A closer look at these hard-hit areas highlights some of the common and unique challenges states face.

This article was first published on Wednesday, June 10, 2020 in Kaiser Health News.

By Martha Bebinger, WBUR and Blake Farmer, Nashville Public Radio and Jackie Fortiér, Southern California Public Radio

Mass protests against police violence across the U.S. have public health officials concerned about an accelerated spread of the coronavirus. But even before the protests began May 26, sparked by the May 25 death of George Floyd in Minneapolis, several states had been recording big jumps in the number of COVID-19 cases.

The head of the Centers for Disease Control and Prevention, Dr. Robert Redfield, registered his concern at a congressional hearing Thursday. He shook his head as a congresswoman showed him photos of throngs of people at the Lake of the Ozarks in Missouri over Memorial Day weekend and crowds in Florida that had assembled to watch the May 30 launch of the SpaceX Dragon crew capsule.

"We're very concerned that our public health message isn't resonating," Redfield said. "We continue to try to figure out how to penetrate the message with different groups. The pictures the chairwoman showed me are great examples of serious problems."

The U.S. is still seeing roughly 20,000 new cases a day. The tally ranges widely by state, from one case a day, on average, last week in Hawaii up to 2,614 new cases a day in California. Specific areas in the Golden State have become hot spots, along with certain counties in every Southern state.

The northeastern states of New York, New Jersey and Massachusetts — which accounted for a quarter of all COVID-19 deaths in the U.S. — are seeing a substantial slowing of new cases.

A closer look at these hard-hit areas highlights some of the common and unique challenges states face as they manage protests and begin efforts to reopen the economy amid the risks of more disease and death.

Officials Try To Publicize Cause When Infections Spike

In the South, the timing of new cases appears to be linked to the reopening of restaurants, barbershops and gyms, which started in most states more than a month ago. Figures tracked by NPR show the number of cases in North Carolina and South Carolina this week is up by roughly 60% from two weeks ago. In Tennessee, that increase is 75%.

Georgia and Louisiana look steadier, but they experienced some of the highest case counts and fatalities in the region in recent weeks, at the height of the pandemic.

In Southern states that reopened sooner than others, officials sometimes felt the need to explain big increases in case counts on certain days. In Georgia, for example, a state health official said a big one-day increase could be attributed to a backlog of reporting cases from a commercial lab. In Tennessee this week, a daily jump of 800 cases was blamed partially on an ongoing prison outbreak that yielded 350 new positive test results.

Populous Los Angeles County Drove Case Counts In California

In California, counties are continuing to allow businesses to reopen even as newly confirmed coronavirus cases climb. The state experienced a 40% jump in cases over the past week. Large metro areas like Los Angeles and San Francisco have gradually lifted restrictions, and Californians have responded by traveling to beaches and neighboring areas, blurring the effectiveness of the varying degrees of restrictions between adjacent counties.

Los Angeles County, home to more than 10 million people, has the highest number of cases in the state. Numbers tracked by NPR show that, on average, health officials report around 1,300 new cases daily. The county has blamed slow lab results for a backlog, while acknowledging that community transmission has been ticking up, especially among communities of color.

In the Northeast, where New York City became the U.S. epicenter of the pandemic for weeks, there are still thousands of new cases every day, although the rate of increase has slowed. It's down 41% in New Jersey over the past two weeks, down 33% in New York and down 13% in Massachusetts. But health officials caution that doesn't mean the coronavirus is under control in these three states. New York is still seeing more than 1,000 new cases a day; over the past week, Massachusetts averaged just over 500 a day, and New Jersey had close to 800.

Ethnic Disparities Persist Across The Country

In Los Angeles, elderly people, particularly those who live in nursing homes have been disproportionately affected. Almost half the people who have died from COVID-19 in the county were nursing home residents. County health officials were slow to test for the virus in nursing homes, and recent data reported by the health department shows that two-thirds of the Los Angeles County health care workers who died from the virus worked in nursing homes.

People of color have been disproportionately affected in California, as elsewhere: Latinos make up over half of the COVID-19 cases in California, where they are about 40% of the state's population. In Los Angeles County, the highest COVID death rates have been among native Hawaiians, Pacific Islanders and black residents. Minorities have an increased risk of developing underlying health conditions like high blood pressure and diabetes, making them more likely to develop a more severe illness if infected with the virus.

In Tennessee, which has one of the nation's fastest-growing case counts, neighborhoods that are home to large immigrant populations have emerged as persistent hot spots for infection. In partnership with advocacy organizations, Nashville's public health department has hired community outreach workers with special skills or unique access to immigrant communities to conduct contact tracing and connect families with coronavirus testing.

"We knew we had to do something different, and that's what we're doing now," said Leslie Waller, a city epidemiologist who oversees the project.

Waller acknowledges that many of the people at risk work in jobs that have been deemed essential or own businesses that can't be run remotely. Public health officials also express concern that co-workers in close-knit immigrant communities often carpool to the same jobs, and some work sites have experienced large outbreaks.

But in Southern states, rising case counts have not slowed the momentum for further lifting of restrictions. On Thursday, Tennessee announced an additional loosening of restrictions for community events, allowing fairs, expos and parades. Instead of limiting the number of people who can gather, the focus has shifted to ensuring everyone can maintain social distance.

"Thanks to the continued hard work of Tennesseans and business owners operating responsibly, we're able to further reopen our state's economy," Tennessee Gov. Bill Lee said in a written statement. "These new guidelines provide useful information so that we can enjoy the events that connect us to our neighbors and communities."

There has been virtually no public discussion of reinstating business restrictions, so long as hospitals can handle any uptick in illness.

Northeast States Take A Slower Approach To Reopening

You still can't sit down in a restaurant in New York City or anywhere in Massachusetts and New Jersey. That may be allowed in the coming weeks, but only outdoors. These states are all still in the early stages of reopening, after residents were told to stay home for almost two months and all but the most essential businesses were closed.

While most states do not have broad requirements for face coverings, rules requiring them are more common in the Northeast. In Massachusetts, some kind of face covering is required indoors and outside, if you can't stay at least 6 feet away from other people. In New York and New Jersey, masks are required in public and while riding buses or trains.

Within some states, rules vary by county, which can cause confusion. In Los Angeles County, health officials made cloth face coverings mandatory at all times when outside your home, while San Diego County requires masks only when you are within 6 feet of another person.

Residents everywhere are chafing at the rules, but the hardest-hit states are experiencing wider acceptance of social-distancing rules. A poll out last week found twice as many New York residents were worried about opening too quickly, compared with the number of New Yorkers who were worried about it happening too slowly. Polls in New Jersey and Massachusetts also have shown better than majority support for gradual, phased openings.

This story is part of a partnership that includes WBUR, Nashville Public Radio, Southern California Public Radio and NPR.

Martha Bebinger, WBUR: marthab@wbur.org, @mbebinger

Blake Farmer, Nashville Public Radio: bfarmer@wpln.org, @flakebarmer

Many primary care doctors have argued that Medicare doesn't reimburse them adequately and requires too much paperwork.

This article was first published on Tuesday, June 9, 2020 in Kaiser Health News.

By Carmen Heredia Rodriguez June 9, 2020

Pneumonia. Heart problems. High cholesterol. Betsy Carrier, 71, and her husband, Don Resnikoff, 79, relied on their primary care doctor in Montgomery County, Maryland, for help managing their ailments.

But after seven years, the couple was surprised when the doctor informed them she was opting out of Medicare, the couple's insurer.

"It's a serious loss," Resnikoff said of their doctor.

Patients can lose doctors for a variety of reasons, including a physician's retirement or when either patient or doctor moves away. But economic forces are also at play. Many primary care doctors have long argued that Medicare, the federal health insurance program for seniors and people with disabilities, doesn't reimburse them adequately and requires too much paperwork to get paid.

These frustrations have prompted some physicians to experiment with converting their practices to more lucrative payment models, such as concierge medicine, in which patients pay a fee upfront to retain the doctor. Patients who cannot afford that arrangement may have to search for a new physician.

The exact number of physicians with concierge practices is unknown, health care experts said. One physician consulting company, Concierge Choice Physicians, estimates that roughly 10,000 doctors practice some form of membership medicine, although it may not strictly apply to Medicare patients.

Shawn Martin, senior vice president of the American Academy of Family Physicians, estimated that fewer than 3% of their 134,000 members use this model but the number is slowly growing.

The move to concierge medicine may be more prevalent in wealthier areas.

Travis Singleton, executive vice president for the medical staffing company Merritt Hawkins, said doctors switching to other payment systems or those charging Medicare patients a higher price for care are likely "in more affluent, well-to-do areas where, frankly, they can get fees."

It is far easier for physicians than hospitals to opt out of taking Medicare patients. Most hospitals have to accept them since they rely on Medicare payments to fund inpatient stays, doctor training and other functions.

The majority of physicians do still accept Medicare, and most people insured by the federal program for seniors and people with disabilities have no problem finding another health care provider. But that transition can be tough, particularly for older adults with multiple medical conditions.

"When transition of care happens, from one provider to another, that trust is often lost and it takes time to build that trust again," said Dr. Fatima Sheikh, a geriatrician and the chief medical officer of FutureCare, which operates 15 rehabilitation and skilled nursing centers in Maryland.

Shuffling doctors also heightens the risk of mishaps.

A study of at least 2,200 older adults published in 2016 found that nearly 4 in 10 were taking at least five medications at the same time. Fifteen percent of them were at risk of drug-to-drug interaction.

Primary care providers mitigate this risk by coordinating among doctors on behalf of the patient, said Dr. Kellie Flood, a geriatrician at the University of Alabama-Birmingham.

"You really need the primary care physicians to serve as the quarterback of the health care team," said Flood. "If that's suddenly lost, there's really not a written document that can sum all that up and just be sent" to the new doctor.

Finding a physician who accepts Medicare depends partly on workforce demographics. From 2010 to 2017, doctors providing primary care services to Medicare beneficiaries increased by 13%, according to the Medicare Payment Advisory Commission (MedPAC), a nonpartisan group that advises Congress.

However, the swell of seniors who qualify for Medicare has outpaced the number of doctors available to treat them. Every day, an estimated 10,000 Americans turn 65 and become eligible for the government program, the Census Bureau reported.

The impact: In 2010, MedPAC reported, there were 3.8 primary care doctors for every 1,000 Medicare enrollees. In 2017, it was 3.5.

Authors of a MedPAC report out last June suggested that the number of available primary care providers could be an overestimate. Their calculation assumed all internal medicine doctors provided these services when, in reality, many specialize in certain medical conditions, or accept only a limited number of Medicare patients into their practices.

But MedPAC concluded seniors are not at a disadvantage finding a doctor.

"We found that beneficiaries have access to clinician services that is largely comparable with (or in some cases better) access for privately insured individuals, although a small number of beneficiaries report problems finding a new primary care doctor," the MedPAC researchers wrote.

The coronavirus outbreak has complicated the ability for many Americans to access care, regardless of their insurer. However, many older patients now have an opportunity to connect with their doctors virtually after the Centers for Medicare & Medicaid Services (CMS) broadened access to telemedicine services under Medicare.

Experts said the long-term effects of the virus on doctors and Medicare remain unknown. But Martin said the shortage of cash that many doctors are experiencing because of the coronavirus epidemic has revealed the shortcomings of how primary care doctors are paid.

"The COVID crisis really brought to life the challenges of fee for service," said Martin.
Despite these challenges, the number of doctors choosing to opt out of Medicare has been on the decline, according to data from CMS.

Singleton, of Merritt Hawkins, said concern about doctors leaving the Medicare system is part of larger workforce issues. Those include the need to recruit more medical students to concentrate on primary care.

One estimate predicts the nation will face a shortage of 23,600 primary care physicians by 2025. The majority of residents in internal medicine ― those who care for adults — are choosing a subspecialty such as cardiac care or gastroenterology, MedPAC reported.

In 2017, MedPAC reported, the median compensation for all doctors was $300,000 a year. Among primary care doctors, it was $242,000.

Creative business models can make up that difference. Under the concierge model, the doctor charges patients an annual fee — akin to a gym membership ― to access their practice. The provider still bills the insurer ― including Medicare — for all patient care.

Another model ― called direct primary care — charges the patient an annual fee for access and care; doctors do not bill health insurance plans.

Proponents say that the model enables them to take more time with their patients without dealing with the bureaucracy of getting paid by health insurers.

"I think what is most attractive to direct primary care is that they just practice medicine," Martin said.

The size of a physician practice can also determine whether it accepts Medicare. Large practices can better offset the lower Medicare payment rates by leveraging their influence with private insurers to raise those reimbursements, said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy. But small, independent clinics may not have the same clout.

"If you're a large primary care practice, private insurers are really going to want to have you in their network," he said. "And they're willing to pay more than they might pay an individual solo practitioner who they're not as concerned [with] because it's only one physician."

Luckily, after more than a dozen calls to physicians, Carrier and Resnikoff said they found another primary care doctor. They said she accepts Medicare and impressed them during their meet-and-greet with her knowledge of their medical history. She also met their criteria for age and expertise.

"At this point in our lives, I'd be eager to find somebody who's young enough that they might be in practice for the next 10 years," Carrier said.

Carmen Heredia Rodriguez: CarmenH@kff.org, @ByCHRodriguez

The tally includes doctors, nurses and paramedics, as well as crucial health care support staff such as hospital janitors, administrators and nursing home workers.

This story was first published on Saturday, June 6, 2020 in Kaiser Health News.

By Christina Jewett and Melissa Bailey and Danielle Renwick, The Guardian  

Nearly 600 front-line health care workers appear to have died of COVID-19, according to Lost on the Frontline, a project launched by The Guardian and KHN that aims to count, verify and memorialize every health care worker who dies during the pandemic.

The tally includes doctors, nurses and paramedics, as well as crucial health care support staff such as hospital janitors, administrators and nursing home workers, who have put their own lives at risk during the pandemic to help care for others. Lost on the Frontline has now published the names and obituaries for more than 100 workers.

A majority of those documented were identified as people of color, mostly African American and Asian/Pacific Islander. Profiles of more victims, and an updated count, will be added to our news sites twice weekly going forward.

There is no other comprehensive accounting of U.S. health care workers' deaths. The Centers for Disease Control and Prevention has counted 368 COVID deaths among health care workers, but

The Guardian and KHN are building an interactive, public-facing database that will also track factors such as race and ethnicity, age, profession, location and whether the workers had adequate access to protective gear. The database — to be released this summer — will offer insight into the workings and failings of the U.S. health care system during the pandemic.

In addition to tracking deaths, Lost on the Frontline reports on the challenges health care workers are facing during the pandemic. Many were forced to reuse masks countless times amid widespread equipment shortages. Others had only trash bags for protection. Some deaths have been met with employers' silence or denials that they were infected at work.

The number released today reflects the 586 names currently in the Lost on the Frontline internal database, which have been collected from family members, friends and colleagues of the deceased, health workers unions, media reports, unions, among other sources. Reporters at KHN and The Guardian are independently confirming each death by contacting family members, employers, medical examiners and others before publishing names and obituaries on our sites. More than a dozen journalists across two newsrooms — as well as student journalists ― are involved in the project.

Many of the health care workers included here studied physiology and anatomy for years. They steeled themselves against the long hours they'd endure. Emergency medical technicians raced by ambulance to help. Others did the cleanup, maintenance, security or transportation jobs needed to keep operations running smoothly.

They undertook their work with passion and dedication. They were also beloved spouses, parents, friends, military veterans and community activists.

None started 2020 knowing that simply showing up to work would expose them to a virus that would kill them.

This project aims to capture the human stories, compassion and heroism behind the statistics. Among those lost were Dr. Priya Khanna, a nephrologist, who continued to review her patients' charts until she was put on a ventilator. Her father, a retired surgeon, succumbed to the disease just days after his daughter.

Susana Pabatao, one of thousands of Philippine health providers in the United States, became a nurse in her late 40s. Susana died just days after her husband, Alfredo, who was also infected with COVID-19.

Dr. James Goodrich, a renowned pediatric neurosurgeon, acclaimed for separating conjoined twins, was also remembered as a renaissance man who collected antique medical books, loved fine wines and played the didgeridoo.

Some of the first to die faced troubling conditions at work. Rose Harrison, 60, a registered nurse, wore no mask while taking care of a COVID-19 patient at an Alabama nursing home, according to her daughter. She felt pressured to work until the day she was hospitalized. The nursing home did not respond to requests for comment.

Thomas Soto, 59, a Brooklyn radiology clerk faced delays in accessing protective gear, including a mask, even as the hospital where he worked was overwhelmed with COVID-19 patients, his son said. The hospital did not respond to requests for comment.

The Lost on the Frontline team is documenting other worrying trends. Health care workers across the U.S. said failures in communication left them unaware they were working alongside people infected with the virus. And occupational safety experts raised alarms about CDC guidance permitting workers treating COVID patients to wear surgical masks ― which are far less protective than N95 masks.

The Occupational Safety and Health Administration, the federal agency responsible for protecting workers, has launched dozens of fatality investigations into health workers' deaths. But recent agency memos raise doubts that many employers will be held responsible for negligence.

As public health guidelines have largely prevented traditional gatherings of mourners, survivors have found new ways to honor the dead: In Manhattan, a medical resident played a violin tribute for a fallen co-worker; a nurses union placed 88 pairs of shoes outside the White House commemorating those who had died among their ranks; fire departments have lined up trucks for funeral processions and held "last call" ceremonies for EMTs.

The Lost on the Frontline death toll includes only health care workers who were potentially exposed while caring for or supporting COVID-19 patients. It does not, for example, include retired doctors who died from the virus but were not working during the pandemic.

The number of reported deaths is expected to grow. But as reporters work to confirm each case, individual deaths may not meet our criteria for inclusion — and, therefore, may be removed from our count.

You can read our first 100 profiles here. And if you know of a health care worker who died of COVID-19, please share their story with us.

Christina Jewett: ChristinaJ@kff.org, @by_cjewett

Melissa Bailey: @mmbaily

Their widespread use in recent weeks while an infectious disease — for which there is no vaccine — continues to spread across the U.S., has stunned experts and physicians.

This article was first published on Friday, June 5, 2020 in Kaiser Health News.

By Will Stone

In nationwide demonstrations sparked by the killing of George Floyd in police custody, protesters have been frequently pepper-sprayed or enveloped in clouds of tear gas. These crowd-control weapons are rarely lethal, but in the middle of the coronavirus pandemic, there are strong calls for police to stop using these chemical irritants because they can damage the body in ways that can spread the coronavirus and increase the severity of COVID-19.

Even before the coronavirus pandemic, some experts said additional research was needed on the risks of tear gas — an umbrella term for several chemical “riot-control agents” used by law enforcement. It’s known that the chemicals can have both immediate and long-term health effects.

Their widespread use in recent weeks while an infectious disease — for which there is no vaccine — continues to spread across the U.S., has stunned experts and physicians. The coronavirus that causes the disease COVID-19 is highly contagious, spreads easily through the air via droplets, and can lead to severe or fatal respiratory illness. Deploying these corrosive, inhalable chemicals could harm people in several ways: exposing more people to the virus, compromising the body’s ability to fight off the infection and even causing mild infections to become more severe illnesses.

“This is a recipe for disaster,” said associate professor Sven Eric Jordt, a researcher at the Duke University School of Medicine who studies the effects of tear gas.

Jordt refers to these chemicals as “pain gases” because they activate certain pain-sensing nerves on the skin and in the mucous membranes of the eyes, mouth and nose.

“You have this excruciating pain, sneezing, coughing, the production of a lot of mucus that obstructs breathing,” Jordt said.

People who have been exposed describe a burning and stinging sensation, even a sense of asphyxiation and drowning. Sometimes the chemicals cause vomiting or allergic reactions. In law enforcement, officers generally use two types of chemicals for crowd control: CS gas and pepper spray.

The active ingredient in pepper spray, called capsaicin, is derived from chiles. It is often sprayed from cans at close quarters or lobbed into crowds in the form of “pepper balls.”

CS gas (o‐chlorobenzylidene malononitrile) is a chlorinated, organic chemical that can induce “very strong inflammation” and “chemical injury” by burning the skin and airways when inhaled, Jordt said.

“Using it in the current situation with COVID-19 around is completely irresponsible,” he added. “There are sufficient data proving that tear gas can increase the susceptibility to pathogens, to viruses.”

Jordt said research on the harms of tear gas has not kept up with its escalating use in the U.S and around the world in recent years. Many of the safety studies that law enforcement officials rely on date to the 1950s and ’60s, he said.

But a 2014 study from the U.S. Army offers an alarming glimpse into how the chemical could escalate the pandemic. The study found that recruits who were exposed to tear gas as part of a training exercise were more likely to get sick with respiratory illnesses like the common cold and the flu.

“We have a lot of antiviral defenses that can inactivate viruses and prevent them from entering cells,” he said. “These are depleted by inhalation of tear gas and also compromised.”

The findings of the Army study led the U.S. military to significantly reduce how much recruits were being exposed to the chemical.

“Even the Army realized they had done something wrong and that this was more toxic than they thought before,” Jordt said.

Even though there is a limited amount of research on this new coronavirus, there are studies from China and Italy about how other irritants, such as smoking and air pollution, affect COVID-19. These studies indicate that tear gas could also make people more likely to develop severe illness, said Dr. John Balmes, a pulmonologist at the University of California-San Francisco and an expert with the American Thoracic Society.

“I actually think we could be promoting COVID-19 by tear-gassing protesters,” said Balmes. “It causes injury and inflammation to the lining of the airways.”

Balmes said this period of inflammation sets back the body’s defenses, and makes it more likely that someone who already harbors the virus will become sick.

“It’s adding fuel to the fire,” said Balmes. “These exposures to tear gas would increase the risk of progression from the asymptomatic infection, to a symptomatic disease.”

Growing evidence shows many people who have the coronavirus are asymptomatic and don’t know they are infected, or are “presymptomatic” — infected with the virus and able to infect others, but not yet showing symptoms.

With thousands of people jammed together at mass protests, the demonstrations are already primed to be “superspreading events,” which can lead to an explosion of new cases. Outdoor gatherings typically decrease the chance of spreading the coronavirus. But activities like singing and yelling can increase the risk.

Tear gas and pepper spray can also sow confusion and panic in a crowd. People may rip off their masks and touch their faces, leading to more contamination.

Dr. Amesh Adalja, with Johns Hopkins University, said the body’s reaction to the chemicals causes people to shed more of the virus.

“If they’re coughing, the particles actually emanate and are projectiles that travel about 6 feet or so and could land on other people,” said Adalja, who is also a spokesperson for the Infectious Diseases Society of America.

“This is a way to almost induce the virus to be expelled from people when they are exposed to these agents.”

Adalja anticipates the protests will inevitably lead to a spike in infections.

“We know that any kind of social unrest, especially in the midst of an outbreak, is only going to make things worse,” he said.

He said the most recent example would be bombings in Yemen that exacerbated a cholera outbreak.

Dr. Rohini Haar, an emergency physician in Oakland, California, has studied the use of riot-control agents around the world.

“These weapons don’t actually deescalate tensions in peaceful community policing,” said Haar who is a lecturer at the University of California-Berkeley.

Haar has also been treating COVID-19 patients. She recognizes there is a danger of spreading the virus at these gatherings, but she would not discourage people from attending the protests and exercising their right to free speech.

“It’s a really tough situation,” said Haar. “I think the irony is that people are rightfully and justifiably protesting police violence and are being met with violence that is worsening the pandemic conditions we’re living under right now.”

This week, more than a thousand physicians and health care professionals signed an open letter in support of the demonstrations.

Dr. Jade Pagkas-Bather, an infectious disease expert at the University of Chicago, is one of them. She said it will be difficult to determine whether any spike in cases was a direct result of the protests, because they’re happening at a time when many states are also allowing businesses to reopen.

“In everyday life, we weigh the risks and benefits of our actions. People who are going out to protests are clearly at a critical juncture where they are saying this state-sanctioned violence is unacceptable, and I am willing to put myself and others potentially at risk,” she said.

The open letter she signed recommends ways that protesters, police and local officials can reduce the transmission of the virus. Among the major recommendations: Police should not use tear gas or pepper spray.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.