Promises made early on in the coronavirus pandemic that testing would be free are being rolled back in ways that are creating turmoil for consumers.

This article was first published on Monday, July 20, 2020 in Kaiser Health News.

By Julie Appleby

In advance of an upcoming road trip with her elderly parents, Wendy Epstein's physician agreed it would be "prudent" for her and her kids to get tested for COVID-19.

Seeing the tests as a "medical need," the doctor said insurance would likely pay for them, with no out-of-pocket cost to Epstein. But her children's pediatrician said the test would count as a screening test — since the children were not showing symptoms — and she would probably have to foot the bill herself.

It made no sense. "That's two different responses for the exact same scenario," said Epstein, a health law professor at DePaul University in Chicago, who deferred the tests as she clarified the options.

Early on in the coronavirus pandemic — when scarce COVID testing was limited to those with serious symptoms or serious exposure — the government and insurers vowed that tests would be dispensed for free (with no copays, deductibles or other out-of-pocket expense) to ensure that those in need had ready access.

Now, those promises are being rolled back in ways that are creating turmoil for consumers, even as testing has become more plentiful and more people — like Epstein — are being advised to get them.

Late last month, the Trump administration issued guidance saying insurers had to waive patient costs only for "medically appropriate" tests "primarily intended for individualized diagnosis or treatment of COVID-19." It made clear that insurers do not have to fully waive cost sharing for screening tests, even when required for employees returning to work or for assisting in public health surveillance efforts.

Left unclear are situations like that faced by Epstein — and others who seek a test to clear a child for summer camp or day care. Public health officials have been unanimous in the opinion that widespread, readily available testing is crucial for getting businesses and schools open again, and society back on its feet.

But who should bear the costs of that testing — or a share of them — is an unresolved question.

Who pays when all employees are required to have a negative COVID test in order to return to work? Or if a factory tests workers every two weeks? Or just because someone wants to know for their own peace of mind?

The questions may be compounded in some cities and states where tests are widely available at clinics or drive-thru centers. In New York, CityMD clinics bill insurers $300 for the service, according to an explanation-of-benefits document given to KHN by a patient. The related charge from the lab that processed the test, according to the same patient's insurance statement, was $55. Most patients don't have to pay a share of those amounts.

The clinic has a partnership with the city allowing anyone who wants a test for the virus to get one. Still, no test is truly free, as labs bill insurers or submit for reimbursement from government programs.

Until a recent spike in virus cases created long delays in many areas, some other regions also took a test-everyone-who-wants-a-test approach. While that is one way to get a picture of where the virus is spreading, it can also become a cash cow providing income to clinics and labs, as residents seek multiple "free" tests after each potential exposure.

In an email, a spokesperson for CityMD would not say how much the clinic is reimbursed for testing. The clinics do not bill for lab testing, she wrote, referring questions about those costs to the laboratories that process them.

Insurers will be making judgment calls — likely on a case-by-case basis — about how they will handle cost sharing for screening tests under the new Trump administration guidance.

What is clear: Insurers have argued against requirements that they waive all cost sharing for workplace COVID testing, noting they don't do that for other screening efforts, such as drug-testing programs. For now, insurers will "continue to pay for tests recommended by a doctor," Kristine Grow, spokesperson for AHIP, an industry group, wrote in an email to KHN.

But AHIP also sent a clear signal that it would not embrace cost sharing waivers for workplace or public health screening efforts. Earlier this month, the organization lobbied federal lawmakers to include funding in the next stimulus package for public health surveillance and workplace testing programs — a cost estimated between $6 billion and $25 billion annually in an earlier study commissioned by the group.

The Evolving Rules for Free Testing

The coronavirus relief legislation passed by Congress in March, and April guidance from the Trump administration implementing it, agreed that patients should not be burdened with payments for COVID testing and treatment that is "medically appropriate."

But as the pandemic has evolved and grown, the definition of that term has both broadened and become fuzzier.

The Centers for Disease Control and Prevention says testing is appropriate for people who fall into five broad categories, including those with suspected exposure and those required to be tested for "purposes of public health surveillance," which it defines as checking for disease hot spots or trends.

"There's definitely a disconnect between what public health experts are recommending for testing and how it's going to be paid for," said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

And tension is mounting among insurers, employers and consumers over who should pay. While insurers say employers should cover the cost for back-to-work testing, many employers are struggling financially and may not be able to do so. At the same time, workers, especially those in lower-wage jobs, also cannot afford out-of-pocket costs for testing, particularly if it is required regularly.

Among those waiting to hear if their insurance will cover the test is Enna Allen of Glencoe, Illinois, who urged her au pair to get a test after the young woman traveled to New Orleans. She had been on a plane, after all, and New Orleans has its share of COVID cases.

"I wanted her to have a test before she returned to work with my kids," said Allen.

As Allen called around to find a testing site, she explained the test was needed for employment — for someone with no symptoms. After some effort, she found a clinic that, for $275, offered a 15-minute rapid test and said it would accept her au pair's insurance.

"I'm assuming they [the insurer] will cover it unless I get a bill weeks from now," said Allen, who said she would pay the bill for her employee if that happens.

There is also a great gray area in deciding who should qualify for free testing after "suspected" exposure. What is suspected exposure? Sharing a small office with an infected co-worker? Participating in a protest? Or simply living in or visiting the Sun Belt, where community spread is accelerating?

"If the au pair went to a clinic and said she was just in New Orleans, and the doctor said that's enough of a risk to order a test, even though she doesn't have symptoms, my read of the guidance is the health plan has to cover it 100%," said Corlette.

Yet a child who's mainly been sheltering at home who needs a test before being admitted to summer camp probably would not meet the definition.

"That's a different story because it's harder to argue there's been exposure or potential exposure," said Corlette. "At the end of the day, there's many ways to interpret the guidance."

Congressional Democrats have accused the Trump administration in its new guidance of "giving insurance companies loopholes instead of getting people the free testing they need."

Insurers, patients and politicians have locked horns before when screening tests were billed differently than those same tests for diagnostic purposes, since the boundary is often unclear. Under the Affordable Care Act, for example, colonoscopy screening for cancer is "free," meaning no patient copayment. But if a polyp is found, doctors sometimes code the procedure as a diagnostic test, which can lead to hundreds or even thousands of dollars in copayments.

While vital, testing is costly — or can be. Medicare reimburses up to $100 for the COVID test. On top of that, there may also be costs associated with the office or clinic visit. And the price is widely variable in the private market, according to a report out last week by KFF, the Kaiser Family Foundation. Prices ranged from $20 to $850 for a single test. (KHN is an editorially independent program of the foundation.)

Media reports have shown tests average $100, but some labs bill insurers for thousands of dollars for each one.

Without a copay, many patients never learn how much their tests actually cost their insurers, which could lead to overuse.

Also, when patients are entirely shielded from the cost, test makers, labs and medical providers are more likely to seek price increases, said Heather Meade, a principal at Washington Council Ernst & Young.

In the end, consumers may still feel a resulting pinch in the form of higher premiums.

Wondering about the sharply different views of her doctors on whether her insurance would fully cover the cost, law professor Epstein called her insurer, which assured her the tests would be covered 100% at in-network providers with no copay or deductible, as long as they were coded correctly. The family will be tested soon, and it appears she's dodged a financial bullet. But Epstein cautioned in an email: "It's unclear to me how many insurers will maintain this policy."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

As public health workers scramble to summon enough of a workforce to address a once-in-a-generation pandemic, they're being pulled from normal mosquito-related tasks.

This article was first published on Thursday, July 16, 2020 in Kaiser Health News.

By Anna Maria Barry-Jester and Lauren Weber 

Bug spray, swollen welts, citronella. It's mosquito season.

The U.S. public health system has been starved for decades and lacks the resources necessary to confront the worst health crisis in a century. Read the investigation from KHN and The Associated Press.

And in a normal year, the health department serving Ohio's Delaware County would be setting out more than 90 mosquito traps a week — black tubs of stagnant water with nets designed to ensnare the little buggers.

But this year, because of COVID-19, the mosquitoes will fly free.

The coronavirus has pulled the staffers away, so they haven't set a single trap yet this year, according to Dustin Kent, the program manager of the residential services unit. Even if workers had the time, the state lab that typically tests the insects for viruses that infect humans isn't able to take the samples because it also is too busy with COVID-19.

That means the surrounding community, just north of Columbus, Ohio, has to wait until potentially deadly mosquito-borne illnesses such as that caused by the West Nile virus sicken humans to find out if the insects are carrying disease.

"It's frustrating knowing that we can do a more preventative approach," Kent said. "But we're stuck reacting."

In Washtenaw County, Michigan, mosquito samples aren't being collected because the health department didn't have the staff or ability to hire and train summer interns who would typically perform the work. In Houston, a COVID-19 hot spot, a third of mosquito control staffers are working the COVID call center, stocking warehouses and preparing coronavirus testing materials. And across Florida, public health officials couldn't test chicken blood for exposure to mosquito-borne viruses — chickens get bitten by the insects, too, so that can serve as a warning — at the overwhelmed state lab until mid-June, a task that normally begins in the spring.

Monitoring and killing mosquitoes is a key public health task used to curb the spread of deadly disease. In recent years, top mosquito-borne illnesses have killed some 200 people annually in the U.S. But that relatively low toll is due in part to the efforts of public health departments to keep the spread at bay, unlike in other countries where hundreds of thousands are sickened and die each year.

"Mosquitoes are the biggest nuisance and pest on this planet. Hands down," said Ary Faraji, president of the American Mosquito Control Association, a nonprofit that supports public agencies dedicated to mosquito control. "They are responsible for more deaths than any other organism on this planet, including humans."

This is a physical job that can't be done by telecommuting from home. Keeping track of mosquitoes and the diseases they carry requires setting up traps, and searching backyards and commercial lots. Public health workers patrol irrigation ditches and overturn the backyard tires, plastic bins and garbage that can hold standing water where mosquitoes breed.

Around the U.S., more than half of public health departments combat mosquitoes. In some states, including Florida and California, specific departments are dedicated to tracking and preventing their spread. The goal is to find infected mosquito populations and kill them before they get to humans, or at least warn the community about their presence as mosquito-borne epidemics are happening more frequently nationally as temperatures rise.

But a joint investigation published this month by KHN and The Associated Press detailed how state and local public health departments across the U.S. have been starved for decades, leaving them underfunded and without adequate resources to confront the coronavirus pandemic, let alone perform the other work like mosquito control they are tasked to handle at the same time. Over 38,000 public health worker jobs have been lost since 2008. Per capita spending on local health departments has been cut by 18% since 2010.

So as public health workers scramble to summon enough of a workforce to address a once-in-a-generation pandemic, they're being pulled from normal mosquito-related tasks. The short staffing is leaving many localities — especially those without separate, dedicated control districts — flying blind on potential mosquito threats.

The Centers for Disease Control and Prevention has stepped in to help and is now running mosquito testing for at least nine states, including Florida, Arizona and the Carolinas, said Roxanne Connelly, entomology and ecology team lead for the CDC's National Center for Emerging and Zoonotic Infectious Diseases, as well as evaluating human blood samples for mosquito-borne disease for 40 states. Concerned about the disruptions, the CDC issued a policy brief with the Environmental Protection Agency on Thursday, stressing that mosquito prevention and spraying of insecticides was an essential service that needs to continue even in a national health emergency.

"Mosquitoes are still going to be around, and still causing diseases, no matter what sort of pandemic is going on," Connelly said.

Even with relatively low rates of disease, in part because of limited testing to measure the problem so far this year, there are worrying signs. Fourteen people in the Florida Keys have come down with locally acquired dengue, which can cause fever, severe body aches and vomiting. Massachusetts has found its first mosquito carrying Eastern equine encephalitis, which kills approximately a third of people infected, according to the CDC. West Nile virus has been found in mosquitoes, birds or other species in at least 18 states and has infected people in nine.

"This year it's more of a wild card; we're not getting the surveillance we'd normally get," said David Brown, the technical adviser for the American Mosquito Control Association.

The flu-like symptoms of diseases like West Nile — fever, body aches — especially worry Nina Dacko, who supervises the mosquito control program for Tarrant County Public Health in Fort Worth, Texas.

"I wonder which cases are going to be missed as everyone is going to expect COVID and then move on when they test negative," she said.

Budget cuts are coming in waves as tax shortfalls rock local health departments. Three municipalities in Texas, including Watauga, Saginaw and Lake Worth, haven't sent any mosquitoes in for testing this year — they don't have the time, or have lost staffing and money due to revenue shortfalls from COVID-19, Dacko said.

Smaller health departments appear to be bearing the brunt of the problems, North Carolina state public health entomologist Michael Doyle said in an email, as they have fewer staffers to fight the coronavirus. Some larger departments and programs — like those covering Houston, California's Central Valley or Maricopa County, Arizona — say they've been able to operate close to normal.

And while public health officials say small outdoor gatherings are safest when it comes to avoiding exposure to the coronavirus, some worry that the risk of acquiring mosquito-borne diseases could rise.

"Everyone knows, if you're outdoors, that's where you're actually going to get exposed," said Chelsea Gridley-Smith, director of environmental health for the National Association of County and City Health Officials.

Labs swamped by COVID tests may be increasing that risk. Local governments often rely on the same public health labs to test whether mosquitoes are carrying diseases like West Nile, dengue or Eastern equine encephalitis that they do to test humans for infectious diseases, like COVID-19. As a result, much of the country is weeks behind where they would typically be in testing mosquitoes for the presence of dangerous diseases, Brown said.   

Stopping mosquitoes requires getting information in real time. If a mosquito is carrying West Nile virus, "you want to know that today, not two weeks from now," Brown said.

When the COVID pandemic hit Salt Lake City, which has its own labs to test mosquitoes, the mosquito department shared its materials with the labs testing for COVID-19 and donated N95 masks that its staff uses when spraying mosquito-killing chemicals, according to Faraji, who is also the executive director of the Salt Lake City Mosquito Abatement District. Utah has done about 5% of the mosquito testing it would usually do by this point, he said.

"Our underlying concern is that one public health emergency doesn't lead into another," Faraji said.

Any grand fix to the hole in the nation's current mosquito netting is going to require some serious cash, Gridley-Smith said, to allow for dedicated staffing, instead of expecting public health workers to juggle it alongside multiple other programs.

The Southern Nevada Health District — which includes Las Vegas — doesn't have a dedicated mosquito department. From April to October, workers there trap, collect and test mosquitoes for viruses, said Vivek Raman, who oversees the efforts. The rest of the year, the same team is in charge of sanitation for all the area hotels and mobile home parks, including those on the casino strip. But restaurant inspections, permitting and sanitation help pay their way.

"One of the challenges with mosquitoes is they don't pay permit fees," he said.

Several bills to support mosquito control efforts, including the Strengthening Mosquito Abatement for Safety and Health Act, have passed through Congress with bipartisan support in recent years but haven't been funded.

For the CDC's Connelly, the lack of dollars is just another part of the boom-bust nature of funding for health departments and mosquito control programs nationally. Infusions of cash after bouts with mosquito-borne Zika or hurricanes aren't enough to fully maintain robust programs, she said, and they often have to start over when the next crisis hits.

Raman and his colleagues did have plans this year to work with the CDC on a project to reduce the population of Aedes aegypti, an invasive mosquito species that can carry a range of deadly viruses, including Zika, and which first showed up in southern Nevada around 2017. That project is on hold until next year.

AP journalists Mike Householder in Canton Township, Michigan, Juan A. Lozano in Houston and Jeannie Ohm in Arlington, Virginia, contributed to this report.

This story is a collaboration between The Associated Press and KHN. To reach the AP's investigative team, email investigative@ap.org.

Anna Maria Barry-Jester: annab@kff.org, @annabarryjester

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Kaiser Health News provides a rundown of the vaccine candidates that are furthest along in the clinical phases.

This article was first published on Thursday, July 16, 2020 in Kaiser Health News.

By Louis Jacobson, PolitiFact July 16, 2020

More than four months into the coronavirus pandemic, how close are the U.S. and the world to a safe and effective vaccine? Scientists say they see steady progress and are expressing cautious optimism that a vaccine could be ready by spring.

As of early July, roughly 160 vaccine projects were underway worldwide, according to the World Health Organization.

Generally, a vaccine trial has several phases. In an initial phase, the vaccine is given to 20 to 100 healthy volunteers. The focus in this phase is to make sure the vaccine is safe, and to note any side effects.

In the second phase, there are hundreds of volunteers. In addition to monitoring safety, researchers try to determine whether shots produce an immune-system response.

The third phase involves thousands of patients. This phase continues the goals of the first two, but adds a focus on how effective the vaccine is in protecting people exposed to the pathogen, in this case the coronavirus. This phase also collects data on more unusual negative side effects.

In ordinary circumstances, these phases take years to complete. But for the coronavirus, the timeline is being shortened. This has spurred more public-private partnerships and significantly increased funding.

Here's a rundown of the vaccine candidates that are furthest along in the clinical phases:

The three vaccine candidates that are furthest along are in phase 3.

One is being developed by researchers at Oxford University in the U.K. It uses a weakened version of a virus that causes common colds in chimpanzees. Researchers then added proteins, known as antigens, from the novel coronavirus, in the hope that these could prime the human immune system to fight the virus once it encounters it.

Another candidate in a phase 3 trial is being developed in China. It uses a killed, and thus safe, version of the novel coronavirus to spur an immune reaction.

And on July 15, the biotech company Moderna, which is partnering with the National Institutes of Health, announced that it would be moving to phase 3 within two weeks.

Two others have made it as far as phase 2, while eight others are finishing their phase 1 trials while also beginning phase 2 trials.

These candidates are being developed by a mix of corporations and institutions in several countries. These efforts seek to leverage a range of technologies.

One uses RNA material that provides the instructions for a body to produce the needed antigens itself. This is a relatively untested approach to vaccination, but if it works, it has aspects that could make it easier to manufacture. Another approach is similar, but uses DNA instead of RNA.

One U.S. biotech firm, Novavax, is receiving federal funding to produce a vaccine that uses a lab-made protein to inspire an immune response.

Beyond these, another 10 vaccine candidates are in phase 1 clinical trials, while 140 haven't reached the clinical phase yet.

Having so many potential vaccines this far along is impressive, experts say, given the short time scientists have known about the novel coronavirus.

"Overall, the pace of development and advancement to phase 3 trials is impressive," said Matthew B. Laurens, associate professor at the University of Maryland School of Medicine's Center for Vaccine Development and Global Health. "The public-private partnerships have been highly successful and are achieving goals for rapid vaccine development."

In addition, the fact that several types of vaccine approaches are being tested means we aren't putting all of our eggs in one basket.

"We will need several candidates should any one of these experience difficulties in manufacturing or show a safety signal when implemented in larger numbers of people," Laurens said.

Meanwhile, at a time of rising public skepticism of government and vaccines, the Food and Drug Administration recently released additional guidelines on vaccine effectiveness. The new guidance requires vaccines to prevent or decrease the severity of the disease at least 50% of the time if they are to win the agency's approval.

The FDA guidelines "reaffirmed the very rigorous FDA process for approving any vaccine. That gives a great deal of reassurance that this was going to be handled by the book," said William Schaffner, a professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center. "The more we talk about doing things fast, the more the public thinks, 'They're probably cutting corners.'"

How fast will we have access to a workable vaccine?

In early April, Kathleen M. Neuzil, director of the University of Maryland's vaccine center, told PolitiFact that if all went well, there might be five or six vaccines in trials within six months. Now, 3 1/2 months later, there are two to three times that number.

Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, and other officials have remained consistent in their estimation of the timeline: 12 to 18 months from the start of the pandemic, or roughly the late spring of 2021.

Schaffner told PolitiFact that he continues to see the first quarter of 2021 as a reasonable target. "I think that's where the needle is pointing," he said.

It remains to be seen how fast vaccines can be manufactured and distributed once approved for general use. Officials are also grappling with which Americans will get access first. So it's unclear how long a person would have to wait to get vaccinated.

Laurens said he is not overly concerned about the distribution, because that is something that officials have long experience with. "Well-established programs exist for vaccine distribution, including for seasonal vaccination of large numbers of individuals," he said.

Another hopeful sign, Schaffner said, is that the coronavirus itself seems to be relatively stable. There had been concern that the novel coronavirus, like many other viruses, is mutating over time. If the virus changes enough, that could become a problem that bedevils vaccine researchers.

But so far, that hasn't happened. Even if evidence emerges that mutations are making the virus more transmissible, or that a new variant is making people sicker, that shouldn't affect the vaccine process. "The central core of the virus would remain the same," Schaffner said.

During the past month, there has been relatively little news about how much progress is being made on particular vaccines. Schaffner is not worried by the relative quiet.

"In a vaccine trial, if there's an adverse safety finding, the guillotine comes down and that trial is stopped," he said. "So quiet is good, because we'd know if something bad happens."

The debate reflects a deepening schism between the major political parties, with Democrats focused on protecting lives and Republicans focused on protecting livelihoods.

By Christina Jewett and Melissa Bailey July 13, 2020

Congressional leaders are squaring off over the next pandemic relief bill in a debate over whom Congress should step up to protect: front-line workers seeking more safeguards from the ravages of COVID-19 or beleaguered employers seeking relief from lawsuits.

Democrats want to enact an emergency standard meant to bolster access to protective gear for health care and other workers and to bar employers from retaliating against them for airing safety concerns.

Republicans seek immunity for employers from lawsuits related to the pandemic, an effort they say would give businesses the confidence to return to normal. The Senate is scheduled to reconvene later this month.

The debate reflects a deepening schism between the major political parties, with Democrats focused on protecting lives and Republicans focused on protecting livelihoods.

Democratic House Speaker Nancy Pelosi expressed frustration over efforts to pass an emergency worker-protection standard, which keeps running into GOP resistance.

"They're saying 'Let's give immunity — no liability — for employers,'" Pelosi said. "We're saying the best protection for the employer is to protect the workers."

Nearly 98,000 health care workers have contracted the novel coronavirus, according to Centers for Disease Control and Prevention data that the agency acknowledges is an undercount. KHN and The Guardian have identified more than 780 who have died and have told the personal stories of 139 of them.

In May, the House passed a $3 trillion relief bill that would require the Occupational Safety and Health Administration to put in place an emergency standard that would call on employers to create a plan based, in part, on CDC or OSHA guidance to protect workers from COVID-19.

It would cover health care workers and also those "at occupational risk of exposure to COVID19." The measure would allow workers to bring protective gear "if not provided by the employer." Similar rules in place in California health care workers have come under fire for offering little added protection.

In action, the new measure would allow OSHA inspectors to request to review an employers' plan and hold them accountable for following it, said David Michaels, former U.S. assistant secretary of Labor and OSHA administrator, who has called for such a standard. Federal guidance is currently optional, not required.

"Many employers want to be law-abiding," Michaels said, "and they know they risk enforcement and possibly a monetary fine if they don't attempt to do this."

Top Democrats, including presumptive presidential nominee Joe Biden, have called for better worker protections, while GOP leaders have called for stronger employer protections.

Senate Majority Leader Mitch McConnell has insisted that the next pandemic relief bill include immunity for employers against coronavirus-related lawsuits.

"If we do another bill, it will have liability protections in it for doctors, for hospitals, for nurses, for businesses, for universities, for colleges," McConnell said July 1. "Nobody knew how to deal with the coronavirus," he said, and unless they've committed gross negligence or intentional harm, those parties should be protected from an "epidemic of lawsuits."

He has proposed a five-year period of immunity from December 2019 through 2024. (McConnell's office declined to comment for this story.)

Such a measure could derail lawsuits already filed by grieving family members such as Florence Dotson, the mother of 51-year-old certified nursing assistant Maurice Dotson, who died in April. Her son cared for nursing home residents with COVID-19 in Austin, Texas, and did not have proper personal protective equipment (PPE), her suit alleges. He later died of complications from the virus.

Another lawsuit alleges that an anonymous New York nurse requested but was denied proper PPE when she was assigned to care for a patient in intensive care with COVID-19 symptoms but who was tested for the virus only after death. The nurse, who contracted COVID-19 shortly after, is seeking $1 million in damages.

U.S. workers in every industry have filed more than 13,300 COVID-related complaints with OSHA, records show, demonstrating widespread concern over their lack of protection at work. Twenty-three complaints reference a fear of retaliation, including among hospital workers who say they were pressured to work while sick.

The agency has closed investigations into those complaints but is investigating 6,600 more open complaints. OSHA has so far issued one citation against an employer, a spokesperson confirmed.

Employers are also struggling, evidenced by layoffs and an 11% unemployment rate, which the Congressional Budget Office projects will hit 16% in the coming weeks.

States have taken some matters in their own hands during months of federal inaction. At least 25 states have created some degree of legal immunity for doctors or facilities, through new laws or executive orders, according to the National Conference of State Legislatures.

Officials in Virginia and Oregon have taken steps to enact their own heightened worker-protection rules related to the virus.

The effort to pass an OSHA rule to protect workers from infectious diseases dates to 2010, when regulators saw the need to better protect health care workers after the H1N1 flu pandemic.

Michaels, the former OSHA director under President Barack Obama, said the effort has stalled out under the Trump administration. Trump administration OSHA officials have defended their track record, saying adequate rules are in place to protect workers.

But a similar push succeeded in California in 2009. State officials passed a plan requiring health care employers to create a plan to protect health care workers from airborne viruses.

The California measure went further, requiring hospitals and nursing homes to stockpile or be prepared to supply workers with an N95 respirator — or an even more protective device — if treating patients with a virus like COVID-19.

Workplace safety experts in California, though, said it hasn't worked as intended.

As more than 17,600 health care workers have become sick and 99 have died in the state, it's become apparent that health care employers did not have plans in place, said Stephen Knight, executive director of Worksafe, a nonprofit focused on workplace safety.

"This was just a massive missed opportunity and one that cost people their lives," Knight said. "People are just dying … with frightening regularity."

California nurses who died after caring for COVID patients without an N95 respirator include Sandra Oldfield, 52, who wore a less-protective surgical mask while caring for a patient who wasn't initially thought to have the virus.

A complaint to OSHA about a lack of N95 respirators that preceded her death put her hospital, Kaiser Permanente Fresno Medical Center, in violation of the state's standard, the state labor department confirmed.

However, alternative guidance is now in place because of global PPE shortages, according to the California Department of Industrial Relations. Kaiser Permanente, which is not affiliated with KHN, confirmed that the patient was not initially thought to have COVID-19 and that the company has followed state, local and CDC guidance on patient screening and use of PPE.

Hospital officials, who have come out against a national OSHA standard, said the plans that were in place did not account for the scope of the current pandemic and global supply chain breakdown.

"It is not for a lack of caring or trying to keep our workers safe," said Gail Blanchard-Saiger, vice president for labor and employment with the California Hospital Association.

Christina Jewett: ChristinaJ@kff.org, @by_cjewett

Melissa Bailey: @mmbaily