Category: From California Healthline.org

DENVER — For Laura Stoutingburg and her family, Halloween has always been a monthlong celebration of corn mazes, pumpkin patches and, of course, trick-or-treating in their suburban Denver neighborhood.

However, the COVID-19 pandemic has forced the mother of two to change their plans.

“Traditional trick-or-treating house to house does not feel like a smart choice to me this year,” Stoutingburg said.

Families across the nation are haunted by the same dilemma: How can they safely keep the pandemic from overshadowing Halloween? Can families trick-or-treat and go to haunted houses, or should they opt for lower-risk activities at home?

Health experts say families should err on the side of caution when it comes to trick-or-treating and other traditional fall activities. Much depends on each family’s comfort with taking risks and ensuring they adhere to safety standards and common sense, they said. Masks should be worn by all, even if not part of a costume.

“My kids love going to the farm … to go pumpkin-picking, apple-picking and all those things we do in the fall,” said Dr. Aaron Milstone, a professor of pediatrics and an associate epidemiologist at Johns Hopkins University in Baltimore. But, he added, “if you show up at the pumpkin patch and it’s packed with people, that’s not the right time for you to be there.”

The Centers for Disease Control and Prevention recently released Halloween guidelines that warn against high-risk activities like traditional trick-or-treating, haunted houses and costume parties, as well as hay and tractor rides, among other things. The federal agency is also clear on the need for social distancing, mask-wearing and hand-washing to continue.

Many parents are coming up with creative alternatives for Halloween night. For Stoutingburg, 30, that means hosting a small sleepover with relatives that features pumpkin-carving, cupcake-decorating and a scavenger hunt.

Jody Allard and her family also will forgo their usual tricks and treats. Allard, 42, lives in Seattle and has a rare genetic disease putting her at higher risk for COVID-19. The mother of seven said her family will make new traditions this year.

“We’re going to make a bunch of different fun foods from the Halloween shows they like to watch on the Food Network, and we’re going to watch kid-friendly Halloween movies,” Allard said.

In Lancaster, Pennsylvania, 44-year-old writer Jamie Beth Cohen’s daughter came up with the idea that she and her brother dress up in costumes and trick-or-treat inside their own home, with their parents behind the doors of various rooms, waiting with candy.

“She’s excited to wear a costume without a jacket and get lots of the kind of candy she likes,” Cohen said.

Maya Brown-Zimmerman and her family of six never miss out on trick-or-treating in Cleveland. But they will this year, with Brown-Zimmerman, 35, at higher risk for COVID-19 because of multiple lung diseases. Instead, her family will use their costume money on new Halloween decor, and her four kids, ages 3 to 11, will search for candy at home.

“I’ll hide eggs of candy in the front yard for my little kids,” she said. “After they go to bed, the older kids will have a hunt for eggs in the dark in our backyard with flashlights.”

For families still hoping to trick-or-treat this year, though, what can be done to stay as safe as possible?

The Harvard Global Health Institute created a website to help parents assess their risk level for Halloween activities with a color-coded map of county COVID data. It shows which counties are “lower-risk” zones for COVID (green and yellow), where parents might feel more comfortable allowing their children to trick-or-treat, and which are higher-risk areas (orange and red), where online parties and very small gatherings are recommended instead.

Milstone said families should think less in terms of green versus red zones and more in terms of staying safe no matter what, especially considering asymptomatic carriers.

“Rather than people getting a false sense of security that ‘My area is a low-risk area, so I’m just gonna go and do whatever,’ I would say ideally everyone practices the same safe things,” he said.

Dr. Heather Isaacson, a pediatrician with UCHealth in Longmont, Colorado, said masks must be worn by all and has a simple suggestion for the reluctant: “Decorate those masks and incorporate them into the costumes.”

People who hand out candy also should wear masks, added Dr. Alok Patel, a pediatrician and co-host of the “Nova” and PBS Digital Studios show “Parentalogic.” If trick-or-treaters see candy-givers without masks, he suggested wishing them a “Happy Halloween” and passing them by for the next home.

“If people are outside serving candy without a mask, consider the added risk of potential respiratory droplets flying around, including in the candy bowl,” said Patel.

When it comes to handing out candy, it’s a good idea to maintain as much distance as possible.

“Think outside of the box with ideas like a reverse trick-or-treating, where kids stay home and dress up and neighbors do a parade and throw candy,” said Isaacson. She also recommended creating individual goody bags in place of bowls of treats.

“You could go all out and make candy chutes or a giant spider web with candy trapped in it. In some ways, the physically distanced candy-delivery ideas sound more fun,” said Patel.

As for the candy itself, Milstone isn’t as concerned about wrappers as about hand-washing. The primary message is, “Don’t let your kid eat candy with dirty hands,” he said. That means no eating candy until they’re able to get home to wash properly.

While you could technically sanitize wrappers, said Dr. Rita Nasseri, a Los Angeles physician and mother of three, “the safest solution is to buy your own candy and give your children that as a treat.”

As for teens, who may want more independence, Dr. Sam Dominguez, a pediatrician specializing in infectious diseases and medical director of the microbiology lab at Children’s Hospital Colorado, recommended that small groups of friends get together outside and carve pumpkins or watch a projected movie — while wearing masks, of course.

Nasseri advised something similar, adding that food served buffet-style and communal candy should be avoided.

In Boone County, Missouri, currently experiencing a rapid uptick in COVID-19 cases, Karina Koji said her family will stay home on Halloween night. They plan to dress up in costumes and face masks and give out bags of individually wrapped candies. They’ll also leave candy bags in the driveway for anyone who doesn’t feel comfortable coming up to the door.

“We shouldn’t let the pandemic take Halloween from us,” said Koji, 45. “We’ve all had to give up so much. It’s entirely possible to celebrate this fun holiday while staying healthy and keeping ourselves and others safe.”

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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Reopening colleges drove a coronavirus surge of about 3,000 new cases a day in the United States, according to a draft study released Tuesday.

The study, done jointly by researchers at the University of North Carolina-Greensboro, Indiana University, the University of Washington and Davidson College, tracked cellphone data and matched it to reopening schedules at 1,400 schools, along with county infection rates.

“Our study was looking to see whether we could observe increases both in movement and in case count — so case reports in counties and all over the U.S.,” said Ana Bento, an infectious disease expert and assistant professor at Indiana University’s School of Public Health.

“Then we tried to understand if these were different in counties where, of course, there were universities or colleges, and particularly, to see if these increases were larger in magnitude in colleges with face-to-face instruction primarily,” she said.

Nearly 900 of those schools opened primarily with in-person classes, according to the draft study.

The research examines the period from July 15 to Sept. 13. It does not name specific institutions or locations, but researchers found a correlation between schools that attempted in-person instruction and greater disease transmission rates.

Just reopening a university added 1.7 new infections per day per 100,000 people in a county, and teaching classes in person was associated with a 2.4 daily case rise, the study found.

“No such increase is observed in counties with no colleges, closed colleges or those that opened primarily online,” the study says.

Factoring in whether students came from places where disease incidence was high added 1.2 daily cases per 100,000 people.

Daily new case counts nationwide during the study period ranged from a high of 70,000 to a low of 30,000, according to data compiled by The New York Times.

The authors are not calling it a mistake for colleges to have opened, considering the many variables each school faced. But earlier reporting on reopening plans around the country found a welter of chaotic efforts that did not conform to a single standard, suggesting the potential for disaster when students returned.

In fact, numerous reports surfaced around the country showing frightening COVID spikes in college towns, often blamed on partying by students. Even at the University of Illinois, a school lauded for its preparations and robust testing, more than 2,000 cases have been reported on campus since students went back last month. Cases there peaked about a week after classes began and have fallen since then.

The authors are not faulting irresponsible young people, either, since they studied class instruction methods, not behavior off campus, where some students have acted extremely poorly.

“I think that it’s slightly unfair, perhaps, to say, ‘Oh, students are congregating and creating these bad behaviors that lead to outbreaks,’” Bento said. “I think it’s more this idea of when you see a huge influx from all over the country, or from different counties, into a college town that we know had a very low burden of COVID throughout the first months, all of a sudden we have this increased probability of infection, because we have a large community of individuals that were susceptible still.”

Rather than lay blame, she said, the idea of the study was to measure the problem and then use that data to better figure out how to respond, which is the subject of a future study.

“In order for you to open online, hybrid or meet face to face, there needs to be a different combination of strategies that allows you to catch [cases] early so you’re able to control community spread, which is the biggest problem here,” Bento said.

The researchers hope to have that work done relatively soon, well before colleges start spring semesters.

There are some unanswered questions, such as how much of the surge in cases is simply from sick students testing positive when they arrive versus catching COVID-19 after they arrive — and how much students spread the virus to the community or the other way around.

Another is how well specific types of responses mitigated the spread, and whether different local safety measures helped or hurt.

And there is an alarming caveat: The work almost certainly did not capture the full extent of the campus-linked surge.

“While this study estimates around a 3,000 increase in daily cases, we have to take into account that this is actually likely an underestimate, because we still don’t see” people who are asymptomatic, Bento 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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For the past month, record-breaking wildfires have torched millions of acres from the Mexican border well into Canada, their smoke producing air so toxic that millions of people remained indoors for days on end while many visited hospitals because of respiratory distress.

Last week, Hurricane Sally left a trail of watery devastation in Mississippi, Alabama and the Florida Panhandle, even as more storms brewed offshore.

All of that on top of the COVID-19 pandemic, which has killed nearly 1 million people worldwide.

The timing couldn’t have been better for the opening this month of the Center for Healthy Climate Solutions at UCLA’s Fielding School of Public Health.

Its mission is to work with policymakers and community groups to help safeguard human health against the ravages of climate change. The center was founded on the premise that the long-feared effects of climate change are already here and must be met with policies not only to slow the warming of the planet but also to help people adapt to its reality.

The center’s co-directors, Dr. Jonathan Fielding and Michael Jerrett, believe the clock is running out and we must quickly reduce the amount of carbon being pumped into the atmosphere to have any hope of preserving a viable planet.

“A lot of the predictions of what could happen with climate change have been wrong. But the predictions have been wrong in that they haven’t been catastrophic enough,” Fielding, a professor of medicine and public health at UCLA and former head of the Los Angeles County Department of Public Health, said in an interview last week.

Jerrett, a professor of environmental health sciences at UCLA’s Fielding School who also participated in the interview, is the principal investigator on a study hypothesizing that long-term exposure to air pollution elevates the risk of severe COVID-19 outcomes. Other studies have yielded similar findings.

The following excerpts of the interview with Fielding and Jerrett were edited for length and clarity:

Q: Could the hazardous air quality from the wildfires burning across much of the West Coast fuel an increase in severe COVID-19 cases and deaths?

Jonathan Fielding: There’s a very good chance of that. There is no doubt the effects of air pollution on the lungs and other organs are substantial and contribute to people with chronic problems being more susceptible to the severe effects of COVID.

Michael Jerrett: When we have wildfire events like this, as people are exposed to these high levels of smoke, we see increases in those indicators of morbidity and mortality. And we’ve seen those effects for several lung diseases that have similarities to COVID, like pneumonia.

Q: How does climate change exacerbate the racial, ethnic and socioeconomic health disparities that are so prevalent in our society?

Fielding: You already have people who have a higher rate and burden of chronic illness. Just look at the rates of obesity, for example, as well as the rate of cardiovascular disease. Those are certainly exacerbated by increased heat and by where people can afford to live. A lot of people can only afford a place that’s going to have a lot of heat islands, it’s not going to be air-conditioned, it might not have much in the way even of public transportation.

Jerrett: If you look through very long periods of time, people who have more resources — whether that’s better social contacts or they’re more highly educated, or have higher incomes, or other factors that put them at a social advantage — have always been able to protect themselves from environmental risks better than people who lack those resources.

Q: Can you explain how wildfires affect mental health?

Jerrett: There’s emerging and increasingly convincing literature that shows air pollution is related to anxiety and depression. It’s thought that the change in the nervous system that seems to be stimulated by air pollution, and perhaps the vascular system changes, can affect brain function and lead people into a more depressive state. … Secondly, the loss of immediate surroundings that people are familiar with: So if you are used to looking out and seeing a beautiful forest, and you walk out and you look in your backyard and you see nothing but smoke, and the whole forest is gone, that can affect mental health.

Q: Can we expect to see pandemics more frequently?

Fielding: What I think most people are missing in discussing this issue is population growth. We’re increasing the interface between humans and other species that have viruses that may not affect them but very severely affect humans. So, that’s one issue. The second issue is that climate change is increasing the area where you have vectors that can thrive. So, for example, we’re going to wind up with mosquitoes that can transmit dengue fever and malaria in the U.S.

Q: You talk about the “health co-benefits” of programs that can help slow climate change while mitigating its impact on public health. What are some examples?

Jerrett: Some of the leading practices in terms of generating benefits involve, say, increasing the green cover. As we increase green cover, we absorb more carbon, so we’re going to reduce the risk of long-term climate change, but you can also have substantial health benefits from that. We know that the introduction of more vegetation generally lowers extreme heat, particularly in disadvantaged neighborhoods where they don’t have a lot of park space or a lot of trees. Another leading practice, where the Europeans are way ahead of us — but we do see signs of improvement across California, in places like Santa Monica — is promoting what’s known as active travel: to get people out of their cars and get them on a bicycle or walking for incidental trips or going to work. We get a benefit in terms of their increased physical activity, and we also reduce the amount of emissions.

Q: Are the climate changes we are already seeing permanent, or can they be halted or even reversed?

Jerrett: We’re already in what I would call a climate crisis. It’s elevating to a climate catastrophe, and that’s going to happen in the next 20 years. We still have a chance to pull back. If we don’t, then we’re going to start seeing massive species die-offs; it’s going to affect the ability of people all over the world to feed themselves. We’re going to have these extraordinary, extreme events like wildfires that are going to dwarf what we’ve seen in the past, and large portions of the planet may become uninhabitable.

Fielding: Here I would draw a parallel to COVID. Even though many of us predicted a pandemic, most people didn’t really believe it, the government didn’t prepare well for it, and we’re learning the same thing with climate change. The difference is we have a way, through vaccination and maybe drugs, to reverse what’s going on with COVID. We don’t know that we have the ability to do that with climate change. You have people politicizing it and calling it a hoax, and that, unfortunately, is very detrimental to what we all want, which is to have a habitable planet.

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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Front-line health care workers are locked in a heated dispute with many infection control specialists and hospital administrators over how the novel coronavirus is spread ― and therefore, what level of protective gear is appropriate.

At issue is the degree to which the virus is airborne ― capable of spreading through tiny aerosol particles lingering in the air ― or primarily transmitted through large, faster-falling droplets from, say, a sneeze or cough. This wonky, seemingly semantic debate has a real-world impact on what sort of protective measures health care companies need to take to protect their patients and workers.

The Centers for Disease Control and Prevention injected confusion into the debate Friday with guidance putting new emphasis on airborne transmission and saying the tiny aerosol particles, as well as larger droplets, are the “main way the virus spreads.” By Monday that language was gone from its website, and the agency explained that it had posted a “draft version of proposed changes” in error and that experts were still working on updating “recommendations regarding airborne transmission.”

Dr. Anthony Fauci, the top U.S. infectious disease expert, addressed the debate head-on in a Sept. 10 webcast for the Harvard Medical School, pointing to scientists specializing in aerosols who argued the CDC had “really gotten it wrong over many, many years.”

“Bottom line is, there’s much more aerosol [transmission] than we thought,” Fauci said.

The topic has been deeply divisive within hospitals, largely because the question of whether an illness spreads by droplets or aerosols drives two different sets of protective practices, touching on everything from airflow within hospital wards to patient isolation to choices of protective gear. Enhanced protections would be expensive and disruptive to a number of industries, but particularly to hospitals, which have fought to keep lower-level “droplet” protections in place.

The hospital administrators and epidemiologists who argue that the virus is mostly droplet-spread cite studies that show it spreads to a small number of people, like a cold or flu. Therefore, N95 respirators and strict patient isolation practices aren’t necessary for routine care of COVID-19 patients, those officials say.

On the other side are many occupational safety experts, aerosol scientists, front-line health care workers and their unions, who are quick to note that the novel coronavirus is far deadlier than the flu ― and argue that the science suggests that high-quality, and costlier, N95 respirators should be required for routine COVID-19 patient care.

The highly protective respirators have been in short supply nationwide and have soared in price, from about $1 to $7 each. Meanwhile, research has shown high rates of asymptomatic virus transmission, putting N95s in high demand among front-line health care workers in virtually every setting.

The debate has come to a head at hospitals from coast to coast, as studies have emerged showing that live virus hangs in COVID-19 patients’ hospital rooms even in the absence of “aerosol-generating” procedures (such as intubations or breathing treatments) and has contributed to outbreaks at a nursing home, shuttle bus and choir practice.

KHN and The Guardian U.S. are examining more than 1,200 health care worker deaths from COVID-19, including many in which their family or colleagues reported they worked with inadequate personal protective gear.

Yet some front-line workers and managers disagree about exactly how and why health care workers are getting sick.

The hospital infection-control and epidemiology leaders cite studies suggesting that many health care workers are contracting the virus outside of work and at rates that mirror what’s happening in their communities.

A group of Penn Medicine epidemiologists in late July characterized research on aerosol transmission as unconvincing and cited “extensive published evidence from across the globe” showing the “overwhelming majority” of coronavirus spread is “via large respiratory droplets.”

Unions, occupational health researchers and aerosol scientists, though, reference another pile of studies showing health care workers have been hit far harder than average people ― and a study that showed active viral particles can drift in the air up to 15 feet from a patient in a hospital room. Such particles can hang in the air for up to three hours.

Backing their concerns, a July 6 letter signed by 239 scientists urged the medical community and World Health Organization to recognize “the potential for airborne spread of Covid-19.”

The letter pointed to studies that say talking, exhaling and coughing emit tiny particles that remain suspended in the air far longer than droplets and “pose a risk of exposure.”

In one ward of a Dutch nursing home with recirculated air, researchers found that 81% of the residents were diagnosed with COVID-19. Half of the workers on the ward ― who all wore surgical masks during patient care but not during breaks ― also tested positive for the virus.

Although researchers couldn’t exclude transmission by another method, the “near-simultaneous detection” of the virus among nearly all the residents pointed to aerosol spread.

The idea that the virus is spread by either droplets or aerosols is an oversimplification, said Dr. Shruti Gohil, associate medical director of epidemiology and infection prevention at the University of California-Irvine School of Medicine.

Gohil said it’s more of a spectrum, with the virus being transmitted by some droplets and some large aerosol particles as well.

One metric people in the hospital infection-control field focus on, though, is how many people one sick person infects. For COVID-19, research has shown that the number is about two ― similar to a cold or the flu. For an unequivocally airborne disease like measles, the number is closer to 12 to 18.

Measles is “what airborne [transmission] looks like,” Gohil said. “If this was truly a primary aerosol-transmissible disease, we’d be in a world of hurt.”

Hospital epidemiologists are also focused on the rate of household spread of the novel coronavirus. With the measles, the risk of an unvaccinated member of a household getting sick is 85%, said Dr. Rachael Lee, a hospital epidemiologist and assistant professor at the University of Alabama-Birmingham. For COVID-19, she said, the risk is closer to 10%.

Though the virus is believed to be spread more by droplets than aerosol particles, Lee said, staffers at UAB University Hospital wear an N95 respirator for an extra layer of protection and because the patients require so many breathing treatments or procedures considered “aerosol-generating.”

Such practices are not universal. At the University of Iowa’s hospital, health care workers use N95s and face shields for aerosol-generating procedures but otherwise use surgical masks and face shields for routine care of COVID patients, said Dr. Daniel Diekema, director of the division of infectious diseases at the university.

He said such “enhanced droplet precautions” are working. Places where workers are correctly using regular medical masks and face shields are finding no significant spread of the disease among staffers, although one such report focused on spread from a single patient.

Elsewhere, patients have also been safe on floors where COVID-19 patients and those without the virus have been placed in adjacent rooms ― a practice those concerned about aerosol spread do not endorse.

“It’s not an airborne disease the way measles or tuberculosis is,” said Dr. Shira Doron, an epidemiologist at Tufts Medical Center in Boston and an assistant professor at Tufts medical school. “We know because we don’t see outbreaks that affect multiple patients on a floor.”

Origin of the Debate

The CDC helped set the stage for the current debate. In March, the agency issued revised guidance essentially saying it was “acceptable” for health care workers to use surgical masks ― instead of N95s ― for routine care. The guidance said respiratory droplets were the most likely source of transmission and recommended N95s only for aerosol-generating procedures.

“The contribution of small respirable particles, sometimes called aerosols or droplet nuclei, to close proximity transmission is currently uncertain. However, airborne transmission from person-to-person over long distances is unlikely,” according to the guidance.

The California Hospital Association sent a letter to the state’s congressional delegation urging the revised guidance be made permanent.

“We need the CDC to clearly, not conditionally, move from airborne to droplet precautions for patients and health care workers,” the letter said. Doing so would enable hospitals to preserve PPE supplies and limit the use of special isolation rooms for COVID patients.

An association spokesperson told KHN that the group wasn’t weighing in on the science, merely pressing for clarity of the rules.

Christopher Friese, professor of nursing, health management and policy at the University of Michigan, is among the experts who think those rules have endangered health care workers.

“We lost a tremendous amount of time and, candidly, lives because the early guidance was to wear N95s only for those specific procedures,” Friese said.

Family members and union leaders from Missouri to Michigan to California have raised concerns about nurses dying of COVID-19 after caring for virus patients without N95 respirators. In such cases, hospitals have said they followed CDC guidance.

Friese echoed some occupational safety experts who suggested stronger guidance from the CDC early on calling the disease airborne might have had an impact ― perhaps pressuring President Donald Trump to invoke the Defense Production Act to boost supplies of N95s so “we might have the supply we need everywhere we need,” Friese said.

Surveys across the country show there’s still a shortage of personal protective equipment at many health care facilities.

The CDC guidance posted Friday would have put pressure on some hospitals to bolster their protective measures, something they have reportedly resisted. It said the virus can spread when a person sings, talks or breathes.

“These particles can be inhaled into the nose, mouth, airways, and lungs and cause infection,” the site said. “This is thought to be the main way the virus spreads.”

By Monday morning, the website was back to saying the virus mainly spreads through droplets, noting that draft language had been posted in error.

The University of Nebraska Medical Center has been taking so-called airborne precautions from the start. There, Dr. James Lawler, a physician and director of the Global Center for Health Security at the university, said his colleagues documented that the virus can drift in the air and live on surfaces at an extensive distance from patients.

He said the hospital tests all admitted patients for the virus and keeps COVID-19 patients apart from the general population. He said they pay close attention to cleaning shared spaces and monitoring airflow within the restricted-access unit. Workers also had N95 respirators or PAPRS, which are fitted hoods with filtered air pumped in.

All of it has added up to a “very low” rate of health care worker infections.

Amid uncertainty about the virus, and as an unprecedented number of health care workers are dying, adopting the “highest possible” forms of protection seems the best course, said Betsy Marville, nurse organizer for the 1199SEIU United Healthcare Workers East union in Florida.

That would mean a departure from CDC guidelines that now say health care workers need an N95 respirator only for “aerosol-generating” procedures, like intubations or other breathing treatments. She said the rule has left the nurses she represents in Florida scrambling for protective gear ― or unprotected ― when patients need such treatments urgently.

“You don’t leave your patient in distress and go looking for a mask,” she said. “That’s crazy.”

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

When the first fire of the season broke out on the Hoopa Valley Reservation in Northern California in July, Greg Moon faced a dilemma.

As Hoopa’s fire chief and its pandemic team leader, Moon feared the impact of the blaze on the dense coniferous forests of the reservation, near Redwood National and State Parks, where 3,000 tribal members depend on steelhead trout and coho salmon fishing. He was even more terrified of a deadly viral outbreak in his tribe, which closed its land to visitors in March.

“We’re a high-risk community because we have a lot of diabetes, heart disease and elders that live in multigenerational homes. If a young person gets it, the whole household is going to get it,” Moon said.

Eventually, the three major blazes that burned nearly 100,000 acres around Hoopa were too much for the tribe’s 25-member fire team. Moon had no choice but to request help from federal wildland rangers and other tribal firefighters.

Native American tribes are no strangers to fire. Working with flames to burn away undergrowth and bring nutrients and biodiversity back to lands is an ingrained part of their heritage. But epidemics are also a familiar scourge. With the devastation that pathogens like smallpox and measles brought to Native populations following the arrival of Europeans, tribes are especially wary of COVID-19’s impact.

“When thinking about the potential of COVID-19 repeating history and wiping out entire communities and tribes, there is concern,” said Vernon Stearns, who as the fuels manager for the Spokane Tribe in eastern Washington is responsible for organizing controlled burns.

Some tribes have abandoned traditional fire suppression techniques, watching large swaths of land burn in order to protect a more fragile and essential resource: their people.

“The biggest fear the tribe had was COVID would hit our elders. And they are a very valuable resource of knowledge and connection to our ancestry and teaching of our ways to our children, who we also felt were at risk, and we obviously want to protect them,” said Ron Swaney, fire management officer for the Confederated Salish and Kootenai Tribes in Montana.

“I’ve seen how [the virus] has affected families close to me. I know the grief,” said Don Jones, fire chief of the Yakama Nation reservation in central Washington, where there have been at least 28 COVID-19 deaths. “I’m not going to send sick people out to fight the fire. I’m not going to say, ‘Come on, guys, toughen up, go out there.’ Life takes precedence over that.”

Around the country, many tribes have full-time fire crews that traditionally aid one another and federal firefighters, sending out teams to help with blazes. But this year’s COVID-19 pandemic has pushed them to reconsider how much help they can give and receive in the face of encroaching infernos.

A Centers for Disease Control and Prevention study found Native Americans and Alaskans were 3.5 times more likely than whites to test positive for the coronavirus. The rapid spread of the virus within tribes early in the pandemic led many reservations to aggressively control outside access. Casinos closed. Entrances to tourist areas such as lakes, hiking trails and fisheries were blocked off. Economically many tribes suffered, but COVID caseloads stabilized or declined.

The ongoing fire season is now threatening that progress.

Tribal families often live in multigenerational housing, sometimes in trailers or other small homes with no running water. Their isolated, tightknit communities can be sequestered from COVID-19 spikes in nearby towns but are ripe for an outbreak if the virus enters. Social distancing is a challenge on small, remote reservations. There may be only a single gas station or supermarket, where visiting fire crews would be likely to interact with the tribal population. Many tribes also lack strong internet connections, forcing fire crews to meet in person rather than stage briefings via Zoom, as federal crews have done elsewhere during the pandemic.

On the Flathead Reservation north of Missoula, Montana, COVID-19 hit the fire crew of the Confederated Salish and Kootenai Tribes before the fires did. A firefighter who came in direct contact with someone who was sick with the virus in early July took the tribe’s entire 12-person aviation team, consisting of an air attack plane and a helicopter crew, out of business for four days. While no fires were burning at the time, it was a worrisome wake-up call for Swaney.

“For a minute there, I really thought we would all be infected with COVID-19 and I was wondering who would be responding to the fires,” he said.

It was enough to convince Swaney that this year the tribe wouldn’t share any of its 60 firefighters with neighbors. It was a tough call because historically “in fire, when our neighbors need help, we go help,” he said.

At the end of July, Swaney had to accept help from nearly 300 outside firefighters when lightning started a blaze in the mountains surrounding the bison-dotted grass valley his tribe calls home.

After the 3,500-acre Magpie Rock Fire was under control, Swaney learned that a federal wildland firefighter involved had tested positive for COVID-19 during his next assignment. He didn’t appear to have infected Swaney’s team, though four members have tested positive this season.

“We’ve had a lot of close calls,” he said.

Other tribes have sought to bolster their fire crews to do without the help of off-reservation teams. The Spokane Tribe in Washington earmarked some of the $19 million it received from the CARES Act to hire an additional 10-person seasonal crew. It hoped to aggressively attack any fire and keep it small, thereby avoiding the need for outside firefighters who might also bring in the coronavirus, Stearns said.

The Yakama Nation, near the Oregon border, was still struggling with a coronavirus outbreak that had infected at least 6% of its population when fires started in July. The crews learned quickly that facing wildfire and a pandemic simultaneously would be an exercise in trade-offs.

Early in the effort, five fire crew members were taken off the line when several people got sick, leaving the 20 remaining members to make do. Federal firefighting is stretched thin as megafires consume vast areas of the West Coast — and other tribes were no help because they’ve restricted their fire teams’ movement to prevent COVID spread.

“We had no one else to call on. … It was pretty tough,” said Jones. “The stress level has gone up. You’re worried about exposure all the time.”

Ultimately, eight Yakama crew members tested positive for COVID-19. One of the firefighters who tested positive had already lost two family members to the virus. Another spread COVID-19 to a family member who ended up at the hospital on a ventilator but survived.

“Everyone in my program was affected one way or another,” Jones said. “Everyone lost somebody.”

The West’s brutal fire season is forcing tribes to concentrate on fires that start by lightning or accident, with no resources to give to prescribed burning.

“These fires are just gobbling up the ground,” said Jones. His tribe canceled the carefully controlled fires it normally conducts in September to avoid bringing together the large numbers of people needed to do them.

“Fires are just going to get bigger,” Jones said. “If we can’t do anything about it, we can’t do anything about it. We have to make sure everyone’s healthy first.”

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).

Note to Readers: Sarah Jane Tribble spent more than a year and half reporting on a small town in Kansas that lost its only hospital. This month, KHN and St. Louis Public Radio will launch “Where It Hurts,” a podcast exploring the often painful cracks growing in America’s health system that leave people vulnerable — and without the care they need. Season One is “No Mercy,” focusing on the hospital closure in Fort Scott, Kansas — and what happens to the people left behind, surviving the best way they know how. You can listen to Episode One on Tuesday, Sept. 29.

David Usher is sitting on $1.7 million he’s scared to spend.

The money lent from the federal government is meant to help hospitals and other health care providers weather the COVID-19 pandemic. Yet some hospital administrators have called it a payday loan program that is now, brutally, due for repayment at a time when they still need help.

Coronavirus cases have “picked up recently and it’s quite worrying,” said Usher, chief financial officer at the 12-bed Edwards County Medical Center in rural western Kansas. Usher said he would like to use the federal loan money to build a negative-pressure room, a common strategy to keep contagious patients apart from those in the rest of the hospital.

But he’s not sure it’s safe to spend that cash. Officially, the total repayment of the loan is due this month. Otherwise, according to the loan’s terms, federal regulators will stop reimbursing the hospitals for Medicare patients’ treatments until the loan is repaid in full.

The federal Centers for Medicare & Medicaid Services has not yet begun trying to recoup its investment, with the coronavirus still affecting communities nationwide, but hospital leaders fear it may come calling for repayment any day now.

Hospital leaders across the country said there has been no communication from CMS on whether or when they will adjust the repayment deadline. A CMS spokesperson had not responded to questions by press time.

“It’s great having the money,” Usher said. “But if I don’t know how much I get to keep, I don’t get to spend the money wisely and effectively on the facility.”

Usher took out the loan from Medicare’s Accelerated and Advance Payments program. The program, which existed long before the pandemic, was generally used sparingly by hospitals faced with emergencies such as hurricanes or tornadoes. It was expanded for use during the coronavirus pandemic — part of billions approved in federal relief funds for health care providers this spring.

A full repayment of a hospital’s loan is technically due 120 days after it was received. If it is not paid, Medicare will stop reimbursing claims until it recoups the money it is owed — a point spelled out in the program’s rules. Medicare reimburses nearly $60 billion in payments to health care providers nationwide under Medicare’s Part A program, which makes payments to hospitals.

More than 65% of the nation’s small, rural hospitals — many of which were operating at a deficit before the pandemic — jumped at the Medicare loans when the pandemic hit because they were the first funds available, said Maggie Elehwany, former vice president of government affairs for the National Rural Health Association.

CMS halted new loan applications to the program at the end of April.

“The pandemic has simply gone on longer than anyone anticipated back in March,” said Joanna Hiatt Kim, vice president of payment policy and analysis for the American Hospital Association. The trade association sent a letter to CMS in late July asking for a delay in the recoupment.

On Monday, the House Appropriations Committee included partial relief for all hospitals in a new government funding plan. The committee’s proposal would extend the start of the repayment period for hospitals and the amount of time they are allowed to take to repay.

The continuing resolution that includes this language about relief for hospitals (among many, many other things) is still being hammered out, though it does face its own deadline: It must be approved by the House and the Senate within the next nine days or the federal government faces a shutdown.

Tom Nickels, executive vice president at the AHA, said his organization appreciates the House committee’s effort to address the loans in the new bill, but full forgiveness of the loans is still needed.

Sen. Jeanne Shaheen (D-N.H.) has called for changes to the loan repayment period for months and said Monday “our work is far from over.”

“We are still in the middle of this crisis — from both health and economic standpoints,” Shaheen said.

Meanwhile, hospital administrators like Peter Wright are holding their breath, waiting to see if, in order to settle the debt, Medicare will stop making payments to hospitals, even as facilities continue to grapple with coronavirus in their communities.

“The feds, if you owe them money, they just take it,” said Wright, who oversees two small hospitals for Central Maine Healthcare in Bridgton, Maine. He said his health care system took the money because “we had no other choice; it was a cash flow issue.”

For many hospitals, Medicare payments make up 40% or more of their revenue. Not being reimbursed by Medicare would be crippling — akin to a household losing nearly half its income.

“We have no idea what we’re going to do if we have to pay it back as quickly as they say,” Wright said.

In rural Kentucky, hospital executive Sheila Currans said she “vacillated” for about a week or so trying to decide whether to tap the loan program for her hospital — she knew it would have to be repaid and worried that could prove difficult.

“It was a desperate time,” said Currans, chief executive of Harrison Memorial Hospital in Cynthiana, Kentucky. Harrison Memorial was the first hospital in Kentucky to treat a COVID-19 patient in early March, she said.

The hospital immediately quarantined dozens of staff members and shut down elective procedures. And with COVID confirmed in the community, there was a “horrible fear,” Currans said, of getting infected that kept people from seeking outpatient care as well.

“Through March and April and most of May, I was in a complete spiral,” Currans said. By the end of April, Currans said, her hospital was losing millions of dollars. To cope with the pandemic, she furloughed staff and turned one wing of the hospital into a “cough clinic” to be used exclusively by patients whose symptoms suggested they might be infected with the coronavirus.

Currans said the hospital is still seeing COVID cases, but patients are beginning to return for other services, such as outpatient clinics.

In terms of the hospital’s finances, “it’s still not a wonderful time,” Currans said. The Medicare loan “as well as all the other support from the federal government helped us at least — for now — survive it.”

She’s hoping the repayment demand will be pushed back to 2021 or, perhaps the loan will be forgiven.

“I know it’s a pipe dream,” Currans said. “But this has been a historic event.”

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).

Michael Costanzo, a Colorado farmer diagnosed with multiple sclerosis in 2016, has a well-honed ritual: Every six months, he takes an IV infusion of a medicine, Rituxan, to manage his disease, which has no cure. Then he figures out how to manage the bill, which costs thousands of dollars.

For a time, the routine held steady: The price billed to his health insurance for one infusion would cost $6,201 to $6,841. Costanzo’s health insurance covered most of it, and he paid the rest out-of-pocket.

But last fall the cost for the same 20-year-old drug and dosage jumped to $10,320, even though he was covered by the same insurance.

“Why does it have to increase in price all of a sudden?” wondered Costanzo, who lives in a small town about 50 miles north of Denver.

“I think greed is a huge problem,” he said.

As drug prices spiral upward, politicians in Washington, D.C., and in state governments across the country have sought to address the problem in limited ways, focusing mostly on one drug: insulin, a drug more than 7 million Americans rely on to manage diabetes and whose price tag more than doubled from 2012 to 2017.

With comprehensive drug price legislation stalled in Washington during the COVID-19 state of emergency, seven states in the midst of the pandemic enacted insulin payment caps of less than $100 per month, bringing the total to eight; five more have proposed legislation. In March, President Donald Trump’s health officials announced a Medicare test project limiting seniors’ monthly out-of-pocket costs to $35. In July, he signed four executive actions targeting insulin and a handful of other medications, boasting, “It’s going to have an incredible impact.”

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Insulin took center stage last year, after moving demonstrations by mothers who caravanned to Canada to buy lifesaving medicine for their children at a tenth of the U.S. price; they swarmed the halls of Congress.

The measures that have resulted so far have not solved a far more widespread problem: escalating drug prices across the board — a problem that voters, left and right, say Congress must fix.

Underlying the problem is that lawmakers spent much of last year at loggerheads about whether the federal government should have the power to set prices or limit price increases. Prospects of comprehensive legislation already in the works slipped away this spring as Congress turned its focus to the COVID-19 pandemic that has killed more than 150,000 Americans and tanked the country’s economy.

So state lawmakers played whack-a-mole, targeting the drug with the most notoriety, and tackled insulin’s cost to patients. But patients like Costanzo — among the millions who rely on other vital drugs — struggle evermore to afford unchecked price increases for everything from HIV/AIDS and depression to asthma, autoimmune disorders and Type 2 diabetes.

A 2019 survey from the Scripps Research Translational Institute published in the Journal of the American Medical Association found that the costs of 17 top-selling brand-name drugs more than doubled from 2012 to 2017. Many of the drugs that made the list are household names: Lipitor and Zetia for high cholesterol, Advair and Symbicort for asthma, Lyrica for pain and Chantix for smoking cessation.

“The general public doesn’t realize this is happening with all sorts of drugs,” Costanzo said. “We’re all suffering from increased prices.”

***

Insulin was a natural poster child for pharmaceutical greed, encapsulating America’s problem with high drug prices in a neat package that few, if any, other medications do as effectively.

“You have an illustration of the problem — politics gone awry and capitalism gone awry,” said Celinda Lake, a veteran Democratic pollster. “They think of it as being emblematic of everything that’s going on with the system.”

Three pharmaceutical companies dominate the market for the diabetes treatment that has essentially the same formula as when it was introduced in the 1920s. Not taking insulin can quickly turn fatal. In 2017, Minnesota resident Alec Smith died at age 26 after rationing his insulin because he couldn’t afford it.

People dying “is what it takes for Congress to actually commit money and act, and then we solve these problems eventually,” said Andy Slavitt, who was acting head of the U.S. Centers for Medicare & Medicaid Services in the Obama administration.

Yet proponents of lowering drug costs say an effort centered on a single drug could backfire, and it did when COVID captured center stage.

“Everywhere in this country people are angry about their drug prices,” said David Mitchell, founder of Patients for Affordable Drugs Now, a Washington, D.C.-based group that lobbies Congress and runs campaign ads in support of lower prices. “The people with cancer, the people with autoimmune problems, the people with multiple sclerosis, the people who are taking a variety of drugs that are wildly overpriced, are going to say, ‘Now, wait a minute, what about me?’”

In early March, University of Pittsburgh researchers published research finding that, without discounts, list prices of brand-name drugs were rising about 9% a year. Late last year, House Democrats passed a bill that would let the federal government set prices for hundreds of drugs and cap seniors’ out-of-pocket costs for medication at $2,000. Trump opposed the bill, calling on Congress to send him a drug pricing bill that has bipartisan support.

“Let’s be clear — these price hikes aren’t because the medicines got better or there was a significant increase in research and development,” said Sen. Chuck Grassley (R-Iowa) in a March 5 floor speech. The chairman of the Senate’s powerful Finance Committee spearheaded a bipartisan drug pricing bill with Oregon Sen. Ron Wyden, a Democrat. “No, this was because the pharmaceutical companies could do it and get away with it.”

While Congress dithers and the topic periodically becomes the subject of a presidential tweet, patients continue to fend for themselves.

Tara Terminiello has seen the total underlying cost of her son’s anti-seizure medication, Topamax, skyrocket to about $1,300 a month, hundreds more than when he started taking it over a decade ago.

In Texas, Joseph Fabian, a public school teacher in San Antonio with health insurance through his job, has relied on inhalers since childhood to manage his allergy-induced asthma. In February 2019, he paid $330.98 for a three-pack of Symbicort inhalers, which he typically uses twice a day but more frequently during allergy season.

A year later and after a change in his health insurance plan, Fabian’s costs tripled, to $348.95 for a single inhaler, he said in an interview. According to the Scripps’ drug pricing study, the median cost of Symbicort rose from $225 in January 2012 to $308 in December 2017.

“There’s no way I can keep working out $350 every month and a half,” Fabian said.

***

Chances that Congress will pass comprehensive drug pricing legislation before the 2020 election have slipped away as lawmakers focus on additional COVID-19 relief. Moreover, the Trump administration, Congress and the public are now hoping for pandemic deliverance by the very same drug companies that have been raising prices as they develop potential virus treatments and vaccines. PhRMA, the powerful industry trade group, has seized the moment with ad campaigns emphasizing the sector’s enormous value.

The stalemate provides little solace for patients like Costanzo, whose medicine, Rituxan, made by Genentech, was first approved by the Food and Drug Administration in 1997 to treat lymphoma and can be used off-label for MS. It is one of seven medications with price increases unsupported by new clinical evidence, according to a report from the Institute for Clinical and Economic Review. ICER noted that over 24 months, the net price — the price after any discounts from drug companies are factored in — “increased by almost 14%, which results in an estimated increase in drug spending of approximately $549 million.”

In a statement, Genentech spokesperson Priscilla White said ICER’s analysis was “significantly limited” because it didn’t account for “meaningful, high-quality, and peer-reviewed evidence supporting the clinical and economic benefits of Rituxan.” White said the company did not increase Rituxan’s price during the period in which Costanzo’s bill rose and wouldn’t speculate on the change without knowing “other factors” that may have contributed.

“We take decisions related to the prices of our medicines very seriously, taking into consideration their value to patients and society, the investments required to continue discovering new treatments, and the need for broad access,” she said.

Costanzo was prescribed the drug by two neurologists and hasn’t had any acute relapses since he started the infusions. He eventually did get a financial reprieve, not thanks to Washington, but by enrolling in a patient discount program operated by the very drug company that sets Rituxan’s price, a program he said was an “absolute lifesaver” financially.

Genentech said its patient foundation provides free medicine to more than 50,000 patients each year. Costanzo got his first free dose in July.

CLEARWATER, Fla. — Betty Jones voted for President Donald Trump in 2016, but the lifelong Republican has her doubts she will do it again this year.

The federal response to the coronavirus pandemic that has killed about 200,000 Americans and forced older adults to restrict their activities has her contemplating a leadership change.

It “makes me unsure,” said Jones, 78, of Largo, in Pinellas County, Florida. Before COVID-19, she said, she would have definitely voted for Trump.

Polls show that many people will have the pandemic and its public health and economic consequences on their minds when they cast their votes — whether by mail or in person — this fall. Early in-person voting starts Oct. 19 in most Florida counties, including Pinellas.

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Even if the issue leads a tiny proportion of them to change their choice for president, it could have huge consequences in battleground states like Florida, which Trump carried in 2016 by about 1 percentage point.

Within the Sunshine State, few places loom as large in the race for the White House as here in Pinellas County, the largest swing county in the ultimate swing state.

Pinellas, with nearly 1 million residents, has been a political bellwether in recent years, having voted for the winning presidential candidate in every election since 1980 — except for the disputed race between George W. Bush and Al Gore in 2000.

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This county just east of Tampa known for its sugar-white beaches is nearly evenly split between the major parties, with 251,000 registered Democrats and 245,000 registered Republicans. An additional 200,000 voters registered as independents.

The city of St. Petersburg, in the southern part of the county, is a Democratic stronghold, while the northern half of the county is more Republican. The county is largely a white suburban area, with a large, older middle-class electorate.

President Barack Obama twice won Pinellas — and Florida — but Trump outpaced Hillary Clinton here by 5,500 votes out of the nearly 500,000 cast.

Democrats are hoping Pinellas will help tip the statewide balance to former Vice President Joe Biden this fall — and they expect a boost from residents spooked by the pandemic. The county has been hit hard by COVID-19 with more than 20,000 cases, 2,000 hospitalizations and 700 deaths. It has the highest COVID-19 death rate of the state’s most populous counties.

Older voters have been deeply affected by the coronavirus since they face a high risk of serious complications and have had to curtail their lives dramatically to avoid the virus. Steve Schale, a Democratic strategist in Tallahassee, said those factors should help Biden do well with this key voting group. About 1 in 4 Pinellas voters are 65 or older.

“There is no world where we win Florida without Pinellas,” Schale said. “If we win there by a few points, it’s a harbinger of good things.”

A tiny shift in voter preferences could have major implications, he added.

“We are talking like 4% to 5% of the electorate in Florida is truly up for grabs, but in a state where the vote was decided by 1%, that is a huge chunk of the electorate,” Schale said.

While about one-third of Florida voters said the economy was their leading issue in the presidential campaign, Democrats were seven times more likely than Republicans to cite the coronavirus outbreak as their top issue, according to a KFF and Cook Political Report survey of three Sun Belt states released Thursday. Nearly a third of Democrats said the pandemic is their most important issue, while just 4% of Republicans and 17% of independents chose the coronavirus outbreak.

The poll of 1,009 Florida voters was conducted Aug. 29 to Sept. 13. The margin of error for Florida results is plus or minus 4 percentage points.

The survey found Biden and Trump virtually tied in Florida with 11% undecided.

National surveys show the pandemic — and its impact on the U.S. economy — are key issues for voters.

A Pew Research Center poll in August found that 62% of voters overall say the outbreak will be a very important factor in their decision about whom to support in the fall. For Trump supporters, however, the economy (88%) and violent crime (74%) are the most salient issues.

By contrast, the largest shares of Biden supporters view health care (84%) and the coronavirus outbreak (82%) as very important. According to an August Georgetown University poll of Florida and other battleground states, 38% of respondents said they approve of how Trump is handling COVID-19, while 60% said they disapprove.

John Andrew Barnes, 33, of Largo, said he knew he liked Biden before the pandemic, but the Trump administration’s response to COVID-19 reinforced his decision. Trump’s “blatant distrust” of the Centers for Disease Control and Prevention and other experts and what Barnes viewed as a lack of national response left him unsatisfied, he said.

Yet, among Republicans, the president’s decisions on coronavirus policies have played well and some are nervous that Biden’s efforts to curb the virus might undercut the economy even more.

Ricard Gregorie, 54, of Largo, said the federal government’s response to the pandemic has “absolutely been incredible.” For Gregorie, the quick distribution of ventilators and maintaining an open economy were decisions that reaffirmed his support for Trump. “We can’t ask for miracles,” he said.

Carl Joyner, 35, a firefighter who lives in St. Petersburg, said COVID-19 has not affected his support for Trump. He opposes anyone who wants to force him to wear a mask. He backs Trump’s position to quickly open businesses and schools.

“People are living paycheck to paycheck here and the hospitality industry here really got lambasted,” he said.

Anthony Pedicini, a GOP political consultant based in Tampa, said the pandemic may not have a big influence because most voters were locked in on their choice for president before the pandemic hit. “If you didn’t like the president before the pandemic you don’t like him after,” Pedicini said. “But if you liked him before you still will.”

That’s also what more than a dozen Pinellas voters said in interviews in shopping centers over the past month.

Pinellas has a large working-class community that is trending Republican, Pedicini said. It’s a county in transition with many elders aging out and a younger, more diverse population moving in.

Most political experts say that even in swing counties fewer than 10% of voters switch their party support from election to election. As a result, victory likely depends on who can turn out his base of voters.

In Florida, Hispanic as well as Black turnout declined markedly in 2016, from 59% in 2012 to 52%, according to the nonpartisan Brookings Institution.

Given Trump’s poor approval ratings, the upheaval in the economy and polls showing voters’ disdain of the federal response to the pandemic, there is just no way you would expect the president to win reelection, said Stephen Craig, a political science professor at the University of Florida. “If history holds, Joe Biden will be president. But Trump is a candidate who breaks all the rules.”

On Feb. 27, 2018, I got an email from the Heritage Foundation, alerting me to a news conference that afternoon held by Republican attorneys general of Texas and other states. It was referred to only as a “discussion about the Affordable Care Act lawsuit.”

I sent the following note to my editor: “I’m off to the Hill anyway. I could stop by this. You never know what it might morph into.”

Few people took that case very seriously — barely a handful of reporters attended the news conference. But it has now “morphed into” the latest existential threat against the Affordable Care Act, scheduled for oral arguments at the Supreme Court a week after the general election in November. And with the death of Justice Ruth Bader Ginsburg on Friday, that case could well morph into the threat that brings down the law in its entirety.

Democrats are raising alarms about the future of the law without Ginsburg. House Speaker Nancy Pelosi, speaking on ABC’s “This Week” Sunday morning, said that part of the strategy by President Donald Trump and Senate Republicans to quickly fill her seat was to help undermine the ACA.

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“The president is rushing to make some kind of a decision because … Nov. 10 is when the arguments begin on the Affordable Care Act,” she said. “He doesn’t want to crush the virus. He wants to crush the Affordable Care Act.”

Ginsburg’s death throws an already chaotic general election campaign during a pandemic into more turmoil. But in the longer term, her absence from the bench could accelerate a trend underway to get cases to the Supreme Court toward invalidating the ACA and rolling back reproductive freedoms for women.

Let’s take them one at a time.

The ACA Under Fire — Again

The GOP attorneys general argued in February 2018 that the Republican-sponsored tax cut bill Congress passed two months earlier had rendered the ACA unconstitutional by reducing to zero the ACA’s penalty for not having insurance. They based their argument on Chief Justice John Roberts’ 2012 conclusion that the ACA was valid, interpreting that penalty as a constitutionally appropriate tax.

Most legal scholars, including several who challenged the law before the Supreme Court in 2012 and again in 2015, find the argument that the entire law should fall to be unconvincing. “If courts invalidate an entire law merely because Congress eliminates or revises one part, as happened here, that may well inhibit necessary reform of federal legislation in the future by turning it into an ‘all or nothing’ proposition,” wrote a group of conservative and liberal law professors in a brief filed in the case.

Still, in December 2018, U.S. District Judge Reed O’Connor in Texas accepted the GOP argument and declared the law unconstitutional. In December 2019, a three-judge 5th Circuit appeals court panel in New Orleans agreed that without the penalty the requirement to buy insurance is unconstitutional. But it sent the case back to O’Connor to suggest that perhaps the entire law need not fall.

Not wanting to wait the months or years that reconsideration would take, Democratic attorneys general defending the ACA asked the Supreme Court to hear the case this year. (Democrats are defending the law in court because the Trump administration decided to support the GOP attorneys general’s case.) The court agreed to take the case but scheduled arguments for the week after the November election.

While the fate of the ACA was and is a live political issue, few legal observers were terribly worried about the legal outcome of the case now known as Texas v. California, if only because the case seemed much weaker than the 2012 and 2015 cases in which Roberts joined the court’s four liberals. In the 2015 case, which challenged the validity of federal tax subsidies helping millions of Americans buy health insurance on the ACA’s marketplaces, both Roberts and now-retired Justice Anthony Kennedy voted to uphold the law.

But without Ginsburg, the case could wind up in a 4-4 tie, even if Roberts supports the law’s constitutionality. That could let the lower-court ruling stand, although it would not be binding on other courts outside of the 5th Circuit. The court could also put off the arguments or, if the Republican Senate replaces Ginsburg with another conservative justice before arguments are heard, Republicans could secure a 5-4 ruling against the law. Some court observers argue that Justice Brett Kavanaugh has not favored invalidating an entire statute if only part of it is flawed and might not approve overturning the ACA. Still, what started out as an effort to energize Republican voters for the 2018 midterms after Congress failed to “repeal and replace” the health law in 2017 could end up throwing the nation’s entire health system into chaos.

At least 20 million Americans — and likely many more who sought coverage since the start of the coronavirus pandemic — who buy insurance through the ACA marketplaces or have Medicaid through the law’s expansion could lose coverage right away. Many millions more would lose the law’s popular protections guaranteeing coverage for people with preexisting health conditions, including those who have had COVID-19.

Adult children under age 26 would no longer be guaranteed the right to remain on their parents’ health plans, and Medicare patients would lose enhanced prescription drug coverage. Women would lose guaranteed access to birth control at no out-of-pocket cost.

But a sudden elimination would affect more than just health care consumers. Insurance companies, drug companies, hospitals and doctors have all changed the way they do business because of incentives and penalties in the health law. If it’s struck down, many of the “rules of the road” would literally be wiped away, including billing and payment mechanisms.

A new Democratic president could not drop the lawsuit, because the Trump administration is not the plaintiff (the GOP attorneys general are). But a Democratic Congress and president could in theory make the entire issue go away by reinstating the penalty for failure to have insurance, even at a minimal amount. However, as far as the health law goes, for now, nothing is a sure thing.

As Nicholas Bagley, a law professor at the University of Michigan who specializes in health issues, tweeted: “Among other things, the Affordable Care Act now dangles from a thread.”

Reproductive Rights

A woman’s right to abortion — and even to birth control — also has been hanging by a thread at the high court for more than a decade. This past term, Roberts joined the liberals to invalidate a Louisiana law that would have closed most of the state’s abortion clinics, but he made it clear it was not a vote for abortion rights. The Louisiana law was too similar to a Texas law the court (without his vote) struck down in 2016, Roberts argued.

Ginsburg had been a stalwart supporter of reproductive freedom for women. In her nearly three decades on the court, she always voted with backers of abortion rights and birth control and led the dissenters in 2007 when the court upheld a federal ban on a specific abortion procedure.

Adding a justice opposed to abortion to the bench — which is what Trump has promised his supporters — would almost certainly tilt the court in favor of far more dramatic restrictions on the procedure and possibly an overturn of the landmark 1973 ruling Roe v. Wade.

But not only is abortion on the line. The court in recent years has repeatedly ruled that employers with religious objections can refuse to provide contraception.

And waiting in the lower-court pipeline are cases involving federal funding of Planned Parenthood in both the Medicaid and federal family planning programs, and the ability of individual health workers to decline to participate in abortion and other procedures.

For Ginsburg, those issues came down to a clear question of a woman’s guarantee of equal status under the law.

“Women, it is now acknowledged, have the talent, capacity, and right ‘to participate equally in the economic and social life of the Nation,’” she wrote in her dissent in that 2007 abortion case. “Their ability to realize their full potential, the Court recognized, is intimately connected to ‘their ability to control their reproductive lives.’’

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Can’t see the audio player? Click here to listen.

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Laura Derrick lived with an undiagnosed medical condition for decades, and when she finally got answers and access to effective treatment, medical bills threatened to swamp her family. During her personal fight for affordable health care, she was inspired by and swept up in a historic political fight.

This is a great time for Derrick’s story, which is all about persistence through difficult and uncertain times. In late 2018, it was one of the first stories on “An Arm and a Leg,” and it has special resonance right now when we’re all enduring a lot.

Bonus: We catch up with Derrick for an update.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

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