Lo que sabemos sobre la transmisión aérea del coronavirus

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El gobierno federal dio un giro rápido a la amenaza de que el coronavirus se propagara por el aire, cambiando una pieza clave en sus guías.

El 18 de septiembre, los Centros para el Control y Prevención de Enfermedades (CDC) advirtieron que las pequeñas partículas en el aire, no solo las gotas más grandes producto de un estornudo o la tos, podrían infectar a otros. Citó en ese momento una “evidencia” creciente.

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Para el 21 de septiembre, esa advertencia desapareció de su sitio web, con una nota al pie que decía que se había publicado por error y que los CDC estaban en proceso de actualizar sus recomendaciones.

La medida puso a los CDC en medio de un debate sobre cómo el coronavirus infecta a las personas. Esas pautas podrían marcar la diferencia entre tener restaurantes, bares y otros lugares donde la gente se está reuniendo a la mitad de su capacidad, o reabrir por completo.

Y generó más preguntas sobre la intromisión de la política en la agencia de salud pública y sobre si los funcionarios de la Casa Blanca están dictando qué decir a las autoridades de salud.

Entonces, ¿qué dice realmente la ciencia sobre la transmisión aérea?

Aunque es una investigación en curso, muchas de las piezas apuntan hacia el potencial de transmisión aérea.

El desafío de probar la transmisión aérea

La narrativa eliminada del sitio web de los CDC decía: “Existe una creciente evidencia de que las gotas y las partículas pueden permanecer suspendidas en el aire y ser inhaladas por otros, y viajar distancias superiores a los 6 pies (por ejemplo, durante el ensayo de un coro, en restaurantes o en clases de gimnasia.”

¿Por qué es esto tan importante? Significa que es posible que sea necesario modificar las pautas para un distanciamiento físico adecuado.

Seis pies es el punto de referencia de seguridad que ha ayudado a dar forma a la reapertura de escuelas y negocios en todo el país. El número se basa en el hallazgo de larga data de que las gotas más grandes de la tos son tan pesadas que la mayoría de ellas caen al suelo antes de llegar a los 6 pies.

Pero las gotas mucho más pequeñas pueden permanecer en el aire por más tiempo. El debate es si portan suficiente virus para infectar a otra persona. Si la respuesta es sí, las implicaciones para la vida cotidiana podrían ser sustanciales.

Donald Milton, profesor de la Escuela de Medicina de la Universidad de Maryland, ha visto muchas pruebas de que la transmisión aérea es un factor importante, pero ha enfatizado que es difícil encontrar una respuesta definitiva.

Nadie está en desacuerdo con que estar cerca de alguien con la enfermedad sea la principal amenaza. Pero Milton dijo que lo que sucede durante ese tiempo es difícil de desentrañar.

“Podría ser que alguien tosa y te infectes al recibir un golpe directo de gotas en el ojo o la boca”, dijo Milton. “O podría ser a través de una partícula en el aire que inhalas. O podrías haber tocado algo y luego tocado tu nariz o tu boca. Es algo extremadamente difícil de dilucidar”.

Dicho esto, muchos incidentes y estudios apuntan hacia la idea de que las partículas en el aire juegan un papel más importante de lo que se pensaba.

La investigación

Un grupo internacional de investigadores de China, Australia y los Estados Unidos revisó recientemente la evidencia de la transmisión aérea. Concluyeron que era muy posible.

Un estudio publicado en Proceedings of the National Academy of Sciences informó que un minuto de hablar en voz alta podría producir “1,000 núcleos de gotitas que contienen virus que podrían permanecer en el aire durante más de ocho minutos”.

¿La conclusión de los autores? “Es probable que otros los inhalen y, por lo tanto, causen nuevas infecciones”.

El transporte público es un campo de pruebas clave.

En China, los científicos observaron a 126 pasajeros en dos autobuses que realizaban un viaje que duró aproximadamente una hora y media. Un autobús estaba libre de virus, el otro tenía un pasajero infectado. Las personas que viajaban en el autobús con el virus tuvieron 41,5 veces más probabilidades de infectarse.

Otros investigadores han analizado un evento de super propagación: la práctica de dos horas y media de duración del coro del Skagit Valley Chorale en Mount Vernon, Washington. De las 61 personas que asistieron, hubo 53 casos confirmados y potenciales, y dos muertes.

Un estudio de la Universidad de Florida tomó muestras del aire en las habitaciones del hospital de dos pacientes con COVID. Encontraron partículas aéreas que tenían suficiente carga viral para infectar a alguien a más de 15 pies de distancia de los pacientes.

En julio, 239 investigadores firmaron conjuntamente una carta abierta que pedía a las agencias de salud nacionales e internacionales que “reconozcan el potencial de propagación a través del aire” de COVID-19.

Escribieron que estudios confiables “han demostrado más allá de cualquier duda razonable que los virus se liberan durante la exhalación, el habla y la tos en microgotas lo suficientemente pequeñas como para permanecer en el aire y representar un riesgo de exposición”.

Aún así, un informe de julio de la Organización Mundial de la Salud (OMS) descubrió que si bien la transmisión aérea era posible, se necesitaba una investigación más sólida para confirmar que presenta un riesgo notable.

Milton dijo que, si los líderes de salud pública se tomaran más en serio la transmisión aérea, esto tendría algunas consecuencias. La mayor parte de la actividad comercial podría continuar, pero los restaurantes y bares, debido a que las máscaras no sirven para comer y beber, enfrentarían un obstáculo mayor.

Más allá de eso, se vuelve crítica una mayor atención a la ventilación en espacios más cerrados, al igual que el suministro de máscaras N95. Esas máscaras siguen siendo escasas.

Clínicas post-Covid reciben a pacientes con síntomas persistentes después de recuperarse

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Clarence Troutman sobrevivió a una estadía de dos meses en el hospital con COVID-19, y volvió casa a principios de junio. Pero está lejos de superar la enfermedad: todavía tiene dificultad para respirar y sus manos se hinchan y ponen rígidas.

“Antes de Covid, era un hombre relativamente sano de 59 años”, dijo el técnico de internet y cable de Denver, Colorado. “Si tuviera que decir dónde estoy ahora, diría alrededor del 50% de mi potencial, pero cuando volví a casa estaba al 20%”.

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Troutman atribuye su progreso en gran parte a la “motivación y educación” de un nuevo programa para pacientes post-Covid de la Universidad de Colorado, una de un número pequeño pero creciente de clínicas cuyo objetivo es tratar, y estudiar, a los que han tenido la impredecible enfermedad causada por el nuevo coronavirus.

Mientras se acerca la elección presidencial en los Estados Unidos, se pone mucha atención en las cifras diarias de infecciones o en el creciente número de muertes. Pero otra medida es importante: los pacientes que sobreviven pero continúan luchando con una variedad de efectos físicos o mentales, como daño pulmonar, problemas cardíacos o neurológicos , ansiedad y depresión.

“Necesitamos pensar en cómo vamos a brindar atención a los pacientes cuya recuperación del virus puede llevar años”, dijo la doctora Sarah Jolley, neumonóloga del Hospital de la Universidad de Colorado de UCHealth y directora de la clínica Post-Covid de la UCHealth, donde se atiende Troutman.

Esa necesidad ha impulsado las clínicas post-Covid, que reúnen a una variedad de especialistas en un solo lugar.

Una de las primeras y más grandes clínicas de este tipo está en Mount Sinai, en la ciudad de Nueva York, pero también se han lanzado programas en la Universidad de California-San Francisco, el Centro Médico de la Universidad de Stanford y la Universidad de Pensilvania. La Clínica Cleveland planea abrir una a principios del próximo año.

Y no se trata solo de centros médicos académicos: St. John’s Well Child and Family Center, parte de una red de clínicas comunitarias en el centro sur de Los Ángeles, dijo recientemente que tiene como meta seguir evaluando a miles de sus pacientes que fueron diagnosticados con Covid desde marzo para analizar los efectos a plazo.

La idea general es reunir a profesionales médicos de un amplio espectro: neumonólogos, cardiólogos, y especialistas en médula espinal. También a expertos en salud mental, trabajadores sociales y farmacéuticos.

Muchos de los centros también realizan investigaciones, con el objetivo de comprender mejor por qué el virus afecta con tanta fuerza a ciertos pacientes.

“Algunos de nuestros pacientes, incluso aquéllos con un ventilador al borde de la muerte, saldrán notablemente ilesos”, dijo el doctor Lekshmi Santhosh, profesor asistente de cuidados críticos pulmonares y líder de la clínica OPTIMAL, el programa post-Covid en UC San Francisco.

“Otros, incluso los que nunca fueron hospitalizados, tienen fatiga incapacitante, dolor de pecho continuo y dificultad para respirar, y hay un gran espectro en el medio”.

Es demasiado pronto para saber cuánto tiempo durarán los síntomas y efectos físicos persistentes, o para hacer estimaciones precisas sobre el porcentaje de pacientes afectados.

Algunos estudios iniciales dan pistas. Un informe austríaco publicado en septiembre encontró que 76 de los primeros 86 pacientes estudiados tenían evidencia de daño pulmonar seis semanas después de haber recibido el alta, número que se redujo a 48 pacientes a las 12 semanas.

Algunos investigadores y clínicas dicen que alrededor del 10% de los pacientes con Covid en los Estados Unidos pueden tener efectos a largo plazo, dijo el doctor Zijian Chen, director médico del Centro de Atención Post-Covid en Mount Sinai, que a la fecha ha inscrito a 400 pacientes.

Si esa estimación es correcta, y Chen enfatizó que se necesita más investigación para asegurarlo, se traducirá en pacientes que ingresan al sistema médico en masa, a menudo con múltiples problemas.

La forma en que respondan los sistemas de salud y las aseguradoras será clave, dijo. Más de 6.5 millones de estadounidenses han dado positivo para la enfermedad. Si menos del 10%, digamos 500,000, ya tienen síntomas persistentes, “esa cifra es asombrosa”, dijo Chen. “¿Cuánta atención médica se necesitará?”.

Aunque los costos iniciales podrían ser un obstáculo, las clínicas mismas pueden eventualmente generar ingresos, que los centros médicos necesitan, al atraer pacientes, muchos de los cuales tienen un seguro para cubrir parte o la totalidad del costo de estas visitas a largo plazo.

Chen, de Mount Sinai, dijo que los centros especializados pueden ayudar a reducir el gasto en salud al brindar una atención coordinada y más rentable que evite la duplicación de pruebas a las que un paciente podría someterse de otra manera.

“Hemos visto pacientes que cuando los internan, ya se han hecho cuatro resonancias magnéticas o tomografías computarizadas y una cantidad de análisis de sangre”, dijo.

El programa consolida esos resultados anteriores y determina si se necesitan pruebas adicionales. A veces, la respuesta a las causas de los síntomas duraderos de los pacientes sigue siendo difícil de obtener. Un problema para los pacientes que buscan ayuda fuera de las clínicas especializadas es que cuando no hay una causa clara para su condición, se les puede decir que los síntomas son imaginarios.

“Creo en los pacientes”, dijo Chen.

Aproximadamente la mitad de los pacientes de la clínica han recibido resultados de pruebas que muestran daños, explicó Chen, endocrinólogo y especialista en medicina interna. Para esos pacientes, la clínica puede desarrollar un plan de tratamiento. Pero, y es frustrante, la otra mitad tiene resultados no concluyentes aunque presenta una variedad de síntomas.

“Eso hace que sea más difícil de tratar”, dijo Chen.

Los expertos ven paralelismos con un impulso en la última década para establecer clínicas especiales para tratar a los pacientes dados de alta de terapias intensivas, que pueden tener problemas relacionados con el reposo en cama a largo plazo o el delirio que muchos experimentan mientras están hospitalizados. Algunas de las clínicas post-Covid siguen el modelo de las de post-terapia intensiva o son versiones ampliadas de este modelo.

Por ejemplo, el Centro de Recuperación de terapia intensiva del Centro Médico de la Universidad de Vanderbilt, que abrió en 2012, está aceptando pacientes post-Covid.

Hay alrededor de una docena de estas clínicas nivel nacional, algunas de las cuales también están trabajando ahora con pacientes de Covid, dijo James Jackson, director de resultados a largo plazo en el centro de Vanderbilt. Al menos otra docena de centros post-Covid están en desarrollo.

Los centros generalmente realizan una evaluación inicial unas semanas después que un paciente es diagnosticado o dado de alta del hospital, generalmente con una videollamada. Luego se programa una visita al mes.

“En un mundo ideal, con estas clínicas post-Covid, se puede identificar a los pacientes y llevarlos a rehabilitación”, dijo. “Incluso si lo principal que hicieron estas clínicas fue decirles a los pacientes: ‘Esto es real, no es un invento’, ese impacto sería importante”, agrego Jackson.

El financiamiento es el mayor obstáculo. Muchos hospitales perdieron ingresos sustanciales por la cancelación de procedimientos electivos durante las cuarentenas.

“Entonces, no es un buen momento para lanzar una nueva actividad que requiere un subsidio inicial”, dijo Glenn Melnick, profesor de Economía de la Salud en la Universidad del Sur de California.

En UCSF, un grupo selecto de miembros de la facultad forman parte del personal de las clínicas post-Covid y algunos profesionales de salud mental ofrecen su tiempo como voluntarios, dijo Santhosh. Chen, de Mount Sinai, dijo que pudo reclutar profesionales de salud entre los que tenían más tiempo libre a  falta de procedimientos electivos.

Jackson, en Vanderbilt, dijo que lamentablemente no ha habido suficiente investigación sobre el costo y la efectividad clínica de los centros post-terapia intensiva.

“En los primeros días, puede haber habido dudas sobre cuánto valor agrega esto”, apuntó. “Ahora, la pregunta no es tanto si es una buena idea, sino si es factible”.

En este momento, los centros post-Covid son ante todo un esfuerzo de investigación, dijo Len Nichols, economista y becario no residente del Urban Institute.

“Si estos pacientes mejoran con el tratamiento de los síntomas a largo plazo, eso es bueno para todos”, dijo Nichols. “Todavía no hay suficientes pacientes para convertirlo en un modelo de negocio, pero si se convierte en el lugar al que acudir luego del alta, podría resultar en un modelo de negocio para algunas de las instituciones de élite”.

Corralling the Facts on Herd Immunity

For a term that’s at least 100 years old, “herd immunity” has gained new life in 2020.

It starred in many headlines last month, when reports surfaced that a member of the White House Coronavirus Task Force and adviser to the president, Dr. Scott Atlas, recommended it as a strategy to combat COVID-19. The Washington Post reported that Atlas, a health care policy expert from the Hoover Institution of Stanford University, suggested the virus should be allowed to spread through the population so people build up immunity, rather than trying to contain it through shutdown measures.

At a town hall event a few weeks later, President Donald Trump raised the idea himself, saying the coronavirus would simply “go away,” as people developed “herd mentality” — a slip-up that nonetheless was understood to reference the same concept.

And as recently as last week, Sen. Rand Paul (R-Ky.) sparked a heated debate at a committee hearing when he suggested that the decline in COVID cases in New York City was due to herd or community immunity in the population rather than public health measures, such as wearing masks and social distancing. Dr. Anthony Fauci, the top U.S. infectious disease official, rebuked Paul, pointing out that only 22% of the city’s residents have COVID antibodies.

“If you believe 22% is herd immunity, I believe you’re alone in that,” Fauci told the senator.

All this talk got us thinking: People seem pretty confused about herd immunity. What exactly does it mean and can it be used to combat COVID-19?

An Uncertain Strategy With Great Cost

Herd immunity, also called community or population immunity, refers to the point at which enough people are sufficiently resistant to a disease that an infectious agent is unlikely to spread from person to person. As a result, the whole community — including those who don’t have immunity — becomes protected.

People generally gain immunity in one of two ways: vaccination or infection. For most diseases in recent history — from smallpox and polio to diphtheria and rubella —vaccines have been the route to herd immunity. For the most highly contagious diseases, like measles, about 94% of the population needs to be immunized to achieve that level of protection. For COVID-19, scientists estimate the percentage falls between 50% to 70%.

Before the COVID pandemic, experts can’t recall examples in which governments intentionally turned to natural infection to achieve herd immunity. Generally, such a strategy could lead to widespread illness and death, said Dr. Carlos del Rio, an expert in infectious disease and vaccines at the Emory University School of Medicine.

“It’s a terrible idea,” del Rio said. “It’s basically giving up on public health.”

A new, large study found fewer than 1 in 10 Americans have antibodies to SARS-CoV-2, the virus that causes COVID-19. Even in the hardest-hit areas, like New York City, estimates of immunity among residents are about 25%.

To reach 50% to 70% immunity would mean about four times as many people getting infected and an “incredible number of deaths,” said Josh Michaud, associate director of global health policy at KFF. Even those who survive could suffer severe consequences to their heart, brain and other organs, potentially leaving them with lifelong disabilities. (KHN is an editorially independent program of KFF.)

“It’s not a strategy to pursue unless your goal is to pursue suffering and death,” Michaud said.

What’s more, some scientists say natural immunity may not even be feasible for COVID-19. While most people presumably achieve some degree of protection after being infected once, cases of people who recovered from the disease and were reinfected have raised questions about how long natural immunity lasts and whether someone with immunity could still spread the virus.

Even the method scientists are using to measure immunity — blood tests that detect antibodies to the coronavirus — may not be an accurate indicator of who is protected against COVID-19, said Dr. Stuart Ray, an infectious disease expert at the Johns Hopkins University School of Medicine.

With so many unanswered questions, he concluded: “We can’t count on natural herd immunity as a way to control this epidemic.”

Vaccines, on the other hand, can be made to trigger stronger immunity than natural infection, Ray said. That’s why people who acquire a natural tetanus infection, for example, are still advised to get the tetanus vaccine. The hope is that vaccines being developed for COVID-19 will provide the same higher level of immunity.

But What About Sweden?

In the political debate around COVID-19, proponents of a natural herd immunity strategy often point to Sweden as a model. Although the Scandinavian country imposed fewer economic shutdown measures, its death toll is less than a fraction of that in the U.S., Paul said at Wednesday’s Senate hearing.

But health experts — including Fauci during the same hearing — argue that’s a flawed comparison. The U.S. has a much more diverse population, with vulnerable groups like Black and Hispanic Americans being disproportionately affected by the coronavirus, said Dr. Jon Andrus, an epidemiology expert at the George Washington University Milken Institute School of Public Health. The U.S. also has greater population density, especially on the coasts, he said.

When compared with other Scandinavian countries, Sweden’s death toll is much higher. It has had 5,880 deaths linked to COVID-19 so far, according to data from Johns Hopkins University. That’s nearly 58 deaths per 100,000 residents — several times higher than the death rates of 5 or 6 per 100,000 in Norway and Finland. In fact, as a result of COVID-19, Sweden has recorded its highest death toll since a famine swept the country 150 years ago. And cases are on the rise.

Despite that level of loss, it’s still unclear if Sweden has reached the threshold for herd immunity. A study by the country’s public health agency found that by late April only 7% of residents in Stockholm had antibodies for COVID-19. In other Swedish cities, the percentage was even lower.

Those findings mirror other studies around the globe. Researchers reported that in several cities across Spain, Switzerland and the U.S. — with the exception of New York City — less than 10% of the population had COVID-19 antibodies by June, despite months of exposure and high infection rates. The results led commentators in the medical research journal The Lancet to write, “In light of these findings, any proposed approach to achieve herd immunity through natural infection is not only highly unethical, but also unachievable.”

Herd Immunity Is Still Far Off

The bottom line, medical experts say, is that natural herd immunity is an uncertain strategy, and attempts to pursue it could result in a slew of unnecessary deaths. A vaccine, whenever one becomes available, would offer a safer route to community-wide protection.

Until then, they emphasize there is still plenty to do to counter the pandemic. Wearing masks, practicing social distancing, hand-washing and ramping up testing and contact tracing have all proven to help curb the virus’s spread.

“As we wait for new tools to be added to the toolbox,” Andrus said, “we have to keep reminding ourselves that there are measures in this very moment that we could be using to save lives.”

KHN reporter Victoria Knight contributed to this article.


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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‘You’re Going to Release Him When He Was Hurting Himself?’

When Joe Prude called Rochester, New York, police to report his brother missing, he was struggling to understand why Daniel Prude had been released from the hospital hours earlier. Joe Prude described his brother’s suicidal behavior.

“He jumped 21 stairs down to my basement, headfirst,” Joe said in a video recorded by the responding officer’s body camera in the early hours of March 23. Joe’s wife, Valerie, described Daniel nearly jumping in front of a train on the tracks that run behind their house the previous day.

“The train missed him by this much,” Joe said, holding his thumb and pointer finger a few inches apart.

“When the doctor called me and told me that they released him, I’m saying, ‘How you going to sit here and tell me you’re going to release him when he was hurting himself? Come on. You weren’t sworn to do that,’” he said on the body camera footage.

At the point of this recorded conversation just after 3 a.m., Joe and Valerie Prude knew only that Daniel was missing, delusional and vulnerable. They didn’t know his next encounter with the police would be fatal.

Police would find Daniel minutes later ― naked, acting irrationally. Because he spat in the direction of officers and allegedly said he had the novel coronavirus, officers placed a white hood, called a “spit hood,” over his head. When he started trying to stand up, despite being restrained by handcuffs, an officer placed much of his body weight over Daniel’s head and pushed it into the pavement.

Daniel died a week later when his family took him off life support. The county medical examiner’s autopsy described his death as a homicide and listed the immediate cause of death as “complications of asphyxia in the setting of physical restraint.” The incident garnered widespread attention as another example of a Black man killed after an encounter with police.

Less attention has been paid to what happened to Daniel Prude in the preceding hours, when he was treated and released after a psychiatric assessment at Strong Memorial Hospital, run by the University of Rochester Medical Center.

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Joe Prude called police at about 7 p.m. on March 22 because he needed help getting Daniel to the hospital. Daniel had been having problems with a PCP addiction, Joe told officers. Now he had begun telling Joe and Valerie that people were out to get him, and he wanted to die.

By about 11 p.m., Daniel was released from the hospital, according to Joe and police records. “He was calm as hell when he got back here,” Joe told police.

That didn’t last.

“He was fine for a little bit, then all of a sudden started acting crazy,” Joe said. He told police that Daniel asked him for a cigarette, and when he went to get one, Daniel took off running. He was barefoot, wearing only a tank top and long johns in 30-degree weather.

“He was gone. Track star status. Hauled ass like Carl Lewis,” Joe told

Around 3 a.m. the next day, four hours after his release from the hospital, emergency dispatchers started fielding calls about Daniel Prude. His brother reported him missing, and a tow truck driver spotted him, naked and bloodied, on West Main Street, police records show.

Police body camera footage shows that by 3:20 a.m., officer Mark Vaughn was pressing Daniel Prude’s head into the pavement.

While restrained, Prude stopped breathing. An ambulance crew resuscitated him, but he was in critical condition. His brain was damaged after being deprived of oxygen. He died a week later at Strong Memorial after being taken off life support.

The University of Rochester Medical Center said patient privacy laws bar it from discussing the specifics of Prude’s treatment and release, but, in general terms, spokesperson Chip Partner said, the hospital is bound by a New York state law that requires patients to be released within 24 hours unless they have a mental illness that is likely to result in serious harm to themselves or others and that requires immediate observation, care and hospital treatment.

The details of Prude’s encounters with law enforcement and the health care system offer a look into the practice of emergency psychiatry, and how, as in many branches of medicine in the U.S., mistakes in that field are disproportionately borne by Black people.

Medical decisions in a case like Daniel Prude’s are high-stakes, with little margin for error, said Dr. Ken Duckworth, chief medical officer of the National Alliance on Mental Illness.

“Emergency psychiatric assessment is very challenging, and the potential for catastrophic outcomes following your decision is very real,” he said.

The hospital where Prude died has faced scrutiny over its treatment of psychiatric patients and discharge procedures before.

In April 2018, federal inspectors found security officers at the hospital had used law enforcement restraint techniques against a pediatric psychiatry patient, breaking her arm and sending her to the emergency room.

Months later, inspectors found the hospital discharged a patient who was in the emergency room with a history of dementia and multiple medical problems despite a discrepancy in her address between her medical record and the information she gave hospital staff.

Two years earlier, inspectors found that hospital staff had placed patients in ankle and wrist restraints without an order to do so, and placed another patient in restraints without documenting when the restraints were released. Restraints are meant to be used only with a physician’s order, and federal rules require precise documentation of their use.

None of these incidents at Strong Memorial Hospital garnered media attention at the time they happened or at the time the reports were made public.

Strong spokesperson Partner said that immediately after the April 2018 inspection the hospital changed its public safety protocol to eliminate the use of law enforcement techniques to manage a violent patient unless that patient is being arrested.

He said updated staff training and discharge protocol after these incidents now mitigates the risk of discharging someone who was not ready to be released. “These protocols were well established in 2020 and had absolutely no bearing on the evaluation or treatment of Daniel Prude on March 22,” Partner said.

Prude’s case is unusual because the consequences of the decision by doctors to release him have played out so publicly, said Duckworth. Usually, emergency room psychiatrists never find out what happened to their patients.

“You make a very big decision, which usually has no known outcome. You put this person in the hospital, you go on to the next patient. You send this person home, you go on to the next patient,” he said.

Duckworth said he would not second-guess the actions of Prude’s hospital team in the moment, but with the benefit of hindsight, “there’s overwhelming evidence that he had a psychotic illness and was quite vulnerable,” he said. “He didn’t need to die.”

In a statement, URMC said its treatment of Prude was “medically appropriate and compassionate.”

Several oversight organizations are investigating.

The Joint Commission, which certifies hospitals to receive federal funding, said it’s reviewing Prude’s treatment at Strong. New York state’s Justice Center is investigating on behalf of the state Office of Mental Health.

The university medical center itself is still conducting an internal clinical review.

In response to questions from NPR and KHN about whether the hospital’s treatment of Prude could have been affected by his race, Partner said the medical center asked Dr. Altha Stewart, past president of the American Psychiatric Association, “to conduct a third-party independent review through her lens as a national expert on racism and bias in psychiatric care.”

In a separate interview before the request from URMC, she described how unconscious bias can cloud clinicians’ judgment and make it difficult for them to make the best possible decisions for their patients.

“It is very clear that in today’s health care system, bias is built in structurally,” Stewart said. “Seeing a tall, imposing Black man who is behaving aggressively puts in place a series of ideas and thoughts and assumptions that direct decision-making.”

Psychiatric disorders in Black patients are less likely to be taken seriously than in white patients, Stewart said. Unequal treatment starts early.

Black boys are viewed as adults more often than white boys of the same age, said Stewart, who is also the director of the Center for Health in Justice Involved Youth.

“So a Black child with a meltdown is described as aggressive, obstinate, oppositional,” she said, “as opposed to traumatized, depressed, anxious.”

Those expectations follow Black boys through adulthood and in the health care system, increasing the odds that doctors will view Black men as a lost cause and provide subpar care, Stewart said.

She stressed that she does not have any direct knowledge of deficiencies in the care of Daniel Prude, but she said that Black men, like Prude, are disproportionately likely to be misdiagnosed, mistreated and written off as a result of structural bias and unconscious racism.

A group of medical students at the University of Rochester wrote in an open letter that Daniel Prude was “sentenced to death by our failed healthcare system.”

“Not only do our current models of healthcare leave gaping holes for individuals such as Daniel to fall through, but they do so in manners which are fraught with racism,” the students wrote.

Partner, the medical center spokesperson, said the psychiatry department’s Office of Diversity, Inclusion, Culture and Equity will evaluate Daniel’s treatment for potential bias. He said the medical center “recognizes that we have a long way to go before we can confidently say that our policies and practices are universally culturally appropriate to the populations we serve.”

Both Stewart and Duckworth said reducing the role that police play in addressing mental health crises would increase the odds of survival for a person released too early from psychiatric care.

Federal inspection reports show that hospitals across the country have released patients who, like Prude, ended up in grave danger only shortly thereafter.

In March 2018, a patient with a history of schizophrenia, post-traumatic stress disorder and suicide attempts arrived at Russell County Hospital in Kentucky complaining of alcohol withdrawal, depression, anxiety and pain. An hour and a half later, the patient was discharged with instructions to “follow up with his/her primary care provider and take medications as prescribed.” Two hours later, the patient was back in the same hospital. A physician’s notes said the patient had drunk a bottle of Benadryl “in effort to kill self.”

In August 2018, federal inspectors found that UT Health East Texas Pittsburg Hospital discharged a patient who had verbalized a plan for suicide. The patient got a ride to his truck from the county sheriff. Later that day, the patient was found dead in the truck from a self-inflicted gunshot wound.

Last summer at Stafford County Hospital in Kansas, a patient arrived in the emergency room saying she had drunk half a liter of vodka because she was upset and wanted to die. She told hospital staff that she started drinking that day after two years of sobriety and that she “did not feel safe to go home due to the presence of alcohol.” The hospital discharged her 11 minutes later.

Earlier this year, inspectors found that a patient with a history of psychosis went to the emergency room at Mercy Hospital in St. Louis and told staff she needed to get back on her medication. She was delusional, disoriented, homeless and unable to give her name. She was discharged with a voucher for cab fare but no follow-up appointments or services and no plan to ensure she got her medication.

A spokesperson for UT Health East Texas said the health system has since implemented a process for staff to more thoroughly document mental health concerns in patient records. Mercy Hospital in St. Louis said it takes the health and safety of each patient very seriously “regardless of race, ethnicity or ability to pay.”

Neither of the other hospitals responded to emails or calls seeking comment.

This story is part of a partnership that includes Side Effects Public MediaNPR and KHN, an editorially independent program of the Kaiser Family Foundation.

‘No Mercy’ Explores the Fallout After a Small Town Loses Its Hospital

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

Each season, “Where It Hurts” takes you somewhere new  — to an overlooked part of the country to explore cracks in the American health system that leave people frustrated — and without the care they need. The story begins in Fort Scott, Kansas. Rural. Deeply Christian. And sicker than other parts of the state. When Mercy Hospital shut its doors, the town’s sense of identity wavered. Season One “No Mercy” is about the people who remain, surviving the best way they know how. Host and investigative journalist Sarah Jane Tribble spent more than a year revisiting southeastern Kansas, where she grew up, to document the sparking tensions, anger and fear many people felt as they struggled to come to terms with the hospital’s closure.

Chapter 1: ‘It Is What It Is’

Midwesterners aren’t known for complaining. But after Mercy Hospital Fort Scott closed, hardship trickled down to people whose lives were already hard. Pat Wheeler has emphysema. Her husband, Ralph, has end-stage kidney failure, and the couple are barely making ends meet as they raise their teenage grandson. Pat is angry with hospital executives who she said yanked a lifeline from residents. “They took more than a hospital from us,” she said.

Click here to read the episode transcript.

Pat Wheeler (Sarah Jane Tribble/KHN)

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

And to hear all KHN podcasts, click here.

Post-COVID Clinics Get Jump-Start From Patients With Lingering Illness

Clarence Troutman survived a two-month hospital stay with COVID-19, then went home in early June. But he’s far from over the disease, still suffering from limited endurance, shortness of breath and hands that can be stiff and swollen.

“Before COVID, I was a 59-year-old, relatively healthy man,” said the broadband technician from Denver. “If I had to say where I’m at now, I’d say about 50% of where I was, but when I first went home, I was at 20%.”

He credits much of his progress to the “motivation and education” gleaned from a new program for post-COVID patients at the University of Colorado, one of a small but growing number of clinics aimed at treating and studying those who have had the unpredictable coronavirus.

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As the election nears, much attention is focused on daily infection numbers or the climbing death toll, but another measure matters: Patients who survive but continue to wrestle with a range of physical or mental effects, including lung damage, heart or neurological concerns, anxiety and depression.

“We need to think about how we’re going to provide care for patients who may be recovering for years after the virus,” said Dr. Sarah Jolley, a pulmonologist with UCHealth University of Colorado Hospital and director of UCHealth’s Post-Covid Clinic, where Troutman is seen.

That need has jump-started post-COVID clinics, which bring together a range of specialists into a one-stop shop.

One of the first and largest such clinics is at Mount Sinai in New York City, but programs have also launched at the University of California-San Francisco, Stanford University Medical Center and the University of Pennsylvania. The Cleveland Clinic plans to open one early next year. And it’s not just academic medical centers: St. John’s Well Child and Family Center, part of a network of community clinics in South Central Los Angeles, said this month it aims to test thousands of its patients who were diagnosed with COVID since March for long-term effects.

The general idea is to bring together medical professionals across a broad spectrum, including physicians who specialize in lung disorders, heart issues and brain and spinal cord problems. Mental health specialists are also involved, along with social workers and pharmacists. Many of the centers also do research studies, aiming to better understand why the virus hits certain patients so hard.

“Some of our patients, even those on a ventilator on death’s door, will come out remarkably unscathed,” said Dr. Lekshmi Santhosh, an assistant professor of pulmonary critical care and a leader of the post-COVID program at UC-San Francisco, called the OPTIMAL clinic. “Others, even those who were never hospitalized, have disabling fatigue, ongoing chest pain and shortness of breath, and there’s a whole spectrum in between.”

‘Staggering’ Medical Need

It’s too early to know how long the persistent medical effects and symptoms will linger, or to make accurate estimates on the percentage of patients affected.

Some early studies are sobering. An Austrian report released this month found that 76 of the first 86 patients studied had evidence of lung damage six weeks after hospital discharge, but that dropped to 48 patients at 12 weeks.

Some researchers and clinics say about 10% of U.S. COVID patients they see may have longer-running effects, said Dr. Zijian Chen, medical director of the Center for Post-COVID Care at Mount Sinai, which has enrolled 400 patients so far.

If that estimate is correct — and Chen emphasized that more research is needed to make sure — it translates to patients entering the medical system in droves, often with multiple issues.

How health systems and insurers respond will be key, he said. More than 6.5 million U.S. residents have tested positive for the disease. If fewer than 10% — say 500,000 — already have long-lasting symptoms, “that number is staggering,” Chen said. “How much medical care will be needed for that?”

Though startup costs could be a hurdle, the clinics themselves may eventually draw much-needed revenue to medical centers by attracting patients, many of whom have insurance to cover some or all of the cost of repeated visits.

Chen at Mount Sinai said the specialized centers can help lower health spending by providing more cost-effective, coordinated care that avoids duplicative testing a patient might otherwise undergo.

“We’ve seen patients that when they come in, they’ve already had four MRI or CT scans and a stack of bloodwork,” he said.

The program consolidates those earlier results and determines if any additional testing is needed. Sometimes the answer to what’s causing patients’ long-lasting symptoms remains elusive. One problem for patients seeking help outside of dedicated clinics is that when there is no clear cause for their condition, they may be told the symptoms are imagined.

“I believe in the patients,” said Chen.

About half the clinic’s patients have received test results showing damage, said Chen, an endocrinologist and internal medicine physician. For those patients, the clinic can develop a treatment plan. But, frustratingly, the other half have inconclusive test results yet exhibit a range of symptoms.

“That makes it more difficult to treat,” said Chen.

Experts see parallels to a push in the past decade to establish special clinics to treat patients released from ICU wards, who may have problems related to long-term bed rest or the delirium many experience while hospitalized. Some of the current post-COVID clinics are modeled after the post-ICU clinics or are expanded versions of them.

The ICU Recovery Center at Vanderbilt University Medical Center, for instance, which opened in 2012, is accepting post-COVID patients.

There are about a dozen post-ICU clinics nationally, some of which are also now working with COVID patients, said James Jackson, director of long-term outcomes at the Vanderbilt center. In addition, he’s heard of at least another dozen post-COVID centers in development.

The centers generally do an initial assessment a few weeks after a patient is diagnosed or discharged from the hospital, often by video call. Check-in and repeat visits are scheduled every month or so after that.

“In an ideal world, with these post-COVID clinics, you can identify the patients and get them into rehab,” he said. “Even if the primary thing these clinics did was to say to patients, ‘This is real, it is not all in your head,’” he added, “that impact would be important.”

A Question of Feasibility

Financing is the largest obstacle, program proponents say. Many hospitals lost substantial revenue to canceled elective procedures during stay-at-home periods.

“So, it’s not a great time to be pitching a new activity that requires a startup subsidy,” said Glenn Melnick, a professor of health economics at the University of Southern California.

Stanford University launched its program with philanthropic funding, which allowed a special clinic to open in April. Initially, the clinic offered in-person and remote care to Stanford Health Care patients with active COVID-19 who were not hospitalized. With the addition of federal research funding, the center has begun a study that will follow patients after recovery — whether hospitalized previously or not — for up to five years to document any long-term effects.

At UCSF, a select group of faculty members staff the post-COVID clinics and some mental health professionals volunteer their time, said Santhosh. Mount Sinai’s Chen said he was able to recruit team members and support staff from the ranks of those whose elective patient caseload had dropped.

Jackson, at Vanderbilt, said unfortunately there’s not been enough research into the cost-and-clinical effectiveness of post-ICU centers.

“In the early days, there may have been questions about how much value does this add,” he noted. “Now, the question is not so much is it a good idea, but is it feasible?”

Right now, the post-COVID centers are foremost a research effort, said Len Nichols, an economist and nonresident fellow at the Urban Institute.

“If these guys get good at treating long-term symptoms, that’s good for all of us,” said Nichols. “There’s not enough patients to make it a business model yet, but if they become the place to go when you get it, it could become a business model for some of the elite institutions.”

Trump’s Executive Order on Preexisting Conditions Lacks Teeth, Experts Say

Protecting people with preexisting medical conditions is an issue that has followed President Donald Trump his entire first term. Now, Trump has signed an executive order that he says locks in coverage regardless of anyone’s health history. “Any health care reform legislation that comes to my desk from Congress must protect the preexisting conditions or I won’t sign it,” Trump said at a Sept. 24 signing event.

With the executive order, Trump said, “This is affirmed, signed and done, so we can put that to rest.”

Health law and health policy experts say Trump has put nothing to rest.

Here’s why.

The core text of the order is brief.

“It has been and will continue to be the policy of the United States to give Americans seeking healthcare more choice, lower costs, and better care and to ensure that Americans with pre-existing conditions can obtain the insurance of their choice at affordable rates.”

Joe Antos with the American Enterprise Institute, a market-oriented think tank, said the order “has no technical content.”

“All it really is, is a statement that he wants one or more of his departments to come up with a plan. And he doesn’t give any guidance or the vaguest outline of what that plan should be.”

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It takes more than a bill title to actually deliver guaranteed coverage. A Republican measure in the Senate is a good example. It’s called the Protect Act, but it has loopholes that would allow insurance companies to drop coverage of certain expensive diseases from all their policies.

So far, Republican proposals have not matched what the Affordable Care Act already provides. And University of Pennsylvania law professor Allison Hoffman said Trump’s executive order doesn’t change that.

“The language itself guarantees nothing near the protections in the Affordable Care Act, and such sweeping protections are only possible by congressional action, not regulation,” Hoffman said.

Trump and other Republicans on the campaign trail have faced repeated questioning about what will happen if the U.S. Supreme Court invalidates the Affordable Care Act. The White House is strongly behind a legal case to declare it unconstitutional. Oral arguments before the court are scheduled for Nov. 10.

Indiana University health law professor David Gamage said the executive order is no stopgap should the White House win that argument.

“Were the court to hold the Affordable Care Act unconstitutional, the executive order would still do nothing, because it has no enforcement power,” Gamage said.

Larry Levitt, head of health policy at KFF, a widely used source of neutral health care data, called Trump’s order “a pinky promise to protect people with preexisting conditions.”

Trump’s critics have said the order runs counter to the administration’s goal of undoing the Affordable Care Act. But as Levitt and others point out, there are other ways to guarantee coverage to everyone.

Lanhee Chen at Stanford University’s Hoover Institution said high-risk pools remain a popular idea in conservative circles.

“Most conservative analysts, for example, have supported a system of well-funded high-risk pools at the state level to provide protections for the impacted population,” Chen said.

High-risk pools have been around for decades. With them, the government, rather than a private insurance company, pays for a person’s care. But as with everything in health care, you don’t get something for nothing. State high-risk pools in the past lacked enough money to cover the large number of people with needs.

Hoffman said some high-risk pools charged very high premiums, making them unaffordable to many people.

Coverage for preexisting conditions is a persistent issue because so many Americans have them or fear having them in the future.

KFF estimates that 54 million Americans have a preexisting condition that would have led to a denial of coverage in the individual insurance market before the Affordable Care Act took effect.

Efforts to Keep COVID-19 out of Prisons Fuel Outbreaks in County Jails

When Joshua Martz tested positive for COVID-19 this summer in a Montana jail, guards moved him and nine other inmates with the disease into a pod so cramped that some slept on mattresses on the floor.

Martz, 44, said he suffered through symptoms that included achy joints, a sore throat, fever and an unbearable headache. Jail officials largely avoided interacting with the COVID patients other than by handing out over-the-counter painkillers and cough syrup, he said. Inmates sanitized their hands with a spray bottle containing a blue liquid that Martz suspected was also used to mop the floors. A shivering inmate was denied a request for an extra blanket, so Martz gave him his own.

“None of us expected to be treated like we were in a hospital, like we’re a paying customer. That’s just not how it’s going to be,” said Martz, who has since been released on bail while his case is pending in court. “But we also thought we should have been treated with respect.”

The overcrowded Cascade County Detention Center in Great Falls, where Martz was held, is one of three Montana jails experiencing COVID outbreaks. In the Great Falls jail alone, 140 cases have been confirmed among inmates and guards since spring, with 60 active cases as of mid-September.

When inmate Joshua Martz tested positive for COVID-19 this summer at the Cascade County Detention Center in Great Falls, Montana, guards moved him and nine other inmates with the disease into a pod so cramped that some slept on mattresses on the floor. (Matt Volz/KHN)

By contrast, the Montana state prison system has the second-lowest infection rate in the nation, according to the COVID Prison Project. No confirmed coronavirus cases have been reported at the men’s prison out of 595 inmates tested. The women’s prison had just one confirmed case out of 305 inmates tested, according to Montana Department of Corrections data.

One reason for the high COVID count in jails and the low count in prisons is that Montana for months halted “county intakes,” or the transfer of people from county jails to the state prison system after conviction. Sheriffs in charge of the county jails blame their outbreaks on overcrowding partly caused by that state policy.

Restricting transfers into state prisons is a practice that’s also been instituted elsewhere in the U.S. as a measure to prevent the spread of the coronavirus. Colorado, California, Texas and New Jersey are among the states that suspended inmate intakes from county jails in the spring.

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But it’s also shifted the problem. Space was already a rare commodity in these local jails, and some sheriffs see the halting of transfers as giving the prisons room to improve the health and safety of their inmates at the expense of those in jail, who often haven’t been convicted.

The Cascade County jail was built to hold a maximum of 372 inmates, but the population has regularly exceeded that since the pandemic began, including dozens of Montana Department of Corrections inmates awaiting transfer.

“I’m getting criticized from various judges and citizens saying, ‘Why aren’t you quarantining everybody appropriately and why aren’t you social-distancing them?’” Cascade County Sheriff Jesse Slaughter said. “The truth is, if I didn’t have 40 DOC inmates in my facility I could better do that.”

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Unlike convicted offenders in state prisons, most jail inmates are only accused of a crime. They include a disproportionately high number of poor people who cannot afford to post bail to secure their release before trial or the resolution of their cases. If they do post bail or are released after spending time in a jail with a COVID outbreak, they risk bringing the disease home with them.

Andrew Harris, a professor of criminology and justice studies at the University of Massachusetts Lowell, said he finds it troubling that more attention is not paid to the conditions that lead to COVID outbreaks in jails.

“Jails are part of our communities,” Harris said. “We have people who work in these jails who go back to their families every night, we have people who go in and out of these jails on very short notice, and we have to think about jail populations as community members first and foremost.”

Some states have tried other ways to ensure county inmates don’t bring COVID-19 into prisons. In Colorado, for example, officials lifted their suspension on county intakes and are transferring inmates first to a single prison in Canon City, Department of Corrections spokesperson Annie Skinner said. There, inmates are tested and quarantined in single cells for 14 days before being relocated to other state facilities.

Outbreaks are also occurring in county jails in states that never stopped transferring inmates to state prison. Several jails in Missouri have experienced significant outbreaks, with Greene County reporting in mid-August that 83 inmates and 29 staffers had tested positive. Missouri Department of Corrections spokesperson Karen Pojmann said the state never opted to stop transfers from county jails, likely because of a robust screening and quarantine procedure implemented early in the pandemic.

At least 1,590 inmates and 440 staff members have tested positive for COVID-19 in Missouri’s 22 prison facilities since March, according to state data. The COVID Prison Project ranks Missouri’s case rate 25th among the states — better than some states that halted inmate transfers, including Colorado, Texas and California.

The halting of transfers was a critical part of the response by officials in California, whose prisons have been among the hardest hit by COVID-19. An outbreak at San Quentin State Prison this summer helped spur Democratic Gov. Gavin Newsom to order the early release of 10,000 inmates from prisons statewide.

Stefano Bertozzi, dean emeritus at the University of California-Berkeley School of Public Health, visited San Quentin before the outbreak, and afterward helped pen an urgent memo outlining immediate actions needed to avert disaster. He recommended halting all intakes at the prison and slashing its population of 3,547 inmates in half. At that point, the California Department of Corrections and Rehabilitation was already more than two months into an intake freeze.

Overcrowding has long been an issue for criminal justice reform advocates. But for Bertozzi, the term “overcrowding” needs to be redefined in the context of COVID-19, with an emphasis on exposure risk. Three inmates sharing a cell designed for two is a bad way to live, he said, “especially for the guy who’s on the floor.” But if those cells are enclosed, they offer far better protection from COVID-19 than 20 inmates sharing a congregate dorm designed for 20.

“It’s how many people are breathing the same air,” Bertozzi said.

Some California county jails struggled. In July, inmates in Tulare County’s facility, where 22 cases had been reported, filed a class action suit against Sheriff Mike Boudreaux alleging he’d failed to provide face masks and other safeguards. U.S. District Court Judge Dale Drozd ruled in favor of the inmates in early September, directing Boudreaux to implement official policies requiring face coverings and social distancing.

California resumed county intakes on Aug. 24 following the development of guidelines designed to control transmission risk and prioritize counties with the greatest need for space. But a huge backlog remains: 6,552 state inmates were still being held in county jails as of mid-September, according to corrections officials.

In Montana, the number of inmates at county jails awaiting transfer to prisons and other state corrections facilities was 238 at the beginning of September, according to state data obtained through a public records request.

Montana and county officials butted heads over delays in inmate transfers before the coronavirus, but the pandemic has increased the stakes.

“Once we had the issue with the pandemic and we had to maintain space for quarantining and isolating inmates, then it became even more critical because the space wasn’t really available,” Yellowstone County Sheriff Mike Linder said.

Montana Department of Corrections Director Reginald Michael acknowledged to state lawmakers in August that halting county intakes places a strain on counties but said it was “the right thing to do.”

“This is one of the reasons why I think our prisons are not inundated with the virus spread,” he told the Law and Justice Interim Committee.

Committee Chairman Rep. Barry Usher, a Republican, gave Michael his endorsement: “Sounds like you guys are doing a good job keeping it controlled and out of our prison systems, and everybody in Montana appreciates that.”

Since then, Montana officials have transferred up to 25 inmates a week, but they continue to block transfers from the three counties with outbreaks: Cascade, Yellowstone and Big Horn.

Martz dreaded the thought of COVID-19 following him out of jail. So much so that, after his release in early September, he walked to an RV park, where his wife met him with a tent.

Despite having tested negative for the virus prior to his release, he self-quarantined for a week before going home. The hardest part, he said, was not being able to immediately hug his 5-year-old stepdaughter. It “sucked,” but it’s what he felt he had to do.

“If somebody’s grandpa or grandmother had gotten it because I was careless and they ended up dying because of it, I’d feel horrible,” said Martz, who has returned home. “That’d be a horrible thing to do.”

Promises Kept? On Health Care, Trump’s Claims of ‘Monumental Steps’ Don’t Add Up

When it comes to health care, President Donald Trump has promised far more than he has delivered. But that doesn’t mean his administration has had no impact on health issues — including the operation of the Affordable Care Act, prescription drug prices and women’s access to reproductive health services.

In a last-ditch effort to raise his approval rating on an issue on which he trails Democrat Joe Biden in most polls, Trump on Thursday unveiled his “America First Healthcare Plan,” which includes a number of promises with no details and pumps some minor achievements into what the administration calls “monumental steps to improve the efficiency and quality of healthcare in the United States.”

As the election nears, here is a brief breakdown of what Trump has done — and has not done — on some key health issues.

Affordable Care Act

Trump has not managed to repeal and replace the Affordable Care Act, despite his claims that the law is dead.

But his administration, and Republicans in Congress, have made changes to weaken the law while not dramatically affecting enrollment in marketplace plans.

Congress failed to rewrite the law in summer 2017, but Republicans who controlled both the House and Senate at the time included in their year-end tax cut bill a provision that reduced the penalty for failing to have health insurance to zero. That change eliminated what was by far the most unpopular provision of the law.

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It also sparked a lawsuit by Republican state attorneys general and governors arguing that the tax change undercuts the law and thus should invalidate it. The case is set to be heard by the Supreme Court the week after the Nov. 3 election. The Trump administration is formally supporting the GOP plaintiffs in that suit.

The administration also used executive and regulatory action to chip away at the law’s efficacy. Trump ended disputed cost-sharing subsidies to help insurers lower out-of-pocket costs for policyholders with low incomes. And the administration shortened the open enrollment period by half and slashed the budget for promoting the plans and paying people to help others navigate the often-confusing process of signing up.

Administration officials have complained that plans sold on the ACA marketplaces are not affordable, so they set new rules that allowed companies to sell competing “short-term” policies that were less expensive than ACA-sanctioned plans. But those plans are not required to provide comprehensive benefits or cover preexisting conditions.

Now, weeks before the election, federal officials are taking credit for premiums coming down, slightly, on ACA plans. “Premiums have gone down across all of our programs, including in healthcare.gov, which had been previously seeing double-digit rate increases,” Seema Verma, who runs Medicare, Medicaid and the ACA exchanges, told reporters in a Sept. 24 conference call.

Premiums have come down this past year, confirmed Sabrina Corlette, who tracks the ACA as co-director of the Center on Health Insurance Reforms at Georgetown University, but only after many of the Trump administration’s changes had driven them even higher. Insurers were spooked by the uncertainty — particularly in 2017, about whether the law would be repealed — and Trump’s cutoff of federal funding for subsidies.

“The bottom line is, rates have gone up under Trump,” Corlette said.

Women’s Reproductive Health

Before he was elected, Trump pledged his allegiance to anti-abortion activists, who in turn urged their supporters to vote for him. But unlike many previous GOP presidents who called themselves “pro-life” but pushed the issue to the back burner, Trump has delivered on many of his promises to abortion foes.

Foremost, Trump has nominated two justices to the Supreme Court who were supported by anti-abortion advocates. With the help of the GOP Senate, Trump has also placed 200 conservative judges on federal district and appeals courts.

While many of the policy proposals advanced by the Trump administration are tied up in court, the sheer volume of activity has been notable, outstripping in less than four years efforts by Presidents Ronald Reagan and George W. Bush over each of their two-term presidencies.

Among those actions is a re-implementation and broadening of the “Mexico City Policy” that restricts foreign aid funding to organizations that “perform or promote” abortion. The administration has also moved to push Planned Parenthood out of the federal family planning program and Medicaid program. In addition, it has moved to make private insurance that covers abortion harder to purchase under the Affordable Care Act.

Trump’s efforts on women’s reproductive health reach beyond abortion to birth control. New rules would make it easier for employers with a “moral or religious objection” to decline to offer birth control as a health insurance benefit. Other rules would make it easier for health workers to decline to participate in any procedure to which they personally object.

COVID-19

Trump often claims that his decision in February to stop most travel from China was a critical factor in keeping the coronavirus pandemic in the U.S. from being worse than it has been. But the “travel ban” not only failed to stop many people from entering the U.S. from China anyway, scientists would later determine that the virus that spread widely in New York and other cities on the East Coast most likely came from Europe.

Although the White House has a coronavirus task force, the administration primarily has allowed states and localities to determine their own restrictions and timetables for closing and opening. The administration also had difficulty distributing medical supplies from a stockpile established for exactly this purpose. The president’s son-in-law and White House adviser, Jared Kushner, said at one point that the purpose of the stockpile was to supplement state supplies, not provide them.

Testing was also a problem. An early test developed by the Centers for Disease Control and Prevention turned out to be faulty, and despite continued promises by administration officials, testing remains less available six months into the pandemic than most experts recommend. Meanwhile, Trump has claimed repeatedly — and falsely — that if the U.S. did less testing there would be fewer cases of the virus.

But many public health observers say the administration’s biggest failing during the pandemic has been the lack of a single national message about the coronavirus and the best ways to prevent its spread.

More than 200,000 people in this country have died. Although the United States has only 4% of the world’s population, it has recorded 21% of the fatalities around the globe.

Prescription Drug Costs

Trump pledged to attack high drug costs as one of his main campaign themes in 2016 and again this year. But he has not had the success he hoped for.

In one of the administration’s biggest moves, the Department of Health and Human Services approved a rule last week that allows states to set up programs to import drugs from Canada, where they are cheaper because the Canadian government limits prices. Yet, it’s unclear if the program will get off the ground, given drug industry opposition and resistance from the Canadian government.

In his health care policy speech Thursday, Trump promised to send each Medicare beneficiary a $200 discount card over the next several months to help them buy prescription drugs. The initiative is being done under a specific innovation program and must not add to the deficit. Administration officials Friday could not answer where they will get the nearly $7 billion to pay for what is perceived by many observers as a last-ditch stunt to win votes from older Americans.

The president previously signed an executive order that seeks to tie the price Medicare pays for drugs to a lower international reference price. The administration, however, hasn’t released formal regulations to implement the policy, which could take years, and the policy is expected to be challenged in court by the drug industry.

In addition, Medicare will cap the price of insulin at $35 per prescription starting in 2021 for people getting coverage through some drug plans. More than 3 million Medicare beneficiaries use insulin to control their diabetes.

Trump also signed a law banning gag clauses used by health plans and pharmacy benefit managers to bar pharmacists from telling consumers about lower-priced drug options.

The administration’s plan to require drug companies to provide prices in pharmaceutical advertising has been beaten back in court.

The administration points to the increased number of generic drugs that have been approved since Trump was elected, but many of those drugs are not on the market. That’s because generic companies sometimes make deals with brand-name manufacturers to delay introducing lower-cost versions of their medicines.

At the same time, several bills the president supported to lower prices have stalled in Congress because of partisan differences and industry opposition.

“I don’t think there has been any meaningful action that has had meaningful effect on drug prices,” said Katie Gudiksen, a senior health policy researcher at The Source on Healthcare Price and Competition, a project of UC Hastings College of the Law in San Francisco.

Yet, she said, it’s possible Trump’s harsh criticism of the industry has had a chilling effect that led to lower prices.

Still, out-of-pocket costs for many individuals continue to climb as private and government insurance shifts more responsibility to the patient via higher cost sharing. Good Rx, an online site that tracks drug prices, noted this month that prescription drug prices have increased by 33% since 2014, faster than any other medical service or product.

Medicaid

The Trump administration has tried — but largely failed — to make many major changes to the state-federal health insurance program that covers more than 70 million low-income Americans.

Efforts by Republicans to repeal the Affordable Care Act would have ended the federal funding for the District of Columbia and the 38 states that expanded their programs for everyone with incomes under 138% of the federal poverty level, or about $17,609 for an individual. About 15 million people have gained coverage through the expansion.

Trump administration officials have argued that Medicaid should be reserved for the most vulnerable Americans, including traditional enrollees such as children, pregnant women and the disabled, and not used for non-disabled adults who gained coverage under the ACA’s expansion. Since Trump took office, seven states have expanded Medicaid — Idaho, Maine, Missouri, Oklahoma, Nebraska, Utah and Virginia.

In 2018, federal officials allowed states for the first time to require some enrollees to work as a condition for Medicaid coverage. The effort resulted in more than 18,000 Medicaid enrollees losing coverage in Arkansas before a federal judge halted implementation in that state and several others. The case has been appealed to the Supreme Court.

The administration also backed a move in Congress to change the way the federal government funds Medicaid. Since Medicaid’s inception in 1966, federal funding has increased with enrollment and health costs. Republicans would like to instead offer states annual block grants that critics say would dramatically reduce state funding but that proponents say would give states more flexibility to meet their needs.

When the congressional attempt to establish block grants failed, the administration tried through executive action to implement a process allowing states to opt into a block grant. Yet only one state — Oklahoma — applied for a waiver to move to block-grant funding, and it withdrew its request in August, two weeks after voters there narrowly passed a ballot initiative to expand Medicaid to 200,000 residents.

Medicaid enrollment fell from 75 million in January 2017 to about 71 million in March 2018. Then the pandemic took hold and caused millions of people to lose jobs and their health coverage. As of May, Medicaid enrollment nationally was 73.5 million.

The administration’s decision to expand the “public charge” rule, which would allow federal immigration officials to more easily deny permanent residency status to those who depend on certain public benefits, such as Medicaid, has discouraged many people from applying for Medicaid, said Judith Solomon, senior fellow with the Center on Budget and Policy Priorities, a research group based in Washington, D.C. 

Medicare

Seniors were among Trump’s most loyal voters in 2016, and he has promised repeatedly to protect the popular Medicare program. But not all his proposals would help the seniors who depend on it.

For example, invalidating the Affordable Care Act would eliminate new preventive benefits for Medicare enrollees and reopen the notorious “doughnut hole” that subjects many seniors to large out-of-pocket costs for prescription drugs, even if they have insurance.

Trump also signed several pieces of legislation that accelerate the depletion of the Medicare trust fund by cutting taxes that support the program. And his budget for fiscal 2021 proposed Medicare cuts totaling $450 billion.

At the same time, however, the administration implemented policies dramatically expanding payment for telehealth services as well as a kidney care initiative for the millions of patients who qualify for Medicare as a result of advanced kidney disease.

Surprise Billing

Trump in May 2019 promised to end surprise billing, which leaves patients on the hook for often-exorbitant bills from hospitals, doctors and other professionals who provide service not covered by insurance.

The problem typically occurs when patients receive care at health facilities that are part of their insurance network but are treated by practitioners who are not. Other sources of surprise billing include ambulance companies and emergency room physicians and anesthesiologists, among other specialties.

An effort to end the practice stalled in Congress as some industry groups pushed back against legislative proposals.

“The administration was supportive of the pretty consumer-friendly approaches, but obviously it doesn’t have any results to speak of,” said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy in Los Angeles.

“At the end of the day, plenty of people in Congress did not really want to get something done,” he said.

Taking a different route, the administration finalized a rule last November that requires hospitals to provide price information to consumers. The rule will take effect Jan. 1. A federal judge shot down an attempt by hospitals to block the rule, although appeals are expected.

Brian Blase, a former Trump adviser, said this effort could soon help consumers. “Arguably, the No. 1 problem with surprise bills is that people have no idea what prices are before they receive care,” he said.

But Adler said the rule would have a “very minor effect” because most consumers don’t look at prices before deciding where to seek care — especially during emergencies.

Public Health/Opioids

Obesity and the opioid addiction epidemic were two of the nation’s biggest public health threats until the coronavirus pandemic hit this year.

The number of opioid deaths has shown a modest decline after a dramatic increase over the past decade. Overall, overdose death rates fell by 4% from 2017 to 2018 in the United States. New CDC data shows that, over the same period, death rates involving heroin also decreased by 4% and overdose death rates involving prescription drugs decreased by 13.5%.

The administration increased funding to expand treatment programs for people using heroin and expanded access to naloxone, a medication that can reverse an overdose, said Dr. Georges Benjamin, executive director of the American Public Health Association.

Meanwhile, the nation’s obesity epidemic is worsening. Obesity, a risk factor for severe effects of COVID-19, continues to become more common, according to the CDC.

Twelve states — Alabama, Arkansas, Indiana, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Oklahoma, South Carolina, Tennessee and West Virginia — have a self-reported adult obesity prevalence of 35% or more, up from nine states in 2018 and six in 2017.

Benjamin said some of the administration’s other policies, such as reducing access to food stamps and undermining clean air and water regulations, have made improving public health more difficult.

But the pandemic has been the major public health issue this administration has faced.

“We were doing a reasonable job addressing the opioid epidemic until COVID hit,” Benjamin said. “This shows the fragility of our health system, that we cannot manage these three epidemics at the same time.”

Health on Wheels: Tricked-Out RVs Deliver Addiction Treatment to Rural Communities

STERLING, Colo. — Tonja Jimenez is far from the only person driving an RV down Colorado’s rural highways. But unlike the other rigs, her 34-foot-long motor home is equipped as an addiction treatment clinic on wheels, bringing lifesaving treatment to the northeastern corner of the state, where patients with substance use disorders are often left to fend for themselves.

As in many states, access to addiction treatment remains a challenge in Colorado, so a new state program has transformed six RVs into mobile clinics to reach isolated farming communities and remote mountain hamlets. And, in recent months, they’ve become more crucial: During the coronavirus pandemic, even as brick-and-mortar addiction clinics have closed or stopped taking new patients, these six-wheeled clinics have kept going, except for a pit stop this summer for air conditioning repair.

Their health teams perform in-person testing and counseling. And as broadband access isn’t always a given in these rural spots, the RVs also provide a telehealth bridge to the medical providers back in the big cities. Working from afar, these providers can prescribe medicine to fight addiction and the ever-present risk of overdose, an especially looming concern amid the isolation and stress of the pandemic.

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Mobile health clinics have been around for years, bringing vision tests, asthma treatment and dentistry to places without adequate care. But using health care on wheels to treat addiction isn’t as common. Nor is equipping such motor homes with telehealth capability that expands the reach of prescribing providers to treat hard-to-reach patients in these hard-to-reach rural areas.

“We really believe we bring treatment to our patients and we meet them where they’re at,” said Donna Goldstrom, clinical director for Front Range Clinic, a Fort Collins, Colorado, practice that operates four of the RVs. “So meeting them where they’re at physically is not a long leap from meeting them where they’re at motivationally and psychologically.”

Each RV has a nurse, a counselor and a peer specialist who has personal experience with addiction — and all had to be trained to drive a vehicle that size.

“I never thought when I went to nursing school that I’d be doing this,” Christi Couron, a licensed practical nurse, said as she pumped 52 gallons of diesel fuel into the motor home she works on with Jimenez.

The crew has driven their RV more than 30,000 miles since January, much of it viewed through a cracked windshield courtesy of a summer afternoon hailstorm. Four days a week, they ply the roads from Greeley to the smaller towns near the Nebraska border, as the view goes from mile-high to miles-wide.

Don a Mask, Pee in a Cup

On a dusty lot outside a halfway house in Sterling, Jimenez, the peer specialist, activates the leveling jacks to balance the RV, and the team readies the unit for the day’s slate of patients. The passenger-side captain’s chair flips around to face a table where Jimenez will check in patients. The tabletop is crowded with a printer, a scanner, a laptop and a label-maker. Underneath lie a box of specimen cups and a gallon of windshield washer fluid. The vehicle now has plenty of masks and cleaning supplies on hand, too.

After patients check in, they go to the RV’s snug bathroom to provide a urine sample. With test strips built into the sides of the cup, results show instantly whether any of 13 categories of drugs — from opiates to antidepressants — are in the urine. The sample is later dropped off at a lab to confirm the results and determine which specific drug is involved. The results help the team understand how best to treat the patients and make sure they use the prescriptions they’re given.

Patients then head to a small exam room in the back, where they connect via video to a nurse practitioner or physician assistant in a brick-and-mortar clinic.

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If all goes well, the provider will send over a prescription for Suboxone (a combination medicine containing buprenorphine, which reduces cravings for opioids) or for Vivitrol (a monthly injectable version of naltrexone, which blocks opioid receptors). Once the staffers have the prescription in hand, the RV nurse can give those Vivitrol shots directly and distribute Narcan, a medication that will reverse an opioid overdose. Suboxone prescriptions must be called into a local pharmacy.

Patients also can drop used needles into a sharps container for disposal, but the staffers are not allowed to distribute clean needles. Some patients will talk with counselor Nicky McLean in a room just large enough to fit a table and two chairs.

Within minutes, a couple, who asked not to be identified by name because of the stigma surrounding addiction, arrive early for their appointments. They’ve brought the staff homemade chicken enchiladas. They had been spending $8,000 a month buying OxyContin on the street, and their lives and finances were a wreck. He lost his house. She needs clean urine tests to see her son. The couple started their addiction treatment only three weeks earlier, after he learned about the RV clinic from a friend.

They no longer have a car, so they walked a half-hour to get to their appointment.

“We would’ve done anything to get our drugs,” she said. “Walking 30 minutes to get better, it’s worth it.”

Even before they’ve finished, another patient is at the door. Spencer Nash, 29, has been using opioids since he was 18. Nine years ago, when his wife got pregnant, the couple decided to get clean, driving two hours each way, six days a week, to a methadone clinic in Fort Collins. Now, he walks to the RV, outside the halfway house where he lives, to get his Suboxone prescription.

Filling the Gaps

A few years ago, Robert Werthwein, director of Colorado’s Office of Behavioral Health, heard about a project using RVs for addiction treatment in rural upstate New York. He thought it would work in his state, too. The agency crunched the numbers to see which regions recorded the highest levels of opioid prescriptions and overdoses but lacked addiction treatment.

“We hear too often that in rural Colorado and the mountain regions of Colorado they don’t have the same access to services as the Denver metro and the Front Range regions,” Werthwein said. The state secured a $10 million federal grant for the program. His team brought in health care providers, such as Front Range Clinic, to staff and operate the RVs.

Once the RVs were ready, the staff had to be trained to drive them, which necessitated “a couple of repairs,” Werthwein said. The vehicles first started rolling out in December, eventually serving six regions — and in a seventh area, a place where narrow mountain roads precluded a large RV, one of Werthwein’s teams travels by SUV.

In some communities, the local doctors and others have been less than thrilled, feeling the RVs would attract drug users to their town.

“We’re hoping to address stigma, not just from a public standpoint, but we’re hoping to show providers ‘there is a demand in your community for medication-assisted treatment,’” Werthwein said.

Once the federal grant runs out in September 2022, Front Range Clinic and the other mobile unit operators will inherit and continue to operate the RVs, billing Medicaid and private insurance as they do now for the appointments.

As the RV crew’s 1 p.m. departure time in Sterling approached, one patient remained. The woman, who asked that her name not be published because she didn’t want to be publicly identified as a drug user, arrived at the mobile clinic without an appointment. But they couldn’t take her as a new patient without a urine sample. For two hours, she was in and out of the bathroom, drinking bottles of water, but unable to fill the little plastic cup. Through the bathroom door, the staffers could hear her crying and cursing at herself.

With the battery power on the RV winding down, they coaxed her out of the bathroom. Perhaps tomorrow would work better, they told her. She could continue to rehydrate through the night and then meet the mobile unit at its next stop, Fort Morgan, some 45 minutes away.

The next day, she was still unable to produce a urine sample, whether because of dehydration from her substance use or simply nerves. They asked her to come back again when the RV returned to Sterling the next week, but she never showed up.