Tagged Trump Administration

Second Time Around? Health Care Issues Trump Might Tackle If Reelected

If President Donald Trump wins a second term in the White House, what health care policies might the nation expect from his administration?

Julie Rovner, Kaiser Health News’ chief Washington correspondent, examines that issue in the new edition of Washington Monthly magazine.

Although changes in health care might not have ranked high on the president’s priorities for a second term ― particularly if Democrats retain a majority in the House of Representatives — external factors such as the coronavirus pandemic could force the White House and Congress to work together to improve the nation’s public health infrastructure. And the administration might move to weaken the Affordable Care Act through regulations. You can read the article here.

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Trump Administration Uses Wartime Powers To Be First In Line On Medical Supplies

The Trump administration quietly invoked the Defense Production Act to force medical suppliers in Texas and Colorado to sell to it first — ahead of states, hospitals or foreign countries.

It took this action more than a week before it announced Thursday that it would use the little-known aspect of the law to force 3M to fill its contract to the U.S. first. Firms face fines or jail time if they don’t comply.

The Cold War-era law gives federal officials the power to edge out the competition and force contractors to provide supplies to them before filling orders for other customers.

While it’s unclear how many times the power has been used during the coronavirus pandemic, federal contracting records examined by Kaiser Health News show that federal authorities staked first rights to $137 million in medical supplies. The orders in late March flew under the radar, even as dog-eat-dog bidding wars raged among states and nations for desperately needed medical protective gear.

“It’s like ‘Lord of the Flies’ out there for states and hospitals as they bid against each other for critical medical supplies and equipment,” Sen. Chris Murphy (D-Conn.) said in a statement to KHN. “Plus, there’s no transparency about what the federal government is doing with the equipment that they purchase when they outbid states and hospitals.”

Without public awareness of what was taken on a federal-first basis — and who it was given to — the states are left in the dark after being told repeatedly to procure their own goods. The federal government, President Donald Trump has said, is not the states’ “shipping clerk.”

“It’s putting people into the free market where the invisible hand doesn’t care who it strangles,” said Arthur Caplan, director of the division of medical ethics at New York University School of Medicine.

Trump enacted the first-in-line power of the DPA for the Health and Human Services Department in an executive order on March 18 — and nine days later extended the power to the Department of Homeland Security, which includes the Federal Emergency Management Agency.

On Thursday at his White House press briefing, Trump announced he had invoked the DPA “against” 3M. His executive order states that the government “shall use any and all authority available under the Act to acquire … the number of N-95 respirators that the Administrator determines to be appropriate.”

“We hit 3M hard today after seeing what they were doing with their Masks. ‘P Act’ all the way,” the president tweeted. “Big surprise to many in government as to what they were doing – will have a big price to pay!”

While the administration had asked the company to stop exporting respirators to the Latin American and Canadian markets, 3M stated in a press release Friday there would be humanitarian implications, since the company supplies a critical amount of those countries’ N95 masks. 3M also warned such a move could create a potential trade war where other countries then refuse to sell N95s to the U.S., potentially resulting in fewer N95s in the United States.

When federal authorities use the DPA to seek a so-called rated order, it relieves companies from having to decide which state or hospital or foreign government gets the goods first, said Eric Crusius, a partner at the Washington, D.C., firm Holland & Knight and a contract law specialist. It makes things simple — the federal government’s order is filled first.

The defense law was cited in contracts for an estimated $54 million in medical supplies from Colorado-based Marathon Medical Corp., a medical supply distributor, and an estimated $84 million from Texas-based Retractable Technologies Inc., which makes retractable needles.

A woman who answered the phone at Marathon Medical declined to give her name and said the company policy is not to talk to the media. Officials for RTI, contacted by phone and email, did not respond by press time.

Contracts show that federal HHS officials also invoked their right to be first in line for an estimated $13.5 million in goods produced by New Jersey-based health care products manufacturer and supplier Becton, Dickinson and Co.

A modification to that contract signed March 23 says it applies to “medical and surgical instruments, equipment and supplies” and cites “delegation of authority” under the Defense Production Act “ordered by President Donald J. Trump in response to” the threat of the coronavirus. It’s not clear what product officials ordered from the company.

Becton, Dickinson and Co. told KHN on Thursday that the contract had been modified — again — so that the Defense Production Act was not invoked. Because there is a lag in federal contract disclosures, it’s possible that the contracts for Retractable Technologies and Marathon Medical also have been modified.

All three records name the contract-awarding agency as the HHS Office of the Assistant Secretary for Preparedness and Response and note: “Only the agency awarding the contract may place orders.”

When federal officials made a similar move in Massachusetts, it took state leaders by surprise. Marylou Sudders, who leads the state coronavirus command center, said an order of 400 masks from MSC Industrial Supply was canceled abruptly due to federal intervention, according to a report in The Boston Globe.

MSC spokesperson Paul Mason told KHN that the Defense Production Act compelled his company to put federal orders first.

That cancellation and a similar seizure of goods sowed so much distrust in Massachusetts that the New England Patriots sent a team plane to ship personal protective gear from China, according to The Boston Globe.

Officials from the White House and FEMA declined to directly answer questions about the use of the 1950 law to put the feds first in line for goods. HHS provided a statement saying the Defense Production Act is “an important tool that may be used when necessary to ensure needed supplies are available and going where they are most urgently needed. HHS and FEMA are and will continue working with the private sector and States to increase supply and allocate needed PPE.”

Top Democratic leaders and even a Republican governor were clamoring for a change in how the market was run in recent weeks, as health care workers warned against being sent out to the coronavirus front lines without proper supplies.

In a letter to the president Thursday, Senate Minority Leader Chuck Schumer called for strong federal intervention and leadership on the issue, citing the need for a military logistician to run such a response.

“While you continue to dismiss the Defense Production Act as not being needed, it is clear that the capacity of American industry has not yet been fully harnessed,” Schumer’s letter says.

Trump fired back with his own letter that evening, stating that Navy Rear Adm. John Polowczyk, currently serving as the leader of FEMA’s supply chain task force, was in charge of “purchasing, distributing, etc.”

“The Defense Production Act (DPA) has been consistently used by my team and me for the purchase of billions of dollars’ worth of equipment, medical supplies, ventilators, and other related items,” he wrote. “It has been powerful leverage, so powerful that companies generally do whatever we are asking, without even a formal notice.”

But if the government is going to take more control — which many health and government leaders have urged it to do — it should be transparent about its actions, said Dr. Atul Grover, executive vice president of the Association of American Medical Colleges. He said medical leaders have been whiplashed by their orders for protective gear falling through and speculated that they lost out to federal agencies.

Some institutions “fully expected to be able to purchase [personal protective equipment] from contractors who then turned around and said, ‘No, we’re going with another buyer instead,’” he said.

When asked about this phenomenon during Thursday’s national briefing, Trump said the governments could work it out.

“If you think there is bidding between federal government and state, let us know and we’ll drop out immediately,” Trump said. “There are 151 countries that have this problem, and they’re ordering, too. It’s really a mess.”

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Must-Reads Of The Week From Brianna Labuskes

Hello! It is once again Friday, which means I’m going to attempt to do my very best to give you a snapshot of some (read: a fraction) of the best stories from the week amid a flood of them.

But first! Take yourself on this journey about how the most well-known coronavirus image (that gray blob with stone-like texture and red crowns and colored flecks) was made. Sometimes when the government is creating informational illustrations it focuses on the vector or the symptoms, but for this coronavirus the CDC’s Alissa Eckert and Dan Higgins went with what’s called a “beauty shot.” It’s a very cool read!

All right, here we go:

The confirmed number of confirmed cases globally ticked past a million this week in a grim milestone that experts still say represents only a percentage of the actual cases out there. The U.S. had recorded over 250,000 cases as of press time, with more than 6,500 deaths.

President Donald Trump invoked his wartime powers to help manufacturers secure supplies needed to make ventilators and protective face masks, but is it too little, too late? New York Gov. Andrew Cuomo, whose state has become the epicenter of the nation’s outbreak, said on Thursday it will use up all available ventilators in less than a week. Meanwhile, FEMA said that most of the ventilators Trump promised to obtain won’t be ready until June.

Governors are distraught over their inability to obtain the needed supplies, likening the process of requesting the equipment to eBay auctions. “You now literally will have a company call you up and say, ‘Well, California just outbid you,’” Cuomo said.

Another roadblock is that 2,000 of the ventilators in the national stockpile are unusable because of a lapse in a contract that left a monthslong gap, during which the machines weren’t being properly maintained.

In the meantime, General Motors has shrugged off Trump’s attacks on the company (he said GM and its chief executive were dragging their feet on the project) and are moving full-throttle ahead at producing the needed equipment. “Every ventilator is a life,” said one GM exec.

With so much focus on ventilators, doctors are being advised on how to ration care and being told that they’ll be supported in their decisions not to perform futile intubations.

One quick note on that front: New York lawmakers are moving on legislation that would grant sweeping civil- and criminal-liability protections to hospitals and health care workers dealing with coronavirus patients.

And even though there’s a ton of attention on ventilators, the survival rate of any patient who requires one is only 20% — meaning that even without a shortage, they can only help a fraction of patients.

In other important news on the preparedness front:

Trump warned Americans this week that “hard days” lie ahead and that people should be braced for a “bad two weeks,” with the White House projecting that the death toll could be somewhere between 100,000 to 240,000. For what it’s worth, disease forecasters were mystified over where the task force got those numbers, mostly because we don’t yet know enough about the virus.

(What helped change Trump’s mind, considering he’d previously mused that the country could return to normal in time to fill the pews on Easter? Polling numbers.)

To help states deal with the crisis, CMS relaxed safety rules for hospitals, giving them unprecedented flexibility. The changes include what counts as a hospital bed, how closely certain medical professionals need to be supervised and what kinds of health care can be delivered at home.

The administration decided not to follow suit after a handful of states reopened their exchanges, though Trump seemed to hint that the possibility was still on the table “as a matter of fairness.” Also, to note, if people have lost their insurance because of their jobs, that counts as a qualifying event and they have 60 days to enroll in the federal exchanges, regardless of what Trump does with a special session.

And although Drs. Anthony Fauci and Deborah Birx, along with Vice President Mike Pence, have emerged as the leading voices of the administration’s pandemic response, Trump’s son-in-law Jared Kushner has taken charge behind the scenes. Critics say its adding confusion to an already chaotic situation.

And reports continue to emerge that the Trump administration was cutting pandemic detection positions in China just months before the outbreak.

In other news on the administration:

House Speaker Nancy Pelosi will be creating a special committee to oversee the implementation of the $2.2 trillion stimulus package and any other coronavirus legislation coming down the pike. “Where there’s money there’s also frequently mischief,” Pelosi said, in perhaps one of my favorite quotes of the week. Meanwhile, House Democrats may be raring to get started on a fourth stimulus package, but Republicans are pumping the brakes. At the very least, they say, they want to see how the current stimulus package plays out.

The news came the same day as it was reported that 6.6 million Americans filed for unemployment benefits. That eye-popping number blows past all previous records. And experts say it represents only a sliver of the economic devastation the virus is wreaking on the country. There are many affected Americans who remain uncounted — some have lost jobs or income and did not initially qualify for benefits, and others, encountering state unemployment offices that were overwhelmed by the deluge of claimants, were unsuccessful in filing.

In other news about Congress and the economic damage from the outbreak:

The Democratic National Convention, expected to draw as many as 50,000 visitors, was postponed from July to August in one of the largest disruptions to the 2020 elections so far. On the other hand, Wisconsin is going ahead with its primary on Tuesday, which is causing mixed reactions … including apoplectic rage.

More stories on elections:

Much focus this week was on serology tests that serve the dual purpose of finding Americans who can safely return to some normalcy and helping researchers find treatments for COVID-19. Experts are fairly unified on the fact that to get the country back into operation, we need a way to identify those who are now immune to the disease. And using plasma collected from recovered patients is a century-old practice (which, to be clear, has had mixed results in past diseases).

Beyond studies on actually treating the coronavirus illness (a small study out this week showed a much-touted malaria drug combo had positive results), doctors are also trying to figure out how to treat the phenomenon known as “cytokine storm,” in which the body’s own immune system attacks its organs. This is thought to be the cause of some of the severe cases seen in younger patients.

On a side note, the Food and Drug Administration on Sunday issued an emergency-use authorization for hydroxychloroquine and chloroquine, despite scant evidence that they work against COVID-19.

With Florida (and three other states who had been hesitating) finally caving into pressure to issue the stay-at-home order, the vast majority of Americans are now huddled at home. The good news is that the extreme measures seem to be working in California, which was an earlier disciple of flattening the curve.

Google, meanwhile, is offering the government a report on “mobility data” to help states recognize where social-distancing measures are failing, with a specific focus on how foot traffic has increased or declined to six categories of destinations: homes; workplaces; retail and recreation establishments; parks; grocery stores and pharmacies; and transit stations.

Although things might seem a bit grim right now because of these measures, a look at data from the 1918 flu pandemic shows cities that locked down emerged from the crisis stronger economically than those that didn’t. One caveat, though: Because working-age people were harder hit by the 1918 flu (and the coronavirus strikes worse among older generations), any comparisons might not hold.

So, onto some of the stories I find most fascinating … aka the science behind all of this.

I’m going to cut this off here, or else this will no longer be able to be called the Breeze. If you want a more comprehensive roundup, please check out the Morning Briefings from the week, which are chock-full of more stories than you could ever finish reading. Including ones on workers’ protests and the supply chain; the gun store debate; how jails are “ticking time bombs;” autocrats’ power grab; snapshots from a New York in crisis; health disparities; and a call to arms for medical workers that doesn’t guarantee coverage of potential hospital bills.

Please have a safe and restful weekend, if possible!

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Fox News’ Jesse Watters Said Travel Bans ‘More Critical In Saving Lives’ Than COVID Testing. He’s Wrong.

Defending President Donald Trump’s coronavirus response, Fox News commentator Jesse Watters highlighted federal efforts to restrict international travelers who may be infected — a ban he claimed mattered more than diagnostic testing.

“We were slow with the testing, but very quick with the travel ban. And that’s been much more critical in saving lives,” Watters said during a March 31 episode of “The Five.”

The administration has attracted stinging criticism from public health experts and state officials, who say the dearth of COVID-19 tests has made it impossible to get a handle on the disease’s spread. But the impact of the restrictions Trump imposed ― on people traveling from China and, by March, Europe — is another story.

So we decided to dig in. We contacted Fox News to find out the evidence on which Watters based his comment but did not hear back.

Early on, those restrictions won plaudits. After the March restrictions were announced, Dr. Anthony Fauci, who heads the National Institute of Allergy and Infectious Diseases and is a member of the White House coronavirus task force, said there was “compelling evidence” to justify restricting travel from those high-infection areas.

But the implementation is another story. Global health specialists told us there is little to no evidence that Trump’s restrictions have restrained COVID-19 ― they came too late and didn’t have the follow-up necessary to make a real dent. By contrast, they said, better and earlier testing could have saved countless lives.

The Wrong Approach At The Wrong Time

Targeted, quick travel restrictions can be part of the public health arsenal to control the spread of an illness such as COVID-19.

The idea is to stop people in hot spots from carrying the virus to uninfected areas. The restrictions also tamp down the risk that an infected traveler will expose others in the closed quarters of an airport, airplane or other mode of transportation.

But the experts we spoke to made clear that these restrictions can work only as one (smaller) part of a comprehensive strategy. Without other aggressive public health measures, they would have little value. The timing of American restrictions — and how they interacted with other domestic efforts ― rendered them ineffective.

The administration’s first coronavirus-related travel restrictions took effect Feb. 2, targeting noncitizens who had recently traveled to or from China. On Feb. 29, it took similar steps with people who had traveled to or from Iran.

For context, the incidence of a severe respiratory illness began to emerge in China late last year. These cases were confirmed to be a novel coronavirus by Jan. 7, and the first American case was reported Jan. 20 — almost two weeks before any travel restrictions were in effect.

Expanded travel restrictions took effect March 13 and 16 to include people in Europe, including the United Kingdom and Ireland.

Experts told us those measures represented the wrong approach at the wrong time.

“When the travel ban was put in place, the risk of importation from China was quite small,” said William Hanage, an associate professor of epidemiology at the Harvard T.H. Chan School of Public Health.

For one thing, China had also put in place its own limitations on travel ― limiting travel to and from Wuhan starting Jan. 23. And, by then, there were already several cases of COVID-19 across the United States and in other countries that had not been targeted by restrictions.

And while European cases shot up in early March — particularly in Italy ― even those travel restrictions were misplaced, Hanage said. At that point, Americans already faced a domestic threat from the virus.

So was the administration “very quick” with a travel ban? Not really.

If anything, the travel limitations gave people “a false sense that something with a big impact was being done,” said Jennifer Kates, a vice president and global health expert at the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

That false security, others said, distracted from the reality that more essential precautions weren’t in place.

Limited Effectiveness Without Widespread Testing

Well-implemented travel restrictions can buy time on the margins, research suggests. But that time has to be used effectively — to ramp up emergency preparedness and bolster activities like testing and isolating people who may have been exposed.

And there is no way to know if the administration’s initial travel restriction ― barring people who had been to China — reduced the spread of the coronavirus.

That’s because the administration limited testing for the virus to people who were sick enough to be hospitalized or who had been to Wuhan recently. Those are people with a heightened risk of exposure and not representative of the broader swath of people affected by the travel limitations, said Jennifer Nuzzo, a senior scholar at the Johns Hopkins Center for Health Security.

“Had we expanded testing during this time and still found few cases, I would be more convinced that the travel ban had an impact. But we didn’t.”

Available research on travel bans isn’t promising, either.

A March 20 analysis run by Think Global Health, a project of the Council on Foreign Relations, compared countries that did and didn’t restrict travel with China. The researchers found no correlation between travel restrictions and preventing a pandemic outbreak.

“The combination of the travel restrictions within China and international travel restrictions against China may have delayed the spread of COVID-19, but more so in nations that used that time to reduce community spread of the virus,” the researchers wrote.

That last part is crucial ― travel restrictions may have bought time, but that mattered only if countries actively fought domestic spread.

Other research backs that up. A paper published in Science last month found that when China imposed its own travel restrictions, it made only a modest difference in curbing the spread of the coronavirus, both domestically and to other countries — at most, buying a few days’ time. And, this paper also notes, travel restrictions were effective only when coupled with other efforts to halt transmission.

By contrast, researchers were unanimous in noting the effectiveness of robust testing of people who may have been exposed — and then isolating those who test positive for the virus. This test-and-quarantine approach has been proven effective in South Korea, which experienced its first case on the same day as in the U.S. but where the number of new COVID-19 cases is now on a dramatic decline.

If you could pick only one strategy ― travel bans or testing — the choice is clear, Nuzzo argued.

“We don’t have any evidence that travel bans did much to stop or slow the spread,” she said. “Conversely, testing is essential. Had we been better able to find and isolate cases and traced their contacts, we could have kept case numbers down.”

The World Health Organization makes a similar point: It says temporary restrictions are justified only in narrow circumstances and as a way to buy time. But that time, the organization says, must be used to “rapidly implement effective preparedness measures” ― like testing.

Another point that supports this position: the real-world experience unfolding in the United States.

The “travel ban didn’t work,” said Lawrence Gostin, a university professor at Georgetown Law who specializes in global health law. “This is self-evident, because the U.S. is now the global epicenter.”

Our Ruling

Arguing in support of the White House coronavirus response, Watters said the United States was “very quick with the travel ban” and that was “much more critical in saving lives.”

This is incorrect. Travel restrictions could have bought a bit of time. But they were instituted after the coronavirus had already entered the United States.

And the evidence at hand suggests travel restrictions are most effective in combating viral spread if they are accompanied by targeted, robust testing and quarantining, which are the areas in which the administration stumbled. If you were to pick only one area to excel in — testing people for the coronavirus, or travel restrictions ― experts told us the research clearly supports testing, even without travel bans.

Watters’ claim has no factual basis and misrepresents real-world evidence on multiple levels. We rate it False.

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More Than 5,000 Surgery Centers Can Now Serve As Makeshift Hospitals During COVID-19 Crisis

The Trump administration cleared the way Monday to immediately use outpatient surgery centers, inpatient rehabilitation hospitals, hotels and even dormitories as makeshift hospitals, health care centers or quarantine sites during the coronavirus crisis.

The Centers for Medicare & Medicaid Services announced it is temporarily waiving a range of rules, thereby allowing doctors to care for more patients.

Hospitals and health systems overwhelmed with COVID-19 patients will be able to transfer people with other medical needs to the nation’s 5,000 outpatient surgery centers, about half of which are affiliated with hospitals. This will give the country thousands of additional hospital beds and operating rooms, some of which have ventilators or anesthesia gas machines that could be repurposed as ventilators.

Outpatient surgery centers will be allowed to treat patients with other critical needs — such as serious injuries, cancer or heart attacks — unrelated to COVID-19, allowing hospitals to conserve scarce resources and reduce the risk of infection to these patients.

Until now, federal regulations allowed outpatient surgery centers to care for patients for a maximum of 24 hours.

“Transferring uninfected patients will help hospital staffs to focus on the most critical COVID-19 patients, maintain infection control protocols, and conserve personal protective equipment,” the agency said in a statement.

Many outpatient surgery centers had closed after being told to halt elective procedures. A coalition of anesthesiologists in recent weeks called for them to stop performing nonessential surgery and assist hospitals.

The waivers “will allow hospitals to save more lives” by performing “surgeries and procedures that can’t wait until the pandemic is over,” said Bill Prentice, CEO the Ambulatory Surgery Center Association, an industry group.

Before the CMS announcement, the California Ambulatory Surgery Association had expressed its willingness to help.

The outpatient centers “want to be part of the solution as the entire healthcare industry must rise to meet this enormous challenge,” said Michelle George, president of the California Ambulatory Surgery Association, in a statement issued Monday morning. “We have valuable resources to lend to this crisis — whether it is staff, space, equipment, supplies or other capabilities. ASCs are coordinating with the public health teams on local and regional levels to identify how their facilities can be utilized most effectively on a case by case basis.”

Advocates who have pushed for surgery centers to assist hospitals praised the move.

“This is a great step in fighting this pandemic,” said Dr. Adam Schlifke, an anesthesiologist and clinical assistant professor at Stanford University in California.

“We recognize that it’s going to be hard,” Schlifke said. “It’s extremely complicated, but we are here to support all the surgery centers that will need to convert as a result of this order.”

The waivers will allow hospitals to hire local physicians and health care providers to address potential surges; transfer critical equipment, including telemedicine equipment, to doctors’ offices; and provide meals and child care for their health care workers.

Hospitals will be able to triage sick patients at community locations, then send them to the most appropriate facility, according to CMS.

“Front-line health care providers need to be able to focus on patient care in the most flexible and innovative ways possible,” said CMS Administrator Seema Verma. “This unprecedented temporary relaxation in regulation will help the health care system deal with patient surges by giving it tools and support to create nontraditional care sites and staff them quickly.”

Even with additional facilities, hospitals and health care systems could run out of staff, especially as health providers become sick with COVID-19. Although surgery centers typically employ their own nurses, they tend to share surgeons with local hospitals.

More than a dozen states and health care associations had requested waivers. The CMS move means that other states will no longer need to apply for waivers.

Texas had taken the lead in recent days, even before the new announcement, by permitting hospitals to use off-site facilities. Texas Gov. Greg Abbott last week signaled his interest in using outpatient surgery centers to expand care by ordering them to tell the state how many ventilators they possess.

Among other sweeping changes:

  • Ambulances will be allowed to transport patients to outpatient surgery centers, community mental health centers, federally qualified health centers, physician’s offices, urgent care facilities and any locations furnishing dialysis services when a dedicated kidney failure treatment center isn’t available. Hospitals will be able to charge for services provided outside their four walls and emergency departments can use telehealth services to evaluate sick people.
  • Physician-owned hospitals can temporarily increase their number of licensed beds, operating rooms and procedure rooms, according to CMS.
  • Instead of going to crowded emergency rooms, patients could go to off-site locations to be evaluated by emergency health care providers using telemedicine. That change will help preserve space in the emergency room for those who need it most. CMS will allow health providers to treat more patients via apps or telephone and bill at the same rate as in-person visits.
  • Physician assistants and nurse practitioners will be allowed to order tests and medications that may have previously required a physician’s order, as long as state law allows it. Also, certified registered nurse anesthetists will no longer have to work under the supervision of a doctor, freeing up physicians to focus more on patients and less on supervising.
  • To reduce the need for patients with health problems unrelated to COVID-19 to go to a doctor’s office or hospital, doctors will be allowed to monitor patients remotely with devices that can measure a patient’s oxygen saturation levels using pulse oximetry.

Health care experts have been suggesting the administration offer such waivers for weeks. The country has “got to muster all reasonable facilities and personnel,” said Arthur Caplan, a bioethics professor at NYU Langone Medical Center. “The best way to ration is to avoid it by stretching resources and sharing.”

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‘Red Dawn Breaking Bad’: Officials Warned About Safety Gear Shortfall Early On, Emails Show

A high-ranking federal official in late February warned that the United States needed to plan for not having enough personal protective equipment for medical workers as they began to battle the novel coronavirus, according to internal emails obtained by Kaiser Health News.

The messages provide a sharp contrast to President Donald Trump’s statements at the time that the threat the coronavirus posed to the American public remained “very low.” In fact, concerns were already mounting, the emails show, that medical workers and first responders would not have enough masks, gloves, face shields and other supplies, known as PPE, to protect themselves against infection when treating COVID-19 patients.

The emails, part of a lengthy chain titled “Red Dawn Breaking Bad,” includes senior officials across the Department of Veterans Affairs, the State Department, the Department of Homeland Security and the Department of Health and Human Services, as well as outside academics and some state health officials. KHN obtained the correspondence through a public records request in King County, Washington, where officials struggled as the virus set upon a nursing home in the Seattle area, eventually killing 37 people. It was the scene of the first major outbreak in the nation.

“We should plan assuming we won’t have enough PPE — so need to change the battlefield and how we envision or even define the front lines,” Dr. Carter Mecher, a physician and senior medical adviser at the Department of Veterans Affairs, wrote on Feb. 25. It would be weeks before front-line health workers would take to social media with the hashtag #GetMePPE and before health systems would appeal to the public to donate protective gear.

In the email, Mecher said confirmed-positive patients should be categorized under two groups with different care models for each: those with mild symptoms should be encouraged to stay home under self-isolation, while more serious patients should go to hospital emergency rooms.

“The demand is rising and there is no guarantee that we can continue with the supply since the supply-chain has been disrupted,” Eva Lee, director of the Center for Operations Research in Medicine and HealthCare at Georgia Tech and a former health scientist at the Atlanta VA Medical Center, wrote that same day citing shortages of personal protective equipment and medical supplies. “I do not know if we have enough resources to protect all frontline providers.”

Reached on Saturday, Lee said she isn’t sure who saw the message trail but “what I want is that we take action because at the end of the day we need to save patients and health care workers.”

Mecher, also reached Saturday, said the emails were an “an informal group of us who have known each other for years exchanging information.” He said concerns aired at the time on medical protective gear were top of mind for most people in health care. More than 35 people were on the email chain, many of them high-ranking government officials.

The same day Mecher and others raised the concern in the messages, Trump made remarks to a business roundtable group in New Delhi, India.

“We think we’re in very good shape in the United States,” he said, noting that the U.S. closed the borders to some areas. “Let’s just say we’re fortunate so far.  And we think it’s going to remain that way.”

The White House declined to comment. In a statement, VA press secretary Christina Mandreucci said, “All VA facilities are equipped with essential items and supplies to handle additional coronavirus cases, and the department is continually monitoring the status of those items to ensure a robust supply chain.”

Doctors and other front-line medical workers in the weeks since have escalated concerns about shortages of medical gear, voicing alarm about the need to protect themselves, their families and patients against COVID-19, which as of Saturday evening had sickened more than 121,000 in the United States and killed at least 2,000.

As Mecher and others sent emails about growing PPE concerns, HHS Secretary Alex Azar testified to lawmakers that the U.S. had 30 million N95 respirator masks stockpiled but needed 300 million to combat the outbreak. Some senior U.S. government officials were also warning the public to not buy masks for themselves to conserve the supply for health care providers.

U.S. Surgeon General Jerome Adams tweeted on Feb. 29: “Seriously people – STOP BUYING MASKS!  They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!”

Still, on Feb. 27, the FDA in a statement said that officials were not aware of widespread shortages of equipment.

“We are aware of reports from CDC and other U.S. partners of increased ordering of a range of human medical products through distributors as some healthcare facilities in the U.S. are preparing for potential needs if the outbreak becomes severe,” the agency said.

Simultaneously, Trump downplayed the risk of the novel coronavirus to the American public even though the Centers for Disease Control and Prevention was warning it was only a matter of time before it would spread across the country. On Feb. 29, the CDC also updated its strategies for health workers to optimize supplies of N95 masks.

An HHS spokesperson said Saturday the department has been in “an all-out effort to mobilize America’s capacity” for personal protective equipment and other supplies, including allowing the use of industrial N95 respirators in health care settings and awarding contracts to several private manufacturers to buy roughly 600 million masks over the next 18 months.

“Health care supply chains are private-sector-driven,” the spokesperson said. “The federal role is to support that work, coordinate information across the industry and with state or local agencies if needed during emergencies, and drive manufacturing demand as best we can.”

The emails from King County officials and others in Washington state also show growing concern about the exposure of health care workers to the virus, as well as a view into local officials’ attempts to get help from the CDC.

In one instance, local medical leaders were alarmed that paramedics and other emergency personnel were possibly exposed after encountering confirmed-positive patients at the Life Care Center of Kirkland, the Seattle-area nursing home where roughly three dozen people have died because of the virus.

“We are having a very serious challenge related to hospital exposures and impact on the health care system,” Dr. Jeff Duchin, the public health officer for Seattle and King County, wrote in a different email to CDC officials March 1. Duchin pleaded for a field team to test exposed health care workers and additional support.

Duchin’s email came hours after a physician at UW Medicine wrote about being “very concerned” about exposed workers at multiple hospitals and their attempts to isolate infected workers.

“I suspect that we will not be able to follow current CDC [recommendations] for exposed HCWs [health care workers] either,” wrote Dr. John Lynch, medical director of employee health for Harborview Medical Center and associate professor of Medicine and Allergy and Infectious Diseases at the University of Washington. “As you migh [sic] imagine, I am very concerned about the hospitals at this point.”

Those concerns have been underscored with an unusual weekend statement from Dr. Patrice Harris, president of the American Medical Association, which represents doctors, calling on Saturday for more coordination of needed medical supplies.

“At this critical moment, a unified effort is urgently needed to identify gaps in the supply of and lack of access to PPE necessary to fight COVID-19,” the statement says. “Physicians stand ready to provide urgent medical care on the front lines in a pandemic crisis. But their need for protective gear is equally urgent and necessary.”

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Centros de salud comunitarios enfrentan al coronavirus, bajo presión financiera

La administración Trump acaba de anunciar $100 millones en fondos suplementarios para centros de salud comunitarios, para apoyar la respuesta a la pandemia de coronavirus.

“Los centros de salud están desempeñando un papel fundamental”, dijo James Macrae, administrador asociado de la Oficina de Atención Primaria de Salud del gobierno federal.

Alrededor de 29 millones de personas en el país dependen de estos centros, que ofrecen atención médica a pacientes de bajos ingresos y sin seguro. Millones de latinos reciben atención en estas clínicas.

A medida que los hospitales reciben más pacientes con COVID-19, los centros están revisando la forma en que atienden a los pacientes y han puesto en marcha nuevos protocolos para el manejo de enfermedades infecciosas.

Los fondos extra del gobierno se repartirán entre 1,381 centros de salud comunitarios (muchos de los cuales operan múltiples clínicas), principalmente para respaldar más pruebas para COVID-19, telemedicina y adquisición de equipos de protección personal.

“No está cerca de lo que se necesita, pero estamos agradecidos”, dijo Bob Marsalli, CEO de la Washington Association for Community Health, un grupo que representa a los centros de salud comunitarios en el estado de Washington.

Marsalli dijo que los centros en el estado están bajo una creciente presión financiera a medida que recrudece la batalla contra el coronavirus, al tiempo que pierden algunas fuentes clave de financiación.

“[Nuestras clínicas] están reasignando su fuerza laboral de manera inteligente, pero frenética, para mantenerse al día con la demanda”, dijo Marsalli.

Nuevas reglas de juego

En circunstancias normales, HealthPoint, un centro de salud comunitario en Auburn, Washington, alentaría a los pacientes a ir a la clínica para todas sus necesidades médicas, tanto para surtir una receta como para aprender sobre nutrición.

“Por lo general, nuestro lobby está colmado”, dijo la doctora Esther Johnston. “Es un espacio abierto y todos están juntos”.

Pero en estos días solo hay unos pocos pacientes con máscaras quirúrgicas esperando que los atiendan. Y Johnston les dice a los pacientes que no vayan a menos que realmente necesiten atención médica.

“Es un poco frustrante y desmoralizante, pero es la realidad de la situación”, dijo.

HealthPoint dirige más de una docena de clínicas en todo el oeste de Washington. Ahora, en la entrada de sus centros, el personal hace preguntas a los pacientes para identificar los síntomas de COVID-19 y controlar los mantiene a distancia uno del otro una vez dentro.

Johnston dijo que la clínica no se abrió para albergar una afluencia de pacientes con enfermedades infecciosas. Tienen un limitado número de cuartos, y cada uno debe cerrarse y limpiarse después que entra un paciente sospechoso de tener COVID-19.

“Simplemente no tenemos suficiente espacio para poder hacer eso de forma rutinaria”, dijo.

Al igual que muchos centros de salud comunitarios, el modelo de HealthPoint es atender a más personas para que no vayan a las salas de emergencia. Pero ahora la organización está tomando nuevas precauciones para prevenir la propagación del coronavirus y mantener al personal seguro. (Will Stone for KHN)

Johnston se preocupa por lo que vendrá a medida que aumenten los casos de COVID-19 en su área.

“Nos enorgullecemos de ser un espacio de atención primaria”, dijo Johnston. “No tenemos suficientes máscaras N95, ni, para ser sinceros, estábamos preparados para una situación en la que todos debían estar bien equipados”.

La doctora Judy Featherstone, directora médica de HealthPoint, dijo que ahora la mayoría de las citas se hacen por teléfono. Su personal está atendiendo llamadas de personas preocupadas por los síntomas, así como de nuevos pacientes que quieren tener un médico en caso que contraigan el coronavirus.

“Es un poco como tomar 20 años de trabajo y rediseñarlo en una semana”, dijo Featherstone. “Creo que estamos anticipando posibles problemas de la fuerza laboral”.

Al igual que muchas clínicas en Washington, HealthPoint ha establecido sitios de pruebas al aire libre, pero el suministro de kits y equipos de protección personal, limita el número de pacientes que pueden hacérselas.

Crece la tensión financiera

A medida que van menos pacientes para recibir atención, autoridades se preocupan por el futuro financiero de los centros. Las clínicas han cambiado a citas telefónicas, pero el programa de Medicaid de Washington tardó varias semanas en ajustar la forma en que paga esas visitas. Mientras tanto, los centros de salud comunitarios están eliminando las visitas dentales de rutina, un flujo de financiación clave.

“Toma esos tres factores… y ya has comenzado a perder ingresos antes de prepararte para nuevas formas de brindar atención”, dijo Michael Erikson, CEO de Neighborcare Health, que atiende a más de 70,000 residentes de Washington, más de la mitad de ellos bajo Medicaid. “Estamos en camino de perder $3 millones al mes”.

La Washington Association for Community Health proyecta que el recorte en la atención dental podría llevar a un déficit de $250 millones para el sistema de centros de salud comunitarios del estado durante los próximos nueve meses.

Rol vital en el sistema de salud

Las clínicas comunitarias juegan un papel importante en el servicio a pacientes que de otro modo terminarían en una sala de emergencias. Erikson dijo que su organización está tratando de aliviar la presión sobre el sistema hospitalario al ver pacientes con problemas de atención médica urgentes no relacionados con COVID-19.

“Por ejemplo, a un paciente para el cuidado de heridas que tiene diabetes subyacente no quieres exponerlo a un posible entorno con COVID-19”, dijo Erikson.

Algunos líderes de clínicas comunitarias también se preocupan por perder personal debido a una infección real o sospechada por coronavirus.

“Es muy crítico que las clínicas permanezcan con todo el personal, de modo que solo aquellos que están gravemente enfermos vayan al hospital”, dijo Sheila Berschauer, directora ejecutiva de Moses Lake Community Health Center, un proveedor de atención médica rural en Washington que atiende a un tercio de la población de su condado, de aproximadamente 100,000 residentes.

Si incluso cinco a 10 trabajadores de salud se enferman, dijo Berschauer, eso podría afectar su organización y, como resultado, posiblemente abrumar al hospital local.

Berschauer agregó que algunos pacientes aún no se dan cuenta de la gravedad de la pandemia y se enojan cuando se los deriva al sitio de prueba al aire libre en lugar de a la clínica.

Un trabajador de alud en un centro en las afueras de Seattle dijo que varios pacientes han tergiversado sus riesgos de COVID-19 para pasar el examen.

“Recibimos una paciente que logró pasar todos los controles y llegó ante un médico para recién entonces revelarnos que su pareja está expuesta a COVID y que se siente enferma”, dijo un empleado (le preocupa perder su trabajo por hablar, por lo que NPR y KHN no están usando su nombre).

Los trabajadores de salud que vieron al paciente no usaron equipo protector porque esos suministros limitados están reservados para pacientes con riesgo conocido de COVID-19.

“Ahora todos los proveedores y el personal de esa instalación deben comenzar a autocontrolarse para detectar signos de infección”, dijo el empleado. “Si se infectan, entonces toda la clínica cierra. Es un problema muy grande”.

Esta historia es parte de una asociación entre NPR y Kaiser Health News

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Must-Reads Of The Week From Brianna Labuskes

Hello! We have once again reached Friday, and I’ll do my best to give you a snapshot of the biggest health news from the week. But, first, I must dispel some bad advice that I’ve seen: Everyone wants to see your pet on those video conferences! Don’t hide them away in this time of need! Show us the doggos, the cats, and the … whatever this is. (A porcupine, I think?) Also make sure you’re following DogsOfKFF on Twitter for some of the best content on that social media platform.

All right, onto the news.

As predicted, the United States has surpassed China in the number of confirmed coronavirus cases, with nearly 93,000 to China’s nearly 82,000, as of 1 p.m. ET Friday. According to Johns Hopkins’ tracker, we also have surpassed 1,300 recorded deaths. (Worldwide, we’re at more than 566,000 and over 25,000 deaths.) Meanwhile, all that data comes with an asterisk in that most experts believe there are far more cases going unrecorded either because of testing flaws or overwhelmed state health departments that can’t keep up. Either way, not exactly something we want to be first in.

Meanwhile, the House came back to Washington to approve the $2.2 trillion stimulus package the Senate managed to send through this week (more on that in a second), despite concerns over lawmakers’ safety. There had been (dim but existent) hope earlier in the week that the House might be able to pass the legislation by unanimous consent. But that seemed too easy to be true, and it was. Concerns that a voice vote would be derailed by objections from a libertarian Kentucky lawmaker went unrealized, and the House passed the legislation Friday afternoon. The bill now goes to President Donald Trump, who is expected to sign it.

So what exactly is in that legislation?

— Direct payments of $1,200 to millions of Americans, including those earning up to $75,000, and an additional $500 per child

— $100 billion for grants to hospitals, public and nonprofit health organizations and Medicare and Medicaid suppliers, including a 20% bump in Medicare payments for treating patients with the virus

— $221 billion in a variety of tax benefits for businesses, including allowing businesses to defer payroll taxes, which finance Medicare and Social Security, for the rest of the year

— More than $25 billion in new money for food assistance programs, like SNAP

— Expanded jobless aid, providing an additional 13 weeks and a four-month enhancement of benefits, and extending the payments for the first time to freelancers and gig workers

— $377 billion in federally guaranteed loans to small businesses and the establishment of a $500 billion government lending program for distressed companies

— Millions in aid for states to begin offering early voting or voting by mail

— A rule that blocks foreclosures and evictions during the crisis on properties where the federal government backs the mortgage

— The suspension of federal student loan payments for six months and waives the interest

Predictably, some sectors (like cruise ships) were unhappy with being left out, but for once some people were pleased — for example, the hospital industry, which got the $100 billion it asked for.

For those of you, like me, who love a good tick-tock, here are a few inside looks at how Senate leaders and White House advisers struck a quick, expansive deal in a Washington that typically seems incapable of compromise.

The New York Times: As Coronavirus Spread, Largest Stimulus in History United a Polarized Senate

Politico: Inside the 10 Days to Rescue the Economy

The Washington Post: The Dealmaker’s Dealmaker: Mnuchin Steps In as Trump’s Negotiator, but President’s Doubts Linger With Economy in Crisis

The urgency of the legislation was underscored by an astronomical jump in jobless claims this week. Nearly 3.3. million Americans applied for benefits, up from 200,000 during pre-outbreak days. The “widespread carnage,” as one economist put it, is expected to get worse. While the stimulus package is expected to help mitigate some of the devastation, many have said it should be looked at as just the beginning.

It seemed strangely appropriate this week that the health law turned 10 amid a pandemic — the legislation’s journey to here has been anything but smooth, why should this anniversary be? But one ripple effect of the pandemic and economic fallout might actually be a boost to the health law, which is likely to serve as a crucial safety net for many Americans who possibly lost their employer-sponsored coverage in the past few weeks. States have already started reopening their marketplaces, and the federal government is being urged to follow suit.

Trump chafed this week at the drastic measures states are putting in place to try to curb the outbreak, raising eyebrows when he said he’d like to see church pews full by Easter. Public health experts have warned that lifting the social-distancing measures would result in a surge of cases that slam an already stretched-thin hospital system. But for Trump, who has tied his reputation to the well-being of the stock market, the economic toll seems too much. (The rhetoric also started a truly bizarre push from conservatives for older Americans to sacrifice themselves for the good of the country.)

The president’s most recent proposal to kick-start parts of the country is identifying places by risk level and applying strategies to match. But experts, like Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, warn that even “cool spots” that aren’t seeing many cases might be in for a surge coming down the pike.

Meanwhile, Gov. Andrew Cuomo has said that New York’s experience presages America’s future. But some say that’s not necessarily accurate. Leading specialists say that while it is likely that devastation similar to New York’s will emerge in other places, there’s hope that in lower-density areas, where there are fewer factors like mass transit to exacerbate the spread, the outcome might be different.

Realistically, though, Americans will need to eventually think about returning to normalcy. Are there exit strategies from this complete lockdown that would work effectively? Here’s the problem: All the experts say success relies on extreme, aggressive and widespread testing to isolate the sick before they can give it to anyone. This has not exactly been America’s strong suit in recent weeks.

There are two storylines that have taken hold to demonstrate how much this pandemic will strain the hospital system, the first being the lack of ventilators available. States and hospitals have been pleading with the federal government to invoke war powers to jump-start the manufacturing process on the equipment. This comes as doctors are being forced to split ventilators between patients (a risky practice), planning to make the tough ethical decisions to ration care, creating policies to not resuscitate, searching for alternative treatments despite the dangers they might pose, and being warned that morgues are reaching capacity.

But Trump, who had been set to announce a partnership with GM to produce up to 80,000 ventilators, balked this week at the $1 billion price tag that came with it. “I don’t believe you need 40,000 or 30,000 ventilators,” he said, in a reference to New York, where Gov. Andrew Cuomo has appealed for federal help in obtaining them. “You go into major hospitals sometimes, and they’ll have two ventilators. And now all of a sudden they’re saying, ‘Can we order 30,000 ventilators?’”

The second notable thread throughout the country is a lack of personal protective equipment for health care workers on the front lines of the epidemic. There might be a long medical tradition of accepting elevated risk in the middle of a crisis, but many health care workers are frustrated that they’re being put in that position. Some are resorting to using hand-sewn masks, which do little to protect them and trash bags for surgical gowns. But others are drawing a line in the sand.

Meanwhile, something that might get missed with everyone’s attention directed at the coasts: Atlanta’s mayor is warning that its hospitals are at capacity.

Gilead, whose antiviral drug is getting a lot of buzz, was granted orphan drug status for the treatment because there are fewer than 200,000 cases of COVID-19 in the States right now. The designation would have granted Gilead lucrative perks, like the ability to keep generic competitors from the marketplace. But the news was meant with rage-filled incredulity from, uh, pretty much everyone, and so the company rescinded the request. As one expert said: “I think it’s embarrassing to take something that’s potentially the most widespread disease in the history of the pharmaceutical industry and claim it’s a rare disease.”

Meanwhile, an antimalarial drug is getting tons of attention after Trump touted it as a possible game changer. But a new, more carefully constructed study that finds it did little to help patients in China shows why people shouldn’t be looking for a quick, miracle cure. Researchers say this doesn’t disprove that the drug works but is a good check on expectations, especially when people are trying to self-medicate with the drug — resulting in shortages for those who need it for other illnesses and fatal consequences for others.

On the good-news front (there is some!), Moderna said there could be a vaccine ready for the fall for health care workers under emergency use authorization, ahead of the wider release that’s not expected to come for about a year.

And another treatment that some scientists are hopeful about is the practice of injecting recovered patients’ blood into new patients. The strategy is at least a century old but has scattershot results. “It’s not exactly a shot in the dark, but it’s not tried and true,” says one scientist. Still, in this era, people are willing to try what they can.

And here are some other interesting stories to get you through the weekend.

Federal Response:

Politico: Trump Team Failed to Follow NSC’s Pandemic Playbook

Politico: Those Who Intentionally Spread Coronavirus Could Be Charged As Terrorists

The New York Times: As Coronavirus Surveillance Escalates, Personal Privacy Plummets

2020 Elections:

The New York Times: Joe Biden, Struggling for Visibility, Faults Trump’s Response to Coronavirus

The New York Times: Is All of 2020 Postponed?

From The States:

Stateline: One Governor’s Actions Highlight the Strengths — and Shortcomings — of State-Led Interventions

The New York Times: Governors Tell Outsiders From ‘Hot Zone’ to Stay Away as Virus Divides States

NBC News: Entire Senior Home in New Jersey, 94 People, Presumed to Have Coronavirus

Science And Innovation:

The New York Times: The Virus Can Be Stopped, But Only With Harsh Steps, Experts Say

The New York Times: Warmer Weather May Slow, But Not Halt Coronavirus

The Washington Post: What Research on Coronavirus Structure Can Tell Us About How to Kill It

The Washington Post: The Science of Why Coronavirus Is So Hard to Stop

Reuters: Smokers Likely to Be More at Risk From Coronavirus: EU Agency

Public Health:

ProPublica: Domestic Violence and Child Abuse Will Rise During Quarantines. So Will Neglect of At-Risk People, Social Workers Say.

NBC News: Anti-Abortion Groups Seek Halt to Abortions During Coronavirus Pandemic

Politico: New York’s Health Care Workforce Braces for Influx of Retirees, Inexperienced Staffers

That’s it from me! Have a safe and healthy weekend!

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In Coronavirus Relief Bill, Hospitals Poised To Get Massive Infusion Of Cash

Congress is on the verge of approving a massive funding bill that would steer an unprecedented amount of cash to the nation’s hospitals that are or soon will be struggling to cope with the COVID-19 pandemic.

While the bottom-line number for that aid is close to $200 billion, it remains to be seen how fast the federal Treasury will move the money and whether it will get to where it is most needed.

“It provides what we asked for,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents for-profit facilities. “Are all the resources here the right ones? We’ll find out.”

The Senate, after nearly a week of negotiations among Republicans, Democrats and the White House passed the bill Wednesday night. It is scheduled for a vote in the House on Friday.

About $100 billion of the funding is intended to, as the bill puts it, “reimburse … eligible health care providers for health care related expenses or lost revenues that are attributable to coronavirus.”

Hospitals are experiencing something unique in this pandemic. Not only are they being forced in many cases to turn away their usual sources of revenue, like joint replacements and other elective procedures, but they are also experiencing a surge in very sick COVID-19 patients likely to consume large amounts of hospital resources for a long time.

That $100 billion will be administered by the U.S. Department of Health and Human Services’ assistant secretary for preparedness and response. The position was created by a 2006 law passed in the wake of Hurricane Katrina intended to centralize authority over public health emergencies. Among other things, the office oversees the Strategic National Stockpile, which stores drugs and other medical equipment to be used in emergencies.

But already people spot potential trouble spots in this bill. That so-called preparedness office “does not have the capacity to run such a massive provider payment program,” wrote Kim Monk, a health policy consultant with Capital Alpha Partners, in a note to clients and reporters. “It will be a major challenge to distribute the funds in an equitable manner and also fast enough to help hospitals and other providers financially devastated by the pandemic, primarily due to the deferral of lucrative elective procedures.”

Christopher Holt of the conservative American Action Forum wrote in his summary of the bill: “Unfortunately, there isn’t much detail in the legislative text regarding this $100 billion or how it will be disbursed.”

That ambiguity hasn’t stopped hospitals from already jockeying to make sure they get their share.

“The money needs to not run out before you get to the big places,” said Dr. Atul Grover of the Association of American Medical Colleges, which represents teaching hospitals. While the federal funds might be the difference between staying open and having to close for some smaller, rural facilities, he said, the large, urban hospitals have a “larger magnitude of losses and concentration of patients.”

But while urban hospitals are caring for the bulk of patients, the need for financial help in rural areas is even more dire, said Maggie Elehwany of the National Rural Health Association. “A lot of these facilities were already vulnerable,” she said, adding that half of all rural hospitals “are already operating at a loss.”

Elehwany said that while rural hospitals are grateful for the help coming their way, the organization is unhappy that a specific amount was not set aside for rural health care. “They just don’t have the cash on hand to deal with this,” she said, particularly after having to close down outpatient and elective services.

The legislation is surprisingly vague on exactly how the money will be distributed, although most of those who have been working to shape it assume that HHS Secretary Alex Azar will likely have a major role to play. Typically a pot of money that large would come with strict formula requirements.

The bill includes several other provisions aimed at helping hospitals.

For example, under the legislation, hospitals would be given an immediate 20% bonus for costs associated with treating patients with COVID-19, the illness caused by the coronavirus. The federal government is also canceling a 2% across-the-board cut in Medicare reimbursements that was set up in an earlier budget bill and putting off some payment reductions planned for hospitals that treat large numbers of low-income and uninsured patients.

It also includes money to help hospitals buy protective gear for doctors, nurses and other personnel working with coronavirus patients.

And most hospitals would be able to collect a no-interest-for-a-year loan equal to a previous six months of Medicare funding they received. Hospitals in rural and other underserved areas would be eligible for 125% of that amount in advance.

But even that could be problematic, according to the National Rural Health Association’s Elehwany. “How are hospitals that are already operating at a loss going to be able to pay that back?” she said. Some of the facilities she’s been in contact with “only have cash on hand for the next couple of days” and are having difficulty obtaining needed supplies and keeping staff.

Kahn of the for-profit hospital group, who has been involved in nearly every major piece of health legislation for the past three decades, noted that “this is an unprecedented program by anybody’s definition. There’s never been a fund this large that was designed to be handed out in grants, particularly a fund with the expectation of all involved that it will be distributed very rapidly. But the crisis is upon us.”

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

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Under Financial Strain, Community Health Centers Ramp Up Coronavirus Response

On Tuesday, the Trump administration announced $100 million in supplemental funding for community health centers to support the response to the coronavirus pandemic.

“Health centers are playing a critical role,” said James Macrae, associate administrator at the federal Bureau of Primary Health Care.

About 29 million people in the U.S. rely on community health centers, which provide care to low-income and uninsured patients. As hospitals take on more COVID-19 patients, community health centers are reworking how they care for patients. Some safety-net clinics have instituted new infectious disease protocols and temporarily shifted resources away from routine primary care.

The new funding goes to 1,381 community health centers (many of which operate multiple clinics), primarily to support more COVID-19 testing, telehealth and the acquisition of personal protective equipment.

“It’s nowhere near what is needed, but we are thankful,” said Bob Marsalli, CEO of the Washington Association for Community Health, a group representing community health clinics in Washington state.

Marsalli said community health centers in the state are under increasing financial strain as they ramp up for the coronavirus battle, while also losing some key sources of funding.

“[Our clinics] are reallocating their workforce intelligently, but frantically, to keep up with the demand,” said Marsalli.

Rapidly Redesigning Systems

Under normal circumstances, HealthPoint, a community health center in Auburn, Washington, would encourage patients to walk into the clinic for all their medical needs, whether refilling a prescription or learning about nutrition.

“Usually our lobby is slammed,” said Dr. Esther Johnston. “It’s open space and everyone is together.”

But recently only a few patients in surgical masks were waiting for appointments. And Johnston is telling patients to stay away unless they absolutely need care.

“It is a bit frustrating and demoralizing, but it’s the reality of the situation,” she said.

HealthPoint runs more than a dozen clinics throughout western Washington. Now, at the entryway of its clinics, staff query everyone to identify COVID-19 symptoms and monitor patients to make sure they remain at a distance from one another once inside.

Johnston said the clinic was not set up to house an influx of patients with infectious diseases. There are limited exam rooms and each one needs to be shut down and cleaned after a patient suspected of having COVID-19 comes in.

“We just don’t have enough space to be able to do that on a routine basis,” she said.

Like many community health centers, HealthPoint’s model is built around bringing people into clinics for primary care. Now the organization is taking new precautions to prevent the spread of coronavirus and keep staff safe.(Will Stone for KHN)

Johnston worries about what’s coming as COVID-19 cases rise in her area.

“We pride ourselves on being a primary care home,” Johnston said. “We don’t have enough N95 masks, nor, to be honest, were we prepared for a situation where everyone had to be properly fitted.”

HealthPoint’s chief medical officer, Dr. Judy Featherstone, said most appointments are now done over the phone. Her staff is fielding calls from people concerned about symptoms, as well as new patients who want to have a doctor in case they contract the COVID-19 virus.

“It is a bit like taking 20 years of work and redesigning it in a week,” said Featherstone. “I think we are anticipating potential workforce problems.”

Like many clinics in Washington, HealthPoint has set up outdoor testing sites, but the supply of kits and personal protective gear, or PPE, limits the number of patients who can be tested for COVID-19.

New Financial Strain On Clinics

As fewer patients come in for care, the leadership worries about the center’s financial future. Clinics have switched to telephone-based appointments, but it took several weeks for Washington’s Medicaid program to adjust how it pays for those visits. Meanwhile, community health centers are eliminating routine dental visits, a key funding stream.

“You take those three factors … and you have already started to lose revenue before you’re gearing up for new ways of providing care,” said Michael Erikson, CEO of Neighborcare Health, which serves more than 70,000 Washington residents, over half of them on Medicaid. “We are on a pathway to losing $3 million a month.”

The Washington Association for Community Health projects that the cutback in dental care could lead to a $250 million shortfall for the state’s community health center system over the next nine months.

Vital Role In The Health System

Community clinics play an important role in serving patients who otherwise might have no place to go besides the ER. Erikson said his organization is trying to relieve some pressure on the hospital system by seeing patients with urgent health care issues not related to COVID-19.

“For instance, a wound care patient who has underlying diabetes, you do not want to expose that patient to a potential COVID environment,” said Erikson.

Some community clinic leaders now worry about losing staff to suspected or actual coronavirus infection.

“It is very critical that the clinics stay at full staff so only those who are critically sick are cared for at the hospital,” said Sheila Berschauer, CEO of Moses Lake Community Health Center, a rural health care provider in Washington that serves about a third of its county’s population of about 100,000.

If even five to 10 health care workers fall ill, Berschauer said, that could strain her organization and, as a result, possibly overwhelm the local hospital.

She said some patients still don’t appreciate the severity of the pandemic and become upset when they are sent to the outdoor testing site rather than into the clinic.

A health care worker at a health center outside Seattle said several patients have misrepresented their COVID-19 risks in order to get past screening.

“We had a patient make it all the way into the exam room before she revealed that her partner is COVID exposed, and she is feeling ill,” the employee said. The worker is worried about losing their job for speaking out, so NPR and KHN are not using the person’s name.

Health care workers who saw the patient were not wearing PPE because those limited supplies are reserved for patients known to be at risk of COVID-19.

“Now all of the providers and staff in that facility need to start self-monitoring for signs of infection,” the employee said. “If they get infected, then the entire clinic closes. It’s a big deal.”

This story is part of a partnership between NPR and Kaiser Health News.

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Trump’s Boast About U.S., South Korea Coronavirus Testing Misses The Mark

Boasting about his administration’s response to the coronavirus crisis — and arguing the outbreak would soon be under control — President Donald Trump claimed that recent American efforts to test widely for COVID-19 surpass those of other countries.

“We’ve done more tests in eight days than South Korea has done in eight weeks,” Trump said during a March 24 virtual town hall hosted by Fox News, reiterating a statement made just moments before by Dr. Deborah Birx, the head of the White House coronavirus response. The statement was repeated during the White House briefing that evening.

Trump doubled down the next day, tweeting that “over an eight day span, the United States now does more testing than what South Korea (which has been a very successful tester) does over an eight week span.”

Why the comparison with South Korea? South Korea has been heralded globally for its swift response to the pandemic, which appears to have slowed its rate of new infections. Meanwhile, a national shortage of tests has hamstrung American efforts, resulting in many people at risk being forced to delay testing until they are seriously ill.

With that context, we were curious. Is the president’s claim accurate? Has American testing been as robust as his statement indicates?

We contacted the White House and Centers for Disease Control and Prevention but never heard back. But the numbers suggest his picture is inaccurate and, more important, missing crucial context to understanding the battle against COVID-19.

The Raw Numbers

South Korea publishes a daily report of how many tests it has performed. As of Tuesday, 348,582 people had been tested, and testing began in early February. About 9,000 of those people were confirmed to have the virus. (The 345,582 figure includes tests that were run but hadn’t yet yielded results.)

In the United States, it’s harder to tell. The CDC doesn’t put out updated, aggregated counts of tests performed in public and private labs — which is important to note. Since the start of March, a large chunk of American-done tests have been conducted in commercial — not government-run — labs.

Experts pointed us to a credible tally that suggests that, on the raw numbers, the president’s stat is flawed.

The COVID Tracking Project, a dataset managed and updated by volunteer journalists and scientists, estimates that, as of Tuesday, American labs had performed a total of about 359,000 tests for COVID-19. That tally comes from state and local health departments around the country, including testing done in both public and commercial labs.

From March 15 through Tuesday, the United States conducted about 331,000 of those tests, per the tracker.

The raw comparison, then, suggests that the United States’ eight-day tally falls short of South Korea’s eight-week tally. Out of curiosity, we looked at the March 23 data for South Korea as well. At that point, it had run 338,036 tests. So even if Trump was off by a day, the American figure falls short.

And, experts reminded us, this raw-data comparison isn’t that meaningful. If you want to compare data between the two countries, you need to look at the bigger picture.

More Effective Comparisons

Put simply, “raw numbers are not the best metric, given population size differences,” said Jennifer Kates, a global health researcher at the nonprofit Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

That’s because the United States is simply a much larger country than South Korea — about 327 million people, compared with about 51.5 million.

To account for that, researchers serious about comparing the nations’ responses would adjust to per capita rates of testing. That shows the extent to which the number of tests performed gauges how many people are at risk of infection.

“If a country has five people in it, of course they could only have five tests,” said Dr. Robert Gallo, director of the Institute of Human Virology at the University of Maryland School of Medicine and a co-discoverer of HIV.

When you control for population, the American response compares poorly. Its tally of 359,000 tests per 327 million people works out to about 1,084 tests per million. South Korea has run closer to 6,768 tests per million.

Put another way, South Korea’s testing rate for coronavirus is more than six times that of the American rate. To catch up, Kates noted, American labs would need to perform 2.24 million more tests — not an insurmountable task, but definitely a lift.

It’s not just the number of tests performed, either. Researchers have stressed repeatedly that the timing of when the tests were run is also a big part of the equation. Both nations reported their first cases on the same day, Jan. 20.

In the entire month of February, American labs ran fewer than 1,000 coronavirus tests, per the volunteer COVID tracker. (Government health officials had begun sounding the alarm in January.)

By Feb. 29, South Korea had completed more than 55,000 tests, with almost 30,000 awaiting confirmation, for a total of more than 80,000 tests performed.

“For the assertion … the U.S. has done more #COVID19 testing in the last 8 days than South Korea cumulatively, that doesn’t mean anything,” tweeted Dr. Eric Topol, a physician and researcher. “Nearly 0 tests were done for 2 months when they were desperately needed.”

What’s Needed Now

Many public health researchers say the U.S. is still not running enough diagnostics daily to meet demand — arguing that, though there has been significant improvement, labs need to be doing about 150,000 tests per day.

Right now, the COVID tracker suggests about 65,000 tests are being run per day. While that is a substantial increase from even a week ago, it’s still well below the target number.

Beyond testing, there’s the question of what happened after results were confirmed. Patients infected, epidemiologists argue, should be targeted, caught early and quickly separated from other people. That’s key to stopping the spread of the virus — and something that still hasn’t happened on a large scale.

“South Korea followed up tests vigorously to support isolation and quarantine — the steps needed to reduce spread,” said Dr. Joshua Sharfstein, vice dean for Public Health Practice and Community Engagement at the Johns Hopkins Bloomberg School of Public Health in Baltimore. “The U.S. has a long ways to go to develop this critical capacity.”

Our Ruling

Trump claimed that the United States has “done more tests in eight days than South Korea has done in eight weeks.”

The CDC has not put out comprehensive data on this. But independent work on the subject suggests the comparison is flawed. In eight days, the United States performed almost as many tests as South Korea did in eight weeks, but not necessarily more.

In addition, that statistic is relatively less important. The American rate of testing per capita is more than six times lower than South Korea’s. It’s certainly possible to catch up, but that hasn’t happened yet.

The president’s statement frames the data in a way that is misleading and doesn’t accurately represent the status of the American response to COVID-19. We rate it False.

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Hospital Suppliers Take To The Skies To Combat Dire Shortages Of COVID-19 Gear

Hospitals in the New York City area are turning to a private distributor to airlift millions of protective masks out of China. The U.S. military is flying specialized swabs out of Italy. And a Chicago-area medical supply firm is taking to the skies as well — because a weekslong boat trip across the ocean just won’t do.

The race to import medical supplies reflects a nationwide panic over a dwindling supply of the masks, gowns and other protective gear that health care workers need amid the growing coronavirus pandemic. Demand is outstripping what’s available due to a damaged supply chain heavily reliant on China and a struggling Strategic National Stockpile. U.S. manufacturing giants like 3M have not yet made up the difference.

A sweeping national survey out Wednesday drives home that nearly a quarter of hospitals have fewer than 100 N95 masks on hand and 20% report an immediate need for ventilators. In the hardest-hit areas, like New York City, the shortages are potentially life-threatening to patients as well as health care workers.

About 260 health systems representing 990 major hospitals responded to the March 16-20 survey by Premier Inc., a group purchasing organization that negotiates with suppliers for discounts. While the survey provides a fresh picture of nationwide hospital operations, the number of U.S. COVID-19 cases has soared tenfold since the survey began ― from fewer than 5,000 to more than 55,000 as of Wednesday afternoon.

“Absent additional interventions from the government or private sector, we don’t foresee the current status quo changing,” said Soumi Saha, senior director of advocacy for Premier. “And the current status quo is not acceptable.”

Saha said the national stockpile “is intended to be a band-aid, not a long-term solution.” Premier called on the Trump administration to either further implement the Defense Production Act to ramp up domestic manufacturing or provide more clear direction on which medical supplies are needed and streamline distribution. FEMA announced Tuesday it did not use the Defense Production Act for test kits after previously stating it would.

The alarm bells ringing from the hospital community come in contrast to a more subdued message from FEMA, which is helping hospitals procure needed goods.

“The private sector can directly purchase [personal protective equipment] from manufacturers and distributors, as they normally do,” FEMA press secretary Lizzie Litzow said in a statement. “The private sector can also accept donations from other private sector entities.” The statement pointed to a “how to help” document that outlines how individuals and companies can share supplies or other resources.

In recent days, volunteer efforts have ramped up to help health providers who’ve taken to Twitter and other social media with pleas for more protective gear. Grassroots efforts have sprung up, with veterinary, computer, construction and industrial businesses donating goods while sewing circles churn out cloth masks.

During a White House press briefing Tuesday, President Donald Trump said FEMA is distributing more than 8 million N95 respirators, 14 million surgical masks and 2.4 million face shields.

“The federal government is using every resource at its disposal to acquire and distribute critical medical supplies,” the president said.

3M, a major American manufacturer of the N95 masks, said on March 20 it had doubled its global output of the crucial N95 respirators and plans to further increase output. Currently, over 30 million industrial and health care specific N95s are being produced for U.S. health care use by the company each month. Shipments totaling half a million 3M masks were scheduled to start arriving in New York and Seattle on Monday from its South Dakota plant.

The influx of goods comes as health care providers are now using four to 10 times more protective gear once a COVID-19 patient enters their doors than they typically use. This has forced hospitals already dealing with cases to scramble even more than health care facilities yet to get any cases, though shortages are crippling all areas of the health care industry.

“It’s a total change in what we are used to as a society around availability,” said Cathy Denning, senior vice president of sourcing operations for Vizient, an analytics and advisory firm that also does health care group purchasing. “From our perspective, it’s this unbelievable place we find ourselves in — realizing we have a vulnerable supply chain.”

As the coronavirus crippled China, the center of commerce for low-margin products like face masks and sanitizing wipes, the U.S. supply chain began to fall apart. With global competition for the same safety gear, the crisis deepened, and big national suppliers aren’t coming up with enough products to meet the crushing demand.

And waiting about a month for a cargo ship of supplies to arrive from China is a luxury of time that hospitals cannot afford ― even though ships can carry over 10 times more supplies than a cargo plane could.

Medline, a Chicago-area medical supplier, started delivering face masks by airplane last week after manufacturing resumed in China. According to spokesperson Stacy Rubenstein, flying the supplies in will shorten the “manufacturing-to-dock” time by three to four weeks, and the firm will not be passing along the “significant increase in cost” to customers.

But the demand is still 300% higher than traditional inventory levels, Rubenstein said in an email.

Elsewhere, hospitals are reaching out to Michael Einhorn, president of Dealmed, the medical products distributor and supplier working with 12 New York metro area hospitals — desperate for products he cannot always secure.

“Does it cost the hospitals a lot of money? No question about it. But right now, that’s what they need to do to secure product,” Einhorn said. “We can’t wait for it to come overseas.”

He’s paying up to $40,000 for shipments arriving on multiple planes from Shanghai to New York’s John F. Kennedy International Airport and Los Angeles International Airport — and sometimes losing money due to the high shipping costs.

The other backstop for hospitals was the national stockpile, which has come up far short.

Despite receiving 49,200 N95 masks, 115,000 surgical masks, 21,420 surgical gowns, 21,800 face shields and 84 coveralls from the national stockpile, the Colorado Department of Public Health and Environment estimated in a press release Monday that those supplies would last approximately one full day of statewide operations.

Einhorn said that hospitals are panicking, having lost faith in the supply chain as they cannot find products they so desperately need.

“The strategic national stockpile, with all due respect, was a failure,” he said.

The hospitals reported in the survey that their supply of N95 masks are their chief concern, with the best-supplied hospitals having about a 10-day supply on hand.

Hospitals identified hand sanitizer as the second-most pressing shortage, with 64% of respondents saying they were already running out. Next was surgical masks, which provide less protection than the N95 masks. Nearly half of hospitals had fewer than 1,000 on hand; a quarter of them reported going through 1,000 per day.

To keep up with that kind of demand, Einhorn said, more needs to be done to secure the products from China.

“One of the things we have been asking for is assistance getting these products quickly from China to here,” said Einhorn. “Instead, we’re doing drives of people dropping off three boxes of face masks.”

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