Lions and Tigers and Anteaters? US Scientists Scan the Menagerie for COVID

KFF Health News, November 4, 2020

At least 2,000 animals in the U.S. have been tested for the coronavirus since the pandemic began, according to federal records.

This article was published on Wednesday, November 4, 2020 in Kaiser Health News.

By JoNel Aleccia

As COVID-19 cases surge in the U.S., one Texas veterinarian has been quietly tracking the spread of the disease — not in people, but in their pets.

Since June, Dr. Sarah Hamer and her team at Texas A&M University have tested hundreds of animals from area households where humans contracted COVID-19. They’ve swabbed dogs and cats, sure, but also pet hamsters and guinea pigs, looking for signs of infection. “We’re open to all of it,” said Hamer, a professor of epidemiology, who has found at least 19 cases of infection.

One pet that tested positive was Phoenix, a 7-year-old part-Siamese cat owned by Kaitlyn Romoser, who works in a university lab. Romoser, 23, was confirmed to have COVID-19 twice, once in March and again in September. The second time she was much sicker, she said, and Phoenix was her constant companion.

“If I would have known animals were just getting it everywhere, I would have tried to distance myself, but he will not distance himself from me,” Romoser said. “He sleeps in my bed with me. There was absolutely no social distancing.”

Across the country, veterinarians and other researchers are scouring the animal kingdom for signs of the virus that causes COVID-19. At least 2,000 animals in the U.S. have been tested for the coronavirus since the pandemic began, according to federal records. Cats and dogs that were exposed to sick owners represent most of the animals tested and 80% of the positive cases found.

But scientists have cast a wide net investigating other animals that could be at risk. In states from California to Florida, researchers have tested species ranging from farmed minks and zoo cats to unexpected critters like dolphins, armadillos and anteaters.

The U.S. Department of Agriculture keeps an official tally of confirmed animal COVID cases that stands at several dozen. But that list is a vast undercount of actual infections. In Utah and Wisconsin, for instance, more than 14,000 minks died in recent weeks after contracting COVID infections initially spread by humans.

So far, there’s limited evidence that animals are transmitting the virus to people. Veterinarians emphasize that pet owners appear to be in no danger from their furry companions and should continue to love and care for them. But scientists say continued testing is one way to remain vigilant in the face of a previously unknown pathogen.

“We just know that coronaviruses, as a family, infect a lot of species, mostly mammals,” said Dr. Peter Rabinowitz, a professor of environmental and occupational health sciences and the director of the University of Washington Center for One Health Research in Seattle. “It makes sense to take a species-spanning approach and look at a wide spectrum.”

Much of the testing has been rooted in scientific curiosity. Since the pandemic began, a major puzzle has been how the virus, which likely originated in bats, spread to humans. A leading theory is that it jumped to an intermediate species, still unknown, and then to people.

In April, a 4-year-old Malayan tiger at the Bronx Zoo tested positive for COVID-19 in a first-of-its-kind case after seven big cats showed signs of respiratory illness. The tiger, Nadia, contracted the virus from a caretaker, federal health officials said. Four other tigers and three African lions were also confirmed to be infected.

In Washington state, the site of the first U.S. outbreak in humans, scientists rushed to design a COVID test for animals in March, said Charlie Powell, a spokesperson for the Washington State University College of Veterinary Medicine. “We knew with warm-blooded animals, housed together, there’s going to be some cross-infection,” he said. Tests for animals use different reagent compounds than those used for tests in people, so they don’t deplete the human supply, Powell added.

Since spring, the Washington Animal Disease Diagnostic Laboratory has tested nearly 80 animals, including 38 dogs, 29 cats, two ferrets, a camel and two tamanduas, a type of anteater. The lab also tested six minks from the outbreak in Utah, five of which accounted for the lab’s only positive tests.

All told, nearly 1,400 animals have been tested for COVID-19 through the National Animal Health Laboratory Network or private labs, said Lyndsay Cole, a spokesperson for the USDA’s Animal and Plant Health Inspection Service. More than 400 animals have been tested through the National Veterinary Services Laboratories. At least 250 more have been tested through academic research projects.

The vast majority of the tests have been in household cats and dogs with suspicious respiratory symptoms. In June, the USDA reported that a dog in New York was the first pet dog to test positive for the coronavirus after falling ill and struggling to breathe. The dog, a 7-year-old German shepherd named Buddy, later died. Officials determined he’d contracted the virus from his owner.

Neither the Centers for Disease Control and Prevention nor the USDA recommends routine testing for house pets or other animals — but that hasn’t stopped owners from asking, said Dr. Douglas Kratt, president of the American Veterinary Medical Association.

“The questions have become a little more consistent at my practice,” he said. “People do want to know about COVID-19 and their pets. Can their pet pick it up at a clinic or boarding or in doggie day care?”

The answer, so far, is that humans are the primary source of infection in pets. In September, a small, unpublished study from the University of Guelph in Canada found that companion cats and dogs appeared to be infected by their sick owners, judging by antibodies to the coronavirus detected in their blood.

In Texas, Hamer started testing animals from households where someone had contracted COVID-19 to learn more about transmission pathways. “Right now, we’re very much trying to describe what’s happening in nature,” she said.

So far, most of the animals — including Phoenix, Romoser’s cat — have shown no signs of illness or disease. That’s true so far for many species of animals tested for COVID-19, veterinarians said. Most nonhuman creatures appear to weather COVID infection with mild symptoms like sniffles and lethargy, if any.

Still, owners should apply best practices for avoiding COVID infection to pets, too, Kratt said. Don’t let pets come into contact with unfamiliar animals, he suggested. Owners should wash their hands frequently and avoid nuzzling and other very close contact, if possible.

Cats appear to be more susceptible to COVID-19 than dogs, researchers said. And minks, which are farmed in the U.S. and elsewhere for their fur, appear quite vulnerable.

In the meantime, the list of creatures tested for COVID-19 — whether for illness or science — is growing. In Florida, 22 animals had been tested as of early October, including three wild dolphins, two civets, two clouded leopards, a gorilla, an orangutan, an alpaca and a bush baby, state officials said.

In California, 29 animals had been tested by the end of September, including a meerkat, a monkey and a coatimundi, a member of the raccoon family.

In Seattle, a plan to test orcas, or killer whales, in Puget Sound was called off at the last minute after a member of the scientific team was exposed to COVID-19 and had to quarantine, said Dr. Joe Gaydos, a senior wildlife veterinarian and science director for the SeaDoc Society, a conservation program at the University of California-Davis. The group missed its September window to locate the animals and obtain breath and fecal samples for analysis.

No one thinks marine animals will play a big role in the pandemic decimating the human population, Gaydos said. But testing many creatures on both land and sea is vital.

“We don’t know what this virus is going to do or can do,” Gaydos said.

No Winner for President Yet and Health Care Hangs in the Balance

KFF Health News, November 4, 2020

At stake is whether the federal government will play a stronger role in financing and setting the ground rules for health care coverage or cede more authority to states and the private sector.

This article was published on Wednesday, November 4, 2020 in Kaiser Health News.

By Julie Rovner

Update: This story was updated Nov. 4 at 7:30 a.m. ET to add more details about vote tallies from states.

With the winner of the presidency and party control of the Senate still unclear the morning after Election Day, the future of the nation’s health system remains uncertain. At stake is whether the federal government will play a stronger role in financing and setting the ground rules for health care coverage or cede more authority to states and the private sector.

Should President Donald Trump win and Republicans retain control of the Senate, Trump still may not be able to make sweeping changes through legislation as long as the House is still controlled by Democrats. But — thanks to rules set up by the Senate GOP — the ability to continue to stack the federal courts with conservative jurists who are likely to uphold Trump’s expansive use of executive power could effectively remake the government’s relationship with the health care system even without signed legislation.

The president has also pledged to continue his efforts to get rid of the Affordable Care Act, and if the Supreme Court overturns the sweeping law as part of a challenge it will hear next week, the Republicans’ promise to protect people with preexisting medical conditions will be put to the test. In a second term, the administration would also likely push to continue to revamp Medicaid with its efforts to institute work requirements for adult enrollees and provide more flexibility for states to change the contours of the program.

If former Vice President Joe Biden wins and Democrats gain a Senate majority, it would represent the first time the party has controlled the White House and both houses of Congress since 2010 — the year the ACA was passed. A top priority will be dealing with the COVID-19 pandemic and the economic fallout. Biden made that a keystone of his campaign, promising to implement policies based on advice from medical and scientific advisers and provide more directives and aid to the states.

But also high on his agenda will be addressing parts of the ACA that haven’t worked as well as its authors hoped. He pledged to add a government-run “public option,” which would be an alternative to private insurance plans on the marketplaces, and to lower the eligibility age for Medicare to 60.

While Democrats will continue to control the House, the final makeup of the Senate is still to be determined. And even if the Democrats win the Senate, they are not expected to come away with a majority that would allow them to pass legislation without support from at least some GOP senators, unless they change the Senate’s rules. That could lower expectations of what the Democrats can accomplish — and may lead to some tensions among members.

But who controls Washington, D.C., is only part of the election’s impact on health policy. Several key health issues are on the ballot both directly and indirectly in many states. Here are a few:

Abortion

In Colorado, a measure that would have banned abortions after 22 weeks of pregnancy — except to save the life of the pregnant person — failed, according to The Associated Press. Colorado is one of seven states that don’t prohibit abortions at some point in pregnancy. It is also home to one of the few clinics in the nation that perform abortions in the third trimester, often for severe medical complications. The clinic draws patients from around the nation, so residents of other states would have been affected if the Colorado amendment passed.

In Louisiana, however, voters easily approved an amendment to the state constitution to say that nothing in the document protects the right to, or requires the funding of, abortion. That would make it easier for the state to outlaw abortion if the Supreme Court overturns Roe v. Wade, which makes state abortion bans unconstitutional.

Medicaid

The fate of the Medicaid program for people with low incomes is not on the ballot directly anywhere this election. (Voters approved expansions of the program in Missouri and Oklahoma earlier this year.) But the program will be affected not only by who controls the presidency and Congress, but also by who controls the legislatures in states that have not expanded the program under the Affordable Care Act. North Carolina is a key swing state where a change in majority in the legislature could turn the expansion tide.

Drug Policy

In six states, voters are deciding the legality of marijuana in one form or another. Montana, Arizona and New Jersey were deciding whether to join the 11 states that allow recreational use of the drug. Mississippi and Nebraska voters were choosing whether to legalize medical marijuana, and South Dakota became the first state to vote on legalizing both recreational and medical pot in the same election.

Magic mushrooms are on two ballots. A measure in Oregon to allow the use of psilocybin-producing mushrooms for medicinal purposes passed, and a District of Columbia proposal to decriminalize the hallucinogenic fungi was leading.

Also approved was a separate ballot question in Oregon to decriminalize possession of small amounts of hard drugs, including heroin, cocaine and methamphetamine, and mandate establishing addiction recovery centers, using some tax proceeds from marijuana sales to establish those centers.

California

As usual, voters in California faced a lengthy list of health-related ballot measures.

For the second time in two years, the state’s profitable kidney dialysis industry was challenged at the ballot box. A union-sponsored initiative would have required dialysis companies to employ a doctor at every clinic and submit infection reports to the state. But the industry spent $105 million against the measure. The measure failed, according to AP.

Voters were also asked to decide, again, whether to fund stem cell research through the California Institute for Regenerative Medicine via Proposition 14. Voters first approved funding for the agency in 2004, and since then, billions have been spent with few cures to show for it. The measure was winning in early returns.

California has been at the forefront of the fight over the so-called gig economy, and this year’s ballot included a proposal pushed by ride-hailing companies like Uber and Lyft that would let them continue to treat drivers as independent contractors instead of employees. Under Proposition 22, the companies would not have to provide direct health benefits to drivers but would have to give those who qualify a stipend they could use toward a premium for health insurance purchased through the state’s individual marketplace, Covered California. The measure was approved.

Finally, voters in the Golden State were asked whether to impose higher property taxes on commercial property owners with land and property holdings valued at $3 million or more, which could help provide new revenue earmarked for economically struggling cities and counties hit hard by COVID-19, as well as K-12 schools and community colleges. Community clinics, California nurses and Planned Parenthood jumped into the thorny political battle over Proposition 15 — taking on powerful business groups — eyeing revenue to help rebuild California’s underfunded public health system. The measure was too close to call in early returns.

Democrats in California, who control all statewide elected offices and hold a supermajority in the legislature, have been positioning for a Biden win, and some were already penning ambitious health care legislation for next year. Should Biden win, they said they plan to crack down on hospital consolidation and end surprise emergency room bills, and some were quietly discussing liberal initiatives such as pursuing a single-payer health care system and expanding Medicaid to cover more unauthorized immigrants.

JoNel Aleccia, Rachel Bluth, Angela Hart, Matt Volz and Samantha Young contributed to this story.

Seniors Form COVID Pods to Ward Off Isolation This Winter

KFF Health News, November 3, 2020

Older adults in all kinds of circumstances are similarly deliberating what to do as days and nights turn chilly and coronavirus cases rise across the country.

This article was published on Tuesday, November 3, 2020 in Kaiser Health News.

By Judith Graham

Over the past month, Dr. Richard Besdine and his wife have been discussing whether to see family and friends indoors this fall and winter.

He thinks they should, so long as people have been taking strict precautions during the coronavirus pandemic.

She’s not convinced it’s safe, given the heightened risk of viral transmission in indoor spaces.

Both are well positioned to weigh in on the question. Besdine, 80, was the longtime director of the division of geriatrics and palliative medicine at Brown University’s Alpert Medical School. His wife, Terrie Wetle, 73, also an aging specialist, was the founding dean of Brown’s School of Public Health.

“We differ, but I respect her hesitancy, so we don’t argue,” Besdine said.

Older adults in all kinds of circumstances — those living alone and those who are partnered, those in good health and those who are not — are similarly deliberating what to do as days and nights turn chilly and coronavirus cases rise across the country.

Some are forming “bubbles” or “pods”: small groups that agree on pandemic precautions and will see one another in person in the months ahead. Others are planning to go it alone.

Judith Rosenmeier, 84, of Boston, a widow who’s survived three bouts of breast cancer, doesn’t intend to invite friends to her apartment or visit them in theirs.

“My oncologist said when all this started, ‘You really have to stay home more than other people because the treatments you’ve had have destroyed a lot of your immune defenses,’” she said.

Since mid-March, Rosenmeier has been outside only three times: once, in September, to go to the eye doctor and twice since to walk with a few friends. After living in Denmark for most of her adult life, she doesn’t have a lot of close contacts. Her son lives in Edinburgh, Scotland.

“There’s a good chance I’ll be alone on Thanksgiving and on Christmas, but I’ll survive,” she said.

A friend who lives nearby, Joan Doucette, 82, is determined to maintain in-person social contacts. With her husband, Harry Fisher, 84, she’s formed a “pod” with two other couples in her nine-unit apartment building. All are members of Beacon Hill Village, an organization that provides various services to seniors aging in place. Doucette sees her pod almost every day.

“We’re always running up and down the stairs or elevator and bringing each other cookies or soup,” she said. “I don’t think I would have survived this pandemic without that companionship.”

About once a week, the couples have dinner together and “we don’t wear masks,” said Jerry Fielder, 74, who moved to Boston two years ago with his partner, Daniel, 73. But he said he feels safe because “we know where everyone goes and what they do: We’re all on the same page. We go out for walks every day, all of us. Otherwise, we’re very careful.”

Eleanor Weiss, 86, and her husband are also members of the group. “I wear a mask, I socially distance myself, but I don’t isolate myself,” Weiss said. This winter, she said, she’ll see “a few close friends” and three daughters who live in the Boston area.

One daughter is hosting Thanksgiving at her house, and everyone will get tested for the coronavirus beforehand. “We’re all careful. We don’t hug and kiss. We do the elbow thing,” Weiss said.

In Chicago, Arthur Koff, 85, and his wife, Norma, 69, don’t yet have plans for Thanksgiving or Christmas. “It’s up in the air depending on what’s happening with the virus,” he said. The couple has a wide circle of friends.

“I think it’s going to be a very hard winter,” said Koff, who has diabetes and blood cancer. He doesn’t plan to go to restaurants but hopes to meet some friends he trusts inside their homes or apartments when the weather turns bad.

Julie Freestone, 75, and her husband, Rudi Raab, 74, are “pretty fanatic” about staying safe during the pandemic. The couple invited six friends over for “Thanksgiving in October” earlier this month — outside, in their backyard in Richmond, California.

“Instead of a seating chart, this year I had a plating chart and I plated everything in advance,” Freestone said. “I asked everybody to tell me what they wanted — White or dark meat? Brussels sprouts or broccoli?”

This winter, Freestone isn’t planning to see people inside, but she’ll visit with people in groups, virtually. One is her monthly women’s group, which has been getting together over Zoom. “In some ways, I feel we’ve reached a new level of intimacy because people are struggling with so many issues — and we’re all talking about that,” she said.

“I think you need to redefine bubbles,” said Freestone, who’s on the board of Ashby Village, a Berkeley, California-based organization for seniors aging in place that’s hosting lots of virtual groups. “It should be something you feel a part of, but it doesn’t have to be people who come into your house.”

In the Minneapolis-St. Paul area in Minnesota, two psychologists — Leni de Mik, 79, and Brenda Hartman, 65 — are calling attention to what they call SILOS, an acronym for “single individuals left out of social circles,” and their need for dependable social contact this winter and fall.

They recommend that older adults in this situation reach out to others with similar interests — people they may have met at church or in book clubs or art classes, for instance — and try to form a group. Similarly, they recommend that families or friends invite a single older friend into their pods or bubbles.

“Look around at who’s in your community. Who used to come to your house that you haven’t seen? Reach out,” de Mik recommended.

Both psychologists are single and live alone. De Mik’s pod will include two friends who are “super careful outside,” as she is. Hartman’s will include her sister, 67, and her father, 89, who also live alone. Because her daughter works in an elementary school, she’ll see her only outside. Also, she’ll be walking regularly with two friends over the winter.

“COVID brings life and death right up in front of us,” Hartman said, “and when that happens, we have the opportunity to make crucial choices — the opportunity to take care of each other.”

Consumer Resources

Public health experts advise that thorough and frequent hand-washing, wearing masks in public meeting in small groups and maintaining at least 6 feet of social distancing can help prevent the transmission of the coronavirus. The federal Centers for Disease Control and Prevention has more detailed advice on its website, including these pages:

The Best COVID Warning System? Poop and Pooled Spit, Says One Colorado School

KFF Health News, November 3, 2020

Emerging research suggests infected people start shedding the coronavirus in their poop early in their infection, and possibly days before they begin shedding it from their mouths and noses. 

This article was published on Tuesday, November 3, 2020 in Kaiser Health News.

By Rae Ellen Bichell

Carol Wilusz’s mornings now often start at 4 a.m., scanning the contents of undergraduates’ feces. Specifically, scanning the data on how much coronavirus they flushed into the shadows, destined to be extracted from 17 manholes connected to dorm buildings on Colorado State University’s Fort Collins campus.

“There are quite extensive numbers of poop jokes,” said Wilusz, a CSU molecular biologist.

Emerging research suggests infected people start shedding the coronavirus in their poop early in their infection, and possibly days before they begin shedding it from their mouths and noses. “It means that we can catch them before they’re actually spreading the infection,” she said.

In normal times, Wilusz studies stem cells and muscular dystrophy. Now, her team is on the front lines of defense against the massive COVID-19 outbreaks that, for a campus with more than 23,000 undergraduates alone, always seem to be lurking around the corner. The sewage review is part of a multipronged attack that includes the usual weapon of contact tracing plus a specialized “paired pooling” form of testing saliva samples. So far, the school has had about 500 cases since the semester started, about half that of the only somewhat bigger University of Colorado-Boulder.

Amid fluctuating scientific recommendations and a virus that still holds uncertainties, colleges across the country are taking a choose-your-own-adventure approach to COVID-19. For those holding in-person classes, the adventure includes an extra puzzle: how to concentrate a lot of people into one place without an outbreak tearing through the student body and spilling into the community, all without safety precautions that would break the bank. Testing is at the core of those plans.

“A lot of these institutions started testing just symptomatic students. And that is really not good, to put it bluntly, because as we’ve seen over the past couple of months, students tend to be asymptomatic,” said Chris Marsicano, an assistant professor at Davidson College in North Carolina who is leading an initiative tracking how universities are responding to the pandemic. “The institutions that have been the most successful are ones that are testing every student at least once a week.”

According to data collected in mid-September, only about 6% of large universities with in-person classes are routinely testing all students, according to an NPR analysis of his group’s data. The University of Illinois at Urbana-Champaign has been leading the pack, testing about 10,000 students each day using a streamlined spit-testing method. But it’s pricey. Despite driving down the cost of an individual test to about $10, Paul Hergenrother, a chemist leading the effort, said the school is still spending about $1 million a week.

At Colorado State University, Lori Lynn, co-chair of the school’s pandemic response team, said initially the school was paying $93 a pop to test students using the usual nose swab method.

“We quickly spent several million dollars on testing,” said Lynn, who added that cost is just one limiting factor. “We can’t test everybody in the community, you know, weekly or twice a week.”

Instead, Mark Zabel, a CSU molecular biologist and immunologist who typically studies neurodegenerative diseases, said his group recently figured out how to screen saliva for less than $20 a person. It involves pooling drool samples in a strategic way reminiscent of the children’s game Battleship.

Traditionally, pooling involves mixing samples from multiple people and testing them all in one go, to save time and materials. If the pool comes back negative for the virus, everyone in the pool can be considered negative. If it’s positive, samples from each person in that pool must be retested. If there are high rates of infection, that means a lot of retesting.

Instead of pooling samples willy-nilly, Zabel and his colleagues are doing something he calls paired pooling: They start with an eight-by-eight grid of saliva from 64 people, arrayed almost like a Battleship board. Each person’s spit sample gets divided up and analyzed in two pools, one pool for the row it sits in and one for the column it sits in, for a grand total of 16 pools per grid.

If the test containing samples in Row A and the test containing samples from Column One appear positive, that would indicate that the person whose spit is in the A-1 slot is a positive case.

“So, it’s super easy if we’ve got one positive among 64,” said Zabel. In that case, they’ve screened 64 people with just 16 tests. No retesting necessary.

Limited retesting is needed only if at least four pools come back positive.

They’re also using a different kind of PCR test than usual, in an effort to avoid competing for limited reagents, whose shortages have hampered labs nationwide.

Zabel said it takes between eight and 24 hours for results. However, some drawbacks exist. If retesting is necessary, total turnaround time could extend to three days. And if the outbreak were to grow beyond a certain point, in which at least 5% of people tested are positive, the process would become more cumbersome because they’d have to add more layers of testing.

It’s a shifting target and the university is continually reevaluating its testing strategy, but Zabel expects his lab could test up to 3,000 people a day, which would enable testing the entire student body every other week.

According to other researchers, that might not be enough.

Daniel Larremore and others writing in the New England Journal of Medicine said it’s time to ditch any approach that relies on highly accurate tests, and instead embrace antigen tests, which are cheap and quick — albeit less accurate — and can be administered frequently.

“You have the science of testing, which says if you’re testing everybody twice a week, you should basically have zero cases,” said Larremore, a computational biologist at the University of Colorado-Boulder, referring to modeling studies from his lab and others.

But then, there’s reality. And no testing system alone will solve the problem, Larremore said, “because there are humans involved.”

Wilusz, the CSU professor, knows how difficult this is. Often people continue shedding virus in their poop long after they’ve recovered, so over the course of the semester more and more dorms have started to yield virus-positive sewage.

“And then there’s also, we can’t stop students pooping in the wrong dorm. So one could poop in this dorm one day and then next door on the other day,” she said, making it hard to know which dorm to screen with saliva tests.

Also, only about 5,000 of the school’s 28,000 enrolled students live in dorms, though Wilusz said those close quarters create a high risk for spreading the disease because “they’re essentially like nursing homes for young people.”

She wonders how long students will remain game to spit into tubes before they get bored. Michigan State University researchers experimenting with paired pooling and saliva have made a habit of double-checking that students have submitted spit instead of something else. (Chewing tobacco and something the color of blue Gatorade have sullied a few CSU samples so far.)

But the shifting, multifaceted approach does seem to be helping at Colorado State. Back in September, Wilusz noticed a concerning spike in the amount of virus in the sewage connected to two dorms that collectively housed about 900 students. The university put the dorms on lockdown and tested everyone inside, revealing nine positive cases that hadn’t been found using other methods.

Now, with pooled-spit screening, Zabel said the team has been able to identify positives without locking down entire dorms, and can then use subsiding levels in sewage to confirm no infections slipped through the cracks.

The goal is to make it to Thanksgiving, when students return home. But then comes 2021. “We’ll see if we can keep on top of it,” Zabel said, knocking on his desk for luck.

How COVID Death Counts Become the Stuff of Conspiracy Theories

KFF Health News, November 2, 2020

We asked experts to explain how death counts are done and to discuss whether the current figure — an estimated 231,000 deaths since the pandemic began — is in the ballpark.

This article was published on Monday, November 2, 2020 in Kaiser Health News.

By Victoria Knight and Julie Appleby

In the waning days of the campaign, President Donald Trump complained repeatedly about how the United States tracks the number of people who have died from COVID-19, claiming, “This country and its reporting systems are just not doing it right.”

He went on to blame those reporting systems for inflating the number of deaths, pointing a finger at medical professionals, who he said benefit financially.

All that feeds into the swirling political doubts that surround the pandemic, and raises questions about how deaths are reported and tallied.

We asked experts to explain how it’s done and to discuss whether the current figure — an estimated 231,000 deaths since the pandemic began — is in the ballpark.

Dismissing Conspiracy Theories, Profit Motives

Trump’s recent assertions have fueled conspiracy theories on Facebook and elsewhere that doctors and hospitals are fudging numbers to get paid more. They’ve also triggered anger from the medical community.

“The suggestion that doctors — in the midst of a public health crisis — are overcounting COVID-19 patients or lying to line their pockets is a malicious, outrageous, and completely misguided charge,” Dr. Susan R. Bailey, American Medical Association president, said in a press release.

Hospitals are paid for COVID treatment the same as for any other care, though generally, the more serious the problem, the more hospitals are paid. So, treating a ventilator patient — with COVID-19 or any other illness — would mean higher payment to a hospital than treating one who didn’t require a ventilator, reflecting the extra cost.

There is one financial difference. Medicare, the government health program for the elderly and disabled, pays 20% on top of its ordinary reimbursement for COVID patients — a result of the CARES Act, the federal stimulus bill that passed in the spring.

That additional payment applies only to Medicare patients.

Experts say there is simply no evidence that physicians or hospitals are labeling patients as having COVID-19 simply to collect that additional payment. Rick Pollack, president and CEO of the American Hospital Association, wrote an opinion piece in September addressing what he called the “myths” surrounding the add-on payments. While many hospitals are struggling financially, he wrote, they are not inflating the number of cases — and there are serious disincentives to do so.

“The COVID-19 code for Medicare claims is reserved for confirmed cases,” he wrote, and using it inappropriately can result in criminal penalties or a hospital being kicked out of the Medicare program.

Public health officials and others also pushed back.

Said Jeff Engel, senior adviser for COVID-19 at the Council of State and Territorial Epidemiologists: “Public health is charged with the duty to collect accurate, timely and complete data. We’re not incentivized to overcount or undercount for any political or funding reason.”

And what about medical examiners? Are they part of a concerted effort to overcount deaths to reap financial rewards?

“Medical examiners and coroners in the U.S. are not organized enough to have a conspiracy. There are 2,300 jurisdictions,” said Dr. Sally Aiken, president of the National Association of Medical Examiners. “That’s not happening.”

Still, there’s an ongoing debate about which mortalities should be considered COVID deaths.

Behind the Numbers

The Centers for Disease Control and Prevention, as well as nongovernmental organizations like the COVID Tracking Project and Johns Hopkins University, compile daily data on COVID deaths. Their statistics rely on state-generated data, which begins at the local level.

States have leeway to decide how to gather and report data. Many rely on death certificates, which list the cause of death, along with contributing factors. They are considered very accurate but can take one to two weeks to be finalized because of the processes involved in filling them out, reviewing and filing them. These reports generally lag behind testing and hospitalization data.

The other way deaths get reported is through what’s known as the case classification method, which reports deaths of people with previously identified cases of COVID, whether listed as confirmed or probable. Confirmed COVID deaths are affirmed by a positive test result. Probable COVID deaths are classified by using medical record evidence, suspected exposure or serology tests for COVID antibodies. The case classification method is faster than using death certificates and makes the data available in a more real-time fashion. Epidemiologists say this information can be helpful in gaining an understanding in the midst of an outbreak of how many people are dying and where.

Some experts point out that, while both methods have their virtues, each shows a different mortality count at a different time, so the best practice is to gather both sets of information.

The federal government, though, has offered conflicting guidance. The National Center for Health Statistics, an arm of the CDC, recommends primarily using death certificate data to count COVID deaths. But in April, the CDC asked jurisdictions to start tracking mortality based on probable and confirmed case classifications. Most states now gather data only one of the two ways, though a couple use both.

This patchwork approach does lead to conflicting data on total deaths.

Why Is the Count So Hard?

For the most part, public health researchers and medical examiners agree that COVID deaths are likely being undercounted.

“It’s very hard in a situation moving as rapidly as this one, and at such a large scale, to be able to count accurately,” said Sabrina McCormick, an associate professor in environmental and occupational health at George Washington University.

For one thing, the processes for certifying deaths vary widely, as does who fills out the death certificates. While physicians certify most death certificates, coroners, medical examiners and other local law enforcement officials can also do so.

Aiken, the medical examiner of Spokane County, Washington, said any time someone in her area dies at home and may have had COVID symptoms, the deceased person will automatically be tested for the disease.

But that doesn’t happen everywhere, she added, which means some who die at home could be omitted from the count.

It’s also unknown how accurate post-mortem COVID testing is, because there haven’t yet been any research studies on the practice — which could lead to missed cases.

Another wrinkle: Doctors in hospitals might not always be trained in the best practices for filling out death certificates, Aiken said.

“These folks are dealing with ERs and ICUs that are crowded. Death certificates are not their priority,” she said.

Emergency room doctors acknowledged the challenges, noting they don’t always have the resources that coroners and medical examiners do to perform autopsies.

“Much of the time, we don’t have an answer as to the final reason that a person died, so we are often stuck with the old cardiopulmonary arrest, which coroners and certifiers hate,” said Dr. Ryan Stanton, a Lexington, Kentucky, ER doctor and board member of the American College of Emergency Physicians.

That gets to how complex it is to determine what, exactly, caused a death — and what some say is a confusion between who died “with” COVID-19 (but may have had other underlying conditions that caused their death) and who died directly “of” COVID-19.

John Fudenberg, the former coroner for Clark County, Nevada, which surrounds Las Vegas, said including some of those who died with COVID-19 could result in an overcount.

“As a general rule, if someone dies with COVID, it’s going to be on the death certificate, but it doesn’t mean they died from COVID,” said Fudenberg, now executive director of the International Association of Coroners and Medical Examiners. For example, “if somebody has end-stage pancreatic cancer and COVID, did they die with COVID or from COVID?”

That question has proven controversial, and Trump has claimed that counting those who died “with COVID” has led to an inflation of the numbers. But most public health experts agree that if COVID-19 caused someone to die earlier than they normally would have, then it certainly contributed to their death. Additionally, those who certify death certificates say they list only contributing factors that are certain.

“Doctors don’t put things on death certificates that have nothing to do with the death,” said Dr. Amesh Adalja, senior scholar at the Johns Hopkins Center for Health Security.

COVID-19 can directly lead to death in someone with cancer or heart problems, even if those conditions were also serious or even expected to be fatal, he said.

And the claim that some states are counting people who die in car accidents, but also test positive for COVID-19, as COVID deaths is just plain unfounded, experts said.

“I can’t imagine a scenario where a medical examiner would test someone for COVID who died in a motor vehicle accident or a homicide,” said Engel, at the epidemiologists council. “I think that’s been greatly exaggerated on the internet.”

Excess Deaths

An additional approach to determining the pandemic’s scope has emerged, and many experts increasingly point to this measure as a useful indicator.

It relies on a concept known as “excess deaths,” which involves comparing the total number of deaths from all causes in a given period with the same period in previous years.

A CDC study estimated that almost 300,000 more people died in the U.S. this year from late January through Oct. 3 than in previous years. Some of those excess deaths were no doubt COVID cases, while others may have been people who avoided medical care because of the pandemic and then died from another cause.

These excess deaths are “the best evidence” that undercounting is ongoing, said Dr. Jeremy Faust, an ER doctor at Brigham and Women’s Hospital in Boston. “The timing of the excess deaths exactly parallels the COVID deaths, so when COVID deaths spike, all causes of deaths spike. They are hugging each other like parallel train tracks on a graph.”

Faust believes the majority of the excess deaths should be attributed in some way to COVID-19.

Even so, it’s unclear if we’ll ever get an accurate count.

Aiken said it is possible but could take years. “I think eventually, when this is said and done, we’ll have a pretty good count,” she said.

McCormick, of George Washington University, isn’t as sure, mostly because the number has become a flashpoint.

“It will always be a controversy, especially because it’s going to be so politically charged,” she said. “I don’t think we’ll come to a final number.”

'His Lies are Killing my Neighbors': Swing-state Health Workers Try to Defeat Trump

KFF Health News, November 2, 2020

Thursday, the night before Trump was scheduled to appear in Green Bay, hospitals released a joint statement urging locals to avoid large crowds.

This article was published on Monday, November 2, 2020 in Kaiser Health News.

By Danielle Renwick, The Guardian

Dr. Chris Kapsner intubated his first COVID-19 patient — a 47-year-old man who arrived short of breath at an emergency room in Minnesota’s Twin Cities — back in April.

Now, seven months later, Kapsner, who lives across the border in Wisconsin, is weary and exhausted from the steady stream of patients arriving with a virus that is spreading across this part of the Midwest. Hospital beds and personal protective equipment are in short supply, and his colleagues are getting sick. “Even if we put up all the field tents in the world, we don’t have the staff for this,” he said.

Kapsner believes political disfunction at the state level and a “disastrous” federal response are responsible for Wisconsin’s spike in cases. It’s part of the reason he’s running for office.

Kapsner is one of at least four health care workers running for Democratic seats in the Wisconsin state assembly, and one of many in his field speaking out against President Donald Trump and the GOP’s response to COVID-19.

Wisconsin is in the throes of one of the country’s worst COVID outbreaks. On Oct. 27, the state reported more than 5,000 new cases and a test positivity rate of over 27%. Nearly 2,000 people have died, and only the Dakotas are currently reporting more cases per capita.

Despite this, Trump has been holding large rallies across the state where crowds gather by the thousands, often without masks. Another Trump rally was planned for Monday evening in Kenosha, the site of unrest last summer after Jacob Blake was shot in the back by police. Wisconsin is a crucial swing state in Tuesday’s election; Trump carried the state by just 27,000 votes in 2016 and is currently trailing Joe Biden in the polls.

Last month, a group of 20 doctors sent an open letter to Trump asking him to stop holding rallies in the state. Thursday, the night before Trump was scheduled to appear in Green Bay, hospitals released a joint statement urging locals to avoid large crowds. Earlier in October, the Trump campaign scuttled plans for a rally in La Crosse, in western Wisconsin, after the city’s mayor asked him not to come amid a spike in cases there.

Dr. Kristin Lyerly, an OB-GYN in Appleton, in eastern Wisconsin, said she struggles to find the right words to describe her anger over the rallies, which have been linked to subsequent coronavirus outbreaks. On Oct. 24, at a rally in Waukesha, about 100 miles south of Appleton, Trump falsely accused health care workers of inflating the number of COVID cases for financial gain.

“His lies are killing my neighbors,” she said.

Lyerly, who is also running for state assembly, said she spends her days trying to reassure terrified pregnant patients, while fearing she might contract the virus herself. She and her colleagues are overwhelmed. She keeps her PPE in her car to ensure she never goes without it. “We’ve completely forgotten about the human impact on our health care workers. Our health care workers are exhausted, they’re burned out and they feel entirely disrespected,” she said.

Lyerly said she decided to run for office in April, after the Republican-controlled assembly refused to postpone a statewide election, in which the Democratic presidential primary and a key state Supreme Court seat were on the ballot. The state GOP also stymied efforts to make it easier for Wisconsinites to vote by mail.

“As a physician, I think many of us were shocked that our legislature would put us in danger, and make us decide between our vote and our health,” she said. She’s running in a district that typically leans conservative but said her campaign’s latest polls put her within the margin of error of her opponent, an incumbent.

Dr. Robert Freedland, an ophthalmologist in southwestern Wisconsin and state lead for the Committee to Protect Medicare, signed the letter asking Trump to stop holding rallies in Wisconsin. He wanted to go on the record as having spoken out in the name of public health.

Freedland, who is 65 and has Type 2 diabetes, said he fears for his health when he goes to work.

Dr. Jeff Kushner, a cardiologist who also signed the letter, said he hasn’t been able to work since March because of the pandemic. Kushner, 65, has non-Hodgkins lymphoma and is on immunosuppressants. “If I got COVID, I wouldn’t survive,” he said.

Though he follows politics closely, Kushner said that he’s not “politically involved” and that he tends to keep his politics to himself and a close inner circle. But he said he doesn’t consider signing the letter to Trump a political act. “It’s a statement of what I believe about our society’s health and not a political statement,” he said. “It wasn’t an anti-Trump letter. We were just saying, ‘Please don’t have these superspreader events in our state.’”

Kapsner, the emergency room doctor, said he still speaks with patients and voters who doubt the severity of COVID-19. “My job isn’t to shame them,” he said. “There are many people out here who have had the good fortune of not being personally affected by COVID. Their friends or families haven’t had it yet. I fear their luck is going to run out.”

They Work in Several Nursing Homes to Eke Out a Living, Possibly Spreading the Virus

KFF Health News, November 2, 2020

Data showed a lot of nursing home workers are working at more than one facility, and findings suggest that staffers who work in multiple nursing homes are one source of the spread of infections.

This article was published on Monday, November 2, 2020 in Kaiser Health News.

By Jackie Fortiér, KPCC

To make ends meet, Martha Tapia works 64 hours a week at two Orange County, California, nursing homes. She is one of thousands of certified nursing assistants who perform the intimate and physical work of bathing, dressing and feeding the nation’s fragile elderly.

“We do everything for them. Everything you do for yourself, you have to do for the residents,” Tapia said.

And she’s one of many in that low-paid field, predominantly women of color, who work at more than one facility.

In March, when the coronavirus began racing through nursing homes, the federal government banned visitors. (That guidance has since been updated.) But even with the ban, infections kept spreading. A team of researchers from UCLA and Yale University decided to examine the people who continued to enter nursing homes during that time: the employees.

Keith Chen, a behavioral economist and UCLA professor, said the key question is this: “The people who, we can infer, work in this nursing home — what other nursing homes do they work at?”

Using location data from 30 million smartphones when the visitor ban was in place helped the scientists “see” the movements of people going into and out of nursing homes. The data showed a lot of nursing home workers are — like Tapia — working at more than one facility. Chen said the findings suggest that staffers who work in multiple nursing homes are one source of the spread of infections.

“When you learn that over 20 of your workers are also spending time in other nursing homes, that should be a real red flag,” Chen said.

The Toll on Patients and Beyond

More than 84,000 residents and staff members of nursing homes and other long-term care facilities have died of COVID-19 across the U.S., representing 40% of all coronavirus fatalities in the country, according to KFF’s most recent analysis. (KHN is an editorially independent program of KFF.)

In California, the analogous toll is more than 5,700 deaths, making up 35% of all coronavirus fatalities in the state.

The UCLA team created maps of movement and found that on average each nursing home is connected to seven others through staff movement. Limiting nursing home employees to one facility could mean fewer COVID-19 infections — but that would hurt the workforce of people who say they work multiple jobs because of low wages.

After each of her shifts, Tapia worries she’ll bring the coronavirus home to her granddaughter. She tries to take precautions, including buying N95 masks from nurses. She knows it’s not just patients who are at risk. Nursing home workers such as Tapia are also contracting COVID-19 — in California alone, 153 of them have died since the pandemic began.

At the nursing home where she works in the morning, Tapia gets an N95 mask that she must only use — and reuse — in that facility. At her other nursing home job, in the afternoons, she gets a blue surgical mask to wear.

“They say they cannot give us N95 [masks],” she said, because she works in the “general area” where residents haven’t tested positive for the coronavirus.

She doesn’t want to work at multiple nursing homes, but her rent in Orange County is $2,200 a month, and her low pay and limited hours at each nursing home make multiple jobs a necessity.

“I don’t want to get sick. But we need to work. We need to eat, we need to pay rent. That’s just how it is,” Tapia said.

Staff Connections Equal Infections

The UCLA study also found that some areas of the country have a much higher overlap in nursing home staffing than others.

“There are some facilities in Florida, in New Jersey, where they’re sharing upwards of 50 to 100 workers,” said UCLA associate professor Elisa Long, who, along with her colleagues, examined data during the federal visitor ban from March to May. “This is over an 11-week time period, but that’s a huge number of individuals that are moving between these facilities; all of these are potential sources of COVID transmission.”

They also found the more shared workers a nursing home has, the more COVID-19 infections among the residents.

“Not only does it matter how connected your nursing home is, but what really matters is how connected your connections are,” Long said.

The researchers say they’ve informally dubbed these highly connected nursing homes as each state’s “Kevin Bacon of nursing homes,” after the Six Degrees of Kevin Bacon parlor game.

“We found that if you’re going to see a nursing home outbreak anywhere, it’s likely to spread to the Kevin Bacon of nursing homes in each state,” Chen said.

The team hopes that local health departments could use similar cellphone data methods as an early warning system. Using the test results from the “Kevin Bacon of nursing homes” as an indicator would be the first step.

“As soon as you detect an outbreak in one nursing home, you can immediately prioritize those other nursing homes that you know are at increased risk,” Chen said.

Prioritize Masks and Hand-Washing

The California Association of Health Facilities represents most nursing homes in the Golden State. In response to the study, the group said its members can’t prevent workers such as Tapia from taking jobs elsewhere, and they can’t pay them more, because California doesn’t pay them enough through Medicaid reimbursements.

Mike Dark, an attorney with the California Advocates for Nursing Home Reform, doesn’t buy that argument. He said the state already tried paying nursing homes more in 2006 — and that made them more profitable but not more safe and efficient. He said he’s skeptical that extra funding to pay staff would reach those workers.

“We know from past experience that money tends to go into the pockets of the executives and administrators who run these places,” Dark said.

He agreed that health workers such as Tapia should be paid more but cautioned against one idea being floated in some policy circles: limiting workers to one nursing home.

“Then you can wind up depriving some of the crucial health caregivers that we have in these facilities of their livelihoods, which can’t be a good solution,” he said.

Instead, he said, regulators need to focus on the basics, especially in the 100 California nursing homes with ongoing outbreaks, since it’s been shown that infection control measures work.

“Right now there’s poor access to [personal protective equipment]. There’s still erratic compliance with things like hand-washing requirements,” he said. “If we spent more time addressing those key issues, there would be much less concern about spread between facilities.”

Jackie Fortiér is health reporter for KPCC and LAist.com. This story is part of a partnership that includes KPCC, NPR and Kaiser Health News.

Hospitalized? You Can Still Vote in Most Parts of the Country

KFF Health News, November 2, 2020

California law protects the rights of voters whore in the hospital or other care facilities, or confined at home.

This article was published on Monday, November 2, 2020 in Kaiser Health News.

By Bernard J. Wolfson

Johnathon Talamantes, of South-Central Los Angeles, broke his hip in a car accident on Oct. 22 and underwent surgery five days later at a public hospital near downtown.

His post-op recovery will keep him in the hospital, L.A. County+USC Medical Center, beyond Election Day, and as he prepared himself for the surgery, he wondered what that would mean.

“One of the first things I asked my nurse this morning was, ‘Oh, how am I going to vote?’” Talamantes, 30, said from his hospital bed the day before the operation.

He initially thought of asking his mom to rummage through a pile of papers at the home he shares with her and bring him the mail-in ballot that he, like all registered California voters, received for this election.

But then staffers at LAC+USC told him about another option: They could help him get an emergency ballot and cast his vote without having to get out of bed. So Talamantes told his mom not to bother.

“I don’t want her coming down here, because of the COVID restrictions,” he said.

California law protects the rights of voters who are in the hospital or other care facilities, or confined at home. It allows them to get help from anyone they choose — other than an employer or a union representative — and to cast an emergency ballot.

At least 37 other states allow emergency voting for medical reasons, according to the National Conference of State Legislatures. But practices vary.

In some states, only family members can assist hospitalized patients with voting from the hospital.

In California, New York and several other states, hospital employees and volunteers can help a patient complete an emergency ballot application. They can pick up the ballot for the patient and deliver the finished ballot back to the election office or deposit it in an official drop box.

In North Carolina, by contrast, it is a felony for a health care worker to assist a patient with voting.

In 18 states, the law allows local election boards to send representatives directly to patients’ bedsides, though six of those states have canceled that service this fall because of the COVID-19 pandemic, said Dr. Kelly Wong, founder of Patient Voting, a nonpartisan organization dedicated to increasing turnout among registered voters unexpectedly hospitalized around election time.

The group’s website features an interactive map of the United States with state-by-state information on voting while in the hospital. It also allows patients to check whether they are registered to vote.

Wong, an emergency room resident at Rhode Island Hospital in Providence, recalled that when she was a medical student working in an ER, patients who were about to be admitted to the hospital would tell her, “‘I can’t be admitted; I have let the dogs out, or I’m the sole caretaker of my grandmother.’” Then during the election of 2016, she heard, “‘I can’t stay. I have to go vote.’”

“That really caught my attention,” Wong said. She did research and learned patients could vote in the hospital using an emergency ballot — something none of her co-workers knew. “Our patients don’t know this, she said. “It should be our job to tell them.”

Some U.S. hospitals have been assisting patients with voting in major elections for two decades or more, part of a broader tendency in the health care industry toward civic engagement.

Community clinics register voters in their waiting rooms or at public registration drives. In an increasing number of ERs, patients and their families are offered the chance to register. Many hospitals, including LAC+USC, this year will have mobile voting units on-site, open to staff members, patients who are well enough to walk, and their families.

These efforts come against the backdrop of health care’s starring role in the nation’s heated political drama: COVID-19 has become a top presidential campaign issue, while the U.S. Supreme Court, its conservative majority fortified this week, prepares to hear a case — one week after the election — that could be the death knell for the Affordable Care Act.

The pandemic has made inpatient voting a challenge because of tight restrictions at hospitals and the many employees furloughed, laid off or working at home. And a significant increase in early voting and the use of mail-in ballots in many states may reduce the number of patients who need help.

“The majority of our patients, I am hoping, will have voted already, because that will alleviate the stress — for them, it’s one less thing to worry about,” said Camille Camello, associate director of volunteer services at the nearly 900-bed Cedars-Sinai Medical Center in Los Angeles, which has a program to help inpatients vote. In past elections, she said, over 200 patients have requested ballots.

At LAC+USC, administrators have been trying to ensure patients know they can get help voting. Posters line the walls of common spaces and staffers are handing out flyers with voting information to every patient who is admitted, said Gabriela Hernandez, the hospital’s director of volunteer services.

Hernandez said she and about 25 volunteers have been walking the halls in the inpatient units of the hospital for the past month, asking patients if they want help voting.

Patients who say yes get emergency ballot applications, which the hospital has been sending to the L.A. County Registrar-Recorder for verification. The ballot applications will continue to be made available to patients up to the morning of Election Day.

Hernandez and her team will collect the ballots and distribute them to patients, then return them to the registrar before the 8 p.m. deadline on Election Day.

Other hospitals have a more collapsed timeline.

At St. Jude Medical Center in Fullerton, California, hospital staffers will start asking patients Monday if they want voting assistance and bring them ballots on Election Day, said Gian Santos, manager of volunteer services at the hospital. In the 2016 election, only about seven or eight patients voted that way, Santos said.

St. Joseph Hospital in Orange, California, plans to do everything — applications and ballots — on Election Day.

For big hospitals, inpatient voting can be a massive undertaking. People often require assistance in multiple languages, and the hospitals frequently contract with translation services to accommodate them.

Many hospitals receive patients from numerous counties — and across state lines.

Lenox Hill Hospital in Manhattan plans to assist as many as 200 patients from nine counties in New York state and three in New Jersey, said Erin Smith, an obstetrical nurse navigator who, along with fellow OB nurse navigator Lisa Schavrien, is leading the effort.

The hospital will assign one or two “runners” to each of the 12 county election boards, Smith said. For her, enabling vulnerable patients to exercise their right to vote is worth the effort.

“If we’re not helping them do it, how many thousands of people are not voting in elections because they were in a car accident, because they had appendicitis, because they had unexpected brain surgery?” Smith asked.

“If we’re not making it happen in the hospital, it kind of feels to me like voter suppression.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

California's Progressive — and Expensive — Health Care Ambitions Rely on Biden Win

KFF Health News, November 2, 2020

If Republican President Donald Trump prevails, Democratic state lawmakers worry, they’ll be forced to scale back their ambitious plans.

This article was published on Monday, November 2, 2020 in Kaiser Health News.

By Angela Hart

For deep blue California, where first-in-the-nation health care proposals regularly flood the Democratic agenda, there could not be more at stake in the presidential race.

If Republican President Donald Trump prevails, Democratic state lawmakers worry, they’ll be forced to scale back their ambitious plans and play defense the next four years, battling Republican attempts to curtail federal Medicaid spending and further unravel the Affordable Care Act.

Should Democratic presidential nominee Joe Biden win, California Democrats — who control all statewide elected offices and hold a supermajority in the legislature — are poised to go big on health care, pushing aggressively for a health care system that covers all Californians, regardless of their immigration status or ability to pay.

“This election will determine whether California has a willing federal partner who can move us forward in the ways we want to see health care expanded,” said Assembly member David Chiu (D-San Francisco).

“It is incredibly unlikely that another four years of Trump will allow us to make significant strides toward universal health care, whereas a Biden-Harris administration would allow us to make real progress toward not just health care for all, but so much more.”

California Dems Counting on Biden Win

Behind the scenes, Democrats in California are positioning for a White House led by Biden and vice presidential nominee Kamala Harris — which they presume would be more supportive of California’s agenda — and some are already planning legislation for next year. Not only are they plotting ways to crack down on hospital consolidation and end surprise emergency room bills, but they are also quietly discussing a trio of liberal initiatives that could again push California to the forefront of health care policy. They include:

  • A new single-payer health care bill that would nix private insurance and create a taxpayer-funded health care system for all Californians. “Just expanding the Affordable Care Act is not nearly enough. We need to be willing to stand up to the drivers of health care costs rather than give Americans an insurance card that they can’t afford to use,” said Assembly member Ash Kalra (D-San Jose), who is considering introducing the measure. A legislative analysis in 2017 estimated that single-payer could cost California $400 billion a year.
  • A wealth tax that could generate $7.5 billion a year to help finance potential coverage expansions. Assembly member Rob Bonta (D-Alameda) said wealthier people should pay more to help finance health care, education and other services, especially for Californians hit hard by the pandemic. “Some people have been offended and think that punishes the doers and innovators, but our intent is to help the most vulnerable,” he said.
  • Expanding its Medicaid program for low-income residents, called Medi-Cal, to more unauthorized immigrants. California currently offers full Medi-Cal benefits to all qualified residents, regardless of immigration status, up to age 26. “To see Latinos in this state testing positive at disproportionate rates of COVID-19, it makes it clear that people are dying and suffering from lack of health coverage,” said state Sen. Maria Elena Durazo (D-Los Angeles), who plans to spearhead the proposal.

Democratic Gov. Gavin Newsom has argued that the future of health care, and California’s ability to combat COVID-19, is at stake this election.

Although Newsom has sought to play nice with Trump — partly because California relies on federal cooperation and federal money to respond to COVID-19 — the first-term governor strongly backs Biden.

“We can quite literally go backward with an administration that actively wants to get rid of health care for tens of millions of people with preexisting conditions,” Newsom said in September. But Biden, he said, will allow California to “accelerate our health care reforms and have a real partner that can advance those reforms to lower costs and improve quality, as well as expand access.”

The governor’s health care agenda includes far-reaching measures to expand access to care and set government-imposed limits on health care spending, possibly penalizing hospitals and doctors for failing to meet cost reduction targets. Though Newsom withdrew his biggest proposals earlier this year, citing a projected $54 billion state budget deficit, Health and Human Services Secretary Dr. Mark Ghaly said the administration is considering reintroducing proposals that died this year, including a new Office of Health Care Affordability.

But these plans could be jettisoned no matter who wins the election, warned Rose Kapolczynski, a California-based Democratic strategist. The state’s pandemic-crippled economy is likely to lead to more budget cuts, making it difficult to adopt new, expensive programs, she said.

“Everyone is going to be fighting for money, and it’s going to be hard to pass big-ticket expensive items like single-payer if California faces massive layoffs of state workers and cuts to health care programs that already exist,” she said.

A Trump Win Could Spur Health Care Innovation

While Democrats fear a rollback of health care funding and benefits should Trump win, his reelection could offer greater opportunity for Medicaid innovation in states, said Lanhee Chen, former adviser to 2012 Republican presidential nominee Mitt Romney and research fellow at Stanford University’s right-leaning Hoover Institution.

“States can be laboratories of innovation,” Chen said at an October presidential election forum at the UCLA Fielding School of Public Health.

In what is known as the waiver process, states can ask the federal government for permission to use federal dollars to offer services or pursue new approaches to health care that go beyond what Medicaid and Obamacare traditionally allow.

If reelected, Trump could help both red and blue states by giving them greater “freedom and flexibility” to undertake new programs, Chen said. The Trump administration has begun to embrace such experiments, including in Minnesota, where it approved a bipartisan effort to establish a reinsurance program that compensates insurers for taking on certain high-cost patients.

In Georgia, Republican Gov. Brian Kemp received permission from the administration to impose work requirements for Medicaid enrollees and require some to pay monthly premiums.

This process “is a way of both satisfying a conservative desire to enhance private marketplaces as well as a progressive desire to expand coverage,” Chen said.

Mark Peterson, a professor of public policy, political science and law at UCLA, is skeptical, saying the process has favored Republicans under Trump.

“The Trump administration has been trying to use Medicaid waivers to go in a more conservative direction, doing things such as allowing Medicaid work requirements,” he said.

The Newsom administration is seeking permission from the Trump administration to dramatically transform Medi-Cal to focus more on preventing enrollees from getting sick, and to invest in getting homeless people into housing and treatment. A COVID-spurred budget crisis forced Newsom to pause the $3.5 billion Medi-Cal overhaul earlier this year.

Newsom is also relying on federal cooperation to respond to COVID-19. The federal government, for example, allows California hospitals in hard-hit communities to relax minimum nursing staff levels.

To go as far as California wants on health care, “we do need the support and cooperation of the federal government — there’s no doubt,” Ghaly said in an interview with California Healthline.

But state Sen. Richard Pan (D-Sacramento) dismissed the idea that the Trump administration’s idea of innovation would help California Democrats, who are pursuing health policies Trump has attacked. “We’ve been hamstrung,” said Pan, who chairs the Senate Health Committee. “Trump has been president for four years and we haven’t seen it.”

The Affordable Care Act

One major issue doesn’t hinge on the presidential election but could nonetheless cast major doubt on Democrats’ big health care plans: the fate of the Affordable Care Act.

The U.S. Supreme Court will hear a case on Nov. 10 brought by Republican states, and backed by the Trump administration, that could invalidate Obamacare. California is leading the defense, and the state “stands to lose much of the historic gains it made,” said Melanie Fontes Rainer, a health care adviser to Attorney General Xavier Becerra.

Should the law be struck down, nearly 5 million Californians could lose health coverage, health insurance premiums could rise, and the state would likely have to make dramatic cuts to health and social safety net programs. Last year alone, the state received $25 billion to help fund its Affordable Care Act programs, according to Ben Johnson, a health care analyst at the nonpartisan Legislative Analyst’s Office.

California has also gone well beyond the requirements of Obamacare. It has expanded Medi-Cal to more people; imposed its own requirement to have insurance or pay a tax penalty after Congress eliminated the federal tax penalty; and offers state-financed premium subsidies for low- and middle-income Californians.

Yet state leaders have not identified a backup plan if Obamacare is struck down, and as they plot a far more aggressive agenda, they fear they would be forced to backtrack and struggle to protect what California has already done.

“We’ll be crippled and our gains would collapse,” Pan said. “We’d have to retrench entirely.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Medicare Fines Half of Hospitals for Readmitting Too Many Patients

KFF Health News, November 2, 2020

The penalties are the ninth annual round of the Hospital Readmissions Reduction Program created as part of the Affordable Care Act’s broader effort to improve quality and lower costs.

This article was published on Monday, November 2, 2020 in Kaiser Health News.

By Jordan Rau

Nearly half the nation’s hospitals, many of which are still wrestling with the financial fallout of the unexpected coronavirus, will get lower payments for all Medicare patients because of their history of readmitting patients, federal records show.

The penalties are the ninth annual round of the Hospital Readmissions Reduction Program created as part of the Affordable Care Act’s broader effort to improve quality and lower costs. The latest penalties are calculated using each hospital case history between July 2016 and June 2019, so the flood of coronavirus patients that have swamped hospitals this year were not included.

The Centers for Medicare & Medicaid Services announced in September it may suspend the penalty program in the future if the chaos surrounding the pandemic, including the spring’s moratorium on elective surgeries, makes it too difficult to assess hospital performance.

For this year, the penalties remain in effect. Retroactive to the federal fiscal year that began Oct. 1, Medicare will lower a year’s worth of payments to 2,545 hospitals, the data show. The average reduction is 0.69%, with 613 hospitals receiving a penalty of 1% or more.

Out of 5,267 hospitals in the country, Congress has exempted 2,176 from the threat of penalties, either because they are critical access hospitals — defined as the only inpatient facility in an area — or hospitals that specialize in psychiatric patients, children, veterans, rehabilitation or long-term care. Of the 3,080 hospitals CMS evaluated, 83% received a penalty.

The number and severity of penalties were comparable to those of recent years, although the number of hospitals receiving the maximum penalty of 3% dropped from 56 to 39. Because the penalties are applied to new admission payments, the total dollar amount each hospital will lose will not be known until after the fiscal year ends on July 30.

“It’s unfortunate that hospitals will face readmission penalties in fiscal year 2021,” said Akin Demehin, director of policy at the American Hospital Association. “Given the financial strain that hospitals are under, every dollar counts, and the impact of any penalty is significant.”

The penalties are based on readmissions of Medicare patients who initially came to the hospital with diagnoses of congestive heart failure, heart attack, pneumonia, chronic obstructive pulmonary disease, hip or knee replacement or coronary artery bypass graft surgery. Medicare counts as a readmission any of those patients who ended up back in any hospital within 30 days of discharge, except for planned returns like a second phase of surgery.

A hospital will be penalized if its readmission rate is higher than expected given the national trends in any one of those categories.

The industry has disapproved of the program since its inception, complaining the measures aren’t precise and it unfairly punishes hospitals that treat low-income patients, who often don’t have the resources to ensure their recoveries are successful.

Michael Millenson, a health quality consultant who focuses on patient safety, said the penalties are a useful but imperfect mechanism to push hospitals to improve their care. The designers of the penalty system envisioned it as a way to neutralize the economic benefit hospitals get from readmitted patients under Medicare’s fee-for-service payment model, as they are otherwise paid for two stays instead of just one.

“Every industry complains the penalties are too harsh,” he said. “if you’re going to tell me we don’t need any economic incentives to do the right thing because we’re always doing the right thing — that’s not true.”

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