Dennis Carroll, former director of the pandemic influenza and emerging threats unit at USAID, says the corona virus represents just one in a wave of zoonotic diseases that have adapted to humans.
This article was first published on Monday, March 16, 2020 in Kaiser Health News.
When the federal government decided to investigate the threat viruses in animals posed to humans, Dennis Carroll helped lead the charge.
Carroll directed the pandemic influenza and emerging threats unit at the federal Agency for International Development (USAID) for nearly 15 years. In that time, he spearheaded Predict, a project that identified more than 2,000 zoonotic viruses, or germs in animals ― the viral "dark matter," as he characterizes it — that could also sicken people.
It operated under Presidents George W. Bush and Barack Obama, but the Trump administration opted to shut down the project. Its operations will cease later this year, Carroll said.
Carroll retired from the federal government and moved to Texas A&M University. He now heads the Global Virome Project, a nonprofit cooperative dedicated to tracking more of these threats and developing a database of viruses.
His work gains relevance as countries around the globe scramble to contain the novel coronavirus that has sickened more than 169,000 people worldwide as of Monday morning with an illness known as COVID-19. The virus, suspected to have jumped to humans from an animal, represents just one in a wave of zoonotic diseases that have adapted to humans, said Carroll.
That wave is likely to continue, he added.
"When you look back over the last 20 years, our whole approach to emerging viral threats from SARS onward has been to wait and react. Wait and react," Carroll said. "And that is a recipe for global disaster."
Carroll spoke with KHN's Carmen Heredia Rodriguez about the Predict program, the likelihood of another novel animal virus threatening humans and whether the world is prepared for this pandemic.
This interview has been edited for length and clarity.
Q: Can you tell me about the purpose of the Predict project and how it worked?
I designed the Predict project a little over 10 years ago. It was coming out of the experience with avian influenza ― the H5N1 virus — that sort of piqued everyone's attention back in 2005.
Predict was really an exploratory effort. Could we begin quantifying what that larger pool of future viral threats might be? By 2018-19, we were able to begin understanding, if you will, that larger viral "dark matter" — what was that unknown pool circulating.
We had it operating in 30 countries in Asia and Africa. Basically, it was a scientific discovery investment. Working with local counterparts in those countries to be able to go out into the field ― into the remote areas where wildlife was circulating and collect samples from bats, non-human primates, rodents, wherever they might be. The samples could be brought back to laboratories to identify novel viruses in those animals and characterize those novel viruses in terms of their relationship to known viruses.
Predict discovered more than 2,000 novel viruses from viral families we know have posed a past threat to people. We calculate now there are about a million and a half of which — maybe 500,000 to 600,000 ― could be potential threats to people. So, you can appreciate that if it took us 10 years to discover 2,000 viruses, really elevating this to the scale that we could discover a million new viruses, Predict was not adequate.
Q: Who is left doing this work?
Congress in the last appropriation in December did signal to USAID its interest in USAID continuing the discovery work and being part of a global partnership that would build the kind of atlas on viruses circulating that could pose a future threat. We now need to translate that support from Congress into USAID stepping forward and investing in this global partnership.
The Global Virome Project is looking to forge [that partnership]. Obviously, this [SARS-CoV-2] virus is a clear example of why a discovery and capacity-building venture like the Global Virome Project is important.
Q: Speaking of COVID-19, how big a threat are zoonotic diseases to humans nowadays?
They're extraordinary.
The threat posed by zoonotic diseases ― those are basically viruses circulating in animals and particular wildlife — is becoming more and more part of our natural landscape and is largely being driven by the increase in population around the world over the last century. If you and I were having this discussion a hundred years ago, we would've been talking about 1.8 billion people on this planet. We're now talking about almost 8 billion. With that comes all of the livestock and animal production to feed the human population. We've expanded our cities, our settlements, our agriculture into wildlife areas.
That means the frequency of interaction between people and wildlife is happening at a scale never before seen. We've calculated based on historical evidence that we're looking at two to three to four new zoonotic disease threats emerging every year. So, it should not come as a surprise that today we're talking about the COVID-19 virus.
Q: For you, what are some of the greatest obstacles to doing this work of predicting and identifying diseases with the potential to jump into humans?
Well, it challenges people to think differently. We can have the information at hand, but if you don't use that information to act, that becomes the big challenge. In the United States and around the world, we are a reactive culture. We're more comfortable waiting for something to happen and then react to it rather than be proactive, use knowledge that allows us to put in place capabilities to prevent future events from happening. So the biggest challenge we have is what you could think of as social engineering ― changing politicians', investors', communities' approach toward facing risk. Don't wait for it to kick your door in when you understand it is in your neighborhood. Step out and act on it now.
Q: For you, what does this outbreak tell you about the world's ability to predict and prepare for a pandemic of a novel virus of any kind?
We knew this was coming. Whether it was this coronavirus … or another influenza virus, we couldn't say that. But we know, as I've said before, the frequency is intensifying. And because of globalization and population movements, an event anywhere becomes a threat everywhere. So, first off, no surprise.
Secondly, I think what we've seen is the fragmentation of the global partnerships that have been forged over the last decade based on the experiences ofSARS, avian influenza, the flu pandemic of 2009 and Ebola. We've seen in the last several years the rise of political tensions, which have fragmented the global community. Our ability to act in a coordinated, forward-leaning way has been greatly compromised. We see that with our own country.
We learned about this virus over two months ago. Scientists took note, public health people took note. The political community could have, should have, taken note. In our own government, nothing happened. [Only this month] Health and Human Services actually put a tender out for urgently needed N95 face masks. They had 30 million face masks in their national strategic stockpile. They had months to bring additional masks. That puts front-line health workers at risk.
And then, in 2018, the White House closed the Global Health Security office in the National Security Council, which was the center for ensuring that the United States government had a forward-leaning capability to monitor what was happening around the world and to inform and guide all agencies in the United States about what needs to be done yesterday, not tomorrow. That agency was shut down, and there is an enormous vacuum. That left a vacuum that is clearly playing itself out in terms of leadership, global responsibility now.
Some hospitals have a surplus of the protective equipment and some not enough. The CDC is working on a system that would track the inventory across the nation.
This article was first published on Friday, March 13, 2020 in Kaiser Health News.
Masks, gloves and other equipment are crucial as health care workers face the COVID-19 outbreak. There is a strategic national stockpile that the U.S. government controls — but no one knows what, beyond that stockpile, is available in the private sector.
Some hospitals have a surplus of the protective equipment and some not enough. The Centers for Disease Control and Prevention is working on a system that would track the inventory across the U.S.
The big hurdle isn't the technology. The issue is getting hospitals comfortable sharing information about their preparedness — information that, until now, they have considered confidential.
Protective masks have become a hot commodity, even within hospitals. At Nashville General Hospital, for example, employees several weeks ago were casually approaching supply chain management director Tom Cooper and asking if they could have a box for personal use.
Cooper told them the masks were available only for "clinicians as needed, for their job duties."
And Cooper said he's feeling more protective of the supply his hospital has on hand — especially N95 respirators. General Hospital's distributor, Medline, already restricted orders of the respirators. Cooper said he can't get any more than his usual monthly allotment, even if he could afford it.
"Right now, we're OK," he said. "But next month, what could happen?"
'Panic Purchasing'
The CDC has tried to avoid such scarcity and the costs associated with shortages. Often, there's plenty of disposable protective gear to go around, but it's not always in the right places ahead of pandemics.
"It can result in 'panic purchasing,'" said Megan Casey, a nurse epidemiologist with the CDC. "This is where facilities buy as much as possible, just to be on the safe side."
Right now, public health agencies know only what's in government stockpiles of protective gear. Health and Human Services Secretary Alex Azar told Congress in recent weeks that the government has 30 million masks, even though 300 million may be needed. (The few U.S. companies manufacturing masks say demand in recent weeks has far outstripped their production capability, though they are ramping up.)
The nation's 6,000 hospitals have been more of a black box — now and in earlier epidemics. In past outbreaks — of H1N1 influenza, for example — some hospitals resorted to informal supply swaps on a street corner, according to project managers with the Center for Medical Interoperability, a Nashville-based nonprofit.
Last year, before COVID-19 emerged, the center was awarded a $3 million contract with the CDC to build a system that calls for hospitals to submit information about their real-time inventory. The information typically can be pulled directly from an institution's electronic medical record system. Using that accumulated data, the CDC should be able to use a digital dashboard to easily identify facilities with the greatest need.
"It could also, potentially, provide a tool for hospitals to request personal protective equipment from state or local health departments, stockpiles or even other hospitals that might have excess," Casey said. "We do see this as a potential opportunity for resource sharing and having those kinds of discussions."
Competitive Advantage
But the prospect of sharing supplies is where the business of health care makes cooperation hard even in a crisis, said Melanie Thomas. She's the chief information officer at Nashville General, one of the pilot sites for the CDC-sponsored project.
"It's difficult and scary sometimes to share data and equipment, especially with your competitors," Thomas said, "because you want to have the advantage."
Nashville General is the smallest of the pilot sites, which include Northwestern Memorial in Chicago and Nashville-based Community Health Systems, a for-profit chain of nearly 100 hospitals around the U.S.
Thomas acknowledged it's easier for her taxpayer-funded hospital to grant access to its inventory system because it doesn't have the buying power to stockpile equipment.
"That's never going to be our problem," she said. "We want the shared information because we're going to have just enough."
And when they run out, she'd like to know where to turn to get more.
A Theoretical Threat Becomes Real
The Center for Medical Interoperability started its work quietly, a few months before COVID-19 emerged. But the project managers have noticed a greater willingness to participate among major health systems now that a theoretical threat has become very real.
"We know … that their supply chains are under strain right now because these products, they come out of China," said Tommy Ragsdale, the center's director of strategy.
China needs the disposable equipment that is manufactured there for its own use. And only a handful of companies in the U.S. still make the protective gear domestically. One has orders for more than a billion masks.
"It has definitely created different discussions at the hospital and health system level than we were having in October or November," Ragsdale said.
The CDC has pumped an additional $600,000 into the data-sharing project, with an accelerated go-live date in May, Ragsdale said. The center plans to hold a webinar on April 1 for additional hospitals interested in participating in later phases.
At this point, the CDC said, there's no mandate for hospitals to participate. But Ragsdale said he hopes they will see the benefit: "This is clearly for the greater good."
This story is part of a partnership that includes Nashville Public Radio, NPR and Kaiser Health News.
In one of the most sweeping moves yet by a nonprofit hospital system to reduce aggressive bill collection, VCU Health is halting seizure of patients' wages and removing thousands of liens against patients' homes, some dating to the 1990s.
"Health care needs to be more affordable for patients, and we want to be part of the solution," said Melinda Hancock, VCU Health's chief administrative and financial officer. "We believe that no hospital bill should change the economic status of a family."
The moves follow an investigation last year by Kaiser Health News that found VCU Health and Virginia's other major teaching-hospital system, UVA Health, pursued tens of thousands of patients over the years for overdue bills, sending many into bankruptcy.
Over six years, the state institution filed 36,000 lawsuits against patients seeking a total of more than $106 million in unpaid bills, a KHN analysis finds.
The practices included filing courthouse liens against the value of patients' homes and garnishing wages, many from workers at lower-pay employers, such as retailers and restaurants.
Canceling liens ends the threat that VCU Health, part of Virginia Commonwealth University in Richmond, will take big chunks of equity when family homes are sold. Liens can easily reach thousands of dollars per property. Virginia allows creditors to garnish up to 25% of someone's earnings.
"That is great news for VCU patients," said Jenifer Bosco, an attorney with the National Consumer Law Center who specializes in medical debt. "I don't recall hearing about other hospitals taking that step and canceling decades of past liens."
Because they accrued interest of 6% annually or more, old liens could let VCU and UVA seize amounts far higher than the original hospital and doctor bills.
Undoing decades of property claims will require VCU lawyers to visit every circuit courthouse across the state, "which could take up to a year to complete," said system spokesperson Laura Rossacher.
VCU's moves are "an instant way to create a lot of goodwill and relieve patients of an incredible financial and emotional burden," said Erin Fuse Brown, a law professor at Georgia State University who studies hospital billing. "UVA should do the same."
VCU and UVA are the two major teaching hospital systems in Virginia, taking in billions annually and recording tens of millions of dollars in profits. UVA Health is part of the University of Virginia, based in Charlottesville.
Virginia Gov. Ralph Northam, a pediatric neurologist, "is proud to see VCU Health System taking significant, in some cases historic, steps to scale back aggressive medical collections and address the pain it's caused," said his spokeswoman, Alena Yarmosky.
Both VCU and UVA, which are state-run, have increased financial assistance and discounts for uninsured patients since KHN published its reports.
VCU pledged earlier to end all routine lawsuits for overdue bills, which are the precursor to garnishments and liens. The latest move cancels such claims resulting from old suits and judgments.
The litigation also included more than 15,000 garnishment cases over that period, some for VCU Medical Center but mostly for the physician group, the data showed.
VCU will not refund money collected in the past.
"They have socked it to a lot of people," said Joseph Robinson, a Richmond church music director garnished last year for $851 by MCV Physicians for treatment he said happened years ago. "They were just going after anybody they could get."
VCU joins Yale New Haven Health among the few hospital systems that have forsworn routine patient lawsuits. Such systems still bill for overdue accounts and try to collect money, but they stop short of seeking the legal right to seize assets.
For its part, UVA has said it will substantially reduce patient lawsuits, seeking court judgments for overdue bills only from families making more than 400% of federal poverty guidelines. That's income of $86,880 for a family of three.
But its current policy of maintaining old liens and continuing to sue at least some patients makes it more aggressive than VCU.
On the other hand, UVA has made its new, wider financial assistance policy retroactive to July 2017 and in recent months has forgiven $15 million in debt for treatment after that date, said UVA spokesman Eric Swensen.
The system has also stopped wage garnishments "at this time," he said. UVA has said changes announced so far are a "first step." A community advisory council meeting monthly since last year will "inform and guide us as we explore changes to our policies," Swensen said. Recommendations are expected this summer, he added.
Neither UVA nor VCU has responded to repeated queries about exactly how many liens they hold or how much they collect in lien proceeds, garnished wages and bank accounts.
"Compared to the harm it causes for patients, I can't imagine that the hospitals are getting a significant amount of revenue from these legal actions," said Fuse Brown.
Hospitals say they see more and more patients who can't pay, even with insurance, because of stagnating incomes and rising insurance deductibles.
Budget legislation in Virginia's General Assembly is expected to increase funding for VCU's and UVA's indigent care programs as well as update the family-asset test for patients seeking financial assistance, which hasn't changed since 1985.
As reported last year by KHN, even $3,000 or $4,000 in a 401(k) or other retirement account could bar a patient from financial help. The legislation increases the asset-test threshold to $50,000, not counting a car and a house on less than 4 acres.
Another bill would prohibit the systems from suing or sending bills to collections before they determine whether patients qualify for Medicaid or financial assistance.
"We're on the right path now," said Jill Hanken, a health care attorney for the Virginia Poverty Law Center, which was behind the bill. "It was very important to put the brakes on these aggressive collection activities and force these hospitals to look more closely at their indigent care policies."
Health care finance experts continue to criticize both VCU and UVA for what they charge the uninsured before factoring in any financial assistance.
Last year, UVA increased its discount for the uninsured from 20% off list prices to 40%. VCU increased the discount from 25% to 45%. But at those levels patients still pay far more than the health systems' costs and far more than what the systems collect from the Medicare program for seniors.
"Until they reduce the amount they are trying to recover by adjusting their charge to what Medicare would have paid, people who owe debts will still face unreasonable demands," said Sara Rosenbaum, a health law professor at George Washington University.
The American Heart Association says that although aspirin can help people with previous heart attacks or strokes, its risks generally outweigh the benefits for others.
This article was first published on Tuesday, March 10, 2020 inKaiser Health News.
The large red-and-white bins at Walmart pharmacies across the country read, in bold all-caps type: "Approximately every 40 seconds an American will have a heart attack."
Inside the 3-foot-tall cartons, adorned with the American Heart Association and Bayer logos, were dozens of boxes of low-dose Bayer aspirin.
The implication was that everyone could reduce their heart attack risk by taking a "baby aspirin." But recent studies have found that's not the case.
In fact, the American Heart Association says that although aspirin can help people with previous heart attacks or strokes, its risks generally outweigh the benefits for others.
After Kaiser Health News inquired about the marketing bins, the heart association in late February said it is having Bayer, one of its major donors, pull them from Walmart — although the campaign was due to wrap up by the end of the month, anyway. But 10 days later, a reporter shopping at a Walmart in Florida found a bin still on display.
About a quarter of Walmart stores nationwide displayed the bins, the association said.
"This was a misstep," said Suzanne Grant, a spokesperson for the American Heart Association. "It was a human error on our end."
Aspirin helps keep the blood from clotting, so there is less chance that blockages will form in key heart arteries. For years, it was generally recommended as an option for healthy individuals to prevent heart attacks. But it also can lead to stomach bleeding, a serious side effect, and a number of studies have raised questions about the safety of aspirin use for people without cardiovascular disease.
Last year, after three new studies were published on the issue, the American Heart Association joined other medical groups advising against aspirin therapy unless a doctor recommends it.
The U.S. Preventive Services Task Force, an expert panel that makes recommendations on medical care, is reexamining its guidelines, which advise low-dose aspirin for people ages 50-59 who have a risk of cardiovascular disease and no history of bleeding problems. It also has noted that individuals ages 60-69 at risk of heart disease may want to consider the therapy, but it should be used selectively. Evidence for other age groups is inconclusive, the task force says.
Grant said the association approved the marketing bins without including "precise language" explaining that people need to talk to a doctor before taking aspirin regularly. That language is printed in smaller type on the Bayer baby aspirin packaging.
The bins promoted the heart association's "Life Is Why We Give," a fundraising effort. Bayer is a financial supporter of the campaign.
Dr. Eduardo Sanchez, the chief medical officer for prevention at the American Heart Association, said the bins could have given people the wrong impression and led to more liberal use of baby aspirin.
"Our position is that aspirin should be used sparingly, if at all, in people who have not had a heart attack or stroke," Sanchez said.
The heart association reviews all products and marketing that contain its logo, Sanchez said. It is unclear why or how the association allowed this display to occur.
"Any inference that Bayer's demonstration of support for the AHA's heart health initiatives could be construed as medical advice is simply preposterous," said Bayer spokesman Chris Loder. "The display contains no medical claims whatsoever and is merely intended to help the AHA raise awareness of a major public health issue."
The case highlights the ongoing challenge of communicating who should take aspirin to prevent heart attacks since the national guidelines changed a year ago.
But it also illustrates potential problems when large pharmaceutical companies team up with nonprofit health groups. Arthur Caplan, a bioethicist at New York University, said those types of connections can invite ethical questions about marketing.
Bayer gave nearly $1 million to the American Heart Association in the most recent fiscal year, according to the association's latest financial records. In all, the association received about $33 million from drug companies, medical device makers, insurers and health firms. It does not endorse any particular product.
But Caplan said the marketing displays at Walmart imply that AHA endorses the Bayer aspirin brand.
That's troublesome because, as the heart association has said, aspirin is recommended only for certain people to reduce the risk of heart attack, and the displays do not disclose that less costly, generic versions of aspirin are also available.
Doctors say they worry many patients still routinely take aspirin for protection without advice from a doctor.
"People see these displays and advertising on television and they think aspirin is like taking candy," said Dr. Jacob Shani, chair of cardiology at Maimonides Heart and Vascular Institute in New York. "The display makes it look like candy and you take this candy and you do not have a heart attack."
Still, Dr. Erin Michos, associate director of preventive cardiology at Johns Hopkins University School of Medicine in Baltimore and one of the physicianswho helped develop the heart association's new position on aspirin last year, said she has seen patients who should be taking aspirin who have stopped because they heard about the new guidelines. "There is a lot of misunderstanding," she said.
"Everyone needs to discuss with their doctor about whether aspirin is recommended for them," she said.
The situation has prompted debate in the health care community about just what standards medical facilities should use before ordering workers quarantined.
This article was first published on Monday, March 9, 2020 in Kaiser Health News.
As the U.S. battles to limit the spread of the highly contagious new coronavirus, the number of health care workers ordered to self-quarantine because of potential exposure to an infected patient is rising at an exponential pace. In Vacaville, California, alone, one case — the first documented instance of community transmission in the U.S. — left more than 200 hospital workers under quarantine and unable to work for weeks.
Across California, dozens more health care workers have been ordered home because of possible contagion in response to more than 80 confirmed cases as of Sunday afternoon. In Kirkland, Washington, more than a quarter of the city's fire department was quarantined after exposure to a handful of infected patients at the Life Care Center nursing home.
With the number of confirmed COVID-19 cases mushrooming by the day, a quarantine response of this magnitude would quickly leave the health care system short-staffed and overwhelmed. The situation has prompted debate in the health care community about just what standards medical facilities should use before ordering workers quarantined — and what safety protocols need to become commonplace in clinics and emergency rooms.
Dr. Jennifer Nuzzo, a senior scholar at the Johns Hopkins Center for Health Security, is among those arguing hospitals need to change course.
"It's just not sustainable to think that every time a health care worker is exposed they have to be quarantined for 14 days. We'd run out of health care workers," Nuzzo said. Anyone showing signs of infection should stay home, she added, but providers who may have been exposed but are not symptomatic should not necessarily be excluded from work.
The correct response, she and others said, comes down to a careful balance of the evolving science with the need to maintain a functioning health care system.
While hospitals are supposed to be prepared for just such a situation, Nuzzo said, their plans often fall short. "Absent any imminent public health crisis, it may not be one of their priorities," she said. From 2003 to 2019, federal funding for the Hospital Preparedness Program in the U.S. was cut almost in half.
In Northern California, potential exposure to the new coronavirus was exacerbated because hospitals were caught unaware by the community spread of the virus and hampered by federal protocols that initially limited diagnostic testing to patients with a history of travel to a country where the virus was known to be circulating or contact with a person with a known infection.
"At the very beginning [of an outbreak] this will happen because you don't know patients are infected and you only realize later that people were exposed," said Grzegorz Rempala, a mathematician at the College of Public Health at Ohio State University who models the spread of infectious diseases.
Now that the disease has started to spread through the community, any patient with respiratory symptoms potentially could be infected, though health officials note the likelihood remains low. As providers start routinely wearing protective gear and employing strict safety protocols, accidental exposure should decline.
The Vacaville case offers stark insight into the fallout from the narrow testing protocols initially established by the Centers for Disease Control and Prevention. When a woman was admitted to NorthBay VacaValley Hospital with respiratory symptoms on Feb. 15, dozens of hospital workers walked in and out of her room performing daily tasks. Days later, as her condition worsened, she was sent to UC Davis Medical Center, where dozens more employees were potentially exposed.
Because the woman did not meet the testing criteria in place at the time, it took days for UC Davis to get approval to have her assessed for the coronavirus. After the test came back positive, about 100 NorthBay workers were sent into self-quarantine for 14 days. At UC Davis, an additional 36 nurses and 88 other employees were quarantined, according to the unions representing those workers. (A spokesman for UC Davis said the figures were not accurate but declined to give an estimate.)
"We're not used to being concerned, before we even do the triage assessment, [about] whether the patient is infectious and could infect hospital workers," said Dr. Kristi Koenig, the EMS medical director of San Diego County. She said that thinking started to evolve during the 2014 Ebola outbreak. Hospitals should routinely mask patients who come in with respiratory symptoms, she said, given any such patient could have an infectious disease such as tuberculosis.
Yet providers don't often think in those terms. "In many ways we're spoiled because we've gone from a society 50 or 100 years ago where the major killers were infectious disease," said Dr. Michael Wilkes, a professor at UC Davis School of Medicine. "Now we've become complacent because the major killers are heart disease and diabetes."
Faced with this new infection risk, many hospitals are scrambling to retrain workers in safety precautions, such as how to correctly don and doff personal protective equipment.
Sutter Health, which has 24 hospitals in Northern California, started ramping up its emergency management system five weeks ago in preparation for COVID-19. Before coming to the emergency room, Sutter patients are asked to call a hotline to be assessed by a nurse or an automated system designed to screen for symptoms of the virus. Those with likely symptoms are guided to a telemedicine appointment unless they need to be admitted to a hospital.
Anyone arriving at a Sutter emergency room with signs of a respiratory infection is given a mask and sequestered. "A runny nose and a cough doesn't tell you much. It could be a cold, it could be a flu, and in this weather it could be allergies," said Dr. Bill Isenberg, Sutter's chief quality and safety officer. A doctor or nurse in protective equipment — including N95 mask, gown and goggles — is deployed to assess the patient's symptoms. If COVID-19 is suspected, the patient is moved into a private room.
Sutter has treated several coronavirus patients who arrived from Travis Air Force Base, which housed evacuees from the Diamond Princess cruise ship quarantined off the coast of Japan after an outbreak was detected on board. The Sutter patients were placed in negative pressure rooms so that contaminated air did not circulate to the rest of the hospital, and staff used an anteroom to take off gowns and masks.
"We do everything humanly possible to minimize the number of people who have to enter [the room]," Isenberg said. Still, he said, some workers have been quarantined; Sutter would not disclose the total.
Not all hospitals are adapting so quickly. National Nurses United, a union representing more than 150,000 nurses, recently held a news conference to call on hospitals to better protect their workers. Of the 6,500 nurses who participated in a survey the union circulated, fewer than half said they had gotten instruction in how to recognize and respond to possible cases of COVID-19. Just 30% said their employer has sufficient protective equipment on hand to protect staff if there were a surge in infected patients.
As the virus continues to spread, hospitals should be stockpiling such equipment, figuring out how to add beds and planning for staffing shortages, said Dr. Richard Waldhorn, a professor of medicine at Georgetown University and contributing scholar at Johns Hopkins who recently co-authored recommendations for hospitals on how to prepare for a COVID-19 pandemic.
Hospitals should already be training providers to take on expanded duties, Waldhorn said. If a hospital becomes overwhelmed, the Medical Reserve Corps can be mobilized, as can networks of providers who have volunteered to aid in emergency situations. Once workers have been infected and recover, it might make sense to have them treat other coronavirus patients since they will have immunity.
Eventually, as a disease becomes widespread, quarantine simply stops being a priority, said Nina Fefferman, a mathematician and epidemiologist at the University of Tennessee-Knoxville.
"There's a point where we stop trying to quarantine anyone and we just say, OK, we're going to have more deaths from the fire department not being able to fight fire than from everyone getting the disease."
The stunning 2019 defeat of a plan to implement such a policy in Connecticut shows how difficult it may be to enact even "moderate" solutions that threaten the nation's most powerful and lucrative industries.
This article was first published on Wednesday, March 4, 2020 in Kaiser Health News.
Health care costs were rising. People couldn't afford coverage. So, in Connecticut, state lawmakers took action.
Their solution was to attempt to create a public health insurance option, managed by the state, which would ostensibly serve as a low-cost alternative for people who couldn't afford private plans.
Immediately, an aggressive industry mobilized to kill the idea. Despite months of lobbying, debate and organizing, the proposal was dead on arrival.
"That bill was met with a steam train of opposition," recalled state Rep. Sean Scanlon, who chairs the legislature's insurance and real estate committee.
Through a string of presidential debates, the idea of a public option was championed by moderate Democrats ― such as former South Bend, Indiana, Mayor Pete Buttigieg, Minnesota Sen. Amy Klobuchar and former Vice President Joe Biden ― as an alternative to a single-payer "Medicare for All" model. Those center-left candidates again touted the idea during the Feb. 25 Democratic debate in South Carolina, with Buttigieg arguing such an approach would deliver universal care without the political baggage. (Buttigieg and Klobuchar have since ended their presidential bids.)
The public option has a common-sense appeal for many Americans who list health care costs as a top political concern: If the market doesn't offer patients an affordable health care insurance they like, why not give them the option to buy into a government-run health plan?
But the stunning 2019 defeat of a plan to implement such a policy in Connecticut — a solidly blue, or liberal-leaning, state — shows how difficult it may be to enact even "moderate" solutions that threaten some of America's most powerful and lucrative industries. The health insurance industry's fear: If the average American could weigh a public option — Medicare or Medicaid or some amalgam of the two — against commercial plans on the market, they might find the latter wanting.
That fear has long blocked political action, said Colleen Grogan, a professor at the University of Chicago's School of Social Service Administration, because "insurance companies are at the table" when health care reform legislation gets proposed.
To be sure, the state calculus is different from what a federal one would be. In the statehouse, a single industry can have an outsize influence and legislators are more skittish about job loss. In Connecticut, that was an especially potent force. Cigna and Aetna are among the state's top 10 employers.
"They became aware of the bill, and they moved immediately to kill it," said Frances Padilla, who heads the Universal Health Care Foundation of Connecticut and worked to generate support for the public option.
And those strategies have been replicated at the national level as a national coalition of health industry players ramps up lobbying against Democratic proposals. Beyond insurance, health care systems and hospitals have joined in mobilizing against both public option and single-payer proposals, for fear a government-backed plan would pay far less than the rates of commercial insurance.
Many states are exploring implementing a public option, and once one is successful, others may well follow, opening the door to a federal program.
"State action is always a precursor for federal action," said Trish Riley, the executive director of the National Academy for State Health Policy. "There's a long history of that."
Virginia state delegate Ibraheem Samirah introduced a new public option bill this session. In Colorado, Gov. Jared Polis is spearheading an effort. And Washington state is the furthest along — it approved a public option last year, and the state-offered plan will be available next year.
But in 2019, Connecticut's legislators were stuck between two diametrically opposed constituencies, both distinctly local.
Health costs had skyrocketed. Across the state, Scanlon said, small-business owners worried that the high price of insurance was squeezing their margins. A state-provided health plan, the logic went, would be highly regulated and offer lower premiums and stable benefits, providing a viable, affordable alternative to businesses and individuals. (It could also pressure private insurance to offer cheaper plans.)
A coalition of state legislators came together around a proposal: Let small businesses and individuals buy into the state employee health benefit plan. Insurers' response was swift.
Lobbyists from the insurance industry swarmed the Capitol, recalled Kevin Lembo, the state comptroller. "There was a lot of pressure put on the legislature and governor's office not to do this."
State ethics filings make it impossible to tease out how much of Aetna and Cigna's lobbying dollars were spent on the public option legislation specifically. In the 2019-20 period, Aetna spent almost $158,000 in total lobbying: $93,000 lobbying the Statehouse, and $65,000 on the governor's office. Cigna spent about $157,000: $84,000 went to the legislature, and $73,000 to the executive.
Anthem, another large insurance company, spent almost $147,000 lobbying during that same period — $23,545 to the governor, and $123,045 to the legislature. Padilla recalled that Anthem also made its opposition clear, though it was less vocal than the other companies. (Anthem did not respond to requests for comment.)
A coalition of insurance companies and business trade groups rolled out an online campaign, commissioning reports and promoting op-eds that argued the state proposal would devastate the local economy.
Lawmakers also received scores of similarly worded emails from Cigna and Aetna employees, voicing concern that a public option would eliminate their jobs, according to documents shared with Kaiser Health News. Cigna declined to comment on those emails, and Aetna never responded to requests for comment.
Connecticut's first public option bill — which would let people directly buy into the publicly run state employee health plan ― flamed out.
So lawmakers put forth a compromise proposal: The state would contract with private plans to administer the government health option, allowing insurance companies to participate in the system.
The night before voting, that too fell apart. Accounts of what happened vary.
Somesay Cigna threatened to pull its business out of the state if a public option were implemented. Publicly, Cigna has said it never issued such a threat but made clear that a public option would harm its bottom line. The company would not elaborate when contacted by KHN.
Now, months later, both Scanlon and Lembo said another attempt is in the works, pegged to legislation resembling last year's compromise bill. But state lawmakers work only from February through early May, which is not a lot of time for a major bill.
Meanwhile, other states are making similar pushes, fighting their own uphill battles.
"It really depends on whether there are other countervailing pressures in the state that allow politicians to be able to go for a public option," Grogan said.
And, nationally, if a public option appears to gain national traction, Blendon said, insurance companies "are clearly going to battle."
"They're going to go after every Republican, every moderate Democrat, to try to say that … it's a backdoor way to have the government take over insurance," he said.
Still, when President Barack Obama first proposed the idea of a public option as part of the Affordable Care Act, it was put aside as too radical. Less than a decade later, support for the idea ― every Democratic candidate backs either an optional public health plan or Medicare for All ― is stronger than it ever has been.
So strong, Grogan said, that it is hard for people to understand "the true extent" of the resistance that must be overcome to realize such a plan.
But in Connecticut, politicians say they're up for a new battle in 2020.
"We can't accept the status quo. … People are literally dying and going bankrupt," Scanlon said. "A public option at the state level is the leading fight we can be taking."
An outbreak of coronavirus disease in a nursing home near Seattle is prompting urgent calls for precautionary tactics at America's elder care facilities, where residents are at heightened risk of serious complications from the illness because of the dual threat of age and close living conditions.
The emergence of the novel contagious illness at the Life Care Center of Kirkland, Washington, has left one resident dead and four others hospitalized, with three in critical condition, local health officials said late Sunday. A health care worker in her 40s also remained in satisfactory condition. The resident who died was a man in his 70s with underlying health conditions, officials said.
Officials previously said that of the nursing home's 108 residents and 180 staff members, more than 50 have shown signs of possible COVID-19 infections, the name given the illness caused by a novel coronavirus that emerged from Wuhan, China, late last year. Visits from families, volunteers and vendors have been halted and new admissions placed on hold, according to a statement from Ellie Basham, the center's executive director.
"Current residents and associates are being monitored closely, and any with symptoms or who were potentially exposed are quarantined," she wrote.
The cluster of illness is the first of its type in the U.S., where 2.2 million people live in long-term care settings and may be at heightened risk because of age and underlying health conditions.
"We are very concerned about an outbreak in a setting where there are many older people," said Dr. Jeff Duchin, health officer for the Seattle and King County public health agency.
The American Health Care Association, which represents 13,500 nonprofit and for-profit facilities for seniors and disabled people, issued updated guidelines Saturday, in response to the Washington outbreak. The new virus is thought to spread primarily via droplets in the air, and the guidelines largely echo strategies recommended to stem the spread of other respiratory viruses, such as influenza. That includes frequent hand sanitation among staff and visitors, grouping people who become ill in the same room or wing, and asking family members who are sick to avoid in-person visits.
But members had been anticipating cases of the new virus, said Dr. David Gifford, AHCA's chief medical officer and senior vice president of quality and regulatory affairs.
"Clearly, it signaled that it's here and that what people knew was likely to come is closer to them than before," he said.
COVID-19 has been identified in more than 85,000 people worldwide and led to nearly 3,000 deaths, including the first U.S. death reported Saturday in another Washington state man in his 50s. That man was not associated with the Kirkland nursing center, officials said.
Studies of hospitalized patients in China suggest the median age of infection is in the 50s and that about 80% of COVID-19 cases are mild.However, a new summary in the journal JAMA reported that the virus has a case fatality rate of 1% to 2% overall — and as high as 8% to 15% in older patients in China.
That is alarming news for U.S. residents in long-term care settings, where illnesses caused by more common pathogens like norovirus and seasonal influenza often spread rapidly among residents, causing severe complications. Immune response wanes as people age, leaving them more vulnerable to infections of all types.
Dr. Karl Steinberg, a geriatrician who serves as medical director for two nursing homes and as chief medical officer for a chain of 20 others in Southern California, said the news of COVID-19 cases at the Washington state nursing center is worrisome.
"That's very scary," Steinberg said. "It worries me that once it gets going, it will be really hard to control the spread."
The situation may be akin to the spread of coronavirus on cruise ships, such as the Diamond Princess that was quarantined off the coast of Japan, with one key exception, Steinberg said. People on cruise ships can be confined to their rooms with minimal interaction with staff and fellow residents. People in nursing centers are there because they need help with activities of daily living, he noted.
In the Washington state center, Duchin said, officials are advising health workers to separate cohorts of sick patients from those who remain well and to don personal protective gear, including eye protection, to avoid infection. "It's a very challenging environment with so many vulnerable patients to manage an outbreak," he said.
Duchin urged older people and those with health conditions such as heart disease, lung disease and diabetes to pay close attention to precautions such as washing hands frequently, keeping their hands away from their faces and avoiding people who show signs of illness.
Just-released guidelines from the Society for Post-Acute and Long-Term Care Medicine call for increasing hand hygiene, isolating infected patients and making plans to ensure that health care workers stay home if they're sick. The guidelines also call for screening visitors and daily temperature checks for residents and staff.
Individual centers should remain in close contact with local health officials about appropriate actions, Gifford said. Authorities — and families — should think carefully before taking steps such as removing patients from nursing centers during an outbreak.
"Evacuating a facility is not a benign event," he said, noting that moving can be traumatic to frail and elderly people.
The nursing home cases are examples of community transmission of the virus, which has now been detected in California, Oregon and Washington. None of the hospitalized people had a known history of travel to other nations where the virus is spreading or contact with a traveler diagnosed with the illness.
However, Seattle researchers reported late Saturday that new genomic analysis suggests the virus may have been spreading in Washington state since mid-January, when a 35-year-old Snohomish County man who had visited Wuhan, China, was confirmed as the first U.S. case of the infection.
"This strongly suggests that there has been cryptic transmission in Washington state for the past 6 weeks," tweeted Trevor Bedford, a computational biologist at Seattle's Fred Hutchinson Cancer Research Center, who is tracking the virus. He estimated there could be "a few hundred" infections in the state.
At least 70 cases of coronavirus infection have been confirmed or presumed positive in the U.S., and officials with the federal Centers for Disease Control and Prevention said Americans should expect to hear more reports of illness in the coming days and weeks.
The new Washington cases and the first reported U.S. deaths were identified only after the CDC expanded the definition of who could be tested for the virus and after states and hospitals were given more leeway and supplies to conduct their own tests.
"What that says to us is that as we test more, we're more likely to find cases of the disease," Duchin said.
A team from the CDC has been sent to help local and state health officials investigate the Life Care Center outbreak. "We have a large investigation ahead of us, a complicated investigation ahead of us," Duchin said.
In the meantime, Steinberg said he and others will take precautions to prevent the possible spread of COVID-19 cases in long-term care settings and act swiftly to contain them, if necessary.
"I guess there's not much to do but hunker down and hope it's not too bad," he said.
This story was updated on March 1, 2020, at 6:40 p.m. PT to reflect news developments.
Colorado has emerged as a potential model for revamping health care in other states — and provided a glimpse of what a sweeping Democratic victory in November might mean for Americans.
This story was first published on Friday, February 28, 2020 in Kaiser Health News.
DENVER — With the nation’s capital mired in gridlock and the Affordable Care Act facing a dire legal challenge, the prospects of lowering health care costs for Americans this year seem unlikely.
Just don’t tell that to Coloradans.
Democratic majorities in the state House and Senate and a Democratic governor eager to push aggressive health care measures have turned Colorado into one of the foremost health policy laboratories in the country. State lawmakers have taken swift action on many of the same health issues being debated at the federal level, including a government-run health plan known as a public option, surprise medical billing, drug importation and high drug costs.
Colorado has emerged as a potential model for revamping health care in other states — and provided a glimpse of what a sweeping Democratic victory in November might mean for Americans.
“From a national perspective, this is known as one of the cool places for health care reform, where people are trying new ideas, where there is leadership, where there is community, where there are all the critical elements to get something done,” said Dr. Jay Want, executive director of the Peterson Center for Healthcare, a New York-based health policy think tank.
Full Speed Ahead
Colorado’s push started in earnest when Gov. Jared Polis took office in January 2019 with the promise of helping consumers cut health care costs. He literally created an Office of Saving People Money on Health Care in his first month on the job. What followed was a four-month legislative session in which lawmakers pushed through a decade’s worth of health care bills.
“You can argue it was the most consequential legislative session for health care since Colorado expanded Medicaid much earlier this decade,” said Joe Hanel, director of communications for the Colorado Health Institute, a nonpartisan nonprofit focused on health policy analysis.
Lawmakers passed a reinsurance bill that shielded insurance plans from the costs of their sickest patients, resulting in a 20% drop in 2020 premiums for Coloradans who buy their coverage on the individual market, not through their employers.
Surprise billing protections, which took effect Jan. 1, cap what out-of-network doctors or other medical providers can charge when patients receive services in hospitals that are not part of their insurance network. The new provision establishes an arbitration process for ongoing billing disputes.
Legislators capped copays for insulin at $100 per month and approved the importation of drugs from Canada, once federal authorities establish the process for doing so.
And the legislature authorized the Polis administration to develop a public option proposal that would provide competition to private insurance carriers selling plans on the individual market.
Hanel said state officials have taken an aggressive approach to reining in health care costs.
“They’ve really transformed their agencies in a short year or so,” he said.
For example, Colorado Insurance Commissioner Michael Conway has shifted the Division of Insurance from mainly an actuarial agency reviewing rate filings into more of an advocate for consumers. The division is developing a standard for insurance that would consider whether premiums are affordable when approving insurance rates.
A Public Option
This year, the legislature will decide whether to implement the public option plan developed by the Polis administration.
While many thought that plan would create a government-run alternative to private insurance similar to a Medicare plan open to anyone, the final draft retains a role for insurance companies in administering public option plans.
The plan would also benchmark hospital payment rates to a percentage above what Medicare pays, developing a formula to adjust those rates for each hospital. A small rural hospital would be paid differently from a large urban hospital, while independent hospitals would be paid differently from chain hospitals.
Insurance carriers would be limited to using no more than 15% of total premiums collected for administrative costs and profits, which is lower than the Affordable Care Act cap. They would also be required to use any rebates from drug companies to reduce patients’ premiums. The state is asking legislators for the authority to force hospitals and health plans to participate if they won’t do so voluntarily.
“What Colorado is doing is very innovative. There is really only one other state, Washington state, that is doing anything comparable to a public option,” said Billy Wynne, a Washington, D.C.-based health policy consultant who recently formed the Public Option Institute. “Other states have been looking at it and will pursue similar programs in the future, especially if [Colorado] can pull off the ‘triple lindy’ and make this successful.”
Industry Pushback
Hospital representatives have expressed skepticism about the public option plan, which they see as mainly targeting hospitals to achieve savings.
“The rate-setting as it is currently proposed is a 40% hit to some hospitals,” said Katherine Mulready, senior vice president and chief strategy officer of the Colorado Hospital Association, which represents more than 100 hospitals. Hospitals and other providers, she said, may not be able to maintain the same level of services and access now available.
But state officials point to recent studies suggesting prices at Colorado hospitals are among the most expensive in the country: A Rand Corp. study found that Colorado hospitals charge three to four times the Medicare rate, and an analysis of the Denver market showed the area’s 27 hospitals netted a combined $2 billion in pretax profits in 2018, with average profit margins exceeding 19%.
Hospitals say they must charge higher rates to privately insured patients to make up for the shortfall from Medicare, Medicaid and uninsured patients. But the state released a report in January showing that even when Medicaid rates went up and the need for charity care went down, hospitals still raised their prices.
“We’re getting close to the mark because some of the hospitals and pharmaceutical companies sent out a mailer against the public option,” Polis said in a Jan. 14 public forum on the proposal. “We must be getting something right if they’re that worried about it. But it also adds insult to injury for those of us who are consumers of medical services … to know they’re using some of that money from overcharging to lobby against reforms that are saving people money. That is rubbing salt in the wounds.”
Insurers are also wary of the plan.
“We are very concerned — and I would say opposed — that the government will tell us the product, the price and the place that we have to sell,” said Amanda Massey, executive director of the Colorado Association of Health Plans. “That is fundamentally opposed to private business and competition.”
The Colorado Medical Society, which represents physicians, issued a statement generally supporting the goals of the public option plan but didn’t go so far as to endorse it.
Blueprint For The Nation?
The public option would initially be available only to those consumers who buy policies on the individual market in 2022, estimated to be fewer than 7% of the state’s population. State officials said that they plan to later expand to the small-group market and that they expect the lower prices will put pressure on rates for large-group employer-sponsored plans as well.
The proposal, while not as disruptive as a “Medicare for All” or single-payer approach, represents a step toward government-run health care.
“What the state is doing is intervening, to some degree, in commercial negotiations between plans and hospitals,” Wynne said. “Let’s be honest: The state will be leaning on hospitals on their participation and reimbursement rate, and that is a tremendous benefit to health plans.”
Colorado’s approach could provide a blueprint for any moderate Democratic presidential candidates promoting a public option on the national level, much in the way Massachusetts provided the basic framework for the Affordable Care Act.
“Colorado is doing it and is ahead of the curve,” Wynne said. “If one of those people wins, they’re going to be looking to this state as a model for what to try to help other states do.”
Locally, Democrats also are betting that by addressing what Coloradans have identified as their highest priority — reducing the cost of health care — they’ll be well positioned to build on their state majority in the 2020 elections.
“I haven’t met a single voter,” Polis quipped recently, “who said, ‘I don’t pay enough for my health care.’”
For much of the 20th century, medical progress seemed limitless.
Antibiotics revolutionized the care of infections. Vaccines turned deadly childhood diseases into distant memories. Americans lived longer, healthier lives than their parents.
Even as the world struggles to control a mysterious new virus known as COVID-19, U.S. health officials are refighting battles they thought they had won, such ashalting measles outbreaks, reducing deaths from heart disease and protecting young people from tobacco. These hard-fought victories are at risk as parents avoid vaccinating children, obesity rates climb, and vaping spreads like wildfire among teens.
Things looked promising for American health in 2014, when life expectancy hit 78.9 years. Then, life expectancy declined for three straight years — the longest sustained drop since the Spanish flu of 1918, which killed about 675,000 Americans and 50 million people worldwide, said Dr. Steven Woolf, a professor of family medicine and population health at Virginia Commonwealth University.
Although life expectancy inched up slightly in 2018, it hasn't yet regained the lost ground, according to the Centers for Disease Control and Prevention.
"These trends show we're going backwards," said Dr. Sadiya Khan, an assistant professor of cardiology and epidemiology at Northwestern University Feinberg School of Medicine.
While the reasons for the backsliding are complex, many public health problems could have been avoided, experts say, through stronger action by federal regulators and more attention to prevention.
"We've had an overwhelming investment in doctors and medicine," said Dr. Sandro Galea, dean of the Boston University School of Public Health. "We need to invest in prevention — safe housing,good schools, living wages, clean air and water."
Superbugs — resistant to even the strongest antibiotics — threaten to turn back the clock on the treatment of infectious diseases. Resistance occurs when bacteria and fungi evolve in ways that let them survive and flourish, in spite of treatment with the best available drugs. Each year, resistant organisms cause more than 2.8 million infections and kill more than 35,000 people in the U.S.
With deadly new types of bacteria and fungi ever emerging, Dr. Robert Redfield, the CDC director, said the world has entered a "post-antibiotic era." Half of all new gonorrhea infections, for example, are resistant to at least one type of antibiotic, and the CDC warns that "little now stands between us and untreatable gonorrhea."
That news comes as the CDC also reports a record number of combined cases of gonorrhea, syphilis and chlamydia, which were once so easily treated that they seemed like minor threats compared with HIV.
The United States has seen a resurgence of congenital syphilis, a scourge of the 19th century, which increases the risk of miscarriage, permanent disabilities and infant death. Although women and babies can be protected with early prenatal care, 1,306 newborns were born with congenital syphilis in 2018 and 94 of them died, according to the CDC.
Those numbers illustrate the "failure of American public health," said Dr. Cornelius "Neil" Clancy, a spokesperson for the Infectious Diseases Society of America. "It should be a global embarrassment."
The proliferation of resistant microbes has been fueled by overuse, by doctors who write unnecessary prescriptionsas well as farmers who give the drugs to livestock, said Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University Medical Center in Nashville, Tennessee.
Although new medications are urgently needed, drug companies are reluctant to develop antibiotics because of the financial risk, said Clancy, noting that two developers of antibiotics recently went out of business. The federal government needs to do more to make sure patients have access to effective treatments, he said. "The antibiotic market is on life support," Clancy said. "That shows the real perversion in how the health care system is set up."
A Slow Decline
A closer look at the data shows that American health was beginning to suffer 30 years ago. Increases in life expectancy slowed as manufacturing jobs moved overseas and factory towns deteriorated, Woolf said.
By the 1990s, life expectancy in the United States was falling behind that of other developed countries.
The obesity epidemic, which began in the 1980s, is taking a toll on Americans in midlife, leading to diabetes and other chronic illnesses that deprive them of decades of life. Although novel drugs for cancer and other serious diseases give some patients additional months or even years, Khan said, "the gains we're making at the tail end of life cannot make up for what's happening in midlife."
Progress against overall heart disease has stalled since 2010. Deaths from heart failure — which can be caused by high blood pressure and blocked arteries around the heart — are rising among middle-aged people. Deaths from high blood pressure, which can lead to kidney failure, also have increased since 1999.
"It's not that we don't have good blood pressure drugs," Khan said. "But those drugs don't do any good if people don't have access to them."
Addicting A New Generation
While the United States never declared victory over alcohol or drug addiction, the country has made enormous progress against tobacco. Just a few years ago, anti-smoking activists were optimistic enough to talk about the "tobacco endgame."
Today, vaping has largely replaced smoking among teens, said Matthew Myers, president of the Campaign for Tobacco-Free Kids. Although cigarette use among high school students fell from 36% in 1997 to 5.8% today, studies show 31% of seniors used electronic cigarettes in the previous month.
FDA officials say they've taken "vigorous enforcement actions aimed at ensuring e-cigarettes and other tobacco products aren't being marketed or sold to kids." But Myers said FDA officials were slow to recognize the threat to children.
With more than5 million teens using e-cigarettes, Myers said, "more kids are addicted to nicotine today than at any time in the past 20 years. If that trend isn't reversed rapidly and dynamically, it threatens to undermine 40 years of progress."
Ignoring Science
Where children live has long determined their risk of infectious disease. Around the world, children in the poorest countries often lack access to lifesaving vaccines.
Yet in the United States — wherea federal program provides free vaccines — some of the lowest vaccination rates are in affluent communities, where some parents disregard the medical evidence that vaccinating kids is safe.
Studies show that vaccination rates are drastically lower in some private schools and "holistic kindergartens" than in public schools.
It could be argued that vaccines have been a victim of their own success.
Before the development of a vaccine in the 1960s, measles infected an estimated 4 million Americans a year, hospitalizing 48,000, causing brain inflammation in about 1,000 and killing 500, according to the CDC.
"Now, mothers say, 'I don't see any measles. Why do we have to keep vaccinating?'" Schaffner said. "When you don't fear the disease, it becomes very hard to value the vaccine."
Last year, a measles outbreak in New York communities with low vaccination rates spread to almost 1,300 people — the most in 25 years — and nearly cost the country its measles elimination status. "Measles is still out there," Schaffner said. "It is our obligation to understand how fragile our victory is."
Health-Wealth Disparities
To be sure, some aspects of American health are getting better.
Cancer death rates have fallen 27% in the past 25 years, according to the American Cancer Society. The teen birth rate is at an all-time low; teen pregnancy rates have dropped by half since 1991, according to the Department of Health and Human Services. And HIV, which was once a death sentence, can now be controlled with a single daily pill. With treatment, people with HIV can live into old age.
Yet the health gap has grown wider in recent years. Life expectancy in some regions of the country grew by four years from 2001 to 2014, while it shrank by two years in others, according to a2016 study in JAMA.
The gap in life expectancy is strongly linked to income: The richest 1% of American men live 15 years longer than the poorest 1%; the richest women live 10 years longer than the poorest, according to the JAMA study.
"We're not going to erase that difference by telling people to eat right and exercise," said Dr. Richard Besser, CEO of the Robert Wood Johnson Foundation and former acting director of the CDC. "Personal choices are part of it. But the choices people make depend on the choices they're given. For far too many people, their choices are extremely limited."
The infant mortality rate of black babies is twice as high as that of white newborns, according to the Department of Health and Human Services. Babies born to well-educated, middle-class black mothers are more likely to die before their 1st birthday than babies born to poor white mothers with less than a high school education, according to a report from the Brookings Institution.
In trying to improve American health, policymakers in recent years have focused largely on expanding access to medical care and encouraging healthy lifestyles. Today, many advocate taking a broader approach, calling for systemic change to lift families out of the povertythat erodes mental and physical health.
Several policies have been shown to improve health.
Children who receive early childhood education, for example, have lower rates of obesity, child abuse and neglect, youth violence and emergency department visits, according to the CDC.
And earned income tax credits — which provide refunds to lower-income people — have been credited with keeping more families and children above the poverty line than any other federal, state or local program, according to the CDC. Among families who receive these tax credits, mothers have better mental health and babies have lower rates of infant mortality and weigh more at birth, a sign of health.
Improving a person's environment has the potential to help them far more than writing a prescription, said John Auerbach, president and CEO of the nonprofit Trust for America's Health.
"If we think we can treat our way out of this, we will never solve the problem," Auerbach said. "We need to look upstream at the underlying causes of poor health."
BAYONNE, N.J. — For five years, Rasha Salama has taken her two children to Dr. Inas Wassef, a pediatrician a few blocks from her home in this blue-collar town across the bay from New York City.
Salama likes the doctor because Wassef speaks her native language — Arabic — and has office hours at convenient times for children.
"She knows my kids, answers the phone, is open on Saturdays and is everything for me," she said.
But UnitedHealthcare is dropping Wassef — and hundreds of other doctors in its central and northern New Jersey Medicaid physician network. The move is forcing thousands of low-income patients such as Salama to forsake longtime physicians.
Across the nation, business and contractual disputes are separating patients from longtime doctors. This often occurs when doctors don't want to accept the rates insurers are willing to pay. It sometimes occurs when insurers' business plans require having a narrower network of doctors — doctors whose practice patterns may be easier to control.
But in this case, the cause of the exclusion goes to even deeper business connections: Wassef and other doctors say the insurer appears to be trying to shift patients to Riverside Medical Group, a 20-office physicians' practice owned by Optum, a sister company of UnitedHealthcare, both of which are subsidiaries of UnitedHealth Group. UnitedHealthcare is essentially forcing patients to transfer to doctors it controls, the doctors allege.
Indeed, several patients said the health plan directed them to Riverside when informing them their doctors were being dropped.
Lawrence Downs, CEO of the Medical Society of New Jersey, said he estimates UnitedHealthcare is trying to remove hundreds of doctors in central and northern New Jersey from its network. That is the same area where Riverside Medical operates, he noted.
"It seems like they are steering patients away from small, community-based doctors to large groups that they own," he said.
Good For Profits
That raises questions about whether this type of "vertical consolidation" — the term for a practice occurring across the country — is a strategy that is good for profits but bad for patients.
UnitedHealthcare said the changes are not part of a campaign to get as many patients as possible to the Riverside practice. It points out that it is retaining the community-based doctors, like Wassef, in its networks to treat its Medicare Advantage and commercial plan members.
But, experts say, traumatic disruptions in doctor-patient relationships are an inevitable result of ongoing shifts in the complicated business of U.S. health care.
Facing a rapid consolidation of doctors' practices and hospital systems — which have hefty negotiating power to demand high fees — insurers have limited options to control costs and maintain a positive balance sheet, said Jacob Wallace, an assistant professor of public health at Yale University. Medicaid plans are especially affected because, unlike commercial plans or even Medicare, they can't increase premiums or demand copayments.
"Plans face a challenging landscape to keep costs down," Wallace said. As a result, health plans have taken other approaches, including narrowing provider networks and buying their own physician practices, he said.
But further complicating matters, many Medicaid and Medicare managed-care programs are contracted out to private, for-profit insurers such as UnitedHealthcare. They are looking to create returns for shareholders. With surging enrollment in government programs, UnitedHealthcare has enjoyed rising profits and a stock price that has soared tenfold since 2010.
Wassef and about two dozen other physicians filed a federal lawsuit in September to get reinstated. Wassef, whose termination is scheduled in May, said the move could seriously affect her practice because 80% of her patients are insured by UnitedHealthcare.
UnitedHealthcare gained millions of new customers after the Affordable Care Act led New Jersey and 35 other states and the District of Columbia to expand Medicaid and states turned to private insurers to handle the business. Salama and some other UnitedHealthcare customers said they like their insurance plan because it offers richer benefits than other Medicaid options and covers the medications they use.
The company operates New Jersey's second-largest Medicaid health plan, with 418,000 members. (The state Department of Human Services has blocked UnitedHealthcare from enrolling any additional Medicaid members, a severe and rare penalty. That move — which is not related to the termination of doctors' contracts — stems from complaints related to care management and discharge planning, the health plan's call center and other issues.)
A company spokesperson acknowledged the health plan is dropping 2% of its Medicaid doctors, saying the move was designed to help control costs.
"As health care costs continue to rise, we are working to mitigate the impact on the customers, states and members we serve by negotiating with care providers on their behalf to keep reimbursement rates affordable," the company said in a statement. "We understand that our members have personal relationships with their doctors and that network changes can be difficult."
A Practice Destroyed
New Jersey Medicaid officials refused to comment on whether they are concerned about UnitedHealthcare's actions. But patients caught up in the standoff have reason to worry, said Linda Schwimmer, CEO of the New Jersey Health Care Quality Institute, a coalition of health plans, providers and a variety of health trade groups.
"Once you have a trusted relationship with a provider, it means a lot and it goes to the quality [of your care] because if you are seeing the same providers and you trust them, you are more likely to take your medication and adhere to whatever care plan you have," she said.
Dr. Alexander Salerno, an internist who runs a 17-doctor multispecialty practice in East Orange, New Jersey, another plaintiff in the lawsuit, is helping lead the court fight. Salerno's main office is in a three-story, 19th-century house that his father used for his medical practice in the 1960s. About 40% of his patients are on Medicaid.
Until the dispute began last year, Salerno advised his patients to sign up for UnitedHealthcare because of its broad array of benefits, including vision and dental care, and because of the ease in referring to specialists.
And UnitedHealthcare never complained about this group's skill. In fact, the group received a $130,000 bonus last year for its good care to patients. Salerno said Riverside Medical offered to buy his group practice in 2018, but he declined.
Since UnitedHealthcare announced it would drop his group from the network, more than 500 of his practices' patients have already changed doctors to stay with the UnitedHealthcare plan, Salerno said.
"It's not a bad insurance company. It just seems like they have become greedy trying to control both ends of the pendulum — wanting to be the payer and provider," Salerno said.
A federal judge ordered the case to be heard by a neutral arbitrator, which in late November granted an emergency injunction that will keep Salerno from being removed from UnitedHealthcare's network until an arbitrator makes a decision on a permanent injunction, which is expected in March.
But that leaves patients in limbo.
Glorida Rivera, 68, said UnitedHealthcare's decision to drop Salerno was upsetting because she relied on him to care for her diabetes, thyroid and heart conditions. She credits Salerno for referring her to a cardiologist, who put stents in her heart to clear a blockage.
"He knows my whole story, so why do I have to change?" wondered Rivera. Nonetheless, she is sticking with UnitedHealthcare.
Velylia McIver, 83, decided in November to search for another plan so she could stay with Salerno. But it took her more than a month to get coverage for some medications.
"I feel caught in the middle of all this, and it's the pits," McIver said.