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Nursing Homes Have Thousands Of Ventilators That Hospitals Desperately Need

As the number of COVID-19 patients climbs and health officials hunt for ventilators to treat them, nursing homes across the United States have a cache ― about 8,200 of the lifesaving machines, according to data from the Centers for Medicare & Medicaid Services.

Most of the machines are in use, often by people who’ve suffered a brain injury or stroke. Some of those residents are in a vegetative state and have remained on a ventilator for years.

State officials are working to consolidate ventilators where they are most urgently needed. But so far, the supply in nursing homes has not drawn the same attention.

Or course, commandeering those units would set up a monumental ethical dilemma: Do you remove life support for a long-term nursing care patient in order to give a COVID-19 patient a better chance of survival?

The highest number of machines, about 2,300, is in California, where the state has created designated nursing home units for people on life support, officially called subacute units but known pejoratively by some doctors as “vent farms.” New York has the second most, 1,822, according to state officials.

Already, one nursing home on Long Island has lent a nearby hospital 11 ventilators that were not being used, leaving just five for its residents.

“The hospital came to us last week and asked, ‘Do you have any ventilators?’” the nursing home assistant administrator said on the condition of anonymity because he was not authorized to speak to the news media.

“We left ourselves with the bare minimum,” he said. In all, three hospitals reached out to the nursing home for ventilators ― it had to say no to the other two.

New York Gov. Andrew Cuomo has announced an executive order that ventilators not in use by hospitals be redeployed to ICUs. And he’s calling in the New York National Guard to facilitate the order. “We know where every ventilator is,” Cuomo said Sunday.

Nursing home ventilators are not included in his order, but they are included in the state’s tally of the machines.

Dr. Michael Kalafer, a pulmonologist and the medical director at two San Diego subacute units, said he can’t imagine taking one of his patients off a ventilator because it’s needed for someone else.

“I severely doubt we’ll take [a hypothetical] Mrs. Smith off a ventilator because she’s 80 and has been on it for a few years and has not gotten better,” Kalafer said.

But these are precisely the decisions bioethicists are being asked to weigh in on as the country confronts the crush of COVID-19 patients overwhelming the health care system.

And in some cases, states have already decided to give people who are severely brain-injured a lower priority when it comes to access to ventilators. Disability advocates oppose such guidelines and filed complaints with the Department of Health and Human Services last month, according to ProPublica. And although states and health associations can draw up recommendations, they are not legally binding.

“From an ethical point of view, for people who are not conscious, if it’s a matter of removing people from a [ventilator] who are not going to recover, I think it’s a hard decision, but one that in an emergency has to be made,” said Ronald Bayer, a professor of sociomedical sciences at the Mailman School of Public Health at Columbia University.

Bayer has been a member of the World Health Organization and in 2011 served on an ethics subcommittee that advised the Centers for Disease Control and Prevention on the allocation of ventilators in the event of a severe pandemic.

He and several other ethicists said these decisions should not be made at the bedside but by triage committees or people in supervisory roles. And the guidelines ought to be uniform and transparent. That’s why the CDC, the state of New York and medical associations like the American College of Chest Physicians have drafted ethical recommendations for deciding how to ration lifesaving equipment like ventilators in the event of a pandemic.

The California Department of Public Health in 2008 released guidelines to follow during a health care surge: They don’t specifically address ventilator allocation, but rather resources in general. Doctors should consider the likelihood of survival and change in the quality of life as opposed to the ability to pay or the perception of a person’s worth when there are not enough medical resources to treat everyone in need.

When the New York State Task Force on Life and the Law updated its ventilator allocation guidelines in 2015, it considered the question of withdrawing ventilators from nursing home residents, or chronic ventilator patients, to save the lives of those who grow critically ill during a pandemic.

“Are we comfortable sacrificing this group in exchange for saving more lives?” asked Stuart Sherman, the executive director of the task force at the time.

That question drew much debate, but the group ultimately decided that “chronic” vent patients should not be included in the pool when considering how to allocate ventilators during a pandemic. The task force does recommend prioritizing ventilator therapy based on who is likely to survive using a SOFA ― Sequential Organ Failure Assessment ― score.

Cuomo, whose daily televised news conferences have made “ventilators” a household word, is not making decisions based on those guidelines. The task force report is not a binding policy document, according to a spokesperson from the governor’s office.

In the U.S., there are about 62,000 “full-featured ventilators,” the kind needed to treat the most severe cases of COVID-19. An additional 10,000 to 20,000 ventilators are in the government’s National Strategic Stockpile, and 98,000 basic models, the kind often in nursing homes, exist that could be used in a crisis.

In the simplest terms, ventilators push oxygen into the lungs. The machines in ICUs are more powerful and have better monitoring systems than those in a nursing home.

Kalafer’s patients need ventilators to do the work for respiratory muscles. He said they could be used in a pinch during the pandemic. But the real issue is finding enough staff trained to operate and monitor the machines.

Meanwhile, a group of bioethicists, physicians and public health experts are recommending that in a shortage, health care workers could disconnect people from ventilators who have little or no chance of recovery to put them in service of those who do.

The recommendation is the first of six listed in an article published in the New England Journal of Medicine last month.

It did not consider the people who’ve been on vents long term.

“Honestly, before you emailed me, I thought about those patients but never thought about the actual number and how important that might be,” said Dr. James Phillips, one of the paper’s authors and chief of disaster and operational medicine at George Washington University Hospital.

“For patients who have devastating neurological injury and are deemed to never recover and who require ventilation for the rest of their lives, I think it’s an ethical conversation to have with those families to determine if it’s a more appropriate use of resources,” Phillips said.

One ventilator can save multiple lives. The average time a person sick with COVID-19 who needed a ventilator was 11 days, according to an NEJM article that looked at critically ill patients in the Seattle region. Using that number, eight people could potentially be saved over three months.

It is an especially complex moral dilemma when considering the withdrawal of treatment from someone who has lived several years on a ventilator, said Govind Persad, an assistant professor at the University of Denver Sturm College of Law and one of the authors of the NEJM paper.

Persad offered a hypothetical scenario.

“A 78-year-old grandmother has been on ventilator support for 5 years in a subacute facility and is expected to remain on it for the foreseeable future. Covid-19 has reached a senior apartment complex nearby, and doctors are looking everywhere for more ventilators,” Persad wrote.

“They think one more ventilator would give them a chance of saving another 78-year-old grandmother in the senior apartments who is growing worse with viral pneumonia, and, once she is off the ventilator, to save some of her neighbors, who are not yet sick but who they expect to be sick in a few weeks.”

Who gets the ventilator?

Persad suggested it should go to the grandmother in the senior apartments because she is likely to need less time on the ventilator, enabling the ventilator to be used to save her neighbors later.

As he put it: “We save her in order to save more lives, not because of quality-of-life judgments.”

The real-life decision is more problematic and heart-wrenching.

Nancy Curcio’s daughter Maria, who was born with a disabling form of cerebral palsy, was on a ventilator as an adult in San Diego for about three months in 2004. She was eventually weaned off the machine but lived the remainder of her life in a nursing home with a breathing and feeding tube, unable to walk or talk. She died in 2017 at age 57.

“I would be very upset if a doctor said I have to take her ventilator away for someone to live,” Curcio said. “But I can understand in triage this is what a doctor has to do. Would I like it? No. I would want to run away with the ventilator.”

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Dispatch From A Country Doctor: Seeing Patients Differently In The Time Of Coronavirus

Patients would often stop by River Bend Family Medicine just to gab with staff at the front desk or bring baked goods to Dr. Matt Hahn.

“I’m a simple country doctor,” said Hahn, who has practiced in Hancock, Maryland, for 20 years ― the past decade at his River Bend office. “Our waiting room is like a social network in and of itself.” Hahn is also a candidate for West Virginia’s 2nd Congressional District though he has backed away from campaigning because of the coronavirus threat.

His waiting room is now closed for the same reason. But Hahn’s practice in this small town — pinned hard up against the borders with West Virginia and Pennsylvania, about 100 miles northwest of Washington, D.C. ― is not.

Patients who need an in-office appointment call when they get to the parking lot and wait there instead. A staff member escorts them in, opening all the doors, telling patients not to touch anything. Those who are ill use one specific entrance, which leads them upstairs where they are met by staff who follow strict infection-control measures. The rest, such as those coming in with a wound or a diabetes checkup, are treated downstairs.

Still, Hahn now sees most of his patients in telehealth appointments, linked to their computers or smartphones. He can do a lot over video and phone, he said. Some things present more of a challenge, though. With rashes, for example, “people are angling their bodies to show a body part to their camera,” said Hahn. “We’ve had some fun with that.”

Humor remains important during this coronavirus crisis. But, jokes aside, Hahn isn’t taking any of it lightly. As of April 6, 37 coronavirus cases were confirmed in Washington County, which encompasses Hancock, and the governor of Maryland on March 30 issued a statewide stay-at-home order.

On March 17, the Trump administration used emergency powers to expand Medicare payments for telemedicine so that more doctors, hospitals and clinics could be paid for such services. While the expansion applies only to Medicare, Hahn said other insurers moved quickly to do the same. Previously, telemedicine coverage was generally limited to people in remote or underserved areas. Even though it’s at least 30 minutes from the nearest hospital, Hancock is not considered remote.

“It’s something we really wanted to do — we didn’t want to shut our doors,” said Hahn, who trained at George Washington University School of Medicine, in Washington, D.C.

Across the country, practices large and small, like River Bend, are enlisting the help of such technological innovations. In addition to the changes to Medicare reimbursement rules, the administration has loosened privacy enforcement for medical providers making “good faith” efforts to use non-public video services: Facebook Messenger is OK, for example, but Facebook Live is not.

Still, online visits are not perfect.

For one thing, internet service can be spotty, Hahn and nurse practitioner Lora Cole said. Another concern: The new rules required the use of both audio and video in consults with patients. But on March 30, the Centers for Medicare & Medicaid Services took an additional step of further loosening telehealth restrictions to allow providers to conduct the telehealth exams for beneficiaries who have audio phones only.

Another concern is that some patients are not that familiar with computers or smartphones, making telehealth consults more challenging, according to Hahn. And a number of them don’t have access to the internet.

For those who do, the staff tries to help them download apps, go to websites, adjust their cameras or turn on the audio.

“The first few days were frustrating. We spent much of the day trying to get people to paste an address into the right line and put in a nine-digit code,” said Hahn.

Part of the problem was they were trying to use a wide variety of different websites or apps. Once they narrowed the choices, the process got easier. Hahn settled on using Google Duo on his phone, while Cole and the other nurses use the web service GoToMeeting in their virtual exam room.

“We give them the code. They click join. It’s a couple of steps that are very quick and easy,” said Cole.

Those who struggle aren’t having problems with the programs themselves, she said, but with maneuvering their smartphone or computer. She and the nurses in the office walk them through it when they can.

“We take a big deep breath,” said Cole. “With some of our patients, we have actually asked them to find someone ― a family member — who can help them.”

The visits themselves work out just fine, even if they are missing a certain, well, human element, both say.

“It has been very hard on my heart,” said Cole, who said her patients know she loves elephants, often bring her presents to add to her collection of pictures, figurines and other tchotchkes. “I miss my patients. I miss being able to see them and give them a hug.”

Clinically, it has limitations, as well.

“I can’t see the entire body. I can’t do a physical exam,” said Hahn. “But, this is a wonderful thing to have right now. Until we have some break in this situation, we want to keep people home. This gives us the opportunity to take care of patients and keep patients safe and staff safe. Under these circumstances, I am not complaining.”

Someday, Hahn and Cole hope things return to normal, whenever that will be.

And what will things look like at River Bend when it’s all over? Will they still rely heavily on video visits? It hasn’t come up yet.

“We just don’t have time to think or even discuss what the future may hold,” said Cole. “We’re just totally focused on what we have to do that day. Personally, I want it to go back. I want to see my patients again.”

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Young People Weigh Pain Of Job Loss Against Risks Of Virus

Emilio Romero, 23, has mixed feelings about losing his job. It’s a major financial setback, but with two previous hospitalizations for pneumonia, a restaurant was not the safest place for the recent college graduate as the COVID-19 pandemic mushroomed.

“Working in a restaurant, there’s obviously exposure to a lot of people and dirty plates,” Romero said. “Even before I was officially laid off, I was getting pretty nervous about the way everything was playing out, for my own safety.”

Romero worked his last shift as a restaurant host in San Diego’s Little Italy on March 16, the same day San Diego County officials ordered all restaurants to switch to takeout and delivery only. Since then, COVID-19 cases in California have increased by more than 22 times, from 598 to 13,438 as of April 4. If his restaurant asked him back tomorrow, Romero said, he wouldn’t risk it.

Yet he worries about his bank balance, which is barely sufficient to cover one month’s rent and expenses.

He’s considering asking his landlord whether he can break his lease to move back in with his parents. But he hopes a government check from the recently passed $2 trillion stimulus package will allow him to stay put as he continues to study for his real estate license — though it’s another industry jeopardized by the virus-driven economic downturn.

As measures to slow the pandemic decimate jobs and threaten to plunge the economy into a deep recession, young adults such as Romero are disproportionately affected. An Axios Harris survey conducted through March 30 showed that 31% of respondents ages 18 to 34 had either been laid off or put on temporary leave because of the outbreak, compared with 22% of those 35 to 49 and 15% of those 50 to 64.

John Gerzema, CEO of the Harris Poll, said it was important to note that the latest survey data does not factor in the doubling of U.S. jobless claims to over 6.6 million in the past week. That number “would suggest further pain and dislocation to 18-34 years olds,” he said.

But the economic fears of many young people, even ones with uncomplicated medical histories, are increasingly counterbalanced by health worries as they grow more aware of the risks of COVID-19. After hearing for months that it threatens primarily seniors and people with chronic diseases, they are now seeing how it imperils their own age group, with consequences such as lung failure.

“It’s natural that as we learn more, it’ll become clear that there are substantial costs for young people, even if the risks are, in fact, much greater for the elderly,” said Jeffrey Clemens, a health and labor economist at the University of California-San Diego. “Whether people want to work depends in part on other qualities of the job, one of which is whether it comes with serious health, physical or other risks.”

Despite the harsh economic impact, “epidemiologists and economists agree that the isolation is necessary, at least for a short period of time, both to avoid the big spike and to have the number of cases go down ideally to low-enough levels,” said Philip Oreopoulos, a labor economist at the University of Toronto and researcher for the Cambridge, Massachusetts-based National Bureau of Economic Research.

However, long-term unemployment and lower wages, associated with entering the workforce during a prolonged down economy, also carry health risks, including higher mortality, said Oreopoulos, who co-authored a paper on recessions and wages.

“That’s the part that gets me restless at night.”

Quinn Stephens, a student at Santa Barbara City College, lost his job as a restaurant server in March as the COVID-19 pandemic spread. Under California’s statewide stay-at-home order, Stephens is spending his time in his apartment, taking his classes online. He plans to study engineering at California Polytechnic State University-San Luis Obispo in the fall.(Courtesy of Quinn Stephens)

A recent study of the recession of the early 1980s shows that people who entered the labor market at the time later suffered increased mortality, starting in their late 30s, due to causes that included lung cancer, liver disease and drug abuse.

About 20 million people age 24 and younger will either seek work or hold jobs in this pandemic-stricken economy, said UCLA economist Till von Wachter, a co-author of the study.

Economists say it’s too soon to predict how a pandemic-induced recession will affect young people. Nobody knows how long businesses will remain closed, and data on workers is still coming in, said Sarah Anzia, faculty director of the Berkeley Institute for Young Americans at UC-Berkeley’s Goldman School of Public Policy.

But a record-smashing 10 million people applied for unemployment benefits in the U.S. over the past two weeks, and Anzia said service industries such as leisure and hospitality — the first to be hit by the shutdowns — have a large share of young service workers who could feel the impact for years.

For now, many young people are just hunkering down, waiting for the COVID-19 storm to pass.

Quinn Stephens, a 22-year-old student at Santa Barbara City College, lost his job as a server at a hotel restaurant earlier this month. Before that, he had continued going to work even after his managers said employees could turn down shifts if they were nervous about COVID-19. He was trying to save money for tuition, and the gravity of the pandemic had not yet sunk in.

But he’s changed his mind now. “I’d lean toward staying home at this point, because I’m seeing how my actions can affect so many others,” and young people are also being “affected pretty severely” by the virus, Stephens said.

“Going outside and continuing life as normal, right now at least, would be a big mistake that could lead to a lot of people dying.”

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‘You Pray That You Got The Drug.’ Ailing Couple Gambles On Trial For COVID-19 Cure

Josie and George Taylor stand on the porch of their home in Everett, Washington, on March 24. They are two of the first people in the U.S. to recover from novel coronavirus infections after joining a clinical trial for the antiviral drug remdesivir.(Dan DeLong for KHN)

For 10 days last month, they lay in side-by-side isolation units in a Seattle-area hospital, tethered to oxygen and struggling to breathe as the coronavirus ravaged their lungs.

After nearly 52 years of marriage, that was the hardest thing: being apart in this moment, too weak to care for each other, each alone with their anxiety and anguish.

“I worried about my husband a lot,” recalled Josie Taylor, 74, who fell ill a few days before George, 76. “Yes, I was concerned about me, but I was more concerned about what was going to happen to him.”

Despite their personal uncertainty, when a doctor approached the Taylors at their bedsides to ask if they would consent to join a study of an experimental drug to help experts learn to treat the devastating infection, each agreed.

“My answer was absolutely yes,” Josie said. “My feeling was anything I can do to help. Even if you’re stuck in an isolation room, this is affecting so many people and we have to do everything we can.”

In late March, the Taylors were discharged from EvergreenHealth medical center, heading home a few days apart. They returned to their tidy white house in Everett, tired, worn — and wondering if the clinical trial they had joined is the reason they survived the deadly disease.

The couple are among the first patients in the U.S. to recover from COVID-19 after agreeing to participate in a National Institutes of Health randomized controlled trial of remdesivir, an antiviral drug made by Gilead Sciences that once aimed to treat another infectious disease, Ebola.

The study is part of a surge in efforts to beat back the virus that as of Sunday evening had sickened more than 337,000 people in the U.S. and led to more than 9,600 known deaths.

“You pray that you got the drug,” said Josie. “The fact that we both recovered so quickly? You hope that’s the reason why.”

But neither the Taylors nor Dr. Diego Lopez de Castilla, the 41-year-old physician heading the trial at the Kirkland, Washington, hospital, know now whether the couple received injections of remdesivir — or an identical-looking placebo.

Nor do they know whether the investigational drug, designed to stop the virus from replicating, is effective at halting the disease. There are a half-dozen studies in progress across the globe testing remdesivir as a COVID-19 treatment.

At the same time, more than two dozen Phase 3 clinical trials are recruiting participants to study interventions to prevent or treat COVID-19. They range from a tuberculosis vaccine being tested on health care workers to a cancer drug that could prevent the deadly fluid buildup occurring in the lungs of COVID-19 patients.

Other drugs, including those used to treat rheumatoid arthritis and even gout are being tested to see if they reduce the body’s inflammatory response to the infection. A few studies aim to confirm whether treatments touted by President Donald Trump, the antimalarial drugs chloroquine and hydroxychloroquine, are indeed effective against COVID-19.

If any of the trials show overwhelming evidence of benefit or harm, they could be called off, with the drug in question accelerated to general use or halted.

So far, no drug appears to be a certain treatment for COVID-19. Early results regarding remdesivir are expected in late April. Officials with the World Health Organization and many media accounts have suggested the treatment could hold promise. But it’s too soon to say, said Lopez de Castilla.

“I don’t think we have enough data to be commenting,” Lopez de Castilla said. “I think it’s very premature. We’re still enrolling patients in the trial.”

Lopez de Castilla is steering clear of the political turmoil that has surrounded remdesivir and Gilead. The firm in March sought and received federal Food and Drug Administration approval for so-called orphan drug designation, but then asked the agency to rescind the designation after critics accused company officials of unfairly seeking a lucrative monopoly for the drug.

Orphan drug designation gives a manufacturer seven years of market exclusivity, a period that essentially bars competition. Consumer advocates criticized the designation because orphan drug status is aimed at products that target rare diseases, those that affect 200,000 people or fewer. Gilead received the status when U.S. cases were still hovering near 40,000 but were expected to rise far higher.

In the past two weeks, Gilead officials announced that, because of “overwhelming demand,” the company would no longer provide the drug on an individual compassionate-use basis to patients not enrolled in clinical trials and was shifting to a broader-access program.

For now, Lopez de Castilla is focused on the science, working to follow strict protocols set by the National Institute of Allergy and Infectious Diseases study expected to enroll 440 patients across 75 sites.

The double-blind trial calls for participants to receive the active drug or placebo for 10 days, and then to evaluate how they do based on a scale that moves from fully recovered to death. The drugs are given free to hospitals and trial patients. In a public letter March 28, Gilead chief executive Daniel O’Day pledged that the company would work to “ensure affordability and access.”

Since Feb. 21, 40 U.S. sites have joined the Adaptive COVID-19 Treatment Trial, with Lopez de Castilla’s team enrolling among the most patients so far: at least 20 as of April 1.

“We are a community hospital,” he said. “Although we don’t have all the resources that bigger hospitals have, we do have amazing people here.”

Still, it hasn’t been easy. For weeks, EvergreenHealth was at the epicenter of the U.S. outbreak, treating dozens of patients from the Life Care Center nursing home in Kirkland, where nearly 40 patients have died. Overall, the hospital has treated nearly 300 COVID-19 patients since Feb. 28.

The patients enrolled in the trial are among the sickest, Lopez de Castilla said. They’re those who are moderately to critically ill, including some who are unconscious and on ventilators. Obtaining consent to participate in a clinical trial from patients or families grappling with an emergency has been “very challenging,” he said.

“One of the challenges is how to enroll a patient who is already intubated,” he said. “We do this through a family member, someone who can make medical decisions for the patient.”

It can take hours to explain the procedure, describe the side effects — which could include gastrointestinal problems or elevated liver enzymes — and provide detailed information so the patient or their legal representative can make an informed decision.

Patients must understand that they could receive an unproven therapy, he said. And they need to know that, because the trial calls for half of the patients to receive the drug and half to receive a placebo, there’s a 50% chance they won’t actually receive the active drug.

One barrier has been that the trial paperwork is available only in English, which is not the first language of some patients. EvergreenHealth is working with the NIH to create at least one translation in Spanish.

Overall, about half of the patients Lopez de Castilla approached have said no.

The Taylors both fell ill in early March and ended up in a Seattle-area hospital with COVID-19, before deciding to join a clinical trial for an experimental drug. For Josie Taylor, a former second-grade teacher who volunteers for social causes, the decision was easy. “It does have to be studied,” she says. “It can’t be a knee-jerk reaction of ‘Take any medication, without knowing what the results will be.’”(Dan DeLong for KHN)

For Josie Taylor, a former second-grade teacher who volunteers for social causes, the decision to join the trial was easy. “It does have to be studied,” she said. “It can’t be a knee-jerk reaction of ‘Take any medication, without knowing what the results will be.’”

She and her husband, a retired banker, fell ill in early March, just weeks after moving from their home of 40 years to a new community 30 miles north of Seattle. Josie got sick first.

“I went to the grocery store and came out, loaded the stuff in the car and realized I was very short of breath — weirdly so,” she recalled.

She ran a fever that night, called her doctor and went to the emergency room the next morning, where she was quickly placed in isolation.

George Taylor is a Vietnam War veteran who was affected by the defoliant Agent Orange used in that war. He has multiple health problems, including prostate cancer, heart disease and Parkinson’s disease. Within a couple of days, he also fell ill.

George was sent to the ER and then to an isolation room — next to his wife’s. For more than a week, they were both seriously ill, on oxygen, uncertain about the future. “It was 10 or 11 days,” Josie said, adding wryly: “Honestly, you lose track when you’re having fun.”

Contracting the novel coronavirus has been scary. But they were heartened by the support of family, friends, even people they barely knew. “I came home to a brand-new place with brand-new neighbors and our yard had been mowed and edged,” Josie said.

Now that they’re both home, the Taylors are gradually getting back to normal. Josie still speaks slowly, pausing to catch her breath between words. She said she hopes her experience underscores the seriousness of the crisis.

“I’m hoping and praying that this drug helps a lot of people,” she said. “It’s not an old person’s issue. It’s an every person’s issue.”

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Long-Standing Racial And Income Disparities Seen Creeping Into COVID-19 Care

The new coronavirus doesn’t discriminate. But physicians in public health and on the front lines said they already can see the emergence of familiar patterns of racial and economic bias in the response to the pandemic.

In one analysis, it appears doctors may be less likely to refer African Americans for testing when they show up for care with signs of infection.

The biotech data firm Rubix Life Sciences, based in Lawrence, Massachusetts, reviewed recent billing information in several states and found that an African American with symptoms like cough and fever was less likely to be given one of the scarce coronavirus tests.

Delays in diagnosis and treatment can be harmful, especially for racial or ethnic minority groups that have higher rates of certain diseases, such as diabetes, high blood pressure and kidney disease. Those chronic illnesses can lead to more severe cases of COVID-19.

In Nashville, three drive-thru testing centers sat empty for weeks because the city couldn’t acquire the necessary testing equipment and protective gear like gloves and masks. All of them are in diverse neighborhoods. One is on the campus of Meharry Medical College — a historically black institution.

“There’s no doubt that some institutions have the resources and clout to maybe get these materials faster and easier,” said Dr. James Hildreth, president of Meharry and an infectious disease specialist.

His school is in the heart of Nashville, where there were no screening centers until this week.

Most of the testing in the region took place at walk-in clinics managed by Vanderbilt University Medical Center, and those are primarily located in historically white areas like Belle Meade and Brentwood, Tennessee.

“There’s no doubt that some institutions have the resources and clout to maybe get these materials faster and easier,” said Dr. James Hildreth, president of Meharry and an infectious disease specialist.(Photo by Ken Morris/Courtesy of Meharry Medical College)

Hildreth said he has observed no overt bias on the part of health care workers and doesn’t suspect any. But he said the distribution of testing sites shows a disparity in access to medical care that has long persisted.

‘I Pray I’m Wrong’

If anyone should be prioritized, Hildreth said, it’s minorities, whose communities already have more risk factors like diabetes and lung disease.

“We cannot afford to not have the resources to be distributed where they need to be,” he said. “Otherwise, the virus will do great harm in some communities and less in others.”

Data from late March show the location of coronavirus testing sites in Shelby County, Tennessee. It reveals that most screening is happening in the predominantly white and well-off Memphis suburbs, not the majority-black, lower-income neighborhoods.

The Rev. Earle Fisher has been warning his African American congregation that the response to the pandemic may fall along the city’s usual divides.

“I pray I’m wrong,” Fisher said. “I think we’re about to witness an inequitable distribution of the medical resources, too.”

Around the nation, leaders are taking note of disproportionate health outcomes. In Wisconsin, African Americans accounted for all of Milwaukee County’s first eight fatalities.

Gov. Tony Evers said he wants to know why black communities seem to be hit so hard. “It’s a crisis within a crisis,” the Democrat said in a video statement.

The Centers for Disease Control and Prevention is also on the ground on the north side of Milwaukee, as well as several other hot spots, looking into the outbreak in black neighborhoods.

Nationwide, it’s difficult to know how minority populations are faring because the CDC isn’t reporting data on race.

A few states are releasing more demographic data, but it’s incomplete. Virginia is reporting race, yet the state’s report is missing that information for two-thirds of confirmed cases.

Dr. Georges Benjamin, executive director of the American Public Health Association, has been pushing health officials to start monitoring race and income in the response to COVID-19.

“We want people to collect the data in an organized, professional, scientific manner and show who’s getting it [appropriate care] and who’s not getting it,” Benjamin said. “Recognize that we very well may see these health inequities.”

The Usual Disparities

Until he’s convinced otherwise, Benjamin said he assumes the usual disparities are at play.

“Experience has taught all of us that if you’re poor, if you’re of color, you’re going to get services second,” he said.

The subjectivity of coronavirus symptoms is what worries Dr. Ebony Hilton the most.

“The person comes in, they’re complaining of chest pain, they’re complaining of shortness of breath, they have a cough — I can’t quantify that,” she said.

Hilton is an anesthesiologist at the University of Virginia Medical Center who has been raising concerns. She sees problems across the board, from the way social media is being used as a primary way of educating the public to the widespread reliance on drive-thru testing.

The first requires an internet connection. The second, a car.

Hilton said the country can’t afford to overlook race, even during a swiftly moving pandemic.

“If you don’t get a test, if you die, you’re not going to be listed as dying from COVID,” she said. “You’re just going to be dead.”

This story is part of a partnership that includes Nashville Public RadioNPR and Kaiser Health News.

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Multimedia Public Health States

‘Staying Away From Grandma’ Isn’t An Option In Multigenerational Homes

FLORISSANT, Missouri — The Walker family never thought having an age range of 3 to 96 under the same roof would be risky.

That was before the coronavirus pandemic.

Wilma Walker’s now nonagenarian mom moved into her daughter and son-in-law’s home about 15 years ago. Their party of three turned into a household of six when the Walkers’ now 30-year-old daughter, Andre’a Walker-Nimrod, moved back in with her young son and a daughter on the way.

Their living arrangement — four generations together under one roof — has its advantages: financial support, shared meals and built-in child care for Andre’a’s kids, now 5 and 3. But this “tier” generational setup also heightens their concerns as the coronavirus continues to march across the world, with young people positioned as potentially inadvertent carriers of the virus to vulnerable elders for whom COVID-19 could be a death sentence.

“With all of us in the same home, I feel like I’m the one that’s kind of guarding everybody,” said 63-year-old Wilma Walker.

Four generations living together has its advantages: financial support, child care and shared meals. Michael “Amir” Nimrod and his sister, Maleeya, have breakfast with everyone at the Walker residence. (Michael B. Thomas for KHN)

(From left) Andre’a Walker-Nimrod, Howard Walker, Evelyn Whitfield and Wilma Walker at the breakfast table. (Michael B. Thomas for KHN)

While nursing homes are banning visitors and many people are preaching the message to stay away from older adults, not everyone has that option. More than 64 million Americans live in multigenerational households like the Walkers’ — often a combination of adult children, their parents and grandchildren. That’s 1 in 5 U.S. residents.

With the omnipresent coronavirus threat looming, those who live in such households around the country are voicing concerns and sharing their experiences online. Some families have decided to practice social distancing within the home, while others worry about being asymptomatic carriers.

“Until further notice, all of us are quarantined,” Tori Dixon said of her two-generation household in Fort Worth, Texas. “We’re trying to stay put and stay in place until we have a better idea of what’s going on.”

Dixon, 42, shares a home with her 69-year-old mother, her 48-year-old sister and 13-year-old brother. For now, they are social distancing from others to keep her mom safe, and her mom has not been out of the house in four weeks. Dixon’s mother was diagnosed with severe bronchitis in 2018, which left her with a compromised immune system.

“She’s nervous,” Dixon said. “I’m nervous for her.”

In some cultures, within the United States and elsewhere, multigenerational households are the norm. In recent years, more American families have adopted the lifestyle, some building homes with “granny flats” as baby boomers move in with their kids and vice versa. To be sure, the idea of combining households has always helped families get through tough economic times and life transitions such as death, divorce or job loss.

“With all of us in the same home, I feel like I’m the one that’s kind of guarding everybody,” says Wilma Walker.(Michael B. Thomas for KHN)

Multigenerational households face a unique set of challenges during the novel coronavirus pandemic because they can’t easily separate children from older family members in the home, said Donna Butts, executive director of Generations United, a national nonprofit that advocates for children, older people and families.

In addition to her group’s online tips, which include cleaning kids’ toys and seeking home delivery of medications, she suggested leaving younger children at home, if possible, when someone has to go out for groceries. Kids are more likely to touch things in stores, risking the spread of germs. Excellent hygiene is strongly encouraged, she said.

In Belleville, Illinois, Maxine Edwards, 74, has been living with her daughter and granddaughter since her husband died. Now, ever since the pandemic shuttered preschools, she is taking care of her 4-year-old granddaughter, Kinsley, during the day while the girl’s mother, Kristi Edwards, continues to work as a patient care coordinator at Southwestern Hearing Centers in Fairview Heights, Illinois.

“She keeps me busy,” Maxine Edwards said. “It’s a lot busier than it was, but I’m glad to have them around.”

Maxine Edwards takes care of granddaughter Kinsley because preschool is closed due to the coronavirus pandemic. Kinsley’s mom, Kristi Edwards, continues working as a patient coordinator at a hearing center.(Courtesy of Kristi Edwards)

Every night, Maxine Edwards sleeps in a plush, brown recliner in the living room. The common space doubles as her bedroom because Edwards, who suffers from arthritis, said it’s too painful to sleep in her bed.

“I always say that I don’t have to make my bed in the morning,” Edwards said, with a chuckle. “My granddaughter gets a kick out of waking Grandma up.”

If they needed to separate, someone else would have to drag her recliner into a bedroom. Edwards isn’t able to physically move around as much as she would like. But she pushes past her pain to keep her granddaughter entertained.

“They love playing Play-Doh, painting and Barbies,” Kristi Edwards, 46, said. “’Frozen’ is a favorite, along with ‘Trolls.’”

To give her mom a break amid the pandemic, she recently found a friend willing to watch her daughter a few days a week.

Kristi Edwards and her daughter, Kinsley, at home in Belleville, Illinois. While Edwards is at work as a patient coordinator at a hearing center, her mom takes care of Kinsley at home. “They love playing Play-Doh, painting and Barbies,” Edwards says. “‘Frozen’ is a favorite, along with ‘Trolls.’”(Courtesy of Kristi Edwards)

But while the coronavirus presents new challenges for these families, communal living with multiple generations gives each person a foundation to withstand the crisis, said Butts, the advocate for elders.

“In our society, we tell people that they have to be independent, they have to be alone, and that’s the way to be. And yet, we are people, we need each other, we’re interdependent,” Butts said. “Multigenerational families are incredibly strong.”

The Walker family has a preparedness plan for illness, just as they do for a fire or natural disaster. As a family of ministers, Walker said, her family is praying for the pandemic to end. But they’re also practicing social distancing and washing their hands more. They canceled an 80th birthday party for Walker’s husband, Howard.

The matriarch of their family, Evelyn Whitfield, the oldest member of their family at 96, is spending more time inside. She loves to give warm hugs. But, for now, she’s avoiding direct contact with anyone who appears sick.

With the coronavirus threat looming, some families practice social distancing at home. Evelyn Whitfield has a basement apartment in the Walker home, a place to go to escape germs.(Michael B. Thomas for KHN)

Long before “social distancing” became a buzzword, her family always put space between Whitfield and anyone who felt sick in their home. Taking it one step further, Walker said, members of their family go into isolation in the home if one of them falls ill.

Both ideas can be hard for younger children to grasp. That’s one reason Whitfield has her own space in their house. It’s a place where she can go if she needs to escape from germs.

“I love being around my family,” Whitfield said during breakfast on a recent Saturday morning. “I wouldn’t want to live alone.”

Walker loves having her mother there, too. She was still learning how to take care of herself when she decided that, later in life, as her parents aged, she would take care of them. Her father, Wiley Whitfield, died in 1992.

“I can remember being a girl, probably about 10, when I started to realize that I wanted to take care of my mother,” Walker said. “I always knew we were all going to live together. I always looked forward to it.”

Complicating matters in these coronavirus times, though, is her effort to keep the family’s business afloat. Six years ago, they opened WTMM Adult Day Health Care Center, a nonprofit adult day care for seniors who have Alzheimer’s, autism or dementia.

The center closed late last month, because the pandemic was reducing visits from the seniors and dried up the insurance payments needed to pay staff. But even when it does reopen, Whitfield, the 96-year-old who serves as a chaplain at the day care center, said she may spend less time there because she’s now more aware of the risks she faces around her.

Wilma and Howard enjoy playtime with their grandchildren.(Michael B. Thomas for KHN)

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Aging Public Health States

Mysterious Heart Damage, Not Just Lung Troubles, Befalling COVID-19 Patients

While the focus of the COVID-19 pandemic has been on respiratory problems and securing enough ventilators, doctors on the front lines are grappling with a new medical mystery.

In addition to lung damage, many COVID-19 patients are also developing heart problems — and dying of cardiac arrest.

As more data comes in from China and Italy, as well as Washington state and New York, more cardiac experts are coming to believe the COVID-19 virus can infect the heart muscle. An initial study found cardiac damage in as many as 1 in 5 patients, leading to heart failure and death even among those who show no signs of respiratory distress.

That could change the way doctors and hospitals need to think about patients, particularly in the early stages of illness. It also could open up a second front in the battle against the COVID-19 pandemic, with a need for new precautions in people with preexisting heart problems, new demands for equipment and, ultimately, new treatment plans for damaged hearts among those who survive.

“It’s extremely important to answer the question: Is their heart being affected by the virus and can we do something about it?” said Dr. Ulrich Jorde, the head of heart failure, cardiac transplantation and mechanical circulatory support for the Montefiore Health System in New York City. “This may save many lives in the end.”

Virus Or Illness?

The question of whether the emerging heart problems are caused by the virus itself or are a byproduct of the body’s reaction to it has become one of the critical unknowns facing doctors as they race to understand the novel illness. Determining how the virus affects the heart is difficult, in part, because severe illness alone can influence heart health.

“Someone who’s dying from a bad pneumonia will ultimately die because the heart stops,” said Dr. Robert Bonow, a professor of cardiology at the Northwestern University Feinberg School of Medicine and editor of the medical journal JAMA Cardiology. “You can’t get enough oxygen into your system and things go haywire.”

But Bonow and many other cardiac specialists believe a COVID-19 infection could lead to damage to the heart in four or five ways. Some patients, they say, might be affected by more than one of those pathways at once.

Doctors have long known that any serious medical event, even something as straightforward as hip surgery, can create enough stress to damage the heart. Moreover, a condition like pneumonia can cause widespread inflammation in the body. That, in turn, can lead to plaque in arteries becoming unstable, causing heart attacks. Inflammation can also cause a condition known as myocarditis, which can lead to the weakening of the heart muscle and, ultimately, heart failure.

But Bonow said the damage observed in COVID-19 patients could be from the virus directly infecting the heart muscle. Initial research suggests the coronavirus attaches to certain receptors in the lungs, and those same receptors are found in heart muscle as well.

Initial Data From China

In March, doctors from China published two studies that gave the first glimpse at how prevalent cardiac problems were among patients with COVID-19 illness. The larger of the two studies looked at 416 hospitalized patients. The researchers found that 19% showed signs of heart damage. And those who did were significantly more likely to die: 51% of those with heart damage died versus 4.5% who did not have it.

Patients who had heart disease before their coronavirus infections were much more likely to show heart damage afterward. But some patients with no previous heart disease also showed signs of cardiac damage. In fact, patients with no preexisting heart conditions who incurred heart damage during their infection were more likely to die than patients with previous heart disease but no COVID-19-induced cardiac damage.

It’s unclear why some patients experience more cardiac effects than others. Bonow said that could be due to a genetic predisposition or it could be because they’re exposed to higher viral loads.

Those uncertainties underscore the need for closer monitoring of cardiac markers in COVID-19 patients, Jorde said. If doctors in New York, Washington state and other hot spots can start to tease out how the virus is affecting the heart, they may be able to provide a risk score or other guidance to help clinicians manage COVID-19 patients in other parts of the country.

“We have to assume, maybe, that the virus affects the heart directly,” Jorde said. “But it’s essential to find out.”

Facing Obstacles

Gathering the data to do so amid the crisis, however, can be difficult. Ideally, doctors would take biopsies of the heart to determine whether the heart muscle is infected with the virus.

But COVID-19 patients are often so sick it’s difficult for them to undergo invasive procedures. And more testing could expose additional health care workers to the virus. Many hospitals aren’t using electrocardiograms on patients in isolation to avoid bringing additional staff into the room and using up limited masks or other protective equipment.

Still, Dr. Sahil Parikh, an interventional cardiologist at Columbia University Irving Medical Center in New York City, said hospitals are making a concerted effort to order the tests needed and to enter findings in medical records so they can sort out what’s going on with the heart.

“We all recognize that because we’re at the leading edge, for better or for worse, we need to try to compile information and use it to help advance the field,” he said.

Indeed, despite the surge in patients, doctors continue to gather data, compile trends and publish their findings in near real time. Parikh and several colleagues recently penned a compilation of what’s known about cardiac complications of COVID-19, making the article available online immediately and adding new findings before the article comes out in print.

Cardiologists in New York, New Jersey and Connecticut are sharing the latest COVID-19 information through a WhatsApp group that has at least 150 members. And even as New York hospitals are operating under crisis conditions, doctors are testing new drugs and treatments in clinical trials to ensure that what they have learned about the coronavirus can be shared elsewhere with scientific validity.

That work has already resulted in changes in the way hospitals deal with the cardiac implications of COVID-19. Doctors have found that the infection can mimic a heart attack. They have taken patients to the cardiac catheterization lab to clear a suspected blockage, only to find the patient wasn’t really experiencing a heart attack but had COVID-19.

For years, hospitals have rushed suspected heart attack patients directly to the catheterization lab, bypassing the emergency room, in an effort to shorten the time from when the patient enters the door to when doctors can clear the blockage with a balloon. Door-to-balloon time had become an important measure of how well hospitals treat heart attacks.

“We’re taking a step back from that now and thinking about having patients brought to the emergency department so they can get evaluated briefly, so that we could determine: Is this somebody who’s really at high risk for COVID-19?” Parikh said. “And is this manifestation that we’re calling a heart attack really a heart attack?”

New protocols now include bringing in a cardiologist and getting an EKG or an ultrasound to confirm a blockage.

“We’re doing that in large measure to protect the patient from what would be an otherwise unnecessary procedure,” Parikh said, “But also to help us decide which sort of level of personal protective equipment we would employ in the cath lab.”

Sorting out how the virus affects the heart should help doctors determine which therapies to pursue to keep patients alive.

Jorde said that after COVID-19 patients recover, they could have long-term effects from such heart damage. But, he said, treatments exist for various forms of heart damage that should be effective once the viral infection has cleared.

Still, that could require another wave of widespread health care demands after the pandemic has calmed.

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‘You’ve Been Served’: Wisconsin Hospitals Sued Patients Even During Pandemic

When her doorbell rang Sunday night, Blanche Jordan was just starting a new Game of Thrones puzzle on her living room floor.

Jordan, 39, is a breast-cancer survivor who is taking social distancing seriously, so she put on a mask before opening the door. A woman handed Jordan a paper and said: “You’ve been served.”

The paper was a court summons that said Froedtert Memorial Lutheran Hospital, Inc. was suing Jordan for $7,150. Just three weeks before, Jordan had paid off a different $5,000-plus Froedtert debt linked to a hysterectomy that her insurance did not cover.

A lawsuit was the last thing Jordan expected during a viral pandemic.

“This lady came to my door. She didn’t have a mask on. She didn’t have gloves. And she looked at me like I’m crazy because I had a mask across my face,” said Jordan, who lives in Milwaukee and works as a caregiver at an assisted living facility outside of the city. “I’m high-risk,” she said.

Life in Wisconsin, as in the rest of the country, has been transformed by COVID-19 in the past three weeks. Wisconsin declared a public health emergency on March 12, yet firms representing health systems in the state continued to sue patients over medical debt.

Jordan is one of at least 46 people sued by Froedtert in small claims court since March 12. Those cases are among at least 104 similar suits filed statewide by health systems over the same period, according to an analysis of small claims cases by Wisconsin Public Radio and Wisconsin Watch.

Steve Schooff, a spokesman for the hospital, said Tuesday that Froedtert “suspended filing small claims suits” as of March 18 in response to COVID-19.

“In addition, we continue to work with patients related to financial counseling and are allowing patients with financial hardship who are on a payment plan to defer payments while financial assistance is discussed with them,” he said.

Yet court records at the time showed at least 18 lawsuits filed on the hospital’s behalf since then, including 15 filed on March 31 alone. (The suit against Jordan was filed on March 17; she was served on March 29.) Schooff did not explain the discrepancy. All 18 of those cases have since been dismissed.

‘Really? In The Middle Of All This?’

Court records show that at least six additional health systems have also sued patients during the pandemic.

UW Health in Madison has filed 19 lawsuits since March 12. Marshfield Clinic, which covers northern, central and western Wisconsin, has filed at least 14 since that date, followed by Bellin Health, based in Green Bay (11); La Crosse-based Gundersen Health System (10); and Aspirus Grand View Health System, which serves parts of northern Wisconsin (3). Froedtert South, which serves southeastern Wisconsin, also filed one suit.

Bellin chief operating officer and chief financial officer Jim Dietsche said Thursday the health system ceased legal actions on debt collection on March 18, and that the nine suits filed since then were “an error and we apologize for that.”

The five other systems contacted for this story said they have since paused certain legal actions, which court records support.

Tom Russell, a UW Health spokesman, said the health system instructed its legal agencies on March 26 “to cease pursuit of any legal activity.”

“These should be stopped for now,” he said.

Tom Duncan, vice president and chief operating officer for Froedtert South, said his system has generally “suspended filing small claim suits” during the pandemic. “However, in rare circumstances, certain small claim suits may be filed to preserve Froedtert South rights. For example: If a medical debt has been in existence for six years, and the statute of limitations is about to end.”

One Madison resident described being “mortified” when a process server knocked on her family’s door on March 28 to serve papers for a UW Health lawsuit over $1,135.90 in medical debt. UW Health filed that lawsuit before March 26. In a phone interview, the resident asked not to be named in this story because she was embarrassed by the debt related to her husband’s heart condition.

“I couldn’t believe someone would do that,” she said about receiving legal papers during a pandemic. “They’re our bills, but really? In the middle of all of this?”

The woman said her husband offered the process server sympathy, apologizing that the man had to serve papers during a public health emergency.

The woman, who works for a Madison-based nonprofit, saw things differently. “That’s a choice, too. I wouldn’t be able to sleep at night.”

Medical Debts And State Response

Some hospitals have stopped the practice of suing patients in recent months following investigative reporting by Kaiser Health News, MLK50, ProPublica and other outlets.

Jessica Roulette, an attorney with Legal Action of Wisconsin, which provides free legal services to low-income people, said medical bills often fall below things like rent, utilities and food in the “hierarchy of bills and obligations.” Most people facing hospital lawsuits are working and “underinsured,” with plans that leave them on the hook for thousands of dollars in health bills, Roulette said.

Bobby Peterson, executive director of ABC for Health, a nonprofit public-interest law firm in Madison, called it stressful under normal circumstances to face a medical debt lawsuit.

“Today it’s a whole new ballgame,” he said, referring to workers who have lost their jobs and possibly health insurance during the pandemic.

Peterson saw a possible disconnect between some hospitals’ recent decisions to stop suing and the law firms they’ve retained.

“Are the hospitals communicating their own policies internally? And are they communicating with their hired guns out there, making sure that they back off?” Peterson asked.

Paycheck To Paycheck

The state of Wisconsin considers Blanche Jordan, the Milwaukee caregiver, an “essential” worker during the pandemic, meaning her job is not subject to the “Safer At Home” order. She works five days each week at an assisted living facility from 7 a.m. to 3 p.m., alternating work on the weekends. The pay — $15.75 per hour — barely covers her expenses.

Rent, health insurance, utilities and the nearly $300 in garnishments by Froedtert that recently ended, left Jordan with little of her $1,300 biweekly paycheck to spend on other necessities. She filed for bankruptcy in 2016 when, despite being insured, she said she could no longer afford to pay off her debts from treating her aggressive breast cancer.

That journey briefly left her homeless following an eviction, but she generally manages to pay her current landlord on time, Jordan said.

“I’m blessed to have a landlord that’s understanding because his wife died of breast cancer,” she said.

Jordan said her most recent medical debt stemmed from a hysterectomy that was separate from but related to her cancer treatment. She chose Froedtert to perform the procedure, considering it “the best hospital that we have in Wisconsin.”

What she did not realize, she said: Froedtert did not accept her insurance, which she purchased on a federal exchange created by the Affordable Care Act. Hospital administrators accepted and ran her insurance card, Jordan said, but never mentioned that her insurer would not cover the procedure.

In 2019, a judge in the Milwaukee County Small Claims Commissioner Court awarded Froedtert a judgment against Jordan for about $5,300, including court fees, which the hospital claimed by garnishment of her wages. She finished paying that debt during the first week of March — only to be served papers for the alleged $7,150 debt three weeks later.

Jordan assumes this covers the remainder of the bill for her hysterectomy, which she remembers totaling around $12,000. Wisconsin caps small claims at $10,000.

She will eventually see her day in court, although it’s not clear when. The coronavirus postponed her court date to May 28, assuming court proceedings resume by then.

Until then, Jordan will continue to take care of people at the assisted living facility, and she will otherwise stay isolated at home, she said, likely playing Scrabble or Uno with her family.

This story is part of a partnership that includes Wisconsin WatchWisconsin Public RadioNPR and Kaiser Health News.

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Medicaid en el “ojo de la tormenta” por nuevos desempleados que buscan cobertura

Con más desempleados aplicando para seguro médico, Medicaid podría colapsar

A medida que el coronavirus agita la economía y deja a millones de estadounidenses sin trabajo, Medicaid surge como el plan de salud obvio para muchos de los nuevos desempleados. Eso podría generar tensiones sin precedentes en este vital programa, según funcionarios estatales y analistas.

A los estadounidenses se los insta a quedarse en casa y a practicar el “distanciamiento social” para evitar la propagación del virus, lo que hace que las empresas cierren sus puertas y despidan a sus trabajadores.

El Departamento de Trabajo informó el jueves 2 de abril que más de 6.6 millones de personas se suscribieron al seguro de desempleo durante la semana que terminó el 28 de marzo. Este número rompió el récord establecido la semana anterior, de 3.3 millones. Muchos de estos nuevos desempleados pueden recurrir a Medicaid para sus familias.

A menudo los legisladores han usado Medicaid para ayudar a las personas a obtener cobertura y atención médica en respuesta a desastres como el huracán Katrina, la crisis del agua en Flint, Michigan, y los ataques terroristas del 11 de septiembre.

Pero nunca ha enfrentado una crisis de salud pública y una emergencia económica en la que las personas en todo el país necesitan la ayuda prácticamente en el mismo mes.

“Medicaid va a estar absolutamente en el ojo de la tormenta”, dijo Joan Alker, directora ejecutiva del Center for Children and Families de la Universidad Georgetown. “Es la columna vertebral de nuestro sistema de salud y cobertura públicas, y verá una mayor inscripción debido a las condiciones económicas”.

Satisfacer esas necesidades requerirá grandes inversiones, tanto en dinero como en mano de obra.

Medicaid, que es administrado conjuntamente por los estados y el gobierno federal, y cubre a unos 70 millones de estadounidenses, ya está experimentando picos de solicitudes tempranas. Debido a que las solicitudes de seguro generalmente van a la zaga de las de otros beneficios, se espera que los números crezcan en los próximos meses.

“Hemos pasado por recesiones en el pasado, como en 2009, y vimos lo que eso significaba”, dijo Matt Salo, quien dirige la Asociación Nacional de Directores de Medicaid. “Vamos a ver eso un aumento dramático”.

Desde 2014, la mayoría de los estados han ampliado sus programas de Medicaid para cubrir a más adultos de bajos ingresos en virtud de una disposición de la Ley de Cuidado de Salud a Bajo Precio (ACA). Eso puede ayudar a proporcionar un colchón en esas áreas. En los 14 estados que han optado por no expandir el programa, muchos de los adultos recién desempleados no serán elegibles para cobertura.

Es posible que la pandemia pueda cambiar el cálculo de la toma de decisiones para los estados sin expansión, dijo Salo. “La pandemia es como un puñetazo en la boca”.

Pero incluso sin expansión en esos estados, las listas de Medicaid podrían aumentar con la llegada de más niños al sistema a medida que las finanzas de sus familias se deterioran. Muchos estados no cuentan con los recursos o sistemas para satisfacer la demanda.

“Va a golpear más rápido y más fuerte que nunca”, enfatizó Salo.

Las circunstancias únicas de distanciamiento social imponen nuevos desafíos para aquellos que trabajan en la inscripción. En California, donde más de un millón de personas han solicitado un seguro de desempleo desde el 13 de marzo, gran parte de la fuerza laboral que normalmente inscribe y procesa documentos ahora trabaja desde casa, lo que agrega una capa de complejidad en términos de acceso a archivos y documentos, y puede complicar la comunicación.

“Va a ser más difícil de lo que fue durante la recesión [2008]”, dijo Cathy Senderling-McDonald, subdirectora ejecutiva de la County Welfare Directors Association de California. Agregó que, aunque se han hecho avances en la última década para establecer mejores formularios en línea y centros de llamadas, aun así, será un gran esfuerzo inscribir a las beneficiarlos sin verlos en persona.

En algunos estados, los desafíos para el sistema ya son notables.

Utah, por ejemplo, ha visto un aumento del 46% en las solicitudes de Medicaid. (Estas solicitudes pueden ser para individuos o familias). En marzo de 2019, unas 14,000 personas presentaron una solicitud. Este marzo, fueron más de 20,400.

“Nuestros servicios se necesitan ahora más que nunca”, dijo Muris Prses, director asistente de servicios de elegibilidad para el Departamento de Servicios Laborales de Utah, que procesa la inscripción a Medicaid, que en todo el país no está sujeta a un período específico, sino que está abierta todo el año. El estado generalmente se toma 15 días para determinar si alguien es elegible, dijo. Ahora serán varios más.

En Nevada, donde la economía dominada por hoteles y casinos se ha visto particularmente afectada, las solicitudes de beneficios públicos, incluidos cupones de alimentos y Medicaid, se dispararon de 200 por día en febrero a 2,000 a mediados de marzo, según el Departamento de Salud y Servicios Humanos estatal. El volumen de llamadas a una línea directa de consumidores para preguntas sobre Medicaid y cobertura de salud es cuatro veces la cifra regular.

En Ohio, el número de solicitudes de Medicaid ya superó lo que es típico para esta época del año. El estado espera que esa cifra continúe subiendo.

Los estados que aún no han visto el aumento advirtieron que casi seguro se avecina. Y a medida que continúan los despidos, algunos ya están experimentando tensiones en el sistema, incluidos los tiempos de procesamiento que podrían dejar a las personas sin seguro durante meses.

Para Kristen Wolfe, de 28 años, de Salt Lake City, que perdió su trabajo y su seguro de salud patrocinado por el empleador el 20 de marzo, es un momento aterrador.

Wolfe, que tiene lupus, un trastorno autoinmune que requiere citas médicas regulares y medicamentos recetados, solicitó rápidamente Medicaid. Pero después de completar el formulario, incluido un ingreso de cero dólares, supo que la decisión sobre su elegibilidad podría demorar hasta 90 días. Llamó a la agencia de Medicaid de Utah y, después de estar en espera durante más de una hora, le dijeron que no sabían cuándo conocería la decisión.

“Con mi salud, da miedo dejar las cosas en el limbo”, dijo Wolfe, quien usó su seguro casi vencido la semana pasada para surtir sus medicamentos por 90 días, por si acaso. “Estoy bastante segura de que calificaré, pero siempre existe la duda… ¿Y si no?”.

Sin embargo, otros han informado una navegación más suave.

Jen Wittlin, de 33 años, quien, hasta hace poco, administraba un bar ahora cerrado en el hotel Dean, en Providence, Rhode Island, calificó para la cobertura de Medicaid a partir del 1 de abril. Pudo registrarse en línea después de esperar media hora por teléfono para que le contestaran preguntas específicas. Una vez que reciba un cheque por desempleo, el estado reevaluará sus ingresos, actualmente cero, para ver si aún califica.

“Todo fue inmediato”, dijo.

De hecho, dijo, ahora está trabajando para ayudar a ex colegas sin seguro médico a inscribirse en el programa, siguiendo los consejos que le dio el estado.

En California, funcionarios están tratando de reasignar algunos empleados, que ahora trabajan de forma remota, para ayudar con este flujo de gente. Pero el sistema para determinar la elegibilidad para Medicaid es complicado y requiere capacitación, dijo Senderling-McDonald. Agregó que está tratando de volver a contratar a las personas que se han jubilado y depende de las horas extras de los empleados.

“Es difícil expandir esta fuerza laboral en particular”, dijo. “No podemos poner a una nueva persona frente a una computadora y decirle comienza. Arruinarían todo”.

Alejarse de las inscripciones en la oficina también es una desventaja para las personas mayores y aquellos que hablan inglés como segundo idioma, dos grupos que con frecuencia se sienten más cómodos al inscribirse en persona, agregó.

Mientras tanto, aumentar la inscripción y las realidades del coronavirus probablemente creará la necesidad de atención médica costosa en toda la población.

“¿Qué pasa cuando comenzamos a tener muchas personas que pueden estar en el hospital, en cuidados intensivos o con ventiladores?”, dijo Maureen Corcoran, directora del programa de Medicaid de Ohio. “Todavía no tenemos respuestas específicas”.

Estos factores afectarán al igual que los estados, que experimentarán una reducción de los ingresos tributarios debido a la economía en picada, tienen menos dinero para pagar su parte de Medicaid.

El gobierno federal paga, en promedio, cerca del 61% de los costos de Medicaid tradicional y aproximadamente el 90% de los costos de las personas que se unieron al programa a través de la expansión de ACA.

El resto proviene de las arcas estatales. Y, a diferencia del gobierno federal, los estados están obligados constitucionalmente a equilibrar sus presupuestos. La restricción financiera podría forzar recortes en otras áreas, como educación, bienestar infantil o fuerzas policiales.

El 18 de marzo, el Congreso acordó aumentar lo que Washington paga en 6.2 puntos porcentuales como parte del segundo gran proyecto de ley de estímulo dirigido a las consecuencias económicas de la pandemia. Eso apenas alcanzará, enfatizó Salo.

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

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Medicaid Nearing ‘Eye Of The Storm’ As Newly Unemployed Look For Coverage

As the coronavirus roils the economy and throws millions of Americans out of work, Medicaid is emerging as a default insurance plan for many of the newly unemployed. That could produce unprecedented strains on the vital health insurance program, according to state officials and policy researchers.

Americans are being urged to stay home and practice “social distancing” to prevent the spread of the virus, causing businesses to shutter their doors and lay off workers. The Labor Department reported Thursday that more than 6.6 million people signed up for unemployment insurance during the week that ended March 28. This number shattered the record set the previous week, with 3.3 million sign-ups. Many of these newly unemployed people may turn to Medicaid for their families.

Policymakers have often used Medicaid to help people gain health coverage and health care in response to disasters such as Hurricane Katrina, the water crisis in Flint, Michigan, and the 9/11 terrorist attacks. But never has it faced a public health crisis and economic emergency in which people nationwide need its help all in virtually the same month.

“Medicaid is absolutely going to be in the eye of the storm here,” said Joan Alker, executive director of the Georgetown University Center for Children and Families. “It is the backbone of our public health system, our public coverage system, and will see increased enrollment due to the economic conditions.”

Meeting those needs will require hefty investments ― both in money and manpower.

Medicaid — which is run jointly by the states and federal government and covers about 70 million Americans ― is already seeing early application spikes. Because insurance requests typically lag behind those for other benefits, the numbers are expected to grow in the coming months.

“We have been through recessions in the past, such as in 2009, and saw what that meant,” said Matt Salo, who heads the National Association of Medicaid Directors. “We are going to see that on steroids.”

The majority of states have expanded their Medicaid programs since 2014 to cover more low-income adults under a provision in the Affordable Care Act. That may help provide a cushion in those areas. In the 14 states that have chosen not to expand, many of the newly unemployed adults will not be eligible for coverage.

It’s possible the pandemic could change the decision-making calculus for non-expansion states, Salo said. “The pandemic is like a punch in the mouth.”

But even without expansion in those states, the Medicaid rolls could increase with more children coming into the system as their families’ finances deteriorate. Many states don’t have the resources or systems in place to meet the demand.

“It is going to hit faster and harder than we’ve ever experienced before,” Salo said.

The unique circumstances of social distancing impose new challenges for those whose jobs are to enroll people for coverage. In California, where more than a million people have filed for unemployment insurance since March 13, much of the workforce that would typically be signing people up and processing their paperwork is now working from home, which adds a layer of complexity in terms of accessing files and documents, and can inhibit communication.

“It’s going to be certainly more difficult than it was under the [2008] recession,” said Cathy Senderling-McDonald, deputy executive director for the County Welfare Directors Association of California. She said that although strides have been made in the past decade to set up better online forms and call centers, it will still be a heavy lift to get people enrolled without seeing them in person.

In some states, the challenges to the system are already noticeable.

Utah, for instance, has seen a 46% increase in applications for Medicaid. (These applications can be for individuals or families.) In March 2019, about 14,000 people applied. This March, it was more than 20,400.

“Our services are needed now more than ever,” said Muris Prses, assistant director of eligibility services for the Utah Department of Workforce Services, which processes Medicaid enrollment. The state typically takes 15 days to determine whether someone is eligible, he said, though that will increase by several days because of the surge in applicants and some staff working at home.

In Nevada, where the hotel- and casino-dominated economy has been hit particularly hard, applications for public benefits programs, including food stamps and Medicaid, skyrocketed from 200 a day in February to 2,000 in mid-March, according to the state Department of Health and Human Services. The volume of calls to a consumer hotline for Medicaid and health coverage questions is four times the regular amount.

In Ohio, the number of Medicaid applications has already exceeded what’s typical for this time of year. The state expects that figure to continue to climb.

States that haven’t yet seen the surge warned that it’s almost certainly coming. And as layoffs continue, some are already experiencing the strains on the system, including processing times that could leave people uninsured for months, while Medicaid applications process.

For 28-year-old Kristen Wolfe, of Salt Lake City, who lost her job and her employer-sponsored health insurance March 20, it’s a terrifying time.

Wolfe, who has lupus — an autoimmune disorder that requires regular doctor appointments and prescription medication ― quickly applied for Medicaid. But after she filled in her details, including a zero-dollar income, she learned the decision on her eligibility could take as long as 90 days. She called the Utah Medicaid agency and, after being on hold for more than an hour, was told they did not know when she would hear back.

“With my health, it’s scary to leave things in limbo,” said Wolfe, who used her almost-expired insurance last week to order 90-day medication refills, just in case. “I am pretty confident I will qualify, but there is always the ‘What if I don’t?’”

Others have reported smoother sailing, though.

Jen Wittlin, 33 — who, until recently, managed the now-closed bar in Providence, Rhode Island’s Dean Hotel ― qualified for Medicaid coverage starting April 1. She was able to sign up online after waiting about half an hour on the phone to get help answering specific questions. Once she receives a check for unemployment insurance, the state will reassess her income — currently zero ― to see if she still qualifies.

“It was all immediate,” she said.

In fact, she said, she is now working to help newly uninsured former colleagues also enroll in the program, using the advice the state gave her.

In California, officials are trying to reassign some employees — who are now working remotely ― to help with the surge. But the system to determine Medicaid eligibility is complicated and requires time-intensive training, Senderling-McDonald said. She’s trying to rehire people who’ve retired and relying on overtime from staffers.

“It’s hard to expand this particular workforce very, very quickly by a lot,” she said. “We can’t just stick a new person in front of a computer and tell them to go. They’re going to screw everything up.”

The move away from in-office sign-ups is also a disadvantage for older people and those who speak English as a second language, two groups who frequently felt more comfortable enrolling in person, she added.

Meanwhile, increasing enrollment and the realities of the coronavirus will likely create a need for costly medical care across the population.

“What about when we start having many people who may be in the hospital, in ICUs or on ventilators?” said Maureen Corcoran, the director of Ohio’s Medicaid program. “We don’t have any specific answers yet.”

These factors will hit just as states ― which will experience shrinking tax revenue because of the plunging economy — have less money to pay their share of the Medicaid tab.

“It’s all compounded,” said Lisa Watson, a deputy secretary at Pennsylvania’s Department of Human Services, which oversees Medicaid.

The federal government pays, on average, about 61% of the costs for traditional Medicaid and about 90% of the costs for people who joined the program through the ACA expansion. The rest comes from state coffers. And, unlike the federal government, states are constitutionally required to balance their budgets. The financial squeeze could force cuts in other areas, like education, child welfare or law enforcement.

On March 18, Congress agreed to bump up what Washington pays by 6.2 percentage points as part of the second major stimulus bill aimed at the economic consequences of the pandemic. That will barely make a dent, Salo argued.

“The small bump is good, and we are glad it’s there, but in no way is that going to be sufficient,” he said.

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Analysis: He Got Tested For Coronavirus. Then Came The Flood Of Medical Bills.

By March 5, Andrew Cencini, a computer science professor at Vermont’s Bennington College, had been having bouts of fever, malaise and a bit of difficulty breathing for a couple of weeks. Just before falling ill, he had traveled to New York City, helped with computers at a local prison and gone out on multiple calls as a volunteer firefighter.

So with COVID-19 cases rising across the country, he called his doctor for direction. He was advised to come to the doctor’s group practice, where staff took swabs for flu and other viruses as he sat in his truck. The results came back negative.

In an isolation room, the doctors put Andrew Cencini on an IV drip, did a chest X-ray and took the swabs.(Courtesy of Andrew Cencini)

By March 9, he reported to his doctor that he was feeling better but still had some cough and a low-grade fever. Within minutes, he got a call from the heads of a hospital emergency room and infectious-disease department where he lives in upstate New York: He should come right away to the ER for newly available coronavirus testing. Though they offered to send an ambulance, he felt fine and drove the hourlong trip.

In an isolation room, the doctors put him on an IV drip, did a chest X-ray and took the swabs.

Now back at work remotely, he faces a mounting array of bills. His patient responsibility, according to his insurer, is close to $2,000, and he fears there may be more bills to come.

“I was under the assumption that all that would be covered,” said Cencini, who makes $54,000 a year. “I could have chosen not to do all this, and put countless others at risk. But I was trying to do the right thing.”

The new $2 trillion coronavirus aid package allocates well over $100 billion to what Senate Minority Leader Chuck Schumer of New York called “a Marshall Plan” for hospitals and medical needs.

But no one is doing much to similarly rescue patients from the related financial stress. And they desperately need protection from the kind of bills patients like Cencini are likely to incur in a system that freely charges for every bit of care it dispenses.

On March 18, President Donald Trump signed a law intended to ensure that Americans could be tested for the coronavirus free, whether they have insurance or not. (He had also announced that health insurers have agreed to waive patient copayments for treatment of COVID-19, the disease caused by the virus.) But their published policies vary widely and leave countless ways for patients to get stuck.

Although insurers had indeed agreed to cover the full cost of diagnostic coronavirus tests, that may well prove illusory: Cencini’s test was free, but his visit to the ER to get it was not.

As might be expected in a country where the price of a knee X-ray can vary by a factor of well over 10, labs so far are charging between about $51 (the Medicare reimbursement rate) and more than $100 for the test. How much will insurers cover?

Those testing laboratories want to be paid — and now. Last week, the American Clinical Laboratory Association, an industry group, complained that they were being overlooked in the coronavirus package.

“Collectively, these labs have completed over 234,000 tests to date, and nearly quadrupled our daily test capacity over the past week,” Julie Khani, president of the ACLA, said in a statement. “They are still waiting for reimbursement for tests performed. In many cases, labs are receiving specimens with incomplete or no insurance information, and are burdened with absorbing the cost.”

There are few provisions in the relief packages to ensure that patients will be protected from large medical bills related to testing, evaluation or treatment — especially since so much of it is taking place in a financial high-risk setting for patients: the emergency room.

In a study last year, about 1 in 6 visits to an emergency room or stays in a hospital had at least one out-of-network charge, increasing the risk of patients’ receiving surprise medical bills, many demanding payment from patients.

That is in large part because many in-network emergency rooms are staffed by doctors who work for private companies, which are not in the same networks. In a Texas study, more than 30% of ER physician services were out-of-network — and most of those services were delivered at in-network hospitals.

The doctor who saw Cencini works with Emergency Care Services of New York, which provides physicians on contract to hospitals and works with some but not all insurers. It is affiliated with TeamHealth, a medical staffing business owned by the private equity firm Blackstone that has come under fire for generating surprise bills.

Some senators had wanted to put a provision in legislation passed in response to the coronavirus to protect patients from surprise out-of-network billing — either a broad clause or one specifically related to coronavirus care. Lobbyists for hospitals, physician staffing firms and air ambulances apparently helped ensure it stayed out of the final version. They played what a person familiar with the negotiations, who spoke on the condition of anonymity, called “the COVID card”: “How could you possibly ask us to deal with surprise billing when we’re trying to battle this pandemic?”

Even without an ER visit, there are perilous billing risks. Not all hospitals and labs are capable of performing the test. And what if my in-network doctor sends my coronavirus test to an out-of-network lab? Before the pandemic, the Kaiser Health News-NPR “Bill of the Month” project produced a feature about Alexa Kasdan, a New Yorker with a head cold, whose throat swab was sent to an out-of-network lab that billed more than $28,000 for testing.

Even patients who do not contract the coronavirus are at a higher risk of incurring a surprise medical bill during the current crisis, when an unrelated health emergency could land you in an unfamiliar, out-of-network hospital because your hospital is too full of COVID-19 patients.

The coronavirus bills passed so far — and those on the table — offer inadequate protection from a system primed to bill patients for all kinds of costs. The Families First Coronavirus Response Act, passed last month, says the test and its related charges will be covered with no patient charge only to the extent that they are related to administering the test or evaluating whether a patient needs it.

That leaves hospital billers and coders wide berth. Cencini went to the ER to get a test, as he was instructed to do. When he called to protest his $1,622.52 bill for hospital charges (his insurer’s discounted rate from over $2,500 in the hospital’s billed charges), a patient representative confirmed that the ER visit and other services performed would be “eligible for cost-sharing” (in his case, all of it, since he had not met his deductible).

This weekend he was notified that the physician charge from Emergency Care Services of New York was $1,166. Though “covered” by his insurance, he owes another $321 for that, bringing his out-of-pocket costs to nearly $2,000.

By the way, his test came back negative.

When he got off the phone with his insurer, his blood was “at the boiling point,” he told us. “My retirement account is tanking and I’m expected to pay for this?”

The coronavirus aid package provides a stimulus payment of $1,200 per person for most adults. Thanks to the billing proclivities of the American health care system, that will not fully offset Cencini’s medical bills.

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Pandemic-Stricken Cities Have Empty Hospitals, But Reopening Them Is Difficult

As city leaders across the country scramble to find space for the expected surge of COVID-19 patients, some are looking at a seemingly obvious choice: former hospital buildings, sitting empty, right downtown.

In Philadelphia, New Orleans, and Los Angeles, where hospitalizations from COVID-19 increase each day, shuttered hospitals that once served the city’s poor and uninsured sit at the center of a public health crisis that begs for exactly what they can offer: more space. But reopening closed hospitals, even in a public health emergency, is difficult.

Philadelphia, the largest city in America with no public hospital, is also the poorest. There, Hahnemann University Hospital shut its doors in September after its owner, Philadelphia Academic Health System, declared bankruptcy. While not public, the 496-bed safety-net hospital mainly treated patients on public insurance. Philadelphia Mayor Jim Kenney began talks with the building’s owner, California-based investment banker Joel Freedman, as soon as his administration saw projections that the demand for hospital beds during the pandemic would outpace the city’s capacity. Not long after negotiations started, city officials announced the talks were going badly.

“Mr. Freedman was difficult to work with at times when he was the owner of the hospital, and he is still difficult to work with as the owner of the shuttered hospital,” said Brian Abernathy, who is Philadelphia’s managing director and heading the city’s COVID-19 response.

In New Orleans, where the soaring COVID-19 infection rate is disproportionately high compared with its population, Charity Hospital sits vacant in the middle of town. The former public hospital never reopened after Hurricane Katrina in 2005. The Louisiana State University System, which owns the building, incorporated Charity Hospital into the city’s new medical center, but the original building remains vacant. Instead of using it during the pandemic, the New Orleans Convention Center is being converted to a “step-down” facility with the capacity to treat up to 2,000 patients after they no longer need critical care.

Elsewhere, city governments have struck deals with the owners of empty hospital buildings to lease their space. At St. Vincent Medical Center in Los Angeles, the city is paying $236 per night per bed, for a total of $2.6 million each month.

In Philadelphia, Freedman offered the Hahnemann building to the city for $27 per bed per night, plus taxes, maintenance and insurance, which the city would pay directly. All told, that added up to just over $900,000 per month.

“I think he is looking at how to turn an asset that is earning no revenue into an asset that earns some revenue, and isn’t thinking through what the impacts are on public health,” Abernathy said of Freedman. “I think he’s looking at this as a business transaction rather than providing an imminent and important aid to the city and our residents.”

This isn’t the first time Freedman has come under fire by Philadelphians for his handling of the hospital. Its closure sparked protests from city officials, health care unions, and even presidential hopeful Bernie Sanders. Critics speculated that Freedman, whose private equity firm bought the struggling hospital in 2018, didn’t try in earnest to save it and planned to flip it for its valuable downtown real estate. Notably, Hahnemann’s real estate was parsed out into a separate company, Broad Street Healthcare Properties, also owned by Freedman, and not included in Philadelphia Academic Health System’s Chapter 11 bankruptcy petition.

A representative for Freedman said the building has an interested buyer, and that is one reason Broad Street Healthcare will not let the city use the building at cost.

“We’re offering this facility because of the public benefit in a health crisis, but it comes at a cost to the property owner,” said Broad Street representative Sam Singer.

As urban hospitals have struggled in recent years, it’s become increasingly common for private equity to get involved: Big firms buy struggling medical centers with the promise of financial support and to improve their operations and business strategy. When things go right, the business succeeds, and the private equity firm sells it in a public offering or to another bidder for more than it paid.

In other cases, though, the firms load companies up with debt, take dividends out for themselves, sell off valuable real estate and charge fees and high-interest loans, leaving a company in a much weaker position than it would have been otherwise, and often on the verge of bankruptcy.

“The house never loses,” said Eileen Appelbaum, co-director at the Center for Economic and Policy Research. “The private equity firm makes money whether the company succeeds or it doesn’t.”

For instance, Steward Health Care was able to expand from its base in Massachusetts to a 36-hospital network nationwide with backing from Cerberus Capital Management. Now, said Appelbaum, the chain of community hospitals is stuck paying rent to Iasis, another private equity-owned company, on all its properties, while also struggling to stay in the black. The network announced last week it would furlough non-clinical workers across nine states because the requirement to cancel elective surgeries caused too great a financial strain.

Freedman’s private equity firm is called Paladin Healthcare, and it has previously bought and managed hospitals in California and Washington, D.C., where it helped the struggling Howard University Hospital out of the red. Paladin then sold the hospital to Adventist HealthCare last summer.

Urban hospitals like Hahnemann have struggled to stay afloat in recent years, in part due to their lack of privately insured patients. Hospitals often finance the care of uninsured patients or those on Medicaid by treating those with private insurance, which reimburses the hospitals faster and at a higher rate. At Hahnemann, two-thirds of patients were on Medicaid or Medicare. While a financially struggling public or nonprofit hospital might continue serving a poorer community, a for-profit hospital has different incentives, said Vickie Williams, a former law professor for Gonzaga University.

“If your urban hospital is purchased by a for-profit company and it doesn’t perform sufficiently, they don’t have the same necessarily mission-driven directives to keep that hospital functioning for the good of the community at a loss,” said Williams, who is now senior counsel for CommonSpirit Health in Tacoma, Washington.

Freedman has said that he tried to sell the Hahnemann property to a nonprofit and requested money from the city and state to keep it open, but neither option worked.

Following news that Philadelphia had abandoned negotiations with Freedman, calls to seize the property in order to save lives came pouring in, including from elected officials.

“Eminent Domain was created for situations like #Hahnemann,” City Council member Helen Gym wrote on Twitter. “This is a public health emergency and Philly is the largest city in the nation WITHOUT a public hospital. We cannot allow unconscionable greed to get in the way of saving lives. Eminent domain this property.” Legal experts say the lengthy process of eminent domain and the requirement to pay the owner fair market value for the building make it an unlikely mechanism for an instance like this.

But in public health emergencies, local, state and federal governments do have broad authority to commandeer private property, such as hotels, convention centers, university dormitories or even defunct hospitals for disaster response. Williams, whose research has focused on preserving hospital infrastructure during a pandemic, said that so far in the United States, that hasn’t had to happen ― at least not in the traditional sense.

In Pennsylvania, the governor’s emergency declaration gives him the authority to “commandeer or utilize any private, public or quasi-public property if necessary to cope with the disaster emergency.” A health department representative said all options remain on the table in the event that the city’s hospital bed capacity is overrun.

In the interim, the mayor made a deal with Temple University to use its basketball arena, which would have the capacity to treat 250 non-critical patients, at no cost to the city.

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

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KHN’s ‘What The Health?’: All Coronavirus All The Time

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

The medical and economic needs laid bare by the coronavirus pandemic are forcing some immediate changes to the U.S. health system. Congress, in its latest relief bill, provided $100 billion in funding for the hospital industry alone. Meanwhile, the federal government has quickly removed previous barriers to telehealth and other sometimes controversial practices.

But big fights are still brewing, including whether the federal government will reopen the Affordable Care Act marketplaces it runs and whether states can use emergency powers to ban abortions as “elective medical procedures.”

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • The ACA was passed on the heels of the Great Recession. The coronavirus outbreak has produced the first big economic downturn since then, and the law’s provisions to expand Medicaid and to provide an insurance option to those without jobs could provide a critical safety net during this crisis.
  • About a dozen states running their own ACA insurance marketplaces have opened up enrollment again to let people who did not enroll in the fall but are feeling the pinch from the coronavirus pandemic to reconsider. President Donald Trump said this week that he is mulling a similar move, but the messages from the administration on such action have been confusing.
  • People who had insurance through work and have lost their jobs don’t need a special enrollment period to sign up for an Obamacare plan. They are eligible because their job situation changed. However, the administration has not been publicizing that message.
  • Hospitals are eager to receive the $100 billion appropriated by Congress in response to the influx of patients with COVID-19, the disease caused by the coronavirus. But the administration has not yet said how that money will be apportioned.
  • A handful of states have prohibited abortions during the coronavirus emergency because, officials say, they are seeking to preserve protective gear for hospital staff treating COVID-19 patients. But it’s not clear that the abortion procedures ― especially medication abortions — are interfering with efforts to safeguard protective clothing or masks needed by hospitals. And women who do not get abortions will consume far more medical care by remaining pregnant and giving birth.

Also, this week, Rovner interviews KHN’s Liz Szabo, who reported the latest KHN-NPR “Bill of the Month” installment about a patient who underwent a very expensive genetic test. 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: The New York Times’ “A Ventilator Stockpile With One Hitch: Thousands Do Not Work,” by David E. Sanger, Zolan Kanno-Youngs and Nicholas Kulish

Joanne Kenen: The New Yorker’s “The Life and Death of Juan Sanabria, One of New York City’s First Cornavirus Victims,” by Jonathan Blitzer

Margot Sanger-Katz: Bloomberg News’ “Hospitals Tell Doctors They’ll Be Fired If They Speak Out About Lack of Gear,” by Olivia Carville, Emma Court and Kristen V. Brown

Alice Miranda Ollstein: The Washington Post’s “Trump Ban on Fetal Tissue Research Blocks Coronavirus Treatment Effort,” by Amy Goldstein

To hear all our podcasts, click here.

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

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California Hospitals Face Surge With Proven Fixes And Some Hail Marys

California’s hospitals thought they were ready for the next big disaster.

They’ve retrofitted their buildings to withstand a major earthquake and  whisked patients out of danger during deadly wildfires. They’ve kept patients alive with backup generators amid sweeping power shutoffs and trained their staff to thwart would-be shooters.

But nothing has prepared them for a crisis of the magnitude facing hospitals today.

“We’re in a battle with an unseen enemy, and we have to be fully mobilized in a way that’s never been seen in our careers,” said Dr. Stephen Parodi, an infectious disease expert for Kaiser Permanente in California. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

As California enters the most critical period in the state’s battle against COVID-19, the state’s 416 hospitals — big and small, public and private — are scrambling to build the capacity needed for an onslaught of critically ill patients.

Hospitals from Los Angeles to San Jose are already seeing a steady increase in patients infected by the virus, and so far, hospital officials say they have enough space to treat them. But they also issued a dire warning: What happens over the next four to six weeks will determine whether the experience of California overall looks more like that of New York, which has seen an explosion of hospitalizations and deaths, or like that of the San Francisco Bay Area, which has so far managed to prevent a major spike in new infections, hospitalizations and death.

Some of their preparations share common themes: Postpone elective surgeries. Make greater use of telemedicine to limit face-to-face contact. Erect tents outside to care for less critical patients. Add beds — hospital by hospital, a few dozen at a time — to spaces like cafeterias, operating rooms and decommissioned wings.

But by necessity — because of shortages of testing, ventilators, personal protective equipment and even doctors and nurses — they’re also trying creative and sometimes untried strategies to bolster their readiness and increase their capacity.

In San Diego, hospitals may use college dormitories as alternative care sites. A large public hospital in Los Angeles is turning to 3D printing to manufacture ventilator parts. And in hard-hit Santa Clara County, with a population of nearly 2 million, public and private hospitals have joined forces to alleviate pressure on local hospitals by caring for patients at the Santa Clara Convention Center.

Yet some hospitals acknowledge that, despite their efforts, they may end up having to park patients in hallways.

“The need in this pandemic is so different and so extraordinary and so big that a hospital’s typical surge plan will be insufficient for what we’re dealing with in this state and across the nation,” said Carmela Coyle, president and CEO of the California Hospital Association.

Across the U.S., more than 213,000 cases of COVID-19 have been confirmed, and at least 4,750 people have died. California accounts for more than 9,400 cases and at least 199 deaths.

Health officials and hospital administrators are singling out April as the most consequential month in California’s effort to combat a steep increase in new infections. State Health and Human Services Secretary Mark Ghaly said Wednesday that the number of hospitalizations is expected to peak in mid-May.

Gov. Gavin Newsom said there were 1,855 COVID-19 cases in hospitals Wednesday, a number that had tripled in six days, and 774 patients in critical care. By mid-May, the number of critical care patients is expected to climb to 27,000, he said.

Newsom said the state needs nearly 70,000 more hospital beds, bringing its overall capacity to more than 140,000 — both inside hospitals and also at alternative care sites like convention centers. The state also needs 10,000 more ventilators than it normally has to aid the crush of patients needing help to breathe, he said, and so far has acquired fewer than half.

Newsom and state health officials worked with the Trump administration to bring a naval hospital ship to the Port of Los Angeles, where it is already treating patients not infected with the novel coronavirus. The state is working with the Army Corps of Engineers to deploy eight mobile field hospitals, including one in Santa Clara County. And it is bringing hospitals back online that were shuttered or slated to close, including one each in Daly City, Los Angeles, Long Beach and Costa Mesa.

The governor is also drafting a plan to make greater use of hotels and motels and nursing homes to house patients, if needed.

But the size of the surge that hits hospitals depends on how well the public follows social distancing and stay-at-home orders, said Newsom and hospital administrators. “This is not just about health care providers caring for the sick,” said Dr. Steve Lockhart, the chief medical officer of Sutter Health, which has 22 hospitals across Northern California.

While hospitals welcomed the state assistance, they’re also undertaking dramatic measures to prepare on their own.

“I’m genuinely very worried, and it scares me that so many people are still out there doing business as usual,” said Chris Van Gorder, CEO of Scripps Health, a system with five major hospitals in San Diego County. “It wouldn’t take a lot to overwhelm us.”

Internal projections show the hospital system could need 8,000 beds by June, he said. It has 1,200.

In addition to taking precautions to protect its health care workers — such as using baby monitors to observe patients without risking infection — it is working with area colleges to use dorm rooms as hospital rooms for patients with mild cases of COVID-19, among other efforts, he said.

“Honestly, I think we should have been better prepared than we are,” Van Gorder said. “But hospitals cannot take on this burden themselves.”

Van Gorder and other hospital administrators say a continued shortage of COVID-19 tests has hampered their response — because they still don’t know exactly which patients have the virus — as has the chronic underfunding of public health infrastructure.

Kaiser Permanente wants to double the capacity of its 36 California hospitals, Parodi said. It is also working with the garment industry to manufacture face masks, and eyeing hotel rooms for less critical patients.

Harbor-UCLA Medical Center, a 425-bed safety-net hospital in Los Angeles, is working to increase its capacity by 200%, said Dr. Anish Mahajan, the hospital’s chief medical officer.

Harbor-UCLA is using 3D printers to produce ventilator piping equipped to serve two patients per machine. And in March it transformed a new emergency wing into an intensive care unit for COVID-19 patients.

“This was a shocking thing to do,” Mahajan said of the unprecedented move to create extra space.

He said some measures are untested, but hospitals across the state are facing extreme pressure to do whatever they can to meet their greatest needs.

In March, Stanford Hospital in the San Francisco Bay Area launched a massive telemedicine overhaul of its emergency department to reduce the number of employees who interact with patients in person. This is the first time the hospital has used telemedicine like this, said Dr. Ryan Ribeira, an emergency physician who spearheaded the project.

Stanford also did some soul-searching, thinking about which of its staff might be at highest risk if they catch COVID-19, and has assigned them to parts of the hospital with no coronavirus patients or areas dedicated to telemedicine. “These are people that we might have otherwise had to drop off the schedule,” Ribeira said.

Nearby, several San Francisco hospitals that were previously competitors have joined forces to create a dedicated COVID-19 floor at Saint Francis Memorial Hospital with four dozen critical care beds.

The city currently has 1,300 beds, including 200 ICU beds. If the number of patients surges as it has in New York, officials anticipate needing 5,000 additional beds.

But the San Francisco Bay Area hasn’t yet seen the expected surge. UCSF Health had 15 inpatients with COVID-19 Tuesday. Zuckerberg San Francisco General Hospital and Trauma Center had 18 inpatients with the disease Wednesday.

While hospital officials are cautiously optimistic that local and state stay-at-home orders have worked to slow the spread of the virus, they are still preparing for what could be a major increase in admissions.

“The next two weeks is when we’re really going to see the surge,” said San Francisco General CEO Susan Ehrlich. “We’re preparing for the worst but hoping for the best.”

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

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Listen: COVID-19 Stresses Rural Hospitals Even Before They Have A Single Case

KHN Midwest correspondent Lauren Weber appeared on WOSU’s “All Sides with Ann Fisher” out of Columbus, Ohio, to talk about the coronavirus pandemic’s impact on rural hospitals. Weber recently reported on the financial implications for such hospitals even before they handle any COVID-19 cases.

Almost half of the nation’s rural hospitals already operated in the red on a good day. Rural hospital CEOs now warn that some soon may be unable to pay their workers because they’ve had to cancel elective procedures, therapy, tests and other visits that bring in most of their revenue. Despite the recent federal bailout, their doors may close when the community most needs them.

Click here to listen on WOSU’s website.

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