KFF Health News

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

Medicare Open Enrollment Is Complicated. Here's How to Get Good Advice.

KFF Health News, November 24, 2020

For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.

This article was published on Tuesday, November 24, 2020 in Kaiser Health News.

By Bernard J. Wolfson

If you’ve been watching TV lately, you may have seen actor Danny Glover or Joe Namath, the 77-year-old NFL legend, urging you to call an 800 number to get fabulous extra benefits from Medicare.

There are plenty of other Medicare ads, too, many set against a red-white-and-blue background meant to suggest officialdom — though if you stand about a foot from the television screen, you might see the fine print saying they are not endorsed by any government agency.

Rather, they are health insurance agents aggressively vying for a piece of a lucrative market.

This is what Medicare’s annual enrollment period has come to. Beneficiaries — people who are 65 or older, or with long-term disabilities — have until Dec. 7 to join, switch or drop health or drug plans, which take effect Jan. 1. By switching plans, they can potentially save money or get benefits not ordinarily provided by the federal insurance program.

For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.

The right choice for you depends on your financial wherewithal and current health status, and on future health scenarios that are often difficult to foresee and unpleasant to contemplate.

Costs and benefits among the multitude of competing Medicare plans vary widely, and the maze of rules and other details can be overwhelming. Indeed, information overload is part of the reason a majority of the more than 60 million people on Medicare, including over 6 million in California, do not comparison-shop or switch to more suitable plans.

“I’ve been doing it for 33 years and my head still spins,” says Jill Selby, corporate vice president of strategic initiatives and product development at SCAN, a Long Beach nonprofit that is one of California’s largest purveyors of Medicare managed care, known as Medicare Advantage. “It’s definitely a college course.”

Which explains why airwaves and mailboxes are jammed with all that promotional material from people offering to help you pass the course.

Many are touting Medicare Advantage, which is administered by private health insurers. It might save you money, but not necessarily, and research suggests that, in some cases, it costs the government more than administering traditional Medicare.

But the hard marketing is not necessarily a sign of bad faith. Licensed insurance agents want the nice commission they get when they sign somebody up, but they can also provide valuable information on the bewildering nuances of Medicare.

Industry insiders and outside experts agree most people should not navigate Medicare alone. “It’s just too complicated for the average individual,” says Mark Diel, chief executive officer of California Coverage and Health Initiatives, a statewide association of local outreach and health care enrollment organizations.

However, if you decide to consult with an insurance agent, keep your antenna up. Ask people you trust to recommend agents, or try eHealth or another established online brokerage. Vet any agent you choose by asking questions on the phone.

“Be careful if you feel like the insurance agent is pushing you to make a decision,” says Andrew Shea, senior vice president of marketing at eHealth. And if in doubt, don’t hesitate to get a second opinion, Shea counsels.

You can also talk to a Medicare counselor through one of the State Health Insurance Assistance Programs, which are present in every state. Find your state’s SHIP at www.shiptacenter.org.

Medicare & You, a comprehensive handbook, is worth reading. Download it at the official Medicare website, www.medicare.gov.

The website offers a deep dive into all aspects of Medicare. If you type in your ZIP code, you can see and compare all the Medicare Advantage plans, supplemental insurance plans, known as Medigap, and stand-alone drug (Part D) plans.

The site also shows you quality ratings of the plans, on a five-star scale. And it will display your drug costs under each plan if you type in all your prescriptions. Explore the website before you talk to an insurance agent.

California Coverage and Health Initiatives can refer you to licensed insurance agents who will provide local advice and enrollment assistance. Call 833-720-2244. Its members specialize in helping people who are eligible for both Medicare and Medicaid, the health insurance program for low-income people.

These so-called dual eligibles — nearly 1.5 million in California and about 12 million nationwide — get additional benefits, and in some cases they don’t have to pay Medicare’s monthly medical (Part B) premium, which will be $148.50 in 2021 for most beneficiaries, but higher for people above certain income thresholds.

If you choose traditional Medicare, consider a Medigap supplement if you can afford it. Without it, you’re liable for 20% of your physician and outpatient costs and a hefty hospital deductible, with no cap on how much you pay out of your own pocket. If you need prescription drugs, you’ll probably want a Part D plan.

Medicare Advantage, by contrast, is a one-stop shop. It usually includes a drug benefit in addition to other Medicare benefits, with cost sharing for services and prescriptions that varies from plan to plan. Medicare Advantage plans typically have low to no premiums — aside from the Part B premium that most people pay in either version of Medicare. And they increasingly offer additional benefits, including vision, dental, transportation, meal deliveries and even coverage while traveling abroad.

Beware of the risks, however.

Yes, the traditional Medicare route is generally more expensive upfront if you want to be fully covered. That’s because you pay a monthly premium for a Medigap policy, which can cost $200 or more. Add to that the premium for Part D, estimated to average $41 a month in 2021, according to KFF. (KHN is an editorially independent program of KFF.)

However, Medigap policies will often protect you against large medical bills if you need lots of care.

In some cases, Medicare Advantage could end up being more expensive if you get seriously ill or injured, because copays can quickly add up. They are typically capped each year, but can still cost you thousands of dollars. Advantage plans also typically have more limited provider networks, and the extra benefits they offer can be subject to restrictions.

Over one-third of Medicare beneficiaries nationally are enrolled in Advantage plans. In California, about 40% are.

The main appeal of traditional Medicare is that it doesn’t have the rules and restrictions of managed care.

Dr. Mark Kalish, a retired psychiatrist in San Diego, says he opted for traditional fee-for-service with Medigap and Part D because he didn’t want a “mother may I” plan.

“I’m 69 years old, so heart attacks happen; cancer happens. I want to be able to pick my own doctor and go where I want,” Kalish says. “I’ve done well, so the money isn’t an issue for me.”

Be aware that if you don’t join a Medigap plan during a six-month open enrollment period that begins when you enroll in Medicare Part B, you could be denied coverage for a preexisting condition if you try to buy one later.

There are a few exceptions to that in federal law, and four states — New York, Massachusetts, Maine, Connecticut — require continuous or yearly access to Medigap coverage regardless of health status.

Make sure you understand the rules and exceptions that apply to you.

Indeed, that is an excellent rule of thumb for all Medicare beneficiaries. Read up and talk to insurance agents and Medicare counselors. Talk to friends, family members, your doctor, your health plan — and other health plans.

When it comes to Medicare, says Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, “it takes a village.”

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

New Legal Push Aims to Speed Magic Mushrooms to Dying Patients

KFF Health News, November 24, 2020

Recently, several U.S. cities and states have voted to decriminalize possession of small amounts of psilocybin.

This article was published on Tuesday, November 24, 2020 in Kaiser Health News.

By JoNel Aleccia

Back in March, just as anxiety over COVID-19 began spreading across the U.S., Erinn Baldeschwiler of La Conner, Washington, found herself facing her own private dread.

Just 48 and the mother of two teenagers, Baldeschwiler was diagnosed with stage 4 metastatic breast cancer after discovering a small lump on her chest, no bigger than a pea. Within weeks, it was the size of a golf ball, angry and red. Doctors gave her two years to live.

"It's heartbreaking," she said. "Frankly, I was terrified."

But instead of retreating into her illness, Baldeschwiler is pouring energy into a new effort to help dying patients gain legal access to psilocybin — the mind-altering compound found in so-called magic mushrooms — to ease their psychic pain.

"I have personally struggled with depression, anxiety, anger," Baldeschwiler said. "This therapy is designed to really dive in and release these negative fears and shadows."

Dr. Sunil Aggarwal, a Seattle palliative care physician, and Kathryn Tucker, a lawyer who advocates on behalf of terminally ill patients and chairs a psychedelic practice group at Emerge Law Group, are championing a novel strategy that would make psilocybin available using state and federal "right-to-try" laws that allow terminally ill patients access to investigational drugs.

They contend that psilocybin — whether found in psychedelic mushrooms or synthetic copies — meets the criteria for use laid out by more than 40 states and the 2017 Right to Try Act approved by the Trump administration.

"Can you look at the statute and see by its terms that it applies to psilocybin?" Tucker said. "I think the answer is yes."

Still, the pair admit they're pushing a legal theory still untested in the courts. "This is untrodden ground," Aggarwal said.

This month, Aggarwal, who works at the Advanced Integrative Medical Science Institute, known as AIMS, took the first step toward federal authorization of the substance in Washington state and perhaps across the nation. He submitted an application to manufacture psilocybin to the state's Pharmacy Quality Assurance Commission, which would allow him to grow psilocybin mushrooms from spores at his clinic and administer them for therapeutic use.

Commission members haven't yet reviewed the application, but Gordon MacCracken, an agency spokesperson, said there "would be a path" for possible license and use — if the application meets the requirements of state regulators and the federal Drug Enforcement Administration.

Currently, psilocybin use is illegal under federal law, classified as a Schedule 1 drug under the U.S. Controlled Substances Act, which applies to chemicals and substances with no accepted medical use and a high potential for abuse, such as heroin and LSD.

Recently, however, several U.S. cities and states have voted to decriminalize possession of small amounts of psilocybin. This month, Oregon became the first state to legalize psilocybin for regulated use in treating intractable mental health problems. The first patients will have access beginning in January 2023.

It's part of a wider movement to rekindle acceptance of psilocybin, which was among psychedelic drugs vilified — and ultimately banned — after the legendary counterculture excesses of the 1960s and 1970s.

"I think a lot of those demons, those fears, have been metabolized in the 50 years since then," Aggarwal said. "Not completely, but we've moved it along so that it's safe to try again."

He points to a growing body of evidence that finds that psilocybin can have significant and lasting effects on psychological distress. The Johns Hopkins Center for Psychedelic and Consciousness Research, launched this year, has published dozens of peer-reviewed studies based on two decades of research. They include studies confirming that psilocybin helped patients grappling with major depressive disorder, thoughts of suicide and the emotional repercussions of a cancer diagnosis.

Psilocybin therapy appears to work by chemically altering brain function in a way that temporarily affects a person's ego, or sense of self. In essence, it plays on the out-of-body experiences made famous in portrayals of America's psychedelic '60s.

By getting out of their heads — and separating from all the fear and emotion surrounding death — people experience "being" as something distinct from their physical forms. That leads to a fundamental shift in perspective, said Dr. Ira Byock, a palliative care specialist and medical officer for the Institute for Human Caring at Providence St. Joseph Health.

"What psychedelics do is foster a frame shift from feeling helpless and hopeless and that life is not worth living to seeing that we are connected to other people and we are connected to a universe that has inherent connection," he said.

"Along with that shift in perspective, there is very commonly a notable dissolution of the fear of dying, of nonexistence and of loss, and that's just remarkable."

The key is to offer the drugs under controlled conditions, in a quiet room supervised by a trained guide, Byock said. "It turned out they are exceedingly safe when used in a carefully screened, carefully guided situation with trained therapists," he said. "Almost the opposite is true when used in an unprepared, unscreened population."

Baldeschwiler is one of several AIMS cancer patients eager to undergo psilocybin therapy. Another is Michal Bloom, 64, of Seattle, who was diagnosed in 2017 with stage 3 ovarian cancer. The anxiety of living with the terminal disease is overwhelming, she said.

"It's as if someone came up to you, put a gun to the back of your head, whispered, 'I have a gun to your head and I'll have a gun to your head for the rest of your life. I may pull the trigger, I may not,'" she said. "How do you live like that?"

Research shows that a single six-hour session of psilocybin therapy may be enough to quell that fear, Aggarwal said. "I'm really interested in a right-to-try approach because it's really what we need for patients right now," he said.

Under the state and federal laws, to be eligible for "right-to-try" status, a treatment must have completed a phase 1 clinical trial approved by the federal Food and Drug Administration, be part of active clinical trials and in ongoing development or production.

So far, psilocybin ticks all those boxes, Tucker said.

The FDA has granted "breakthrough therapy" status to psilocybin for use in U.S. clinical trials conducted by Compass Pathways, a psychedelic research group in Britain, and by the Usona Institute, a nonprofit medical research group in Wisconsin. More than three dozen trials are recruiting participants or completed, federal records show.

But access to the drug remains a hurdle. Though psychedelic mushrooms grow wild in the Pacific Northwest and underground sources of the drug are available, finding a legal supply is nearly impossible.

Tucker and Aggarwal asked Usona last summer for a supply of the synthetic psilocybin its researchers produce for clinical trials, but so far have received nothing. Penny Patterson, a Usona spokesperson, said there's been no "definitive resolution" and that conversations are continuing.

The firm's reluctance may reflect a larger unease with employing right-to-try laws to speed use of psilocybin, said Dr. Anthony Back, a palliative care physician at the University of Washington.

Back supports the use of psilocybin for cancer patients and has even tried the drug to better understand the experience. But he said using psilocybin outside of formal clinical trials might endanger Usona's ability to get traditional FDA approval. Adverse events may occur that will have to be reported to the FDA, an agency already watching the research closely.

"I can see why they're hesitant, to be honest," Back said. "I think right-to-try is an uphill battle."

Still, Tucker and other advocates say it's a battle worth fighting. End of Life Washington, a group focused on helping terminally ill patients use the state's Death With Dignity Act, recently published a policy that supports psilocybin therapy as a form of palliative care. Other treatments for anxiety and depression, such as medication and counseling, may simply not be practical or effective at that point, said Judith Gordon, a psychologist and member of the group's board of directors.

"When people are dying, they don't have the time or the energy to do a lot of psychotherapy," she said.

Baldeschwiler agrees. With perhaps less than two years to live, she wants access to any tool that can ease her pain. Immunotherapy has helped with the physical symptoms, dramatically shrinking the size of the tumor on her chest. Harder to treat has been the gnawing anxiety that she won't see her 16-year-old daughter, Shea McGinnis, and 13-year-old son, Gibson McGinnis, become adults.

"They are beautiful children, good spirits," she said. "To know I might not be around for them sucks. It's really hard."

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

For Nurses Feeling the Strain of the Pandemic, Virus Resurgence Is 'Paralyzing'

KFF Health News, November 24, 2020

Adding to that stress is that nurses are caught betwixt caring for the bedside needs of their patients and implementing policies set by others, such as physician-ordered treatment plans and strict hospital rules to ward off the coronavirus.

This article was published on Tuesday, November 24, 2020 in Kaiser Health News.

By Charlotte Huff

For Christina Nester, the pandemic lull in Massachusetts lasted about three months through summer into early fall. In late June, St. Vincent Hospital had resumed elective surgeries, and the unit the 48-year-old nurse works on switched back from taking care of only COVID-19 patients to its pre-pandemic roster of patients recovering from gallbladder operations, mastectomies and other surgeries.

That is, until October, when patients with coronavirus infections began to reappear on the unit and, with them, the fear of many more to come. "It's paralyzing, I'm not going to lie," said Nester, who's worked at the Worcester hospital for nearly two decades. "My little clan of nurses that I work with, we panicked when it started to uptick here."

Adding to that stress is that nurses are caught betwixt caring for the bedside needs of their patients and implementing policies set by others, such as physician-ordered treatment plans and strict hospital rules to ward off the coronavirus. The push-pull of those forces, amid a fight against a deadly disease, is straining this vital backbone of health providers nationwide, and that could accumulate to unstainable levels if the virus's surge is not contained this winter, advocates and researchers warn.

Nurses spend the most sustained time with a patient of any clinician, and these days patients are often incredibly fearful and isolated, said Cynda Rushton, a registered nurse and bioethicist at Johns Hopkins University in Baltimore.

"They have become, in some ways, a kind of emotional surrogate for family members who can't be there, to support and advise and offer a human touch," Rushton said. "They have witnessed incredible amounts of suffering and death. That, I think, also weighs really heavily on nurses."

A study published this fall in the journal General Hospital Psychiatry found that 64% of clinicians working as nurses, nurse practitioners or physician assistants at a New York City hospital screened positively for acute distress, 53% for depressive symptoms and 40% for anxiety — all higher rates than found among physicians screened.

Researchers are concerned that nurses working in a rapidly changing crisis like the pandemic — with problems ranging from staff shortages that curtail their time with patients to enforcing visitation policies that upset families — can develop a psychological response called "moral injury." That injury occurs, they say, when nurses feel stymied by their inability to provide the level of care they believe patients require.

Dr. Wendy Dean, co-founder of Moral Injury of Healthcare, a nonprofit organization based in Carlisle, Pennsylvania, said, "Probably the biggest driver of burnout is unrecognized unattended moral injury."

In parts of the country over the summer, nurses got some mental health respite when cases declined, Dean said.

"Not enough to really process it all," she said. "I think that's a process that will take several years. And it's probably going to be extended because the pandemic itself is extended."

Before the pandemic hit her Massachusetts hospital "like a forest fire" in March, Nester had rarely seen a patient die, other than someone in the final days of a disease like cancer.

Suddenly she was involved with frequent transfers of patients to the intensive care unit when they couldn't breathe. She recounts stories, imprinted on her memory: The woman in her 80s who didn't even seem ill on the day she was hospitalized, who Nester helped transport to the morgue less than a week later. The husband and wife who were sick in the intensive care unit, while the adult daughter fought the virus on Nester's unit.

"Then both parents died, and the daughter died," Nester said. "There's not really words for it."

During these gut-wrenching shifts, nurses can sometimes become separated from their emotional support system — one another, said Rushton, who has written a book about preventing moral injury among healthcare providers. To better handle the influx, some nurses who typically work in noncritical care areas have been moved to care for seriously ill patients. That forces them to not only adjust to a new type of nursing, but also disrupts an often-well-honed working rhythm and camaraderie with their regular nursing co-workers, she said.

At St. Vincent Hospital, the nurses on Nester's unit were told one March day that the primarily postsurgical unit was being converted to a COVID unit. Nester tried to squelch fears for her own safety while comforting her COVID-19 patients, who were often elderly, terrified and sometimes hard of hearing, making it difficult to communicate through layers of masks.

"You're trying to yell through all of these barriers and try to show them with your eyes that you're here and you're not going to leave them and will take care of them," she said. "But yet you're panicking inside completely that you're going to get this disease and you're going to be the one in the bed or a family member that you love, take it home to them."

When asked if hospital leaders had seen signs of strain among the nursing staff or were concerned about their resilience headed into the winter months, a St. Vincent spokesperson wrote in a brief statement that during the pandemic "we have prioritized the safety and well-being of our staff, and we remain focused on that."

Nationally, the viral risk to clinicians has been well documented. From March 1 through May 31, 6% of adults hospitalized were healthcare workers, one-third of them in nursing-related occupations, according to data published last month by the Centers for Disease Control and Prevention.

As cases mount in the winter months, moral injury researcher Dean said, "nurses are going to do the calculation and say, 'This risk isn't worth it.'"

Juliano Innocenti, a traveling nurse working in the San Francisco area, decided to take off for a few months and will focus on wrapping up his nurse practitioner degree instead. Since April, he's been seeing a therapist "to navigate my powerlessness in all of this."

Innocenti, 41, has not been on the front lines in a hospital battling COVID-19, but he still feels the stress because he has been treating the public at an outpatient dialysis clinic and a psychiatric hospital and seen administrative problems generated by the crisis. He pointed to issues such as inadequate personal protective equipment.

Innocenti said he was concerned about "the lack of planning and just blatant disregard for the basic safety of patients and staff." Profit motives too often drive decisions, he suggested. "That's what I'm taking a break from."

Building Resiliency

As cases surge again, hospital leaders need to think bigger than employee assistance programs to backstop their already depleted ranks of nurses, Dean said. Along with plenty of protective equipment, that includes helping them with everything from groceries to transportation, she said. Overstaff a bit, she suggested, so nurses can take a day off when they hit an emotional cliff.

The American Nurses Association, the American Association of Critical-Care Nurses (AACN) and several other nursing groups have compiled online resources with links to mental health programs as well as tips for getting through each pandemic workday.

Kiersten Henry, an AACN board member and nurse practitioner in the intensive care unit at MedStar Montgomery Medical Center in Olney, Maryland, said that the nurses and other clinicians there have started to gather for a quick huddle at the end of difficult shifts. Along with talking about what happened, they share several good things that also occurred that day.

"It doesn't mean that you're not taking it home with you," Henry said, "but you're actually verbally processing it to your peers."

When cases reached their highest point of the spring in Massachusetts, Nester said there were some days she didn't want to return.

"But you know that your friends are there," she said. "And the only ones that really truly understand what's going on are your co-workers. How can you leave them?"

Rural Areas Send Their Sickest Patients to Cities, Straining Hospitals

KFF Health News, November 24, 2020

Many rural communities across the U.S. have resisted masks and calls for social distancing during the coronavirus pandemic, but now rural counties are experiencing record-high infection and death rates.

This article was published on Tuesday, November 24, 2020 in Kaiser Health News.

By Alex Smith, KCUR

Registered nurse Pascaline Muhindura has spent the past eight months treating COVID patients at Research Medical Center in Kansas City, Missouri.

But when she returns home to her small town of Spring Hill, Kansas, she's often stunned by what she sees, like on a recent stop for carryout food.

"No one in the entire restaurant was wearing a mask," Muhindura said. "And there's no social distancing. I had to get out, because I almost had a panic attack. I was like, 'What is going on with people? Why are we still doing this?'"

Many rural communities across the U.S. have resisted masks and calls for social distancing during the coronavirus pandemic, but now rural counties are experiencing record-high infection and death rates.

Critically ill rural patients are often sent to city hospitals for high-level treatment and, as their numbers grow, some urban hospitals are buckling under the added strain.

Kansas City has a mask mandate, but in many smaller communities nearby, masks aren't required — or masking orders are routinely ignored. In the past few months, rural counties in both Kansas and Missouri have seen some of the highest rates of COVID-19 in the country.

At the same time, according to an analysis by KHN, about 3 in 4 counties in Kansas and Missouri don't have a single intensive care unit bed, so when people from these places get critically ill, they're sent to city hospitals.

A recent patient count at St. Luke's Health System in Kansas City showed a quarter of COVID patients had come from outside the metro area.

Two-thirds of the patients coming from rural areas need intensive care and stay in the hospital for an average of two weeks, said Dr. Marc Larsen, who leads COVID-19 treatment at St. Luke's.

"Not only are we seeing an uptick in those patients in our hospital from the rural community, they are sicker when we get them because [doctors in smaller communities] are able to handle the less sick patients," said Larsen. "We get the sickest of the sick."

Dr. Rex Archer, head of Kansas City's health department, warns that capacity at the city's 33 hospitals is being put at risk by the influx of rural patients.

"We've had this huge swing that's occurred because they're not wearing masks, and yes, that's putting pressure on our hospitals, which is unfair to our residents that might be denied an ICU bed," Archer said.

A study newly released by the Centers for Disease Control and Prevention showed that Kansas counties that mandated masks in early July saw decreases in new COVID cases, while counties without mask mandates recorded increases.

Hospital leaders have continued to plead with Missouri Republican Gov. Mike Parson, and with Kansas' conservative legislature, to implement stringent, statewide mask requirements but without success.

Parson won the Missouri gubernatorial election on Nov. 3 by nearly 17 percentage points. Two days later at a COVID briefing, he accused critics of "making the mask a political issue." He said county leaders should decide whether to close businesses or mandate masks.

"We're going to encourage them to take some sort of action," Parson said Thursday. "The holidays are coming and I, as governor of the state of Missouri, am not going to mandate who goes in your front door."

In an email, Dave Dillon, a spokesperson for the Missouri Hospital Association, agreed that rural patients might be contributing to hospital crowding in cities but argued that the strain on hospitals is a statewide problem.

The reasons for the rural COVID crisis involve far more than the refusal to mandate or wear masks, according to healthcare experts.

Both Kansas and Missouri have seen rural hospitals close year after year, and public health spending in both states, as in many largely rural states, is far below national averages.

Rural populations also tend to be older and to suffer from higher rates of chronic health conditions, including heart disease, obesity and diabetes. Those conditions can make them more susceptible to severe illness when they contract COVID-19.

Rural areas have been grappling with health problems for a long time, but the coronavirus has been a sort of tipping point, and those rural health issues are now spilling over into cities, explained Shannon Monnat, a rural health researcher at Syracuse University.

"It's not just the rural healthcare infrastructure that becomes overwhelmed when there aren't enough hospital beds, it's also the surrounding neighborhoods, the suburbs, the urban hospital infrastructure starts to become overwhelmed as well," Monnat said.

Unlike many parts of the U.S., where COVID trend lines have risen and fallen over the course of the year, Kansas, Missouri and several other Midwestern states never significantly bent their statewide curve.

Individual cities, such as Kansas City and St. Louis, have managed to slow cases, but the continual emergence of rural hot spots across Missouri has driven a slow and steady increase in overall new case numbers — and put an unrelenting strain on the states' hospital systems.

The months of slow but continuous growth in cases created a high baseline of cases as autumn began, which then set the stage for the sudden escalation of numbers in the recent surge.

"It's sort of the nature of epidemics that things often look like they're relatively under control, and then very quickly ramp up to seem that they are out of hand," said Justin Lessler, an epidemiologist at Johns Hopkins Bloomberg School of Public Health.

Now, a recent local case spike in the Kansas City metro area is adding to the statewide surge in Missouri, with an average of 190 COVID patients per day being admitted to the metro region's hospitals. The number of people hospitalized throughout Missouri increased by more than 50% in the past two weeks.

Some Kansas City hospitals have had to divert patients for periods of time, and some are now delaying elective procedures, according to the University of Kansas Health system's chief medical officer, Dr. Steven Stites.

But bed space isn't the only hospital resource that's running out. Half of the hospitals in the Kansas City area are now reporting "critical" staffing shortages. Pascaline Muhindura, the nurse who works in Kansas City, said that hospital workers are struggling with anxiety and depression.

"The hospitals are not fine, because people taking care of patients are on the brink," Muhindura said. "We are tired."

This story is from a reporting partnership that includes KCUR, NPR and KHN.

Alex Smith, KCUR: @AlexSmithKCUR

Need a COVID-19 Nurse? That'll Be $8,000 a Week

KFF Health News, November 24, 2020

With virtually every part of the country experiencing a surge, the competition for the finite number of available nurses is becoming more intense.

This article was published on Tuesday, November 24, 2020 in Kaiser Health News.

By Markian Hawryluk and Rae Ellen Bichell

DENVER — In March, Claire Tripeny was watching her dream job fall apart. She'd been working as an intensive care nurse at St. Anthony Hospital in Lakewood, Colorado, and loved it, despite the mediocre pay typical for the region. But when COVID-19 hit, that calculation changed.

She remembers her employers telling her and her colleagues to "suck it up" as they struggled to care for six patients each and patched their protective gear with tape until it fully fell apart. The $800 or so a week she took home no longer felt worth it.

"I was not sleeping and having the most anxiety in my life," said Tripeny. "I'm like, 'I'm gonna go where my skills are needed and I can be guaranteed that I have the protection I need.'"

In April, she packed her bags for a two-month contract in then-COVID hot spot New Jersey, as part of what she called a "mass exodus" of nurses leaving the suburban Denver hospital to become traveling nurses. Her new pay? About $5,200 a week, and with a contract that required adequate protective gear.

Months later, the offerings — and the stakes — are even higher for nurses willing to move. In Sioux Falls, South Dakota, nurses can make more than $6,200 a week. A recent posting for a job in Fargo, North Dakota, offered more than $8,000 a week. Some can get as much as $10,000.

Early in the pandemic, hospitals were competing for ventilators, COVID tests and personal protective equipment. Now, sites across the country are competing for nurses. The fall surge in COVID cases has turned hospital staffing into a sort of national bidding war, with hospitals willing to pay exorbitant wages to secure the nurses they need. That threatens to shift the supply of nurses toward more affluent areas, leaving rural and urban public hospitals short-staffed as the pandemic worsens, and some hospitals unable to care for critically ill patients.

"That is a huge threat," said Angelina Salazar, CEO of the Western Healthcare Alliance, a consortium of 29 small hospitals in rural Colorado and Utah. "There's no way rural hospitals can afford to pay that kind of salary."

Surge Capacity

Hospitals have long relied on traveling nurses to fill gaps in staffing without committing to long-term hiring. Early in the pandemic, doctors and nurses traveled from unaffected areas to hot spots like California, Washington state and New York to help with regional surges. But now, with virtually every part of the country experiencing a surge — infecting medical professionals in the process — the competition for the finite number of available nurses is becoming more intense.

"We all thought, 'Well, when it's Colorado's turn, we'll draw on the same resources; we'll call our surrounding states and they'll send help,'" said Julie Lonborg, a spokesperson for the Colorado Hospital Association. "Now it's a national outbreak. It's not just one or two spots, as it was in the spring. It's really significant across the country, which means everybody is looking for those resources."

In North Dakota, Tessa Johnson said she's getting multiple messages a day on LinkedIn from headhunters. Johnson, president of the North Dakota Nurses Association, said the pandemic appears to be hastening a brain drain of nurses there. She suspects more nurses may choose to leave or retire early after North Dakota Gov. Doug Burgum told healthcare workers to stay on the job even if they've tested positive for COVID-19.

All four of Utah's major healthcare systems have seen nurses leave for traveling nurse positions, said Jordan Sorenson, a project manager for the Utah Hospital Association.

"Nurses quit, join traveling nursing companies and go work for a different hospital down the street, making two to three times the rate," he said. "So, it's really a kind of a rob-Peter-to-pay-Paul staffing situation."

Hospitals not only pay the higher salaries offered to traveling nurses but also pay a commission to the traveling nurse agency, Sorenson said. Utah hospitals are trying to avoid hiring away nurses from other hospitals within the state. Hiring from a neighboring state like Colorado, though, could mean Colorado hospitals would poach from Utah.

"In the wake of the current spike in COVID hospitalizations, calling the labor market for registered nurses 'cutthroat' is an understatement," said Adam Seth Litwin, an associate professor of industrial and labor relations at Cornell University. "Even if the healthcare sector can somehow find more beds, it cannot just go out and buy more front-line caregivers."

Litwin said he's glad to see the labor market rewarding essential workers — disproportionately women and people of color — with higher wages. Under normal circumstances, allowing markets to determine where people will work and for what pay is ideal.

"On the other hand, we are not operating under normal circumstances," he said. "In the midst of a severe public health crisis, I worry that the individual incentives facing hospitals on the one side and individual RNs on the other conflict sharply with the needs of society as whole."

Some hospitals are exploring ways to overcome staffing challenges without blowing the budget. That could include changing nurse-to-patient ratios, although that would likely affect patient care. In Utah, the hospital association has talked with the state nursing board about allowing nursing students in their final year of training to be certified early.

Growth Industry

Meanwhile business is booming for companies centered on healthcare staffing such as Wanderly and Krucial Staffing.

"When COVID first started and New York was an epicenter, we at Wanderly kind of looked at it and said, 'OK, this is our time to shine,'" said David Deane, senior vice president of Wanderly, a website that allows healthcare professionals to compare offers from various agencies. "'This is our time to help nurses get to these destinations as fast as possible. And help recruiters get those nurses.'"

Deane said the company has doubled its staff since the pandemic started. Demand is surging — with Rocky Mountain states appearing in up to 20 times as many job postings on the site as in January. And more people are meeting that demand.

In 2018, according to data from a national survey, about 31,000 traveling nurses worked nationwide. Now, Deane estimated, there are at least 50,000 travel nurses. Deane, who calls travel nurses "superheroes," suspects a lot of them are postoperative nurses who were laid off when their hospitals stopped doing elective surgeries during the first lockdowns.

Competition for nurses, especially those with ICU experience, is stiff. After all, a hospital in South Dakota isn't competing just with facilities in other states.

"We've sent nurses to Aruba, the Bahamas and Curacao because they've needed help with COVID," said Deane. "You're going down there, you're making $5,000 a week and all your expenses are paid, right? Who's not gonna say yes?"

Krucial Staffing specializes in sending healthcare workers to disaster locations, using military-style logistics. It filled hotels and rented dozens of buses to get nurses to hot spots in New York and Texas. CEO Brian Cleary said that, since the pandemic started, the company has grown its administrative staff from 12 to more than 200.

"Right now we're at our highest volume we've been," said Cleary, who added that over Halloween weekend alone about 1,000 nurses joined the roster of "reservists."

With a base rate of $95 an hour, he said, some nurses working overtime end up coming away with $10,000 a week, though there are downsides, like the fact that the gig doesn't come with health insurance and it's an unstable, boom-and-bust market.

Hidden Costs

Amber Hazard, who lives in Texas, started as a traveling ICU nurse before the pandemic and said eye-catching sums like that come with a hidden fee, paid in sanity.

"How your soul is affected by this is nothing you can put a price on," she said.

At a high-paying job caring for COVID patients during New York's first wave, she remembers walking into the break room in a hospital in the Bronx and seeing a sign on the wall about how the usual staff nurses were on strike.

"It said, you know, 'We're not doing this. This is not safe,'" said Hazard. "And it wasn't safe. But somebody had to do it."

The highlight of her stint there was placing a wedding ring back on the finger of a recovered patient. But Hazard said she secured far more body bags than rings on patients.

Tripeny, the traveling nurse who left Colorado, is now working in Kentucky with heart surgery patients. When that contract wraps up, she said, she might dive back into COVID care.

Earlier, in New Jersey, she was scarred by the times she couldn't give people the care they needed, not to mention the times she would take a deceased patient off a ventilator, staring down the damage the virus can do as she removed tubes filled with blackened blood from the lungs.

She has to pay for mental health therapy out-of-pocket now, unlike when she was on staff at a hospital. But as a so-called traveler, she knows each gig will be over in a matter of weeks.

At the end of each week in New Jersey, she said, "I would just look at my paycheck and be like, 'OK. This is OK. I can do this.'"

Markian Hawryluk: MarkianH@kff.org, @MarkianHawryluk

Rae Ellen Bichell: rbichell@kff.org, @raelnb

What Biden Can Do to Combat COVID Right Now

KFF Health News, November 23, 2020

Until the formal transition begins, there are critical — and usually routine — things the incoming Biden officials cannot do.

This article was published on Monday, November 23, 2020 in Kaiser Health News.

By Julie Rovner

When Barack Obama was elected president in 2008, the country was in the midst of a dire economic crisis. Twelve years later, his vice president, Joe Biden, has been elected president in the midst of a dire economic crisis and a worldwide, worsening coronavirus pandemic.

In 2008, Obama’s team and that of outgoing President George W. Bush worked together to allow the new administration to be as prepared as possible on Jan. 20, 2009. That’s not happening for Biden, as President Donald Trump continues to fight the election results and block the official transition.

Particularly when it comes to the COVID-19 pandemic, experts say, that delay could cost lives.

“If the new team has to waste time getting up to speed, that’s a huge waste of resources,” said Donald Kettl, a professor at the LBJ School of Public Affairs at the University of Texas-Austin and an expert in presidential transitions.

Until the formal transition begins, there are critical — and usually routine — things the incoming Biden officials cannot do, said Kettl. “Among the things not allowed right now are formal briefings by government officials, including Tony Fauci,” the head of the National Institute of Allergy and Infectious Diseases and the top federal infectious disease expert. In addition, Kettl said, Biden’s landing teams — the handful of people who go inside government agencies to start the actual transition work — “cannot actually land and talk to the people doing front-line planning. And they can’t see some of the front-line documents.”

Biden can — and is — meeting with plenty of people who will be vital to carry out his administration’s fight against COVID. On Thursday, he met remotely with a bipartisan group of governors and vowed afterward to continue to work with state and local officials. He also has his own COVID advisory board, led by former Surgeon General Vivek Murthy; former commissioner of the Food and Drug Administration, David Kessler; and Yale researcher Dr. Marcella Nunez-Smith.

But Kettl warned that it’s not enough for Biden to surround himself with smart, experienced people with good policy ideas. “The biggest risk they face is in managing these details, and that’s where a direct connection with the bureaucracy is so important, and we can’t afford to fumble this handoff,” he said.

So what can Biden do between now and Jan. 20?

Some public health advocates suggest he could set up a shadow COVID effort, to compete with the Trump administration’s task force. “He could do briefings three times a week telling us what we know and what we don’t,” said Dr. Arthur Kellermann, a longtime public health expert who is now CEO of the Virginia Commonwealth University Health System. Without better information for the public, Kellermann said, “we could lose tens of thousands of people between now and” Inauguration Day.

But others worry that Biden needs to be careful not to appear to have more power than he does, lest he end up with the blame if things don’t go well, particularly on the complicated issue of getting a vaccine distributed and accepted by the general public.

“I think we have to have reasonable expectations of what they can do,” said Farzad Mostashari, a senior health official at HHS in the Obama administration. “A lot has got to be planning and creating a ‘whole of government’ approach to tackling COVID.”

Kettl said the incoming Biden administration is better positioned than many others would have been because they have such recent experience running the government. Incoming White House chief of staff Ron Klain, for example, coordinated the federal government’s response to the Ebola outbreak in 2014. “There’s never been a group or team more prepared to run the government than this one,” Kettl said.

But it won’t be as easy as just picking up where they left off, he said, because of how politicized health and science has become. “The places they are walking into are not the same places they walked out of four years ago. The CDC is a shell of itself, the FDA is not the same.”

Mostashari, though, said he is confident the federal government can do more to combat the virus. “There are plenty of experts [still in the government] who are amazing at what they do,” he said. “They just have to unshackle them.”

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

Were You Notified About Missing Tax Forms for Your ACA Subsidy? Blame COVID.

KFF Health News, November 23, 2020

Officials at the Centers for Medicare & Medicaid Services confirmed that some consumers received notices from the agency alerting them that, according to the IRS, they hadn’t filed a tax return or reconciled their advance payments for tax credits.

This article was published on Monday, November 23, 2020 in Kaiser Health News.

By Michelle Andrews

The notice from the federal health insurance marketplace grabbed Andrew Schenker’s attention: ACT NOW: YOU’RE AT RISK OF LOSING FINANCIAL ASSISTANCE STARTING JANUARY 1, 2021.

As he read the notice, though, the Blacksburg, Virginia, resident became exasperated. Schenker, his wife and their teenage son have a bronze-level marketplace plan. Based on their income of about $40,000 a year, they receive tax credits that cover the $2,036 monthly premium in full.

When they file their annual taxes they complete an IRS form that reconciles how much they received in advance tax credits against their actual income for the year. The letter from the marketplace said they hadn’t filed for 2019, but Schenker knew they had — just as they have every year.

“I was more annoyed than anything else,” Schenker, 55, said, remembering an earlier enrollment problem that took months to resolve. “I didn’t want to get stuck in some sort of appeals category.”

Schenker’s 25-year-old daughter, Kaily Schenker, who is part owner of the family’s organic farm, got the same letter about her plan. Schenker helps her with her taxes, and she also filed the Form 8962 paperwork, he said.

Officials at the Centers for Medicare & Medicaid Services, which oversees the ACA marketplaces, confirmed that some consumers received notices from the agency alerting them that, according to the IRS, they hadn’t filed a tax return or reconciled their advance payments for tax credits. The letters, consumer advocates suggested, may be a result of the IRS extending the deadline for filing income taxes due to the coronavirus to July 15.

State-based marketplaces have similar requirements and likely send some version of this notice as well, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities who works on income tax issues related to the Affordable Care Act.

People who don’t file their taxes and the reconciliation form aren’t eligible for financial assistance with their marketplace coverage next year, including premium tax credits and any cost-sharing reductions they qualify for.

Because of the filing deadline extension, the tax form data may not have yet arrived when the federal marketplace initially asked the IRS for it in the fall, Straw said. Or other issues, including longer processing times for paper tax returns, could be responsible for a delay, Straw said.

“We don’t know how many people are in this boat,” Straw said. “We think it’s higher than in previous years because of anecdotal accounts from marketplace assisters around the country.”

Schenker said he and his daughter both filed paper returns — his family’s, in the spring, while his daughter took advantage of the pandemic extension.

Under ACA rules, people with incomes up to 400% of the poverty level ($86,880 for a family of three) can qualify for advance tax credits to help pay for coverage purchased through state or federal health insurance exchanges. When they sign up for insurance during open enrollment, their tax credits are based on estimates of their income for the coming year, and the exchanges pay insurers that amount directly. Then when people file their income taxes the following year, they use Form 8962 to reconcile their actual income against what they estimated and square off the amount in tax credits they received. If they received too much in subsidies, they must pay that back to the government.

According to the notice Schenker received, people who have already filed their 2019 tax return and Form 8962 don’t need to take any action.

Straw recommends a more hands-on approach.

“It’s really a dangerous thing to just wait and cross your fingers and hope that the data will resolve your issue,” she said.

Consumers who filed and reconciled taxes for 2019 can keep their tax credit in 2021, CMS officials said, by updating their 2021 HealthCare.gov application on or before Dec. 15 and checking the box that says, “Yes, I reconciled premium tax credits for past years.”

Straw encouraged marketplace customers to follow that advice. (State-based marketplaces generally follow the same process as the federal marketplace, perhaps with slight variations.)

Still, that might not be sufficient. Straw also recommends that people contact the IRS directly and ask for a tax transcript that shows their return was received, including Form 8962.

That way, if the marketplace does cut off premium tax credits and people have to appeal, they have documentation proving they filed the necessary forms. (If it comes to this, consumers can elect to continue receiving premium tax credits while they appeal.)

Unfortunately, people who run into this trouble might not get much expert help. Navigators are no longer required to help consumers with problems after they’ve enrolled, though they may still do so, Straw said.

Likewise, insurance brokers generally don’t help people with these problems, said Karen Pollitz, a senior fellow at KFF. (KHN is an editorially independent program of KFF.) Marketplace plan commissions are so low, “they’re much less likely to help people with complex problems,” she said.

After he got the letter, Schenker called marketplace representatives and was told to go ahead and apply for a plan for next year. He did so, making sure to check the box that said he’d filed his taxes, including the reconciliation form. And at the end of the application process, the system told him that, based on his income, his family is eligible for a tax credit of $2,000 a month. He picked a bronze plan.

He hopes that’s the end of it.

Parents Complain That Pediatricians, Wary of COVID, Shift Sick Kids to Urgent Care

KFF Health News, November 23, 2020

As doctors and medical practices nationwide navigate a new normal with COVID-19 again surging, some are relying on urgent care sites and emergency departments to care for sick patients, even those with minor ailments.

This article was published on Monday, November 23, 2020 in Kaiser Health News.

By Kristy P. Kennedy

A mom of eight boys, Kim Gudgeon was at her wits' end when she called her family doctor in suburban Chicago to schedule a sick visit for increasingly fussy, 1-year-old Bryce.

He had been up at night and was disrupting his brothers' e-learning during the day. "He was just miserable," Gudgeon said. "And the older kids were like, 'Mom, I can't hear my teacher.' There's only so much room in the house when you have a crying baby."

She hoped the doctor might just phone in a prescription since Bryce had been seen a few days earlier for a well visit. The doctor had noted redness in one ear but opted to hold off on treatment.

To Gudgeon's surprise, that's not what happened. Instead, when she called, her son was referred to urgent care, a practice that has become common for the Edward Medical Group, which included her family doctor and more than 100 other doctors affiliated with local urgent care and hospital facilities. Because of concerns about the transmission of the coronavirus, the group is now generally relying on virtual visits for the sick, but often refers infants and young children to urgent care to be seen in person.

"We have to take into consideration the risk of exposing chronically ill and well patients, staff and visitors in offices, waiting areas or public spaces," said Adam Schriedel, chief medical officer and a practicing internist with the group.

Gudgeon's experience is not unusual. As doctors and medical practices nationwide navigate a new normal with COVID-19 again surging, some are relying on urgent care sites and emergency departments to care for sick patients, even those with minor ailments.

That policy is troubling to Dr. Arthur "Tim" Garson Jr., a clinical professor in the College of Medicine at the University of Houston who studies community health and medical management issues. "It's a practice's responsibility to take care of patients," Garson said. He worries about patients who can't do video visits if they don't have a smartphone or access to the internet or simply aren't comfortable using that technology.

Garson supports protocols to protect staff and patients, including in some instances referrals to urgent care. In those cases, practices should be making sure their patients are referred to good providers, he said. For instance, children should be seen by urgent care facilities with pediatric specialists.

Referrals for children have become so prevalent that the American Academy of Pediatrics came out with interim guidance on how practices can safely see patients, in an effort to promote patient-centered care and to ease the strain on other medical facilities as the peak of flu season approaches. The academy recommended that pediatricians strive "to provide care for the same variety of visits that they provided prior to the public health emergency."

The academy raises concerns about unintended consequences of referrals, such as the fragmentation of care and increased exposure to other illnesses, both caused by patients seeing multiple providers; higher out-of-pocket costs for families; and an unfair burden shifting to the urgent care system as illnesses surge.

"I think this is all being driven by fear, not really knowing how to do this safely, and not really thinking about all of the sorts of consequences that are going to come as flu and other respiratory illnesses surge this fall and winter," said Dr. Susan Kressly, who recently retired from her practice in Warrington, Pennsylvania, and authored the AAP guidance.

Fear is not unfounded. More than 900 healthcare workers, 20 of them pediatricians and pediatric nurses, have died of COVID-19, according to a KHN-Guardian database of front-line healthcare workers lost to the coronavirus.

For the Edward Medical Group, referrals are a safe way to treat patients by using all the resources of its medical system, Schriedel said.

"We can assure patients, regardless of COVID-19, we have multiple options to provide the care and services they need," he said.

Besides urgent care referrals and virtual visits, doctors have been given guidelines on how to safely see sick patients. That might mean requesting a negative COVID test before a doctor visit or having staff escort a sick patient from the car directly to an exam room. Also, a pilot program is underway with designated offices taking patients with a respiratory illness that could be flu or COVID-19.

It is a balancing act with some risks. In August, friends sent Kressly screenshots of parents' online message boards from states such as Texas, Indiana and Florida that were seeing a summer spike in COVID-19 cases. Mothers felt abandoned by their pediatricians because they were being sent to urgent care and emergency departments. Kressly fears some patients will fall through the cracks if they are seen by several different providers and don't have a continuity of care.

Also, there's the expense. Bryce's case is a good example. Gudgeon reluctantly took him to an urgent care facility, worried about exposure and frustrated because she felt her doctor knew Bryce best. His exam included a COVID test. "They barely looked in his ears, and we went home to wait for the results," she said, and got no medicine to treat Bryce. The next day, she had a negative test and still a fussy, sick baby.

Urgent care facilities across the country are reporting higher numbers of patients, said Dr. Franz Ritucci, president of the American Board of Urgent Care Medicine. His clinic in Orlando, Florida, is seeing twice as many patients, both children and adults, as it did at this time last year.

"In urgent care, we're seeing all comers, whether they are sick with COVID or not," he said.

Meanwhile, ERs are seeing far fewer pediatric patients than usual, said Alfred Sacchetti, a spokesperson for the American College of Emergency Physicians and the director of clinical services at Virtua Our Lady of Lourdes Emergency Department in Camden, New Jersey. Although adult emergency room visits have largely returned to pre-COVID levels, pediatric visits are 30% to 40% lower, he said. Sacchetti suspects several factors are at play, including fewer kids in daycare and school with less opportunity to spread illness and people avoiding emergency rooms for fear of the coronavirus.

"You see parents looking around the department and if someone clears their throat, you can look in their eyes and see the concern," Sacchetti said. "We reassure them" that the precautions taken in hospitals will help keep them safe, he added.

Gudgeon considered taking Bryce to an emergency room, but she felt increasingly uncomfortable both with the thought of exposing him to another healthcare facility and the cost. In the end, she called an out-of-state doctor she had seen often years before moving to Illinois. That doctor phoned in an antibiotic prescription, and Bryce quickly improved, she said.

"I just wish he didn't have to suffer for so long," Gudgeon said.

Kressly hopes doctors become more creative in finding ways to provide direct care. She likes the "Swiss cheese" approach of layering several imperfect solutions to see patients and offer protection from COVID-19: screening for symptoms before the patient comes in, requiring everyone to wear masks, allowing only one caregiver to accompany a sick child and offering parking lot visits for sick kids in their cars.

Most important is good communication, Kressly said. Not only does that help the patient, it can also help protect the doctor from patients who may not want to admit they have COVID symptoms.

"We can't create this barrier to care for uncomplicated, acute illnesses," Kressly said. "This is not temporary. We all have to creatively figure out how to get patients and families connected to the right care at the right place at the right time."

Kristy P. Kennedy: @kristypkennedy

Trump's Lame-Duck Status Leaves Governors to Wing It on COVID

KFF Health News, November 20, 2020

With record hospitalizations and new cases, many governors have decided they can't afford to wait.

This article was published on Friday, November 20, 2020 in Kaiser Health News.

By Matt Volz

Not long after the world learned that President Donald Trump had lost his reelection bid, states began issuing a new round of crackdowns and emergency declarations against the surging coronavirus.

Taking action this time were Republican governors who had resisted doing so during the spring and summer. Now they face an increasingly out-of-control virus and fading hope that help will come from a lame-duck president who seems consumed with challenging the election results.

President-elect Joe Biden has promised a more unified national effort once he takes office on Jan. 20, and pressure is building on Congress to pass a new financial relief package. But with record hospitalizations and new cases, many governors have decided they can’t afford to wait.

“I don’t know any governor who’s sitting there waiting for the knight to come in on the horse,” said Lanhee Chen, a fellow at the Hoover Institution and a former senior health official in President George W. Bush’s administration. “There’s no way for these guys to just sit and wait. The virus and the crisis is getting worse hour by hour, day by day.”

As new measures trickle out across states, public health policy experts worry many don’t go far enough. For those states attempting to impose meaningful restrictions, their success depends on cooperation from a population with pandemic fatigue. And people may be reluctant to curtail their holiday gatherings.

Residents of many conservative states don’t acknowledge the depth of the health problem, especially given Trump and some of his allies have stressed the crisis is being overplayed and will end quickly.

The bottom line is that many people just aren’t sufficiently scared of the virus to do what must be done to stop the spread, said Rodney Whitlock, a health policy consultant and former adviser to Sen. Chuck Grassley (R-Iowa).

“You’re dealing with folks there who definitely put liberty over everything else because they’re not afraid enough,” Whitlock said. “Even in the face of cases, even in the face of people around them getting it. They’re just not afraid.”

Among the first governors to act was outgoing Utah Gov. Gary Herbert. The day after The Associated Press called the presidential election for Biden on Nov. 7, the Republican announced Utah’s first-ever statewide mask mandate and clamped down on social gatherings and other activities until Nov. 23.

“All of us need to work together and see if there’s a better way,” Herbert said in a news conference.

Republican and Democratic governors alike followed with measures of their own in Colorado, Iowa, Michigan, Nebraska, New York, Ohio, Oregon, Pennsylvania, Washington and other states. Strategies included partial lockdowns, limits on crowds, canceling in-person classes for schools and reducing hours and capacity for bars and restaurants.

Health policy experts largely agree that the virus’s spread, not the end of the election, is what’s driving these changes — though the end of the campaign season does take political pressure off governors inclined to issue COVID-preventive policies.

“It’s much easier to act when you don’t have attention on you than when you do, but I would hope that the action is taking place regardless of what the political circumstances are,” Chen said.

No state has yet resorted to the sort of full lockdowns enacted in the spring, which resulted in mass business closures and layoffs and sent the economy crashing.

Christopher Adolph, an associate professor at the University of Washington, and his team with the university’s COVID-19 State Policy Project have been studying states’ responses to the pandemic. Some states have made a show of taking action, without much substance behind it, he said. For example, Alaska Gov. Mike Dunleavy, a Republican, declared an emergency on Nov. 12 — but only recommended, not ordered, that people wear masks and maintain social distance.

Other governors first took small steps only to follow up with tighter restrictions. In Iowa, for example, Republican Gov. Kim Reynolds, who opposed mask mandates during the presidential campaign, initially announced that all people over age 2 would be required to wear masks at gatherings of certain sizes. On Nov. 16, she issued a simpler but stricter three-week statewide mask mandate.

North Dakota Gov. Doug Burgum, a Republican, also ordered mandatory face coverings for the first time. Hospitals there have been reporting they have more patients than capacity, and the state has been leading the country in new per capita COVID cases.

At the very least, each state should make it clear that people must not gather indoors, Adolph said. Restaurants, bars, gymnasiums and large indoor events should be closed, he said, and gatherings inside people’s homes should not happen.

“We’re not seeing enough clear, broadly communicated, well-stated, unambiguous policies,” Adolph said.

An exception is Herbert, one of two governors who will leave office in January. The two-term Utah governor will turn over the reins to his current lieutenant governor, Spencer Cox, who has been a part of the state’s response to the pandemic since the beginning. Both Republicans have promised a smooth, seamless transition between administrations.

The nation’s other lame-duck governor is Montana’s Steve Bullock, a Democrat. But unlike Herbert, the term-limited Bullock will be replaced by a governor from a different party. Republican U.S. Rep. Greg Gianforte defeated Bullock’s lieutenant governor, Mike Cooney, in the Nov. 3 election. And Bullock lost his bid for the U.S. Senate.

Bullock said in a Nov. 12 news conference that he would not take additional COVID-intervention measures without a federal aid package to blunt the economic fallout. Five days later, he reversed himself to expand a previous mask requirement and limit capacity and hours in bars, restaurants and other entertainment venues.

Gianforte has not directly answered whether he would continue Bullock’s restrictions. When asked, the governor-elect has spoken instead of personal responsibility and reopening the economy while protecting the most vulnerable people. In July, he referenced the unfounded hope that the virus would be slowed by the U.S. reaching “herd immunity” by the end of the year.

Another obstacle is that a district judge essentially ruled Bullock’s mask mandate unenforceable. State health department lawyers had asked District Judge Dan Wilson to enforce the mandate against five businesses accused of flouting the measure.

“The businesses and the owners have been put on the front line of implementing a state policy that has more exceptions than directives and would be about as effective in bailing water from the leaky boat of our present health circumstances as would a colander,” the judge said in denying the request.

That leaves Bullock with the task of managing a crisis in his final weeks of office with local officials already looking past him to a new administration.

In Flathead County, where the five businesses were sued for violating the mask mandate, local leaders were already chafing from what they saw as Bullock’s heavy hand.

“He has angered a lot of people in Flathead County,” County Commissioner Randy Brodehl, a Republican, said of Bullock. “He didn’t come here, he didn’t talk to us.”

Bullock’s troubles show that even if governors take measures to stem the spread of COVID-19, they may still have a difficult time persuading people to go along with them. That’s particularly an issue in the Upper Midwest and the Rocky Mountains, libertarian-leaning COVID hot spots where the medical infrastructure is already strained.

Some Trump supporters have followed the president’s lead in downplaying the virus and others are fatigued after months of isolation and precautions, said Whitlock.

In rural and conservative areas, people protest that COVID measures come at the expense of their personal freedom and their ability to earn a living, and some feel as though they’re being talked down to by mask advocates and public health officials, Whitlock said.

It’s going to take smart and consistent messaging to change attitudes — but that means more than Biden telling people to wear masks once he takes office, Whitlock added.

“Everybody has to own it,” he said. “You have to scream at the top of your lungs at the protests, at the celebrations, at the football games, at the concerts. It has to be, ‘Stop it!’”

Fear of Flying Is a COVID-Era Conundrum

KFF Health News, November 20, 2020

Americans who do choose to fly will be subject to evolving COVID safety policies that vary by airline, a result of the continuing lack of a unified federal strategy.

This article was published on Friday, November 20, 2020 in Kaiser Health News.

By Victoria Knight

The holidays are approaching just as COVID-19 case rates nationwide are increasing at a record-breaking pace, leading to dire warnings from public health experts.

The Centers for Disease Control and Prevention has issued cautions and updated guidelines related to family gatherings. Dr. Anthony Fauci, a White House coronavirus adviser and director of the National Institute of Allergy and Infectious Diseases, said in interviews that his kids won’t be coming home for Thanksgiving because of coronavirus risks. “Relatives getting on a plane, being exposed in an airport,” he told CBS News. “And then walking in the door and saying ‘Happy Thanksgiving’ — that you have to be concerned about.”

Are Americans listening? Maybe not. Especially as airlines, reeling from major revenue blows since the pandemic took hold in March, tell passengers they can travel with peace of mind and sweeten the deal with special holiday fares.

The airlines argue more is now known about the virus and recent industry-sponsored studies show flying is just as safe as regular daily activities. They also tout policies such as mask mandates and enhanced cleaning to protect travelers from the coronavirus.

Time for a reality check.

Americans who do choose to fly will be subject to evolving COVID safety policies that vary by airline, a result of the continuing lack of a unified federal strategy. Under the Trump administration, government agencies such as the Federal Aviation Administration and the Centers for Disease Control and Prevention have failed to issue and enforce any national directives for air travel.

And, though President-elect Joe Biden has signaled he will take a more robust federal approach to addressing COVID-19, which may result in such actions, the Trump administration remains in charge during the upcoming holiday season.

Here’s what you need to know before you book.

Airlines Say It’s Safe to Fly During the Pandemic. Is it?

The airline industry pins its safety clearance to a study funded by its leading trade group, Airlines for America, and conducted by Harvard University researchers, as well as one headed by the Department of Defense, with assistance from United Airlines.

Both reports modeled disease transmission on a plane, assuming all individuals were masked and the airplane’s highly effective air filtration systems were working. The Harvard report concluded the risk of in-flight COVID-19 transmission was “below that of other routine activities during the pandemic, such as grocery shopping or eating out,” while the DOD study concluded an individual would need to, hypothetically, sit for 54 straight hours on an airplane to catch COVID-19 from another passenger.

But these studies’ assumptions have limitations.

Despite airlines’ ramped-up enforcement of mask-wearing, reports of noncompliance among passengers continue. Most airlines say passengers who outright refuse to wear masks will not only be refused boarding, but will also be putting their future travel privileges at risk. Recent press reports indicate Delta has placed hundreds of these passengers on a no-fly list. Some passengers may still try to skirt around the rule by removing their mask to eat or drink for an extended time on the flight, and flight attendants may or may not feel they can stop them.

And though public health experts agree that airplanes do have highly effective filtration systems spaced throughout the cabin that filter and circulate the air every couple of minutes, if someone who unknowingly has COVID-19 takes off their mask to eat or drink, there is still time for viral particles to reach others seated nearby before they get sucked up by the filter.

Public health experts said comparing time on an airplane with time at the grocery store is apples and oranges.

Even if you wear a mask in both places, said Dr. Henry Wu, director of Emory TravelWell Center and associate professor of infectious diseases at Emory University School of Medicine, the duration of contact in both locales can be very different.

“If it’s a long flight and you are in that situation for several hours, then you are accumulating exposure over time. So a one-hour flight is 1/10 the risk of a 10-hour flight,” said Wu. “Whereas most people don’t spend more than an hour in the grocery store.”

Also, both studies analyzed only one aspect of a travel itinerary — risk on board the aircraft. Neither considered the related risks involved in air travel, such as getting to the airport or waiting in security lines. And public health experts say those activities pose opportunities for COVID exposure.

“Between when you arrive in the airport and you get into a plane seat, there is a lot of interaction that happens,” said Lisa Lee, a former CDC official and associate vice president for research and innovation at Virginia Tech.

And while Wu said he agrees that an airplane cabin is likely safer than other environments, with high rates of COVID-19 in communities across the U.S., “there is no doubt people are flying when they’re sick, whether they know it or not.”

Another data point touted by the airline industry has been that out of the estimated 1.2 billion people who have flown so far in 2020, only 44 cases of COVID-19 have been associated with air travel, according to data from the International Air Transport Association, a worldwide trade group.

But this number reflects only case reports published in the academic literature and isn’t likely capturing the true picture of how many COVID cases are associated with flights, experts said.

“It’s very difficult to prove, if you get sick after a trip, where exactly you got exposed,” said Wu.

The low count could also stem from systemic contact-tracing inconsistencies after a person with COVID-19 has traveled on a flight. In a recent case, a woman infected with the coronavirus died during a flight and fellow passengers weren’t notified of their exposure.

That may be due to the decentralized public health system the U.S. has in place, said Lee, the former CDC official, since contact tracing is done through state and local health departments. The CDC will step in to help with contact tracing only if there is interstate travel, which is likely during a flight — but, during the pandemic, the agency has “been less consistently effective than in the past,” said Lee.

“Let’s say there is a case of COVID on a flight. The question is, who is supposed to deal with that? The state that [the flight] started in? That it ended in? The CDC? It’s not clear,” said Lee.

Is Now the Time to Fly?

Most airlines have implemented safety measures beyond requiring masks, such as asking passengers to fill out health questionnaires, enhancing cleaning on planes, reducing interactions between crew members and passengers, and installing plexiglass stations and touchless check-in at service desks.

But many have also stepped back from other efforts, such as pledging to block middle seats. United relaxed its social distancing policy for allowing empty middle seats between customers at the end of May, though there were complaints from customers before then about flights being full. American Airlines stopped blocking middle seats in July. Other airlines plan to fill seats after the Thanksgiving holiday, with Southwest stopping the practice of blocking middle seats starting Dec. 1, and JetBlue planning to increase capacity to 85% on Dec. 2. In January, Alaska Airlines plans to stop blocking middle seats and JetBlue will fly at full capacity. Delta announced this week that it will continue to block the middle seat until March 30.

This policy change is a result of airlines’ lack of cash on hand, said Robert Mann, an aviation analyst. It also reflects a rising demand from consumers who feel increasingly comfortable traveling again, especially as holiday gatherings beckon.

“It was easy to keep middle seats empty when there wasn’t much demand,” said Mann.

Now, they’re instead hoping that new COVID-era services will calm passengers’ fears.

American, United, Alaskan and Hawaiian, among others, offer some form of preflight COVID test for customers traveling to Hawaii or specific foreign destinations that also require a negative test or quarantine upon arrival. JetBlue recently partnered with a company to offer at-home COVID tests that give rapid results for those traveling to Aruba.

Airlines are likely to expand their preflight COVID testing options in the next couple of months. “This is the new dimension of airline competition,” said Mann.

But is it a new dimension of travel safety?

Emory’s Wu said there is certainly a risk of catching the coronavirus if you travel by plane, and travelers should have a higher threshold in making the decision to travel home for the holidays than they would in years past.

After all, COVID case rates are surging nationwide.

“I think the less folks crowding the airports, the less movement in general around the country, will help us control the epidemic,” said Wu. “We are worried things will get worse with the colder weather.”

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