Two states looking for approval to customize their health insurance systems under the Affordable Care Act reversed course after the Trump administration said their applications couldn’t be approved in time for next year.

Iowa withdrew its proposal to the Centers for Medicare & Medicaid Services for a waiver to alter its Affordable Care Act markets. Massachusetts’ proposal was effectively denied by the administration.

Both states sought to use some of the money that would have gone toward subsidies for consumers to instead create reinsurance programs that would protect insurers from major losses. Reinsurance often lowers premiums.

Iowa Gov. Kim Reynolds, a Republican, blamed the rules of the Affordable Care Act for the failure of her state’s proposal. “Obamacare gives states very little flexibility for innovation,” Reynolds said at a news conference.

She gave credit to CMS Administrator Seema Verma for trying to get the waiver approved. “Unfortunately Obamacare is an unworkable law,” Reynolds said. She then urged Congress to pass a law to repeal the Affordable Care Act.

But there’s another way of looking at it. CMS took a “hard line” on its interpretation of the law, said Larry Levitt, a senior vice president at the Kaiser Family Foundation. In a letter to Iowa, the agency said the state’s proposal doesn’t meet the law’s requirements that the alternative plan not add to the federal deficit.

“The question is how sharp the pencils have to be that reviewers in HHS are using” Levitt said. “They could be a little looser in their analysis, but would risk a negative report down the road.”

On the same day that Iowa withdrew its waiver, CMS told Massachusetts that the agency couldn’t approve the state’s waiver in time for open enrollment, which begins Nov. 1. The Affordable Care Act requires all proposals to allow 90 days for public comment. CMS said Massachusetts’ application came too late.

The failures of the two states’ waiver applications follow a trend. Several states have seen their proposals delayed, denied or only partly approved, after administration officials actively encouraged states to apply.

Some critics say the denials are part of an administration effort to force the ACA marketplaces to fail. But Levitt says the agency is on solid legal ground in its strict interpretation of the rules.

Still , there appears to be a switch, given the administration’s previous invitation to states to seek permission for insurance market changes.

Former HHS Secretary Tom Price, who resigned last month, encouraged states to apply for the waivers. Just weeks after he was sworn in in February, Price wrote a letter to every governor in the country urging them to consider creating reinsurance programs and high-risk pools.

HHS “invites states to pursue approval of waiver proposals that include high-risk pool/state-operated reinsurance programs,” the letter says. “The Departments will work with states to review all applications within the timeframe provided … and do our best to work with states to review their applications on an expedited basis.”

Sen. Lamar Alexander, R-Tenn., has sought to relax the waiver process. A bipartisan bill he co-authored with Sen. Patty Murray, D-Wash., would cut the wait time for waivers to be approved and allow states to go ahead with just the approval of the governor rather than a vote from the legislature. The bill would also make it easier for states to get copycat waivers once a program has been approved elsewhere.

Alexander said his bill would fix the problems that doomed the Massachusetts proposal. “Under the Alexander-Murray bill, states can get waivers approved in 45 days if the situation requires urgent action,” he said in a statement. “So Massachusetts could have had its waiver approved by now to help reduce chaos when open enrollment begins next week. This is further evidence that the Affordable Care Act needs changes and that states need our bill to get flexibility from the law.”

The Alexander-Murray bill, which was co-sponsored by 24 senators, has yet to be scheduled for a vote, and President Trump has wavered on whether he supports the plan.

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Undiagnosed diabetes may not be as big of a public health problem as thought.

That’s the takeaway from a study published Monday in the Annals of Internal Medicine that says that some previous efforts have likely overestimated the number of people with undiagnosed diabetes because they relied on a single positive test result.

By contrast, this new measure used the American Diabetes Association’s diagnostic criteria, which recommend that people with one positive fasting blood glucose or A1C test should have a second test to confirm a diagnosis in all but the most severe and obvious cases of Type 2 diabetes. That’s because there’s some inherent variability in the tests and because blood sugar levels fluctuate naturally because of exercise, illness and even the time of day.

If left untreated, Type 2 diabetes can contribute to kidney disease, nerve damage, high blood pressure and stroke.

The Centers for Disease Control and Prevention has applied the less stringent standard to data from the National Health and Nutrition Examination Survey and the U.S. Census to come up with an estimate of 33.3 million people with diabetes in 2015, 7.2 million of whom, or almost 24 percent, were undiagnosed. When researchers in this study applied the stricter clinical diagnostic standard to the same data, they came up with an estimate of 25.5 million people with diabetes, with about 2.8 million, or about 11 percent, of them undiagnosed.

“This is good news,” says Elizabeth Selvin, a professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health and the lead author of the study. “We’re doing a good job with screening and diagnosis.”

But she says that doesn’t mean diabetes isn’t a public health problem, and a significant one at that; the study found the prevalence of diabetes in the U.S. population has risen from 5.5 percent in 1988-1994 to 10.8 percent in 2011-2014. The proportion of undiagnosed cases has dropped from 16.3 percent over the same period, the study found.

The difference in how the estimates are calculated is due to the difference between epidemiological studies, which track patterns and trends across an entire population, and clinical practice, which focuses on individual patients. If you’re just studying historical trends, using a single-test value isn’t such a big deal, says Selvin. “But if we are focused on the burden of undiagnosed diabetes, or the percentage of diabetes that’s undiagnosed, it becomes important,” she says. (A CDC spokeswoman says the agency doesn’t directly comment on studies that aren’t its own.)

The results suggest that public health efforts to promote screening should be focused more closely on the people who are most likely to have undiagnosed diabetes rather than the population as a whole. According to the study, that group includes people who are obese, a racial or ethnic minority, and who don’t have health insurance or get regular health care. While increased age is also a risk factor, the authors noted that there’s an undiagnosed group of overweight and obese younger adults with very high A1C levels who are likely not engaged with the health care system and are falling through the cracks.

“We’re not missing hordes of people, which isn’t to say we aren’t missing some people,” says Anne Peters, an endocrinologist and professor of medicine at the Keck School of Medicine at USC, who wrote an editorial accompanying the study. “We need to continue to reach out to the people who do need help.”

She says more and more programs are focused on preventing diabetes in the first place, focusing on people with risk factors such as obesity and high cholesterol. That can help people avoid the complications of full-blown diabetes, and the label of having a chronic disease, which have long-term psychological effects as well as consequences for buying life insurance and long-term care insurance, Peters says. (And health insurance, if current Affordable Care Act rules about pre-existing conditions should change.)

The study’s authors pointed out some limitations of their work. Among them: the data includes fasting glucose and A1C levels taken only at one point in time, and the results might differ if samples were taken later. And the diagnosis of diabetes depends on study participants’ self-reports, which may not be accurate.

Katherine Hobson is a freelance health and science writer based in Brooklyn, N.Y. She’s on Twitter: @katherinehobson.

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Rose Crumb can’t even count the number of people she’s helped die.

The former nurse, 91, who retired in her mid-80s, considers the question and then shakes her head, her blue eyes sharp above oval spectacles.

“Oh, hundreds,” estimates Crumb, the woman who almost single-handedly brought hospice care to the remote Pacific Northwest city of Port Angeles, Wash., nearly 40 years ago.

But the actual number of deaths she has witnessed is likely far higher — and Crumb’s impact far greater — than even she will admit, say those affiliated with the Volunteer Hospice of Clallam County.

“[Rose] let people know hospice is not all about dying,” said Bette Wood, who manages patient care for VHOCC. “Hospice is about how to live each and every day.”

In a nation where Medicare pays nearly $16 billion a year for hospice care, and nearly two-thirds of providers are for-profit businesses, the tiny volunteer hospice is an outlier.

Since 1978, the hospice founded by Crumb — a mother of 10 and devoted Catholic — has offered free end-of-life care to residents of Port Angeles and the surrounding area. She was the first in the region to care for dying AIDS patients in the early days of the epidemic. Her husband, “Red” Crumb, who died in 1984 of leukemia, was an early patient.

“He died the most perfect death,” Rose Crumb told visitors on a recent afternoon. “He spent time alone with each of our kids. That meant so much to him.”

At the same time, Crumb and her successors have refused to accept federal funding or private insurance, relying instead on a mostly volunteer staff and community donations to keep the hospice going.

That’s rare, said Jon Radulovic, a spokesman for the National Hospice and Palliative Care Organization, NHPCO, a trade group. Most of the nation’s 4,000-plus hospices receive Medicare payments for their services. He estimates there are only a few volunteer hospices like Crumb’s in the U.S.

There was pressure in the early years to “take the money,” as Crumb put it. But she had little use for the regulations that accompanied federal Medicare reimbursement starting in 1982.

“It was our experience that we could operate on a much smaller budget and we could be more flexible in providing services,” Crumb wrote in a 2007 newsletter.

Today, the hospice relies on 10 paid staff, 160 volunteers and an annual budget of less than $400,000 to provide end-of-life care for 300 patients each year, according to federal records.

Patients don’t have to meet Medicare’s criteria of having six months or less to live to be enrolled, though most do. They can keep their own doctors instead of turning over care to a hospice physician. If families need medical equipment, the hospice supplies it for free.

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Eve Farrell holds a portrait of her husband, Daniel, in her Port Angeles, Wash., home. He died in January of chronic obstructive pulmonary disease.

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“I don’t know how I would have made it without them,” said Eve Farrell, 82, whose husband, Daniel, had chronic obstructive pulmonary disease, or COPD. He died in January at age 80 after four months of hospice care at the couple’s Port Angeles home.

Staffers helped her husband shower when she couldn’t lift him, offered advice about medication and gave her breaks from relentless caregiving.

“We felt like Dan was the only patient they had,” Eve Farrell said.

Crumb was drawn to hospice care in the 1970s, after the book “On Death and Dying” by Dr. Elisabeth Kübler-Ross galvanized conversations in the U.S. about how to treat the terminally ill. Years earlier, when Crumb’s father was diagnosed with lymphoma, she helped him die at home.

“It was the most meaningful experience in my nursing career,” she said.

In April 1977, when Crumb attended a convention that included a program on hospice, she was hooked.

“Everything clicked,” she recalled. “I thought ‘Yes!’ “

Organizers had little money and less support, Crumb said. The local medical community was skeptical about hospice, which started in the U.S. in Connecticut in 1974.

“Some of the doctors called us ‘the death squad,'” Crumb said. Crumb’s refusal to take federal funds put her at odds with the for-profit hospice industry, which lobbied state lawmakers in 1992 to eliminate an exemption that allowed volunteer hospices to remain unlicensed.

Crumb had to enlist the services of her eighth child, Patrick Crumb, then a corporate lawyer, to fight back.

“In my view, they were clearly misrepresenting the current status of the law,” recalled Patrick Crumb, 55, who is now president of the AT&T Sports Network. “I told them, ‘If you do what you’re threatening to do, I’m going to sue you and I’m going to win.’ “

Lawmakers eventually agreed to create an exemption to state law that allows volunteer hospices to remain unlicensed and unregulated. Crumb’s hospice remains the only agency in state history to use it.

In 2002, the volunteer hospice faced a for-profit rival, Assured Home Health and Hospice, now owned by the LHC Group based in Lafayette, La. Documents show that Assured officials predicted they’d serve 70 percent of the local hospice market within two years.

Since 1978, the Volunteer Hospice of Clallam County has offered free end-of-life care to residents of Port Angeles, Wash.

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But competition was fierce, recalled Dr. Tom Kummet, medical director at the Olympic Medical Cancer Center, who referred dying patients to hospice care.

“It was a bit of an awkward time,” he said. “Assured hospice wanted to be a successful business. And Volunteer Hospice was going to negatively impact their chances of being a successful business.”

Fifteen years later, Assured still struggles, said Leslie Emerick, director of public policy and outreach for the Washington State Hospice and Palliative Care Organization.

“They tread lightly up there because of Rose,” Emerick said. “Rose is a beloved person in that community.”

Officials with LHC declined to discuss competition in the Port Angeles market or to say how many patients Assured has enrolled.

“We value the care that Volunteer Hospice provides for our community,” Candace Hammer Chaney, a local Assured manager and community liaison, said in a statement.

Emerick and other hospice industry officials said volunteer hospices don’t offer the range of services required of those who receive federal funding. And, Emerick added, there’s little oversight.

“They don’t have a reputation of negligence or complaints as far as I’m aware, but there’s always the possibility of that when they’re unlicensed or unregulated,” she said.

But Astrid Raffinpeyloz, VHOCC’s volunteer services manager, said the hospice wouldn’t have lasted long in a small town if there were problems.

“We don’t have oversight from the government, but we have minute oversight from the community,” said Raffinpeyloz.

Mike Clapshaw poses with a picture of him and his wife, Deborah, in his Port Angeles, Wash., home.

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For Mike Clapshaw, 71, there was no question about who would care for his wife, Deborah, when her cancer came back for the third time, leading to her death in December 2014. She was 60. For the last four months of her life, VHOCC staff eased her pain — and his.

“It was always, ‘What can I do to help?’ ” he said.

Helping was always the point, said Rose Crumb, whether the pain at the end of life was physical, emotional — or both.

“Some people just need someone to listen to them,” she said.

Crumb at nearly 92, now suffers from osteoporosis, congestive heart failure and other ailments that plagued her patients in earlier years. But she’s not worried about her final days.

“I’m all signed up for hospice,” she said. “I have everything written down.”

KHN’s coverage of end-of-life and serious illness issues is supported byThe Gordon and Betty Moore Foundation.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

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Updated at 3:55 p.m. ET

A bipartisan coalition of 24 senators — 12 Republicans and 12 Democrats — has signed on to health care legislation to prop up the individual insurance market and keep premiums down. With the expected support of all Senate Democrats, it could have the votes to pass the chamber. But questions remain over when it might actually get a vote, as well as whether President Trump and House Republicans would bring the bill over the finish line.

“This is a first step: Improve it, and pass it sooner rather than later. Our purpose is to stabilize and then lower the cost of premiums in the individual insurance market for the year 2018 and 2019,” said Sen. Lamar Alexander, R-Tenn., on the Senate floor. Alexander and Sen. Patty Murray, D-Wash., crafted the compromise bill.

Alexander and Murray have been working on this legislation for months. Negotiations initially began after the Senate failed to pass legislation to repeal and replace Obamacare back in July.

Most Americans get health insurance through their employer or from the government. About 18 million Americans get their insurance through the individual market established by the Affordable Care Act. “They’re the ones we’re worried about; they’re the ones we’re seeking to help,” Alexander said, noting that includes about 350,000 people in his home state.

“I have to say that after seven years of intense partisanship on these issues, which would lead everyone to believe there was no hope for Republicans and Democrats to come together and work to strengthen our health care, I’m really pleased with this common ground we’ve been able to find,” Murray said on the Senate floor.

President Trump’s decision last week to end subsidies to insurance companies that were allowed under the ACA revived congressional talks. The Trump administration argued — and initial court rulings backed it up — that the payments were illegal because they had not been appropriated by Congress, which has the constitutional authority to spend the government’s money. Although the 2010 health care law required insurers to provide discounts to some low-income consumers and said the government would reimburse them, without authorizing the spending.

The Alexander-Murray proposal would appropriate those subsidies for two years, and tie them to permanent changes to the law that give states more flexibility to seek waivers from the Health and Human Services Department from the ACA’s requirements. It would also allow insurances companies to sell less comprehensive plans to all customers, not just those under age 29 as is the case under current law.

The nonpartisan Congressional Budget Office estimates that without the subsidies, premiums will go up, the deficit will rise and up to 16 million Americans could live in counties with no insurance providers at all.

“Unless they are replaced with something else temporarily, there will be chaos in this country and millions of Americans will be hurt,” Alexander warned.

Alexander said Trump has been privately encouraging of the talks, but the president cast doubts on the legislation this week by suggesting it was a “bailout” for insurance companies that he could not support. However, the bill’s sponsors counter that the legislation requires that the subsidies go directly to the consumer to keep premiums down.

The bipartisan bill has potentially critical GOP support from Sens. Susan Collins of Maine, Lisa Murkowski of Alaska and John McCain of Arizona. The trio played a defining role in the defeat of previous GOP health care bills this year. It also has the backing of Sens. Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, who have competing legislation to dismantle the ACA and replace it with a block grant system to the states.

GOP backers say the bill does not pre-empt the party’s ongoing effort to end Obamacare but rather buys time to keep working on legislation that can muster enough support to pass Congress. Conservatives have balked at Alexander-Murray as a tacit admission that Obamacare will remain the law of the land. House Speaker Paul Ryan said through a spokesman Wednesday that the speaker believes the Senate should remain focused on legislation to end Obamacare, not prop it up.

The proposal puts the GOP in a bind between the policy necessity to act to protect millions of Americans from premium hikes and the political necessity to continue to keep up its effort to dismantle the current system. An August poll from the Kaiser Family Foundation found that 60 percent of Americans think Trump and Republicans in Congress are responsible for what happens to the ACA in the future.

Senate Majority Leader Mitch McConnell has not taken a position on the bill, but he is unlikely to bring something to the floor unless it has Trump’s support and the 60 votes needed to clear a potential filibuster, which it should if all 48 Senate Democrats support it along with the 12 Republicans who have signed on. The legislation crowds an already limited legislative calendar. It would need to become law before the end of the year when Congress needs to pass a spending bill package to keep the government running. That spending bill would be the vehicle to fund the insurance subsidies.

Along with Alexander, Collins, Murkowski, McCain, Graham and Cassidy, the additional GOP co-sponsors include Sens. Mike Rounds of South Dakota, Joni Ernst and Chuck Grassley of Iowa, Bob Corker of Tennessee, Richard Burr of North Carolina and Johnny Isakson of Georgia.

The Democratic co-sponsors joining Murray include Sens. Angus King, independent of Maine, Jeanne Shaheen and Maggie Hassan of New Hampshire, Joe Donnelly of Indiana, Amy Klobuchar and Al Franken of Minnesota, Heidi Heitkamp of North Dakota, Joe Manchin of West Virginia, Tom Carper of Delaware, Tammy Baldwin of Wisconsin and Claire McCaskill of Missouri.

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Updated at 10:25 p.m. ET

Less than a week after President Trump said he is cutting off subsidies to health insurance companies, lawmakers say they have a deal to restore the money and take other actions that could stabilize insurance markets for next year.

Sens. Lamar Alexander, R-Tenn., and Patty Murray, D-Wash., say they have a tentative agreement to appropriate the subsidies for the next two years, restore money used to encourage people to sign up for Affordable Care Act health plans, and make it easier for states to design their own alternative health care systems.

Alexander said the idea is to stabilize the markets in the short term while Congress continues to debate long-term changes to the ACA.

“Over the next two years, I think Americans won’t have to worry about the possibility of being able to buy insurance in the counties where they live,” he said in a conversation with reporters at the Capitol on Tuesday.

He said he spoke with President Trump over the weekend and that Trump said he supports the idea. However, Senate Majority Leader Mitch McConnell, R-Ky., would not commit to bringing the bill up for a vote, as Murray and Alexander seek enough support to ensure it could pass. The bill would need 60 votes to get across the finish line and would require at least a dozen Republicans to take a difficult political step in voting to shore up parts of Obamacare.

In a speech to the Heritage Foundation on tax changes on Tuesday evening, Trump mentioned the tentative deal.

“And I’m pleased the Democrats have finally responded to my call for them to take responsibility for their Obamacare disaster and work with Republicans to provide much-needed relief to the American people. While I commend the bipartisan work done by Senators Alexander and Murray — and I do commend it — I continue to believe Congress must find a solution to the Obamacare mess instead of providing bailouts to insurance companies.”

Earlier, during a news conference with Greek Prime Minister Alexis Tsipras Tuesday in the Rose Garden, Trump declared the Affordable Care Act “virtually dead” but said he supports the Alexander-Murray deal.

“It’s a short-term solution,” Trump said in response to a question about the deal. “The solution will be for about a year or two years and it will get us over this intermediate hump.”

The deal comes just days after the president said he is cutting off reimbursements to insurance companies for discounts they are required by law to give to low-income customers to reduce the burden of copayments and deductibles. They’re known as “cost-sharing reduction” payments.

The deal reached Tuesday, if it becomes law, would restore those payments for at least the next two years.

The agreement, which Murray says has not yet been finalized, would also make it easier for states to get waivers so they can set up alternative health insurance systems and offer a wider variety of insurance policies.

Alexander said those plans would retain the minimum coverage requirements under the ACA but could vary the definition of what is affordable. The deal also allows more people to buy so-called catastrophic plans that cover major illness but pay for less routine care.

“This is a small step,” Alexander said. “I’d like to undersell it rather than oversell it.”

An analysis by Charles Gaba, who runs a website, ACASignups.net, that tracks enrollment and costs of ACA insurance, showed that premiums are set to rise an average of 30 percent next year, with premiums in some states, including Iowa, rising much more.

As premiums rise, consumers who don’t think they need much health care are less likely to buy coverage, leaving sicker people in the market. Because those sicker customers spend a lot of money on care, they drive premiums up even higher. With restoration of the cost-sharing subsidies, those premium increases could be far smaller.

For much of this year, Trump had been threatening to cut off the subsidies. So insurance companies in many states filed paperwork to sell policies on the ACA exchanges next year that included two sets of premiums — one if the cost-sharing payments continued, and another if they were cut off. The deadline to finalize those prices was in late September, however, and it’s not clear companies will be allowed to cut their prices if the Alexander-Murray deal becomes law.

The agreement would also restore $106 million in money to publicize the open enrollment period for ACA health insurance. Trump had cut the budget for ACA outreach by 90 percent earlier this year, a move many advocates said would suppress enrollment.

Lori Lodes, who ran ACA outreach during the Obama administration, said that money will only be effective if it is approved early enough to reach those who need coverage. Open enrollment on the federal exchange begins on Nov. 1 and ends on Dec. 15.

Murray said she and Alexander had had discussions with more than half the Senate about the bill and she believed the plan would get broad support. Alexander said they’ll work to get co-sponsors for the legislation throughout the week so they can bring a bill to McConnell for consideration. McConnell has not said whether he supports the effort.

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Julayne Smithson was working an overnight shift in the Intensive Care Unit at the Kaiser Permanente hospital in Santa Rosa, Calif., when massive wildfires started racing through the city late last Sunday.

Smithson had no idea how close they were. She was too busy taking care of her patient. Then, she says, “One of the nurses came up to me and she said, ‘Julayne, I’m sorry, but your house is not going to make it.'”

Smithson, 55, recently moved from Indiana and had just bought a new home a few weeks ago. From the hospital window, she could see the flames moving through her neighborhood.

“I was so busy working the last couple of weeks that I didn’t get my insurance, which I never do. I never ever, ever go uninsured,” she says. “I kept saying, ‘Tomorrow, I’m going to do that. Tomorrow, I’m going to do that.’ “

Smithson asked a colleague to watch her patient while she raced home to try to save a few things. The fire was a block away.

“I knew I didn’t have much time,” she says. “So I ran inside and I thought, ‘I have to get my nursing documents, because if I’m going to lose everything I own, I have to be able to work, to care for patients.'”

She grabbed the papers, a pair of scrubs and a nightgown, and raced back to the ICU. Over the next two hours, smoke filled the hospital.

“All of a sudden the police busted in the door and they said, ‘Everybody out! ‘Grab what you can carry, get your patients, and go now,'” she recalls.

One of Kaiser’s emergency room doctors took charge as the fire approached, setting up a disaster command center, and making the call to evacuate the hospital’s 130 patients.

“It’s a really challenging decision to make, one you don’t make lightly,” says Joshua Weil, Kaiser’s ER doctor in charge that night. “You have to weigh the potential risk of moving hospitalized patients and patients from the emergency department, versus the risk of keeping them where they are.”

He decided to evacuate when the fire moved suddenly toward the hospital. Firefighters told him the blaze was 100 to 200 yards from the property, posing an imminent threat to the hospital structure.

“They literally used the words, ‘We’re making the last stand,'” Weil says.

Staff immediately started assessing and triaging patients.

Patients who could walk, staff guided to a bus provided by the city. Patients who couldn’t walk, like Smithson’s critical patient, had to wait.

Nearby Sutter Santa Rosa Regional Hospital was also evacuating, and they had close to 80 patients, so ambulances were in high demand.

“A lot of nurses and staff were putting patients in their cars and driving them to the hospital,” she says. “And then other people were carrying people on blankets, people who couldn’t walk, and putting them in cars.”

In the end, Smithson says they waited about 15 minutes for an ambulance, but it was a long 15 minutes. Her team was manually pumping air into her patient’s mouth with an air bag. A team of five had to push him, in his bed with all the monitors, through the parking lot several times to get away from fast-moving smoke and flames. His medication was running low and he was getting agitated.

“The pharmacy pre-mixes those medicines for us, but we didn’t have time to prepare extra medication for a trip like that because it just came up so fast,” she says.

Three hours passed from the moment the evacuation was called to the moment the last patient was out of the hospital, Weil says.

Smithson’s patient and others made it safely to Santa Rosa Memorial Hospital, about four miles away. About a hundred less critical patients were transferred to Kaiser’s hospital in San Rafael, about 40 miles away.

Beatrice Immoos was one of the nurses there getting prepped to receive the influx.

“We were essentially told that we were in a disaster situation and all ratios were out the window,” she says, meaning nurses would be assigned more patients than usually allowed under California law. “They were going to start triaging people through the ER.”

She remembers patients arriving wearing colored armbands, indicating the severity of their health status. These were likely assigned by paramedics during transport, Weil says.

“This level of disaster is a new one for us,” says Immoos. “It was very emotional, but there was a lot of resolve. Every day, nurses are always working with the common goal of taking care of our patients, and in a disaster, it’s just even more hands on deck working to get them the best treatment.”

The hospital put out calls for volunteer nurses to come help in San Rafael. Many responded, including Julayne Smithson. Her husband was supposed to fly in from Indiana in two days, but with their new home gone, she told him to wait.

“I said, ‘Well, I don’t have anywhere to go right now. And we don’t know what’s going on,'” she says. “So I said ‘I’ll go to San Rafael and help there.'”

Another nurse offered Smithson a pullout couch in a spare room. She’s been sleeping there during the day, and working 7 p.m. to 7 a.m. every night since the fire. She says all she wants to do right now is help patients, so she doesn’t have to think about what she’s lost.

This story is part of a reporting partnership with NPR, KQED and Kaiser Health News, which is not affiliated with Kaiser Permanente.

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