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Tuesday 30 June 2020

Workers Filed More Than 4,100 Complaints About Protective Gear. Some Still Died.


COVID-19 cases were climbing at Michigan’s McLaren Flint hospital. So Roger Liddell, 64, who procured supplies for the hospital, asked for an N95 respirator for his own protection, since his work brought him into the same room as COVID-positive patients.


But the hospital denied his request, said Kelly Indish, president of the American Federation of State, County and Municipal Employees Local 875.


On March 30, Liddell posted on Facebook that he had worked the previous week in both the critical care unit and the ICU and had contracted the virus. “Pray for me God is still in control,” he wrote. He died April 10.


Roger Liddell(Courtesy of Bill Sohmer)



The hospital’s problems with personal protective equipment (PPE) were well documented. In mid-March, the state office of the Occupational Safety and Health Administration (OSHA) received five complaints, which described employees receiving “zero PPE.” The cases were closed April 21, after the hospital presented paperwork saying problems had been resolved. There was no onsite inspection, and the hospital’s written response was deemed sufficient to close the complaints, a local OSHA spokesperson confirmed.


The grief and fear gripping workers and their families reflect a far larger pattern. Since March, more than 4,100 COVID-related complaints regarding health care facilities have poured into the nation’s network of federal and state OSHA offices, which are tasked with protecting workers from harm on the job.


A KHN investigation found that at least 35 health care workers died after OSHA received safety complaints about their workplaces. Yet by June 21, the agency had quietly closed almost all of those complaints, and none of them led to a citation or a fine.


The complaint logs, which have been made public, show thousands of desperate pleas from workers seeking better protective gear for their hospitals, medical offices and nursing homes.


The quick closure of complaints underscores the Trump administration’s hands-off approach to oversight, said former OSHA official Deborah Berkowitz. Instead of cracking down, the agency simply sent letters reminding employers to follow Centers for Disease Control and Prevention guidelines, said Berkowitz, now a director at the National Employment Law Project.


“This is a travesty,” she said.


A third of the health care-related COVID-19 complaints, about 1,300, remain open and about 275 fatality investigations are ongoing.


During a June 9 legislative hearing, Labor Secretary Eugene Scalia said OSHA had issued one coronavirus-related citation for violating federal standards. A Georgia nursing home was fined $3,900 for failing to report worker hospitalizations on time, OSHA’s records show.


“We have a number of cases we are investigating,” Scalia said at the Senate Finance Committee hearing. “If we find violations, we will certainly not hesitate to bring a case.”


Texts between Barbara Birchenough and her daughter, (in blue) Kristin Carbone.(Courtesy of Kristin Carbone)



A March 16 complaint regarding Clara Maass Medical Center in Belleville, New Jersey, illustrates the life-or-death stakes for workers on the front lines. The complaint says workers were “not allowed to wear” masks in the hallway outside COVID-19 patients’ rooms even though studies have since shown the highly contagious virus can spread throughout a health care facility. It also said workers “were not allowed adequate access” to PPE.


Nine days later, veteran Clara Maass registered nurse Barbara Birchenough texted her daughter: “The ICU nurses were making gowns out of garbage bags. … Dad is going to pick up large garbage bags for me just in case.”


Kristin Carbone, the eldest of four, said her mother was not working in a COVID area but was upset that patients with suspicious symptoms were under her care.


In a text later that day, Birchenough admitted: “I have a cough and a headache … we were exposed to six patients who we are now testing for COVID 19. They all of a sudden got coughs and fevers.”


“Please pray for all health care workers,” the text went on. “We are running out of supplies.”


By April 15, Birchenough, 65, had died of the virus. “They were not protecting their employees in my opinion,” Carbone said. “It’s beyond sad, but then I go to a different place where I’m infuriated.”


OSHA records show six investigations into a fatality or cluster of worker hospitalizations at the hospital. A Labor Department spokesperson said the initial complaints about Clara Maass remain open and did not explain why they continue to appear on a “closed” case list.


Nestor Bautista, 62, who worked closely with Birchenough, died of COVID-19 the same day as she did, according to Nestor’s sister, Cecilia Bautista. She said her brother, a nursing aide at Clara Maass for 24 years, was a quiet and devoted employee: “He was just work, work, work,” she said.



Barbara Birchenough(Courtesy of Kristin Carbone)



Nestor Bautista(Courtesy of Cecilia Bautista)




Responding to allegations in the OSHA complaint, Clara Maass Medical Center spokesperson Stacie Newton said the virus has “presented unprecedented challenges.”


“Although the source of the exposure has not been determined, several staff members” contracted the virus and “a few” have died, Newton said in an email. “Our staff has been in regular contact with OSHA, providing notifications and cooperating fully with all inquiries.”


Other complaints have been filed with OSHA offices across the U.S.


Twenty-one closed complaints alleged that workers faced threats of retaliation for actions such as speaking up about the lack of PPE. At a Delaware hospital, workers said they were not allowed to wear N95 masks, which protected them better than surgical masks, “for fear of termination or retaliation.” At an Atlanta hospital, workers said they were not provided proper PPE and were also threatened to be fired if they “raise[d] concerns about PPE when working with patients with Covid-19.”


Of the 4,100-plus complaints that flooded OSHA offices, over two-thirds are now marked as “closed” in an OSHA database. Among them was a complaint that staffers handling dead bodies in a small room off the lobby of a Manhattan nursing home weren’t given appropriate protective gear.


More than 100 of those cases were resolved within 10 days. One of those complaints said home health nurses in the Bronx were sent to treat COVID-19 patients without full protective gear. At a Massachusetts nursing home that housed COVID patients, staff members were asked to wash and reuse masks and disposable gloves, another complaint said. A complaint about an Ohio nursing home said workers were not required to wear protective equipment when caring for COVID patients. That complaint was closed three days after OSHA received it.


It remains unclear how OSHA resolved hundreds of the complaints. A Department of Labor spokesperson said in an email that some are closed based on an exchange of information between the employer and OSHA, and advised reporters to file Freedom of Information Act requests for details on others.


“The Department is committed to protecting America’s workers during the pandemic,” the Labor Department said in a statement. “OSHA has standards in place to protect employees, and employers who fail to take appropriate steps to protect their employees may be violating them.”


The agency advised its inspectors on May 19 to place reports of fatalities and imminent danger as a top priority, with a special focus on health care settings. Since late March, OSHA has opened more than 250 investigations into fatalities at health care facilities, government records show. Most of those cases are ongoing.


According to the mid-March complaints against McLaren Flint, workers did not receive needed N95 masks and “are not allowed to bring them from home.” They also said patients with COVID-19 were kept throughout the hospital.


Patrick Cain and his wife, Kate(Courtesy of Kelly Indish)



Filing complaints, though, did little for Liddell, or for his colleague, Patrick Cain, 52. After the complaints were filed, Cain, a registered nurse, was treating people still awaiting the results of COVID-19 diagnostic tests — potentially positive patients ― without an N95 respirator. He was also working outside a room where potential COVID-19 patients were undergoing treatments that research supported by the University of Nebraska has since shown can spread the virus widely in the air.


At the time, there was a debate over whether supply chain breakdowns of PPE and weakened CDC guidelines on protective gear were putting workers at risk.


Cain felt vulnerable working outside of rooms where COVID patients were undergoing infection-spreading treatments, he wrote in a text to Indish on March 26.


Texts between union president Kelly Indish and Patrick Cain (right)(Courtesy of Kelly Indish)



“McLaren screwed us,” he wrote.


He fell ill in mid-March and died April 4.


McLaren has since revised its face-covering policy to provide N95s or controlled air-purifying respirators (CAPRs) to workers on the COVID floor, union members said.


A spokesperson for the McLaren Health Care system said the OSHA complaints are “unsubstantiated” and that its protocols have consistently followed government guidelines. “We have always provided appropriate PPE and staff training that adheres to the evolving federal, state, and local PPE guidelines,” Brian Brown said in an email.


Separate from the closed complaints, OSHA investigations into Liddell and Cain’s deaths are ongoing, according to a spokesperson for the state’s Department of Labor and Economic Opportunity.


Nurses at Kaiser Permanente Fresno Medical Center also said the complaints they aired before a nurse’s death have not been resolved. (KHN is not affiliated with Kaiser Permanente.)


On March 18, nurses filed an initial complaint. They told OSHA they were given surgical masks, instead of N95s. Less than a week later, other complaints said staffers were forced to reuse those surgical masks and evaluate patients for COVID without wearing an N95 respirator.


Several nurses who cared for one patient who wasn’t initially suspected of having COVID-19 in mid-March wore no protective gear, according to Amy Arlund, a Kaiser Fresno nurse and board member of the National Nurses Organizing Committee board of directors. Sandra Oldfield, a 53-year-old RN, was among them.


Arlund said Oldfield had filed an internal complaint with management about inadequate PPE around that time. Arlund said the patient’s illness was difficult to pin down, so dozens of workers were exposed to him and 10 came down with COVID-19, including Oldfield.


Sandra Oldfield(Courtesy of Lori Rodriguez)



Lori Rodriguez, Oldfield’s sister, said Sandra was upset that the patient she cared for who ended up testing positive for COVID-19 hadn’t been screened earlier.


“I don’t want to see anyone else lose their life like my sister did,” she said. “It’s just not right.”


Wade Nogy, senior vice president and area manager of Kaiser Permanente Fresno, confirmed that Oldfield had exposure to a patient before COVID-19 was suspected. He said Kaiser Permanente “has years of experience managing highly infectious diseases, and we are safely treating patients who have been infected with this virus.”


Kaiser Permanente spokesperson Marc Brown said KP “responded to these complaints with information, documents and interviews that demonstrated we are in compliance with OSHA regulations to protect our employees.” He said the health system provides nurses and other staff “with the appropriate protective equipment.”


California OSHA officials said the initial complaints were accurate and the hospital was not in compliance with a state law requiring workers treating COVID patients to have respirators. However, the officials said the requirement had been waived due to global shortages.


Kaiser Fresno is now in compliance, Cal/OSHA said in a statement, but the agency has ongoing investigations at the facility.


Arlund said tension around protective gear remains high at the hospital. On each shift, she said, nurses must justify their need for a respirator, face shield or hair cap. She expressed surprise that the OSHA complaints were considered “closed.”


“I’m very concerned to hear they are closing cases when I know they haven’t reached out to front-line nurses,” Arlund said. “We do not consider any of them closed.”


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‘More Than Physical Health’: Gym Helps 91-Year-Old Battle Isolation


MONROVIA, Calif. — Most mornings, like clockwork, you could find Art Ballard pumping iron.


At least five days a week, he drove to Foothill Gym, where he beat on the punching bag, rode a stationary bike and worked his abs. After he joined the gym five years ago, he dropped 20 pounds, improved his balance and made friends.


At 91, he’s still spry and doesn’t take any medication other than an occasional Tylenol for aches and pains.


“Doctors love me,” he said.


But when California enacted a statewide stay-at-home order in mid-March, his near-daily physical exercise and social interactions abruptly ended.


Ballard’s health started to deteriorate: His back hurt, his legs cramped and he started becoming short of breath. As happens too often with older people, he also started to feel isolated and depressed.


“I was deeply concerned for myself because I didn’t have an exercise routine at home,” he said.



Art Ballard is proud that he doesn’t have to rely on several medications at his age. He takes only Tylenol as needed for aches and pains.(Heidi de Marco/KHN)



Art Ballard worked out at Foothill Gym a few weeks before it was officially open to the public. “I’m feeling so good,” he says. “I snapped back.”(Heidi de Marco/KHN)




The University of Southern California’s Dornsife Center for Economic and Social Research conducted an analysis in late March, as the coronavirus established a foothold in the U.S., that found that older adults over 60 who lived alone were more likely to report feeling anxious or depressed than those living with companions.


The combination of the pandemic and nationwide lockdown orders put this already vulnerable population at greater risk, said Julie Zissimopoulos, co-director of the aging and cognition program at USC’s Leonard D. Schaeffer Center for Health Policy & Economics. Social distancing measures have weakened the support systems that older people who live alone depend on for basic activities, such as help with grocery shopping and transportation to doctor appointments.


“There’s a huge, disproportionate impact on older adults with this virus and the health outcomes,” said Lisa Marsh Ryerson, president of AARP Foundation. “During this shutdown, we’ve had growing public health and community acknowledgement of how serious it can be to sever the ties with our network.”


Ballard, a retired jeweler, lives alone in a one-bedroom condo in Monrovia, a city of about 36,000 people about 20 miles northeast of downtown Los Angeles. He lost his wife of more than 50 years, Dorothy, to Alzheimer’s disease in 2015. Since then, he has embraced his solitude and reveled in his newfound bachelorhood. He enjoys cooking and trying out recipes, listening to 1950s music and watching YouTube videos about World War II.


Ballard holds a photograph of himself and his wife, Dorothy. She died from complications of Alzheimer’s disease almost five years ago. (Heidi de Marco/KHN)



He has a girlfriend he met online — a retired greyhound trainer who lives in Arkansas. They haven’t yet met in person.


Ballard felt he could handle the isolation of the lockdown order. He didn’t have visitors during quarantine, but his son, Dan Ballard, checked on him by phone weekly.


In the beginning, Ballard tried to keep busy. He did his shopping early in the morning and took strolls around his neighborhood. But after a couple of months of not visiting the gym, Ballard began feeling sad and frustrated, and his health started to slide. He relied more on his walker and sometimes struggled to breathe.


“My girlfriend was concerned with how I was thinking,” said Ballard, who speaks to her on the phone several times a day.


For Ballard, a self-proclaimed gym addict, Foothill Gym was a second home. Just as in the 1980s sitcom “Cheers,” it’s a place where everybody knows his name. Not going to the “club,” as he calls it, was taking a toll on his mental and physical health, so he decided to visit Brian Whelan, the owner of the small, family-run gym, in late May.


“He comes in, out of breath, with a walker,” Whelan recalled. “He couldn’t hold his head up straight and it took him five minutes to catch his breath.”


During the lockdown, Ballard started having difficulty keeping his balance. His solution was to walk around his neighborhood with a walker. (Heidi de Marco/KHN)




Art Ballard takes a break between sets to chat with Foothill Gym owner Brian Whelan on June 13. For Ballard, the benefits of the gym are twofold. “It’s the health factor and the social aspect,” he says. “Everybody there is so positive. It makes my day worthwhile.”(Heidi de Marco/KHN)



Art Ballard performs seated cable pulls during his total body workout at the gym. “I try to get my heart rate up to 140,” Ballard says.(Heidi de Marco/KHN)




Whelan felt sad and angry. “Everyone here was almost in tears because this vibrant man was gone,” he said. So Whelan broke the rules. He invited Ballard to visit the gym even before it officially reopened to the public.


“The gym business is more than physical health,” said Whelan. “It’s mental health.”


Ballard resumed his beloved routine the last week of May, with the gym mostly to himself.


“Every day for the past two months, I’ve been sad,” Ballard said on the first day back. “Today, I woke up and I was happy.”


Day after day, Ballard improved. “Now he comes in without a walker, head up straight, and the spark in his eyes is getting brighter,” Whelan said.


Ballard says it took him a while to get his hands on a mask. He wears it when he goes grocery shopping and to doctor appointments. (Heidi de Marco/KHN)




Art Ballard lives alone in a one-bedroom apartment. He’s self-sufficient and says he wants to live independently as long as possible. More than one-quarter of adults 65 and older live by themselves, according to 2018 U.S. Census Bureau statistics.(Heidi de Marco/KHN)



Art Ballard combs his freshly cut hair before heading to the gym. He has always had a crew cut, and the quarantine forced him, for the first time, to grow it out.(Heidi de Marco/KHN)




The gym reopened June 15. Despite the threat of COVID-19, Ballard is back to working out six days a week. Masks are required to enter the gym but can be removed when exercising.


Ballard isn’t worried. “I’m 100% comfortable,” he said. “I’ll wear a mask if they ask me to.”


Son Dan said he’s worried about his dad being around people, but realizes the benefits.


“It’s a scary balance. If he stops going to the gym and can’t see anybody, I know he’s going to deteriorate,” he said. “At the end of the day, it’s a quality-of-life decision that’s his to make.”


Ballard believes not being able to socialize was a bigger threat to his health than the risk of contracting the coronavirus.


“I found out how important my routine and exercise is,” said Ballard. “It’s given me back my life. And it’s only going to get better.”


Ballard always ends his gym session punching the heavy bag at least 60 times in a row, he says. “The most important thing to do is to shake those bones up, especially when you’re old,” he says. (Heidi de Marco/KHN)



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Hospital Executive Charged In $1.4B Rural Hospital Billing Scheme


A Miami entrepreneur who led a rural hospital empire was charged in an indictment unsealed Monday in what federal prosecutors called a $1.4 billion fraudulent lab-billing scheme.


In the indictment, prosecutors said Jorge A. Perez, 60, and nine others exploited federal regulations that allow some rural hospitals to charge substantially higher rates for laboratory testing than other providers. The indictment, filed in U.S. District Court in Jacksonville, Florida, alleges Perez and the other defendants sought out struggling rural hospitals and then contracted with outside labs, in far-off cities and states, to process blood and urine tests for people who never set foot in the hospitals. Insurers were billed using the higher rates allowed for the rural hospitals.


Perez and the other defendants took in $400 million since 2015, according to the indictment. Many of the hospitals run or managed by Perez’s Empower companies have since failed as they ran out of money when insurers refused to pay for the suspect billing. Half of the nation’s rural hospital bankruptcies in 2019 were affiliated with his empire.


“This was allegedly a massive, multi-state scheme to use small, rural hospitals as a hub for millions of dollars in fraudulent billings of private insurers,” said Assistant Attorney General Brian Benczkowski of the Justice Department’s Criminal Division in a statement.


Attempts to reach Perez for comment Monday evening were unsuccessful. But last year when Perez spoke to KHN, he said he was losing sleep over the possibility he could go to jail after propping up struggling rural hospitals.


“I wanted to see if I could save these rural hospitals in America,” Perez said. “I’m that kind of person.”


Pam Green, a former night charge nurse at the now-shuttered Horton Community Hospital in Horton, Kansas (population under 1,700), said she hopes Perez and his colleagues receive long prison sentences.


“He just devastated so many people, not just in Kansas, but in Oklahoma and all the other places where he had hospitals,” said Green, 58, of nearby Muscotah, Kansas. “I went months and months without pay, without health insurance. He robbed the community.”


Green recalled that money was so tight under Perez’s management of her former hospital that the electricity was shut off at least twice and staffers had to bring in their own supplies. She said she is owed about $12,000 in back pay, as well as money for uncovered dental expenses and a workplace injury that would have been covered had employees’ insurance or workers’ compensation premiums been paid.


A KHN investigation published in August 2019 detailed the rise and fall of Perez’s rural hospitals. At the height of his operation, Perez and his Miami-based management company, EmpowerHMS, helped oversee a rural empire encompassing 18 hospitals across eight states. Perez owned or co-owned 11 of those hospitals and was CEO of the companies that provided their management and billing services.


Perez styled himself a savior of rural hospitals, swooping into small towns with promises to save their struggling facilities using his “secret sauce” of financial ventures. Multiple employees told KHN they had no idea what happened to the money their hospitals earned after Perez and his associates took control, since the facilities seemed perpetually starved for cash.


Over the past two years, amid mounting legal challenges and concerns about the lab-billing operation, insurers cut off funding and his empire crumbled. Overall, 12 of the hospitals have entered bankruptcy and eight have closed. The staggering collapse left hundreds of employees without jobs and small towns across the Midwest and South without lifesaving medical care.


The four rural hospitals named in the indictment are Campbellton-Graceville Hospital in Graceville, Florida; Regional General Hospital of Williston, Florida; Chestatee Regional Hospital in Dahlonega, Georgia; and Putnam County Memorial Hospital in Unionville, Missouri.


The indictment marks the third major case federal prosecutors have filed alleging billing fraud at Perez-affiliated hospitals. In October, David Byrns pleaded guilty to a federal charge of conspiracy to commit health care fraud involving a Missouri hospital he managed with Perez. A Missouri Auditor General report previously found that the 15-bed hospital, Putnam County Memorial in Unionville, had received about $90 million in questionable insurance payments in less than a year.


In July 2019, Kyle Marcotte, owner of a Jacksonville Beach, Florida, addiction treatment center, pleaded guilty for his part in a $57 million lab-billing scheme involving two Perez-affiliated hospitals, Campbellton-Graceville and Regional General Hospital. Marcotte admitted cooperating with unnamed hospital managers to provide urine samples from his patients for lab testing that was billed through the rural hospitals and, in exchange, getting a cut of the proceeds.


Perez, on his own and through Empower-affiliated companies, in 2016 and 2017 purchased South Florida properties that totaled more than $3.7 million, including three condos on Key Largo, according to property records. He told KHN last year that the Florida properties were bought with earnings from unrelated software companies but declined to give details. He and his brother Ricardo Perez, if convicted, must forfeit over $46 million, according to the indictment, as well as two Key Largo condos and other properties.


Another defendant, Aaron Durall, if convicted, could lose $184.4 million and a six-bedroom, 6,500-square-foot home in the affluent Parkland district north of Fort Lauderdale, Florida.


Perez-affiliated hospitals also face ongoing lawsuits in Missouri and other states filed by dozens of insurers asking for hundreds of millions in restitution for allegedly fraudulent billings. In those court documents, Perez repeatedly has denied wrongdoing. He told KHN last year that his lab-billing setup was “done according to Medicare and state guidelines.”


For former employees of EmpowerHMS and members of the affected communities, the indictment represents vindication. As the company foundered, hundreds of employees worked without pay in vain efforts to keep their hospitals afloat. They would discover later that, along with the missing paychecks, their insurance premiums had not been paid and their medical policies had been discontinued. In the June 2019 interview, Perez acknowledged that, as finances withered, he stopped paying employee payroll taxes.


“It’s nice to think he might be held accountable,” said Melva Price Lilley, a former X-ray technician at Washington County Hospital in Plymouth, North Carolina, which has reopened with new owners under a new name. “At least there’s a chance that he might have to suffer some consequences. That gives me some hope.”


Lilley, 56, said she and other employees could not retrieve their retirement savings from the bankrupt hospital until about three weeks ago. She has been trying to pay off about $68,000 in medical bills from a back surgery she needed for a workplace injury that wasn’t covered by workers’ compensation insurance premiums that went unpaid for hospital employees. She remains unable to work full time.


I-70 Community Hospital, an Empower facility in Sweet Springs, Missouri, has remained closed since February 2019. Tara Brewer, head of the Sweet Springs Chamber of Commerce and the local health department, said she was almost shocked to hear that Perez had gotten indicted after months of wondering if anything would happen.


While she hopes these charges bring closure to her community, she said, the charges do little to fix the closed hospital doors for a county that has had one of the highest per capita rates of coronavirus cases in Missouri.


“What he did to us will linger on for a long time,” Brewer said.


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Essential Worker Shoulders $1,840 Pandemic Debt Due To COVID Cost Loophole


Carmen Quintero works an early shift as a supervisor at a 3M distribution warehouse that ships N95 masks to a nation under siege from the coronavirus. On March 23, she had developed a severe cough, and her voice, usually quick and enthusiastic, was barely a whisper.


A human resources staff member told Quintero she needed to go home.


“They told me I couldn’t come back until I was tested,” said Quintero, who was also told that she would need to document that she didn’t have the virus.


Her primary care doctor directed her to the nearest emergency room for testing because the practice had no coronavirus tests.


The Corona Regional Medical Center is just around the corner from her house in Corona, California, and there a nurse tested her breathing and gave her a chest X-ray. But the hospital didn’t have any tests either, and the nurse told her to go to Riverside County’s public health department. There, a public health worker gave her an 800 number to call to schedule a test. The earliest the county could test her was April 7, more than two weeks later.


At the hospital, Quintero got a doctor’s note saying she should stay home from work for a week, and she was told to behave as if she had COVID-19, isolating herself from vulnerable household members. That was difficult — Quintero lives with her grandmother and her girlfriend’s parents — but she managed. No one else in her home got sick, and by the time April 7 came, she felt better and decided not to get the coronavirus test.


Then the bill came.


The Patient: Carmen Quintero, 35, a supervisor at a 3M distribution warehouse who lives in Corona, California. She has an Anthem Blue Cross health insurance plan through her job with a $3,500 annual deductible.


Total Bill: Corona Regional Medical Center billed Quintero $1,010, and Corona Regional Emergency Medical Associates billed an additional $830 for physician services. She also paid $50 at Walgreens to fill a prescription for an inhaler.


Service Provider: Corona Regional Medical Center, a for-profit hospital owned by Universal Health Services, a company based in King of Prussia, Pennsylvania, which is one of the largest health care management companies in the nation. The hospital contracts with Corona Regional Emergency Medical Associates, part of Emergent Medical Associates.


Medical Service: Quintero was evaluated in the emergency room for symptoms consistent with COVID-19: a wracking cough and difficulty breathing. She had a chest X-ray and a breathing treatment and was prescribed an inhaler.



What Gives: On that day in late March when her body shook from coughing, Quintero’s immediate worry was infecting her family, especially her girlfriend’s parents, both over 65, and her 84-year-old grandmother.

“If something was to happen to them, I don’t know if I would have been able to live with it,” said Quintero.


Quintero wanted to isolate in a hotel, but she could hardly afford to for the week that she stayed home. She had only three paid sick days and was forced to take vacation time until her symptoms subsided and she was allowed back at work. At the time, few places provided publicly funded hotel rooms for sick people to isolate, and Quintero was not offered any help.


For her medical care, Quintero knew she had a high-deductible plan yet felt she had no choice but to follow her doctor’s advice and go to the nearest emergency room to get tested. She assumed she would get the test and not have to pay. Congress had passed the CARES Act just the week before, with its headlines saying coronavirus testing would be free.


That legislation turned out to be riddled with loopholes, especially for people like Quintero who needed and wanted a coronavirus test but couldn’t get one early in the pandemic.


“I just didn’t think it was fair because I went in there to get tested,” she said.


Carmen Quintero (right) still tries to keep a safe distance from her grandmother, Teresa Carapia, and two other family members over 65. Quintero says she worried about them as she tried to self-isolate with COVID-like symptoms.(Heidi de Marco/KHN)



Some insurance companies are voluntarily reducing copayments for COVID-related emergency room visits. Quintero said her insurer, Anthem Blue Cross, would not reduce her bill. Anthem would not discuss the case until Quintero signed its own privacy waiver; it would not accept a signed standard waiver KHN uses. The hospital would not discuss the bill with a reporter unless Quintero could also be on the phone, something that has yet to be arranged around Quintero’s workday, which begins at 4 a.m. and ends at 3:30 p.m.


Three states have gone further than Congress to waive cost sharing for testing and diagnosis of pneumonia and influenza, given these illnesses are often mistaken for COVID-19. California is not one of them, and because Quintero’s employer is self-insured — the company pays for health services directly from its own funds — it is exempt from state directives anyway. The U.S. Department of Labor regulates all self-funded insurance plans. In 2019, nearly 2 in 3 covered workers were in these types of plans.


Resolution: As lockdown restrictions ease and coronavirus cases rise around the country, public health officials say quickly isolating sick people before the virus spreads through families is essential.


But isolation efforts have gotten little attention in the U.S. Nearly all local health departments, including Riverside County, where Quintero lives, now have these programs, according to the National Association of County and City Health Officials. Many were designed to shelter people experiencing homelessness but can be used to isolate others.


Raymond Niaura, interim chairman of the Department of Epidemiology at New York University, said these programs are used inconsistently and have been poorly promoted to the public.


“No one has done this before and a lot of what’s happening is that people are making it up as they go along,” said Niaura. “We’ve just never been in a circumstance like this.”


Quintero still worries about bringing the virus home to her family and fears being in the same room with her grandmother. Quintero returns from work every day now, puts her clothes in a separate hamper and diligently washes her hands before she interacts with anyone.


The bills have been another constant worry. Quintero called the hospital and her insurance company and complained that she should not have to pay since she was seeking a test on her doctor’s orders. Neither budged, and the bills labeled “payment reminders” soon became “final notices.” She reluctantly agreed to pay $100 a month toward her balance — $50 to the hospital and $50 to the doctors.


“None of them wanted to work with me,” Quintero said. “I just have to give the first payment on each bill so they wouldn’t send me to collections.”


The Takeaway: If you suspect you have COVID-19 and need to isolate to protect vulnerable members of your household, call your local public health department. Most counties have isolation and quarantine programs, but these resources are not well known. You may be placed in a hotel, recreational vehicle or other type of housing while you wait out the infection period. You do not need to have a positive COVID test to qualify for these programs and can use these programs while you await your test result. But this is an area in which public health officials repeatedly offer clear guidance — 14 days of isolation — which most people find impossible to follow.


At this point in the pandemic, tests are more widely available and federal law is very clearly on your side: You should not be charged any cost sharing for a coronavirus test.


Be wary, though, if your doctor directs you to the emergency room for a COVID test, because any additional care you get there could come at a high price. Ask if there are any other testing sites available.


If you do find yourself with a big bill related to suspected COVID, push beyond a telephone call with your insurance company and file a formal appeal. If you feel comfortable, ask your employer’s human resources staff to argue on your behalf. Then, call the help line for your state insurance commissioner and file a separate appeal. Press insurers — and big companies that offer self-insured plans — to follow the spirit of the law, even if the letter of the law seems to let them off the hook.


Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!


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Monday 29 June 2020

KHN’s ‘What The Health?’: High Court’s Surprising Abortion Decision



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The Supreme Court surprised both sides in the polarized abortion battle Monday by ruling, 5-4, that a Louisiana law requiring doctors who perform the procedure to have admitting privileges at a nearby hospital is an unconstitutional infringement of a woman’s right to an abortion.


As expected, the court’s four liberals in the case, June Medical Services v. Russo, said that the law did not provide any protections for women and merely made it harder for them to obtain an abortion and that it was nearly identical to a Texas law struck down in 2016. The four conservatives said the Louisiana law should be upheld, although that would have left the state with only a single abortion provider. The swing vote was Chief Justice John Roberts, who, in a concurring opinion, said he disagreed with the ruling in the Texas case but it is now precedent and thus should not be overturned.


This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico and Jennifer Haberkorn of the Los Angeles Times.


The panelists broke down the decision along several lines, including:


  • Why a court with five justices who have all voted to back abortion restrictions did not uphold the first major abortion law to come before it since Anthony Kennedy retired and was replaced by Brett Kavanaugh.

  • How the ruling could have gone much further than merely upholding the Louisiana law. The court had been asked to use the case to overturn Roe v. Wade in its entirety and to bar abortion providers from filing suit on behalf of their patients. The justices did neither.

  • Why Justice Roberts’ vote in this case does not suggest he will vote with abortion-rights supporters in other cases, but might offer a clue on how he will vote in the upcoming case challenging the constitutionality of the Affordable Care Act.

  • How this case could play at the polls in November.

“What the Health?” is taking a break on Thursday but will return July 9.



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Supreme Court, Rejecting Restrictive La. Law, Refuses To Roll Back Abortion Rights


In a decision certain to roil the fall elections, a Supreme Court with a majority of anti-abortion justices Monday refused to use its first opportunity to roll back abortion rights. In a 5-4 ruling, the justices said a Louisiana law requiring doctors who perform abortions to have admitting privileges at a nearby hospital is an unconstitutional burden on a woman’s right.


The decision in June Medical Services v. Russo effectively upholds a case from just four years ago. In 2016, in Whole Woman’s Health v. Hellerstedt, a 5-3 majority struck down portions of a controversial Texas law, including not only the admitting privileges requirement, but also a requirement for abortion clinics to meet the same standards as surgical centers that perform more advanced procedures.


The deciding vote was cast by Chief Justice John Roberts, who voted in the past case to uphold the Texas law. In a concurring opinion, he said his vote here was based on the court’s unwritten rules about precedent.


“The legal doctrine of stare decisis requires us, absent special circumstances, to treat like cases alike,” Roberts wrote. “The Louisiana law imposes a burden on access to abortion just as severe as that imposed by the Texas law, for the same reasons. Therefore Louisiana’s law cannot stand under our precedents.”


Had the law been upheld, it would likely have resulted in the closure of two of the three remaining abortion clinics in the state, the plaintiffs argued before the court in March. Justices had numerous questions about how doctors at each of the clinics tried and failed to obtain the required privileges. That was not because the doctors were not qualified, but because most hospitals do not extend privileges to doctors who do not admit patients, and outpatient abortions rarely result in hospital admissions.


The decision is likely to touch off a major backlash by conservatives who had hoped to see progress rolling back abortion rights since Anthony Kennedy — who often sided with the court’s liberals to uphold abortion rights — retired and was replaced by Brett Kavanaugh.


As usual, abortion is likely to be a galvanizing issue in the fall presidential and congressional campaigns.


Conservative and anti-abortion groups wasted no time venting their fury, particularly at Roberts. “Today, the Supreme Court betrayed the rule of law and the dignity of the bench,” said a statement from Heritage Action for America. “This is the latest in a series of judicial power grabs from the Chief Justice and the liberal wing of the court.”


Supporters of abortion rights worried that if the Louisiana law were upheld, the case would open the door to other states that want to restrict abortion without outright banning it. According to the Guttmacher Institute, which tracks reproductive health legislation, 15 states either already have admitting privileges laws on the books, or would have been likely to enact them because they have anti-abortion governors and legislative majorities.


Still, abortion rights at the high court are far from secured. As of June 1, 11 states have passed laws that would ban abortion in the first trimester of pregnancy, according to Guttmacher. Tennessee joined that group just days ago. Several of those laws are in the pipeline heading for the high court.


“Unfortunately, the Court’s ruling today will not stop those hell-bent on banning abortion,” said a statement from Nancy Northup, president and CEO of the Center for Reproductive Rights, which argued the case before the court. “We will be back in court tomorrow and will continue to fight state by state, law by law to protect our constitutional right to abortion.”


The court also declined to rule on a technicality that could have had far-reaching implications. Louisiana had asked the court to rule that abortion providers lacked standing to sue on behalf of women seeking abortions. Doctors and clinics have been filing suits on behalf of their patients since at least the 1980s and the Supreme Court has always allowed it. And those doctors, of course, are in some ways more directly affected by the law because the penalties for violation accrue to them, not their patients.


The court, however, did not accept that argument either.


Wrote Justice Stephen Breyer in the majority opinion, “We have long permitted abortion providers to invoke the rights of their actual or potential patients in challenges to abortion-related regulations.”


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Conflicting COVID Messages Create Cloud Of Confusion Around Public Health And Prevention


Regina Fargis didn’t know what to do.


Fargis runs Summit Hills — a health and retirement community in Spartanburg, South Carolina, that offers skilled nursing, activities and communal meals for its residents, most of whom are over 60, the highest-risk category for coronavirus complications. In South Carolina, more than a hundred new cases were emerging daily. So she took precautions: no visitors, hand sanitizer everywhere and regular reminders for residents about the importance of social distancing.


For a time, it worked. Many similar facilities were hit hard by the virus, but Summit Hills remained COVID-free. Summit Hills’ first cases didn’t emerge until mid-June. Three residents and four employees have now tested positive and are being quarantined. For months, though, Fargis was able to protect her residents.


Still, even under the best circumstances, she couldn’t prevent one thing. By mid-May, two residents had become convinced that the COVID-19 death count — which has surpassed 125,000 people in the U.S. — was a talking point manufactured by Democrats. Some people may be dying, they said, but it wasn’t actually that severe. They didn’t think her precautions were necessary.


“I don’t know how to respond, to tell you the truth,” Fargis said. “If someone has that kind of mindset, what kind of conversation do you have” to convince them of the pandemic’s severity and the need for strict precautions?


Since the start of the pandemic, the public has been barraged by conflicting messages in part because the country is dealing with a new and still poorly understood virus and in part because politicians and scientists deliver conflicting advice. But rumors, misinformation and outright falsehoods — some intentionally propagated — have also flourished in that cauldron of confusion.


As the nation reopens for business and retreats from protective stay-at-home orders, those widely circulating lies could prove deadly.


NewsGuard, a startup by two former journalists that vets the internet for misinformation, has identified 217 websites in Europe and the United States that publish “materially false” information about COVID-19. The volume is so great that NewsGuard, which was launched to check political fabrications, has pivoted to full-time COVID-19 fact-checking.


The misinformation includes the “Plandemic” video, Facebook posts claiming 5G cell networks cause the virus and articles suggesting it can be cured with garlic or using a combination of hot water with baking soda and lemon.


Health scares always spawn scurrilous stories. But with COVID-19, “there’s lots of opportunity for misinformation,” said Dhavan Shah, a professor of mass communication at the University of Wisconsin-Madison.


That is particularly true in the United States, where the coronavirus has somehow morphed into a right-versus-left political issue — and Americans increasingly reject information that doesn’t match their leanings.


Research shows people who support the Trump administration and rely on right-leaning news organizations are more likely to believe the virus has been exaggerated. In general, Republicans are more likely, according to recent polling, than Democrats to think that COVID-19 was never a threat and that the worst is over. That possibly contributed to the push for early reopening in some states that had not met the requirements recommended by the Centers for Disease Control and Prevention for doing so. In many of them, daily case counts are now spiking. And Republicans are less likely than Democrats to don protective masks, which are believed to reduce the spread of the virus. (President Donald Trump famously has refused to wear a mask in public.)


Groups like anti-vaxxers, conspiracy theorists and immigration opponents have also used the virus to push their own misinformation, per a report from Data & Society, a research institute in New York.


“It’s become a political football now,” said Steven Brill, a co-CEO of NewsGuard. “That tends to get the misinformation and disinformation amplified. People on one side or the other tend to want to amplify what endorses or strengthens their position.”


Misinformation Grows In A Vacuum


Federal health officials from agencies such as the CDC and the Food and Drug Administration usually are tasked with providing the public with understandable, scientifically supported guidance. But the advice from experts like Dr. Anthony Fauci, who heads the National Institute of Allergy and Infectious Diseases, has consistently been undermined by Trump, who instead touts unproven treatments and frequently challenges the severity of the virus.


In fact, political figures like Trump have held outsize influence in shaping public understanding. “The news feed abhors a vacuum,” said Jeff Hancock, a professor of communication at Stanford University who has studied the implications of COVID misinformation. “Since the expertise of the CDC and others have been called into question … it exacerbates the problem.”


Experts’ initial confusion about how to respond to a new virus has also allowed for suspicion. When the coronavirus arrived in the United States, the prevailing thought was that asymptomatic patients couldn’t spread it and that people needn’t wear face coverings. Subsequent studies reversed those judgments.


All that helps explain why falsehoods took hold. Researchers from the University of Oxford’s Reuters Institute for the Study of Journalism reviewed 225 pieces of online misinformation about COVID-19. Misinformation spread by political figures and celebrities made up only 20% of the sample but accounted for 69% of engagement.


Independent groups, including NewsGuard and Hancock’s Stanford Social Media Lab, have launched projects meant to combat misinformation — teaching older people through peer-to-peer tutoring to navigate digital content or launching websites that point people toward more credible data and analysis. But these efforts, usually difficult, are almost impossible now in the age of social distancing.


The “volume and velocity” of social media spread means claims spread farther, faster, Shah said.


At Summit Hills, the politicization of COVID-19 has “without a doubt” made it harder for Fargis, its executive director, to convince her residents — many of whom would typically look to the federal government for credible information — of the pandemic’s severity.


Some cons deliberately target seniors, offering more than misinformation: Bad actors pretended to have access to their victims’ stimulus checks, asking for bank account and Social Security information. Others sell fake protective equipment.


At Hebrew SeniorLife, a hospital and living center in Massachusetts, which operates rehab centers and senior-living facilities around the Boston area, misinformation and online scams — such as fake fundraisers on Facebook for first responders — are serious concerns, said Rachel Lerner, the organization’s general counsel.


Older Americans experience a “perfect storm,” Hancock said. “They’re more susceptible to the virus. They are targets of misinformation and online scams at a much higher rate than regular folks are.”


When South Carolina began opening up, Fargis decided to see if the numbers of new COVID-19 cases declined significantly before lifting precautions. Now, with the virus in her facility, she has no intention of letting up social distancing rules and other prevention strategies.


And since May, at least one of her residents has since come around to understanding the pandemic’s severity. But another, she said, still emails her arguing that the virus has been overblown or that social distancing does not work and suggesting that unproven medicines — like hydroxychloroquine or beta-glucans — can treat or prevent the illness.


“We’d all be far better off if we kept those nonsensical remarks out of the news,” she said. “The more misinformation we have, the more likely we are going to have lives at stake.”


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In Arizona Race, McSally Makes Health Care Pledge At Odds With Track Record


Trailing Democratic challenger Mark Kelly in one of the country’s most hotly contested Senate races, Arizona Sen. Martha McSally is seeking to tie herself to an issue with across-the-aisle appeal: insurance protections for people with preexisting health conditions.


“Of course I will always protect those with preexisting conditions. Always,” the Republican said in a TV ad released June 22.


The ad comes in response to criticisms by Kelly, who has highlighted McSally’s votes to undo the Affordable Care Act. That, he argued, would leave Americans with medical conditions vulnerable to higher-priced insurance.


The Arizona Senate race has attracted national attention and is considered a toss-up, though Kelly is leading in many polls. McSally’s attempt to present herself as a supporter of protecting people with preexisting conditions — a major component of the 2010 health law — is part of a larger pattern in which vulnerable Republican incumbents stake out positions advocating for this protection while also maintaining the GOP’s strong stance against the ACA.


McSally, who was appointed by the governor to take over John McCain’s Senate seat in 2019, used similar messaging in her failed 2018 bid for the state’s other Senate position. And President Donald Trump echoed the declaration at a June 23 rally in Phoenix, saying McSally — along with the rest of the Republican Party — “will always protect people with preexisting conditions.”


With that in mind, we decided to take a closer look. We contacted McSally’s campaign, which cited her support of a different piece of legislation, the Protect Act. But independent experts told us that legislation doesn’t satisfy the standard she sets out.


Past and Present


Only one national law makes sure people with preexisting medical conditions don’t face discrimination or higher prices from insurers. It’s the Affordable Care Act.


Both as a member of the House of Representatives and as a senator, McSally has supported efforts to undo the health law — voting in 2015 to repeal it and in 2017 to replace it with the Republican-backed American Health Care Act, which would have permitted insurers to charge higher premiums for people with complicated medical histories.


“Anyone who voted for that bill was voting to take away the ACA’s preexisting condition protections,” said Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill. “Sen. McSally is trying to erase history for electoral purposes.”


Especially as COVID-19 cases climb, health care — and, in particular, the ACA — has emerged as a flashpoint in the Arizona election, said Dr. Daniel Derksen, a professor of public health, medicine and nursing at the University of Arizona.


“Martha McSally has in her actions, in her votes, been pretty consistent about cutting back benefits and trying to repeal the ACA without any clear plan in mind that would protect people who gained insurance through the ACA,” Derksen added. “Her words on preexisting condition protections don’t align with any votes I’ve seen.”


McSally’s campaign argued that the ACA is just one strategy, and a flawed one at that. Dylan Lefler, her campaign manager, instead pointed to her support of the Republican-backed Protect Act as evidence to back up her promise. Specifically, it ostensibly bans insurance plans from “impos[ing] any preexisting condition exclusion with respect to … coverage,” per the bill text.


The problem, though, is that simply banning that exclusion isn’t enough, because the law also has to make sure the health insurance plans that cover preexisting conditions remain affordable. The bill, sponsored by Sen. Thom Tillis (R-N.C.), does nothing to provide subsidies or cost-sharing mechanisms — meaning people both with and without preexisting conditions wouldn’t necessarily be able to afford those plans. Without that framework, the act remains a “meaningless promise,” argued Linda Blumberg, a fellow at the Urban Institute, a social policy think tank.


And it has other holes: for instance, permitting insurers to charge women more than men.


“No six-page bill is ever the way of achieving something,” said Thomas Miller, a scholar at the American Enterprise Institute. “This is a check-the-box effort to try to say, ‘We’re [moving] in that direction.’”


It’s not just legislation. There’s also Texas v. Azar, a pending case in which a group of Republican attorneys general are arguing the Supreme Court should strike the entire health law, including its preexisting condition protections. The Trump administration has sided with the Republican states.


McSally has consistently declined to comment on the lawsuit, saying she doesn’t want to weigh in on “a judicial proceeding.” In reporting this fact check, we asked where she stood on the case. The campaign didn’t specifically answer but pointed to her general disapproval of the ACA. Meanwhile, Senate Democrats have called on the administration to reverse its stance.


That context makes McSally’s silence especially relevant, said Sabrina Corlette, a research professor at Georgetown University.


“When given the opportunity, she has declined to oppose this lawsuit, which would essentially eliminate the protections that exist,” Corlette said.


So — big picture? McSally’s record in Washington hasn’t been one of preserving or building on preexisting condition protections.


Our Ruling


In her new TV ad, McSally claims she will “always protect those with preexisting conditions.”


But nothing in her voting record, which tracks closely with the Republican repeal-and-replace philosophy, supports this claim. And she has continually declined opportunities to oppose a pending legal threat to the ACA, including its provisions related to preexisting conditions, by a group of GOP governors and supported by the Trump administration.


Meanwhile, the legislation her campaign cited to justify her stance falls short in terms of meaningfully protecting Americans with preexisting medical conditions.


McSally has not in the past or present taken actions that back up her statement. We rate it False.


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