Tagged COVID-19

Social Media Fears About Lack Of Coverage For Protest Injuries May Be Overblown

Thousands of protesters thronged the streets in recent days to express their anger over the killing of an African American man, George Floyd, in police custody in Minneapolis. The mostly peaceful rallies have turned violent at times, with police using batons, tear gas and rubber bullets that caused serious injuries.

That led to online social media postings that health plans might deny coverage for medical treatment of injured protesters, some suggesting it might be better for protesters not to tell providers how they got hurt.

Plans do sometimes have exclusions for coverage related to “illegal acts” that could leave people on the hook for at least part of their medical costs. But health policy experts said it’s unclear how common these clauses are or when they’re used to deny coverage.

In addition, even if a plan denies those claims, protesters would generally have strong grounds for appeal, the experts said. Success would hinge on the policy language and the circumstances around the protesters’ involvement.

“There’s a strong argument to be made that someone was participating in a civil protest, and that’s not illegal,” said Karen Pollitz, a senior fellow at KFF (the Kaiser Family Foundation). (KHN is an editorially independent program of the foundation.)

America’s Health Insurance Plans, a trade group, played down the concerns that have been mentioned on social media. “We are not aware of any blanket exclusions that would deny coverage for injuries or illnesses received during a protest,” said David Allen, a spokesperson for the group.

In general, health plans have broad leeway to exclude certain things from coverage, said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

For example, plans may note that they won’t cover injuries from certain dangerous activities, such as skydiving or bungee jumping. Some states allow insurers to refuse to pay claims related to drug or alcohol use.

Likewise, people who commit felonies or other illegal acts might have their claims denied. And if a lawful protest turned violent, insurers might consider it an illegal riot and deny medical coverage.

But that exclusion has to be part of the insurance contract, not something the company decides after receiving a claim.

“These exclusions need to be written down in your policy document,” Corlette said. “The plan description is supposed to outline all the things it won’t cover, in very specific language.”

Most people don’t read their policy’s fine print, but the document is generally available from insurers or employers.

Exclusion examples are not that hard to find. A sample benefits handbook for Florida Blue large group policies, for instance, specifically excludes treatment for injuries that result from “your participation in, or commission of, any act punishable by law as a misdemeanor or felony, or which constitutes riot, or rebellion.” A Cigna plan says it wouldn’t pay for care for “a Member participating in an insurrection, rebellion, or riot.”

All Florida Blue plans incorporate that exclusion language, said spokesperson Ilyssa Drumm. The company is not aware of any instances in which it has denied coverage for injuries specifically related to a riot or protest, she said.

“[We] would not apply this to someone who was injured when peacefully protesting and the actions of others led to their injury,” Drumm said.

Cigna did not reply to a request for comment.

It’s unclear the extent to which employers and insurers exclude coverage for injuries from dangerous or illegal activities or reject related claims, experts said. Researchers in at least one state have looked into this. A 2016 analysis by the Connecticut General Assembly Office of Legislative Research said the state insurance department found no coverage exclusions related to illegal acts among major medical or HMO forms filed by major carriers in the state.

The analysis noted that the National Conference of State Legislatures says that at least 18 states have laws related to coverage exclusions for “illegal acts.” Some prohibit such exclusions, while others allow them, the Connecticut study said. NCSL could not be reached to confirm the number. (State laws apply to state-regulated insurance policies, but federal laws regulate employer plans that are self-funded, meaning the company pays employee claims itself rather than buying insurance for that purpose.)

If a health plan did have an exclusion for medical services related to rioting, for example, determining how that applied to an individual policyholder’s claims would depend on specific details. How does the policy define “riot”? What does it mean to “participate” in one? Does the policy differentiate between “riot” and “protest”? Did the injured policyholder plan to attend a peaceful protest that subsequently got out of hand?

“There are probably a lot of fact-based questions that would need to be answered,” said Corlette.

Sometimes language in a policy may be very broad, allowing insurers to deny coverage for injuries sustained in the “commission of a crime,” for example, said Phyllis Borzi, a former assistant secretary of Labor who headed the Employee Benefits Security Administration and is now a consultant.

That kind of language could trip up protesters who have been arrested for offenses such as violating curfew or failing to leave the street when ordered to do so by police.

“These exclusions are designed to make sure that the plan isn’t going to be responsible if you go off and do things that are unwise and illegal and as a result you get injured,” Borzi said. “If you do get arrested, it’s just another little indicia of the fact that maybe it wasn’t just a benign activity on your part.”

Lying about how an injury occurred probably isn’t a good idea, said Borzi.

“You don’t have to volunteer the information, but if they ask you and you don’t tell them or lie, they could not just exclude the coverage but prosecute you under an insurance fraud argument,” she said.

Medicaid, the federal-state health program for low-income people, doesn’t typically have these types of provisions, said Sara Rosenbaum, professor of health law and policy at George Washington University.

Medicare, the insurance program for people age 65 and older and people with disabilities, doesn’t have these exclusions either.

The sight of crowds of protesters giving full-throated, generally unmasked, voice to their grievances has raised the specter of a resurgence of COVID-19. But insurers would be unlikely to deny coverage for treatment of the virus if someone gets sick after going to a rally, experts say.

“The employer would have to prove that the protest was the cause” of the infection, said Borzi, and given how widespread the coronavirus is, that would be practically impossible.

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COVID-19 Overwhelms Border ICUs

CHULA VISTA, Calif. — Even as most California hospitals have avoided an incapacitating surge in coronavirus patients, some facilities near the Mexican border have been overwhelmed. They include El Centro Regional Medical Center in Imperial County and Scripps Mercy Hospital Chula Vista in San Diego County, which link the spike in COVID-19 patients to their communities’ cross-border lifestyle.

Some U.S. citizens and legal residents who live in Mexico are crossing the border from Tijuana and Mexicali into the U.S. for treatment. Dr. Juan Tovar, an emergency physician and chief operations executive for Scripps Mercy Hospital Chula Vista, said 48% of COVID-positive patients who visited the emergency room between May 24 and May 30 said they had recently traveled to Mexico. That figure jumped to 60% between May 31 and June 2. The hospital is about 10 miles from the San Ysidro Port of Entry, the busiest land border crossing in the Western Hemisphere.

Only about 5% of COVID-19 patients reported they’d recently been to Mexico at Scripps’ three other emergency rooms farther north, he said.

“We are now transferring COVID-19 patients out of Chula Vista to other Scripps hospitals farther north on a fairly regular basis — 21 over the last week — to help decompress our hospital here,” Tovar said.

About two hours east, El Centro Regional Medical Center was so overwhelmed by COVID-19 patients it had to divert some to health care facilities in San Diego, National City and elsewhere. There have been more than 2,025 confirmed cases in Imperial County, which has the highest COVID-19 hospitalization rate in the state, said Andrea Bowers, special projects coordinator for the county health department.

“We know that our community has family on both sides of the border, so we’re relating the uptick to Mother’s Day weekend,” said Suzanne Martinez, assistant chief nursing officer at the medical center. “That means more risk as people travel back and forth over the border.”

KHN’s Heidi de Marco visited the intensive care units at both hospitals and documented the efforts to keep patients alive.


Patients suspected of having COVID-19 are screened inside a makeshift triage center outside El Centro Regional Medical Center in El Centro, California. The hospital is trying to keep patients who do not require acute care out of the hospital to limit spread.(Heidi de Marco/KHN)


Nurse Brianna Mendoza wheels a patient with coronavirus symptoms into the triage tent on May 28, 2020. “I’ve had a few people saying that they have had to cross the border to come here” because they prefer to get care in the U.S., Mendoza says.(Heidi de Marco/KHN)

Sylvia Cervantes, a medical assistant, assesses a patient who might have COVID-19. Cervantes usually works in the oncology department but was assigned to help in the triage tent.(Heidi de Marco/KHN)


A health care worker prepares to treat a COVID-19 patient on the medical-surgical floor. On May 28, the hospital had 41 coronavirus patients.(Heidi de Marco/KHN)


A registered nurse wearing protective equipment treats a COVID-19 patient in the intensive care unit. Ten beds in the hospital’s 12-bed ICU were filled with coronavirus patients.(Heidi de Marco/KHN)


Health care workers must wear a special respirator, a gown and gloves before entering a COVID-19 patient’s room.(Heidi de Marco/KHN)


Hospital staff members tending to COVID-19 patients must put on full-body protective suits to enter an isolation room in the emergency department.(Heidi de Marco/KHN)


El Centro Regional Medical Center is about 20 minutes north of Calexico, California, an ordinarily bustling border town with street shops and food vendors. But during the COVID-19 pandemic, the streets are quiet and nearly empty.(Heidi de Marco/KHN)

People make their way to Mexicali, Mexico, through the border crossing at Calexico. According to the U.S. Department of State, about 1.5 million U.S. citizens live in Mexico. In the Mexican state of Baja California, there are more than 5,380 confirmed coronavirus cases. Mexicali, the capital, has at least 2,630, more than any other city in the state.(Heidi de Marco/KHN)


About two hours to the west, Scripps Mercy Hospital Chula Vista has had roughly 35 to 40 COVID-19 patients every day in recent weeks, says Dr. Juan Tovar, an emergency physician and chief operations executive. That’s quadruple the number of coronavirus patients the hospital was treating at the beginning of April.(Heidi de Marco/KHN)


Paloma Garza-Johnson is a registered nurse at Scripps Mercy Hospital Chula Vista.(Heidi de Marco/KHN)

Garza-Johnson dons her personal protective gear in the hallway outside an ICU patient’s room on May 29.(Heidi de Marco/KHN)


ICU staffers sometimes communicate with one another through the windows using a whiteboard.(Heidi de Marco/KHN)


Registered nurse Christina Campolongo (left), certified nursing assistant Vanessa Aquino and registered nurse Paloma Garza-Johnson turn a sedated coronavirus patient into the prone position, face down, which may allow more oxygen into the patient’s lungs.(Heidi de Marco/KHN)


The Rev. Mark Weber, coordinator of chaplaincy services at Scripps Mercy Hospital Chula Vista (left), and the Rev. Emmanuel Ochigbo, a chaplain, pray outside a coronavirus patient’s room before performing the sacrament of healing.(Heidi de Marco/KHN)

Ochigbo wets his finger with oil before entering the room to anoint the patient.(Heidi de Marco/KHN)


Ochigbo administers the sacrament of healing. The Anointing of the Sick is given to seriously ill and dying people. Ochigbo has modified it for COVID-19 patients, applying oil only to the forehead and feet.(Heidi de Marco/KHN)

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

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KHN’s ‘What The Health?’: Protests And The Pandemic


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Following the death of George Floyd while in custody in Minneapolis, protests have mushroomed around the U.S. to decry police violence, raising concerns among public health officials about the potential for further spread of the coronavirus.

Meanwhile, the economic toll of the continuing pandemic is prompting some states to cancel or scale back plans to expand health coverage to more of their residents.

And President Donald Trump said he will withdraw the United States from the World Health Organization. But it seems he lacks the legal authority to do that on his own.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Mary Agnes Carey of KHN and Joanne Kenen of Politico.

Among the takeaways from this week’s podcast:

  • Although public health officials are warning about the dangers of a resurgence of COVID-19 caused by the mass gatherings to protest Floyd’s death, if cases do spike, it may be hard to separate out that effect from the general reopening of the economy occurring about the same time.
  • The concerns about racial inequalities highlighted by the massive demonstrations include health disparities that have taken a big toll on minority communities. But fixing those inequities would be very expensive, and it’s not clear given the current economic downturn how federal or state officials would come up with funding to tackle those issues.
  • Also, as they observe the demonstrations, many experts are noting that racism and violence are public health issues, too.
  • Trump’s decision to pull out of the World Health Organization hampers U.S. efforts to play a role in pivotal decisions around the globe, especially on issues such as HIV/AIDS, malaria, flu and Ebola. Those are areas in which the WHO is seen as a leader on policy and research.
  • The sudden slowdown in the economy is causing some states such as Kansas and California to put the brakes on plans to help more people get coverage, especially efforts to expand Medicaid programs that serve low-income residents.
  • In a surprise opinion late last week, Chief Justice John Roberts sided with liberals on the Supreme Court to uphold California and Illinois regulations limiting church services to help curb the risk of COVID-19 infections. Roberts based his opinion on public health issues. Yet unknown is whether this signals how he might rule on a bigger case coming to the court in the fall over the fate of the Affordable Care Act.

Also this week, Rovner interviews Jonathan Oberlander, professor of health policy at the University of North Carolina-Chapel Hill and editor of the Journal of Health Policy, Politics and Law. The journal has released several articles examining the nexus between COVID-19, health inequities and social determinants of health. Those articles are temporarily free for the public to read, here.

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

Julie Rovner: The New York Times’ “The C.D.C. Waited ‘Its Entire Existence for This Moment.’ What Went Wrong?” by Eric Lipton, Abby Goodnough, Michael D. Shear, Megan Twohey, Apoorva Mandavilli, Sheri Fink and Mark Walker

Joanne Kenen: ProPublica’s “Senior Citizens in Subsidized Housing Have Been Dying Alone at Home, Unnoticed Because of Coronavirus Distancing,” by Mick Dumke and Haru Coryne

Alice Miranda Ollstein: Politico’s “States Brace for Disasters As Pandemic Collides With Hurricane Season,” by Dan Goldberg and Brianna Ehley

Mary Agnes Carey: Kaiser Health News’ “Police Using Rubber Bullets On Protesters That Can Kill, Blind Or Maim For Life,” by Liz Szabo


To hear all our podcasts, click here.

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

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Efforts To Curb Congenital Syphilis Falter In COVID’s Shadow

U.S. public health officials are closer to identifying a road map for curbing the rising rates of syphilis infections in newborn babies, but with so many resources diverted to stopping the spread of COVID-19, many fear the rate of deadly infections will only get worse.

Congenital syphilis — the term used when a mother passes the infection to her baby during pregnancy — is often a devastating legacy, potentially leaving babies blind or in excruciating pain or with bone deformities, blood abnormalities or organ damage. It’s one of the most preventable infectious diseases, experts say. Prevention, which means treating Mom so she doesn’t pass it on to her baby, requires just a few shots of penicillin.

Yet rates of infection and death from congenital syphilis have been on the rise for years. In 2018, 1,306 babies acquired syphilis from their mothers, a 40% increase over 2017 and the largest number since 1995. Nearly 100 were stillborn or died soon after birth. Federal researchers say 2019 data will show yet another jump.

A new report, released Thursday by the federal Centers for Disease Control and Prevention, aims to pinpoint the reasons so many women aren’t getting the care they need. It found that nationally 28% of women who gave birth to a baby with syphilis in 2018 had no prenatal care and weren’t tested in time for treatment. Nearly a third of the mothers were diagnosed but didn’t receive timely or thorough treatment.

How women slip through the cracks of the public health system varies by race and geography. Syphilis rates are highest in the South and West but have been rising across the nation, particularly in rural areas of the Midwest and West.

The burden of the disease falls disproportionately on African American women and families. Nearly 40% of moms who gave birth to babies with syphilis in 2018 were black, even though they made up about 15% of deliveries.

“That falls on public health as an institution,” said Matthew Prior, communications director for the National Coalition of STD Directors. “We need to think about why we do what we do, and we need to hear from the voices we are trying to serve.”

The CDC researchers identified four core reasons that mothers who gave birth to babies with syphilis weren’t treated: lack of prenatal care; prenatal care that did not include testing; improper treatment after a positive diagnosis; and getting infected during pregnancy.

In the South, a lack of prenatal care was the most common reason white women who gave birth to infected babies didn’t get treatment, while black women tended to have been diagnosed but not treated. In the West, 41% of women of all races who gave birth to infected babies had no prenatal care.

The CDC study provides clues for how to prevent infections, but taking advantage of that information will be a challenge for many local health departments. The COVID-19 pandemic has strained the nation’s frayed public health system.

In many communities, the same people who work on preventing the spread of sexually transmitted diseases such as syphilis have been called on to help prevent the spread of COVID-19. Departments are reporting mass interruptions in STD care and prevention services.

“COVID-19 is an obstacle to a lot of the interventions that we will try to roll out,” said Rebekah Horowitz, a senior program analyst with the National Association of County and City Health Officials (NACCHO).

In mid-March, the National Coalition of STD Directors surveyed a panel of its members; 83% of responding STD programs said they had deferred services. Nearly two-thirds said they cannot keep up with their HIV and syphilis caseloads.

“A lot of our enhancement projects have been scaled back,” said Amanda Reich, congenital syphilis coordinator for Texas. “Our staff are doing the best that they can do.”

Shuttered clinics and delayed prenatal care — yet another consequence of COVID-related shutdowns — are likely to exacerbate rates of congenital syphilis and sexually transmitted diseases in general. Testing for syphilis is key since there’s often a lag between contracting the disease and developing symptoms, said Dr. Anne Kimball, a pediatrician in the Epidemic Intelligence Service of the CDC and lead author of the study. “You can have it and give it to your unborn child without knowing you have it,” she said.

Because syphilis is so easy to test for, treat and prevent, it’s often seen as the canary in the coal mine, signaling a warning about what’s happening with other infectious diseases. Cases of syphilis, gonorrhea and chlamydia combined reached an all-time national high in 2018.

“It is a symptom of under-supporting public health and STD programs for decades,” Prior said. “It’s not surprising.”

Even before the global coronavirus pandemic, many health departments around the country were working with bare-bones staffing and aggressively tracking and treating syphilis only among pregnancy-age women. Men who have sex with men have the highest rate of the disease nationally.

Arkansas reorganized its disease investigation unit after a spike in cases in 2018, assigning one person to follow up with all pregnant women with syphilis, said Brandi Roberts, the state’s STD Prevention Program Manager. She said the reorganization has been successful, and even as resources have been redeployed to COVID-19, that employee’s assignment hasn’t changed. But like many states, Arkansas has seen a decrease in reported STD cases, which Roberts believes is likely a sign of reduced testing, not a drop in cases.

NACCHO and the CDC are helping to fund and evaluate programs at six health departments — ranging from New York City to rural Tulare County, California — that they hope will offer further clues for how to curb the spread of disease.

But their success will rely on resources, said Horowitz.

“This was true two years ago, it is true now, and it will be true in the future: These missed opportunities will continue as long as we are not investing in a robust way in our public health infrastructure,” she said.

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

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Judges Try To Balance Legal Rights And Courtroom Health

It’s tough getting people to report for jury duty in normal times. It’s even harder during a pandemic.

The kidnapping and rape trial of Kenneth Weathersby Jr. opened Feb. 24 in Vallejo, California, but three weeks later two jurors refused to show up after the state ordered people to stay home. Then the state’s chief justice stopped jury trials for 60 days, later extending the suspension into June.

Eventually, Solano County Superior Court Judge Robert Bowers had had enough.

At 10:24 a.m. on May 20, Bowers called the jurors who were left ― 11, and an alternate ― into Courtroom 101. Bailiffs offered each of the six men and six women a squirt of hand sanitizer before showing them to their seats. Four were led into the jury box, the rest to the gallery, with yellow tape covering groups of three seats to enforce social distancing.

“Citizens have a right to trials,” the tall, furrow-browed Bowers told the jurors, pulling down his blue mask to speak. “We have to find a way going forward.”

Solano was the first California county to resume a jury trial. Three others — Contra Costa, Santa Clara and Monterey — have notified Chief Justice Tani Cantil-Sakauye that they are resuming trials in the coming weeks, despite rising COVID-19 infection rates in the state.

In reopening, judges are trying to balance the constitutional rights of the accused to a speedy trial against the safety of jurors, bailiffs, clerks, attorneys, court reporters and others who work in their courthouses.

But courtrooms can be snug. Jury rooms almost always are. It will be very hard for people to keep the recommended distance, even as they abstain from the usual buttonholing, emoting and hugging in courthouse hallways.

Judges are conferring with health departments to limit the risks. Some courts, but not all, are requiring masks. Some are checking people’s temperatures before allowing them to enter the courthouse. Others may install plexiglass or plastic barriers.

Gone, for now at least, are the days when jury duty began with scores of prospective jurors packed into halls and waiting rooms. Courthouses in Contra Costa and Monterey are staggering the times and days of the week when potential jurors report, and calling only 50 people at a time to prevent large groups from gathering. Some are adding temperature checks to their usual security screenings.

“If they have a temperature over 100, they won’t be allowed in,” said Barry Baskin, presiding judge for Contra Costa County.

All the courts resuming trials say they’ll allow people to delay jury duty if they have concerns about the coronavirus. “We’re doing everything we can for their protection,” Baskin said.

Forty-eight states and territories — all except Illinois, Nebraska, Nevada, Ohio, South Dakota, Texas, American Samoa and the U.S. Virgin Islands — have restricted jury trials, according to the National Center for State Courts. So far, 14 states have reported coordinated statewide plans to reopen. California isn’t one of them.

At the federal level, decisions to resume jury trials are made on a district-by-district basis. All federal courts moved hearings to videoconferencing on April 8.

Health concerns and the legal rights of the accused are bound to be in conflict sooner or later in every jurisdiction.

Under the U.S. Constitution’s Sixth Amendment, defendants have a right to confront their accusers in a speedy public trial by a jury of their peers. In California, trial is supposed to start within 60 days of arraignment for a felony case and within 45 days for a misdemeanor. The chief justice’s order can provide relief from those deadlines on a case-by-case basis in the interest of public safety.

Still, some counties are reluctant and want Cantil-Sakauye to delay trials into July. The chief justice’s ruling allows courts to reopen earlier if they can do so “in compliance with applicable health and safety laws, regulations, and orders, including through the use of remote technology, when appropriate.”

“The further we get away from the height of the pandemic, the more likely people are to show up,” said Alameda County District Attorney Nancy O’Malley, president of the California District Attorneys Association.

“We are still hoping and pressing that people will respond,” said Chris Ruhl, court executive officer for Monterey County. “Jurors are real heroes in these times.”

While health officials recommend masks to prevent the spread of the coronavirus, testifying while wearing one may violate the Sixth Amendment, which allows a defendant to literally face their accuser, Baskin said.

The U.S. Supreme Court determined in Coy v. Iowa in 1988 that witnesses can’t testify behind curtains or other visual obstructions. In the current pandemic, the Ohio Supreme Court ruled in April that witnesses must lower or remove their masks when testifying.

Courts are looking to erect plexiglass barriers around witness stands, or have attorneys and witnesses wear clear plastic face shields, so everyone in the courtroom can see and hear what is said.

But mandates for such measures will come on a county-by-county basis. That frustrates Oscar Bobrow, chief deputy public defender in Solano County and the president of the California Public Defenders Association. He wants a consistent state policy and notes that Ohio released a 93-page guide to resuming jury trials after consulting with people from across that state’s legal community.

Bobrow worries that fear of infection will result in juries with fewer African Americans and Hispanics, two groups that have suffered the brunt of the pandemic. People over 60 might also be reluctant to appear; some counties would exclude them from jury service, according to guidelines posted on various websites.

“The whole process is going to be slowed down, if it’s done right,” he said.

If courthouses don’t do enough to protect jurors from the virus, the panels may be unable to concentrate on testimony. “You’ll be more worried about someone sneezing than what’s being said to you,” Bobrow said.

When Weathersby’s trial resumed May 20, fewer than 25 people sat in the courtroom, which has a new maximum capacity of 53. Yellow tape over seats assured they sat at least 6 feet apart.

Masks were “strongly recommended” but not required — and four jurors declined the ones offered by bailiffs.

“We have a balance of personal freedoms and human protections,” Bowers told the jurors. “This is the new norm. This is what jury trials will look like in the future.”

The jury found Weathersby guilty on 10 counts, including forcible rape and kidnapping to commit rape. He faces multiple life terms at sentencing, scheduled for July 14.


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

Newsom Likes To ‘Go Big’ But Doesn’t Always Deliver

Gavin Newsom knew it was a political gamble when, as the newly elected mayor of San Francisco, he promised to eradicate chronic homelessness.

“I recognize that I’m setting myself up. I’m not naive to that,” he told his hometown newspaper in 2003 as he embarked on a campaign to sell his controversial plan. It hinged on slashing welfare payments for homeless people and redirecting those funds to acquire single-room occupancy hotels, converting them into long-term housing with health and social services.

“I don’t want to over-promise, but I also don’t want to under-deliver,” he said.

Over-promise he did, and the venture ultimately failed. But that pledge by Newsom — who at the time was a young, politically connected wine shop owner relatively new to public office — previewed a brand of political leadership on full display today as the first-term governor confronts an unprecedented public health emergency that has decimated the state’s economy and killed more than 4,280 Californians.

The COVID-19 pandemic has catapulted the 52-year-old Democrat into greater national prominence, winning him praise and voter support for taking decisive action to control the spread of infection in the absence of strong federal leadership.

But it has also exposed his penchant for making ambitious, showy announcements — often broadcast to a national audience — that aren’t necessarily ready for prime time. His plans regularly lack detail and, in some cases, follow-through.

“This governor wants to get a lot done even if all the details aren’t quite there yet. It’s uniquely his approach,” said Democratic strategist Dana Williamson, longtime adviser to former Gov. Jerry Brown. “He isn’t afraid to go big. The upside is establishing yourself as a real leader and, in the case of COVID, saving lives. But the downside is it doesn’t always work out quite perfectly.”

Newsom has a long history of pushing big ideas before they become popular, including legalizing gay marriage and recreational marijuana use, halting death penalty executions and expanding free health care for undocumented immigrants. Since his entry into public life, he has cultivated the image of a political risk-taker willing to buck the Democratic Party establishment. And although he has demurred, there is widespread speculation that Newsom has presidential ambitions.

Since the start of the pandemic, Newsom has been praised by public health experts and Democratic strategists for making politically courageous decisions such as enacting the nation’s first statewide stay-at-home order, preventing widespread sickness and death. He has dramatically expanded hospital capacity while seeking to attack major problems as they erupt, from dire shortages of protective gear for hospital workers to inadequate testing in rural towns and poor, inner-city neighborhoods.

But as the crisis wears on, the list of Newsom’s unfulfilled promises is growing:

  • On April 7, he told MSNBC host Rachel Maddow that he had inked a deal securing “upwards” of 200 million protective masks per month, enough to “supply the needs of the state of California — potentially the needs of other Western states.” But nearly two months later, just 61 million surgical masks have arrived in California, while no higher-caliber N95 masks have been delivered, according to Brian Ferguson, spokesperson for the state Office of Emergency Services — despite Newsom’s promise that the deal included at least 150 million N95s. The $1 billion effort has been riddled with flaws, and the state so far has taken back nearly $250 million from the Chinese contractor, BYD Ltd. Co.
  • Later that month, Newsom announced a deal with Motel 6 that would provide thousands of rooms for homeless people in need of shelter. At least 5,025 Motel 6 rooms at 47 sites would open their doors to homeless people, “effective immediately,” should counties opt in, he said. But to date, just 628 Motel 6 rooms are open to homeless people at six sites.
  • Newsom also said in April that California must dramatically expand COVID-19 testing before it reopens to at least 60,000 — ideally 80,000 — tests per day. But the state still has not consistently reached 60,000 tests per day, even as it has allowed most counties to ease their stay-at-home restrictions.

In other cases, the governor has artfully avoided making specific promises. For instance, he has called the safety of nursing home patients and staff members a “top priority” without detailing plans, allowing him to dodge criticism even as more than half the deaths in California have occurred in long-term care facilities, according to state data.

Yet so far Newsom is showing strong support from Californians. Nearly 70% of likely voters say he’s doing a good job of handling the pandemic, according to a new poll released Wednesday by the Public Policy Institute of California. His overall approval rating has climbed by double digits since February, rising from 52% to 64%.

But his support could erode if the public begins to notice that his promises — and lofty rhetoric — do not match reality, said Mark Baldassare, president and CEO of the institute.

“People can be forgiving and give the governor the benefit of the doubt, but that can turn from positive to negative very quickly,” Baldassare said. “The risk is public opinion can shift very quickly if people get a sense that it’s not going well or according to expectations.”

Although Newsom himself has acknowledged criticism that the state is falling short on some fronts, his chief spokesperson Nathan Click defended the governor’s approach.

“When it’s your life or livelihood on the line, wouldn’t you want leaders who are moving aggressively to help people on every possible front?” Click said in a statement. “He’s not afraid to swing for the fences — especially in a time of massive need.”

Daniel Zingale, Newsom’s former chief adviser, who retired earlier this year, argued that the governor’s handling of the pandemic has saved countless lives while bolstering the social safety net for those at greatest risk of contracting the coronavirus.

“When you have a crisis like this that is unprecedented, there is no real playbook,” Zingale said. “I think Gavin Newsom was made for this moment. This is a situation where you want a governor who is high-energy, deeply earnest and prone to action rather than inaction.”

***

Newsom’s political career dates back to the late 1990s, when he was appointed to San Francisco’s parking and traffic commission by its then-mayor, Willie Brown. Soon thereafter, Brown tapped Newsom to fill an open seat on the San Francisco Board of Supervisors. Running as the incumbent in 1998, Newsom was elected that year to his first full term on the board.

During his early years in public life, he honed his approach to politics — aggressively seeking national media attention for first-in-the-country social and economic policies. In 2004, the year he took office as mayor, Newsom granted same-sex couples marriage licenses before it was legal, and in 2006 he signed into law the nation’s first universal health care program, which covered all city residents regardless of their immigration status or ability to pay.

Newsom, in his 2013 book “Citizenville,” described his leadership approach as “Ready, fire, aim.”

“I’m as proud of some of my failures in business and politics as I am of my successes,” he wrote. “Failure isn’t something to be embarrassed about; it’s just proof that you’re pushing your limits, trying new things, daring to innovate.”

Newsom believes strongly in setting “audacious goals,” even if he risks over-promising or alienating supporters, said Peter Ragone, who was press secretary for part of Newsom’s mayoral tenure.

“Gavin has always believed that if you show people you’re thinking big and trying hard, they will take that over timidity, even if you might fail,” said Ragone, who remains a close, informal adviser to Newsom and also advises New York City Mayor Bill de Blasio. “He wasn’t able to completely eradicate homelessness, but the voters were OK with that because they saw he was trying. Success doesn’t have to be an absolute policy triumph.”

***

Now Newsom is facing the biggest challenge of his political career, with several high-profile crises slamming California at once: A global public health emergency. Widespread civil unrest sparked by the killing of an African American man in Minnesota, George Floyd, at the hands of a white police officer, Derek Chauvin. Rising unemployment that could reach 30%. And another potentially devastating wildfire season.

The coronavirus pandemic, in particular, could have long-lasting consequences for Newsom’s future, said Dr. Leonard Marcus, co-director of the National Preparedness Leadership Initiative, a joint program of the Harvard T.H. Chan School of Public Health and the Harvard Kennedy School of Government.

“The politics of crisis leadership are high-consequence,” Marcus said. “For every political leader, a crisis like this is going to make or break their career.”

George Chin, 80, lived in a nursing home in Woodland, California, until April 22, when he died of COVID-19, according to his family. Chin died six days after he first complained of shortness of breath and spiked a high fever. (Courtesy of Simon Chin)

Davis resident Simon Chin has grown disillusioned with Newsom since the start of the crisis.

Chin’s father, 80-year-old George Chin, lived in Stollwood Convalescent Hospital in nearby Woodland. Chin regularly tuned into Newsom’s public briefings on the crisis to hear the governor say he was committed to preventing infections in nursing homes and protecting staff members and residents.

But infections in senior care homes continued to rise. And although Newsom has called for universal testing of residents and staffers, the state hasn’t provided the resources to make that happen, said Jason Belden, emergency preparedness director for the California Association of Health Facilities, which represents California’s roughly 1,200 state-regulated nursing homes.

State Health and Human Services Secretary Mark Ghaly said it’s the responsibility of nursing homes, not the state, to test.

“It’s not what we’re doing, and it’s, in our view, not feasible,” Ghaly said in an interview, noting that across the state, there are about 119,000 nursing home beds and about 90,000 staff members.

Newsom’s rhetoric at times has given the public a false sense of hope, said Dr. Michael Wasserman, president of the California Association of Long Term Care Medicine.

“When it comes to vulnerable older adults in California, all this governor has been doing is saying he’s going to act, he’s going to help them, but he hasn’t actually taken action,” Wasserman said. “People are dying because of it.”

Newsom’s reassuring statements during his public briefings made Chin feel like the state was doing more to prevent widespread infections, he said.

But Chin’s father died of COVID-19 on April 22. State records show 15 residents — roughly half of the nursing home’s capacity — died of the disease.

“We had no idea that there were such big problems in skilled nursing facilities based on what the governor was saying,” Chin said. “By the time we found out, it was too late.”


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

In Hard-Hit Areas, COVID’s Ripple Effects Strain Mental Health Care Systems

In late March, Marcell’s girlfriend took him to the emergency room at Henry Ford Wyandotte Hospital, about 11 miles south of Detroit.

“I had [acute] paranoia and depression off the roof,” said Marcell, 46, who asked to be identified only by his first name because he wanted to maintain confidentiality about some aspects of his illness.

Marcell’s depression was so profound, he said, he didn’t want to move and was considering suicide.

“Things were getting overwhelming and really rough. I wanted to end it,” he said.

Marcell, diagnosed with schizoaffective disorder seven years ago, had been this route before but never during a pandemic. The Detroit area was a coronavirus hot spot, slamming hospitals, attracting concerns from federal public health officials and recording more than 1,000 deaths in Wayne County as of May 28. Michigan ranks fourth among states for deaths from COVID-19.

The crisis enveloping the hospitals had a ripple effect on mental health programs and facilities. The emergency room was trying to get non-COVID patients out as soon as possible because the risk of infection in the hospital was high, said Jaime White, director of clinical development and crisis services for Hegira Health, a nonprofit group offering mental health and substance abuse treatment programs. But the options were limited.

Still, the number of people waiting for beds at Detroit’s crisis centers swelled. Twenty-three people in crisis had to instead be cared for in a hospital.

This situation was hardly unique. Although mental health services continued largely uninterrupted in areas with low levels of the coronavirus, behavioral health care workers in areas hit hard by COVID-19 were overburdened. Mobile crisis teams, residential programs and call centers, especially in pandemic hot spots, had to reduce or close services. Some programs were plagued by shortages of staff and protective supplies for workers.

At the same time, people battling mental health disorders became more stressed and anxious.

“For people with preexisting mental health conditions, their routines and ability to access support is super important. Whenever additional barriers are placed on them, it could be challenging and can contribute to an increase in symptoms,” said White.

After eight hours in the emergency room, Marcell was transferred to COPE, a community outreach program for psychiatric emergencies for Wayne County Medicaid patients.

“We try to get patients like him into the lowest care possible with the least restrictive environment,” White said. “The quicker we could get him out, the better.”

Marcell was stabilized at COPE over the next three days, but his behavioral health care team couldn’t get him a bed in one of two local residential crisis centers operated by Hegira. Social distancing orders had reduced the beds from 20 to 14, so Marcell was discharged home with a series of scheduled services and assigned a service provider to check on him.

However, Marcell’s symptoms ― suicidal thoughts, depression, anxiety, auditory hallucinations, poor impulse control and judgment ― persisted. He was not able to meet face-to-face with his scheduled psychiatrist due to the pandemic and lack of telehealth access. So, he returned to COPE three days later. This time, the staff was able to find him a bed immediately at a Hegira residential treatment program, Boulevard Crisis Residential in Detroit.

Residents typically stay for six to eight days. Once they are stabilized, they are referred elsewhere for more treatment, if needed.

Marcell ended up staying for more than 30 days. “He got caught in the pandemic here along with a few other people,” said Sherron Powers, program manager. “It was a huge problem. There was nowhere for him to go.”

Marcell couldn’t live with his girlfriend anymore. Homeless shelters were closed and substance abuse programs had no available beds.

“The big problem here is that all crisis services are connected to each other. If any part of that system is disrupted you can’t divert a patient properly,” said Travis Atkinson, a behavioral consultant with TBD Solutions, which collaborated on a survey of providers with the American Association of Suicidology, the Crisis Residential Association and the National Association of Crisis Organization Directors.

White said the crisis took a big toll on her operations. She stopped her mobile crisis team on March 14 because, she said, “we wanted to make sure that we were keeping our staff safe and our community safe.”

Her staff assessed hospital patients, including Marcell, by telephone with the help of a social worker from the emergency room.

People like Marcell have struggled during the coronavirus crisis and continue to face hurdles because emergency preparedness measures didn’t provide enough training, funds or thought about the acute mental health issues that could develop during a pandemic and its aftermath, said experts.

“The system isn’t set up to accommodate that kind of demand,” said Dr. Brian Hepburn, a psychiatrist and executive director of the National Association of State Mental Health Program Directors.

“In Detroit and other hard-hit states, if you didn’t have enough protective equipment you can’t expect people to take a risk. People going to work can’t be thinking ‘I’m going to die,’” said Hepburn.

For Marcell, “it was bad timing to have a mental health crisis,” said White, the director at Hegira.

At one time Marcell, an African American man with a huge grin and a carefully trimmed goatee and mustache, had a family and a “pretty good job,” White said. Then “it got rough.” Marcell made some bad decisions and choices. He lost his job and got divorced. Then he began self-medicating with cocaine, marijuana and alcohol.

By the time he reached the residential center in Detroit on April 1, he was at a low point. “Schizoaffective disorder comes out more when you’re kicked out of the house and it increases depression,” said Powers, the program manager who along with White was authorized by Marcell to talk about his care. Marcell didn’t always take his medications and his use of illicit drugs magnified his hallucinations, she said.

While in the crisis center voluntarily, Marcell restarted his prescription medications and went to group and individual therapy. “It is a really good program,” he said while at the center in early May. “It’s been one of the best 30 days.”

Hepburn said the best mental health programs are flexible, which allows them more opportunities to respond to problems such as the pandemic. Not all programs would have been able to authorize such a long stay in residential care.

Marcell was finally discharged on May 8 to a substance abuse addiction program. “I felt good about having him do better and better. He had improved self-esteem to get the help he needed to get back to his regular life,” Powers said.

But Marcell left the addiction program after only four days.

“The [recovery] process is so individualized and, oftentimes, we only see them at one point in their journey. But, recovering from mental health and substance use disorders is possible. It can just be a winding and difficult path for some,” said White.

Seeking Help

If you or someone you know is in immediate danger, call 911. Below are other resources for those needing help:

— National Helpline: 1-800-662-HELP (4357) or https://findtreatment.samhsa.gov.

— National Suicide Prevention Lifeline: 1-800-273-TALK (8255).

— Disaster Distress Helpline: 1-800-985-5990 or text TalkWithUs to 66746.

Hype Collides With Science As FDA Tries To Rein In ‘Wild West’ of COVID Blood Tests

“Save your business while saving lives,” reads the website of Because Health, a Seattle tech startup selling two types of tests to employers willing to pay $350 a pop to learn whether their workers have been infected with COVID-19.

The “Workplace Health” plan includes not only nasal swab tests to detect infection, but also blood tests aimed at indicating whether workers have developed antibodies to the virus — and, possibly, future protection.

“There’s a tremendous consumer demand,” said Dr. Lars Boman, the Boston-based medical director for the firm. “Can they return to work? Can they return to life?”

What the website does not make clear, however, is that public health officials have explicitly warned that antibody tests should not be used to make decisions about workplace staffing.

“This is a personal choice of the business, of the consumer,” Boman said.

Across America, untold numbers of employers, employees and ordinary citizens are turning to a slew of sometimes pricey new COVID-19 blood tests. Knowing who’s already been infected could have important implications for understanding the spread of the disease, scientists say. But serious questions about the accuracy of some of the serology tests — and the usefulness of the results they provide — have prompted the federal Food and Drug Administration to try to rein in what several infectious disease experts described as “the wild, wild West” of antibody testing.

“It does look as if companies sprang up overnight both importing these tests and distributing them,” said Dr. Michael Busch, director of the nonprofit Vitalant Research Institute in San Francisco. “It’s outrageous that people were trying to make money off of this fear.”

More than 200 tests have flooded the market in a matter of weeks, promising to detect antibodies, which are proteins that develop in the blood as part of the body’s immune response to an invading virus. These are different from the molecular tests, typically done with nasal swabs, used to diagnose infection.

As of June 1, only 15 antibody tests had received FDA “emergency-use authorizations,” which allow tests that haven’t been fully vetted to be used in a crisis. Even that standard has become a selling point for some large companies, such as LabCorp and Quest Diagnostics, which emphasize that they rely on tests that have received the FDA nod.

In late May, the FDA removed more than 30 serology tests from a list of commercially available kits, saying they “should not be distributed” for sale. Removal could result from a manufacturer not submitting an emergency-use authorization request within a “reasonable period of time,” or if the test shows “significant problems” that cannot be or have not been addressed in a timely manner, the agency said. The manner of enforcement remains unclear.

Last month, the CDC issued new guidelines warning that, given the low prevalence of the virus in the general population, even the most accurate tests could be wrong half of the time.

“Serologic test results should not be used to make decisions about grouping persons residing in or being admitted to congregate settings, such as schools, dormitories, or correctional facilities,” the guidelines state. “Serologic test results should not be used to make decisions about returning persons to the workplace.”

Such tests are most useful for understanding the epidemiology of the virus, not for making individual decisions, said Dr. Mary Hayden, director of the division of clinical microbiology at Rush Medical Laboratories in Chicago. Even the best tests can’t yet answer the crucial question about whether antibodies confer immunity from future COVID infections, Hayden said.

“The best possible scenario is that people get infected and they have protective immunity for a long time,” she said. “That would be awesome. But we just don’t have that right now.”

But a plethora of tests being pitched to consumers explicitly promise results aimed at allowing a return to work, school and other social arenas.

The tests offered by Because Health are among hundreds churned out since March, ranging from those offered by commercial labs and academic research centers to small developers seeking a toehold in the lucrative market spurred by a global pandemic. Because Health is using two antibody tests in tandem, one of which received emergency-use authorization on May 29; the other is still pending.

Anders Boman, the son of the medical director and co-founder of Because Health, said that until the COVID crisis occurred, the company, which launched in Seattle last year, was focused on “a niche of integrative care and sexual health,” including hormone treatments for men and women.

“Consumers are not concerned about sexual health right now,” Boman said, explaining the change in focus. “They’re concerned about how to get back to work, how to return to normal and are they safe?”

The FDA normally follows a stringent approval process for tests to detect diseases, often a costly effort that can take months or years. That typically requires independent validation of the accuracy of the tests. But after being criticized for the fumbled rollout of diagnostic tests during the start of a global pandemic, the FDA swung hard in the other direction, waiving its usual requirements and letting firms rush self-validated tests into the market.

“They sort of relaxed all regulatory oversight,” Hayden said.

Several experts interviewed by Kaiser Health News said the FDA faced tremendous political pressure to make antibody tests available.

“It was really a single pressure — and that was the fact that the original inability to get a [diagnostic] test on the market in the U.S. as the outbreak escalated means they were trying to do basically everything they could to get these out,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

The relaxed rules drew concern from Congress, where a subcommittee of the Committee on Oversight and Reform detailed the FDA’s failure to “police the test market.” Groups such as the Association of Public Health Laboratories also raised questions. Scott Becker, the APHL’s chief executive, said he spoke to top officials at the U.S. Department of Health and Human Services in early April.

“We just let loose and we said, ‘This is a really bad policy,’” Becker said. “‘We’re going to get flooded and we’re going to lose control of quality. We’re not going to know what to do with the results.’”

That’s exactly what has happened, said Osterholm. “The FDA needs to bring much more discipline to this area and they need to articulate it clearly,” he said.

A key issue is the accuracy of the tests, which rely on measures known as sensitivity and specificity. A highly sensitive test will capture all true positive results. A highly specific test would identify all true negative results.

In April, researchers at the University of California-San Francisco, led by immunologist Dr. Alexander Marson, analyzed 14 COVID-19 serology tests on the market and found that all but one turned up false-positive results, indicating that someone had antibodies to the coronavirus when they actually did not. False-positive rates reached as high as 16% in the study, which has not yet been peer-reviewed.

Unreliable results worry Dr. Jeff Duchin, the public health officer for Seattle and King County, Washington, where the first surge of COVID cases emerged in the U.S. A person who tests positive for antibodies that don’t exist may mistakenly believe he or she is free to ignore guidance about preventing infection, potentially spreading the disease. “Regardless of whether you test positive or negative, the workplace still needs to take steps,” he said. “They shouldn’t think a testing program in any way relieves them of that responsibility.”

FDA officials said they’re working now with the National Cancer Institute to independently validate serology tests on the market. Until that list is public, users must rely on the relatively few that have received the emergency-use authorizations to date. More than 190 others have asked for that authorization, pending FDA review.

But consumers may have little control, because they are most likely getting tests from their employers or doctors, with little understanding of why those products were chosen.

“There isn’t a national standard, there isn’t a one-stop shop or a Consumer Reports for antibody tests,” Becker said. “I don’t expect a member of the public is going to be able to figure this out.”

Even savvy physicians can have trouble. US Acute Care Solutions, a physician-owned medical services group, was trying out a Chinese-made test supplied by Minneapolis-based Premier Biotech, with plans to test its staff of more than 3,500 doctors and employees, said the group’s chief medical officer, Dr. Amer Aldeen. That test has been widely used, including in recent controversial serology surveys conducted by Stanford University and the University of Southern California.

When USACS used it, the Premier test failed to detect antibodies in several employees who had been ill and tested positive for the coronavirus on diagnostic tests, Aldeen said. The results could have been caused by faulty instructions rather than flaws in the test itself, he said. Still, the Premier test has not received FDA authorization and the results gave him pause.

“It does no good to select a test that isn’t FDA-approved,” he said.

In a statement, Premier Biotech officials said they anticipate exceeding FDA standards, which call for tests that are at least 90% accurate in identifying positive antibodies in a sample and 95% accurate in identifying samples that contain no antibody.

Some might ask why the FDA didn’t just identify several reliable antibody tests and require their use to avoid the chaos. An FDA official said making that type of choice would be outside the scope of the agency’s responsibilities.

“FDA’s lane is to review these tests and make sure that they are safe and accurate for the American people,” said spokesperson Emma Spaulding. “It wouldn’t be within our lane to say which test must be used.”

Although health officials understand the desire for a test that could provide comfort amid the uncertainty of COVID-19, Duchin advised employers and consumers to wait a little longer.

“There are costs to testing with unvalidated tests that might outweigh the benefits of satisfying your curiosity,” he said.

Related Topics

Public Health

ICUs Become A ‘Delirium Factory’ For COVID Patients

Doctors are fighting not only to save lives from COVID-19, but also to protect patients’ brains.

Although COVID-19 is best known for damaging the lungs, it also increases the risk of life-threatening brain injuries — from mental confusion to hallucinations, seizures, coma, stroke and paralysis. The virus may invade the brain, as well as starve the organ of oxygen by damaging the lungs. To fight the infection, the immune system sometimes overreacts, battering the brain and other organs it normally protects.

Yet the pandemic has severely limited the ability of doctors and nurses to prevent and treat neurological complications. The severity of the disease and the heightened risk of infection have forced medical teams to abandon many of the practices that help them protect patients from delirium, a common side effect of mechanical ventilators and intensive care.

And while COVID-19 increases the risk of strokes, the pandemic has made it harder to diagnose them.

When doctors suspect a stroke, they usually order a brain MRI — a sophisticated type of scan. But many patients hospitalized with COVID-19 are too sick or unstable to be wheeled across the hospital to a scanner, said Dr. Kevin Sheth, a professor of neurology and neurosurgery at the Yale School of Medicine.

“Our hands are much more tied right now than before the pandemic,” says Dr. Sherry Chou, associate professor of critical care medicine, neurology and neurosurgery at the University of Pittsburgh School of Medicine.(Courtesy of Dr. Sherry Chou)

Many doctors also hesitate to request MRIs for fear that patients will contaminate the scanner and infect other patients and staff members.

“Our hands are much more tied right now than before the pandemic,” said Dr. Sherry Chou, an associate professor of critical care medicine, neurology and neurosurgery at the University of Pittsburgh School of Medicine.

In many cases, doctors can’t even examine patients’ reflexes and coordination because patients are so heavily sedated.

“We may not know if they’ve had a stroke,” Sheth said.

A study from Wuhan, China — where the first COVID-19 cases were detected — found 36% of patients had neurological symptoms, including headaches, changes in consciousness, strokes and lack of muscle coordination.

A smaller, French study observed such symptoms in 84% of patients, many of which persisted after people left the hospital.

Some hospitals are trying to get around these problems by using new technology to monitor and image the brain.

New York’s Northwell Health is using a mobile MRI machine for COVID patients, said Dr. Richard Temes, the health system’s director of neurocritical care. The scanner uses a low-field magnet, so it can be wheeled into hospital rooms and take pictures of the brain while patients are in bed.

New York’s Northwell Health is using a mobile MRI machine for patients with COVID-19, says Dr. Richard Temes, the health system’s director of neurocritical care.(Courtesy of Northwell Health)

Staffers at Northwell were also concerned about the infection risk from performing EEGs, tests that measure the brain’s electrical activity and help diagnose seizures, Temes said. Typically, technicians spend 30 to 40 minutes in close contact with patients in order to place electrodes around their skulls.

To reduce the risk of infection, Northwell is using a headband covered in electrodes, which can be placed on patients in just a couple of minutes, he said.

The Brain Under Attack

“Right now, we actually don’t know enough to say definitely how COVID-19 affects the brain and nervous system,” said Chou, who is leading an international study of neurological effects of the virus. “Until we can answer some of the most fundamental questions, it would be too early to speculate on treatments.”

Answering those questions is complicated by the limited data from patient autopsies, said Lena Al-Harthi, a professor and the chair of the microbial pathogens and immunity department at Rush Medical College in Chicago.

Authors of a recent study from Germany found the novel coronavirus in patients’ brains.

But many neuropathologists are unwilling or unable to perform brain autopsies, Al-Harthi said.

That’s because performing autopsies on patients who died of COVID-19 carries special risks, such as the aerosolization of the virus during brain removal. Pathologists need specialized facilities and equipment to conduct an autopsy safely.

Some of the best-known symptoms of COVID-19 might be caused by the virus invading the brain, said Dr. Robert Stevens, an associate professor of anesthesiology and critical care medicine at Johns Hopkins University.

Some of the best-known symptoms of COVID-19 could be caused by the virus’s invasion of nerve cells, says Dr. Robert Stevens, an associate professor of anesthesiology and critical care medicine at Johns Hopkins University.(Courtesy of Johns Hopkins)

Research shows that the coronavirus may enter a cell through a gateway known as the ACE-2 receptor. These receptors are found not only in the lung, but also on organs throughout the body, including many parts of the brain.

In a recent study, Japanese researchers reported finding the novel coronavirus in the cerebrospinal fluid that surrounds the brain and spinal cord.

Some of the most surprising symptoms of COVID-19 ― the loss of the senses of smell and taste ― remain incompletely understood, but may be related to the brain, Stevens said.

A study from Europe published in May found that 87% of patients with mild or moderate COVID-19 lost their sense of smell. Patients’ loss of smell couldn’t be explained by inflammation or nasal congestion, the study said. Stevens said it’s possible that the coronavirus interacts with nerve pathways from the nose to the brain, potentially affecting systems involved with processing scent.

A new study in JAMA provides additional evidence that the coronavirus invades the brain. Italian researchers found abnormalities in an MRI of the brain of a COVID-19 patient who lost her sense of smell.

Many COVID patients develop “silent hypoxia,” in which they are unaware that their oxygen levels have plummeted dangerously low, Stevens added.

When hypoxia occurs, regulatory centers in the brain stem — which control respiration — signal to the diaphragm and the muscles of the chest wall to work harder and faster to get more oxygen into the body and force out more carbon dioxide, Stevens said. The lack of this response in some patients with COVID-19 could indicate the brain stem is impaired.

Scientists suspect the virus is infecting the brain stem, preventing it from sending these signals, Temes said.

Collateral Damage

Well-intentioned efforts to save lives can also cause serious complications.

Many doctors put patients who are on mechanical ventilators into a deep sleep to prevent them from pulling out their breathing tubes, which would kill them, said Dr. Pratik Pandharipande, chief of anesthesiology and critical care medicine at Vanderbilt University School of Medicine in Nashville, Tennessee.

Both the disease itself and the use of sedatives can cause hallucinations, delirium and memory problems, said Dr. Jaspal Singh, a pulmonologist and critical care specialist at Atrium Health in Charlotte, North Carolina.

Many sedated patients experience terrifying hallucinations, which may return in recovery as nightmares and post-traumatic stress disorder.

Research shows 70% to 75% of patients on ventilators traditionally develop delirium. Delirious patients often “don’t realize they’re in the hospital,” Singh said. “They don’t recognize their family.”

In the French study in the New England Journal of Medicine, one-third of discharged COVID-19 patients suffered from “dysexecutive syndrome,” which can be characterized by inattention, disorientation or poorly organized movements in response to commands.

Research shows that patients who develop delirium — which can be an early sign of brain injury — are more likely to die than others. Those who survive often endure lengthy hospitalizations and are more likely to develop a long-term disability.

Under normal circumstances, hospitals would invite family members into the ICU to reassure patients and keep them grounded, said Dr. Carla Sevin, director of the ICU Recovery Center, also at Vanderbilt.

Many doctors now feel forced to prescribe heavy sedatives to COVID patients, says Dr. Carla Sevin, director of the ICU Recovery Center at Vanderbilt University School of Medicine in Nashville, Tennessee.(Courtesy of Vanderbilt)

Just allowing a family member to hold a patient’s hand can help, according to Dr. Lee Fleisher, chair of an American Society of Anesthesiologists committee on brain health. Nurses normally spend considerable time each day orienting patients by talking to them, reminding them where they are and why they’re in the hospital.

“You can decrease the need for some of these drugs just by talking to patients and providing light touch and comfort,” Fleisher said.

These and other innovative practices — such as helping patients to move around and get off a ventilator as soon as possible — can reduce the rate of delirium to 50%.

Hospitals have banned visitors, however, to avoid spreading the virus. That leaves COVID-19 patients to suffer alone, even though it’s well known that isolation increases the risk of delirium, Fleisher said.

Although many hospitals offer patients tablets or smartphones to allow them to videoconference with family, these devices provide limited comfort and companionship.

Doctors are also positioning patients with COVID-19 on their stomachs, rather than their backs, because a prone position seems to help clear the lungs and let patients breathe more comfortably.

But a prone position also can be uncomfortable, so that patients need more medication, Pandharipande said.

All of these factors make COVID-19 patients extremely vulnerable to delirium. In a recent article in Critical Care, researchers said the intensive care unit has become a “delirium factory.”

“The way we’re having to care for patients right now is probably contributing to more mortality and bad outcomes than the virus itself,” said Dr. Sharon Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, a long-term care facility in Boston. “A lot of the things we’d like to do are just very difficult.”

Related Topics

Global Health Watch Public Health

Open (Your Wallet) Wide: Dentists Charge Extra For Infection Control

After nearly two months at home due to the COVID-19 pandemic, Erica Schoenradt was making plans in May to see her dentist for a checkup.

Then she received a notice from Swish Dental that the cost of her next visit would include a new $20 “infection control fee” that would likely not be covered by her insurer.

“I was surprised and then annoyed,” said Schoenradt, 28, of Austin, Texas. She thought it made no sense for her dentist to charge her for keeping the office clean since the practice should be doing that anyway. She canceled the appointment for now.

Swish Dental is just one of a growing number of dental practices nationwide that in the past month have begun charging patients an infection control fee between $10 and $20.

Swish and others say they need the extra money to cover the cost of masks, face shields, gowns and air purifiers to help keep their offices free of the coronavirus. The price of equipment has risen dramatically because of unprecedented demand from health workers.

Dentists say they struggle to pay these extra costs particularly after most states shut down dental offices in March and April for all but emergency care to reserve personal protective equipment for hospital use. They are also seeing fewer patients than before the pandemic because some fear going back to the dentist and at the same time dentists need to space out appointments to keep the waiting room uncrowded.

Nearly two-thirds of dental offices across the country have reopened for routine care, according to the American Dental Association.

The association, which sets industry standards, says dentists who opt to charge the extra infection control fee should disclose it to patients ahead of each visit, a spokesperson said.

“The infection control fee is helping us mitigate the costs of the extra expenses,” said Michael Scialabba, a dentist and vice president of 42 North Dental, whose 75 dental offices in New England are charging an extra $10.

Why don’t dentists just raise prices instead? Dentists said they have little or no leverage with large insurance companies to force them to raise their reimbursement rates. The ADA asked insurers to take into account additional COVID costs dentists face and many insurers responded by agreeing to pay extra fees.

For example, Harrisburg, Pennyslvania-based United Concordia Dental agreed to pay dentists $10 per patient per visit in May and June to offset their PPE expenses for all fully insured clients. The company has more than 9 million members nationwide.

The new infection control fee upsets some patients, although most understand that the cost of dentistry has increased, said Rishi Desai, director of operations and finance at Swish Dental, which has eight locations in the Austin area. “We are just as frustrated with all of these, too, but as a small business we had to reassess things.”

Erica Schoenradt, of Austin, Texas, canceled her appointment with her dentist after learning that the practice would charge a $20 fee to help defray costs of masks, gowns and other equipment needed to guard against the coronavirus. (Courtesy of Erica Schoenradt)

Desai, whose wife, Viraj, is a dentist and the founder of the dental chain, said the extra money will help the practice survive. “We are not making money off this,” he said. “This is just to sustain us so we are not bleeding out cash.”

He noted that last year Swish was paying about $6 for a box of 20 face masks. Today, $6 buys a single mask. The dental office has installed sneeze guards, staffers are wearing face shields over their masks, and the offices have added air filtration systems and hired additional sanitation staff members to clean their offices every day.

He estimates the offices are working at only about half capacity since reopening in mid-May. In weighing how to handle the extra costs, Swish was reluctant to cut employee wages, he said. “Everyone is trying to figure this out,” he added.

Kim Hartlage, office manager of Klein Dental Group in Louisville, Kentucky, said insurers recommended the office add an infection control fee. The insurers balked at raising their reimbursement rates.

She said the small office has had to buy many more disposable masks and gloves. “We’ve had to step up our game,” she said. So far, she hasn’t heard any feedback on the $10 fee. “We have very understanding clients,” she said.

Tamar Lasky, an epidemiologist, said she likes her Owings Mills, Maryland, dentist and was glad the office was communicating the many precautions it was taking to prevent the spread of COVID-19. But she was stunned when informed by email that a $15 “infection control charge” would be added to her bill.

“I can readily imagine there are a range of additional expenses, as well as a loss of revenue associated with the pandemic, but infection control is not an extra service. It is part of the practice of dentistry,” Lasky said.

“I’m not sure what is the best solution to the increased costs of tighter infection control, but this new charge may not be covered by insurance, and that passes all the burden to the patient.”

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Health Care Costs

Contratar a un “ejército” diverso para rastrear COVID-19 durante la reapertura

Como rastreadora de contactos, a Teresa Ayala-Castillo a veces le preguntan si los tés de hierbas y el Vicks VapoRub pueden tratar a COVID-19.

Estas terapias no son exactamente una guía oficial de salud, pero Ayala-Castillo no se sorprende. Escucha y luego sugiere otras ideas, como descansar y beber mucho líquido.

“No quiero decirles que son cuentos, porque estos remedios son cosas con las que estoy 100% familiarizada ya que mi mamá los usó conmigo”, dijo Ayala-Castillo, una ecuatoriana-estadounidense bilingüe, de primera generación, que trabaja para la ciudad de Long Beach, California.

Los departamentos de salud de los Estados Unidos trabajan a un ritmo frenético para dotar de personal a sus “ejércitos” de rastreadores de contactos para controlar la propagación del coronavirus que causa COVID-19.

Los expertos estiman que los departamentos de salud locales y estatales tendrán que agregar entre 100.000 y 300.000 personas para que la economía vuelva a funcionar.

Mientras organizan estos grupos, muchos estados y localidades quieren contratar a personas de minorías raciales y étnicas más afectadas por el virus. Entienden la necesidad de contar con rastreadores capacitados y culturalmente competentes que puedan convertir a contactos desconfiados o renuentes en participantes entusiastas en la campaña para erradicar el virus.

Las actividades de rastreo del virus varían según el estado. La mayoría han creado planes para añadir rastreadores de contactos mediante la contratación o el voluntariado, pero los más ricos —incluidos California, Connecticut, Massachusetts, Nueva Jersey, Nueva York y Washington— llevan ventaja, aseguró Marcus Plescia, director médico de la Asociación de Funcionarios de Salud Estatales y Territoriales.

Delaware, cuya meta es comenzar las contrataciones en un mes, dará prioridad a personas de comunidades vulnerables y que sean bilingües. Y Minnesota contrata personal con cuotas de diversidad que coinciden con la demografía de los casos de COVID-19 del estado.

“No hay una fórmula mágica que asegure el éxito de esa llamada y establezca una conversación productiva”, señaló Chris Elvrum, del Departamento de Salud de Minnesota. “Tenemos que entender que existen diferentes maneras de abordar el tema para las diferentes comunidades”.

El rastreo de la enfermedad funciona así: luego que alguien da positivo para COVID-19, un investigador del departamento de salud local llama al paciente para hacerle preguntas específicas sobre su salud, sus movimientos y con quién interactuó durante un cierto período de tiempo.

Luego, un rastreador llama a las personas identificadas por el paciente para hacerles saber que estuvieron potencialmente expuestos al virus. A estos contactos se les pide permanecer en casa por 14 días. Si viven con otras personas, la recomendación puede extenderse a esos individuos.

Si se siguen las órdenes de permanecer en casa, resulta relativamente fácil averiguar quién puede haber estado expuesto a la enfermedad, dicen funcionarios de salud.

Las personas infectadas por lo general sólo han estado con familiares o amigos cercanos y a menudo advierten a los contactos que esperen una llamada del departamento de salud, explicó Emily Holman, quien maneja el área enfermedades contagiosas de Long Beach.

Pero en algunos casos se puede requerir la presencia de trabajadores de campo, indicó la doctora Kara Odom Walker, secretaria del Departamento de Salud y Servicios Sociales de Delaware.

“Hay algunas comunidades que no van a responder a una llamada telefónica, a un mensaje de texto o a una carta”, dijo Walker. “Eso podría deberse a una falta de cultura de la salud, al miedo, o al estatus migratorio”.

Hasta ahora, la mayoría sigue las instrucciones, aseguran los funcionarios. Holman estima que menos del 1% de los contactados en Long Beach se negaron a participar.

Pero surgen problemas, especialmente entre quienes no pueden trabajar desde casa o son el único sustento de sus hijos, apuntó Elvrum.

Las personas notificadas sobre su contacto con alguien con COVID pueden pensar que la llamada es parte de un fraude, o preocuparse de que la información sea compartida con las autoridades de inmigración o que les cueste su trabajo.

Los departamentos de salud no tienen que entregar la información recopilada con fines médicos a las autoridades federales de inmigración, pero se necesita un rastreador de contactos sensible, empático y conocedor de la cultura para explicar esto.

“Necesitas a alguien que sea un agente cultural para decir, no sólo que estas medidas son para protegerte, sino para decir que confíes en mí y que todo irá bien”, comentó Walker. “Yo voy a asegurarme personalmente de que tienes lo que necesitas para una cuarentena segura”.

Teresa Ayala-Castillo, quien ha trabajado para la ciudad de Long Beach durante 20 años, fue supervisora de facturación antes de ser reasignada para localizar a los pacientes con COVID-19 en marzo. Ella dice que su experiencia como ecuatoriana estadounidense de primera generación ayuda a las personas a sentirse a gusto con ella por teléfono. (Cortesía de Teresa Ayala-Castillo)

Minnesota pondrá a 1,400 empleados a trabajar en la localización de contactos para julio, informó Elvrum. Los contratos estipulan que buscan a personas de grupos raciales y étnicos proporcionales a su número en el estado o al porcentaje de casos positivos de COVID-19 en esos grupos. Lo que sea más alto.

Se contrata a personas que hablen hmong, somalí y español, según Kou Thao, quien dirige el Centro para la Equidad en la Salud del Departamento de Salud de Minnesota.

Un 23% de los casos positivos del estado se registran entre personas de raza negra, que constituye sólo el 7% de la población total del estado. Los hispanos constituyen el 19% de los casos y el 6% de la población. Sin embargo, alrededor del 22% de los casos son desconocidos.

Virginia, que cuenta con 200 rastreadores de contactos y espera contratar un total de 1,300 empleados para apoyar el esfuerzo, busca personas que hablen de mandarín, criollo haitiano, español y bengalí, según Mona Bector, comisionada del Departamento de Salud del estado.

Virginia ha recibido más de 6,000 curriculums para estos puestos, dijo Bector.

Long Beach se enorgullece de una fuerza laboral diversa que refleja la población de la ciudad. Los funcionarios sacaron a sus rastreadores de contactos e intérpretes, incluyendo a Ayala-Castillo, de los miembros del personal municipal que hablan samoano, jemer, tagalo, español, vietnamita, mandarín y otros idiomas para crear una plantilla de 60 personas. Su objetivo es tener 200 personas entrenadas y listas para ser desplegadas cuando sea necesario.

Tener trabajadores que puedan hablar con los contactos en el idioma que prefieran es un paso importante, expresó Crystal Watson, del Centro de Seguridad Sanitaria de Johns Hopkins. Ser capaz de extraer información mientras se es sensible a las preocupaciones y desconfianzas de los pacientes es primordial, añadió.

El sargento Jairo Paulino, de 38 años, miembro de la Guardia Nacional de Delaware, es uno de los militares bilingües que se ofrecen a ayudar con las llamadas a los contactos de COVID-19. Cuando empezó el trabajo a mediados de mayo, notó que había un “gran atraso” en la lista de nombres porque el estado no tenía suficientes hispanohablantes para contactarlos a todos con rapidez.

Paulino nació en la República Dominicana y llegó a Nueva York de niño. Creció traduciendo para su padre y asistiendo a la iglesia; ambas referencias ayudan a construir la confianza en la comunidad latina, dijo.

El escaso acceso a Internet también plantea un desafío. En Tulare, un condado rural en el centro de California, los trabajadores de la salud piden a los pacientes que utilicen un portal en línea para ayudar a agilizar la recopilación de datos de sus contactos. Sin embargo, entre el 5% y el 10% de las personas no pueden conectarse a Internet, explicó Tiffany Swarthout, del departamento de salud del condado. En esos casos, los trabajadores de la salud hablarán con el paciente por teléfono.

Las preocupaciones laborales representan otra área de dificultad para los rastreadores de contactos. Algunas personas son reacias a quedarse en casa porque no tienen ingresos, especialmente si la pandemia ha dejado a miembros de la familia sin trabajo, señaló Jody Menick, una enfermera que supervisa la localización de contactos en el condado de Montgomery, Maryland, en las afueras de Washington, D.C.

Algunos empleadores solicitan pruebas de que los pacientes y sus contactos pueden regresar con seguridad después de la cuarentena, y algunas jurisdicciones proporcionan cartas oficiales que especifican el período de cuarentena del trabajador.

Pero los trabajadores indocumentados, que cuentan con menos protecciones que los empleados con estatus legal, han sido presionados para que se presenten a trabajar, contó Menick, poniéndoles en una situación muy difícil.

“¿Voy a conseguir dinero para comprar comida para mi familia, o me voy a quedar en casa?”

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Hiring A Diverse Army To Track COVID-19 Amid Reopening

As a contact tracer, Teresa Ayala-Castillo is sometimes asked whether herbal teas and Vicks VapoRub can treat COVID-19. These therapies aren’t exactly official health guidance, but Ayala-Castillo isn’t fazed. She listens and then suggests other ideas — like getting rest and drinking plenty of fluids.

“I don’t want to call them old wives’ tales, but these remedies are things that I’m 100% familiar with because my mom used them on me,” said Ayala-Castillo, a bilingual first-generation Ecuadorian American who works for the city of Long Beach, California.

Health departments across the U.S. are working at a furious pace to staff their armies of contact tracers to control the spread of the coronavirus that causes COVID-19. Experts estimate local and state health departments will have to add 100,000 to 300,000 people to get the economy back on track.

As they build these forces, many states and localities are trying hard to hire from the racial and ethnic minority communities hit hardest by the virus. They’re anticipating a need for skilled, culturally competent tracers who can convert suspicious or hesitant contacts into enthusiastic, willing participants in the drive to stamp out the virus.

Virus-tracking activities vary by state. Most states have created plans to add contact tracers through hiring or volunteering, but wealthier ones — including California, Connecticut, Massachusetts, New Jersey, New York and Washington — are further along than others, said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials.

Delaware, which aims to begin hiring in a month, plans to prioritize hires from vulnerable communities with bilingual language skills. Minnesota is hammering out staffing contracts with diversity quotas that match the demographics of the state’s COVID-19 cases.

“One size does not fit all for making that first call and being successful in having them pick up the phone and have a good conversation,” said Chris Elvrum, a deputy incident manager at the Minnesota Department of Health. “We need to recognize that we have to approach it in different ways for different cultural communities in the state.”

Tracking the disease works like this: After someone tests positive for COVID-19, a case investigator from the local health department calls the patient to ask detailed questions about her health, movements and whom she interacted with over a certain time frame. A contact tracer then calls everyone the patient named to let them know they were potentially exposed to the virus. These contacts are instructed to stay home and self-quarantine for 14 days after the exposure. If they live with other people, the recommendation may extend to those individuals.

Under stay-at-home orders, it’s often relatively easy to figure out who may have been exposed to the disease, health officials say. Infected people usually have been around only family or close friends and will often warn contacts to expect a call from the health department, said Emily Holman, communicable disease controller for Long Beach.

But shoe-leather fieldworkers may be required in some instances, said Dr. Kara Odom Walker, secretary of the Delaware Department of Health and Social Services. “There are some communities that aren’t going to respond to a phone call, a text message or a letter,” said Walker. “That could be due to health literacy issues, which could be due to fear, or documentation status.”

So far, most people are following instructions, say officials. Holman estimates that fewer than 1% of those contacted in Long Beach refused to participate.

Teresa Ayala-Castillo, who has worked for the city of Long Beach for 20 years, was a billing supervisor before being reassigned to contact tracing for COVID-19 patients in March. She says her background as a first-generation Ecuadorian American helps people feel at ease with her on the phone. (Courtesy of Teresa Ayala-Castillo)

But some defiance is likely, especially among those who cannot work from home or are the only provider for their children, Elvrum said. People being notified about contacts with a COVID-positive patient might think the call is a scam, or worry the information will be shared with immigration authorities or cost them their job. Health departments do not have to turn information collected for medical purposes over to federal immigration enforcement, but it takes a sensitive, empathetic and knowledgeable contact tracer to explain this.

“You need someone to be a cultural broker to say, not only are these policies in place to protect you, but I’m telling you to trust me that this will be OK,” Walker said. “I’m going to make sure you have what you need to safely quarantine.”

Minnesota plans to dedicate 1,400 staffers to contact tracing by July, Elvrum said. Contracts with two companies involved in the hiring stipulate that they bring on people of racial and ethnic groups proportional to their numbers in the state or the percentage of positive COVID-19 cases in those groups — whichever is higher.

They’re seeking hires who speak Hmong, Somali and Spanish, said Kou Thao, director of the Center for Health Equity in the Minnesota Department of Health.

About 23% of the state’s positive cases are among black people, who make up only 7% of the state population. Hispanics make up 19% of cases — and 6% of the population. However, about 22% of the cases are unknown.

Virginia, which has 200 contact tracers and hopes to hire a total of 1,300 staff to support the effort, is looking for speakers of Mandarin, Haitian Creole, Spanish and Bengali, said Mona Bector, deputy commissioner for administration at the Virginia Department of Health.

The state has received more than 6,000 résumés for these positions, Bector said.

Long Beach prides itself on a diverse workforce that reflects the city’s population. Officials pulled their contact tracers and interpreters, including Ayala-Castillo, from municipal staff members who speak Samoan, Khmer, Tagalog, Spanish, Vietnamese, Mandarin and other languages to create a staff of 60. Their goal is to have 200 people trained and ready to deploy as needed.

Having workers who can speak to contacts in the language they prefer is a step forward, said Crystal Watson, a senior scholar from the Johns Hopkins Center for Health Security. Being able to extract information while being sensitive to patients’ concerns and mistrust is paramount, she added.

Sgt. Jairo Paulino, a 38-year-old member of the Delaware National Guard, is one of several bilingual guardsmen volunteering to help call COVID-19 contacts. When he started the job in mid-May, he noticed there was a “major backlog” of names because the state didn’t have enough Spanish speakers to reach out to everyone quickly.

Paulino was born in the Dominican Republic and moved to New York as a boy. He grew up translating for his father and attending church — both elements that help build trust in the Latino community, he said.

Poor access to the internet also poses a challenge. In Tulare, a rural county in central California, health workers ask patients to use an online portal to help streamline data collection of their contacts. However, 5% to 10% of people cannot get online, said Tiffany Swarthout, an administrative specialist at the county health department. In those cases, health workers will speak to the patient on the phone.

Employment concerns represent another tricky area for contact tracers. Some people they reach out to may hesitate to stay home because they are strapped for cash, especially if the pandemic has left members of the family without work, said Jody Menick, a nurse who supervises contact tracing in Montgomery County, Maryland, just outside Washington, D.C.

Some employers are requesting proof that patients and contacts were safe to return after quarantine, and some areas provide official letters that specify the worker’s quarantine period.

But undocumented workers — who have fewer protections than employees with legal status — have been pressured to show up to work in her area, Menick said, leaving them with a difficult decision.

“Am I going to have money to buy food for my family, or am I going to stay home?”

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Pandemic Presents New Hurdles, And Hope, For People Struggling With Addiction

Before Philadelphia shut down to slow the spread of the coronavirus, Ed had a routine: most mornings he would head to a nearby McDonald’s to brush his teeth, wash his face and — when he had the money — buy a cup of coffee. He would bounce between homeless shelters and try to get a shower. But since businesses closed and many shelters stopped taking new admissions, Ed has been mostly shut off from that routine.

He’s still living on the streets.

“I’ll be honest, I don’t really sleep too much,” said Ed, who’s 51 and struggling with addiction. “Every four or five days I get a couple hours.”

KHN agreed not to use his last name because he uses illegal drugs.

Philadelphia has the highest overdose rate of any big city in America — in 2019, more than three people a day died of drug overdoses there, on average. Before the coronavirus began spreading across the United States, the opioid overdose epidemic was the biggest health crisis on the minds of many city officials and public health experts. The coronavirus pandemic has largely eclipsed the conversation around the opioid crisis. But the crisis still rages on despite business closures, the cancellation of in-person treatment appointments and the strain on many addiction resources in the city.

When his usual shelter wasn’t an option anymore, Ed tried to get into residential drug treatment. He figured that would be a good way to try to get back on his feet and, if nothing else, get a few good nights of rest. But he had contracted pinkeye, a symptom thought to be associated with the virus that leads to COVID-19, so the evaluation center didn’t want to place him in an inpatient facility until he’d gotten the pinkeye checked out. But he couldn’t see a doctor because he didn’t have a phone for a telehealth appointment.

“I got myself stuck, and I’m trying to pull everything back together before it totally blows up,” he said.

Rosalind Pichardo wants to help people in Ed’s situation. Before the pandemic, Pichardo would hit the streets of her neighborhood, Kensington, which has the highest drug overdose rate in Philadelphia. She’d head out with a bag full of snack bars, cookies and Narcan, the opioid overdose reversal drug.

She’d hand Narcan out to people using drugs, and people selling drugs — anyone who wanted it. Pichardo started her own organization, Operation Save Our City, which initially set out to work with survivors of gun violence in the neighborhood. When she realized that overdoses were killing people too, she began getting more involved with the harm reduction movement and started handing out Narcan through the city’s syringe exchange.

When Pennsylvania’s stay-at-home order went into effect, Pichardo and others worried that more people might start using drugs alone, and that fewer first responders would be patrolling the streets or nearby and able to revive them if they overdosed.

So, Pichardo and other harm reduction activists gave out even more Narcan. A representative for Prevention Point Philadelphia, the group that operates a large syringe exchange program in the city, said that during the first month of the city’s stay-at-home order, they handed out almost twice as much Narcan as usual.

After the lockdowns and social distancing began, Pichardo worried that more people would be using drugs alone, leading to more overdoses. But Philadelphia’s fatal overdose rate during the pandemic remains about the same as it was this time last year. Pichardo said she thinks that’s evidence that flooding the streets with Narcan is working — that people are continuing to use drugs, and maybe even using more drugs, but that users are utilizing Narcan more often and administering it to one another.

That is the hope. But Pichardo said users don’t always have a buddy to keep watch, and during the pandemic first responders have seemed much more hesitant to intervene. For example, she recently administered Narcan to three people in Kensington who overdosed near a subway station, while two police officers stood by and watched. Before the pandemic, they would often be right there with her, helping.

To reverse the overdoses, Pichardo crouched over the people who she said had started turning blue as their oxygen levels dropped. She injected the Narcan into their noses, using a disposable plastic applicator. Normally, she would perform rescue breathing, too, but since the pandemic began she has started carrying an Ambu bag, which pumps air into a person’s lungs and avoids mouth-to-mouth resuscitation. Among the three people, she said, it took six doses of Narcan to revive them. The police officers didn’t step in to help but did toss several overdose-reversal doses toward Pichardo as she worked.

“I don’t expect ’em to give ’em rescue breaths if they don’t want to, but at least administer the lifesaving drug,” Pichardo said.

In her work as a volunteer, she has reversed almost 400 overdoses, she estimated.

“There’s social distancing — to a limit,” Pichardo said, “I think when someone’s life is in jeopardy, they’re worth saving. You just can’t watch people die.”

Even before Philadelphia officially issued its stay-at-home order, city police announced they would stop making low-level arrests, including for narcotics. The idea was to reduce contact overall, help keep the jail population low and reduce the risk of the virus getting passed around inside. But Pichardo and other community activists said the decreased law enforcement emboldened drug dealers in the Kensington neighborhood, where open-air drug sales and use are common.

“You can tell they have everything down pat, from the lookout to the corner boys to the one actually holding the product — the one holding the product’s got some good PPE gear,” said Pichardo.

More dealers working openly on the street has led to more fights over territory, she added, which in turn has meant more violence. While overall crime in Philadelphia and other major cities has declined during the pandemic, gun violence has spiked.

Police resumed arrests at the beginning of May.

Now when she goes out to offer relief and hand out Narcan, Pichardo packs a few extra things in her bag of supplies: face masks, gloves and gun locks.

“It’s like the survival kit of the ’hood,” she said.

For those struggling with addiction who are ready to start recovery, newly relaxed federal restrictions have made it easier to get medications that curb opioid cravings and stem withdrawal. Several efforts are underway among Philadelphia-based public health groups and criminal justice advocacy organizations to give cellphones to people who are homeless or coming out of jail, so they can make a telehealth appointment and get quicker access to a prescription for those medicines.

During the pandemic, people taking medication-assisted treatment can renew their prescription every month instead of every week, which helps decrease trips to the pharmacy. It is too soon to know if more people are taking advantage of the new rules, and accessing medication-assisted treatment via telehealth, but if that turns out to be the case, many addiction medicine specialists argue the new rules should become permanent, even after the pandemic ends.

“If we find that these relaxed restrictions are bringing more people to the table, that presents enormous ethical questions about whether or not the DEA should reinstate these restrictive policies that they had going in the first place,” said Dr. Ben Cocchiaro, a physician who treats people with substance-use disorder.

Cocchiaro said the whole point of addiction treatment is to facilitate help as soon as someone is ready for it. He hopes if access to recovery can be made simpler during a pandemic, it can remain that way afterward.

This story is part of a partnership that includes WHYY, NPR and Kaiser Health News.

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Mental Health Public Health States

California AG Seeks More Power To Battle Merger-Hungry Health Care Chains

California’s health care industry has a consolidation problem.

Independent physician practices, outpatient clinics and hospitals are merging or getting gobbled up by private equity firms or large health care systems. A single company can dominate an entire community, and in some cases, vast swaths of the state.

Such dominance can inflate prices, and consumers end up facing higher insurance premiums, more expensive outpatient services and bigger out-of-pocket costs to see specialists.

Now that COVID-19 has slammed the health care industry, especially the small practices that are barely seeing patients, the trend is likely to accelerate.

“I don’t see anything that’s going to stop this wave of consolidations amongst docs,” said Glenn Melnick, a health care economist at the University of Southern California.

“If this thing goes on a long time,” he said of the coronavirus, “then it becomes a tsunami.”

California Attorney General Xavier Becerra has made battling health care consolidation a signature issue since he took office in 2017. With the additional pressure that COVID-19 is putting on vulnerable practices and facilities, Becerra is now pressing the state legislature to expand his authority to slow health care mergers.

“We find that in these times of crisis, economic and health crisis, that the smaller health care players and stakeholders are oftentimes most at risk of being swallowed up by the big fish,” Becerra told California Healthline.

His success would fundamentally change how the health care industry merges and grows in California.

When a health care system, private equity firm or hedge fund plans to merge with or acquire another practice or facility — whether that means buying a small practice or joining a multistate hospital chain — Becerra wants to know about it. He wants written notice, and the ability to deny any sale that doesn’t deliver better access, cost or quality health care to Californians.

Becerra already can regulate mergers among nonprofit health care facilities. Under SB-977, a collaboration between Becerra’s office and the legislature, he would get the ability to regulate the for-profit sector as well.

“Certainly it would put California where it’s accustomed to being,” Becerra said. “At the head of the pack.”

The bill has support from organized labor and consumer advocacy groups. Gov. Gavin Newsom has come out against health care consolidation in the past but hasn’t taken an official stance on the bill.

Yet Becerra isn’t convinced passage will be smooth.

“The biggest concern I have is the legislation will be killed by the industry,” he said. “We’ll end up seeing over-consolidation because decent practices that got on the edge could not swim with sharks.”

Indeed, health care industry players are already lining up against the bill. Alex Hawthorne, a lobbyist for the California Hospital Association, said that hospitals are stretched thin because of the pandemic, and that now isn’t the time for Becerra to be meddling in routine agreements between practices.

“It bestows absolute and arbitrary discretion on the office of the attorney general,” Hawthorne said at a budget hearing in May.

In 2010, about 25% of California physicians worked in a practice owned by a hospital. By 2016, more than 40% of doctors worked in hospital-owned practices, according to research published in the journal Health Affairs in 2018.

There’s evidence that consolidation can hurt consumers. A separate 2018 study found that the cost of medical procedures in highly consolidated Northern California was 20% to 30% higher than in Southern California.

Since 2018, California’s attorney general has had the authority to regulate mergers among nonprofit health care systems, which Becerra exercised the same year when considering a merger between two health care giants: Dignity Health and Catholic Health Initiatives. He said he would approve the deal only if the systems agreed to certain requirements, such as starting a homelessness program.

Later that year, Becerra joined a suit against Sutter Health for using its market power to drive up health care costs in Northern California.

The lawsuit alleged that Sutter, which has 24 hospitals and 34 surgery centers, had spent years buying up practices and facilities, giving insurers little choice but to include them in their networks and agree to higher rates for services.

In October 2019, Becerra secured a $575 million settlement against Sutter, which has yet to be finalized or paid out, that requires Sutter to change how it charges insurance companies and give patients more information about prices.

Sutter Health opposes SB-977, which was introduced in February by state Sen. Bill Monning (D-Carmel). The measure is intended to address some of the challenges Becerra encountered with the Sutter case, Becerra said.

“The best way to prevent problems from occurring in a merger is just to prevent the merger altogether,” said Jaime King, associate dean at UC Hastings College of the Law in San Francisco. “It’s really hard to unwind a merger after you’ve already done it.”

Under the measure, the attorney general must be notified before a system, hedge fund or private equity firm attempts to enter into a merger, acquisition or another kind of affiliation change with another practice or facility. The bill defines a health care system as one with two or more hospitals in multiple counties, or three or more hospitals within one county.

That would trigger a public review process allowing supporters and opponents to make their cases to a review board. The board would assess the transaction, using criteria to determine whether it would improve access, quality and price.

The bill also would make it illegal for systems to act anti-competitively and give the attorney general the power to bring a civil suit against monopolistic systems.

The Senate Health Committee approved the bill, which is expected to be heard in another committee this week.

“Maybe it does mean consolidation should occur, but only because we’ve done the oversight to make sure it’s because of quality and access,” Becerra said. “Not because a big fish wants to make bigger profit.”

The measure includes waivers for rural practices and a fast-track review process for transactions under $500,000.

The California Chamber of Commerce opposes the bill, as does the California Medical Association, which represents doctors. While the California Medical Association is concerned about the survival of small physician practices, it believes the bill is too broad and should focus more tightly on hospital consolidation, said spokesperson Anthony York.

“This approach will only further force smaller providers out of business,” especially as the health systems respond to the COVID-19 emergency, the group’s legislative advocate, Amy Durbin, wrote in a letter of opposition.

For many independent practices struggling for survival, the debate over Becerra’s powers is academic.

Dr. Sarah Azad, who owns a women’s health practice in Mountain View, California, said at least three independent practices in her area have started the process to merge or sell since March because of dramatically lower patient volume.

Her practice is fine for now, despite the fact that her patient volume was only about 30% of normal in March and 60% of normal in April. Azad received a loan from the federal Paycheck Protection Program for small businesses so she could pay her five doctors in May.

“If you catch me on a bad month, I feel like we’re one disaster away from bankruptcy,” Azad said.

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

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California Health Industry

Por qué los recortes en salud perjudican siempre a los californianos más vulnerables

Shirley Madden, de 83 años, depende de un cuidador y de sus dos hijas para seguir viviendo en casa, y no en una residencia.

Sus hijas, Carrie, de 55 años, y Kristy Madden, de 60, usan sillas de ruedas y necesitan un segundo cuidador que las ayude en su vida diaria.

Pero ese apoyo crítico para el cuidado, además de otros beneficios de atención médica para millones de californianos, podrían reducirse para ayudar a cubrir el enorme déficit presupuestario provocado por el coronavirus.

El gobernador de California, Gavin Newsom, ha propuesto recortes presupuestarios drásticos a los programas de salud pública, incluyendo Medi-Cal, el programa de Medicaid de California para personas de bajos ingresos, cuando se espera un aumento de inscripciones debido a la pérdida récord de empleos por culpa de la pandemia.

Los expertos temen que estos recortes puedan poner en peligro los miles de millones de dólares en fondos federales de emergencia para la salud asignados a California.

“Entiendo que hay una pandemia y que la situación es mala y que todo el mundo sufre”, dijo Carrie Madden de Chatsworth, California. Carrie y su hermana padecen distrofia muscular y su madre ha sobrevivido a un ataque al corazón mientras lucha contra la demencia.

Los temores de Madden se ven agravados por la crisis de COVID-19, que ha afectado con más fuerza a los mayores y a quienes tienen enfermedades crónicas. No quiere que su madre, su hermana o ella misma terminen en una residencia o en cualquier centro de cuidados a largo plazo, que son los lugares con más brotes.

“Este es el enfoque equivocado”, señaló. “Hará que las personas discapacitadas terminen en residencias para mayores”.

En todo el país, los estados consideran recortes a Medicaid para equilibrar sus presupuestos. En parte porque la salud suele ser la mayor parte del gasto estatal, después de la educación.

También proyectan que más gente se inscribirá en el programa de salud pública, a medida que el número de estadounidenses desempleados alcance niveles astronómicos. Más de 20 millones de estadounidenses solicitaron el subsidio de desempleo en abril, elevando la tasa de personas sin trabajo al 14,7%, la peor desde la Gran Depresión de la década de 1930.

Nueva York aprobó recortes a Medicaid que entrarán en vigor cuando termine la emergencia federal, mientras que Georgia ha dado instrucciones a todas sus agencias para reducir el gasto en un 14%.

En California, donde casi 2,9 millones de personas han solicitado el desempleo en los últimos dos meses, Newsom describió los recortes propuestos como “prudentes” y “estratégicos”, un giro enorme a los grandes planes que dio a conocer a principios de este año para ampliar la atención médica a algunos de los residentes más necesitados.

Para hacer frente a un déficit estimado de $54 mil millones en el presupuesto estatal 2020-21, Newsom propone un recorte de $205 millones —una reducción del 7% en las horas de los cuidadores— al programa de Servicios de Apoyo en el Hogar del que dependen los Maddens.

El programa, financiado principalmente por Medi-Cal, paga a los cuidadores para dar de comer a las personas que necesitan ayuda para vivir de forma independiente, lavar su ropa, bañarlos, administrarles tratamientos médicos y mantener su hogar limpio.

La lista de los otros recortes es larga: reducirá o eliminará programas que permiten a los mayores de bajos ingresos y a los discapacitados vivir en su propio hogar, como la atención médica diurna y el apoyo de los trabajadores sociales.

Propone facilitar al estado el cobro del pago póstumo de los fallecidos, mayores de 55 años, y afiliados a Medi-Cal, por una amplia gama de gastos médicos a través del controvertido “Programa de Recuperación de Bienes“. Sugiere que se reinstauren requisitos de ingresos más estrictos para que algunas personas mayores y las que tengan discapacidades puedan tener derecho a Medi-Cal gratuito.

Y ha pedido a los legisladores que eliminen $54,7 millones en beneficios “opcionales” de Medi-Cal, como la atención de podología para adultos, gafas, terapia del habla y exámenes de audición; beneficios que los mismos legisladores restauraron recientemente después de recortarlos durante la última recesión.

“No son beneficios opcionales para una persona que ha sufrido un derrame cerebral o necesita dientes para comer”, explicó Tricia Berke Vinson, una abogada de la Sociedad de Ayuda Legal del condado de San Mateo.

“Entiendo que estamos en una crisis presupuestaria”, añadió. “Pero no creo que se pueda equilibrar a costa de adultos mayores y enfermos”.

Médicos, dentistas y otros proveedores de atención de salud que tratan a pacientes de Medi-Cal también podrían perder $1,200 millones en pagos suplementarios que se derivan de la Propuesta 56, un impuesto sobre el tabaco que los votantes aprobaron en 2016.

La propuesta del gobernador demócrata incluye un “detonante” automático para eliminar los recortes si el estado obtiene más dólares federales para la crisis de la COVID, trasladando la responsabilidad al Congreso para negociar otro paquete de estímulo.

No se sabe si los legisladores aceptarán los enormes recortes a Medi-Cal que el gobernador ha propuesto. Por ejemplo, el plan del Senado estatal preserva la financiación de Medi-Cal y supone que el Congreso aprobará otro proyecto de ley de estímulo.

Ambas cámaras de la legislatura deben llegar a un acuerdo y presentar su versión del presupuesto al gobernador antes del 15 de junio.

“Salvar estos programas es salvar vidas y ahorrar dinero”, indicó el legisador Jim Wood (demócrata de Santa Rosa), presidente del Comité de Salud de la Asamblea. “Corten estos programas y los costos aumentarán y se perderán vidas”.

Tanto los expertos como algunos legisladores temen que el enfoque de Newsom pueda poner en peligro los miles de millones de dólares, en fondos federales de emergencia para la salud, que ya están asignados a California.

Los estados que abandonan a los inscritos en Medicaid, o reducen sus beneficios, corren el riesgo de perder los pagos federales de salud adicionales autorizados por el Congreso esta primavera, expresó Edwin Park, experto en Medicaid y profesor de la Escuela McCourt de Política Pública de la Universidad de Georgetown.

“El gobierno federal ha dicho que no se puede reducir la elegibilidad ni cancelar o recortar los beneficios”, dijo Park, y señaló que los legisladores de Nueva York retrasaron los recortes de Medicaid del estado hasta después de que terminara la emergencia federal, para asegurarse de que recibirán la ayuda federal ahora.

Los Centros de Servicios de Medicare y Medicaid no respondieron a las solicitudes de comentarios. La guía publicada en su sitio web sugiere que los estados deben mantener intactos los programas de Medicaid.

Se espera que California reciba $5.1 mil millones en fondos federales adicionales para Medi-Cal hasta el 30 de junio de 2021, según el presupuesto que Newsom hizo público a mediados de mayo.

La administración Newsom no cree que los recortes presupuestarios de Medi-Cal le cuesten al estado el dinero federal adicional ya aprobado por el Congreso.

“Nunca hay una garantía hasta que hablemos con el gobierno federal. Así que hasta entonces, es difícil decir qué se va a hacer a nivel federal”, dijo Yang Lee, analista del Departamento de Finanzas del estado.

La administración Newsom calcula que unos dos millones de californianos se inscribirán en Medi-Cal para julio como resultado de la pandemia, lo que eleva la inscripción en el programa a 14.5 millones, más de un tercio de todos los californianos.

La administración estima $3,100 millones en gastos adicionales para cubrir a los nuevos inscritos. La Legislative Analyst’s Office cree que esa cifra representa un exceso de $750 millones, en parte porque los nuevos inscritos serán principalmente personas más jóvenes y saludables que no necesitan tanta atención como los mayores de bajos ingresos y las personas con discapacidades.

Para muchos de los inscritos, las propuestas de Newsom recortarían múltiples beneficios.

Cynde Soto, de 63 años, dijo que se sintió como si “alguien me hubiera dado un puñetazo en el estómago” cuando supo que el plan del gobernador recortaría el presupuesto de los Servicios de Apoyo en el Hogar. Esta residente de Long Beach, que es tetrapléjica,  teme que los recortes del estado la obliguen a ir a una residencia de mayores. Además, teme perder la atención dental y de visión de Medi-Cal si se aprueban los otros recortes de Newsom.

“Es una pesadilla. No sé qué voy a hacer”, comentó Soto. “¿Por qué siempre somos los primeros a los que golpean?”.

Related Topics

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‘An Arm And A Leg’: The $7,000 COVID Test And Other Lessons From SEASON-19


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


Host Dan Weissmann spoke with three people who have very different reflections on what the COVID-19 pandemic is costing us.

  • A doctor and advocate in Brooklyn looked back on the wave of black and brown patients that filled her clinic in March.
  • A nurse practitioner in Texas shared how new tech is — and isn’t — helping the older patients she cares for.
  • One of the country’s top insurance nerds conceded that her initial policy ideas to keep people from getting stuck with expensive bills for COVID tests were wrong.

Here’s the season recap: A new abnormal. A shortage of hugs. And the $7,000 COVID test.

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Thank you in advance!


“SEASON-19” of “An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

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‘Why Do We Always Get Hit First?’ Proposed Budget Cuts Target Vulnerable Californians

Shirley Madden, 83, relies on a caregiver and her two grown daughters to remain living at home — and not in a nursing home.

Her daughters, 55-year-old Carrie and 60-year-old Kristy Madden, both use wheelchairs and need a second caregiver to help them navigate their own daily lives.

But that critical caregiving support, along with other health care benefits for millions of Californians, could be scaled back to help plug a massive budget deficit triggered by the coronavirus.

California Gov. Gavin Newsom has proposed sweeping budget cuts to safety-net health care programs ― including Medi-Cal, California’s Medicaid program for low-income people ― just as enrollment is projected to spike because of record job losses related to the pandemic.

Health care experts also fear the cuts could jeopardize billions of dollars in emergency federal health funding allotted to California.

“I understand there’s a pandemic and it’s really bad and everybody is hurting,” said Carrie Madden of Chatsworth, California. Carrie and her sister have muscular dystrophy and their mother is a heart attack survivor who struggles with dementia.

Madden’s fears are compounded by the COVID-19 crisis, which has hit older people and those with chronic health conditions the hardest. She doesn’t want her mother, her sister or herself to end up in a nursing home or other long-term care facility — the settings with the most outbreaks of COVID-19.

“This is the wrong approach,” she said. “This will make disabled people end up in nursing homes.”

States across the country are eyeing Medicaid cuts to balance their budgets, in part because health care is usually the biggest portion of state spending, after education. They also project that more people will sign up for the public health care program, as the number of unemployed Americans hits astronomical heights. More than 20 million Americans filed for unemployment in April, raising the unemployment rate at least to 14.7%, the worst since the Great Depression of the 1930s.

New York approved Medicaid cuts that will take effect after the federal emergency ends, while Georgia has instructed all its agencies to reduce spending by 14%.

In California, where almost 2.9 million people have filed for unemployment in the past two months, Newsom described the proposed budget cuts as “prudent” and “strategic,” a huge pivot from the grand plans he unveiled earlier this year to expand health care to some of the neediest residents.

To address an estimated $54 billion deficit in the 2020-21 state budget, Newsom proposes a $205 million cut — or a 7% reduction in caregiver hours — to the In-Home Supportive Services program the Maddens rely on. The program, primarily funded by Medi-Cal, pays caregivers to make meals for people who need help to live independently, do their laundry, bathe them, administer medical treatments and keep their home clean.

The list of his other proposed cuts is lengthy: He would scale back or eliminate other programs intended to keep low-income seniors and people with disabilities in their own homes, such as adult day health care and support from social workers. He proposes to make it easier for the state to collect posthumous payback from deceased Medi-Cal enrollees 55 and older for a broad range of medical costs through the controversial “Estate Recovery Program.” He suggests reinstituting stricter income requirements for some older people and those with disabilities to qualify for free Medi-Cal.

And he is calling on lawmakers to remove $54.7 million in “optional” Medi-Cal benefits, such as adult podiatry care, eyeglasses, speech therapy and hearing exams — benefits that lawmakers recently restored after they were cut during the last recession.

“These don’t feel optional to people if they have had a stroke or need teeth to eat their food,” said Tricia Berke Vinson, an attorney with the Legal Aid Society of San Mateo County.

“I understand we are in a budget crisis,” she added. “I just don’t think it can be balanced on the old and the sick.”

Physicians, dentists and other health care providers who treat Medi-Cal patients also stand to lose $1.2 billion in supplemental Medi-Cal payments that flow from Proposition 56, a tobacco tax that voters approved in 2016.

The Democratic governor’s proposal includes an automatic “trigger” to restore the cuts if the state gets more federal COVID relief dollars, shifting the responsibility to Congress to negotiate another stimulus package.

Whether lawmakers will make the sweeping Medi-Cal cuts the governor has proposed is uncertain. For example, the state Senate plan preserves Medi-Cal funding and assumes Congress will pass another stimulus bill.

Both houses of the legislature must come to an agreement and present their version of the budget to the governor for consideration by June 15.

“Save these programs and you save lives and money,” said Assembly member Jim Wood (D-Santa Rosa), chair of the Assembly Health Committee. “Cut these programs and costs will increase and lives will be lost.”

Health care experts and some lawmakers also fear Newsom’s approach could jeopardize billions of dollars in emergency federal health funding already allotted to California.

States that drop Medicaid enrollees or reduce benefits risk losing out on additional federal health payments authorized by Congress this spring, said Edwin Park, an expert on Medicaid and a professor at Georgetown University McCourt School of Public Policy.

“The federal government has said you can’t cut eligibility or disenroll or cut benefits,” Park said. He noted that New York lawmakers delayed their state Medicaid cuts until after the federal emergency ends to ensure they still receive the added federal help now.

The Centers for Medicare & Medicaid Services did not respond to requests for comment. Guidance posted on its website suggests states must keep Medicaid programs intact.

California is expected to receive $5.1 billion in additional federal funding for Medi-Cal through June 30, 2021, according to the proposed budget Newsom released in mid-May.

The Newsom administration is not convinced its Medi-Cal budget cuts will cost the state the additional federal money already approved by Congress.

“There’s never a guarantee until we have that conversation with the federal government. So until then, it’s hard for us to tell what the fed’s going to do,” said Yang Lee, an analyst at the state Department of Finance.

Newsom’s administration predicts about 2 million Californians will sign up for Medi-Cal by July as a result of the pandemic, bringing the program’s enrollment to 14.5 million, more than one-third of all Californians.

The administration anticipates $3.1 billion in added costs to cover the new enrollees. The Legislative Analyst’s Office believes that figure is $750 million too high, in part because new sign-ups will primarily be younger and healthier individuals who do not need as much care as low-income seniors and people with disabilities.

For many current enrollees, Newsom’s proposals would cut into multiple benefits.

Cynde Soto, 63, said it felt like “someone had punched me in the gut” when she heard about the governor’s plan to cut the In-Home Supportive Services budget. As a quadriplegic, the Long Beach resident worries state cutbacks could force her into a nursing home. On top of that, she fears she might lose her Medi-Cal dental and vision care if Newsom’s other cuts are approved.

“I’ve had nightmares about it. I don’t know what I’m going to do,” Soto said. “Why do we always get hit first?”

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

Related Topics

California Cost and Quality Insurance Medi-Cal Medicaid States

Coronavirus Surprise: IRS Allows Midyear Insurance And FSA Changes

The economic upheaval and social disruption caused by the coronavirus pandemic have upended the assumptions many people made last fall about which insurance plan to sign up for, or how much of their pretax wages to sock away in health or dependent care flexible spending accounts.

You may find yourself in a high-priced health plan you can no longer afford because of a temporary pay cut, unable to get the medical care you might have planned and budgeted for, or not sending the kids to day care. Normally you’d be stuck with the choices you made unless you had a major life event such as losing your job, getting married or having a child. But this year, things may be different.

Last month, the Internal Revenue Service announced it would let employees add, drop or alter some of their benefits for the remainder of 2020. But there’s a catch: Your employer has to allow the changes.

The new guidance applies to employers that buy health insurance to cover their workers as well as those that pay claims on their own, called self-insuring. It’s unclear how many employers will take advantage of the new flexibility to offer what amounts to a midyear open enrollment period. If you’re wondering what your company will do, ask.

“If a consumer finds themselves economically strapped and their finances have changed, and they’re in a situation where they really would like to rethink their coverage, they may want to approach their employer and see if they’re planning to adopt any of these changes,” said Jay Savan, a partner at human resources consultant Mercer.

Some health care policy experts are unimpressed with the new coverage options, noting that earlier this spring the Trump administration opted not to create a special enrollment period for uninsured workers to buy subsidized health insurance on the Affordable Care Act’s health insurance marketplaces.

“It’s not likely that many people will take up this new coverage opportunity, and it won’t address the problem of lack of coverage that many people are facing,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

Assuming you still have employer-sponsored coverage, here are examples of circumstances workers may face and what the IRS changes could mean for them.

You want to switch to a cheaper plan to put more money into savings during these uncertain times. Can you do that?

If your employer decides to allow it, you can.

One consideration: If you switch plans midyear, you may have to start all over again paying down your deductible and working toward reaching your annual out-of-pocket maximum spending limit for the year, said Katie Amin, a principal at Groom Law Group in Washington, D.C., a firm specializing in health care and benefits.

“Some employer plans would credit you under the new option if you switched plans,” Amin said. “It depends.”

You’ve got a high-deductible plan and are worried about high medical bills if you get COVID-19. Can you switch to a plan with more generous coverage?

The IRS guidance allows it, but your employer probably won’t, say experts. It’s impossible for workers or their bosses to know who will develop COVID-19. But the concern among employers is that people willing to pay more for generous coverage may be sicker and have higher health care costs than other workers, and could therefore cost the plan more, a phenomenon called adverse selection.

In addition to evaluating whether employees could benefit from midyear changes, an employer will weigh financial considerations, said Steven Wojcik, vice president of public policy at the Business Group on Health, which represents large employers.

They’ll ask, “What is the adverse selection risk, and what is going to be the uptake [in coverage] if you open up enrollment?” he said.

Under the new rules, if you haven’t had health insurance on the job before but would like to sign up now, you can do that, too, if the employer decides to permit it.

What if one spouse gets laid off but the other is still employed? Can the couple switch their family coverage to the employed spouse’s plan?

Yes. But this was already allowed before the new IRS guidance came out. Under long-standing rules, if workers’ life circumstances change they’re entitled to change their coverage during the year.

Can you drop your employer coverage altogether?

Yes, if your employer permits it. Normally, once you sign up for health insurance through your employer and agree to have your premiums deducted from your paycheck, you can’t drop coverage during the year unless you experience a qualifying life event. Under the new IRS rules, you can drop your coverage, but only if you replace it with another form of comprehensive coverage such as through a health insurance exchange or Tricare, the military health insurance program.

One thing that won’t qualify as comprehensive coverage: a short-term plan, said Amin. The Trump administration has encouraged the adoption of limited-duration plans with terms that can last for nearly a year. They don’t typically cover preventive care or preexisting conditions, and renewal is not guaranteed.

You’ve put thousands of dollars into a flexible spending account to cover day care expenses this year, but now the kids are home full time. Can you change the amount?

Yes, but once again this is allowed only if your employer agrees to it. Likewise, if you want to increase your pretax contribution because you need to hire someone to care for your kids at home while you work, you can do that, too. You can also establish a new flexible spending account for dependent care expenses in 2020 if you don’t already have one.

Employees are legally entitled to put up to $5,000 annually into a dependent care FSA to pay for day care, preschool, after-school programs or summer camp.

“Since it’s the employees’ money, my guess is employers will allow them to make changes,” said David Speier, who is in charge of the benefit accounts group at human resources consultant Willis Towers Watson.

You planned to use money left over in last year’s FSA to cover the cost of a medical procedure in early March. But that was postponed because of the coronavirus and you’ve missed the March 15 deadline for using those funds. Do you have any recourse?

Under the new IRS guidance, employers can opt to extend the grace period for using leftover 2019 FSA funds through the end of 2020. Typically, those funds would have disappeared under “use it or lose it” rules if they hadn’t been used by March 15. In 2019, the maximum pretax contribution to a health care FSA was $2,700; this year it’s $2,750.

Similar to the changes now permitted for dependent care FSAs, employers can also decide to permit workers to prospectively decrease or rescind their elected health care FSA amounts altogether.

If you decide to stop contributing to your FSA, you can spend down the money that’s accumulated there on health care expenses, but you can’t cash out the account, said Amin. For example, if you’ve accumulated $500 in your FSA, you can use that money for eyeglasses or other approved expenses through the end of the year. But your employer can’t give you the $500 outright, essentially cashing out the account.

Employers have expressed a lot of interest in implementing the flexible spending account changes, said Mercer’s Savan.

“We expect them to have a lot of traction,” he said.

Related Topics

Insurance Public Health

Must-Reads Of The Week

The Big News

It was a short work week for those still able to work, but there was a considerable amount of health care news. That hasn’t changed.

The story that probably got the most attention was that the death toll in the United States from COVID-19 passed 100,000 people. It can be hard to get a handle on what that means. The Washington Post looked at the people who count the deaths and track the deaths.

There will be more. The Texas Tribune noted how the coronavirus was a threat to people living in homeless shelters. Nursing homes continue to be a major hot spot in this pandemic. Same goes for areas where poorer people live.

The Reopening

But another source of infections just might be the crowds of people who think all danger has passed and it’s time to frolic in close proximity with others.

You probably saw the photos and video of the crowds Memorial Day weekend in the pool at Lake of the Ozarks, Missouri, or on the boardwalk of Ocean City, Maryland. Missouri health officials pondered how to somehow place the partiers in self-quarantine, but that is unlikely. Cities, states and counties may also play fast and loose with the metrics that indicate when it is safe. The Centers for Disease Control and Prevention quietly removed a recommendation to limit singing in churches. (Singing has been shown to propel saliva particles.) So on it goes.

Disneyland is likely to open in July. Las Vegas casinos also announced their reopening and issued rules. Players can’t touch cards and slot machines will be fewer and farther apart.

Things That Don’t Change

Meanwhile, health care providers continue to find ways to make consumers pay more. The federal government’s Department of Health and Human Services said it will watch for “upcoding” of medical procedures — billing for a more expensive procedure.

We are already seeing it. KHN reporter Phil Galewitz wrote about a large bill for what was supposed to be a free COVID test. (This was not a fluke. We’ve already heard of other similar cases and will be writing about them.)

Drugmakers are also a source of concern. Critics note that the development of remdesivir, a possible COVID treatment, was heavily subsidized by the government, yet Gilead Sciences will be able to place whatever price tag it wants on the drug. Not that what was available went to the right places, The Washington Post reported.

And Stat did an excellent analysis of how there was a lot less to President Donald Trump’s announcement Tuesday about lower insulin prices for seniors. Stat also reported how executives of Moderna, a drug company that reported it was having success with a COVID vaccine, cashed out as the share price soared. The shares have since fallen as investors took another look at the hype.

And NPR noted a White House staffer with some interesting health care investments.

Toolkits

All of us are looking for ways to measure the epidemic, to quantify it, to find patterns that either agitate or reassure. Here are a few classics and newer ones that I and the staff at KHN found this week.

ProPublica created a quite amazing tool that tracks the companies that won federal contracts related to COVID-19. It helped them develop several very interesting stories about some of those contractors. (Related stories: The federal government’s efforts to get Americans tested for the virus are still failing in myriad ways.)

Stuff You Should Know

For the past couple of weeks, you could hear discussion of “herd immunity” protecting us from the coronavirus bubbling up in conversations on cable TV news shows, on Twitter and among neighbors still observing social distancing. It’s the notion that if enough people are immune from a disease, the few who are not are protected. It’s the basic concept that makes measles shots so important; it protects the young children and vulnerable people who can’t be immunized. It’s why we want a coronavirus vaccine so quickly.

So The Upshot at The New York Times looked at the possibility of herd immunity in a series of tight graphics. Their conclusion: “Even in some of the hardest-hit cities in the world, the studies suggest, the vast majority of people still remain vulnerable to the virus.”

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Cost and Quality Health Care Costs Insurance Pharmaceuticals Public Health States Uninsured

As COVID Cuts Deadly Path Through Indiana Prisons, Inmates Say Symptoms Ignored

Scottie Edwards died of COVID-19 just weeks before he would have gotten out of the Westville Correctional Facility in Indiana.

Edwards, 73, began showing symptoms of the disease in early April, according to the accounts of three inmates who lived with him in a dormitory. He was short of breath, had chest pain and could barely talk. He was also dizzy, sweaty and throwing up.

Edwards was serving a 40-year sentence for attempting to kill someone in 2001. He would have been released to home detention on May 1 but died on April 13. The next day, the Indiana Department of Correction sent out a statement that indicated Edwards’ symptoms came on suddenly: “The offender, a male over the age of 70, who did not have indications of illness, reported experiencing chest pains and trouble breathing on Monday.”

Edwards’ fellow inmates dispute the statement and say he had been seeking medical attention at the prison for days before he died.

Since the start of the pandemic, prisoners and their families have contradicted state officials about the conditions inside Indiana prisons. Many inmates report they’ve had no way to protect themselves from close contact with other inmates and staff members. They believe contracting the disease is inevitable. Indeed, 85% of the prisoners tested at Westville have been positive for the virus. Many of them were housed in the same dorm as Edwards.

As of May 22, at least 18 Indiana prisoners had died from confirmed or presumed coronavirus infections, and 650 inmates had tested positive for the virus. And while the state has maintained it isolates men and women with symptoms, inmates say even severely ill prisoners have been left in their dorms until it is too late. Their accounts call into question efforts to contain the virus, along with the care inmates receive once they have it.

“[Edwards] had been sick for approximately about a week and a half,” said one inmate named Josh. Josh allowed a family member to record a call about Edwards, and he asked to be identified only by his first name because he fears retaliation from prison staff.

His fellow prisoners say Edwards couldn’t even make it to see medical staff on his own — they pushed him in a wheelchair. Each time, he was sent back to his quarters.

“Those bastards said I’m fine, I just need to drink water and rest,” Josh recounted Edwards saying. “I’m clearly not fine — I can’t breathe.” Another prisoner wrote in an electronic message to a reporter that Edwards’ room “smelled like sickness and death.”

On the day he died, Josh said Edwards looked pale before he stumbled on his way to the bathroom. A pair of fellow inmates caught him and helped him sit down. “He sounded like he was winded, like he had just ran a marathon,” Josh wrote via the prison system’s electronic communications software. “He was just saying ‘I can’t breathe, I can’t breathe.’” He said an officer called the prison medical staff, who tended to Edwards in the bathroom for about 45 minutes.

“They finally took him out on oxygen,” Josh said. “Next thing we know, five hours later, he died.”

The Westville inmates emphasize that Edwards didn’t wait until that Monday to report his symptoms — he had complained to staff for days. “There is a major problem here with this place and it’s outta control,” wrote Josh.

Dr. Kristen Dauss, chief medical officer for the Indiana Department of Correction, declined to explain the different accounts of his death. “We do not talk about specific cases and patient clinical status,” she said.

Across the nation, at least 415 prisoners had died of the infection as of the week of May 20, and more than 29,000 had tested positive, according to the Marshall Project.

The American Civil Liberties Union and other advocacy groups have called for the early release of some prisoners, especially the old and sick. Protesters have demonstrated outside Westville and other Indiana prisons to call attention to the conditions inside. Governors in the nearby states of Ohio and Kentucky have ordered some prisoners released, but Indiana Gov. Eric Holcomb has refused. He said it’s up to local judges to decide, on a case-by-case basis.

In the meantime, Dauss said Indiana prisons are taking steps to control the spread of the coronavirus. “We move quickly and, in fact, immediately to separate those who are sick from those who are not sick,” said Dauss.

But according to accounts from numerous inmates, that kind of quick isolation of sick prisoners hasn’t always happened, at least through much of April.

Three different prisoners described another COVID-19 death in a different Indiana prison, the Plainfield Correctional Facility, on April 19. Lonnell Chaney, they said, had been asking for medical help for days.

“He didn’t even know where he was,” one inmate wrote to a reporter. Medical staff had checked on Chaney, who mumbled in response, but left him in the quarters. A prisoner tried to convince officers that the man’s condition was serious — Chaney couldn’t catch his breath — but the officers brushed it off.

The prisoners say Chaney, who was 61, died in his bed in the crowded dorm. “You must be almost dead to get outside help,” wrote the Plainfield inmate.

Six Plainfield prisoners have died during the coronavirus pandemic. The Department of Correction has not released a statement about any of those men. Of 145 Plainfield prisoners tested for the virus, 119 were positive. Forty-five staffers tested positive, as well. Indiana has reported two deaths of prison staffers, as of May 22.

At the Westville prison, Josh said another man in his dorm complained about similar symptoms, and correctional officers wrote the man up for being disruptive.

“Everybody here is terrified,” Josh said.

As the virus spreads, prisoners’ families are told very little. They say prisons refuse to disclose basic information that would put them at ease, including whether an inmate is alive. In Scottie Edwards’ case and others, families didn’t know their loved ones were sick until after they had died — even though a department policy calls for notification when “death may be imminent.”

Crystal Gillispie talked to her father, Lonnell Chaney, for the last time on April 13. Their call lasted five minutes but felt shorter. He told her to send pictures of his grandchildren. And even though the coronavirus had started to spread in his dorm at the Plainfield Correctional Facility, he was more concerned about his family.

“He was like, ‘Just make sure you’re wearing your gloves and masks,’” Gillispie remembered. “I was like, ‘OK, Daddy. You do the same.’ He was so worried about us, and he ended up catching it.”

The next time she heard news of her father, it was from her aunt, his sister: The prison had called her to say Chaney was dead.

Edwards’ sister, Gloria Sam, said her brother was new to Westville prison, because he’d recently requested a transfer to a facility with a law library. He ended up at Westville just before the pandemic started.

“He said, ‘I am afraid of this virus because we’re here close together, and if it comes out, it’ll spread like wildfire,’” she said. Sam hadn’t heard from Edwards in more than a week when her phone rang on April 14. She remembers that even though her caller ID said it was from the State of Indiana, it didn’t occur to her that it was about her brother.

“They said, ‘Well, we have some bad news.’ I thought they were gonna say he was sick,” she said. They told her he had died.

If possible, Sam said, she would have wanted to say goodbye.

“It’s one of the most hurtful things I’ve experienced in my life,” she said.

This story is part of a partnership that includes Side Effects Public Media, WFYI, NPR and Kaiser Health News.

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Public Health States

Hate Unmasked In America

“You are the most selfish f—ing people on the planet.”

I jerked my head to the left, where I saw a neighbor glaring at us from his driveway while unloading groceries from his trunk.

“Where’s your f—ing mask?” he said. “Unbelievable.”

My jaw dropped. I had just walked three blocks home with my toddler and my dad in our leafy, mostly empty Los Angeles neighborhood because my kid had thrown a tantrum in the car.

And we had forgotten our masks. Four days earlier, Mayor Eric Garcetti had ordered protective face coverings anytime we left home, not just when we entered essential businesses.

I pointed out my house to the neighbor to explain how close we were, just a few doors down from him. He cut me off.

“I don’t give a f– where you live, and I don’t give a f– what your reason is.”

Then my dad jumped in. “Sorry, sir, we forgot our masks. I’m sorry, sir.”

Still, the man didn’t soften.

“You should be sorry. And you should make her be sorry, too,” he gestured toward me. After a few more agonizing seconds, he dismissed us.

Our neighbor’s mask, by the way? It was off his face, hanging loosely around his neck. All the better to shout at us.

As a health care reporter, I had covered America’s evolution on masks as the coronavirus spread across the globe. Back in January, I wrote an article about why Chinese immigrants insisted on wearing surgical and construction masks in the U.S., even though it went against official health recommendations at the time. In February, I wrote about Asian families in California clashing with schools over whether their children should be allowed to wear masks in class.

At that time, Asian people wearing masks were targets for verbal and physical abuse. Attackers saw masks on Asian faces as signs of disease and invasion; people were punched and kicked, harassed in the supermarket, bullied at school and worse.

Now, of course, masks are the norm. And they’ve become more than just personal protection; they are symbols of courtesy and scientific buy-in. They have, to some extent, also become political signifiers. In a new poll from the Kaiser Family Foundation, 70% of Democrats said they wear a protective mask “every time” they leave their house, versus 37% of Republicans. (Kaiser Health News is an editorially independent program of KFF.)

After our verbal beatdown, my dad and I walked home stone-faced, and then retreated to our separate rooms to nurse our wounds.

I have no idea if the neighbor’s comments had a racist undertone. But it felt like the times in my childhood, first in New Zealand, then in a Bay Area suburb, when I had seen my Philippines-born parents, stunned and silent, get dressed down or humiliated by angry, callous white people. Now it was my 3-year-old daughter’s turn to see me dumbstruck. As I began telling my husband the story, I started crying so hard that I got a headache.

Marigold, 3, wore this mask for five minutes outside and then threw it away. We haven’t been able to find it since. In the background is her grandfather, Jovit Almendrala, trying his own mask out for the first time. (Courtesy of Anna Almendrala)

After my tears came reflection, and an attempt at empathy.

My neighbor was obviously scared. He was older, and potentially more medically vulnerable. His trunk had been packed with overstuffed shopping bags ― probably enough food for weeks, to avoid leaving his house.

He had just come from the grocery store, an enclosed space full of things and people that could potentially infect him. I understand the stress that comes with shopping during the pandemic.

Like many of us, my neighbor could be struggling with how to live in mortal fear of the coronavirus. And for him, at least that morning, that struggle got the better of him.

Later that day, I wrote the neighbor a card introducing ourselves. I apologized for making him feel unsafe and acknowledged that he was right about the masks. But I also said he had unfairly used us as a target for his fear and frustration, and I told him I was shocked and saddened he would treat a neighbor with so much hate. I haven’t heard back from him.

My dad spent the rest of that morning praying that the man didn’t get the coronavirus — lest he blame us and all Asians, forever.

Since that day, no one in my family has left the house without a mask on their face, and I’m anxious to train my daughter to wear one, although she resists it the way she has refused hats and headbands in the past.

We can’t stop noticing that most other exercisers and dog-walkers in our neighborhood ― all white ― fly past us without them. They don’t seem to worry about getting caught on the wrong side of whatever America happens to believe about masks on any given day. But my family can’t risk it.

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KHN’s ‘What The Health?’: Still Seeking A Federal Coronavirus Strategy


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


The Trump administration sent its COVID-19 testing strategy plan to Congress, formalizing its policy that most testing responsibilities should remain with individual states. Democrats in Congress complained that the U.S. needs a national strategy, but so far none has emerged.

Meanwhile, President Donald Trump, noticing that his popularity among seniors has been falling since the pandemic began, unveiled a plan to lower the cost of insulin for Medicare beneficiaries. However, while diabetes is a major problem for seniors in general and for Medicare’s budget, only a small minority takes insulin.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Anna Edney of Bloomberg News and Erin Mershon of STAT News.

Among the takeaways from this week’s podcast:

  • The difficulties caused by the lack of a unified federal response to the pandemic can be seen by looking at other countries. Communities around the world face some of the same problems U.S. cities and states do, such as high numbers of cases in nursing homes and other congregate living facilities, and test shortages. But in other countries, the governments have taken the lead in working through the issues.
  • Recent episodes of crowds gathering as states reopen point to a breakdown in public health messaging. That may be partly attributable to the president’s ambivalence or a result of the recent cutback in press briefings and other direct communication from federal public health officials. But much of it could also be directly related to political divisiveness, which runs rampant.
  • With a Rose Garden ceremony, Trump announced the deal with drugmakers to limit Medicare beneficiaries’ out-of-pocket costs for insulin to $35. That is expected to save those patients on average more than $400 a year. But the announcement is a long way from the promises made by the administration to bring down drug prices for all Americans.
  • Republicans have touted short-term insurance plans as a cheaper alternative to health coverage offered under the Affordable Care Act’s marketplaces. But the COVID-19 pandemic has highlighted shortcomings of those plans, including that many don’t cover prescription medications or experimental treatments.
  • The pandemic has also spotlighted the administration’s intent to get more drug manufacturing — which has become concentrated in India and China — to return to the United States. The government recently announced it is starting a project with a Virginia company to add manufacturing capacity stateside.

Also this week, Rovner interviews KHN’s Phil Galewitz, who reported the latest KHN-NPR “Bill of the Month” installment about a patient with a suspected case of COVID-19 who did what he was told by his health plan and got billed, anyway. If you have an outrageous medical bill you would like to share with us, you can do that here.

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

Julie Rovner: ProPublica’s “The Feds Gave a Former White House Official $3 Million to Supply Masks to Navajo Hospitals. Some May Not Work,” by Yeganeh Torbati and Derek Willis

Also, The New York Times’ “My Mother Died of the Coronavirus. It’s Time She Be Counted,” by Elisabeth Rosenthal

Joanne Kenen: The New Yorker’s “The Town That Tested Itself,” by Nathan Heller

Anna Edney: The New York Times’ “Wealthiest Hospitals Got Billions in Bailout for Struggling Health Providers,” by Jesse Drucker, Jessica Silver-Greenberg and Sarah Kliff

Erin Mershon: The Washington Post’s “Coronavirus May Never Go Away, Even With a Vaccine,” by William Wan and Carolyn Y. Johnson


To hear all our podcasts, click here.

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

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Some Ivory Towers Are Ideal For A Pandemic. Most Aren’t.

Saint Mary’s College in Moraga, California, is open for business this fall — but to get there, you really have to want it. Tucked amid verdant hills 23 miles east of San Francisco, accessible by a single road and a single entrance, the small, private Roman Catholic school receives almost no visitors by accident.

This, in the age of a pandemic, is good news indeed for its administrators.

“We can control who comes in or out in a way that larger, urban campuses perhaps can’t do,” said William Mullen, the school’s vice provost for enrollment. “Those campuses are in many cases more permeable.”

As colleges and universities across the country juggle student and staff safety, loss of opportunities and loss of revenue during the COVID-19 pandemic, even seemingly secondary considerations — how many entrances a school has, how close it sits to community foot traffic, how food is served — loom large.

And while officials are loath to make broad guarantees about safety, they can’t ignore public health advice and thus are immersed in an effort to at least minimize the potential for harm. What that looks like will vary wildly from campus to campus, but in almost every case it will include attempts to limit close contact with others — a difficult job for educational institutions.

The stakes are enormous. Some universities are already projecting financial losses in the tens of millions due to declining enrollment and the uncertainty ahead. But at its core, this is a health problem that remains both simple and vexing: How do you open up a campus without inviting mass infection?

One preliminary answer: Don’t let too many people hang around at the same time.

“I would never use the term ‘make it safe,’” said Dr. Sarah Van Orman, who oversees student health services at the University of Southern California, a private school in the heart of Los Angeles. “I would say we’re going to reduce the risk to the degree possible to have everything in place.”

On many campuses, that means reducing class size (even if it requires adding new sections), making large survey courses online-only, cutting dorm residencies by as much as 50%, limiting or eliminating common-area food service, and perhaps even alternating students’ in-person attendance according to class level (freshman, sophomore, etc.) by quarters or semesters.

That’s in addition to the protocols recommended by the American College Health Association. The ACHA, to which more than 800 institutions belong, has called for a phased reopening of campuses “based on local public health conditions as well as [school] capacity.” Its guidelines include widespread testing, contact tracing, and isolation or quarantine of both ill and exposed individuals.

The Centers for Disease Control and Prevention laid out even more daunting instructions for what a campus should do in the event of a positive test, calling for potential short-term closures of buildings and classrooms that might extend into weeks in the middle of a semester. Among other things, the CDC said, the scenario could include having to move some on-campus residents into short-term alternative housing in the surrounding community.

Van Orman is a past president of the ACHA, but her school has yet to announce a definitive plan for the fall. That puts USC in good company. Although a rolling survey by the Chronicle of Higher Education suggests that nearly 70% of schools are planning for on-campus education, almost every institution directly contacted by Kaiser Health News was actually planning for all contingencies, with fully or partly opened campuses simply being the best-case and most publicly touted scenarios.

Making a campus virus-ready could take all summer, according to officials at several schools. Most of them don’t yet know how many students will return, and about half the schools contacted by KHN said they’ve pushed back the decision deadline for incoming freshmen to June 1, a month later than usual.

Those decisions have huge ramifications for university budgets. Ben Kennedy, whose Kennedy & Co. consults higher education institutions, said most are planning for an enrollment drop of 5% to 10%. “They’ll experience the big financial hit this fall,” Kennedy said.

At Georgetown University in Washington, D.C., a projected $50 million shortfall prompted voluntary furloughs, suspended retirement contributions and construction stops. The Massachusetts Institute of Technology reported $50 million in unexpected costs, while Janet Napolitano, president of the University of California’s 10-campus system, estimated combined losses of $1.2 billion from mid-March through April in announcing salary cuts and some freezes.

At the same time, large-scale restructuring will be required at bigger campuses in response to the pandemic. Converting some multiperson dorm rooms to singles will become the norm at many schools, although not every campus — or community — is prepared to handle a surge of students needing to find other housing as a result. Solutions are still being studied to address those who will be in close quarters in shared dining halls, bathrooms and common rooms. Some schools plan to set aside dorms for students who test positive and need to be isolated or quarantined.

“Students with existing health issues will have priority for single occupancy,” said Debbie Beck, executive director of health services for the University of South Carolina’s 33,000-student Columbia campus. “Testing in the residence halls will be critical.”

Several schools are considering ending their fall semesters before Thanksgiving, which Beck said “would further reduce risks and control the spread of COVID” as students are sent home until January. Stanford University, meanwhile, is pondering a range of possibilities that include permitting only a couple of class years on campus, perhaps alternating by quarters.

A common misperception, several officials said, is that college campuses have been “closed” since the outbreak of the coronavirus. Although student life has been restricted, other parts of many campuses have remained in operation, particularly at research institutions.

“We have research departments and laboratories that really don’t work if you’re not there,” said Dr. Jorge Nieva of USC’s Keck School of Medicine. “It’s difficult to do mouse experiments with cancer if you’re not doing mouse experiments with cancer.”

California’s two massive public university systems embody that dichotomy. California State University Chancellor Timothy White said the 23-campus CSU system, primarily instruction-focused, will mostly conduct remote learning. Napolitano expects the research-heavy University of California campuses to be open “in some kind of hybrid mode,” which many other schools likely will adopt.

“These kids are digital natives,” said Nieva, whose son was a freshman living on campus at USC before students were sent home. “A lot of what they’re experiencing, they’re perhaps better equipped to handle than another generation might be.”

Back in Moraga, Saint Mary’s will reduce dorm capacity, record lectures for online retrieval and institute strict guidelines to prevent the spread of illness — but it plans to continue a 150-plus-year tradition of close, personal education for its 2,500 undergraduates. In its case, being small is the biggest advantage.

“If we already only have 15 or 18 students in a classroom that can hold 30, then it becomes much easier to adapt to the new guidelines and protocols,” said Dr. Margaret Kasimatis, the school’s provost. “That’s a pretty good start.”

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

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California Public Health

For Seniors, COVID-19 Sets Off A Pandemic Of Despair

As states relax coronavirus restrictions, older adults are advised, in most cases, to keep sheltering in place. But for some, the burden of isolation and uncertainty is becoming hard to bear.

This “stay at home awhile longer” advice recognizes that older adults are more likely to become critically ill and die if infected with the virus. At highest risk are seniors with underlying medical conditions such as heart, lung or autoimmune diseases.

Yet after two months at home, many want to go out into the world again. It is discouraging for them to see people of other ages resume activities. They feel excluded. Still, they want to be safe.

“It’s been really lonely,” said Kathleen Koenen, 77, who moved to Atlanta in July after selling her house in South Carolina. She’s living in a 16th-floor apartment while waiting to move into a senior housing community, which has had cases of COVID-19.

“I had thought that would be a new community for me, but everyone there is isolated,” Koenen said. “Wherever we go, we’re isolated in this situation. And the longer it goes on, the harder it becomes.”

(Georgia residents age 65 and older are required to shelter in place through June 12, along with other vulnerable populations.)

Her daughter, Karestan Koenen, is a professor of psychiatric epidemiology at Harvard University’s T.H. Chan School of Public Health. During a Facebook Live event this month, she said her mother had felt in March and April that “everyone was in [this crisis] together.” But now, that sense of communality has disappeared.

Making it worse, some seniors fear that their lives may be seen as expendable in the rush to reopen the country.

“[Older adults] are wondering if their lives are going to end shortly for reasons out of their control,” said Dr. Linda Fried, dean of the Mailman School of Public Health at Columbia University, in a university publication. “They’re wondering if they’ll be able to get the care they need. And most profoundly, they’re wondering if they are going to be cast out of society. If their lives have value.”

On the positive side, resilience is common in this age group. Virtually all older adults have known adversity and loss; many have a “this too shall pass” attitude. And research confirms that they tend to be adept at regulating their reactions to stressful life events — a useful skill in this pandemic.

“If anything, I’ve seen a very strong will to live and acceptance of whatever one’s fate might be,” said Dr. Marc Agronin, a geriatric psychiatrist and vice president of behavioral health at Miami Jewish Health, a 20-acre campus with independent living, assisted living, nursing home care and other services.

Several times a week, psychologists, nurses and social workers are calling residents on the campus, doing brief mental health checks and referring anyone who needs help for follow-up attention. There’s “a lot of loneliness,” Agronin said, but many seniors are “already habituated to being alone or are doing OK with contact [only] from staff.”

Still, “if this goes on much longer,” he said, “I think we’ll start to see less engagement, more withdrawal, more isolation — a greater toll of disconnection.”

Erin Cassidy-Eagle, a clinical associate professor of psychiatry at Stanford University, shares that concern.

From mid-March to mid-April, all her conversations with older patients revolved around several questions: “How do we keep from getting COVID-19? How am I going to get my needs met? What’s going to happen to me?”

But more recently, Cassidy-Eagle said, “older adults have realized the course of being isolated is going to be much longer for them than for everyone else. And sadness, loneliness and some hopelessness have set in.”

She tells of a woman in her 70s who moved into independent living in a continuing care community because she wanted to build a strong social network. Since March, activities and group dining have been canceled. The community’s director recently announced that restrictions would remain until 2021.

“This woman had a tendency to be depressed, but she was doing OK,” Cassidy-Eagle said. “Now she’s incredibly depressed and she feels trapped.”

Especially vulnerable during this pandemic are older adults who have suffered previous trauma. Dr. Gary Kennedy, director of the division of geriatric psychiatry at Montefiore Medical Center in New York City, has seen this happen to several patients, including a Holocaust survivor in her 90s.

This woman lives with her son, who got COVID-19. Then she did as well. “It’s like going back to the terror of the [concentration] camp,” Kennedy said, “an agonizing emotional flashback.”

Jennifer Olszewski, an expert in gerontology at Drexel University, works in three nursing homes in the Philadelphia area. As is true across most of the country, no visitors are allowed and residents are mostly confined to their rooms.

“I’m seeing a lot of patients with pronounced situational depression,” she said — “decreased appetite, decreased energy, a lack of motivation and overall feelings of sadness.”

“If this goes on for months longer, I think we’ll see more people with functional decline, mental health decline and failure to thrive,” Olszewski said.

Some are simply giving up. Anne Sansevero, a geriatric care manager in New York City, has a 93-year-old client who plunged into despair after her assisted living facility went on lockdown in mid-March. Antidepressant and anti-anxiety medications have not helped.

“She’s telling her family and her health aides ‘life’s not worth living. Please help me end it,’” Sansevero said. “And she’s stopped eating and getting out of bed.”

The woman’s attentive adult children are doing all they can to comfort their mother at a distance and are feeling acute anguish.

What can be done to ease this sort of psychic pain? Kennedy of Montefiore has several suggestions.

“Don’t try to counter the person’s perception and offer false reassurance. Instead, say, yes, this is bad, no doubt about it. It’s understandable to be angry, to be sad. Then provide a sense of companionship. Tell the person, ‘I can’t change this situation but I can be with you. I’ll call tomorrow or in a few days and check in with you again.’”

“Try to explore what made life worth living before the person started feeling this way,” she said. “Remind them of ways they’ve coped with adversity in the past.”

If someone is religiously-inclined, encourage them to reach out to a pastor or a rabbi. “Tell them, I’d like to pray together or read this Bible passage and discuss it,” Kennedy said. “Comforting person-to-person interaction is a very effective form of support.”

Do not count on older adults to own up to feeling depressed. “Some people will acknowledge that, yes, they’ve been feeling sad, but others may describe physical symptoms — fatigue, difficulty sleeping, difficulty concentrating,” said Julie Lutz, a geropsychologist and postdoctoral fellow at the University of Rochester.

If someone has expressed frequent concerns about being a burden to other people or has become notably withdrawn, that’s a worrisome sign, Lutz said.

In nursing homes, ask for a referral to a psychologist or social worker, especially for a loved one who’s recovering from a COVID hospitalization.

“Almost everybody that I’m seeing has some kind of adjustment disorder because their whole worlds have been turned upside down,” said Eleanor Feldman Barbera, an elder care psychologist in New York City. “Talking to a psychologist when they first come in can help put people on a good trajectory.”

The National Alliance on Mental Illness has compiled a COVID-19 information and resource guide, available at https://www.nami.org/covid-19-guide. The American Psychological Association has created a webpage devoted to this topic and recently wrote about finding local mental health resources. The Substance Abuse and Mental Health Services Administration has a 24-hour hotline, 1-800-662-4357. And the national suicide prevention hotline for those in acute distress is 1-800-273-8255.

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Aging Navigating Aging Public Health

Antibody Tests Were Hailed As Way To End Lockdowns. Instead, They Cause Confusion.

Aspen was an early COVID-19 hot spot in Colorado, with a cluster of cases in March linked to tourists visiting for its world-famous skiing. Tests were in short supply, making it difficult to know how the virus was spreading.

So in April, when the Pitkin County Public Health Department announced it had obtained 1,000 COVID-19 antibody tests that it would offer residents at no charge, it seemed like an exciting opportunity to evaluate the efforts underway to stop the spread of the virus.

“This test will allow us to get the epidemiological data that we’ve been looking for,” Aspen Ambulance District director Gabe Muething said during an April 9 community meeting held online.

However, the plan soon fell apart amid questions about the reliability of the test from Aytu BioScience. Other ski towns such as Telluride, Colorado, and Jackson, Wyoming, as well as the less wealthy border community of Laredo, Texas, were also drawn to antibody testing to inform decisions about how to exit lockdown. But they, too, determined the tests weren’t living up to their promise.

The allure of antibody tests is understandable. Although they can’t find active cases of COVID-19, they can identify people who previously have been infected with the coronavirus that causes the disease, which could give health officials important epidemiological information about how widely it has spread in a community and the extent of asymptomatic cases. In theory, at least, antibodies would be present in such people whether they had a severe case, little more than a dry cough or no complaints at all.

Even more enticing: These tests were billed as a path to restart local economies by identifying people who might be immune to the virus and could therefore safely return to the public sphere.

But, in these and other communities, testing programs initially slated to test hundreds or thousands have been scaled back or put on hold.

“I don’t think these tests are ready for clinical use yet,” said University of California-San Francisco immunologist Dr. Alexander Marson, who has studied their reliability. He and his team vetted 12 different antibody tests and found all but one turned up false positives — implying that someone had antibodies when they didn’t ― with false-positive rates reaching as high as 16%. (The study is preliminary and has not been peer-reviewed yet.)

More than 100 antibody tests are currently available in the U.S., including offerings by commercial labs, academic centers and small entrepreneurial ventures. As serious questions emerged earlier this month about the accuracy of the tests and the usefulness of the results, the U.S. Food and Drug Administration said it will require companies to submit validation data on their products and apply for emergency-use authorizations for their products. (Previously, companies were allowed to sell their tests without review from the FDA, as long as they did their own validation and included a disclaimer.) And the American Medical Association said on May 14 that the tests should not be used to assess an individual’s immunity or when to end physical distancing.

And this week, the Centers for Disease Control and Prevention released new guidelines warning that antibody test results can have high false positive rates and should not be used to make decisions about returning people to work, schools, dorms or other places where people congregate.

Once hailed as a solution, the current crop of tests, which have not been thoroughly vetted by any regulatory agency, now seem more likely to add chaos and uncertainty to a situation already fraught with anxiety. “To give people a false sense of security has a lot of danger right now,” said Dr. Travis Riddell, the health officer for Teton County, which includes Jackson, Wyoming.

Accuracy Questions Raised

The gold standard for confirming an active COVID-19 infection is to take a swab from the nasopharynx and test it for the presence of viral RNA. The antibody tests instead parse the blood for antibodies against the COVID-19 virus. It takes time for an infected person to produce antibodies, so these tests can’t diagnose an ongoing infection, only indicate that a person has encountered the virus.

In Aspen, county officials knew the FDA had not approved the Aytu BioScience test, which the Colorado-based company was importing from China. So they first conducted their own validation tests, said Bill Linn, spokesperson for the Pitkin County Incident Management Team. “We weren’t reassured enough by our own testing to feel like we should move ahead.”

In Laredo, officials had been told by one of the community members helping to arrange the purchase of 20,000 tests from the Chinese company Anhui DeepBlue Medical Technology that they were FDA-approved, but the city’s own validation trials revealed only about a 20% accuracy rate, said Laredo spokesperson Rafael Benavides. Before Laredo could pay for the tests, Benavides said, an arm of U.S. Immigration and Customs Enforcement seized them and launched an investigation.

Neither Anhui DeepBlue Medical Technology, nor Aytu returned requests for comment.

In March, Covaxx, a company led by two part-time Telluride residents, offered to test residents of the town and the surrounding county with an antibody test it had developed. But the project was suspended indefinitely when the company’s testing facility fell behind on processing them.

The county is committed to doing a second round of testing but is evaluating how to proceed, said San Miguel County spokesperson Susan Lilly. “The question is how do you target it to be the most relevant clinically and for the public health team’s decision-making moving forward?”

Officials Back Off, Community Members Step In

On May 4, the FDA updated its antibody test policy to require that manufacturers submit validation data, but it is still allowing the tests to be sold without the normal lengthy vetting and approval process, which includes demonstrating safety and effectiveness.

In some wealthy areas, government officials had been offering free tests from startups with local investors. In Jackson, for example, a venture capitalist with an investment in Covaxx, the test used in Telluride, offered to help the city obtain 1,000 tests. But after reviewing the offer, Teton County declined over concerns about the test’s accuracy. “If a person tests positive, what does that mean? And is that useful information? We just don’t know yet,” Riddell said.

Covaxx spokesperson John Schaefer said in a statement that the test had been validated on more than 900 blood samples and is being reviewed by the FDA.

After Teton County officials decided against community antibody testing, a private nonprofit, Test Teton Now, sprung up to provide free COVID-19 antibody testing using the Covaxx test for roughly 8,000 people, about a third of the county’s residents. As of May 22, they’d raised $396,000 and tested 843 samples. The group has “done a lot” to verify the Covaxx tests, said Test Teton Now president Shaun Andrikopoulos. “I don’t want to call it validation, because we didn’t go through an independent review board, but we have sent our samples out to other labs.”

Organizers of Test Teton Now don’t share others’ concerns about the test’s utility. “We don’t encourage people to make any decisions about what they’re going to do or how they’re going to behave based on the results,” said the nonprofit’s spokesperson, Jennifer Ford.

What good is a test that can’t be used for practical purposes? “We think knowledge is power, and data is the beginning of knowledge,” Ford said. But unreliable data doesn’t give knowledge, it gives an illusion of knowledge.

So many unknowns remain, and false data may be worse than none. Even a very accurate test will produce a large number of false positives when used in a population where few people have been infected. If only 4% of people have actually been infected, a test with 95% accuracy would produce nine positive results for every 100 tests, five of which are false positives.

And that creates a danger that the tests could lead people to incorrectly think that they have antibodies that make them immune, which could have disastrous consequences if they changed their behavior as a result. Consider, for example, a person falsely told she had antibodies going to work at a nursing home, believing she couldn’t catch or spread the virus to anyone.

It’s not even known for sure that having antibodies makes someone immune. Researchers are hopeful that exposure can confer some level of immunity, but how strong that immunity might be and how long it might last remain unknown, said Harvard epidemiologist Marc Lipsitch.

So, having been burned once, Aspen has put antibody testing on hold and is instead focusing on identifying and isolating people who are sick or at risk of becoming so. “It’s actually a step back to where we started,” Linn said.

Given the remaining unknowns about immunity and COVID-19, the best methods for addressing the pandemic in communities may be the most time-tested ones, Linn said. “Put the sick people in places where they can’t get anyone else sick. It’s the bread and butter of epidemiology.”

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