Health Care Reform Articles - May 9, 2020

McDonald’s Workers in Denmark Pity Us

Danes haven’t built a “socialist” country. Just one that works.

by Nicholas Kristof- NYT - May 8,2020

President Trump thunders that Democrats are trying to drag America toward “socialism,” Vice President Mike Pence warns that Democrats aim to “impose socialism on the American people,” and even some Democrats warn against becoming, as one put it, “[expletive] Denmark.”

So, before the coronavirus pandemic, I crept behind [expletive] Danish lines to explore: How scary is Denmark? How horrifying would it be if the United States took a step or two in the direction of Denmark? Would America lose its edge, productivity and innovation, or would it gain well-being, fairness and happiness?

So, here, grab a Danish, and we’ll chat about how a [expletive] progressive country performs under stress. The pandemic interrupted my reporting, but I’d be safer if I still were in Denmark: It has had almost twice as much testing per capita as the United States and fewer than half as many deaths per capita.

Put it this way: More than 35,000 Americans have already died in part because the United States could not manage the pandemic as deftly as Denmark.

Denmark lowered new infections so successfully that last month it reopened elementary schools and day care centers as well as barber shops and physical therapy centers. In the coming days, it will announce further steps to reopen the economy.

Moreover, Danes kept their jobs. The trauma of massive numbers of people losing jobs and health insurance, of long lines at food banks — that is the American experience, but it’s not what’s happening in Denmark. America’s unemployment rate may be 20 percent, but Denmark’s is hovering in the range of 4 percent to 5 percent.

“Our aim was that businesses wouldn’t fire workers,” Labor Minister Peter Hummelgaard told me. Denmark’s approach is simple: Along with some other European countries, it paid companies to keep employees on the payroll, reimbursing up to 90 percent of wages of workers who otherwise would have been laid off.

Denmark also helped hard-hit companies pay fixed costs like rent — on the condition that they suspend dividends, don’t buy back stock and don’t use foreign havens to evade taxes.

Some of the $3 trillion that the United States has poured into unemployment benefits, stimulus payments, business rescues and industry bailouts has gone to worker retention, but the attention to avoiding layoffs is far less serious.

As a share of G.D.P., Denmark’s coronavirus relief spending is a bit less than America’s, but it seems more effective at protecting the population.

The upshot is that Denmark staggered through the pandemic with employees still on the payroll and still paying rent. As the economy sputters back to life, Danish companies are in a position to bounce back quickly without the cost of having to rehire workers.

“We can be up and running in a week, back where we were,” explained Peter Lykke Nielsen, a negotiator for unionized workers at hamburger chains. This European approach to avoiding unemployment won admiration in Washington, and not exclusively from liberals: Senator Josh Hawley, a Republican from Missouri, advocates something similar in the United States.

Some Americans cite Sweden as a model for coronavirus response because it has not imposed a major lockdown. But, in fact, Denmark, separated from Sweden by a bridge, has been far more successful: Denmark’s death rate from Covid-19 per million people is less than one-third of Sweden’s, and forecasters predict that Denmark’s economy will do better than Sweden’s this year.

Denmark, by saving lives, has also saved its economy, at least so far.

Covid-19 will not last forever, and skeptical Americans may think that [expletive] Denmark coddles workers in ways that hobble economic dynamism and ultimately hurt workers themselves. I raised that argument with a McDonald’s worker I met in Copenhagen, Muhammad Abu Sayeed, a Bangladeshi immigrant. He looked at me quizzically.

Starting pay for the humblest burger-flipper at McDonald’s in Denmark is about $22 an hour once various pay supplements are included. The McDonald’s workers in Denmark get six weeks of paid vacation a year, life insurance, a year’s paid maternity leave and a pension plan. And like all Danes, they enjoy universal medical insurance and paid sick leave.

One reason Denmark was more effective than the United States in responding to the crisis is that no Dane hesitated to seek treatment because of concerns about medical bills.

Abu Sayeed knew that Americans working in fast food don’t do so well. “I heard about the movement,” he said, trying to remember its name. “Fight for something. Fight for $20? What was it?”

“Fight for $15,” I explained. “They want $15 an hour.”
There was an awkward silence. He nodded sympathetically. Then he tried not to sound condescending.

“I feel for them,” he said earnestly of American workers at McDonald’s. “We are from the same brand.”

Some American companies scoff that a $15 minimum wage or stronger unions would be a disastrous blow to business. Denmark challenges that narrative, for it shows that it’s possible to have a thriving economy that pays workers decently and treats them respectfully.

Workers get their schedules a month in advance, and they can’t be assigned back-to-back shifts. American politicians speak solemnly about the dignity of work, but you’re more likely to find it in Copenhagen than in New York.

This wasn’t always so. The golden age of American capitalism, from 1945 to 1980, was a period of high tax rates (up to 91 percent for the very wealthy), strong labor unions and huge initiatives, such as the G.I. Bill of Rights to help disadvantaged (albeit mostly white) Americans. This was a period of rapid growth in which income inequality declined — and in some ways it looked like today’s Denmark.

One Republican strategy this year has been to demonize Democrats as socialists who would destroy the economy. Trump warns that Democrats “want to model America’s economy after Venezuela.”

Well, no. In fact, what liberal Democrats have in mind is a step in the direction of the Nordic model found in Denmark, Sweden, Norway and Finland. But paradoxically, while Americans on both left and right often think of Scandinavia as quasi-socialist, Scandinavians flinch at that characterization. They see themselves as simply pursuing market economies, just with higher taxes and greater social benefits than the United States.

Danes pay an extra 19 cents of every dollar in taxes, compared with Americans, but for that they get free health care, free education from kindergarten through college, subsidized high-quality preschool, a very strong social safety net and very low levels of poverty, homelessness, crime and inequality. On average, Danes live two years longer than Americans.

A Big Mac flipped by $22-an-hour workers isn’t even that much more expensive than an American one. Big Mac prices vary by outlet, but my spot pricing suggested that one might cost about 27 cents more on average in Denmark than in the United States. That 27 cents is the price of dignity.

Americans might suspect that the Danish safety net encourages laziness. But 79 percent of Danes ages 16 to 64 are in the labor force, five percentage points higher than in the United States.

Danes earn about the same after-tax income as Americans, even though they work on average 22 percent fewer hours; on the other hand, money doesn’t go as far in Denmark because prices average 18 percent higher. My own rough guess is that the top quarter of earners live better in America, but that the bottom three-quarters live better in Denmark.

Indeed, polls find that Danes are among the world’s happiest people, along with Finns; Denmark is sometimes called “the happiest country.”

You can agree or disagree that the trade-offs are worth it, but as you sit at a cafe in Copenhagen, sipping coffee and enjoying a Danish (called Viennese bread), Denmark hardly seems like a socialist nightmare.

Indeed, Danes — very politely — express concern for what they perceive as a dystopia on the other side of the Atlantic.

“We look to America for a lot of things,” Nielsen, the labor negotiator, told me. “And then we meet people in the fast-food sector, and. …” He paused, struggling for the right words. “Look, all countries have flaws, right? But you look at labor rights in America, and it’s crazy. If you work full time you should be able to support your family.”

Kristina Hansen, 27, who works at a nonunion hamburger chain called Cock’s & Cows, told me she is now thinking of buying an apartment. Surprised, I noted that few Americans working at hamburger chains are buying their own homes, and we discussed American fast-food pay.

“How can they survive on that money over there?” she asked me. “It’s so expensive to live in New York. I wonder how they live on that kind of money.”

Americans assume that Danish wages must be high because of regulations, but Denmark has no national minimum wage, and it would be perfectly legal for a construction company or a corner pizzeria to hire workers at $5 an hour. Yet that doesn’t happen. The typical bottom market wage seems to be about $15 — about twice the federal minimum wage in the United States, a country with a roughly similar standard of living. Why is that?

One reason is Denmark’s strong unions. More than 80 percent of Danish employees work under collective bargaining contracts, although strikes are rare. There is also “sectoral bargaining,” in which contracts are negotiated across an entire business sector — so in Denmark, McDonald’s and Burger King pay exactly the same — something that Joe Biden suggests the United States consider as well.

Yet there’s another, more important reason for high wages in Denmark.
“Workers are more productive” in Denmark, Lawrence Katz, a labor economist at Harvard, noted bluntly. “They have had access to more and higher-quality human capital investment opportunities starting at birth.”

Think of it this way. Workers at McDonald’s outlets all over the world tend to be at the lower end of the labor force, say the 20th percentile. But Danish workers at the 20th percentile are high school graduates who are literate and numerate.

In contrast, after half a century of underinvestment in the United States, many 20th-percentile American workers haven’t graduated from high school, can’t read well, aren’t very numerate, struggle with drugs or alcohol, or have impairments that reduce productivity.

Increasingly, I came to see that emulating a Danish-style system of high wages wasn’t just about lifting the minimum wage but, even more, about investing in children.

Many Danes see the nurturing of children as part of their nation’s secret sauce, so I dropped in on a public day care center in the city of Soborg. It turned out to be bright and pleasant, with 68 children and 12 teachers, plus a cook who serves mostly organic meals.

This center is open from 7 a.m. to 5 p.m., and some other branches offer extended hours. It costs (a heavily subsidized) $516 per month for children ages 4 months to 3 years, and $354 for children from 3 to 6. Children of low-income parents attend free.

The focus isn’t so much on learning reading or numbers, but rather on using play to learn social skills and creativity. “‘Learning to learn’ is a popular expression here,” explained Helle Olsen, the manager.

One critical purpose of the system is to allow both parents to work, and that’s why day care centers were among the first institutions reopened as the number of coronavirus cases fell. But families commonly send children to the centers even if there is a grandparent or other person at home (nannies are rare), because they are seen as training kids to be good Danish citizens. For that reason, attendance is mandatory for families where Danish is not spoken at home.

If we want to understand why burger-flippers in Denmark earn so much, I realized, part of the answer involves giving little children equal access to the starting line so that they will be educated and become productive workers two decades later.

For all of Denmark’s successes, its model faces challenges. A central one is that the Danish system emerged from a homogeneous society with strong social trust, and some experts wonder whether Denmark can indefinitely sustain its high-wage, high-productivity economy as less-skilled immigrants stream in from poorer countries. Denmark compiled a heroic record resisting the Nazis to save most of its Jewish population in World War II, so it surprised me to encounter strong anti-immigrant feelings, even xenophobia.

Yet the success of the Nordic model seems undeniable — although it’s not obvious to all Americans. Last year, Nikki Haley tweeted contemptuously about Finland’s health care system. “Comparing us to Finland is ridiculous,” she said scornfully. “Ask them how their health care is. You won’t like their answer.”

She apparently was unaware that Finns live longer than Americans, that Finnish children are only one-third as likely to die by the age of 5, and that Finnish women are one-fifth as likely to die in childbirth.

Even on the Democratic side, the television personality Donny Deutsch scoffed on Bill Maher’s HBO show that Medicare for All would mean “we are going backwards. We’re [expletive] Denmark!”

At a time when a pandemic lays bare longstanding inequities in the United States, maybe we should approach the Nordic countries with a bit more curiosity and humility. Hummelgaard, the labor minister, is the son of a porter and a cleaner but received an excellent free education and spoke to me in perfect English. He admires the United States but is sometimes baffled by it.

“Danes love America,” Hummelgaard told me. “But there’s no admiration for the level of inequality in America, for the lack of job security, for the lack of health security, for all those things that normally can create a good society.”
https://www.nytimes.com/2020/05/08/opinion/us-denmark-economy.html?fellback=false&algoTimeout=false&algo=combo_lda_unique_hot_ranking_50_diversified&renderPosition=0&imp_id=532678908&action=click&module=fromYourInterests&pgtype=Article&region=Footer

Opinion Today By James Bennett -Editorial Page Editor- NYT - May 8, ,2020 My colleagues and I have been talking a lot lately about how distorted the American conversation about freedom has become — and even the American idea of freedom itself.

Take the debate about achieving both economic vitality and public health. Surely everyone wants as much of both as possible.

Yet a small but passionate and attention-snatching minority (with an assist from the White House) has managed to hijack what should be a conversation about figuring out the right balance. They’ve turned it into a cartoon, an either/or proposition in which even the suggestion that people should wear masks in public becomes a jack-booted assault on individual liberty, as my colleague Charlie Warzel wrote this week, drawing a compelling parallel to the warped debate over gun safety.

This raises a deeper question: What does it really mean to be free?

Before our office shut down and we all dispersed, one of the last editorial board meetings we held in person was with the prime minister of Finland, Sanna Marin. At 34, she’s the youngest female prime minister in the world.

She spoke about Finland’s challenges in coping with climate change, immigration and a movement of people to cities that is hollowing out rural communities. Again and again, as she talked about sustaining political consensus to confront these challenges, she returned to the importance of the sense of security Finns feel because of their strong social safety net, including free health care and university.

“It gives people freedom when you have a very strong welfare state,” she told us.

That formulation stands the American politics of freedom on its head. Franklin Roosevelt may have envisioned freedom from want, but in recent decades freedom here has come to mean freedom from taxes, freedom from regulation, freedom from having to wear a mask in public. The American left has largely conceded the rhetoric and even the idea of freedom to the right.

Told that some Americans look at Finland and fear socialism, the prime minister smiled. As neighbors of the Soviet Union, Finns had seen a socialist experiment up close and wanted no part of it. “We are an open-market society,” she said proudly.

Our columnist Nicholas Kristof, in a deeply reported exploration of the Nordic model, had the brilliant idea to look at what it’s like to work for McDonald’s in Denmark. The answer is that, even though Denmark has no minimum wage, you make about $22 an hour and get “six weeks of paid vacation a year, life insurance, a year’s paid maternity leave and a pension plan.” All that plus the Danish guarantees of medical insurance and paid sick leave.

To get a sense of what it’s like to work for McDonald’s in the United States, watch this video.

Please read Nick’s piece and consider whether, as he suggests, we might “approach the Nordic countries with a bit more curiosity and humility.

Particularly now, during this pandemic, I think people like me who are lucky to have health care, housing and the benefits of a good education should be asking: If we’d never had any of these things, would we really consider ourselves free? It’s to confront that question that we’re conducting our project on The America We Need.

And if you want to see what a true assault on freedom looks like, please read our columnist Charles Blow on the killing of Ahmaud Arbery.

I’m a nurse in a Covid-19 unit. My hospital’s leaders frighten me more than the virus

By Jaclyn O'Halloran - STAT - May 6, 2020

I’ve been a nurse for almost 10 years, working mainly on a hospital’s cardiac floor.

One day I was assigned to a makeshift intensive care unit that had previously been an observation unit for highly stable patients waiting for test results. Many of the patients in this new Covid-19 unit were intubated, with ventilators breathing for them.
When I started the shift, a trained intensive care unit nurse was crying in the supply closet. She was overwhelmed and anxious, hadn’t worked on her familiar unit in weeks, and had been told that her next shift would be an overnight one — and she had no choice in the matter.
Many of us don’t have a choice. We are assigned to work in unfamiliar units, with patients who are outside our expertise, without any training. We’re lost.
Most shifts start with nurses crying. Most shifts end that way too.
“It’s out of our hands,” we hear from hospital administrators.
Nurses who typically work in outpatient clinics are being sent to inpatient floors and assigned to care for patients who are acutely ill. Many haven’t worked at the bedside in decades. The number of patients who have fallen in this unit has risen exponentially in the past two weeks due to lack of training of outpatient nurses.
I wonder if the patients know their nurses are overwhelmed, and that many of them are scared they’ll make a deadly mistake.
“Everyone is out of their comfort zone, just hang in there,” we’re told.
Doctors have been instructed not to enter patients’ rooms unless they must as a way to minimize their exposure to the virus that causes Covid-19 while nurses go from one room to the next, medicating, bathing, turning, and comforting their patients without changing their uncomfortable personal protective equipment, since supplies are limited. This work can take hours. It is not uncommon for nurses to go all day without drinking water or eating because that would mean removing our protective gear.
During one of my shifts, a doctor at my hospital posted several TikToks he made while sitting at the nurses’ station of a busy Covid-19 unit as nurses whispered words of encouragement to patients clinging to life supported by ventilators. Over our words and the hum of the ventilators, I wondered if our patients heard music coming from this doctor’s TikToks.
“We hear your concerns, but there’s nothing we can do,” doesn’t reassure or encourage us.
One day as I worked in the makeshift ICU, one of the hospital’s leaders went floor to floor making an important delivery. She approached our nursing station in her crisp professional attire and fresh disposition, and proudly delivered a supply of makeup-removing wipes. She told us to use the wipes to clean our faces before putting on our N95 masks so we could reuse the masks later, then moved on to the next nurses’ station without asking how our staff was doing or if we needed anything. I wonder if she had noticed the nurse crying in the supply closet.
“That’s above us, we don’t make those decisions,” is passing the buck at its worst.
Excuses from hospital administrators seem to have punctuated every shift for the past six weeks. The praise and applause from hospital leadership only go so far.
I can read in my co-workers’ faces and hear from the stories they tell that the biggest danger we face is not Covid-19. It’s the hospital’s administration.
Leadership is failing us, even as we stand firm in not failing our patients. We care for your loved ones, Covid-19 or not, monitor their vital signs, give them medications, rub lotion on their backs, help them to the bathroom, and brush their hair. We FaceTime their families from our personal phones so they can see their loved ones fighting to live. This is important care that nurses are proud to provide.
The narrative is simple. Nursing, and nurses, are not valued. It’s a shame, and maybe even a deadly shame, that hospital leaders don’t care about nurses like we care for our patients.
https://www.statnews.com/2020/05/06/nurse-frightened-hospital-administrators-more-than-covid-19/
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Push for Profits Left Nursing Homes Struggling to Provide Care

Some with private equity owners, focused on making money, were particularly ill equipped and understaffed to handle Covid-19.

By Matthew Goldstein, Jessica Silver-Greenberg and Robert Gebeloff - NYT - May 7, 2020

When the pandemic struck, the majority of the nation’s nursing homes were losing money, some were falling into disrepair, and others were struggling to attract new occupants, leaving many of them ill equipped to protect workers and residents as the coronavirus raged through their properties.

Their troubled state was years in the making. Decades of ownership by private equity and other private investment firms left many nursing homes with staggering bills and razor-thin margins, while competition from home care attendants and assisted-living facilities further gutted their business. Even so, many of their owners still found creative ways to wring profits out of them, according to an analysis of federal and state data by The New York Times.

In many cases, investors created new companies to hold the real estate assets because the buildings were more valuable than the businesses themselves, especially with fewer nursing homes being built. Sometimes, investors would buy a nursing home from an operator only to lease back the building and charge the operator hefty management and consulting fees. Investors also pushed nursing homes to buy ambulance transports, drugs, ventilators and other products or services at above-market rates from other companies they owned.

These strategies paid off handsomely for investors, but they forced nursing homes to skimp on quality. For instance, for-profit nursing homes — roughly 70 percent of the country’s 15,400 nursing homes and often owned by private investors — disproportionately lag behind their nonprofit counterparts across a broad array of measures for quality, The Times found. Also, they are cited for violations at a higher rate than nonprofit facilities.

The toll of putting profits first started to show when the outbreak began. No nursing home could be completely prepared for a pandemic as devastating as Covid-19, but some for-profit homes were particularly ill equipped and understaffed, which undercut their ability to contain the spread of the coronavirus, according to interviews with more than a dozen nursing home workers and elder-care lawyers.

The pandemic “has brought a lot of these issues to the forefront,” said David Grabowski, professor of health care policy at Harvard Medical School. “With this huge health crisis and economic downturn, we are all of a sudden seeing how risky it is to have the ownership split between the real estate side that has the most valuable asset and the operator, who is left with much less.”

Controlling the real estate gives investors, including real estate investment trusts, leverage to raise rents. Separating the real estate from the operating business can also help limit liability in wrongful-death lawsuits, because the latter typically has little cash and few assets.

“The structure is designed to keep liability on the company that has the fewest assets and the most debt,” said William Murray, a plaintiffs lawyer who specializes in suing nursing homes.

Private equity firms and other investors first gravitated to nursing homes more than a decade ago, betting that aging baby boomers would create demand irrespective of economic cycles and counting on a steady stream of Medicare and Medicaid reimbursements.

A recent report on private equity buyouts of nursing homes, which studied 119 transactions from 2000 to 2017, said private equity owners tended to put “high-powered profit maximizing incentives” first. The researchers found that after private equity stepped in, nursing staff hours per patient fell 2.4 percent, and staff quality as measured by federal regulators fell 3.6 percent.

“The quality of care declines after the private equity buyout, which seems to reflect staffing cuts,” said one of the report’s authors, Sabrina T. Howell, assistant professor of finance at New York University’s Stern School of Business.

Ruthie Moore, a 68-year-old certified nursing assistant who works at Burbank Rehabilitation Center, a for-profit nursing home in Illinois owned by a prominent local investor, said she had been overwhelmed with patients even before the pandemic. The facility provided below-average staffing that was also highly inconsistent, records show. On some days, there was one certified nursing assistant for every 10 residents, according to payroll records. On other days, there was one for every 19.

Things got much worse when the virus hit, Ms. Moore said. Residents, including ones with possible symptoms of Covid-19, were mixing with other patients. Personal protective equipment was scarce, and members of the staff were told to wear the same mask for up to two weeks, she said.

Six residents of the Burbank facility have died of Covid-19 and 41 others have fallen sick, according to local reports citing state health officials. The facility gets a one-star rating — the lowest ranking in the federal government’s five-star rating system for nursing home care. In a document filed with federal regulators for 2018, Burbank’s operator listed assets of $4.4 million and liabilities of $10 million.

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“Had we had more staff and protective equipment, there would have been fewer deaths,” said Ms. Moore, who recently began showing symptoms and is awaiting a diagnosis.

Burbank’s owner is a Chicago-area investor, William Rothner. He and his family run a network of companies that have stakes — owning a piece of either the operating business or the building — in at least 60 nursing homes across the country, according to disclosures and other documents. Companies owned by Mr. Rothner also provide ventilators, pharmaceuticals, management services and payroll services to many of those facilities, according to financial filings with Illinois.

Most of the nursing homes in which Mr. Rothner has an interest in Illinois reported a net loss from operations in 2018, regulatory filings show. For instance, the Parc at Joliet, which has had at least seven coronavirus-related deaths, reported an operating loss of $714,000. But other companies that Mr. Rothner owns charged the home $1.4 million in rent as well as $138,000 in professional fees and $335,000 in fees to an affiliated pharmaceutical supply company, among other charges, according to those filings.

Mr. Rothner said in an email that there had been no “recent citations for inadequate staffing” and “no valid assertions or claims on inadequate P.P.E.” at Burbank. He also said his firm, Altitude Health Services, monitored management fees taken by the separate firms that run the nursing homes to make sure they were not excessive. He added that his firm provided ancillary services at competitive prices that were often lower than other companies and complied with all regulations.

Mr. Rothner’s company also owns the buildings for two nursing homes in Sussex County, N.J., where more than 60 residents have died of Covid-19 and where 17 of the bodies were hidden in a small on-site morgue. His company leases the facilities for about $8 million a year to Alliance Healthcare, which runs the nursing homes.

On Thursday, federal health regulators said they had fined the operator $220,000, and that the fine could keep growing until the problems are remedied. Specifically, regulators found that one of the facilities was not following infection control safety practices and guidance recommended by federal officials during the pandemic.

The nursing home industry is pushing for broad immunity in the wake of the pandemic. So far, 16 states, including New York, New Jersey, Michigan, Georgia and Illinois, have already approved measures granting immunity from lawsuits — a development that worries longtime critics of the industry.

“A lot of these nursing homes are trying to get immunity because of Covid, and that is really scary because some of these companies are so negligent,” said Charlene Harrington, a professor emerita of nursing at the University of California, San Francisco. Many for-profit nursing home operators report meager profits only because income is “drained off in their management contracts,” she said.

Not all nursing home buyouts have worked well for private equity firms. In 2018, HCR ManorCare, which was the nation’s second-largest nursing home operator, filed for bankruptcy protection — a decade after the Carlyle Group, a big private equity firm, acquired it. When it filed, ManorCare had $7.1 billion in debt, and its facilities had racked up numerous citations for failure to treat infections and properly monitor residents’ medications, records show.

Years before ManorCare declared bankruptcy, Carlyle sold the homes for $6.1 billion to a real estate investment trust, a move that largely wiped out the debt of the nursing homes. ManorCare then rented many of those facilities.

In November, Senators Elizabeth Warren of Massachusetts and Sherrod Brown of Ohio sent letters to four private equity firms, including Carlyle, seeking information about their involvement with nursing homes. Carlyle, in its response to the two Democrats, said that patient care had not been affected during the bankruptcy and that all employees were paid. A spokeswoman for Carlyle, which no longer owns any nursing homes in the United States, declined to comment.

A representative for Ms. Warren said that only Formation Capital, an Atlanta private equity firm that specializes in nursing home investments, hadn’t responded.

Formation led the buyout of Genesis Healthcare, the nation’s largest nursing home operator, in 2007; Genesis returned to the public markets seven years later. The private equity firm has a consulting arm that sells services to nursing homes, including some that Formation owns or has a financial interest in.

Formation has said in a filing that it had policies “that are intended to mitigate this potential conflict of interest.” The firm did not respond to requests for comment.
https://www.nytimes.com/2020/05/07/business/coronavirus-nursing-homes.html?referringSource=articleShare

We Knew the Coronavirus Was Coming, Yet We Failed

The vulnerabilities that Covid-19 has revealed were a predictable outgrowth of our market-based health care system.

by Elizabeth Rosenthal - NYT - May 6, 2020

The arrival of Covid-19 has provided a nuclear-level stress test to the American health care system and our grade isn’t pretty: At least 71,100 dead, 1.2 million infected and 30 million unemployed; nursing homes, prisons and meat packing plants that have become hotbeds of infection. The actual numbers are certainly far higher, since there still hasn’t been enough testing to identify all those who have died or have been infected.

By all accounts a number of other countries have responded — and fared — far better.
In some ways Covid-19 seemed the biological equivalent of Sept. 11 — unthinkable until it happened. Who would have thought individuals would fly jets filled with people into skyscrapers filled with workers? Likewise, who would have predicted the onslaught of a new virus that was stealthy, easily transmissible and also often perilous?

Actually, many public health specialists, including Dr. Anthony Fauci, did. And yet, our system failed in its response. Heroic health care providers were left to jury-rig last-minute solutions to ensure that the toll wasn’t even worse.

But the saddest part is that most of the failings and vulnerabilities that the pandemic has revealed were predictable — a direct outgrowth of the kind of market-based system that Americans generally rely on for health care.

Our system requires every player — from insurers to hospitals to the pharmaceutical industry to doctors — be financially self-sustaining, to have a profitable business model. As such it excels at expensive specialty care. But there’s no return on investment in being primed and positioned for the possibility of a once-in-a-lifetime pandemic.

Combine that with an administration unwilling to intervene to force businesses to act en masse to resolve a public health crisis like this, and you get what we got: a messy, uncoordinated under-response, defined by shortages and finger-pointing.

No institutional players — not hospitals, not manufacturers of ventilators, masks, tests or drugs — saw it as their place to address the Covid-19 train coming down the tracks. Meanwhile, the Trump administration, loath to deploy the Defense Production Act, did so only sparingly and slowly, mostly relying on back channel arm-twisting and “incentives” like forgiving liability to get business buy in. That’s because in the current iteration of American health care, tens of thousands of people dying is not incentive enough.

Let’s look at the failures.
1. Ventilators. As images of overwhelmed Italian hospitals flashed across screens, American hospitals projected they might not have enough ventilators for their mounting caseload. They turned to government, which didn’t have enough either. President Trump castigated the states and hospitals for not being prepared.

But, operated as businesses, hospitals have zero incentive to stockpile. Like hotels, they aim to keep their beds full, or nearly so, with well-paying customers, such as those in need of artificial-joint or heart procedures. Supply-chain management dictates they stock for those needs. A vast storeroom in the basement filled with ventilators that might be needed once in a generation or never?

Long ago, before hospitals had lucrative revenue streams from billing and insurance, they relied on philanthropy to meet urgent health needs. The March of Dimes helped finance the treatment of polio victims and the development of improved iron lungs. Today hospitals instead solicit donations for more glamorous projects — cancer centers, new wings, genomics research — with donors’ names affixed.

Indeed in a 2017 paper, an official with the Centers for Disease Control and Prevention warned that the country needed a better strategy for stockpiling ventilators, highlighting a “practical problem”: “hospitals must accept responsibility for the costs and resources needed to manage and maintain an excess of ventilators that are likely to be unused in the absence of pandemic-related surges in demand.”

They are unlikely to do so unless government requires them. We’ve long required ocean liners to have lifeboats and life preservers even though their operators hope to never hit an iceberg.

2. Testing has proved the persistent Achilles’ heel in the U.S. response. Even in “hot zones,” because of a shortage of tests, they were often rationed to the very ill or essential workers. That makes it difficult to guide treatment and nearly impossible to reopen society. In January, fearing that the virus would hit the United States, researchers at university labs — notably the University of Washington — jumped in and developed a test. But the commercial and hospital labs that deal with the actual blood work and viral analysis in this country did not. Why would they? There was no market.

At that time, it wasn’t clear that the coronavirus would produce a pandemic, and there was no billing code for a test and no sense of the price it could garner. With requirements for Food and Drug Administration approval expensive and cumbersome, developing a test was a business non-starter. Indeed, months later, after the billing code was created and the Medicare price was set at $51, labs complained that it didn’t cover costs and wasn’t attractive enough to motivate adequate response. The price was doubled. (Even that most likely seemed somewhat paltry for labs that often charge $200 for basic blood tests.)

On March 16, the Trump administration set aside the F.D.A. approval requirement, bringing a host of new players into the fray. But in our market-driven, decentralized system it’s every provider for himself, and there is no efficient way to connect the new supply with demand. Despite the fact that the administration appointed a national coordinator, by mid-April newly able labs were taking to Twitter to plead for business, like this one in Ann Arbor, Mich.: “We have restructured our lab to help with testing. The problem has become finding samples! Can’t get in touch w/ anyone who needs us.”

In contrast, South Korea, with its national health system, engaged its private test manufacturers with a plan in January, promising them quick approval for a coronavirus test and the widespread use of it in nationally organized and financed testing. With a guaranteed market, 10,000 tests a day were available within weeks, allowing the country to avert a shutdown. The federal government or the C.D.C. might have played that role in the United States, but did not.

3. Testing components and P.P.E. The Trump administration insists that there are plenty of tests that states are not using. Governors say they can’t do nearly enough tests and need help. That’s partly because conducting tests involves access to a number of components — kits, chemical reagents, swabs, personal protective equipment, sometimes custom cartridges for machines. Miss any one of those things and testing becomes impossible. It’s like trying to make bread with all the ingredients except yeast.

Just as we patients pay item by item — the blood test, the X-ray, the acetaminophen pill — hospitals and doctors’ offices also order item by item, with different sources for each component, as they search for the best deals. And medical manufacturers, which make dozens of products — some very profitable and some not — have no “incentive” to produce low-margin items in excess of usual needs. In recent years, this has increasingly led to intermittent shortages during which hospitals find themselves competing to procure IV fluids, cheap old anti-nausea meds and some cancer drugs. So it is no surprise that a similar phenomenon is handicapping a coronavirus response that has required a huge increase in simple accessories like masks.

“The private sector can directly purchase” personal protective equipment “from manufacturers and distributors, as they normally do,” a press officer for the Federal Emergency Management Agency said in late March, explaining why the president chose not to use the Defense Production Act even as states like New York were begging for help, facing over 5,000 new cases and nearly 100 deaths a day.

Initially they could not find enough of that equipment, and when they did, it came at a price — as market forces would dictate: When demand for the items exceeded supply, prices rose and bidding wars began. In our market, you get companies to ramp up production of low-margin items by offering ever higher prices. So $1 masks cost $6. Without a national system for such purchases in a crisis, we are essentially forcing hospitals and states to negotiate the price of water during a drought. (Alternatively, we could require all hospitals to have a 90-day supply of essential response items on hand, as Gov. Andrew Cuomo of New York has now done.)

4. Hospitals did not coordinate. Early on, New York’s elite hospitals — staring down a crisis themselves — did not jump in to set up outpatient testing centers. That task was left largely to the public hospitals, resulting in crowded lines, which may have risked more infection spread. The elite hospitals also generally did not share precious protective gear with those harder hit.

In our market-based system, hospitals are primed to compete, not coordinate. They compete for patients who need lucrative procedures and for ratings in magazines like U.S. News & World Report. While legally they have to treat anyone who turns up in the emergency room, they are not eager to treat infectious diseases like Covid-19, which disproportionately hits people with poor insurance and carries a stigma. “No. 1 in Covid-19 Treatment!” is bad for the brand. The lack of coordination likewise meant that in California, one hospital had the beds and protective equipment to continue doing elective procedures, while another — 75 miles away — was overwhelmed by Covid-19. In a national or nationally coordinated health system they would have been obligated to help each other.

5. The hospital rescue. Hospitals will receive tens of billions of dollars as part of coronavirus relief packages passed since late March. This is partly because they have delivered extraordinary treatment of Covid-19 (which doesn’t pay well) but also because they’ve had to cancel high-profit procedures like joint replacements and sophisticated scans to make room for this low-profit-margin illness.

In the past quarter-century, we have evolved a reimbursement system that showers cash on elective and specialty care and discourages hospitals from serving the health needs of society. That is true even though two-thirds of our hospitals are tax exempt because they — in theory — perform community benefit. In a functioning health system, pandemic preparedness and response would be part of the expected job. In the 1980s when H.I.V./AIDS was overwhelming hospitals in New York, treating those patients was simply part of each system’s obligation — though some did so far better than others.

All this doesn’t necessarily mean that we need a government-run health system or should eliminate all market influence in health care. In fact, Medicare for All would not by itself solve the above problems, since it’s mostly a payment system that largely relies on providers to come through with services when needed.

But the Covid-19 stress test has laid bare a market that is broken, lacking the ability to attend to the public health at a time of desperate need and with a government unwilling — in some ways unable — to force it to do so. This time around, thousands of medical professionals have stoicly answered the call to treat the ill, doing their best to plug the longstanding holes and vulnerabilities that the pandemic has revealed.

Whether regulated or run by the government, or motivated by new incentives, we need a system that responds more to illness and less to profits.
https://www.nytimes.com/2020/05/06/opinion/coronavirus-health-care-market.html?action=click&module=Opinion&pgtype=Homepage

Trump vows complete end of Obamacare law despite pandemic

by Devlin Barrett - Washington Post - May 6, 2020

President Trump said Wednesday he will continue trying to toss out all of the Affordable Care Act, even as some in his administration, including Attorney General William P. Barr, have privately argued parts of the law should be preserved amid a pandemic.
“We want to terminate health care under Obamacare,” Trump told reporters Wednesday, the last day for his administration to change its position in a Supreme Court case challenging the law. “Obamacare, we run it really well. . . . But running it great, it’s still lousy health care.”

While the president has said he will preserve some of the Affordable Care Act’s most popular provisions, including guaranteed coverage for preexisting medical conditions, he has not offered a plan to do so, and his administration’s legal position seeks to end all parts of the law, including those provisions.
Democrats, who view the fight over the Affordable Care Act as a winning election issue for them, denounced the president’s decision.
House Speaker Nancy Pelosi (D-Calif.) said in a statement that “the President’s insistence on doubling down on his senseless and cruel argument in court to destroy the ACA and every last one of its benefits and protections is unconscionable, particularly in the middle of a pandemic.”
Trump’s declaration caps months of debate within his administration about the best course of action, in which the stakes have only become greater now that the nation’s health-care system is struggling to deal with the spread of the coronavirus, which has killed more than 70,000 Americans.
On Monday, Barr attended a meeting of senior officials in which he argued the administration should temper its opposition to Obamacare, leaving some parts of the law intact, according to people familiar with the discussion, who spoke on the condition of anonymity because the conversation was private.
The case before the court was brought by a group of Republican states, and as part of that case, the Trump administration is seeking to invalidate the entire Affordable Care Act, which passed in 2010 and became one of President Barack Obama’s most significant legislative victories.
Barr and others in the administration have argued that killing Obamacare completely could be politically damaging to Republicans in an election year, particularly when there is a national health crisis. In two previous case, the Supreme Court upheld the law, but if the high court were to strike it down, millions of people could find themselves without affordable health care.
The high court plans to hear arguments in the case later this year, and a decision may not come until 2021, well after the November election.
The latest ACA suit was organized by Republican attorneys general in Texas and other states. When the Trump administration declined to defend the law, a coalition of Democratic-led states entered.
The case began after the Republican-led Congress in 2017, unable to secure the votes to abolish the law, reduced to zero the penalty for a person not buying health insurance. Lawyers for the state of Texas argued that in doing so, Congress had removed the essential tax element that the Supreme Court had previously ruled made the program constitutional.
A district judge in Texas agreed and said the entire law must fall. Eventually the Trump administration agreed with that assessment.

 

https://www.washingtonpost.com/world/national-security/trump-obamacare-supreme-court/2020/05/06/4a53ba54-8fe1-11ea-9e23-6914ee410a5f_story.html 

 

 

‘Devastating’ number of Mainers could lose health insurance as pandemic continues

by Caitlin Andrews - Bangor Daily News - May 7, 2020

Up to 221,000 Maine residents could lose the health insurance they receive through their jobs if unemployment levels this year reach Great Depression heights, ultimately increasing the ranks of Maine’s uninsured by almost 50 percent, a new analysis shows.

More than 15 percent of Maine’s workforce has filed for unemployment during the last six weeks due to the economic slowdown caused by the coronavirus pandemic. New claims have slowed over the past two weeks, but that could change this week as people who previously were not covered by the unemployment system — those who are self-employed and work as contractors — start to receive benefits.

The official unemployment rate in the state and country hovered around 4 percent in March, but that rate covered the period before most pandemic-related job losses began to happen.

Some analyses are anticipating dire increases: the Federal Reserve Bank of Chicago predicted total unemployment may have reached 25 percent in April, a level not seen since the Great Depression. Financial firm JP Morgan made a slightly less grim prediction in early April, estimating a 20 percent job loss by last month, CNBC reported.

Those job losses would have a direct effect on health coverage for those who receive insurance through their employers. About 48 percent of Mainers received health insurance through an employer in 2018, according to the Kaiser Family Foundation.

A newly released study from the Robert Wood Johnson Foundation and the Urban Institute created two scenarios for how deep the loss of health insurance could be.

In the low scenario, 72,000 people in the state could lose their employer-sponsored health insurance if unemployment climbs to 15 percent, and up to 131,000 would lose it if unemployment increases to 25 percent. Its forecast for the high scenario is that 122,000 to 221,000 people would lose employer-provided insurance under 15 and 25 percent unemployment respectively.

According to the U.S. Census Bureau, about 106,000 Maine residents, or 8 percent, were uninsured in 2018.

About 77 percent of those who lose employer health insurance would seek insurance through Medicaid or the Affordable Care Act marketplace, the analysis projects. In the worst-case scenario, that would leave about 51,000 more people uninsured; 17,000 more people would have no insurance in the 15 percent unemployment scenario.

Those who lose insurance “may be newly eligible for Medicaid or marketplace-based subsidized coverage but not realize it,” the study notes. More people are likely to get covered by Medicaid in states that expanded coverage under the Affordable Care Act, which Maine did last year.

Such a loss would be “devastating,” said Mitchell Stein, an independent health policy consultant in Maine.

“It’s just mind-boggling if you think about the fact that our population is only about 1.3 million,” he said. “These numbers of additional uninsured would just kind of blow up our support system.”

Stein also noted the change could have a detrimental effect on primary care providers. Those practices get most of their revenue from non-emergency care services, which providers largely canceled or delayed as the state’s health care system prepared for a potential surge of coronavirus cases. That’s creating “incredible financial pressure,” he said.

Even when those services return — providers were allowed to start offering more care again this month, although they were advised to prioritize care for time-sensitive conditions — people may not have the ability to pay, he said.

That shift in health care has already changed the economic landscape. The health care sector of the economy shrank by 2.5 percent in the first quarter of the year, according to estimates from the U.S. Department of Commerce’s Bureau of Economic Analysis. National gross domestic product is believed to have dropped overall by 4.8 percent.

Rebecca Boulos, the executive director of the Maine Public Health Association, said the situation shows how precarious access to health care coverage can be when it is tied to employment.

“While employer-based health insurance is often a benefit that people seek when they look for employment, if that benefit ends, it not only impacts the individual, but also everyone else in their family who was covered,” she said.

A record amount of people have enrolled in MaineCare since the pandemic began, and applications are surging. But it’s hard to know how many people will seek health insurance through Affordable Care Act marketplace coverage.

While someone can enroll in Medicaid anytime, a person is entitled to a special enrollment period in the marketplace only when they lose their employer-provided health coverage.

The Trump administration has so far declined to open a special, nationwide enrollment period for marketplace plans that would allow others without insurance coverage to enroll. The typical enrollment period for those plans opens in November.

https://bangordailynews.com/2020/05/07/business/devastating-number-of-mainers-could-lose-health-insurance-as-pandemic-continues/ 

Why 1.4 Million Health Jobs Have Been Lost During a Huge Health Crisis

The industry used to be recession-proof. Not anymore. The postponement of elective procedures has crushed the bottom line.

by Margot Sanger-Katz - NYT - May 8, 2020

The industry used to be recession-proof. Not anymore. The postponement of elective procedures has crushed the bottom line.

For more than half a century, in good economic times and bad, health care jobs in the United States just kept increasing. Economists and health analysts thought of them as nearly recession-proof: a buffer against the business cycle.

But like so many other patterns, the coronavirus pandemic has broken this relationship. With the virus and its fallout deterring Americans from using the health system, health care jobs started being cut in March and plummeted last month by more than 1.4 million.

“This is a disruption unlike any we’ve seen in decades,” said Ani Turner, the co-director of sustainable health spending strategies at the Altarum Institute, which tracks trends in health care spending and employment. Ms. Turner recently wrote an essay titled “Health Sector Won’t Be the Backstop in This Downturn.”

A sudden drop in health spending and employment amid a pandemic that is overloading hospitals with sick patients might seem like a paradox. But it reflects how the health industry tends to make its money: Treating patients for a deadly illness is far less profitable than offering them elective surgeries. When the federal government asked hospitals to stop such procedures to free up capacity, that changed their economics profoundly.

And even if various governments across the nation hadn’t then ordered such a pause, many patients would have probably avoided doctors’ offices and hospitals to lessen the risk of contracting the coronavirus. Independent medical practices have seen huge reductions in their business, as some patients connect with doctors virtually, while many others patient visits have simply vanished.

In previous recessions, the health industry has not taken such a hit. Because most Americans have health insurance, health services are more insulated from the business cycle than other kinds of spending. The biggest users of the system are older Americans. Besides being likelier to have health problems, they also tend to have comprehensive insurance coverage through Medicare and a stable source of income from Social Security. The Medicaid program, which is structured to allow people to enroll when their incomes fall, tends to offer access to health care for the poor, even if their jobs disappear.

And, of course, many of the problems that send people to the doctor — heart disease, appendicitis, cancer or the flu — do not go away during a struggling economy. As a result, the doctors and nurses and medical assistants and billing clerks who work in health care are usually protected from an economic downturn.

But lately Medicare beneficiaries, the age group at highest risk of serious disease or death from the coronavirus, have been particularly spooked from seeking medical care. And emergency rooms have reported shocking declines in visits for what doctors had always thought of as life-threatening emergencies. A recent survey of nine major U.S. hospitals showed visits for a common but serious kind of heart attack have fallen by nearly 40 percent. Those declines were seen even in places without major coronavirus outbreaks.

The industry still seems somewhat protected: Health care jobs have fallen by less than jobs in the rest of the economy. But in the Great Recession, as jobs of nearly every kind plummeted, health jobs kept growing at a good clip. In the eyes of many economists, it was health care that led the economic recovery, by providing a powerful and reliable jobs engine. All those new health workers helped strengthen their local economies.

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And in many places hit hard by the recession, the local hospital became a dominant employer, supporting entire communities. There were some small reductions in the use of health services in the following years; those led to a slowdown in what had been seen as the inexorable growth of health spending. Those changes, which earned the nickname “slowth” among health care analysts, were unusual enough to be major news. Health care still grew, however, just more slowly. About 60 percent of health care spending goes to labor, so all the growth, almost by definition, meant new jobs.

That growth was seen as good news in the short term for the economy. But health care’s ever-growing share of the national economy has not always been seen in a positive light. The rising costs of the Medicare and Medicaid programs have meant that health care has come to represent a larger share of the federal budget, limiting capacity for other government investments. Strain under the growing costs has caused many employers to switch from older forms of insurance, which were comprehensive, to plans with high deductibles for workers, shifting the financial burden onto individuals and families, and leaving them vulnerable to big bills.

This downturn is clearly different, and the enormous reductions in the health work force mean the recovery may be different, too. Some of the lost jobs in health care are likely to come back later. Cancer patients who postponed chemotherapy, or people who canceled their hip replacements, will eventually want that care. But other changes may be permanent.

Over just a few weeks, there has been a shift to telemedicine visits, in which patients can talk with their doctors by video, telephone or even email. Those visits seem to be less profitable for doctors, and many health systems had long avoided setting up an infrastructure for them. But the new virtual visits have many advantages: Patients can avoid travel and waiting rooms; caregivers can easily participate; and several doctors can talk to the same patient at once. There are no clipboards full of personal information to fill out by hand, and no person needed to retype the answers into a computer system before such visits.

Other changes are more invisible. Hospitals have been forced to find small ways to digitize processes and share records that used to involve labor and bureaucracy. Bob Kocher, a partner at the venture capital firm Venrock, has been acting as an adviser to Gov. Gavin Newsom of California through the crisis. He said he had seen hospitals adapt quickly to begin sharing their daily bed counts with one another and the state, for example, a task that used to involve hours of phone calls and faxes. Data about laboratory testing — how much is being done, how many patients have been found to have coronavirus — has been similarly digitized in real time.

Are those sorts of on-the-fly tweaks enough to have an appreciable effect on long-term health care employment? Mr. Kocher thinks so, describing the recent cuts in health care administration as a “silver lining” of the crisis, while acknowledging the short-term pain of the job losses.

“I will passionately say that’s a good thing, because health care costs in America are high, and most of the health care cost in America is labor,” he said.

Another possibility is that the financial shock hitting smaller and less capitalized hospitals and physician practices could lead to a wave of consolidation, as bigger competitors gobble them up for a discount. Those kinds of mergers have typically led to rising health costs, since bigger systems can demand higher prices from private health insurers. That could make the legacy of this shock a more expensive health system instead of a cheaper one.

“We have a great opportunity ahead of us, but I don’t see us making any progress,” said Amitabh Chandra, a health economist at Harvard, who once was a co-author of an essay describing health care as “recession-free,” and not in a good way. “I think we’ll go back to business as usual.”

Either way, health care is unlikely be the economic stabilizer it has been in the past. The loss of industry jobs on top of the major losses in other sectors are likely to make the recession deeper, and the recovery slower.
https://www.nytimes.com/2020/05/08/upshot/health-jobs-plummeting-virus.html?searchResultPosition=7

Hospitals Struggle to Restart Lucrative Elective Care After Coronavirus Shutdowns

The nation’s medical centers were forced to stop offering many surgeries, and sustained severe financial losses. Reopening is a daunting task amid the threat of more infection.

by Reed Abelson - NYT - May 9, 2020

The shutdown of elective surgeries and other “nonessential” medical care by federal and state officials during the pandemic has left the nation’s 5,200 hospitals, particularly in places where there have been relatively few infections, with idle clinics, vacant operating rooms and a dearth of patients.

“Our hospitals, like every other hospital in the country, are half empty,” said Marvin O’Quinn, the president and chief operating officer for CommonSpirit Health, a Catholic system that operates 137 hospitals across 21 states.

As restrictions ease around the country, some states have begun allowing procedures unrelated to the coronavirus, like knee replacements, colonoscopies and mammogram screenings.

“As anyone waiting for an elective surgery knows, ‘non-urgent’ does not mean ‘minor,’” said Gov. Kate Brown of Oregon in allowing the state’s hospitals to resume business on May 1. “This is incredibly important medical care that we would not have told providers to delay if the threat of Covid-19 had not made it necessary.”

Once considered a bulwark during economic downturns, health care is proving vulnerable during the coronavirus-induced recession, with spending down and significant job losses. More than 1.4 million jobs in the sector were lost last month, part of a historic economic decline that included 20.5 million fewer jobs and an unemployment rate reaching nearly 15 percent.

Hospitals, often the biggest employer in cities and states, are furloughing workers amid industry losses that total as much as $50 billion a month, largely the result of forgone surgeries and procedures, according to some estimates. For many institutions, back surgeries and heart procedures provided a financial stream of revenue that was critical to staying open. The majority of the nation’s hospitals are nonprofit, but they still need a steady roster of patients to survive.

All hospitals rely on these elective surgeries for much of their revenue because both Medicare and private insurers tend to pay more for such procedures than they do for other kinds of hospital care. Hospitals say they are losing money when they treat Covid-19 patients because of the lengthy and intensive medical care these patients need. Health insurers like UnitedHealth Group, one of the nation’s largest, have said that the amount of money they are saving from the decline in elective care is now more than the amount they are reimbursing hospitals for treating the coronavirus.

And while Congress is funneling $175 billion in relief to hospitals, much of the money has flowed to the biggest hospital systems serving the highest number of Medicare patients. HCA Healthcare, the for-profit hospital chain, said it received $700 million. Rural hospitals, already ill-equipped to deal with the virus, and hospitals serving low-income patients have received much less. Some hospitals filing for bankruptcy are challenging federal rules that would prevent them from being eligible for small-business loans.

But even at hospitals with small numbers of coronavirus patients, reopening is likely to be a painstaking process as states and local governments take different approaches and hospitals grapple with how to keep patients and workers safe. Oregon Health & Science University Hospital, the state’s academic medical center with 562 beds, admitted fewer than 50 Covid-19 patients, and its occupancy rate fell to about 60 percent.

Under guidelines established by a state advisory panel, the hospital is beginning to reschedule patients while staying prepared if there is a sudden surge in new infections, said Dr. Renee Edwards, the chief medical officer. The hospital is also reaching out to patients who do not have the virus but whose conditions may significantly deteriorate if they do not get care.

“We are ramping up our surgical volume in phases, because we have to demonstrate that as we increase our surgical volumes, we’re able to maintain the available capacity in our hospital,” she said.

And hospitals are also trying to reconfigure spaces, isolating infected patients and those suspected of being infected in distinct units, and ensuring patients have enough physical distance from others. “Hospitals tend to be crowded places,” Dr. Edwards said.

While hospitals are eager to resume moneymaking elective services, which can account for roughly half of their revenues, by one estimate, hospital executives and consultants say they may be constrained by shortages of supplies and testing equipment as well as the need to make sure they have enough isolation gowns and intensive care beds.

“It is a big question mark: How quickly you can ramp up and how you manage it,” said Suzie Desai, who follows nonprofit hospitals for S&P Global Ratings.

Some hospitals are already reaching out to patients. “Now we’re on the other side of this and we have begun to re-engage people,” said Dr. Donald Yealy, the chair of emergency medicine at the University of Pittsburgh Medical Center, whose surgeries dropped as much as 70 percent because of the pandemic. Since restarting, the center says the number of surgeries they are doing for procedures like removing a tumor has already started to rebound.

But the specter of second waves of the virus and a fear of contagion may deter patients from returning, especially to those hospitals that have treated large numbers of coronavirus patients. “Even if we reopen, will they come?” said Matthew Murer, the chair of the health care practice of Polsinelli, a law firm.

That question is hardly rhetorical for small and large medical centers, which have reported staggering declines in revenue. Hospitals say they are losing an estimated $50 billion a month, according to a recent analysis by the American Hospital Association, which predicts a four-month loss of $200 billion by the end of June.

Canceled surgeries, decreases in doctor’s visits and a decline in emergency room care account for the bulk of the losses, some $160 billion.

Hospitals could find themselves in a Catch-22, where they do not have enough money for the supplies and staff necessary to restart the elective procedures they need to generate cash, said Christopher Kerns, an executive with Advisory Board, a consulting unit owned UnitedHealth Group, the giant insurer. “If hospitals can’t start earning revenue, they will close,” he said.

At Stamford Health, a 305-bed hospital in Connecticut that is not part of a larger system, much of the focus over the last few weeks has been on caring for more than 500 Covid-19 patients as the hospital more than tripled the number of intensive care beds it was operating. About 350 of the Covid-19 patients have since been discharged.

With cases stabilizing, and the hospital losing roughly $25 million a month, Kathleen Silard, the chief executive of Stamford Health, is eager to resume offering the procedures she describes as “our lifeblood.” Stamford has so far received $40 million in federal funds, including money aimed at hospitals in coronavirus hot spots, and has furloughed 375 of its workers.

But Ms. Silard says she, too, will be cautious, making sure the hospital has enough personal protective equipment and personnel before she fully resumes operations. “It’s not going to be a switch-on, switch-off situation,” she said.

While the hospital will continue to perform emergency surgeries, it may hold off on complicated cases like open-heart surgeries, which require a lot of protective equipment and supplies, if patients can wait, she said.

“The logical step is to do the least invasive procedures,” agreed Mr. O’Quinn of CommonSpirit.
Some executives and consultants warn there could be shortages like the ones that created the mad scramble for masks and gowns back in March. Supply disruptions are “going to contaminate the ability to stand up elective procedures,” said Kenneth Kaufman, one of the founding partners of Kaufman Hall, which advises hospitals.

And hospitals also have to ramp up coronavirus testing of patients scheduled for surgeries to reduce the risk of spreading the virus to hospital staff and other patients. A recent survey by Premier, which buys medical supplies on behalf of many U.S. hospitals, suggests hospitals would have to more than triple their current testing capacity to begin resuming their services.

Given the high demand, hospitals could have trouble getting swabs and testing reagents. While officials from the Federal Emergency Management Agency have said they will be providing supplies to state governments, it is not clear how the products will be distributed, said Meg Wyatt, an executive with Premier. “Our health systems are flying blind to develop a ramp up plan,” she said.

The agency says state governments determine the distribution of the supplies within their state.
In former hot spots, hospitals that have treated large numbers of coronavirus patients may have the hardest time convincing people to come in for something routine.

“Hospitals are safe, Rush is safe,” said Dr. Omar Lateef, the chief executive of Rush University Medical Center, which says it treated Covid-19 patients at the same time it was caring for patients without the virus who had urgent medical needs.

“We have not had an infection travel from a Covid patient to a non-Covid patient in our hospital,” Dr. Lateef said.

But he acknowledges some people will be frightened by images of overrun hospitals and very sick patients with the coronavirus. “It’s human,” he said. “People are scared to go out right now. People are scared to give each other a hug.”

Many hospital executives say they are also fearful of what will happen if there are future waves of infection in their community that result in a repeat of March with high numbers of seriously ill patients that require another shutdown.

“Everyone is talking about a second wave,” said Mr. O’Quinn. “I don’t think the country can shut down in a second wave. Hospitals can’t afford to shut down in a second wave.”
https://www.nytimes.com/2020/05/09/health/hospitals-coronavirus-reopening.html?searchResultPosition=9

AP Exclusive: Docs show top WH officials buried CDC report 

by Jason Dearen - Associated Press - May 8, 2020

GAINESVILLE, Fla. (AP) — The decision to shelve detailed advice from the nation’s top disease control experts for reopening communities during the coronavirus pandemic came from the highest levels of the White House, according to internal government emails obtained by The Associated Press.
The files also show that after the AP reported Thursday that the guidance document had been buried, the Trump administration ordered key parts of it to be fast-tracked for approval.
The trove of emails show the nation's top public health experts at the Centers for Disease Control and Prevention spending weeks working on guidance to help the country deal with a public health emergency, only to see their work quashed by political appointees with little explanation.
The document, titled “Guidance for Implementing the Opening Up America Again Framework,” was researched and written to help faith leaders, business owners, educators and state and local officials as they begin to reopen. It included detailed “decision trees,” or flow charts aimed at helping local leaders navigate the difficult decision of whether to reopen or remain closed.
White House spokeswoman Kayleigh McEnany said Friday that the documents had not been approved by CDC Director Robert Redfield. The new emails, however, show that Redfield cleared the guidance.
This new CDC guidance — a mix of advice already released along with newer information — had been approved and promoted by the highest levels of its leadership, including Redfield. Despite this, the administration shelved it on April 30.
As early as April 10, Redfield, who is also a member of the White House coronavirus task force, shared via email the guidance and decision trees with President Donald Trump's inner circle, including his son-in-law Jared Kushner, top adviser Kellyanne Conway and Joseph Grogan, assistant to the president for domestic policy. Also included were Dr. Deborah Birx, Dr. Anthony Fauci and other task force members.
Three days later, CDC’s upper management sent the more than 60-page report with attached flow charts to the White House Office of Management and Budget, a step usually taken only when agencies are seeking final White House approval for documents they have already cleared.
The 17-page version later released by The AP and other news outlets was only part of the actual document submitted by the CDC, and targeted specific facilities like bars and restaurants. The AP obtained a copy Friday of the full document. That version is a more universal series of phased guidelines, “Steps for All Americans in Every Community,” geared to advise communities as a whole on testing, contact tracing and other fundamental infection control measures.
On April 24, Redfield again emailed the guidance documents to Birx and Grogan, according to a copy viewed by The AP. Redfield asked Birx and Grogan for their review so that the CDC could post the guidance publicly. Attached to Redfield’s email were the guidance documents and the corresponding decision trees — including one for meat packing plants.
“We plan to post these to CDC’s website once approved. Peace, God bless r3,” the director wrote. (Redfield's initials are R.R.R.)
Redfield’s emailed comments contradict the White House assertion Thursday that it had not yet approved the guidelines because the CDC’s own leadership had not yet given them the green light.
Two days later, on April 26, the CDC still had not received any word from the administration, according to the internal communications. Robert McGowan, the CDC chief of staff who was shepherding the guidance through the OMB, sent an email seeking an update. “We need them as soon as possible so that we can get them posted,” he wrote to Nancy Beck, an OMB staffer.
Beck said she was awaiting review by the White House Principals Committee, a group of top White House officials. “They need to be approved before they can move forward. WH principals are in touch with the task force so the task force should be aware of the status,” Beck wrote to McGowan.
The next day, April 27, Satya Thallam of the OMB sent the CDC a similar response: “The re-opening guidance and decision tree documents went to a West Wing principals committee on Sunday. We have not received word on specific timing for their considerations.
“However, I am passing along their message: they have given strict and explicit direction that these documents are not yet cleared and cannot go out as of right now — this includes related press statements or other communications that may preview content or timing of guidances.”
OMB spokeswoman Rachel Semmel said the office has reviewed hundreds of pages of pandemic-related documents.
"The initial submission to OMB is the start of the deliberative process, not the end, and everyone knows that,” Semmel said in an email.
According to the documents, CDC continued inquiring for days about the guidance that officials had hoped to post by Friday, May 1, the day Trump had targeted for reopening some businesses, according to a source who was granted anonymity because they were not permitted to speak to the press.
On April 30 the CDC’s documents were killed for good.
The agency had not heard any specific critiques from either the White House Principals Committee or the coronavirus task force in days, so officials asked for an update.
“The guidance should be more cross-cutting and say when they should reopen and how to keep people safe. Fundamentally, the Task Force cleared this for further development, but not for release,” wrote Quinn Hirsch, a staffer in the White House's office of regulatory affairs (OIRA), in an email to the CDC’s parent agency, the Department of Health and Human Services.
CDC staff working on the guidance decided to try again.
The administration had already released its Opening Up America Again Plan, and the clock was ticking. Staff at CDC thought if they could get their reopening advice out there, it would help communities do so with detailed expert help.
But hours later on April 30, CDC’s Chief of Staff McGowan told CDC staff that neither the guidance documents nor the decision trees “would ever see the light of day,” according to three officials who declined to be named because they were not authorized to speak to reporters.
The next day, May 1, the emails showed, a staffer at CDC was told “we would not even be allowed to post the decision trees. We had the team (exhausted as they are) stand down.”
The CDC’s guidance was shelved. Until May 7.
That morning The Associated Press reported that the Trump administration had buried the guidance, even as many states had started allowing businesses to reopen.
After the story ran, the White House called the CDC and ordered them to refile all of the decision trees, except one that targeted churches. An email obtained by the AP confirmed the agency resent the documents late Thursday, hours after news broke.
“Attached per the request from earlier today are the decision trees previously submitted to both OIRA and the WH Task Force, minus the communities of faith tree,” read the email. “Please let us know if/when/how we are able to proceed from here.”
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