Category: From California Healthline.org

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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If we really want to stem the spread of the coronavirus as winter looms and we wait for a vaccine, here’s an idea: The government should pay bars, many restaurants and event venues to close for some months.

That may sound radical, but it makes scientific sense and even has a political precedent. We pay farmers not to cultivate some fields (in theory, at least, to protect the environment), so why not compensate owners to shut their indoor venues (to protect public health)?

In the past nine months, we’ve learned a lot about this particular coronavirus and how it’s most likely to spread. Drinking establishments and indoor event venues have emerged as ideal environments for transmission. And there’s good scientific logic to explain that.

Viruses are not villains who go after their prey; they’re passive opportunists. Some spread through food or when left on surfaces. Others, like this coronavirus, can be transmitted through tiny droplets that can linger in the air after an infected person coughs, talks or breathes. The virus spreads most easily indoors and particularly in crowded, poorly ventilated places.

More important, people can be infectious while their bodies are incubating this virus for a couple of days before they develop symptoms, or even if they never develop symptoms at all. So you might go to a bar or a wedding feeling top-notch, or just maybe a little off. Drink, kiss and dance till you drop. Then you wake up the next morning feeling awful. It’s not just a hangover. It’s COVID-19.

That explains why this virus is exceedingly contracted at “superspreader” events. (More so than the flu, according to the Centers for Disease Control and Prevention.) A person who is shedding a good deal of the virus still feels well enough to hang out in a tight (likely indoor) space where people mingle boisterously with others they don’t know or don’t see often. And they can’t wear masks, because they’re drinking.

No wonder bars are a problem.

In scientific parlance, the coronavirus is more of a “heterogeneous” than a homogeneous spreader, according to Bjarke Frost Nielsen, a researcher at the Niels Bohr Institute at the University of Copenhagen. Along with his colleague Kim Sneppen, he uses mathematical modeling to study the pattern of the spread of the virus. That heterogeneous spread means that it tends to expand in burst-like outbreaks, often centered on a meeting place — a hot spot — rather than oozing slowly across a country.

There is some good news in this finding, Nielsen told me: “You can close down certain types of gatherings and a few types of places and tamp down the majority of the spread of the disease. And you can carry on with the rest as pretty normal.”

Back when we knew little about the novel coronavirus, the government responded with a hammer. The Paycheck Protection Program treated all small businesses equally, providing them with loans to shut down so long as they paid their employees. Now we can use more delicate instruments.

Food and clothing stores — indeed, most any kind of shop — can function safely with masking and attention to distancing and sanitizing. We don’t go to these places to chat, and we can all wear masks inside them. Factories and assembly lines can protect workers with masking and spacing. Schools can do the same for students.

Even movie theaters can arguably safely operate with masked patrons, quality ventilation systems and spacing between viewers or viewing groups. They just won’t be able to sell as many seats.

But bars and restaurants that depend on packed indoor dining and concert halls with dance floors? Most are attractive for exactly the reasons that make them such petri dishes for the coronavirus — the crowding, the drinking, the carousing with new, different people.

That’s why some bar and restaurant owners say they would welcome a program that compensated them to shut their doors this winter. Peter Kurzweg, who co-owns three of what he calls “drink forward” establishments in Pittsburgh that used to have bustling happy hours, says that “bars and restaurants are unique in that to be really safe, they have to mitigate to a point that it’s not a bar or restaurant experience anymore.”

He and his partners have so far weathered the pandemic with outdoor seating on the sidewalk and in an alley. They have taken advantage of government loan programs. They have invested in tents and heaters and encouraged patrons to “lean in” to having fun outside. But as fall turns to winter in Pittsburgh, he knows it won’t last. “I walk around saying, ‘Winter is coming. Winter is coming.’ We need to do everything we can to survive.”

Some states have allowed restaurants to open indoors at 25% or 50% capacity — indeed, that is permitted now in Pittsburgh. But Kurzweg has not done so, because he doesn’t feel it’s safe. Anyway, he added, “No bar or restaurant can make it at that capacity — on the best days in normal years, our profit margin is 10%.”

Some very spacious high-end restaurants, and those in temperate climates, might be able to make it work. Most can’t.

Bars and other venues that depend on drinks are not essential services. We want them to survive so that in the future we can enjoy them. So why not pay owners who cannot keep their businesses afloat safely this COVID-tainted year an average of their normal monthly income to shut down for some months? They would keep paying their employees and help break the chain of coronavirus transmission. Maybe we could get creative and ask them to use their kitchens to help feed Americans who are going hungry.

With bars closed, you could still drink and socialize with smaller groups of people at home or outdoors, when the weather allows it. That may not be quite as much fun, but nothing is much fun while the coronavirus is around.

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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This story can be republished for free (details).

Facing a pandemic, record unemployment and unknown future costs for COVID-19 treatments, health insurers selling Affordable Care Act plans to individuals reacted by lowering rates in some areas and, overall, issuing only modest premium increases for 2021.

“What’s been fascinating is that carriers in general are not projecting much impact from the pandemic for their 2021 premium rates,” said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University in Washington, D.C.

Although final rates have yet to be analyzed in all states, those who study the market say the premium increases they have seen to date will be in the low single digits — and decreases are not uncommon.

That’s good news for the more than 10 million Americans who purchase their own ACA health insurance through federal and state marketplaces. The federal market, which serves 36 states, opens for 2021 enrollment Nov. 1, with sign-up season ending Dec. 15. Some of the 14 states and the District of Columbia that operate their own markets have longer enrollment periods.

The flip side of flat or declining premiums is that some consumers who qualify for subsidies to help them purchase coverage may also see a reduction in that aid.

Here are a few things to know about 2021 coverage:

It might cost about the same this year — or even less.

Despite the ongoing debate about the ACA — compounded by a Supreme Court challenge brought by 20 Republican states and supported by the Trump administration — enrollment and premium prices are not forecast to shift much.

“It’s the third year in a row with premiums staying pretty stable,” said Louise Norris, an insurance broker in Colorado who follows rates nationwide and writes about insurance trends. “We’ve seen modest rate changes and influx of new insurers.”

That relative stability followed ups and downs, with the last big increases coming in 2018, partly in response to the Trump administration cutting some payments to insurers.

Those increases priced out some enrollees, particularly people who don’t qualify for subsidies, which are tied both to income and the cost of premiums. ACA enrollment has fallen since its peak in 2016.

Charles Gaba, a web developer who has since late 2013 tracked enrollment data in the ACA on his ACASignups.net website, follows premium changes based on filings with state regulators. Each summer, insurers must file their proposed rates for the following year with states, which have varying oversight powers.

Gaba said the average requested increase next year nationwide is 2.1%. When he looked at 18 states for which regulators have approved insurers’ requested rates, the percentage is lower at 0.4%.

Another study, by KFF, of preliminary premiums filed this summer had similar findings: Premium changes in 2021 would be modest, only a few percentage points up or down. (KHN is an editorially independent program of KFF.)

It’s still worth it to shop around.

Actuaries and other experts say premiums vary by state or region — even by insurer — for a number of reasons, including the number and relative market power of insurers or hospitals in an area, which affects the ability of insurers to negotiate rates with providers.

Because subsidies are tied to each region’s benchmark plan, and those premium costs may have gone down, subsidies also could decrease. (Benchmark plans are the second-lowest-priced silver plan in a region.)

Switching to the benchmark plan can help consumers maintain how much they spend in premiums.

Enrollees should update their financial information, particularly this year when many are affected by work reduction or job losses. “They might be eligible for a bigger” subsidy, said Myra Simon, executive director of commercial policies for America’s Health Insurance Plans, the industry lobbying group.

Enrollees can update their information online, or call their federal or state marketplace for assistance. Insurance brokers, too, can aid people in signing up for ACA plans. When shopping, consumers should check whether the doctors and hospitals they want to use are included in the plan’s network.

Premiums are just one part of the equation. Consumers should also look closely at annual deductibles, because the trade-off of going with a lower-cost premium may well be higher annual deductibles that must be met before much of the coverage kicks in.

“We encourage people to consider all their options,” said Simon.

What’s behind the variation.

Enrollees in some states next year will see premium decreases, according to Gaba’s website: Maine, for example, shows a 13% drop in weighted average premium prices, while Maryland’s is down almost 12%. At the same time, Indiana’s average is up 10%. And Kentucky is up 5%.

Both Maine and Maryland attribute the decrease to state programs that provide reinsurance payments to health insurers to help offset high-cost medical claims.

In Florida, regulators say insurance premiums will rise about 3%, while the state exchange in California is reporting just over a half-percent increase, its lowest average increase since opening in 2014. Officials in California cite factors that include an influx of healthier enrollees and a reduction in fees that insurers pay.

Other factors affecting rates include how much state regulators step in to alter initial rate filings, along with a provision of the ACA that requires insurers to spend at least 80% of revenue on direct medical care. If insurers don’t meet that standard, they must issue rebates to policyholders. Many insurers were already on the hook to return money in 2020 for previous years.

Most insurers did not cite additional COVID treatment or testing costs as factors in their requested rate increase, Gaba said. Even those that did, however, mainly found them unnecessary because of reduced expenditures resulting from patients delaying elective care during the spring and summer.

Indeed, many insurers in the second quarter posted record profits.

“Some of them thought, ‘We’re going to make more than we thought this year in profits, so let’s not be aggressive with pricing next year,’” said Donna Novak, a member of the American Academy of Actuaries’ Individual and Small Group Markets Committee.

A smaller factor may be the repeal of a fee paid by insurers on premiums. Part of the ACA, the fee was permanently eliminated by the Trump administration effective for 2021.

Your choice of insurers may have widened.

More insurers, including UnitedHealth Group, either stepped back into that individual market or expanded into new counties.

“Insurers are seeing a profit or potential for it,” said John Dodd, an insurance broker in Columbus and past president of the Ohio Association of Health Underwriters.

Rates are down in general across his state for ACA plans, he said, and he expects agents to be busier than ever, simply because there are more plan offerings and choices to make and people want help.

Insurers, he said, like the way the ACA is working.

“People on TV who say it’s not working, they don’t know what they’re talking about,” said Dodd. “It’s working well [for insurers] and every year it gets better.”

New stuff in some states, including a public option.

Residents of New Jersey and Pennsylvania will buy coverage from new state-based marketplaces for 2021, after those states pulled out of the federal healthcare.gov, which now covers 36 states.

Lawmakers in those states said running their own marketplaces gives them more control and may save them money over time.

In 19 Washington state counties, insurers are offering “public option plans,” which have all the standard benefits, including lower deductibles, and must meet additional quality standards.

As envisioned, the public option plans aimed to be less expensive, with the legislation tying payment rates to Medicare. Insurers offering a public option must stick to an aggregate cap of paying doctors, hospitals and other medical providers an average of 160% of what Medicare would pay for the same services.

When the premium rates came in, however, the five insurers offering the plans had varying prices. Not all parts of the state have the option, but where they do, two of the public option insurers have premiums that are either lower than other plans in the area or are the lowest-cost plan the insurer offers.

But three are more expensive.

The state’s marketplace staff said the higher prices may reflect a number of things, from difficulty getting the program started during COVID-19 to a lack of incentives to get providers to participate.

It could also just be normal first-year jitters.

“It’s Year One. As with any market entry strategy, people are pretty conservative,” said Michael Marchand, chief marketing officer of the Washington Health Benefit Exchange.

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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If Joe Biden wins the presidency in November, health is likely to play a high-profile role in his agenda. Just probably not in the way he or anyone else might have predicted.

Barring something truly unforeseen, it’s fairly certain that on Jan. 20 the U.S. will still be in the grip of the coronavirus pandemic — and the economic dislocation it has caused. Coincidentally, that would put a new President Biden in much the same place as President Barack Obama at his inauguration in 2009: a Democratic administration replacing a Republican one in the midst of a national crisis.

Obama had only a financial crisis to deal with. Still, Biden would have a couple of advantages his Democratic predecessor lacked, including the fact that, as vice president, he helped guide the country through that financial meltdown. He’s also had time to plan how to address the crisis, which was not the case in 2009, when the economy was in freefall just as the new administration was taking office.

But like Obama before him, Biden will face a long must-do list on taking office. He will have to tackle the pandemic and economic crisis before he can turn to some of the big health changes he’s promised, such as expanding the reach of the Affordable Care Act, creating a “public option” that would allow every American to enroll in a government-sponsored plan and lowering the eligibility age for Medicare from 65 to 60.

And even if Democrats do retake the Senate majority and keep control of the House, it is unlikely the majority in either chamber will be as large as in 2009, when Obama had 60 Senate votes.

Still, no matter what the partisan makeup of Congress, “priority one is to get the COVID response going,” said Len Nichols, a professor of health policy at George Mason University.

Biden’s COVID plan includes taking major responsibility for the pandemic back from the states. His federal response would include more money for, and coordination of, testing and contact tracing; ensuring adequate protective equipment for health professionals; and assuring the public that new treatments and vaccines will be based on science, not politics.

In an updated version of his plan, Biden has also promised that one of his first calls if he is elected will be to Dr. Anthony Fauci, the government’s top infectious disease expert, who has been derided by President Donald Trump. “Dr. Fauci will have full access to the Oval Office and an uncensored platform to speak directly to the American people — whether delivering good news or bad,” says Biden’s website.

Biden’s COVID plan also addresses the economy — including calls for emergency paid leave for workers dislocated by the pandemic and more financial aid for workers, families and small businesses.

“If we’ve learned anything, it is that the health sector and the economy are not two separate spheres. They are connected,” said Nichols. “I think health care and the economy are complementary and will be for the foreseeable future.”

Assuming Biden gets beyond the pandemic and recession, he could move onto some of his bigger health promises, including expanding eligibility for Medicare, creating a “public option” health plan and boosting premium subsidies for the ACA.

Biden took heat throughout the primaries for his “moderate” approach to improving health insurance access and costs, compared with the “Medicare for All” plans for a government-run system supported by his top rivals, Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.). But that doesn’t mean his far less sweeping approach would be easy to get through Congress.

“There’s a really big difference when you’re running the government than when you’re running for office,” said Dan Mendelson, a former Clinton administration health official and founder of the health consulting firm Avalere Health.

Many of Biden’s proposals, including a public option and larger subsidies to help low- and middle-income people pay for insurance, are the very things that an overwhelmingly Democratic Congress could not pass as part of the original Affordable Care Act in 2010. Conservative Democratic senators objected to the plan.

“We pushed,” Obama said in a recent interview on the podcast “Pod Save America,” talking about the public option. “I needed 60 votes to get it through the Senate. Joe Lieberman, Ben Nelson and a couple others said, ‘I’m not voting for a public option.’”

Mendelson said another big obstacle is that for all the detail Biden has in his health plan, concepts like the public option “are not well-defined, and there are many different theories of what it should be and where it should be fielded. There’s no common vision about what it really means.”

The same thing is true, he added, for something that seems as simple as reducing the Medicare eligibility age. “More than half these people have commercial insurance,” he said. “What will happen to them?”

Grace-Marie Turner, of the conservative Galen Institute, suggested Biden — or Trump, if he’s reelected — might be better served by pursuing one of the more bipartisan health issues that already have broad support from the public, like prescription drug prices or “surprise” medical bills patients receive after getting care from a doctor outside their insurance network while being treated at an in-network facility. “It would be a big statement,” she said. “Whoever wins would then have the wind at their back.”

But even those issues have a way of getting complicated. Both Democrats and Republicans say they want to bring down drug prices, but Republicans are vehemently against one of the Democrats’ preferred ways of doing that: by allowing Medicare to negotiate with drugmakers. And surprise medical billing has so far defied efforts to fix it, as Congress seems unable to choose between health insurers and health providers, who each want the other to bear the additional costs.

As always, even when health is at the top of the agenda, it proves difficult to address.

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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President Donald Trump has repeatedly claimed to have saved 2 million lives from COVID-19 through his actions to combat the disease.

Recently, he made the assertion during the NBC News town hall on Oct. 15 that replaced the second presidential debate.

“But we were expected to lose, if you look at the original charts from original doctors who are respected by everybody, 2,200,000 people,” Trump said. “We saved 2 million people,” he added.

He mentioned the same ballpark figure during a Sept. 15 ABC News town hall and posted a tweet about it on Oct. 13.

Others in the Trump administration have also pointed to the 2.2 million figure. Vice President Mike Pence referenced it during the vice presidential debate on Oct. 7. So did Health and Human Services Secretary Alex Azar during a Sept. 20 “Meet the Press” television interview.

Where did this number come from? And is there any truth to the idea that Trump is responsible for saving 2 million lives from COVID-19? Since Trump continues to use it to claim success, we decided to look into it.

What We Know About the ‘2 Million’

The White House and the Trump presidential campaign did not respond to our request for evidence supporting the idea that roughly 2 million lives were spared.

It appears to have first been mentioned by the president during a March 29 White House coronavirus task force press briefing, when Trump and Dr. Deborah Birx, task force coordinator, explained they were asking Americans to stay home from mid-March through the end of April, because mathematical models showed 1.6 million to 2.2 million people could die from COVID-19.

The warning stemmed from a paper authored by Neil Ferguson, an epidemiology professor at Imperial College London. He modeled how COVID-19 can spread through a population in different scenarios, including what would happen if no interventions were put in place and people continued to live their daily lives as normal.

In the paper, Ferguson wrote, “In total, in an unmitigated epidemic, we would predict approximately 510,000 deaths in [Great Britain] and 2.2 million in the US.”

Ferguson did not respond to our request to talk through the study with him. But in a July email interview with HuffPost, he said Trump’s boasting of saving 2.2 million lives isn’t true, because the pandemic isn’t over.

Andrea Bertozzi, a mathematics professor at UCLA, said it was important to remember the 2.2 million figure was derived from a modeling scenario that would almost certainly never happen — which is that neither the government nor individuals would change their behavior at all in light of COVID-19.

The study didn’t mean to say 2.2 million people were absolutely going to die, but rather to say, “Hold on, if we let this thing run its course, bad things could happen,” said Bertozzi. Indeed, the results from the study did cause government leaders in both the U.S. and the United Kingdom to implement social distancing measures.

Experts also pointed out that the U.S. has the highest COVID-19 death toll of any country in the world — more than 220,000 people — and among the highest death rates, according to the Johns Hopkins Coronavirus Resource Center.

“I don’t think we can say we’ve prevented 2 million deaths, because people are still dying,” said Justin Lessler, an associate professor of epidemiology at Johns Hopkins Bloomberg School of Public Health.

In some instances when using the 2 million estimate, Trump and others in his administration cited the China travel restrictions for saving lives, while other times they’ve credited locking down the economy. We’ll explore whether either statement holds water.

Did Travel Restrictions Do Anything?

Trump implemented travel restrictions for some people traveling from China beginning Feb. 2 and for Europe on March 11. But experts say and reports show the restrictions don’t appear to have had much effect because they were put in place too late and had too many holes.

The Centers for Disease Control and Prevention reported the first cases of coronavirus in the U.S. arrived in mid-January. So, since the travel bans were put in place after COVID-19 was already spreading in the U.S., they weren’t effective, said Josh Michaud, associate director for global health policy at the KFF. (KHN is an editorially independent program of KFF.)

A May study supports that assessment. The researchers found the risk of transmission from domestic air travel exceeded that of international travel in mid-March.

Many individuals also still traveled into the U.S. after the bans, according to separate investigations by The New York Times and the Associated Press.

Based on all this, experts said there isn’t evidence to support the idea that the travel restrictions were the principal intervention to reduce the transmission of COVID-19.

What About Lockdowns?

On the other hand, the public health experts we talked to said multiple global and U.S.-focused studies show that lockdowns and implementing social distancing measures helped to contain the spread of the coronavirus and thus can be said to have prevented deaths.

However, Trump can’t take full credit for these so-called lockdown measures, which ranged from closing down all but essential businesses to implementing citywide curfews and statewide stay-at-home orders. On March 16, after being presented with the possibility of the national death tally rising to 2.2. million, the White House issued federal recommendations to limit activities that could transmit the COVID-19 virus. But these were just guidelines and were recommended to be in effect only through April 30.

Most credit for putting in place robust social distancing measures belongs to state and local government and public health officials, many of whom enacted stronger policies than those recommended by the White House, our experts said.

“I don’t think you can directly credit the federal government or the Trump administration with the shutdown orders,” said Lessler. “The way our system works is that the power for public health policy lies with the state. And each state was making its own individual decision.”

Some studies also explore the potential human costs of missed opportunities. If lockdowns had been implemented one or two weeks earlier than mid-March, for instance, which is when most of the U.S. started shutting down, researchers estimated that tens of thousands of American lives could have been saved. A model also shows that if almost everyone wore a mask in the U.S., tens of thousands of deaths from COVID-19 could have been prevented.

Despite these scientific findings, Trump started encouraging states — even those with high transmission rates — to open back up in May, after the White House’s recommendations to slow the spread of COVID-19 expired. He has also questioned the efficacy of masks, said he wouldn’t issue a national mask mandate and instead left mask mandate decisions up to states and local jurisdictions.

Our Ruling

President Trump is claiming that without his efforts, there would have been 2 million deaths in the U.S. from COVID-19.

But that 2 million number is taken from a model that shows what would happen without any mitigation measures — that is, if citizens had continued their daily lives as usual, and governments did nothing. Experts said that wouldn’t have happened in real life.

And while lockdowns and social distancing have indeed been proven to prevent COVID-19 illness and deaths, credit for that doesn’t go solely to Trump. The White House issued federal recommendations asking Americans to stay home, but much stronger social distancing measures were enforced by states.

Travel restrictions implemented by Trump perhaps helped hold down transmission in the context of broader efforts, but on their own, they don’t seem to have significantly reduced the transmission rate of the coronavirus.

We rate this claim Mostly False.

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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SACRAMENTO — In an election year dominated by a chaotic presidential race and splashy statewide ballot initiative campaigns, Californians are being asked to weigh in on the value of stem cell research — again.

Proposition 14 would authorize the state to borrow $5.5 billion to keep financing the California Institute for Regenerative Medicine (CIRM), currently the second-largest funder of stem cell research in the world. Factoring in interest payments, the measure would cost the state about $7.8 billion over about 30 years, according to the nonpartisan state Legislative Analyst’s Office.

In 2004, voters approved a $3 billion, 30-year bond via Proposition 71 to get the state agency up and running and to seed research. That measure will end up costing taxpayers about $6 billion, including interest.

During that first campaign, voters were told research funded by the measure could lead to cures for cancer, Alzheimer’s and other devastating diseases, and that the state could reap millions in royalties from new treatments.

Yet most of those ambitions remain unfulfilled.

“I think the initial promises were a little optimistic,” said Kevin McCormack, CIRM’s senior director of public communications, about how quickly research would yield cures. “You can’t rush this kind of work.”

So advocates are back after 16 years for more research money, and to increase the size of the state agency.

Stem cells hold great potential for medicine because of their ability to develop into different types of cells in the body, and to repair and renew tissue.

When the first bond measure was adopted in 2004, the George W. Bush administration refused to fund stem cell research at the national level because of opposition to the use of one kind of stem cell: human embryonic stem cells. They derive from fertilized eggs, which has made them controversial among politicians who oppose abortion.

Federal funding resumed in 2009, and thus far this year the National Institutes of Health has spent about $321 million on human embryonic stem cell research.

But advocates for Proposition 14 say the ability to do that research is still tenuous. In September, Republican lawmakers sent a letter to President Donald Trump urging him to cut off those funds once again.

The funding from California’s original bond measure was used to create the new state institute and fund grants to conduct research at California hospitals and universities for diseases such as blood cancer and kidney failure. The money has paid for 90 clinical trials.

A 2019 report from the University of Southern California concluded the center has contributed about $10.7 billion to the California economy, which includes hiring, construction and attracting more research dollars to the state. CIRM funds more than 56,500 jobs, more than half of which are considered high-paying.

Despite the campaign promises, just two treatments developed with some help from CIRM have been approved by the Food and Drug Administration in the past 13 years, one for leukemia and one for scarring of the bone marrow.

But it’s a bit of a stretch for the institute to take credit for these drugs, said Jeff Sheehy, a CIRM board member who does not support the new bond measure. He said the agency funded the researcher whose lab discovered and developed the drugs, but CIRM holds no rights to those drugs and doesn’t receive royalties from them.

The state has received about $518,000 in revenue from licensing other institute-funded discoveries, such as devices, McCormack said.

McCormack also pointed to some promising stem cell therapies still in clinical trials, such as a treatment that has cured 50 children of severe combined immunodeficiency, a genetic disorder often called “bubble baby” disease, and others that have led to “dramatic” improvements in paralysis and blindness, he said.

The campaigns for both bond measures may be giving people unrealistic expectations and false hope, said Marcy Darnovsky, executive director of the Center for Genetics and Society. “It undermines people’s trust in science,” Darnovsky said. “No one can promise cures, and nobody should.”

Robert Klein, a real estate developer who wrote both ballot measures, disagrees. He was inspired to invest in stem cell research after he lost his youngest son to Type 1 diabetes. He said some of CIRM’s breakthroughs are helping patients right now.

“What are you going to do if this doesn’t pass? Tell those people we’re sorry, but we’re not going to do this?” Klein said. “The thought of other children needlessly dying is unbearable.”

Sheehy, who has served on the agency’s board for 16 years, said he’s proud of the work the institute has done but believes it should be funded through the legislature, not by borrowing more money.

“The promise was that it would pay for itself and it hasn’t,” Sheehy said. “We can’t really afford it, and this is the worst way to pay for it.”

Even if CIRM isn’t turning a profit, some researchers and private companies are benefiting from the public money. Take the company Forty Seven Inc., named after a human protein and co-founded by Irving Weissman, director of Stanford University’s stem cell research program. The state stem cell agency awarded more than $15 million to Forty Seven, and $30 million to Weissman at Stanford for research.

That money fueled research that uncovered a promising treatment for several different cancers. Gilead Sciences, the pharmaceutical giant, bought Forty Seven in 2018 for $4.9 billion. Of that, $21.2 million went back to CIRM to pay back Forty Seven’s research grants, with interest.

“Gilead will make far more than that if it turns out to be lucrative,” said Ameet Sarpatwari, a professor of medicine at Harvard Medical School who studies drug development.

Because this kind of work is both expensive and risky, private companies are reluctant to pay for early research, when scientists have no idea if their work will yield results, let alone profits, Sarpatwari said. So the state pays for this work, and drug companies come in to finance later-stage research once a molecule looks promising — and ultimately reap the profits.

Case in point: Fedratinib, one of the two FDA-approved drugs funded partly by CIRM, can cost about $20,000 for 120 capsules, according to GoodRx.

“We’re socializing the risk of drug development and privatizing the gains,” Sarpatwari said.

On paper, the institute has stricter pricing regulations than the NIH, which does not require that drugs developed with public money are accessible to the public. In California, companies have to submit plans for how uninsured patients will get medicine and are required to sell those medications to the state’s public health programs at a specified rate.

But in practice, the regulations have never really been tested.

Proposition 14 would add a new rule. It would take the money California makes from royalties and use it to help patients afford those treatments. It also benefits drug companies: Whatever revenue the state makes from these drugs will go back to the companies in the form of state-financed patient subsidies.

The measure also would establish a new working group (complete with 15 new, full-time staffers) that would help make clinical trials more affordable for patients by paying for lodging and transportation to the trials.

And it would increase the size of CIRM’s governing board from 29 to 35. This contradicts recommendations from the Institute of Medicine, which suggested shrinking the board to avoid conflicts of interest. Klein argues the extra board positions are necessary to represent different regions and areas of expertise.

Ultimately, California voters must weigh the possibility of new treatments against the cost of financing them with debt.

“We want to develop new therapies, and initiatives like what California is doing are well positioned to do that,” Sarpatwari said. “But at the end of the day, they’re only as good as people being able to access them affordably.”

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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Donella Pogue has trouble finding dentists in her rural area willing to accommodate her 21-year-old son, Justin, who is 6 feet, 8 inches tall, is on the autism spectrum and has difficulty sitting still when touched.

And this summer, he had a cavity and his face swelled. Pogue, of Bristol, New York, reached out to the Eastman Institute for Oral Health in Rochester, which offers teledentistry.

Dr. Adela Planerova looked into his mouth from 28 miles away as Pogue pointed her laptop’s camera into her son’s mouth. Planerova determined they did not need to make an emergency one-hour drive to her clinic. Instead, the dentist prescribed antibiotics and anti-inflammatory drugs, and weeks later he had surgery.

Teledentistry allows dental professionals like Planerova to remotely review records and diagnose patients over video. Some smile about its promise, seeing it as a way to become more efficient, to reach the one-third of U.S. adults who federal figures from 2017 estimate hadn’t seen a dentist in the previous year and to practice more safely during the pandemic.

But others see it as lesser-quality care that’s cheaper for dental professionals to provide, allowing them to make more money. At the same time, widespread adoption is hindered by issues such as spotty internet and insurance companies unwilling to reimburse for teledentistry procedures.

Dr. Christina Carter, an orthodontist in Morristown, New Jersey, said teledentistry has its place but shouldn’t replace time in the dental chair.

“It cannot be used for a full diagnosis because we need other tools, like X-rays,” she said. “We have all tried to see things on our phone or even on a Zoom call, and there is still just a different feel.”

Still, as the pandemic curbs in-person visits and reduces dentists’ revenue, more dentists are seeking guidance from Dr. Nathan Suter, a leading teledentistry advocate who owns the consulting company Access Teledentistry. Since March, he said, he’s done webinars for about 9,000 dental professionals, up from fewer than 1,000 in the three years before the pandemic.

Teledentistry providers trace the practice to 1994, when the Army launched a pilot program in which health care providers used an intra-oral camera to take photos of a patient’s mouth at a fort in Georgia and then sent them over the internet to a dental clinic at a fort 120 miles away.

Over the next two decades, dentists in upstate New York and the San Francisco Bay Area led teledentistry pilot programs for underserved children, some of whom were in preschool and already had cavities. The number of children who completed the prescribed dental treatment rose significantly.

Supporters say teledentistry can help reach the 43% of rural Americans who lack access to dental care. Medicaid and the Children’s Health Insurance Program will pay for many dental procedures for those enrolled in those programs, but only 38% of dentists participate in those programs, according to the American Dental Association. One reason: Medicaid typically reimburses at a significantly lower rate than those of private insurance plans.

Teledentistry could help dentists treat more patients and make more money a number of ways. If dentists remotely review data captured by hygienists, they can see more patients. Because video appointments save them time, dentists then have room for the people “who need the more expensive services” while also focusing on preventive care, said Kirill Zaydenman, vice president of innovation for DentaQuest, an administrator of dental insurance and oral health care provider.

But dentists have not widely adopted teledentistry — mainly because they’ve had difficulty getting insurers to pay for it, said Dr. Dorota Kopycka-Kedzierawski, a Rochester dentist. That’s partly because of insurers’ concerns about fraud. Dr. Paul Glassman, who started the Virtual Dental Home project to reach underserved preschool children in the Bay Area, considers those fears “completely incorrect.”

“If you want to bill for something you didn’t do,” he said, “you can do that just as easily in an in-person environment as you can using teledentistry.”

Since March, as the pandemic descended, most, if not all, private dental plans have been reimbursing for teledentistry, said Tom Meyers, vice president of public policy for America’s Health Insurance Plans, a trade organization. And all state Medicaid programs now reimburse for teledentistry in some form, Glassman said, though policies differ by state and some practices may not be covered in some places.

But teledentistry isn’t reimbursable under Medicare. (Most dentistry isn’t.) Another obstacle to widespread adoption: Some dentists and lawmakers connect teledentistry to companies offering at-home teeth aligners with little or no in-person contact with a dentist. Glassman has promoted teledentistry throughout the United States and reviewed proposed legislation or regulations in states such as Idaho, Massachusetts and Texas. He said he hears concerns from dentists about the lack of an in-person exam during which X-rays are taken. Such concerns are reflected in some legislation.

SmileDirectClub, an at-home teeth-aligner company, has argued in statehouse testimony that in-person care is not always needed. The company opposed a 2019 bill in Texas that aimed to improve access to dentistry in rural areas because it included a number of restrictions on teledentistry, including one that would have required an in-person dentist’s examination if a teledentistry provider treated that patient for more than 12 months.

SmileDirect’s attorney argued at a hearing the rule “could interrupt the course of a patient’s treatment.”

The measure failed.

Proponents argue teledentistry isn’t just about making more money. Pogue, the New York woman, said it was the best option for her son with special needs.

“He is really afraid of dentistry, so when he goes to see someone, he is really tense and really jumpy, so that’s another reason the teledentistry was nice was because he was in my bedroom doing it, so he was really comfortable,” said Pogue, 53, whose son is covered by Medicaid.

A few weeks later, Justin did have to have surgery, which went “perfect,” his mom said.

Some dentists say teledentistry faces particular stumbling blocks in rural areas. Dr. Mack Taylor, 36, a dentist who grew up in the small town of Dexter, Missouri, now practices in a health center just down the road. Twenty years ago, he said, Dexter had eight dentists. Now there are only three.

Technology is a major obstacle for local residents, many of whom lack reliable internet service. Taylor recently applied for a U.S. Department of Agriculture grant that would give him $26,500 to buy equipment so that, for example, a hygienist can take photos inside the mouths of nursing home residents and send them to Taylor to review.

“It’s not like medicine where you can discuss someone’s ailments and have a good idea what’s going on,” Taylor said. “Maybe all you can tell me is ‘I have a broken tooth,’ but I can’t physically see what’s going on and prescribe the right treatment.”

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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Just 15 days ahead of the election, Montana Lt. Gov. Mike Cooney laid out his ideas on how he’d handle the COVID-19 pandemic if elected governor. Details were few, but the Democrat’s plan became one of only a handful being offered by candidates in the 11 U.S. governor’s races about how they’ll approach what’s certain to be the dominant issue of their terms, should they win.

While much of the nation’s focus is on who will be president come January, voters who are deciding the next occupant of their governor’s mansion are also effectively choosing the next leader of their state’s COVID-19 response. The virus has made governors’ power highly visible to voters. As the states’ top executives, they decide whether to issue mask mandates, close businesses and order people to stay home.

All but two races for governor feature incumbents running for reelection: Montana’s Democratic Gov. Steve Bullock can’t run again because of term limits and Utah’s Republican Gov. Gary Herbert decided not to run for another term. In several other competitive races for governor this year, such as those in North Carolina and Missouri, opponents clash on the role of state mandates in slowing the virus. Still, COVID-19 often fades into the backdrop of many long-standing platforms or primarily comes up as candidates talk about the need to revive the economy.

Cooney’s proposal, released Monday, suggested using the National Guard to transport patients in extreme weather and subsidizing heating bills to help those quarantining at home. But other parts vaguely described how he would “develop a robust plan” to come.

His opponent, Republican U.S. Rep. Greg Gianforte, has acknowledged the health crisis but has focused primarily on the economy, saying the state has to “cure the economic pandemic” the virus caused.

Bryce Ward, a health economist with the University of Montana, said Cooney’s list was one of the first times he’s seen long-term planning for COVID-19 come up in what appears to be the nation’s tightest governor’s race. But, he added, neither Montana candidate has offered a concrete plan to deal with the dual crises that risk public health when people gather and businesses’ bottom lines when they don’t. Meanwhile, the state’s number of COVID-19 cases climbs and its economy suffers.

“Whoever wins, this is going to be the bulk of their term,” Ward said. “How are the candidates going to keep people afloat as long as they can? What are we doing in terms of planning for what we think our post-COVID world is going to look like?”

An October KFF poll found 29% of registered voters said the economy was the most important issue in choosing a president, while 18% said the coronavirus outbreak was their top issue. Republican voters were more likely to pick the economy, the survey found, and Democrats were more likely to pick the coronavirus. (KHN is an editorially independent program of KFF.)

“There are voters that feel that the government needs to lead, and there are voters that feel that the government is utilizing a pandemic to become too invasive,” said Capri Cafaro, a former Democratic Ohio state senator now teaching in American University’s public administration and policy department. “People are not necessarily making their decisions on ‘Did you do contact tracing? Are you going to slow the spread?’”

Among the incumbent governors seeking reelection this year, most of their campaigns’ focus on COVID-19 has been on how well they’ve responded to the crisis. Several pledge more of what they’ve been doing. “We’ll continue to follow the science and wear masks,” Delaware Democratic Gov. John Carney said in a recent debate.

Meanwhile, their challengers generally seek to cast the incumbents as mismanaging their states’ response and promising to undo what’s been done. Those who have put out actual plans to handle the pandemic are Democratic challengers to Republican governors, and their plans are similar to what Cooney released — some specific ideas and promises to fill in the gaps later.

In Missouri, Democratic challenger Nicole Galloway, who is the state auditor, made health care the center of her campaign and released a plan to respond to the virus with a statewide mask mandate and a limit on when public school classes can meet in person based on the community’s rate of infection.

Republican Gov. Mike Parson is the apparent front-runner in that state’s race. He has pledged to lead “the greatest economic comeback that we’ve ever seen in Missouri history.” The former Polk County sheriff also has focused on supporting law enforcement amid backlash against police brutality and racial injustice.

Curbing the coronavirus has taken a back seat to boosting the economy in Parson’s campaign. And, as governor, Parson has refused to issue a statewide mask mandate, despite a White House recommendation to do so. In late September, the governor and his wife tested positive for COVID-19. Parson has returned to work, which includes traveling across the state.

One of the more heated races is in North Carolina, where Democratic Gov. Roy Cooper is defending his seat against a challenge by his lieutenant governor, Republican Dan Forest. Forest sued Cooper this year to challenge the governor’s authority to impose COVID-related restrictions by executive order.

Forest dropped the lawsuit in August after a judge made a preliminary ruling against his case, then said on Twitter, “I did my part. If y’all want your freedoms back you’ll have to make your voices heard in November.”

Cooper’s campaign called the lawsuit “a desperate tactic to garner attention” for Forest’s political campaign. Since then, the governor has slowly eased COVID restrictions, updating an executive order to allow a limited number of people in bars, sporting events, movie theaters and amusement parks. Cooper is leading the race in recent polls.

Back in Montana, the pandemic surfaced in the gubernatorial campaign after health officials announced on Oct. 16 that a Helena concert, which Gianforte attended, was linked to several COVID-19 cases. More than 100 health professionals blasted him in an open letter for flouting local health restrictions, going maskless and making light of safety precautions at campaign events. Cooney called on him to suspend his campaign events until tested. Gianforte’s campaign has said he’s taking proper precautions and accused Cooney of politicizing a public health issue.

Cooney has said he’ll keep Montana’s COVID-19 response on the track he is helping set as lieutenant governor, with science guiding that work. Gianforte, who built a tech startup in Bozeman, has touted his business experience as proof he can lead Montana’s comeback. Both have said more needs to be learned about this virus and have pitched themselves as the one to steer the state’s economy through the crisis.

Ward, the University of Montana health economist, said the details are missing, such as how the winner will support businesses through the winter without federal aid. Or what the new governor would cut from the state budget if the economic crisis hits its coffers.

The state has a public mask mandate and a plan for reopening the economy with no apparent thresholds or timelines. The option for stricter rules has been left to county governments as the state sees its largest COVID surge yet.

Jeremy Johnson, a political scientist at Carroll College in Helena, said the initial lack of detailed pandemic policy in the state’s race could be attributed to both candidates trying to win over swing voters with safe themes. President Donald Trump won Montana in 2016 by 20 points, but the state has also had a Democratic governor for 16 years. While polls show Gianforte leading Cooney slightly, election handicappers Real Clear Politics and the Cook Political Report still consider the race a toss-up.

Yet as Election Day nears, the question of how to address the pandemic only looms larger. Montana’s case count is rising, adding to its total of more than 23,000 cases in the state of roughly 1 million.

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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