From Health Care

Ink Rx? Welcome To The Camouflaged World Of Paramedical Tattoos

Tattoo artist Eric Catalano performs an areola tattoo procedure on Terri Battista’s breasts at Eternal Ink Tattoo Studio in Hecker, Illinois, in November. After a double mastectomy following cancer in 2013, Battista had reconstructive surgery ― but held off on areola tattoos because of the cost. Then she heard about Catalano’s shop, where breast cancer survivors could get the procedure done for free.(Michael B. Thomas for KHN)

HECKER, Ill. — The first fingernail tattoo started off as a joke by a man who lost the tips of two fingers in a construction accident in 2018.

But that shifted after Eric Catalano, an auto finance manager turned tattoo artist, finished with his needle.

“The mood changed in here,” Catalano recalled as he stood in his Eternal Ink Tattoo Studio. “Everything turned from funny to wow.”

When Catalano posted a photo of the inked fingernails online last January, he thought maybe 300 people would like the realistic tattoo. He had no idea the image would be viewed by millions of people around the world. Even “Ripley’s Believe It or Not!” tracked him down to feature the viral tattoo: a pair of fingernails that looked so real no one could believe their eyes.

The viral photo pushed Catalano, 39, further into the world of paramedical tattooing. Now people with life-altering scars come from as far as Ireland to visit Catalano’s tattoo shop in this rural village about 30 miles outside St. Louis. They enter Eternal Ink looking for the healing touch they saw online. With flesh-toned ink and a needle, Catalano makes his clients feel whole again with an art form and industry that picks up where doctors leave off.

Mark Bertram lost the tips of two fingers in a construction accident last year. Bertram was trapped in a fan belt at work when the tips of his fingers were severed off. Eric Catalano tattooed fingernails for Bertram.(Courtesy of Eric Catalano)

Catalano is known for his talent with intricate fingernails and filling in the blanks left empty by accidents or surgeries, but other paramedical tattoo artists also are trying out flesh-toned pigments to camouflage imperfections, scars and discolorations for all skin colors.

Using tattoos to blend in rather than stand out is a relatively new field. A school started outside Atlanta about four years ago has trained more than 100 aspiring paramedical tattoo artists.

Because the work is considered cosmetic, though, it typically isn’t covered by medical insurance. Still, the mostly unregulated industry continues to grow even as health care professionals debate the safety of tattoo ink. Many people are willing to pay out-of-pocket for that final piece of healing.

Leslie Pollan, 32, a stay-at-home mom and dog breeder in Oxford, Mississippi, feels this service is priceless. She was bitten on the face by a puppy in 2014. She underwent countless surgeries to correct a scar on her lip.

“I went to plastic surgeons that were supposed to be the best in Memphis,” Pollan said. “They gave me no hope, so I started looking for other options.”

She ultimately traveled six hours for a paramedical tattoo session with Catalano. He used ink and his tattoo needle to camouflage Pollan’s lip scar, giving her back a piece of her confidence.

“You don’t understand until you’ve been through it,” Pollan said. “It really made me have a different outlook on life.”

José Alvarado, of Pingree Grove, Illinois, winces while getting two fingernail tattoos at Eric Catalano’s studio in Hecker, Illinois, in November.(Michael B. Thomas for KHN)

A Booming Business

More than 500 miles from Catalano’s shop, industry expert and paramedical tattoo trainer Feleshia Sams, 41, shows artists and health professionals how to cover stretch marks, surgery scars and discolored skin with flesh-toned pigment in the course she launched at the Academy of Advanced Cosmetics in Alpharetta, Georgia.

While a tattoo license is required for such work, separate paramedical tattoo training is not.

Catalano is self-taught. He uses the techniques he picked up years ago while helping breast cancer survivors who wanted tattoos of areolas — the dark area around nipples — after having mastectomies. Those tattoos are among the most common paramedical requests.

His grandmother had breast cancer. Her battle with the disease is one reason Catalano is so dedicated to helping those with the diagnosis.

People with life-altering scars come from as far away as Ireland to visit Eric Catalano’s small tattoo shop, Eternal Ink Tattoo Studio, in Hecker, Illinois, about 30 miles outside St. Louis. (Michael B. Thomas for KHN)

Eric Catalano, an auto finance manager turned tattoo artist, specializes in the art of healing. The single father of three performs up to eight reconstructive medical tattoos for free each “Wellness Wednesday” in his small Illinois shop, drawing in nails on finger amputees, mocking up belly buttons after tummy tucks or fleshing out lips on a woman mauled by a dog.(Michael B. Thomas for KHN)

“Cancer took away a part of my body I can never get back,” said Sarah Penberthy, a breast cancer survivor who came from Festus, Missouri, for areola tattoos. “I felt like I wasn’t even human.”

Penberthy, 39, said she was grateful for her life but still felt incomplete until Catalano stepped in. He tattooed nipples and a creative design of a ship’s anchor on her chest that says “I REFUSE TO SINK.”

Catalano now does up to eight reconstructive tattoos each “Wellness Wednesday,” drawing in nail beds on finger amputees and mocking up belly buttons after tummy tucks.

Catalano doesn’t charge for paramedical tattoos. A GoFundMe page established last year brought in more than $12,000, allowing Catalano to donate his skills for the time being.

“Financially it doesn’t make sense, but it’s just something that I love to do,” Catalano said.

But the single father of three will need more to keep things going. He wants to find other ways to fund his work.

Terri Battista, of Myrtle Beach, South Carolina, shows her completed tattoos to her husband, Joe Battista. After a double mastectomy following cancer in 2013, Battista had reconstructive surgery ― but held off on areola tattoos because of the cost. Then she heard about Catalano’s shop, where, as a breast cancer survivor, she could get the procedure done for free.(Michael B. Thomas for KHN)

Elsewhere, the business of paramedical tattoos is supported by the booming interest in cosmetic and plastic surgery, Sams said. Americans spent more than $16.5 billion on cosmetic procedures in 2018. After tummy tucks, breast augmentations and other procedures, some patients want to cover their scars.

“It’s going to take off even more so than what we’ve seen in the past,” said Sams. “We’re providing students with a nontraditional way to make a career.”

She added that one of her graduates reports a six-figure salary after establishing a business of her own.

Every time I see that emotion, I’m 100% sure this is something that I can’t stop doing.

Eric Catalano

Trial-And-Error Tattoos

Catalano’s first fingernail client, Mark Bertram, 46, lost the tips of two fingers at work when his hand became trapped in a fan belt.

“It’s life changing but it’s not life ending,” Bertram said. “Doing work is harder now. Everything is just a little different.”

He can’t tie his shoes with ease, type on a keyboard or hold food the same way anymore. But after two surgeries and occupational therapy, he decided to make light of his new condition by asking Catalano to create the fingernail tattoo. The idea made everyone in the studio laugh until they saw the final result.

Bertram has returned to the shop for a touch-up. The maintenance helps his nails keep their realistic look. The ink in fingernail tattoos, however, doesn’t always absorb into the scar-tissued skin.

The two fingernail tattoos that José Alvarado, 44, of Pingree Grove, Illinois, got from Catalano in November wore off within weeks.

After losing part of two fingers in a work accident 16 years ago, José Alvarado receives two fingernail tattoos at Eternal Ink Tattoo Studio.(Michael B. Thomas for KHN)

Alvarado had become an amputee 16 years ago when he damaged two fingers on the job at a printing factory. He endured two surgeries after the accident and had decided to visit Catalano’s tattoo studio from his home outside Chicago after seeing the artist’s work online. Although he was upset when the tattoos first wore off, he said, he’d like to try them again because he liked how it looked.

Catalano’s not sure why they work for some and not others.

Getting the same results for people with darker skin tones is also a challenge because the color of their nail beds doesn’t match the color of their skin. And paramedical tattoos of any kind for people of color can be more difficult to execute, which is one reason Sams created a line of 30 skin-colored and undertone pigments for trained professionals that she sells online and at her school. Catalano tracks the ink he uses as he continues to figure things out along the way.

“It may not be a one-size-all thing that fits everybody,” he said.

Catalano still does regular tattoos out of the studio he established more than 10 years ago. His rate of $100 per hour for those tattoos has stayed the same while he donates his paramedical work every Wednesday.

“Every time I see that emotion, I’m 100% sure this is something that I can’t stop doing,” he said.

José Alvarado looks at his two new fingernail tattoos after the November procedure. Alvarado later said the tattoos wore off within weeks but he hopes to try again. The ink in fingernail tattoos doesn’t always absorb into the scarred skin.(Michael B. Thomas for KHN)

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Public Health States

Abortion-Rights Supporters Fear Loss Of Access If Adventist Saves Hospital

For more than two years, physician assistant Dawn Hofberg fought to bring access to abortions back to California’s Mendocino Coast, a picturesque stretch of shoreline about three hours north of San Francisco and 90 minutes from the nearest facility offering abortions.

Hofberg enlisted help from local health care providers and the American Civil Liberties Union, which sent letters to the Mendocino Coast Health Care District that operates the hospital in Fort Bragg and other medical services. The letters noted that the state constitution requires public hospitals to offer abortions if they offer other pregnancy-related care.

Late last year, district CEO Wayne Allen granted a doctor at its North Coast Family Health Center permission to start providing medication abortions, which involve two drugs that can end a pregnancy.

But Hofberg and others worry that the community’s newly won abortion access could be in peril. With a net loss of $1.2 million in the 2018 fiscal year alone, the district says its only shot at survival is to lease its operations to Adventist Health, a Roseville, California-based system affiliated with the Seventh-day Adventist Church, which opposes most abortions.

Dawn Hofberg, a physician assistant in Fort Bragg, California, turned to other local health care providers and the American Civil Liberties Union to help persuade the local hospital to make abortions available to some patients in her community. (Courtesy of Dawn Hofberg)

Voters will decide whether to approve the 30-year lease agreement on March 3.

Adventist officials said that despite their religious teachings that abortions should be limited to cases of life- or health-threatening pregnancies, rape, incest or severe fetal anomalies, they will not restrict the use of medication abortions at the clinic.

“We don’t control our physician practices in the way some others do and we don’t put constraints around what they can and can’t prescribe,” said Bob Beehler, an Adventist Health mergers and acquisitions executive.

Beehler said the introduction of abortion-inducing pills had changed the system’s approach to abortions. “Our historical position has been based on the way they used to be done, in a hospital.”

But abortion-rights supporters still fear what could be coming.

“Obviously, we do have a lot of concerns about Adventist’s position with respect to restricting abortion access in its facilities, and so we’re going to keep a close eye on the situation,” said Phyllida Burlingame, director of reproductive justice and gender equity for the ACLU of Northern California.

Burlingame said the deal also raises broader concerns about the spread of religious health systems that restrict care. “Not only are they taking over the private marketplace, but now they’re even spreading into these public spheres,” Burlingame said.

Similar objections from the ACLU and staff at the University of California-San Francisco last year scuttled a proposed affiliation between UCSF Medical Center and Dignity Health, a Catholic-affiliated system that restricts reproductive and transition-related care for transgender patients.

The expansion of religious systems can leave leaders of struggling hospitals with few choices when they seek to affiliate. Of the five systems to which the Mendocino hospital district issued its request for proposals last year, three were faith-based. Two responded, and Adventist was the only one that met the community’s needs, according to the district board’s treasurer, John Redding.

Nationwide, four of the largest 10 health systems and 1 in 6 acute care hospital beds are Catholic-owned or -affiliated. Seventh-day Adventists are Protestant Christian, and Adventist-affiliated systems run 87 hospitals and more than 300 other facilities in the United States, according to the Adventist Health Policy Association.

As these systems have grown, rural health care districts across California are struggling with waning patient volume and a lack of leverage to negotiate with insurers, said Sherreta Lane, senior vice president of finance policy at the District Hospital Leadership Forum, a trade association that represents all the state’s district and municipal hospitals. Many of these hospitals have closed or affiliated with private systems.

When the forum launched a decade ago, 45 districts or municipalities ran hospitals; now 35 do, Lane said.

While Catholic-affiliated systems like Dignity have received greater scrutiny for policies that restrict access to abortion, contraception, sterilization and end-of-life care, the impact of Adventist teachings on church-affiliated health systems is less known. In October, the Seventh-day Adventist Church raised concerns among reproductive health care advocates when it approved a statement saying it “considers abortion out of harmony with God’s plan for human life.”

Officials said at the time that they would develop updated protocols for church-affiliated health care institutions, where, they emphasized, few abortions are performed.

Adventist Health spokesperson Jill Kinney said in an emailed statement that the hospital system’s usual practice “is not to provide elective abortions, but we respect that patients may wish to have them.” If that’s the case, she added, “clinicians help coordinate referral and transfer to capable facilities without prejudice.”

In a response to detailed questions from California Attorney General Xavier Becerra before his office approved the system’s takeover of Delano Regional Medical Center in November, Adventist Health said it bans “elective abortions” but allows the procedure “for fetal distress and other medical reasons.” It added: “Medical abortions are performed in Adventist Health facilities,” without providing details.

In 2014, Adventist Health purchased a clinic in Fort Bragg where Dr. Eric Gutnick and his colleagues had provided reproductive health services since the 1970s. Under a contract with Adventist, Gutnick continued to see abortion patients for preoperative care in the clinic and performed surgical abortions at the Mendocino Coast District Hospital, until he retired later that year.

The Seventh-day Adventist Church’s teachings can influence other issues, too. It has opposed what it calls “transgenderism,” stating that gender identity “is determined by our biological sex at birth,” and has called homosexuality “a manifestation of the disturbance and brokenness in human inclinations and relations caused by the entrance of sin into the world.”

Arneta Rogers, an attorney for the ACLU of Northern California, voiced concern about these beliefs. “It’s not about shutting down religious entities; we just don’t want people to be discriminated against,” Rogers said in an interview.

Jason Wells, president of the Adventist Health hospitals in Ukiah and Willits, said the system cherishes diversity and its LGBTQ employees. In its statement to the attorney general, Adventist said some of its physicians provide hormones for transgender patients but none of its facilities offer “gender reconstruction surgery.”

In a statement provided by Kinney, Adventist Health said that it “strives to be free from biases related to gender identity” but that its hospitals “are not currently equipped to offer the complex, comprehensive programmatic approach necessary to provide gender reassignment treatments and surgeries.”

For many in the Mendocino community, uncertainty over the hospital’s finances has overshadowed concerns about Adventist Health’s religious affiliation as residents prepare for the vote next month. “If the affiliation doesn’t go through, I don’t know how we’ll stay in business,” said Karen Arnold, secretary of the district board.

Redding said lease payments from Adventist would allow the district to afford the estimated $24 million needed to finance upgrades required by the state to protect against catastrophic earthquake damage to its facilities.

“I wasn’t sure how we were going to do this, and now I feel that we’ve secured the future of a hospital here on the coast,” Redding said.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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California Health Industry

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! And Happy Valentine’s Day, where we at KHN have compiled some of the best #HealthPolicyValentines from Twitter (this seems the right group for that level of wonkiness!). Check out some great ones, like this from Laura Marston:

“One vial a week
Keeps me alive
Used to cost $20
Now it’s $275.”

Now on to equally fun things, like budgets!

President Donald Trump released his proposed budget this week with only the vaguest of a health care plan mentioned. A mystery pot of $844 billion signaled deep cuts to Medicaid and subsidies under the health law. In particular, an obscure passage referred to “ending the financial bias that currently favors able-bodied working-age adults over the truly vulnerable.” Critics were scratching their heads how the released budget aligned with Trump’s promise to protect people’s coverage. “You can’t cut $1 trillion from these programs and protect the most vulnerable,” said Aviva Aron-Dine of the Center on Budget and Policy Priorities.

The Associated Press: Mystery $844B Pot in Trump Budget Signals Medicaid Cuts

The budget also calls for an almost 16% cut to the CDC (yes, the agency handling the coronavirus outbreak). But top officials say that’s because the administration wants the CDC to narrow its focus to its core mission of preventing and controlling infectious diseases and handling public health crises.

The Washington Post: Trump Budget Cuts Funding for Health, Science, Environment Agencies

Trump also wants to cut the budget for the National Institutes of Health by 6.5%. (Yes, that would affect the National Institute of Allergy and Infectious Diseases, which is working on a vaccine for the coronavirus.)

The Wall Street Journal: Trump Proposes $4.8 Trillion Budget, With Cuts to Safety Nets

Another odd little nugget in the budget: Trump wants to strip the FDA of its authority over tobacco products and create an agency within HHS solely for that purpose.

Stat: Trump Doesn’t Want the FDA to Regulate Tobacco

For a full breakdown of the budget’s details, check out our roundup here.

This week, the coronavirus strain got an official name, which is — drum roll, please —COVID-19. Although the announcement probably set off celebrations among scientists and researchers who have been driven up a wall because everyone has been simply calling it “coronavirus,” I am here to report that a day into its official designation 95% of headlines are stilling using only the generic term.

— It is, however, important to note that WHO officials were careful not to name the disease after a particular region or people so as to avoid further stigmatization surrounding any outbreaks.

Time: What’s in a Name? Why WHO’s Formal Name for the New Coronavirus Disease Matters

— As the death toll climbs in China, officials have expanded their “wartime” campaign to round up all the people who may be infected. But, as you can imagine, that is not going perfectly. Not only is it stoking tensions among an angry and scared nation whose residents aren’t happy with how the government is handling the crisis, but also it’s thrusting people who haven’t even tested positive for the virus into situations where they become vulnerable to infection.

The New York Times: China Expands Chaotic Dragnet in Coronavirus Crackdown

— Readers of The Friday Breeze know I’ve been harping on the fact that our national attention has been focused on COVID-19 even though we have only 15 (non-fatal) confirmed cases of it here and the common flu is far more deadly to us. Well, there’s a psychological basis for why we tend to panic over things that statistically are unlikely to affect us. Pretty much we can be terrible at accurately assessing risk.

The New York Times: Coronavirus ‘Hits All the Hot Buttons’ for How We Misjudge Risk

— It was a bit of a roller-coaster week with data coming out of China. At first, it seemed the cases were slowing down, but then the diagnostic criteria were tweaked, and all of a sudden we had nearly 15,000 cases added in one night.

The New York Times: Coronavirus Cases Seemed to Be Leveling Off. Not Anymore.

— CDC Director Robert Redfield said that the United States is essentially trying to buy time with its containment strategy, but it is quite likely there will eventually be person-to-person transmission of the virus here. (Which means people other than evacuees from Wuhan will start getting it.)

Stat: CDC Director: More Person-To-Person Coronavirus Infections in U.S. Likely

— And you can see how easily that could happen, given a U.S. evacuee was mistakenly released from the hospital even though she was infected with the coronavirus.

CNN: First US Evacuee Infected With Coronavirus Was Mistakenly Released From Hospital

— In an update from the cruise from h-e-double-hockey-sticks: Tensions continue to rise along with COVID-19 cases among the passengers and crew of a ship quarantined off the coast of Japan. As one health official said this week: Remember, quarantines are to keep those outside of its boundaries safe, not those within.

The New York Times: Quarantined Cruise Passengers Have Many Questions. Japan Has Few Answers.

— WHO has been heaping praise on China for its response to the crisis. And while other experts acknowledge the organization is in the tenuous position of not wanting to anger China enough that they break off relations, critics say the excessive compliments are setting a bad precedent about what a good pandemic response looks like.

The Wall Street Journal: The World Health Organization Draws Flak for Coronavirus Response

— Meanwhile, the coronavirus research filed is quite small. That’s because, despite the buzz these kinds of outbreaks create, eventually the world’s attention will be caught by a different shiny object and both the funding and interest in researching the virus will fade.

Stat: Fluctuating Funding and Flagging Interest Hurt Coronavirus Research

Supporters of Sen. Bernie Sanders (I-Vt.) got their wrists slapped by a powerful Nevada union this week for “viciously attacking” members and their families online. At the heart of the matter: The union had released information critical of Sanders’ “Medicare for All” plan. The clash put Sanders — who denounced any harassment as “unacceptable” — in an awkward spot just before the Nevada caucuses next week.

Politico: Nevada Culinary Union Lays Into Sanders Supporters After Health Care Backlash

A new survey found that even when patients plan ahead, many are still hit with surprise medical bills, especially if they receive anesthesia during a procedure. With health care spending rising again (driven by high costs like the out-of-pocket price tag for an emergency room visit), the report is a reminder that the issue is likely to be top of mind with voters come November.

Meanwhile, lawmakers well aware of that fact are moving forward with legislation that would favor an arbitration method for dealing with the surprise costs. This strategy is favored by hospitals and providers, and not embraced by insurers.

Reuters: Surprise Surgery Bills Happen Even When Patients Plan Ahead

Modern Healthcare: House Committee Advances Provider-Friendly Surprise Billing Fix

In a little bit of breaking news, a federal appellate court just shut down CMS’ approval of Arkansas’ Medicaid work requirement. The panel upheld a lower-court ruling that found the requirements arbitrary and capricious.

Modern Healthcare: D.C. Circuit Nixes Arkansas Medicaid Work Requirement

Juul has vowed time and again that it hasn’t marketed its products to teenagers. But new revelations from a Massachusetts lawsuit that the vaping company bought ads on Nickelodeon and the Cartoon Network are challenging those promises.

The New York Times: Juul Bought Ads Appearing on Cartoon Network and Other Youth Sites, Suit Claims

The VA is no stranger to controversy, but the latest bout comes at a bad time for the agency. The abrupt firing of the agency’s well-liked undersecretary in combination with allegations that VA Secretary Robert Wilkie sought to dig up dirt on a woman after she said she was sexually assaulted at a VA facility have shaken the agency just as it is preparing to launch an ambitious health plan.

The New York Times: Veterans Affairs, a Trump Signature Issue, Is Facing Turmoil Again

Meanwhile, Trump continued to downplay brain injuries sustained by troops from an Iran missile strike even as the number of cases jumped past 100.

The New York Times: More Than 100 Troops Have Brain Injuries From Iran Missile Strike, Pentagon Says

In the miscellaneous file for the week:

— It’s notoriously hard to get any gun measures passed … except these advocates seem to be having some success. Their strategy? Go hyper-local.

NBC News: How Moms Are Quietly Passing Gun Safety Policy Through School Boards

— What’s going on with the Equal Rights Amendment and why has it become a fight over abortion? Politico takes a deep dive into its history about how the battle around the amendment has shifted in the nearly 40 years since it was introduced.

Politico: How the Debate Over the ERA Became a Fight Over Abortion

— New parents eager to better balance family and work life in the only industrialized country in the world without a paid family leave policy have started bringing their babies to their offices.

Stateline: You Can Bring Your Baby to Work (But Wouldn’t You Rather Be at Home?)

— In another crushing disappointment, an Alzheimer’s drug that had sparked high hopes was the latest to fail to live up to expectations.

The Associated Press: Drugs Fail to Slow Decline in Inherited Alzheimer’s Disease

That’s it from me. And remember, if you ever feel like flexing your poetic muscles outside of Valentine’sDay, we accept haiku submissions year-round. Have a great weekend!

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We (Heart) Health Policy Poets

Who says health policy can’t be fun? Experts lit up Twitter in recent days with valentine messages about topics ranging from drug prices and surprise medical bills to the Affordable Care Act and Kaiser Health News. Here are some of our favorites.

Robert Longyear:

Hey, don’t break my heart. I don’t have prior authorization!

Joanne Kenen:

Roses are red
Podcast at Kaiser.
We hope ‘What the Health?’
Makes you wiser.

→KHN’s ‘What The Health?’: Live from D.C. With Rep. Donna Shalala

Laura Marston:

One vial a week
Keeps me alive
Used to cost $20
Now it’s $275.

Joshua Israel:

The red roses are ready
The champagne is still chilling.
I love you more than private equity
Loves surprise medical billing.

Avery Stewart:

Our love is like a hospital bill: no one understands it.

Tara Straw:

Roses are red
And given with love
You don’t need a web-broker
Because we’ve got

Sarah Gollust:

Will it be your place or mine?
We have to make choices, my Valentine.
Should we expand benefits or reduce costs?
Health policy, like love, requires tradeoffs.

Ariel Cohen:

Roses are red,
Violets are blue,
Stop panicking about coronavirus,
You’re more likely to get the flu.

Meril Pothen:

The White House is red
But some states are blue
So health policy by litigation
Is all that we do.

Related Topics

Health Care Costs Health Industry

Perspectives: Lessons About Silencing Chinese Doctor Who Warned About Coronavirus; Supporting U.S. Chinese Communities Needs To Replace Blaming

Viewpoints: No Surprise That No One Seriously Plans To Fix Surprise Medical Bills; ‘Medicare For All’ Isn’t What’s Hurting Warren, Other Dems

Longer Looks: Violent Crime And Head Trauma; The Battle Over A Plant; Warship Accidents; And More

State Highlights: LA Mayor Works With Trump Administration To Pave Way For Homeless Beds; Baltimore Mayor Kept Reselling Same ‘Healthy Holly’ Books For Profit In Illegal Scheme

Advocates Cheer Growing Trend Allowing Babies In Workplace Even In States Where Family Leave Is Available

Georgia Senate Bill Aims To Regulate Pharmacy Middlemen To Achieve Lower Medication Prices

Opioids’ Serious Adverse Effects Came Up In Only 12% Of Doctor, Sales Rep Interactions, Analysis Finds

Even Governors Who Have Steadfastly Supported Trump Are Raising Concerns About Medicaid Changes

CEO Faces Criminal Investigation Following Accusations He Has Not Operated Hospitals With Eye On Public Safety

Americans Are Still Paying More And More In Health Costs But Not Because Amount Of Care Is Increasing

First Edition: February 14, 2020

Facts Vs. Fears: Five Things To Help Weigh Your Coronavirus Risk

The news about the novel coronavirus in China grows more urgent daily. The number of related deaths is now greater than 1,300, while tens of thousands of people have been infected — most of them in China. People returning to the U.S. from China are quarantined for 14 days. It can be frightening to think about the threat, but public health officials in this country constantly remind people that the risk of the disease here is low.

Still, scientists have more questions than answers about important issues surrounding the coronavirus, now officially named COVID-19. Here’s some help in understanding the unknowns and evaluating the risks.

More than 1,300 people have died from this virus since December. That sounds pretty scary. Should I be worried?

All but two of those fatalities occurred in China, where the virus emerged. That country has reported the lion’s share of cases, said Dr. William Schaffner, a professor of preventive medicine, health policy and infectious diseases at Vanderbilt University Medical Center.

The 15 Americans identified so far with the disease had recently been in China or had close contact with someone who became infected in China. In addition, public health officials report that many of the U.S. cases have been relatively mild infections.

The number of deaths in China is startling, but remember, even a virus with a low fatality rate can kill many people if the number of infections is large. For example, influenza kills 0.14% of infected patients, said Dr. Peter Hotez, a professor of pediatrics, molecular virology and microbiology at Baylor College of Medicine in Houston. But because the flu is so common — infecting up to 45 million Americans a season — deaths could climb as high as 61,000 people each flu season just in the U.S., according to the Centers for Disease Control and Prevention.

But the statistics coming out of China are also suspect, and experts don’t yet know how to evaluate them. For example, Chinese officials Thursday suddenly changed their criteria for confirming the disease and added more than 15,000 cases to the patient tally — after two days of reporting a downturn in the number of people affected.

To be sure, it is often difficult to get a good assessment of cases while using most of your public health resources to fight an outbreak.

The number of coronavirus cases may be much higher than China is reporting, said Lawrence Gostin, director of the World Health Organization Collaborating Center on Public Health Law & Human Rights. That may not be a deliberate effort to downplay the outbreak but could signal problems “with China’s capacity for testing and surveillance,” he said. “They are just not picking up all the cases and deaths. An even greater problem is that there is no independent verification.”

The World Health Organization “is relying on data from China and has no ability at present to independently verify those data,” Gostin said. That could change, he added, if WHO experts are allowed into the center of the outbreak, the city of Wuhan in Hubei province. “But I have significant concerns that even then [WHO] won’t have access to full information,” he said.

What is the mortality rate from this virus?

News reports and health officials have reported widely varied estimates of death rates for this outbreak. Schaffner cautions that calculating those numbers in a fast-moving outbreak is difficult.

Mortality rates are determined by dividing the number of deaths by the number of infections. While counting the dead is generally straightforward, it can be impossible to find the total number of infections because some people with the virus develop few noticeable symptoms. Since COVID-19 is new, doctors don’t know what percentage of infections fall into this category, Schaffner said.

It’s not surprising that mortality rates for the coronavirus vary dramatically, based on where diagnoses were made, Schaffner said. For example, a report Monday from the Imperial College of London found a mortality rate of 18% for cases detected in Hubei, where only patients with unusual pneumonia or severe breathing problems were being tested for the virus. Outside China, health officials test anyone with a cough and fever who has visited Hubei — a much larger number — producing a mortality rate of 1.2% to 5.6%.

(Hannah Norman/KHN Illustration; Getty Images)

How is the virus spreading? Do you need to worry only about people sneezing next to you?

The rapid spread of the coronavirus suggests it is transmitted person-to-person, much like influenza: An infected person coughs out moist droplets containing the virus and another person breathes them in, said Schaffner.

Because the moist droplets fall to the ground within 3 to 6 feet, patients are most likely to infect people with whom they are in close contact. These droplets can also land on surfaces, such as door handles, and infect other people who touch the contaminated surface, then touch their mouth or eyes.

It’s much less common for viruses to spread through so-called airborne transmission, in which viruses float in the air for a long time, like measles or chickenpox, said Hotez.

The diagnosis this week of a woman who lived in a Hong Kong apartment with an unsealed pipe raised the question of whether COVID-19 may have been transmitted through the building’s plumbing. A 2003 outbreak of SARS — or severe acute respiratory syndrome, caused by another type of coronavirus ― is believed to have infected 321 residents of the Amoy Gardens apartment complex in Hong Kong because the virus may have spread through a plume of warm air that traveled through the pipes.

While the Amoy Gardens outbreak was striking, experts believe it was a one-time phenomenon. No one has found another example of a coronavirus spreading through plumbing, said Michael Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy.

Anecdotal reports that patients without symptoms can spread COVID-19 have been widely publicized. But scientists have not confirmed such transmissions, said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security in Baltimore. Other coronaviruses, such as SARS and Middle East respiratory syndrome, have not been shown to spread in patients without symptoms.

A report from Germany, published this year in the New England Journal of Medicine, pointing to a case in which someone was infected by an asymptomatic person “has been shown to be inaccurate” because the primary patient “did have symptoms at the time she spread the virus,” he said. She had taken medication to reduce her fever.

I read about one man who infected nearly a dozen people as he traveled in Europe. Some articles call him a “super spreader.” Can people transmit the virus so easily?

So-called super spreaders are people who infect a larger-than-average number of people.

While some people with coronavirus never infect anyone else, others infect dozens. In 2003, a Hong Kong SARS patient infected 136 people at one hospital. As a general rule, health officials estimate that 20% of people with a given infectious disease cause roughly 80% of the cases, Hotez said.

Although it’s not known how large a role super spreaders are playing in the COVID-19 outbreak, anecdotes have dotted the press. A British man, for example, is believed to have infected 11 others at a French ski resort.

Scientists don’t know why some people are more contagious than others, Hotez said. It’s possible that these people have a higher viral load and “shed” more of the virus when they cough or sneeze. Scientists don’t know if personal habits also come into play. For example, do these patients cough more vigorously than others? Do they socialize more? Are they more apt to touch objects or other people?

People are being quarantined on military bases and cruise ships. Does that work?

Quarantines have been used since the 14th century, when cities such as Venice ordered ships to remain at anchor for 40 days before landing as a way to prevent the spread of the plague. The word “quarantine” comes from the Italian word for 40.

But quarantines are effective only when they’re limited and based on good scientific evidence, Gostin said.

The two-week quarantines that U.S. officials have imposed on people evacuating Wuhan — who had a high risk of being exposed to the virus — make sense, he suggested, because people aren’t being housed together. Evacuees are protected from exposure to the virus and prevented from transmitting it to others, Gostin said.

The quarantines imposed in China on major cities and a Japanese cruise ship aren’t effective, Gostin said.

“They are overbroad and under conditions that could fuel the epidemic,” said Gostin, who is also faculty director at Georgetown University’s O’Neill Institute for National and Global Health Law. “People are being forced to remain in close, congested conditions, so they are likely to spread infection among themselves.”

Forcing passengers on a cruise ship to remain in their cabins for two weeks “is a cruel human experiment,” Osterholm said. “They should be released as soon as possible. We’re just facilitating transmission” on the ship.

Passengers should be asked to “shelter in place” at home for two weeks instead, he added.

“Most people will comply,” Osterholm said.

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Public Health

Changing Clocks Is Bad For Your Health, But Which Time To Choose?

Changing over to daylight saving time — a major annoyance for many people — may be on its way out as lawmakers cite public health as a prime reason to ditch the twice-yearly clock-resetting ritual.

The time change, especially in the spring, has been blamed for increases in heart attacks and traffic accidents as people adjust to a temporary sleep deficit. But as legislatures across the country consider bills to end the clock shift, a big question looms ahead of this year’s March 8 change: Which is better, summer hours or standard time?

There are some strong opinions, it turns out. And they are split, with scientists and politicians at odds.

Retailers, chambers of commerce and recreational industries have historically wanted the sunny evenings that allow more time to shop and play.

Researchers on human biological rhythms come down squarely on the side of the standard, wintertime hours referred to as “God’s time” by angry farmers who objected to daylight saving time when it was first widely adopted during World War I.

What’s not in question is that the clock switching is unpopular. Some 71% of people want to stop springing forward and falling back, according to a 2019 Associated Press-NORC Center for Public Affairs Research poll.

Politicians have reacted accordingly. More than 200 state bills have been filed since 2015 to either keep summer hours or go to permanent standard time, according to the National Conference of State Legislatures.

The measures getting the most traction right now are for permanent daylight saving time, which makes more sun available for after-work activities. In 2018, Florida passed a bill and California voters backed a ballot measure to do so. Maine, Delaware, Tennessee, Oregon and Washington joined in 2019, passing permanent daylight saving bills. President Donald Trump even joined the conversation last March, tweeting: “Making Daylight Saving Time permanent is O.K. with me!”

But none of those efforts can become reality without the blessing of Congress. States have always been able to opt out of summer hours and adopt standard time permanently, as Arizona and Hawaii have done. But making daylight saving time year-round is another story.

Still, Scott Yates, whose #Lock the Clock website has become a resource for lawmakers pushing for change, believes this year will be another big year. Yates is particularly encouraged by the attitude he saw from state legislators in August when he presented on the issue at the legislators’ annual national summit in Nashville, Tennessee.

“I wasn’t the court jester and it wasn’t entertainment,” he said. “It was like, ‘What are the practical ways we can get this thing passed?’”

Seeking To End ‘Spring Ahead, Fall Back’ Cycle

Yates, 54, a tech startup CEO based in Denver, has been promoting an end to clock switching for six years. He doesn’t pick a side. It’s the switching itself that he wants to end. At first, it was just about the grogginess and annoyance of being off schedule, he said. But then he began to see scientific studies that showed the changes were doing actual harm.

A German study of autopsies from 2006 to 2015, for instance, showed a significant uptick just after the spring switch in deaths caused by cardiac disease, traffic accidents and suicides. Researchers have also noted a significant increased risk for heart attacks and strokes.

Three measures pending in Congress would allow states to make daylight saving time permanent. But, in the meantime, state lawmakers who want the extra evening sunlight are preparing resolutions and bills, some of which would be triggered by congressional approval and the adoption of daylight time in surrounding states.

The Illinois Senate passed such a bill, and Kansas is considering one after a bill to end daylight saving time died there last year. Utah passed a resolution in support of the congressional bill last year, and state Rep. Ray Ward, a Republican family physician from Bountiful, is steering a recently passed state Senate permanent daylight bill through the House.

“The human clock was not built to jump back and forth. That’s why we get jet lag,” said Ward, who was a co-presenter with Yates at the NCSL summit. “It is very easy to show that if you knock people off an hour of sleep there’s a bump temporarily in bad things that will happen.”

Efforts have been particularly strong in California, where 60% of voters passed a ballot issue for permanent daylight time in 2018. A bill is pending in the state Assembly.

Science Backs Sticking With Standard Time

All of this alarms scientists who study human biological rhythms.

Researchers in the U.S. and the European Union have taken strong positions about permanent summer hours. The Society for Research on Biological Rhythms posts its opposition prominently at the top of its website.

Messing with the body’s relationship to the sun can negatively affect not only sleep but also cardiac function, weight and cancer risk, the society’s members wrote. According to one often-quoted study on different health outcomes within the same time zones, each 20 minutes of later sunrise corresponded to an increase in certain cancers by 4% to 12%.

“Believe it or not, having light in the morning actually not only makes you feel more alert but helps you go to bed at the right time at night,” said Dr. Beth Malow, director of the sleep division of Vanderbilt University School of Medicine. Malow has seen a lot of anecdotal evidence to back that up at the sleep clinic. Parents report their children with autism have a particularly hard time adjusting to the time change, she said.

Jay Pea, a freelance software engineer in San Francisco, was unhappy enough about California’s proposed permanent daylight time that he started the Save Standard Time website to promote the health arguments for keeping it permanent. He said he doesn’t think the scientific community is being heard.

“Essentially it’s like science denial,” he said. “It’s bizarre to me that politicians are not hearing the experts on this.”

Pea, 41 and an amateur astronomer, understands the human need to have the sun directly overhead at noon. “It’s a wonderful connection to natural reality that unfortunately is lost on many people,” he said. Daylight saving time “distances us from the natural world.”

At the very least, lawmakers ought to consider history, he said. Daylight saving time was originally a plan to save energy during the two world wars but wasn’t popular enough to be uniformly embraced after the conflicts were over. In 1974, the federal government decided to make it temporarily year-round as a way to deal with the energy crisis (although energy savings were later found to be underwhelming).

Its popularity fell off a cliff after the first winter, when people discovered the sun didn’t rise until 8 a.m. or later and parents worried for the safety of kids waiting in the dark for school buses.

Pea finds it frustrating that the momentum now is for permanent summer hours — a fact he attributes to the emotional attachment with summer. “It’s a shame that every generation we have to revisit this issue,” he said.

The AP-NORC poll found 40% of its respondents support permanent standard time, with 31% opting for permanent daylight saving time.

Ward said people have gotten comfortable with daylight saving time since its duration has been lengthened to eight months by extensions in 1986 and 2007. (Before 1986, daylight saving time lasted six months.)

“So now really most of the year we are on the summer schedule, and people are used to that and they like it,” he said. “That makes them more aggrieved when we change back to the winter schedule.”

In any case, changing the clocks is a rare issue in that it isn’t partisan, Ward said. “If the government can’t respond to people when they want something and it’s not even a partisan issue, that’s just a sad commentary,” he said. “Can’t we please fix something that doesn’t make sense anymore?”

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California Public Health States

Would ‘Medicare For All’ Cost More Than U.S. Budget? Biden Says So. Math Says No.

During the Feb. 7 Democratic presidential debate, former Vice President Joe Biden once again questioned the price tag of “Medicare for All,” the single-payer health care proposal championed by one of his key rivals, Sen. Bernie Sanders of Vermont.

Biden argued that the plan was fiscally irresponsible and would require raising middle-class taxes. Specifically, he claimed, the plan “would cost more than the entire federal budget that we spend now.”

Medicare for All’s price — and whether it’s worth it — is a subject of fierce discussion among Democratic presidential candidates. But we had never heard this figure before. It caught our attention, so we decided to dig in.

Biden’s campaign directed us to the 2018 federal budget, which totaled $4.1 trillion. It compared that amount with the estimated cost of Sanders’ single-payer proposal: between $30 trillion and $40 trillion over a decade. The math, they said, shows Medicare for All would cost more than the national budget.

But it turns out, based on the numbers and interviews with independent experts, Biden’s comparison of Medicare for All’s price to total federal spending misses the mark because the calculation is flawed.

The Numbers

Sanders has said publicly that economists estimate Medicare for All would cost somewhere between $30 trillion and $40 trillion over 10 years. Research by the nonpartisan Urban Institute, a Washington, D.C., think tank, puts the figure in the $32 trillion to $34 trillion range.

We pointed out to Biden’s campaign that comparing 10-year spending estimates to one-year budgets is like comparing apples to oranges. The campaign suggested that if you take 10 times the current federal budget, you get a figure smaller than the estimated cost of Medicare for All over that 10-year window.

That calculation would lead you to multiply $4.1 trillion by 10 to get $41.1 trillion. That result is close to the high mark Sanders set for his program’s cost but well above the $34 trillion that Urban researchers projected.

Still, that’s not the correct way to formulate a comparison, experts say. “That’s not good math,” said Marc Goldwein, the senior vice president and senior policy director at the Committee for a Responsible Federal Budget. “That’s taking a 2018 number and multiplying it by 10, whereas the $34 trillion is a 10-year number that assumes a lot of growth.”

What you would need to do is add up the Congressional Budget Office’s projected budget outlays from 2020 to 2029, and compare the sum to the Medicare for All spending figure.

So we spoke to Linda Blumberg, an institute fellow at Urban’s Health Policy Center, who arrived at the $34 trillion estimate. She ran the CBO’s numbers: The next 10 years of on-budget outlay, the government office projects, add up to $44.8 trillion.

To be clear, $34 trillion (34 followed by 12 zeros) is no small sum. It accounts for about 75% of that nearly $45 trillion budget estimate and would represent a bigger single increase to the federal budget than we’ve ever experienced, Blumberg said.

That raises one point on which Biden may have some ground. Goldwein argued that you would indeed need significant tax increases to finance the Sanders proposal.

But its price tag still would be less than the projected budget.

“If he said [Medicare for All] was as big as the current federal budget, that would be incorrect,” Blumberg said.

Goldwein looked at the numbers another way: Including interest, he found, the federal budget would consume about $55 trillion between now and 2030. Again, that’s more than what Medicare for All would cost during the same period.

Big picture: No matter how you slice Biden’s math, his numbers are off.

“If what he said was Medicare for All will cost as much as the entire rest of the budget, that would be fair,” Goldwein said. But that’s not the same thing.

Our Ruling

Biden argued that Medicare for All “would cost more than the entire federal budget that we spend now.”

This relies on faulty math. Medicare for All would certainly represent a substantial increase to the federal budget. But it would neither match nor dwarf current federal spending overall. We rate this claim False.

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Elections Health Care Costs Insurance Medicare

‘An Arm And A Leg’: What We’ve Learned And What’s Ahead For The Show

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In this bonus episode of “An Arm and a Leg,” reporter and colleague Sally Herships (“Planet Money,” “Marketplace”) takes a turn in the host’s chair.

The conversation covers what we have learned so far and what’s ahead for the show.

You’ll hear stories culled from the cutting-room floor, including an early adventure from the medical-bill ninja profiled early on in Season 3.

We also dig into the stories — and lessons — listeners have shared with the show.

Looking ahead to Season 4, our question is: “How do we make this into kind of a community education project? We’ve profiled a ninja. Now, how do we build a dojo?”

Season 3 is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

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KHN’s ‘What The Health?’: Live from D.C. With Rep. Donna Shalala

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President Donald Trump’s proposed budget for the fiscal year that begins in October proposes big cuts to popular programs, including Medicaid and the National Institutes of Health. Although those cuts are unlikely to be enacted by Congress, both Republicans and Democrats are likely to use the budget blueprint as a campaign issue.

Meanwhile, several House committees this week relaunched work on legislation to address “surprise” medical bills — unexpected charges from out-of-network providers. And Congress is still trying to come to a bipartisan agreement on how to address drug prices.

Rep. Donna Shalala (D-Fla.) was the special guest for this week’s podcast, taped before a live audience at the Kaiser Family Foundation headquarters in Washington, D.C. Also joining host Julie Rovner of Kaiser Health News were Paige Winfield Cunningham of The Washington Post, Rebecca Adams of CQ Roll Call and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • One surprise in the president’s budget is a proposal to move tobacco regulation out from under the Food and Drug Administration’s purview. That comes despite a law Congress passed several years ago that specifically named the FDA as the regulator for tobacco.
  • Last year, it seemed clear that Congress and the White House were determined to find a way to protect consumers from surprise medical bills. But heavy lobbying on the issue and deep fissures in pinpointing the best remedy have slowed that effort. Shalala said she thinks Congress will produce a bill this year that will be balanced so that insurers and medical providers have to compromise.
  • Shalala said that in the 21 town meetings she has held in South Florida, no one has asked about efforts to end surprise bills. Most of the health questions focus on high drug prices and out-of-pocket costs. High out-of-pocket costs have been driven by the large number of people shifted into high-deductible insurance plans.
  • Shalala also said she doesn’t expect a plan to import drugs from Canada, endorsed by the Trump administration and some states, to go forward. Drugmakers sell Canada enough medicine to cover the population there, and not consumers in Florida, she added.

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

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Coronavirus Tests Public Health Infrastructure In The Heartland

JEFFERSON CITY, Mo. — Every weekday at noon since Jan. 27, the Missouri Department of Health and Senior Services Director Randall Williams gathers his outbreak response team for a meeting on coronavirus.

Missouri has yet to have a confirmed case of what officials are now calling COVID-19, but about 20 people statewide are being monitored for the novel viral infection originating from Wuhan, China. While 15 cases have been confirmed in the U.S. so far, tens of thousands of people have been infected worldwide and more than 1,300 have died. Global — and local — fears of the spread of the respiratory virus are fueling concerns about a lack of preparation in the U.S.

Missouri health department staff have been working overtime preparing for if, and when, the cases come by ensuring they have adequate supplies of non-expired protective gear like masks and planning how to trace the movements of those who have come in contact with potentially infected people.

They’re also helping set up coronavirus testing capabilities at a regional lab based here in the state capital to evaluate potential cases from Missouri, Kansas, Nebraska and Iowa. The U.S. Centers for Disease Control and Prevention has started shipping testing kits around the country.

Coronavirus may not require a front-line battle yet in places like Missouri as it does in states with confirmed cases, such as Washington, California, Illinois and Texas. But it’s still taxing public health officials in Missouri, which has one of the lowest levels in the nation for public health spending per person. And they, like health officials in other states, are stuck in the tricky position of trying not to be over- or underprepared for a potential public health crisis that may never come.

Missouri’s legislature is considering an additional $300,000 in emergency funding for events like coronavirus. This money is vital for responding to outbreaks in the state, Williams said, including more common concerns like mumps and measles or ongoing fights against hepatitis A and tuberculosis.

However, according to Williams, the legislature denied such an appeal for $300,000 last year.

“We are essentially like a fire department, right? People want us to be available when there’s a fire,” the director said. “But when there’s not a fire, they don’t really give a lot of thought to it.”

Limited Budget

As state officials gear up for possible problems from coronavirus, local health departments in Missouri are at a disadvantage because they have lost staff amid state budget cuts, according to Lindsey Baker, research director for the Missouri Budget Project, a nonprofit focused on public policy decisions.

Similar patterns hold true across the nation. Almost a quarter of local health department jobs have been lost since 2008, according to the National Association of County and City Health Officials, and a quarter of local health departments experienced budget cuts last year.

While federal funding has supplemented public health funding in Missouri, Baker said, the federal cash comes with strict rules on how it can be used.

Williams stressed that, despite Missouri’s limited budget, his state ranked in the top tier for emergency preparedness by Trust for America’s Health, a nonprofit advocacy group promoting public health.

Money notwithstanding, viruses like COVID-19 force the staff to work longer hours, according to state epidemiologist Dr. George Turabelidze, as the health department juggles its existing workload with pressing concerns.

“Everything else is happening — it’s not like we can switch, we have to do all this at once,” Turabelidze said.

Plus, he added, since this outbreak involves world travelers arriving at all times of the day, his staff has had to work weekends to track down where travelers have come from and whether they’ve had contact with infected people. For now, salaried staffers — who do not receive overtime — are expected to shoulder the extra load.

Even as they work extra hours, some routine health department matters such as onsite sewage inspections “get put in the back seat,” said Adam Crumbliss, chief director of Missouri’s Division of Community and Public Health.

If coronavirus reaches a pandemic level — in which it spreads worldwide — Crumbliss said the National Guard could be activated.

Relying On Existing Relationships And Stockpiles

Vital to any public health emergency response are the underlying relationships, stressed Paula Nickelson, the state’s program coordinator for health care system readiness. Knowing whom to call and having an established rapport with key health care providers such as the Missouri Hospital Association is critical during a crisis.

As is experience. Nickelson said the state’s response capabilities were tested and strengthened during a successful practice transport of a hypothetical Ebola patient from St. Louis to the University of Iowa in May.

Through that exercise, they learned that the material of their ISOPODs — portable, see-through isolation units that quarantine infected patients while allowing them to still see and speak to other people — was so thick it made it hard to hear those inside. Now, they are equipping them with walkie-talkies.

Another major question in recent days is a potential onslaught of shortages of protective medical equipment — everything from masks to latex gloves ― often manufactured in China. Nickelson said the state has assessed what materials are on hand.

“They’re fairly small amounts,” she said. “What we found over the course of a decade is that a lot of that stuff sits on the shelf, doesn’t necessarily get used, and so we’re better off to have just-in-time, vendor-managed processes in place.”

Still, Nickelson noted, that could become a problem for everyone if a pandemic occurs and those vendors become swamped with orders.

“This is by no means a sprint,” Crumbliss said. “This is a long wind race.”

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Cost and Quality Public Health States

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