From Health Care

Arguing to Undo the ACA. Harming Medicare. Do They Go Hand in Hand?

It’s a tried-and-true campaign strategy.

Candidates go on the attack, claiming their opponent will do harm to Medicare. After all, people 65 and older are good about making it to the polls on Election Day. These voters are also generally motivated to protect the federal health insurance program for seniors.

It’s no surprise, then, that in an ad released this month, former Vice President Joe Biden’s campaign played the Medicare card.

“Donald Trump is lying about Medicare and Social Security,” an ominous, mature, male voice warns viewers in the ad. He goes on to say that “Trump’s pushing to slash Medicare benefits.”

Clearly, we’ve heard this dire message before — from candidates of both parties through the years.

We issued a skeptical rating of a claim that Trump promised to gut Social Security and Medicare if re-elected, noting that his deferral of payroll taxes did not mention Medicare at all. But Trump has not mentioned cuts to Medicare benefits on the trail, and he’s promised to make cuts to the program in the future. So what is Biden’s claim talking about?

As a rationale for the statement, a Biden campaign spokesperson pointed us to the Trump administration’s support of Republicans’ efforts in a court case, California v. Texas, which seeks to overturn the Affordable Care Act. But the ad does not include any reference or explanation of how the case would affect Medicare benefits.

The legal challenge, brought by a group of Republican attorneys general, is pegged to the 2017 tax bill, which zeroed out the tax that functioned as a penalty for not having health coverage — known as the individual mandate. Without this linchpin tax, the Republicans argue, the entire law should be struck down. They based that on the Supreme Court decision in 2012 that the law was constitutional because the penalty was a valid use of Congress’ ability to levy taxes.

In the current case, lower courts have found the law unconstitutional, and a group of Democratic attorneys general appealed to the Supreme Court.

Oral arguments are scheduled for Nov. 10. The Trump administration filed a brief in support of invalidating the entire law unconstitutional.

Though best known for its vast expansion of health coverage through marketplace plans and Medicaid, the ACA also included a range of consumer protections — such as the ban on discrimination against people with preexisting conditions — and an estimated 165 Medicare-related provisions.

The Biden spokesperson pointed to one, which ended Medicare’s so-called doughnut hole.

We asked experts for their take. Immediately, we found differences in opinion.

That’s a “perfectly fair claim,” said Nicholas Bagley, a professor at the University of Michigan Law School. Closing the doughnut hole matters to many people, he said.

Case Western Reserve University law professor Jonathan Adler took a different view. The argument that Medicare would be affected “is a very aggressive reading of the filing in this case,” he said, referring to the Trump administration’s brief in support of nullifying the ACA.

The next step seemed to be getting a better grasp of what’s at stake.

A Quick Review of the Doughnut Hole, Other Medicare Provisions

The Medicare doughnut hole refers to the gap in Part D prescription drug coverage that begins after a beneficiary spends a set amount — usually a few thousand dollars. Before the ACA, beneficiaries who reached that threshold were responsible for 100% of their medication costs until they spent enough for catastrophic coverage to kick in, which could be more than $1,000 in additional spending. Even with this coverage, beneficiaries were responsible for 5% of their drug expenditures. (If beneficiaries were responsible for 100% of costs today, people with high drug costs would obviously pay a lot more without the ACA provision.)

The ACA would have gradually ended that coverage gap. But, in 2018, Congress adopted changes to expedite the process. As of 2019, the doughnut hole was closed. Adler pointed to that congressional intervention as a step that could keep the doughnut hole closed if the ACA were overturned. Based on this legislative history, the argument could be made that closing the coverage gap was something Congress had an interest in apart from the ACA. Since the doughnut hole is officially closed, some analysts said this provision may not be vulnerable to the upcoming Supreme Court decision on the ACA.

“You can make a lot of claims,” said Gail Wilensky, a former head of the Centers for Medicare & Medicaid Services. “That one is really a stretch.”

Other ACA provisions tied to Medicare benefits seem more at risk, such as the one that mandated annual wellness visits and certain preventive services, such as mammograms, bone mass measurement for those with osteoporosis, and depression and diabetes screening, with no patient cost sharing.

“It’s not clear that the administration actively supports any change to the Medicare benefits with the case before SCOTUS,” said Tricia Neuman, KFF senior vice president and executive director of the KFF’s program on Medicare policy. “But if they didn’t explicitly seek to wall off certain provisions, it is at least conceivable — though maybe not likely — that Medicare benefits in the ACA could be collateral damage.” (KHN is an editorially independent program of KFF.)

According to an amicus brief filed by the AARP, the Center for Medicare Advocacy and Justice in Aging in 2016, an estimated 40.1 million Medicare beneficiaries received at least one preventive service and 10.3 million had an annual wellness visit with no copay or deductible.

Other experts pointed to a troubling implication for Medicare: the nullification of the ACA provisions related to costs and slowing the growth of the program’s spending. Those efforts had been credited with extending the solvency of the Health Insurance Trust Fund and slowing the growth in Medicare premiums.

It “would impair the financial fitness” of the trust fund, said Paul Van de Water, a senior fellow at the Center on Budget and Policy Priorities.

Trump “may not say it is his intent to slash Medicare benefits,” agreed David Lipschutz, associate director of the Center for Medicare Advocacy, but overturning the ACA entirely would “cause chaos writ large.” And, because of the program’s size, that chaos “would upend the financial markets and the entire health care system,” according to the brief filed by Medicare advocates.

What Comes Next Is Complicated

Enter the concept of severability. Many court watchers are quick to say the high court’s decision could go beyond upholding the entire law or declaring it unconstitutional. Instead, the justices could separate or sever parts of it not directly related to the zeroed-out tax penalty, the so-called individual mandate.

Of course, the Trump administration argued in its brief that the interwoven nature of the ACA’s provisions demanded that the entire law be invalidated.

“If you just go on that basis, they are not arguing for severability,” said Van de Water.

But others point out another layer that warrants consideration.

“Everyone who comments on this focuses on the administration’s argument for inseverability,” Adler said. But he said it was more complicated than that.

The Trump administration’s position is “simultaneously that the entire ACA should be invalidated” and also that relief should be provided only where injury to the plaintiffs is shown. (The administration defines the plaintiffs as the two individuals who signed on to the original challenge.)

Another view is that this point in the administration’s argument is not clear-cut, mostly because it gives no hint as to which programs or provisions would fit into the category of harming the plaintiffs.

Ultimately, the fate of the sweeping health law is in the hands of the Supreme Court.

“Legal analysts didn’t anticipate the case getting as far as it has,” said Lipschutz.

But “the White House threw its weight behind the lawsuit,” said Bagley, at the University of Michigan. “So, they own the consequences. Especially in the context of this presidential campaign.”

Our Ruling

An attack ad by the Biden campaign states that Trump is “pushing to slash Medicare benefits” and ties this charge to the administration’s position on the pending legal challenge to the ACA.

The Biden campaign pointed to an ACA provision that sought to close the Medicare doughnut hole to support this claim. It may not be the best example, though, because some experts suggest it may not be as vulnerable as other parts of the law.

Experts outlined a range of other Medicare provisions that either provided new benefits or shored up the program’s financial fitness. If the whole law were to be nullified, as the administration has advocated, these changes could also be erased — a step that would affect benefits and potentially cause premiums to rise.

Overall, the Biden ad seems plausible, even though the link between Trump’s position on the legal challenge and its impact on Medicare benefits is less straightforward than in similar claims we have checked regarding preexisting conditions.

We rate the claim Half True.

Related Topics

Elections Medicare The Health Law

¿Viajas para el Día de Acción de Gracias? Deberás atravesar la barrera de COVID

Molly Wiese estaba perpleja. Sus padres y hermanos viven en el sur de California, y Wiese, abogada de 35 años, ha viajado cada Navidad desde que se mudó a Minnesota en 2007.

Por la pandemia, Wiese pensó que esta vez sería más prudente quedarse. Pero en junio, el padre de Wiese fue diagnosticado con cáncer en estadio 4 y la familia teme que éstas sean sus últimas fiestas.

¿Debería volar con su esposo y sus dos hijos pequeños a California, poniendo a su padre inmunodeprimido en riesgo de COVID-19? ¿O quedarse en casa y perderse la oportunidad de crear recuerdos de estas fiestas?

Sus hijos están en la guardería y el marido de Wiese trabaja en una escuela. No tienen suficiente tiempo de vacaciones para ponerse en cuarentena antes o después de un vuelo, y conducir ocho días de ida y vuelta está fuera de discusión.

Teme transmitirle el coronavirus a su padre. Pero sus padres, que viven en la ciudad de Yucaipa de Inland Empire, creen que vale la pena correr el riesgo de ver a sus nietos y tener “nuestra Navidad normal”, contó Wiese.

“Idealmente, tendríamos una vacuna”, dijo. “Pero no creo que sea una expectativa realista”. Pfizer, el aparente líder en la carrera para una vacuna contra COVID, dice que ni siquiera estará listo para solicitar la aprobación hasta fines de noviembre, como muy pronto.

El padre de Molly Wiese tiene cáncer avanzado y Wiese teme que ésta sea su última temporada de fiestas. Pero duda en viajar al sur de California para visitar a su familia, por temor de ponerlo en riesgo de contraer COVID. De izquierda a derecha: Molly Wiese, su hijo Calvin, su esposo Phil Wiese, su hijo Bennett, y sus padres, Becky y Bill Miller.

Si bien el enigma de Wiese es especialmente importante, su historia ilustra la difícil decisión a la que se enfrentan millones de estadounidenses sobre si viajar o no durante las vacaciones de invierno, y cómo hacerlo.

La mejor forma de evitar la propagación de enfermedades sería evitar los viajes o ampliar los círculos sociales. Para las celebraciones locales, la cuarentena durante dos semanas antes de un evento festivo minimizaría el riesgo, pero solo si todos los comensales se comprometieran a seguirla. Pero algunas personas tienen que trabajar fuera de casa.

Después de al menos siete meses de estar prácticamente encerrados, las vacaciones de invierno representan una tentación casi insuperable. Incluso expertos en salud pública y enfermedades infecciosas reconocen el dilema.

“Hay mucho que ganar con el contacto físico, en la misma sala y no en una pantalla de Zoom o FaceTime”, dijo el doctor Peter Chin-Hong, especialista en enfermedades infecciosas y profesor de medicina en la Universidad de California-San Francisco.

El doctor Anthony Fauci, la autoridad nacional en enfermedades infecciosas en los Institutos Nacionales de Salud, no es inmune al problema. El 13 de octubre, le dijo a “The World” que él y sus tres hijas adultas, que viven en distintos estados, todavía estaban decidiendo si estar juntos “valdría la pena”.

Al día siguiente, Fauci le dijo a “CBS Evening News” que la reunión de Acción de Gracias de su familia estaba cancelada, dados los riesgos que plantean los vuelos. “Puede que tenga que sacrificar esa reunión social, a menos que esté bastante seguro de que las personas con las que está tratando no están infectadas”, dijo.

El doctor Robert Redfield, director de los Centros para el Control y Prevención de Enfermedades (CDC), y la doctora Deborah Birx, coordinadora del equipo de respuesta a COVID de la administración Trump, advirtieron que las reuniones de Thanksgiving podrían propagar el virus.

En California, funcionarios de salud pública están adoptando un enfoque de “reducción de daño”: no están fomentando las reuniones de varias familias, pero han emitido pautas para hacer que las reuniones sean más seguras si se realizan al aire libre y duran menos de dos horas.

Funcionarios del condado de Los Ángeles, que ha visto un aumento en las tasas de transmisión en las últimas semanas, publicaron una guía similar, reconociendo que las personas separadas de sus seres queridos durante meses anhelan cada vez más ese contacto.

“Estamos tratando de encontrar un balance, pero creo que es apropiado que intentemos llevar a cabo algunas de las actividades que la gente está desesperada por poder hacer, con total apego a la guía”, dijo Barbara Ferrer, directora de del departamento de salud pública del condado, en una conferencia de prensa el 14 de octubre.

En todo el mundo, los feriados nacionales han impulsado la propagación de COVID-19 de manera explosiva. En China, donde comenzó la pandemia, se estima que 5 millones de personas que viajaban por el Año Nuevo chino abandonaron Wuhan, el epicentro del brote, antes de que se promulgara una prohibición de viajar.

En Irán, la pandemia se impulsó por Nowruz, una celebración de primavera de dos semanas durante la que viajan millones. En Israel, las fiestas y reuniones religiosas de Purim provocaron una transmisión generalizada a fines de marzo.

Las celebraciones de Memorial Day, el 4 de julio y el Día del Trabajo impulsaron aumentos repentinos de casos en los Estados Unidos, por eso el Día de Acción de Gracias asusta a los funcionarios de salud pública.

El año pasado, viajaron más de 55 millones de personas durante los días que rodearon ese cuarto jueves de noviembre.

Sin embargo, funcionarios de todo el país están siendo suaves cuando se trata de advertencias.

En Minnesota, donde vive Wiese y los casos están alcanzando niveles récord, funcionarios instan al público a evitar las tiendas abarrotadas y las grandes reuniones en interiores con varias familias.

Pero dicen que las cenas de Acción de Gracias al aire libre con amigos y familiares locales son menos riesgosas. Su guía no explica cómo tolerar un Día de Acción de Gracias al aire libre en Minnesota. La temperatura máxima promedio en Minneapolis el 26 de noviembre es de 33 grados.

Michael Osterholm, director del Centro de Investigación y Política de Enfermedades Infecciosas de la Universidad de Minnesota, dice “paremos un poco”.

Osterholm explicó que si no puedes ponerte en cuarentena durante 10 a 14 días antes del evento, es decir, sin contacto con personas además de los miembros de tu hogar que también están en cuarentena, no vayas a la cena de Acción de Gracias en otra casa: el estado ya ha visto demasiados ejemplos de personas vulnerables que se enferman y mueren después de asistir a bodas, funerales y cumpleaños.

“Que este sea tu año COVID”, dijo Osterholm. “Es un año muy desafiante, pero no quieres introducir este virus en entornos familiares y experimentar las consecuencias”.

Osterholm y su pareja pasarán el Día de Acción de Gracias y la Navidad sin familiares, a pesar de que sus hijos y nietos son todos locales. Debido a que todos sus nietos están en la guardería o en la escuela, no hay suficiente tiempo para que sus familias se pongan en cuarentena antes de disfrutar juntos de una comida navideña.

Sintió empatía con la difícil situación de Wiese. Si decide volar a California, dijo, debería acuartelar a su familia lo más posible durante 10 días antes, y luego no pasar más de dos días con su padre.

“Incluso si se infectara, no sería más contagiosa hasta probablemente el tercer día”, dijo. “Entonces, si ella pasa esos dos días con él, puede sentirse relativamente bien por el hecho de que no los puso en riesgo”.

Para aquellos que viajan, conducir es mucho más seguro que volar porque los conductores pueden estar aislados en un compartimento doméstico y evitar la exposición al coronavirus renunciando a los restaurantes y desinfectando las manijas del baño y la bomba de gasolina antes de tocarlos.

El doctor Iahn Gonsenhauser, director de calidad y seguridad del paciente del Centro Médico Wexner de la Universidad Estatal de Ohio, dijo que planea conducir con su familia, pasando la noche en un hotel en el camino, para pasar el Día de Acción de Gracias con la familia de su hermana en Colorado.

Él y su familia se mantienen aislados y trabajan desde casa tanto como sea posible, dejando la casa solo para compras y mandados básicos mientras evitan restaurantes y centros comerciales, dijo. Si alguien en cualquiera de las familias comenzara a mostrar síntomas de COVID, o confirmara la exposición a una persona con COVID positivo, todo el viaje se cancelaría instantáneamente.

“Es por eso que hacemos todos los planes con una reserva reembolsable”, dijo. “Si las personas no tienen forma de salirse de sus reservas, están más inclinadas a tomar un riesgo aparente”.

Chin-Hong ofreció este consejo para los viajeros de vacaciones: házte la prueba antes del vuelo para tu tranquilidad, compra boletos en un avión que deje los asientos del medio vacíos, usa máscaras N95 altamente protectoras y escudos faciales, y coloca las rejillas de ventilación individuales del avión directamente sobre cada miembro de la familia para romper las posibles partículas de virus. Y, por supuesto, lávate las manos con frecuencia.

Chin-Hong está adoptando ese enfoque en un viaje familiar planificado a la ciudad de Nueva York para visitar a su madre, que tiene más de 80 años y quiere ver a su hijo, nuera y nietos. Cada visita podría ser la última, dijo Chin-Hong.

“Para mí, la relación riesgo-beneficio apoya la idea ir a verla”.

Después de escuchar los consejos de Chin-Hong y otros expertos en enfermedades infecciosas, Wiese decidió el fin de semana pasado comprar boletos de avión para visitar a sus padres.

“Realmente nos ayudó a tomar una decisión que me estaba dando mucha ansiedad”, expresó.

Related Topics

Noticias En Español Public Health States

Did Trump Confuse the Public Option With ‘Medicare for All’?

During the final presidential debate, President Donald Trump claimed that 180 million people would lose their private health insurance to socialized medicine if the Democratic presidential nominee, former Vice President Joe Biden, is elected president.

“They have 180 million people, families under what he wants to do, which will basically be socialized medicine — you won’t even have a choice — they want to terminate 180 million plans,” said Trump.

Trump has repeated this claim throughout the week, and we thought the linkage of Biden’s proposed health care plan with socialism was something we needed to check out. Especially since Biden opposed “Medicare for All,” the proposal by Sen. Bernie Sanders (I-Vt.) that would have created a single-payer health system run completely by the federal government, and has long been attacked by Republicans as “socialist.”

The Trump campaign did not respond to our request asking where the evidence for this claim came from. Experts called it a distortion of Biden’s plan.

Where the Number Comes From

Experts agreed the number of people who have private health insurance either through an employer-sponsored plan or purchased on the Affordable Care Act’s health insurance marketplace is around 180 million people.

KFF, a nonpartisan health policy organization, estimated in 2018 that about 157 million Americans had health insurance through their employer, while almost 20 million had insurance they purchased for themselves. Together, that adds up to about 177 million with private health insurance. (KHN is an editorially independent program of KFF.)

What Does Biden Support?

Biden supports expanding the ACA through several measures, including a public option. Under his plan, this public option would be a health insurance plan run by the federal government that would be offered alongside other private health insurance plans on the insurance marketplace.

“The marketplace is made up of multiple insurers in areas,” said Linda Blumberg, a health policy fellow at the Urban Institute. “Sometimes there are five or more [plans]; sometimes there is only one. Biden is talking about adding a public option in the marketplace. You could pick between these private insurers or you could pick the public option.”

Getting rid of the so-called employer firewall is also part of Biden’s proposal.

This firewall was implemented during the rollout of the ACA. It was designed to maintain balance in the insurance risk pools by preventing too many healthy people who have work-based coverage from opting instead to move to a marketplace plan. And it all came down to who qualified for the subsidies that made these plans more affordable.

Currently, those who are offered a health insurance plan through their employer that meets certain minimum federal standards aren’t eligible to receive these subsidies, which come in the form of tax credits. But that leaves many low-income workers with health care plans that aren’t as affordable or comprehensive as marketplace plans.

Biden’s plan would eliminate that firewall, meaning anyone could choose to get health insurance either through their employer or through the marketplace. That’s where many Republicans argue that we could start to see leakage from private health insurance plans to the public option.

“The problem is healthy people leaving employer plans,” said Joseph Antos, a scholar in health care at the conservative-leaning American Enterprise Institute. That could mean the entire workplace plan’s premiums would go up. “You could easily imagine a plan where it spirals, the premiums go up, and then even more people start leaving the plans to go to the public option.”

Blumberg, though, said that because the marketplace would still include private health insurance plans alongside the public option, it doesn’t mean everyone who chooses to leave their employer plan would go straight to the public option.

She has done estimates based on a plan similar to the one Biden is proposing. She estimates that only about 10% to 12% of Americans would choose to leave their employer-sponsored plans, which translates to about 15 million to 18 million Americans.

KFF also did an estimate and found that 12.3 million people with employer coverage could save money by buying on the exchange under the Biden plan.

But “it’s not clear all of those people would choose to leave their employer coverage, though, as there are other reasons besides costs that people might want to have job-based insurance,” Cynthia Cox, vice president and director of the program on the ACA at KFF, wrote in an email.

Either way, none of the estimates are anywhere close to the 180 million that Trump claimed.

Is This Type of Public Option Socialism?

Overall, experts said no, what Biden supports isn’t socialized medicine.

“Socialized medicine means that the government runs hospitals and employs doctors, and that is not part of Biden’s plan,” Larry Levitt, executive vice president for health policy at KFF, wrote in an email. “Under Biden’s plans, doctors and hospitals would remain in the private sector just like they are today.”

However, Antos said that, in his view, the definition of socialism can really vary when it comes to health care.

“I would argue in one sense, we would already have socialized medicine. We have massive federal subsidies for everybody, so in that sense, we’re already there,” said Antos. “But, if socialized medicine means the government is going to dictate how doctors practice or how health care is delivered, we are obviously not in that situation. I don’t think the Biden plan would lead you that way.”

And in the end, Antos said, invoking socialism is a scare tactic that politicians have been using for years.

“It’s just a political slur,” said Antos. “It’s meant to inflame the emotions of those who will vote for Trump and meant to annoy the people who will vote for Biden.”

Our Ruling

Trump said 180 million people would lose their private health insurance plans to socialized medicine under Biden.

While about 180 million people do have private health insurance, there is no evidence that all of them would lose their private plans if Biden were elected president.

Biden supports implementing a public option on the health insurance marketplace. It would exist alongside private health insurance plans, and Americans would have the option to buy either the private plan or the public plan. While estimates show that a number of Americans would likely leave their employer-sponsored coverage for the public plan, they would be doing that by choice and the estimates are nowhere near Trump’s 180 million figure.

Experts also agree that the public option is not socialized medicine, and it’s ridiculous to conflate Biden’s plan with Medicare for All.

We rate this claim Pants on Fire.

Related Topics

Elections Insurance The Health Law

In Tamer Debate, Trump and Biden Clash (Again) on President’s Pandemic Response

In the second and final debate of the 2020 presidential race, President Donald Trump and former Vice President Joe Biden sparred over Trump’s handling of the pandemic and Biden’s plan to reform health care. In stark contrast to the first debate, there was more policy talk. There was also less interrupting.

Trump said a COVID-19 vaccine is “ready” and will be announced “within weeks,” shortly before conceding that it is “not a guarantee.”

Biden said Trump still has no comprehensive plan to deal with the pandemic, even as case counts continue to climb. “We’re about to go into a dark winter, and he has no clear plan,” Biden said.

Trump claimed Biden’s health care plan would lead to “socialized medicine,” conflating Biden’s proposal to introduce a government insurance option with more progressive proposals that would eliminate private insurance. “I support private insurance,” Biden said, promising, “Not a single person with private insurance would lose their insurance under my plan.”

You can read a full fact check for the evening, done in partnership with PolitiFact, here.

Meanwhile, we broke down the candidates’ closing coronavirus and other health-related claims so you can do your part: vote.

Here are the highlights:

Trump: “We are rounding the turn [on the pandemic]. We are rounding the corner.”
False.“Rounding the corner” suggests that significant and sustained progress is being made in the fight against the coronavirus, and that’s not the case, according to the data.

The number of COVID cases is climbing once again, after falling consistently between late July and mid-September. Cases are now at their highest point since early August, with almost 60,000 new confirmed infections a day. That’s only about 10% lower than the peak in late July.

New daily hospitalizations today are lower than in previous spikes, but in the past few weeks there has been a modest increase. The positivity rate, which measures the percentage of tests that come up positive for the virus, has also been going up again in the past few weeks. Higher positivity rates are an indicator of community spread.

The one encouraging change is that, since a peak in August, deaths have fallen fairly consistently. That’s due to a combination of factors, including improved understanding of how to treat the disease. Yet COVID deaths have settled in at about 800 a day, keeping total deaths per week in the U.S. above normal levels.

Trump: His administration has done “everything” Biden suggested to address COVID-19. “He was way behind us.”
We rated a similar claim Pants on Fire. While there are some similarities between Biden’s and Trump’s plans to combat COVID-19, experts told us any pandemic response plan should have certain core strategies. The Trump administration has released no comprehensive plan to battle the disease, except with regard to the development and distribution of vaccines. Trump’s main intervention was implementing travel restrictions, while efforts to roll out a widespread testing plan faced difficulties.

Biden released a public COVID plan; the first draft was published March 12. It included public health measures such as deploying free testing and personal protective equipment, as well as implementing economic measures such as emergency paid leave and a state and local emergency fund.

Trump: “As you know, 2.2 million people were expected to die. We closed the greatest economy in the world to fight this horrible disease that came from China.”
His claim about the estimated deaths rates Mostly False. Trump frequently refers to this number to claim that his administration’s moves saved 2 million lives. However, the number is from a mathematical model that hypothesized what would happen if, during the pandemic in the U.S., neither people nor governments changed their behaviors, a scenario that experts considered unrealistic. The U.S. has the highest death toll from COVID-19 of any country, and one of the highest death rates. Also, credit for shutting down the economy doesn’t go primarily to Trump, but rather to states and local jurisdictions. In fact, Trump encouraged states to open back up beginning in May, even when there were high rates of COVID transmission in those areas.

Trump: “We cannot lock ourselves in a basement like Joe does.”
We rated a similar claim False. It is one of Trump’s favored shots to say Biden isolated himself in his basement. In the first few months of the pandemic, Biden did run much of his campaign from his Delaware home. He built a TV studio in his basement to interact with voters virtually. But that changed.

In September alone, Biden gave remarks and held events in, among other places, Kenosha, Wisconsin; Lancaster, Pennsylvania; Warren, Michigan; Tampa, Florida; and Charlotte, North Carolina. We counted 14 locations.

Trump: Said of Dr. Anthony Fauci, “I think he’s a Democrat, but that’s OK.”
This is wrong. Fauci, director of the National Institute of Allergy and Infectious Diseases, is not affiliated with a political party. He hasn’t endorsed any parties or candidates.

Biden: “We are in a circumstance where the president still has no plan, no comprehensive plan.”
This is largely accurate. When Biden claimed during the first debate that Trump “still won’t offer a plan,” we noted the Trump administration’s “Operation Warp Speed” for vaccine development as well as its more detailed plan for vaccine distribution. But the administration has not released a comprehensive plan to address COVID-19.

Trump: “There was a spike in Florida. That is gone. There was a spike in Texas. That is gone. There was a spike in Arizona. It is gone.” 

This is inaccurate. Over the summer, Florida, Texas and Arizona experienced record surges in cases that later eased — but now they are all seeing new surges. Over the past week, The New York Times’ tracker notes, as of Friday, new infections are up 37% in Florida, 13% in Texas and 47% in Arizona, from the average two weeks earlier.

Trump: “When I closed [travel from China], he said I should not have closed. … He said this is a terrible thing, you are a xenophobe; I think he called me racist. Now he says I should have closed it earlier.”

Mostly False. Joe Biden did not directly say he thought Trump shouldn’t have restricted travel from China to stem the spread of the coronavirus.

Biden did accuse Trump of “xenophobia” in an Iowa campaign speech the same day the administration announced the travel restrictions — Jan. 31 — but his campaign said that his remarks were not related and that he made similar comments before the restrictions were imposed. Biden didn’t take a definitive stance on the subject until April 3, when his campaign said he supported Trump’s decision to impose travel restrictions on China.

Trump: “They have 180 million people, families under what he wants to do, which will basically be socialized medicine — you won’t even have a choice — they want to terminate 180 million plans.” 

Pants on Fire. About 180 million people have private health insurance. But there is absolutely no evidence that under Biden’s health care proposal all 180 million would be removed from their insurance plans. Biden supports creating a public option, which would be a government-run insurance program that would exist alongside and compete with other private plans on the health insurance marketplace.

Under Biden’s plan, even people with employer-sponsored coverage could choose a public plan if they wanted to. And estimates show that only a small percentage of Americans would likely leave their employer-sponsored coverage if a public option were available, and certainly not all 180 million. Experts said it is not socialized medicine.

Biden: “Not one single person with private insurance” lost their insurance “under Obamacare … unless they chose they wanted to go to something else.”

This is inaccurate. This is a variation of a claim that earned President Barack Obama our Lie of the Year in 2013. The Affordable Care Act tried to allow existing health plans to continue under a complicated process called “grandfathering,” but if the plans deviated even a little, they would lose their grandfathered status. And if that happened, insurers canceled plans that didn’t meet the new standards.

No one determined with any certainty how many people got cancellation notices, but analysts estimated that about 4 million or more had their plans canceled. Many found insurance elsewhere, and the percentage was small — out of a total insured population of about 262 million, fewer than 2% lost their plans. However, that still amounted to 4 million people who faced the difficulty of finding a new plan and the hassle of switching their coverage.

This story includes reporting by KHN reporters Victoria Knight and Emmarie Huetteman, and Jon Greenberg, Louis Jacobson, Amy Sherman, Miriam Valverde, Bill McCarthy, Samantha Putterman, Daniel Funke and Noah Y. Kim of PolitiFact.

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COVID Spikes Exacerbate Health Worker Shortages in Rocky Mountains, Great Plains

COVID-19 cases are surging in rural places across the Mountain States and Midwest, and when it hits health care workers, ready reinforcements aren’t easy to find.

In Montana, pandemic-induced staffing shortages have shuttered a clinic in the state’s capital, led a northwestern regional hospital to ask employees exposed to COVID-19 to continue to work and emptied a health department 400 miles to the east.

“Just one more person out and we wouldn’t be able to keep the surgeries going,” said Dr. Shelly Harkins, chief medical officer of St. Peter’s Health in Helena, a city of roughly 32,000 where cases continue to spread. “When the virus is just all around you, it’s almost impossible to not be deemed a contact at some point. One case can take out a whole team of people in a blink of an eye.”

In North Dakota, where cases per resident are growing faster than any other state, hospitals may once again curtail elective surgeries and possibly seek government aid to hire more nurses if the situation gets worse, North Dakota Hospital Association President Tim Blasl said.

“How long can we run at this rate with the workforce that we have?” Blasl said. “You can have all the licensed beds you want, but if you don’t have anybody to staff those beds, it doesn’t do you any good.”

The northern Rocky Mountains, Great Plains and Upper Midwest are seeing the highest surge of COVID-19 cases in the nation, as some residents have ignored recommendations for curtailing the virus, such as wearing masks and avoiding large gatherings. Montana, Idaho, Utah, Wyoming, North Dakota, South Dakota, Nebraska, Iowa and Wisconsin have recently ranked among the top 10 U.S. states in confirmed cases per 100,000 residents over a seven-day period, according to an analysis by The New York Times.

Such coronavirus infections — and the quarantines that occur because of them — are exacerbating the health care worker shortage that existed in these states well before the pandemic. Unlike in the nation’s metropolitan hubs, these outbreaks are scattered across hundreds of miles. And even in these states’ biggest cities, the ranks of medical professionals are in short supply. Specialists and registered nurses are sometimes harder to track down than ventilators, N95 masks or hospital beds. Without enough care providers, patients may not be able to get the medical attention they need.

Hospitals have asked staffers to cover extra shifts and learn new skills. They have brought in temporary workers from other parts of the country and transferred some patients to less-crowded hospitals. But, at St. Peter’s Health, if the hospital’s one kidney doctor gets sick or is told to quarantine, Harkins doesn’t expect to find a backup.

“We make a point to not have excessive staff because we have an obligation to keep the cost of health care down for a community — we just don’t have a lot of slack in our rope,” Harkins said. “What we don’t account for is a mass exodus of staff for 14 days.”

Some hospitals are already at patient capacity or are nearly there. That’s not just because of the growing number of COVID-19 patients. Elective surgeries have resumed, and medical emergencies don’t pause for a pandemic.

Some Montana hospitals formed agreements with local affiliates early in the pandemic to share staff if one came up short. But now that the disease is spreading fast — and widely — the hope is that their needs don’t peak all at once.

Montana state officials keep a list of primarily in-state volunteer workers ready to travel to towns with shortages of contact tracers, nurses and more. But during a press conference on Oct. 15, Democratic Gov. Steve Bullock said the state had exhausted that database, and its nationwide request for National Guard medical staffing hadn’t brought in new workers.

“If you are a registered nurse, licensed practical nurse, paramedic, EMT, CNA or contact tracer, and are able to join our workforce, please do consider joining our team,” Bullock said.

This month, Kalispell Regional Medical Center in northwestern Montana even stopped quarantining COVID-exposed staff who remain asymptomatic, a change allowed by Centers for Disease Control and Prevention guidelines for health facilities facing staffing shortages.

“That’s very telling for what staffing is going through right now,” said Andrea Lueck, a registered nurse at the center. “We’re so tight that employees are called off of quarantine.”

Financial pressure early in the pandemic led the hospital to furlough staff, but it had to bring most of them back to work because it needs those bodies more than ever. The regional hub is based in Flathead County, which has recorded the state’s second-highest number of active COVID-19 cases.

Mellody Sharpton, a hospital spokesperson, said hospital workers who are exposed to someone infected with the virus are tested within three to five days and monitored for symptoms. The hospital is also pulling in new workers, with 25 traveling health professionals on hand and another 25 temporary ones on the way.

But Sharpton said the best way to conserve the hospital’s workforce is to stop the disease surge in the community.

Earlier in the pandemic, Central Montana Medical Center in Lewistown, a town of fewer than 6,000, experienced an exodus of part-time workers or those close to retirement who decided their jobs weren’t worth the risk. The facility recently secured two traveling workers, but both backed out because they couldn’t find housing. And, so far, roughly 40 of the hospital’s 322 employees have missed work for reasons connected to COVID-19.

“We’re at a critical staffing shortage and have been since the beginning of COVID,” said Joanie Slaybaugh, Central Montana Medical Center’s director of human resources. “We’re small enough, everybody feels an obligation to protect themselves and to protect each other. But it doesn’t take much to take out our staff.”

Roosevelt County, where roughly 11,000 live on the northeastern edge of Montana, had one of the nation’s highest rates of new cases as of Oct. 15. But by the end of the month, the county health department will lose half of its registered nurses as one person is about to retire and another was hired through a grant that’s ending. That leaves only one registered nurse aside from its director, Patty Presser. The health department already had to close earlier during the pandemic because of COVID exposure and not enough staffers to cover the gap. Now, if Presser can’t find nurse replacements in time, she hopes volunteers will step in, though she added they typically stay for only a few weeks.

“I need someone to do immunizations for my community, and you don’t become an immunization nurse in 14 days,” Presser said. “We don’t have the workforce here to deal with this virus, not even right now, and then I’m going to have my best two people go.”

Back in Helena, Harkins said St. Peter’s Health had to close a specialty outpatient clinic that treats chronic diseases for two weeks at the end of September because the entire staff had to quarantine.

Now the hospital is considering having doctors take turns spending a week working from home, so that if another wave of quarantines hits in the hospital, at least one untainted person can be brought back to work. But that won’t help for some specialties, like the hospital’s sole kidney doctor.

Every time Harkins’ phone rings, she said, she takes a breath and hopes it’s not another case that will force a whole division to close.

“Because I think immediately of the hundreds of people that need that service and won’t have it for 14 days,” she said.

Mountain States editor Matt Volz contributed to this story.

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Travel on Thanksgiving? Pass the COVID

Molly Wiese was truly stumped. Her parents and siblings live in Southern California, and Wiese, a 35-year-old lawyer, has returned home every Christmas since she moved to Minnesota in 2007.

Because of the pandemic, Wiese thought it would be wiser to stay put for once. But in June, Wiese’s father was diagnosed with stage 4 cancer, and they feared this could be his final holiday season.

Should she fly with her husband and two young sons to California, putting her immunocompromised father at risk of COVID-19? Or stay home and miss out on making treasured holiday memories with her parents and children?

Her children are in day care, and Wiese’s husband works at a school. They don’t have enough vacation time to self-quarantine before or after a flight, and driving eight days round trip isn’t practical.

She fears giving her father coronavirus. But her parents, who live in the Inland Empire city of Yucaipa, believe it’s worth the risk to see Wiese’s children and have “our normal Christmas,” she said.

“Ideally, we’d have a vaccine,” she said. “But I don’t think that’s a realistic expectation.” Pfizer, the apparent leader in the COVID vaccine race, says it won’t even be ready to apply for vaccine approval until late November at the earliest.

Molly Wiese’s father has late-stage cancer and she fears this could be his last holiday season. She struggled with whether she and her family should fly to Southern California to visit him for Christmas because she doesn’t want to put him at risk of contracting COVID-19. From left: Molly Wiese, son Calvin, husband Phil Wiese, son Bennett, and Wiese’s parents, Becky and Bill Miller. (Molly Wiese)

While Wiese’s conundrum is especially high-stakes, her story illustrates the tough decision millions of Americans are facing about whether and how to travel for the winter holidays.

The best way to avoid spreading disease would be to avoid traveling or widening one’s social circles. For local celebrations, self-quarantining for two weeks before a holiday event would minimize risk if all those invited committed to doing the same. But some people have to work outside the home.

For everyone, after at least seven months of being mostly sequestered, the winter holidays pose an almost insurmountable temptation. Even public health and infectious disease experts recognize the dilemma.

“There’s so much to be gained by physical touch, by being in that room and not in a two-dimensional Zoom or FaceTime screen,” said Dr. Peter Chin-Hong, an infectious disease specialist and professor of medicine at the University of California-San Francisco. “And even to embrace, with the right preparation.”

Dr. Anthony Fauci, the nation’s authority on infectious diseases at the National Institutes of Health, isn’t immune to the problem. He told PRI’s “The World” on Oct. 13 that he and his three adult daughters, each living in a different state, were still deciding whether being together would be “worth it.”

The next day, Fauci told “CBS Evening News” that his family’s Thanksgiving reunion was off, given the risks posed by air travel. “You may have to bite the bullet and sacrifice that social gathering, unless you’re pretty certain that the people that you’re dealing with are not infected,” he said.

Dr. Robert Redfield, director of the Centers for Disease Control and Prevention, and Dr. Deborah Birx, the Trump administration’s senior coordinator in the COVID fight, have both warned that Thanksgiving gatherings could spread the virus.

In California, public health officials are taking a “harm reduction” approach: They aren’t encouraging multi-household gatherings, but they’ve issued guidelines to make get-togethers safer if they happen outdoors and last less than two hours.

Officials in Los Angeles County, which has seen transmission rates increase in recent weeks, released similar guidance, acknowledging that people separated from their loved ones for months increasingly yearn for that contact.

“We are threading the needle here, but I think it is appropriate for us to try to do some of the activities that people are desperate to be able to do, with absolute adherence to the guidance,” Barbara Ferrer, director of the county’s public health department, said at an Oct. 14 news conference.

Around the world, national holidays have fueled the spread of COVID-19 in explosive ways. In China, where the pandemic started, an estimated 5 million people traveling for Chinese New Year left Wuhan, the epicenter of the outbreak, before a travel ban was enacted. In Iran, the pandemic was aided by Nowruz, a two-week spring celebration that prompted millions to travel. In Israel, parties and religious gatherings for Purim caused widespread transmission in late March.

Memorial Day, Fourth of July and Labor Day celebrations fueled surges in the United States, which is why Thanksgiving frightens public health officials. Last year, more than 55 million people were expected to travel during the days surrounding that fourth Thursday in November.

Nevertheless, officials across the nation are using a light touch when it comes to warnings.

In Minnesota, where Wiese lives and cases are hitting record highs, officials urge the public to avoid crowded stores and large indoor gatherings with other households, but say outdoor Thanksgiving dinners with local friends and family are less risky. Their guidance doesn’t explain how to endure an outdoor Thanksgiving in Minnesota. The average high in Minneapolis on Nov. 26 is 33 degrees.

Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, is waving his hands to stop the game.

If you can’t self-quarantine for 10 to 14 days before the event — that is, no contact with people besides members of your household who are also quarantining — don’t go to another household’s Thanksgiving dinner, he said: The state has already seen too many examples of vulnerable people becoming sick and dying after attending weddings, funerals and birthday parties.

“Let this be your COVID year,” Osterholm said. “It’s a very challenging year, but you don’t want to introduce this virus into family settings and experience the consequences.”

Osterholm and his partner will spend Thanksgiving and Christmas without extended family, even though their children and grandchildren are all local. Because all his grandchildren are in day care or school, there isn’t enough time for their families to self-quarantine before enjoying a holiday meal together.

He was sympathetic to Wiese’s “compelling” plight. If she decides to fly to California, he said, she should sequester her family as much as possible for 10 days beforehand, then spend no more than two days with her father.

“Even if she got infected, she wouldn’t be most infectious until probably day three,” he said. “So if she spends those two days with him, she can feel relatively good about the fact that she didn’t put them at risk.”

For those who do travel, driving is much safer than flying because drivers can be isolated in a household pod and avoid exposure to the coronavirus by forgoing restaurants and by disinfecting bathroom and gas pump handles before touching them.

Dr. Iahn Gonsenhauser, chief quality and patient safety officer for the Ohio State University’s Wexner Medical Center, said he plans to drive with his family — overnighting at a hotel on the way — to spend Thanksgiving with his sister’s family in Colorado.

He and his family keep to themselves and work from home as much as possible, leaving the house only for groceries and basic errands while eschewing restaurants and malls, he said. If anyone in either family began showing COVID symptoms, or had confirmed exposure to a COVID-positive person, the whole trip would be called off instantly.

“This is why we make all plans with a refundable reservation,” he said. “If people have no way of backing out of their reservations, they’re more inclined to push through an apparent risk.”

Chin-Hong offered this advice for holiday flyers: Get tested before the flight for peace of mind, buy tickets on a plane that is leaving middle seats empty, use highly protective N95 masks and possibly face shields, and blast the individual airplane vents directly onto each family member to disrupt potential virus particles. And, of course, wash your hands frequently.

Chin-Hong is taking that approach on a planned family trip to New York City to visit his mother, who is in her 80s and wants to see her son, daughter-in-law and grandchildren. Every visit they have could be their last, Chin-Hong said.

“To me, the risk-benefit ratio really supports me going to see her.”

After hearing the advice from Chin-Hong and other infectious disease experts, Wiese decided last weekend to buy plane tickets to visit her parents.

“It really did help us make a decision that was giving me a lot of anxiety,” she said.

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KHN on the Air This Week

KHN chief Washington correspondent Julie Rovner discussed the impact of the election and the upcoming Supreme Court challenge on the Affordable Care Act with New Hampshire Public Radio’s “The Exchange” and WNYC’s “The Brian Lehrer Show” on Wednesday. Rovner also spoke with Newsy’s “Morning Rush” on Thursday about the roles of health care and COVID-19 in the presidential campaign.

KHN Midwest correspondent Lauren Weber discussed COVID vaccine distribution with “Newsy Reports” on Oct. 16.

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Workers Fired, Penalized for Reporting COVID Safety Violations

When COVID-19 began making headlines in March, Charles Collins pulled out a protective face mask from the supply at the manufacturing company in Rockaway, New Jersey, where he was the shop foreman and put it on. The dozen or so other workers at the facility followed suit. There was no way to maintain a safe distance from one another on the shop floor, where they made safety mats for machines, and a few of the men had been out sick with flu-like symptoms. Better safe than sorry.

Management was not pleased. Collins got a text message from one of his supervisors saying masks were to be used to protect workers from wood chips, metal particles and other occupational safety hazards. “We don’t provide or for that matter have enough masks to protect anybody from CORVID-19 [sic]!” If workers didn’t stop using the masks for that purpose, the supervisor texted, “we’ll have to store them away just like the candy!”

“I was shocked,” said Collins, 38. “They weren’t taking it seriously.”

Shortly after that, Collins left for a planned vacation. When he returned a week later, the company told him to quarantine at home for two weeks because he’d been traveling.

But when the quarantine ended, Collins didn’t want to go back to work. Co-workers, he said, told him that recommended safety measures such as wearing masks and maintaining social distancing hadn’t been implemented. When he told human resources that he feared becoming infected and endangering his mother and his 8-year-old nephew who live with him, he said, he got an ultimatum: Return to work or resign.

Collins stayed home and says he was fired. He hired a lawyer and filed a complaint in the Superior Court of New Jersey under the state’s whistleblower law, the Conscientious Employee Protection Act. The law prohibits employers from firing, demoting or otherwise retaliating against workers who refuse to take part in activities they believe are incompatible with public health and safety mandates.

As many employers, with the strong encouragement of the Trump administration, move to bring employees back, a growing number of workers are resisting what they feel are unsafe, unhealthy conditions. In recent months, a few states have passed laws specifically aimed at protecting workers who face COVID-related safety risks and retaliation for speaking up about them. Some states, like New Jersey, have whistleblower protection laws already. But advocates say stronger federal protections are needed.

The Occupational Safety and Health Administration, part of the U.S. Department of Labor, is responsible for enforcing 23 federal whistleblower statutes that protect workers from retaliation if they report workplace safety violations, among other problems.

But according to a new analysis, the agency isn’t up to the task. The National Employment Law Project, a workers’ advocacy and research group, found that of 1,744 COVID-related retaliation complaints filed with OSHA between April and mid-August, 20% were docketed for investigation and 2% were resolved. More than half were dismissed or closed without investigation.

“Even before COVID, workers had a really bad track record of getting any justice for their concerns if they were retaliated against,” said Debbie Berkowitz, director of the worker health and safety program at the National Employment Law Project and a former senior OSHA official.

The numbers are growing. Whistleblower complaints filed with OSHA increased by 30% between February and May, to 4,101, according to an August report by the Department of Labor’s Office of the Inspector General that criticized the agency’s handling of the complaints.

Nearly 40% of the complaints — 1,618 — were related to COVID-19, the report found, filed primarily by workers who claimed they were punished for reporting workplace safety violations. Those could include, for example, not having appropriate personal protective equipment or sanitation materials, or a lack of social distancing on the job.

While complaints rose, the number of whistleblower investigators decreased from the previous year, according to the report. The average time it took to close an investigation at the end of March was roughly nine months.

Worker whistleblower protections under the Occupational Safety and Health law are “incredibly weak” compared with whistleblower statutes that protect employees who report other types of wrongdoing, Berkowitz said. If OSHA dismisses a complaint, workers have no right to appeal the decision, and once they file a complaint with OSHA they aren’t permitted to take their case to court on their own, she said.

Consumer advocates would like to see those provisions changed.

Advocates have urged OSHA to adopt mandatory COVID safety standards for workplaces, but the agency has declined to do so, maintaining that its “general duty clause,” which requires employers to maintain a workplace free from hazards likely to cause death or physical harm, is sufficient.

“The Administration has remained committed to providing the Whistleblower Protection program with the resources it needs to fulfill its mission,” a spokesperson for the Department of Labor wrote in an email to KHN. “In fiscal year 2020, OSHA asked for and received five new full-time employees and requested an additional ten in the President’s budget for fiscal year 2021.”

If workers don’t pursue a whistleblower complaint through OSHA, they can file a state lawsuit claiming “wrongful discharge” or use a state’s whistleblower law, as Collins did.

According to a COVID employment litigation tracker by Fisher Phillips, an employment law firm, since the beginning of the year 169 retaliation/whistleblower lawsuits have been filed across the country — the second-biggest category, behind suits related to remote work/leave, with 206 cases. An additional 27 lawsuits have been filed for wrongful discharge.

Juan Carlos Fernandez, the Morristown, New Jersey, attorney representing Charles Collins, said he’s seen a significant uptick in inquiries from workers about safety concerns in recent months. Before the pandemic began, he typically received one or two such calls per month. Now, he gets three or four a day.

Many callers say they were terminated after they asked for protective equipment on the job, Fernandez said. Others had asked for time off to care for a family member or a child whose school had closed because of COVID-19 and then were told not to come back to work.

In addition to reporting safety violations, Collins’ lawsuit claims, he was fired for asking to take time off. Under the federal Families First Coronavirus Response Act, employees are generally entitled to two weeks’ paid leave if they’re quarantined, and another two weeks’ paid sick leave at two-thirds pay to care for a child whose school has closed, as well as expanded family and medical leave. Collins has cared for his nephew since his sister died two years ago in a car accident. His nephew’s school closed in March because of COVID-19.

Collins said his employer, ASO Safety Solutions, paid him for only the first week of his company-ordered quarantine. Any additional time off would come out of his accrued sick and vacation time, he was told.

ASO Safety Solutions didn’t respond to requests for comment, nor did the law firm representing the company.

In his response to the complaint submitted to the court, the lawyer representing the company denied that ASO had retaliated against Collins for whistleblowing, asserting he had resigned. The response, by John Olsen, with Ferdinand IP Law Group, also said that the provisions of the Families First Coronavirus Response Act do not apply to the company. The lawyers have exchanged requests for discovery, Fernandez said, which should be answered in the next several weeks.

A few states and cities have stepped in to help whistleblowers. Virginia was the first to put in place statewide workplace safety standards related to COVID-19, spurred by concerns from workers in poultry plants, said Rachel McFarland, a staff attorney at the Legal Aid Justice Center in Charlottesville. The standards include specific provisions protecting workers from retaliation for raising safety concerns or refusing to work in a location they believe is unsafe.

Colorado and the cities of Philadelphia and Chicago likewise passed laws prohibiting employers from retaliating against workers who raise COVID-related safety concerns, refuse to work in unsafe conditions or take time off to minimize the transmission of the virus.

But these laws are the exceptions, said Brent Newell, a senior attorney at Public Justice in Oakland, California, who has represented the interests of workers in meatpacking plants. “Many states haven’t done that and won’t do that,” he said. “For the federal government to put it on the states to protect workers is wholly and fundamentally inadequate.”

KHN’s ‘What the Health?’: A Little Good News and Some Bad on COVID-19

Can’t see the audio player? Click here to listen on SoundCloud.

For the first time in a long time, there is some good news about the coronavirus pandemic: Although cases continue to climb, fewer people seem to be dying. And there are fewer cases than expected among younger pupils in schools with in-person learning. But the bad news continues as well — including a push for “herd immunity” that could result in the deaths of millions of Americans.

Meanwhile, the Trump administration is doubling down on efforts to allow states to require certain people with low incomes to prove they work, go to school or perform community service in order to keep their Medicaid health benefits. The administration is appealing a federal appeals court ruling to the Supreme Court and just granted Georgia the right to impose a work requirement.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • Opinions seem to be slowly shifting on opening schools around the country. As fall approached, many people were hesitant to send their children back to school because they feared a resurgence of coronavirus infections, but early experiences seem to show that there has been little transmission among young kids in classrooms.
  • Even with good results in those school districts that have reopened, however, the debate about whether schools should be conducting in-person learning is quite polarized. President Donald Trump repeatedly calls for all schools to resume, while groups, such as unions representing teachers and other employees, are more likely to be calling for continued online learning.
  • California, which had a strong resurgence of the virus during the summer, is seeing signs of success in fighting back. The state has been among the most aggressive in shutting down normal activities to reduce case levels. It devised a county-specific method to determine closures, restrictions and reopenings — and it appears to be working.
  • A proposal by some researchers to move the country toward a “herd immunity” plan, in which officials would expect the virus to spread among the general population while also trying to protect the most vulnerable — such as people living in nursing homes — is gaining support among some of Trump’s advisers. Public health advocates are raising alarms because it would likely lead to hundreds of thousands more deaths. They also fear the administration’s focus on restoring normalcy would by default move in this direction.
  • Federal researchers this week announced that nearly 300,000 excess deaths have been recorded this year and much of it is attributed to COVID-19 or the lack of other health care by people who could not or did not seek treatments because they were frightened by the pandemic.
  • With the Senate poised to confirm Amy Coney Barrett, who opposes abortion, to the Supreme Court within days, the fate of the landmark Roe v. Wade decision is in question. If the court overruled that decision, abortion policies would likely fall back to individual states. A recent report on the effects of such a scenario finds that a huge swath of the South and the Midwest would be left without a local facility offering abortion services.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Cook’s Illustrated’s “The Best Reusable Face Masks,” by Riddley Gemperlein-Schirm, and The Washington Post’s “Consumer Masks Could Soon Come With Labels Saying How Well They Work,” by Yeganeh Torbati and Jessica Contrera

Margot Sanger-Katz: The Hill’s “Republicans: Supreme Court Won’t Toss ObamaCare,” by Peter Sullivan

Paige Winfield Cunningham: The Wall Street Journal’s “Some California Hospitals Refused Covid-19 Transfers for Financial Reasons, State Emails Show,” by Melanie Evans, Alexandra Berzon and Daniela Hernandez

Alice Miranda Ollstein: ProPublica’s “Inside the Fall of the CDC,” by James Bandler, Patricia Callahan, Sebastian Rotella and Kirsten Berg

To hear all our podcasts, click here.

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

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Aunque el destino de ACA es incierto, la inscripción ya comienza. Y hay cosas nuevas

Frente a una pandemia, un desempleo sin precedentes y unos costos inciertos para los tratamientos de COVID-19, las aseguradoras que venden planes médicos en los mercados establecidos por la Ley de Cuidado de Salud a Bajo Precio (ACA) reaccionaron, en general, con sólo aumentos modestos de las primas para 2021.

“Lo que resulta fascinante es que las aseguradoras, en general, no proyectan el impacto de la pandemia en sus primas para 2021”, dijo Sabrina Corlette, profesora del Centro de Reformas de Seguros de Salud de la Universidad de Georgetown, en Washington, D.C

Aunque las tasas finales todavía deben analizarse en todos los estados, quienes estudian el mercado dicen que los aumentos de las primas que han visto, hasta la fecha, serán de un solo dígito, y las reducciones abundan.

Esa es una buena noticia para los más de 10 millones de estadounidenses que compran su propio seguro médico a través de los mercados estatales y el federal.

El mercado federal, que sirve a 36 estados, abre del 1 de noviembre al 15 de diciembre, para la inscripción de 2021. Algunos de los 14 estados y el Distrito de Columbia que operan sus propios mercados tienen períodos de inscripción más largos.

La otra cara de las primas más bajas, es que también puede haber menos subsidios para aquéllos que reciben ayuda para pagarlas.

Estas son algunas cosas que hay que saber sobre la cobertura de 2021:

Podría costar lo mismo que este año, o incluso menos.

A pesar del debate en curso sobre ACA, agravado por una impugnación en la Corte Suprema presentada por 20 estados republicanos y apoyada por la administración Trump, no se prevé que los precios cambien mucho.

“Es el tercer año consecutivo con primas que se mantienen bastante estables”, aseguró Louise Norris, una corredora de seguros en Colorado que escribe sobre las tendencias en el mundo de los seguros. “Hemos visto modestos cambios en las tarifas y la llegada de nuevas aseguradoras”.

A esa relativa estabilidad siguieron altibajos, y los últimos aumentos significativos se produjeron en 2018, como respuesta, en parte, a los recortes en los pagos a las aseguradoras de la administración Trump.

Esos incrementos afectaron a algunos inscritos, particularmente a los que no califican para  subsidios, que están ligados tanto a los ingresos como al costo de las primas. La inscripción en ACA ha disminuido desde su pico en 2016.

Charles Gaba, un desarrollador web que desde finales de 2013 ha rastreado los datos de inscripción en ACA en su sitio web, sigue los cambios en las primas en base a las solicitudes ante los reguladores estatales. Cada verano, las aseguradoras deben presentar las tarifas para el año siguiente ante los estados, que tienen diferentes poderes de supervisión.

Gaba dijo que aumento promedio solicitado para el próximo año a nivel nacional es del 2,1%. Cuando se fijó en 18 estados para los cuales los reguladores han aprobado las tarifas solicitadas por las aseguradoras, el porcentaje resultó ser menor, un 0,4%.

Un estudio de KFF sobre primas preliminares presentadas este verano tuvo resultados similares: Los cambios en las primas en 2021 serían modestos, sólo unos pocos puntos porcentuales al alza o a la baja. (KHN es un programa editorialmente independiente de KFF.)

Aún así vale la pena comparar precios.

Los actuarios y otros expertos dicen que las primas varían según el estado o la región —incluso según el asegurador— por varias razones, entre ellas el número y el poder relativo de mercado de los aseguradores u hospitales en una zona, lo que afecta a la capacidad de los aseguradores para negociar las tarifas con los proveedores.

Dado que los subsidios están vinculados al plan de referencia de cada región, y que esos costos de las primas pueden haber disminuido, los subsidios también podrían disminuir. (Los planes de referencia son el segundo plan de plata de menor precio en una región).

El cambio al plan de referencia puede ayudar a los consumidores a mantener lo que gastan en primas.

Los inscritos deben actualizar su información financiera, particularmente este año cuando muchos se ven afectados por la reducción de trabajo o la pérdida de empleos. “Podrían ser elegibles para un subsidio mayor”, señaló Myra Simon, directora ejecutiva de políticas comerciales de America’s Health Insurance Plans, el grupo de presión de la industria.

Los inscritos pueden actualizar su información en línea, o llamar a su mercado federal o estatal para solicitar asistencia. Los corredores de seguros también pueden ayudar a las personas a inscribirse en los planes de ACA. Al comprar, los consumidores deben verificar si los médicos y hospitales que desean utilizar están incluidos en la red del plan.

Las primas son sólo una parte de la ecuación. Los consumidores también deben examinar detenidamente los deducibles anuales, porque la contrapartida de optar por una prima de menor costo puede ser que los deducibles anuales sean más altos y deban cumplirse antes de que se active gran parte de la cobertura.

“Animamos a la gente a considerar todas sus opciones”, dijo Simon.

Lo que hay detrás de la variación. 

Los inscritos en algunos estados el próximo año verán disminuidas las primas, según el sitio web de Gaba: Maine, por ejemplo, muestra una caída del 13% en el promedio ponderado de los precios de las primas, mientras que Maryland ha bajado casi un 12%. Al mismo tiempo, el promedio de Indiana ha subido un 10%. Y Kentucky sube un 5%.

Tanto Maine como Maryland atribuyen la disminución a los programas estatales que proporcionan pagos de reaseguro a las aseguradoras de salud para ayudar a compensar las reclamaciones médicas de alto costo.

En Florida, los reguladores dicen que las primas de los seguros aumentarán alrededor de un 3%, mientras que el intercambio estatal en California reporta un aumento de poco más de medio punto porcentual, su menor aumento promedio desde la apertura en 2014. Los funcionarios en California citan factores que incluyen un flujo de inscritos más saludables y una reducción de las tarifas que pagan las aseguradoras.

Otros factores que afectan a las tasas incluyen la intervención de los reguladores estatales para alterar las solicitudes iniciales, junto con una disposición de ACA que exige a las aseguradoras gastar al menos el 80% de los ingresos en atención médica directa. Si las aseguradoras no cumplen con esa norma, deben emitir reembolsos a los asegurados. Muchas aseguradoras ya estaban obligadas a devolver el dinero en 2020 por años anteriores.

La mayoría de las aseguradoras no citaron costos adicionales de tratamiento o pruebas de COVID como factores en el aumento de la tarifa solicitada, explicó Gaba. Sin embargo, incluso aquellas que lo hicieron, las consideraron innecesarias debido a la reducción de gastos al retrasar los pacientes el cuidado electivo durante la primavera y el verano.

De hecho, muchas aseguradoras en el segundo trimestre registraron beneficios récord.

“Algunos pensaron: ‘Vamos a ganar más de lo que pensábamos este año, así que no seamos agresivos con los precios el año que viene’”, explicó Donna Novak, miembro del Comité de Mercados Individuales y de Grupos Pequeños de la Academia Americana de Actuarios.

Un factor menor puede ser la derogación de una tasa pagada por las aseguradoras en las primas. La tasa, que era parte de ACA, fue eliminada permanentemente por la administración de Trump a partir de 2021.

Su elección de aseguradores puede haberse ampliado.

Más aseguradoras, incluyendo UnitedHealth Group, o bien volvieron a ese mercado individual o se expandieron a nuevos condados.

“Las aseguradoras están viendo un beneficio o un potencial en esto”, comentó John Dodd, un corredor de seguros de Columbus y ex presidente de la Asociación de Aseguradores de Salud de Ohio.

Las tarifas de los planes de ACA han bajado en general en todo su estado, dijo, y espera que los agentes estén más ocupados que nunca, simplemente porque hay más ofertas de planes, más dónde elegir, y la gente quiere ayuda.

A las aseguradoras les gusta la forma en que funciona ACA, añadió.

“La gente que sale en televisión diciendo que no funciona, no saben de qué están hablando”, expresó Dodd. “Funciona bien [para las aseguradoras] y cada año mejora”.

Cosas nuevas en algunos estados, incluyendo una opción pública.

Los residentes de Nueva Jersey y Pennsylvania comprarán cobertura en nuevos mercados estatales para el 2021, después de que esos estados se retiraran del federal, que ahora cubre 36 estados.

Los legisladores de esos estados dijeron que dirigir sus propios mercados les da más control y puede ahorrarles dinero con el tiempo.

En 19 condados del estado de Washington, las aseguradoras ofrecen “planes de opción pública”, que cuentan con todos los beneficios, incluyendo deducibles más bajos, y deben cumplir con estándares de calidad adicionales.

Tal como se había previsto, los planes de opción pública pretendían ser menos costosos, y la legislación vinculaba las tasas de pago a Medicare. Los aseguradores que ofrezcan una opción pública deben atenerse a un tope agregado de pago a médicos, hospitales y otros proveedores de salud en un promedio del 160% de lo que Medicare pagaría por los mismos servicios.

Sin embargo, cuando las tarifas de las primas entraron en vigor, las cinco aseguradoras que ofrecían los planes tenían precios variables. No todas las partes del estado tienen la opción, pero donde la tienen, dos de las aseguradoras de opción pública tienen primas que o bien son más bajas que otros planes en el área o son el plan de más bajo costo que la aseguradora ofrece.

Pero tres son más caros.

El personal del mercado estatal explicó que los precios más altos pueden reflejar varias cosas, desde la dificultad para iniciar el programa durante COVID-19 hasta la falta de incentivos para que los proveedores participen.

También podría ser, simplemente, el nerviosismo normal del primer año.

“Es el primer año. Como con cualquier estrategia de entrada al mercado, la gente es bastante conservadora”, apuntó Michael Marchand, director de marketing del Washington Health Benefit Exchange.

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Análisis: el invierno llega para los bares. Cómo salvarlos. Y salvarnos.

Si realmente queremos detener la propagación del coronavirus a medida que se acerca el invierno y esperamos una vacuna, aquí una idea: el gobierno debería pagar a los bares, y a muchos restaurantes y lugares de eventos, para que cierren durante algunos meses.

Puede sonar radical, pero tiene sentido científico e incluso tiene un precedente político. Pagamos a los agricultores para que no cultiven algunos campos (en teoría, para proteger el medio ambiente), así que ¿por qué no compensar a los propietarios para que cierren sus negocios para proteger la salud pública?

En los últimos nueve meses, hemos aprendido mucho sobre este coronavirus en particular y cómo es más probable que se propague. Los establecimientos que venden alcohol y los lugares de eventos en interiores se han convertido en entornos ideales para la transmisión. Y hay una buena lógica científica para explicar eso.

Los virus no son villanos que persiguen a sus presas; son oportunistas pasivos. Algunos se propagan a través de los alimentos o cuando se dejan en superficies. Otros, como este coronavirus, pueden transmitirse a través de pequeñas gotas que pueden permanecer en el aire después que una persona infectada tose, habla o respira. El virus se disemina con mayor facilidad en interiores y, en particular, en lugares concurridos y mal ventilados.

Más importante aún, las personas pueden infectar mientras sus cuerpos están incubando este virus durante un par de días antes de que desarrollen síntomas, o incluso si nunca los desarrollan. Así que podrías ir a un bar o una boda y beber, besar y bailar hasta desmayarte. Luego te despiertas a la mañana siguiente sintiéndote fatal. Pero no es solo una resaca. Es COVID-19.

Eso explica por qué este virus se contrae en los eventos de “superpropagación”. (Más que la gripe, según los Centros para el Control y Prevención de Enfermedades). Una persona que está eliminando una gran cantidad de virus todavía se siente lo suficientemente bien como para pasar el rato en un espacio estrecho (probablemente interior) donde las personas comparten ruidosamente con otras. Y no pueden usar máscaras porque están bebiendo.

No es de extrañar que las barras de los bares sean un problema.

En el lenguaje científico, el coronavirus es más un esparcidor “heterogéneo” que homogéneo, según Bjarke Frost Nielsen, investigador del Instituto Niels Bohr de la Universidad de Copenhague. Junto con su colega Kim Sneppen, Nielsen utiliza modelos matemáticos para estudiar el patrón de propagación del virus.

Es una propagación heterogénea, lo que significa que tiende a expandirse en brotes similares a explosiones, a menudo centrados en un lugar de reunión o un punto caliente, en vez de “avanzar” por todo el país.

Nielsen me dijo que hay buenas noticias en este hallazgo: “Puedes evitar ciertas reuniones y cerrar algunos lugares, y reducir la mayor parte de la propagación de la enfermedad. Y puedes seguir con el resto de manera bastante normal “.

Cuando sabíamos poco sobre el nuevo coronavirus, el gobierno respondió con un martillo. El Paycheck Protection Program trató a todas las pequeñas empresas por igual, brindándoles préstamos para cerrar siempre que pagaran a sus empleados. Ahora podemos utilizar herramientas más delicadas.

De hecho, los supermercados y las tiendas de ropa, u otras, pueden funcionar de manera segura con máscaras mandatorias, distanciamiento y desinfección. No vamos a estos lugares para charlar y todos podemos usar máscaras en su interior.

Las fábricas y las líneas de montaje pueden proteger a los trabajadores con las mismas normas. Las escuelas pueden hacer lo mismo por los estudiantes.

Incluso las salas de cine pueden funcionar de forma segura con clientes con cubrebocas, sistemas de ventilación de calidad y espacio entre espectadores o grupos de espectadores. Simplemente no podrán vender tantos asientos.

¿Pero los bares y restaurantes que dependen de comedores interiores abarrotados y salas de conciertos con pistas de baile? La mayoría son atractivos exactamente por las razones que los convierten en focos infecciosos para el coronavirus: el hacinamiento, la bebida, la fiesta con personas desconocidas.

Es por eso que algunos dueños de bares y restaurantes dicen que agradecerían un programa que los compensara por cerrar sus puertas este invierno. Peter Kurzweg, que es copropietario de tres de lo que él llama establecimientos de “bebida avanzada” en Pittsburgh que solían tener happy hours animados, dice que “los bares y restaurantes son únicos en el sentido de que, para ser realmente seguros, deben mitigar hasta el punto que ya no es una experiencia de bar o restaurante”.

Hasta ahora, él y sus socios han resistido la pandemia con asientos al aire libre en la acera y en un callejón. Han sacado provecho de los programas de préstamos del gobierno. Han invertido en carpas y calentadores y han animado a los clientes a divertirse al aire libre.

Pero a medida que el otoño se convierte en invierno en Pittsburgh, sabe que esta opción no durará. “Camino diciendo: ‘Se acerca el invierno. Se acerca el invierno “. Tenemos que hacer todo lo posible para sobrevivir”.

Algunos estados han permitido que los restaurantes abran en interiores al 25% o 50% de su capacidad; de hecho, eso está permitido ahora en Pittsburgh. Pero Kurzweg no lo ha hecho porque no cree que sea seguro.

Algunos restaurantes muy espaciosos, y aquellos en climas templados, podrían hacer que funcione. La mayoría no puede.

Los bares y otros locales que dependen de las bebidas no son servicios esenciales. Queremos que sobrevivan para que en el futuro podamos disfrutarlos. Entonces, ¿por qué no pagar a los propietarios que no pueden mantener sus negocios a flote de manera segura este año contaminado con COVID un promedio de sus ingresos mensuales normales para que cierren durante algunos meses?

De esta forma podrían seguir pagándoles a sus empleados y ayudarían a romper la cadena de transmisión del coronavirus. Tal vez podríamos ser creativos y pedirles que usen sus cocinas para ayudar a alimentar a los estadounidenses que pasan hambre.

Con los bares cerrados, aún se puede beber y socializar con grupos más pequeños de personas en casa o al aire libre, cuando el clima lo permita. Puede que no sea tan divertido, pero nada será muy divertido mientras el coronavirus esté presente.

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Californians Asked to Pony Up for Stem Cell Research — Again

SACRAMENTO, Calif. — In an election year dominated by a chaotic presidential race and splashy statewide ballot initiative campaigns, Californians are being asked to weigh in on the value of stem cell research — again.

Proposition 14 would authorize the state to borrow $5.5 billion to keep financing the California Institute for Regenerative Medicine (CIRM), currently the second-largest funder of stem cell research in the world. Factoring in interest payments, the measure could cost the state roughly $7.8 billion over about 30 years, according to an estimate from the nonpartisan state Legislative Analyst’s Office.

In 2004, voters approved Proposition 71, a $3 billion bond, to be repaid with interest over 30 years. The measure got the state agency up and running and was designed to seed research.

During that first campaign, voters were told research funded by the measure could lead to cures for cancer, Alzheimer’s and other devastating diseases, and that the state could reap millions in royalties from new treatments.

Yet most of those ambitions remain unfulfilled.

“I think the initial promises were a little optimistic,” said Kevin McCormack, CIRM’s senior director of public communications, about how quickly research would yield cures. “You can’t rush this kind of work.”

So advocates are back after 16 years for more research money, and to increase the size of the state agency.

Stem cells hold great potential for medicine because of their ability to develop into different types of cells in the body, and to repair and renew tissue.

When the first bond measure was adopted in 2004, the George W. Bush administration refused to fund stem cell research at the national level because of opposition to the use of one kind of stem cell: human embryonic stem cells. They derive from fertilized eggs, which has made them controversial among politicians who oppose abortion.

Federal funding resumed in 2009, and thus far this year the National Institutes of Health has spent about $321 million on human embryonic stem cell research.

But advocates for Proposition 14 say the ability to do that research is still tenuous. In September, Republican lawmakers sent a letter to President Donald Trump urging him to cut off those funds once again.

The funding from California’s original bond measure was used to create the new state institute and fund grants to conduct research at California hospitals and universities for diseases such as blood cancer and kidney failure. The money has paid for 90 clinical trials.

A 2019 report from the University of Southern California concluded the center has contributed about $10.7 billion to the California economy, which includes hiring, construction and attracting more research dollars to the state. CIRM funds more than 56,500 jobs, more than half of which are considered high-paying.

Despite the campaign promises, just two treatments developed with some help from CIRM have been approved by the Food and Drug Administration in the past 13 years, one for leukemia and one for scarring of the bone marrow.

But it’s a bit of a stretch for the institute to take credit for these drugs, said Jeff Sheehy, a CIRM board member who does not support the new bond measure. He said the agency funded the researcher whose lab discovered and developed the drugs, but CIRM holds no rights to those drugs and doesn’t receive royalties from them.

The state has received about $518,000 in revenue from licensing other institute-funded discoveries, such as devices, McCormack said.

McCormack also pointed to some promising stem cell therapies still in clinical trials, such as a treatment that has cured 50 children of severe combined immunodeficiency, a genetic disorder often called “bubble baby” disease, and others that have led to “dramatic” improvements in paralysis and blindness, he said.

The campaigns for both bond measures may be giving people unrealistic expectations and false hope, said Marcy Darnovsky, executive director of the Center for Genetics and Society. “It undermines people’s trust in science,” Darnovsky said. “No one can promise cures, and nobody should.”

Robert Klein, a real estate developer who wrote both ballot measures, disagrees. He was inspired to invest in stem cell research after he lost his youngest son to Type 1 diabetes. He said some of CIRM’s breakthroughs are helping patients right now.

“What are you going to do if this doesn’t pass? Tell those people we’re sorry, but we’re not going to do this?” Klein said. “The thought of other children needlessly dying is unbearable.”

Sheehy, who has served on the agency’s board for 16 years, said he’s proud of the work the institute has done but believes it should be funded through the legislature, not by borrowing more money.

“The promise was that it would pay for itself and it hasn’t,” Sheehy said. “We can’t really afford it, and this is the worst way to pay for it.”

Even if CIRM isn’t turning a profit, some researchers and private companies are benefiting from the public money. Take the company Forty Seven Inc., named after a human protein and co-founded by Irving Weissman, director of Stanford University’s stem cell research program. The state stem cell agency awarded more than $15 million to Forty Seven, and $30 million to Weissman at Stanford for research.

That money fueled research that uncovered a promising treatment for several different cancers. Gilead Sciences, the pharmaceutical giant, bought Forty Seven in 2018 for $4.9 billion. Of that, $21.2 million went back to CIRM to pay back Forty Seven’s research grants, with interest.

“Gilead will make far more than that if it turns out to be lucrative,” said Ameet Sarpatwari, a professor of medicine at Harvard Medical School who studies drug development.

Because this kind of work is both expensive and risky, private companies are reluctant to pay for early research, when scientists have no idea if their work will yield results, let alone profits, Sarpatwari said. So the state pays for this work, and drug companies come in to finance later-stage research once a molecule looks promising — and ultimately reap the profits.

Case in point: Fedratinib, one of the two FDA-approved drugs funded partly by CIRM, can cost about $20,000 for 120 capsules, according to GoodRx.

“We’re socializing the risk of drug development and privatizing the gains,” Sarpatwari said.

On paper, the institute has stricter pricing regulations than the NIH, which does not require that drugs developed with public money are accessible to the public. In California, companies have to submit plans for how uninsured patients will get medicine and are required to sell those medications to the state’s public health programs at a specified rate.

But in practice, the regulations have never really been tested.

Proposition 14 would add a new rule. It would take the money California makes from royalties and use it to help patients afford those treatments. It also benefits drug companies: Whatever revenue the state makes from these drugs will go back to the companies in the form of state-financed patient subsidies.

The measure also would establish a new working group (complete with 15 new, full-time staffers) that would help make clinical trials more affordable for patients by paying for lodging and transportation to the trials.

And it would increase the size of CIRM’s governing board from 29 to 35. This contradicts recommendations from the Institute of Medicine, which suggested shrinking the board to avoid conflicts of interest. Klein argues the extra board positions are necessary to represent different regions and areas of expertise.

Ultimately, California voters must weigh the possibility of new treatments against the cost of financing them with debt.

“We want to develop new therapies, and initiatives like what California is doing are well positioned to do that,” Sarpatwari said. “But at the end of the day, they’re only as good as people being able to access them affordably.”

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

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Analysis: Winter Is Coming for Bars. Here’s How to Save Them. And Us.

If we really want to stem the spread of the coronavirus as winter looms and we wait for a vaccine, here’s an idea: The government should pay bars, many restaurants and event venues to close for some months.

That may sound radical, but it makes scientific sense and even has a political precedent. We pay farmers not to cultivate some fields (in theory, at least, to protect the environment), so why not compensate owners to shut their indoor venues (to protect public health)?

In the past nine months, we’ve learned a lot about this particular coronavirus and how it’s most likely to spread. Drinking establishments and indoor event venues have emerged as ideal environments for transmission. And there’s good scientific logic to explain that.

Viruses are not villains who go after their prey; they’re passive opportunists. Some spread through food or when left on surfaces. Others, like this coronavirus, can be transmitted through tiny droplets that can linger in the air after an infected person coughs, talks or breathes. The virus spreads most easily indoors and particularly in crowded, poorly ventilated places.

More important, people can be infectious while their bodies are incubating this virus for a couple of days before they develop symptoms, or even if they never develop symptoms at all. So you might go to a bar or a wedding feeling top-notch, or just maybe a little off. Drink, kiss and dance till you drop. Then you wake up the next morning feeling awful. It’s not just a hangover. It’s COVID-19.

That explains why this virus is exceedingly contracted at “superspreader” events. (More so than the flu, according to the Centers for Disease Control and Prevention.) A person who is shedding a good deal of the virus still feels well enough to hang out in a tight (likely indoor) space where people mingle boisterously with others they don’t know or don’t see often. And they can’t wear masks, because they’re drinking.

No wonder bars are a problem.

In scientific parlance, the coronavirus is more of a “heterogeneous” than a homogeneous spreader, according to Bjarke Frost Nielsen, a researcher at the Niels Bohr Institute at the University of Copenhagen. Along with his colleague Kim Sneppen, he uses mathematical modeling to study the pattern of the spread of the virus. That heterogeneous spread means that it tends to expand in burst-like outbreaks, often centered on a meeting place — a hot spot — rather than oozing slowly across a country.

There is some good news in this finding, Nielsen told me: “You can close down certain types of gatherings and a few types of places and tamp down the majority of the spread of the disease. And you can carry on with the rest as pretty normal.”

Back when we knew little about the novel coronavirus, the government responded with a hammer. The Paycheck Protection Program treated all small businesses equally, providing them with loans to shut down so long as they paid their employees. Now we can use more delicate instruments.

Food and clothing stores — indeed, most any kind of shop — can function safely with masking and attention to distancing and sanitizing. We don’t go to these places to chat, and we can all wear masks inside them. Factories and assembly lines can protect workers with masking and spacing. Schools can do the same for students.

Even movie theaters can arguably safely operate with masked patrons, quality ventilation systems and spacing between viewers or viewing groups. They just won’t be able to sell as many seats.

But bars and restaurants that depend on packed indoor dining and concert halls with dance floors? Most are attractive for exactly the reasons that make them such petri dishes for the coronavirus — the crowding, the drinking, the carousing with new, different people.

That’s why some bar and restaurant owners say they would welcome a program that compensated them to shut their doors this winter. Peter Kurzweg, who co-owns three of what he calls “drink forward” establishments in Pittsburgh that used to have bustling happy hours, says that “bars and restaurants are unique in that to be really safe, they have to mitigate to a point that it’s not a bar or restaurant experience anymore.”

He and his partners have so far weathered the pandemic with outdoor seating on the sidewalk and in an alley. They have taken advantage of government loan programs. They have invested in tents and heaters and encouraged patrons to “lean in” to having fun outside. But as fall turns to winter in Pittsburgh, he knows it won’t last. “I walk around saying, ‘Winter is coming. Winter is coming.’ We need to do everything we can to survive.”

Some states have allowed restaurants to open indoors at 25% or 50% capacity — indeed, that is permitted now in Pittsburgh. But Kurzweg has not done so, because he doesn’t feel it’s safe. Anyway, he added, “No bar or restaurant can make it at that capacity — on the best days in normal years, our profit margin is 10%.”

Some very spacious high-end restaurants, and those in temperate climates, might be able to make it work. Most can’t.

Bars and other venues that depend on drinks are not essential services. We want them to survive so that in the future we can enjoy them. So why not pay owners who cannot keep their businesses afloat safely this COVID-tainted year an average of their normal monthly income to shut down for some months? They would keep paying their employees and help break the chain of coronavirus transmission. Maybe we could get creative and ask them to use their kitchens to help feed Americans who are going hungry.

With bars closed, you could still drink and socialize with smaller groups of people at home or outdoors, when the weather allows it. That may not be quite as much fun, but nothing is much fun while the coronavirus is around.

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Even With ACA’s Fate in Flux, Open Enrollment Starts Soon. Here’s What’s New.

Facing a pandemic, record unemployment and unknown future costs for COVID-19 treatments, health insurers selling Affordable Care Act plans to individuals reacted by lowering rates in some areas and, overall, issuing only modest premium increases for 2021.

“What’s been fascinating is that carriers in general are not projecting much impact from the pandemic for their 2021 premium rates,” said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University in Washington, D.C.

Although final rates have yet to be analyzed in all states, those who study the market say the premium increases they have seen to date will be in the low single digits — and decreases are not uncommon.

That’s good news for the more than 10 million Americans who purchase their own ACA health insurance through federal and state marketplaces. The federal market, which serves 36 states, opens for 2021 enrollment Nov. 1, with sign-up season ending Dec. 15. Some of the 14 states and the District of Columbia that operate their own markets have longer enrollment periods.

The flip side of flat or declining premiums is that some consumers who qualify for subsidies to help them purchase coverage may also see a reduction in that aid.

Here are a few things to know about 2021 coverage:

It might cost about the same this year — or even less.

Despite the ongoing debate about the ACA — compounded by a Supreme Court challenge brought by 20 Republican states and supported by the Trump administration — enrollment and premium prices are not forecast to shift much.

“It’s the third year in a row with premiums staying pretty stable,” said Louise Norris, an insurance broker in Colorado who follows rates nationwide and writes about insurance trends. “We’ve seen modest rate changes and influx of new insurers.”

That relative stability followed ups and downs, with the last big increases coming in 2018, partly in response to the Trump administration cutting some payments to insurers.

Those increases priced out some enrollees, particularly people who don’t qualify for subsidies, which are tied both to income and the cost of premiums. ACA enrollment has fallen since its peak in 2016.

Charles Gaba, a web developer who has since late 2013 tracked enrollment data in the ACA on his website, follows premium changes based on filings with state regulators. Each summer, insurers must file their proposed rates for the following year with states, which have varying oversight powers.

Gaba said the average requested increase next year nationwide is 2.1%. When he looked at 18 states for which regulators have approved insurers’ requested rates, the percentage is lower, at 0.4%.

Another study, by KFF, of preliminary premiums filed this summer had similar findings: Premium changes in 2021 would be modest, only a few percentage points up or down. (KHN is an editorially independent program of KFF.)

It’s still worth it to shop around.

Actuaries and other experts say premiums vary by state or region — even by insurer — for a number of reasons, including the number and relative market power of insurers or hospitals in an area, which affects the ability of insurers to negotiate rates with providers.

Because subsidies are tied to each region’s benchmark plan, and those premium costs may have gone down, subsidies also could decrease. (Benchmark plans are the second-lowest-priced silver plan in a region.)

Switching to the benchmark plan can help consumers maintain how much they spend in premiums.

Enrollees should update their financial information, particularly this year when many are affected by work reduction or job losses. “They might be eligible for a bigger” subsidy, said Myra Simon, executive director of commercial policies for America’s Health Insurance Plans, the industry lobbying group.

Enrollees can update their information online, or call their federal or state marketplace for assistance. Insurance brokers, too, can aid people in signing up for ACA plans. When shopping, consumers should check whether the doctors and hospitals they want to use are included in the plan’s network.

Premiums are just one part of the equation. Consumers should also look closely at annual deductibles, because the trade-off of going with a lower-cost premium may well be higher annual deductibles that must be met before much of the coverage kicks in.

“We encourage people to consider all their options,” said Simon.

What’s behind the variation.

Enrollees in some states next year will see premium decreases, according to Gaba’s website: Maine, for example, shows a 13% drop in weighted average premium prices, while Maryland’s is down almost 12%. At the same time, Indiana’s average is up 10%. And Kentucky is up 5%.

Both Maine and Maryland attribute the decrease to state programs that provide reinsurance payments to health insurers to help offset high-cost medical claims.

In Florida, regulators say insurance premiums will rise about 3%, while the state exchange in California is reporting just over a half-percent increase, its lowest average increase since opening in 2014. Officials in California cite factors that include an influx of healthier enrollees and a reduction in fees that insurers pay.

Other factors affecting rates include how much state regulators step in to alter initial rate filings, along with a provision of the ACA that requires insurers to spend at least 80% of revenue on direct medical care. If insurers don’t meet that standard, they must issue rebates to policyholders. Many insurers were already on the hook to return money in 2020 for previous years.

Most insurers did not cite additional COVID treatment or testing costs as factors in their requested rate increase, Gaba said. Even those that did, however, mainly found them unnecessary because of reduced expenditures resulting from patients delaying elective care during the spring and summer.

Indeed, many insurers in the second quarter posted record profits.

“Some of them thought, ‘We’re going to make more than we thought this year in profits, so let’s not be aggressive with pricing next year,’” said Donna Novak, a member of the American Academy of Actuaries’ Individual and Small Group Markets Committee.

A smaller factor may be the repeal of a fee paid by insurers on premiums. Part of the ACA, the fee was permanently eliminated by the Trump administration effective for 2021.

Your choice of insurers may have widened.

More insurers, including UnitedHealth Group, either stepped back into that individual market or expanded into new counties.

“Insurers are seeing a profit or potential for it,” said John Dodd, an insurance broker in Columbus and past president of the Ohio Association of Health Underwriters.

Rates are down in general across his state for ACA plans, he said, and he expects agents to be busier than ever, simply because there are more plan offerings and choices to make and people want help.

Insurers, he said, like the way the ACA is working.

“People on TV who say it’s not working, they don’t know what they’re talking about,” said Dodd. “It’s working well [for insurers] and every year it gets better.”

New stuff in some states, including a public option.

Residents of New Jersey and Pennsylvania will buy coverage from new state-based marketplaces for 2021, after those states pulled out of the federal, which now covers 36 states.

Lawmakers in those states said running their own marketplaces gives them more control and may save them money over time.

In 19 Washington state counties, insurers are offering “public option plans,” which have all the standard benefits, including lower deductibles, and must meet additional quality standards.

As envisioned, the public option plans aimed to be less expensive, with the legislation tying payment rates to Medicare. Insurers offering a public option must stick to an aggregate cap of paying doctors, hospitals and other medical providers an average of 160% of what Medicare would pay for the same services.

When the premium rates came in, however, the five insurers offering the plans had varying prices. Not all parts of the state have the option, but where they do, two of the public option insurers have premiums that are either lower than other plans in the area or are the lowest-cost plan the insurer offers.

But three are more expensive.

The state’s marketplace staff said the higher prices may reflect a number of things, from difficulty getting the program started during COVID-19 to a lack of incentives to get providers to participate.

It could also just be normal first-year jitters.

“It’s Year One. As with any market entry strategy, people are pretty conservative,” said Michael Marchand, chief marketing officer of the Washington Health Benefit Exchange.

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Insurance Uninsured

Biden’s Big Health Agenda Won’t Be Easy to Achieve

If Joe Biden wins the presidency in November, health is likely to play a high-profile role in his agenda. Just probably not in the way he or anyone else might have predicted.

Barring something truly unforeseen, it’s fairly certain that on Jan. 20 the U.S. will still be in the grip of the coronavirus pandemic — and the economic dislocation it has caused. Coincidentally, that would put a new President Biden in much the same place as President Barack Obama at his inauguration in 2009: a Democratic administration replacing a Republican one in the midst of a national crisis.

Obama had only a financial crisis to deal with. Still, Biden would have a couple of advantages his Democratic predecessor lacked, including the fact that, as vice president, he helped guide the country through that financial meltdown. He’s also had time to plan how to address the crisis, which was not the case in 2009, when the economy was in freefall just as the new administration was taking office.

But like Obama before him, Biden will face a long must-do list on taking office. He will have to tackle the pandemic and economic crisis before he can turn to some of the big health changes he’s promised, such as expanding the reach of the Affordable Care Act, creating a “public option” that would allow every American to enroll in a government-sponsored plan and lowering the eligibility age for Medicare from 65 to 60.

And even if Democrats do retake the Senate majority and keep control of the House, it is unlikely the majority in either chamber will be as large as in 2009, when Obama had 60 Senate votes.

Still, no matter what the partisan makeup of Congress, “priority one is to get the COVID response going,” said Len Nichols, a professor of health policy at George Mason University.

Biden’s COVID plan includes taking major responsibility for the pandemic back from the states. His federal response would include more money for, and coordination of, testing and contact tracing; ensuring adequate protective equipment for health professionals; and assuring the public that new treatments and vaccines will be based on science, not politics.

In an updated version of his plan, Biden has also promised that one of his first calls if he is elected will be to Dr. Anthony Fauci, the government’s top infectious disease expert, who has been derided by President Donald Trump. “Dr. Fauci will have full access to the Oval Office and an uncensored platform to speak directly to the American people — whether delivering good news or bad,” says Biden’s website.

Biden’s COVID plan also addresses the economy — including calls for emergency paid leave for workers dislocated by the pandemic and more financial aid for workers, families and small businesses.

“If we’ve learned anything, it is that the health sector and the economy are not two separate spheres. They are connected,” said Nichols. “I think health care and the economy are complementary and will be for the foreseeable future.”

Assuming Biden gets beyond the pandemic and recession, he could move onto some of his bigger health promises, including expanding eligibility for Medicare, creating a “public option” health plan and boosting premium subsidies for the ACA.

Biden took heat throughout the primaries for his “moderate” approach to improving health insurance access and costs, compared with the “Medicare for All” plans for a government-run system supported by his top rivals, Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.). But that doesn’t mean his far less sweeping approach would be easy to get through Congress.

“There’s a really big difference when you’re running the government than when you’re running for office,” said Dan Mendelson, a former Clinton administration health official and founder of the health consulting firm Avalere Health.

Many of Biden’s proposals, including a public option and larger subsidies to help low- and middle-income people pay for insurance, are the very things that an overwhelmingly Democratic Congress could not pass as part of the original Affordable Care Act in 2010. Conservative Democratic senators objected to the plan.

“We pushed,” Obama said in a recent interview on the podcast “Pod Save America,” talking about the public option. “I needed 60 votes to get it through the Senate. Joe Lieberman, Ben Nelson and a couple others said, ‘I’m not voting for a public option.’”

Mendelson said another big obstacle is that for all the detail Biden has in his health plan, concepts like the public option “are not well-defined, and there are many different theories of what it should be and where it should be fielded. There’s no common vision about what it really means.”

The same thing is true, he added, for something that seems as simple as reducing the Medicare eligibility age. “More than half these people have commercial insurance,” he said. “What will happen to them?”

Grace-Marie Turner, of the conservative Galen Institute, suggested Biden — or Trump, if he’s reelected — might be better served by pursuing one of the more bipartisan health issues that already have broad support from the public, like prescription drug prices or “surprise” medical bills patients receive after getting care from a doctor outside their insurance network while being treated at an in-network facility. “It would be a big statement,” she said. “Whoever wins would then have the wind at their back.”

But even those issues have a way of getting complicated. Both Democrats and Republicans say they want to bring down drug prices, but Republicans are vehemently against one of the Democrats’ preferred ways of doing that: by allowing Medicare to negotiate with drugmakers. And surprise medical billing has so far defied efforts to fix it, as Congress seems unable to choose between health insurers and health providers, who each want the other to bear the additional costs.

As always, even when health is at the top of the agenda, it proves difficult to address.

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Elections HealthBent Medicare The Health Law

Trump Says He Saved 2 Million Lives From COVID. Really?

President Donald Trump has repeatedly claimed to have saved 2 million lives from COVID-19 through his actions to combat the disease.

Recently, he made the assertion during the NBC News town hall on Oct. 15 that replaced the second presidential debate.

“But we were expected to lose, if you look at the original charts from original doctors who are respected by everybody, 2,200,000 people,” Trump said. “We saved 2 million people,” he added.

He mentioned the same ballpark figure during a Sept. 15 ABC News town hall and posted a tweet about it on Oct. 13.

Others in the Trump administration have also pointed to the 2.2 million figure. Vice President Mike Pence referenced it during the vice presidential debate on Oct. 7. So did Health and Human Services Secretary Alex Azar during a Sept. 20 “Meet the Press” television interview.

Where did this number come from? And is there any truth to the idea that Trump is responsible for saving 2 million lives from COVID-19? Since Trump continues to use it to claim success, we decided to look into it.

What We Know About the ‘2 Million’

The White House and the Trump presidential campaign did not respond to our request for evidence supporting the idea that roughly 2 million lives were spared.

It appears to have first been mentioned by the president during a March 29 White House coronavirus task force press briefing, when Trump and Dr. Deborah Birx, task force coordinator, explained they were asking Americans to stay home from mid-March through the end of April, because mathematical models showed 1.6 million to 2.2 million people could die from COVID-19.

The warning stemmed from a paper authored by Neil Ferguson, an epidemiology professor at Imperial College London. He modeled how COVID-19 can spread through a population in different scenarios, including what would happen if no interventions were put in place and people continued to live their daily lives as normal.

In the paper, Ferguson wrote, “In total, in an unmitigated epidemic, we would predict approximately 510,000 deaths in [Great Britain] and 2.2 million in the US.”

Ferguson did not respond to our request to talk through the study with him. But in a July email interview with HuffPost, he said Trump’s boasting of saving 2.2 million lives isn’t true, because the pandemic isn’t over.

Andrea Bertozzi, a mathematics professor at UCLA, said it was important to remember the 2.2 million figure was derived from a modeling scenario that would almost certainly never happen — which is that neither the government nor individuals would change their behavior at all in light of COVID-19.

The study didn’t mean to say 2.2 million people were absolutely going to die, but rather to say, “Hold on, if we let this thing run its course, bad things could happen,” said Bertozzi. Indeed, the results from the study did cause government leaders in both the U.S. and the United Kingdom to implement social distancing measures.

Experts also pointed out that the U.S. has the highest COVID-19 death toll of any country in the world — more than 220,000 people — and among the highest death rates, according to the Johns Hopkins Coronavirus Resource Center.

“I don’t think we can say we’ve prevented 2 million deaths, because people are still dying,” said Justin Lessler, an associate professor of epidemiology at Johns Hopkins Bloomberg School of Public Health.

In some instances when using the 2 million estimate, Trump and others in his administration cited the China travel restrictions for saving lives, while other times they’ve credited locking down the economy. We’ll explore whether either statement holds water.

Did Travel Restrictions Do Anything?

Trump implemented travel restrictions for some people traveling from China beginning Feb. 2 and for Europe on March 11. But experts say and reports show the restrictions don’t appear to have had much effect because they were put in place too late and had too many holes.

The Centers for Disease Control and Prevention reported the first cases of coronavirus in the U.S. arrived in mid-January. So, since the travel bans were put in place after COVID-19 was already spreading in the U.S., they weren’t effective, said Josh Michaud, associate director for global health policy at the KFF. (KHN is an editorially independent program of KFF.)

A May study supports that assessment. The researchers found the risk of transmission from domestic air travel exceeded that of international travel in mid-March.

Many individuals also still traveled into the U.S. after the bans, according to separate investigations by The New York Times and the Associated Press.

Based on all this, experts said there isn’t evidence to support the idea that the travel restrictions were the principal intervention to reduce the transmission of COVID-19.

What About Lockdowns?

On the other hand, the public health experts we talked to said multiple global and U.S.-focused studies show that lockdowns and implementing social distancing measures helped to contain the spread of the coronavirus and thus can be said to have prevented deaths.

However, Trump can’t take full credit for these so-called lockdown measures, which ranged from closing down all but essential businesses to implementing citywide curfews and statewide stay-at-home orders. On March 16, after being presented with the possibility of the national death tally rising to 2.2. million, the White House issued federal recommendations to limit activities that could transmit the COVID-19 virus. But these were just guidelines and were recommended to be in effect only through April 30.

Most credit for putting in place robust social distancing measures belongs to state and local government and public health officials, many of whom enacted stronger policies than those recommended by the White House, our experts said.

“I don’t think you can directly credit the federal government or the Trump administration with the shutdown orders,” said Lessler. “The way our system works is that the power for public health policy lies with the state. And each state was making its own individual decision.”

Some studies also explore the potential human costs of missed opportunities. If lockdowns had been implemented one or two weeks earlier than mid-March, for instance, which is when most of the U.S. started shutting down, researchers estimated that tens of thousands of American lives could have been saved. A model also shows that if almost everyone wore a mask in the U.S., tens of thousands of deaths from COVID-19 could have been prevented.

Despite these scientific findings, Trump started encouraging states — even those with high transmission rates — to open back up in May, after the White House’s recommendations to slow the spread of COVID-19 expired. He has also questioned the efficacy of masks, said he wouldn’t issue a national mask mandate and instead left mask mandate decisions up to states and local jurisdictions.

Our Ruling

President Trump is claiming that without his efforts, there would have been 2 million deaths in the U.S. from COVID-19.

But that 2 million number is taken from a model that shows what would happen without any mitigation measures — that is, if citizens had continued their daily lives as usual, and governments did nothing. Experts said that wouldn’t have happened in real life.

And while lockdowns and social distancing have indeed been proven to prevent COVID-19 illness and deaths, credit for that doesn’t go solely to Trump. The White House issued federal recommendations asking Americans to stay home, but much stronger social distancing measures were enforced by states.

Travel restrictions implemented by Trump perhaps helped hold down transmission in the context of broader efforts, but on their own, they don’t seem to have significantly reduced the transmission rate of the coronavirus.

We rate this claim Mostly False.

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Global Health Watch Public Health

“Todo lo que quieres es que te crean”: el prejuicio inconciente en la atención de salud

A mediados de marzo, Karla Monterroso voló a su casa en Alameda, California, después de una excursión al Parque Nacional Zion de Utah. Cuatro días después, comenzó a tener una tos seca y fuerte. Sentía los pulmones pegajosos.

La fiebre durante esas semanas por momentos subía tanto (100,4, 101,2, 101,7, 102,3) que, en la peor de las noches, tenía que estar bajo una ducha de agua helada, para intentar bajarla.

“Esa noche había escrito en un diario cartas a todas las personas cercanas, lo que quería que supieran si me moría”, recordó.

Al mes, surgieron nuevos síntomas: dolores de cabeza y calambres punzantes en las piernas y el abdomen que le hicieron pensar que podía estar en riesgo de tener coágulos de sangre y accidentes cerebrovasculares, complicaciones que habían informado otros pacientes con COVID-19 en sus 30 años.

Aún así, no estaba segura de si debía ir al hospital.

“Como mujeres de color, te cuestionan mucho tus emociones y la realidad de tu estado físico. Te dicen que exageras”, dijo Monterroso, quien es latina. “Así que tenía ese extraño sentimiento de ‘no quiero usar los recursos para nada’”.

Fueron necesarios cuatro amigos para convencerla de que tenia que llamar al 911.

Lo que pasó en la sala de emergencias del Hospital Alameda confirmó sus peores temores.

Monterroso dijo que durante casi toda su visita, los proveedores de salud ignoraron sus síntomas y preocupaciones. ¿La presión arterial está baja? Esa es una lectura falsa. ¿Sus niveles cíclicos de oxígeno? La máquina está mal. ¿Los dolores punzantes en la pierna? Probablemente solo sea un quiste.

“El médico entró y dijo: ‘No creo que esté pasando mucho aquí. Creo que podemos enviarte a casa’”, recordó Monterroso.

Su experiencia, razona, son parte de por qué las personas de color se ven afectadas de manera desproporcionada por el coronavirus. No es simplemente porque es más probable que tengan trabajos de primera línea que los exponen más, y las condiciones subyacentes que empeoran COVID-19.

“Eso es parte de ello, pero la otra parte es la falta de valor que la gente le da a nuestras vidas”, escribió Monterroso en Twitter detallando su experiencia.

Investigaciones muestran cómo el prejuicio inconsciente de los médicos afecta la atención que reciben las personas. Los pacientes latinos (que pueden ser de cualquier raza) y los afroamericanos suelen ser menos propensos a recibir analgésicos o a ser referidos para atención avanzada que los pacientes blancos no hispanos con las mismas quejas o síntomas. Y es más probable que las mujeres mueran en el parto por causas prevenibles.

Ese día de mayo, en el hospital, Monterroso se sentía mareada y tenía problemas para comunicarse, por lo que estaban con ella en el teléfono para ayudarla una amiga y la prima de su amiga, que es enfermera especializada en cardiología. Las dos mujeres comenzaron a hacer preguntas: ¿Qué pasa con la frecuencia cardíaca acelerada de Karla? ¿Sus bajos niveles de oxígeno? ¿Por qué sus labios están azules?

El médico salió de la habitación. Se negó a atender a Monterroso mientras sus amigas estaban al teléfono, dijo, y cuando regresó, de lo único que quería hablar era del tono de Monterroso y el tono de sus amigos.

“La implicación era que éramos insubordinadas”, dijo Monterroso.

Monterroso le dijo al médico que no quería hablar sobre su tono. Quería hablar sobre su atención médica. Estaba preocupada por posibles coágulos de sangre en su pierna y pidió una tomografía computada.

“Bueno, ya sabes, la tomografía computarizada es radiación justo al lado del tejido mamario. ¿Quieres tener cáncer de mama?”, Monterroso recuerda que le dijo el médico. “Solo me siento cómodo ordenándote esa prueba si dices que no tienes problema en tener cáncer de seno”.

Monterroso pensó para sí misma: “Trágatelo, Karla. Necesitas estar bien”. Entonces le dijo al médico: “Estoy bien con el cáncer de mama”.

Nunca ordenó la prueba.

Monterroso pidió otro médico, un abogado del hospital. Le dijeron que no. Comenzó a preocuparse por su seguridad. Quería irse. Sus amigos estaban llamando a todos los profesionales médicos que conocían para confirmar que no estaba siendo bien atendida. Vinieron a recogerla y la llevaron a la Universidad de California-San Francisco. El equipo le hizo un electrocardiograma, una radiografía de tórax y una tomografía computada.

“Una de las enfermeras entró y dijo: ‘Me enteré de tu terrible experiencia. Solo quiero que sepas que te creo. Y no te vamos a dejar ir hasta que sepamos que estás segura”, dijo Monterroso. “Comencé a llorar. Porque eso es todo lo que quieres: que te crean. Es realmente difícil que te cuestionen de esa manera”.

Alameda Health System, que opera el Hospital Alameda, se negó a comentar sobre los detalles del caso de Monterroso, pero dijo en un comunicado que está “profundamente comprometido con la equidad en el acceso a la atención médica” y que “brinda atención culturalmente sensible para todos”. ” Después que Monterroso presentó una queja ante el hospital, la gerencia la invitó a hablar con su personal y residentes, pero se negó.

Monterroso cree que su experiencia es un ejemplo de por qué a las personas de color les va tan mal con la pandemia.

“Porque cuando vamos a buscar atención, si nos defendemos, podemos ser tratados como insubordinados”, dijo. “Y si no nos defendemos, podemos ser tratados como invisibles”.

Sesgo inconsciente en la atención médica

Los expertos dicen que esto sucede de forma rutinaria y sin importar las intenciones o la raza del médico. Por ejemplo, el médico de Monterroso no era blanco.

Investigaciones muestran que todos los médicos, todos los seres humanos, tienen prejuicios de los que no son conscientes, explicó el doctor René Salazar, decano asistente de diversidad en la Escuela de Medicina de la Universidad de Texas-Austin.

“¿Interrogo a un hombre blanco con traje que llega luciendo como un profesional cuando pide analgésicos de la misma manera que a un hombre negro?”, se preguntó Salazar, señalando uno de sus posibles sesgos.

El prejuicio inconsciente suele aparecer en entornos de alto estrés, como las salas de emergencia, donde los médicos se encuentran bajo una tremenda presión y tienen que tomar decisiones rápidas y de gran importancia. Si se agrega una pandemia mortal, en la que la ciencia cambia día a día, las cosas pueden complicarse.

“Hay tanta incertidumbre”, dijo. “Cuando existe esta incertidumbre, siempre hay un nivel de oportunidad para que el sesgo se abra paso y tenga un impacto”.

A vehicle parked in Oakland, California, during the first weeks of the 2020 Black Lives Matter demonstrations.(April Dembosky)

Salazar solía enseñar en UCSF, donde ayudó a desarrollar una formación sobre prejuicios inconscientes para estudiantes de medicina y farmacia. Aunque docenas de escuelas de medicina están retomando la capacitación, dijo, no se realiza con tanta frecuencia en los hospitales. Incluso cuando se aborda un encuentro negativo como el de Monterroso, la intervención suele ser débil.

“¿Cómo le digo a mi médico, ‘Bueno, el paciente cree que eres racista’?”, apuntó Salazar. “Es una conversación difícil: debo tener cuidado, no quiero decir la palabra sobre la raza porque voy a presionar algunos botones complejos. Así que comienza a complicarse mucho”.

Un enfoque basado en datos

El doctor Ronald Copeland dijo que recuerda que los médicos también se resistían a estas conversaciones cuando eran estudiantes. Las sugerencias para talleres sobre sensibilidad cultural o prejuicios inconscientes recibían una reacción violenta.

“Era visto casi como un castigo. Es como, ‘Usted es un mal médico, por lo que su castigo es que tiene que ir a capacitarse’, explicó Copeland, quien es jefe de equidad, inclusión y diversidad en el sistema de salud de Kaiser Permanente. (KHN es un programa editorialmente independiente de KFF, que no está afiliado a Kaiser Permanente).

Ahora, el enfoque de Kaiser Permanente se basa en datos de encuestas a pacientes que preguntan si la persona se sintió respetada, si la comunicación fue buena y si quedó satisfecha con la experiencia.

Luego se desglosan estos datos por demografía, para ver si un médico puede obtener buenas calificaciones en respeto y empatía de los pacientes blancos no hispanos, pero no de los pacientes de raza negra.

“Si ves un patrón que evoluciona alrededor de un grupo determinado y es un patrón persistente, entonces eso te dice que hay algo que proviene de una cultura, de una etnia, de un género, algo que el grupo tiene en común, que no estás abordando, dijo Copeland. “Entonces comienza el verdadero trabajo”.

Cuando a los médicos se les presentan los datos de sus pacientes y la ciencia sobre el sesgo inconsciente, es menos probable que se resistan o nieguen, agregó. En su sistema de salud, han reformulado el objetivo de la capacitación en torno a brindar una atención de mejor calidad y obtener mejores resultados para los pacientes, por lo que los médicos quieren hacerlo.

“La gente no se inmuta”, dijo. “Están ansiosos por aprender más al respecto, especialmente sobre cómo mitigarlo”.

Todavía se siente mal

Han pasado casi seis meses desde que Monterroso se enfermó por primera vez y todavía no se siente bien.

Su frecuencia cardíaca sigue aumentando y los médicos le dijeron que podría necesitar una cirugía de vesícula para tratar los cálculos biliares que desarrolló como resultado de la deshidratación relacionada con COVID. Recientemente decidió dejar el Área de la Bahía y mudarse a Los Ángeles para poder estar más cerca de su familia durante su larga recuperación.

Rechazó la invitación del Hospital Alameda para hablar con su personal sobre su experiencias porque concluyó que no era su responsabilidad arreglar el sistema. Pero sí quiere que el sistema de salud más amplio asuma la responsabilidad del sesgo sistémico en hospitales y clínicas.

Reconoce que el Hospital Alameda es público y no tiene el tipo de recursos que tienen Kaiser Permanente y UCSF. Una auditoría reciente advirtió que el Sistema de Salud de Alameda estaba al borde de la insolvencia. Pero Monterroso es la directora ejecutiva de Code2040, una organización sin fines de lucro sobre equidad racial en el sector tecnológico e incluso para ella, dijo, se necesitó un ejército de apoyo para que la escucharan.

“El 90% de las personas que van a pasar por ese hospital no van a tener los recursos que yo tengo para enfrentarlos”, dijo. “Y si no digo lo que está sucediendo, entonces personas con muchos menos recursos van tener esta experiencia y se van a morir”.

Esta historia es parte de una asociación que incluye a KQED, NPR y KHN.

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Bridging the Miles — And the Pandemic — Teledentistry Makes Some Dentists Wince

Donella Pogue has trouble finding dentists in her rural area willing to accommodate her 21-year-old son, Justin, who is 6 feet, 8 inches tall, is on the autism spectrum and has difficulty sitting still when touched.

And this summer, he had a cavity and his face swelled. Pogue, of Bristol, New York, reached out to the Eastman Institute for Oral Health in Rochester, which offers teledentistry.

Dr. Adela Planerova looked into his mouth from 28 miles away as Pogue pointed her laptop’s camera into her son’s mouth. Planerova determined they did not need to make an emergency one-hour drive to her clinic. Instead, the dentist prescribed antibiotics and anti-inflammatory drugs, and weeks later he had surgery.

Teledentistry allows dental professionals like Planerova to remotely review records and diagnose patients over video. Some smile about its promise, seeing it as a way to become more efficient, to reach the one-third of U.S. adults who federal figures from 2017 estimate hadn’t seen a dentist in the previous year and to practice more safely during the pandemic.

But others see it as lesser-quality care that’s cheaper for dental professionals to provide, allowing them to make more money. At the same time, widespread adoption is hindered by issues such as spotty internet and insurance companies unwilling to reimburse for teledentistry procedures.

Dr. Christina Carter, an orthodontist in Morristown, New Jersey, said teledentistry has its place but shouldn’t replace time in the dental chair.

“It cannot be used for a full diagnosis because we need other tools, like X-rays,” she said. “We have all tried to see things on our phone or even on a Zoom call, and there is still just a different feel.”

Still, as the pandemic curbs in-person visits and reduces dentists’ revenue, more dentists are seeking guidance from Dr. Nathan Suter, a leading teledentistry advocate who owns the consulting company Access Teledentistry. Since March, he said, he’s done webinars for about 9,000 dental professionals, up from fewer than 1,000 in the three years before the pandemic.

Teledentistry providers trace the practice to 1994, when the Army launched a pilot program in which health care providers used an intra-oral camera to take photos of a patient’s mouth at a fort in Georgia and then sent them over the internet to a dental clinic at a fort 120 miles away.

Over the next two decades, dentists in upstate New York and the San Francisco Bay Area led teledentistry pilot programs for underserved children, some of whom were in preschool and already had cavities. The number of children who completed the prescribed dental treatment rose significantly.

Supporters say teledentistry can help reach the 43% of rural Americans who lack access to dental care. Medicaid and the Children’s Health Insurance Program will pay for many dental procedures for those enrolled in those programs, but only 38% of dentists participate in those programs, according to the American Dental Association. One reason: Medicaid typically reimburses at a significantly lower rate than those of private insurance plans.

Teledentistry could help dentists treat more patients and make more money a number of ways. If dentists remotely review data captured by hygienists, they can see more patients. Because video appointments save them time, dentists then have room for the people “who need the more expensive services” while also focusing on preventive care, said Kirill Zaydenman, vice president of innovation for DentaQuest, an administrator of dental insurance and oral health care provider.

Donella Pogue says that teledentistry was the best option for her 21-year-old son, Justin, when he had a cavity this summer that caused his face to swell. Justin has special needs and was able to see the dentist from the comfort of home. (Donella Pogue)

But dentists have not widely adopted teledentistry — mainly because they’ve had difficulty getting insurers to pay for it, said Dr. Dorota Kopycka-Kedzierawski, a Rochester dentist. That’s partly because of insurers’ concerns about fraud. Dr. Paul Glassman, who started the Virtual Dental Home project to reach underserved preschool children in the Bay Area, considers those fears “completely incorrect.”

“If you want to bill for something you didn’t do,” he said, “you can do that just as easily in an in-person environment as you can using teledentistry.”

Since March, as the pandemic descended, most, if not all, private dental plans have been reimbursing for teledentistry, said Tom Meyers, vice president of public policy for America’s Health Insurance Plans, a trade organization. And all state Medicaid programs now reimburse for teledentistry in some form, Glassman said, though policies differ by state and some practices may not be covered in some places.

But teledentistry isn’t reimbursable under Medicare. (Most dentistry isn’t.) Another obstacle to widespread adoption: Some dentists and lawmakers connect teledentistry to companies offering at-home teeth aligners with little or no in-person contact with a dentist. Glassman has promoted teledentistry throughout the United States and reviewed proposed legislation or regulations in states such as Idaho, Massachusetts and Texas. He said he hears concerns from dentists about the lack of an in-person exam during which X-rays are taken. Such concerns are reflected in some legislation.

SmileDirectClub, an at-home teeth-aligner company, has argued in statehouse testimony that in-person care is not always needed. The company opposed a 2019 bill in Texas that aimed to improve access to dentistry in rural areas because it included a number of restrictions on teledentistry, including one that would have required an in-person dentist’s examination if a teledentistry provider treated that patient for more than 12 months.

SmileDirect’s attorney argued at a hearing the rule “could interrupt the course of a patient’s treatment.”

The measure failed.

Proponents argue teledentistry isn’t just about making more money. Pogue, the New York woman, said it was the best option for her son with special needs.

“He is really afraid of dentistry, so when he goes to see someone, he is really tense and really jumpy, so that’s another reason the teledentistry was nice was because he was in my bedroom doing it, so he was really comfortable,” said Pogue, 53, whose son is covered by Medicaid.

A few weeks later, Justin did have to have surgery, which went “perfect,” his mom said.

Some dentists say teledentistry faces particular stumbling blocks in rural areas. Dr. Mack Taylor, 36, a dentist who grew up in the small town of Dexter, Missouri, now practices in a health center just down the road. Twenty years ago, he said, Dexter had eight dentists. Now there are only three.

Technology is a major obstacle for local residents, many of whom lack reliable internet service. Taylor recently applied for a U.S. Department of Agriculture grant that would give him $26,500 to buy equipment so that, for example, a hygienist can take photos inside the mouths of nursing home residents and send them to Taylor to review.

“It’s not like medicine where you can discuss someone’s ailments and have a good idea what’s going on,” Taylor said. “Maybe all you can tell me is ‘I have a broken tooth,’ but I can’t physically see what’s going on and prescribe the right treatment.”

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‘All You Want Is to Be Believed’: The Impacts of Unconscious Bias in Health Care

In mid-March, Karla Monterroso flew home to Alameda, California, after a hiking trip in Utah’s Zion National Park. Four days later, she began to develop a bad, dry cough. Her lungs felt sticky.

The fevers that persisted for the next nine weeks grew so high — 100.4, 101.2, 101.7, 102.3 — that, on the worst night, she was in the shower on all fours, ice-cold water running down her back, willing her temperature to go down.

“That night I had written down in a journal, letters to everyone I’m close to, the things I wanted them to know in case I died,” she remembered.

Then, in the second month, came a new batch of symptoms: headaches and shooting pains in her legs and abdomen that made her worry she could be at risk for the blood clots and strokes that other COVID-19 patients in their 30s had reported.

Still, she wasn’t sure if she should go to the hospital.

“As women of color, you get questioned a lot about your emotions and the truth of your physical state. You get called an exaggerator a lot throughout the course of your life,” said Monterroso, who is Latina. “So there was this weird, ‘I don’t want to go and use resources for nothing’ feeling.”

It took four friends to convince her she needed to call 911.

But what happened in the emergency room at Alameda Hospital only confirmed her worst fears.

At nearly every turn during her emergency room visit, Monterroso said, providers dismissed her symptoms and concerns. Her low blood pressure? That’s a false reading. Her cycling oxygen levels? The machine’s wrong. The shooting pains in her leg? Probably just a cyst.

“The doctor came in and said, ‘I don’t think that much is happening here. I think we can send you home,’” Monterroso recalled.

Her experiences, she reasons,  are part of why people of color are disproportionately affected by the coronavirus. It is not merely because they’re more likely to have front-line jobs that expose them to it and the underlying conditions that make COVID-19 worse.

“That is certainly part of it, but the other part is the lack of value people see in our lives,” Monterroso wrote in a Twitter thread detailing her experience.

Research shows how doctors’ unconscious bias affects the care people receive, with Latino and Black patients being less likely to receive pain medications or get referred for advanced care than white patients with the same complaints or symptoms, and more likely to die in childbirth from preventable complications.

In the hospital that day in May, Monterroso was feeling woozy and having trouble communicating, so she had a friend and her friend’s cousin, a cardiac nurse, on the phone to help. They started asking questions: What about Karla’s accelerated heart rate? Her low oxygen levels? Why are her lips blue?

The doctor walked out of the room. He refused to care for Monterroso while her friends were on the phone, she said, and when he came back, the only thing he wanted to talk about was Monterroso’s tone and her friends’ tone.

“The implication was that we were insubordinate,” Monterroso said.

She told the doctor she didn’t want to talk about her tone. She wanted to talk about her health care. She was worried about possible blood clots in her leg and she asked for a CT scan.

“Well, you know, the CT scan is radiation right next to your breast tissue. Do you want to get breast cancer?” Monterroso recalled the doctor saying to her. “I only feel comfortable giving you that test if you say that you’re fine getting breast cancer.”

Monterroso thought to herself, “Swallow it up, Karla. You need to be well.” And so she said to the doctor: “I’m fine getting breast cancer.”

He never ordered the test.

A vehicle parked in Oakland, California, during the first weeks of the 2020 Black Lives Matter demonstrations.(April Dembosky)

Monterroso asked for a different doctor, for a hospital advocate. No and no, she was told. She began to worry about her safety. She wanted to get out of there. Her friends, all calling every medical professional they knew to confirm that this treatment was not right, came to pick her up and drove her to the University of California-San Francisco. The team there gave her an EKG, a chest X-ray and a CT scan.

“One of the nurses came in and she was like, ‘I heard about your ordeal. I just want you to know that I believe you. And we are not going to let you go until we know that you are safe to go,’” Monterroso said. “And I started bawling. Because that’s all you want is to be believed. You spend so much of the process not believing yourself, and then to not be believed when you go in? It’s really hard to be questioned in that way.”

Alameda Health System, which operates Alameda Hospital, declined to comment on the specifics of Monterroso’s case, but said in a statement that it is “deeply committed to equity in access to health care” and “providing culturally-sensitive care for all we serve.” After Monterroso filed a grievance with the hospital, management invited her to come talk to their staff and residents, but she declined.

She believes her experience is an example of why people of color are faring so badly in the pandemic.

“Because when we go and seek care, if we are advocating for ourselves, we can be treated as insubordinate,” she said. “And if we are not advocating for ourselves, we can be treated as invisible.”

Unconscious Bias in Health Care

Experts say this happens routinely, and regardless of a doctor’s intentions or race. Monterroso’s doctor was not white, for example.

Research shows that every doctor, every human being, has biases they’re not aware of, said Dr. René Salazar, assistant dean for diversity at the University of Texas-Austin medical school.

“Do I question a white man in a suit who’s coming in looking like he’s a professional when he asks for pain meds versus a Black man?” Salazar said, noting one of his own possible biases.

Unconscious bias most often surfaces in high-stress environments, like emergency rooms — where doctors are under tremendous pressure and have to make quick, high-stakes decisions. Add in a deadly pandemic, in which the science is changing by the day, and things can spiral.

“There’s just so much uncertainty,” he said. “When there is this uncertainty, there always is a level of opportunity for bias to make its way in and have an impact.”

Salazar used to teach at UCSF, where he helped develop unconscious-bias training for medical and pharmacy students. Although dozens of medical schools are picking up the training, he said, it’s not as commonly performed in hospitals. Even when a negative patient encounter like Monterroso’s is addressed, the intervention is usually weak.

“How do I tell my clinician, ‘Well, the patient thinks you’re racist?’” Salazar said. “It’s a hard conversation: ‘I gotta be careful, I don’t want to say the race word because I’m going to push some buttons here.’ So it just starts to become really complicated.”

A Data-Based Approach

Dr. Ronald Copeland said he remembers doctors also resisting these conversations in the early days of his training. Suggestions for workshops in cultural sensitivity or unconscious bias were met with a backlash.

“It was viewed almost from a punishment standpoint. ‘Doc, your patients of this persuasion don’t like you and you’ve got to do something about it.’ It’s like, ‘You’re a bad doctor, and so your punishment is you have to go get training,” said Copeland, who is chief of equity, inclusion and diversity at the Kaiser Permanente health system. (KHN is an editorially independent program of KFF, which is not affiliated with Kaiser Permanente.)

Now, KP’s approach is rooted in data from patient surveys that ask if a person felt respected, if the communication was good and if they were satisfied with the experience.

KP then breaks this data down by demographics, to see if a doctor may get good scores on respect and empathy from white patients, but not Black patients.

“If you see a pattern evolving around a certain group and it’s a persistent pattern, then that tells you there’s something that from a cultural, from an ethnicity, from a gender, something that group has in common, that you’re not addressing,” Copeland said. “Then the real work starts.”

When doctors are presented with the data from their patients and the science on unconscious bias, they’re less likely to resist it or deny it, Copeland said. At his health system, they’ve reframed the goal of training around delivering better quality care and getting better patient outcomes, so doctors want to do it.

“Folks don’t flinch about it,” he said. “They’re eager to learn more about it, particularly about how you mitigate it.”

Still Unwell

It’s been nearly six months since Monterroso first got sick, and she’s still not feeling well.

Her heart rate continues to spike and doctors told her she may need gallbladder surgery to address the gallstones she developed as a result of COVID-related dehydration. She decided recently to leave the Bay Area and move to Los Angeles so she could be closer to her family for the long recovery.

She declined Alameda Hospital’s invitation to speak to their staff about her experience, concluding it wasn’t her responsibility to fix the system. But she wants the broader health care system to take responsibility for the bias perpetuated in hospitals and clinics.

She acknowledges that Alameda Hospital is public, and it doesn’t have the kind of resources that KP and UCSF do. A recent audit warned that the Alameda Health System was on the brink of insolvency. But Monterroso is the CEO of Code2040, a racial equity nonprofit in the tech sector and even for her, she said, it took an army of support for her to be heard.

“Ninety percent of the people that are going to come through that hospital are not going to have what I have to fight that,” she said. “And if I don’t say what’s happening, then people with much less resources are going to come into this experience, and they’re going to die.”

This story is part of a partnership that includes KQED, NPR and KHN.

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Lost on the Frontline: Explore the Database

Journalists from KHN and the Guardian have identified 1,318 workers who reportedly died of complications from COVID-19 they contracted on the job. Reporters are working to confirm the cause of death and workplace conditions in each case. They are also writing about the people behind the statistics — their personalities, passions and quirks — and telling the story of every life lost.

Explore the new interactive tool tracking those health worker deaths.

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Despite Pandemic Threat, Gubernatorial Hopefuls Avoid COVID Nitty-Gritty

Just 15 days ahead of the election, Montana Lt. Gov. Mike Cooney laid out his ideas on how he’d handle the COVID-19 pandemic if elected governor. Details were few, but the Democrat’s plan became one of only a handful being offered by candidates in the 11 U.S. governor’s races about how they’ll approach what’s certain to be the dominant issue of their terms, should they win.

While much of the nation’s focus is on who will be president come January, voters who are deciding the next occupant of their governor’s mansion are also effectively choosing the next leader of their state’s COVID-19 response. The virus has made governors’ power highly visible to voters. As the states’ top executives, they decide whether to issue mask mandates, close businesses and order people to stay home.

All but two races for governor feature incumbents running for reelection: Montana’s Democratic Gov. Steve Bullock can’t run again because of term limits and Utah’s Republican Gov. Gary Herbert decided not to run for another term. In several other competitive races for governor this year, such as those in North Carolina and Missouri, opponents clash on the role of state mandates in slowing the virus. Still, COVID-19 often fades into the backdrop of many long-standing platforms or primarily comes up as candidates talk about the need to revive the economy.

Cooney’s proposal, released Monday, suggested using the National Guard to transport patients in extreme weather and subsidizing heating bills to help those quarantining at home. But other parts vaguely described how he would “develop a robust plan” to come.

His opponent, Republican U.S. Rep. Greg Gianforte, has acknowledged the health crisis but has focused primarily on the economy, saying the state has to “cure the economic pandemic” the virus caused.

Rep. Greg Gianforte, Mike Cooney’s Republican opponent, joins President Donald Trump at a rally at the Bozeman Yellowstone International Airport on Nov. 3, 2018, in Belgrade, Montana.(William Campbell/Corbis via Getty Images)

Bryce Ward, a health economist with the University of Montana, said Cooney’s list was one of the first times he’s seen long-term planning for COVID-19 come up in what appears to be the nation’s tightest governor’s race. But, he added, neither Montana candidate has offered a concrete plan to deal with the dual crises that risk public health when people gather and businesses’ bottom lines when they don’t. Meanwhile, the state’s number of COVID-19 cases climbs and its economy suffers.

“Whoever wins, this is going to be the bulk of their term,” Ward said. “How are the candidates going to keep people afloat as long as they can? What are we doing in terms of planning for what we think our post-COVID world is going to look like?”

An October KFF poll found 29% of registered voters said the economy was the most important issue in choosing a president, while 18% said the coronavirus outbreak was their top issue. Republican voters were more likely to pick the economy, the survey found, and Democrats were more likely to pick the coronavirus. (KHN is an editorially independent program of KFF.)

“There are voters that feel that the government needs to lead, and there are voters that feel that the government is utilizing a pandemic to become too invasive,” said Capri Cafaro, a former Democratic Ohio state senator now teaching in American University’s public administration and policy department. “People are not necessarily making their decisions on ‘Did you do contact tracing? Are you going to slow the spread?’”

Among the incumbent governors seeking reelection this year, most of their campaigns’ focus on COVID-19 has been on how well they’ve responded to the crisis. Several pledge more of what they’ve been doing. “We’ll continue to follow the science and wear masks,” Delaware Democratic Gov. John Carney said in a recent debate.

Meanwhile, their challengers generally seek to cast the incumbents as mismanaging their states’ response and promising to undo what’s been done. Those who have put out actual plans to handle the pandemic are Democratic challengers to Republican governors, and their plans are similar to what Cooney released — some specific ideas and promises to fill in the gaps later.

In Missouri, Democratic challenger Nicole Galloway, who is the state auditor, made health care the center of her campaign and released a plan to respond to the virus with a statewide mask mandate and a limit on when public school classes can meet in person based on the community’s rate of infection.

Republican Gov. Mike Parson is the apparent front-runner in that state’s race. He has pledged to lead “the greatest economic comeback that we’ve ever seen in Missouri history.” The former Polk County sheriff also has focused on supporting law enforcement amid backlash against police brutality and racial injustice.

Curbing the coronavirus has taken a back seat to boosting the economy in Parson’s campaign. And, as governor, Parson has refused to issue a statewide mask mandate, despite a White House recommendation to do so. In late September, the governor and his wife tested positive for COVID-19. Parson has returned to work, which includes traveling across the state.

One of the more heated races is in North Carolina, where Democratic Gov. Roy Cooper is defending his seat against a challenge by his lieutenant governor, Republican Dan Forest. Forest sued Cooper this year to challenge the governor’s authority to impose COVID-related restrictions by executive order.

Forest dropped the lawsuit in August after a judge made a preliminary ruling against his case, then said on Twitter, “I did my part. If y’all want your freedoms back you’ll have to make your voices heard in November.”

Cooper’s campaign called the lawsuit “a desperate tactic to garner attention” for Forest’s political campaign. Since then, the governor has slowly eased COVID restrictions, updating an executive order to allow a limited number of people in bars, sporting events, movie theaters and amusement parks. Cooper is leading the race in recent polls.

Back in Montana, the pandemic surfaced in the gubernatorial campaign after health officials announced on Oct. 16 that a Helena concert, which Gianforte attended, was linked to several COVID-19 cases. More than 100 health professionals blasted him in an open letter for flouting local health restrictions, going maskless and making light of safety precautions at campaign events. Cooney called on him to suspend his campaign events until tested. Gianforte’s campaign has said he’s taking proper precautions and accused Cooney of politicizing a public health issue.

Cooney has said he’ll keep Montana’s COVID-19 response on the track he is helping set as lieutenant governor, with science guiding that work. Gianforte, who built a tech startup in Bozeman, has touted his business experience as proof he can lead Montana’s comeback. Both have said more needs to be learned about this virus and have pitched themselves as the one to steer the state’s economy through the crisis.

Ward, the University of Montana health economist, said the details are missing, such as how the winner will support businesses through the winter without federal aid. Or what the new governor would cut from the state budget if the economic crisis hits its coffers.

The state has a public mask mandate and a plan for reopening the economy with no apparent thresholds or timelines. The option for stricter rules has been left to county governments as the state sees its largest COVID surge yet.

Jeremy Johnson, a political scientist at Carroll College in Helena, said the initial lack of detailed pandemic policy in the state’s race could be attributed to both candidates trying to win over swing voters with safe themes. President Donald Trump won Montana in 2016 by 20 points, but the state has also had a Democratic governor for 16 years. While polls show Gianforte leading Cooney slightly, election handicappers Real Clear Politics and the Cook Political Report still consider the race a toss-up.

Yet as Election Day nears, the question of how to address the pandemic only looms larger. Montana’s case count is rising, adding to its total of more than 23,000 cases in the state of roughly 1 million.

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¿Pueden los pacientes de COVID tener el tratamiento de Trump? Está bien preguntar

Cuando Terry Mutter se despertó con dolor de cabeza y músculos adoloridos, el levantador de pesas amateur lo atribuyó a un entrenamiento duro.

Sin embargo, ese miércoles a la noche tuvo 101 grados de fiebre y estaba claramente enfermo. “Me sentía como si me hubiera atropellado un camión”, recuerda Mutter, que vive cerca de Seattle.

Al día siguiente le diagnosticaron COVID-19. El sábado, el hombre de 58 años estaba inscrito en un ensayo clínico para el mismo cóctel de anticuerpos que el presidente Donald Trump afirmó que le había “curado” el coronavirus.

“Lo había escuchado en las noticias”, dijo Mutter, que se unió al ensayo del laboratorio Regeneron para probar si su combinación de dos anticuerpos artificiales puede neutralizar al virus mortal.

Mutter se enteró del estudio por medio de su cuñada, quien trabaja en el Centro de Investigación del Cáncer Fred Hutchinson de Seattle, uno de decenas de sitios de ensayos en todo el país. Es uno de los cientos de miles de estadounidenses, incluido el presidente, que se arriesgaron con terapias experimentales para tratar o prevenir COVID-19.

Pero con casi 8 millones de personas infectadas y más de 217,000 muertes por COVID en el país, muchos pacientes desconocen estas opciones o no pueden acceder a ellas. Otros desconfían de los tratamientos no probados.

“Honestamente, creo que nunca hubiera recibido una llamada si no hubiera conocido a alguien que me dijera sobre el ensayo”, dijo Mutter, ejecutivo jubilado de Boeing Co.

El sitio web registra más de 3,600 estudios que involucran a COVID-19 o a SARS-CoV-2, el virus que causa la enfermedad. Más de 430,000 personas se han ofrecido como voluntarias a través de la Red de Prevención de COVID-19. Otras miles han recibido terapias, como el medicamento antiviral remdesivir, que tiene una autorización federal de emergencia.

Ante un diagnóstico grave de COVID, ¿cómo saben los pacientes o sus familias si pueden, o deben, buscar agresivamente estos tratamientos? Por el contrario, ¿cómo pueden decidir si rechazarlos o no si se los ofrecen?

Tales decisiones médicas nunca son fáciles, y son aún más difíciles durante una pandemia, dijo Annette Totten, profesora asociada de informática médica y epidemiología clínica en la Universidad de Salud y Ciencias de Oregon.

“El desafío es que la evidencia no es buena porque todo con COVID es nuevo”, dijo Totten, quien se especializa en la toma de decisiones médicas.

Es comprensible que a los consumidores los haya afectado la información contradictoria sobre posibles tratamientos para COVID por parte de líderes políticos, incluido Trump, y la comunidad científica.

El fármaco contra la malaria hidroxicloroquina, promocionado por el presidente, recibió una autorización de emergencia de la Administración de Drogas y Alimentos (FDA), solo para que la decisión se revocara varias semanas después por temor a que causara daño.

El plasma convalescente, que utiliza hemoderivados de personas recuperadas de COVID-19 para tratar a las que aún están enfermas, se administró a más de 100,000 pacientes en un programa de acceso ampliado y se puso a disposición de todos a través de otra autorización de emergencia, aunque los científicos no están seguros de sus beneficios.

Regeneron y la empresa farmacéutica Eli Lilly and Co. han solicitado autorización de uso de emergencia para sus terapias con anticuerpos monoclonales, incluso cuando los científicos dicen que esto podría poner en peligro la inscripción en los ensayos que probarán si funcionan, o cuán bien funcionan.

Hasta ahora, unas 2,500 personas se han inscrito en los ensayos de Regeneron, y, de ellas, unas 2,000 reciben la terapia, dijo un vocero de la compañía. Otras han recibido el tratamiento a través de los llamados programas de uso compasivo, aunque la empresa no dijo cuántas.

La semana del 12 de octubre, los Institutos Nacionales de Salud detuvieron el ensayo de anticuerpos de Lilly después que una junta de monitoreo independiente planteara preocupaciones de seguridad.

“Con toda la información dando vueltas en los medios, es difícil para los pacientes tomar buenas decisiones, y para los médicos tomar esas decisiones”, dijo el doctor Benjamin Rome, internista e investigador de políticas de salud en el programa Portal de la Escuela de Medicina de Harvard.

Aun así, las personas que enfrentan COVID no deberían tener miedo de preguntar si tienen opciones de tratamiento disponibles, agregó Rome. “Como médico, no me importa cuando los pacientes preguntan”, dijo.

Los pacientes y las familias deben comprender cuáles podrían ser las implicaciones de esos tratamientos, aconsejó Totten. Los primeros ensayos clínicos de fase 1 se centran principalmente en la seguridad, mientras que los ensayos más amplios de fase 2 y fase 3 determinan la eficacia. Cualquier tratamiento experimental plantea la posibilidad de efectos secundarios graves.

Idealmente, los proveedores de atención médica proporcionarían la información sobre tratamientos y riesgos sin previo aviso. Pero durante una pandemia, y especialmente en un entorno de mucho estrés, es posible que no lo hagan, observó Totten.

“Es importante ser insistente”, dijo. “Y Volver a preguntar. A veces tienes que estar dispuesto a ser un poco agresivo”, sugirió.

Los pacientes y las familias deben tomar nota o grabar las conversaciones para su posterior revisión. Deberían preguntar sobre la compensación económica por participar. A muchos pacientes en los ensayos de COVID-19 se les paga cantidades modestas por su tiempo y viajes.

Y deberían pensar en cómo encaja cualquier tratamiento en su sistema más amplio de valores y objetivos, dijo Angie Fagerlin, profesora y directora del departamento de ciencias de la salud de la población de la Universidad de Utah.

“¿Cuáles son los pros y los contras?”, se preguntó Fagerlin. Una consideración puede ser el beneficio para la sociedad en general, no solo para el paciente, dijo.

Para Mutter, ayudar al avance de la ciencia fue una gran razón por la que aceptó inscribirse en el ensayo de Regeneron.

“Me interesó para que la terapéutica avanzara, necesitan personas”, dijo. “En un momento en el que hay tantas cosas que no podemos controlar, ésta sería una forma de encontrar algún tipo de solución”.

Esto fue lo que impulsó a Fred Hutch, que participa en dos ensayos de Regeneron, uno para la prevención de COVID-19 y otro para el tratamiento de la enfermedad.

“Fue una visita de seis horas”, dijo. “Son dos horas para recibir la infusión. Es un goteo intravenoso muy lento”.

Mutter fue la segunda persona inscrita en el ensayo de Fred Hutch, dijo la doctora Shelly Karuna, co-investigadora principal. El estudio está probando dosis altas y bajas del cóctel de anticuerpos monoclonales frente a un placebo.

“Me sorprende el profundo altruismo de las personas a las que estamos evaluando”, dijo.

Mutter no está seguro de cómo contrajo COVID-19. Él y su familia han tenido cuidado con las máscaras y el distanciamiento social, y han criticado a otros que no.

“La ironía ahora es que fuimos nosotros los que nos enfermamos”, dijo Mutter, cuya esposa, Gina Mutter, de 54 años, también tiene COVID.

Mutter sabe que tiene una probabilidad de 1 en 3 de recibir un placebo en lugar de una de las dos dosis de tratamiento activo, pero dijo que estaba dispuesto a correr ese riesgo. Su esposa no se inscribió.

“Dije, hay algunos riesgos involucrados. Uno de nosotros puede tomar el riesgo, no los dos”, dijo.

Hasta ahora, Mutter ha luchado contra una tos y fatiga persistente. No puede decir si su infusión ha sido útil.

“Simplemente no hay forma de saber si tengo los anticuerpos o no”, dijo. “¿Los obtuve y eso me mantuvo fuera del desastre?, ¿o tuve el placebo y mi propio sistema inmunológico hizo su trabajo?”.

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Older COVID Patients Battle ‘Brain Fog,’ Weakness and Emotional Turmoil

“Lord, give me back my memory.”

For months, as Marilyn Walters has struggled to recover from COVID-19, she has repeated this prayer day and night.

Like other older adults who’ve become critically ill from the coronavirus, Walters, 65, describes what she calls “brain fog” — difficulty putting thoughts together, problems with concentration, the inability to remember what happened a short time before.

This sudden cognitive dysfunction is a common concern for seniors who’ve survived a serious bout of COVID-19.

“Many older patients are having trouble organizing themselves and planning what they need to do to get through the day,” said Dr. Zijian Chen, medical director of the Center for Post-COVID Care at Mount Sinai Health System in New York City. “They’re reporting that they’ve become more and more forgetful.”

Other challenges abound: overcoming muscle and nerve damage, improving breathing, adapting to new impairments, regaining strength and stamina, and coping with the emotional toll of unexpected illness.

Most seniors survive COVID-19 and will encounter these concerns to varying degrees. Even among the age group at greatest risk — people 85 and older — just 28% of those with confirmed cases end up dying, according to data from the Centers for Disease Control and Prevention. (Because of gaps in testing, the actual death rate may be lower.)

As she recovers from COVID-19, Marilyn Walters finds it difficult to put thoughts together and remember recent events. She calls it “brain fog.” “Emotionally, it’s been hard because I’ve always been able to do for myself, and I can’t do that as I like. I’ve been really nervous and jittery,” she says.(Tammia Sanders)

Walters, who lives in Indianapolis, spent almost three weeks in March and April heavily sedated, on a ventilator, fighting for her life in intensive care. Today, she said, “I still get tired real easy and I can’t breathe sometimes. If I’m walking sometimes my legs get wobbly and my arms get like jelly.”

“Emotionally, it’s been hard because I’ve always been able to do for myself, and I can’t do that as I like. I’ve been really nervous and jittery,” Walters said.

Younger adults who’ve survived a serious course of COVID-19 experience similar issues but older adults tend to have “more severe symptoms, and more limitations in terms of what they can do,” Chen said.

“Recovery will be on the order of months and years, not days or weeks,” said Dr. E. Wesley Ely, co-director of the Critical Illness, Brain Dysfunction and Survivorship Center at Vanderbilt University Medical Center. Most likely, he speculated, a year after fighting the disease at least half of the critically ill older patients will not have fully recovered.

The aftereffects of delirium — an acute, sudden change of consciousness and mental acuity — can complicate recovery from COVID-19. Seniors hospitalized for serious illness are susceptible to the often-unrecognized condition when they’re immobilized for a long time, isolated from family and friends, and given sedatives to ease agitation or narcotics for pain, among other contributing factors.

In older adults, delirium is associated with a heightened risk of losing independence, developing dementia and dying. It can manifest as acute confusion and agitation or as uncharacteristic unresponsiveness and lethargy.

“What we’re seeing with COVID-19 and older adults are rates of delirium in the 70% to 80% range,” said Dr. Babar Khan, associate director of Indiana University’s Center for Aging Research at the Regenstrief Institute, and one of Walters’ physicians.

Gordon Quinn, 77, a Chicago documentary filmmaker, believes he contracted COVID-19 at a conference in Australia in early March. At Northwestern Memorial Hospital, he was put on a ventilator twice in the ICU, for a total of nearly two weeks, and remembers having “a lot of hallucinations” — a symptom of delirium.

“I remember vividly believing I was in purgatory. I was paralyzed — I couldn’t move. I could hear snatches of TV — reruns of ‘Law & Order: Special Victims Unit’ — and I asked myself, ‘Is this my life for eternity?’” Quinn said.

Given the extent of delirium and mounting evidence of neurological damage from COVID-19, Khan said he expects to see “an increased prevalence of ICU-acquired cognitive impairment in older COVID patients.”

Ely agrees. “These patients will urgently need to work on recovery,” he said. Family members should insist on securing rehabilitation services — physical therapy, occupational therapy, speech therapy, cognitive rehabilitation — after the patient leaves the hospital and returns home, he advised.

Gordon Quinn spent nearly two weeks at Chicago’s Shirley Ryan AbilityLab while recuperating from a life-threatening case of COVID-19. Today, he’s able to walk nearly 2 miles and has returned to work, feeling almost back to normal.(Meg Gerken)

“Even at my age, people can get incredible benefit from rehab,” said Quinn, who spent nearly two weeks at Chicago’s Shirley Ryan AbilityLab, a rehabilitation hospital, before returning home and getting several weeks of home-based therapy. Today, he’s able to walk nearly 2 miles and has returned to work, feeling almost back to normal.

James Talaganis, 72, of Indian Head Park, Illinois, also benefited from rehab at Shirley Ryan AbilityLab after spending nearly four months in various hospitals beginning in early May.

Talaganis had a complicated case of COVID-19: His kidneys failed and he was put on dialysis. He experienced cardiac arrest and was in a coma for almost 58 days while on a ventilator. He had intestinal bleeding, requiring multiple blood transfusions, and was found to have crystallization and fibrosis in his lungs.

When Talaganis began his rehab on Aug. 22, he said, “my whole body, my muscles were atrophied. I couldn’t get out of bed or go to the toilet. I was getting fed through a tube. I couldn’t eat solid foods.”

In early October, after getting hours of therapy each day, Talaganis was able to walk 660 feet in six minutes and eat whatever he wanted. “My recovery — it’s a miracle. Every day I feel better,” he said.

James Talaganis began his COVID-19 rehab at Shirley Ryan AbilityLab in late August. After hours of daily therapy, his walking has measurably improved. “My recovery — it’s a miracle. Every day I feel better,” he says.(Megan Washburn)

Unfortunately, rehabilitation needs for most older adults are often overlooked. Notably, a recent study found that one-third of critically ill older adults who survive a stay in the ICU did not receive rehab services at home after hospital discharge.

“Seniors who live in more rural areas or outside bigger cities where major hospital systems are providing cutting-edge services are at significant risk of losing out on this potentially restorative care,” said Dr. Sean Smith, an associate professor of physical medicine and rehabilitation at the University of Michigan.

Sometimes what’s most needed for recovery from critical illness is human connection. That was true for Tom and Virginia Stevens of Nashville, Tennessee, in their late 80s, who were both hospitalized with COVID-19 in early August.

Ely, one of their physicians, found them in separate hospital rooms, frightened and miserable. “I’m worried about my husband,” he said Virginia told him. “Where am I? What is happening? Where is my wife?” the doctor said Tom asked, before crying out, “I have to get out of here.”

Ely and another physician taking care of the couple agreed. Being isolated from each other was dangerous for this couple, married for 66 years. They needed to be put in a room together.

When the doctor walked into their new room the next day, he said, “it was a night-and-day difference.” The couple was sipping coffee, eating and laughing on beds that had been pushed together.

“They both got better from that point on. I know that was because of the loving touch, being together,” Ely said.

That doesn’t mean recovery has been easy. Virginia and Tom still struggle with confusion, fatigue, weakness and anxiety after their two-week stay in the hospital, followed by two weeks in inpatient rehabilitation. Now, they’re in a new assisted living residence, which is allowing outdoor visits with their family.

“Doctors have told us it will take a long time and they may never get back to where they were before COVID,” said their daughter, Karen Kreager, also of Nashville. “But that’s OK. I’m just so grateful that they came through this and we get to spend more time with them.”

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Can Ordinary COVID Patients Get the Trump Treatment? It’s OK to Ask

When Terry Mutter woke up with a headache and sore muscles on a recent Wednesday, the competitive weightlifter chalked it up to a hard workout.

By that evening, though, he had a fever of 101 degrees and was clearly ill. “I felt like I had been hit by a truck,” recalled Mutter, who lives near Seattle.

The next day he was diagnosed with COVID-19. By Saturday, the 58-year-old was enrolled in a clinical trial for the same antibody cocktail that President Donald Trump claimed was responsible for his coronavirus “cure.”

“I had heard a little bit about it because of the news,” said Mutter, who joined the study by drugmaker Regeneron to test whether its combination of two man-made antibodies can neutralize the deadly virus. “I think they probably treated him with everything they had.”

Mutter learned about the study from his sister-in-law, who works at Seattle’s Fred Hutchinson Cancer Research Center, one of dozens of trial sites nationwide. He is among hundreds of thousands of Americans — including the president — who’ve taken a chance on experimental therapies to treat or prevent COVID-19.

But with nearly 8 million people in the U.S. infected with the coronavirus and more than 217,000 deaths attributed to COVID, many patients are unaware of such options or unable to access them. Others remain wary of unproven treatments that can range from drugs to vaccines.

“Honestly, I don’t know whether I would have gotten a call if I hadn’t known somebody who said, ‘Hey, here’s this study,’” said Mutter, a retired executive with Boeing Co.

The website, which tracks such research, reports more than 3,600 studies involving COVID-19 or SARS-CoV-2, the virus that causes the disease. More than 430,000 people have volunteered for such studies through the COVID-19 Prevention Network. Thousands of others have received therapies, like the antiviral drug remdesivir, under federal emergency authorizations.

Faced with a dire COVID diagnosis, how do patients or their families know whether they can — or should — aggressively seek out such treatments? Conversely, how can they decide whether to refuse them if they’re offered?

Such medical decisions are never easy — and they’re even harder during a pandemic, said Annette Totten, an associate professor of medical informatics and clinical epidemiology at Oregon Health & Science University.

“The challenge is the evidence is not good because everything with COVID is new,” said Totten, who specializes in medical decision-making. “I think it’s hard to cut through all the noise.”

Consumers have been understandably whipsawed by conflicting information about potential COVID treatments from political leaders, including Trump, and the scientific community. The antimalarial drug hydroxychloroquine, touted by the president, received emergency authorization from the federal Food and Drug Administration, only to have the decision revoked several weeks later out of concern it could cause harm.

Convalescent plasma, which uses blood products from people recovered from COVID-19 to treat those who are still ill, was given to more than 100,000 patients in an expanded-access program and made widely available through another emergency authorization — even though scientists remain uncertain of its benefits.

Regeneron and the pharmaceutical firm Eli Lilly and Co. have both requested emergency use authorization for their monoclonal antibody therapies, even as scientists say such approval could jeopardize enrollment in the randomized controlled trials that will prove whether or how well they work. So far, about 2,500 people have enrolled in the Regeneron trials, with about 2,000 of them receiving the therapy, a company spokesperson said. Others have received the treatment through so-called compassionate use programs, though the company wouldn’t say how many.

Last week, the National Institutes of Health paused the Lilly antibody trial after an independent monitoring board raised safety concerns.

“With all of the information swirling around in the media, it’s hard for patients to make good decisions — and for doctors to make those decisions,” said Dr. Benjamin Rome, a general internist and health policy researcher at Harvard Medical School’s Portal program. “You shouldn’t expect that what you’ve heard about on the news is the right treatment for you.”

Even so, people facing COVID shouldn’t be afraid to question whether treatment options are available to them, Rome said. “As a doctor, I never mind when patients ask,” he said.

Patients and families should understand what the implications of those treatments might be, Totten advised. Early phase 1 clinical trials focus largely on safety, while larger phase 2 and phase 3 trials determine efficacy. Any experimental treatment raises the possibility of serious side effects.

Ideally, health care providers would provide such information about treatments and risks unprompted. But during a pandemic, especially in a high-stress environment, they might not, Totten noted.

“It’s important to be sort of insistent,” she said. “If you ask a question, you have to ask it again. Sometimes you have to be willing to be a little pushy,” she said.

Patients and families should take notes or record conversations for later review. They should ask about financial compensation for participation. Many patients in COVID-19 trials are paid modest amounts for their time and travel.

And they should think about how any treatment fits into their larger system of values and goals, said Angie Fagerlin, a professor and the chair of the population health sciences department at the University of Utah.

“What are the pros and what are the cons?” Fagerlin said. “Where would your decision regret be: Not doing something and getting sicker? Or doing something and having a really negative reaction?”

One consideration may be the benefit to the wider society, not just yourself, she said. For Mutter, helping advance science was a big reason he agreed to enroll in the Regeneron trial.

“The main thing that made me interested in it was in order for therapeutics to move forward, they need people,” he said. “At a time when there’s so much we can’t control, this would be a way to come up with some kind of a solution.”

That decision led him to Fred Hutch, which is collaborating on two Regeneron trials, one for prevention of COVID-19 and one for treatment of the disease.

“It was a six-hour visit,” he said. “It’s two hours to get the infusion. It’s a very slow IV drip.”

Mutter was the second person enrolled in the treatment trial at Fred Hutch, said Dr. Shelly Karuna, a co-principal investigator. The study is testing high and low doses of the monoclonal antibody cocktail against a placebo.

“I am struck by the profound altruism of the people we are screening,” she said.

Mutter isn’t sure how he contracted COVID-19. He and his family have been careful about masks and social distancing — and critical of others who weren’t.

“The irony now is that we’re the ones who got sick,” said Mutter, whose wife, Gina Mutter, 54, is also ill.

Mutter knows he has a 1-in-3 chance that he got a placebo rather than one of two active treatment dosages, but he said he was willing to take that chance. His wife didn’t enroll in the trial.

“I said, there’s some risks involved. We’re taking one for the team here. I don’t think we both need to do that,” he said.

So far, Mutter has struggled with a persistent cough and lingering fatigue. He can’t tell if his infusion has been helpful, never mind whether it’s a cure.

“Just no way of telling if I got the antibodies or not,” he said. “Did I get them and that kept me out of disaster, or did I get the placebo and my own immune system did its job?”

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‘No Mercy’ Chapter 4: So, 2 Nuns Step Off a Train in Kansas … A Hospital’s Origin Story

Can’t see the audio player? Click here to listen.

Ever since Mercy Hospital went “corporate,” things just haven’t been the same — that’s what lots of locals in Fort Scott, Kansas, said when the Mercy health system shuttered the only hospital in town.

It’s been years since Catholic nuns led Mercy Hospital Fort Scott, but town historian Fred Campbell is wistful for his boyhood in the 1940s when sisters in habits walked the hallways.

“Well, I had never, ever been in a hospital. And here came these ladies in flowing robes and white bands around their faces. And I was scared to death. But it wasn’t long ’til I found that, first thing I know, they had some iced Coca-Cola. I still remember them putting their hand on my head to see if I had a fever.”

For more than 100 years, Mercy Hospital — and the nuns who started it all — cared for local people. But in recent years, Fort Scott’s economy and the hospital’s finances faltered. Campbell hoped both could survive.

“Mercy Corporation, can you stay with us longer?” he wondered.

In Chapter 4 of Season One: No Mercy, podcast host Sarah Jane Tribble carries that question to Sister Mary Roch Rocklage, the powerhouse who consolidated all the Mercy hospitals in the Midwest.

Click here to read the episode transcript.

Fred Campbell(Sarah Jane tribble/KHN)

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

And to hear all KHN podcasts, click here.

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