Editor's Note -
The following short but important essay was written by Vikas Saini, MD. Saini is a practicing cardiolist at Brigham and Womens Hospital in Boston and is the President of the Lown Institute.
- SPC
For the health of us all, racism must be dismantled and destroyed:
A personal message from Dr. Vikas Saini
by Vikas Saini - Lown Institute Newsletter - June 5, 2020
I join the vast majority of Americans in condemning the murder of George Floyd at the hands of the police and share the grief and rage so many are feeling. We stand in solidarity with all those who oppose the violent policing of black and minority communities. Though it should not need to be said, it must be said that black lives matter.
What we saw on the smug face of Derek Chauvin was a vivid display of the sense of complete impunity that so many police officers apparently have. And it reminds us that of all the inequalities in our society, the most important one is the inequality of power.
There are a myriad of changes needed to extinguish the culture of arrogance that has taken deep root in too many police departments, but to get real change, this new movement must exercise real power.
More and more Americans are getting the picture that none of us are safe if any of us are not safe on the streets, in our cars, in our homes. The police cannot be an occupying army but must instead be answerable to the community. Exercising real power means that communities control the police department and they define what safety and security mean.
A good start would be the demilitarization of local police forces; the creation of civilian review boards with subpoena powers; an end to immunity from prosecution for cops involved in violent assaults on members of the public; and a systematic effort to remove racist cops from the force and prevent their hiring in the first place.
However, as a member of the health care community, I recognize that the recurring spasms of police brutality are a symptom of a deeper and wider illness, that has percolated, insinuated, its way into every aspect of American life. We will not be able to achieve a just and caring system of health for everyone in the country, until we acknowledge the enormous amount of work that is going to be necessary to eradicate the legacy of racism and white supremacy that contributes to the daily oppression and perpetual violence inflicted on Americans of African descent, ongoing for 400 years.
In their hearts, everyone in white America knows this to be true, but has looked the other way and carried on with their own lives. Most have their own struggles with economic and health insecurity to deal with. Only after a shock that is desperate, tragic, and undeniable, like the murder of George Floyd or Ahmaud Arbery or Breonna Taylor are people roused from political resignation and forced to face the grim reality of the society they live in.
The health of the African American community has suffered for decades and decades with higher rates of poverty, high maternal and infant mortality, hypertension, diabetes, food insecurity, income insecurity, and more. These are the results of a structural racism woven into the fabric of American life.
How are we to behave from this moment forward? An unbiased police force is a necessary beginning, but it won’t solve the problems of unemployment or lack of access to healthcare or education.
And in those areas, there is much common ground for solidarity with the majority of white America. What’s needed is a serious plan to uproot and obliterate structural racism in our society. That project is good for all of us because it can only succeed by destroying the inequalities of housing, income, education, and healthcare that have been dividing us more and more by race and by class. It means abolishing the conditions that have led to America having the highest rate of incarceration in the world.
What black Americans need is also what the vast majority of white and brown Americans need: security. It means having national health insurance for all Americans, employed or unemployed, rich or poor. It means access to the highest quality of care for all, based in neighborhoods provided by people from the neighborhood. It also means massive investments in primary and primordial prevention of hypertension, diabetes, strokes and heart attacks by erasing food deserts, crowded housing, college debt and providing a jobs program and financial support as millions struggle to survive in the midst of the COVID-19 economic collapse.
We are witnessing for ourselves our own Arab spring, the breathtaking power of social media to mobilize people rapidly. But permanent victory will not be won on Twitter; it will take time and effort and will demand a long view and political resilience. If we are to fix these problems finally and completely, we must move from protest to commitment. It requires those who march for justice to build durable new organizations that have the finesse and tactical flexibility to mobilize in the streets or at the ballot box. We have to build an infrastructure for organized popular participation that enables vigilance and exerts enough power to stop that the sabotage of legislation by lobbying.
Suddenly, all of that seems possible. The killing of Floyd is not the news; what’s news is the massive uprising across the land, led by black Americans, whose voices and shouts indicate that their tolerance of pain has been saturated beyond endurance and that large numbers of people of all races have withdrawn their consent from the old order. The protests in the streets, across big cities and small towns, are cause for enormous hope.
We are witnessing genuine evidence that a mass movement is emerging, powered by young people, black, white and brown, who feel compelled, like so many before them, to advance the cause of American freedom. This is a moment to rejuvenate our withering democracy and to reimagine a country dedicated to liberty, justice and the pursuit of health and happiness for all. The crowds of protestors are telling America that none of it can be achieved without the destruction of racism in our society and that all Americans will be liberated if black Americans win their liberation. We must all follow their lead.
In solidarity,
Vikas
The Plague Here and There
By Rosa Miriam Elizalde on May 28, 2020
The
state of Pennsylvania has a population similar to that of Cuba, but has
35 times more confirmed cases of coronavirus and 63 times more lethal
victims. From May 13 to this past Wednesday, the island has reported one death; Pennsylvania, 1,251.The figures, no matter what they are, are tragic, but the comparisons feed the perplexity; how are the statistics so disparate between the world’s richest country and the nation that is the victim of “the longest genocidal attempt in history?” as Gabriel Garcia Marquez called the U.S. economic blockade. Does it have to do with the fact that President Miguel Diaz-Canel does not play golf in the midst of a deadly epidemic, nor has he suggested that bleach is a “revolutionary drug”?
The dead are counted one by one, no matter what the weight, the final result is always the same. An individual is the exact measure of the universe and that he or she is gone hurts his or her family and friends in Cuba, just like in Pennsylvania. Now, knowing the difference between such diametrically opposed facts helps orient us in a highly polluted information environment, where the island is reduced to a “nation of the poor and the well-to-do,” as one Trump enthusiast in Miami would say. Meanwhile, the dead in the United States come and go without going into the depths of stories of overcrowded hospitals, doctors rushing to work without rest, the scarcity of evidence and crowds defying the pandemic on beaches and resorts.
For Cubans, the most hopeful thing is knowing that, if you get sick, you have a good chance of surviving. In the United States, where there are 6,146 hospitals and only 965 are operated by the state and municipal governments, and 209 by the federal government, health is a private business. So the delayed, then ignorant, then contradictory, and at this point inconsistent response of the federal government can be attributed in part to the president, the reality is that the commodification of medical services did not begin with Donald Trump. “The health care system is not set up to help patients. It’s been structured just to make money,” Dr. Nick Sawyer, of the University of California’s Department of Emergency Medicine, told the Washington Post recently.
Trump made the situation worse when he eliminated funds for disaster preparedness organizations. He then appointed Vice President Mike Pence as his cabinet minister responsible for the coronavirus crisis; a man guilty for deaths during the time of the HIV/AIDS epidemic by voting against funding for testing and recommending prayer to God as an alternative.
As a result, society has begun to adapt to the numbers of deaths, as it has resigned itself to the fact that anyone can buy an assault rifle and shoot at schools, churches, cinemas and even embassies, and that this is the price of “freedom” to carry weapons or do whatever comes in handy, even while disregarding the lives of others. “The coronavirus scenario that I can’t stop thinking about is one where we simply get used to all the deaths,” wrote New York Times columnist Charlie Warzel a few days ago.
At this point, the main difference between Cuba and the United States does not lie in their diametrically opposed health systems. It does not even have to do with political differences, but with the scale of values in both societies. On the island, the feelings of cooperation and solidarity have been around since colonial times, in tension with the U.S. claims of annexing the country. They did not begin with the 1959 revolution, even though the latter enshrined them in the most adverse conditions.
The individualism of American society did not begin with Donald Trump either, nor with the plague that affects us now. It has historically been accompanied by a perverse idea of freedom, which José Martí portrayed in a memorable speech in Tampa in 1891. The Cuban national hero, who lived most of his adult life in the United States and who came to know the soul of that country like none of his contemporaries, warned what would be the limit of the freedom that the Republic would consecrate in Cuba, as “the integral exercise of self”, instead of “the respect, as a family honor, for the integral exercise of others”. The individual freedom that he claimed for Cubans would not be that which characterized the nascent US empire; one made up of selfishness, amoral individualism, caprice, abuse of some over others. It would be collective justice, what he called “the passion, in short, for the decorum of man”.
Source: La Jornada, translation Resumen Latinoamericano, North America bureau
https://www.jornada.com.mx/2020/05/28/opinion/018a2pol
https://www.resumen-english.org/2020/05/the-plague-here-and-there/
Arundhati Roy: ‘The pandemic is a portal’
by Arundhati Roy - Financial Times -
April 3 2020
Who can use the term “gone viral” now without shuddering a little?
Who can look at anything any more — a door handle, a cardboard carton, a
bag of vegetables — without imagining it swarming with those unseeable,
undead, unliving blobs dotted with suction pads waiting to fasten
themselves on to our lungs?
Who can think of kissing a stranger, jumping on to a bus or sending their child to school without feeling real fear? Who can think of ordinary pleasure and not assess its risk? Who among us is not a quack epidemiologist, virologist, statistician and prophet? Which scientist or doctor is not secretly praying for a miracle? Which priest is not — secretly, at least — submitting to science?
And even while the virus proliferates, who could not be thrilled by the swell of birdsong in cities, peacocks dancing at traffic crossings and the silence in the skies?
The number of cases worldwide this week crept over a million. More than 50,000 people have died already. Projections suggest that number will swell to hundreds of thousands, perhaps more. The virus has moved freely along the pathways of trade and international capital, and the terrible illness it has brought in its wake has locked humans down in their countries, their cities and their homes.
But unlike the flow of capital, this virus seeks proliferation, not profit, and has, therefore, inadvertently, to some extent, reversed the direction of the flow. It has mocked immigration controls, biometrics, digital surveillance and every other kind of data analytics, and struck hardest — thus far — in the richest, most powerful nations of the world, bringing the engine of capitalism to a juddering halt. Temporarily perhaps, but at least long enough for us to examine its parts, make an assessment and decide whether we want to help fix it, or look for a better engine.
The mandarins who are managing this pandemic are fond of speaking of war. They don’t even use war as a metaphor, they use it literally. But if it really were a war, then who would be better prepared than the US? If it were not masks and gloves that its frontline soldiers needed, but guns, smart bombs, bunker busters, submarines, fighter jets and nuclear bombs, would there be a shortage?
Night after night, from halfway across the world, some of us watch the New York governor’s press briefings with a fascination that is hard to explain. We follow the statistics, and hear the stories of overwhelmed hospitals in the US, of underpaid, overworked nurses having to make masks out of garbage bin liners and old raincoats, risking everything to bring succour to the sick. About states being forced to bid against each other for ventilators, about doctors’ dilemmas over which patient should get one and which left to die. And we think to ourselves, “My God! This is America!”
The tragedy is immediate, real, epic and unfolding before our eyes. But it isn’t new. It is the wreckage of a train that has been careening down the track for years. Who doesn’t remember the videos of “patient dumping” — sick people, still in their hospital gowns, butt naked, being surreptitiously dumped on street corners? Hospital doors have too often been closed to the less fortunate citizens of the US. It hasn’t mattered how sick they’ve been, or how much they’ve suffered.
At least not until now — because now, in the era of the virus, a poor person’s sickness can affect a wealthy society’s health. And yet, even now, Bernie Sanders, the senator who has relentlessly campaigned for healthcare for all, is considered an outlier in his bid for the White House, even by his own party.
And what of my country, my poor-rich country, India, suspended somewhere between feudalism and religious fundamentalism, caste and capitalism, ruled by far-right Hindu nationalists?
In December, while China was fighting the outbreak of the virus in Wuhan, the government of India was dealing with a mass uprising by hundreds of thousands of its citizens protesting against the brazenly discriminatory anti-Muslim citizenship law it had just passed in parliament.
The first case of Covid-19 was reported in India on January 30, only days after the honourable chief guest of our Republic Day Parade, Amazon forest-eater and Covid-denier Jair Bolsonaro, had left Delhi. But there was too much to do in February for the virus to be accommodated in the ruling party’s timetable. There was the official visit of President Donald Trump scheduled for the last week of the month. He had been lured by the promise of an audience of 1m people in a sports stadium in the state of Gujarat. All that took money, and a great deal of time.
Then there were the Delhi Assembly elections that the Bharatiya Janata Party was slated to lose unless it upped its game, which it did, unleashing a vicious, no-holds-barred Hindu nationalist campaign, replete with threats of physical violence and the shooting of “traitors”.
It lost anyway. So then there was punishment to be meted out to Delhi’s Muslims, who were blamed for the humiliation. Armed mobs of Hindu vigilantes, backed by the police, attacked Muslims in the working-class neighbourhoods of north-east Delhi. Houses, shops, mosques and schools were burnt. Muslims who had been expecting the attack fought back. More than 50 people, Muslims and some Hindus, were killed.
Thousands moved into refugee camps in local graveyards. Mutilated bodies were still being pulled out of the network of filthy, stinking drains when government officials had their first meeting about Covid-19 and most Indians first began to hear about the existence of something called hand sanitiser.
March was busy too. The first two weeks were devoted to toppling the Congress government in the central Indian state of Madhya Pradesh and installing a BJP government in its place. On March 11 the World Health Organization declared that Covid-19 was a pandemic. Two days later, on March 13, the health ministry said that corona “is not a health emergency”.
Finally, on March 19, the Indian prime minister addressed the nation. He hadn’t done much homework. He borrowed the playbook from France and Italy. He told us of the need for “social distancing” (easy to understand for a society so steeped in the practice of caste) and called for a day of “people’s curfew” on March 22. He said nothing about what his government was going to do in the crisis, but he asked people to come out on their balconies, and ring bells and bang their pots and pans to salute health workers.
He didn’t mention that, until that very moment, India had been exporting protective gear and respiratory equipment, instead of keeping it for Indian health workers and hospitals.
Not surprisingly, Narendra Modi’s request was met with great enthusiasm. There were pot-banging marches, community dances and processions. Not much social distancing. In the days that followed, men jumped into barrels of sacred cow dung, and BJP supporters threw cow-urine drinking parties. Not to be outdone, many Muslim organisations declared that the Almighty was the answer to the virus and called for the faithful to gather in mosques in numbers.
On March 24, at 8pm, Modi appeared on TV again to announce that, from midnight onwards, all of India would be under lockdown. Markets would be closed. All transport, public as well as private, would be disallowed.
He said he was taking this decision not just as a prime minister, but as our family elder. Who else can decide, without consulting the state governments that would have to deal with the fallout of this decision, that a nation of 1.38bn people should be locked down with zero preparation and with four hours’ notice? His methods definitely give the impression that India’s prime minister thinks of citizens as a hostile force that needs to be ambushed, taken by surprise, but never trusted.
Locked down we were. Many health professionals and epidemiologists have applauded this move. Perhaps they are right in theory. But surely none of them can support the calamitous lack of planning or preparedness that turned the world’s biggest, most punitive lockdown into the exact opposite of what it was meant to achieve.
The man who loves spectacles created the mother of all spectacles.
As an appalled world watched, India revealed herself in all her shame — her brutal, structural, social and economic inequality, her callous indifference to suffering.
The lockdown worked like a chemical experiment that suddenly illuminated hidden things. As shops, restaurants, factories and the construction industry shut down, as the wealthy and the middle classes enclosed themselves in gated colonies, our towns and megacities began to extrude their working-class citizens — their migrant workers — like so much unwanted accrual.
Many driven out by their employers and landlords, millions of impoverished, hungry, thirsty people, young and old, men, women, children, sick people, blind people, disabled people, with nowhere else to go, with no public transport in sight, began a long march home to their villages. They walked for days, towards Badaun, Agra, Azamgarh, Aligarh, Lucknow, Gorakhpur — hundreds of kilometres away. Some died on the way.
They knew they were going home potentially to slow starvation. Perhaps they even knew they could be carrying the virus with them, and would infect their families, their parents and grandparents back home, but they desperately needed a shred of familiarity, shelter and dignity, as well as food, if not love.
As they walked, some were beaten brutally and humiliated by the police, who were charged with strictly enforcing the curfew. Young men were made to crouch and frog jump down the highway. Outside the town of Bareilly, one group was herded together and hosed down with chemical spray.
A few days later, worried that the fleeing population would spread the virus to villages, the government sealed state borders even for walkers. People who had been walking for days were stopped and forced to return to camps in the cities they had just been forced to leave.
Among older people it evoked memories of the population transfer of 1947, when India was divided and Pakistan was born. Except that this current exodus was driven by class divisions, not religion. Even still, these were not India’s poorest people. These were people who had (at least until now) work in the city and homes to return to. The jobless, the homeless and the despairing remained where they were, in the cities as well as the countryside, where deep distress was growing long before this tragedy occurred. All through these horrible days, the home affairs minister Amit Shah remained absent from public view.
When the walking began in Delhi, I used a press pass from a magazine I frequently write for to drive to Ghazipur, on the border between Delhi and Uttar Pradesh.
The scene was biblical. Or perhaps not. The Bible could not have known numbers such as these. The lockdown to enforce physical distancing had resulted in the opposite — physical compression on an unthinkable scale. This is true even within India’s towns and cities. The main roads might be empty, but the poor are sealed into cramped quarters in slums and shanties.
Every one of the walking people I spoke to was worried about the virus. But it was less real, less present in their lives than looming unemployment, starvation and the violence of the police. Of all the people I spoke to that day, including a group of Muslim tailors who had only weeks ago survived the anti-Muslim attacks, one man’s words especially troubled me. He was a carpenter called Ramjeet, who planned to walk all the way to Gorakhpur near the Nepal border.
“Maybe when Modiji decided to do this, nobody told him about us. Maybe he doesn’t know about us”, he said.
“Us” means approximately 460m people.
State governments in India (as in the US) have showed more heart and understanding in the crisis. Trade unions, private citizens and other collectives are distributing food and emergency rations. The central government has been slow to respond to their desperate appeals for funds. It turns out that the prime minister’s National Relief Fund has no ready cash available. Instead, money from well-wishers is pouring into the somewhat mysterious new PM-CARES fund. Pre-packaged meals with Modi’s face on them have begun to appear.
In addition to this, the prime minister has shared his yoga nidra videos, in which a morphed, animated Modi with a dream body demonstrates yoga asanas to help people deal with the stress of self-isolation.
The narcissism is deeply troubling. Perhaps one of the asanas could be a request-asana in which Modi requests the French prime minister to allow us to renege on the very troublesome Rafale fighter jet deal and use that €7.8bn for desperately needed emergency measures to support a few million hungry people. Surely the French will understand.
As the lockdown enters its second week, supply chains have broken, medicines and essential supplies are running low. Thousands of truck drivers are still marooned on the highways, with little food and water. Standing crops, ready to be harvested, are slowly rotting.
The economic crisis is here. The political crisis is ongoing. The mainstream media has incorporated the Covid story into its 24/7 toxic anti-Muslim campaign. An organisation called the Tablighi Jamaat, which held a meeting in Delhi before the lockdown was announced, has turned out to be a “super spreader”. That is being used to stigmatise and demonise Muslims. The overall tone suggests that Muslims invented the virus and have deliberately spread it as a form of jihad.
The Covid crisis is still to come. Or not. We don’t know. If and when it does, we can be sure it will be dealt with, with all the prevailing prejudices of religion, caste and class completely in place.
Today (April 2) in India, there are almost 2,000 confirmed cases and 58 deaths. These are surely unreliable numbers, based on woefully few tests. Expert opinion varies wildly. Some predict millions of cases. Others think the toll will be far less. We may never know the real contours of the crisis, even when it hits us. All we know is that the run on hospitals has not yet begun.
India’s public hospitals and clinics — which are unable to cope with the almost 1m children who die of diarrhoea, malnutrition and other health issues every year, with the hundreds of thousands of tuberculosis patients (a quarter of the world’s cases), with a vast anaemic and malnourished population vulnerable to any number of minor illnesses that prove fatal for them — will not be able to cope with a crisis that is like what Europe and the US are dealing with now.
All healthcare is more or less on hold as hospitals have been turned over to the service of the virus. The trauma centre of the legendary All India Institute of Medical Sciences in Delhi is closed, the hundreds of cancer patients known as cancer refugees who live on the roads outside that huge hospital driven away like cattle.
People will fall sick and die at home. We may never know their stories. They may not even become statistics. We can only hope that the studies that say the virus likes cold weather are correct (though other researchers have cast doubt on this). Never have a people longed so irrationally and so much for a burning, punishing Indian summer.
What is this thing that has happened to us? It’s a virus, yes. In and of itself it holds no moral brief. But it is definitely more than a virus. Some believe it’s God’s way of bringing us to our senses. Others that it’s a Chinese conspiracy to take over the world.
Whatever it is, coronavirus has made the mighty kneel and brought the world to a halt like nothing else could. Our minds are still racing back and forth, longing for a return to “normality”, trying to stitch our future to our past and refusing to acknowledge the rupture. But the rupture exists. And in the midst of this terrible despair, it offers us a chance to rethink the doomsday machine we have built for ourselves. Nothing could be worse than a return to normality.
Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next.
We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it.
https://www.ft.com/content/10d8f5e8-74eb-11ea-95fe-fcd274e920ca
Who can think of kissing a stranger, jumping on to a bus or sending their child to school without feeling real fear? Who can think of ordinary pleasure and not assess its risk? Who among us is not a quack epidemiologist, virologist, statistician and prophet? Which scientist or doctor is not secretly praying for a miracle? Which priest is not — secretly, at least — submitting to science?
And even while the virus proliferates, who could not be thrilled by the swell of birdsong in cities, peacocks dancing at traffic crossings and the silence in the skies?
The number of cases worldwide this week crept over a million. More than 50,000 people have died already. Projections suggest that number will swell to hundreds of thousands, perhaps more. The virus has moved freely along the pathways of trade and international capital, and the terrible illness it has brought in its wake has locked humans down in their countries, their cities and their homes.
But unlike the flow of capital, this virus seeks proliferation, not profit, and has, therefore, inadvertently, to some extent, reversed the direction of the flow. It has mocked immigration controls, biometrics, digital surveillance and every other kind of data analytics, and struck hardest — thus far — in the richest, most powerful nations of the world, bringing the engine of capitalism to a juddering halt. Temporarily perhaps, but at least long enough for us to examine its parts, make an assessment and decide whether we want to help fix it, or look for a better engine.
The mandarins who are managing this pandemic are fond of speaking of war. They don’t even use war as a metaphor, they use it literally. But if it really were a war, then who would be better prepared than the US? If it were not masks and gloves that its frontline soldiers needed, but guns, smart bombs, bunker busters, submarines, fighter jets and nuclear bombs, would there be a shortage?
Night after night, from halfway across the world, some of us watch the New York governor’s press briefings with a fascination that is hard to explain. We follow the statistics, and hear the stories of overwhelmed hospitals in the US, of underpaid, overworked nurses having to make masks out of garbage bin liners and old raincoats, risking everything to bring succour to the sick. About states being forced to bid against each other for ventilators, about doctors’ dilemmas over which patient should get one and which left to die. And we think to ourselves, “My God! This is America!”
The tragedy is immediate, real, epic and unfolding before our eyes. But it isn’t new. It is the wreckage of a train that has been careening down the track for years. Who doesn’t remember the videos of “patient dumping” — sick people, still in their hospital gowns, butt naked, being surreptitiously dumped on street corners? Hospital doors have too often been closed to the less fortunate citizens of the US. It hasn’t mattered how sick they’ve been, or how much they’ve suffered.
At least not until now — because now, in the era of the virus, a poor person’s sickness can affect a wealthy society’s health. And yet, even now, Bernie Sanders, the senator who has relentlessly campaigned for healthcare for all, is considered an outlier in his bid for the White House, even by his own party.
And what of my country, my poor-rich country, India, suspended somewhere between feudalism and religious fundamentalism, caste and capitalism, ruled by far-right Hindu nationalists?
In December, while China was fighting the outbreak of the virus in Wuhan, the government of India was dealing with a mass uprising by hundreds of thousands of its citizens protesting against the brazenly discriminatory anti-Muslim citizenship law it had just passed in parliament.
The first case of Covid-19 was reported in India on January 30, only days after the honourable chief guest of our Republic Day Parade, Amazon forest-eater and Covid-denier Jair Bolsonaro, had left Delhi. But there was too much to do in February for the virus to be accommodated in the ruling party’s timetable. There was the official visit of President Donald Trump scheduled for the last week of the month. He had been lured by the promise of an audience of 1m people in a sports stadium in the state of Gujarat. All that took money, and a great deal of time.
Then there were the Delhi Assembly elections that the Bharatiya Janata Party was slated to lose unless it upped its game, which it did, unleashing a vicious, no-holds-barred Hindu nationalist campaign, replete with threats of physical violence and the shooting of “traitors”.
It lost anyway. So then there was punishment to be meted out to Delhi’s Muslims, who were blamed for the humiliation. Armed mobs of Hindu vigilantes, backed by the police, attacked Muslims in the working-class neighbourhoods of north-east Delhi. Houses, shops, mosques and schools were burnt. Muslims who had been expecting the attack fought back. More than 50 people, Muslims and some Hindus, were killed.
Thousands moved into refugee camps in local graveyards. Mutilated bodies were still being pulled out of the network of filthy, stinking drains when government officials had their first meeting about Covid-19 and most Indians first began to hear about the existence of something called hand sanitiser.
March was busy too. The first two weeks were devoted to toppling the Congress government in the central Indian state of Madhya Pradesh and installing a BJP government in its place. On March 11 the World Health Organization declared that Covid-19 was a pandemic. Two days later, on March 13, the health ministry said that corona “is not a health emergency”.
Finally, on March 19, the Indian prime minister addressed the nation. He hadn’t done much homework. He borrowed the playbook from France and Italy. He told us of the need for “social distancing” (easy to understand for a society so steeped in the practice of caste) and called for a day of “people’s curfew” on March 22. He said nothing about what his government was going to do in the crisis, but he asked people to come out on their balconies, and ring bells and bang their pots and pans to salute health workers.
He didn’t mention that, until that very moment, India had been exporting protective gear and respiratory equipment, instead of keeping it for Indian health workers and hospitals.
Not surprisingly, Narendra Modi’s request was met with great enthusiasm. There were pot-banging marches, community dances and processions. Not much social distancing. In the days that followed, men jumped into barrels of sacred cow dung, and BJP supporters threw cow-urine drinking parties. Not to be outdone, many Muslim organisations declared that the Almighty was the answer to the virus and called for the faithful to gather in mosques in numbers.
On March 24, at 8pm, Modi appeared on TV again to announce that, from midnight onwards, all of India would be under lockdown. Markets would be closed. All transport, public as well as private, would be disallowed.
He said he was taking this decision not just as a prime minister, but as our family elder. Who else can decide, without consulting the state governments that would have to deal with the fallout of this decision, that a nation of 1.38bn people should be locked down with zero preparation and with four hours’ notice? His methods definitely give the impression that India’s prime minister thinks of citizens as a hostile force that needs to be ambushed, taken by surprise, but never trusted.
Locked down we were. Many health professionals and epidemiologists have applauded this move. Perhaps they are right in theory. But surely none of them can support the calamitous lack of planning or preparedness that turned the world’s biggest, most punitive lockdown into the exact opposite of what it was meant to achieve.
The man who loves spectacles created the mother of all spectacles.
As an appalled world watched, India revealed herself in all her shame — her brutal, structural, social and economic inequality, her callous indifference to suffering.
The lockdown worked like a chemical experiment that suddenly illuminated hidden things. As shops, restaurants, factories and the construction industry shut down, as the wealthy and the middle classes enclosed themselves in gated colonies, our towns and megacities began to extrude their working-class citizens — their migrant workers — like so much unwanted accrual.
Many driven out by their employers and landlords, millions of impoverished, hungry, thirsty people, young and old, men, women, children, sick people, blind people, disabled people, with nowhere else to go, with no public transport in sight, began a long march home to their villages. They walked for days, towards Badaun, Agra, Azamgarh, Aligarh, Lucknow, Gorakhpur — hundreds of kilometres away. Some died on the way.
They knew they were going home potentially to slow starvation. Perhaps they even knew they could be carrying the virus with them, and would infect their families, their parents and grandparents back home, but they desperately needed a shred of familiarity, shelter and dignity, as well as food, if not love.
As they walked, some were beaten brutally and humiliated by the police, who were charged with strictly enforcing the curfew. Young men were made to crouch and frog jump down the highway. Outside the town of Bareilly, one group was herded together and hosed down with chemical spray.
A few days later, worried that the fleeing population would spread the virus to villages, the government sealed state borders even for walkers. People who had been walking for days were stopped and forced to return to camps in the cities they had just been forced to leave.
Among older people it evoked memories of the population transfer of 1947, when India was divided and Pakistan was born. Except that this current exodus was driven by class divisions, not religion. Even still, these were not India’s poorest people. These were people who had (at least until now) work in the city and homes to return to. The jobless, the homeless and the despairing remained where they were, in the cities as well as the countryside, where deep distress was growing long before this tragedy occurred. All through these horrible days, the home affairs minister Amit Shah remained absent from public view.
When the walking began in Delhi, I used a press pass from a magazine I frequently write for to drive to Ghazipur, on the border between Delhi and Uttar Pradesh.
The scene was biblical. Or perhaps not. The Bible could not have known numbers such as these. The lockdown to enforce physical distancing had resulted in the opposite — physical compression on an unthinkable scale. This is true even within India’s towns and cities. The main roads might be empty, but the poor are sealed into cramped quarters in slums and shanties.
Every one of the walking people I spoke to was worried about the virus. But it was less real, less present in their lives than looming unemployment, starvation and the violence of the police. Of all the people I spoke to that day, including a group of Muslim tailors who had only weeks ago survived the anti-Muslim attacks, one man’s words especially troubled me. He was a carpenter called Ramjeet, who planned to walk all the way to Gorakhpur near the Nepal border.
“Maybe when Modiji decided to do this, nobody told him about us. Maybe he doesn’t know about us”, he said.
“Us” means approximately 460m people.
State governments in India (as in the US) have showed more heart and understanding in the crisis. Trade unions, private citizens and other collectives are distributing food and emergency rations. The central government has been slow to respond to their desperate appeals for funds. It turns out that the prime minister’s National Relief Fund has no ready cash available. Instead, money from well-wishers is pouring into the somewhat mysterious new PM-CARES fund. Pre-packaged meals with Modi’s face on them have begun to appear.
In addition to this, the prime minister has shared his yoga nidra videos, in which a morphed, animated Modi with a dream body demonstrates yoga asanas to help people deal with the stress of self-isolation.
The narcissism is deeply troubling. Perhaps one of the asanas could be a request-asana in which Modi requests the French prime minister to allow us to renege on the very troublesome Rafale fighter jet deal and use that €7.8bn for desperately needed emergency measures to support a few million hungry people. Surely the French will understand.
As the lockdown enters its second week, supply chains have broken, medicines and essential supplies are running low. Thousands of truck drivers are still marooned on the highways, with little food and water. Standing crops, ready to be harvested, are slowly rotting.
The economic crisis is here. The political crisis is ongoing. The mainstream media has incorporated the Covid story into its 24/7 toxic anti-Muslim campaign. An organisation called the Tablighi Jamaat, which held a meeting in Delhi before the lockdown was announced, has turned out to be a “super spreader”. That is being used to stigmatise and demonise Muslims. The overall tone suggests that Muslims invented the virus and have deliberately spread it as a form of jihad.
The Covid crisis is still to come. Or not. We don’t know. If and when it does, we can be sure it will be dealt with, with all the prevailing prejudices of religion, caste and class completely in place.
Today (April 2) in India, there are almost 2,000 confirmed cases and 58 deaths. These are surely unreliable numbers, based on woefully few tests. Expert opinion varies wildly. Some predict millions of cases. Others think the toll will be far less. We may never know the real contours of the crisis, even when it hits us. All we know is that the run on hospitals has not yet begun.
India’s public hospitals and clinics — which are unable to cope with the almost 1m children who die of diarrhoea, malnutrition and other health issues every year, with the hundreds of thousands of tuberculosis patients (a quarter of the world’s cases), with a vast anaemic and malnourished population vulnerable to any number of minor illnesses that prove fatal for them — will not be able to cope with a crisis that is like what Europe and the US are dealing with now.
All healthcare is more or less on hold as hospitals have been turned over to the service of the virus. The trauma centre of the legendary All India Institute of Medical Sciences in Delhi is closed, the hundreds of cancer patients known as cancer refugees who live on the roads outside that huge hospital driven away like cattle.
People will fall sick and die at home. We may never know their stories. They may not even become statistics. We can only hope that the studies that say the virus likes cold weather are correct (though other researchers have cast doubt on this). Never have a people longed so irrationally and so much for a burning, punishing Indian summer.
What is this thing that has happened to us? It’s a virus, yes. In and of itself it holds no moral brief. But it is definitely more than a virus. Some believe it’s God’s way of bringing us to our senses. Others that it’s a Chinese conspiracy to take over the world.
Whatever it is, coronavirus has made the mighty kneel and brought the world to a halt like nothing else could. Our minds are still racing back and forth, longing for a return to “normality”, trying to stitch our future to our past and refusing to acknowledge the rupture. But the rupture exists. And in the midst of this terrible despair, it offers us a chance to rethink the doomsday machine we have built for ourselves. Nothing could be worse than a return to normality.
Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next.
We can choose to walk through it, dragging the carcasses of our prejudice and hatred, our avarice, our data banks and dead ideas, our dead rivers and smoky skies behind us. Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it.
https://www.ft.com/content/10d8f5e8-74eb-11ea-95fe-fcd274e920ca
Couple Bilked Medicaid for $13 Million to Pay for Lavish Lifestyle, U.S. Says
Latisha
and Timothy Harron spent the money on a private jet, shopping sprees at
Tiffany, wine and clothes that they flaunted on social media,
prosecutors said.
They shared
photos on social media of their private jet, stacks of Tiffany &
Company boxes and a crystal decanter of Louis XIII cognac, often
accompanied by the hashtags #jetsetter, #millionaire, #billionaire and
#entrepreneur.
But prosecutors said that the lavish
lifestyle that Latisha and Timothy Harron flaunted online was one that
they could not afford and was attained through fraud.
On
Wednesday, the Harrons were indicted in a yearslong Medicaid billing
scheme, in which the couple back-billed the program for $13 million in
home health care services that they didn’t provide, according to a
criminal complaint unsealed on Wednesday.
The Harrons,
who live in Las Vegas, spent the money on real estate, exercise
equipment, jewelry that included a $58,455 Tiffany ring and clothes from
Brioni in Beverly Hills, the complaint said. The couple’s Aston Martin
and wine collection were among the items that could be seized, according
to the complaint.
Prosecutors said that the husband
and wife combed through obituary listings in North Carolina to get the
names of people who had recently died and then charged bogus services to
those who had been eligible to receive Medicaid benefits in the state.
Robert
J. Higdon Jr., the U.S. attorney for the Eastern District of North
Carolina, said in a statement on Wednesday that the scheme was one of
the most brazen and egregious cases of Medicaid fraud that had taken
place in his jurisdiction.
“The indictment alleges a
$13 million fraud that funded a gluttonous, social media-marketed
lifestyle — one filled with private jets, penthouses and luxury
resorts,” Mr. Higdon said. “Most reprehensible is the fact that this
crime is alleged to have been carried out on the backs of our most
vulnerable: the poor, the deceased, the elderly and the disabled.”
Mr. Harron, 50, and Ms. Harron, 44, a former North Carolina resident, were taken into custody on Wednesday in Las Vegas.
The charges against them
include 54 counts of wire fraud, one count of health care fraud, six
counts of aggravated identity theft, one count of conspiracy to commit
money laundering and 11 counts of conducting transactions in criminally
derived property with fraud and money laundering, according to
prosecutors.
Each of the wire fraud charges carries a penalty of up to 20 years in prison.
Public defenders for Ms. Harron in North Carolina and Mr. Harron in Nevada did not immediately respond to requests for comment on Wednesday.
Public defenders for Ms. Harron in North Carolina and Mr. Harron in Nevada did not immediately respond to requests for comment on Wednesday.
Prosecutors
said that the Harrons both concealed previous felony convictions on
Medicaid provider enrollment forms for two businesses that they
operated: Agape Healthcare Systems Inc. and Assured Healthcare Systems
L.L.C.
Ms. Harron had previously been convicted of
identity theft and Mr. Harron had been convicted of wire fraud,
conspiracy to commit wire fraud and conspiracy to commit money
laundering, according to the criminal complaint.
Ms.
Harron was also charged on Wednesday with making false statements
relating to health care matters, which prosecutors said stemmed from her
lying about her identity theft conviction.
As part of
the fraud scheme, the Harrons checked funeral home websites for the
obituaries of people who had recently died in North Carolina, according
to the complaint. They obtained the person’s Medicaid identification
number from a state verification system and checked to see whether the
person had unused coverage for home health care services, the
authorities said. Then they billed the system for fictitious services,
the complaint said.
“Stealing taxpayer money from a
health care program designed to care for the poor and disabled just to
bankroll a private jet and other luxury products — as alleged in this
case — is reprehensible,” Derrick L. Jackson, a special agent in charge
at the Health and Human Services Office of Inspector General, said in a
statement on Wednesday.
In addition to images of a
decadent lifestyle, Mr. Harron’s Instagram profile is filled with
inspirational quotes, including some that he attributed to himself.
“I’m not doing a business that’s new, I’m doing a new way of doing business,” Mr. Harron wrote in one.
https://www.nytimes.com/2020/05/28/us/medicare-fraud-las-vegas.html?action=click&module=
Wondering if he had COVID-19, Regan called a nurse hotline run by Denver Health, a large public health system in his city. A nurse listened to him describe his symptoms and told him to immediately go to the hospital system's urgent care facility.
When he arrived at Denver Health — where the emergency room and urgent care facility sit side by side at its main location downtown — a nurse directed him to the ER after he noted chest pain as one of his symptoms.
Regan was seen quickly and given a chest X-ray and electrocardiogram, known as an EKG, to check his lungs and heart. Both were normal.
A doctor prescribed an inhaler to help his breathing and told him he might have bronchitis. The doctor advised that he had to presume he had COVID-19 and must quarantine at home for two weeks.
At the time, on April 3, Denver Health reserved COVID-19 tests for sicker patients. Two hours after arriving at the hospital, Regan was back home. His longest wait was for his inhaler prescription to be filled.
Regan wasn't concerned about just his own health. His wife, Elissa, who is expecting their second child in August, and their 1-year-old son, Finn, also felt sick with symptoms like those of COVID-19 in April. "Nothing terrible but enough to make me worry," he said.
Regan, who is an estimator for a construction firm, worked from home throughout his sickness — including while quarantined. (Construction in Colorado and many states has been considered an essential business and has continued to operate.) Regan said he was worried about taking a day off and losing his job.
"I was thinking I had to make all the money I could in case we all had to be hospitalized," he said. "All I could do was keep working in hopes that everything would be OK."
Within a couple of weeks, the whole family indeed was OK. "We got lucky," Elissa said.
Then the bill came.
The patient: Timothy Regan, 40, an estimator for a construction company. The family has health insurance through Elissa's job at a nonprofit in Denver.
Total bill: Denver Health billed Regan $3,278 for the ER visit. His insurer paid $1,042, leaving him with $2,236 to pay based on his $3,500 in-network deductible. The biggest part of the bill was the $2,921 general ER fee.
Service provider: Denver Health, a large public health system
Medical service: Regan was evaluated in the emergency room for COVID-19-like symptoms, including a severe cough, fever and chest pain. He was given several tests to check his heart and lungs, prescribed an inhaler and sent home.
What gives: When patients use hospital emergency rooms — even for short visits with few tests — it's not unusual for them to get billed thousands of dollars no matter how minor the treatment received. Hospitals say the high fees come from having to staff the ER with specialists 24 hours a day and keep lifesaving equipment up to date.
Denver Health coded Timothy's ER visit as a Level 4 — the second highest and second most expensive — on a 5-point scale. The other items on his bill were $225 for the EKG, $126 for the chest X-ray and $6 for his albuterol inhaler, a medication that provides quick relief for breathing problems.
The Regans knew they had a high deductible, and they try to avoid unnecessarily using the ER. But with physician offices not seeing patients with COVID-19 symptoms in April, Timothy said he had little choice when Denver Health directed him first to its urgent care and then to its ER. "I felt bad, but I had been dealing with it for a while," he said.
Elissa said they were trying hard to do everything by the book, including using a health provider in their plan's network.
"We did not anticipate being hit with such a huge bill for the visit," Elissa said. "We had intentionally called the nurse's line trying to be responsible, but that did not work."
In an effort to remove barriers to people getting tested and evaluated for COVID-19, UnitedHealthcare is one of many insurers that announced it will waive cost sharing for COVID-19 testing-related visits and treatment. But it is not clear how many people who had COVID-19 symptoms but who did not get tested when tests were in short supply have been billed as the Regans were.
Resolution: A Denver Health spokesperson said Regan was not tested for COVID-19 because he was not admitted and did not have risk factors such as diabetes, heart disease or asthma. He was not billed as a COVID-19 patient because he was not tested for the virus. The medical center has since expanded its testing capacity, the spokesperson said.
UnitedHealthcare officials reviewed Regan's case at the request of Kaiser Health News. Based on Regan's symptoms and the tests performed, Denver Health should have billed them using a COVID-19 billing code, an insurer spokesperson said. "We reprocessed Mr. Regan's original claims after reviewing the services that he received," a UnitedHealthcare spokesperson said. "All cost share for that visit has been waived."
The Regans said they were thrilled with UHC's decision.
"That is wonderful news," Elissa said upon hearing from a KHN reporter that UHC would waive their costs. "We are very thankful. It is a huge relief."
The takeaway: The Regans said they initially found no satisfaction in calling the hospital or the insurer to resolve their dispute — but it was the right thing to do.
"He's definitely not alone," said Sabrina Corlette, a research professor at Georgetown University's Center on Health Insurance Reforms. "The takeaway here is both the provider as well as insurance company are still on a learning curve with respect to this virus and how to bill and pay for it."
Corlette said Timothy should not have second-guessed his decision to use the Denver Health ER when directed there by a nurse. That, too, was the right call.
Insurers' move to waive costs associated with COVID-19 testing and related treatment is vital to stem the outbreak — but it works only if patients can trust they won't get stuck with a large bill, she said. "It's a critical piece of the public health strategy to beat this disease," Corlette said.
To help with billing, she said, patients could ask their provider to note on their medical chart when they seek care for a possible case of COVID-19. But it's not patients' responsibility to make sure providers use the right billing code, she said. Patients need to know they have rights to appeal costs to their insurer. They can also seek assistance from their employer's benefits department and state insurance department.
https://www.npr.org/sections/health-shots/2020/05/26/860266113/er-visit-for-a-covid-like-cough-stuck-man-with-a-3-278-bill
For 42 years, James Hay, MD, had been seeing patients at the family practice he started in the Southern California beach town of Encinitas. Hay, the former president of the California Medical Association, loved his work and thought he'd keep at it at least through the end of the year.
On March 6, however, one of his partners saw a patient who -- according to a call from a county health official -- was the first confirmed case of COVID-19 in a resident who hadn't recently traveled out of town. That meant the virus was now being transmitted locally.
That turned out to be incorrect; the patient had been skiing in another state. But the positive test sent shockwaves through his practice.
It was all the more disconcerting for Hay, 73, who knew his age and a minor medical issue put him at greater risk for severe illness if he were to get infected because so little was known about how the virus behaved. When his practice partner Amy Kakimoto, MD, called him that night with the patient's test result, "she said, 'Stay home.' So I haven't been inside the office since March 11."
County public health officials issued a shut-down order a few days later and soon, office visits and revenue for Hay's six-physician practice -- and tens of thousands of others throughout the country -- plummeted as few patients ventured in for care. His group had to cut way back as many on his team took weeks off.
"I've stayed home, because of my age, doing video visits with patients instead," he said.
All that prompted Hay to come to a difficult decision. He told MedPage Today that he was retiring early, and May 28 was his last day seeing patients. He would save the practice his salary and he wouldn't have to worry as much about risks to his own health.
Hay is not alone. Dozens of physicians, practice managers, and medical society executives around the country said that among older doctors still practicing -- 120,000 of whom were 65 or older in 2017, according to one survey -- talk of an earlier-than-planned retirement is getting louder in the eye of the pandemic. While far from a groundswell, Don Palmisano Jr., executive director and CEO of the Medical Association of Georgia, heard from doctors in one health system that "older physicians have voiced their intent to possibly retire."
Three Factors
The reasons for early retirement are threefold, according to physicians interviewed for this story, some of whom asked they not be named because they haven't made a decision, haven't told their spouses, or don't want to go public with their fear that they could unknowingly bring the virus home to their families.
First among the influential factors is analysts' projections of a looming major decrease in commercial coverage, in a mid-May update from the national consulting firm Health Management Associates, for example, and a similar report from the Kaiser Family Foundation. The HMA report estimated the number of people with employer sponsored-plans could drop from 165 million as of February (pre-COVID) to as low as 138 million by year's end, depending on whether job losses are moderate, heavy, or severe.
Meanwhile, the number of uninsured are estimated to increase from 29 million to as high as 34 million, the HMA report projects.
While some laid-off workers will be able to afford an individual marketplace plan (though not in the Obamacare exchanges, which the Trump administration decided not to reopen), millions more are expected to enroll in Medicaid, which reimburses at 50% to 60% of commercial payers' rates, and 70% to 75% of what Medicare pays for the same services.
HMA estimates Medicaid enrollment could go from 71 million people to 76-89 million by the end of this year, said Eric Hammelman, an author of the HMA analysis.
"There will be drastically reduced 'churning,' of patients going on and off Medicaid for the duration of the emergency," especially since the Families First Coronavirus Response Act (FFCRA), which took effect in mid-March, limited the ability of states to involuntarily disenroll or terminate people from the Medicaid project if they didn't reaffirm their eligibility. That alone is adding between three to four million people to the Medicaid rolls, Hammelman said.
Many doctors now limit the number of Medicaid and underinsured patients they see, balancing their practices' bottom lines with profits from commercial payers; if the number of commercially insured goes down, so will a practice's ability to accept Medicaid, several acknowledged.
Nathan Kaufman, a health system consultant, said the impact will be particularly severe for California. "There are large health systems in that state that are going to get creamed because so much of their commercial business will shift to Medicaid." The recent HMA analysis projected an increase in Medicaid enrollment in California between 1.5 million and 3 million by late summer.
Glenn Melnick, PhD, health economist at the University of Southern California, said that while not all people who lose their jobs will be without coverage, the bad news is millions will not have access to their regular providers, realizing that many will not accept Medicaid payment. "And the question is, how quickly the Medi-Cal system will expand," he said, referring to California's Medicaid program.
Several analysts said it's unclear whether employers will hire workers back, but on a part-time basis without health coverage, until the pandemic subsides. It wasn't part of the HMA analysis, but Hammelman said they've been hearing stories suggesting "a lot of folks are shifting over to the gig economy. And what does that mean longer term for jobs and what does that mean longer term for insurance?"
More Hassle
The second reason is the dramatically increased amount of time and level of difficulty and hassle now required to treat a patient under COVID-19 rules, especially in practices where restrictions allow one patient or family member into an office at a time, or when doctors feel compelled to see a coughing patient in the parking lot instead of an exam room. That greatly reduces the number of patients a doctor can see in a day.
Telemedicine can suffice, but the satisfaction -- compared with seeing a patient in person -- is less than optimal, several physicians said, especially for some older doctors who have been less eager to embrace technology.
Doctors and their teams must gown and mask with appropriate personal protective equipment (PPE), which some doctors said is still difficult to find. They may insist that their patients do so as well, which can meet with resistance. Many physicians have learned to get by with video consults instead of face-to-face encounters.
"I had one patient tell me he didn't want to wear a mask," said Barbara Hummel, MD, 76, a family doctor in solo practice in Greenfield, Wisconsin. "He said it was his right not to. I said, 'well, unfortunately it's my right not to see you, if you're not willing to wear a mask.'"
Providers who decide to stick it out are having to come up with novel ways to organize and sanitize their practices, said pediatrician David Arkin, MD, owner of a three-physician practice in suburban Richmond, Virginia.
"It's cumbersome to be seeing patients one at a time, to clean the rooms in between each patient, seeing the sick ones out in their cars in the parking lot, and taking co-pay money over the phone," said Arkin, but it's all necessary to keep themselves and patients safe.
Age Group at Risk
The third major impact on the older physician is the health risk they and their families face should they become infected. Even a pediatrician like Arkin, 70, can become ill. In fact he did, with three weeks in March spent at home with his worried wife, being "the sickest I've ever been."
Arkin believes he was infected by an undiagnosed asymptomatic child. "I only saw a few sick patients and none of them had anything that looked or sounded like COVID. Kids don't have to be sick in order to spread an illness."
He hopes he has protective antibodies and isn't too worried about getting sick again, so for now, he'll keep going. "So far I'm doing okay with that, but it might come back to haunt me. I don't know."
Hummel also said she's "not ready to quit," but she noted her office is in Milwaukee County, which as of Monday had by far the greatest number of COVID-19 cases and deaths in Wisconsin, at 7,799 and 299, respectively. Two of her patients have tested positive.
A past president of the Wisconsin Medical Society and former chair of the American Medical Association's Senior Physicians Governing Council, she said a lot of her colleagues are "really nervous. We're in an age group that puts us at high risk."
Personal Decisions
Hummel limits her practice to one patient at a time, which means she's seeing one patient every 45 minutes to an hour, and gloving, masking, and "gowning up like crazy so I look like something from another planet."
Telemedicine helps, but not so much for Hummel. "I'm old fashioned enough to believe in hands-on medical care. How do you deal with a sore throat by telemedicine? I can't look at their chest pain or their shortness of breath."
But Hummel loves seeing patients so much, she's willing to risk it, even "supporting my practice with my own personal funds, my personal savings account." She got some federal Paycheck Protection Program (PPP) funds, and that helped, but it only went so far. By September, she said, she'll make a decision. "I can't leave myself with nothing to get through the rest of my life."
Another solo practice physician in his early 60s, in the COVID-19 high-risk specialty of otolaryngology, said he too will retire early because of the pandemic.
"The COVID risks -- and more so the COVID financial impacts on practicing, with low patient volumes, no elective surgery, increased costs for PPE when available, and liability issues -- make early exits for those already considering retirement more attractive," he said, requesting anonymity.
The physician fears another COVID wave this fall or next year, when further federal support may be limited, a kind of coup-contrecoup to practices as they struggle to recover.
Bottom Line
While all three factors have prompted doctors to reconsider their roles in the healthcare workforce, the financial bottom line may be the most important, said R. Shawn Martin, CEO-designate for the American Academy of Family Physicians (AAFP).
"Cash flow problems are putting a lot of pressure on doctors now," Martin said. And for physicians who are older, or under pressure financially, there's this risk, and "there's an incentive for them to leave the workforce."
Martin said AAFP members are reporting that hospitals and corporations are seeking to buy their practices.
Some will retire and sell out, Martin said. "What we're really worried about is the people ... in their mid-50s who sell their practice in a fire sale back to some venture or private equity company, because it's not worth it to kind of ride out this wave and they just want to unload the asset."
He added that what AAFP and other physician groups really want right now are federal dollars to maintain practice operations. "Do we need to pay telemedicine better? Of course. Do we need to figure out ways to provide more robust services in an asynchronous way? Of course. But right now, they just need to keep their doors open."
Matt Salo, executive director of the National Association of Medicaid Directors, said a lot of providers across the treatment spectrum have seen utilization and revenue drop by as much as 90% or more. "What is going to happen to them? Can they sustain two, four, six, nine months more where their revenue takes a hit like that?"
Compounding the issue is how states will reduce the amount they spend on Medicaid, even if the federal government approves plans to raise the federal match. They can reduce the number of people covered, reduce the benefits offered, or reduce provider payment, he said.
In California, for example, where 13 million people were enrolled in Medi-Cal before the pandemic -- one-third of the state's population -- the May revised budget calls for reductions or cancellations of coverage in many prevention and treatment programs.
On the chopping block: adult dental, audiology, incontinence creams, speech therapy, optician and podiatric care, acupuncture, optometry, nurse anesthetists, occupational and physical therapy, pharmacist services and referrals for treatment for opioids and other illicit drugs, pharmacist services and diabetes prevention programs, a projected saving to the general fund of $54.7 million.
"States have to balance their budgets," Salo continued. It's "a really unfortunate perfect storm where states are scrambling over the next couple of months figuring out what to do. And the unfortunate answer is, barring significant congressional intervention [to] massively reduce reimbursement rates."
Bob Doherty, senior vice president at the American College of Physicians, echoed that concern. "As people lose employer-sponsored care, more will end up in Medicaid, especially in expansion states," he said. And without increases in the federal Medicaid match rates, "states will likely respond by cutting payments to physicians and hospitals, and optional benefits and eligibility. Physicians will not be able to accept more Medicaid patients if the already-low Medicaid rates are cut further."
For Hay, retirement plans are evolving. He's long been active in AMA leadership and hopes to spend time promoting a return to civil discourse, and running and birding and maybe, when it's safer to travel, going on a few trips with his wife. At least he won't have to worry so much about COVID-19.
https://www.medpagetoday.com/publichealthpolicy/workforce/86857?xid=nl_popmed_2020-06-04&eun=g415976d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=CoronaBreak_060420&utm_term=NL_Daily_Breaking_News_Active
https://www.nytimes.com/2020/05/28/us/medicare-fraud-las-vegas.html?action=click&module=
ER Visit For COVID-19 Symptoms Stuck Man With A $3,278 Bill
by Paul Gelewitz - SHOTS - May 26, 2020
From late March into April, Timothy Regan had severe coughing fits several times a day that often left him out of breath. He had a periodic low-grade fever too.Wondering if he had COVID-19, Regan called a nurse hotline run by Denver Health, a large public health system in his city. A nurse listened to him describe his symptoms and told him to immediately go to the hospital system's urgent care facility.
When he arrived at Denver Health — where the emergency room and urgent care facility sit side by side at its main location downtown — a nurse directed him to the ER after he noted chest pain as one of his symptoms.
Regan was seen quickly and given a chest X-ray and electrocardiogram, known as an EKG, to check his lungs and heart. Both were normal.
A doctor prescribed an inhaler to help his breathing and told him he might have bronchitis. The doctor advised that he had to presume he had COVID-19 and must quarantine at home for two weeks.
At the time, on April 3, Denver Health reserved COVID-19 tests for sicker patients. Two hours after arriving at the hospital, Regan was back home. His longest wait was for his inhaler prescription to be filled.
Regan wasn't concerned about just his own health. His wife, Elissa, who is expecting their second child in August, and their 1-year-old son, Finn, also felt sick with symptoms like those of COVID-19 in April. "Nothing terrible but enough to make me worry," he said.
Regan, who is an estimator for a construction firm, worked from home throughout his sickness — including while quarantined. (Construction in Colorado and many states has been considered an essential business and has continued to operate.) Regan said he was worried about taking a day off and losing his job.
"I was thinking I had to make all the money I could in case we all had to be hospitalized," he said. "All I could do was keep working in hopes that everything would be OK."
Within a couple of weeks, the whole family indeed was OK. "We got lucky," Elissa said.
Then the bill came.
The patient: Timothy Regan, 40, an estimator for a construction company. The family has health insurance through Elissa's job at a nonprofit in Denver.
Total bill: Denver Health billed Regan $3,278 for the ER visit. His insurer paid $1,042, leaving him with $2,236 to pay based on his $3,500 in-network deductible. The biggest part of the bill was the $2,921 general ER fee.
Service provider: Denver Health, a large public health system
Medical service: Regan was evaluated in the emergency room for COVID-19-like symptoms, including a severe cough, fever and chest pain. He was given several tests to check his heart and lungs, prescribed an inhaler and sent home.
What gives: When patients use hospital emergency rooms — even for short visits with few tests — it's not unusual for them to get billed thousands of dollars no matter how minor the treatment received. Hospitals say the high fees come from having to staff the ER with specialists 24 hours a day and keep lifesaving equipment up to date.
Denver Health coded Timothy's ER visit as a Level 4 — the second highest and second most expensive — on a 5-point scale. The other items on his bill were $225 for the EKG, $126 for the chest X-ray and $6 for his albuterol inhaler, a medication that provides quick relief for breathing problems.
The Regans knew they had a high deductible, and they try to avoid unnecessarily using the ER. But with physician offices not seeing patients with COVID-19 symptoms in April, Timothy said he had little choice when Denver Health directed him first to its urgent care and then to its ER. "I felt bad, but I had been dealing with it for a while," he said.
Elissa said they were trying hard to do everything by the book, including using a health provider in their plan's network.
"We did not anticipate being hit with such a huge bill for the visit," Elissa said. "We had intentionally called the nurse's line trying to be responsible, but that did not work."
In an effort to remove barriers to people getting tested and evaluated for COVID-19, UnitedHealthcare is one of many insurers that announced it will waive cost sharing for COVID-19 testing-related visits and treatment. But it is not clear how many people who had COVID-19 symptoms but who did not get tested when tests were in short supply have been billed as the Regans were.
Resolution: A Denver Health spokesperson said Regan was not tested for COVID-19 because he was not admitted and did not have risk factors such as diabetes, heart disease or asthma. He was not billed as a COVID-19 patient because he was not tested for the virus. The medical center has since expanded its testing capacity, the spokesperson said.
UnitedHealthcare officials reviewed Regan's case at the request of Kaiser Health News. Based on Regan's symptoms and the tests performed, Denver Health should have billed them using a COVID-19 billing code, an insurer spokesperson said. "We reprocessed Mr. Regan's original claims after reviewing the services that he received," a UnitedHealthcare spokesperson said. "All cost share for that visit has been waived."
The Regans said they were thrilled with UHC's decision.
"That is wonderful news," Elissa said upon hearing from a KHN reporter that UHC would waive their costs. "We are very thankful. It is a huge relief."
The takeaway: The Regans said they initially found no satisfaction in calling the hospital or the insurer to resolve their dispute — but it was the right thing to do.
"He's definitely not alone," said Sabrina Corlette, a research professor at Georgetown University's Center on Health Insurance Reforms. "The takeaway here is both the provider as well as insurance company are still on a learning curve with respect to this virus and how to bill and pay for it."
Corlette said Timothy should not have second-guessed his decision to use the Denver Health ER when directed there by a nurse. That, too, was the right call.
Insurers' move to waive costs associated with COVID-19 testing and related treatment is vital to stem the outbreak — but it works only if patients can trust they won't get stuck with a large bill, she said. "It's a critical piece of the public health strategy to beat this disease," Corlette said.
To help with billing, she said, patients could ask their provider to note on their medical chart when they seek care for a possible case of COVID-19. But it's not patients' responsibility to make sure providers use the right billing code, she said. Patients need to know they have rights to appeal costs to their insurer. They can also seek assistance from their employer's benefits department and state insurance department.
https://www.npr.org/sections/health-shots/2020/05/26/860266113/er-visit-for-a-covid-like-cough-stuck-man-with-a-3-278-bill
For Some Private Practices, COVID-19 Is the Last Straw
— Pandemic seen decimating physician workforce as at-risk older doctors cash out
by Cheryl Clark - MedPage Today - June 3, 2020
For 42 years, James Hay, MD, had been seeing patients at the family practice he started in the Southern California beach town of Encinitas. Hay, the former president of the California Medical Association, loved his work and thought he'd keep at it at least through the end of the year.
On March 6, however, one of his partners saw a patient who -- according to a call from a county health official -- was the first confirmed case of COVID-19 in a resident who hadn't recently traveled out of town. That meant the virus was now being transmitted locally.
That turned out to be incorrect; the patient had been skiing in another state. But the positive test sent shockwaves through his practice.
It was all the more disconcerting for Hay, 73, who knew his age and a minor medical issue put him at greater risk for severe illness if he were to get infected because so little was known about how the virus behaved. When his practice partner Amy Kakimoto, MD, called him that night with the patient's test result, "she said, 'Stay home.' So I haven't been inside the office since March 11."
County public health officials issued a shut-down order a few days later and soon, office visits and revenue for Hay's six-physician practice -- and tens of thousands of others throughout the country -- plummeted as few patients ventured in for care. His group had to cut way back as many on his team took weeks off.
"I've stayed home, because of my age, doing video visits with patients instead," he said.
All that prompted Hay to come to a difficult decision. He told MedPage Today that he was retiring early, and May 28 was his last day seeing patients. He would save the practice his salary and he wouldn't have to worry as much about risks to his own health.
Hay is not alone. Dozens of physicians, practice managers, and medical society executives around the country said that among older doctors still practicing -- 120,000 of whom were 65 or older in 2017, according to one survey -- talk of an earlier-than-planned retirement is getting louder in the eye of the pandemic. While far from a groundswell, Don Palmisano Jr., executive director and CEO of the Medical Association of Georgia, heard from doctors in one health system that "older physicians have voiced their intent to possibly retire."
Three Factors
The reasons for early retirement are threefold, according to physicians interviewed for this story, some of whom asked they not be named because they haven't made a decision, haven't told their spouses, or don't want to go public with their fear that they could unknowingly bring the virus home to their families.
First among the influential factors is analysts' projections of a looming major decrease in commercial coverage, in a mid-May update from the national consulting firm Health Management Associates, for example, and a similar report from the Kaiser Family Foundation. The HMA report estimated the number of people with employer sponsored-plans could drop from 165 million as of February (pre-COVID) to as low as 138 million by year's end, depending on whether job losses are moderate, heavy, or severe.
Meanwhile, the number of uninsured are estimated to increase from 29 million to as high as 34 million, the HMA report projects.
While some laid-off workers will be able to afford an individual marketplace plan (though not in the Obamacare exchanges, which the Trump administration decided not to reopen), millions more are expected to enroll in Medicaid, which reimburses at 50% to 60% of commercial payers' rates, and 70% to 75% of what Medicare pays for the same services.
HMA estimates Medicaid enrollment could go from 71 million people to 76-89 million by the end of this year, said Eric Hammelman, an author of the HMA analysis.
"There will be drastically reduced 'churning,' of patients going on and off Medicaid for the duration of the emergency," especially since the Families First Coronavirus Response Act (FFCRA), which took effect in mid-March, limited the ability of states to involuntarily disenroll or terminate people from the Medicaid project if they didn't reaffirm their eligibility. That alone is adding between three to four million people to the Medicaid rolls, Hammelman said.
Many doctors now limit the number of Medicaid and underinsured patients they see, balancing their practices' bottom lines with profits from commercial payers; if the number of commercially insured goes down, so will a practice's ability to accept Medicaid, several acknowledged.
Nathan Kaufman, a health system consultant, said the impact will be particularly severe for California. "There are large health systems in that state that are going to get creamed because so much of their commercial business will shift to Medicaid." The recent HMA analysis projected an increase in Medicaid enrollment in California between 1.5 million and 3 million by late summer.
Glenn Melnick, PhD, health economist at the University of Southern California, said that while not all people who lose their jobs will be without coverage, the bad news is millions will not have access to their regular providers, realizing that many will not accept Medicaid payment. "And the question is, how quickly the Medi-Cal system will expand," he said, referring to California's Medicaid program.
Several analysts said it's unclear whether employers will hire workers back, but on a part-time basis without health coverage, until the pandemic subsides. It wasn't part of the HMA analysis, but Hammelman said they've been hearing stories suggesting "a lot of folks are shifting over to the gig economy. And what does that mean longer term for jobs and what does that mean longer term for insurance?"
More Hassle
The second reason is the dramatically increased amount of time and level of difficulty and hassle now required to treat a patient under COVID-19 rules, especially in practices where restrictions allow one patient or family member into an office at a time, or when doctors feel compelled to see a coughing patient in the parking lot instead of an exam room. That greatly reduces the number of patients a doctor can see in a day.
Telemedicine can suffice, but the satisfaction -- compared with seeing a patient in person -- is less than optimal, several physicians said, especially for some older doctors who have been less eager to embrace technology.
Doctors and their teams must gown and mask with appropriate personal protective equipment (PPE), which some doctors said is still difficult to find. They may insist that their patients do so as well, which can meet with resistance. Many physicians have learned to get by with video consults instead of face-to-face encounters.
"I had one patient tell me he didn't want to wear a mask," said Barbara Hummel, MD, 76, a family doctor in solo practice in Greenfield, Wisconsin. "He said it was his right not to. I said, 'well, unfortunately it's my right not to see you, if you're not willing to wear a mask.'"
Providers who decide to stick it out are having to come up with novel ways to organize and sanitize their practices, said pediatrician David Arkin, MD, owner of a three-physician practice in suburban Richmond, Virginia.
"It's cumbersome to be seeing patients one at a time, to clean the rooms in between each patient, seeing the sick ones out in their cars in the parking lot, and taking co-pay money over the phone," said Arkin, but it's all necessary to keep themselves and patients safe.
Age Group at Risk
The third major impact on the older physician is the health risk they and their families face should they become infected. Even a pediatrician like Arkin, 70, can become ill. In fact he did, with three weeks in March spent at home with his worried wife, being "the sickest I've ever been."
Arkin believes he was infected by an undiagnosed asymptomatic child. "I only saw a few sick patients and none of them had anything that looked or sounded like COVID. Kids don't have to be sick in order to spread an illness."
He hopes he has protective antibodies and isn't too worried about getting sick again, so for now, he'll keep going. "So far I'm doing okay with that, but it might come back to haunt me. I don't know."
Hummel also said she's "not ready to quit," but she noted her office is in Milwaukee County, which as of Monday had by far the greatest number of COVID-19 cases and deaths in Wisconsin, at 7,799 and 299, respectively. Two of her patients have tested positive.
A past president of the Wisconsin Medical Society and former chair of the American Medical Association's Senior Physicians Governing Council, she said a lot of her colleagues are "really nervous. We're in an age group that puts us at high risk."
Personal Decisions
Hummel limits her practice to one patient at a time, which means she's seeing one patient every 45 minutes to an hour, and gloving, masking, and "gowning up like crazy so I look like something from another planet."
Telemedicine helps, but not so much for Hummel. "I'm old fashioned enough to believe in hands-on medical care. How do you deal with a sore throat by telemedicine? I can't look at their chest pain or their shortness of breath."
But Hummel loves seeing patients so much, she's willing to risk it, even "supporting my practice with my own personal funds, my personal savings account." She got some federal Paycheck Protection Program (PPP) funds, and that helped, but it only went so far. By September, she said, she'll make a decision. "I can't leave myself with nothing to get through the rest of my life."
Another solo practice physician in his early 60s, in the COVID-19 high-risk specialty of otolaryngology, said he too will retire early because of the pandemic.
"The COVID risks -- and more so the COVID financial impacts on practicing, with low patient volumes, no elective surgery, increased costs for PPE when available, and liability issues -- make early exits for those already considering retirement more attractive," he said, requesting anonymity.
The physician fears another COVID wave this fall or next year, when further federal support may be limited, a kind of coup-contrecoup to practices as they struggle to recover.
Bottom Line
While all three factors have prompted doctors to reconsider their roles in the healthcare workforce, the financial bottom line may be the most important, said R. Shawn Martin, CEO-designate for the American Academy of Family Physicians (AAFP).
"Cash flow problems are putting a lot of pressure on doctors now," Martin said. And for physicians who are older, or under pressure financially, there's this risk, and "there's an incentive for them to leave the workforce."
Martin said AAFP members are reporting that hospitals and corporations are seeking to buy their practices.
Some will retire and sell out, Martin said. "What we're really worried about is the people ... in their mid-50s who sell their practice in a fire sale back to some venture or private equity company, because it's not worth it to kind of ride out this wave and they just want to unload the asset."
He added that what AAFP and other physician groups really want right now are federal dollars to maintain practice operations. "Do we need to pay telemedicine better? Of course. Do we need to figure out ways to provide more robust services in an asynchronous way? Of course. But right now, they just need to keep their doors open."
Matt Salo, executive director of the National Association of Medicaid Directors, said a lot of providers across the treatment spectrum have seen utilization and revenue drop by as much as 90% or more. "What is going to happen to them? Can they sustain two, four, six, nine months more where their revenue takes a hit like that?"
Compounding the issue is how states will reduce the amount they spend on Medicaid, even if the federal government approves plans to raise the federal match. They can reduce the number of people covered, reduce the benefits offered, or reduce provider payment, he said.
In California, for example, where 13 million people were enrolled in Medi-Cal before the pandemic -- one-third of the state's population -- the May revised budget calls for reductions or cancellations of coverage in many prevention and treatment programs.
On the chopping block: adult dental, audiology, incontinence creams, speech therapy, optician and podiatric care, acupuncture, optometry, nurse anesthetists, occupational and physical therapy, pharmacist services and referrals for treatment for opioids and other illicit drugs, pharmacist services and diabetes prevention programs, a projected saving to the general fund of $54.7 million.
"States have to balance their budgets," Salo continued. It's "a really unfortunate perfect storm where states are scrambling over the next couple of months figuring out what to do. And the unfortunate answer is, barring significant congressional intervention [to] massively reduce reimbursement rates."
Bob Doherty, senior vice president at the American College of Physicians, echoed that concern. "As people lose employer-sponsored care, more will end up in Medicaid, especially in expansion states," he said. And without increases in the federal Medicaid match rates, "states will likely respond by cutting payments to physicians and hospitals, and optional benefits and eligibility. Physicians will not be able to accept more Medicaid patients if the already-low Medicaid rates are cut further."
For Hay, retirement plans are evolving. He's long been active in AMA leadership and hopes to spend time promoting a return to civil discourse, and running and birding and maybe, when it's safer to travel, going on a few trips with his wife. At least he won't have to worry so much about COVID-19.
https://www.medpagetoday.com/publichealthpolicy/workforce/86857?xid=nl_popmed_2020-06-04&eun=g415976d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=CoronaBreak_060420&utm_term=NL_Daily_Breaking_News_Active
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