As Coronavirus Testing Gears Up, Specialized Swabs Running Out

KFF Health News, March 18, 2020

These swabs are currently singled out by CDC and FDA guidelines as suitable for most coronavirus testing.

This article was first published on Tuesday, March 17, 2020 in Kaiser Health News.

By Lauren Weber and Christina Jewett

The two top makers of the highly specialized swabs used to test patients for the novel coronavirus are straining to keep up with the demand, even as both the Italian and U.S. governments are working with them to increase production, including at a key manufacturing site in the midst of Italy's outbreak.

The nasopharyngeal swabs required for the coronavirus tests are quite different from your standard Q-tips — and the exploding need for them has created a bottleneck in the soaring demand for diagnoses.

The swabs have to be long and skinny enough to get to the nasopharynx, the upper part of the throat, behind the nose. They must be made of synthetic fiber and cannot have a wooden shaft. Nor can they contain calcium alginate, a substance typically used for swab tips in wound care, as that can kill the virus, according to the Centers for Disease Control and Prevention.

These swabs are currently singled out by CDC and Food and Drug Administration guidelines as suitable for most coronavirus testing. Once used, they're typically mailed in transportable vials full of a solution known as "viral transport media," which keeps the virus testable.

While last week's critical shortage was a reagent chemical used in the diagnostic tests, now the specialized swabs are in dire demand, according to Soumi Saha, a pharmacist who is the senior director of advocacy for Premier Inc., a group purchasing organization that procures supplies for 4,000 U.S. hospitals and health systems. As testing finally ramps up in the U.S., hospitals especially are having a hard time getting enough of these swabs, Saha said.

"We have folks that can't get a hand on any of them right now," Saha said. "Hospitals want to do their part and want to expand access to testing, but they're hamstrung by the fact that they can't access the actual swabs."

Former FDA commissioner Scott Gottlieb pointed out on Twitter on Monday that a lack of swabs could be the new bottleneck even as the number of sites with the capacity to test has increased, showcasing that the weakest link in the supply chain becomes the limiting factor.

Missouri has been among the places seeing a shortage of swabs, state Department of Health and Senior Services spokesperson Lisa Cox confirmed over the weekend. Ontario, Canada, plus counties in Washington and Michigan have announced that limitations on swabs were creating a logjam in their testing capabilities, according to news reports. Axios first reported on the national swab shortages last week.

Part of the problem lies in the nature of current test procedures for COVID-19. Typically, one needs to use two swabs per person: one swab for a flu test to potentially rule out the need for a coronavirus test, then another for the coronavirus if the flu test is negative.

Since the swabs are a product that is regulated, patented and specialized, they're hard to make on the fly, Saha said. That puts additional pressure on the two largest manufacturers.

One of them, Puritan Medical Products, based in Guilford, Maine, has been working to keep up with demand even as its workforce, like many in America, has been affected by the spread of the virus, spokesperson Timothy Templet said.

The U.S. Department of Health and Human Services, along with working groups from the White House and other federal agencies, has been in discussion with the company over the past week to redirect some of their manufacturing capabilities away from other clients to COVID-19 specialty swab production, Templet said.

Currently, Templet estimated, Puritan is producing between 800,000 and a million swabs a week that could go to COVID-19 efforts. If the government decides to redirect its manufacturing efforts, cutting off the supply of its other medical products for items like flu kits, it could make millions more.

Still, Templet said that ramping up production so drastically would take a few weeks to get fully off the ground, considering manufacturing capabilities and protocols.

Templet said HHS plans to open 37 testing sites across the country in the coming days to account for increased testing needs — which will require even more specialty swabs. He also said the government is considering expanding its recommended testing material options to allow for more general nasal swabs to keep up with the increased testing demand.

FDA spokesperson Stephanie Caccomo said in an email that the agency is aware of "supply chain pressures on obtaining certain materials for running tests" and that it is continuing to evaluate other options for specimen collection supplies, which it will list on its website.

Another specialty swab manufacturer, Copan Diagnostics Inc., which is based in the Lombardy region of northern Italy, is working 24/7 in a "tremendous effort" to produce products such as its CDC-recommended and patent-protected FLOQSwabs, all while asking customers and distributors to ration orders to maximize output, spokesperson Gabriela Franco said in an email.

While produced in a region hit hard by the novel coronavirus, where most other work has stopped, Franco said, the Italian government has allowed the business to continue production. And it is working with local and national authorities on keeping production up in case stricter health restrictions are adopted.

Copan could produce 720,000 specialized swabs in a day and as many as 100 million per year for the global market, according to records the firm filed in a 2018 patent lawsuit.

Amid the crunch, Copan CEO Stefania Triva said in an emailed statement that her company is working round-the-clock to keep up with demand.

"Without full commitment and sacrifices from all of my staff, we would not be able to meet this unexpected demand," Triva said. "COPAN's more than 660 members of staff, many of whom are women, without hesitation, once made aware of the Coronavirus emergency, have stepped up from five working days and two shifts to seven working days and night shifts also."

The volume of Copan swabs arriving in the U.S. has been increasing, according to data from Import Genius, which tracks container ships arriving in American ports. Six tons of Copan culture swabs arrived at the port of Norfolk, Virginia, on March 4. Before that, 4.5 tons of swabs arrived at the same port on Jan. 20. The swabs then tend to go to domestic test-kit assemblers that package them for health care use.

New Jersey-based Becton, Dickinson and Co., a leading assembler of those kits involved in ramping up coronavirus testing, has seen extremely high demand for swab products this year, company spokesperson Troy Kirkpatrick said. But now that Copan is "running operations 24/7" to increase production, Kirkpatrick said, "we will be providing hundreds of thousands of swabs to the U.S. market each week."

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Christina Jewett: ChristinaJ@kff.org, @by_cjewett

In Face Of Coronavirus, Many Hospitals Cancel On-Site Training For Nursing And Med Students

KFF Health News, March 17, 2020

As university campuses close and disease prevention efforts intensify, hospitals, nursing homes and other health care venues in California and nationally are canceling clinical rotations for student nurses.

This article was first published on Tuesday, March 17, 2020 in Kaiser Health News.

By Barbara Feder Ostrov

Yet another casualty of the COVID-19 pandemic may be the clinical training that's so essential for America's future nurses and doctors.

As university campuses close and disease prevention efforts intensify, hospitals, nursing homes and other health care venues in California and nationally are canceling clinical rotations for student nurses — and, in some cases, medical students. The rationale is to protect both students and patients from getting sick and to reserve personal protective equipment, including masks, that may be in short supply.

But medical educators worry the students won't get the hours of direct patient care experience required to graduate on time, slowing the pipeline of new health care professionals precisely at a time when the country may need them most.

"We are in unprecedented times," said Dr. John Prescott, chief academic officer of the Association of American Medical Colleges. "Medical education hasn't faced anything quite like this since the beginning of the second World War."

The risk that hospitals and other health care facilities fear was underscored this month when an instructor was diagnosed with COVID-19 after bringing a group of nursing students to the Kirkland, Washington, nursing home where at least 63 residents have been stricken by the illness — 29 of them fatally, as of Monday afternoon. Those students are now in self-quarantine.

On March 5, Kaiser Permanente requested that nursing schools temporarily discontinue student clinical rotations in its 21 medical centers in Northern California. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.) "We are in a dynamic situation and our highest priority is ensuring the safety of KP members, staff and students participating in clinical training," a Kaiser Permanente executive wrote in an email to the nursing schools obtained by KHN.

A spokeswoman for the health system, which serves 4.4 million Northern Californians, confirmed the cancellations.

Two other large hospital chains in California, Adventist Health and Dignity Health, soon followed suit.

As a result, the nursing schools at the University of California-Davis and Samuel Merritt University have had to scramble to find new clinical training opportunities for dozens of students. Some landed at the University of California-Davis' medical center or clinics and others at Veterans Affairs hospitals.

Nursing education leaders in California appealed to the state's Board of Registered Nursing on Thursday to ease the number of on-site clinical hours required for student nurses to graduate and allow them to learn from simulations instead.

State law requires nursing students to receive 75% of their clinical training in health care settings such as hospitals or nursing homes approved by the board; only 25% can be completed using simulations, such as computerized mannequins. The educators, in a letter to the board, requested that students be allowed to do 50% of their training through simulation.

"Many schools in California are experiencing serious clinical displacement. The effects of the lost clinical hours will be devastating to the students we serve," more than 60 officials from community colleges and nurse training programs around the state said in the letter.

As of Monday, Board of Registered Nursing officials had not responded to a request for comment.

Even before the COVID-19 pandemic, some private nursing schools had pressed state regulators to allow more simulation training, arguing it has advanced to the point where it can be as effective as training in a hospital or clinic.

The move to cancel clinical training is the opposite of what happened during the 1918 flu pandemic, when student nurses were called to hospitals to care for patients. Some fell sick and died along with those in their care.

Most hospitals have not canceled clinical rotations for doctors-in-training, but some have, and Prescott, of the Association of American Medical Colleges, said more may do so in the coming weeks.

On Thursday, the University of Arkansas for Medical Sciences asked all its students to immediately leave their clinical rotations to prevent the spread of COVID-19. The University of North Carolina School of Medicine canceled clinical rotations for visiting students from other medical schools from March 30 to April 24.

The University of Pennsylvania has suspended clinical rotations for some medical students, as has the University of Minnesota. SUNY Downstate College of Medicine also suspended emergency room rotations for its medical students.

Some teaching hospitals have banned medical students from emergency and intensive care units while allowing them elsewhere in their facilities.

For medical students in the University of California system, clinical training continues for now, but they've been directed to avoid contact with suspected or confirmed COVID-19 patients, as have medical students across the nation.

One Baltimore nursing student learned Friday that her psychiatric nursing rotation had been canceled for at least two weeks. She must complete more than 100 more clinical hours before graduation in May and has no idea whether her school, the University of Maryland, would be able to quickly find her a new placement.

"I understand why they did it, for the precaution and the liability," said the 26-year-old, who asked that her name not be used to protect her future career prospects. "But I had eight shifts scheduled in those two weeks. I'm in a kind of panic mode, worried I'm not going to finish in time for graduation."

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

Barbara Feder Ostrov: barbarao@kff.org, @barbfederostrov

And Then There Were Two: Biden, Sanders Debate With Coronavirus On Everyone's Mind

KFF Health News, March 16, 2020

Amid the coronavirus crisis, a near empty bar screens the Democratic Party 2020 presidential debate between Democratic presidential candidate former Vice President Joe Biden and Democratic presidential candidate Sen. Bernie Sanders.

This article was first published on Monday, March 16, 2020 in Kaiser Health News.

By Emmarie Huetteman

In the midst of a global health crisis that has disrupted daily life and heightened anxieties for millions of Americans, former Vice President Joe Biden and Vermont Sen. Bernie Sanders on Sunday urged people showing symptoms of the novel coronavirus to seek medical attention without fear of the cost.

But the remaining major Democratic candidates offered two starkly different images of leadership in a time of crisis. Biden insisted that the federal government should help pay consumers’ bills in this unusual time, while Sanders focused on how the coronavirus pandemic underscores the need to overhaul the health system.

“This is a crisis. We’re at war with a virus,” Biden said. “It has nothing to do with copays or anything.”

The debate came just two days before the primaries in Arizona, Florida, Illinois and Ohio, contests in which Biden is expected to do well. His commanding wins in several states have given Biden a dramatic lead in convention delegates over Sanders.

The 11th primary debate took place without an audience on a television set in Washington, D.C., after being moved from Phoenix because of concerns about the virus spreading within crowds. It looked remarkably different from any debate in recent memory, let alone the last debate less than three weeks ago, when seven presidential hopefuls stood on the stage.

Following the guidance of health officials urging people to practice “social distancing,” Biden and Sanders replaced the traditional handshake at the contest’s start with something like a forearm-bump. They then took positions standing at least 6 feet apart.

Because both are considered at high risk of COVID-19 due to their age and, in Sanders’ case, a recent heart attack, the candidates said they were avoiding handshakes and crowds, with Biden moving to virtual campaign events while Sanders said he had held a fireside chat instead of a recent rally.

Sanders said the pandemic had emphasized the need to care for the most vulnerable, especially low-income Americans who feared unaffordable medical bills, lost wages or even lost jobs. He said even a bill just passed by the House and endorsed by President Donald Trump to support American workers had “enormous loopholes,” presumably referencing the exemption of large employers from its paid sick leave requirements. He said he planned to take steps to fix that.

“Let’s be honest and understand that this coronavirus pandemic exposes the incredible weakness and dysfunctionality of our current health care system,” Sanders said, pushing his “Medicare for All” plan that would replace the current health insurance system with a government-run program.

Biden responded that Italy, which has been overwhelmed by the virus’s spread, has a single-payer system and was not prepared for the emergency. He said Sanders’ talk of coverage inequality was important but misplaced in a time of immediate crisis.

Biden also criticized the Trump administration’s scattershot approach, pushing his own experience with the widespread Ebola outbreak in 2014 as part of the Obama administration.

The response, he said, “should be directed from the White House, from the Situation Room, laying out in detail like we did in the Ebola crisis, and we beat it.”

On points like this, the candidates went into greater detail:

Using The Military To Aid In the Coronavirus Response

Biden is right that the military added to hospital capacity during previous epidemics, but it’s not clear they were as large or as effective as he said they were.

We asked the Biden campaign for details but didn’t hear back. But there are a couple of potential past examples.

First, the Ebola crisis. While Biden was vice president, the U.S. military helped increase the capacity for treatment in Liberia. According to a 2014 White House press release, American efforts to curb the spread of the disease included “build[ing] additional Ebola Treatment Units in affected areas,” “establish[ing] a site to train up to 500 health care providers per week” and sending a “field-deployable hospital to Liberia.”

But it’s also important to note that the efficacy was limited, especially regarding the treatment units. An April 2015 New York Times report found that of the 11 Ebola treatment units the military built, nine had never treated a single patient with the disease. In total, they had treated only 28 patients.

It’s unclear, though, whether the Ebola units are the same as these 500-person tents Biden was referencing. We checked his campaign’s coronavirus plan. It does allude to deploying another existing resource: “multi-hundred-bed temporary hospitals” known as Federal Medical Stations.

These stations have been used in previous public health crises, including countless hurricanes over the past 15 years. They are, according to the Centers for Disease Control and Prevention, an important resource in building the health system’s holding capacity, especially in times of such difficulty.

Biden’s numbers are off, though. These temporary medical facilities can house between 50 and 250 patients and are treated as a stopgap when hospitals overflow. They can provide low-acuity care and other support. But that’s far short of 500-bed hospital equivalents.

— Shefali Luthra

Another Take On The Health System’s Capacity

Sanders is clearly not the only one to worry — and the facts are on his side. Public health experts are sounding the alarm that if the virus infects people quickly, and enough of patients show symptoms, the system will be overwhelmed.

In a March 12 op-ed in The New York Times, health policy experts pointed out that the nation has insufficient hospital beds, even if only 5% of the country contracts the illness. The authors — Ezekiel J. Emanuel at the University of Pennsylvania, James Phillips of George Washington University Hospital and Govind Persad at the University of Denver — specifically pointed to worries about “shortages of medical staff and equipment.”

Those worries are widespread. In New York state, Gov. Andrew Cuomo has suggested temporarily halting elective surgeries and re-certifying retired doctors and nurses. And if the virus afflicts health care workers, too, that would further constrain the system’s capacity.

Put simply, “we do not have anywhere near capacity to take care of tens of thousands of people with [COVID-19] who might need hospitalization,” Dr. Ashish Jha, a health policy researcher at Harvard University, recently told WBUR, the local NPR station.

A February report put out by researchers at Johns Hopkins University tallied a total of 46,500 intensive care unit beds across the entire United States. If the virus spreads at a moderate pace, the researchers estimated, 200,000 Americans would ultimately need ICU beds. A separate Hopkins report found only 160,000 ventilators in the country — enough for a moderate outbreak, but not enough if it spirals into something worse.

Not all those beds would necessarily be needed at once, of course. But that’s still a lot more sick people than beds — especially when you consider that many ICU beds are already in use for people with other medical conditions, such as the flu.

— Shefali Luthra

Beyond The Crisis

While coronavirus dominated much of the debate, Biden and Sanders also made claims about their support for reproductive rights.

Biden did earn 100% ratings from NARAL, the abortion-rights group, four times during his final years in Congress, but his framing in the debate left out several ratings that were much lower.

Biden received a 100% rating from NARAL Pro-Choice America in 2001, 2004, 2005 and 2006. That is based on how closely his votes aligned with the group’s priorities. Meanwhile, Biden was just below that in 2000 with a 90% rating and had a 75% rating in 2007.

In other years, however, Biden’s ratings from NARAL were significantly lower.

For instance, 17 years ago, in 2003, he earned a 36% rating. In 1999, his rating was 46%. In 1997, his rating was 34%. And in 1996, Biden’s rating was 43%.

It was only in 2019 that Biden backed off his long-standing support for the Hyde Amendment, which bans the use of federal funds to pay for abortions. In 1994, for instance, Biden wrote to constituents that he had “on no fewer than 50 occasions” voted against federal funding for abortions. “Those of us who are opposed to abortions should not be compelled to pay for them,” he wrote, according to NBC News.

Sanders, for his part, has earned a 100% rating from the group consistently, going back to 1996.

This is Half True. Sanders has a point that he has consistently voted in favor of abortion rights when it comes to stand-alone votes on the Hyde Amendment. The amendment is a long-standing measure that bars federal dollars from being used to pay for most abortions.

But when broad spending packages that include a version of the amendment have come up, Sanders has voted to send them through numerous times. The amendment’s language is often plugged into the annual bills that fund the Department of Health and Human Services.

CNN’s Dana Bash, a moderator of the March 15 debate, asked Sanders about his voting for broad spending bills in June. He said that sometimes, “in a large bill, you have to vote for things you don’t like. But I think my record as being literally 100% pro-choice is absolutely correct.”

— Louis Jacobson and Bill McCarthy, PolitiFact

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Former Federal Virus Hunter Says U.S. Needs To Act Before New Germs 'Kick Your Door In'

KFF Health News, March 16, 2020

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.

By Carmen Heredia Rodriguez

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 of SARS, 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.

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

Coronavirus Pushes Hospitals To Share Information About Stocks Of Protective Gear

KFF Health News, March 13, 2020

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.

By Blake Farmer, Nashville Public Radio

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.

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

VCU Health Halts 30-Year Campaign That Seized Patients' Wages, Put Liens On Homes

KFF Health News, March 11, 2020

VCU Health pursued tens of thousands of patients over the years for overdue bills, sending many into bankruptcy.

This article was first published on Wednesday, March 11, 2020 in Kaiser Health News.

By Jay Hancock and Elizabeth Lucas

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.

VCU's in-house doctor group, MCV Physicians, filed more than 56,000 lawsuits against patients for $81 million over seven years, KHN found. VCU's flagship hospital, VCU Medical Center, stopped filing patient suits seven years ago.

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.

UVA Health and affiliates filed 36,000 lawsuits against patients over six years, seeking a total of more than $106 million, KHN found.

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.

Jay Hancock: jhancock@kff.org, @JayHancock1

Heart Association Puts Halt To Bayer's Giant Displays Of Baby Aspirin

KFF Health News, March 10, 2020

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 in Kaiser Health News.

By Phil Galewitz

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 physicians who 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.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Surging Health Care Worker Quarantines Raise Concerns As Coronavirus Spreads

KFF Health News, March 9, 2020

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.

By Jenny Gold

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."

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

Jenny Gold: jgold@kff.org, @JennyAGold

Insurers Sank Connecticut's 'Public Option.' Would A National Version Survive?

KFF Health News, March 4, 2020

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.

By Shefali Luthra

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.

Some say 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."

Shefali Luthra: ShefaliL@kff.org, @Shefalil

Nursing Home Outbreak Spotlights Coronavirus Risk In Elder Care Facilities

KFF Health News, March 2, 2020

More than two million people living in long-term care settings in the U.S. may be at heightened risk because of age and underlying health conditions.

This article was first published on Sunday, March 1, 2020 in Kaiser Health News.

By JoNel Aleccia

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.

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

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