for that.

In Florida, more than four Medicare members out of every 10 are in Medicare Advantage plans, one of the highest portions in the country, . (KHN is an editorially independent program of the foundation.)

In New York, 39% of beneficiaries are in Medicare Advantage. In Montana, by contrast, the figure is 17%. In Wyoming, it’s 3%.

Jackson’s South Florida location and patient mix “both skew heavily away from the fee-for-service model,” Migoya wrote. “No one wants to talk about money in the middle of a health crisis, but hope alone will not cash checks to employees or suppliers.”

KHN correspondent Rachana Pradhan contributed to this report.

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Intensive care units have sophisticated equipment, such as bedside machines to monitor a patient’s heart rate and ventilators to help them breathe. Even in communities with ICU beds, the numbers vary wildly ― with some having just one bed available for thousands of senior residents, according to the analysis based on a review of data hospitals report each year to the federal government.

Note: This data was updated on March 30.

Download the ICU Beds By County Data (.zip)

Consider the homes of two midsize cities: The Louisville area of Jefferson County, Kentucky, for instance, has one ICU bed for every 442 people age 60 or older, while in Santa Cruz, California, that number stands at one bed for every 2,601 residents.

Differences are vast within each state as well: San Francisco, with one bed for every 532 older residents, and Los Angeles, with 847 residents per bed, both have greater bed availability than does Santa Cruz.

Even counties that rank in the top 10% for ICU bed count still have as many as 450 older people potentially competing for each bed.

The KHN findings put in stark relief a wrenching challenge hospitals in many communities — both urban and rural ― could face during the coronavirus pandemic: deciding how to ration scarce resources.

“This is just another example of geography determining access to health care,” Arthur Caplan, a bioethics professor at NYU Langone Medical Center, said when told of KHN’s findings.

Overall, 18 million people live in counties that have hospitals but no ICU, about a quarter of them 60 or older, the analysis shows. Nearly 11 million more Americans reside in counties with no hospital, some 2.7 million of them seniors.

Dr. Karen Joynt Maddox, a professor at Washington University School of Medicine in St. Louis, said that hospitals with larger numbers of ICU beds tend to cluster in higher-income areas where many patients have private health insurance.

“Hospital beds and ICU beds have cropped up where the economics can support them,” she said. “We lack capacity everywhere, but there are pretty big differences in terms of per capita resources.”

“I liken it to sitting on a Gulf shore when a hurricane is offshore,” said Dr. Graham, from Michigan. “It’s a question of how soon and how hard.” KHN senior correspondent JoNel Aleccia contributed to this report.

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More nursing homes have been faulted for failing to follow practices designed to prevent and control infections — such as staffers washing their hands before and after helping each resident and wearing gowns and masks around contagious patients — than for any other type of error. Such lapses have become matters of heightened concern with the spread of the coronavirus this spring, especially as the virus is a bigger threat to the elderly and those with underlying health conditions.

Despite their frequency, these citations rarely are reflected in the overall star rating Medicare assigns each facility on its website. Even among nursing homes crowned with the maximum government rating of five stars for overall quality, nearly half have been cited for an infection-control lapse.

Health inspectors visit nursing homes every nine to 15 months for comprehensive evaluations. The KHN tool draws from a database of health inspection records during the past two regular survey cycles, which go as far back as 2016 for some facilities. The data also includes inspections initiated by complaints as well as those prompted by a problem a nursing home identifies.

The tool shows how often health inspectors have cited each nursing home for violating infection-control rules. It also shows the level of the most serious violation and the date it occurred.

Infections are a persistent challenge for skilled nursing facilities. As many as 3.8 million occur in homes each year, killing nearly 388,000 residents. Bacteria and viruses can spread through urinary catheters used by immobile patients and attack patients through soft tissues exposed as bedsores or wounds. Influenza and a serious infection caused by a bacteria known as MRSA (methicillin-resistant Staphylococcus aureus) can also spread from casual contact among residents and visitors. The infection threats have grown more serious with the spread of bacteria such as MRSA that are resistant to antibiotics.

The Centers for Medicare & Medicaid Services all nursing homes that accept government insurance payments such as Medicaid and Medicare to have a written plan to prevent and control infections. Each home must have a surveillance system to identify possible communicable diseases and contain them before they spread to other people in the facility and lay out the steps to report contagions to the authorities.

The program must instruct workers on all the precautions they should take to avoid contracting and transmitting diseases, such as , disinfecting equipment and distributing linens and cleaning laundry in a hygienic manner.

The program also explains when employees must wear , such as gowns, masks and gloves, and tells them exactly how to don and remove the equipment. It must also describe when a potentially contagious resident should be isolated and how long that should last.

When inspectors visit a nursing home, either for a regular survey or in response to a complaint, they issue a deficiency if they see the nursing home not following its infection-control program. They also categorize its seriousness into one of these four levels, which the KHN tool identifies:

Level 4: Immediate Jeopardy, the most serious violation, is typically assigned when there is evidence that the home’s faulty practice is putting residents at continued risk. That could include actions such as staff failing to sanitize equipment used on multiple residents. Nursing homes must remedy the problem at once, unlike lesser citations, for which they generally have 10 days to provide regulators with their plan to correct the violations.

Level 3: Actual Harm is usually assigned, as its name suggests, when a failure to follow proper procedures led to a resident contracting an infection or sustaining another tangible injury. An actual harm deficiency might be issued, for instance, if a nursing home overlooked or failed to treat a case of scabies on a resident and it spread to other residents, causing severely itchy rashes.

Only about 1% of deficiencies are categorized as immediate jeopardy or actual harm. Both levels can incur federal or state fines or other financial punishments, such as Medicare refusing to pay for new admissions for a set number of days. On rare occasions, a nursing home can be banned from Medicare and Medicaid.

Level 2: Potential for Harm, the most common citation level, is issued when no resident was hurt but a deficient practice might lead to a greater-than-minimal injury. Inspectors might use this if they observed staff members not washing their hands properly or allowing linens or wound care supplies to touch potentially contaminated surfaces, such as a resident’s bed.

Level 1: Potential for Minimum Harm, the mildest violation level, refers to a deviation from safety rules that did not lead to a patient’s injury and carried the potential for minimal harm, at most. It can be issued against a nursing home that failed to review its infection-control and prevention plan at least once a year, for instance.

Nursing home inspection reports can be found on . After you locate a home, select the “Health Inspections” tab and then click on the link near the bottom to view all details on health inspections, complaints and facility-reported issues.

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“Health care needs to be more affordable for patients, and we want to be part of the solution,” said Melinda Hancock, VCU Health’s chief administrative and financial officer. “We believe that no hospital bill should change the economic status of a family.”

The moves follow an investigation last year by Kaiser Health News that found VCU Health and Virginia’s other major teaching-hospital system, UVA Health, pursued tens of thousands of patients over the years for overdue bills, sending many into bankruptcy.

The practices included filing courthouse liens against the value of patients’ homes and garnishing wages, many from workers at lower-pay employers, such as retailers and restaurants.

Canceling liens ends the threat that VCU Health, part of Virginia Commonwealth University in Richmond, will take big chunks of equity when family homes are sold. Liens can easily reach thousands of dollars per property. Virginia allows creditors to garnish up to 25% of someone’s earnings.

“That is great news for VCU patients,” said Jenifer Bosco, an attorney with the National Consumer Law Center who specializes in medical debt. “I don’t recall hearing about other hospitals taking that step and canceling decades of past liens.”

Because they accrued interest of 6% annually or more, old liens could let VCU and UVA seize amounts far higher than the original hospital and doctor bills.

Undoing decades of property claims will require VCU lawyers to visit every circuit courthouse across the state, “which could take up to a year to complete,” said system spokesperson Laura Rossacher.

VCU’s moves are “an instant way to create a lot of goodwill and relieve patients of an incredible financial and emotional burden,” said Erin Fuse Brown, a law professor at Georgia State University who studies hospital billing. “UVA should do the same.”

VCU and UVA are the two major teaching hospital systems in Virginia, taking in billions annually and recording tens of millions of dollars in profits. UVA Health is part of the University of Virginia, based in Charlottesville.

Virginia Gov. Ralph Northam, a pediatric neurologist, “is proud to see VCU Health System taking significant, in some cases historic, steps to scale back aggressive medical collections and address the pain it’s caused,” said his spokeswoman, Alena Yarmosky.

Both VCU and UVA, which are state-run, have increased financial assistance and discounts for uninsured patients since KHN published its reports.

VCU pledged earlier to end all routine lawsuits for overdue bills, which are the precursor to garnishments and liens. The latest move cancels such claims resulting from old suits and judgments.

VCU’s in-house doctor group, MCV Physicians, filed more than 56,000 lawsuits against patients for $81 million over seven years, KHN found. VCU’s flagship hospital, VCU Medical Center, stopped filing patient suits seven years ago.

The litigation also included more than 15,000 garnishment cases over that period, some for VCU Medical Center but mostly for the physician group, the data showed.

VCU will not refund money collected in the past.

“They have socked it to a lot of people,” said Joseph Robinson, a Richmond church music director garnished last year for $851 by MCV Physicians for treatment he said happened years ago. “They were just going after anybody they could get.”

VCU joins Yale New Haven Health among the few hospital systems that have forsworn routine patient lawsuits. Such systems still bill for overdue accounts and try to collect money, but they stop short of seeking the legal right to seize assets.

For its part, UVA has said it will substantially reduce patient lawsuits, seeking court judgments for overdue bills only from families making more than 400% of federal poverty guidelines. That’s income of $86,880 for a family of three.

But its current policy of maintaining old liens and continuing to sue at least some patients makes it more aggressive than VCU.

On the other hand, UVA has made its new, wider financial assistance policy retroactive to July 2017 and in recent months has forgiven $15 million in debt for treatment after that date, said UVA spokesman Eric Swensen.

The system has also stopped wage garnishments “at this time,” he said. UVA has said changes announced so far are a “first step.” A community advisory council meeting monthly since last year will “inform and guide us as we explore changes to our policies,” Swensen said. Recommendations are expected this summer, he added.

UVA Health and affiliates filed 36,000 lawsuits against patients over six years, seeking a total of more than $106 million, KHN found.

Neither UVA nor VCU has responded to repeated queries about exactly how many liens they hold or how much they collect in lien proceeds, garnished wages and bank accounts.

“Compared to the harm it causes for patients, I can’t imagine that the hospitals are getting a significant amount of revenue from these legal actions,” said Fuse Brown.

Hospitals say they see more and more patients who can’t pay, even with insurance, because of stagnating incomes and rising insurance deductibles.

in Virginia’s General Assembly is expected to increase funding for VCU’s and UVA’s indigent care programs as well as update the family-asset test for patients seeking financial assistance, which hasn’t changed since 1985.

As reported last year by KHN, even $3,000 or $4,000 in a 401(k) or other retirement account could bar a patient from financial help. The legislation increases the asset-test threshold to $50,000, not counting a car and a house on less than 4 acres.

Another bill would prohibit the systems from suing or sending bills to collections before they determine whether patients qualify for Medicaid or financial assistance.

“We’re on the right path now,” said Jill Hanken, a health care attorney for the Virginia Poverty Law Center, which was behind the bill. “It was very important to put the brakes on these aggressive collection activities and force these hospitals to look more closely at their indigent care policies.”

Health care finance experts continue to criticize both VCU and UVA for what they charge the uninsured before factoring in any financial assistance.

Last year, UVA increased its discount for the uninsured from 20% off list prices to 40%. VCU increased the discount from 25% to 45%. But at those levels patients still pay far more than the health systems’ costs and far more than what the systems collect from the Medicare program for seniors.

“Until they reduce the amount they are trying to recover by adjusting their charge to what Medicare would have paid, people who owe debts will still face unreasonable demands,” said Sara Rosenbaum, a health law professor at George Washington University.

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