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Cindy Rodriguez: I'm Cindy Rodriguez, an investigative reporter with WNYC news, in for Tanzina Vega this week. This is The Takeaway.

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Audio clip: The goal of vaccinating 100 million people in the first 100 days is a realistic goal. We can do one million people per day.

Cindy: The rollout of the COVID-19 vaccine kicked off in the United States last month. Though it's off to a slow start, at least 4.3 million doses of either the Pfizer and Moderna vaccines have been given so far, starting first with healthcare workers that have borne the brunt of the COVID-19 pandemic. Another top priority group is residents and staff of long-term care facilities like nursing homes, which have been hit especially hard by the pandemic. According to the COVID tracking project, more than 120,000 deaths have been linked to these facilities. That's nearly 40% of all COVID-19 deaths nationwide, despite less than 1% of the population living in these facilities.

So far, the CDC has reported that about 365,000 people in long-term care facilities have gotten vaccine shots through a federal partnership with pharmacies like CVS and Walgreens. The process of vaccinating this vulnerable population hasn't been without hurdles, whether that's nursing home staff refusing to get vaccinated, or difficulty getting consent to vaccinate residents with dementia or Alzheimer's. All this is happening as COVID-19 continues to sweep through long-term care facilities nationwide.

For more on this, we're joined by Tamara Konetzka, health economist and professor at the University of Chicago. Tamara, glad to have you with us.

Tamara Konetzka: Happy to be here. Thank you.

Cindy: Also here is Nathaniel Weixel, health reporter at The Hill. Nathaniel, welcome as well.

Nathaniel Weixel: Thanks for having me.

Cindy: Nathaniel, vaccine distribution is very different from state to state, but can you give us an overall picture of what the rollout has looked like for the nation's long-term care facilities?

Nathaniel: Most of the states right now are part of this federal long-term care partnership with CVS and Walgreens, and basically as part of that program, every state orders a set amount of vaccines every week for their long-term care facilities. The vaccines go to the pharmacies and these pharmacies show up at the long-term care facilities to hold, essentially, vaccination clinics.

Cindy: I see. Is your sense that this is the way it's working for most facilities or have some facilities chosen not to go that route?

Nathaniel: Some facilities have chosen not to that route, but really, all but two states in the country are part of this program. We're not really going to know how well it's worked completely, until we can compare what's happened with the states that are part of this program and the states that haven't done it. It's a little ways to go before we can draw any major conclusions, but as you pointed out at the top, like most of the rest of the country, vaccinations have been off to a pretty slow start in nursing homes.

Cindy: Tamara, can you tell us a little bit about why things have been slow. Are staff resistant? Are the residents resistant? What's happening?

Tamara: I don't think it's so much resistance. I think just like the vaccine rollout more generally, there have been a couple of things that have made it a little bit slower than we would have hoped. It's hard to pin down the exact reasons, but one reason is that there just wasn't enough overall planning for this rollout. The second reason might be resources, Congress was late to approve the necessary funding for the vaccine rollout. We're asking a lot of the same people who are involved in the healthcare system already to now get involved in vaccine administration and so the rollout has been slow in general.

I do think that it's picking up both in long-term care facilities and in the rest of the country. It is a huge undertaking. I think we have to keep sight of the fact that this is, even if it's slower than we would like, this is undoubtedly a really great thing for nursing homes and hopefully, will dramatically decrease the number of deaths that we're seeing across the nation.

Cindy: Nathaniel, have you had a chance to interview nursing home workers and if so, what have you heard from them?

Nathaniel: Not workers so much. They have been reluctant to talk specifically, but I've talked to some clinics and some of the larger associations, talking about what they have heard from their members. First it was hesitation, I guess would be the way to describe it. It's not with every worker and it's not in every clinic, but you hear from some of these clinics, you hear from some of these governors talking about their clinics.

For example, in Ohio, Governor DeWine said yesterday, that more than 50% of the workers are just reluctant to get vaccinated. From what I'm hearing, it's not necessarily that they're anti-vaccine, there's just some hesitation about what's going on and the reasons why things are moving so quickly. General questions about why and whether it's safe.

Cindy: Tamara, what do you know about who should get vaccinated first? Are most places vaccinating residents first or are they vaccinating workers first?

Tamara: It seems, anecdotally at least, because we don't have a lot of data on this yet. It seems that both are being done at the same time, which makes a lot of sense. We're not requiring nursing home staff to go elsewhere to try to track down the vaccine. Generally a vaccine day or clinic is set up, and the Walgreens or CVS representatives come in, and staff and residents are vaccinated at the same time, those who have agreed.

Picking up on the issue of consent and willingness to take the vaccine. It seems at least again, anecdotally, that the vast majority of residents have agreed and are eager to get vaccinated, perhaps because they have so much at stake. The death rates among nursing home residents are just so much higher than among the younger population.

Cindy: What about the residents that have dementia or Alzheimer's and that are unable to give meaningful consent?

Tamara: What happens in that case, and that is certainly very common, in fact the majority of nursing home residents have some kind of cognitive impairment. In that case there's often a power of attorney or a family member who can give consent for that resident. This caused some hiccups in the beginning in that the consent process wasn't entirely clear, whether it could be oral or whether forms had to be filled out, physical forms.

Even if it's just oral, those kinds of things take time for facilities that are already stretched pretty thin just dealing with this pandemic and so that caused some hiccups. My sense is that it's been getting smoothed out and that facilities have been able to get the appropriate consent so that we know that residents and their families actually want to get the vaccine.

Cindy: Either of you, do you have a sense of how long it takes for the vaccine to actually work? How long does it take for a person to build up the antibodies necessary?

Nathaniel: From my reporting, it takes about two weeks after the second dose to build up the full immunity. Each dose right now is given three weeks apart for the Pfizer one, and four weeks apart for Moderna. It's not an instantaneous thing. It's still going to take some time.

Cindy: People are celebrating right now, but the reality is that the relief is still a month or so away.

Tamara: With either one of these vaccines we also need the second dose. It's actually going to take a little while yet before even those residents that get vaccinated have the fullest protection possible from the vaccines.

Nathaniel: This program, it takes three different visits, so people have different opportunities. They have multiple options to make sure that every resident and staff is able to get vaccinated. There's the first visit. There's a follow-up and then there's a third one, just to make sure that they sweep and make sure that everybody is covered.

Cindy: I see. Tamara, do you think that there's going to be huge lessons learned from this? Nursing homes are notoriously understaffed and when you're understaffed it is hard to contain the spread of infectious diseases. What do you think will come of all of this?

Tamara: That's an interesting question. I've been hoping all along through the tragedy of this pandemic, that the silver lining will be that we really rethink how we deliver and pay for long-term care in this country. Chronic under-staffing is certainly pervasive in the industry. All kinds of quality problems have been challenges for decades, but we also just don't pay for the quality of care that we would like to have, that we'd all like to have as we age. Long-term care is one of those sectors that I think we just don't want to think about and don't really invest in.

The pandemic has revealed how problematic the entire structure of that is in this country. I'm hoping we'll have learned a couple of things. I'm hoping we have learned that we have to invest more in long-term care, that we have to think about the Medicaid rates that fund so much of long-term care. That we have to think about the fragmented way in which we pay for long-term care. Really as a society try a little bit harder to create a system that we'd all like to have available to us as we age.

Cindy: Tamara, remind us why and how COVID-19 spreads so rapidly.

Tamara: There are a couple of factors. One is that nursing homes house, generally in very close quarters, a lot of residents, mostly older adults, but also younger individuals with disabilities, who have many underlying health conditions. That's why they're there. Those are exactly the risk factors that make them most vulnerable to adverse effects from the Coronavirus. It's partly just their health related vulnerability but then there's also the setting itself. A lot of nursing homes are large facilities, basically congregate settings, where there are sometimes two or more people per room, and nursing home staff have to go from room to room caring for residents for hours a day.

That setting in itself is just the perfect storm for transmission of an airborne virus like this. Then at the same time, we have staff going in and out of the facility every day. As much as you lock down a facility like this, it is connected to society. You can't really just wall off the residents and not have them see people who enter and exit the facility on a daily basis. That also facilitates transmission of a virus like this.

Cindy: Community spread plays a big part. Nathaniel, is that why we're seeing spikes right now?

Nathaniel: Yes. When you're seeing spikes in the community as we are throughout the entire country right now, you're going to see a corresponding spike in nursing homes. As Tamara just said, nursing homes are connected to the community. There's not really a way to, as she said, completely wall it off. You've got the staff that are working sometimes multiple jobs, sometimes outside of the facility. They have to go into the community, they have to go grocery shopping, they're exposed. They're really the risk factor here to bring the virus in.

Cindy: Nathaniel, how do you protect against that? Is it testing of staff or temperature taking? Does that even help?

Nathaniel: The biggest thing is mainly to test, to isolate once you see a positive test, and to make sure that the nursing home staff have appropriate protective equipment. Both of those things were were issues throughout the early part of the pandemic and again into the fall. It's just making sure that facilities had enough tests to give to all of their staff and residents, making sure that they had enough of this critical PPE. Then that just also comes back to money and making sure that they have the funding to do those things.

Cindy: Are we doing any better right now?

Nathaniel: In some places, but there have been really some issues with the rollouts of everything back in the fall. The Trump administration tried to give nursing homes these rapid point of care tests. Some of those tests work, some of those didn't. Some of the funding had dried up, up until-- They just passed the new stimulus package, so that included some more money to help out with the testing and with the PPE, but like most of this pandemic, it comes down to a lack of a coordinated federal response.

Everything mostly has been left up to the individual states. Individual states have a conflict with the nursing homes which have a conflict with the federal government. Everybody is at odds with different policies so it's hard to have one underlying way to make things right.

Cindy: Along with the health risks, there's also the isolation that has really taken a toll on residents. Tamara, can you talk a little bit about that?

Tamara: Certainly. Back in March already, nursing homes basically locked down and stopped allowing visitors according to federal guidance. The idea of course was that family members entering and exiting the facility would be at risk of bringing the virus in. In order to protect residents, visitors were prohibited, but it's become increasingly clear over the course of the pandemic that this kind of social isolation of nursing home residents has really taken its toll as well. We have to find a balance between the benefits of having visitors and keeping out any risk of the virus.

They're at risk anyway because staff come and go every day. What some states have done, which is very encouraging, is set up programs called essential caregiver programs, where a designated family member can come in and visit. That family member also gets tested and wears the same PPE that staff does, but at least that resident then has interaction with the family. That family member can monitor the care that the resident is getting and prevent some of the worst effects of the social isolation.

Cindy: Sure. That's interesting that some places have figured out a way to address the isolation. Do you think that there are COVID deaths and then there are COVID-related deaths? What I mean by that is do you think that people are also dying from the isolation?

Tamara: That's almost certainly true. There's been very little research on this so far, but more will be emerging I'm sure, where we can look at the indirect effects of the virus. Look at the effects of some of the policies we implemented and start counting those indirect deaths as well.

Cindy: Tamara Konetzka is a health economist and professor at the University of Chicago, and Nathaniel Weixel is a health reporter at The Hill. Tamara and Nathaniel, thank you so much for being here.

Tamara: Thank you.

Nathaniel: Thank you.

Cindy: Are you, or is someone you know, in a long-term care facility? How present is COVID there and is the vaccine available? Tell us about your experience by sending us a voice memo recorded on your phone and email it to takeawaycallers@gmail.com.

Arthur: My name is Arthur [unintelligible 00:17:28] and my relative is in an assisted living facility in New York state. I have to say that I feel that she's getting good care because we receive constant emails regarding the staff and who has COVID. They are very responsible in terms of keeping us informed. She has not had COVID which I consider to be a little bit of a miracle. She is also a little bit confused and doesn't realize, since she's been in lock-down since the beginning of the pandemic.

It's a little hard for her to understand what the fuss is all about, but nonetheless she has stayed safe and the facility is hoping to have the vaccine within the next week or two, and we both signed releases so that she'll be able to get the vaccine as soon as it's made available.

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