HHS secretary says preexisting conditions have the protections originally offered under HIPAA.

This article was first published on Tuesday, July 14, 2020 in Kaiser Health News.

By Julie Rovner July 14, 2020

One of the most popular features of the Affordable Care Act is its guarantee of insurance coverage — at no greater cost — for people with preexisting health conditions.

Thus, even as the Trump administration argues before the Supreme Court that the entire Affordable Care Act should be declared invalid, the president and his administration officials maintain that regardless of what happens to the ACA, they will protect people who have had health problems in the past.

Speaking to a "virtual health summit" sponsored by the political newspaper The Hill, Health and Human Services Secretary Alex Azar answered a question about the case, Texas v. Azar, by pointing out "it's in statute already in HIPAA that preexisting conditions are covered," implying that if the ACA were declared unconstitutional, those protections would remain in place for everyone.

Umm … not so much.

When we checked with HHS for more information about Azar's comment, a spokesperson reiterated the secretary's statement, adding that Azar was "clear that the story on preexisting conditions doesn't end with HIPAA" and that affordability is a critical component.

So we investigated.

A Little About HIPAA

The Health Insurance Portability and Accountability Act, a law we have examined before, was passed by a Republican-led Congress and signed by Democratic President Bill Clinton in 1996. It is best known for safeguarding medical privacy and patient access to medical records, even though the privacy provisions were added toward the end of congressional deliberations.

HIPAA's original purpose was to end what was known as "job lock," a situation in which people with preexisting conditions were reluctant to leave jobs with health insurance even for other positions with health insurance for fear their conditions would not be covered or they would be subject to long waiting periods for coverage. Both scenarios were common at the time.

HIPAA addressed that problem — as long as people maintained "continuous" coverage, defined as having health insurance for at least 12 months without a break of more than 63 days. People who met that requirement could not have waiting periods or denials of coverage imposed upon their own or a family member's preexisting condition. HIPAA included protections for people with coverage in the small-group insurance market, which primarily comprises small businesses, by requiring insurers who sold policies in that market to sell to all small groups, regardless of health status, and to cover every eligible member of the groups — again, regardless of health status.

But HIPAA was not designed to comprehensively address the problem of people with preexisting conditions getting and keeping affordable health insurance.

For starters, the protections were only for people who already had job-based insurance, to make it easier for them to move to other job-based insurance. It did nothing for those in the individual insurance market who needed to purchase their own coverage — such as self-employed people and those working for companies that did not offer health insurance.

HIPAA attempted to create a pathway for people transitioning from employer-sponsored to individual coverage. It ensured that, after leaving a job, people who secured insurance through another law, the 1986 Consolidated Omnibus Budget Reconciliation Act, or COBRA, would be eligible to buy a "conversion" plan from their insurer once their previous job-based benefits were exhausted.

However, two giant problems arose. First, COBRA, which allows individuals to continue their employer-provided coverage for up to 18 months if they pay the entire premium themselves (plus a small administrative fee), is prohibitively expensive for most people. In 2019, the average premium for a single worker was $599 per month.

The other problem was that even if a former worker did manage to pay for COBRA coverage until that 18-month period ended, there was no limit on how much insurers could charge for the conversion policies. So, even if they were technically available, they were frequently unaffordable.

There were other problems. COBRA coverage was not available to people who worked for small businesses, or for those who became unemployed because the business they worked for failed and no longer offered insurance to anyone. HIPAA also did not stipulate which benefits had to be offered.

Next, the ACA

Sources

Health Insurance Portability and Accountability Act of 1996 

Affordable Care Act of 2010 

Email exchange with a Department of Health and Human Services spokesperson, July 10, 2020

Email exchange with Timothy Jost, emeritus professor at Washington and Lee University School of Law in Virginia, July 10, 2020

Email exchange with Karen Pollitz, a senior fellow at KFF (the Kaiser Family Foundation; KHN is an editorially independent program of the foundation), July 10, 2020

"Trump Administration Asks Supreme Court to Strike Down Obamacare," The Washington Post, June 26, 2020

"Did The ACA Create Preexisting Condition Protections For People In Employer Plans?" May 21, 2019

The HIPAA Privacy Rule, Department of Health and Human Services, April 16, 2015

"Average Annual Single Premium per Enrolled Employee for Employer-Based Health Insurance," Kaiser Family Foundation, time frame 2018

The ACA sought to deal with HIPAA's shortcomings. It required most employers to offer coverage and, for those purchasing their own, it required insurers to provide a comprehensive package of benefits at the same price to all purchasers, regardless of health status.

However, the ACA rewrote the HIPAA provisions regarding preexisting conditions, so if the ACA is struck down by the Supreme Court, it's not clear whether even HIPAA's lesser provisions would remain. Experts disagree about this, but there is a possibility that HIPAA's protections could be swept away along with the ACA.

Later in his answer to the question posed at The Hill's summit, Azar pointed out that there are significant affordability problems with coverage under the ACA, as well. "So we will work with Congress if the time ever comes, to get real affordable solutions," he said. That's true. ACA plans, even with subsidies, can be too expensive for some people, and prohibitive for those who earn just slightly too much to qualify for government help. Earlier this month, Democrats in the House passed a bill to make ACA plans more affordable.

Our Ruling

Azar's statement suggested that if the Supreme Court rules against the ACA and that sweeping law is nullified, Americans with preexisting conditions would continue to have the protections originally offered under HIPAA.

Though it contains an element of truth, it leaves out critical pieces of information. For instance, the HIPAA protections are not equivalent to those provided by the ACA. First, they are geared toward people who have work-based insurance coverage — as long as that coverage is continuous for at least 12 months with lapses no longer than 63 days. One expert we consulted pointed out that this window could be especially problematic now, during a time of "enormous economic dislocation."

Additionally, the ACA rewrote the HIPAA provisions regarding preexisting conditions — bringing into question what might become of them, too.

We rate Azar's claim Mostly False.

Julie Rovner: jrovner@kff.org, @jrovner

Across the country, the recession has cut state revenues at the same time the pandemic has increased costs, forcing lawmakers into painful decisions about how to balance their budgets.

This article was first published on Friday, July 10, 2020 in Kaiser Health News.

By Markian Hawryluk

As a teenager, Paulina Castle struggled for years with suicidal thoughts. When her mental health was at its most fragile, she would isolate herself, spending days in her room alone.

“That’s the exact thing that makes you feel significantly worse,” the 26-year-old Denver woman said. “It creates a cycle where you’re constantly getting dug into a deeper hole.”

Part of her recovery involved forcing herself to leave her room to socialize or to exercise outside. But the COVID-19 pandemic has made all of that much harder. Instead of interacting with people on the street in her job as a political canvasser, she is working at home on the phone. And with social distancing rules in place, she has fewer opportunities to meet with friends.

“Since the virus started,” she said, “it’s been a lot easier to fall back into that cycle.”

Between the challenges of the pandemic, the social unrest and the economic crisis, mental health providers are warning that the need for behavioral health services is growing. Yet faced with budgetary shortfalls, Colorado is cutting spending on a number of mental health and substance use treatment programs.

Across the country, the recession has cut state revenues at the same time the pandemic has increased costs, forcing lawmakers into painful decisions about how to balance their budgets. State legislatures have been forced to consider health care cuts and delay new health programs even in the midst of a health care crisis. But many lawmakers and health experts are concerned the cuts needed to balance state budgets now could exacerbate the pandemic and the recession down the line.

“Health care cuts tend to be on the table, and of course, it’s counterproductive,” said Edwin Park, a health policy professor at Georgetown University. When there’s a recession, people lose their jobs and health insurance, he noted, the very moment when people need those health programs the most.

‘Everything Has To Be On The Table’

In Colorado, for example, lawmakers had to fill a $3.3 billion hole in the budget for fiscal year 2020, which started July 1. That included cuts to a handful of mental health programs, with small overall savings but potentially significant impact on those who relied on them.

They cut $1 million from a program designed to keep people with mental illness out of the hospital and another million from mental health services for juvenile and adult offenders. Lawmakers reduced funding for substance abuse treatment in county jails by $735,000 and eliminated $5 million earmarked for addiction treatment programs in underserved communities. And that’s all on top of a 1% cut to Medicaid community providers who offer health care to the state’s poorest residents.

Some of those cuts were offset by $15.2 million in federal CARES Act funding allocated to behavioral health care programs. But some programs were completely defunded. Cuts were targeted primarily at programs that hadn’t started yet or hadn’t been fully implemented. The rationale: Those cuts wouldn’t have as deep an impact.

Doyle Forrestal, CEO of the Colorado Behavioral Healthcare Council, which represents 23 behavioral health care providers, worries that resources won’t be there for an emerging wave of people who have developed mental health or addiction issues during the pandemic.

“People who are isolated at home are drinking a lot more, maybe having other problems — isolation, economic despair,” she said. “There’s going to be a whole new influx once all of this takes hold.”

State legislators said they tried to avoid cutting programs that would hamper the response to the pandemic or the economic recovery.

“There was a desire on both sides to do everything we could to protect health care spending in Colorado,” said Democratic Rep. Dylan Roberts. “But when you’re looking at across-the-board cuts, everything has to be on the table.”

Every state is facing a similar conundrum. With tax filing deadlines pushed back to July 15, states are unsure how much income tax revenue they will collect.

So in addition to cutting back where possible, states are raiding discretionary funds — Colorado repurposed money from the tobacco settlement and marijuana taxes — to shore up their budgets. States are also tapping rainy day funds, which, according to the National Association of State Budget Officers, grew to record levels after the 2008 recession.

New Policies Delayed

Overall, at least 43 states have made some changes to facilitate access to Medicaid or the Children’s Health Insurance Program as many people have lost their job-based health insurance in the COVID crisis. And in late June, voters in Oklahoma approved expanding Medicaid to more residents. But since the start of the pandemic, states including Kansas and California have put off plans to expand eligibility for Medicaid, which provides health care to low-income people.

“These are symptoms of states that can’t deficit-spend, despite this great need for more coverage,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, an independent health policy research foundation based in New York. “If they spend more in one area, that means cuts in another.”

Colorado has had an aggressive health agenda in recent years but had to defer plans for a public health insurance option that could have provided a more affordable plan for people buying insurance on their own.

The legislature killed a proposal to create an annual mental health checkup. The measure would have cost the state only $13,000, but Democratic Gov. Jared Polis signaled he wouldn’t sign any bills that included new mandates for insurance companies.

Democratic Rep. Dafna Michaelson Jenet, who sponsored the checkup measure, was disappointed.

“Not every one of us is going to catch COVID, but every single one of us will have a mental health impact,” she said.

Long-Term Implications

Once the economic crisis eases, Roberts said, lawmakers will look to restore funding to some of the programs they cut.

But cuts are often easier to make than to restore — as illustrated by cutbacks made during the 2008 recession, according to Georgetown’s Park.

“Many cuts were never fully restored, even though we were in one of the longer economic expansion periods in our country’s history,” Park said.

He also worries many of the smaller primary care and behavioral health providers, who saw fewer patients come through their doors because of stay-at-home orders during the pandemic, might not survive.

“That means less access to care, including routine care like vaccinations,” he said. “If kids aren’t vaccinated, they may be more vulnerable to flu and measles, making them more vulnerable to COVID-19. That makes it more difficult for a stressed health care system to try to deal with a potential second wave of infections.”

The longer-term mental health toll may be harder to catalog.

Castle, for one, has focused on establishing routines to help her manage her mental health during the pandemic. Every Wednesday night, she plays games online with her friends. And every Friday night, she and her boyfriend build a fire in the backyard.

“If I know people are expecting me to be somewhere at 6 o’clock, that obligation encourages me to go out,” she explained. “There are days it’s a struggle. I have to focus on baby steps.”

Still, Castle worries about others who may be struggling during the pandemic. She has signed on to work with the Colorado chapter of Young Invincibles, which lobbies for health care, higher education and workforce policies to help young adults. Even as states and the federal government have found the money to help hospitals and doctors treat the physical effects of the COVID pandemic, she doesn’t see the same commitment to treating its mental health toll.

“We need to start treating mental health the same as we do physical health,” she said. This is an issue we need to stop keeping in the dark.”

If you or someone you know is thinking about suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Chat, both available 24 hours a day, seven days a week.

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

"If Donald Trump has his way, complications from COVID-19 could become a new preexisting condition," says former Vice President Joe Biden during a campaign speech in Lancaster, Pennsylvania.

This article was first published on Thursday, July 9, 2020 in Kaiser Health News.

By Julie Appleby

The same day the Trump administration reaffirmed its support of a lawsuit that would invalidate all of the Affordable Care Act, Joe Biden sharply warned that the suit endangers millions of Americans.

The presumptive Democratic presidential nominee said the law is even more important now, more than a decade after it was enacted, as the COVID-19 epidemic sweeps the U.S. The virus has killed more than 130,000, and Biden noted that some who survive may have long-lasting health problems.

His speech in the battleground state of Pennsylvania focused on a legal challenge headed to the Supreme Court and the fallout if the court upholds a 2018 U.S. District Court decision that struck down the entire ACA, including preexisting condition protections that bar insurers from rejecting people with medical problems or charging them more.

“And perhaps most cruelly of all, if Donald Trump has his way, complications from COVID-19 could become a new preexisting condition,” Biden said.

The Trump administration has supported the challenge. A decision from the Supreme Court is expected next year, after the November presidential election.

But would a decision against the health law affect COVID-19 patients in the way Biden described?

We decided to check because it’s likely to come up a lot in the presidential electioneering. We reached out to the Biden campaign to find out the basis for his statement. A campaign spokesperson responded by reiterating the points made by the former vice president in his speech and sharing various news stories about COVID-19 and the preexisting condition coverage issue.

Several law and health policy experts noted that Biden is on fairly firm ground, though the issue — like many others in health care — is complicated.

First, A Little History

Before the ACA went into effect in 2014, insurers on the private market could reject applicants for coverage if they had any number of medical conditions, such as cancer, depression, heart disease — even high blood pressure, acne or plantar fasciitis. Consumers had to fill out forms listing their medical conditions when applying for coverage. An estimated 54 million Americans have a preexisting condition that could have led to a denial under pre-ACA rules, researchers estimate.

Also, at the time, some consumers had coverage cancelled retroactively once they fell ill with a serious or costly disease, as insurers would then comb through years of medical records looking for anything the consumer had failed to report as preexisting, even if it seemed to have little or nothing to do with the patient’s current medical concern.

Those rejections and cancellations mainly affected people who bought their own coverage, not those who got insurance through their jobs.

Job-based coverage, which is the main way most insured people get their plans, had some protections prior to the passage of the ACA. For example, the federal Health Insurance Portability and Accountability Act of 1996 said people who held health insurance continuously for at least a year could not face preexisting condition limits when they enrolled in a new employer plan, as long as they didn’t go uninsured for more than 63 days.

Those who didn’t meet that yearlong coverage requirement or went uninsured between jobs could find their medical conditions excluded for up to a year in a new group plan.

Before the ACA, insurers broadly defined preexisting conditions. Many included any condition for which a patient had received treatment, or even undiagnosed conditions for which a reasonable person should have sought treatment.

The ACA changed that. Among other things, it barred insurers from rejecting applicants based on their health, excluding coverage of preexisting medical conditions and charging sick people more than healthier ones. It also ended annual or lifetime dollar limits on coverage and said employers that offer insurance can’t make new workers wait more than 90 days for coverage to kick in.

Could COVID-19 Become A Preexisting Condition?

Biden’s comment raises the question of whether COVID-19 would be considered a preexisting condition in a future without the sweeping health law on the books.

Because the virus is so new, there’s no definitive answer on its long-term health effects.

But media reports note hospitals and physician groups are finding evidence that some recovered COVID patients suffer from lung damage, blood clots, neurological conditions, strokes or fatigue.

Researchers are now starting to follow patients to track long-term effects.

Given insurers’ history, it’s certainly reasonable to assume they would put what are now cropping up as potential COVID complications in the preexisting-condition category, said Sabrina Corlette, who studies the individual insurance market as co-director of the Center on Health Insurance Reforms at Georgetown University.

“There is a real concern that if those preexisting condition protections are overruled or taken down by the Supreme Court, people who have COVID-19 could be medically underwritten, charged more or be denied a policy,” said Corlette.

That is possible, said Joe Antos, resident scholar in health policy at the conservative American Enterprise Institute. But many of the people most likely to suffer complications from the coronavirus likely already had conditions like diabetes, asthma or heart disease that would already have put them in danger of being rejected for coverage under pre-ACA business practices, he added.

In other words, COVID-19 could simply find a place on a long list of other conditions that could disqualify consumers from obtaining insurance.

And even if the high court tossed out the ACA, insurers might choose to keep offering coverage to people with health problems, say some analysts, including Antos.

But this take triggers skepticism.

“Insurance companies have an obligation to shareholders, and that obligation is to maximize profits,” Corlette said. “They don’t do that by covering a lot of sick people when competitors are not doing it.”

The Biggest Unknown

Just how would Congress and the president react if the ACA is struck down?

Under a Biden presidency, coupled with Democrats holding the House and possibly winning the Senate, the ACA would definitely be replaced, the experts all agreed.

Under a second-term Trump administration, Republicans would face a dilemma because — even though the party has called for the law’s repeal since its enactment –— they have been unable to agree on how to replace it. Yet polls have consistently shown that parts of the law, especially the preexisting condition protections, are very popular with a wide swath of voters.

“They don’t want to come across as coming up hard against people who have health conditions,” said Antos.

Private practice attorney Christopher Condeluci, who served as tax and benefit counsel to the Senate Finance Committee when the ACA was drafted, agreed. He thinks Congress or the president would act to save the preexisting condition protections at least.

But how to do so is problematic. That provision is intricately tied with many other parts of the ACA, those aimed at getting as many healthy people to enroll as possible in order to spread costs out among the many, rather than the few.

The ACA did that partly by requiring most Americans to carry insurance coverage — the provision at the heart of the Texas lawsuit seeking to overturn the legislation. Restoring that requirement might be tricky, so the path forward for a split Congress or a second-term Trump presidency to come up with a solution quickly — or at all — if the Supreme Court tosses the entire law is a difficult one.

Our Ruling

Biden said that if Trump had his way, COVID complications could become a preexisting condition. He said this while discussing what might happen if the ACA is overturned by the Supreme Court. Though the statement can’t be definitively proven, there’s a lot of evidence backing it up.

First, some patients are showing at least short-term aftereffects of COVID-19, some of which could be costly. Some may prove long-term.

Second, insurers dislike costly medical conditions. Their business model is designed to have enough healthy enrollees to offset those with costly conditions. Before the ACA, they did that by rejecting people with medical conditions, charging them more or excluding coverage for those conditions. Some also temporarily delayed coverage for specific conditions in group plans offered by employers. Without the ACA, no federal law would prevent them from returning to these practices when selling plans on the individual market.

We rate Biden’s statement Mostly True.

The Texas Medical Center has predicted that unless the spread of the virus is mitigated, Houston hospitals could exceed existing capacity by mid-July.

This article was first published on Wednesday, July 8, 2020 in Kaiser Health News.

By Sandy West

HOUSTON — The Fourth of July was a little different this year here in Texas’ biggest city. Parades were canceled and some of the region’s beaches were closed. At the city’s biggest fireworks show, “Freedom Over Texas,” fireworks were shot higher in the air to make it easier to watch from a distance. Other fireworks displays encouraged people to stay in their cars.

After weeks of surging COVID-19 cases and dire warnings that Houston’s massive medical infrastructure would not be able to keep pace, Republican Gov. Greg Abbott issued an executive order on July 2 requiring Texans to wear masks in public, after previously reversing course on the state’s reopening by again closing bars and reducing restaurant capacity.

While most Houstonians appear to be taking heed, not everyone is on board. Small protests against the orders occurred over the holiday weekend. Lawsuits have been filed. At least one Houston-area law enforcement agency said it would not enforce the mask requirement. The State Republican Executive Committee plans to hold its mid-July convention downtown, drawing an expected 6,000 people from around the state.

Democratic Mayor Sylvester Turner said he and other local leaders sent a letter to GOP leaders asking them to convert the convention into a virtual event. But the party remains steadfast.

“There simply is no substitute for the in-person debate we value so strongly,” Texas GOP Chairman James Dickey said, adding that the party committee explicitly affirmed it would not voluntarily cancel the convention. He said there would be thermal scanners, social distancing, deep cleaning between meetings, hand sanitizer and thousands of donated masks available for those in attendance.

“My sincerest sympathies go out to anyone who is affected by any severe disease, including this one,” he said. “But on a per capita basis, Harris County, and Texas in general, are both dramatically better than most of the states in the United States.”

However, confirmed cases in Houston’s surrounding county, Harris, more than doubled in a month to reach more than 37,000 positive cases as of July 6. Hospitals in the Texas Medical Center had 2,261 COVID-positive patients that day in intensive care or medical-surgical units, up from 1,747 the week before, according to the center’s tracking website. All told, the nine-county Houston region has had more than 52,000 confirmed cases and 572 deaths.

The Texas Medical Center has predicted that unless the spread of the virus is mitigated, Houston hospitals could exceed existing capacity by mid-July. A federal assessment team came to Houston to determine how the federal government can help the city respond to the current surge.

Local officials had tried to protect Houston. Early in the pandemic, Harris County Judge Lina Hidalgo, a Democrat who serves as the county’s top elected leader, implemented business closures and stay-at-home and masking orders. But Lt. Gov. Dan Patrick and U.S. Rep. Dan Crenshaw, both Republicans, called them an “overreach” that “could lead to unjust tyranny.” On April 27, Abbott overruled the county guidance, and announced plans to reopen businesses and relax social distancing guidelines.

For those who live in Houston, it’s all meant lots of confusion.

“This whole thing has been a messaging nightmare from the beginning,” said Joe Garcia, 50, who works in data management. “When a flood happens, when a hurricane happens, nobody cares what side you’re on — blue, red, whatever else — all you know is it’s a disaster and everybody comes in and helps. That’s just the way things are. This wasn’t treated as a disaster.”

Public discourse about the pandemic has been disheartening, said Norma Ybarbo, 55, who avoids leaving home beyond socially distant visits with her father and attending a lightly populated early morning mass. She said the political arguments and conflicting communication from the Texas Medical Center in June about hospital capacity have made an already stressful situation worse.

“It’s worrisome, for sure,” Ybarbo said. “It’s really hard to determine what is right and what is true.”

Marine veteran S.D. Panter, 44, said it all has deepened his concern about bias in doctors and politicians who are advocating for businesses to be shut down. Panter, who doesn’t deny the virus is troublesome, said he prefers to do his own research because, for him, the dire picture being painted by those in the spotlight doesn’t make sense. He does wear a mask in public, even though he is not sure it is necessary.

“There’s just so much information. Just let me make my own decision, my own informed decision,” said Panter, who helps his parents and his wife’s parents stay socially isolated. “The older population should probably stay indoors, and let’s protect them the best we can.”

The state’s reopening this spring coincided with Mother’s Day, graduations, Memorial Day and Black Lives Matter protests. Once Texans were released from pandemic-induced restrictions, many happily took advantage of the chance to socialize.

Alyssa Guerra, 27, who lost her job when the store she managed closed, said she now knows people who have contracted the virus, and a few who have become sick or lost loved ones. She has friends who went to bars and social events, without masks, when the state reopened. She went out to eat once, but felt so uncomfortable she hasn’t done it since.

“It’s affecting us in greater numbers now because of the selfish decisions we are making,” said Guerra. “At some point, yes, we are going to have to start living our lives again, but we did it so quickly this time that people just had no care in the world.”

While the number of confirmed COVID-19 infections is rising in all age groups here, those seeing the most rapid growth in positive tests and hospitalizations are 20 to 40 years old. Dr. David Persse, public health authority with the Houston Health Department, said recently that 15% of COVID patients being admitted to the hospital are younger than 50, and 30% are younger than 60.

That could explain lower rates of death now than earlier in the pandemic, said Dr. Angela Shippy, chief medical and quality officer at Memorial Hermann Health System. Another reason for the lower death rates could be that providers have learned more effective treatments for the virus, using different respiratory and drug therapies to avoid intensive care units and intubation.

Still, Houston’s hospitals are being challenged by the rapid spike in COVID patients as a whole. Without taking steps to slow the spread of the virus, hospitals could become unable to manage the load. That has been the message from hospitals — including in multiple full-page ads in the Houston Chronicle advising people to stay home or wear a mask in public.

“We still have the ability to grow capacity, but there will come a limit to how much capacity you can grow,” said Roberta Schwartz, executive vice president, chief innovation officer and CEO of Houston Methodist Hospital.

The area’s public hospitals, which had been steadily handling COVID cases since March, have been transferring adult patients the past several weeks to private hospitals, including Texas Children’s Hospital, which had 29 COVID patients as of July 6. Houston Fire Chief Sam Peña said it has been taking an hour, in some cases, to transfer patients from ambulances to some emergency rooms — which Schwartz said have been “inundated.”

The fire and police departments have large numbers of staff in quarantine. Hospitals report staffers are testing positive, which they attribute to contracting the virus outside the hospital. Some area hospitals are bringing in traveling nurses to help.

“We encourage everyone to do their part and always wear a mask when leaving home, wash your hands often and maintain social distance,” Mark A. Wallace, president and CEO of Texas Children’s Hospital, said in an emailed statement. “This is the best way to protect yourself, your loved ones and our health care workers.”