Lawmakers compromised — mainly over how to determine how much providers will ultimately be paid for their services.

This article was published on Tuesday, December 22, 2020 in Kaiser Health News.

By Julie Appleby

Most Americans tell pollsters they're worried about being able to afford an unexpected medical bill.

Late Monday, Congress passed a bill to allay some of those fears. The measure is included in a nearly 5,600-page package providing coronavirus economic relief and government funding for the rest of the fiscal year.

Specifically, the legislation addresses those charges that result from a long-running practice in which out-of-network medical providers — from doctors to air ambulance companies — send insured Americans "surprise bills," sometimes for tens of thousands of dollars.

The legislation itself was a bit of a surprise, coming after two years of debate that featured high-stakes lobbying by all who stood to gain or lose: hospitals, insurers, patient advocacy groups, physicians, air ambulance companies and private equity firms, which own a growing number of doctor practices. A similar effort failed at the last minute a year ago after intense pressure from a range of interests, including those private equity groups.

This time around, no group got everything it wanted. Lawmakers compromised — mainly over how to determine how much providers will ultimately be paid for their services.

"No law is perfect," said Zack Cooper, an associate professor of public health and economics at Yale who studies healthcare pricing. "But it fundamentally protects patients from being balance-billed," he said, referring to out-of-network medical providers billing patients for amounts their insurer did not cover. "That's a remarkable achievement."

The bottom line: Patients may still be surprised by the high cost of healthcare overall. But they will now be protected against unexpected bills from out-of-network providers.

Here's a rundown on what this legislation means for consumers:

Fewer Surprise Bills

Starting in 2022, when the law goes into effect, consumers won't get balance bills when they seek emergency care, when they are transported by an air ambulance, or when they receive nonemergency care at an in-network hospital but are unknowingly treated by an out-of-network physician or laboratory.

Patients will pay only the deductibles and copayment amounts that they would under the in-network terms of their insurance plans.

Medical providers won't be allowed to hold patients responsible for the difference between those amounts and the higher fees they might like to charge. Instead, those providers will have to work out with insurers acceptable payments. For the uninsured, for whom everything is out of network, the bill requires the secretary of Health and Human Services to create a provider-patient bill dispute resolution process.

The measure takes aim at situations in which patients have little choice about whether they are in network, including emergencies. A recent survey found 18% of emergency room visits, on average, resulted in at least one surprise bill. (A growing number of emergency rooms are staffed by private equity-owned agencies that sign few in-network agreements.)

The legislative agreement also applies to nonemergency care provided at in-network facilities, where patients receive care and services from out-of-network providers, such as anesthesiologists and laboratories.

Also included in the bar on balance billing is air ambulance transportation, which is among the most expensive medical services, often costing tens of thousands of dollars.

Still, the bill does not extend its consumer protections to the far more commonly used ground ambulance services. But it does call for an advisory committee to recommend how to take this step.

An Option for Consumers to Agree to Balance Billing

In some cases, physicians can balance-bill their patients, but they must get consent in advance.

This part of the bill is aimed at patients who want to see an out-of-network physician, perhaps a surgeon or obstetrician recommended by a friend.

In those cases, physicians must provide a cost estimate and get patient consent at least 72 hours before treatment. For shorter-turnaround situations, the bill requires that patients receive the consent information the day the appointment is made.

In a sense, though, this provision allows consumers to forfeit protection.

Health providers "have to give you a good-faith cost estimate. If you sign that, then you can be billed whatever that physician wants to bill you," said Jack Hoadley, research professor emeritus in the Health Policy Institute at Georgetown University.

The legislation allows this only in nonemergency circumstances and bars many types of physicians from the practice. Anesthesiologists, for example, can't seek consent to balance-bill for their services, nor can radiologists, pathologists, neonatologists, assistant surgeons or laboratories.

Payment Will Be Sorted Out in Negotiations

While lawmakers agreed that patients will be held harmless, the real fight was over how to decide what amounts providers would be paid by insurers.

Some groups — including hospitals and physicians — opposed any kind of benchmark or standard to which all bills would be held. On the other side, insurers, employers and consumer groups argued for a benchmark, warning that, without one, providers would angle for much higher payments.

The legislation carves out some middle ground.

It gives insurers and providers 30 days to try to negotiate payment of out-of-network bills. If that fails, the claims would go through an independent dispute resolution process with an arbitrator, who would have the final say.

The bill does not specify a benchmark, but it bars physicians and hospitals from using their "billed charges" during arbitration. Such charges are generally far higher than negotiated rates and bear little or no relation to the actual cost of providing the care.

That was considered a win for insurers, employers and consumer advocates, who argued that allowing billed charges would mean higher prices — potentially driving up premiums — in cases sent to arbitration.

Billed charges "are totally made up" by providers, said Cooper, at Yale. "So, the big deal is that arbitrators are not considering charges."

But hospitals and doctors won a limit they sought, too.

In last-minute changes over the weekend, they succeeded in barring consideration of Medicare or Medicaid prices during arbitration. Those government payments are often far lower than the negotiated rates paid by insurers and self-insured employers.

Instead, the bill says negotiators can consider the median in-network prices paid by each insurer for the services in dispute. Other factors, too, can come into play, including whether the medical provider tried to join the insurers' network, and how sick the patient was compared with others. It also allows consideration of network rates a provider may have agreed to during the previous four years, which might help some high-priced services, such as air ambulances, remain costly even in arbitration.

Overall, the legislation "did include some wins for provider groups," said Loren Adler, associate director at the USC-Brookings Schaeffer Initiative for Health Policy.

Even so, he expects the legislation will help insurers contain some prices and provide "some downward pressure on premiums, even if relatively minor at the end of the day."

State Laws May Change

More than 30 states have enacted some type of surprise billing protections, but only 17 are considered comprehensive, according to the Commonwealth Fund.

Comprehensive states — California, New York and New Mexico, for example — extend protections to cover nonemergency situations at in-network hospitals, but that isn't the case in less comprehensive states, the fund noted.

And state laws have another limitation: They apply only to certain types of insurance, and often do not cover Americans who get their health insurance through self-insured employers, which tend to be midsize to large companies because they fall under federal rules.

But the new federal rules will cover most types of insurance plans, including those offered by self-insured employers.

"States can't fully deal with these situations, but this covers it," said Hoadley, at Georgetown.

Still, some provisions in state law, such as how to determine a payment, differ from the federal law. In such cases, the federal law defers to states.

Statehouse lawmakers may eventually alter their legislation or adopt new proposals to avoid confusion, said policy experts. If they don't, they could be left with rules that affect people differently depending on whether their insurance comes through a large self-insured employer or directly from an insurance plan subject to state law. "I would be surprised if, over time, states don't just glom onto the federal law," said Adler.

Julie Appleby: jappleby@kff.org, @Julie_Appleby

KHN's in-depth examination of the year-long pandemic shows that many leading infectious disease specialists underestimated the fast-moving outbreak in its first weeks and months.

This article was published on Monday, December 21, 2020 in Kaiser Health News.

By Liz Szabo

A year ago, while many Americans were finishing their holiday shopping and finalizing travel plans, doctors in Wuhan, China, were battling a mysterious outbreak of pneumonia with no known cause.

Chinese doctors began to fear they were witnessing the return of severe acute respiratory syndrome, or SARS, a coronavirus that emerged in China in late 2002 and spread to 8,000 people worldwide, killing almost 800.

The disease never gained a foothold in the U.S. and disappeared by 2004.

Although the disease hasn't been seen in 16 years, SARS cast a long shadow that colored how many nations — and U.S. scientists — reacted to its far more dangerous cousin, the novel coronavirus that causes COVID-19.

When Chinese officials revealed that their pneumonia outbreak was caused by another new coronavirus, Asian countries hit hard by SARS knew what they had to do, said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security. Taiwan and South Korea had already learned the importance of a rapid response that included widespread testing, contact tracing and isolating infected people.

The U.S., by contrast, learned all the wrong lessons.

This country's 20-year run of good luck with emerging pathogens —including not just SARS, but also the relatively mild H1N1 pandemic, Middle East respiratory syndrome, Ebola, Zika virus and two strains of bird flu — gave us a "false sense of security," Adalja said.

KHN's in-depth examination of the year-long pandemic shows that many leading infectious disease specialists underestimated the fast-moving outbreak in its first weeks and months, assuming that the United States would again emerge largely unscathed. American hubris prevented the country from reacting as quickly and effectively as Asian nations, Adalja said.

During the first two decades of this century, "there were a lot of fire alarms with no fire, so people tended to ignore this one," said Lawrence Gostin, director of Georgetown's O'Neill Institute for National and Global Health Law, who acknowledges he underestimated the virus in its first few weeks.

In a Jan. 24 story, Dr. William Schaffner told KHN the real danger to Americans was the common flu, which can kill up to 61,000 Americans a year.

"Coronavirus will be a blip on the horizon in comparison," said Schaffner, a professor of preventive medicine and health policy at Vanderbilt University Medical Center. "The risk is trivial."

The same day, The Washington Post published a column by Dr. Howard Markel, who questioned China's lockdown of millions of people. "It's possible that this coronavirus may not be highly contagious, and it may not be all that deadly," wrote Markel, director of the Center for the History of Medicine at the University of Michigan.

JAMA, one of the most prestigious medical journals in the world, published a podcast Feb. 18 titled, "The 2020 Influenza Epidemic — More Serious Than Coronavirus in the US." A week later, JAMA published a large infographic illustrating the dangers of flu and minimizing the risks from the novel virus.

Dr. Paul Offit, who led development of a rotavirus vaccine, predicted that the coronavirus, like most respiratory bugs, would fade in the summer.

"I can't imagine, frankly, that it would cause even one-tenth of the damage that influenza causes every year in the United States," Offit told Christiane Amanpour in a March 2 appearance on PBS.

President Donald Trump picked up on many of these remarks, predicting that the coronavirus would disappear by April and that it was no worse than the flu. Trump later said the country was "rounding the turn" on the pandemic, even as the number of deaths exploded to record levels.

Caitlin Rivers, an epidemiologist and assistant professor at the Johns Hopkins Bloomberg School of Public Health, worried — and tweeted — about the novel coronavirus from the beginning. But she said public health officials try to balance those fears with the reality that most small outbreaks in other countries typically don't become global threats.

"If you cry wolf too often, people will never pay attention," said epidemiologist Mark Wilson, an emeritus professor at the University of Michigan School of Public Health.

Experts were hesitant to predict the novel coronavirus was the big pandemic they had long anticipated "for fear of seeming alarmist," said Dr. Céline Gounder, an infectious disease specialist advising President-elect Joe Biden.

Many experts fell victim to wishful thinking or denial, said Dr. Nicole Lurie, who served as assistant secretary for preparedness and response during the Obama administration.

"It's hard to think about the unthinkable," Lurie said. "For people whose focus and fear was bioterrorism, they had a world view that Mother Nature could never be such a bad actor. If it wasn't bioterrorism, then it couldn't be so bad."

Had more experts realized what was coming, the nation could have been far better prepared. The U.S. could have gotten a head start on manufacturing personal protective equipment, ventilators and other supplies, said Dr. Nicholas Christakis, author of "Apollo's Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live."

"Why did we waste two months that the Chinese essentially bought for us?" Christakis asked. "We could have gotten billions of dollars into testing. We could have had better public messaging that we were about to be invaded. … But we were not prepared."

Dr. Fauci Doesn't Cast Blame

Dr. Anthony Fauci, the nation's top infectious disease official, isn't so critical. In an interview, he said there was no way for scientists to predict how dangerous the coronavirus would become, given the limited information available in January.

"I wouldn't criticize people who said there's a pretty good chance that it's going to turn out to be like SARS or MERS," said Fauci, director of the National Institute of Allergy and Infectious Diseases, noting this was "a reasonable assumption."

It's so easy to go back with the retrospect-o-scope and say 'You coulda, shoulda, woulda.'

— Dr. Anthony Fauci

Fauci noted that solutions are always clearer in hindsight, adding that public health authorities lose credibility if they respond to every new germ as if it's a national disaster. He has repeatedly said scientists need to be humble enough to recognize how little we still don't know about this new threat.

"It's so easy to go back with the retrospect-o-scope and say 'You coulda, shoulda, woulda,'" Fauci said. "You can say we should have shut things down much earlier because of silent spread in the community. But what would the average man or woman on the street have done if we said, 'You've got to close down the country because of three or four cases?'"

Scientists largely have been willing to admit their errors and update their assessments when new data becomes available.

"If you're going to be wrong, be wrong in front of millions of people," Offit joked about his PBS interview. "Make a complete ass of yourself."

Scientists say their response to the novel coronavirus would have been more aggressive if people had realized how easily it spreads, even before infected people develop symptoms — and that many people remain asymptomatic. "For a virus to have pandemic potential, that is one of the greatest assets it can have," Adalja said.

Although COVID-19 has a lower death rate than SARS and MERS, its ability to spread silently throughout a community makes it more dangerous, said Dr. Kathleen Neuzil, director of the Center for Vaccine Development at the University of Maryland School of Medicine.

People infected with SARS and MERS are contagious only after they begin coughing and experiencing other symptoms; patients without symptoms don't spread either disease.

With SARS and MERS, "when people got sick, they got sick pretty badly and went right to the hospital and weren't walking around transmitting it," Christakis said.

Because it's possible to quarantine people with SARS and MERS before they begin spreading the virus, "it was easier to put a moat around them," said Offit.

Based on their knowledge of SARS and MERS, doctors believed they could contain the novel coronavirus by telling sick people to stay home. In the first few months of the pandemic, there appeared to be no need for healthy people to wear masks. That led health officials, including U.S. Surgeon General Jerome Adams, to admonish Americans not to buy up limited supplies of face masks, which were desperately needed by hospitals.

"We are always fighting the last epidemic," Markel said. "Our experiences with coronaviruses was that they kind of burn themselves out in warm weather and they didn't have the capacity to spread as viciously as this one has."

Many scientists were skeptical of early anecdotes of pre-symptomatic spread.

"It takes a lot to overturn established dogma," Wilson said. "Jumping on an initial finding, without corroborating it, can be just as bad as missing a new finding."

As evidence of pre-symptomatic spread accumulated, the Centers for Disease Control and Prevention in April changed its advice and urged Americans to mask up in public.

I continue to be baffled that we keep making the same mistakes. It's almost like we're doomed to repeat this cycle endlessly.

— Dr. Amesh Adalja

Adalja notes that the CDC's earlier advice against wearing masks was based on research that found them to be ineffective against spreading influenza. New research, however, has shown masks reduce the transmission of the novel coronavirus, which spreads mainly through respiratory droplets but can travel in the air as tiny particles.

Adalja said the U.S. should have learned from its early stumbles. Yet in spite of abundant evidence, many communities still resist mandating masks or physical distancing.

"I continue to be baffled that we keep making the same mistakes," Adalja said. "It's almost like we're doomed to repeat this cycle endlessly."

Some Saw It Coming

There were scientists and journalists who immediately recognized the threat from the novel coronavirus.

"We had to immediately react as if this were going to hit every corner of the Earth," said Adalja, who began blogging about the novel virus Jan. 20. It was clear "this was not a containable virus."

Adalja led a 2018 project identifying the features that allow emerging viruses to become pandemic. In that prescient report, Adalja and his co-authors highlighted the threat of certain respiratory viruses that use RNA as their genetic material.

The more Adalja learned about the novel coronavirus, the more it seemed to embody the very type of threat he had warned about: one with "efficient human-to-human transmissibility, an appreciable case fatality rate, the absence of an effective or widely available medical countermeasure, an immunologically naïve population, virulence factors enabling immune system evasion, and respiratory mode of spread."

Although the CDC set the wheels of its response in motion early, establishing an incident management structure on Jan. 7, the agency's early missteps with testing are well known. The outbreak escalated rapidly, leading the World Health Organization to declare a health emergency on Jan. 30 and the U.S. to announce a public health emergency the next day.

Adalja and other experts dismissed some of the Trump administration's early responses, such as quarantines and a travel ban on China, as "window dressing" that "squandered resources" and did little to contain the virus.

"There was political inertia about the public health actions that could have avoided lockdowns," Adalja said. "We let this spill into hospitals … [and] if you give a virus a three-month head start, what do you expect?"

In a Jan. 7 post on a website of the Infectious Diseases Society of America, Dr. Daniel Lucey labeled the pneumonia "Disease X," using the WHO's term for an emerging pathogen capable of causing a devastating epidemic, for which there are no tests, treatments or vaccines.

Lucey, adjunct professor of infectious diseases at Georgetown University Medical Center, notes that the international response was hampered by misinformation from Chinese officials. "The Chinese government said there was no person-to-person spread," said Lucey, who traveled to China hoping to visit Wuhan. "That was a lie."

When China revealed on Jan. 20 that 14 health workers had been infected, Lucey knew the virus would spread much farther. "To me, that was like Pandora's box," Lucey said. "I knew there would be more."

When the number of infected health workers grew to 1,716 on Feb. 14, Lucey said, "I almost threw up."

Although his blog is read by thousands of infectious disease specialists, Lucey emailed a special warning to journalists and a dozen doctors and public health officials, hoping to alert influential leaders.

"I put this heartfelt commentary in my email and just got silence," Lucey said.

Succeeding With Vaccines

At the National Institute of Allergy and Infectious Diseases, scientists had studied the protein structure of coronaviruses for years.

Researchers had developed a vaccine against SARS, Fauci said, although the epidemic ended before researchers could widely test it in humans.

"We showed it was safe and induced an immune response," Fauci said. "The cases of SARS disappeared, so we couldn't test it. … We put the vaccine in cold storage. If SARS comes back, we will do a phase 3 [clinical] trial."

Dr. Barney Graham, deputy director of the Vaccine Research Center, asked Chinese scientists to share the coronavirus's genetic information. After the genome was published, Graham went immediately to work.

"We jumped all over it," Fauci said. "We had a meeting on Jan. 10 and five days later they started [working on] a vaccine."

Although scientists knew the COVID outbreak might end before a vaccine was needed, "we couldn't take the chance," Fauci said.

"We said, 'We have no idea what is going to happen, so why don't we just go ahead and proceed with a vaccine anyway?'"

Although his team worried about finding the money to pay for it all, Fauci told them, "'Don't worry about the money. I'll find it, you do it, if we really need it, I'm sure we'll get it.'"

Health experts hope the U.S. will learn from its mistakes and be better prepared for the next threat.

Given how many novel viruses have emerged in the past two decades, it's likely that "pandemics are going to become more frequent," Gounder said, making it critical to be ready for the next one.

Of all the lessons learned during the pandemic, the most important is that "we can't be this unprepared again," said Dr. Tom Frieden, who directed the CDC during the Obama administration.

"To me, this should be the most teachable moment of our lifetime, in terms of the need to strengthen public health in the United States and globally," Frieden said.

But Gounder notes that U.S. public health funding tends to follow a cycle of crisis and neglect. The U.S. increased spending on public health and emergency preparedness after the 9/11 and anthrax attacks in 2001, but that funding has declined sharply over the years.

"We tend to invest a lot in that moment of crisis," Gounder said. "When the crisis fades, we cut the budget. That leads us to be really vulnerable."

Liz Szabo: lszabo@kff.org, @LizSzabo

The executive mansion will get a deep clean after two COVID-19 outbreaks this fall led to President Donald Trump and members of his staff and family becoming infected.

This article was published on Monday, December 21, 2020 in Kaiser Health News.

By Phil Galewitz   

It was a down-in-the-mud presidential campaign, but the dirtiest part comes on Inauguration Day.

As Joe Biden lifts his right hand to take the oath of office at noon on Jan. 20 at the Capitol, a team of specially trained cleaners will be lifting their hands to disinfect the White House.

The executive mansion will get a deep clean after two COVID-19 outbreaks this fall led to President Donald Trump and members of his staff and family becoming infected.

The departure of one president and the arrival of another is always a fast but highly synchronized behind-the-scenes ballet by White House staff members and moving crews.

But this year is different. The shift means more than rearranging the Oval Office and putting new clothes in bedroom closets: It means a top-to-bottom disinfection amid a pandemic. Biden, who at 78 is taking office as the oldest president in U.S. history, is at high risk of complications from the virus.

So, the General Services Administration will oversee a thorough cleaning and disinfection of every doorknob, toilet handle, light switch, stair railing, telephone, elevator button, computer keyboard and other objects inside the 55,000-square-foot mansion at 1600 Pennsylvania Ave.

But can such a large building get fully clean in just five or six hours?

Experts say that should not be a problem with a large enough team and preparation time.

K. Mark Wiencek, lead microbiologist for South Carolina-based Contec Inc., which sells cleaning supplies to hospitals, said GSA cleaners should focus on the rooms last occupied by the Trump staff, since the virus can't survive long on surfaces. Cleaning crews, he added, should wear masks and gloves to protect themselves and not introduce any germs.

He recommended replacing the air filters and using fogging and spraying disinfectant to kill viruses.

The GSA said it is already cleaning the White House East Wing and West Wing offices daily with disinfectant.

GSA officials said they expect no difficulties in making the transition and pledged that all furniture and surfaces would be cleaned. "GSA will thoroughly clean and disinfect the building spaces between the administrations and ensure that everything is up to standard," a spokesperson said in a statement.

It's vital that cleaners leave the cleaning chemicals on surfaces a full 10 minutes before wiping them down, said O.P. Almaraz, a disaster relief expert in West Covina, California, and president of Allied Restoration, which has cleaned dozens of businesses after suspected COVID cases.

"With a large enough crew, a professional disinfection company could apply disinfectants to the entire White House in six hours," he said. It's important, he explained, that the crew pay "special attention to points that may be touched often, like tabletops, door handles and light switches."

As long as cleaners have an organized plan for each room, Almaraz doesn't see them having trouble getting done before the Bidens move in at the end of the day.

Sheldon Yellen, CEO of Michigan-based Belfor Property Restoration, said cleaning crews need to be rehearsed and in fully ventilated suits to clean the White House in one afternoon.

"It's a level 3 clean," he said, noting the building needs the most intensive service because of confirmed COVID cases. That means disposing of anything that doesn't have to stay for the Bidens, including pillows and bedsheets. He said books need to be wiped down, not just on the binding but all sides. He recommended cleaning the ductwork and ventilation systems as well.

Jack Shevel, co-founder of San Diego disinfection company Zappogen, said that because COVID-19 spreads by airborne transmission, it is best to disinfect using an electrostatic sprayer or fogger filled with a disinfectant designed to kill airborne pathogens. That covers a large area more easily than just wiping surfaces.

"To truly disinfect all those rooms quickly and thoroughly, they should be sprayed with a fine micron mist that can reach all crevices and surfaces evenly," he said.

Still, the White House cleaners must be careful to remove paintings, antiques and other valuable items before spraying with disinfectant, said Ernesto Abel-Santos, professor of biochemistry at the University of Nevada-Las Vegas. Those items should be cleaned by hand.

Abel-Santos said a simple alcohol-based disinfectant should be enough to kill the COVID virus. Although the virus can be detected on some surfaces for days, it typically degrades within hours. People are much more likely to be infected by droplets expelled when someone coughs, sneezes or talks.

During the turnover, cleaners should focus on the most commonly used areas of the building, he said, such as the Oval Office and bedrooms. "The rest can get deep-cleaned as needed," he added.

Even more important than cleaning, however, is asking the new president and his family and staff to physically distance, wear their masks and wash their hands, according to Abel-Santos.

"You don't realize how many times in a day you touch your face with your hands," he said. "If you touch a surface and then touch your face, it increases the probability of contagion."

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Unions and workers' rights and consumer advocacy groups are this week waging a last-ditch effort to get Congress to extend the program into 2021.

This article was published on Friday, December 18, 2020 in Kaiser Health News.

By Steven Findlay

Like tens of millions of other parents nationwide, Jonathan and Sara Sadowski struggle to assist their four children, ages 5 to 11, with their online schooling at home. In addition, their eldest child, who has cerebral palsy and is in a wheelchair, needs special care.

So to help the kids and keep them safe — especially their oldest child — Jonathan opted to take 12 weeks of paid leave from his teaching job under a program authorized by an emergency federal law enacted in March.

“Qualifying for paid leave was a huge relief and has worked out really well,” said Jonathan, who lives in Concord, New Hampshire.

But the family has learned about a new wrinkle: The 11-year old needs surgery in January. The operation is expected to require a month or two of recovery. Unfortunately, Jonathan’s leave will be used up by then; what’s more, the emergency federal paid leave program it is based on lapses Dec. 31.

Unions and workers’ rights and consumer advocacy groups are this week waging a last-ditch effort to get Congress to extend the program into 2021. They argue that the program is a critical component helping to prevent the spread of the virus and providing financial assistance to struggling families.

They also assert that a number of unwise exemptions — plus a lack of enforcement and public awareness — have limited the program’s effectiveness.

“The emergency paid-leave provisions have been one important step in helping American families deal with this crisis,” said Sen. Kirsten Gillibrand (D-N.Y.). “Congress must extend the provision until this crisis is over. Paid leave is critical as the economy recovers.”

The program is among two dozen pandemic-related relief measures set to expire at the end of the year. Those include unemployment benefits, protections against evictions, student loan relief and payments for COVID testing.

The Democratic-controlled House twice approved bills extending most of those, including paid leave. But Republican leaders in the Senate have until this month refused to consider new relief and stimulus legislation. This week, negotiations have intensified on a compromise bill that extends some of the expiring measures. But an extension of paid sick days and paid leave is not included in that bill.

Capitol Hill staffers and workers’ rights advocates say a paid-leave extension could still be added to the relief bill or a government spending bill that Congress must pass this month.

“It’s outrageous that paid leave is not in this legislation,” said Vicki Shabo, a senior fellow for paid-leave policy and strategy at New America, a Washington think tank. “The evidence is very clear paid sick days and leave help prevent spread of the virus, and it’s a benefit families overwhelmingly want and need.” 

Neither the Trump administration nor President-elect Joe Biden responded to requests for comment, and neither has announced a position on the issue.

Paid Sick Leave ‘Is in the Public Interest’

The current law requires businesses with fewer than 500 workers to allow their employees to take up to 10 days of sick leave at full pay and up to 50 more at two-thirds pay to care for a child when schools or day care centers are closed because of COVID-19.

The federal government covers the cost via tax credits to employers. The benefit covers mandatory 14-day quarantine periods for those exposed to the virus, whether they get sick or not.

Larger firms were exempted on the theory that most already provide paid sick days and some forms of extended paid leave — and don’t need federal subsidies.

But an analysis after the law was enacted found that the exemption leaves about 70 million workers in large businesses — roughly half the nation’s workforce — without the full protections offered under the COVID law.

The law and subsequent Department of Labor rules also permit firms with 50 or fewer employees to opt out of providing paid sick days or leave if they think their business will be adversely affected.

About 34 million people work for those small businesses — and the majority offer fewer than 10 paid sick days, if any. Few have extended paid leave.

In addition, the law has no guarantee of paid sick days or leave for the nation’s 13 million health care and emergency response workers.

The justification for that when the measure was enacted: Hospitals, clinics, nursing homes and emergency response companies needed to ensure that these essential workers would show up in a time of crisis.

“This was extremely shortsighted and bad policy,” said Pronita Gupta, director of job quality at the Center for Law and Social Policy in Washington, D.C. “We have seen the harmful outcome — the high number of coronavirus cases in health care facilities, especially among low-wage nursing home workers.”

Nor does the law offer extended paid leave for people who have COVID-19 or need to care for a family member with the disease beyond 10 days. Republicans opposed a broad-based benefit beyond at-home child care, advocates for the benefit noted.

“The problem is we now know that thousands of people who have COVID are sick for more than two weeks, some for months,” said Shabo. “These people need to be able to stay home and recover; that’s in the public interest as well.”

In a letter this month, a coalition of nine national public health groups urged Congress to extend the paid-leave benefits. “Paid sick leave can reduce the spread of COVID-19 in workplaces and communities by removing the barrier to employees staying home if they might have the virus,” the groups wrote. “Even one infection can set off an outbreak.”

Business groups are sympathetic, but some still oppose extending paid leave. Chief among them is the National Federation of Independent Business, a lobbying powerhouse that represents small businesses. Beth Milito, the group’s senior executive counsel, said that while small-business owners have been “highly sensitive” to their workers’ needs during the pandemic, mandating paid sick days and extended leave puts an undue burden on them.

“Figuring out who qualifies, monitoring who takes leave and then applying for the tax credit is all too much red tape,” Milito said. “It’s the hassle factor at a time when many businesses are barely making ends meet.”

Estimates of the Program’s Costs Vary Widely

Surveys show a majority of the estimated 70 million private- and public-sector workers covered under the law — after all the exemptions and carve-outs — don’t know about their right to paid sick days or leave.

“The lack of awareness has limited the potential of this benefit,” said Dawn Huckelbridge, director of the Paid Leave for All campaign, which is supported by a coalition of unions and employees and other groups. The Department of Labor, which administers the benefit, “simply fell down on the job,” she said.

Estimates last spring of the use and cost of the benefit varied widely — from around $20 billion to $105 billion.

But more recent estimates suggest it may be less. According to a Government Accountability Office report citing IRS data, as of the end of October about 150,000 employers had filed for paid family and sick leave tax credits, totaling $1.3 billion. The report noted, however, that many employers will likely wait until filing their taxes in the spring to claim the credit and recoup their costs.

The congressional Joint Committee on Taxation last month released fresh projections on the cost of an extension of paid leave — $1.4 billion if extended for two months and $1.8 billion for three months.

Although it’s too early for any full assessment of the paid-leave program’s impact, advocates point to a key study, published online in October in the journal Health Affairs. Researchers at Cornell University and the KOF Swiss Economic Institute found that in states where workers gained the right to paid sick leave under the emergency law, 400 fewer confirmed COVID cases were reported per day.

The researchers conclude: “Our findings suggest that the U.S. emergency sick leave provision was a highly effective policy tool to flatten the curve in the short run.”