In summary

Cash-strapped clinics provided thousands of mpox vaccines, but their reimbursements have been mired in red tape.

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Update: California Gov. Gavin Newsom ended the mpox state of emergency on Jan. 31, 2023 several hours after publication of the original article.

Seven months ago, California battled its second widespread infectious disease outbreak in as many years — mpox, formerly referred to as monkeypox. Cases spread exponentially, primarily among the state’s male LGBTQ population, and officials struggled to roll out limited vaccine supplies from the federal government.

Community clinics and LGBTQ health centers opened mass mpox vaccination sites as quickly as possible and clamored for assistance from local and legislative leaders, but oftentimes red tape at both the federal and state level hampered a speedy response.

Today, as the federal government ends its mpox state of emergency, those clinics say bureaucracy is once again standing in the way. State and federal reimbursement for services — potentially in the millions of dollars — has not been approved and likely won’t be for months. 

“I’m not clear what the holdup is,” said Craig Pulsipher, former associate director of government affairs at APLA Health, a clinic in Los Angeles specializing in LGBTQ populations. APLA Health administered more than 4,000 vaccines and was one of the largest vaccinators in the city. It received an $83,000 grant for mpox work from the state Office of AIDS, but dedicated “hundreds of thousands of dollars” to vaccination and shifted funding from other programs to the response effort.

The Legislature released $41 million in emergency funding for mpox response efforts last year, half of which has stayed with the state Department of Public Health. Approximately $1.4 million went directly to community organizations helping directly with vaccine efforts, but organizations say it’s not nearly enough to cover their costs.

“The virus isn’t gone. It’s not surging right now, but it’s not gone, so we’re at risk of a resurgence.”

Dr. Ward Carpenter, chief health officer with the Los Angeles LGBT Center

Although the vaccine itself was given to states free-of-charge from the federal stockpile, community organizations dispensing the shots still had to invest staff time, equipment and other resources to respond. Typically, shots and other minor procedures are billed as part of a “provider visit,” but that requires being seen by a doctor, which doesn’t happen during the kind of mass vaccine drives that became commonplace for COVID-19 and mpox. 

Instead, the state must petition the federal government to use Medi-Cal dollars for standalone vaccine reimbursement to try to recoup some of the labor expenses. Medi-Cal is the state’s insurance program for low-income people, and it’s funded through state and federal dollars.

“This was everything we did for probably three months,” said Dr. Ward Carpenter, chief health officer with the Los Angeles LGBT Center. “We were barely able to keep our urgent care visits open for non-mpox related things…. It was at least as busy as the early days of COVID if not more so.”

The LGBT Center doled out more than 6,500 vaccines, Carpenter said, and has more than $500,000 in outstanding expenses. It received an $116,000 mpox grant from the AIDS office in November.

In September, California’s Department of Health Care Services submitted a federal request for reimbursement. Shortly after, members of California’s Congressional delegation, led by Democratic Rep. Jimmy Gomez of Los Angeles, sent a letter to the U.S. Health and Human Services branch urging timely approval of the request. Community clinics, which often serve as safety nets for poor and underrepresented patients, have little financial wiggle room and already had to wait two years for COVID-19 payment

“Your rapid and urgent attention to these requests will help to ensure that critical providers and community clinics in our districts are able to continue their vital work,” the letter read.

People cue up outside General Hospital in San Francisco waiting for a shot of the mpox vaccine on July 20, 2022. Photo by Karl Mondon, Bay Area News Group

Pulsipher said in November, Gomez’s office asked APLA Health if additional pressure on federal partners would be helpful, but the organization turned him down at the time because state officials were confident the approval was coming soon.

“What we heard from (the state Department of Health Care Services) was they were moving forward and that pressure wouldn’t be needed,” Pulsipher said. “It has yet to be approved.”

The department told CalMatters in a statement that the federal government must approve California’s plan to use Medi-Cal dollars for mpox reimbursement. The federal government sent the state comments and revisions to the plan in December with a 90-day review window, which potentially pushes the timeline for clinics to receive checks past March. Although clinics will eventually be able to ask for payment for services they provided as far back as August, when mpox was at its height, the more time that goes by, the less likely overburdened staff will be able to bill retroactively, Pulsipher said.

“It is extremely time-intensive to go back and submit those claims,” he said. “Some clinics will do that and some probably won’t.”

Mpox outbreak today

California reported its first mpox case in Sacramento last May. What began as an isolated travel-related infection quickly ballooned into a statewide outbreak, which peaked in August at 145 cases in one day, according to state data. More than 5,700 cases have been reported in California, the most of any state, including the country’s first death.

“It would be hard to kind of overstate how frantic and frenetic and all-consuming it was at that point versus now,” Carpenter said.

In stark contrast, there were the two cases reported on Jan. 10, the most recent data available. 

Although state officials have not set an end date for California’s state of emergency, the Department of Public Health plans to roll routine surveillance and response duties into its Sexually Transmitted Disease Control Branch and Office of AIDS, according to an unsigned email from its media department.

“As cases decline, the outbreak comes under control, and the public health components for a robust response are fully operational, there should be no impact to providers, (local health jurisdictions), or patients of ending the state of emergency,” the email said.

But the end of the emergency does not mean “the end of disease,” Carpenter said. Plenty of L.A. LGBT Center patients are vaccinated during routine doctor’s visits, often having been unaware of the outbreak and the need for protection.

“The virus isn’t gone. It’s not surging right now, but it’s not gone, so we’re at risk of a resurgence,” Carpenter said.

Pulsipher, with APLA Health, said his organization is still working hard to educate and vaccinate Black and Latino patients, who often face the greatest health care barriers — even though the expense for that work will likely never be reimbursed. 

“It’s important to remain vigilant,” he said, “to continue outreach and education, continue to reach folks that aren’t vaccinated and to recognize the inequities around vaccine uptake.”

Black and Latino Californians account for 58% of all mpox cases but only 33% of all vaccinations, according to state data.

“What has become so clear between COVID and mpox is that one person’s poor access to health care affects all of us,” Carpenter said. “That’s, again, why we are not putting these vaccines down and going back to business as usual. Even within our own community we know that we still have a lot more work to do.”

Monkeypox resources are scarce in California’s Central Valley

While monkeypox vaccines are targeted to the state’s largest cities, where case numbers are highest, other communities are struggling to respond. In the Central Valley, public health officials are waiting for resources and trying to get information to residents seeking help.

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Kristen Hwang reports on health care and policy for CalMatters. She is passionate about humanizing data-driven stories and examining the intersection of public health and social justice. Prior to joining...