Category: From California Healthline.org

School librarian Amanda Brasfield bent over to grab her lunch from a small refrigerator and felt her heart begin to race. Even after lying on her office floor and closing her eyes, her heart kept pounding and fluttering in her chest.

The school nurse checked Brasfield’s pulse, found it too fast to count and called 911 for an ambulance. Soon after the May 2018 incident, Brasfield, now 39, got a $1,206 bill for the 4-mile ambulance ride across the northwestern Ohio city of Findlay — more than $300 a mile. And she was on the hook for $859 of it because the only emergency medical service in the city has no contract with the insurance plan she has through her government job.

More than two years later, what was diagnosed as a relatively minor heart rhythm problem hasn’t caused any more health issues for Brasfield, but the bill caused her some heartburn.

“I felt like it was too much,” she said. “I wasn’t dying.”

Brasfield’s predicament is common in the U.S. health care market, where studies show the majority of ambulance rides leave patients saddled with hundreds of dollars in out-of-network medical bills. Yet ground ambulances have mostly been left out of federal legislation targeting “surprise” medical bills, which happen when out-of-network providers charge more than insurers are willing to pay, leaving patients with the balance.

However, the COVID-19 pandemic has prompted temporary changes that could help some patients. For instance, ambulance services that received federal money from the CARES Act Provider Relief Fund aren’t allowed to charge presumptive or confirmed coronavirus patients the balance remaining on bills after insurance coverage kicks in. Also during the pandemic, the Centers for Medicare & Medicaid Services is letting Medicare pay for ambulance trips to destinations besides hospitals, such as doctors’ offices or urgent care centers equipped to treat recipients’ illnesses or injuries.

But researchers and patient advocates said consumers need more, and lasting, protections.

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“You call 911. You need an ambulance. You can’t really shop around for it,” said Christopher Garmon, an assistant professor at the University of Missouri-Kansas City who has studied the issue.

A Health Affairs study, published in April, found 71% of all ambulance rides in 2013-17 for members of one large, national insurance plan involved potential surprise bills. The median out-of-network surprise ground ambulance bill was $450, for a combined impact of $129 million a year.

And a study published last summer in JAMA Internal Medicine found 86% of ambulance rides to ERs — the vast majority by ground ambulances, not helicopters — resulted in out-of-network bills.

Caitlin Donovan, senior director of the National Patient Advocate Foundation in Washington, D.C., said she hears from consumers who get such bills and resolve to call Uber the next time they need to get to the ER. Although experts — and Uber — agree an ambulance is the safest option in an emergency, research out of the University of Kansas found that the Uber ride-sharing service has reduced per-person ambulance use by at least 7%.

Only Ambulance in Town

When Brasfield was rushed to the hospital, her employer, Findlay City Schools, offered insurance plans only from Anthem, and none included the Hanco EMS ambulance service in its network. School system treasurer Michael Barnhart said the district couldn’t insist that Hanco participate. Starting Sept. 1, Barnhart said the school system will have a different insurer, UMR/United Healthcare, but the same plans.

“There is no leverage when they are the only such service around. If it were a particular medical procedure, we could encourage employees to seek another doctor or hospital even if it was further away,” Barnhart said in an email. “But you can’t encourage anyone to use an ambulance service from 50 miles away.”

There is great disagreement about what an ambulance ride is worth.

Brasfield’s insurer paid $347 for her out-of-network ambulance ride. She said Anthem representatives told her that was consistent with in-network rates and Hanco’s $1,206 charge was simply too high.

Jeff Blunt, a spokesperson for Anthem, said that 90% of ambulance companies in Ohio agree to Anthem’s payment rates; Hanco is among the few medical transport providers that don’t participate in its network. He said Anthem reached out to Hanco twice to negotiate a contract but never heard back.

Brasfield sent three letters appealing Anthem’s decision and called Hanco to negotiate the bill down. The companies wouldn’t budge. Hanco sent her a collections notice.

An Ohio school librarian took a 4-mile ambulance ride across Findlay, Ohio, to nearby Blanchard Valley Hospital for what turned out to be a relatively minor heart rhythm problem. But the trip led to a $1,206 ambulance bill.

Rob Lawrence of the American Ambulance Association pointed out that nearly three-quarters of the nation’s 14,000 ambulance providers have low transport volumes but need to staff up even when not needed, creating significant overhead. And because of the pandemic, ambulance providers have seen reduced revenue, higher costs and more uncompensated care, the association’s executive director, Maria Bianchi, said in an email.

Officials at Blanchard Valley Health System, which owns Hanco, said Brasfield’s ambulance charge was on par with the national average for this type of medical emergency, in which EMTs started an IV line and set up a heart monitor.

Fair Health, a nonprofit that analyzes billions of medical claims, estimates an ambulance ride costs $408 in-network and $750 out-of-network in Toledo, which is about 50 miles away from Findlay and has several ambulance companies. Even the higher of those two costs is $456 less than Brasfield’s bill.

Widespread Problem, No Action

Similar stories play out across the nation.

Ron Brooks, 72, received two bills of more than $690 each when his wife had to be rushed about 6 miles to a hospital in Inverness, Florida, after two strokes in November 2018. The only ambulance service in the county, Nature Coast EMS, was out-of-network for his insurer, Florida Blue. Neither had responded to requests for comment by publication time. Brooks’ wife died, and it took him months to pay off the bills.

“There should be an exception if there was no other option,” he said.

Sarah Goodwin of Shirley, Massachusetts, got a $3,161 bill after her now-14-year-old daughter was transported from a hospital to another facility about an hour away after a mental health crisis in November. That was the balance after her insurer, Tricare Prime, paid $491 to Vital EMS. Despite reaching out to the ambulance company and her insurer, she received a call from a collection agency.

“I feel bullied,” she said earlier this year. “I don’t plan to pay it.”

Since KHN asked the companies questions about the bill and the pandemic began, she said, she hadn’t gotten any more bills or calls as of late August.

In an emailed response to KHN, Vital EMS spokesperson Tawnya Silloway said the company wouldn’t discuss an individual bill, and added: “We make every effort to take patients out of the middle of billing matters by negotiating with insurance companies in good faith.”

Last year, an initial attempt at federal legislation to ban surprise billing left out ground ambulances. This February, a bill was introduced in the U.S. House that calls for an advisory committee of government officials, patient advocates and representatives of affected industries to study ground ambulance costs. The bill remains pending, without any action since the pandemic began.

In the meantime, consumer advocates suggest patients try to negotiate with their insurers and the ambulance providers.

Michelle Mello, a Stanford University professor who specializes in health law and co-authored the JAMA Internal Medicine study that examined surprise ambulance bills, was able to appeal to her insurer to pay 90% of such a bill she got after a bike accident last year.

That tactic, however, proved futile for Brasfield, the Ohio librarian. She set up a $100-a-month payment plan with Hanco and, eventually, paid off the bill.

From now on, she said, she’ll think twice about taking an ambulance unless she feels her life is in imminent danger. For anything less, she said, she’d ask a relative or friend to drive her to the hospital.

Before the coronavirus pandemic shut down the entertainment industry in March, Jeffrey Farber had a steady flow of day jobs in film and television, including work on “Hunters” and “Blue Bloods.” But when theaters, movies and TV shows stopped production, not only did Farber lose his acting income, he also stopped accruing the hours and earnings he needed to qualify for health insurance through his labor union, SAG-AFTRA.

Without the acting jobs, his insurance would be ending this month.

When the pandemic halted film and television production, Jeffrey Farber lost his acting income and stopped accruing the hours and earnings he needed to qualify for health insurance through his labor union, SAG-AFTRA.

“This is an unbelievable situation,” said Farber, 65, a survivor of pancreatic cancer. “There are going to be so many people who aren’t going to be able to make it.”

From Broadway to Hollywood, many actors, directors, backstage workers, musicians and others in the performing arts face similar coverage suspensions. Those in the entertainment industry often have several employers over the course of a year as they move from show to show. In some ways, they’re quintessential gig workers.

Their employers generally make financial contributions to a benefit fund under the terms of the union contract. And the workers pay premiums on their coverage. If workers accumulate a predetermined number of hours or earnings, they can qualify for coverage for up to a year. Coverage is typically comprehensive and quite inexpensive. Farber paid just $408 every three months to cover him and his husband.

It’s a model some academics think might work for others in the gig economy. “It makes coverage possible in industries like retail, construction and entertainment where it might not otherwise be offered,” said JoAnn Volk, a research professor at Georgetown University’s Center on Health Insurance Reforms.

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As the COVID pandemic period has shown, it doesn’t always work well. Someone in the entertainment industry may be able to weather a dry spell without any work because he’s already qualified for coverage based on past employment. But once coverage lapses, this system could leave entertainers at a disadvantage over other workers returning to a more conventional job, where coverage can start immediately. Plus, members may continue to owe union dues, even though they aren’t eligible for health benefits.

The timing of the shutdown couldn’t be worse for Farber, who needed just 12 days of work or $249 in earnings by the end of June to qualify for continued coverage in October. Accumulating that would have been “easy as pie,” he said.

In the entertainment unions’ benefit plans, “coverage is always prospective,” said Phyllis Borzi, a former assistant secretary in the Department of Labor who headed the Employee Benefits Security Administration and is now a consultant. “That works fine if you have a short interruption, but they’ve been out so long, to the extent they have hours banked, they must be out of them by now.”

SAG-AFTRA represents about 160,000 professionals in TV, radio, film and other media. The union requires that members this year generally must accumulate at least 84 days of qualifying work or earn $18,040 over four quarters to be eligible for coverage for the next four quarters.

Farber eventually got a temporary reprieve because he learned he could qualify for coverage with lower earnings under a separate category for people who are least 40 years old and have 10 or more years of health plan eligibility. But he doesn’t know how coverage changes planned for next year will affect his eligibility.

The health plan has taken some steps to alleviate concerns raised by members. In April, it cut health care premiums in half for the second quarter and this month announced a temporary reduction of COBRA premiums for some members.

The SAG-AFTRA benefit fund didn’t respond to requests for comment.

Even in the best of times, it can be difficult for those in the entertainment industry whose names appear in small print in the credits to string together enough work to qualify for coverage. If social restrictions were to ease and people could get work heading into fall, any accumulated hours and income may be too far in the past to count toward future coverage, leaving them no choice but to start accumulating them all over again.

In contrast, when employers hire someone eligible for on-the-job coverage, they typically can’t impose waiting periods longer than 90 days for health insurance under the Affordable Care Act.

Like people who work for a single employer, workers who lose coverage through their union benefit plan can continue their coverage for up to 18 months under federal COBRA law, but workers who make that choice generally have to pick up the entire cost of the plan. And COBRA coverage is not cheap. They may also enroll in a plan on their state marketplace set up by the Affordable Care Act or, if they qualify, in Medicaid, the federal-state program for low-income people.

When the pandemic hit in mid-March, Dee Nichols had logged 512 of the 600 hours he needed to accumulate in a six-month period to qualify for health coverage with the Motion Picture Industry health plan.

“You’re trying to fill a tub of water and it keeps getting holes,” says Dee Nichols, a camera operator in Los Angeles. “They’re fine with guys like me contributing and then not being able to pull [benefits] out of it. It drives me insane.”Nichols, a camera operator in Los Angeles who is a member of Local 600 of the International Cinematographers Guild, had two shows lined up in early March that would have brought him up to the threshold by March 21, the end of his qualifying period for coverage. Then production was canceled.

It wasn’t the first time that Nichols, 49, had missed the hours target for coverage through his union plan. “You’re trying to fill a tub of water and it keeps getting holes,” Nichols said. Meanwhile, he pays $400 a month for an individual marketplace plan with a $6,000 deductible. “They’re fine with guys like me contributing and then not being able to pull [benefits] out of it,” he said. “It drives me insane.”

The Motion Picture Industry health plan also offered some relief to members, including extending them some hours of credit, waiving premiums for dependents and offering COBRA subsidies.

But the assistance didn’t help Nichols qualify for coverage.

He and another member are part of a class action lawsuit arguing that the health plan has a responsibility under federal law to treat all plan participants equally.

The health plan didn’t respond to a request for comment.

Unclear When ‘We’ll Work Again’

To assist its members during the pandemic, the Actors’ Equity Association health plan waived premiums for three months starting in May and is temporarily offering a lower-cost plan through the end of the year.

But since these multi-employer plans are self-funded, they pay members’ claims directly. That can cause problems when work is scant and employers aren’t paying into the fund.

“All of these health funds have different financial positions, and they have to maintain reserves in order to maintain coverage for their members,” said Brandon Lorenz, communications director of the Actors’ Equity Association, which represents approximately 52,000 actors and stage managers.

SAG-AFTRA, which has projected a $141 million deficit in its health plan this year, announced far-reaching changes to coverage for next year, including higher thresholds on earnings and days worked to qualify for coverage.

That could prove an added challenge for Jeffrey Farber, who is concerned about what job opportunities will be available when the industry recovers.

“None of us knows when production is going to start again or if we’ll work again,” he said.

Antes que la pandemia paralizara la industria del entretenimiento en marzo, Jeffrey Farber tenía un flujo constante de trabajo en cine y televisión, incluyendo apariciones en “Hunters” y “Blue Boods”.

Pero cuando se cancelaron las producciones teatro, cine y TV, Farber no sólo perdió sus ingresos como actor, sino que también dejó de acumular las horas y ganancias que necesitaba para calificar para el seguro médico a través de su sindicato, SAG-AFTRA.

Sin estos trabajos en actuación, su seguro terminaría en septiembre.

“Es una situación increíble”, dijo Farber, de 65 años y sobreviviente de cáncer de páncreas. “Va a haber mucha gente que no va a poder vivir así”.

Desde Broadway hasta Hollywood, muchos actores, directores, trabajadores de producción, músicos y otros se enfrentan a situaciones similares. Los trabajadores en la industria del entretenimiento a menudo tienen varios empleadores en el transcurso de un año, a medida que pasan de un espectáculo a otro. En cierto modo, son trabajadores por cuenta propia.

Sus empleadores generalmente hacen contribuciones financieras a un fondo de beneficios bajo los términos del contrato del sindicato. Y los trabajadores pagan primas por su cobertura.

Si acumulan un número predeterminado de horas o ganancias, pueden calificar para la cobertura por un año. La cobertura suele ser amplia y bastante económica. Farber pagaba sólo $408 cada tres meses para él y su esposo.

Es un modelo que algunos académicos piensan que podría funcionar para otros en este tipo de industria. “Hace posible la cobertura en sectores como la venta al por menor, la construcción y el entretenimiento donde de otra manera no se ofrecería”, señaló JoAnn Volk, investigadora del Centro de Reformas del Seguro de Salud de la Universidad Georgetown.

Pero como ha mostrado este tiempo de pandemia, no siempre funciona bien. Alguien en la industria del entretenimiento puede ser capaz de  sobrellevar un período de sequía, sin trabajo, porque califica para la cobertura basada en un empleo anterior.

Pero una vez que la cobertura caduca, este sistema podría dejar a los artistas en desventaja sobre otros trabajadores que regresan a un trabajo más convencional, donde la cobertura puede comenzar inmediatamente. Además, los miembros pueden seguir debiendo cuotas sindicales, aunque no sean elegibles para los beneficios de salud.

El momento del cierre no podría ser peor para Farber, que sólo necesitaba 12 días de trabajo o $249 en ingresos, a fines de junio, para calificar para la continuidad de la cobertura en octubre.

En los planes de los sindicatos del entretenimiento, “la cobertura siempre es prospectiva”, explicó Phyllis Borzi, ex secretaria adjunta del Departamento de Trabajo que dirigió la Administración de Seguridad de Beneficios del Empleado y que ahora es consultora. “Eso funciona bien si tienes una interrupción corta, pero han estado sin trabajo tanto tiempo, que si tuvieran horas acumuladas, ya las habrían perdido”.

SAG-AFTRA representa a unos 160,000 profesionales de la televisión, la radio, el cine y otros. El sindicato exige que los miembros de este año deberían acumular al menos 84 días de trabajo calificado o ganar $18,040 en cuatro trimestres para tener derecho a la cobertura de los próximos cuatro trimestres.

Farber finalmente obtuvo un aplazamiento temporal porque se enteró que podía calificar para la cobertura, con menores ingresos, en una categoría separada para las personas que tienen al menos 40 años y 10 o más de elegibilidad para el plan de salud. Pero no sabe cómo los cambios de cobertura planeados para el próximo año afectarán su elegibilidad.

El plan de salud ha tomado algunas medidas para aliviar las preocupaciones planteadas por los miembros. En abril, redujo las primas de atención médica a la mitad para el segundo trimestre y en septiembre anunció una reducción temporal de las primas de COBRA para algunos miembros.

El fondo de beneficios SAG-AFTRA no respondió a las solicitudes de comentarios.

Al igual que las personas que trabajan para un solo empleador, los trabajadores que pierden la cobertura de su plan de beneficios del sindicato pueden continuar su cobertura hasta 18 meses bajo la ley federal COBRA, pero los trabajadores que toman esa decisión generalmente tienen que pagar el costo total del plan.

Y la cobertura de COBRA no es barata. También pueden inscribirse en un plan en el mercado de su estado establecido por ACA o, si califican, en Medicaid, el programa federal-estatal para personas de bajos ingresos.

Cuando la pandemia golpeó a mediados de marzo, Dee Nichols había registrado 512 de las 600 horas que necesitaba acumular, en un período de seis meses, para calificar para la cobertura de salud con el plan de salud de la Industria Cinematográfica.

Nichols, un operador de cámara de Los Angeles que es miembro del Local 600 del International Cinematographers Guild, tenía programados dos contratos a principios de marzo que le habrían permitido alcanzar el umbral para el 21 de marzo, el final de su período de calificación para la cobertura. Pero la producción se canceló.

El plan de salud de la Industria Cinematográfica también ofreció cierto alivio a los miembros, incluyendo la extensión de algunas horas de crédito, la renuncia a las primas para los dependientes y la oferta de subsidios para COBRA.

Pero la asistencia no ayudó a Nichols a calificar para la cobertura.

Él y otro miembro forman parte de una demanda colectiva que argumenta que el plan de salud tiene la responsabilidad, según la ley federal, de tratar a todos los participantes por igual.

El plan de salud no respondió a una solicitud de comentarios.

No está claro cuándo “Volveremos a trabajar”

Para ayudar a sus miembros durante la pandemia, el plan de salud de la Actors’ Equity Association renunció a las primas durante tres meses a partir de mayo y ofrece, temporalmente, un plan de menor costo hasta fin de año.

Pero como estos planes de varios empleadores se autofinancian, pagan los reclamos de los miembros directamente. Eso puede causar problemas cuando el trabajo es escaso y los empleadores no pagan al fondo.

“Todos estos fondos de salud tienen diferentes capacidades financieras, y deben mantener reservas para preservar la cobertura de sus miembros”, explicó Brandon Lorenz, director de comunicaciones de la Actors’ Equity Association, que representa a aproximadamente 52,000 actores y directores.

SAG-AFTRA, que ha proyectado un déficit de $141 millones en su plan de salud este año, anunció cambios de gran alcance en la cobertura para el próximo año, incluyendo umbrales más altos en las ganancias y días trabajados para calificar para la cobertura.

Esto podría ser un desafío adicional para Jeffrey Farber, quien está preocupado por las oportunidades de trabajo que estarán disponibles cuando la industria se recupere.

“Nadie sabe cuándo se reanudarán las producciones o si volveremos a trabajar”, señaló.

Esta historia fue producida por Kaiser Health News, un programa editorial independiente de la 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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After shutting down in the spring, America’s empty gyms are beckoning a cautious public back for a workout. To reassure wary customers, owners have put in place — and now advertise — a variety of coronavirus control measures. At the same time, the fitness industry is trying to rehabilitate itself by pushing back against what it sees as a misleading narrative that gyms have no place during a pandemic.

In the first months of the coronavirus outbreak, most public health leaders advised closing gyms, erring on the side of caution. As infections exploded across the country, states ordered gyms and fitness centers closed, along with restaurants, movie theaters and bars. State and local officials consistently branded gyms as high-risk venues for infection, akin to bars and nightclubs.

In early August, New York Gov. Andrew Cuomo called gym-going a “dangerous activity,” saying he would keep them shut — only to announce later in the month that most gyms could reopen in September at a third of the capacity and under tight regulations.

New York, New Jersey and North Carolina were among the last state holdouts — only recently allowing fitness facilities to reopen. Many states continue to limit capacity and have instituted new requirements.

The benefits of gyms are clear. Regular exercise staves off depression and improves sleep, and staying fit may be a way to avoid a serious case of COVID-19. But there are clear risks, too: Lots of people moving around indoors, sharing equipment and air, and breathing heavily could be a recipe for easy viral spread. There are scattered reports of coronavirus cases traced back to specific gyms. But gym owners say those are outliers and argue the dominant portrayal overemphasizes potential dangers and ignores their brief but successful track record of safety during the pandemic.

A Seattle gym struggles to comply with new rules and survive

At NW Fitness in Seattle, everything from a set of squats to a run on the treadmill requires a mask. Every other cardio machine is off-limits. The owners have marked up the floor with blue tape to show where each person can work out.

Esmery Corniel, a member, has resumed his workout routine with the punching bag.

“I was honestly just losing my mind,” said Corniel, 27. He said he feels comfortable in the gym with its new safety protocols.

“Everybody wears their mask, everybody socially distances, so it’s no problem here at all,” Corniel said.

There’s no longer the usual morning “rush” of people working out before heading to their jobs.

Under Washington state’s coronavirus rules, only about 10 to 12 people at a time are permitted in this 4,000-square-foot gym.

“It’s drastically reduced our ability to serve our community,” said John Carrico. He and his wife, Jessica, purchased NW Fitness at the end of last year.

Meanwhile, the cost of running the businesses has gone up dramatically. The gym now needs to be staffed round-the-clock to keep up with the frequent cleaning requirements, and to ensure people are wearing masks and following the rules.

Keeping the gym open 24/7 — previously a big selling point for members — is no longer feasible. In the past three months, they’ve lost more than a third of their membership.

“If the trend continues, we won’t be able to stay open,” said Jessica Carrico, who also works as a nurse at a homeless shelter run by Harborview Medical Center.

Given her medical background, Jessica Carrico was initially inclined to trust the public health authorities who ordered all gyms to shut down, but gradually her feelings changed.

“Driving around the city, I’d still see lines outside of pot shops and Baskin-Robbins,” she said. “The arbitrary decision that had been made was very clear, and it became really frustrating.”

Even after gyms in the Seattle area were allowed to reopen, their frustrations continued — especially with the strict cap on operating capacity. The Carricos believe that falls hardest on smaller gyms that don’t have much square footage.

“People want this space to be safe, and will self-regulate,” said John Carrico. He believes he could responsibly operate with twice as many people inside as currently allowed. Public health officials have mischaracterized gyms, he added, and underestimated their potential to operate safely.

“There’s this fear-based propaganda that gyms are a cesspool of coronavirus, which is just super not true,” Carrico said.

Gyms seem less risky than bars. But there’s very little research either way

The fitness industry has begun to push back at the pandemic-driven perceptions and prohibitions. “We should not be lumped with bars and restaurants,” said Helen Durkin, an executive vice president for the International Health, Racquet & Sportsclub Association (IHRSA).

John Carrico called the comparison with bars particularly unfair. “It’s almost laughable. I mean, it’s almost the exact opposite. … People here are investing in their health. They’re coming in, they’re focusing on what they’re trying to do as far as their workout. They’re not socializing, they’re not sitting at a table and laughing and drinking.”

Since the pandemic began, many gyms have overhauled operations and now look very different: Locker rooms are often closed and group classes halted. Many gyms check everyone for symptoms upon arrival. They’ve spaced out equipment and begun intensive cleaning regimes.

Gyms have a big advantage over other retail and entertainment venues, Durkin said, because the membership model means those who may have been exposed in an outbreak can be easily contacted.

A company that sells member databases and software to gyms has been compiling data during the pandemic. (The data, drawn from 2,877 gyms, is by no means comprehensive because it relies on gym owners to self-report incidents in which a positive coronavirus case was detected at the gym, or was somehow connected to the gym.) The resultant report said that the overall “visits to virus” ratio of 0.002% is “statistically irrelevant” because only 1,155 cases of coronavirus were reported among more than 49 million gym visits. Similarly, data collected from gyms in the United Kingdom found only 17 cases out of more than 8 million visits in the weeks after gyms reopened there.

Only a few U.S. states have publicly available information on outbreaks linked to the fitness sector, and those states report very few cases. In Louisiana, for example, the state has identified five clusters originating in “gym/fitness settings,” with a total of 31 cases. None of the people died. By contrast, 15 clusters were traced to “religious services/events,” sickening 78, and killing five of them.

“The whole idea that it’s a risky place to be … around the world, we just aren’t seeing those numbers anywhere,” said IHRSA’s Durkin.

A study from South Korea published by the Centers for Disease Control and Prevention is often cited as evidence of the inherent hazards of group fitness activities.

The study traced 112 coronavirus infections to a Feb. 15 training workshop for fitness dance instructors. Those instructors went on to teach classes at 12 sports facilities in February and March, transmitting the virus to students in the dance classes, but also to co-workers and family members.

But defenders of the fitness industry point out that the outbreak began before South Korea instituted social distancing measures.

The study authors note that the classes were crowded and the pace of the dance workouts was fast, and conclude that “intense physical exercise in densely populated sports facilities could increase the risk for infection” and “should be minimized during outbreaks.” They also found that no transmission occurred in classes with fewer than five people, or when an infected instructor taught “lower-intensity” classes such as yoga and Pilates.

Public health experts continue to urge gym members to be cautious

It’s clear that there are many things gym owners — and gym members — can do to lower the risk of infection at a gym, but that doesn’t mean the risk is gone. Infectious disease doctors and public health experts caution that gyms should not downplay their potential for spreading disease, especially if the coronavirus is widespread in the surrounding community.

“There are very few [gyms] that can actually implement all the infection control measures,” said Saskia Popescu, an infectious disease epidemiologist in Phoenix. “That’s really the challenge with gyms: There is so much variety that it makes it hard to put them into a single box.”

Popescu and two colleagues developed a COVID-19 risk chart for various activities. Gyms were classified as “medium high,” on par with eating indoors at a restaurant or getting a haircut, but less risky than going to a bar or riding public transit.

Popescu acknowledges there’s not much recent evidence that gyms are major sources of infection, but that should not give people a false sense of assurance.

“The mistake would be to assume that there is no risk,” she said. “It’s just that a lot of the prevention strategies have been working, and when we start to loosen those, though, is where you’re more likely to see clusters occur.”

Any location that brings people together indoors increases the risk of contracting the coronavirus, and breathing heavily adds another element of risk. Interventions such as increasing the distance between cardio machines might help, but tiny infectious airborne particles can travel farther than 6 feet, Popescu said.

The mechanics of exercising also make it hard to ensure people comply with crucial preventive measures like wearing a mask.

“How effective are masks in that setting? Can they really be effectively worn?” asked Dr. Deverick Anderson, director of the Duke Center for Antimicrobial Stewardship and Infection Prevention. “The combination of sweat and exertion is one unique thing about the gym setting.”

“I do think that, in the big picture, gyms would be riskier than restaurants because of the type of activity and potential for interaction there,” Anderson said.

The primary way people could catch the virus at a gym would be coming close to someone who is releasing respiratory droplets and smaller airborne particles, called “aerosols,” when they breathe, talk or cough, said Dr. Dean Blumberg, chief of pediatric infectious diseases at UC Davis Health.

He’s less worried about people catching the virus from touching a barbell or riding a stationary bike that someone else used. That’s because scientists now think “surface” transmission isn’t driving infection as much as airborne droplets and particles.

“I’m not really worried about transmission that way,” Blumberg said. “There’s too much attention being paid to disinfecting surfaces and ‘deep cleaning,’ spraying things in the air. I think a lot of that’s just for show.”

Blumberg said he believes gyms can manage the risks better than many social settings like bars or informal gatherings.

“A gym where you can adequately social distance and you can limit the number of people there and force mask-wearing, that’s one of the safer activities,” he said.

Adapting to the pandemic’s prohibitions doesn’t come cheap

In Bellevue, Washington, PRO Club is an enormous, upscale gym with spacious workout rooms — and an array of medical services such as physical therapy, hormone treatments, skin care and counseling. PRO Club has managed to keep the gym experience relatively normal for members since reopening, according to employee Linda Rackner. “There is plenty of space for everyone. We are seeing about 1,000 people a day and have capacity for almost 3,000,” Rackner said. “We’d love to have more people in the club.”

The gym uses the same air-cleaning units as hospital ICUs, deploys ultraviolet robots to sanitize the rooms and requires temperature checks to enter. “I feel like we have good compliance,” said Dean Rogers, one of the personal trainers. “For the most part, people who come to a gym are in it for their own health, fitness and wellness.”

But Rogers knows this isn’t the norm everywhere. In fact, his own mother back in Oklahoma believes she contracted the coronavirus at her gym.

“I was upset to find out that her gym had no guidelines they were following, no safety precautions,” he said. “There are always going to be some bad actors.”

This story is part of a partnership that includes NPR and Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Carrie Feibel, an editor for the NPR-KHN reporting partnership, contributed to this story.

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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CLEVELAND — Families skipping or delaying pediatric appointments for their young children because of the pandemic are missing out on more than vaccines. Critical testing for lead poisoning has plummeted in many parts of the country.

In the Upper Midwest, Northeast and parts of the West Coast — areas with historically high rates of lead poisoning — the slide has been the most dramatic, according to the Centers for Disease Control and Prevention. In states such as Michigan, Ohio and Minnesota, testing for the brain-damaging heavy metal fell by 50% or more this spring compared with 2019, health officials report.

“The drop-off in April was massive,” said Thomas Largo, section manager of environmental health surveillance at the Michigan Department of Health and Human Services, noting a 76% decrease in testing compared with the year before. “We weren’t quite prepared for that.”

Blood tests for lead, the only way to tell if a child has been exposed, are typically performed by pricking a finger or heel or tapping a vein at 1- and 2-year-old well-child visits. A blood test with elevated lead levels triggers the next critical steps in accessing early intervention for the behavioral, learning and health effects of lead poisoning and also identifying the source of the lead to prevent further harm.

Because of the pandemic, though, the drop in blood tests means referrals for critical home inspections plus medical and educational services are falling, too. And that means help isn’t reaching poisoned kids, a one-two punch, particularly in communities of color, said Yvonka Hall, a lead poisoning prevention advocate and co-founder of the Cleveland Lead Safe Network. And this all comes amid COVID-related school and child care closures, meaning kids who are at risk are spending more time than ever in the place where most exposure happens: the home.

“Inside is dangerous,” Hall said.

The CDC estimates about 500,000 U.S. children between ages 1 and 5 have been poisoned by lead, probably an underestimate due to the lack of widespread testing in many communities and states. In 2017, more than 40,000 children had elevated blood lead levels, defined as higher than 5 micrograms per deciliter of blood, in the 23 states that reported data.

While preliminary June and July data in some states indicates lead testing is picking up, it’s nowhere near as high as it would need to be to catch up on the kids who missed appointments in the spring at the height of lockdown orders, experts say. And that may mean some kids will never be tested.

“What I’m most worried about is that the kids who are not getting tested now are the most vulnerable — those are the kids I’m worried might not have a makeup visit,” said Stephanie Yendell, senior epidemiology supervisor in the health risk intervention unit at the Minnesota Department of Health.

Lifelong Consequences

There’s a critical window for conducting lead poisoning blood tests, timed to when children are crawling or toddling and tend to put their hands on floors, windowsills and door frames and possibly transfer tiny particles of lead-laden dust to their mouths.

Children at this age are more likely to be harmed because their rapidly growing brains and bodies absorb the element more readily. Lead poisoning can’t be reversed; children with lead poisoning are more likely to fall behind in school, end up in jail or suffer lifelong health problems such as kidney and heart disease.

That’s why lead tests are required at ages 1 and 2 for children receiving federal Medicaid benefits, the population most likely to be poisoned because of low-quality housing options. Tests are also recommended for all children living in high-risk ZIP codes with older housing stock and historically high levels of lead exposure.

Testing fell far short of recommendations in many parts of the country even before the pandemic, though, with one recent study estimating that in some states 80% of poisoned children are never identified. And when tests are required, there has been little enforcement of the rule.

Early in the pandemic, officials in New York’s Erie County bumped up the threshold for sending a public health worker into a family’s home to investigate the source of lead exposure from 5 micrograms per deciliter to 45 micrograms per deciliter (a blood lead level that usually requires hospitalization), said Dr. Gale Burstein, that county’s health commissioner. For all other cases during that period, officials inspected only the outside of the child’s home for potential hazards.

About 700 fewer children were tested for lead in Erie County in April than in the same month last year, a drop of about 35%.

Ohio, which has among the highest levels of lead poisoning in the country, recently expanded automatic eligibility for its Early Intervention program to any child with an elevated blood lead test, providing the opportunity for occupational, physical and speech therapy; learning supports for school; and developmental assessments. If kids with lead poisoning don’t get tested, though, they won’t be referred for help.

In early April, there were only three referrals for elevated lead levels in the state, which had been fielding nine times as many on average in the months before the pandemic, said Karen Mintzer, director of Bright Beginnings, which manages them for Ohio’s Department of Developmental Disabilities. “It basically was a complete stop,” she said. Since mid-June, referrals have recovered and are now above pre-pandemic levels.

“We should treat every child with lead poisoning as a medical emergency,” said John Belt, principal investigator for the Ohio Department of Health’s lead poisoning program. “Not identifying them is going to delay the available services, and in some cases lead to a cognitive deficit.”

Pandemic Compounds Worries

One of the big worries about the drop in lead testing is that it’s happening at a time when exposure to lead-laden paint chips, soil and dust in homes may be spiking because of stay-at-home orders during the pandemic.

Exposure to lead dust from deteriorating paint, particularly in high-friction areas such as doors and windows, is the most common cause of lead exposure for children in the U.S.

“I worry about kids in unsafe housing, more so during the pandemic, because they’re stuck there during the quarantine,” said Dr. Aparna Bole, a pediatrician at Cleveland’s University Hospitals Rainbow Babies & Children’s Hospital.

The pandemic may also compound exposure to lead, experts fear, as both landlords and homeowners try to tackle renovation projects without proper safety precautions while everyone is at home. Or the economic fallout of the crisis could mean some people can no longer afford to clean up known lead hazards at all.

“If you’ve lost your job, it’s going to make it difficult to get new windows, or even repaint,” said Yendell.

The CDC says it plans to help state and local health departments track down children who missed lead tests. Minnesota plans to identify pediatric clinics with particularly steep drops in lead testing to figure out why, said Yendell.

But, Yendell said, that will likely have to wait until the pandemic is over: “Right now I’m spending 10-20% of my time on lead, and the rest is COVID.”

The pandemic has stretched already thinly staffed local health departments to the brink, health officials say, and it may take years to know the full impact of the missed testing. For the kids who’ve been poisoned and had no intervention, the effects may not be obvious until they enter school and struggle to keep up.

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 California, the cradle of renowned tech startups and the Silicon Valley, elementary school students have had to figure out how to work remotely, but lawmakers have not.

Since March, Californians have scrambled to comply with public health orders that required most office and school work to occur at home. But in one of the most iconic office spaces in the state — the Capitol building in Sacramento — most lawmakers and their staffers have gathered in large numbers for months (except when COVID-19 infections forced them to take unplanned recesses).

And as the end-of-session frenzy gripped them in late August, pandemic no-nos spiked: Lawmakers huddled closely, let their masks slip below their noses, smooshed together for photos and shouted “Aye!” and “No!” when voting in the Senate, potentially spraying virus-laden particles at their colleagues.

“It’s terrible role-modeling,” said Dr. Sadiya Khan, assistant professor of cardiology and epidemiology at Northwestern University. “Why do we have to do this if they’re not doing it?”

Legislative leaders are divided on whether remote voting violates the state constitution. Nonetheless, it was authorized — should it be needed — on a limited basis by both chambers in late July.

In the last week of the session, the Democratic leader of the state Senate ordered 10 Republican senators who lunched together to vote via video after one of them, Sen. Brian Jones (R-Santee), announced he had tested positive for the coronavirus. The lone Republican senator who did not dine with them was allowed to vote on the floor.

But the remote-voting option didn’t extend to others such as Assembly member Buffy Wicks (D-Oakland), who brought her newborn onto the floor for a late-night vote on Aug. 31.

.@BuffyWicks should’ve been home with her baby voting by proxy. That she came to #caleg is a testament to her but it didn’t have to be this way. Expecting + new moms can be “in the room where it happens” by being in the zoom where it happens. #WeSaidEnough https://t.co/Bh00nohICv

— Christine Pelosi (@sfpelosi) September 2, 2020

Lawmakers insist the guiding forces behind their decision-making have been “science-based protocols.”

But the science is pretty clear: Stay home, wear a mask that covers your nose and mouth, wash your hands and keep at least 6 feet away from people indoors. Maybe let your pregnant and nursing colleagues work from home.

Here at California Healthline, we let science and data guide our decisions, so we ran some of the legislators’ behavior by epidemiologists and infectious disease experts.

This isn’t (solely) to COVID-shame our elected officials for violating local, state and national recommendations governing how to conduct themselves in a pandemic — while crafting and debating the laws that govern our lives. Instead, we aim to be constructive. The pandemic rages on, and lawmakers may face similar conditions when they return in December to swear in newly elected members, or possibly sooner if Gov. Gavin Newsom calls for a special legislative session this fall.

Should Lawmakers Meet Indoors?

Health officials have pleaded with the public to stay home when possible to minimize the spread of COVID-19. The virus, they say, is extremely contagious, especially indoors.

But elected officials around the country continue to meet in person.

In California’s Capitol, everyone must wear masks, the number of visitors to the Assembly and Senate floors were limited to provide more social-distancing space among members, and plexiglass dividers were installed in both chambers.

“These are absolutely unprecedented times in the California State Senate, and there was no prior experience with live remote voting or participation,” Senate President Pro Tem Toni Atkins said in a statement to California Healthline. “So, we proceeded with a method that maximized participation while respecting public safety and meeting the legislature’s constitutional duties, which, as you know, private businesses do not have to consider in their remote decision making.”

Despite the precautions, congregating indoors is not wise, public health experts say.

“I don’t think it’s a good idea for any large group to have gathered, even if you were all wearing masks in an indoor environment,” Khan said.

“We know that wearing a mask — consistently and correctly — substantially reduces the risk of coronavirus spread but certainly does not eliminate it,” said Dr. Leana Wen, an emergency physician and visiting public health professor at George Washington University. “And in this time of a pandemic, we should all be doing what we can to switch to virtual meetings and gatherings, when possible.”

Broken Social-Distancing Rules

Time after time, California lawmakers flagrantly broke social-distancing rules.

Some didn’t wear masks that properly sealed their faces, or pulled their masks down to sip coffee. Impassioned senators yelled to cast votes, while their colleagues in the Assembly quietly voted at their desks by simply pushing a button. And lawmakers in both chambers huddled closely to confer.

“Physical distance is quite important, actually,” said Dr. George Rutherford, a professor of epidemiology and biostatistics at the University of California-San Francisco. It’s the “second layer” of protection after masks, he said.

“I realize it doesn’t lend itself well to this kind of business, but you have to figure it out,” he said.

Thank you Majority Leader @IanCalderon for your incredible service to our legislature & all Californians! You’ll be dearly missed but you’ve earned some well deserved quality time with your family. I know we’ll see you in service again. Until then, wish you nothing but happiness! pic.twitter.com/phXFcXVPKf

— Ash Kalra 🌱 (@Ash_Kalra) September 2, 2020

Lawmakers, Rutherford noted, are prone to dramatic speeches and like to yell passionately into microphones to make a point, which is not particularly good behavior under COVID.

“I mean, the louder you talk, the greater your exhalational force, the more likely you are to overwhelm the protections of the mask,” he said.

The Cry Heard ’Round the World

A baby’s cry from the Assembly floor triggered national rebuke of California’s legislature. When Wicks came to the floor to vote on a housing bill Aug. 31, her month-old daughter, Elly, wasn’t pleased that her late-night feeding had been interrupted.

And Elly agrees! #CALeg https://t.co/U3E1KIChmA pic.twitter.com/ETodCXCjv3

— M Franco (@rjactivista) September 1, 2020

Wicks had asked Assembly leadership if she could vote by proxy but was told she was not at high risk for COVID-19. Assembly Speaker Anthony Rendon later apologized.

“Inclusivity and electing more women into politics are core elements of our Democratic values,” Rendon said in a statement. “Nevertheless, I failed to make sure our process took into account the unique needs of our Members. The Assembly needs to do better. I commit to doing better.”

The photo of Wicks holding her swaddled baby in her arms went viral — a rallying cry for mothers across the country balancing the demands of work with children at home. Plus, requiring that she appear in person was not only unnecessary, Wen said, but dangerous.

“Newborns are extremely high-risk because they have no immunity, other than the immunity that they obtained from their mother, said Wen, who is the mother of a 5-month-old. “Every employer, every entity needs to do everything they can to be flexible during this time of a pandemic.”

Why Not Legislate Virtually?

Congress continues to gavel into session in person, and many state constitutions require legislatures to meet in person. At least 30 states have allowed remote voting, extended bill deadlines or made other legislative accommodations since the start of the pandemic, according to the National Conference of State Legislatures.

Only Wisconsin and Oregon already had rules in place for remote voting in case of an emergency.

California dabbled with online hearings this spring and summer and witnesses testified remotely. There were the usual trip-ups: mute buttons still engaged, a crackly phone line or a lawmaker caught uttering a bad word.

This moment says everything about 2020. State Sen. @ScottWilkCA, struggling with mute on his Zoom voting in Senate session, looked to have mouthed one of those not-so-nice words in frustration. The chamber laughed and his face was priceless.

Senator, thanks for this moment! pic.twitter.com/2yphFgOp3M

— John Myers (@johnmyers) August 28, 2020

But the technology is available to conduct the people’s business, and public health experts urged lawmakers to consider updating their rules.

“It’s not the same as being in person for sure. It is really hard to accomplish things the same way,” Khan acknowledged. But “in 2020, we’re very blessed with a million different ways to remotely interact for video and audio that should be explored and exhausted before saying that there is no better option.”

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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The headlines from this week will be about how President Donald Trump knew early on how serious the coronavirus pandemic was likely to become but purposely played it down. Potentially more important during the past few weeks, though, are reports of how White House officials have pushed scientists at the federal government’s leading health agencies to put politics above science.

Meanwhile, Republicans appear to have given up on using the Affordable Care Act as an electoral cudgel, judging, at least, from its scarce mention during the GOP convention. Democrats, on the other hand, particularly those running for the U.S. House and Senate, are doubling down on their criticism of Republicans for failing to adequately protect people with preexisting health conditions. That issue was key to the party winning back the House in 2018.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Mary Ellen McIntire of CQ Roll Call and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s podcast:

• The Affordable Care Act has become a political vulnerability for Republican officials, who have no interest in reopening the debate on it during this campaign. Trump vowed before his 2016 election to repeal the law immediately after taking office and members of Congress had berated it for years. But they could not gain the political capital to overturn Obamacare.
• Trump’s comments to journalist-author Bob Woodward about holding back information on the risks of the coronavirus pandemic from the public may not have a major effect on the election since so many voters’ minds are already set on their choices. For many, the president’s statements are seen by partisans as identifying what they already believe: for Trump’s supporters, that he is protecting the public; for his critics, that he is a liar.
• The number of COVID-19 cases appears to have hit another plateau, but it’s still twice as high as the count last spring. Officials are waiting to see if end-of-the-summer activities over the Labor Day holiday will create another surge.
• The stalemate on Capitol Hill over coronavirus relief funding shows no sign of easing soon. Republicans in the Senate are resisting Democrats’ insistence on a massive package, but it’s not exactly clear what the GOP can agree on.
• The vaccine being developed by AstraZeneca ran into difficulty this week as experts seek to determine whether a neurological problem that developed in one volunteer was caused by the vaccine. Some public health officials, such as NIH Director Francis Collins, said this helps show that even with the compressed testing timeline, safeguards are working.
• Nonetheless, another vaccine maker, Pfizer, said it might still have its vaccine ready before the election.
• The recent controversy at the FDA over the emergency authorization of plasma to treat COVID patients and the awkward decision at the Centers for Disease Control and Prevention to change guidelines for testing asymptomatic people have created a credibility gap among some Americans and played into concerns that the administration is undercutting science.

Also this week, Rovner interviews KHN’s Elizabeth Lawrence, who reported the August NPR-KHN “Bill of the Month” installment, about an appendectomy gone wrong, and the very big bill that followed. If you have an outrageous medical bill you would like to share with us, you can do that here.

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

Julie Rovner: ProPublica’s “A Doctor Went to His Own Employer for a COVID-19 Antibody Test. It Cost $10,984,” by Marshall Allen

Joanne Kenen: The Atlantic’s “America Is Trapped in a Pandemic Spiral,” by Ed Yong

Sarah Karlin-Smith: Politico’s “Emails Show HHS Official Trying to Muzzle Fauci,” by Sarah Owermohle

Mary Ellen McIntire: The Atlantic’s “What Young, Healthy People Have to Fear From COVID-19,” by Derek Thompson

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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Nurses at Alta Bates Summit Medical Center were on edge as early as March when patients with COVID-19 began to show up in areas of the hospital that were not set aside to care for them.

The Centers for Disease Control and Prevention had advised hospitals to isolate COVID patients to limit staff exposure and help conserve high-level personal protective equipment that’s been in short supply.

Yet COVID patients continued to be scattered through the Oakland hospital, according to complaints to California’s Division of Occupational Safety and Health. The concerns included the sixth-floor medical unit where veteran nurse Janine Paiste-Ponder worked.

COVID patients on that floor were not staying in their rooms, either confused or uninterested in the rules. Staff was not provided highly protective N95 respirators, said Mike Hill, a nurse in the hospital intensive care unit and the hospital’s chief representative for the California Nurses Association, which filed complaints to Cal/OSHA, the state’s workplace safety regulator.

“It was just a matter of time before one of the nurses died on one of these floors,” Hill said.

Two nurses fell ill, including Paiste-Ponder, 59, who died of complications from the virus on July 17.

The concerns raised in Oakland also have swept across the U.S., according to interviews, a review of government workplace safety complaints and health facility inspection reports. A KHN investigation found that dozens of nursing homes and hospitals ignored official guidelines to separate COVID patients from those without the coronavirus, in some places fueling its spread and leaving staff unprepared and infected or, in some cases, dead.

As recently as July, a National Nurses United survey of more than 21,000 nurses found that 32% work in a facility that does not have a dedicated COVID unit. At that time, the coronavirus had reached all but 17 U.S. counties, data collected by Johns Hopkins University shows.

KHN discovered that COVID victims have been commingled with uninfected patients in health care facilities in states including California, Florida, New Jersey, Iowa, Ohio, Maryland and New York.

A COVID-19 outbreak was in full swing at the New Jersey Veterans Home at Paramus in late April when health inspectors observed residents with dementia mingling in a day room — COVID-positive patients as well as others awaiting test results. At the time, the center had already reported COVID infections among 119 residents and 46 virus-related deaths, according to a Medicare inspection report.

The assistant director of nursing at an Iowa nursing home insisted April 28 that they did “not have any COVID in the building” and overrode the orders of a community doctor to isolate several patients with fevers and falling oxygen levels, an inspection report shows.

By mid-May, the facility’s COVID log showed 61 patients with the virus and nine dead.

Federal work-safety officials have closed at least 30 complaints about patient mixing in hospitals nationwide without issuing a citation. They include a claim that a Michigan hospital kept patients who tested negative for the virus in the COVID unit in May. An upstate New York hospital also had COVID patients in the same unit as those with no infection, according to a closed complaint to the federal Occupational Safety and Health Administration.

Federal Health and Human Services officials have called on hospitals to tell them each day if they have a patient who came in without COVID-19 but had an apparent or confirmed case of the coronavirus 14 days later. Hospitals filed 48,000 reports from June 21 through Aug. 28, though the number reflects some double or additional counting of individual patients.

COVID patients have been mixed in with others for a variety of reasons. Some hospitals report having limited tests, so patients carrying the virus are identified only after they had already exposed others. In other cases, they had false-negative test results or their facility was dismissive of federal guidelines, which carry no force of law.

And while federal Medicare officials have inspected nearly every U.S. nursing home in recent months and states have occasionally levied fines and cut off new admissions for isolation lapses, hospitals have seen less scrutiny.

The Scene Inside Sutter

At Alta Bates in Oakland, part of the Sutter Health network, hospital staff made it clear in official complaints to Cal/OSHA that they wanted administrators to follow the state’s unique law on aerosol-transmitted diseases. From the start, some staffers wanted all the state-required protections for a virus that has been increasingly shown to be transmitted by tiny particles that float through the air.

The regulations call for patients with a virus like COVID-19 to be moved to a specialized unit within five hours of identification — or to a specialized facility. The rules say those patients should be in a room with a HEPA filter or with negative air pressure, meaning that air is circulated out a window or exhaust fan instead of drifting into the hallway.

Initially, in March, the hospital outfitted a 40-bed COVID unit, according to Hill. But when a surge of patients failed to materialize, that unit was pared to 12 beds.

Since then, a steady stream of virus patients have been admitted, he said, many testing positive only days after admission — and after they’d been in regular rooms in the facility.

From March 10 through July 30, Hill’s union and others filed eight complaints to Cal/OSHA, including allegations that the hospital failed to follow isolation rules for COVID patients, some on the cancer floor.

So far, regulators have done little. Gov. Gavin Newsom had ordered workplace safety officials to “focus on … supporting compliance” instead of enforcement except on the “most serious violations.”

State officials responded to complaints by reaching out by mail and phone to “ensure the proper virus prevention measures are in place,” according to Frank Polizzi, a spokesperson for Cal/OSHA.

A third investigation related to transport workers not wearing N95 respirators while moving COVID-positive or possible coronavirus patients at a Sutter facility near the hospital resulted in a $6,750 fine, Cal/OSHA records show.

The string of complaints also says the hospital did not give staff the necessary personal protective equipment (PPE) under state law — an N95 respirator or something more protective — for caring for virus patients.

Instead, Hill said, staff on floors with COVID patients were provided lower-quality surgical masks, a concern reflected in complaints filed with Cal/OSHA.

Hill believes that Paiste-Ponder and another nurse on her floor caught the virus from COVID patients who did not remain in their rooms.

“It is sad, because it didn’t really need to happen,” Hill said.

Polizzi said investigations into the July 17 death and another staff hospitalization are ongoing.

A Sutter Health spokesperson said the hospital takes allegations, including Cal/OSHA complaints, seriously and its highest priority is keeping patients and staff safe.

The statement also said “cohorting,” or the practice of grouping virus patients together, is a tool that “must be considered in a greater context, including patient acuity, hospital census and other environmental factors.”

Concerns at Other Hospitals

CDC guidelines are not strict on the topic of keeping COVID patients sectioned off, noting that “facilities could consider designating entire units within the facility, with dedicated [staff],” to care for COVID patients.

That approach succeeded at the University of Nebraska Medical Center in Omaha. A recent study reported “extensive” viral contamination around COVID patients there, but noted that with “standard” infection control techniques in place, staffers who cared for COVID patients did not get the virus.

The hospital set up an isolation unit with air pumped away from the halls, restricted access to the unit and trained staff to use well-developed protocols and N95 respirators — at a minimum. What worked in Nebraska, though, is far from standard elsewhere.

Cynthia Butler, a nurse and National Nurses United member at Fawcett Memorial Hospital in Port Charlotte, on Florida’s west coast, said she actually felt safer working in the COVID unit — where she knew what she was dealing with and had full PPE — than on a general medical floor.

She believes she caught the virus from a patient who had COVID-19 but was housed on a general floor in May. A similar situation occurred in July, when another patient had an unexpected case of COVID — and Butler said she got another positive test herself.

She said both patients did not meet the hospital’s criteria for testing admitted patients, and the lapses leave her on edge, concerns she relayed to an OSHA inspector who reached out to her about a complaint her union filed about the facility.

“Every time I go into work it’s like playing Russian roulette,” Butler said.

A spokesperson for HCA Healthcare, which owns the hospital, said it tests patients coming from long-term care, those going into surgery and those with virus symptoms. She said staffers have access to PPE and practice vigilant sanitation, universal masking and social distancing.

The latter is not an option for Butler, though, who said she cleans, feeds and starts IVs for patients and offers reassurance when they are isolated from family.

“I’m giving them the only comfort or kind word they can get,” said Butler, who has since gone on unpaid leave over safety concerns. “I’m in there doing that and I’m not being protected.”

Given research showing that up to 45% of COVID patients are asymptomatic, UCSF Medical Center is testing everyone who’s admitted, said Dr. Robert Harrison, a University of California-San Francisco School of Medicine professor who consults on occupational health at the hospital.

It’s done for the safety of staff and to reduce spread within the hospital, he said. Those who test positive are separated into a COVID-only unit.

And staff who spent more than 15 minutes within 6 feet of a not-yet-identified COVID patient in a less-protective surgical mask are typically sent home for two weeks, he said.

Outside of academic medicine, though, front-line staff have turned to union leaders to push for such protections.

In Southern California, leaders of the National Union of Healthcare Workers filed an official complaint with state hospital inspectors about the risks posed by intermingled COVID patients at Fountain Valley Regional Hospital in Orange County, part of for-profit Tenet Health. There, the complaint said, patients were not routinely tested for COVID-19 upon admission.

One nursing assistant spent two successive 12-hour shifts caring for a patient on a general medical floor who required monitoring. At the conclusion of the second shift, she was told the patient had just been found to be COVID-positive.

The worker had worn only a surgical mask — not an N95 respirator or any form of eye protection, according to the complaint to the California Department of Public Health. The nursing assistant was not offered a COVID test or quarantined before her next two shifts, the complaint said.

The public health department said it could not comment on a pending inspection.

Barbara Lewis, Southern California hospital division director with the union, said COVID patients were on the same floor as cancer patients and post-surgical patients who were walking the halls to speed their recovery.

She said managers took steps to separate the patients only after the union held a protest, spoke to local media and complained to state health officials.

Hospital spokesperson Jessica Chen said the hospital “quickly implemented” changes directed by state health authorities and does place some COVID patients on the same nursing unit as non-COVID patients during surges. She said they are placed in single rooms with closed doors. COVID tests are given by physician order, she added, and employees can access them at other places in the community.

It’s in contrast, Lewis said, to high-profile examples of the precautions that might be taken.

“Now we’re seeing what’s happening with baseball and basketball — they’re tested every day and treated with a high level of caution,” Lewis said. “Yet we have thousands and thousands of health care workers going to work in a very scary environment.”

Nursing Homes Face Penalties

More than 40% of the people who’ve died of COVID-19 lived in nursing homes or assisted living facilities, researchers have found.

Patient mixing has been a scattered concern at nursing homes, which Medicare officials discovered when they reviewed infection control practices at more than 15,000 facilities.

News reports have highlighted the problem at an Ohio nursing home and at a Maryland home where the state levied a $70,000 fine for failing to keep infected patients away from those who weren’t sick — yet.

Another facing penalties was Fair Havens Center, a Miami Springs, Florida, nursing home where inspectors discovered that 11 roommates of patients who tested positive for COVID-19 were put in rooms with other residents — putting them at heightened risk.

Florida regulators cut off admissions to the home and Medicare authorities levied a $235,000 civil monetary penalty, records show.

The vice president of operations at the facility told inspectors that isolating exposed patients would mean isolating the entire facility: Everyone had been exposed to the 32 staff members who tested positive for the virus, the report says.

Fair Havens Center did not respond to a request for comment.

In Iowa, Medicare officials declared a state of “immediate jeopardy” at Pearl Valley Rehabilitation and Care Center in Muscatine. There, they discovered that staffers were in denial over an outbreak in their midst, with a nursing director overriding a community doctor’s orders to isolate or send residents to the emergency room. Instead, officials found, in late April, the assistant nursing director kept COVID patients in the facility, citing a general order by their medical director to avoid sending patients to the ER “if you can help it.”

Meanwhile, several patients were documented by facility staff to have fevers and falling oxygen levels, the Medicare inspection report shows. Within two weeks, the facility discovered it had an outbreak, with 61 residents infected and nine dead, according to the report.

Medicare officials are investigating Menlo Park Veterans Memorial Home in New Jersey, state Sen. Joseph Vitale said during a recent legislative hearing. Resident council president Glenn Osborne testified during the hearing that the home’s residents were returned to the same shared rooms after hospitalizations.

Osborne, an honorably discharged Marine, said he saw more residents of the home die than fellow service members during his military service. The Menlo Park and Paramus veterans homes — where inspectors saw dementia patients with and without the virus commingling in a day room — both reported more than 180 COVID cases among residents, 90 among staff and at least 60 deaths.

A spokesperson for the homes said he could not comment due to pending litigation.

“These deaths should not have happened,” Osborne said. “Many of these deaths were absolutely avoidable, in my humble opinion.”

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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Florida Gov. Ron DeSantis tried to alleviate fears of flying during the pandemic at an event with airline and rental car executives. “The airplanes have just not been vectors when you see spread of the coronavirus,” DeSantis said during a discussion at Fort Lauderdale-Hollywood International Airport on Aug. 28. “The evidence is the evidence. And I think it’s something that is safe for people to do.”

Is the evidence really so clear?

DeSantis’ claim that airplanes have not been “vectors” for the spread of the coronavirus is untrue, according to experts. A “vector” spreads the virus from location to location, and airplanes have ferried infected passengers across geographies, making COVID-19 outbreaks more difficult to contain. Joseph Allen, an associate professor of exposure assessment science at Harvard University called airplanes “excellent vectors for viral spread” in a press call.

In context, DeSantis seemed to be making a point about the safety of flying on a plane rather than the role airplanes played in spreading the virus from place to place.

When we contacted the governor’s office for evidence to back up DeSantis’ comments, press secretary Cody McCloud didn’t produce any studies or statistics. Instead, he cited the Florida Department of Health’s contact tracing program, writing that it “has not yielded any information that would suggest any patients have been infected while travelling on a commercial aircraft.”

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Florida’s contact tracing program has been mired in controversy over reports that it is understaffed and ineffective. For instance, CNN called 27 Floridians who tested positive for COVID-19 and found that only five had been contacted by health authorities. (The Florida Department of Health did not respond to requests for an interview.)

In the absence of reliable data, we decided to ask the experts about the possibility of contracting the virus while on a flight. On the whole, airplanes on their own provide generally safe environments when it comes to air quality, but experts said the risk for infection depends largely on policies airlines may have in place regarding passenger seating, masking and boarding time.

So How Safe Is Air Travel?

According to experts, the risk of catching the coronavirus on a plane is relatively low if the airline is following the procedures laid out by public health experts: enforcing mask compliance, spacing out available seats and screening for sick passengers.

“If you look at the science across all diseases, you see few outbreaks” on planes, Allen said. “It’s not the hotbed of infectivity that people think it is.”

Airlines frequently note that commercial planes are equipped with HEPA filters, the Centers for Disease Control-recommended air filters used in hospital isolation rooms. HEPA filters capture 99.97% of airborne particles and substantially reduce the risk of viral spread. In addition, the air in plane cabins is completely changed over 10 to 12 times per hour, raising the air quality above that of a normal building.

Because of the high air exchange rate, it’s unlikely you’ll catch the coronavirus from someone several rows away. However, you could still catch the virus from someone close by.

“The greatest risk in flight would be if you happen to draw the short straw and sit next to or in front, behind or across the aisle from an infector,” said Richard Corsi, who studies indoor air pollution and is the dean of engineering at Portland State University.

It’s also important to note that airplanes’ high-powered filtration systems aren’t sufficient on their own to prevent outbreaks. If an airline isn’t keeping middle seats open or vigilantly enforcing mask use, flying can actually be rather dangerous. Currently, the domestic airlines keeping middle seats open include Delta, Hawaiian, Southwest and JetBlue.

The reason for this is that infected people send viral particles into the air at a faster rate than the airplanes flush them out of the cabin. “Whenever you cough, talk or breathe, you’re sending out droplets,” said Qingyan Chen, professor of mechanical engineering at Purdue University. “These droplets are in the cabin all the time.”

This makes additional protective measures such as mask-wearing all the more necessary.

Chen cited two international flights from earlier stages of the pandemic where infection rates varied depending on mask use. On the first flight, no passengers were wearing masks, and a single passenger infected 14 people as the plane traveled from London to Hanoi, Vietnam. On the second flight, from Singapore to Hangzhou in China, all passengers were wearing face masks. Although 15 passengers were Wuhan residents with either suspected or confirmed cases of COVID-19, the only man infected en route had loosened his mask mid-flight and had been sitting close to four Wuhan residents who later tested positive for the virus.

Traveling Is Still a Danger

Even though flying is a relatively low-risk activity, traveling should still be avoided unless absolutely necessary.

“Anything that puts you in contact with more people is going to increase your risk,” said Cindy Prins, a clinical associate professor of epidemiology at the University of Florida College of Public Health and Health Professions. “If you compare it to just staying at home and quick trips to the grocery store, you’d have to put it above” that level of risk.

The real danger of traveling isn’t the flight itself. However, going through security and waiting at the gate for your plane to dock are both likely to put you in close contact with people and increase your chances of contracting the virus. In addition, boarding — when the plane’s ventilation system is not running and people are unable to stay distanced from one another — is one of the riskiest parts of the travel process. “Minimizing this time period is important to reduce exposure,” wrote Corsi. “Get to your seat with your mask on and sit down as quickly as possible.”

Viral Outbreaks Related to Planes

All in all, it’s too early to determine how much person-to-person transmission has occurred on plane flights.

Julian Tang, an honorary associate professor in the Department of Respiratory Sciences at the University of Leicester in England, said he is aware of several clusters of infection related to air travel. However, it is challenging to prove that people have caught the virus on a flight.

“Someone who presents with COVID-19 symptoms several days after arriving at their destination could have been infected at home before arriving at the airport, whilst at the airport or on the flight — or even on arrival at their destination airport — because everyone has a variable incubation period for COVID-19,” Tang said.

Katherine Estep, a spokesperson for Airlines for America, a U.S.-focused industry trade group, said the CDC has not confirmed any cases of transmission onboard a U.S. airline.

The absence of confirmed transmission is not necessarily evidence that fliers are safe. Instead, the lack of data reflects the fact that the U.S. has a higher infection rate relative to other countries, said Chen. Since the U.S. has so many confirmed cases, it’s more difficult to determine exactly where somebody contracted the virus. ​

(KFF)

[partner-box]The public is deeply skeptical about any coronavirus vaccine approved before the November election, and only 42% would be willing to get a vaccine in that scenario, according to a new poll.

The results of the poll by KFF reveal widespread concern that the Trump administration will bring pressure on drug regulators to approve a vaccine before the election without ensuring it is safe and effective. (KHN is an editorially independent program of KFF.)

Six of 10 adults said they were worried the Food and Drug Administration will rush to allow a vaccine because of political pressure. The concern is held by 85% of Democrats, 35% of Republicans and 61% of independent voters.

Resistance to taking the vaccine is strong among respondents of all stripes, with 60% of Republicans saying they would not want to be inoculated if a vaccine were available before the Nov. 3 election. Among Democrats, 46% would decline the vaccine.

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The wariness may reflect the ongoing political jockeying over a vaccine, and it may also be influenced by strains of general anti-vaccine sentiment in the populace. The Trump administration has suggested a vaccine could be ready by November, and the Centers for Disease Control and Prevention has instructed states to be prepared to distribute a vaccine by Nov. 1.

Democrats have raised fears that President Donald Trump is trying to accelerate vaccine approval to boost his reelection chances. Forty-three percent of the public approves of Trump’s handling of the pandemic — an improvement since July, when just a third liked his response.

Partisans are largely united in doubting that a vaccine will be available before the presidential election, with 81% expecting it will take longer. The poll found the public divided on whether the worst of the pandemic is over or still to come, although optimism has increased since July. Nearly 1 in 5 Americans said the virus, which has stricken more than 6 million and killed more than 190,000 people in the U.S., is not a major problem and won’t become one.

(KFF)

Trust in the government’s health experts and institutions has become highly partisan, the poll found. Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, and the CDC have the widest level of trust, with more than two-thirds of Americans believing they are providing reliable information. But the credibility of both has decreased since April.

Only 48% of Republicans trust Fauci, while 70% trust Dr. Deborah Birx, the response coordinator for the White House Coronavirus Task Force, who has remained in Trump’s good graces more than has Fauci. Conversely, 86% of Democrats have confidence in Fauci while only 44% trust Birx.

Democrats still trust the CDC more than Republicans do, but more than half of Democrats say the CDC and the FDA pay too much attention to politics. Overall, only 43% of the public says the two agencies pay the appropriate amount of attention to science.

The poll also found that intense hostility to the Affordable Care Act among Republicans has decreased substantially since the 2018 midterm elections. Only 5% of Republicans in September identified repealing the ACA as the most important health issue influencing their vote, down from 18% in October 2018.

The survey found nearly half of the public holds at least one misconception about coronavirus treatment. Twenty percent said that a face mask is dangerous to wear, and 24% said hydroxychloroquine, a drug touted by Trump but not yet validated by rigorous studies, is an effective treatment for COVID-19. Just more than half of Republicans believe in hydroxychloroquine and a third say face masks are ineffective.

Fourteen percent of Americans believe there is already a cure for the coronavirus.

The telephone poll was conducted Aug. 28-Sept. 3 among a nationally representative random sample of 1,199 adults. The margin of sampling error is plus or minus 3 percentage points.