His last night as a prisoner in North Florida, Kelvin Bolton couldn’t sleep. Fifty-five years old, with a wispy goatee the same color as the gray flecks in his hair, he was about to get out after serving a 2 1/2-year sentence for theft and battery. The last time he’d seen his brothers and sisters at a big family gathering, he’d marched onto the dance floor ostentatiously, turned away and wrapped his arms around himself to caress his own back. As he swayed goofily to the music, everybody laughed.

Now Bolton was so close to being free and seeing his family again. The next morning, a bright Wednesday in April, he was already dressed in his street clothes and cleared to go when the woman processing his paperwork stopped him.

“The lady said, ‘Hold on, you can’t go anywhere,’” Bolton remembered in a recent phone call.

Confused, he asked her what was going on, he recalled. There was a warrant out for his arrest for incidents in 2020, she explained gruffly. But that was impossible. He’d been in jail at the time, awaiting his prison stint.

Guards loaded Bolton into a van, then drove an hour and a half south to deposit him in Alachua County Jail.

There, he found out what he’d done wrong.

He’d voted.

In 2018, Florida voters overwhelmingly passed Amendment 4, in a historic ballot initiative that restored the right to vote to most state residents with felony convictions. Until then, Florida had been one of only four states — the others were Iowa, Kentucky and Virginia — where people who had committed felonies needed to petition the governor to have their voting rights restored. It was a grim legacy of 19th-century laws passed after the 15th Amendment granted African American men the right to vote.

Supporters applauded the law as restoring voting rights to what experts estimate is over 1 million people in Florida, about 5% of the population of the state.

But the state’s dominant Republican lawmakers quickly installed a financial hurdle to those new rights. The following year, they passed a law to clarify that people convicted of felonies could only vote if they first paid off any money they owed for committing their crimes. The penalty for registering or voting without doing so: a felony charge for voter fraud.

On the surface, the mandate seemed reasonable: Even advocates for Amendment 4 agreed that requiring paying off fines and restitution to victims was just. In Florida, however, that task proved a sometimes insurmountable challenge — one that disproportionately hit Black people. Florida has no centralized database to allow people to figure out what legal financial obligations they owe to the state. Instead, its 67 counties and various state agencies each maintain their own databases. The state also does not track information for federal or out-of-state convictions, which people are also required to pay off before voting.

On top of the fines and restitution, Florida layers on court fees that can run into the hundreds of dollars. Together, a voter’s debt can run into the thousands, a financial hole that some may never climb out of.

“That’s kind of the bottom line of the absurdity of this — it’s Kafkaesque,” said Dan Smith, chair of the political science department at the University of Florida. “It’s very troubling that we would have state attorneys prosecuting individuals who did not know their status, and there was no way for them to determine their status.”

Florida’s voting hurdles are part of a national pattern. For years across the country, Republican state lawmakers have been implementing new restrictive voting laws, including reducing access to vote-by-mail ballots, stricter voter identification rules and limits on early voting. These efforts have accelerated since Donald Trump promoted the false claims that Joe Biden stole the 2020 presidential election. Democrats, meanwhile, have pushed to expand voting access.

Republican Gov. Ron DeSantis boasted that in 2020, Florida, a swing state with a history of contentious elections, “held the smoothest, most successful election of any state in the country,” while he also signed a flurry of voting law changes that he said would further strengthen the integrity of future votes. And DeSantis has tacitly endorsed prosecuting people convicted of felonies for voter fraud. In April, he signed a bill establishing the Office of Election Crimes and Security, which will investigate alleged election violations.

Despite the increased scrutiny, voting fraud remains so rare in Florida that it hasn’t come close to altering election outcomes. The Florida Department of State in 2020 received 262 election fraud complaints, just 75 of which were referred to law enforcement or prosecuting authorities, according to the agency.

“Florida is an outlier, because the intentional targeting of citizens with felony convictions as a way to undermine democracy has been a throughline in that state,” said Nicole Porter, senior director of advocacy for the Sentencing Project. “And the attempt to address that, by popular vote, has been undermined by the legislature.”

In 2020, a representative of the Alachua County Supervisor of Elections conducted a series of outreach efforts at the local county jail to let inmates know of their new rights and offer to help them add their names to the voter rolls.

During three visits to the jail, the official helped sign up at least 10 inmates, including John Boyd Rivers, Dedrick Baldwin and Bolton.

Rivers, 44, felt a visceral thrill at the prospect. Sitting in his cell in February 2020 facing a battery charge for hitting his wife, he was told by the county representative that he could register to vote. The official, he said, told him that he could disregard the check box on the form that asks whether the applicant has a felony conviction because he didn’t have a disqualifying felony. That seemed odd to Rivers, since he had a previous felony conviction. (He subsequently was sentenced for the battery charge.) No one told him anything about needing to pay off his financial obligations before registering to vote, Rivers said, and the jail didn’t give him an accounting of those debts when he was later released.

Back at home, Rivers was excited when his voter registration card arrived in the mail. He’d lost his right to vote at 18, he said, after voting just once. Now he could vote in a presidential election. He and his wife went to their polling place, and he cast his vote for Donald Trump.

Bolton, too, was excited to sign up. He also said no one told him he’d need to pay off his debts before casting his ballot. Although he registered as a Republican, he said he decided to vote for Biden.

In all, 10 of the men who the official helped register to vote have been charged with voter fraud on the grounds they were ineligible.

Their alleged illegal voting was first spotted by a citizen who analyzed Florida’s voting rolls and then shared the information with the state. The Florida Department of Law Enforcement subsequently launched an eight-month investigation, after which it identified the 10 inmates.

State investigators found that some jail employees remembered the elections official giving clear directions to inmates about having to pay off financial obligations, while others did not. The investigation concluded that the jail visits were “lacking in both quality and longevity” and “showed a haphazard registration of inmates.” But the state prosecutor nevertheless proceeded with charges, although not against county officials.

Officials at the Alachua Supervisor of Elections office declined to comment to ProPublica. But Supervisor of Elections Kim Barton denied any wrongdoing in a statement released in June.

Brian Kramer, the state attorney for the Eighth Judicial Circuit of Florida, defended his office’s prosecutions to ProPublica, saying he believed the 10 men knew they were committing fraud. “I’m not going to say I will prosecute or not prosecute because it’s politically popular or unpopular,” he said.

Four of the 10 have pleaded guilty and have been sentenced to between 364 days and three years in prison. Bolton and three others have vowed to go to trial, while the remaining two await arraignment. They face charges that carry a penalty of up to five years in prison, five years of probation or $5,000 in fines. Eight of the men are Black, and two are white.

Critics say the charges are unjust and, at a bare minimum, excessive. In nearby Lake County, the state prosecutor declined to bring charges against sex offenders who had registered to vote despite the law prohibiting voting rights restoration for those charged with sex offenses or murder. In April, two white men living in The Villages in Sumter County, an overwhelmingly white county in central Florida, pleaded guilty to each casting two ballots for Donald Trump during the 2020 election. Rather than face prosecution, they entered a pretrial intervention program, under which they must serve 50 hours of community service and attend an adult civics class, among other requirements. Because the men in Alachua County have prior felony convictions, they are ineligible for pretrial intervention and face harsher sentences.

“I’m thinking I’m doing something good for the community, so that’s why I chose to try to do it,” Bolton said. “It was not malicious — I was not trying to commit a felony of voting fraud. I never would have voted.”

Baldwin, 47, who is in prison on a manslaughter conviction, was sentenced to an additional 364 days. He felt “set up,” he said, since nobody told him he wasn’t eligible.

“There’s no way Biden was that important to me to vote for him,” he said in an email to ProPublica from prison. “We were flat out tricked into voting.”

The elections official who visited the jail denied telling the men that they could disregard the check box and said he warned them that they’d need to pay off their financial obligations, according to a person familiar with the matter who declined to be named because he feared reprisals. The elections official declined to comment to ProPublica on the record.

The voter fraud charges were especially bitter for Rivers. By the time they were filed, Rivers said, he had already used part of his federal stimulus check to pay off more than $3,000 in costs related to his criminal record so he could reinstate his driver’s license and return to work.

“I should have known there would be some kind of catch,” Rivers said.

Florida’s history of felon disenfranchisement dates back to 1838, when the state’s first constitution prohibited people convicted of bribery or assorted “high crimes and misdemeanors” from voting. After the Civil War, faced with the prospect of formerly enslaved Black men voting, the state expanded the law so that anyone convicted of a felony lost the franchise. But in 2018, 64% of Florida voters approved Amendment 4, allowing people convicted of felonies, except for murder or sexual offense convictions, to vote.

This embrace of new voters became more complicated the following year when the state legislature passed its law. It required that people convicted of felonies must determine their own eligibility before registering to vote. The Florida Department of Corrections and county detention facilities are required to provide notice to inmates at the time of their release of their outstanding financial obligations.

But it is unclear if all of the facilities do so.

Florida charges those convicted of crimes with an array of fines and fees, some of which statutorily cannot be eliminated or reduced. Defendants facing felony charges are assessed $100 to use a public defender, as well as a $100 prosecution fee. At least one person already sentenced in the Alachua County cases has been charged an additional $671 for his voting fraud charges on top of the financial obligations he already owed.

Finding out what someone owes is time-consuming and expensive. An analysis led by Traci Burch, a political science professor at Northwestern University, tried to determine the legal financial obligations owed by a random sample of 153 Florida residents convicted of felonies and found consistent information for only three of them. Counties often keep poor records, have cumbersome websites and employ unhelpful clerks.

What’s more, it can cost money merely to find out how much money you owe. Four in 10 Florida counties charged either a payment or processing fee to look at their databases, and 15% charged a fee to access certain records, according to Burch’s research.

In 2020, Smith, the Florida political scientist, estimated that just over 1 million people would be eligible to vote under Amendment 4. Of that number, about 77% had outstanding legal financial obligations, rendering them ineligible to vote under Florida’s new law until they paid their debts. Four out of five Floridians with felony convictions owed at least $500 in fines and fees, Smith’s analysis found. More than 59% owed more than $1,000.

The state legislature immediately disqualified about 750,000 people from being able to vote when it passed its law requiring people convicted of felonies to pay their debts first, Smith estimated. And the new law’s impact was felt much more harshly by Black people, who faced greater fines and fees: 26% of white Floridians with a felony conviction would be eligible to get their voting rights restored under the new requirement, but only 18% of Black people, according to Smith.

In May 2020, a district court judge ruled that parts of the law were unconstitutional and that the law had established a pay-to-vote system. The 11th Circuit Court of Appeals overturned the ruling the following September, saying it was in the state’s power to require the payoffs and the law didn’t violate people’s rights. The state Supreme Court has also issued an advisory opinion that deemed the law legitimate.

Unsurprisingly, the number of people with felony convictions who have registered to vote has fallen far short of what supporters hoped. More than 85,000 such people registered in Florida ahead of the 2020 election.

Supporters of the law say that it’s only fair to have people fulfill their full sentences, including paying any crime-related debts. Some state attorneys, including Kramer, the attorney prosecuting the Alachua cases, have also developed processes within their jurisdictions by which people with felony convictions can verify their voting eligibility or request to reduce their fines and fees.

Felons who have not yet registered to vote can also appeal to the state to have certain fees reduced or eliminated, said Republican State Sen. Jeff Brandes, the sponsor of the law demanding the payoffs before voting rights restoration.

“We truly believe there are people who are indigent that will just simply never be able to pay,” he said. “The court only collects a fraction of what is given out anyways. And so there should be a way for the state to grant some grace or for the court to grant some grace and provide people flexibility.”

Kelvin Bolton has been sitting in the Alachua Council Jail since April, waiting for his case to proceed.

He’s been in and out of the system since he was 16, piling up a long record of mostly nonviolent crimes, most recently for stealing a car, groping a woman in a store and taking cigarettes from a Dollar General.

He aims this time to keep a vow he made to his family and himself to stay straight. He said he is frustrated that the prosecutor subsequently created a program for people convicted of felonies to check their voting eligibility while he and the others are still facing charges.

“Why would they want to keep charging us for something that they’re in the wrong for?” he said. “The state is in the wrong for what they did to us.”

After the pandemic shut down schools across the country, the federal government provided about $190 billion in aid to help them reopen and respond to the effects of the pandemic. In the year and a half since millions of children were sent home, the Education Department has done only limited tracking of how the money has been spent. That has left officials in Washington largely in the dark about how effective the aid has been in helping students, especially those whose schools and communities were among the hardest hit by the pandemic.

“We've been in the pandemic now for nearly a year and a half," said Anne Hyslop, the director of policy development at the education advocacy group Alliance for Excellent Education. “There is a responsibility to the public to make sure the funds are spent responsibly, but also make sure that the funding that is spent is accountable to supporting students and educators."

Provisional annual reports submitted to the federal government by state education agencies underscored the dearth of clear, detailed data. Agencies classified how the funds were spent using six very broad categories, including technology and sanitization. According to a ProPublica analysis of more than 16,000 of the reports covering March 2020 to September 2020, just over half of the $3 billion in aid was categorized as “other," providing no insight into how the funds were allocated.

In the absence of a centralized and detailed federal tracking system, the monitoring of relief funds flowing to the nation's more than 13,000 school districts has largely been left to states. Some districts have been found to be spending their federal funds on projects seemingly at odds with the spirit of the aid program, such as track and field facilities and bleachers.

While such spending is not prohibited by the federal government, the stated goals of the relief program were to open schools safely to maximize in-person learning and, more broadly, to address the impact of the pandemic.

The Biden administration wants to collect more data. But its efforts have come more than a year after the previous administration began disbursing the relief funds, and some school districts have bristled at the belated push for more detailed data collection.

Hyslop said that while this may place an added burden on districts, the information is essential. “We need this data to make sure the needs are met, to make sure high-needs schools are not being shortchanged. … We have to make sure this is actually supporting students."

The majority of the school aid was allocated from March 2020 to March 2021 and funneled through state education departments into K-12 school districts, which have until 2024 to budget the last of the funds.

Under the terms laid out by the federal government, states are responsible for developing tracking systems to ensure districts are spending the money on countering the effects of the pandemic.

The federal government has long given states considerable latitude in setting standards and curriculum. Christine Pitts, a fellow at the Center on Reinventing Public Education, said responsibility for tracking COVID-19 relief funds has similarly been delegated to the states, creating a patchwork of oversight practices. “There's 50 states, and oftentimes in education that means there's 50 different ways of doing the business," said Pitts.

The federal government has started to request limited information from states on how districts have spent their funds. The department also requires spending plans from states, and those plans must be approved before the last round of funds is released.

These limited reporting requirements reflect the early, urgent days of the pandemic, when officials wanted to get money to school districts as quickly as possible.

In June 2020, as the first federal relief dollars were beginning to flow to districts, the office of inspector general of the Education Department warned in a report that the department must improve its oversight, monitoring and data collection to reduce potential fraud and waste. The OIG noted that after the 2007-2008 financial crisis, the Education Department was responsible for allocating $98 billion through the American Recovery and Reinvestment Act, which led to numerous investigations into abuse and waste.

When the OIG raised concerns last year to then-Deputy Education Secretary Mick Zais, Zais said the pandemic aid legislation itself had created “enormous pressure" to distribute funds quickly, according to an OIG report.

A spokesperson for the OIG, Catherine Grant, said that while distributing pandemic aid presented its own challenges, oversight and monitoring were “longstanding" issues for the department.

Luke Jackson, a spokesperson for the Education Department, said in an emailed statement that the department was working with states and districts to collect preliminary data to “to ensure federal funds are being spent to best serve the needs of students, educators, and school communities."

The law places few restrictions on how districts can spend the federal aid, as long as the investments are loosely connected to the effects of the pandemic. This wide latitude has enabled districts to fund projects that some education experts have deemed questionable.

In Iowa, the Creston Community School District allocated about $231,000 of its pandemic relief funds to upgrade its outdoor stadium, including an expansion of its bleachers. According to district documents, the construction is intended to provide increased space for social distancing and to make the bleachers wheelchair accessible.

Creston's superintendent, Deron Stender, did not respond to ProPublica's requests for comment.

Last month in Pulaski County, Kentucky, the school board approved the reconstruction of its track and field facilities, allocating about $1 million in federal pandemic funding for the track replacement.

“We want to have facilities that are great for our students," the district superintendent, Patrick Richardson, told a local paper after the project was approved. Richardson did not respond to ProPublica's requests for comment.

“There is certainly a lot of flexibility on how the money can be used," said Hyslop of the Alliance for Excellent Education, but said athletic investments are “not in the spirit of the law."

The statement from Jackson, the Education Department spokesman, did not address a question from ProPublica about using relief funds for athletic projects.

In other cases, the spending priorities of school districts have drawn complaints from some parents. In Virginia, Fairfax County Public Schools spent more than $45 million of its early pandemic funding on ventilation systems and personal protective equipment. But some parents said that more federal aid should have been directed to services for students with special needs, who represent about 14.4% of the 178,000 students enrolled in the district.

Debra Tisler, a former special education teacher, said that her 15-year-old son, who has dyslexia, saw the 20 hours a month of specialized instruction that he received before the pandemic cut in half over the course of more than a year of virtual learning.

In January 2021, the federal education department opened up an investigation into Fairfax schools because of “disturbing reports involving the district's provision of educational services to children with disabilities during the COVID-19 pandemic." Asked on Tuesday about the status of the Fairfax investigation, the Education Department's press office did not have that information readily available.

“They have the ability to do it and they are choosing not to. It's heartbreaking," said Tisler, who has had a contentious relationship with the district. In August, her son went back to school in person.

In the first two waves of pandemic aid from the county, state and federal governments, Fairfax schools received at least $157.5 million, of which it spent $9.6 million on direct services for students with disabilities to help them catch up, according to budget documents. Helen Lloyd, a spokesperson for Fairfax County Public Schools, said that much of the initial coronavirus relief funds paid for “systemwide technology, school safety mitigation measures and equipment and PPE costs." She said it is not possible to calculate the proportion of the funding that paid only for services for students with disabilities.

Lloyd did not specifically address Tisler's concerns, citing privacy protections, but the spokesperson said that the district's spending plan was based on extensive community input and that learning loss was found to be a priority. She added that from the third wave of pandemic aid, which passed this year, the district has allocated $46.2 million, which is being used to extend the contracts of special education teachers by 30 minutes a day, and $500,000 to counter learning loss of students with disabilities.

In Texas, the McAllen Independent School District decided to spend $4 million of its education pandemic relief funds to construct a 5-acre outdoor learning environment connected to a local nature and birding center owned by the city. Tory Guerra, whose children attend McAllen's schools, expressed concerns that the project, which will not be completed until December 2024, is not prioritizing the urgent learning needs of children who have been directly impacted by the pandemic.

“There are so many other programs that we could invest in that we could use immediately and see benefits immediately rather than years down the road," Guerra said. She believes that the federal aid should directly address the pressing emotional and academic wellbeing of students, many of whom have struggled to keep up in the classroom. “Half the kids won't even get to reap the benefit because the nature center isn't even built."

Mark May, a spokesperson for the McAllen independent district, said the cost of the project is a small fraction of the district's $139.5 million in aid. He said the outdoor space will provide students with resources and experiences that will bolster children's scientific knowledge.

Some states and districts have developed their own public reporting platforms. In Georgia, the education department built a dashboard that shows how much money each district has received and the programs they have spent it on. But other states have not offered as much visibility into districts' spending. Indiana, for example, has so far made little information public, but it is currently developing an online portal.

In the provisional federal reports that categorize how aid money is spent, some of the largest districts in the nation marked all of their aid as going to the “other" category, including Los Angeles Unified, which spent $49.5 million, and New York City's schools, which spent $111.5 million.

Instead of spending the aid on summer school or technology, New York City's district, the largest in the country, used its federal funds to plug a gap in its budget, which had been cut by the state. Katie O'Hanlon, a spokesperson for the district, told ProPublica that the district used the funds to cover the wages and operations of custodial workers. O'Hanlon said the district had followed state reporting requirements. J.P. O'Hare, a spokesperson for the New York State Education Department, said the state is using the “other" category until the federal government provides more direction on reporting requirements.

Shannon Haber, a spokesperson for Los Angeles Unified, said the district's reporting was submitted based on the state's requirements. Many districts categorized their spending as “other" initially, but as the school year progressed, the spending categories diversified, said Scott Roark, a spokesperson for the California Department of Education.

Even if the information is publicly available on a local level, the lack of standardization from state to state makes it impossible to get a national picture of how the funds are being directed.

Some experts said it may be too soon to get a larger view of how the aid was spent. “There's going to be a natural lag between a district receiving the money, spending the money and reporting up to the state," said Paige Kowalski, executive vice president for the education advocacy group Data Quality Campaign.

But other experts say that without real-time insight into district spending, schools will not be able to shift priorities if they find certain programs are working better than others.

“There can be an opportunity to do mid-course corrections, if we find something working well or not well," said Dan Goldhaber, director of the Center for Education Data & Research at the University of Washington. “We will be in a bad place if we don't have much evidence that $200 billion didn't move the needle."

This past July, the federal Education Department announced plans to increase its data collection from districts in 2022, but dozens of districts and state education agencies said that more oversight could leave them overburdened.

“It will take another block of time," said Brenda Turner, the business manager of Haskell Consolidated Independent School District in central Texas, adding that her district already filed detailed plans to the state's education department explaining how Haskell planned to spend its aid. “They need to figure out how to pull it out of their own system to report to the federal government instead of putting it on us."

One company that received a $39 million contract was CRE8AD8 LLC (pronounced “Create a Date"), a wedding and event planning firm. The owner compared the contract to his usual work of “putting tchotchkes in a bag."

In response to the report, the firm's CEO said in a statement, “We delivered far more boxes/pounds than many other contractors and as a for-profit company, we're allowed to make a profit."

The congressional report also highlighted the application of an avocado grower who was initially awarded a $40 million contract before it was canceled after a review. Under the section of the application that required applicants to list references, the farmer wrote, “I don't have any."

The Food to Families program was created by the Department of Agriculture in the early days of the pandemic to give away produce that might have otherwise gone to waste as a result of disruptions in distribution chains. The boxes included produce, milk, dairy and cooked meats — and many also included a signed letter from then-President Trump.

The program was unveiled in May 2020 by Ivanka Trump. “I'm not shy about asking people to step up to the plate," the president's older daughter said in an interview to promote the initiative.

According to congressional investigators, Ivanka Trump was involved in getting the letter from her father added to the boxes. The USDA told contractors that including the letter was mandatory. Food bank operators told the investigators the letter concerned them because it didn't appear to be politically neutral.

On the first day of the Republican National Convention in August 2020, President Trump and his daughter headlined a nearby event to announce an additional $1 billion for the food box program. Then-Secretary of Agriculture Sonny Perdue also spoke at the event and encouraged attendees to reelect the president.

A federal ethics office later found that Perdue's speech violated a federal law that prohibits officials from using their office for campaign purposes. The USDA at the time disputed the notion that Perdue was electioneering, saying that Perdue's comments merely “predicted future behavior based on the president's focus on helping 'forgotten people.'"

The yearlong congressional investigation also identified problems with the deliveries themselves, including food safety issues, failed deliveries and uneven food distribution. Some contractors also forced recipient organizations to accept more food than they could distribute or store.

Committee chair Rep. James Clyburn, D-S.C., said in a statement that the mismanagement of the program is another example of the previous administration's failures.

“The Program was marred by a structure that prioritized industry over families, by contracting practices that prioritized cutting corners over competence, and by decisions that prioritized politics over the public good," he said.

ProPublica also found that the Trump administration hired a lobbyist to counter the criticism that contracts were going to unqualified contractors.

President Joe Biden ended the program in May.

Representatives of the former president did not respond to a request for comment.

They are two sisters in two states. Both are dedicated health care professionals who watched in horror as COVID-19 swept through the nation's nursing homes, killing a staggering number of residents and staff alike.

One sister is now vaccinated. The other is not.

“ Dude. Get vaccinated!" Heidi Lucas texted her sister Ashley in May from her home in Jefferson City, Missouri.

“Nope lol," Ashley Lucas texted back from Orbisonia, Pennsylvania.

“Don't you work with old people?"

“Yeah"

“What if you killed one of them? Get vaccinated," Heidi wrote.

Neither sister is budging as the Delta variant brings a new spike in coronavirus numbers across the nation.

Their divide mirrors America's larger one, where the vaccine to combat COVID-19 is eagerly embraced by some, yet eyed with suspicion and rejected by others.

It is the refusal group, including a significant percentage who work in the nation's nursing homes, that has confounded and alarmed health care officials who are at a loss as to how to sway them.

Nursing homes faced a shocking mortality rate during the pandemic. In the U.S., COVID-19 killed more than 133,000 residents and nearly 2,000 staff members between May 31, 2020 and this July 4, according to Centers for Medicare & Medicaid Services reports. The true toll is thought to be even higher as data gathering lagged in the early months of the crisis, health experts say.

Working in a nursing home became one of the “most dangerous jobs" in America in 2020, according to an analysis of work-related deaths by Scientific American.

Yet seven months after the first vaccines became available to medical professionals, only 59% of staff at the nation's nursing homes and other long-term care facilities are fully or partially vaccinated — with eight states reporting an average rate of less than half, according to CMS data updated last week.

Twenty-three individual facilities had vaccination rates of under 1%, the data showed.

Staff vaccinations have lagged even as the overall rate for residents climbed to 83%, according to the CMS data.

The strong vaccination percentage among nursing home residents is credited, in part, to an early campaign to bring the vaccine directly to facilities. That suggests availability is not necessarily the issue behind staff going without.

So, what is?

The question defies easy answers. Vaccine refusal is regional and often aligns not only with individuals' political alignment but also with their preferred news sources and which social media they follow.

Last week, President Joe Biden took aim at Facebook and other social media giants for failing to police vaccine misinformation that amplifies conspiracy theories and discourages people from getting vaccinated. “They're killing people," he said, directly blaming the platforms. On Monday, he recast the accusation to say it was specific individuals posting dangerous information who are culpable.

On Tuesday, U.S. Sen. Mitch McConnell, R-Ky., pleaded to “anyone out there willing to listen: Get vaccinated." While not mentioning skeptics specifically — including those in his own party — the Republican leader urged the unvaccinated to ignore “demonstrably bad advice."

COVID-19 cases are now surging in every state, with new hospitalizations and deaths almost entirely occurring among the unvaccinated. “This is becoming a pandemic of the unvaccinated," Centers for Disease Control and Prevention Director Rochelle Walensky warned last week during a White House briefing.

In May, CMS began requiring weekly reports on vaccinations of residents and staff at nursing homes and other long-term care facilities. The emerging data confirms many health care experts' worst fears, especially for Southern states.

Louisiana has the lowest statewide average: Just 44.5% of the staff at its long-term care facilities have been at least partially vaccinated, according to CMS data released last week.

Florida, the second lowest-vaccinated state, had a rate of just under 46% among its nursing home and long-term care staff, with Missouri, Oklahoma, Tennessee, Georgia, Mississippi and Wyoming all showing rates of less than 50 percent, according to the data.

Vaccination rates in assisted living facilities are not included in the data.

A separate American Association of Retired Persons analysis, released last week, showed that only one in five of the nation's more than 15,000 nursing homes were able to hit a goal, set by two industry trade groups, of vaccinating 75% of their staff by the end of June.

While cases in nursing homes have recently slowed, and most of the new COVID-19 infections are among younger people, some experts still worry of a return to darker days.

The CDC recently launched an investigation into deaths of residents at several western Colorado senior facilities possibly linked to unvaccinated staff, the Associated Press reported Wednesday.

“We need to sound the alarm," said Susan Reinhard, senior vice president of AARP and director of its Public Policy Institute. “Nursing homes were devastated by COVID-19, and many residents remain highly vulnerable to the virus."

Nationally, more than 89% of people 65 or older have received at least partial vaccination, the CDC reported this week. Still, public health experts have warned that even if fully vaccinated, the elderly may be vulnerable to “breakthrough" coronavirus infection because of compromised immune systems and other underlying health problems.

In Missouri's southern region, the overall rate of full vaccination in some rural counties is less than 20%, according to state health department and CDC tracking. The latest surge of the delta variant has turned the area into a “tinderbox," Steven Edwards, CEO of the CoxHealth hospital system in Springfield, recently told reporters.

On Thursday, 160 patients were being treated for COVID-19 at CoxHealth, a spokesperson told ProPublica. On May 14, there were 18.

Heidi Lucas directs the Missouri Nurses Association. She is pro-vaccine and has been pushing hard for nurses to get vaccinated, especially those on the front lines of patient care.

Lucas said it is impossible to separate the lack of vaccination among staff from the lack of vaccinations in individual communities. “Nurses are people too," she said. “They are on social media and are inundated with false information. How do you fight it?"

Her sister, Ashley Lucas, lives 900 miles away in Orbisonia, a small town of around 500 people about an hour south of State College. She's a traveling certified nursing assistant at area nursing homes and chose to skip the vaccine.

Her fiance and her children, ages 12 and 13, are also unvaccinated. “I don't consider myself an anti-vaxxer," she told ProPublica, bristling that some might see her as reckless or ill-informed.

Instead, she said her decision was carefully considered. It never made sense to her, she said, that the virus seemed to strike randomly, with some residents getting sick while others did not. She said she is not convinced the vaccine would change the odds.

She's also concerned after hearing that the vaccine could interfere with fertility — a contention that has been deemed false by the Centers for Disease Control and Prevention and the World Health Organization. It all leads her to believe more research is needed into the vaccines' long-term effects.

“This is just a personal choice and I feel it should be a free choice," she said. “I think it's been forced on us way too much."

Certified nursing assistants make up the largest group of employees working in nursing homes and other long-term care facilities, providing roughly 90 percent of direct patient care. They are typically overworked and underpaid, most earning about $13 per hour and receiving no paid sick leave or other benefits, said Lori Porter, co-founder and CEO of the National Association of Health Care Assistants.

Porter said she is not completely surprised by the low vaccination rate. It comes down to trust, she said, both of the vaccines and of facility administrators who now say staff must get vaccinated. Refusal may feel like empowerment. “It's the first time ever they have had the ball in their court," Porter said.

On March 31, Houston Methodist Hospital mandated that all of its 26,000 employees be vaccinated by June 7 or lose their jobs. Jennifer Bridges, a nurse, sued along with 116 other employees, claiming the health care system had overstepped its rights and that she and the others refused to be “human guinea pigs," evoking the Nuremberg Code, a set of ethical standards established in response to Nazi medical experimentation in concentration camps.

On June 12, U.S. District Judge Lynn N. Hughes dismissed the closely watched case, taking offense to likening the vaccine to the Holocaust, which he called “reprehensible." Ten days later, 153 Houston Methodist employees either were fired or quit after refusing the vaccine. The judge's ruling has been appealed.

A handful of long-term care chains have similarly sought to mandate worker vaccines, but such action is far from widespread in the industry. One sticking point has been whether vaccination can legally be required, since all three available vaccines have only emergency use authorization, not full approval from the U.S. Food and Drug Administration.

The thornier issue, though, is whether the facilities can risk losing staff when they're already short-handed. Many workers have vowed to quit rather than be forced into vaccinations.

Aegis Living, a long-term senior care provider in three Western states, made vaccines mandatory for its roughly 2,600 employees on July 1. Dwayne Clark, founder and CEO, said initially 400 employees refused but when the deadline arrived, only about 100 left rather than be vaccinated.

“We lost some staff that we didn't want to lose," Clark told ProPublica, “but it felt like the right moral protocol to impose."

Recently the U.S. Equal Employment Opportunity Commission issued guidelines stating that employers can require workers to be vaccinated as long as medical or religious exemptions are permitted.

“Nursing home workers certainly have the right to make decisions about their own health and welfare, but they don't have the right to place vulnerable residents at risk," said Lawrence Gostin, a health law professor at Georgetown University. “Nursing homes don't just have the power to require vaccinations, they have the duty."

Still, the issue is far from resolved.

“America is a highly litigious country," Gostin said, “I expect the courts to consistently uphold nursing home mandates, because they are entirely lawful and justified. But there will likely be lawsuits at least until it is quite clear they are futile."

Diane Peters is a registered nurse in the Chicago suburbs who last year worked at a nursing home and is now working at a senior rehabilitation center. She does not trust the science behind the vaccine and is unvaccinated. So is her fiance.

Everything about the rollout felt like propaganda, she said. Development was too rushed. Clinical trials typically take years, she said, not months. “I don't think it's safe right now, it needs more time," she said she tells patients if they ask.

Most don't, she said. Neither do her co-workers. She has only been asked once by her employer if she was vaccinated, she said, declining to name the company.

Peters guesses about 40 percent of her colleagues are also unvaccinated, but said no one likes to talk about it because the divide surrounding the vaccine is “surreal." Staff members are tested regularly and are required to wear masks, she said.

She is doubtful mandates would stick. “They can threaten," she said, “but a lot of nurses would walk."

She trusts her instincts and her own research for now. When asked what would change her mind, she had one word: “Nothing."

They are two sisters in two states. Both are dedicated health care professionals who watched in horror as COVID-19 swept through the nation's nursing homes, killing a staggering number of residents and staff alike.

One sister is now vaccinated. The other is not.

“ Dude. Get vaccinated!" Heidi Lucas texted her sister Ashley in May from her home in Jefferson City, Missouri.

“Nope lol," Ashley Lucas texted back from Orbisonia, Pennsylvania.

“Don't you work with old people?"

“Yeah"

“What if you killed one of them? Get vaccinated," Heidi wrote.

Neither sister is budging as the Delta variant brings a new spike in coronavirus numbers across the nation.

Their divide mirrors America's larger one, where the vaccine to combat COVID-19 is eagerly embraced by some, yet eyed with suspicion and rejected by others.

It is the refusal group, including a significant percentage who work in the nation's nursing homes, that has confounded and alarmed health care officials who are at a loss as to how to sway them.

Nursing homes faced a shocking mortality rate during the pandemic. In the U.S., COVID-19 killed more than 133,000 residents and nearly 2,000 staff members between May 31, 2020 and this July 4, according to Centers for Medicare & Medicaid Services reports. The true toll is thought to be even higher as data gathering lagged in the early months of the crisis, health experts say.

Working in a nursing home became one of the “most dangerous jobs" in America in 2020, according to an analysis of work-related deaths by Scientific American.

Yet seven months after the first vaccines became available to medical professionals, only 59% of staff at the nation's nursing homes and other long-term care facilities are fully or partially vaccinated — with eight states reporting an average rate of less than half, according to CMS data updated last week.

Twenty-three individual facilities had vaccination rates of under 1%, the data showed.

Staff vaccinations have lagged even as the overall rate for residents climbed to 83%, according to the CMS data.

The strong vaccination percentage among nursing home residents is credited, in part, to an early campaign to bring the vaccine directly to facilities. That suggests availability is not necessarily the issue behind staff going without.

So, what is?

The question defies easy answers. Vaccine refusal is regional and often aligns not only with individuals' political alignment but also with their preferred news sources and which social media they follow.

Last week, President Joe Biden took aim at Facebook and other social media giants for failing to police vaccine misinformation that amplifies conspiracy theories and discourages people from getting vaccinated. “They're killing people," he said, directly blaming the platforms. On Monday, he recast the accusation to say it was specific individuals posting dangerous information who are culpable.

On Tuesday, U.S. Sen. Mitch McConnell, R-Ky., pleaded to “anyone out there willing to listen: Get vaccinated." While not mentioning skeptics specifically — including those in his own party — the Republican leader urged the unvaccinated to ignore “demonstrably bad advice."

COVID-19 cases are now surging in every state, with new hospitalizations and deaths almost entirely occurring among the unvaccinated. “This is becoming a pandemic of the unvaccinated," Centers for Disease Control and Prevention Director Rochelle Walensky warned last week during a White House briefing.

In May, CMS began requiring weekly reports on vaccinations of residents and staff at nursing homes and other long-term care facilities. The emerging data confirms many health care experts' worst fears, especially for Southern states.

Louisiana has the lowest statewide average: Just 44.5% of the staff at its long-term care facilities have been at least partially vaccinated, according to CMS data released last week.

Florida, the second lowest-vaccinated state, had a rate of just under 46% among its nursing home and long-term care staff, with Missouri, Oklahoma, Tennessee, Georgia, Mississippi and Wyoming all showing rates of less than 50 percent, according to the data.

Vaccination rates in assisted living facilities are not included in the data.

A separate American Association of Retired Persons analysis, released last week, showed that only one in five of the nation's more than 15,000 nursing homes were able to hit a goal, set by two industry trade groups, of vaccinating 75% of their staff by the end of June.

While cases in nursing homes have recently slowed, and most of the new COVID-19 infections are among younger people, some experts still worry of a return to darker days.

The CDC recently launched an investigation into deaths of residents at several western Colorado senior facilities possibly linked to unvaccinated staff, the Associated Press reported Wednesday.

“We need to sound the alarm," said Susan Reinhard, senior vice president of AARP and director of its Public Policy Institute. “Nursing homes were devastated by COVID-19, and many residents remain highly vulnerable to the virus."

Nationally, more than 89% of people 65 or older have received at least partial vaccination, the CDC reported this week. Still, public health experts have warned that even if fully vaccinated, the elderly may be vulnerable to “breakthrough" coronavirus infection because of compromised immune systems and other underlying health problems.

In Missouri's southern region, the overall rate of full vaccination in some rural counties is less than 20%, according to state health department and CDC tracking. The latest surge of the delta variant has turned the area into a “tinderbox," Steven Edwards, CEO of the CoxHealth hospital system in Springfield, recently told reporters.

On Thursday, 160 patients were being treated for COVID-19 at CoxHealth, a spokesperson told ProPublica. On May 14, there were 18.

Heidi Lucas directs the Missouri Nurses Association. She is pro-vaccine and has been pushing hard for nurses to get vaccinated, especially those on the front lines of patient care.

Lucas said it is impossible to separate the lack of vaccination among staff from the lack of vaccinations in individual communities. “Nurses are people too," she said. “They are on social media and are inundated with false information. How do you fight it?"

Her sister, Ashley Lucas, lives 900 miles away in Orbisonia, a small town of around 500 people about an hour south of State College. She's a traveling certified nursing assistant at area nursing homes and chose to skip the vaccine.

Her fiance and her children, ages 12 and 13, are also unvaccinated. “I don't consider myself an anti-vaxxer," she told ProPublica, bristling that some might see her as reckless or ill-informed.

Instead, she said her decision was carefully considered. It never made sense to her, she said, that the virus seemed to strike randomly, with some residents getting sick while others did not. She said she is not convinced the vaccine would change the odds.

She's also concerned after hearing that the vaccine could interfere with fertility — a contention that has been deemed false by the Centers for Disease Control and Prevention and the World Health Organization. It all leads her to believe more research is needed into the vaccines' long-term effects.

“This is just a personal choice and I feel it should be a free choice," she said. “I think it's been forced on us way too much."

Certified nursing assistants make up the largest group of employees working in nursing homes and other long-term care facilities, providing roughly 90 percent of direct patient care. They are typically overworked and underpaid, most earning about $13 per hour and receiving no paid sick leave or other benefits, said Lori Porter, co-founder and CEO of the National Association of Health Care Assistants.

Porter said she is not completely surprised by the low vaccination rate. It comes down to trust, she said, both of the vaccines and of facility administrators who now say staff must get vaccinated. Refusal may feel like empowerment. “It's the first time ever they have had the ball in their court," Porter said.

On March 31, Houston Methodist Hospital mandated that all of its 26,000 employees be vaccinated by June 7 or lose their jobs. Jennifer Bridges, a nurse, sued along with 116 other employees, claiming the health care system had overstepped its rights and that she and the others refused to be “human guinea pigs," evoking the Nuremberg Code, a set of ethical standards established in response to Nazi medical experimentation in concentration camps.

On June 12, U.S. District Judge Lynn N. Hughes dismissed the closely watched case, taking offense to likening the vaccine to the Holocaust, which he called “reprehensible." Ten days later, 153 Houston Methodist employees either were fired or quit after refusing the vaccine. The judge's ruling has been appealed.

A handful of long-term care chains have similarly sought to mandate worker vaccines, but such action is far from widespread in the industry. One sticking point has been whether vaccination can legally be required, since all three available vaccines have only emergency use authorization, not full approval from the U.S. Food and Drug Administration.

The thornier issue, though, is whether the facilities can risk losing staff when they're already short-handed. Many workers have vowed to quit rather than be forced into vaccinations.

Aegis Living, a long-term senior care provider in three Western states, made vaccines mandatory for its roughly 2,600 employees on July 1. Dwayne Clark, founder and CEO, said initially 400 employees refused but when the deadline arrived, only about 100 left rather than be vaccinated.

“We lost some staff that we didn't want to lose," Clark told ProPublica, “but it felt like the right moral protocol to impose."

Recently the U.S. Equal Employment Opportunity Commission issued guidelines stating that employers can require workers to be vaccinated as long as medical or religious exemptions are permitted.

“Nursing home workers certainly have the right to make decisions about their own health and welfare, but they don't have the right to place vulnerable residents at risk," said Lawrence Gostin, a health law professor at Georgetown University. “Nursing homes don't just have the power to require vaccinations, they have the duty."

Still, the issue is far from resolved.

“America is a highly litigious country," Gostin said, “I expect the courts to consistently uphold nursing home mandates, because they are entirely lawful and justified. But there will likely be lawsuits at least until it is quite clear they are futile."

Diane Peters is a registered nurse in the Chicago suburbs who last year worked at a nursing home and is now working at a senior rehabilitation center. She does not trust the science behind the vaccine and is unvaccinated. So is her fiance.

Everything about the rollout felt like propaganda, she said. Development was too rushed. Clinical trials typically take years, she said, not months. “I don't think it's safe right now, it needs more time," she said she tells patients if they ask.

Most don't, she said. Neither do her co-workers. She has only been asked once by her employer if she was vaccinated, she said, declining to name the company.

Peters guesses about 40 percent of her colleagues are also unvaccinated, but said no one likes to talk about it because the divide surrounding the vaccine is “surreal." Staff members are tested regularly and are required to wear masks, she said.

She is doubtful mandates would stick. “They can threaten," she said, “but a lot of nurses would walk."

She trusts her instincts and her own research for now. When asked what would change her mind, she had one word: “Nothing."