The AHA is asking Congress for $100 billion for all hospitals to offset coronavirus costs, citing rural hospitals' inability to withstand huge losses for long.
This article was first published on Saturday, March 21, 2020 in Kaiser Health News.
Rural hospitals may not be able to keep their doors open as the coronavirus pandemic saps their cash, their CEOs warn, just as communities most need them.
As the coronavirus sweeps across the United States, all hospitals are facing cancellations of doctor visits and procedures by a terrified populace — profitable services that usually help fund hospitals. Meanwhile, the institutions also find themselves needing to pay higher prices for personal protective equipment such as face masks and other gear that's in short supply. Vice President Mike Pence called on hospitals nationwide Wednesday to delay elective surgeries to free up capacity and resources for future coronavirus patients.
The American Hospital Association responded Thursday by asking Congress for $100 billion for all hospitals to offset coronavirus costs, citing rural hospitals' inability to withstand huge losses for long.
"If we're not able to address the short-term cash needs of rural hospitals, we're going to see hundreds of rural hospitals close before this crisis ends," warned Alan Morgan, the head of the National Rural Health Association, which represents 21,000 health care providers and hospitals. "This is not hyperbole."
Well before the COVID-19 threat, rural health care's profitability had collapsed nationwide due to a combination of narrowing Medicare reimbursements, a larger share of patients lacking high-paying private insurance and the hollowing out of rural America. Given such pressures, more than 120 rural hospitals have been forced to close over the past decade.
Those hospitals in small-town America that have survived rely heavily on moneymakers such as elective surgeries, physical therapy and lab tests to make their razor-thin margins work. But, according to the Chicago-based Chartis Center for Rural Health, almost half of them still operate in the red.
So the added financial hit from the coronavirus outbreak could be the final straw for many rural hospitals — exposing the complicated business dynamics at play within the United States' critical public health infrastructure.
"This virus, and what it is causing for these hospitals, is the perfect storm that will close these hospitals at a time this country critically needs them," said Robin Rau, CEO of Miller County Hospital in southwestern Georgia. "This is going to be the death blow to them."
Two weeks ago, she started eliminating all medical services that were not urgent. She estimated that has cut off at least half of the hospital's revenue. Other CEOs warned similar cuts at their hospitals mean they won't make payroll in the coming weeks.
The National Rural Health Association, along with many rural hospital executives, is lobbying for immediate cash assistance, no-interest loans, Medicare reimbursement adjustments and other suggestions to alleviate the pain. The association favors a bailout plan being from Sens.John Barrasso (R-Wyo.) and Michael Bennet (D-Colo.), which in initial drafts called for the equivalent of a three-month advance based on hospitals' previous patient numbers, according to Bennet's office.
"Rural hospitals have already been closing their doors at startling rates, and this crisis will only exacerbate that fact," Bennet said in a statement to KHN. "There is an incredible opportunity for rural hospitals to shoulder some of the burdens of caring for patients and helping to meet possible bed shortages."
Still, many rural hospital CEOs worry any assistance may come too late.
"And yet I hear they're going to bail out the cruise lines? Really?" Missouri's Scotland County Hospital CEO Dr. Randy Tobler said.
As Tobler looks at his older, sicker, underinsured patient population, he said he is afraid the hospital, located on the state's northeastern rural border, might last only until May before running out of money for payroll.
"In the truly safety-net areas, we're being called to high duty," he said. "And we're running on fumes."
Michael Purvis, CEO of Candler County Hospital in Metter, Georgia, said he's already fallen into a negative cash flow situation in the past week. The number of patients coming to his hospital, which is about 65 miles outside Savannah, for profitable outpatient procedures has dropped by half as people in droves have canceled their surgeries, MRIs and physical therapy.
Purvis has implemented fever checks of people at the entrance. But he remains fearful that his billing staff could be forced to quarantine themselves if they fall ill — effectively shutting off the hospital's revenue.
"If my billers and coders stay healthy, I can make it to April, maybe end of June," Purvis said.
On top of the massive loss of revenue, Julie Jones, CEO at Community Hospital-Fairfax in northwestern Missouri, said she can only get specialty N95 respirator masks that offer critical protection for her front-line providers for about $5 each — more than 16 times the normal cost of 30 cents.
Angela Ammons, CEO of Clinch Memorial Hospital in Homerville, Georgia, said she has warned staff that if hand sanitizer and disinfecting wipes continue to go missing, she'll watch the video footage and fire on the spot anyone caught stealing supplies. And she is so worried about running out of protective equipment, she's asking any of her "crafty" staff with sewing machines to sew cotton masks.
"I would rather staff go in with a fabric mask than no mask at all," she said.
To be sure, rural hospitals are not as equipped as larger hospital systems to handle the most serious coronavirus cases. Many are not outfitted with ICUs or enough doctors and staff to handle multiple intensive care patients. That means they have to transfer those patients to larger hospitals.
Still, rural experts argue that their bed and health care capacity can be leveraged to keep potential coronavirus cases out of the major hospitals. Plus, rural facilities could be places for initial triage or eventual recovery care.
And if nothing changes, Rau worries, the country is about to lose this critical public health infrastructure.
"We can talk all we want about the cost of health care in this country in this ridiculous health care system we have," she said. "But at a time like this, who for a minute would think about getting rid of rural hospitals?"
[Correction: This story was updated at 9:25 a.m. ET on March 21 to correct the first name of the CEO of Clinch Memorial Hospital in Homerville, Georgia. Her name is Angela Ammons.]
Pharmacy staff who prepare IV drugs inside hospitals are the latest health care workers decrying a shortage of masks as they scramble to prepare medications for patients with everything from cancer to COVID-19.
The staffers wear surgical masks while preparing liquid medications injected into patients' veins to avoid breathing any droplets of saliva into the formulas, a crucial step in ensuring the medication remains sterile. Pharmacists are also in need of N95 masks to protect them as they counsel patients at hospitals — but tend to be behind front-line medical providers in line for protective gear.
The American Society of Health-System Pharmacists surveyed about 400 members about the shortages.
"I can tell you we had some very concerned members who indicated that they're in danger of running out," says Michael Ganio, a pharmacist and director of pharmacy practice and quality with the pharmacists' group. "Over half said their institution has implemented a conservation plan. It's something that's very concerning."
Medications that require sterile preparation include those needed for treating COVID-19 patients, such as medications to calm, sedate or paralyze patients on a mechanical ventilator. Other such medications could supply IV nutrition or boost the blood pressure of patients who develop sepsis or shock.
Geriatric and pediatric patients are also frequent recipients of sterile compounded medications because they need doses tailored to their weight or have age-related health problems that require specially made medicine they can tolerate.
The survey of hospital pharmacists, released Thursday, found that 15% of them have already seen a "major or moderate" disruption in surgical mask supplies. That meant they went without masks or used alternatives with "mixed or poor" results.
Nearly 20% of them reported that mask prices were marked up compared with December 2019. And 70% of pharmacists said their organizations had already implemented plans to conserve masks.
To be sure, these conservation efforts are more optimal for pharmacists, who use masks to preserve a sterile environment, than they are for front-line COVID-19 clinicians working in a contaminated environment.
University of Utah Health Hospitals are still receiving masks. But pharmacists are reusing masks for sterile drug preparation to conserve them for other staff members and patients who need them during the outbreak, said Erin Fox, senior director of drug information and support services at the University of Utah Health Hospitals.
"That will allow more PPE [personal protective equipment] to be available for front-line emergency department folks that need it way more than we do," she said, adding that there's guidance on how to safely reuse masks.
A tornado that cut through Tennessee this month is making things even more complicated in the state, said Mark Sullivan, the executive director of pharmacy operations for Vanderbilt University Hospital and Clinics in Nashville. That's because it damaged a warehouse that held hospital supplies.
"We are able to get masks," he said. "Given the tornado and coronavirus situation, they are obviously in short supply in our area."
Vanderbilt University Hospital and Clinics are also following guidelines for conserving masks and other personal protective equipment, like gowns and gloves, as demand has spiked, Sullivan said.
"It's just a tough situation we're all in, trying to make sure front-line folks have what they all need," he said. "And behind the scenes, we're just trying to make sure we have what we need to make safe products for patients."
Before coronavirus became a reality, pharmacists at NYU Langone Health used to change masks and gowns when they went out on break. Now, if that gear isn't soiled, they hang it up in a clean room and reuse it, said Arash Dabestani, the hospital's senior director of pharmacy. His team is also keeping all personal protective equipment in an electronically locked cabinet to control use.
For weeks, hospitals have been getting fewer masks than they ask for from their suppliers. Health care facilities were getting only 44% of the N95 masks and 82% of the surgical masks they ordered, according to a survey released March 2 by Premier, a group-purchasing organization that procures supplies for 4,000 U.S. hospitals and health systems.
Most of the masks sitting in hospitals are redirected to front-line staff who care for patients, said Soumi Saha, a pharmacist who is senior director of advocacy for Premier Inc.
Saha said many state laws require pharmacists to wear masks when mixing sterile compounds. Her fear, she said, is that if the mask shortage is dire enough, hospitals will move to an unregulated way to get those crucial medications to patients: bedside compounding.
That means that clinicians such as nurses would mix the medications right in the patient's room and put them straight into an IV, she said. She worries such a sudden shift means "we could start seeing a surge in unfortunate patient medication errors and patient harm."
Premier has asked the federal government to waive the state requirements on pharmacists wearing medical masks to mix compounds or allow them to use industrial masks or expired ones, Saha said.
For now, the choice is up to individual states, said Carmen Catizone, executive director of the National Association of Boards of Pharmacy. He said the national standards-setting organization that advises state boards, called USP, has urged states to make their own risk assessments when weighing whether to waive rules.
So far, California, Iowa and Connecticuthave made moves to relax the rules for pharmacists' personal protective equipment.
Interviews with California physicians on the front lines of COVID-19 offer a sobering portrait of a health care system preparing for the worst of a pandemic that could be months from peaking.
This article was first published on Wednesday, March 18, 2020 in Kaiser Health News.
On Tuesday, Dr. Jeanne Noble devoted time between patient visits to hanging clear 2-gallon plastic bags at each of her colleagues' workstations. Noble is a professor of emergency medicine and director of the UC-San Francisco medical center response to the novel coronavirus that has permeated California and reached into every U.S. state.
The bags were there to hold personal protective equipment — the masks, face shields, gowns and other items that health care providers rely on every day to protect themselves from the viruses shed by patients, largely through coughs and sneezes. In normal times, safety protocols would require these items be disposed of after one use. But just weeks into the COVID-19 pandemic, supplies of protective gear at UCSF are already so low that doctors and nurses are wiping down and reusing almost everything except gloves.
"It is not a foolproof strategy at all; we all realize the risk we are taking," Noble said. But as supplies dwindle, she increasingly finds herself asking the folks in charge of infection control at the hospital if they can make changes to protocols. "As days go by, one regulation after the other goes out," she said.
Noble is among the Bay Area physicians applauding the decision this week by seven Bay Area counties and multiple others across California to order residents to shelter in place for the foreseeable future, directives that are upending life for millions of people and shuttering schools and businesses across the state. Without swift and dramatic changes to curb transmission of the virus, hospital officials say, it is just a matter of time before their health systems are overwhelmed.
Interviews with California physicians on the front lines of COVID-19 offer a sobering portrait of a health care system preparing for the worst of a pandemic that could be months from peaking. In the Bay Area, the battle is being waged hospital by hospital, with wide variations in resources.
The tent where Noble tended to patients this week was set up to deal with a recent rise in people showing up with respiratory illness. Even without the coronavirus threat, UCSF's emergency room is a busy one, and doctors frequently see patients in hallways and other spaces. But the current outbreak makes that close contact unsafe. So instead, everyone who comes to the hospital is being triaged. Most people with fever, cough or shortness of breath are diverted to the tent, which is heated and has negative air pressure to prevent the spread of infection. For now, the pace is manageable, but Noble fears what's ahead.
Farther south, in Palo Alto, Stanford Medical Center was testing patients with respiratory problems in its parking garage. The private university hospital has more protective gear than the public one in San Francisco; a global scavenger hunt several weeks ago bolstered supplies, though Stanford, too, has adapted protocols to be more sparing with some items.
"We don't have an unlimited supply," said Dr. Andra Blomkalns, professor and chair of the Stanford School of Medicine's Department of Emergency Medicine. "But at least we're not looking at our last box."
The entire country is short on protective gear, a result of both the surging demand for such equipment as the virus spreads and the implosion of supply chains from China, where much of the equipment is manufactured.
Noble believes some equipment will need to be made locally. "If the [federal] government doesn't step in and force manufacturing of these products here now, we are going to run out," she said.
Empty supply closets affect everyone who needs care, including heart attack victims and people in need of emergency surgery, said Dr. Vivian Reyes, president of the California chapter of the American College of Emergency Physicians and a practicing emergency physician in the Bay Area.
"I know it's really hard for us Americans because we're never told no," she said of the shortfall of supplies. "But we're not in normal times right now."
And protective equipment isn't the only thing in short supply.
Until a few days ago, UCSF had to rely on the San Francisco Department of Public Health for coronavirus testing, and a shortage of test kits meant clinicians could test only the most critically ill. The situation improved March 9, when the university started running tests created in its own lab. First, there were 40 tests a day. By Tuesday, there were 60 to 80. But a new shortage looms: The hospital has just 500 testing swabs left.
Stanford pathologist Benjamin Pinsky built an in-house test that has been approved for use by the federal Food and Drug Administration. Since March 3, Stanford has used it to test more than 500 patients, 12% of whom had tested positive as of Tuesday. The university has been running tests for other hospitals as well, including UCSF. It's a dramatic improvement from a few weeks ago, when Stanford relied on its county lab.
Blomkalns saw a sick patient in mid-February, before the hospital had its own test kits, who had symptoms of COVID-19 but didn't qualify for testing under the narrow federal guidelines in place at the time. He went home, only to return to the hospital after his condition deteriorated. This time, he was tested and it came back positive.
In Santa Clara County, home to Stanford, 175 people have tested positive for COVID-19 and six have died. Late last week, the medical center's emergency department saw the highest number of patients in one day in its history. Blomkalns doubts it's because there are more cases in her area. "If you don't test, you don't have any cases," she said.
Blomkalns worries about staffing shortages as health care workers are inevitably exposed to the virus. As of Tuesday, one doctor in the Stanford ER had tested positive. At UCSF, six health care providers had.
Not all Bay Area hospitals are seeing a flood of patients. In fact, some have fewer patients than usual, as they have canceled elective surgeries in anticipation of a COVID-19 surge.
The doctors treating COVID-19 patients say nearly all who test positive have a cough. They complain of fatigue, body aches, headaches, runny noses and sore throats. While most people are well enough to recover at home, those who get critically ill tend to do so in their second week of symptoms, and can deteriorate very quickly, several doctors noted. "We are recommending that patients get intubated a little earlier than they might otherwise," said Reyes.
In general, officials are asking people who have mild cases of COVID-19 to treat their symptoms at home, as they would a cold or flu, and refrain from seeking care at hospitals. People experiencing shortness of breath, however, should definitely go to the emergency room, said Blomkalns.
For children, the criteria may be a bit different. Shortness of breath should trigger a visit, as should altered mental state, excessive irritability, or an inability to eat or drink, said Dr. Nicolaus Glomb, a pediatric emergency care physician at UCSF Benioff Children's Hospital.
Gov. Gavin Newsom said Tuesday that rough projections suggest the state could need anywhere from 4,000 to 20,000 additional beds to treat patients with serious cases of COVID-19.
The testing problems worry Noble, as do the equipment shortages, but not nearly as much as the potential for a lot of sick people. "I'm mostly worried about a tsunami of very ill patients that we're not equipped to take care of," said Noble.
Blomkalns isn't sure whether or when Stanford might exceed capacity, saying the caseload trajectory may hinge on how aggressively state and national authorities move to cut off routes of community transmission. "It all depends on what happens in the coming weeks and days," she said. "We know what we need to do, and we're doing the job."
KHN Senior Correspondents JoNel Aleccia and Jenny Gold contributed to this report.
The two top makers of the highly specialized swabs used to test patients for the novel coronavirus are straining to keep up with the demand, even as both the Italian and U.S. governments are working with them to increase production, including at a key manufacturing site in the midst of Italy's outbreak.
The nasopharyngeal swabs required for the coronavirus tests are quite different from your standard Q-tips — and the exploding need for them has created a bottleneck in the soaring demand for diagnoses.
The swabs have to be long and skinny enough to get to the nasopharynx, the upper part of the throat, behind the nose. They must be made of synthetic fiber and cannot have a wooden shaft. Nor can they contain calcium alginate, a substance typically used for swab tips in wound care, as that can kill the virus, according to the Centers for Disease Control and Prevention.
These swabs are currently singled out byCDC and Food and Drug Administration guidelines as suitable for most coronavirus testing. Once used, they're typically mailed in transportable vials full of a solution known as "viral transport media," which keeps the virus testable.
While last week's critical shortage was a reagent chemical used in the diagnostic tests, now the specialized swabs are in dire demand, according to Soumi Saha, a pharmacist who is the senior director of advocacy for Premier Inc., a group purchasing organization that procures supplies for 4,000 U.S. hospitals and health systems. As testing finally ramps up in the U.S., hospitals especially are having a hard time getting enough of these swabs, Saha said.
"We have folks that can't get a hand on any of them right now," Saha said. "Hospitals want to do their part and want to expand access to testing, but they're hamstrung by the fact that they can't access the actual swabs."
Former FDA commissioner Scott Gottlieb pointed out on Twitter on Monday that a lack of swabs could be the new bottleneck even as the number of sites with the capacity to test has increased, showcasing that the weakest link in the supply chain becomes the limiting factor.
Missouri has been among the places seeing a shortage of swabs, state Department of Health and Senior Services spokesperson Lisa Cox confirmed over the weekend. Ontario, Canada, plus counties in Washingtonand Michigan have announced that limitations on swabs were creating a logjam in their testing capabilities, according to news reports. Axios first reported on the national swab shortages last week.
Part of the problem lies in the nature of current test procedures for COVID-19. Typically, one needs to use two swabs per person: one swab for a flu test to potentially rule out the need for a coronavirus test, then another for the coronavirus if the flu test is negative.
Since the swabs are a product that is regulated, patented and specialized, they're hard to make on the fly, Saha said. That puts additional pressure on the two largest manufacturers.
One of them, Puritan Medical Products, based in Guilford, Maine, has been working to keep up with demand even as its workforce, like many in America, has been affected by the spread of the virus, spokesperson Timothy Templet said.
The U.S. Department of Health and Human Services, along with working groups from the White House and other federal agencies, has been in discussion with the company over the past week to redirect some of their manufacturing capabilities away from other clients to COVID-19 specialty swab production, Templet said.
Currently, Templet estimated, Puritan is producing between 800,000 and a million swabs a week that could go to COVID-19 efforts. If the government decides to redirect its manufacturing efforts, cutting off the supply of its other medical products for items like flu kits, it could make millions more.
Still, Templet said that ramping up production so drastically would take a few weeks to get fully off the ground, considering manufacturing capabilities and protocols.
Templet said HHS plans to open 37 testing sites across the country in the coming days to account for increased testing needs — which will require even more specialty swabs. He also said the government is considering expanding its recommended testing material options to allow for more general nasal swabs to keep up with the increased testing demand.
FDA spokesperson Stephanie Caccomo said in an email that the agency is aware of "supply chain pressures on obtaining certain materials for running tests" and that it is continuing to evaluate other options for specimen collection supplies, which it will list on its website.
Another specialty swab manufacturer, Copan Diagnostics Inc., which is based in the Lombardy region of northern Italy, is working 24/7 in a "tremendous effort" to produce products such as its CDC-recommended and patent-protected FLOQSwabs, all while asking customers and distributors to ration orders to maximize output, spokesperson Gabriela Franco said in an email.
While produced in a region hit hard by the novel coronavirus, where most other work has stopped, Franco said, the Italian government has allowed the business to continue production. And it is working with local and national authorities on keeping production up in case stricter health restrictions are adopted.
Copan could produce 720,000 specialized swabs in a day and as many as 100 million per year for the global market, according to records the firm filed in a 2018 patent lawsuit.
Amid the crunch, Copan CEO Stefania Triva said in an emailed statement that her company is working round-the-clock to keep up with demand.
"Without full commitment and sacrifices from all of my staff, we would not be able to meet this unexpected demand," Triva said. "COPAN's more than 660 members of staff, many of whom are women, without hesitation, once made aware of the Coronavirus emergency, have stepped up from five working days and two shifts to seven working days and night shifts also."
The volume of Copan swabs arriving in the U.S. has been increasing, according to data from Import Genius, which tracks container ships arriving in American ports. Six tons of Copan culture swabs arrived at the port of Norfolk, Virginia, on March 4. Before that, 4.5 tons of swabs arrived at the same port on Jan. 20. The swabs then tend to go to domestic test-kit assemblers that package them for health care use.
New Jersey-based Becton, Dickinson and Co., a leading assembler of those kits involvedin ramping up coronavirus testing, has seen extremely high demand for swab products this year, company spokesperson Troy Kirkpatrick said. But now that Copan is "running operations 24/7" to increase production, Kirkpatrick said, "we will be providing hundreds of thousands of swabs to the U.S. market each week."
As university campuses close and disease prevention efforts intensify, hospitals, nursing homes and other health care venues in California and nationally are canceling clinical rotations for student nurses.
This article was first published on Tuesday, March 17, 2020 in Kaiser Health News.
Yet another casualty of the COVID-19 pandemic may be the clinical training that's so essential for America's future nurses and doctors.
As university campuses close and disease prevention efforts intensify, hospitals, nursing homes and other health care venues in California and nationally are canceling clinical rotations for student nurses — and, in some cases, medical students. The rationale is to protect both students and patients from getting sick and to reserve personal protective equipment, including masks, that may be in short supply.
But medical educators worry the students won't get the hours of direct patient care experience required to graduate on time, slowing the pipeline of new health care professionals precisely at a time when the country may need them most.
"We are in unprecedented times," said Dr. John Prescott, chief academic officer of the Association of American Medical Colleges. "Medical education hasn't faced anything quite like this since the beginning of the second World War."
The risk that hospitals and other health care facilities fear was underscored this month when an instructor was diagnosed with COVID-19 after bringing a group of nursing students to the Kirkland, Washington, nursing home where at least 63 residents have been stricken by the illness — 29 of them fatally, as of Monday afternoon. Those students are now in self-quarantine.
On March 5, Kaiser Permanente requested that nursing schools temporarily discontinue student clinical rotations in its 21 medical centers in Northern California. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.) "We are in a dynamic situation and our highest priority is ensuring the safety of KP members, staff and students participating in clinical training," a Kaiser Permanente executive wrote in an email to the nursing schools obtained by KHN.
Two other large hospital chains in California, Adventist Health and Dignity Health, soon followed suit.
As a result, the nursing schools at the University of California-Davis and Samuel Merritt University have had to scramble to find new clinical training opportunities for dozens of students. Some landed at the University of California-Davis' medical center or clinics and others at Veterans Affairs hospitals.
Nursing education leaders in California appealed to the state's Board of Registered Nursing on Thursday to ease the number of on-site clinical hours required for student nurses to graduate and allow them to learn from simulations instead.
State law requires nursing students to receive 75% of their clinical training in health care settings such as hospitals or nursing homes approved by the board; only 25% can be completed using simulations, such as computerized mannequins. The educators, in a letter to the board, requested that students be allowed to do 50% of their training through simulation.
"Many schools in California are experiencing serious clinical displacement. The effects of the lost clinical hours will be devastating to the students we serve," more than 60 officials from community colleges and nurse training programs around the state said in the letter.
As of Monday, Board of Registered Nursing officials had not responded to a request for comment.
Even before the COVID-19 pandemic, some private nursing schools had pressed state regulators to allow more simulation training, arguing it has advanced to the point where it can be as effective as training in a hospital or clinic.
The move to cancel clinical training is the opposite of what happened during the 1918 flu pandemic, when student nurses were called to hospitals to care for patients. Some fell sick and died along with those in their care.
Most hospitals have not canceled clinical rotations for doctors-in-training, but some have, and Prescott, of the Association of American Medical Colleges, said more may do so in the coming weeks.
On Thursday, the University of Arkansas for Medical Sciences asked all its students to immediately leave their clinical rotations to prevent the spread of COVID-19. The University of North Carolina School of Medicine canceled clinical rotations for visiting students from other medical schools from March 30 to April 24.
Some teaching hospitals have banned medical students from emergency and intensive care units while allowing them elsewhere in their facilities.
For medical students in the University of California system, clinical training continues for now, but they've been directed to avoid contact with suspected or confirmed COVID-19 patients, as have medical students across the nation.
One Baltimore nursing student learned Friday that her psychiatric nursing rotation had been canceled for at least two weeks. She must complete more than 100 more clinical hours before graduation in May and has no idea whether her school, the University of Maryland, would be able to quickly find her a new placement.
"I understand why they did it, for the precaution and the liability," said the 26-year-old, who asked that her name not be used to protect her future career prospects. "But I had eight shifts scheduled in those two weeks. I'm in a kind of panic mode, worried I'm not going to finish in time for graduation."
Amid the coronavirus crisis, a near empty bar screens the Democratic Party 2020 presidential debate between Democratic presidential candidate former Vice President Joe Biden and Democratic presidential candidate Sen. Bernie Sanders.
This article was first published on Monday, March 16, 2020 in Kaiser Health News.
In the midst of a global health crisis that has disrupted daily life and heightened anxieties for millions of Americans, former Vice President Joe Biden and Vermont Sen. Bernie Sanders on Sunday urged people showing symptoms of the novel coronavirus to seek medical attention without fear of the cost.
But the remaining major Democratic candidates offered two starkly different images of leadership in a time of crisis. Biden insisted that the federal government should help pay consumers’ bills in this unusual time, while Sanders focused on how the coronavirus pandemic underscores the need to overhaul the health system.
“This is a crisis. We’re at war with a virus,” Biden said. “It has nothing to do with copays or anything.”
The debate came just two days before the primaries in Arizona, Florida, Illinois and Ohio, contests in which Biden is expected to do well. His commanding wins in several states have given Biden a dramatic lead in convention delegates over Sanders.
The 11th primary debate took place without an audience on a television set in Washington, D.C., after being moved from Phoenix because of concerns about the virus spreading within crowds. It looked remarkably different from any debate in recent memory, let alone the last debate less than three weeks ago, when seven presidential hopefuls stood on the stage.
Following the guidance of health officials urging people to practice “social distancing,” Biden and Sanders replaced the traditional handshake at the contest’s start with something like a forearm-bump. They then took positions standing at least 6 feet apart.
Because both are considered at high risk of COVID-19 due to their age and, in Sanders’ case, a recent heart attack, the candidates said they were avoiding handshakes and crowds, with Biden moving to virtual campaign events while Sanders said he had held a fireside chat instead of a recent rally.
Sanders said the pandemic had emphasized the need to care for the most vulnerable, especially low-income Americans who feared unaffordable medical bills, lost wages or even lost jobs. He said even a bill just passed by the House and endorsed by President Donald Trump to support American workers had “enormous loopholes,” presumably referencing the exemption of large employers from its paid sick leave requirements. He said he planned to take steps to fix that.
“Let’s be honest and understand that this coronavirus pandemic exposes the incredible weakness and dysfunctionality of our current health care system,” Sanders said, pushing his “Medicare for All” plan that would replace the current health insurance system with a government-run program.
Biden responded that Italy, which has been overwhelmed by the virus’s spread, has a single-payer system and was not prepared for the emergency. He said Sanders’ talk of coverage inequality was important but misplaced in a time of immediate crisis.
Biden also criticized the Trump administration’s scattershot approach, pushing his own experience with the widespread Ebola outbreak in 2014 as part of the Obama administration.
The response, he said, “should be directed from the White House, from the Situation Room, laying out in detail like we did in the Ebola crisis, and we beat it.”
On points like this, the candidates went into greater detail:
Using The Military To Aid In the Coronavirus Response
Biden is right that the military added to hospital capacity during previous epidemics, but it’s not clear they were as large or as effective as he said they were.
We asked the Biden campaign for details but didn’t hear back. But there are a couple of potential past examples.
First, the Ebola crisis. While Biden was vice president, the U.S. military helped increase the capacity for treatment in Liberia. According to a 2014 White House press release, American efforts to curb the spread of the disease included “build[ing] additional Ebola Treatment Units in affected areas,” “establish[ing] a site to train up to 500 health care providers per week” and sending a “field-deployable hospital to Liberia.”
But it’s also important to note that the efficacy was limited, especially regarding the treatment units. An April 2015 New York Times report found that of the 11 Ebola treatment units the military built, nine had never treated a single patient with the disease. In total, they had treated only 28 patients.
It’s unclear, though, whether the Ebola units are the same as these 500-person tents Biden was referencing. We checked his campaign’s coronavirus plan. It does allude to deploying another existing resource: “multi-hundred-bed temporary hospitals” known as Federal Medical Stations.
These stations have been used in previous public health crises, including countless hurricanes over the past 15 years. They are, according to the Centers for Disease Control and Prevention, an important resource in building the health system’s holding capacity, especially in times of such difficulty.
Biden’s numbers are off, though. These temporary medical facilities can house between 50 and 250 patients and are treated as a stopgap when hospitals overflow. They can provide low-acuity care and other support. But that’s far short of 500-bed hospital equivalents.
— Shefali Luthra
Another Take On The Health System’s Capacity
Sanders is clearly not the only one to worry — and the facts are on his side. Public health experts are sounding the alarm that if the virus infects people quickly, and enough of patients show symptoms, the system will be overwhelmed.
In a March 12 op-ed in The New York Times, health policy experts pointed out that the nation has insufficient hospital beds, even if only 5% of the country contracts the illness. The authors — Ezekiel J. Emanuel at the University of Pennsylvania, James Phillips of George Washington University Hospital and Govind Persad at the University of Denver — specifically pointed to worries about “shortages of medical staff and equipment.”
Those worries are widespread. In New York state, Gov. Andrew Cuomo has suggested temporarily halting elective surgeries and re-certifying retired doctors and nurses. And if the virus afflicts health care workers, too, that would further constrain the system’s capacity.
Put simply, “we do not have anywhere near capacity to take care of tens of thousands of people with [COVID-19] who might need hospitalization,” Dr. Ashish Jha, a health policy researcher at Harvard University, recently told WBUR, the local NPR station.
A February report put out by researchers at Johns Hopkins University tallied a total of 46,500 intensive care unit beds across the entire United States. If the virus spreads at a moderate pace, the researchers estimated, 200,000 Americans would ultimately need ICU beds. A separate Hopkins report found only 160,000 ventilators in the country — enough for a moderate outbreak, but not enough if it spirals into something worse.
Not all those beds would necessarily be needed at once, of course. But that’s still a lot more sick people than beds — especially when you consider that many ICU beds are already in use for people with other medical conditions, such as the flu.
— Shefali Luthra
Beyond The Crisis
While coronavirus dominated much of the debate, Biden and Sanders also made claims about their support for reproductive rights.
Biden did earn 100% ratings from NARAL, the abortion-rights group, four times during his final years in Congress, but his framing in the debate left out several ratings that were much lower.
Biden received a 100% rating from NARAL Pro-Choice America in 2001, 2004, 2005 and 2006. That is based on how closely his votes aligned with the group’s priorities. Meanwhile, Biden was just below that in 2000 with a 90% rating and had a 75% rating in 2007.
In other years, however, Biden’s ratings from NARAL were significantly lower.
For instance, 17 years ago, in 2003, he earned a 36% rating. In 1999, his rating was 46%. In 1997, his rating was 34%. And in 1996, Biden’s rating was 43%.
It was only in 2019 that Biden backed off his long-standing support for the Hyde Amendment, which bans the use of federal funds to pay for abortions. In 1994, for instance, Biden wrote to constituents that he had “on no fewer than 50 occasions” voted against federal funding for abortions. “Those of us who are opposed to abortions should not be compelled to pay for them,” he wrote, according to NBC News.
Sanders, for his part, has earned a 100% rating from the group consistently, going back to 1996.
This is Half True. Sanders has a point that he has consistently voted in favor of abortion rights when it comes to stand-alone votes on the Hyde Amendment. The amendment is a long-standing measure that bars federal dollars from being used to pay for most abortions.
But when broad spending packages that include a version of the amendment have come up, Sanders has voted to send them through numerous times. The amendment’s language is often plugged into the annual bills that fund the Department of Health and Human Services.
CNN’s Dana Bash, a moderator of the March 15 debate, asked Sanders about his voting for broad spending bills in June. He said that sometimes, “in a large bill, you have to vote for things you don’t like. But I think my record as being literally 100% pro-choice is absolutely correct.”
— Louis Jacobson and Bill McCarthy, PolitiFact
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
Dennis Carroll, former director of the pandemic influenza and emerging threats unit at USAID, says the corona virus represents just one in a wave of zoonotic diseases that have adapted to humans.
This article was first published on Monday, March 16, 2020 in Kaiser Health News.
When the federal government decided to investigate the threat viruses in animals posed to humans, Dennis Carroll helped lead the charge.
Carroll directed the pandemic influenza and emerging threats unit at the federal Agency for International Development (USAID) for nearly 15 years. In that time, he spearheaded Predict, a project that identified more than 2,000 zoonotic viruses, or germs in animals ― the viral "dark matter," as he characterizes it — that could also sicken people.
It operated under Presidents George W. Bush and Barack Obama, but the Trump administration opted to shut down the project. Its operations will cease later this year, Carroll said.
Carroll retired from the federal government and moved to Texas A&M University. He now heads the Global Virome Project, a nonprofit cooperative dedicated to tracking more of these threats and developing a database of viruses.
His work gains relevance as countries around the globe scramble to contain the novel coronavirus that has sickened more than 169,000 people worldwide as of Monday morning with an illness known as COVID-19. The virus, suspected to have jumped to humans from an animal, represents just one in a wave of zoonotic diseases that have adapted to humans, said Carroll.
That wave is likely to continue, he added.
"When you look back over the last 20 years, our whole approach to emerging viral threats from SARS onward has been to wait and react. Wait and react," Carroll said. "And that is a recipe for global disaster."
Carroll spoke with KHN's Carmen Heredia Rodriguez about the Predict program, the likelihood of another novel animal virus threatening humans and whether the world is prepared for this pandemic.
This interview has been edited for length and clarity.
Q: Can you tell me about the purpose of the Predict project and how it worked?
I designed the Predict project a little over 10 years ago. It was coming out of the experience with avian influenza ― the H5N1 virus — that sort of piqued everyone's attention back in 2005.
Predict was really an exploratory effort. Could we begin quantifying what that larger pool of future viral threats might be? By 2018-19, we were able to begin understanding, if you will, that larger viral "dark matter" — what was that unknown pool circulating.
We had it operating in 30 countries in Asia and Africa. Basically, it was a scientific discovery investment. Working with local counterparts in those countries to be able to go out into the field ― into the remote areas where wildlife was circulating and collect samples from bats, non-human primates, rodents, wherever they might be. The samples could be brought back to laboratories to identify novel viruses in those animals and characterize those novel viruses in terms of their relationship to known viruses.
Predict discovered more than 2,000 novel viruses from viral families we know have posed a past threat to people. We calculate now there are about a million and a half of which — maybe 500,000 to 600,000 ― could be potential threats to people. So, you can appreciate that if it took us 10 years to discover 2,000 viruses, really elevating this to the scale that we could discover a million new viruses, Predict was not adequate.
Q: Who is left doing this work?
Congress in the last appropriation in December did signal to USAID its interest in USAID continuing the discovery work and being part of a global partnership that would build the kind of atlas on viruses circulating that could pose a future threat. We now need to translate that support from Congress into USAID stepping forward and investing in this global partnership.
The Global Virome Project is looking to forge [that partnership]. Obviously, this [SARS-CoV-2] virus is a clear example of why a discovery and capacity-building venture like the Global Virome Project is important.
Q: Speaking of COVID-19, how big a threat are zoonotic diseases to humans nowadays?
They're extraordinary.
The threat posed by zoonotic diseases ― those are basically viruses circulating in animals and particular wildlife — is becoming more and more part of our natural landscape and is largely being driven by the increase in population around the world over the last century. If you and I were having this discussion a hundred years ago, we would've been talking about 1.8 billion people on this planet. We're now talking about almost 8 billion. With that comes all of the livestock and animal production to feed the human population. We've expanded our cities, our settlements, our agriculture into wildlife areas.
That means the frequency of interaction between people and wildlife is happening at a scale never before seen. We've calculated based on historical evidence that we're looking at two to three to four new zoonotic disease threats emerging every year. So, it should not come as a surprise that today we're talking about the COVID-19 virus.
Q: For you, what are some of the greatest obstacles to doing this work of predicting and identifying diseases with the potential to jump into humans?
Well, it challenges people to think differently. We can have the information at hand, but if you don't use that information to act, that becomes the big challenge. In the United States and around the world, we are a reactive culture. We're more comfortable waiting for something to happen and then react to it rather than be proactive, use knowledge that allows us to put in place capabilities to prevent future events from happening. So the biggest challenge we have is what you could think of as social engineering ― changing politicians', investors', communities' approach toward facing risk. Don't wait for it to kick your door in when you understand it is in your neighborhood. Step out and act on it now.
Q: For you, what does this outbreak tell you about the world's ability to predict and prepare for a pandemic of a novel virus of any kind?
We knew this was coming. Whether it was this coronavirus … or another influenza virus, we couldn't say that. But we know, as I've said before, the frequency is intensifying. And because of globalization and population movements, an event anywhere becomes a threat everywhere. So, first off, no surprise.
Secondly, I think what we've seen is the fragmentation of the global partnerships that have been forged over the last decade based on the experiences ofSARS, avian influenza, the flu pandemic of 2009 and Ebola. We've seen in the last several years the rise of political tensions, which have fragmented the global community. Our ability to act in a coordinated, forward-leaning way has been greatly compromised. We see that with our own country.
We learned about this virus over two months ago. Scientists took note, public health people took note. The political community could have, should have, taken note. In our own government, nothing happened. [Only this month] Health and Human Services actually put a tender out for urgently needed N95 face masks. They had 30 million face masks in their national strategic stockpile. They had months to bring additional masks. That puts front-line health workers at risk.
And then, in 2018, the White House closed the Global Health Security office in the National Security Council, which was the center for ensuring that the United States government had a forward-leaning capability to monitor what was happening around the world and to inform and guide all agencies in the United States about what needs to be done yesterday, not tomorrow. That agency was shut down, and there is an enormous vacuum. That left a vacuum that is clearly playing itself out in terms of leadership, global responsibility now.
Some hospitals have a surplus of the protective equipment and some not enough. The CDC is working on a system that would track the inventory across the nation.
This article was first published on Friday, March 13, 2020 in Kaiser Health News.
Masks, gloves and other equipment are crucial as health care workers face the COVID-19 outbreak. There is a strategic national stockpile that the U.S. government controls — but no one knows what, beyond that stockpile, is available in the private sector.
Some hospitals have a surplus of the protective equipment and some not enough. The Centers for Disease Control and Prevention is working on a system that would track the inventory across the U.S.
The big hurdle isn't the technology. The issue is getting hospitals comfortable sharing information about their preparedness — information that, until now, they have considered confidential.
Protective masks have become a hot commodity, even within hospitals. At Nashville General Hospital, for example, employees several weeks ago were casually approaching supply chain management director Tom Cooper and asking if they could have a box for personal use.
Cooper told them the masks were available only for "clinicians as needed, for their job duties."
And Cooper said he's feeling more protective of the supply his hospital has on hand — especially N95 respirators. General Hospital's distributor, Medline, already restricted orders of the respirators. Cooper said he can't get any more than his usual monthly allotment, even if he could afford it.
"Right now, we're OK," he said. "But next month, what could happen?"
'Panic Purchasing'
The CDC has tried to avoid such scarcity and the costs associated with shortages. Often, there's plenty of disposable protective gear to go around, but it's not always in the right places ahead of pandemics.
"It can result in 'panic purchasing,'" said Megan Casey, a nurse epidemiologist with the CDC. "This is where facilities buy as much as possible, just to be on the safe side."
Right now, public health agencies know only what's in government stockpiles of protective gear. Health and Human Services Secretary Alex Azar told Congress in recent weeks that the government has 30 million masks, even though 300 million may be needed. (The few U.S. companies manufacturing masks say demand in recent weeks has far outstripped their production capability, though they are ramping up.)
The nation's 6,000 hospitals have been more of a black box — now and in earlier epidemics. In past outbreaks — of H1N1 influenza, for example — some hospitals resorted to informal supply swaps on a street corner, according to project managers with the Center for Medical Interoperability, a Nashville-based nonprofit.
Last year, before COVID-19 emerged, the center was awarded a $3 million contract with the CDC to build a system that calls for hospitals to submit information about their real-time inventory. The information typically can be pulled directly from an institution's electronic medical record system. Using that accumulated data, the CDC should be able to use a digital dashboard to easily identify facilities with the greatest need.
"It could also, potentially, provide a tool for hospitals to request personal protective equipment from state or local health departments, stockpiles or even other hospitals that might have excess," Casey said. "We do see this as a potential opportunity for resource sharing and having those kinds of discussions."
Competitive Advantage
But the prospect of sharing supplies is where the business of health care makes cooperation hard even in a crisis, said Melanie Thomas. She's the chief information officer at Nashville General, one of the pilot sites for the CDC-sponsored project.
"It's difficult and scary sometimes to share data and equipment, especially with your competitors," Thomas said, "because you want to have the advantage."
Nashville General is the smallest of the pilot sites, which include Northwestern Memorial in Chicago and Nashville-based Community Health Systems, a for-profit chain of nearly 100 hospitals around the U.S.
Thomas acknowledged it's easier for her taxpayer-funded hospital to grant access to its inventory system because it doesn't have the buying power to stockpile equipment.
"That's never going to be our problem," she said. "We want the shared information because we're going to have just enough."
And when they run out, she'd like to know where to turn to get more.
A Theoretical Threat Becomes Real
The Center for Medical Interoperability started its work quietly, a few months before COVID-19 emerged. But the project managers have noticed a greater willingness to participate among major health systems now that a theoretical threat has become very real.
"We know … that their supply chains are under strain right now because these products, they come out of China," said Tommy Ragsdale, the center's director of strategy.
China needs the disposable equipment that is manufactured there for its own use. And only a handful of companies in the U.S. still make the protective gear domestically. One has orders for more than a billion masks.
"It has definitely created different discussions at the hospital and health system level than we were having in October or November," Ragsdale said.
The CDC has pumped an additional $600,000 into the data-sharing project, with an accelerated go-live date in May, Ragsdale said. The center plans to hold a webinar on April 1 for additional hospitals interested in participating in later phases.
At this point, the CDC said, there's no mandate for hospitals to participate. But Ragsdale said he hopes they will see the benefit: "This is clearly for the greater good."
This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News.
In one of the most sweeping moves yet by a nonprofit hospital system to reduce aggressive bill collection, VCU Health is halting seizure of patients' wages and removing thousands of liens against patients' homes, some dating to the 1990s.
"Health care needs to be more affordable for patients, and we want to be part of the solution," said Melinda Hancock, VCU Health's chief administrative and financial officer. "We believe that no hospital bill should change the economic status of a family."
The moves follow an investigation last year by Kaiser Health News that found VCU Health and Virginia's other major teaching-hospital system, UVA Health, pursued tens of thousands of patients over the years for overdue bills, sending many into bankruptcy.
Over six years, the state institution filed 36,000 lawsuits against patients seeking a total of more than $106 million in unpaid bills, a KHN analysis finds.
The practices included filing courthouse liens against the value of patients' homes and garnishing wages, many from workers at lower-pay employers, such as retailers and restaurants.
Canceling liens ends the threat that VCU Health, part of Virginia Commonwealth University in Richmond, will take big chunks of equity when family homes are sold. Liens can easily reach thousands of dollars per property. Virginia allows creditors to garnish up to 25% of someone's earnings.
"That is great news for VCU patients," said Jenifer Bosco, an attorney with the National Consumer Law Center who specializes in medical debt. "I don't recall hearing about other hospitals taking that step and canceling decades of past liens."
Because they accrued interest of 6% annually or more, old liens could let VCU and UVA seize amounts far higher than the original hospital and doctor bills.
Undoing decades of property claims will require VCU lawyers to visit every circuit courthouse across the state, "which could take up to a year to complete," said system spokesperson Laura Rossacher.
VCU's moves are "an instant way to create a lot of goodwill and relieve patients of an incredible financial and emotional burden," said Erin Fuse Brown, a law professor at Georgia State University who studies hospital billing. "UVA should do the same."
VCU and UVA are the two major teaching hospital systems in Virginia, taking in billions annually and recording tens of millions of dollars in profits. UVA Health is part of the University of Virginia, based in Charlottesville.
Virginia Gov. Ralph Northam, a pediatric neurologist, "is proud to see VCU Health System taking significant, in some cases historic, steps to scale back aggressive medical collections and address the pain it's caused," said his spokeswoman, Alena Yarmosky.
Both VCU and UVA, which are state-run, have increased financial assistance and discounts for uninsured patients since KHN published its reports.
VCU pledged earlier to end all routine lawsuits for overdue bills, which are the precursor to garnishments and liens. The latest move cancels such claims resulting from old suits and judgments.
The litigation also included more than 15,000 garnishment cases over that period, some for VCU Medical Center but mostly for the physician group, the data showed.
VCU will not refund money collected in the past.
"They have socked it to a lot of people," said Joseph Robinson, a Richmond church music director garnished last year for $851 by MCV Physicians for treatment he said happened years ago. "They were just going after anybody they could get."
VCU joins Yale New Haven Health among the few hospital systems that have forsworn routine patient lawsuits. Such systems still bill for overdue accounts and try to collect money, but they stop short of seeking the legal right to seize assets.
For its part, UVA has said it will substantially reduce patient lawsuits, seeking court judgments for overdue bills only from families making more than 400% of federal poverty guidelines. That's income of $86,880 for a family of three.
But its current policy of maintaining old liens and continuing to sue at least some patients makes it more aggressive than VCU.
On the other hand, UVA has made its new, wider financial assistance policy retroactive to July 2017 and in recent months has forgiven $15 million in debt for treatment after that date, said UVA spokesman Eric Swensen.
The system has also stopped wage garnishments "at this time," he said. UVA has said changes announced so far are a "first step." A community advisory council meeting monthly since last year will "inform and guide us as we explore changes to our policies," Swensen said. Recommendations are expected this summer, he added.
Neither UVA nor VCU has responded to repeated queries about exactly how many liens they hold or how much they collect in lien proceeds, garnished wages and bank accounts.
"Compared to the harm it causes for patients, I can't imagine that the hospitals are getting a significant amount of revenue from these legal actions," said Fuse Brown.
Hospitals say they see more and more patients who can't pay, even with insurance, because of stagnating incomes and rising insurance deductibles.
Budget legislation in Virginia's General Assembly is expected to increase funding for VCU's and UVA's indigent care programs as well as update the family-asset test for patients seeking financial assistance, which hasn't changed since 1985.
As reported last year by KHN, even $3,000 or $4,000 in a 401(k) or other retirement account could bar a patient from financial help. The legislation increases the asset-test threshold to $50,000, not counting a car and a house on less than 4 acres.
Another bill would prohibit the systems from suing or sending bills to collections before they determine whether patients qualify for Medicaid or financial assistance.
"We're on the right path now," said Jill Hanken, a health care attorney for the Virginia Poverty Law Center, which was behind the bill. "It was very important to put the brakes on these aggressive collection activities and force these hospitals to look more closely at their indigent care policies."
Health care finance experts continue to criticize both VCU and UVA for what they charge the uninsured before factoring in any financial assistance.
Last year, UVA increased its discount for the uninsured from 20% off list prices to 40%. VCU increased the discount from 25% to 45%. But at those levels patients still pay far more than the health systems' costs and far more than what the systems collect from the Medicare program for seniors.
"Until they reduce the amount they are trying to recover by adjusting their charge to what Medicare would have paid, people who owe debts will still face unreasonable demands," said Sara Rosenbaum, a health law professor at George Washington University.
The American Heart Association says that although aspirin can help people with previous heart attacks or strokes, its risks generally outweigh the benefits for others.
This article was first published on Tuesday, March 10, 2020 inKaiser Health News.
The large red-and-white bins at Walmart pharmacies across the country read, in bold all-caps type: "Approximately every 40 seconds an American will have a heart attack."
Inside the 3-foot-tall cartons, adorned with the American Heart Association and Bayer logos, were dozens of boxes of low-dose Bayer aspirin.
The implication was that everyone could reduce their heart attack risk by taking a "baby aspirin." But recent studies have found that's not the case.
In fact, the American Heart Association says that although aspirin can help people with previous heart attacks or strokes, its risks generally outweigh the benefits for others.
After Kaiser Health News inquired about the marketing bins, the heart association in late February said it is having Bayer, one of its major donors, pull them from Walmart — although the campaign was due to wrap up by the end of the month, anyway. But 10 days later, a reporter shopping at a Walmart in Florida found a bin still on display.
About a quarter of Walmart stores nationwide displayed the bins, the association said.
"This was a misstep," said Suzanne Grant, a spokesperson for the American Heart Association. "It was a human error on our end."
Aspirin helps keep the blood from clotting, so there is less chance that blockages will form in key heart arteries. For years, it was generally recommended as an option for healthy individuals to prevent heart attacks. But it also can lead to stomach bleeding, a serious side effect, and a number of studies have raised questions about the safety of aspirin use for people without cardiovascular disease.
Last year, after three new studies were published on the issue, the American Heart Association joined other medical groups advising against aspirin therapy unless a doctor recommends it.
The U.S. Preventive Services Task Force, an expert panel that makes recommendations on medical care, is reexamining its guidelines, which advise low-dose aspirin for people ages 50-59 who have a risk of cardiovascular disease and no history of bleeding problems. It also has noted that individuals ages 60-69 at risk of heart disease may want to consider the therapy, but it should be used selectively. Evidence for other age groups is inconclusive, the task force says.
Grant said the association approved the marketing bins without including "precise language" explaining that people need to talk to a doctor before taking aspirin regularly. That language is printed in smaller type on the Bayer baby aspirin packaging.
The bins promoted the heart association's "Life Is Why We Give," a fundraising effort. Bayer is a financial supporter of the campaign.
Dr. Eduardo Sanchez, the chief medical officer for prevention at the American Heart Association, said the bins could have given people the wrong impression and led to more liberal use of baby aspirin.
"Our position is that aspirin should be used sparingly, if at all, in people who have not had a heart attack or stroke," Sanchez said.
The heart association reviews all products and marketing that contain its logo, Sanchez said. It is unclear why or how the association allowed this display to occur.
"Any inference that Bayer's demonstration of support for the AHA's heart health initiatives could be construed as medical advice is simply preposterous," said Bayer spokesman Chris Loder. "The display contains no medical claims whatsoever and is merely intended to help the AHA raise awareness of a major public health issue."
The case highlights the ongoing challenge of communicating who should take aspirin to prevent heart attacks since the national guidelines changed a year ago.
But it also illustrates potential problems when large pharmaceutical companies team up with nonprofit health groups. Arthur Caplan, a bioethicist at New York University, said those types of connections can invite ethical questions about marketing.
Bayer gave nearly $1 million to the American Heart Association in the most recent fiscal year, according to the association's latest financial records. In all, the association received about $33 million from drug companies, medical device makers, insurers and health firms. It does not endorse any particular product.
But Caplan said the marketing displays at Walmart imply that AHA endorses the Bayer aspirin brand.
That's troublesome because, as the heart association has said, aspirin is recommended only for certain people to reduce the risk of heart attack, and the displays do not disclose that less costly, generic versions of aspirin are also available.
Doctors say they worry many patients still routinely take aspirin for protection without advice from a doctor.
"People see these displays and advertising on television and they think aspirin is like taking candy," said Dr. Jacob Shani, chair of cardiology at Maimonides Heart and Vascular Institute in New York. "The display makes it look like candy and you take this candy and you do not have a heart attack."
Still, Dr. Erin Michos, associate director of preventive cardiology at Johns Hopkins University School of Medicine in Baltimore and one of the physicianswho helped develop the heart association's new position on aspirin last year, said she has seen patients who should be taking aspirin who have stopped because they heard about the new guidelines. "There is a lot of misunderstanding," she said.
"Everyone needs to discuss with their doctor about whether aspirin is recommended for them," she said.