Category: From California Healthline.org

OAKLAND, Calif. — Amid fanfare in March, California officials celebrated the launch of a multimillion-dollar contract with Verily — Google’s health-focused sister company — that they said would vastly expand COVID testing among the state’s impoverished and underserved communities.

But seven months later, San Francisco and Alameda counties — two of the state’s most populous — have severed ties with the company’s testing sites amid concerns about patients’ data privacy and complaints that funding intended to boost testing in low-income Black and Latino neighborhoods instead was benefiting higher-income residents in other communities.

San Francisco and Alameda are among at least 28 counties, including Los Angeles, where California has paid Verily to boost testing capacity through contracts collectively worth $55 million, according to a spokesperson for the California Governor’s Office of Emergency Services. About half of them have received COVID tests through six mobile units that travel among rural areas.

Gov. Gavin Newsom has heralded the investment as a game changer in addressing persistent inequities in access to COVID testing across the state that tend to fall along lines of ethnicity and income. The goal, he said in April, touting six new Verily testing sites, was to “make sure we’re truly testing California broadly defined, not just parts of California and those that somehow have the privilege of getting ahead of the line.”

Yet the roadblocks for getting underrepresented populations to use the program soon became apparent to Alameda County officials. In a June letter to California Secretary of Health Mark Ghaly, Oakland Mayor Libby Schaaf and other members of the county’s COVID-19 Racial Disparities Task Force raised numerous concerns about the Verily protocols.

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Among their complaints: People signing up for a test through Verily had to do so online, using an existing or newly created Gmail account; the sign-ups were offered only in English or Spanish; and participants were asked to provide sensitive personal information, including their home address and whether they were managing chronic health conditions such as diabetes, obesity or congestive heart failure, which could expose their data to third-party use.

“It is critical in this crisis that we continue to build trust between government and healthcare providers and vulnerable communities,” the task force members wrote.

Verily had two sites in Alameda County, and one was shuttered by May. The second, located at an Oakland church, closed in August and is set to reopen using a different testing vendor. Alameda County testing director Dr. Jocelyn Freeman Garrick said that while the Verily sites helped the county reach testing goals in terms of raw numbers, they were phased out because of long wait times of a week or more for results, and because the tests were not reaching the residents in greatest need.

Verily does not manufacture the COVID tests used at its California sites. It contracts with major corporations such as Quest Diagnostics and Thermo Fisher Scientific to provide the test kits and perform the lab work. What Verily provides is a digital platform where people are screened for symptoms, schedule testing appointments at participating sites and check back for test results.

Dr. Noha Aboelata is CEO of Roots Community Health Center, an East Oakland clinic that serves mostly African Americans and is one of the original Verily sites in Oakland. Her experience with Verily is best described as a tale of two lines.

Roots Community Health Center in East Oakland is among the Alameda County COVID testing sites that have severed ties with Verily. People were suspicious of the requirement that they sign up for testing with a Gmail account and the request for personal information, according to center officials.

In May, Aboelata worked with Verily to establish a walk-up site at her clinic, rather than the drive-thru model the company typically uses. There would be two lines: one for people who scheduled their appointments through Verily’s online portal; and a second for people who had not preregistered with Verily. Roots would staff both lines, and Verily would supply test kits and personal protective equipment including masks, which were “like gold” at the time, Aboelata said.

Problems emerged almost immediately, she said. People were suspicious of the requirement that they sign up with a Gmail account, and the request for personal information, such as health status and risk factors. “You don’t necessarily want to share that with Google,” Aboelata said.

Then there was the language in the privacy policy that allows for sharing data with third parties. “That always is going to raise suspicion and concern in our community,” she said.

The people who ended up in the Verily-registered line, she said, tended to be white and to come from wealthier ZIP codes outside East Oakland. And because Verily never changed the website language describing Roots as a drive-thru site, many were angry at having to walk up.

“We had people coming from all over the Bay Area who were frustrated that they had to park in Oakland, where they had probably never been and didn’t seem to want to be,” she said. “They were creating quite a scene, and some were saying, ‘I want to talk to the manager.’” She had to ask a few people to leave. “One of them was saying, ‘This is so Oakland, and I hope you all get the virus.’ It was pretty awful.”

The Roots line for clients who did not register through Verily, on the other hand, was made up mostly of people of color from the community who long had come to the clinic for medical care, she said.

When Aboelata looked at the data, the disparities were obvious: 12.9% of people tested in the non-Verily line were positive for COVID-19, while just 1.5% of people tested in the Verily-registered line were positive. For Aboelata, it was clear that the two lines were testing two entirely different populations.

After just six days of testing, Aboelata asked Verily to leave.

“From where we sit, this is an old story,” she said. “Corporations that are not really invested in the community come helicoptering in, bearing gifts, but what they’re taking away is much more valuable.” That thing of value, Aboelata believes, is the data Verily requests from everyone who signs up for a test.

In San Francisco, Verily mobile testing clinics have also been sidelined. County officials declined to provide an explanation. However, multiple people with knowledge of the testing efforts said the Verily registration process proved chaotic for homeless people and others in the Tenderloin district, one of the city’s poorest neighborhoods.

Kenneth Kim, clinical director of Glide, an outreach center that helped run the Tenderloin site, said many homeless residents coming in for testing had Gmail accounts, as Verily required, but could not remember their passwords. When staffers at the testing site tried to help them retrieve their passwords, they found that Google’s two-factor authentication process required users to have the same phone number as when they signed up, which few of the homeless participants did.

Dr. Jonathan Fuchs, who leads San Francisco County’s testing strategy at the Department of Public Health, confirmed that the partnership with Verily was “currently on hold.” He declined to provide further details.

In response to questions, Verily spokesperson Kathleen Parkes said the program requires users to register with Gmail accounts because Google’s authentication procedures safeguard sensitive data and protect “against unknown individuals sending or receiving information with serious consequences for health or well-being.” Conversations with San Francisco and Alameda remain “active,” Parkes said. The company did not respond to specific questions about the testing disparities cited by community leaders.

Verily’s role in COVID-19 testing has been shadowed by controversy since President Donald Trump told reporters at a Rose Garden news conference in March that “Google” was developing a screening website and testing tool. “Google has 1,700 engineers working on this right now,” he said. “They’ve made tremendous progress.”

At the time, COVID tests were in short supply and Trump was under pressure to increase capacity as infections ballooned in California, New York and other states. But Google was not building such a website. Instead, Verily, another Alphabet Inc. subsidiary focused on life sciences, was in the early stages of developing a website to help triage people in need of COVID testing, Google clarified in a tweet. It planned to unveil a pilot program in two Bay Area counties.

Days later, Newsom announced a California partnership with Verily that so far has paid the company $55 million to establish both mobile and brick-and-mortar testing sites. In addition, Verily has partnered with Rite Aid to manage testing at approximately 300 sites in multiple states under a $122.6 million federal contract between the pharmacy chain and the U.S. Department of Health and Human Services. California’s Verily contracts are in place through Nov. 30; the HHS contract is set to expire in January.

Participants in the Verily initiative sign an authorization form that says their information can be shared with multiple third parties involved in the testing program, including unnamed contractors and state and federal health authorities.

“While the form tells you that Verily may share data with ‘entities that assist with the testing program,’ it doesn’t say who those entities are. If one of those unnamed and unknown entities violates your privacy by misusing your data, you have no way to know and no way to hold them accountable,” said Lee Tien, senior staff attorney for the Electronic Frontier Foundation, a nonprofit that advocates for digital privacy.

The policy states Verily will not use the data collected for its own research or meld it with other Google products without the user’s permission. But it notes participants may be invited to share their data for such research, and the testing portal prominently features links inviting participants to sign up for other Verily research.

In California, as of Oct. 8, the Verily sites had processed an average of 1,583 patient samples per day over the prior seven days, according to the California Department of Public Health. Verily, the state health department and Alameda County all declined requests to provide race and ethnicity data by testing site.

Dr. Kim Rhoads, a UCSF professor and former colorectal surgeon who leads a COVID testing project for Black communities, said Aboelata’s experience with Verily is emblematic of widespread racial disparities in the testing and treatment of COVID-19. “We can’t keep talking about the consequences being unintended,” Rhoads said. “We are six months into this pandemic and anyone who is surprised by the repetitive findings of inequity in testing, the spread of virus and COVID-19 mortality just isn’t paying attention.”

In an interview, Ghaly, California’s health secretary, said he believed the state’s partnerships with Verily and other companies continue to be a national model for addressing problems with testing disparities, including setting up venues for minority and rural populations. For example, in counties in northern parts of the state, sometimes the only regular testing available was through mobile testing set up under the program, he said.

“I think there’s lots of success and lots of lessons learned and we continue to apply them,” Ghaly said. “Until the entire effort is completed, I always look at where we are as part success and part opportunity to keep learning.”

In a September response to the Oakland COVID-19 disparities task force, Ghaly outlined several actions the state had taken or would take in response to the concerns, including having Verily update its platform to include additional languages and work with testing vendors on alternative methods for data collection to address privacy concerns.

“Some of the things we learned specifically in our experience in Alameda and other parts of the Bay Area is language matters,” Ghaly told KHN.

After working with the homeless for 25 years, Dr. Margot Kushel, director of the UCSF Benioff Homelessness and Housing Initiative, said she wasn’t surprised to learn some community leaders ran into problems with Verily.

“It turns out that in public health, the highest-tech solution is usually not the right one,” she said. To bring COVID cases down, she explained, requires a “laser focus” on the highest-risk communities. And people in those communities often don’t want to turn over the protected information Verily asks for, whether because of fears about their immigration status or a history of mistrust of the medical establishment and policing.

“You can imagine a million and a half reasons why people would distrust it,” Kushel said. “The very structure of this is set up to fail. And by failing the communities who need it most, we fail everybody.”

California Healthline correspondent Angela Hart contributed to this report.

Florida’s plan to import cheaper prescription drugs from Canada — designed by Gov. Ron DeSantis and endorsed by President Donald Trump — has tasted its first bitter pill.

No private firms bid on Florida’s $30 million contract to set up and operate a drug importation program. Bids were due at the end of September.

The setback is likely to delay by at least several months Florida’s effort to become the first state to import drugs.

A spokesperson for the Florida Agency for Health Care Administration said the state is exploring its options. “The agency remains confident it will find a qualified vendor soon,” the spokesperson said. The state had planned to award a contract to a private vendor in December.

The disclosure of no bidders comes less than a month after the Trump administration cleared the way for states to apply for federal permission to set up an importation program — reversing nearly two decades of U.S. policy.

A 2003 law allows drug importation from Canada, but only if the head of the federal Department of Health and Human Services deems it safe and cost-effective. HHS Secretary Alex Azar made that declaration Sept. 24 and approved final rules for such initiatives.

Jane Horvath, a health consultant in College Park, Maryland, said potential bidders on the Florida contract were likely put off because the final federal rules were not set until late September. And private firms didn’t want to bid on a contract that would have to change if the Florida rules conflicted with those from Washington, she said.

Several inconsistencies are apparent between the Florida plan and what is allowed under the HHS final rules, she said. For example, Florida aims to give bonus-scoring points to contractors that repackage and relabel drugs in Florida, which is not allowed under the federal rules.

Another problem is that the private contractor has to determine which prescription drugs will produce the most savings for Florida’s Medicaid program, which is difficult since Medicaid rebates and other discount pricing are confidential.

“It could be that the $30 million contract is not enough either,” Horvath said.

Drug prices are lower in Canada because the country limits how much drugmakers can charge for medicines. The United States lets drugmakers and their distributors dictate prices.

Trump, who made lowering prescription drug prices a key campaign issue in 2016, has promoted importation, especially in messages geared to seniors during his reelection bid.

Critics say importing drugs from Canada would threaten the drug supply with counterfeit products. Because high-cost biologic drugs, including insulin, and intravenously injected medicines are not allowed to be imported under current law, the strategy could have limited impact.

Even with HHS backing, drug importation faces several challenges. Most notably, Canada has vowed to stop any effort that would exacerbate drug shortages there, which could make it challenging to identify a Canadian exporter. And the pharmaceutical industry opposes the program and is likely to sue to stop it.

Florida plans to set up an importation program to help lower drug prices for people covered by state programs such as Medicaid and the Corrections Department. The state has projected savings of up to $150 million a year.

The federal rules take effect Nov. 30, which is when states can formally apply to HHS to set up their program.

A chief architect of Florida’s importation plan, Mary Mayhew, who was secretary of the Florida Agency for Health Care Administration, resigned in September to become CEO of the Florida Hospital Association.

Mayhew refused to comment for this story.

Vermont, Colorado, Maine, New Hampshire and New Mexico are also devising programs to import drugs from Canada.

Colorado officials plan to seek out private contractors for that state’s program in 2021, and they hope to get final federal approval by summer 2022, officials said during a recent call with stakeholder groups.

Colorado plans to allow consumers to get drugs from Canada at their U.S. pharmacy or through mail order. It estimates residents could save an average of 61% off the price of medicines in Colorado today.

It’s unclear what impact the outcome of the presidential election will have on drug importation. Democratic nominee Joe Biden said he supports importing drugs from Canada. But, if elected, he is also likely to review many of the Trump administration’s actions.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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

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As COVID-19 took hold in March, U.S. doctors limited in-person appointments — and many patients avoided them — for fear of infection. The result was a huge increase in the volume of remote medical and behavioral health visits.

Doctors, hospitals and mental health providers across the country reported a 50- to 175-fold rise in the number of virtual visits, according to a report released in May by the consulting firm McKinsey & Co.

The COVID-fueled surge has tapered off as patients venture back to doctors’ offices. But medical professionals and health experts predict that when the pandemic is over, telehealth will still play a much larger role than before.

Studies show patient satisfaction with telehealth is high. And for physicians who previously were skeptical of remote care, necessity has been the mother of invention.

“There are still a few doubting Thomases, but now that we’ve run our practices this way for three months, people have learned that it’s pretty useful,” says Dr. Joseph Kvedar, president of the American Telemedicine Association and a practicing dermatologist who teaches at Harvard Medical School in Boston.

For patients, the advantages of telemedicine are clear: You typically can get an appointment sooner, in the safety of your own home or workplace, saving time and money on gas and parking — in some cases, even avoiding a loss in wages for missing work.

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James Wolfrom, a 69-year-old retired postal executive in San Francisco, has had mostly virtual health care appointments since the pandemic started. He particularly appreciates the video visits.

“It’s just like I’m in the room with the doctor, with all of the benefits and none of the disadvantages of having to haul my body over to the facility,” says Wolfrom, who has Type 2 diabetes. “Even after the pandemic, I’m going to prefer doing the video conferencing over having to go there.”

Telemedicine also provides care for people in rural areas who live far from medical facilities.

The growth of virtual care has been facilitated by Medicare rule changes for the COVID-19 emergency, including one that reimburses doctors for telemedicine at the same rate as in-person care for an expanded list of services. State regulators and commercial health plans also loosened their telehealth policies.

In California, the Department of Managed Health Care, which regulates health plans covering the vast majority of the state’s insured residents, requires commercial plans and most Medi-Cal managed care plans during the pandemic to pay providers for telehealth at parity with regular appointments and limit cost sharing by patients to no more than what they would pay for in-person visits. Starting Jan. 1, a state law — AB-744 — will make that permanent for commercial plans.

Five other states — Delaware, Georgia, Hawaii, Minnesota and New Mexico — have pay-parity laws already in effect, according to Mei Wa Kwong, executive director of the Center for Connected Health Policy. Washington state has one that also will begin Jan. 1.

If you are planning a telehealth appointment, be sure to ask your health plan if it is covered and how much the copay or coinsurance will be. The appointment may be through your in-network provider or a telehealth company your insurer contracts with, such as Teladoc, Doctor On Demand or MD Live.

You can also contact one of those companies directly for a medical consultation if you don’t have insurance, and pay between $75 and $82 for a regular doctor visit.

If you are one of the 13 million Californians enrolled in Medi-Cal, the state’s Medicaid program, you can get telehealth services at little to no cost.

Large medical offices and health systems usually have their own telemedicine platforms. In other cases, your provider may use a publicly available platform such as FaceTime, Skype or Zoom. Either way, you will need access to a laptop, tablet or smartphone — though, for a phone conversation, a landline or simple cellphone will suffice.

Smartphones with good cameras can be particularly useful in telemedicine because high-resolution photos can help doctors see certain medical problems more clearly. For example, a photo from a good smartphone camera usually provides enough detail for a dermatologist to determine whether a mole requires further attention, Kvedar said.

Relatively inexpensive apps and at-home tools enable you to measure your own blood pressure, pulse rate, oxygen saturation level and blood sugar. It’s a good idea to monitor your vitals and have the numbers ready before you start a virtual visit.

Be aware that a remote visit is not right for every situation. In the case of serious injury, severe chest pain or a drug overdose, for example, you should call 911 or get to the ER as quickly as possible.

Virtual visits also are not recommended in other cases for which the doctor needs to lay hands on you.

Wolfrom has had only a few in-person health visits this year, one of them with a podiatrist who checks his feet every six to 12 months for diabetes-related neuropathy. “That can only be done when you are in the room and the podiatrist is touching and feeling your feet,” Wolfrom says.

Face-to-face visits are generally better for young children. Kids often require vaccinations, and it’s easier for doctors to monitor their growth and development in person, says Dr. Dan Vostrejs, a pediatrician at Santa Clara Valley Medical Center in San Jose.

In general, telemedicine is effective in cases that would typically send you to an urgent care clinic, such as minor injuries or flu-like symptoms, including fever, cough and sore throat.

It is also increasingly used for post-surgical follow-ups. Telemedicine can be a godsend for geriatric or disabled patients with reduced mobility. And it’s a no-brainer for mental health care, which is mostly talking anyway.

Among the top telehealth adopters are medical specialists who treat chronic illnesses such as diabetes, hypertension, cardiovascular disease and asthma, says Dr. Peter Alperin, a San Francisco internist and vice president of product at Doximity, a kind of LinkedIn for medical professionals.

Providers can monitor patients’ vitals remotely and discuss lab results, diet, medications and any symptoms in a video chat or a phone conversation. “If you happen to see something that’s awry, you can bring them into your office,” Alperin says, adding it’s “a better form of triage.”

But telemedicine has some serious disadvantages. For one thing, the less formal setting can allow some routine medical practices to slip through the cracks.

In the second quarter of this year, blood pressure was recorded in 70% of doctor office visits compared with about 10% of telemedicine visits, according to a study published early this month.

Elsa Pearson, a resident of Dedham, Massachusetts, had a medical appointment scheduled in March, which was switched to a telephone call because of the pandemic-induced lockdown.

“It was honestly the most efficient appointment I’ve had in my life,” says Pearson, 30. But, “I must admit, without the push of having the labs right there when you leave the appointment, I’ve yet to get them done.”

Perhaps the biggest pitfall in telehealth is the loss of a more intimate and valuable doctor-patient relationship.

In a recent essay, Dr. Paul Hyman, a Maine physician, reflected on the times when an unexpected discovery during an in-person examination had possibly saved a patient’s life: “A discovery of an irregular mole, a soft tissue mass, or a new murmur — I do not forget these cases, and I do not think the patients do either.”

During the final presidential debate, President Donald Trump claimed that 180 million people would lose their private health insurance to socialized medicine if the Democratic presidential nominee, former Vice President Joe Biden, is elected president.

“They have 180 million people, families under what he wants to do, which will basically be socialized medicine — you won’t even have a choice — they want to terminate 180 million plans,” said Trump.

Trump has repeated this claim throughout the week, and we thought the linkage of Biden’s proposed health care plan with socialism was something we needed to check out. Especially since Biden opposed “Medicare for All,” the proposal by Sen. Bernie Sanders (I-Vt.) that would have created a single-payer health system run completely by the federal government, and has long been attacked by Republicans as “socialist.”

The Trump campaign did not respond to our request asking where the evidence for this claim came from. Experts called it a distortion of Biden’s plan.

Where the Number Comes From

Experts agreed the number of people who have private health insurance either through an employer-sponsored plan or purchased on the Affordable Care Act’s health insurance marketplace is around 180 million people.

KFF, a nonpartisan health policy organization, estimated in 2018 that about 157 million Americans had health insurance through their employer, while almost 20 million had insurance they purchased for themselves. Together, that adds up to about 177 million with private health insurance. (KHN is an editorially independent program of KFF.)

What Does Biden Support?

Biden supports expanding the ACA through several measures, including a public option. Under his plan, this public option would be a health insurance plan run by the federal government that would be offered alongside other private health insurance plans on the insurance marketplace.

“The marketplace is made up of multiple insurers in areas,” said Linda Blumberg, a health policy fellow at the Urban Institute. “Sometimes there are five or more [plans]; sometimes there is only one. Biden is talking about adding a public option in the marketplace. You could pick between these private insurers or you could pick the public option.”

Getting rid of the so-called employer firewall is also part of Biden’s proposal.

This firewall was implemented during the rollout of the ACA. It was designed to maintain balance in the insurance risk pools by preventing too many healthy people who have work-based coverage from opting instead to move to a marketplace plan. And it all came down to who qualified for the subsidies that made these plans more affordable.

Currently, those who are offered a health insurance plan through their employer that meets certain minimum federal standards aren’t eligible to receive these subsidies, which come in the form of tax credits. But that leaves many low-income workers with health care plans that aren’t as affordable or comprehensive as marketplace plans.

Biden’s plan would eliminate that firewall, meaning anyone could choose to get health insurance either through their employer or through the marketplace. That’s where many Republicans argue that we could start to see leakage from private health insurance plans to the public option.

“The problem is healthy people leaving employer plans,” said Joseph Antos, a scholar in health care at the conservative-leaning American Enterprise Institute. That could mean the entire workplace plan’s premiums would go up. “You could easily imagine a plan where it spirals, the premiums go up, and then even more people start leaving the plans to go to the public option.”

Blumberg, though, said that because the marketplace would still include private health insurance plans alongside the public option, it doesn’t mean everyone who chooses to leave their employer plan would go straight to the public option.

She has done estimates based on a plan similar to the one Biden is proposing. She estimates that only about 10% to 12% of Americans would choose to leave their employer-sponsored plans, which translates to about 15 million to 18 million Americans.

KFF also did an estimate and found that 12.3 million people with employer coverage could save money by buying on the exchange under the Biden plan.

But “it’s not clear all of those people would choose to leave their employer coverage, though, as there are other reasons besides costs that people might want to have job-based insurance,” Cynthia Cox, vice president and director of the program on the ACA at KFF, wrote in an email.

Either way, none of the estimates are anywhere close to the 180 million that Trump claimed.

Is This Type of Public Option Socialism?

Overall, experts said no, what Biden supports isn’t socialized medicine.

“Socialized medicine means that the government runs hospitals and employs doctors, and that is not part of Biden’s plan,” Larry Levitt, executive vice president for health policy at KFF, wrote in an email. “Under Biden’s plans, doctors and hospitals would remain in the private sector just like they are today.”

However, Antos said that, in his view, the definition of socialism can really vary when it comes to health care.

“I would argue in one sense, we would already have socialized medicine. We have massive federal subsidies for everybody, so in that sense, we’re already there,” said Antos. “But, if socialized medicine means the government is going to dictate how doctors practice or how health care is delivered, we are obviously not in that situation. I don’t think the Biden plan would lead you that way.”

And in the end, Antos said, invoking socialism is a scare tactic that politicians have been using for years.

“It’s just a political slur,” said Antos. “It’s meant to inflame the emotions of those who will vote for Trump and meant to annoy the people who will vote for Biden.”

Our Ruling

Trump said 180 million people would lose their private health insurance plans to socialized medicine under Biden.

While about 180 million people do have private health insurance, there is no evidence that all of them would lose their private plans if Biden were elected president.

Biden supports implementing a public option on the health insurance marketplace. It would exist alongside private health insurance plans, and Americans would have the option to buy either the private plan or the public plan. While estimates show that a number of Americans would likely leave their employer-sponsored coverage for the public plan, they would be doing that by choice and the estimates are nowhere near Trump’s 180 million figure.

Experts also agree that the public option is not socialized medicine, and it’s ridiculous to conflate Biden’s plan with Medicare for All.

We rate this claim Pants on Fire.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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

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In the second and final debate of the 2020 presidential race, President Donald Trump and former Vice President Joe Biden sparred over Trump’s handling of the pandemic and Biden’s plan to reform health care. In stark contrast to the first debate, there was more policy talk. There was also less interrupting.

Trump said a COVID-19 vaccine is “ready” and will be announced “within weeks,” shortly before conceding that it is “not a guarantee.”

Biden said Trump still has no comprehensive plan to deal with the pandemic, even as case counts continue to climb. “We’re about to go into a dark winter, and he has no clear plan,” Biden said.

Trump claimed Biden’s health care plan would lead to “socialized medicine,” conflating Biden’s proposal to introduce a government insurance option with more progressive proposals that would eliminate private insurance. “I support private insurance,” Biden said, promising, “Not a single person with private insurance would lose their insurance under my plan.”

You can read a full fact check for the evening, done in partnership with PolitiFact, here.

Meanwhile, we broke down the candidates’ closing coronavirus and other health-related claims so you can do your part: vote.

Here are the highlights:

Trump: “We are rounding the turn [on the pandemic]. We are rounding the corner.”False.“Rounding the corner” suggests that significant and sustained progress is being made in the fight against the coronavirus, and that’s not the case, according to the data.

The number of COVID cases is climbing once again, after falling consistently between late July and mid-September. Cases are now at their highest point since early August, with almost 60,000 new confirmed infections a day. That’s only about 10% lower than the peak in late July.

New daily hospitalizations today are lower than in previous spikes, but in the past few weeks there has been a modest increase. The positivity rate, which measures the percentage of tests that come up positive for the virus, has also been going up again in the past few weeks. Higher positivity rates are an indicator of community spread.

The one encouraging change is that, since a peak in August, deaths have fallen fairly consistently. That’s due to a combination of factors, including improved understanding of how to treat the disease. Yet COVID deaths have settled in at about 800 a day, keeping total deaths per week in the U.S. above normal levels.

Trump: His administration has done “everything” Biden suggested to address COVID-19. “He was way behind us.”We rated a similar claim Pants on Fire. While there are some similarities between Biden’s and Trump’s plans to combat COVID-19, experts told us any pandemic response plan should have certain core strategies. The Trump administration has released no comprehensive plan to battle the disease, except with regard to the development and distribution of vaccines. Trump’s main intervention was implementing travel restrictions, while efforts to roll out a widespread testing plan faced difficulties.

Biden released a public COVID plan; the first draft was published March 12. It included public health measures such as deploying free testing and personal protective equipment, as well as implementing economic measures such as emergency paid leave and a state and local emergency fund.

Trump: “As you know, 2.2 million people were expected to die. We closed the greatest economy in the world to fight this horrible disease that came from China.”His claim about the estimated deaths rates Mostly False. Trump frequently refers to this number to claim that his administration’s moves saved 2 million lives. However, the number is from a mathematical model that hypothesized what would happen if, during the pandemic in the U.S., neither people nor governments changed their behaviors, a scenario that experts considered unrealistic. The U.S. has the highest death toll from COVID-19 of any country, and one of the highest death rates. Also, credit for shutting down the economy doesn’t go primarily to Trump, but rather to states and local jurisdictions. In fact, Trump encouraged states to open back up beginning in May, even when there were high rates of COVID transmission in those areas.

Trump: “We cannot lock ourselves in a basement like Joe does.”We rated a similar claim False. It is one of Trump’s favored shots to say Biden isolated himself in his basement. In the first few months of the pandemic, Biden did run much of his campaign from his Delaware home. He built a TV studio in his basement to interact with voters virtually. But that changed.

In September alone, Biden gave remarks and held events in, among other places, Kenosha, Wisconsin; Lancaster, Pennsylvania; Warren, Michigan; Tampa, Florida; and Charlotte, North Carolina. We counted 14 locations.

Trump: Said of Dr. Anthony Fauci, “I think he’s a Democrat, but that’s OK.”This is wrong. Fauci, director of the National Institute of Allergy and Infectious Diseases, is not affiliated with a political party. He hasn’t endorsed any parties or candidates.

Biden: “We are in a circumstance where the president still has no plan, no comprehensive plan.”This is largely accurate. When Biden claimed during the first debate that Trump “still won’t offer a plan,” we noted the Trump administration’s “Operation Warp Speed” for vaccine development as well as its more detailed plan for vaccine distribution. But the administration has not released a comprehensive plan to address COVID-19.

Trump: “There was a spike in Florida. That is gone. There was a spike in Texas. That is gone. There was a spike in Arizona. It is gone.” 

This is inaccurate. Over the summer, Florida, Texas and Arizona experienced record surges in cases that later eased — but now they are all seeing new surges. Over the past week, The New York Times’ tracker notes, as of Friday, new infections are up 37% in Florida, 13% in Texas and 47% in Arizona, from the average two weeks earlier.

Trump: “When I closed [travel from China], he said I should not have closed. … He said this is a terrible thing, you are a xenophobe; I think he called me racist. Now he says I should have closed it earlier.”

Mostly False. Joe Biden did not directly say he thought Trump shouldn’t have restricted travel from China to stem the spread of the coronavirus.

Biden did accuse Trump of “xenophobia” in an Iowa campaign speech the same day the administration announced the travel restrictions — Jan. 31 — but his campaign said that his remarks were not related and that he made similar comments before the restrictions were imposed. Biden didn’t take a definitive stance on the subject until April 3, when his campaign said he supported Trump’s decision to impose travel restrictions on China.

Trump: “They have 180 million people, families under what he wants to do, which will basically be socialized medicine — you won’t even have a choice — they want to terminate 180 million plans.” 

Pants on Fire. About 180 million people have private health insurance. But there is absolutely no evidence that under Biden’s health care proposal all 180 million would be removed from their insurance plans. Biden supports creating a public option, which would be a government-run insurance program that would exist alongside and compete with other private plans on the health insurance marketplace.

Under Biden’s plan, even people with employer-sponsored coverage could choose a public plan if they wanted to. And estimates show that only a small percentage of Americans would likely leave their employer-sponsored coverage if a public option were available, and certainly not all 180 million. Experts said it is not socialized medicine.

Biden: “Not one single person with private insurance” lost their insurance “under Obamacare … unless they chose they wanted to go to something else.”

This is inaccurate. This is a variation of a claim that earned President Barack Obama our Lie of the Year in 2013. The Affordable Care Act tried to allow existing health plans to continue under a complicated process called “grandfathering,” but if the plans deviated even a little, they would lose their grandfathered status. And if that happened, insurers canceled plans that didn’t meet the new standards.

No one determined with any certainty how many people got cancellation notices, but analysts estimated that about 4 million or more had their plans canceled. Many found insurance elsewhere, and the percentage was small — out of a total insured population of about 262 million, fewer than 2% lost their plans. However, that still amounted to 4 million people who faced the difficulty of finding a new plan and the hassle of switching their coverage.

This story includes reporting by KHN reporters Victoria Knight and Emmarie Huetteman, and Jon Greenberg, Louis Jacobson, Amy Sherman, Miriam Valverde, Bill McCarthy, Samantha Putterman, Daniel Funke and Noah Y. Kim of PolitiFact.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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

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When COVID-19 began making headlines in March, Charles Collins pulled out a protective face mask from the supply at the manufacturing company in Rockaway, New Jersey, where he was the shop foreman and put it on. The dozen or so other workers at the facility followed suit. There was no way to maintain a safe distance from one another on the shop floor, where they made safety mats for machines, and a few of the men had been out sick with flu-like symptoms. Better safe than sorry.

Management was not pleased. Collins got a text message from one of his supervisors saying masks were to be used to protect workers from wood chips, metal particles and other occupational safety hazards. “We don’t provide or for that matter have enough masks to protect anybody from CORVID-19 [sic]!” If workers didn’t stop using the masks for that purpose, the supervisor texted, “we’ll have to store them away just like the candy!”

“I was shocked,” said Collins, 38. “They weren’t taking it seriously.”

Shortly after that, Collins left for a planned vacation. When he returned a week later, the company told him to quarantine at home for two weeks because he’d been traveling.

But when the quarantine ended, Collins didn’t want to go back to work. Co-workers, he said, told him that recommended safety measures such as wearing masks and maintaining social distancing hadn’t been implemented. When he told human resources that he feared becoming infected and endangering his mother and his 8-year-old nephew who live with him, he said, he got an ultimatum: Return to work or resign.

Collins stayed home and says he was fired. He hired a lawyer and filed a complaint in the Superior Court of New Jersey under the state’s whistleblower law, the Conscientious Employee Protection Act. The law prohibits employers from firing, demoting or otherwise retaliating against workers who refuse to take part in activities they believe are incompatible with public health and safety mandates.

As many employers, with the strong encouragement of the Trump administration, move to bring employees back, a growing number of workers are resisting what they feel are unsafe, unhealthy conditions. In recent months, a few states have passed laws specifically aimed at protecting workers who face COVID-related safety risks and retaliation for speaking up about them. Some states, like New Jersey, have whistleblower protection laws already. But advocates say stronger federal protections are needed.

The Occupational Safety and Health Administration, part of the U.S. Department of Labor, is responsible for enforcing 23 federal whistleblower statutes that protect workers from retaliation if they report workplace safety violations, among other problems.

But according to a new analysis, the agency isn’t up to the task. The National Employment Law Project, a workers’ advocacy and research group, found that of 1,744 COVID-related retaliation complaints filed with OSHA between April and mid-August, 20% were docketed for investigation and 2% were resolved. More than half were dismissed or closed without investigation.

“Even before COVID, workers had a really bad track record of getting any justice for their concerns if they were retaliated against,” said Debbie Berkowitz, director of the worker health and safety program at the National Employment Law Project and a former senior OSHA official.

The numbers are growing. Whistleblower complaints filed with OSHA increased by 30% between February and May, to 4,101, according to an August report by the Department of Labor’s Office of the Inspector General that criticized the agency’s handling of the complaints.

Nearly 40% of the complaints — 1,618 — were related to COVID-19, the report found, filed primarily by workers who claimed they were punished for reporting workplace safety violations. Those could include, for example, not having appropriate personal protective equipment or sanitation materials, or a lack of social distancing on the job.

While complaints rose, the number of whistleblower investigators decreased from the previous year, according to the report. The average time it took to close an investigation at the end of March was roughly nine months.

Worker whistleblower protections under the Occupational Safety and Health law are “incredibly weak” compared with whistleblower statutes that protect employees who report other types of wrongdoing, Berkowitz said. If OSHA dismisses a complaint, workers have no right to appeal the decision, and once they file a complaint with OSHA they aren’t permitted to take their case to court on their own, she said.

Consumer advocates would like to see those provisions changed.

Advocates have urged OSHA to adopt mandatory COVID safety standards for workplaces, but the agency has declined to do so, maintaining that its “general duty clause,” which requires employers to maintain a workplace free from hazards likely to cause death or physical harm, is sufficient.

“The Administration has remained committed to providing the Whistleblower Protection program with the resources it needs to fulfill its mission,” a spokesperson for the Department of Labor wrote in an email to KHN. “In fiscal year 2020, OSHA asked for and received five new full-time employees and requested an additional ten in the President’s budget for fiscal year 2021.”

If workers don’t pursue a whistleblower complaint through OSHA, they can file a state lawsuit claiming “wrongful discharge” or use a state’s whistleblower law, as Collins did.

According to a COVID employment litigation tracker by Fisher Phillips, an employment law firm, since the beginning of the year 169 retaliation/whistleblower lawsuits have been filed across the country — the second-biggest category, behind suits related to remote work/leave, with 206 cases. An additional 27 lawsuits have been filed for wrongful discharge.

Juan Carlos Fernandez, the Morristown, New Jersey, attorney representing Charles Collins, said he’s seen a significant uptick in inquiries from workers about safety concerns in recent months. Before the pandemic began, he typically received one or two such calls per month. Now, he gets three or four a day.

Many callers say they were terminated after they asked for protective equipment on the job, Fernandez said. Others had asked for time off to care for a family member or a child whose school had closed because of COVID-19 and then were told not to come back to work.

In addition to reporting safety violations, Collins’ lawsuit claims, he was fired for asking to take time off. Under the federal Families First Coronavirus Response Act, employees are generally entitled to two weeks’ paid leave if they’re quarantined, and another two weeks’ paid sick leave at two-thirds pay to care for a child whose school has closed, as well as expanded family and medical leave. Collins has cared for his nephew since his sister died two years ago in a car accident. His nephew’s school closed in March because of COVID-19.

Collins said his employer, ASO Safety Solutions, paid him for only the first week of his company-ordered quarantine. Any additional time off would come out of his accrued sick and vacation time, he was told.

ASO Safety Solutions didn’t respond to requests for comment, nor did the law firm representing the company.

In his response to the complaint submitted to the court, the lawyer representing the company denied that ASO had retaliated against Collins for whistleblowing, asserting he had resigned. The response, by John Olsen, with Ferdinand IP Law Group, also said that the provisions of the Families First Coronavirus Response Act do not apply to the company. The lawyers have exchanged requests for discovery, Fernandez said, which should be answered in the next several weeks.

A few states and cities have stepped in to help whistleblowers. Virginia was the first to put in place statewide workplace safety standards related to COVID-19, spurred by concerns from workers in poultry plants, said Rachel McFarland, a staff attorney at the Legal Aid Justice Center in Charlottesville. The standards include specific provisions protecting workers from retaliation for raising safety concerns or refusing to work in a location they believe is unsafe.

Colorado and the cities of Philadelphia and Chicago likewise passed laws prohibiting employers from retaliating against workers who raise COVID-related safety concerns, refuse to work in unsafe conditions or take time off to minimize the transmission of the virus.

But these laws are the exceptions, said Brent Newell, a senior attorney at Public Justice in Oakland, California, who has represented the interests of workers in meatpacking plants. “Many states haven’t done that and won’t do that,” he said. “For the federal government to put it on the states to protect workers is wholly and fundamentally inadequate.”

This story was produced by KHN, an editorially independent program of  KFF.

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

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KHN chief Washington correspondent Julie Rovner discussed the impact of the election and the upcoming Supreme Court challenge on the Affordable Care Act with New Hampshire Public Radio’s “The Exchange” and WNYC’s “The Brian Lehrer Show” on Wednesday. Rovner also spoke with Newsy’s “Morning Rush” on Thursday about the roles of health care and COVID-19 in the presidential campaign.

• Click here to hear Rovner on New Hampshire Public Radio
• Click here to hear Rovner on WNYC
• Click here to watch Rovner on Newsy
• Read Rovner’s “Biden’s Big Health Agenda Won’t Be Easy to Achieve”
• Read Rovner’s “Without Ginsburg, Judicial Threats to the ACA, Reproductive Rights Heighten”

KHN Midwest correspondent Lauren Weber discussed COVID vaccine distribution with “Newsy Reports” on Oct. 16.

• Click here to watch Weber on Newsy

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

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SACRAMENTO — The survival of California’s dialysis clinics is in the hands of its voters this November.

Sound familiar?

Voters heard the same dire campaign claim two years ago, when the dialysis industry spent a record $111 million to defeat a statewide ballot measure that would have limited clinic revenues.

Industry giants DaVita and Fresenius Medical Care are back on the defense again this year with their checkbooks open, flooding voters’ mailboxes and screens with political ads highlighted by heartfelt testimonials from patients against Proposition 23. With more than a week left before Election Day, the industry is on track to break its own spending record.

This time, the measure’s sponsor, the Service Employees International Union-United Healthcare Workers West, which represents more than 95,000 health care workers in California, focused the ballot measure less on dialysis clinic profits and more on patient safety.

The union, which has tried but failed to organize dialysis clinic workers, has been the driving force behind both ballot measures, putting voters squarely in the middle of a long-running brawl — and forcing them to make decisions that could affect the health of tens of thousands of Californians.

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“There’s no reasonable evidence that this would improve patient health,” said Erin Trish, associate director of the University of Southern California’s Leonard D. Schaeffer Center for Health Policy & Economics. “It seems largely to be driven by retaliation by SEIU-United Healthcare Workers West, who are mad the dialysis facilities wouldn’t let their workers unionize.”

Proposition 23 would require dialysis clinics to have a licensed physician on-site during all dialysis treatments, but that doctor wouldn’t need to be a nephrologist, a kidney specialist. Clinics would have to report infection data every three months to the California Department of Public Health, and those that plan to close would need state approval.

About 80,000 patients visit the state’s 600 licensed chronic dialysis clinics, three-quarters of which are owned or operated by DaVita or Fresenius, the largest dialysis companies in the country, according to a report by the nonpartisan state Legislative Analyst’s Office.

Patients with kidney failure often need a dialysis machine to filter toxins and remove excess fluid from their blood when their kidneys can no longer do the job. The treatment is arduous, taking roughly four hours at least three times a week.

Dialysis patients are susceptible to infection for a variety of reasons: Their immune systems are already compromised by their kidney failure, they are around other sick patients while receiving treatment, they require catheters to access their veins, and their blood is cycled through a machine.

Even though mortality rates have dropped among outpatient dialysis patients nationwide, infections remain a leading cause of death. In California, about one-third of outpatient clinics have fallen short of federal performance standards so far this year, resulting in lower Medicare payments to those clinics, according to federal payment records.

“With this initiative, we’ll make sure that they put more of those huge profits back into the clinics to improve safety and improve care,” said Steve Trossman, spokesperson for the union.

Dialysis clinics are once again threatening to close if the measure passes and they’re faced with higher operating costs.

Shama Aslam, 50, spoke at the behest of the union. Aslam, who visits a dialysis clinic in Stockton three times a week, described swatting fruit flies off her face and arms for hours while hooked up to a dialysis machine. She has polycystic kidney disease and has been waiting three years for a kidney transplant.

“It was really bad today,” Aslam said on a recent October afternoon. “It’s very uncomfortable. And because we’re dealing with blood all the time, we don’t want any infection. That’s a huge thing, at least for me.”

Aslam wishes she could see a doctor more than once a month. Nephrologists oversee their patients’ dialysis care, but clinic staff members administer the treatments. Federal regulations require a medical director, who is a board-certified physician, to oversee every dialysis clinic in the country. But there is no requirement that those directors remain physically present at the clinic when it is open. That’s what the California ballot measure would mandate.

Rick Barnett, chief executive officer and president of Satellite Healthcare, which operates 80 dialysis clinics in Texas, Tennessee, New Jersey and California, including Aslam’s clinic, said he had not heard of fruit flies at that Stockton facility. Medicare has not penalized that clinic this year, according to the payment database.

Many nonprofits like San Jose-based Satellite Healthcare could not afford to hire on-site doctors if Proposition 23 passes, Barnett said. Currently, medical directors often oversee multiple clinics in addition to their other job responsibilities.

The Legislative Analyst’s Office estimated it would cost each clinic several hundred thousand dollars a year, while the industry says $600,000 a year. Each clinic likely would have to hire more than one doctor to cover all hours.

Barnett estimates Satellite would close up to 40% of its 67 clinics in California should the ballot measure pass.

“It comes down to an attack on the industry,” he said. “This is one of the few sectors of health care they haven’t organized.”

Trossman vehemently disagreed that the union is trying to punish the dialysis companies over its failed unionization effort, saying the union invests in improving people’s lives.

“In terms of the idea that we would spend millions of dollars because essentially we’re ticked off is just ludicrous,” he said. “We don’t spend money that way.”

The California Medical Association, which represents physicians, opposes the measure, saying it would exacerbate the state’s doctor shortage by diverting physicians into dialysis clinics.

“This will bring physicians who are not trained in kidney disease or dialysis to just be present without any role or purpose, or even a clear path to any intervention because they won’t know what to do,” said Dr. Edgard Vera, a nephrologist and the medical director of DaVita dialysis clinics in Southern California’s High Desert towns of Hesperia and Victorville.

Critical emergencies, such as wild swings in blood pressure, already are handled by technicians and nurses certified in dialysis care, Vera said. Should a patient go into cardiac arrest, “if a physician is there, they are going to call the ambulance anyway,” he said.

DaVita alone had given nearly $67 million to the “No on 23” campaign as of Wednesday, more than half of the $105 million raised so far by the industry, according to campaign finance reports filed with the California secretary of state. The campaign’s other contributors include Fresenius, Satellite Healthcare, U.S. Renal Care and Dialysis Clinic Inc.

The “Yes on 23” campaign has reported just a fraction of that, with nearly $9 million in contributions. SEIU-United Healthcare Workers West gave the bulk of the money, with the rest — about $40,000 — coming from non-monetary donations from the California Democratic Party.

Proposition 23 follows an uneven record of wins and losses for the union on dialysis issues in California. The union tried but failed to organize dialysis workers three years ago, arguing that they needed safer working conditions and job protection. It also lost its 2018 ballot initiative that would have capped dialysis clinic profits.

But, last year, the union helped persuade state lawmakers to adopt a bill that aimed to stop a billing practice dialysis companies use to get higher insurance reimbursements for some low-income patients. A federal judge in January temporarily blocked the law from taking effect while the court considers its constitutionality.

“It’s not unusual for us to be voting on similar issues over and over again if they’re backed by powerful enough interests,” said Danielle Joesten Martin, associate professor of political science at California State University-Sacramento, pointing to other repeat ballot measures on the November ballot, such as the Realtor-backed Proposition 19. That measure would give Californians over 55 years old a property tax break when buying a new home.

They’re “powerful interest groups who didn’t get what they wanted the last time around.”

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For the first time in a long time, there is some good news about the coronavirus pandemic: Although cases continue to climb, fewer people seem to be dying. And there are fewer cases than expected among younger pupils in schools with in-person learning. But the bad news continues as well — including a push for “herd immunity” that could result in the deaths of millions of Americans.

Meanwhile, the Trump administration is doubling down on efforts to allow states to require certain people with low incomes to prove they work, go to school or perform community service in order to keep their Medicaid health benefits. The administration is appealing a federal appeals court ruling to the Supreme Court and just granted Georgia the right to impose a work requirement.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

• Opinions seem to be slowly shifting on opening schools around the country. As fall approached, many people were hesitant to send their children back to school because they feared a resurgence of coronavirus infections, but early experiences seem to show that there has been little transmission among young kids in classrooms.
• Even with good results in those school districts that have reopened, however, the debate about whether schools should be conducting in-person learning is quite polarized. President Donald Trump repeatedly calls for all schools to resume, while groups, such as unions representing teachers and other employees, are more likely to be calling for continued online learning.
• California, which had a strong resurgence of the virus during the summer, is seeing signs of success in fighting back. The state has been among the most aggressive in shutting down normal activities to reduce case levels. It devised a county-specific method to determine closures, restrictions and reopenings — and it appears to be working.
• A proposal by some researchers to move the country toward a “herd immunity” plan, in which officials would expect the virus to spread among the general population while also trying to protect the most vulnerable — such as people living in nursing homes — is gaining support among some of Trump’s advisers. Public health advocates are raising alarms because it would likely lead to hundreds of thousands more deaths. They also fear the administration’s focus on restoring normalcy would by default move in this direction.
• Federal researchers this week announced that nearly 300,000 excess deaths have been recorded this year and much of it is attributed to COVID-19 or the lack of other health care by people who could not or did not seek treatments because they were frightened by the pandemic.
• With the Senate poised to confirm Amy Coney Barrett, who opposes abortion, to the Supreme Court within days, the fate of the landmark Roe v. Wade decision is in question. If the court overruled that decision, abortion policies would likely fall back to individual states. A recent report on the effects of such a scenario finds that a huge swath of the South and the Midwest would be left without a local facility offering abortion services.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Cook’s Illustrated’s “The Best Reusable Face Masks,” by Riddley Gemperlein-Schirm, and The Washington Post’s “Consumer Masks Could Soon Come With Labels Saying How Well They Work,” by Yeganeh Torbati and Jessica Contrera

Margot Sanger-Katz: The Hill’s “Republicans: Supreme Court Won’t Toss ObamaCare,” by Peter Sullivan

Paige Winfield Cunningham: The Wall Street Journal’s “Some California Hospitals Refused Covid-19 Transfers for Financial Reasons, State Emails Show,” by Melanie Evans, Alexandra Berzon and Daniela Hernandez

Alice Miranda Ollstein: ProPublica’s “Inside the Fall of the CDC,” by James Bandler, Patricia Callahan, Sebastian Rotella and Kirsten Berg

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunes, Stitcher, Google Play, Spotify, or Pocket Casts.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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

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Molly Wiese was truly stumped. Her parents and siblings live in Southern California, and Wiese, a 35-year-old lawyer, has returned home every Christmas since she moved to Minnesota in 2007.

Because of the pandemic, Wiese thought it would be wiser to stay put for once. But in June, Wiese’s father was diagnosed with stage 4 cancer, and they feared this could be his final holiday season.

Should she fly with her husband and two young sons to California, putting her immunocompromised father at risk of COVID-19? Or stay home and miss out on making treasured holiday memories with her parents and children?

Her children are in day care, and Wiese’s husband works at a school. They don’t have enough vacation time to self-quarantine before or after a flight, and driving eight days round trip isn’t practical.

She fears giving her father coronavirus. But her parents, who live in the Inland Empire city of Yucaipa, believe it’s worth the risk to see Wiese’s children and have “our normal Christmas,” she said.

“Ideally, we’d have a vaccine,” she said. “But I don’t think that’s a realistic expectation.” Pfizer, the apparent leader in the COVID vaccine race, says it won’t even be ready to apply for vaccine approval until late November at the earliest.

While Wiese’s conundrum is especially high-stakes, her story illustrates the tough decision millions of Americans are facing about whether and how to travel for the winter holidays.

The best way to avoid spreading disease would be to avoid traveling or widening one’s social circles. For local celebrations, self-quarantining for two weeks before a holiday event would minimize risk if all those invited committed to doing the same. But some people have to work outside the home.

For everyone, after at least seven months of being mostly sequestered, the winter holidays pose an almost insurmountable temptation. Even public health and infectious disease experts recognize the dilemma.

“There’s so much to be gained by physical touch, by being in that room and not in a two-dimensional Zoom or FaceTime screen,” said Dr. Peter Chin-Hong, an infectious disease specialist and professor of medicine at the University of California-San Francisco. “And even to embrace, with the right preparation.”

Dr. Anthony Fauci, the nation’s authority on infectious diseases at the National Institutes of Health, isn’t immune to the problem. He told PRI’s “The World” on Oct. 13 that he and his three adult daughters, each living in a different state, were still deciding whether being together would be “worth it.”

The next day, Fauci told “CBS Evening News” that his family’s Thanksgiving reunion was off, given the risks posed by air travel. “You may have to bite the bullet and sacrifice that social gathering, unless you’re pretty certain that the people that you’re dealing with are not infected,” he said.

Dr. Robert Redfield, director of the Centers for Disease Control and Prevention, and Dr. Deborah Birx, the Trump administration’s senior coordinator in the COVID fight, have both warned that Thanksgiving gatherings could spread the virus.

In California, public health officials are taking a “harm reduction” approach: They aren’t encouraging multi-household gatherings, but they’ve issued guidelines to make get-togethers safer if they happen outdoors and last less than two hours.

Officials in Los Angeles County, which has seen transmission rates increase in recent weeks, released similar guidance, acknowledging that people separated from their loved ones for months increasingly yearn for that contact.

“We are threading the needle here, but I think it is appropriate for us to try to do some of the activities that people are desperate to be able to do, with absolute adherence to the guidance,” Barbara Ferrer, director of the county’s public health department, said at an Oct. 14 news conference.

Around the world, national holidays have fueled the spread of COVID-19 in explosive ways. In China, where the pandemic started, an estimated 5 million people traveling for Chinese New Year left Wuhan, the epicenter of the outbreak, before a travel ban was enacted. In Iran, the pandemic was aided by Nowruz, a two-week spring celebration that prompted millions to travel. In Israel, parties and religious gatherings for Purim caused widespread transmission in late March.

Memorial Day, the Fourth of July and Labor Day celebrations fueled surges in the United States, which is why Thanksgiving frightens public health officials. Last year, more than 55 million people were expected to travel during the days surrounding that fourth Thursday in November.

Nevertheless, officials across the nation are using a light touch when it comes to warnings.

In Minnesota, where Wiese lives and cases are hitting record highs, officials urge the public to avoid crowded stores and large indoor gatherings with other households, but say outdoor Thanksgiving dinners with local friends and family are less risky. Their guidance doesn’t explain how to endure an outdoor Thanksgiving in Minnesota. The average high in Minneapolis on Nov. 26 is 33 degrees.

Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, is waving his hands to stop the game.

If you can’t self-quarantine for 10 to 14 days before the event — that is, no contact with people besides members of your household who are also quarantining — don’t go to another household’s Thanksgiving dinner, he said: The state has already seen too many examples of vulnerable people becoming sick and dying after attending weddings, funerals and birthday parties.

“Let this be your COVID year,” Osterholm said. “It’s a very challenging year, but you don’t want to introduce this virus into family settings and experience the consequences.”

Osterholm and his partner will spend Thanksgiving and Christmas without extended family, even though their children and grandchildren are all local. Because all his grandchildren are in day care or school, there isn’t enough time for their families to self-quarantine before enjoying a holiday meal together.

He was sympathetic to Wiese’s “compelling” plight. If she decides to fly to California, he said, she should sequester her family as much as possible for 10 days beforehand, then spend no more than two days with her father.

“Even if she got infected, she wouldn’t be most infectious until probably day three,” he said. “So if she spends those two days with him, she can feel relatively good about the fact that she didn’t put them at risk.”

For those who do travel, driving is much safer than flying because drivers can be isolated in a household pod and avoid exposure to the coronavirus by forgoing restaurants and by disinfecting bathroom and gas pump handles before touching them.

Dr. Iahn Gonsenhauser, chief quality and patient safety officer for the Ohio State University’s Wexner Medical Center, said he plans to drive with his family — overnighting at a hotel on the way — to spend Thanksgiving with his sister’s family in Colorado.

He and his family keep to themselves and work from home as much as possible, leaving the house only for groceries and basic errands while eschewing restaurants and malls, he said. If anyone in either family began showing COVID symptoms, or had confirmed exposure to a COVID-positive person, the whole trip would be called off instantly.

“This is why we make all plans with a refundable reservation,” he said. “If people have no way of backing out of their reservations, they’re more inclined to push through an apparent risk.”

Chin-Hong offered this advice for holiday flyers: Get tested before the flight for peace of mind, buy tickets on a plane that is leaving middle seats empty, use highly protective N95 masks and possibly face shields, and blast the individual airplane vents directly onto each family member to disrupt potential virus particles. And, of course, wash your hands frequently.

Chin-Hong is taking that approach on a planned family trip to New York City to visit his mother, who is in her 80s and wants to see her son, daughter-in-law and grandchildren. Every visit they have could be their last, Chin-Hong said.

“To me, the risk-benefit ratio really supports me going to see her.”

After hearing the advice from Chin-Hong and other infectious disease experts, Wiese decided last weekend to buy plane tickets to visit her parents.

“It really did help us make a decision that was giving me a lot of anxiety,” she said.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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

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