From Medicine and Health

After Kid’s Minor Bike Accident, Major Bill Sets Legal Wheels in Motion

Adam Woodrum was out for a bike ride with his wife and kids on July 19 when his then 9-year-old son, Robert, crashed.

“He cut himself pretty bad, and I could tell right away he needed stitches,” said Woodrum.

Because they were on bikes, he called the fire department in Carson City, Nevada.

“They were great,” said Woodrum. “They took him on a stretcher to the ER.”

Robert received stitches and anesthesia at Carson Tahoe Regional Medical Center. He’s since recovered nicely.

Then the denial letter came.

The Patient: Robert Woodrum, covered under his mother’s health insurance plan from the Nevada Public Employees’ Benefits Program

Total Bill: $18,933.44, billed by the hospital

Service Provider: Carson Tahoe Regional Medical Center, part of not-for-profit Carson Tahoe Health

Medical Service: Stitches and anesthesia during an emergency department visit

What Gives: The Aug. 4 explanation of benefits (EOB) document said the Woodrum’s claim had been rejected and their patient responsibility would be the entire sum of $18,933.44.

This case involves an all-too-frequent dance between different types of insurers about which one should pay a patient’s bill if an accident is involved. All sides do their best to avoid paying. And, no surprise to Bill of the Month followers: When insurers can’t agree, who gets a scary bill? The patient.

The legal name for the process of determining which type of insurance is primarily responsible is subrogation.

Could another policy — say, auto or home coverage or workers’ compensation — be obligated to pay if someone was at fault for the accident?

Subrogation is an area of law that allows an insurer to recoup expenses should a third party be found responsible for the injury or damage in question.

Health insurers say subrogation helps hold down premiums by reimbursing them for their medical costs.

About two weeks after the accident, Robert’s parents — both lawyers — got the EOB informing them of the insurer’s decision.

The note also directed questions to Luper Neidenthal & Logan, a law firm in Columbus, Ohio, that specializes in helping insurers recover medical costs from “third parties,” meaning people found at fault for causing injuries.

The firm’s website boasts that “we collect over 98% of recoverable dollars for the State of Nevada.”

Another letter also dated Aug. 4 soon arrived from HealthScope Benefits, a large administrative firm that processes claims for health plans.

The claim, it said, included billing codes for care “commonly used to treat injuries” related to vehicle crashes, slip-and-fall accidents or workplace hazards. Underlined for emphasis, one sentence warned that the denied claim would not be reconsidered until an enclosed accident questionnaire was filled out.

Adam Woodrum, who happens to be a personal injury attorney, runs into subrogation all the time representing his clients, many of whom have been in car accidents. But it still came as a shock, he said, to have his health insurer deny payment because there was no third party responsible for their son’s ordinary bike accident. And the denial came before the insurer got information about whether someone else was at fault.

“It’s like deny now and pay later,” he said. “You have insurance and pay for years, then they say, ‘This is denied across the board. Here’s your $18,000 bill.’”

Although Adam Woodrum is a personal injury attorney, he says it still came as a shock to have his health insurer deny the claim after his son, Robert, got stitches in July following a bike crash. (Maggie Starbard for KHN)
Woodrum and his son, Robert, get ready to bike near their home in Carson City, Nevada, on Nov. 7. (Maggie Starbard for KHN)

When contacted, the Public Employees’ Benefits Program in Nevada would not comment specifically on Woodrum’s situation, but a spokesperson sent information from its health plan documents. She referred questions to HealthScope Benefits about whether the program’s policy is to deny claims first, then seek more information. The Little Rock, Arkansas-based firm did not return emails asking for comment.

The Nevada health plan’s documents say state legislation allows the program to recover “any and all payments made by the Plan” for the injury “from the other person or from any judgment, verdict or settlement obtained by the participant in relation to the injury.”

Attorney Matthew Anderson at the law firm that handles subrogation for the Nevada health plan said he could not speak on behalf of the state of Nevada, nor could he comment directly on Woodrum’s situation. However, he said his insurance industry clients use subrogation to recoup payments from other insurers “as a cost-saving measure,” because “they don’t want to pass on high premiums to members.”

Despite consumers’ unfamiliarity with the term, subrogation is common in the health insurance industry, said Leslie Wiernik, CEO of the National Association of Subrogation Professionals, the industry’s trade association.

“Let’s say a young person falls off a bike,” she said, “but the insurer was thinking, ‘Did someone run him off the road, or did he hit a pothole the city didn’t fill?’”

Statistics on how much money health insurers recover through passing the buck to other insurers are hard to find. A 2013 Deloitte consulting firm study, commissioned by the Department of Labor, estimated that subrogation helped private health plans recover between $1.7 billion and $2.5 billion in 2010 — a tiny slice of the $849 billion they spent that year.

Medical providers may have reason to hope that bills will be sent through auto or homeowner’s coverage, rather than health insurance, as they’re likely to get paid more.

That’s because auto insurers “are going to pay billed charges, which are highly inflated,” said attorney Ryan Woody, who specializes in subrogation. Health insurers, by contrast, have networks of doctors and hospitals with whom they negotiate lower payment rates.

Resolution: Because of his experience as an attorney, Woodrum felt confident it would eventually all work out. But the average patient wouldn’t understand the legal quagmire and might not know how to fight back.

“I hear the horror stories every day from people who don’t know what it is, are confused by it and don’t take appropriate action,” Woodrum said. “Then they’re a year out with no payment on their bills.” Or, fearing for their credit, they pay the bills.

After receiving the accident questionnaire, Woodrum filled it out and sent it back. There was no liable third party, he said. No driver was at fault.

His child just fell off his bicycle.

HealthScope Benefits reconsidered the claim. It was paid in September, two months after the accident. The hospital received less than half of what it originally billed, based on rates negotiated through his health plan.

The insurer paid $7,414.76 of the cost, and the Woodrums owed $1,853.45, which represented their share of the deductibles and copays.

Adam Woodrum and his son, Robert, bike near their home in Carson City, Nevada, on Nov. 7.(Maggie Starbard for KHN)

The Takeaway: The mantra of Bill of the Month is don’t just write the check. But also don’t ignore scary bills from insurers or hospitals.

It’s not uncommon for insured patients to be questioned on whether their injury or medical condition might have been related to an accident. On some claim forms, there is even a box for the patient to check if it was an accident.

But in the Woodrums’ case, as in others, it was an automatic process. The insurer denied the claim based solely on the medical code indicating a possible accident.

If an insurer denies all payment for all medical care related to an injury, suspect that some type of subrogation is at work.

Don’t panic.

If you get an accident questionnaire, “fill it out, be honest about what happened,” said Sean Domnick, secretary of the American Association for Justice, an organization of plaintiffs lawyers. Inform your insurer and all other parties of the actual circumstances of the injury.

And do so promptly.

That’s because the clock starts ticking the day the medical care is provided and policyholders may face a statutory or contractual requirement that medical bills be submitted within a specific time frame, which can vary.

“Do not ignore it,” said Domnick. “Time and delay can be your enemy.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Why Employers Find It So Hard to Test for COVID

Brandon Hudgins works the main floor at Fleet Feet, a running-shoe store chain, for more than 30 hours a week. He chats with customers, measuring their feet and dashing in and out of the storage area to locate right-sized shoes. Sometimes, clients drag their masks down while speaking. Others refuse to wear masks at all.

So he worries about COVID-19. And with good reason. Across the U.S., COVID hospitalizations and deaths are hitting record-shattering new heights. The nation saw 198,633 new cases on Friday alone.

Unlike in the early days of the pandemic, though, many stores nationwide aren’t closing. And regular COVID-19 testing of those working remains patchy at best.

“I’ve asked, what if someone on staff gets symptoms? ‘You have to stay home,’” said Hudgins, 33, who works in High Point, North Carolina. But as an hourly employee, staying home means not getting paid. “It’s stressful, especially without regular testing. Our store isn’t very big, and you’re in there all day long.”

To the store’s credit, Hudgins said the manager has instituted a locked-door policy, where employees determine which customers can enter. They sanitize the seating area between customers and administer regular employee temperature checks. Still, there’s no talk of testing employees for COVID-19. Fleet Feet did not respond to multiple requests to talk about its testing policies.

The federal Centers for Disease Control and Prevention issued guidance to employers to include COVID testing, and it advised that people working in close quarters be tested periodically. However, the federal government does not require employers to offer those tests.

But the board overseeing the California Division of Occupational Safety and Health, known as Cal/OSHA, on Thursday approved emergency safety rules that are soon likely to require the state’s employers to provide COVID testing to all workers exposed to an outbreak on the job at no cost to the employees. Testing must be repeated a week later, followed by periodic testing.

California would be the first state to mandate this, though the regulation doesn’t apply to routine testing of employees. That is up to individual businesses.

Across the nation, workplaces have been the source of major coronavirus outbreaks: meat-processing plants, grocery stores, farms, schools, Amazon warehouses — largely among the so-called essential workers who bear the brunt of COVID infections and deaths.

The U.S. Occupational Safety and Health Administration inspects workplaces based on workers’ complaints — over 40,000 of which related to COVID-19 have been filed with the agency at the state and federal levels.

Workers “have every right to be concerned,” said Dr. Peter Chin-Hong, an epidemiologist at the University of California-San Francisco. “They are operating in a fog. There is little economic incentive for corporations to figure out who has COVID at what sites.”

Waiting for symptoms to emerge before testing is ill-considered, Chin-Hong noted. People can exhibit no symptoms while spreading the virus. A CDC report found that, among people with active infections, 44% reported no symptoms.

Yet testing alone cannot protect employees. While workplaces can vary dramatically, Chin-Hong emphasized the importance of enforcing safety guidelines like social distancing and wearing face masks, as well as being transparent with workers when someone gets sick.

Molly White, who works for the Missouri state government, was required to return to the office once a week starting in July. But White, who is on drugs to suppress her immune system, feared her employer’s “cavalier attitude toward COVID and casual risk taking.” Masks are encouraged for employees but are not mandatory, and there’s no testing policy or even guidance on where to get tested, she said. White filed for and received an Americans With Disabilities Act exception, which lasts through the end of the year, to avoid coming into the office.

After a cluster of 39 COVID cases emerged in September in the building where she normally works, White was relieved to at least get an email notifying her of the outbreak. A few days later, Gov. Mike Parson visited the building, and he tested positive for COVID-19 soon after.

Following pressure from labor groups, Amazon reported in a blog post last month that almost 20,000 employees had tested positive or been presumed positive for COVID-19 since the pandemic began. To help curb future outbreaks, the online retailing giant, which also owns Whole Foods, built its own testing facilities, hired lab technicians and said it planned to conduct 50,000 daily tests across 650 sites by this month.

The National Football League tests players and other essential workers daily. An NFL spokesperson said the league conducts 40,000 to 45,000 tests a week through New Jersey-based BioReference Laboratories, though both organizations declined to share a price tag. Reports over the summer estimated the season’s testing program would cost about $75 million.

Not all companies, particularly those not in the limelight, have the interest — or the money — to regularly test workers.

“It depends on the company how much they care,” said Gary Glader, president of Horton Safety Consultants in Orland Park, Illinois. Horton works with dozens of companies in the manufacturing, construction and transportation industries to write exposure control plans to limit the risk of COVID-19 outbreaks and avoid OSHA citations. “Some companies could care less about their people, never have.”

IGeneX, a diagnostic testing company in Milpitas, California, gets around 15 calls each day from companies across the country inquiring about its employer testing program. The lab works with about 100 employers — from 10-person outfits to two pro sports teams — mainly in the Bay Area. IGeneX tests its own workers every other week.

One client is Tarana Wireless, a nearby telecommunications company that needs about 30 employees in the office at a time to operate equipment. In addition to monthly COVID tests, the building also gets cleaned every two hours, and masks are mandatory.

“It’s definitely a burden,” said Amy Beck, the company’s director of human resources. “We are venture-backed and have taken pay cuts to make our money extend longer. But we do this to make everyone feel safe. We don’t have unlimited resources.”

IGeneX offers three prices, depending on how fast a company wants the results: $135 for a polymerase chain reaction (PCR) test with a 36- to 48-hour turnaround — down to around $100 a test for some higher-volume clients; one-day testing costs $250, and it’s $400 for a six-hour turnaround.

In some cases, IGeneX is able to bill the companies’ health insurance plan.

“Absolutely, it’s expensive,” said IGeneX spokesperson Joe Sullivan. “I don’t blame anyone for wanting to pay as little as possible. It’s not ‘one and done,’ which companies are factoring in.”

Plus, cheaper, rapid options like Abbott’s antigen test, touted by the Trump administration, have come under fire for being inaccurate.

For those going into work, Chin-Hong recommends that companies test their employees once a week with PCR tests, or twice a week with the less sensitive antigen tests.

Ideally, Chin-Hong said, public health departments would work directly with employers to administer COVID testing and quash potential outbreaks. But, as KHN has reported extensively, these local agencies are chronically underfunded and overworked. Free community testing sites can sometimes take days to weeks to return results, bogged down by extreme demand at commercial labs like Quest Diagnostics and LabCorp and supply chain problems.

Hudgins, who receives his health insurance through North Carolina’s state exchange, tries to get a monthly COVID test at CVS on his own time. But occasionally, his insurance — which requires certain criteria to qualify — has declined to pay for it, he said.

“Being in the service industry in a state where numbers are ridiculously high,” he said in an email, “I see volumes of people every day, and I think getting tested is the smart and considerate thing to do.”

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Public Health States

California Businesses Go From Simmer to Boil Over Newsom’s Fine Dining

California Gov. Gavin Newsom’s maskless dinner with medical industry lobbyists and others at a Napa County restaurant where meals cost a minimum of $350 per head was just about the last straw for some beleaguered California small-business owners.

With their livelihoods on the line, a growing number of them are openly defying the latest orders to shut down as COVID cases skyrocket in California — and pointing to Newsom’s bad behavior.

“We are definitely not complying. We have enough information to make an educated decision: The data do not back another shutdown,” said Miguel Aguilar, founder and owner of Self Made Training Facility, based in Temecula, California, which leases space to physical trainers and nutrition advisers and has 40 locations across 11 states, including 15 in California.

The news of Newsom’s Nov. 6 dinner at the French Laundry in Yountville only strengthened Aguilar’s resolve. “Yes, we all make mistakes, but his apology was pathetic,” Aguilar said. “He told us he was outdoors, but then the photos surfaced. He can attend in-person gatherings, but we can’t? There’s absolutely no trust there.”

New COVID-19 cases and hospitalizations have surged at an alarming rate in California, with a seven-day average of over 11,500 cases Saturday, more than triple the number of a month earlier. Hospitalizations have doubled over the same period, according to the Los Angeles Times, part of a national trend that has pushed total COVID infections in the U.S. above 12 million.

In most California counties, restaurants, fitness clubs, yoga studios, churches, movie theaters and museums that have already been through two previous shutdowns and reopenings since March are once again required to cease indoor operations — just as winter hits. Some are laying off workers for the third time this year.

Add to that the failure of Congress to pass another stimulus package and, in many cases, a preexisting mistrust of government mandates. It all amounts to more disgruntled entrepreneurs.

Larry McNamer, owner of Major’s Diner in the tiny San Diego County community of Pine Valley, said he is continuing to serve people indoors, even though the county closed indoor dining on Nov. 14 in accordance with state regulations. He doesn’t believe the government has the right to impose such an ordinance on him. And, he said, Newsom’s dinner fiasco helped him make his decision to stay open.

“We’re having to deal with all of the lying, the hypocrisy — you’ve got a governor that’s running around ignoring his own mandates,” McNamer said.

McNamer knows the pandemic is real, he said. He is seating only a quarter of his normal indoor capacity and has added distance between tables. But after closing the restaurant from March 15 to May 23, laying off half his employees and falling $200,000 behind on rent and other bills, McNamer isn’t sure how much more his business can take.

Last Wednesday, he was hit with a cease-and-desist order from the county, threatening him with a fine of $1,000 for each offense. San Diego County law enforcement officers are aggressively pursuing violations of public health orders, and the county has issued at least 83 citations to businesses since Nov. 16.

In many other counties, including Riverside, Orange, San Bernardino and Placer, sheriffs and police departments have rejected the COVID ordinances or expressed reluctance to enforce them.

Last week, Newsom announced that 41 of California’s 58 counties — representing 94% of the population — were in the state’s “purple” tier — the most severe of four color-coded risk levels that impose increasingly restrictive limits on business activities. That was up from 13 purple counties the week before.

A few days later, the governor ordered a curfew, requiring people in the purple counties to stay at home between 10 p.m. and 5 a.m. unless they’re performing essential activities, including certain jobs, grocery shopping or going to the doctor.

Los Angeles County went a step further Sunday, banning outdoor dining for at least three weeks. Unlike earlier in the year when that measure was ordered, now no federal financial aid is available to restaurants or their employees. Indoor dining has been shut down in the county for months.

Despite plunging revenue, mounting debt and the frustrating uncertainty of shifting goal posts, many small-business owners are not defying the latest public health restrictions, either out of a sense of responsibility or fear of enforcement actions — or of contracting the virus themselves.

Those who do flout public health ordinances are doing so for a variety of reasons, with economics topping the list.

“There are people who are protecting their employment, protecting their income,” said Vickie Mays, a clinical psychologist and professor of health policy and management at UCLA’s Fielding School of Public Health. “There are no stimulus checks coming. There’s no alternative.”

Many people who own their own businesses “have taken other risks in their lives, and the risks they have taken have paid off, so there’s a belief that despite this risk, you’re not going to get infected,” Mays said.

Many business owners, whether they comply with the health orders or not, believe their industries are being unfairly targeted and that the risk of viral spread in their establishments is not as great as officials say.

Scott Slater, who owns two restaurants in San Diego’s seaside community of La Jolla, said he was frustrated by the public health focus on restaurants when a lot of COVID transmission is happening in private home gatherings.

“We’re a perfect scapegoat,” Slater said. “They can control us, but they can’t control someone’s own home.” He called Newsom’s dinner “a slap in the face” but said he and his wife are complying with the new restrictions, scraping by on catering, takeout and delivery — though he estimates they are $200,000 behind on rent.

Francesca Schuler, CEO of Stockton, California-based In-Shape Health Clubs, which has more than 60 fitness centers and just laid off most of its staff for the third time this year, said gyms should be viewed as part of the solution, not the problem.

“I look at people who are dying of COVID, and it’s people who are overweight, who have high blood pressure or diabetes,” said Schuler, who is respecting the closure orders despite her objection to them. “There are a lot of people who are trying to exercise to stay healthy, yet they shut down gyms while people can still go to tattoo parlors, to McDonald’s and to liquor stores. I just don’t get it.”

Mays, however, said gyms are considered high-risk because “people are breathing hard; they are expelling air further.”

And there are multiple ways people can stay fit without going to a gym, though outdoor exercise can be difficult sometimes because of heat and wildfire smoke, or in high-crime areas.

In many cases, the pandemic restrictions are crushing enterprises small-business owners have struggled to build over a lifetime. They’ve invested their savings, time, sweat and dreams in building something from the ground up, and now it’s threatened.

Aguilar, who owns the training facility company, said he comes from a broken family, was homeless and penniless at age 16 and later got his start giving physical training lessons out of his garage. From that, he built his coast-to-coast chain.

“At this point,” he said, “if I’m going to lose it all, I might as well go down fighting.”

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

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Rural Areas Send Their Sickest Patients to Cities, Straining Hospitals

Registered nurse Pascaline Muhindura has spent the past eight months treating COVID patients at Research Medical Center in Kansas City, Missouri.

But when she returns home to her small town of Spring Hill, Kansas, she’s often stunned by what she sees, like on a recent stop for carryout food.

“No one in the entire restaurant was wearing a mask,” Muhindura said. “And there’s no social distancing. I had to get out, because I almost had a panic attack. I was like, ‘What is going on with people? Why are we still doing this?’”

Many rural communities across the U.S. have resisted masks and calls for social distancing during the coronavirus pandemic, but now rural counties are experiencing record-high infection and death rates.

Critically ill rural patients are often sent to city hospitals for high-level treatment and, as their numbers grow, some urban hospitals are buckling under the added strain.

Kansas City has a mask mandate, but in many smaller communities nearby, masks aren’t required — or masking orders are routinely ignored. In the past few months, rural counties in both Kansas and Missouri have seen some of the highest rates of COVID-19 in the country.

At the same time, according to an analysis by KHN, about 3 in 4 counties in Kansas and Missouri don’t have a single intensive care unit bed, so when people from these places get critically ill, they’re sent to city hospitals.

A recent patient count at St. Luke’s Health System in Kansas City showed a quarter of COVID patients had come from outside the metro area.

Two-thirds of the patients coming from rural areas need intensive care and stay in the hospital for an average of two weeks, said Dr. Marc Larsen, who leads COVID-19 treatment at St. Luke’s.

“Not only are we seeing an uptick in those patients in our hospital from the rural community, they are sicker when we get them because [doctors in smaller communities] are able to handle the less sick patients,” said Larsen. “We get the sickest of the sick.”

Dr. Rex Archer, head of Kansas City’s health department, warns that capacity at the city’s 33 hospitals is being put at risk by the influx of rural patients.

“We’ve had this huge swing that’s occurred because they’re not wearing masks, and yes, that’s putting pressure on our hospitals, which is unfair to our residents that might be denied an ICU bed,” Archer said.

study newly released by the Centers for Disease Control and Prevention showed that Kansas counties that mandated masks in early July saw decreases in new COVID cases, while counties without mask mandates recorded increases.

Hospital leaders have continued to plead with Missouri Republican Gov. Mike Parson, and with Kansas’ conservative legislature, to implement stringent, statewide mask requirements but without success.

Parson won the Missouri gubernatorial election on Nov. 3 by nearly 17 percentage points. Two days later at a COVID briefing, he accused critics of “making the mask a political issue.” He said county leaders should decide whether to close businesses or mandate masks.

“We’re going to encourage them to take some sort of action,” Parson said Thursday. “The holidays are coming and I, as governor of the state of Missouri, am not going to mandate who goes in your front door.”

In an email, Dave Dillon, a spokesperson for the Missouri Hospital Association, agreed that rural patients might be contributing to hospital crowding in cities but argued that the strain on hospitals is a statewide problem.

The reasons for the rural COVID crisis involve far more than the refusal to mandate or wear masks, according to health care experts.

Both Kansas and Missouri have seen rural hospitals close year after year, and public health spending in both states, as in many largely rural states, is far below national averages.

Rural populations also tend to be older and to suffer from higher rates of chronic health conditions, including heart disease, obesity and diabetes. Those conditions can make them more susceptible to severe illness when they contract COVID-19.

Rural areas have been grappling with health problems for a long time, but the coronavirus has been a sort of tipping point, and those rural health issues are now spilling over into cities, explained Shannon Monnat, a rural health researcher at Syracuse University.

“It’s not just the rural health care infrastructure that becomes overwhelmed when there aren’t enough hospital beds, it’s also the surrounding neighborhoods, the suburbs, the urban hospital infrastructure starts to become overwhelmed as well,” Monnat said.

Unlike many parts of the U.S., where COVID trend lines have risen and fallen over the course of the year, Kansas, Missouri and several other Midwestern states never significantly bent their statewide curve.

Individual cities, such as Kansas City and St. Louis, have managed to slow cases, but the continual emergence of rural hot spots across Missouri has driven a slow and steady increase in overall new case numbers — and put an unrelenting strain on the states’ hospital systems.

The months of slow but continuous growth in cases created a high baseline of cases as autumn began, which then set the stage for the sudden escalation of numbers in the recent surge.

“It’s sort of the nature of epidemics that things often look like they’re relatively under control, and then very quickly ramp up to seem that they are out of hand,” said Justin Lessler, an epidemiologist at Johns Hopkins Bloomberg School of Public Health.

Now, a recent local case spike in the Kansas City metro area is adding to the statewide surge in Missouri, with an average of 190 COVID patients per day being admitted to the metro region’s hospitals. The number of people hospitalized throughout Missouri increased by more than 50% in the past two weeks.

Some Kansas City hospitals have had to divert patients for periods of time, and some are now delaying elective procedures, according to the University of Kansas Health system’s chief medical officer, Dr. Steven Stites.

But bed space isn’t the only hospital resource that’s running out. Half of the hospitals in the Kansas City area are now reporting “critical” staffing shortages. Pascaline Muhindura, the nurse who works in Kansas City, said that hospital workers are struggling with anxiety and depression.

“The hospitals are not fine, because people taking care of patients are on the brink,” Muhindura said. “We are tired.”

This story is from a reporting partnership that includes KCUR, NPR and KHN.

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For Nurses Feeling the Strain of the Pandemic, Virus Resurgence Is ‘Paralyzing’

For Christina Nester, the pandemic lull in Massachusetts lasted about three months through summer into early fall. In late June, St. Vincent Hospital had resumed elective surgeries, and the unit the 48-year-old nurse works on switched back from taking care of only COVID-19 patients to its pre-pandemic roster of patients recovering from gallbladder operations, mastectomies and other surgeries.

That is, until October, when patients with coronavirus infections began to reappear on the unit and, with them, the fear of many more to come. “It’s paralyzing, I’m not going to lie,” said Nester, who’s worked at the Worcester hospital for nearly two decades. “My little clan of nurses that I work with, we panicked when it started to uptick here.”

Adding to that stress is that nurses are caught betwixt caring for the bedside needs of their patients and implementing policies set by others, such as physician-ordered treatment plans and strict hospital rules to ward off the coronavirus. The push-pull of those forces, amid a fight against a deadly disease, is straining this vital backbone of health providers nationwide, and that could accumulate to unstainable levels if the virus’s surge is not contained this winter, advocates and researchers warn.

Nurses spend the most sustained time with a patient of any clinician, and these days patients are often incredibly fearful and isolated, said Cynda Rushton, a registered nurse and bioethicist at Johns Hopkins University in Baltimore.

“They have become, in some ways, a kind of emotional surrogate for family members who can’t be there, to support and advise and offer a human touch,” Rushton said. “They have witnessed incredible amounts of suffering and death. That, I think, also weighs really heavily on nurses.”

A study published this fall in the journal General Hospital Psychiatry found that 64% of clinicians working as nurses, nurse practitioners or physician assistants at a New York City hospital screened positively for acute distress, 53% for depressive symptoms and 40% for anxiety — all higher rates than found among physicians screened.

Researchers are concerned that nurses working in a rapidly changing crisis like the pandemic — with problems ranging from staff shortages that curtail their time with patients to enforcing visitation policies that upset families — can develop a psychological response called “moral injury.” That injury occurs, they say, when nurses feel stymied by their inability to provide the level of care they believe patients require.

Dr. Wendy Dean, co-founder of Moral Injury of Healthcare, a nonprofit organization based in Carlisle, Pennsylvania, said, “Probably the biggest driver of burnout is unrecognized unattended moral injury.”

In parts of the country over the summer, nurses got some mental health respite when cases declined, Dean said.

“Not enough to really process it all,” she said. “I think that’s a process that will take several years. And it’s probably going to be extended because the pandemic itself is extended.”

Sense of Powerlessness

Before the pandemic hit her Massachusetts hospital “like a forest fire” in March, Nester had rarely seen a patient die, other than someone in the final days of a disease like cancer.

Suddenly she was involved with frequent transfers of patients to the intensive care unit when they couldn’t breathe. She recounts stories, imprinted on her memory: The woman in her 80s who didn’t even seem ill on the day she was hospitalized, who Nester helped transport to the morgue less than a week later. The husband and wife who were sick in the intensive care unit, while the adult daughter fought the virus on Nester’s unit.

“Then both parents died, and the daughter died,” Nester said. “There’s not really words for it.”

During these gut-wrenching shifts, nurses can sometimes become separated from their emotional support system — one another, said Rushton, who has written a book about preventing moral injury among health care providers. To better handle the influx, some nurses who typically work in noncritical care areas have been moved to care for seriously ill patients. That forces them to not only adjust to a new type of nursing, but also disrupts an often-well-honed working rhythm and camaraderie with their regular nursing co-workers, she said.

At St. Vincent Hospital, the nurses on Nester’s unit were told one March day that the primarily postsurgical unit was being converted to a COVID unit. Nester tried to squelch fears for her own safety while comforting her COVID-19 patients, who were often elderly, terrified and sometimes hard of hearing, making it difficult to communicate through layers of masks.

“You’re trying to yell through all of these barriers and try to show them with your eyes that you’re here and you’re not going to leave them and will take care of them,” she said. “But yet you’re panicking inside completely that you’re going to get this disease and you’re going to be the one in the bed or a family member that you love, take it home to them.”

When asked if hospital leaders had seen signs of strain among the nursing staff or were concerned about their resilience headed into the winter months, a St. Vincent spokesperson wrote in a brief statement that during the pandemic “we have prioritized the safety and well-being of our staff, and we remain focused on that.”

Nationally, the viral risk to clinicians has been well documented. From March 1 through May 31, 6% of adults hospitalized were health care workers, one-third of them in nursing-related occupations, according to data published last month by the Centers for Disease Control and Prevention.

As cases mount in the winter months, moral injury researcher Dean said, “nurses are going to do the calculation and say, ‘This risk isn’t worth it.’”

Juliano Innocenti, a traveling nurse working in the San Francisco area, decided to take off for a few months and will focus on wrapping up his nurse practitioner degree instead. Since April, he’s been seeing a therapist “to navigate my powerlessness in all of this.”

Innocenti, 41, has not been on the front lines in a hospital battling COVID-19, but he still feels the stress because he has been treating the public at an outpatient dialysis clinic and a psychiatric hospital and seen administrative problems generated by the crisis. He pointed to issues such as inadequate personal protective equipment.

Innocenti said he was concerned about “the lack of planning and just blatant disregard for the basic safety of patients and staff.” Profit motives too often drive decisions, he suggested. “That’s what I’m taking a break from.”

Building Resiliency

As cases surge again, hospital leaders need to think bigger than employee assistance programs to backstop their already depleted ranks of nurses, Dean said. Along with plenty of protective equipment, that includes helping them with everything from groceries to transportation, she said. Overstaff a bit, she suggested, so nurses can take a day off when they hit an emotional cliff.

The American Nurses Association, the American Association of Critical-Care Nurses (AACN) and several other nursing groups have compiled online resources with links to mental health programs as well as tips for getting through each pandemic workday.

Kiersten Henry, an AACN board member and nurse practitioner in the intensive care unit at MedStar Montgomery Medical Center in Olney, Maryland, said that the nurses and other clinicians there have started to gather for a quick huddle at the end of difficult shifts. Along with talking about what happened, they share several good things that also occurred that day.

“It doesn’t mean that you’re not taking it home with you,” Henry said, “but you’re actually verbally processing it to your peers.”

When cases reached their highest point of the spring in Massachusetts, Nester said there were some days she didn’t want to return.

“But you know that your friends are there,” she said. “And the only ones that really truly understand what’s going on are your co-workers. How can you leave them?”

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Public Health

New Legal Push Aims to Speed Magic Mushrooms to Dying Patients

Back in March, just as anxiety over COVID-19 began spreading across the U.S., Erinn Baldeschwiler of La Conner, Washington, found herself facing her own private dread.

Just 48 and the mother of two teenagers, Baldeschwiler was diagnosed with stage 4 metastatic breast cancer after discovering a small lump on her chest, no bigger than a pea. Within weeks, it was the size of a golf ball, angry and red. Doctors gave her two years to live.

“It’s heartbreaking,” she said. “Frankly, I was terrified.”

But instead of retreating into her illness, Baldeschwiler is pouring energy into a new effort to help dying patients gain legal access to psilocybin — the mind-altering compound found in so-called magic mushrooms — to ease their psychic pain.

“I have personally struggled with depression, anxiety, anger,” Baldeschwiler said. “This therapy is designed to really dive in and release these negative fears and shadows.”

Dr. Sunil Aggarwal, a Seattle palliative care physician, and Kathryn Tucker, a lawyer who advocates on behalf of terminally ill patients and chairs a psychedelic practice group at Emerge Law Group, are championing a novel strategy that would make psilocybin available using state and federal “right-to-try” laws that allow terminally ill patients access to investigational drugs.

They contend that psilocybin — whether found in psychedelic mushrooms or synthetic copies — meets the criteria for use laid out by more than 40 states and the 2017 Right to Try Act approved by the Trump administration.

“Can you look at the statute and see by its terms that it applies to psilocybin?” Tucker said. “I think the answer is yes.”

Still, the pair admit they’re pushing a legal theory still untested in the courts. “This is untrodden ground,” Aggarwal said.

This month, Aggarwal, who works at the Advanced Integrative Medical Science Institute, known as AIMS, took the first step toward federal authorization of the substance in Washington state and perhaps across the nation. He submitted an application to manufacture psilocybin to the state’s Pharmacy Quality Assurance Commission, which would allow him to grow psilocybin mushrooms from spores at his clinic and administer them for therapeutic use.

Commission members haven’t yet reviewed the application, but Gordon MacCracken, an agency spokesperson, said there “would be a path” for possible license and use — if the application meets the requirements of state regulators and the federal Drug Enforcement Administration.

Currently, psilocybin use is illegal under federal law, classified as a Schedule 1 drug under the U.S. Controlled Substances Act, which applies to chemicals and substances with no accepted medical use and a high potential for abuse, such as heroin and LSD.

Recently, however, several U.S. cities and states have voted to decriminalize possession of small amounts of psilocybin. This month, Oregon became the first state to legalize psilocybin for regulated use in treating intractable mental health problems. The first patients will have access beginning in January 2023.

It’s part of a wider movement to rekindle acceptance of psilocybin, which was among psychedelic drugs vilified — and ultimately banned — after the legendary counterculture excesses of the 1960s and 1970s.

“I think a lot of those demons, those fears, have been metabolized in the 50 years since then,” Aggarwal said. “Not completely, but we’ve moved it along so that it’s safe to try again.”

He points to a growing body of evidence that finds that psilocybin can have significant and lasting effects on psychological distress. The Johns Hopkins Center for Psychedelic and Consciousness Research, launched this year, has published dozens of peer-reviewed studies based on two decades of research. They include studies confirming that psilocybin helped patients grappling with major depressive disorder, thoughts of suicide and the emotional repercussions of a cancer diagnosis.

Psilocybin therapy appears to work by chemically altering brain function in a way that temporarily affects a person’s ego, or sense of self. In essence, it plays on the out-of-body experiences made famous in portrayals of America’s psychedelic ’60s.

By getting out of their heads — and separating from all the fear and emotion surrounding death — people experience “being” as something distinct from their physical forms. That leads to a fundamental shift in perspective, said Dr. Ira Byock, a palliative care specialist and medical officer for the Institute for Human Caring at Providence St. Joseph Health.

“What psychedelics do is foster a frame shift from feeling helpless and hopeless and that life is not worth living to seeing that we are connected to other people and we are connected to a universe that has inherent connection,” he said.

“Along with that shift in perspective, there is very commonly a notable dissolution of the fear of dying, of nonexistence and of loss, and that’s just remarkable.”

The key is to offer the drugs under controlled conditions, in a quiet room supervised by a trained guide, Byock said. “It turned out they are exceedingly safe when used in a carefully screened, carefully guided situation with trained therapists,” he said. “Almost the opposite is true when used in an unprepared, unscreened population.”

Baldeschwiler is one of many cancer patients eager to undergo psilocybin therapy to help quell the psychic pain that can accompany a terminal illness. Advocates say the therapy appears to work by temporarily altering brain function in a way that affects a person’s sense of self, helping them separate from the fear and emotion surrounding death.(Dan DeLong for KHN )

Baldeschwiler is one of several AIMS cancer patients eager to undergo psilocybin therapy. Another is Michal Bloom, 64, of Seattle, who was diagnosed in 2017 with stage 3 ovarian cancer. The anxiety of living with the terminal disease is overwhelming, she said.

“It’s as if someone came up to you, put a gun to the back of your head, whispered, ‘I have a gun to your head and I’ll have a gun to your head for the rest of your life. I may pull the trigger, I may not,’” she said. “How do you live like that?”

Research shows that a single six-hour session of psilocybin therapy may be enough to quell that fear, Aggarwal said. “I’m really interested in a right-to-try approach because it’s really what we need for patients right now,” he said.

Under the state and federal laws, to be eligible for “right-to-try” status, a treatment must have completed a phase 1 clinical trial approved by the federal Food and Drug Administration, be part of active clinical trials and in ongoing development or production.

So far, psilocybin ticks all those boxes, Tucker said.

The FDA has granted “breakthrough therapy” status to psilocybin for use in U.S. clinical trials conducted by Compass Pathways, a psychedelic research group in Britain, and by the Usona Institute, a nonprofit medical research group in Wisconsin. More than three dozen trials are recruiting participants or completed, federal records show.

But access to the drug remains a hurdle. Though psychedelic mushrooms grow wild in the Pacific Northwest and underground sources of the drug are available, finding a legal supply is nearly impossible.

Tucker and Aggarwal asked Usona last summer for a supply of the synthetic psilocybin its researchers produce for clinical trials, but so far have received nothing. Penny Patterson, a Usona spokesperson, said there’s been no “definitive resolution” and that conversations are continuing.

The firm’s reluctance may reflect a larger unease with employing right-to-try laws to speed use of psilocybin, said Dr. Anthony Back, a palliative care physician at the University of Washington.

Back supports the use of psilocybin for cancer patients and has even tried the drug to better understand the experience. But he said using psilocybin outside of formal clinical trials might endanger Usona’s ability to get traditional FDA approval. Adverse events may occur that will have to be reported to the FDA, an agency already watching the research closely.

“I can see why they’re hesitant, to be honest,” Back said. “I think right-to-try is an uphill battle.”

Still, Tucker and other advocates say it’s a battle worth fighting. End of Life Washington, a group focused on helping terminally ill patients use the state’s Death With Dignity Act, recently published a policy that supports psilocybin therapy as a form of palliative care. Other treatments for anxiety and depression, such as medication and counseling, may simply not be practical or effective at that point, said Judith Gordon, a psychologist and member of the group’s board of directors.

“When people are dying, they don’t have the time or the energy to do a lot of psychotherapy,” she said.

Baldeschwiler agrees. With perhaps less than two years to live, she wants access to any tool that can ease her pain. Immunotherapy has helped with the physical symptoms, dramatically shrinking the size of the tumor on her chest. Harder to treat has been the gnawing anxiety that she won’t see her 16-year-old daughter, Shea McGinnis, and 13-year-old son, Gibson McGinnis, become adults.

“They are beautiful children, good spirits,” she said. “To know I might not be around for them sucks. It’s really hard.”

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Mental Health Pharmaceuticals States

Medicare Open Enrollment Is Complicated. Here’s How to Get Good Advice.

If you’ve been watching TV lately, you may have seen actor Danny Glover or Joe Namath, the 77-year-old NFL legend, urging you to call an 800 number to get fabulous extra benefits from Medicare.

There are plenty of other Medicare ads, too, many set against a red-white-and-blue background meant to suggest officialdom — though if you stand about a foot from the television screen, you might see the fine print saying they are not endorsed by any government agency.

Rather, they are health insurance agents aggressively vying for a piece of a lucrative market.

This is what Medicare’s annual enrollment period has come to. Beneficiaries — people who are 65 or older, or with long-term disabilities — have until Dec. 7 to join, switch or drop health or drug plans, which take effect Jan. 1. By switching plans, they can potentially save money or get benefits not ordinarily provided by the federal insurance program.

For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.

The right choice for you depends on your financial wherewithal and current health status, and on future health scenarios that are often difficult to foresee and unpleasant to contemplate.

Costs and benefits among the multitude of competing Medicare plans vary widely, and the maze of rules and other details can be overwhelming. Indeed, information overload is part of the reason a majority of the more than 60 million people on Medicare, including over 6 million in California, do not comparison-shop or switch to more suitable plans.

“I’ve been doing it for 33 years and my head still spins,” says Jill Selby, corporate vice president of strategic initiatives and product development at SCAN, a Long Beach nonprofit that is one of California’s largest purveyors of Medicare managed care, known as Medicare Advantage. “It’s definitely a college course.”

Which explains why airwaves and mailboxes are jammed with all that promotional material from people offering to help you pass the course.

Many are touting Medicare Advantage, which is administered by private health insurers. It might save you money, but not necessarily, and research suggests that, in some cases, it costs the government more than administering traditional Medicare.

But the hard marketing is not necessarily a sign of bad faith. Licensed insurance agents want the nice commission they get when they sign somebody up, but they can also provide valuable information on the bewildering nuances of Medicare.

Industry insiders and outside experts agree most people should not navigate Medicare alone. “It’s just too complicated for the average individual,” says Mark Diel, chief executive officer of California Coverage and Health Initiatives, a statewide association of local outreach and health care enrollment organizations.

However, if you decide to consult with an insurance agent, keep your antenna up. Ask people you trust to recommend agents, or try eHealth or another established online brokerage. Vet any agent you choose by asking questions on the phone.

“Be careful if you feel like the insurance agent is pushing you to make a decision,” says Andrew Shea, senior vice president of marketing at eHealth. And if in doubt, don’t hesitate to get a second opinion, Shea counsels.

You can also talk to a Medicare counselor through one of the State Health Insurance Assistance Programs, which are present in every state. Find your state’s SHIP at www.shiptacenter.org.

Medicare & You, a comprehensive handbook, is worth reading. Download it at the official Medicare website, www.medicare.gov.

The website offers a deep dive into all aspects of Medicare. If you type in your ZIP code, you can see and compare all the Medicare Advantage plans, supplemental insurance plans, known as Medigap, and stand-alone drug (Part D) plans.

The site also shows you quality ratings of the plans, on a five-star scale. And it will display your drug costs under each plan if you type in all your prescriptions. Explore the website before you talk to an insurance agent.

California Coverage and Health Initiatives can refer you to licensed insurance agents who will provide local advice and enrollment assistance. Call 833-720-2244. Its members specialize in helping people who are eligible for both Medicare and Medicaid, the health insurance program for low-income people.

These so-called dual eligibles — nearly 1.5 million in California and about 12 million nationwide — get additional benefits, and in some cases they don’t have to pay Medicare’s monthly medical (Part B) premium, which will be $148.50 in 2021 for most beneficiaries, but higher for people above certain income thresholds.

If you choose traditional Medicare, consider a Medigap supplement if you can afford it. Without it, you’re liable for 20% of your physician and outpatient costs and a hefty hospital deductible, with no cap on how much you pay out of your own pocket. If you need prescription drugs, you’ll probably want a Part D plan.

Medicare Advantage, by contrast, is a one-stop shop. It usually includes a drug benefit in addition to other Medicare benefits, with cost sharing for services and prescriptions that varies from plan to plan. Medicare Advantage plans typically have low to no premiums — aside from the Part B premium that most people pay in either version of Medicare. And they increasingly offer additional benefits, including vision, dental, transportation, meal deliveries and even coverage while traveling abroad.

Beware of the risks, however.

Yes, the traditional Medicare route is generally more expensive upfront if you want to be fully covered. That’s because you pay a monthly premium for a Medigap policy, which can cost $200 or more. Add to that the premium for Part D, estimated to average $41 a month in 2021, according to KFF. (KHN is an editorially independent program of KFF.)

However, Medigap policies will often protect you against large medical bills if you need lots of care.

In some cases, Medicare Advantage could end up being more expensive if you get seriously ill or injured, because copays can quickly add up. They are typically capped each year, but can still cost you thousands of dollars. Advantage plans also typically have more limited provider networks, and the extra benefits they offer can be subject to restrictions.

Over one-third of Medicare beneficiaries nationally are enrolled in Advantage plans. In California, about 40% are.

The main appeal of traditional Medicare is that it doesn’t have the rules and restrictions of managed care.

Dr. Mark Kalish, a retired psychiatrist in San Diego, says he opted for traditional fee-for-service with Medigap and Part D because he didn’t want a “mother may I” plan.

“I’m 69 years old, so heart attacks happen; cancer happens. I want to be able to pick my own doctor and go where I want,” Kalish says. “I’ve done well, so the money isn’t an issue for me.”

Be aware that if you don’t join a Medigap plan during a six-month open enrollment period that begins when you enroll in Medicare Part B, you could be denied coverage for a preexisting condition if you try to buy one later.

There are a few exceptions to that in federal law, and four states — New York, Massachusetts, Maine, Connecticut — require continuous or yearly access to Medigap coverage regardless of health status.

Make sure you understand the rules and exceptions that apply to you.

Indeed, that is an excellent rule of thumb for all Medicare beneficiaries. Read up and talk to insurance agents and Medicare counselors. Talk to friends, family members, your doctor, your health plan — and other health plans.

When it comes to Medicare, says Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, “it takes a village.”

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

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Need a COVID-19 Nurse? That’ll Be $8,000 a Week

DENVER — In March, Claire Tripeny was watching her dream job fall apart. She’d been working as an intensive care nurse at St. Anthony Hospital in Lakewood, Colorado, and loved it, despite the mediocre pay typical for the region. But when COVID-19 hit, that calculation changed.

She remembers her employers telling her and her colleagues to “suck it up” as they struggled to care for six patients each and patched their protective gear with tape until it fully fell apart. The $800 or so a week she took home no longer felt worth it.

“I was not sleeping and having the most anxiety in my life,” said Tripeny. “I’m like, ‘I’m gonna go where my skills are needed and I can be guaranteed that I have the protection I need.’”

In April, she packed her bags for a two-month contract in then-COVID hot spot New Jersey, as part of what she called a “mass exodus” of nurses leaving the suburban Denver hospital to become traveling nurses. Her new pay? About $5,200 a week, and with a contract that required adequate protective gear.

Months later, the offerings — and the stakes — are even higher for nurses willing to move. In Sioux Falls, South Dakota, nurses can make more than $6,200 a week. A recent posting for a job in Fargo, North Dakota, offered more than $8,000 a week. Some can get as much as $10,000.

Early in the pandemic, hospitals were competing for ventilators, COVID tests and personal protective equipment. Now, sites across the country are competing for nurses. The fall surge in COVID cases has turned hospital staffing into a sort of national bidding war, with hospitals willing to pay exorbitant wages to secure the nurses they need. That threatens to shift the supply of nurses toward more affluent areas, leaving rural and urban public hospitals short-staffed as the pandemic worsens, and some hospitals unable to care for critically ill patients.

“That is a huge threat,” said Angelina Salazar, CEO of the Western Healthcare Alliance, a consortium of 29 small hospitals in rural Colorado and Utah. “There’s no way rural hospitals can afford to pay that kind of salary.”

Surge Capacity

Hospitals have long relied on traveling nurses to fill gaps in staffing without committing to long-term hiring. Early in the pandemic, doctors and nurses traveled from unaffected areas to hot spots like California, Washington state and New York to help with regional surges. But now, with virtually every part of the country experiencing a surge — infecting medical professionals in the process — the competition for the finite number of available nurses is becoming more intense.

“We all thought, ‘Well, when it’s Colorado’s turn, we’ll draw on the same resources; we’ll call our surrounding states and they’ll send help,’” said Julie Lonborg, a spokesperson for the Colorado Hospital Association. “Now it’s a national outbreak. It’s not just one or two spots, as it was in the spring. It’s really significant across the country, which means everybody is looking for those resources.”

In North Dakota, Tessa Johnson said she’s getting multiple messages a day on LinkedIn from headhunters. Johnson, president of the North Dakota Nurses Association, said the pandemic appears to be hastening a brain drain of nurses there. She suspects more nurses may choose to leave or retire early after North Dakota Gov. Doug Burgum told health care workers to stay on the job even if they’ve tested positive for COVID-19.

All four of Utah’s major health care systems have seen nurses leave for traveling nurse positions, said Jordan Sorenson, a project manager for the Utah Hospital Association.

“Nurses quit, join traveling nursing companies and go work for a different hospital down the street, making two to three times the rate,” he said. “So, it’s really a kind of a rob-Peter-to-pay-Paul staffing situation.”

Hospitals not only pay the higher salaries offered to traveling nurses but also pay a commission to the traveling nurse agency, Sorenson said. Utah hospitals are trying to avoid hiring away nurses from other hospitals within the state. Hiring from a neighboring state like Colorado, though, could mean Colorado hospitals would poach from Utah.

“In the wake of the current spike in COVID hospitalizations, calling the labor market for registered nurses ‘cutthroat’ is an understatement,” said Adam Seth Litwin, an associate professor of industrial and labor relations at Cornell University. “Even if the health care sector can somehow find more beds, it cannot just go out and buy more front-line caregivers.”

Litwin said he’s glad to see the labor market rewarding essential workers — disproportionately women and people of color — with higher wages. Under normal circumstances, allowing markets to determine where people will work and for what pay is ideal.

“On the other hand, we are not operating under normal circumstances,” he said. “In the midst of a severe public health crisis, I worry that the individual incentives facing hospitals on the one side and individual RNs on the other conflict sharply with the needs of society as whole.”

Some hospitals are exploring ways to overcome staffing challenges without blowing the budget. That could include changing nurse-to-patient ratios, although that would likely affect patient care. In Utah, the hospital association has talked with the state nursing board about allowing nursing students in their final year of training to be certified early.

Growth Industry

Meanwhile business is booming for companies centered on health care staffing such as Wanderly and Krucial Staffing.

“When COVID first started and New York was an epicenter, we at Wanderly kind of looked at it and said, ‘OK, this is our time to shine,’” said David Deane, senior vice president of Wanderly, a website that allows health care professionals to compare offers from various agencies. “‘This is our time to help nurses get to these destinations as fast as possible. And help recruiters get those nurses.’”

Deane said the company has doubled its staff since the pandemic started. Demand is surging — with Rocky Mountain states appearing in up to 20 times as many job postings on the site as in January. And more people are meeting that demand.

In 2018, according to data from a national survey, about 31,000 traveling nurses worked nationwide. Now, Deane estimated, there are at least 50,000 travel nurses. Deane, who calls travel nurses “superheroes,” suspects a lot of them are postoperative nurses who were laid off when their hospitals stopped doing elective surgeries during the first lockdowns.

Competition for nurses, especially those with ICU experience, is stiff. After all, a hospital in South Dakota isn’t competing just with facilities in other states.

“We’ve sent nurses to Aruba, the Bahamas and Curacao because they’ve needed help with COVID,” said Deane. “You’re going down there, you’re making $5,000 a week and all your expenses are paid, right? Who’s not gonna say yes?”

Krucial Staffing specializes in sending health care workers to disaster locations, using military-style logistics. It filled hotels and rented dozens of buses to get nurses to hot spots in New York and Texas. CEO Brian Cleary said that, since the pandemic started, the company has grown its administrative staff from 12 to more than 200.

“Right now we’re at our highest volume we’ve been,” said Cleary, who added that over Halloween weekend alone about 1,000 nurses joined the roster of “reservists.”

With a base rate of $95 an hour, he said, some nurses working overtime end up coming away with $10,000 a week, though there are downsides, like the fact that the gig doesn’t come with health insurance and it’s an unstable, boom-and-bust market.

Hidden Costs

Amber Hazard, who lives in Texas, started as a traveling ICU nurse before the pandemic and said eye-catching sums like that come with a hidden fee, paid in sanity.

“How your soul is affected by this is nothing you can put a price on,” she said.

At a high-paying job caring for COVID patients during New York’s first wave, she remembers walking into the break room in a hospital in the Bronx and seeing a sign on the wall about how the usual staff nurses were on strike.

“It said, you know, ‘We’re not doing this. This is not safe,’” said Hazard. “And it wasn’t safe. But somebody had to do it.”

The highlight of her stint there was placing a wedding ring back on the finger of a recovered patient. But Hazard said she secured far more body bags than rings on patients.

Tripeny, the traveling nurse who left Colorado, is now working in Kentucky with heart surgery patients. When that contract wraps up, she said, she might dive back into COVID care.

Earlier, in New Jersey, she was scarred by the times she couldn’t give people the care they needed, not to mention the times she would take a deceased patient off a ventilator, staring down the damage the virus can do as she removed tubes filled with blackened blood from the lungs.

She has to pay for mental health therapy out-of-pocket now, unlike when she was on staff at a hospital. But as a so-called traveler, she knows each gig will be over in a matter of weeks.

At the end of each week in New Jersey, she said, “I would just look at my paycheck and be like, ‘OK. This is OK. I can do this.’”

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Health Industry Public Health States

Consejos para inscribirse bien en Medicare durante la complicada inscripción abierta

Puede que hayas visto al actor Danny Glover o a Joe Namath, la leyenda de la NFL de 77 años, en comerciales de TV animándote a que llames a un número 800 para obtener fabulosos beneficios extra de Medicare.

Hay muchos otros anuncios de Medicare, algunos de ellos con un fondo rojo, blanco y azul para sugerir que son oficiales; aunque si te acercas a la pantalla del televisor, podrás ver que la letra chica dice que no están respaldados por ninguna agencia del gobierno.

En realidad, son agentes de seguros de salud compitiendo agresivamente por un pedazo de un mercado lucrativo.

A esto es a lo que ha llegado el período de inscripción anual de Medicare. Los beneficiarios —personas de 65 años o más, o con discapacidades a largo plazo— tienen hasta el 7 de diciembre para participar, cambiar o dejar los planes de salud o de medicamentos, que entran en vigencia el 1 de enero.

Al cambiar de plan, se podría ahorrar dinero o conseguir beneficios que normalmente no ofrece el programa federal.

A pesar de toda su complejidad y de sus opciones casi infinitas, Medicare se reduce fundamentalmente a dos alternativas: la clásica tarifa por servicio del Medicare Tradicional o el enfoque de atención administrada de Medicare Advantage.

La elección correcta para cada uno depende de los recursos financieros y del estado de salud, así como de los futuros escenarios de atención médica que a menudo son difíciles de pronosticar.

Los costos y beneficios entre la multitud de planes de Medicare que compiten entre sí varían, y el laberinto de normas y otros detalles puede resultar abrumador.

De hecho, la sobrecarga de información explica, en parte, porqué la mayoría de las más de 60 millones de personas que tienen Medicare, incluidos más de 6 millones en California, no hacen comparaciones ni se cambian a planes más adecuados.

“LLevo haciendo esto 33 años y mi cabeza todavía da vueltas”, dijo Jill Selby, vicepresidenta de iniciativas estratégicas y desarrollo de productos de SCAN, una organización sin fines de lucro de Long Beach que es una de las mayores proveedoras de cuidados administrados de Medicare de California, conocida como Medicare Advantage. “Definitivamente es un curso universitario”.

Esta es la razón por la que los medios de comunicación y los buzones de los correos electrónicos se abarrotan con publicidad de gente que se ofrece a ayudarle a aprobar “el curso”.

Muchos promocionan Medicare Advantage, que es administrado por aseguradoras de salud privadas. Puede que se ahorre dinero, pero no necesariamente, y las investigaciones sugieren que, en algunos casos, le cuesta al gobierno más que administrar el Medicare tradicional.

Pero el marketing no es necesariamente un signo de mala fe. Los agentes de seguros autorizados buscan la buena comisión que reciben cuando contratan a alguien, pero también pueden proporcionar información valiosa sobre los desconcertantes matices de Medicare.

Los conocedores de la industria y los expertos coinciden en que la mayoría de las personas no debería navegar solas por Medicare. “Es demasiado complicado”, asegura Mark Diel, director ejecutivo de California Coverage and Health Initiatives, una asociación estatal de organizaciones de alcance local y de inscripción en el cuidado de la salud.

Pero si la decisión es consultar con un agente de seguros, hay que mantenerse alerta. Pídeles a personas de confianza que te recomienden agentes, o visita eHealth o cualquier otra agencia en línea establecida. Pon a prueba al agente que elijas haciéndole preguntas por teléfono.

“Tenga cuidado si siente que el agente de seguros lo está presionando para que tome una decisión”, advierte Andrew Shea, vicepresidente de marketing de eHealth. Y si tienes dudas, busca una segunda opinión, aconseja Shea.

También puedes hablar con un consejero de Medicare a través de uno de los Programas Estatales de Asistencia de Seguros de Salud (SHIP), presentes en todos los estados. Encuentra el SHIP de su estado en www.shiptacenter.org.

Vale la pena leer Medicare & You, un manual completo. Descárgalo en el sitio web oficial de Medicare, www.medicare.gov.

El sitio web ofrece una inmersión profunda en todos los aspectos de Medicare. Si escribes tu código postal, puedes ver y comparar todos los planes de Medicare Advantage, los planes de seguro suplementario, conocidos como Medigap, y los planes de medicamentos (Parte D).

El sitio también te muestra las calificaciones de calidad de los planes, en una escala de cinco estrellas. Y los costos de tus medicamentos en cada plan. Explora el sitio web antes de hablar con un agente de seguros.

California Coverage y Health Initiatives puede remitirte a agentes de seguros autorizados que te proporcionarán asesoramiento local y asistencia para la inscripción. Llama al 833-720-2244. Sus miembros se especializan en ayudar a quienes son elegibles tanto para Medicare como para Medicaid, el programa de seguro de salud para personas de bajos ingresos.

Los llamados elegibles duales —casi 1.5 millones en California y cerca de 12 millones en todo el país— obtienen beneficios adicionales, y en algunos casos no tienen que pagar la prima médica mensual de Medicare (Parte B), que será de $148.50 en 2021 para la mayoría de los beneficiarios, pero más alta para las personas que superan ciertos umbrales de ingresos.

Si eliges el Medicare tradicional, considera un suplemento de Medigap si puedes pagarlo. Sin él, serás responsable del 20% de los costos de tu médico y de servicios ambulatorios, así como un elevado deducible de hospital, sin un límite a lo que pagas de tu propio bolsillo. Si necesitas medicamentos recetados, probablemente convendrá un plan de la Parte D.

Por su parte, Medicare Advantage es una ventanilla única. Por lo general, incluye un beneficio de medicamentos además de otros beneficios de Medicare, con un costo compartido para servicios y recetas que varía de un plan a otro. Los planes de Medicare Advantage suelen tener primas bajas o nulas, aparte de la prima de la Parte B que la mayoría de las personas paga en cualquiera de las dos versiones de Medicare. Y cada vez más ofrecen servicios adicionales, incluyendo visión, dental, transporte, entrega de comidas e incluso cobertura en el extranjero.

Pero ten cuidado con los riesgos.

Sí, la ruta tradicional de Medicare suele ser más cara al principio si deseas estar totalmente cubierto. Eso se debe a que pagas una prima mensual por una póliza Medigap, que puede costar $200 o más. Añade a eso la prima de la Parte D, estimada en un promedio de $41 al mes en 2021, según KFF. (KHN es un programa editorialmente independiente de KFF.)

Sin embargo, las pólizas Medigap a menudo te protegerán contra grandes facturas médicas si necesitas muchos cuidados.

En algunos casos, Medicare Advantage podría terminar siendo más caro si te enferma o lesionas gravemente, porque los copagos pueden sumar rápidamente. Por lo general, tienen un límite máximo cada año, pero aun así pueden costarte miles de dólares. Los planes Advantage también suelen tener redes de proveedores más limitadas, y los beneficios adicionales que ofrecen pueden estar sujetos a restricciones.

Más de un tercio de los beneficiarios de Medicare a nivel nacional están inscritos en los planes Advantage. En California, alrededor del 40%.

El principal atractivo del Medicare tradicional es que no tiene las reglas y restricciones de la atención médica administrada.

El doctor Mark Kalish, un psiquiatra retirado de San Diego, dijo que optó por el tradicional pago por servicio con Medigap y la Parte D porque no quería un plan en que tuviera que “pedir permiso”.

“Tengo 69 años, así que los ataques al corazón ocurren; el cáncer ocurre. Quiero poder elegir mi propio médico e ir a donde quiera”, señala Kalish. “Me ha ido bien en la vida, así que el dinero no es un problema para mí”.

Ten en cuenta que si no te inscribes en un plan Medigap durante el período de inscripción abierta de seis meses, que comienza cuando te inscribes en la Parte B de Medicare, se te podría negar la cobertura de una condición preexistente si intentas comprar una más tarde.

Hay algunas excepciones a esto en la ley federal, y cuatro estados —Nueva York, Massachusetts, Maine, Connecticut— exigen el acceso continuo o anual a la cobertura Medigap sin importar el estado de salud.

Asegúrate de entender las reglas y excepciones que aplican en tu caso.

De hecho, esa es una excelente regla general para todos los beneficiarios de Medicare. Lee y habla con los agentes de seguros y los consejeros de Medicare. Habla con amigos, familiares, tu médico, tu plan y otros planes de salud.

Cuando se trata de Medicare, dijo Erin Trish, directora adjunta del Centro Schaeffer de Política y Economía de la Salud de la Universidad del Sur de California, “se necesita de una comunidad”.

Esta historia de KHN fue publicada primero en California Healthline, un servicio de la California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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California Law Banning Toxic Chemicals in Cosmetics Will Transform Industry

A toxic chemical ban signed into law in California will change the composition of cosmetics, shampoos, hair straighteners and other personal care products used by consumers across the country, industry officials and activists say.

The ban, signed by Gov. Gavin Newsom at the end of September, covers 24 chemicals, including mercury, formaldehyde and several types of per- and polyfluoroalkyl substances, known as PFAS. All the chemicals are carcinogenic or otherwise toxic — and advocates argue they have no place in beauty products.

When the law takes effect in 2025, it will mark the first major action to remove toxic substances from beauty products in almost a century. Federal regulation of cosmetics has not been updated meaningfully since 1938, and only 11 ingredients in personal care products are regulated by the Food and Drug Administration. By contrast, the European Union bans more than 1,600 cosmetic substances and ingredients from cosmetics.

The California law, passed by wide margins in both houses of the legislature, “is a milestone for cosmetic safety in the United States,” said Emily Rusch, executive director of the California Public Interest Research Group, which was heavily involved in shaping the bill.

The Personal Care Products Council, which represents big companies like Amway and Chanel, was hesitant but eventually supported the bill and worked directly with legislators on its final form. The industry’s buy-in will help give the California law national repercussions.

“If you’re doing business in the United States, you’re doing business in California,” said Mike Thompson, senior vice president for government affairs at the council. “I would assume that this would really, in many ways, set up a new standard.”

Breast Cancer Prevention Partners, another activist group, advocated strongly for the measure because many of the banned chemicals have been linked to breast cancer, said Janet Nudelman, the group’s director of program and policy.

For salon workers like Kristi Ramsburg, the bill could offer the peace of mind that comes from knowing her workplace is freer of toxics. Over the 20 years she’s worked as a hairdresser in Wilmington, North Carolina, Ramsburg has done hundreds of straightening jobs on her clients’ naturally frizzy hair. Performing the procedure known as a Brazilian Blowout three to four times a week exposed her to harsh and dangerous/toxic products including formaldehyde and phthalates.

She experienced “sore throats, dizziness. My vision changed, definitely,” she said. “You’d be almost crying at first.”

Studies dating to the early 1900s show that inhaling even small quantities of formaldehyde can lead to pneumonia or swelling of the liver. It’s been classified as a carcinogen, according to the FDA.

Ramsburg believes her exposure severely damaged her health. Over six years, she had surgeries to remove her gallbladder, ovaries and appendix. After her liver swelled dangerously, she suspected, based on medical consults and studies she read, that the formaldehyde she had been breathing for decades was to blame.

“I was just inundated with toxins constantly. I literally almost died,” she said.

Horror stories like Ramsburg’s are what motivated legislators, as well as the cosmetic industry, to support the California law.

Federal legislation that would have given the FDA more power to control or recall products containing the 11 federally regulated ingredients failed to gain traction in either chamber in recent sessions, despite the support of celebrities like Kourtney Kardashian.

Advocates say the inadequacies in federal regulation have been apparent for years. Current law does not require cosmetics to be reviewed and approved by the FDA before being sold to consumers. And the agency can take post-marketing action only if a cosmetic’s ingredients were found to be tampered with or its labeling is wrong or misleading.

The FDA couldn’t even intervene when asbestos was found in cosmetics sold at the youth-oriented Claire’s and Justice stores. In a 2019 letter, then-FDA Commissioner Scott Gottlieb wrote that his hands were tied because “there are currently no legal requirements for any cosmetic manufacturer marketing products to American consumers to test their products for safety.” No action was taken.

FDA scientists moved to ban formaldehyde from hair straighteners as early as 2016, according to internal agency emails, but weren’t successful. A 2019 study by government investigators found that using hair straighteners was linked with a higher risk of breast cancer, which rose with increased use. The study also found that using permanent hair dye was linked with an increased breast cancer risk.

After the federal legislation stalled, advocates changed their focus to California. The Golden State’s liberal leanings made it a likely place to pass a bill, while its status as the world’s fifth-largest economy meant any new law would have national impact. That has previously been the case, as when California set its own limits on car emissions or demanded nutrition labels for restaurant menus.

“It plays that pivotal role nationwide and has such a large economy, and so much of the cosmetic industry has a huge base here,” said Rusch, of the California Public Interest Research Group. “This type of landmark legislation has the effect essentially of setting a national standard. That was our intent.”

The Personal Care Products Council was open to the ban since the chemicals on the list — after some pruning during negotiations on the bill — include only those already prohibited in the European Union.

“You don’t want a patchwork of rules, either around the country or around the world. You want consistency,” Thompson said. “A lot of our companies may be already there, because they’re designing products for the European Union. … It’s just simpler for them to put out one product versus two.”

In recent years, growing consumer demand for transparency in beauty products has led to the development of a “clean cosmetics industry” whose products make up about 13% of high-end sales, double the percentage four years ago, according to the market research company NPD Group.

Drug and department stores have also increasingly moved toward “clean” products. CVS in 2019 removed parabens, phthalates and chemicals that contain or can give off formaldehyde from its store-brand products.

Advocates argue that the state law will force all companies to provide transparency and consistency about what, exactly, is in the products consumers put on their hair and faces.

“In order to ensure and give assurance to the public that the worst of the worst stuff is out of cosmetics, we felt we really needed to standardize and to put that into statute,” Rusch said.

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California Public Health

Parents Complain That Pediatricians, Wary of COVID, Shift Sick Kids to Urgent Care

A mom of eight boys, Kim Gudgeon was at her wits’ end when she called her family doctor in suburban Chicago to schedule a sick visit for increasingly fussy, 1-year-old Bryce.

He had been up at night and was disrupting his brothers’ e-learning during the day. “He was just miserable,” Gudgeon said. “And the older kids were like, ‘Mom, I can’t hear my teacher.’ There’s only so much room in the house when you have a crying baby.”

She hoped the doctor might just phone in a prescription since Bryce had been seen a few days earlier for a well visit. The doctor had noted redness in one ear but opted to hold off on treatment.

To Gudgeon’s surprise, that’s not what happened. Instead, when she called, her son was referred to urgent care, a practice that has become common for the Edward Medical Group, which included her family doctor and more than 100 other doctors affiliated with local urgent care and hospital facilities. Because of concerns about the transmission of the coronavirus, the group is now generally relying on virtual visits for the sick, but often refers infants and young children to urgent care to be seen in person.

“We have to take into consideration the risk of exposing chronically ill and well patients, staff and visitors in offices, waiting areas or public spaces,” said Adam Schriedel, chief medical officer and a practicing internist with the group.

Gudgeon’s experience is not unusual. As doctors and medical practices nationwide navigate a new normal with COVID-19 again surging, some are relying on urgent care sites and emergency departments to care for sick patients, even those with minor ailments.

That policy is troubling to Dr. Arthur “Tim” Garson Jr., a clinical professor in the College of Medicine at the University of Houston who studies community health and medical management issues. “It’s a practice’s responsibility to take care of patients,” Garson said. He worries about patients who can’t do video visits if they don’t have a smartphone or access to the internet or simply aren’t comfortable using that technology.

Garson supports protocols to protect staff and patients, including in some instances referrals to urgent care. In those cases, practices should be making sure their patients are referred to good providers, he said. For instance, children should be seen by urgent care facilities with pediatric specialists.

Referrals for children have become so prevalent that the American Academy of Pediatrics came out with interim guidance on how practices can safely see patients, in an effort to promote patient-centered care and to ease the strain on other medical facilities as the peak of flu season approaches. The academy recommended that pediatricians strive “to provide care for the same variety of visits that they provided prior to the public health emergency.”

The academy raises concerns about unintended consequences of referrals, such as the fragmentation of care and increased exposure to other illnesses, both caused by patients seeing multiple providers; higher out-of-pocket costs for families; and an unfair burden shifting to the urgent care system as illnesses surge.

“I think this is all being driven by fear, not really knowing how to do this safely, and not really thinking about all of the sorts of consequences that are going to come as flu and other respiratory illnesses surge this fall and winter,” said Dr. Susan Kressly, who recently retired from her practice in Warrington, Pennsylvania, and authored the AAP guidance.

Fear is not unfounded. More than 900 health care workers, 20 of them pediatricians and pediatric nurses, have died of COVID-19, according to a KHN-Guardian database of front-line health care workers lost to the coronavirus.

For the Edward Medical Group, referrals are a safe way to treat patients by using all the resources of its medical system, Schriedel said.

“We can assure patients, regardless of COVID-19, we have multiple options to provide the care and services they need,” he said.

Besides urgent care referrals and virtual visits, doctors have been given guidelines on how to safely see sick patients. That might mean requesting a negative COVID test before a doctor visit or having staff escort a sick patient from the car directly to an exam room. Also, a pilot program is underway with designated offices taking patients with a respiratory illness that could be flu or COVID-19.

Kim Gudgeon, a Chicago-area mom, was frustrated to be referred to an urgent care facility when she suspected her son Bryce had an ear infection. (Kim Gudgeon)

It is a balancing act with some risks. In August, friends sent Kressly screenshots of parents’ online message boards from states such as Texas, Indiana and Florida that were seeing a summer spike in COVID-19 cases. Mothers felt abandoned by their pediatricians because they were being sent to urgent care and emergency departments. Kressly fears some patients will fall through the cracks if they are seen by several different providers and don’t have a continuity of care.

Also, there’s the expense. Bryce’s case is a good example. Gudgeon reluctantly took him to an urgent care facility, worried about exposure and frustrated because she felt her doctor knew Bryce best. His exam included a COVID test. “They barely looked in his ears, and we went home to wait for the results,” she said, and got no medicine to treat Bryce. The next day, she had a negative test and still a fussy, sick baby.

Urgent care facilities across the country are reporting higher numbers of patients, said Dr. Franz Ritucci, president of the American Board of Urgent Care Medicine. His clinic in Orlando, Florida, is seeing twice as many patients, both children and adults, as it did at this time last year.

“In urgent care, we’re seeing all comers, whether they are sick with COVID or not,” he said.

Meanwhile, ERs are seeing far fewer pediatric patients than usual, said Alfred Sacchetti, a spokesperson for the American College of Emergency Physicians and the director of clinical services at Virtua Our Lady of Lourdes Emergency Department in Camden, New Jersey. Although adult emergency room visits have largely returned to pre-COVID levels, pediatric visits are 30% to 40% lower, he said. Sacchetti suspects several factors are at play, including fewer kids in daycare and school with less opportunity to spread illness and people avoiding emergency rooms for fear of the coronavirus.

“You see parents looking around the department and if someone clears their throat, you can look in their eyes and see the concern,” Sacchetti said. “We reassure them” that the precautions taken in hospitals will help keep them safe, he added.

Gudgeon considered taking Bryce to an emergency room, but she felt increasingly uncomfortable both with the thought of exposing him to another health care facility and the cost. In the end, she called an out-of-state doctor she had seen often years before moving to Illinois. That doctor phoned in an antibiotic prescription, and Bryce quickly improved, she said.

“I just wish he didn’t have to suffer for so long,” Gudgeon said.

Kressly hopes doctors become more creative in finding ways to provide direct care. She likes the “Swiss cheese” approach of layering several imperfect solutions to see patients and offer protection from COVID-19: screening for symptoms before the patient comes in, requiring everyone to wear masks, allowing only one caregiver to accompany a sick child and offering parking lot visits for sick kids in their cars.

Most important is good communication, Kressly said. Not only does that help the patient, it can also help protect the doctor from patients who may not want to admit they have COVID symptoms.

“We can’t create this barrier to care for uncomplicated, acute illnesses,” Kressly said. “This is not temporary. We all have to creatively figure out how to get patients and families connected to the right care at the right place at the right time.”

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Public Health

Were You Notified About Missing Tax Forms for Your ACA Subsidy? Blame COVID.

The notice from the federal health insurance marketplace grabbed Andrew Schenker’s attention: ACT NOW: YOU’RE AT RISK OF LOSING FINANCIAL ASSISTANCE STARTING JANUARY 1, 2021.

As he read the notice, though, the Blacksburg, Virginia, resident became exasperated. Schenker, his wife and their teenage son have a bronze-level marketplace plan. Based on their income of about $40,000 a year, they receive tax credits that cover the $2,036 monthly premium in full.

When they file their annual taxes they complete an IRS form that reconciles how much they received in advance tax credits against their actual income for the year. The letter from the marketplace said they hadn’t filed for 2019, but Schenker knew they had — just as they have every year.

“I was more annoyed than anything else,” Schenker, 55, said, remembering an earlier enrollment problem that took months to resolve. “I didn’t want to get stuck in some sort of appeals category.”

Schenker’s 25-year-old daughter, Kaily Schenker, who is part owner of the family’s organic farm, got the same letter about her plan. Schenker helps her with her taxes, and she also filed the Form 8962 paperwork, he said.

Andrew Schenker (left) stands with his daughter, Kaily Schenker; wife, Lauren Cooper; and son, Julian Schenker. Andrew received a letter saying he was at risk of losing financial assistance for the bronze-level plan he shares with his wife and son. His daughter got the same letter about her plan.(Winema Lanoue)

Officials at the Centers for Medicare & Medicaid Services, which oversees the ACA marketplaces, confirmed that some consumers received notices from the agency alerting them that, according to the IRS, they hadn’t filed a tax return or reconciled their advance payments for tax credits. The letters, consumer advocates suggested, may be a result of the IRS extending the deadline for filing income taxes due to the coronavirus to July 15.

State-based marketplaces have similar requirements and likely send some version of this notice as well, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities who works on income tax issues related to the Affordable Care Act.

People who don’t file their taxes and the reconciliation form aren’t eligible for financial assistance with their marketplace coverage next year, including premium tax credits and any cost-sharing reductions they qualify for.

Because of the filing deadline extension, the tax form data may not have yet arrived when the federal marketplace initially asked the IRS for it in the fall, Straw said. Or other issues, including longer processing times for paper tax returns, could be responsible for a delay, Straw said.

“We don’t know how many people are in this boat,” Straw said. “We think it’s higher than in previous years because of anecdotal accounts from marketplace assisters around the country.”

Schenker said he and his daughter both filed paper returns — his family’s, in the spring, while his daughter took advantage of the pandemic extension.

Under ACA rules, people with incomes up to 400% of the poverty level ($86,880 for a family of three) can qualify for advance tax credits to help pay for coverage purchased through state or federal health insurance exchanges. When they sign up for insurance during open enrollment, their tax credits are based on estimates of their income for the coming year, and the exchanges pay insurers that amount directly. Then when people file their income taxes the following year, they use Form 8962 to reconcile their actual income against what they estimated and square off the amount in tax credits they received. If they received too much in subsidies, they must pay that back to the government.

According to the notice Schenker received, people who have already filed their 2019 tax return and Form 8962 don’t need to take any action.

Straw recommends a more hands-on approach.

“It’s really a dangerous thing to just wait and cross your fingers and hope that the data will resolve your issue,” she said.

Consumers who filed and reconciled taxes for 2019 can keep their tax credit in 2021, CMS officials said, by updating their 2021 HealthCare.gov application on or before Dec. 15 and checking the box that says, “Yes, I reconciled premium tax credits for past years.”

Straw encouraged marketplace customers to follow that advice. (State-based marketplaces generally follow the same process as the federal marketplace, perhaps with slight variations.)

Still, that might not be sufficient. Straw also recommends that people contact the IRS directly and ask for a tax transcript that shows their return was received, including Form 8962.

That way, if the marketplace does cut off premium tax credits and people have to appeal, they have documentation proving they filed the necessary forms. (If it comes to this, consumers can elect to continue receiving premium tax credits while they appeal.)

Unfortunately, people who run into this trouble might not get much expert help. Navigators are no longer required to help consumers with problems after they’ve enrolled, though they may still do so, Straw said.

Likewise, insurance brokers generally don’t help people with these problems, said Karen Pollitz, a senior fellow at KFF. (KHN is an editorially independent program of KFF.) Marketplace plan commissions are so low, “they’re much less likely to help people with complex problems,” she said.

After he got the letter, Schenker called marketplace representatives and was told to go ahead and apply for a plan for next year. He did so, making sure to check the box that said he’d filed his taxes, including the reconciliation form. And at the end of the application process, the system told him that, based on his income, his family is eligible for a tax credit of $2,000 a month. He picked a bronze plan.

He hopes that’s the end of it.

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Cost and Quality Health Care Costs Insurance The Health Law

Surging LA

March 2020 (Heidi de Marco/KHN)
November 2020: Cars wait at the corner of Hollywood and Highland, a bustling intersection that was deserted in March. Some shops on Hollywood Boulevard are open to the public, but many remain shuttered. (Heidi de Marco/KHN)

On a Monday afternoon in March, four days after Gov. Gavin Newsom issued the nation’s first statewide stay-at-home order to slow the spread of the coronavirus, some of Southern California’s most famous landmarks were deserted and few cars traveled the region’s notoriously congested freeways.

Eight months later, businesses are open, traffic is back — and COVID-19 cases in the state are surging. 

“This is simply the fastest increase California has seen since the beginning of this pandemic,” Newsom said in a press conference Monday, when he announced a major rollback of the state’s reopening process, saying the state’s daily case numbers had doubled in the previous 10 days.

That same day, California Healthline’s Heidi de Marco returned to the landmarks she photographed in March. This time, it took her nearly two days — Monday and Tuesday — to document them because of traffic.

The biggest change was the greater number of vehicles on the road. Foot traffic had also stepped up, but most pedestrians and shoppers were wearing masks and not gathering in large numbers.

It turns out that activities such as strolling along the beach and window-shopping are not the primary way the disease is spreading in Los Angeles County. Public health officials there blame the surge on an increase in social gatherings, such as private dinners and sports-watching parties with people from multiple households, and the virus is spreading mostly among adults ages 18 to 29. In a bid to slow the virus, county public health director Barbara Ferrer announced additional restrictions on businesses, effective Friday. Among them, outdoor dining and drinking at restaurants and breweries will be limited to 50% of capacity, and outdoor gatherings can include only 15 people from no more than three households, including the host’s household.

March 2020 (Heidi de Marco/KHN)
November 2020: The TCL Chinese Theatre shops are open for business in Hollywood, but the theater itself is closed. (Heidi de Marco/KHN)
March 2020: Pedro Castro used to book about 20 bus tour tickets on Hollywood Boulevard per day, he said, but ticket sales fell dramatically right after the shutdown. (Heidi de Marco/KHN)
November 2020: The Hollywoodland Experience shop is empty Monday afternoon. The tour guide stationed outside the store, who didn’t want to be photographed or named, said business is steady but not nearly as heavy as before the pandemic. (Heidi de Marco/KHN)
March 2020 (Heidi de Marco/KHN)
November 2020: The Hollywood Freeway started to get busy at about 3:30 p.m. Monday and cars were moving fast. It was bumper-to-bumper by 5:30 p.m., hitting peak gridlock later than in pre-pandemic days — but still much busier than in March. (Heidi de Marco/KHN)
March 2020 (Heidi de Marco/KHN)
November 2020: Some shops on Olvera Street remain closed, but most restaurants are open and offer outside seating for customers. (Heidi de Marco/KHN)
March 2020: Ricardo Gaytan, a cook at Cielito Lindo on Olvera Street, said he feared that with only a few customers a day, the restaurant could close completely. (Heidi de Marco/KHN)
November 2020: Gaytan now wears a mask while working and stands behind a plexiglass barrier when taking orders. The restaurant has remained open during the pandemic, he said, and business is steady. He said he has had to deal with only a few customers who didn’t want to wear a mask. (Heidi de Marco/KHN)
March 2020 (Heidi de Marco/KHN)
November 2020: People wander through the Rodeo Drive Walk of Style in Beverly Hills, which is again open to the public. Most people wore masks as they visited the stores that were open. (Heidi de Marco/KHN)

November 2020: The city of Santa Monica has closed its famous pier to cars. (Heidi de Marco/KHN) November 2020: People are allowed to walk onto the pier as long as they wear a face covering.(Heidi de Marco/KHN) November 2020: Despite the haze, a handful of people work out at Muscle Beach in Santa Monica on Tuesday afternoon. (Heidi de Marco/KHN) November 2020: Beachgoers said they didn’t feel the need to wear a mask since they were outside, and because wearing a mask makes it harder to breathe while working out.(Heidi de Marco/KHN)

March 2020 (Heidi de Marco/KHN)
November 2020: There weren’t many customers at Randy’s Donuts in Inglewood on Tuesday, but the shop is hiring. (Heidi de Marco/KHN)

KHN correspondent Anna Almendrala contributed to this report.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

What Biden Can Do to Combat COVID Right Now

When Barack Obama was elected president in 2008, the country was in the midst of a dire economic crisis. Twelve years later, his vice president, Joe Biden, has been elected president in the midst of a dire economic crisis and a worldwide, worsening coronavirus pandemic.

In 2008, Obama’s team and that of outgoing President George W. Bush worked together to allow the new administration to be as prepared as possible on Jan. 20, 2009. That’s not happening for Biden, as President Donald Trump continues to fight the election results and block the official transition.

Particularly when it comes to the COVID-19 pandemic, experts say, that delay could cost lives.

“If the new team has to waste time getting up to speed, that’s a huge waste of resources,” said Donald Kettl, a professor at the LBJ School of Public Affairs at the University of Texas-Austin and an expert in presidential transitions.

Until the formal transition begins, there are critical — and usually routine — things the incoming Biden officials cannot do, said Kettl. “Among the things not allowed right now are formal briefings by government officials, including Tony Fauci,” the head of the National Institute of Allergy and Infectious Diseases and the top federal infectious disease expert. In addition, Kettl said, Biden’s landing teams — the handful of people who go inside government agencies to start the actual transition work — “cannot actually land and talk to the people doing front-line planning. And they can’t see some of the front-line documents.”

Biden can — and is — meeting with plenty of people who will be vital to carry out his administration’s fight against COVID. On Thursday, he met remotely with a bipartisan group of governors and vowed afterward to continue to work with state and local officials. He also has his own COVID advisory board, led by former Surgeon General Vivek Murthy; former commissioner of the Food and Drug Administration, David Kessler; and Yale researcher Dr. Marcella Nunez-Smith.

But Kettl warned that it’s not enough for Biden to surround himself with smart, experienced people with good policy ideas. “The biggest risk they face is in managing these details, and that’s where a direct connection with the bureaucracy is so important, and we can’t afford to fumble this handoff,” he said.

So what can Biden do between now and Jan. 20?

Some public health advocates suggest he could set up a shadow COVID effort, to compete with the Trump administration’s task force. “He could do briefings three times a week telling us what we know and what we don’t,” said Dr. Arthur Kellermann, a longtime public health expert who is now CEO of the Virginia Commonwealth University Health System. Without better information for the public, Kellermann said, “we could lose tens of thousands of people between now and” Inauguration Day.

But others worry that Biden needs to be careful not to appear to have more power than he does, lest he end up with the blame if things don’t go well, particularly on the complicated issue of getting a vaccine distributed and accepted by the general public.

“I think we have to have reasonable expectations of what they can do,” said Farzad Mostashari, a senior health official at HHS in the Obama administration. “A lot has got to be planning and creating a ‘whole of government’ approach to tackling COVID.”

Kettl said the incoming Biden administration is better positioned than many others would have been because they have such recent experience running the government. Incoming White House chief of staff Ron Klain, for example, coordinated the federal government’s response to the Ebola outbreak in 2014. “There’s never been a group or team more prepared to run the government than this one,” Kettl said.

But it won’t be as easy as just picking up where they left off, he said, because of how politicized health and science has become. “The places they are walking into are not the same places they walked out of four years ago. The CDC is a shell of itself, the FDA is not the same.”

Mostashari, though, said he is confident the federal government can do more to combat the virus. “There are plenty of experts [still in the government] who are amazing at what they do,” he said. “They just have to unshackle them.”

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

KHN’s ‘What the Health?’: Transition Troubles Mount as COVID Spreads


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President-elect Joe Biden is still being blocked from launching his official transition while President Donald Trump contests the outcome of the election. That could be particularly dangerous for public health as COVID-19 spreads around the country at an alarming rate.

Meanwhile, a second vaccine to prevent COVID — the one made by Moderna — is showing excellent results of its early trials. And unlike the one made by Pfizer, Moderna’s vaccine does not need to be kept ultra-cold, which could ease distribution.

There is news on prescription drug prices, as well. Amazon announced plans to get into the drug delivery market, and the Trump administration was set to announce a new rule that could base some U.S. drug prices on the price-controlled prices of other industrialized countries.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Alice Miranda Ollstein of Politico and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s podcast:

  • The dramatic resurgence of the coronavirus pandemic is prompting new urgency on public health measures from federal and state officials. Republican governors who once played down the threat are instituting new restrictions, the Centers for Disease Control and Prevention called on Americans not to travel for Thanksgiving, and the White House coronavirus task force, which hadn’t been seen in months, held a briefing this week.
  • Nonetheless, the communications still lack a consistent message. Even as health officials and the White House task force underlined the dangers this week, the White House press secretary railed against some state restrictions, calling them “Orwellian.”
  • And public health efforts often seem inconsistent, such as closing schools while allowing bars and restaurants to continue to operate, albeit often with earlier mandated closing times. Part of the reluctance to close bars and restaurants comes from concerns about the economic impact — both to the businesses and the tax revenue they generate for their states and localities.
  • Even with the crisis deepening, efforts on Capitol Hill to negotiate a new stimulus package appear mired, with little sign of serious talks.
  • The biggest issue facing hospitals overrun with COVID-19 patients is a concern about having enough trained personnel. With the entire country feeling the effects of the pandemic, it is hard to shift workers to deal with outbreaks in specific areas.
  • Many states are using National Guard troops to help support overburdened hospitals and run testing sites, but the Trump administration has not said whether it will continue funding for that effort after the end of the year.
  • As vaccine candidates move ever closer to approval, some officials worry that states are not equipped to handle the logistics of distribution. And it’s not clear whether the Trump administration, which took serious missteps on getting PPE and testing supplies out earlier, is prepared to step in adequately.
  • Biden says efforts by the Trump administration to deny him the usual access to government officials and information could impair his efforts to make vaccine distribution effective when he takes office.
  • Amazon’s announcement this week that it will start selling prescription drugs has the potential to shake up the industry — but probably not right away. And it’s not clear that the giant retailer’s entrance into the market will have any effect on lowering prices.

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

Julie Rovner: Politico’s “The Biden Adviser Focused on the Pandemic’s Stark Racial Disparities,” by Joanne Kenen

Margot Sanger-Katz: The Washington Post’s “Dolly Parton Helped Fund Moderna’s Vaccine. It Began With a Car Crash and an Unlikely Friendship,” by Timothy Bella

Sarah Karlin-Smith: Vox’s “Social Distancing Is a Luxury Many Can’t Afford. Vermont Actually Did Something About It,” by Julia Belluz

Alice Miranda Ollstein: The New York Timess “What 635 Epidemiologists Are Doing for Thanksgiving,” by Claire Cain Miller, Margot Sanger-Katz and Quoctrung Bui


To hear all our podcasts, click here.

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

Trump’s Lame-Duck Status Leaves Governors to Wing It on COVID

Not long after the world learned that President Donald Trump had lost his reelection bid, states began issuing a new round of crackdowns and emergency declarations against the surging coronavirus.

Taking action this time were Republican governors who had resisted doing so during the spring and summer. Now they face an increasingly out-of-control virus and fading hope that help will come from a lame-duck president who seems consumed with challenging the election results.

President-elect Joe Biden has promised a more unified national effort once he takes office on Jan. 20, and pressure is building on Congress to pass a new financial relief package. But with record hospitalizations and new cases, many governors have decided they can’t afford to wait.

“I don’t know any governor who’s sitting there waiting for the knight to come in on the horse,” said Lanhee Chen, a fellow at the Hoover Institution and a former senior health official in President George W. Bush’s administration. “There’s no way for these guys to just sit and wait. The virus and the crisis is getting worse hour by hour, day by day.”

As new measures trickle out across states, public health policy experts worry many don’t go far enough. For those states attempting to impose meaningful restrictions, their success depends on cooperation from a population with pandemic fatigue. And people may be reluctant to curtail their holiday gatherings.

Residents of many conservative states don’t acknowledge the depth of the health problem, especially given Trump and some of his allies have stressed the crisis is being overplayed and will end quickly.

The bottom line is that many people just aren’t sufficiently scared of the virus to do what must be done to stop the spread, said Rodney Whitlock, a health policy consultant and former adviser to Sen. Chuck Grassley (R-Iowa).

“You’re dealing with folks there who definitely put liberty over everything else because they’re not afraid enough,” Whitlock said. “Even in the face of cases, even in the face of people around them getting it. They’re just not afraid.”

Among the first governors to act was outgoing Utah Gov. Gary Herbert. The day after The Associated Press called the presidential election for Biden on Nov. 7, the Republican announced Utah’s first-ever statewide mask mandate and clamped down on social gatherings and other activities until Nov. 23.

“All of us need to work together and see if there’s a better way,” Herbert said in a news conference.

Republican and Democratic governors alike followed with measures of their own in Colorado, Iowa, Michigan, Nebraska, New York, Ohio, Oregon, Pennsylvania, Washington and other states. Strategies included partial lockdowns, limits on crowds, canceling in-person classes for schools and reducing hours and capacity for bars and restaurants.

Health policy experts largely agree that the virus’s spread, not the end of the election, is what’s driving these changes — though the end of the campaign season does take political pressure off governors inclined to issue COVID-preventive policies.

“It’s much easier to act when you don’t have attention on you than when you do, but I would hope that the action is taking place regardless of what the political circumstances are,” Chen said.

No state has yet resorted to the sort of full lockdowns enacted in the spring, which resulted in mass business closures and layoffs and sent the economy crashing.

Christopher Adolph, an associate professor at the University of Washington, and his team with the university’s COVID-19 State Policy Project have been studying states’ responses to the pandemic. Some states have made a show of taking action, without much substance behind it, he said. For example, Alaska Gov. Mike Dunleavy, a Republican, declared an emergency on Nov. 12 — but only recommended, not ordered, that people wear masks and maintain social distance.

Other governors first took small steps only to follow up with tighter restrictions. In Iowa, for example, Republican Gov. Kim Reynolds, who opposed mask mandates during the presidential campaign, initially announced that all people over age 2 would be required to wear masks at gatherings of certain sizes. On Nov. 16, she issued a simpler but stricter three-week statewide mask mandate.

North Dakota Gov. Doug Burgum, a Republican, also ordered mandatory face coverings for the first time. Hospitals there have been reporting they have more patients than capacity, and the state has been leading the country in new per capita COVID cases.

At the very least, each state should make it clear that people must not gather indoors, Adolph said. Restaurants, bars, gymnasiums and large indoor events should be closed, he said, and gatherings inside people’s homes should not happen.

“We’re not seeing enough clear, broadly communicated, well-stated, unambiguous policies,” Adolph said.

An exception is Herbert, one of two governors who will leave office in January. The two-term Utah governor will turn over the reins to his current lieutenant governor, Spencer Cox, who has been a part of the state’s response to the pandemic since the beginning. Both Republicans have promised a smooth, seamless transition between administrations.

The nation’s other lame-duck governor is Montana’s Steve Bullock, a Democrat. But unlike Herbert, the term-limited Bullock will be replaced by a governor from a different party. Republican U.S. Rep. Greg Gianforte defeated Bullock’s lieutenant governor, Mike Cooney, in the Nov. 3 election. And Bullock lost his bid for the U.S. Senate.

Bullock said in a Nov. 12 news conference that he would not take additional COVID-intervention measures without a federal aid package to blunt the economic fallout. Five days later, he reversed himself to expand a previous mask requirement and limit capacity and hours in bars, restaurants and other entertainment venues.

Gianforte has not directly answered whether he would continue Bullock’s restrictions. When asked, the governor-elect has spoken instead of personal responsibility and reopening the economy while protecting the most vulnerable people. In July, he referenced the unfounded hope that the virus would be slowed by the U.S. reaching “herd immunity” by the end of the year.

Another obstacle is that a district judge essentially ruled Bullock’s mask mandate unenforceable. State health department lawyers had asked District Judge Dan Wilson to enforce the mandate against five businesses accused of flouting the measure.

“The businesses and the owners have been put on the front line of implementing a state policy that has more exceptions than directives and would be about as effective in bailing water from the leaky boat of our present health circumstances as would a colander,” the judge said in denying the request.

That leaves Bullock with the task of managing a crisis in his final weeks of office with local officials already looking past him to a new administration.

In Flathead County, where the five businesses were sued for violating the mask mandate, local leaders were already chafing from what they saw as Bullock’s heavy hand.

“He has angered a lot of people in Flathead County,” County Commissioner Randy Brodehl, a Republican, said of Bullock. “He didn’t come here, he didn’t talk to us.”

Bullock’s troubles show that even if governors take measures to stem the spread of COVID-19, they may still have a difficult time persuading people to go along with them. That’s particularly an issue in the Upper Midwest and the Rocky Mountains, libertarian-leaning COVID hot spots where the medical infrastructure is already strained.

Some Trump supporters have followed the president’s lead in downplaying the virus and others are fatigued after months of isolation and precautions, said Whitlock.

In rural and conservative areas, people protest that COVID measures come at the expense of their personal freedom and their ability to earn a living, and some feel as though they’re being talked down to by mask advocates and public health officials, Whitlock said.

It’s going to take smart and consistent messaging to change attitudes — but that means more than Biden telling people to wear masks once he takes office, Whitlock added.

“Everybody has to own it,” he said. “You have to scream at the top of your lungs at the protests, at the celebrations, at the football games, at the concerts. It has to be, ‘Stop it!’”

Related Topics

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KHN on the Air This Week

KHN Midwest correspondent Lauren Weber discussed COVID-19 surges in Wisconsin with Wisconsin Public Radio’s “Central Time” on Nov. 13.


California Healthline correspondent Angela Hart and editor Emily Bazar discussed how the Supreme Court case about the Affordable Care Act could affect California with the CalMatters and Capital Public Radio’s “California State of Mind” podcast.


KHN chief Washington correspondent Julie Rovner discussed open enrollment for ACA marketplace plans with Maine Public Radio’s “Maine Calling” on Monday.


KHN Midwest correspondent Cara Anthony discussed protections against race-based hair discrimination with KTVU Fox 2 on Tuesday.


KHN senior correspondent Liz Szabo discussed COVID vaccine candidates with Newsy on Tuesday.


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Fear of Flying Is a COVID-Era Conundrum

The holidays are approaching just as COVID-19 case rates nationwide are increasing at a record-breaking pace, leading to dire warnings from public health experts.

The Centers for Disease Control and Prevention has issued cautions and updated guidelines related to family gatherings. Dr. Anthony Fauci, a White House coronavirus adviser and director of the National Institute of Allergy and Infectious Diseases, said in interviews that his kids won’t be coming home for Thanksgiving because of coronavirus risks. “Relatives getting on a plane, being exposed in an airport,” he told CBS News. “And then walking in the door and saying ‘Happy Thanksgiving’ — that you have to be concerned about.”

Are Americans listening? Maybe not. Especially as airlines, reeling from major revenue blows since the pandemic took hold in March, tell passengers they can travel with peace of mind and sweeten the deal with special holiday fares.

The airlines argue more is now known about the virus and recent industry-sponsored studies show flying is just as safe as regular daily activities. They also tout policies such as mask mandates and enhanced cleaning to protect travelers from the coronavirus.

Time for a reality check.

Americans who do choose to fly will be subject to evolving COVID safety policies that vary by airline, a result of the continuing lack of a unified federal strategy. Under the Trump administration, government agencies such as the Federal Aviation Administration and the Centers for Disease Control and Prevention have failed to issue and enforce any national directives for air travel.

And, though President-elect Joe Biden has signaled he will take a more robust federal approach to addressing COVID-19, which may result in such actions, the Trump administration remains in charge during the upcoming holiday season.

Here’s what you need to know before you book.

Airlines Say It’s Safe to Fly During the Pandemic. Is it?

The airline industry pins its safety clearance to a study funded by its leading trade group, Airlines for America, and conducted by Harvard University researchers, as well as one headed by the Department of Defense, with assistance from United Airlines.

Both reports modeled disease transmission on a plane, assuming all individuals were masked and the airplane’s highly effective air filtration systems were working. The Harvard report concluded the risk of in-flight COVID-19 transmission was “below that of other routine activities during the pandemic, such as grocery shopping or eating out,” while the DOD study concluded an individual would need to, hypothetically, sit for 54 straight hours on an airplane to catch COVID-19 from another passenger.

But these studies’ assumptions have limitations.

Despite airlines’ ramped-up enforcement of mask-wearing, reports of noncompliance among passengers continue. Most airlines say passengers who outright refuse to wear masks will not only be refused boarding, but will also be putting their future travel privileges at risk. Recent press reports indicate Delta has placed hundreds of these passengers on a no-fly list. Some passengers may still try to skirt around the rule by removing their mask to eat or drink for an extended time on the flight, and flight attendants may or may not feel they can stop them.

And though public health experts agree that airplanes do have highly effective filtration systems spaced throughout the cabin that filter and circulate the air every couple of minutes, if someone who unknowingly has COVID-19 takes off their mask to eat or drink, there is still time for viral particles to reach others seated nearby before they get sucked up by the filter.

Public health experts said comparing time on an airplane with time at the grocery store is apples and oranges.

Even if you wear a mask in both places, said Dr. Henry Wu, director of Emory TravelWell Center and associate professor of infectious diseases at Emory University School of Medicine, the duration of contact in both locales can be very different.

“If it’s a long flight and you are in that situation for several hours, then you are accumulating exposure over time. So a one-hour flight is 1/10 the risk of a 10-hour flight,” said Wu. “Whereas most people don’t spend more than an hour in the grocery store.”

Also, both studies analyzed only one aspect of a travel itinerary — risk on board the aircraft. Neither considered the related risks involved in air travel, such as getting to the airport or waiting in security lines. And public health experts say those activities pose opportunities for COVID exposure.

“Between when you arrive in the airport and you get into a plane seat, there is a lot of interaction that happens,” said Lisa Lee, a former CDC official and associate vice president for research and innovation at Virginia Tech.

And while Wu said he agrees that an airplane cabin is likely safer than other environments, with high rates of COVID-19 in communities across the U.S., “there is no doubt people are flying when they’re sick, whether they know it or not.”

Another data point touted by the airline industry has been that out of the estimated 1.2 billion people who have flown so far in 2020, only 44 cases of COVID-19 have been associated with air travel, according to data from the International Air Transport Association, a worldwide trade group.

But this number reflects only case reports published in the academic literature and isn’t likely capturing the true picture of how many COVID cases are associated with flights, experts said.

“It’s very difficult to prove, if you get sick after a trip, where exactly you got exposed,” said Wu.

The low count could also stem from systemic contact-tracing inconsistencies after a person with COVID-19 has traveled on a flight. In a recent case, a woman infected with the coronavirus died during a flight and fellow passengers weren’t notified of their exposure.

That may be due to the decentralized public health system the U.S. has in place, said Lee, the former CDC official, since contact tracing is done through state and local health departments. The CDC will step in to help with contact tracing only if there is interstate travel, which is likely during a flight — but, during the pandemic, the agency has “been less consistently effective than in the past,” said Lee.

“Let’s say there is a case of COVID on a flight. The question is, who is supposed to deal with that? The state that [the flight] started in? That it ended in? The CDC? It’s not clear,” said Lee.

Is Now the Time to Fly?

Most airlines have implemented safety measures beyond requiring masks, such as asking passengers to fill out health questionnaires, enhancing cleaning on planes, reducing interactions between crew members and passengers, and installing plexiglass stations and touchless check-in at service desks.

But many have also stepped back from other efforts, such as pledging to block middle seats. United relaxed its social distancing policy for allowing empty middle seats between customers at the end of May, though there were complaints from customers before then about flights being full. American Airlines stopped blocking middle seats in July. Other airlines plan to fill seats after the Thanksgiving holiday, with Southwest stopping the practice of blocking middle seats starting Dec. 1, and JetBlue planning to increase capacity to 85% on Dec. 2. In January, Alaska Airlines plans to stop blocking middle seats and JetBlue will fly at full capacity. Delta announced this week that it will continue to block the middle seat until March 30.

This policy change is a result of airlines’ lack of cash on hand, said Robert Mann, an aviation analyst. It also reflects a rising demand from consumers who feel increasingly comfortable traveling again, especially as holiday gatherings beckon.

“It was easy to keep middle seats empty when there wasn’t much demand,” said Mann.

Now, they’re instead hoping that new COVID-era services will calm passengers’ fears.

American, United, Alaskan and Hawaiian, among others, offer some form of preflight COVID test for customers traveling to Hawaii or specific foreign destinations that also require a negative test or quarantine upon arrival. JetBlue recently partnered with a company to offer at-home COVID tests that give rapid results for those traveling to Aruba.

Airlines are likely to expand their preflight COVID testing options in the next couple of months. “This is the new dimension of airline competition,” said Mann.

But is it a new dimension of travel safety?

Emory’s Wu said there is certainly a risk of catching the coronavirus if you travel by plane, and travelers should have a higher threshold in making the decision to travel home for the holidays than they would in years past.

After all, COVID case rates are surging nationwide.

“I think the less folks crowding the airports, the less movement in general around the country, will help us control the epidemic,” said Wu. “We are worried things will get worse with the colder weather.”

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Florida’s New Hospital Industry Head Ran Medicaid in State and Fought Expansion

With its choice of a new leader, the Florida Hospital Association has signaled that seeking legislative approval to expand Medicaid to nearly 850,000 uninsured adults won’t be among its top priorities.

In October, Mary Mayhew became the association’s CEO. Mayhew, who led the state’s Medicaid agency since 2019, has been a vocal critic of the Affordable Care Act’s Medicaid expansion adopted by 38 other states. She has argued that expansion puts states in a difficult position because the federal government is unlikely to keep its financial commitment to pay its share of the costs.

Had Medicaid been expanded in Florida, hospitals there would have gained thousands of paying patients. But the institutions have done little in recent years to persuade the Republican-led legislature and Gov. Ron DeSantis, also Republican, who oppose such a move.

Mayhew acknowledged in an interview with KHN that expanding Medicaid to cover more uninsured patients could help hospitals financially, especially at a time when facilities have seen demand for services decline as people avoid care for fear of contracting COVID-19.

With that in mind, she said, she is now open to the idea of expanding Medicaid. “We need to look at all options on the table,” she said. “Is it doable? Yes.”

Still, she was quick to point out concerns about whether Florida can afford to expand.

Under the ACA, the federal government pays 90% of the costs for newly enrolled Medicaid recipients. In the traditional Medicaid program — which covers children, people who are disabled and pregnant women — the federal government pays nearly two-thirds of Florida’s Medicaid costs.

“It will be financially challenging in our state budget as revenues have dropped,” Mayhew said, echoing comments of state officials. “That 10% cost has to come from somewhere.”

Mayhew’s hire worries advocates who have spent more than seven years lobbying lawmakers to expand Medicaid. Without strong support from the hospital industry, they fear they’re unlikely to change many votes.

“It may make it harder,” said Karen Woodall, executive director of Florida People’s Advocacy Center, a group that lobbies for policies to help low-income citizens. Marshaling hospital support is important, she said, because of the industry’s money and political clout.

In many state capitals, hospitals have led the fight for Medicaid expansion either by lobbying lawmakers or bankrolling ballot initiatives. The latest example was in Missouri, which this summer expanded Medicaid via a voter initiative. The campaign for the measure was partly funded by hospitals.

But in Florida, hospitals appear to have made a calculated decision to avoid pushing an initiative that Republican leaders have said they don’t want. Among the dozen states that have not expanded Medicaid, Florida is second only to Texas in the number of residents who could gain coverage.

Aurelio Fernandez, CEO of Memorial Healthcare System in Hollywood, Florida, who was chair of the hospital association board when it hired Mayhew, said her opposition to Medicaid expansion never came up in the process. The association hired Mayhew because of the “phenomenal job” she did guiding hospitals amid the COVID pandemic, he said.

“There is no appetite at this juncture [for the legislature] to expand the Medicaid program with Obamacare,” said Fernandez, despite his belief that expansion would help hospitals and patients.

Mayhew, sounding more like a state official than a hospital industry spokesperson, said the ultimate decision on expansion will be up to lawmakers, who must review spending priorities. When states face a financial crunch, lawmakers look to reduce spending in education and Medicaid, which are the biggest parts of the budget, she said.

“The last thing we want to see is the state budget balanced on the backs of hospitals with deep Medicaid reimbursement cuts,” Mayhew said.

Mayhew said her previous opposition to expanding Medicaid occurred when she was responsible for balancing the state budget and managing the programs in Florida and, before that, in Maine. When she ran Maine’s program, she said she opposed expanding Medicaid to allow nondisabled adults into the program while there were disabled enrollees already on waiting lists to get care.

The Florida Hospital Association, which represents more than 200 hospitals, spent years lobbying state lawmakers to expand Medicaid. But since DeSantis was elected in 2018, the group has focused on other issues because the governor and Republican lawmakers made clear they would not expand the program.

Asked what the association’s current position is on Medicaid expansion, Mayhew noted she has been in her job less than a month and “we have not had that policy decision by the board for me to answer that.”

Miriam Harmatz, executive director of the Florida Health Justice Project, an advocacy group, said Mayhew’s hire suggests that hospitals are unlikely to get behind a fledgling effort to put the expansion question to voters in 2022.

Others advocating for Medicaid expansion agree.

“It does not look like they [Florida’s hospitals] are on board with helping us expand Medicaid at the moment,” said Louisa McQueeney, program director of Florida Voices for Health, a consumer group helping with the ballot initiative.

Related Topics

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These Front-Line Workers Could Have Retired. They Risked Their Lives Instead.

Sonia Brown’s husband died on June 10. Two weeks later, the 65-year-old registered nurse was back at work. Her husband’s medical bills and a car payment loomed over her head.

“She wanted to make sure all those things were taken care of before she retired,” her son David said.

David and his sister begged her not to go back to work during the coronavirus pandemic — explaining their concerns about her age and diabetes — but she didn’t listen.

“She was like the Little Engine That Could. She just powered through everything,” David said.

But her invincibility couldn’t withstand COVID-19, and on 29 July she died after contracting the deadly virus.

Sonia’s death is far from unusual. Despite evidence from the Centers for Disease Control and Prevention that adults 65 and older are at a higher risk from COVID-19, KHN and The Guardian have found that 338 front-line workers in that age group continued to work and likely died of complications from the virus after exposure on the job. Some were in their 80s — oftentimes physicians or registered nurses who cherished decades-long relationships with their patients and didn’t see retirement as an option.

The aging workers had a variety of motivations for risking their lives during the pandemic. Some felt pressured by employers to compensate for staffing shortages as the virus swept through departments. Others felt a higher sense of duty to their profession. Now their families are left to grapple with the same question: Would their loved one still be alive if he or she had stayed home?

‘All of This Could Have Been Prevented’

Aleyamma John was what her son, Ginu, described as a “prayerful woman.” Her solace came from working and caring for others. Her 38-year nursing career started in Mumbai, India. She immigrated with her husband to Dubai in the United Arab Emirates, where she worked for several years and had her two children. In 2002, the family moved to New York, and she took a job at NYC Health + Hospitals in Queens.

In early March, as cases surged across New York, Ginu asked his 65-year-old mother to retire. Her lungs were already weakened by an inflammatory disease, sarcoidosis.

“We told her very clearly, ‘Mom, this isn’t something that we should take lightly, and you definitely need to stay home.’”

“I don’t feel like the hospital will allow me to do that,” she responded.

Ginu described the camaraderie his mother shared with her co-workers, a bond that grew deeper during the pandemic. Many of her fellow nurses got sick themselves, and Aleyamma felt she had to step up.

Some of her co-workers “were quarantined [and did] not come into work,” he said. “Her department took a pretty heavy hit.”

By the third week of March, she started showing symptoms of COVID-19. A few days in, she suggested it might be best for her to go to the hospital.

“I think she knew it was not going to go well,” Ginu said. “But she found it in her heart to give us strength, which I thought was just insanely brave.”

Aleyamma ended up on a ventilator, something she assured Ginu wouldn’t be necessary. Her family was observing a virtual Palm Sunday service on 5 April when they got the call that she had died.

“We prayed that she would be able to come back, but that didn’t happen,” Ginu said.

Aleyamma and her husband, Johnny, who retired a few years ago, had been waiting to begin their next adventure.

“If organizations cared about their staff, especially staff who were vulnerable, if they provided for them and protected them, all of this could have been prevented,” Ginu said.

Commitment to Their Oath

In non-pandemic times, Sheena Miles considered herself semi-retired. She worked every other weekend at Scott Regional Hospital in Morton, Mississippi, mainly because she loved nursing and her patients. When Scott County emerged as a hot spot for the virus, Sheena worked four weekends in a row.

Her son, Tom, a member of Mississippi’s House of Representatives, called her one night to remind her she did not need to go to work.

“You don’t understand,” Sheena told her son. “I have an oath to do this. I don’t have a choice.”

Over Easter weekend, she began exhibiting COVID-like symptoms. By Thursday, her husband drove her to the University of Mississippi Medical Center in Jackson.

“She walked in and she never came out,” Tom said.

Tom said his mom “laid her life down” for the residents of Morton.

“She knew the chances that she was taking,” he said. “She just felt it was her duty to serve and to be there for people.”

Serving the community also was at the heart of Dr. Robert “Ray” Hull’s family medicine clinic in Rogers, Arkansas. He opened the clinic in 1972 and, according to his son Keith, had no intentions of leaving until his last breath.

“He was one of the first family physicians in northwest Arkansas,” Keith said. “Several people asked him if he was going to retire. His answer was always no.”

At the ripe age of 78, Dr. Hull continued to make house calls, black bag in hand. His wife worked alongside him in the office. Keith said the whole staff took proper precautions to keep the virus at bay, so when his father tested positive for COVID-19, it came as a shock.

Keith wasn’t able to visit his father at the hospital before he died on June 7. He said the funeral was even harder. Due to COVID restrictions on crowd sizes, he had to ask patients from Arkansas, Oklahoma and Missouri to stay home.

“There’s not a coliseum, arena or stadium that would have held his funeral,” Keith said. “Everybody knew my dad.”

‘She Was Afraid She Was Going to Get Sick’

Nancy MacDonald, at 74, got bored at home. That’s why her daughter, Bethany, said retirement never stuck for her. So in 2017, Nancy took a job as a receptionist at Orchard View Manor, a nursing home in East Providence, Rhode Island.

Although technically she worked the night shift, her co-workers could rely on her to pick up extra shifts without question.

“If somebody called her and said, ‘Oh, I’m not feeling well. I can’t come in,’ she was right there. That was just the way she was,” Bethany said.

Nursing homes across the country have struggled to contain breakouts of COVID-19, and Orchard View was no exception. By mid-April, the facility reportedly had 20 deaths. Nancy’s position was high-contact; residents and staff were in and out of the reception area all day.

At the onset of the pandemic, Orchard View had a limited supply of PPE. Bethany said they prioritized giving it to workers “on the floor,” primarily those handling patient care. Her mother’s position was on the back burner.

“When they gave her a[n N95] mask, they also gave her a brown paper bag,” she said. “When she left work, they told her to put the mask in the bag.”

Nancy’s managers reiterated that she was an essential employee, so she continued showing up. In personal conversations with her daughter, however, she was fearful about what might happen. At her age, she was considered high-risk. Nancy saw the isolation that Orchard View residents experienced when they contracted the coronavirus. She didn’t want that to be her.

“She was afraid she was going to get sick,” Bethany said. “She was afraid to die alone.”

Following her death on April 25, the Occupational Safety and Health Administration opened an investigation into the facility. So far, Orchard View has been fined more than $15,000 for insufficient respiratory protection and recording criteria.

A spokesperson for Orchard View told KHN the facility had “extensive infection control.” The facility declined to comment further.

Bethany MacDonald believes health care systems often exclude receptionists, janitors and technical workers from conversations on protecting the front line.

“It doesn’t matter what the job is, they are on the front line. You don’t have to be a doctor to be on the front line,” she said.

Related Topics

Aging Public Health States

Voz de un experto: los niveles de seguridad que propone Fauci durante COVID

Como periodista de salud, médica y ex corresponsal que vivió el SARS en Beijing, recibo preguntas de amigos, colegas y personas que ni siquiera conozco sobre cómo vivir durante una pandemia. ¿Creo que es seguro planear una boda en persona el próximo junio? ¿Enviaría a mis hijos a la escuela con las precauciones adecuadas? ¿Cuándo confiaré en una vacuna?

A la última pregunta, siempre respondo: vuando vea a Anthony Fauci recibir una.

Como muchos estadounidenses, sigo la palabra del doctor Fauci, el principal experto en enfermedades infecciosas del país y miembro del grupo de trabajo de la Casa Blanca sobre el coronavirus.

Cuando le dijo a The Washington Post que no estaba limpiando los paquetes sino que los dejaba reposar durante un par de días, comencé a hacer lo mismo. En octubre, comentó que ya entraba las bolsas del mercado a su casa. Simplemente se lava las manos después de sacar los productos. (¡Yo también!)

Ahora nos encontramos en una peligrosa transición política, con casos que se disparan alrededor del país, y Fauci y el grupo de trabajo original, en gran parte marginado.

El presidente electo Joe Biden ha designado a su equipo, pero no puede hacer mucho hasta que la Administración de Servicios Generales (GSA) acepte los resultados de las elecciones. Y Fauci me dijo que aún no ha hablado con el grupo de trabajo de Biden.

El presidente Donald Trump se ha resistido a las normas sobre la transición del gobierno, en las que los equipos nuevos y los salientes se coordinan entre sí.

Los tumultuosos meses pasados ​​se han llenado de brechas de información (todavía estamos aprendiendo sobre el nuevo coronavirus), datos erróneos (a menudo de boca del presidente) y una serie de “expertos”: personal de salud pública, matemáticos, cardiólogos y médicos de emergencias, como yo, ofreciendo opiniones en la televisión.

Pero todo este tiempo, la persona de la que más he querido saber es Fauci. Es directo, sin aparentes conflictos de intereses, políticos o financieros, o, a los 79 años, ambiciones profesionales. Al parecer, no tiene otros intereses más que los tuyos y los míos.

Así que le pregunté cómo podrían esperar vivir los estadounidenses en los próximos seis a nueve meses. ¿Cómo debemos comportarnos? ¿Y qué debería hacer la próxima administración? Algunas respuestas se han editado para mayor claridad y brevedad.

¿Qué dos o tres cosas cree que la administración Biden debería hacer el primer día de gobierno?

Algunos estados regiones parecen no haber aprendido las lecciones que podrían o deberían haberse aprendido cuando la ciudad de Nueva York y otras grandes ciudades fueron afectadas. Como implementar algunas medidas básicas de salud pública.

Quiero ser realmente explícito sobre esto, porque siempre que hablo de cosas simples como el uso consistente de máscaras faciales, mantener la distancia física, evitar las multitudes (particularmente en interiores), hacer cosas al aire libre si el clima lo permite, y lavarse las manos con frecuencia, eso no significa cerrar el país.

Aún puedes tener un margen considerable para los negocios, para la recuperación económica, si haces esas cosas simples. Pero lo que estamos viendo, desafortunadamente, es una respuesta muy dispar. Y eso conduce inevitablemente al tipo de olas [de nuevos casos] que vemos ahora.

¿Cree que necesitamos una norma como un mandato de máscara nacional? La administración actual ha delegado gran parte de la gestión de COVID-19 a los estados.

Creo que debería haber un uso universal de cubrebocas. Es ideal lograrlo con los alcaldes, gobernadores, autoridades locales. Si no, deberíamos considerar seriamente la norma nacional. La única razón por la que evito hacer una recomendación fuerte en ese sentido es que las cosas que vienen del nivel nacional hacia abajo generalmente generan un poco de rechazo por parte de una población ya reacia a que le digan qué hacer. Por lo tanto, podría terminar teniendo el efecto contrario: que se retroceda aún más.

¿Cómo sería un uso mandatorio de máscaras a nivel nacional? Significaría diferentes cosas en diferentes estados. Muchos estados requieren que la persona se cubra la cara, pero no específicamenteque que use cubrebocas. Muchos veinteañeros usan solo un pañuelo.

Creo que es poco probable que exista una diferencia sustancial. Quiero decir, el tipo común de máscara es la máscara quirúrgica. No es una máscara N95. Una tela gruesa puede ser igualmente efectiva. Creemos que puede haber algunas pequeñas diferencias, pero el objetivo principal es evitar infectar a otros. Estudios recientes han demostrado que [usar una máscara] también tiene el buen efecto de protegerte parcialmente. Por lo tanto, el beneficios es en ambas direcciones.

Muchos lugares que tienen mandatos de uso de cubrebocas han tenido problemas para hacerlos cumplir.

Esa es realmente una de las razones por las que hay una reticencia de parte de muchas personas, incluido yo mismo [a apoyar un mandato nacional]. Si tienes un mandato, debes hacerlo cumplir. Y, con suerte, podemos convencer a la gente cuando vean lo que está sucediendo en el país. Pero tengo que decirte que me sorprendió el hecho de que en ciertas áreas del país, aunque la devastación del brote es clara, algunas personas todavía dicen que son noticias falsas. Eso es algo muy difícil de superar: por qué la gente todavía insiste en que algo que tiene bajo sus narices no es real.

La gente suele pensar en los cierres como blanco o negro. Estás abierto o estás cerrado. Me gustaría escuchar la jerarquía del doctor Fauci de “es seguro e importante mantenerse abierto con precauciones” y “cosas que no son seguras bajo ninguna circunstancia”.

La razón por la que respondo con cierto grado de inquietud es porque las personas que son propietarias de estos negocios se enojan mucho conmigo. Hay algunos negocios esenciales que quieres mantener abiertos. Quieres mantener abiertos los supermercados, cosas que la gente necesita para su subsistencia. Si se hace correctamente, es posible que puedas mantener abiertos algunos negocios no esenciales, como tiendas de ropa, grandes almacenes.

Se acerca el invierno. Se podría mantener la distancia social en un restaurante o reunión en interiores. ¿Pero se sentiría bien estando ahí sin una máscara?

Si estamos en la zona caliente como estamos ahora, donde hay tantas infecciones alrededor, me sentiría bastante incómodo incluso solo estando en un restaurante. Sobre todo si está funcionando a capacidad completa.

Veo que te has cortado el cabello. ¿Qué opinas de las barberías y salones?

De nuevo, depende. Solía ​​cortarme el cabello cada cinco semanas. Ahora me lo corto cada 12, usando un cubrebocas, yo y el peluquero, claro.

¿Transporte? ¿Trenes? ¿Aviones? ¿Metro? ¿Cuál es la situación?

Depende de tus circunstancias individuales. Si eres alguien que se encuentra en la categoría de mayor riesgo, lo mejor es no viajar a ningún lado. O si tienes un automóvil, mejor que subirse a un metro, un autobús o un avión lleno de gente. Ahora, si tienes 25 años y no tienes condiciones subyacentes, es muy diferente.

¿Bares?

Las barras son realmente problemáticas. Si miras algunos de los brotes, ocurren cuando la gente entra en bares abarrotados. Yo mismo solía ir a un bar. Me gustaba sentarme en la barra, tomar una cerveza y comerme una hamburguesa. Pero cuando estás en un bar, la gente se inclina sobre tu hombro para pedir una copa, están pegados unos a otros. Es divertido porque es social, pero no es divertido cuando este virus está en el aire. Así que creo que si hay algo para evitar, por el momento, son los bares.

Algunas aerolíneas y algunos estados le dicen a la gente que debe hacerse una prueba de coronavirus antes de subir al avión o visitar otro estado. ¿Tiene eso algún sentido médico?

Si eres negativo cuando subes al avión, excepto en la rara circunstancia de que estés en esa pequeña ventana de incubación antes de volverte positivo, es algo bueno.

Si tuviera un plan nacional de pruebas, ¿cuál sería?

Pruebas de vigilancia. Inundando literalmente el sistema con pruebas. Obtener una prueba casera que puedas hacerte tú mismo, que sea muy sensible y específica. ¿Sabes por qué sería fantástico? Porque si decidiste que quieres tener una pequeña reunión con tus suegros y un par de niños, puedes hacerte la prueba en ese momento. No es 100%. No dejes que lo perfecto sea enemigo de lo bueno. Pero el riesgo que tienes disminuye dramáticamente si todos se hacen la prueba antes de reunirse para cena. Puede que nunca sea cero, pero, ya sabes, no vivimos en una sociedad completamente libre de riesgos.

Hay varias vacunas candidatas que son prometedoras. Pero también hay mucho escepticismo porque hemos visto a la FDA estar bajo presión tanto comercial como, cada vez más, política. ¿Cuándo sabremos que está bien recibir una vacuna? ¿Y cuál?

Es bastante fácil cuando hay vacunas que tienen un 95% de efectividad. No hay nada mejor que eso. Creo que lo que la gente debe apreciar, y es por eso que lo he dicho tal vez 100 veces en las últimas semanas, es el proceso mediante el cual se toma una decisión. La empresa analiza los datos. Observo los datos. Luego, se envían a la FDA. La FDA tomará la decisión de realizar una autorización de uso de emergencia o una aprobación de solicitud de licencia. Y tienen científicos de carrera que son realmente independientes. No le deben nada a nadie. Luego está otro grupo independiente, el Comité Asesor de Vacunas y Productos Biológicos Relacionados. El comisionado de la FDA ha prometido públicamente que actuará de acuerdo con la opinión de los científicos de carrera y del consejo asesor.

¿Cree que los científicos profesionales tendrán la última palabra?

Sí. Sí.

¿Y las decisiones que se están tomando en este período de transición, como el plan de distribución de vacunas, limitarán de alguna manera las opciones de una nueva administración?

No, no lo creo. Creo que una nueva administración tendrá la opción de hacer lo que sienta. Pero puedo decirles lo que va a pasar, independientemente de la transición o no, porque tenemos personas totalmente comprometidas con hacer esto bien que van a estar involucradas en el proceso. Tengo confianza.

¿Cuándo cree que todos podremos tirar nuestras máscaras?

Creo que vamos a tener algún grado de medidas de salud pública junto con la vacuna durante un período de tiempo considerable. Pero comenzaremos a acercarnos a lo normal, si la gran mayoría de las personas se vacuna, a medida que nos adentremos en el tercer o cuarto trimestre [de 2021].

Rosenthal es editora jefe de KHN

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Take It From an Expert: Fauci’s Hierarchy of Safety During COVID

As a health journalist, a physician and a former foreign correspondent who lived through SARS in Beijing, I often get questions from friends, colleagues and people I don’t even know about how to live during the pandemic. Do I think it’s safe to plan a real wedding next June? Would I send my kids to school, with appropriate precautions? When will I trust a vaccine?

To the last question, I always answer: When I see Anthony Fauci take one.

Like many Americans, I take my signals from Dr. Fauci, the country’s top infectious disease expert and a member of the White House task force on the coronavirus. When he told The Washington Post that he was not wiping down packages but just letting them sit for a couple of days, I started doing the same. In October, he remarked that he was bringing shopping bags into the house. He merely washes his hands after unpacking them. (Me too!)

Now we are in a dangerous political transition, with cases spiking in much of the country and Fauci and the original task force largely sidelined. President-elect Joe Biden has appointed his own, but it can’t do much until the General Services Administration signals that it accepts the results of the election. And Fauci told me he has not yet spoken with the Biden task force. President Donald Trump has resisted the norms on government transition, in which the old and new teams brief each other and coordinate.

The past tumultuous months have been filled with information gaps (we’re still learning about the novel coronavirus), misinformation (often from the president) and a host of “experts” — public health folks, mathematical modelers, cardiologists and emergency room doctors like me — offering opinions on TV. But all this time, the person I’ve most wanted to hear from is Fauci. He’s a straight shooter, with no apparent conflicts of interest — political or financial — or, at 79, career ambition. He seemingly has no interests other than yours and mine.

So I asked him how Americans might expect to live in the next six to nine months. How should we behave? And what should the next administration do? Some answers have been edited for clarity and brevity.

Q: Are there two or three things you think a Biden administration should do on Day One?

There were some states in some regions of the country that somehow didn’t seem to have learned the lessons that could have been learned or should have been learned when New York City and other big cities got hit. And that is to do some fundamental public health measures. I want to really be explicit about this, because whenever I talk about simple things like uniform wearing of masks, keeping physical distance, avoiding crowds (particularly indoors), doing things outdoors to the extent possible with the weather, and washing hands frequently, that doesn’t mean shutting down the country. You can still have a considerable amount of leeway for business, for economic recovery, if you just do those simple things. But what we’re seeing, unfortunately, is a very disparate response to that. And that inevitably leads to the kind of surges that we see now.

Q: Do you think we need a national policy like a national mask mandate? The current administration has left a lot of COVID-19 management to the states.

I think that there should be universal wearing of masks. If we can accomplish that with local mayors, governors, local authorities, fine. If not, we should seriously consider national. The only reason that I shy away from making a strong recommendation in that regard is that things that come from the national level down generally engender a bit of pushback from an already reluctant populace that doesn’t like to be told what to do. So you might wind up having the countereffect of people pushing back even more.

Q: What would a national mask mandate look like to you? It means different things in different states. Many states require face coverings, but not specifically masks. Many 20-somethings use only a bandanna.

I think it is unlikely that there’s a substantial difference. I mean, the typical type of a mask is the surgical mask. It’s not an N95 mask. One that has thick cloth, you know, can be equally as effective. We believe there may be some small differences between them, but the main purpose is that you prevent yourself from infecting others. Recent studies have shown that [wearing a mask] also has the good effect of partially protecting you. So it goes both ways.

Q: Many places that have mask mandates have had trouble enforcing them.

That’s really one of the reasons there’s a reticence on the part of many people, including myself [to support a national mandate]. If you have a mandate, you have to enforce it. And, hopefully, we can convince people when they see what is going on in the country. But I have to tell you, Elisabeth, I was stunned by the fact that in certain areas of the country, even though the devastation of the outbreak is clear, some people are still saying it’s fake news. That is a very difficult thing to get over: why people still insist that something that’s staring you right in the face is not real.

Q: People often think of shutdowns as binary. You’re open or you’re shut. Often, when you answer questions about how to live, you start with. ‘Well, I’m in a high-risk group. …” So I would love to hear Dr. Fauci’s hierarchy of “Safe and important to keep open with precautions” and “Things that aren’t safe under any circumstances.”

The reason I answer with some degree of trepidation is because the people who are the proprietors of these businesses start getting very, very upset with me. There are some essential businesses that you want to keep open. You want to keep grocery stores open, supermarkets open, things that people need for their subsistence. You might, if it’s done properly, keep open some nonessential businesses, you know, things like clothing stores, department stores.

Q: We’re heading into the winter months. You could social distance in a restaurant or in an indoor gathering. But would you feel OK being in there without a mask?

If we’re in the hot zone the way we are now, where there’s so many infections around, I would feel quite uncomfortable even being in a restaurant. And particularly if it was at full capacity.

Q: I see you’ve been getting your hair cut. What do you think about hair salons?

I mean, again, it depends. I used to get a haircut every five weeks. I get a haircut every 12 weeks now — with a mask on me, as well as a mask on the person who’s cutting the hair, for sure.

Q: Transportation? Trains? Planes? Metro? Where are we at the moment?

It depends on your individual circumstances. If you are someone who is in the highest risk category, as best as possible, don’t travel anywhere. Or if you go someplace, you have a car, you’re in your car by yourself, not getting on a crowded subway, not getting on a crowded bus or even flying in an airplane. If you’re a 25-year-old who has no underlying conditions, that’s much different.

Q: Bars?

Bars are really problematic. I have to tell you, if you look at some of the outbreaks that we’ve seen, it’s when people go into bars, crowded bars. You know, I used to go to a bar. I used to like to sit at a bar and grab a hamburger and a beer. But when you’re at a bar, people are leaning over your shoulder to get a drink, people next to each other like this. It’s kind of fun because it’s social, but it’s not fun when this virus is in the air. So I would think that if there’s anything you want to clamp down on, for the time being, it’s bars.

Q: Some airlines and some states are telling people you have to get a coronavirus test before you get on the plane or visit another state. Does that make sense medically?

If you’re negative when you get on the plane — except in the rare circumstance that you’re in that little incubation window before you turn positive — that’s a good thing.

Q: If you had a national plan for testing, what would it be?

Surveillance testing. Literally flooding the system with tests. Getting a home test that you could do yourself, that’s highly sensitive and highly specific. And you know why that would be terrific? Because if you decided that you wanted to have a small gathering with your mother-in-law and father-in-law and a couple of children, and you had a test right there. It isn’t 100%. Don’t let the perfect be the enemy of the good. But the risk that you have — if everyone is tested before you get together to sit down for dinner — dramatically decreases. It might not ever be zero but, you know, we don’t live in a completely risk-free society.

Q: There are a number of vaccine candidates that are promising. But there’s also a lot of skepticism because we’ve seen the FDA come under both commercial and, increasingly, political pressure. When will we know it’s OK to take a vaccine? And which?

It’s pretty easy when you have vaccines that are 95% effective. Can’t get much better than that. I think what people need to appreciate — and that’s why I have said it like maybe 100 times in the last week or two — is the process by which a decision is made. The company looks at the data. I look at the data. Then the company puts the data to the FDA. The FDA will make the decision to do an emergency use authorization or a license application approval. And they have career scientists who are really independent. They’re not beholden to anybody. Then there’s another independent group, the Vaccines and Related Biological Products Advisory Committee. The FDA commissioner has vowed publicly that he will go according to the opinion of the career scientists and the advisory board.

Q: You feel the career scientists will have the final say?

Yes, yes.

Q: And will the decisions that are being made in this transition period — like the vaccine distribution plan — in any way limit the options of a new administration?

No, I don’t think so. I think a new administration will have the choice of doing what they feel. But I can tell you what’s going to happen, regardless of the transition or not, is that we have people totally committed to doing it right that are going to be involved in this. So I have confidence in that.

Q: When do you think we’ll all be able to throw our masks away?

I think that we’re going to have some degree of public health measures together with the vaccine for a considerable period of time. But we’ll start approaching normal — if the overwhelming majority of people take the vaccine — as we get into the third or fourth quarter [of 2021].

Q: Thank you so much. And have a nice Thanksgiving.

Take care, and you too.

[Editor’s note: Dr. Fauci has said his family is forgoing the usual family Thanksgiving gathering this year because his adult children would have to fly home and that travel would expose him to risk.] 

You can listen to the full interview on KHN’s “What the Health?” podcast.

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KHN’s ‘What the Health?’: What Would Dr. Fauci Do?


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


Since the mid-1980s, whenever there’s been a public health crisis, America — and six U.S. presidents — have turned to Dr. Anthony Fauci. As director of the National Institute of Allergy and Infectious Diseases (one of the National Institutes of Health), Fauci has helped guide the U.S. and the world through the HIV/AIDS epidemic, as well as various flu epidemics and outbreaks of SARS, Ebola and Zika.

Now Fauci is facing the difficult task of navigating the turbulent waters between the outgoing Trump administration and incoming Biden administration in the midst of an escalating pandemic. As a member of the Trump administration’s COVID-19 task force, Fauci has taken heat from President Donald Trump and his supporters for delivering news and advice that does not match what the president wants to hear. And with the transition delayed because the federal government has not yet recognized Joe Biden as president-elect, Fauci is not free to meet with Biden’s team.

On this special episode of KHN’s “What the Health?” podcast, Fauci sits down for an interview with KHN Editor-in-Chief Elisabeth Rosenthal, a fellow physician. They explore the thorny political landscape and discuss how regular Americans should prepare to get through the coming months — as the pandemic surges and we wait for vaccines to become available.


To hear all our podcasts, click here.

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Family Mourns Man With Mental Illness Killed by Police, Calls for Change

Rulennis Muñoz remembers the phone ringing on Sept. 13. Her mother was calling from the car, frustrated. Rulennis could also hear her brother Ricardo shouting in the background. Her mom told her that Ricardo, who had been diagnosed with paranoid schizophrenia five years earlier, wouldn’t take his medication.

Within an hour, Ricardo Muñoz, 27, was dead. Muñoz, who had a knife, was killed by a police officer in Lancaster, Pennsylvania. The incident has striking similarities to the killing of Walter Wallace Jr. in Philadelphia six weeks later but has received far less national attention.

According to a Washington Post tracker, as of Nov. 18, police had killed 987 people in the U.S. in the past 12 months. Like Muñoz and Wallace, almost a quarter of those people had a diagnosis of a serious mental illness.

Two Sisters, Two Different Calls for Help

Ricardo Muñoz lived with his mother in Lancaster, but earlier on that September Sunday he had been across town at his sister Rulennis Muñoz’s house. Rulennis recalled that her brother had been having what she calls “an episode” that morning. Ricardo became agitated because his phone charger was missing. When she found it for him, he insisted it wasn’t the same one.

Rulennis knew her brother was in crisis and needed psychiatric care. But she also knew from experience that there were few emergency resources available for Ricardo unless a judge deemed him a threat to himself or others.

After talking with her mom, Rulennis called a county crisis intervention line to see if Ricardo could be committed for inpatient care. It was Sunday afternoon. The crisis worker told her to call the police to see if the officers could petition a judge to force Ricardo to go to the hospital for psychiatric treatment, an involuntary commitment. Reluctant to call 911, and wanting more information, Rulennis dialed the nonemergency police number.

Meanwhile, her mother, Miguelina Peña, was back in her own neighborhood. Her other daughter, Deborah, lives a few doors down. Peña started telling Deborah what was going on. Ricardo was becoming aggressive; he had punched the inside of the car. Back on their block, he was still yelling and upset and couldn’t be calmed. Deborah called 911 to get help for Ricardo. She didn’t know her sister was trying the nonemergency line.

The 911 Call

recording and transcript of the 911 call show that the dispatcher gave Deborah three options: police, fire or ambulance. Deborah wasn’t sure, so she said “police.” Then she went on to explain that Ricardo was being aggressive, had a mental illness and needed to go to the hospital.

Meanwhile, Ricardo walked up the street to where he and his mother lived. When the dispatcher questioned Deborah further, she mentioned that Ricardo was trying “to break into” his mom’s house. She didn’t mention that Ricardo also lived in that house. She did mention that her mother “was afraid” to go back home with him.

The Muñoz family has since emphasized that Ricardo was never a threat to them. However, by the time police got the message, they believed they were responding to a domestic disturbance.

“Within minutes of … that phone call, he was dead,” Rulennis said.

Ricardo’s mom, Miguelina Peña, recalls what she saw that day. A Lancaster police officer walked toward the house. Ricardo saw the officer approach through the living room window, and he ran upstairs to his bedroom. When he came back down, he had a hunting knife in his hand.

In video from a police body camera, an unidentified officer walks toward the Muñoz residence. Ricardo steps outside, and shouts “Get the f–k back.” Ricardo comes down the stairs of the stoop and runs toward the officer. The officer starts running down the sidewalk, but after a few steps, he turns back toward Ricardo, gun in hand, and shoots him several times. Within minutes, Ricardo is dead.

After Ricardo crumples to the sidewalk, his mother’s screams can be heard, off-camera. Police made the body camera video public a few hours after Ricardo’s death, in an effort to dispel rumors about Ricardo’s death and quell rioting in the city. The county district attorney has since deemed the shooting justified, and the officer’s name was never made public.

Spotty Care, Dangerous Crises

Across the U.S., people with mental illnesses are 16 times more likely than the overall population to be killed by police, according to one study from the mental health nonprofit Treatment Advocacy Center.

Miguelina Peña said she tried for years to get help for her son.

Among the problems, the family couldn’t find a psychiatrist who was taking new patients, she said. Additionally, Peña speaks little English, and that made it difficult to help Ricardo enroll in health insurance, or for her to understand what treatments he was receiving. Ricardo got his prescriptions through a local nonprofit clinic for Latino men, Nuestra Clínica.

Instead of consistent medical care and a trusted therapeutic relationship, Ricardo got treatment that was sporadic and fueled by crisis: He often ended up in the hospital for a few days, then would be discharged back home with little or no follow-up care. This happened more times than his mother and sisters can recall.

“There was an occasion where a judge was involved, and the judge determined that he should be released home,” Peña said. “And my question is, why would the judge allow him to go home if he wasn’t doing well?”

Immediate Threats and Escalation

Laws in Pennsylvania and many other states make it difficult for a family to get psychiatric care for someone who doesn’t want it; it can be imposed on the person only if he or she poses an immediate threat, said Angela Kimball, advocacy and public policy director at the National Alliance on Mental illness. By that point, it’s often law enforcement, rather than mental health professionals, who are called in to help.

“Law enforcement comes in and exerts a threatening posture,” Kimball said. “For most people, that causes them to be subdued. But if you’re experiencing a mental illness, that only escalates the situation.”

People who have a family member with mental illness should learn what local resources are available and plan for a crisis, Kimball advised. But she acknowledged that many of the services she frequently recommends, such as crisis hotlines or special response teams for mental health, aren’t available in most parts of the country.

If 911 is the only option, calling it can be a difficult decision, Kimball said.

“Dialing 911 will accelerate a response by emergency personnel, most often police,” she said. “This option should be used for extreme crisis situations that require immediate intervention. These first responders may or may not be appropriately trained and experienced in de-escalating psychiatric emergencies.”

The National Alliance on Mental Illness continues to advocate for more resources for families dealing with a mental health crisis. The group says more cities should create crisis response teams that can respond at all hours, without involving armed police officers in most situations.

There has been progress on the federal level, as well. Kimball was happy when President Donald Trump signed a bipartisan congressional bill, on Oct. 17, to implement a three-digit national suicide prevention hotline. The number — 988 — will eventually summon help when dialed anywhere in the country. But it could take a few years before the system is up and running.

Rulennis Muñoz said the family never got to see how Ricardo would have responded to someone other than a police officer.

“And instead of a cop just being there, there should have been other responders,” Rulennis said. “There should have been someone that knew how to deal with this type of situation.”

This story comes from a reporting partnership with WITF, NPR and KHN.

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People Proving to Be Weakest Link for Apps Tracking COVID Exposure

The app builders had planned for pranksters, ensuring that only people with verified COVID-19 cases could trigger an alert. They’d planned for heavy criticism about privacy, in many cases making the features as bare-bones as possible. But, as more states roll out smartphone contact-tracing technology, other challenges are emerging. Namely, human nature.

The problem starts with downloads. Stefano Tessaro calls it the “chicken-and-egg” issue: The system works only if a lot of people buy into it, but people will buy into it only if they know it works.

“Accuracy of the system ends up increasing trust, but it is trust that increases adoptions, which in turn increases accuracy,” Tessaro, a computer scientist at the University of Washington who was involved in creating that state’s forthcoming contact-tracing app, said in a lecture last month.

In other parts of the world, people are taking that necessary leap of faith. Ireland and Switzerland, touting some of the highest uptake rates, report more than 20% of their populations use a contact-tracing app.

Americans seem not so hot on the idea. As with much of the U.S. response to the pandemic, this country hasn’t had a national strategy. So it’s up to states. And only about a dozen, including the recent addition of Colorado, have launched the smartphone feature, which sends users a notification if they’ve crossed paths with another app user who later tests positive for COVID-19.

Within those few states, enthusiasm appears dim. In Wyoming, Alabama and North Dakota, some of the few states with usage data beyond initial downloads, under 3% of the population is using the app.

The service, built by Google and Apple and adapted by individual countries, states or territories, either appears as a downloadable app or as a setting, depending on the state and the device. It uses Bluetooth to identify other phones using the app within about 6 feet for more than 15 minutes. If a user tests positive for COVID-19, they’re given a verification code to input so that each contact can be notified they were potentially exposed. The person’s identity is shielded, as are those of the people notified.

“The more people who add their phone to the fight against COVID, the more protection we all get. Everyone should do it,” Sarah Tuneberg, who leads Colorado’s test and containment effort, told reporters on Oct. 29. “The sky’s the limit. Or the population is the limit, really.”

But the population could prove to be quite a limit. Data from early-adopter governments suggests even those who download the app and use it might not follow directions at the most critical juncture.

According to the Virginia Health Department, from August to November, about 613 app users tested positive and received a code to alert their contacts that they may have exposed them to the virus. About 60% of them actually activated it.

In North Dakota, where the outbreak is so big that human contact tracers can’t keep up, the data is even more dire. In October, about 90 people tested positive and received the codes required to alert their contacts. Only about 30% did so.

Researchers in Dublin tracking app usage in 33 regions around the world have encountered echoes of the same issue. In October, they wrote that in parts of Europe fewer people were alerting their contacts than expected, given the scale of the outbreaks and the number of active app users. Italy and Poland ranked lowest. There, they estimated, just 10% of the app users they’d expect were submitting the codes necessary to warn others.

“I’m not sure that anybody working in this field had foreseen that that could be a problem,” said Lucie Abeler-Dörner, part of a team at the Big Data Institute at Oxford studying COVID-19 interventions, including digital contact tracing. “Everybody just assumed that if you sign up for a voluntary app … why would you then not push that button?”

So far, people in the field only have guesses. Abeler-Dörner wonders how much of it has to do with people going into panic mode when they find out they’re positive.

Tessaro, the University of Washington computer scientist, asks if the health officials who provide the code need more training on how to provide clear instructions to users.

Elissa Redmiles, a faculty member at the Max Planck Institute for Software Systems who is studying what drives people to install contact-tracing apps, worries that people may have difficulty inputting their test results.

But Tim Brookins, a Microsoft engineer who developed North Dakota’s contact-tracing app as a volunteer, has a bleaker outlook.

“There’s a general belief that some people want to load the app so that they can be notified if someone else was positive, in a self-serving way,” he said. “But if they’re positive, they don’t want to take the time.”

Abeler-Dörner called the voluntary notification a design flaw and said the alerts should instead be automatically triggered.

Even with the limitations of the apps, the technology can help identify new COVID cases. In Switzerland, researchers looked at data from two studies of contact-tracing app users. They wrote in a not-yet-peer-reviewed paper that while only 13% of people with confirmed cases in Switzerland used the app to alert their contacts from July to September, that prompted about 1,700 people who had potentially been exposed to call a dedicated hotline for help. And of those, at least 41 people discovered they were, indeed, positive for COVID-19.

In the U.S., another non-peer-reviewed modeling study from Google and Oxford University looking at three Washington state counties found that even if only 15% of the population uses a contact-tracing app, it could lead to a drop in COVID-19 infections and deaths. Abeler-Dörner, a study co-author, said the findings could be applicable elsewhere, in broad strokes.

“It will avert infections,” she said. “If it’s 200 or 1,000 and it prevents 10 deaths, it’s probably worth it.”

That may be true even at low adoption rates if the app users are clustered in certain communities, as opposed to being scattered evenly across the state. But prioritizing privacy has required health departments to forgo the very data that would let them know if users are near one another. While an app in the United Kingdom asks users for the first few digits of their postal code, very few U.S. states can tell if users are in the same community.

Some exceptions include North Dakota, Wyoming and Arizona, which allow app users to select an affiliation with a college or university. At the University of Arizona, enough people are using the app that about 27% of people contacted by campus contact tracers said they’d already been notified of a possible exposure. Brookins of Microsoft, who created Care19 Alert, the app used in Wyoming and North Dakota, said that offering an affiliation option also allows people who’ve been exposed to get campus-specific instructions on where to get tested and what to do next.

“In theory, we can add businesses,” he said. “It’s so polarizing, no businesses have wanted to sign up, honestly.”

The privacy-focused design also means researchers don’t have what they need to prove the apps’ usefulness and therefore encourage higher adoption.

“Here there is actually some irony because the fact that we are designing this solution with privacy in mind somehow prevents us from accurately assessing whether the system works as it should,” Tessaro said.

In states including Colorado, Virginia and Nevada, the embedded privacy protections mean no one knows who has enabled the contact-tracing technology. Are they people who barely interact with anyone, or are they essential workers, interacting regularly with many people that human contact tracers would never be able to reach? Are they crossing paths and trading signals with other app users or, if they test positive, will their warning fall silently like a tree in an empty forest? Will they choose to notify people at all?

Colorado’s health department said it’s issuing thousands of COVID codes a day. As of Wednesday, 3,400 people have used the codes to notify their contacts, it said. An automated system issues codes for positive COVID-19 tests even if the infected people don’t have the app, making it impossible to know how many users are acting on the codes.

“I have hope that the vast majority of Coloradans will take this opportunity to give this gift of exposure notification to other people,” said Tuneberg. “I believe Coloradans will do it.”

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