This Week in Coronavirus: May 14 to 21

Published: May 22, 2020

Every Friday, we’re recapping the latest on the coronavirus from our tracking, policy analysis, polling, and journalism. Total cases in the U.S. are still climbing, and this week increased by 159,400, bringing the cumulative total of cases past 1.5 million. This week, approximately 8,880 people died from COVID-19 in the U.S., bringing the total to 94,500. Across 38 states reporting this data yesterday, 42% of deaths occurred in long-term care facilities.

Meanwhile, since last Thursday, 11 more states have eased at least one social distancing requirement. Restaurants have reopened to dine-in service in 8 more states, and 7 states have eased or lifted their gatherings ban.

Recent KFF analysis finds that while non-metro areas currently have fewer coronavirus cases per capita, both cases and deaths are growing at a faster rate compared to metro counties. For example, non-metro counties saw a 56% increase in cases over a two week period, versus 32% in metro counties in the same period.

Our global COVID-19 Coronavirus Tracker has a new tab displaying cases/deaths by country on a timeline along with the actions world governments have taken to address the pandemic – such as closures of businesses and public services, school closures, and international travel restrictions. The United States timeline only shows federal actions. State-level policy actions can be found in our State Data and Policy Actions to Address Coronavirus tracker.

 

Here are more of the latest coronavirus stats from KFF’s tracking resources:

Global Cases and Deaths: This week, total cases worldwide passed 5 million – with approximately 660,300 new confirmed cases added between May 14 and May 21. There were approximately 30,500 new confirmed deaths worldwide between May 14 and May 21.

U.S. Cases and Deaths: There have been over 1.5 million total confirmed cases in the U.S. There were approximately 159,400 new confirmed cases and 8,880 confirmed deaths in the United States between May 14 and May 21.

U.S. Tests: There have been over 13 million total COVID-19 tests with results in the United States — with approximately 3 million added since May 14. 12% of the total tests were positive. There have been 39.8 tests with results per 1,000 people in the U.S.

State Reports of Long-Term Care Facility Cases and Deaths Related to COVID-19 (Includes Washington D.C.)

  • Data Reporting Status: 47 states are reporting COVID-19 data in long-term care facilities, 4 states are not reporting
  • Long-term care facilities with known cases: 7,732 (in 43 states)
  • Cases in long-term care facilities: 174,381 (in 42 states)
  • Deaths in long-term care facilities: 35,118 (in 37 states)
  • Long-term care facilities as a share of total state cases: 16% (across 42 states)
  • Long-term care facility deaths as a share of total state deaths: 42% (across 38 states)

State Social Distancing Actions (includes Washington D.C.):

  • Social Distancing: 48 states have eased at least one social distancing measure.
  • Stay At Home Order: Original stay at home order in place in 20 states, stay at home order eased or lifted in 25 states, no action in 6 states
  • Mandatory Quarantine for Travelers: Original traveler quarantine mandate in place in 16 states, traveler quarantine mandate eased or lifted in 8 states, no action in 27 states
  • Non-Essential Business Closures: Original non-essential business closures still in place in 3 states, some or all non-essential business permitted to reopen (some with reduced capacity) in 42 states, no action in 6 states
  • Large Gatherings Ban: Original gathering ban/limit in place in 32 states, gathering/ban limit eased or lifted in 18 states, no action in 1 states
  • State-Mandated School Closures: Closed in 7 states, closed for school year in 36 states, recommended closure in 1 state, recommended closure for school year in 6 states, rescinded in 1 state
  • Restaurant Limits: Original restaurant closures still in place in 22 states, restaurants re-opened to dine-in service in 28 states, no action in 1 state
  • Primary Election Postponement: Postponement in 14 states, cancelled in 1 state, no postponement in 36 states
  • Emergency Declaration: There are emergency declarations in all states and D.C.

State COVID-19 Health Policy Actions (Includes Washington D.C.)

  • Waive Cost Sharing for COVID-19 Treatment: 3 states require, state-insurer agreement in 3 states; no action in 45 states
  • Free Cost Vaccine When Available: 9 states require, state-insurer agreement in 1 state, no action in 41 states
  • States Requires Waiver of Prior Authorization Requirements: For COVID-19 testing only in 5 states, for COVID-19 testing and treatment in 6 states, no action in 40 states
  • Early Prescription Refills: State requires in 18 states, no action in 33 states
  • Premium Payment Grace Period: Grace period extended for all policies in 11 states, grace period extended for COVID-19 diagnosis/impacts only in 5 states, no action in 35 states
  • Marketplace Special Enrollment Period: Marketplace special enrollment period in 12 states, no special enrollment period in 39 states
  • Paid Sick Leave: 13 states enacted, 2 proposed, no action in 36 states

State Actions on Telehealth (Includes Washington D.C.)

38 states overall have taken mandatory action expanding access to telehealth services through private insurers, including:

  • New Requirements for Coverage of Telehealth Services: Parity with in-person services in 6 states, broad coverage of telehealth services in 6 states, limited coverage of telehealth services in 6 states, no action in 33 states
  • Waiving or Limiting Cost-Sharing for Telehealth Services: Waived for COVID-19 services only in 7 states, waived or limited for all services in 9 states, no action in 35 states
  • Reimbursement Parity for Telehealth and In-Person Services: Required for all services in 17 states, no action in 34 states
  • Require Expanded Options for Delivery of Telehealth Services: Yes in 35 states, for behavioral health services only in 1 state, no action in 15 states

Approved Medicaid State Actions to Address COVID-19 (Includes Washington D.C.)

  • Approved Section 1115 Waivers to Address COVID-19: 1 state (Washington) has an approved waiver
  • Approved Section 1135 Waivers: 51 states have approved waivers
  • Approved 1915 (c) Appendix K Waivers: 43 states have approved waivers
  • Approved State Plan Amendments (SPAs): 34 states have temporary changes approved under Medicaid or CHIP disaster relief SPAs, 1 state has an approved traditional SPA
  • Other State-Reported Medicaid Administrative Actions: 51 states report taking other administrative actions in their Medicaid programs to address COVID-19

Adults at Higher Risk of Serious Illness if Infected with Coronavirus: 38% of all U.S. adults are at risk of serious illness if infected with coronavirus (92,560,223 total) due to their age (65 and over) or pre-existing medical condition. Of those at higher risk, 45% are at increased risk of serious illness if infected with coronavirus due to their existing medical condition such as such as heart disease, diabetes, lung disease, uncontrolled asthma or obesity. Among nonelderly adults — low-income, American Indian/Alaska Native & Black adults have a higher risk of serious illness if infected with coronavirus. In both cases – for race and household income – the higher risk of serious illness if infected with coronavirus is chiefly due to a higher prevalence of underlying health conditions and longstanding disparities in health care and other socio-economic factors.

 

This week’s posts in Coronavirus Policy Watch:  

  • Drew Altman on Big Questions for the Health Policy Community Emerging From the Coronavirus Crisis (Post)

The latest KFF COVID-19 resources:

  • KFF Health Tracking Poll – May 2020 (Poll Finding)
  • State Actions to Facilitate Access to Medicaid and CHIP Coverage in Response to COVID-19 (Issue Brief)
  • COVID-19 in Metropolitan and Non-Metropolitan Counties (Slideshow)
  • Drew Altman: The Coronavirus Economy Could Make a Medicare Buy-In More Popular (Axios Column)
  • How Have Healthcare Utilization and Spending Changed So Far During the Coronavirus Pandemic? (Chart Collection)
  • Impact of Coronavirus on Community Health Centers (Issue Brief)
  • COVID-19 & PEPFAR: Implications for the Future (Issue Brief)
  • Updated: State Action to Limit Abortion Access During the COVID-19 Pandemic (Issue Brief)
  • COVID-19 Pandemic Threatens To Push Millions Of People Into Poverty, U.N. SG, World Bank President Warn; Response Requires Coordination To Keep SDGs On Track, Guterres Says (KFF Daily Global Health Policy Report)

Trackers and Tools

 

The latest KHN COVID-19 stories:

  • Reopening Dental Offices For Routine Care Amid Pandemic Touches A Nerve (KHN, NBC)
  • Scientist Has ‘Invisible Enemy’ In Sights With Microscopic Portraits Of Coronavirus (KHN, Time)
  • Analysis: Get Ready For The Vaccine — They’re Never Simple (KHN, LA Times)
  • KHN’s ‘What The Health?’: When It Comes To COVID-19, States Are On Their Own (Podcast)
  • Congress Said COVID-19 Tests Should Be Free — But Who’s Paying? (KHN, NPR)
  • The 30-Somethings Who Fled Big Cities To Shelter With Mom And Dad (KHN)
  • Coronavirus Tests The Value Of Artificial Intelligence In Medicine (KHN, LA Times)
  • Going The Distance By Bus Through A Pandemic (KHN, US News)
  • Medicaid Providers At The End Of The Line For Federal COVID Funding (KHN, NPR)
  • Tennessee’s Secret To Plentiful Coronavirus Testing? Picking Up The Tab (KHN, NPR)
  • To Stem COVID, This Small Indiana City Decided To Test All Public-Facing Employees (KHN, Side Effects Public Media)
  • Lost On The Frontline (KHN, The Guardian)
  • ‘Last Responders’ Seek To Expand Postmortem COVID Testing In Unexplained Deaths (KHN, NPR)
  • Drugmakers Tout COVID-19 Vaccines To Refurbish Their Public Image (KHN, Daily Beast)
  • The Pandemic Is Hurting Pediatric Hospitals, Too (KHN, San Francisco Chronicle)
  • How A Company Misappropriated Native American Culture To Sell Health Insurance (KHN, Fortune)
  • Fewer Traffic Collisions During Shutdown Means Longer Waits For Organ Donations (KHN, KQED)
  • Tourists, Beware: Foreign Visitors’ Travel Health Insurance Might Exclude Pandemics (KHN, The Guardian)
  • ‘An Arm And A Leg’: Angst And Advice From A Health Insurance Insider (KHN)
  • In The COVID Age, Bring A Mask And Gloves To A Protest (KHN)
  • Listen: Tough Talk On Capitol Hill (KHN)
More On
COVID-19

Also of Interest

State Actions to Facilitate Access to Medicaid and CHIP Coverage in Response to COVID-19

Authors: Rachel Dolan and Samantha Artiga
Published: May 22, 2020
Section:
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Issue Brief

Summary

As many people lose jobs and income due to the COVID-19 outbreak, a growing number will become eligible for Medicaid. To support states as enrollment in Medicaid grows and ensure enrollees maintain coverage, federal legislation provides states a temporary 6.2 percentage point increase in the federal matching rate and establishes conditions states must meet to access the enhanced funding. Beyond the conditions to access the enhanced funding, states can take a range of actions to expand Medicaid eligibility and make it easier for people to enroll. This brief summarizes state changes to Medicaid and CHIP eligibility and enrollment policies in response to the COVID-19 outbreak, beyond those required to access enhanced federal funding. It is based on KFF analysis of approved Medicaid and CHIP state plan amendments (SPAs) and information on state websites as of May 21, 2020.

Overall, 43 states have made changes to facilitate access to Medicaid and/or CHIP coverage in response to the COVID-19 crisis, beyond those required to access enhanced federal funding. These include changes to expand eligibility or modify eligibility rules, eliminate or waive premiums, and streamline application and enrollment processes (Figure 1).

Figure 1: State Eligibility and Enrollment Policy Changes to Facilitate Access to Medicaid/CHIP Coverage in Response to COVID-19, as of May 21, 2020

Background

As many people lose jobs and income due to the COVID-19 outbreak, a growing number will become eligible for Medicaid. A recent KFF analysis shows that, by January 2021, when unemployment insurance benefits cease for most people who lost jobs between March 1 and May 2, 2020, nearly 17 million people could be newly eligible for Medicaid. The Affordable Care Act (ACA) has better positioned state Medicaid and CHIP programs to respond to an emergency such as the COVID-19 outbreak by expanding coverage in many states and establishing streamlined and modernized eligibility and enrollment systems across all states. However, there remains significant variation in eligibility and enrollment policies across states, and states still may face capacity issues as demand grows. To date, 37 states, including DC, have adopted the ACA Medicaid expansion to low-income adults, which will enable many more individuals to qualify for coverage as their incomes decrease.1  However, in the 14 states that have not adopted expansion, low-income adults will continue to face a coverage gap. All states have taken certain steps to streamline eligibility and enrollment under the ACA, but some states have taken up additional options to facilitate enrollment in coverage and the capacity of state eligibility and enrollment systems varies widely across states.2  Further, there are differences in eligibility and enrollment policies for children, pregnant women, parents and other adults compared to policies for people who qualify for age- or disability-based pathways (referred to non-MAGI groups), since some of the ACA simplifications did not extend to or remained optional for these groups.3 

Federal legislation provides temporary enhanced federal Medicaid funding to states and establishes maintenance of eligibility requirements to access the funding. To help support states as enrollment in Medicaid grows and ensure existing enrollees maintain coverage, the Families First Coronavirus Response Act, as amended by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, provides states with a temporary 6.2 percentage point increase in the regular federal matching rate for the emergency period. To receive the enhanced match states cannot implement more restrictive eligibility standards or higher premiums; must provide continuous eligibility for enrollees through the end of the month of the emergency period; and may not charge cost sharing for SARS-CoV-2 or COVID-19 related testing services or treatments.4 ,5  These provisions help ensure continuous coverage for existing Medicaid enrollees during the emergency period. However, they do not extend to children or pregnant women enrolled through CHIP.

Beyond the conditions to access the enhanced funding, states can take a range of actions to expand Medicaid eligibility and make it easier for people to enroll through existing state options and waivers. The Centers for Medicare and Medicaid Services created a Medicaid Disaster Relief SPA as well as waiver templates to facilitate states’ ability to make program changes in response to COVID-19. States can also make changes through regular SPAs. Moreover, states can make some changes that do not require federal approval. Changes made through a disaster SPA or waiver are tied to the duration of the public health emergency period, which was extended at the end of April for an additional 90 days.

State Actions to Facilitate Access to Medicaid or CHIP

This brief summarizes changes states are making to Medicaid and CHIP eligibility and enrollment policies to facilitate access to coverage in response to the COVID-19 outbreak, beyond those required to access enhanced federal funding. It is based on KFF analysis of approved Medicaid and CHIP SPAs posted on Medicaid.gov, as well as analysis of state actions in response to COVID-19 posted on state websites and in verification plans as of May 20, 2020. States are continuing to take actions, and regularly updated information is available on the KFF Medicaid Emergency Authority Tracker. This analysis does not include changes to comply with the requirements to access enhanced federal funding or other changes states are making to Medicaid or CHIP programs, such as changes to benefits, cost sharing, or payment policies.

Overall, 43 states have taken action to facilitate access to Medicaid and/or CHIP coverage in response to the COVID-19 crisis, beyond those required to obtain enhanced federal funding (Figure 1). Among these, a number of states have taken multiple actions.

Eligibility Expansions and Other Eligibility Policy Changes

Optional Coverage of Coronavirus Testing for Uninsured Individuals. Twenty states have taken up the new optional Medicaid eligibility pathway that provides 100% federal matching funds for states to cover coronavirus testing and testing-related services for uninsured individuals, which was established by the Families First Coronavirus Response Act, as amended by the CARES Act.6 

Twenty-one states have made other changes to eligibility criteria or processes, with some states making multiple changes. These actions include:

Other optional expansions. New Mexico has extended coverage to adults up to 200% FPL as part of their adult expansion group.

Changes to state residency criteria. Nine states are continuing eligibility for beneficiaries who have had to evacuate during the emergency or are temporarily out of state. Alaska and Washington are covering non-residents that are in the state temporarily.

Modifications to Eligibility Criteria for Non-MAGI Groups. States also have made changes to eligibility criteria for seniors and individuals that qualify for Medicaid on the basis of a disability to facilitate access to coverage. Five states (CA, IL, MO, WA, and VT) are applying less restrictive income or resource asset methodologies for these beneficiaries, who can be subject to income limits and asset tests as part of eligibility determinations.7  Missouri expanded coverage to adults who test positive for coronavirus by considering it a qualifying disability for its aged/blind/disabled pathway.8  Massachusetts is allowing people with disabilities whose eligibility is subject to a medical spend down to obtain a temporary hardship waiver of the spend down requirement during the public health emergency.

Allowing self-attestation of additional eligibility criteria. All states must verify citizenship or immigration status, as well as income, to determine Medicaid and CHIP eligibility.9  States can verify income prior to enrollment or enroll based on the applicant’s reported income and verify post-enrollment. For other eligibility criteria, including age/date of birth, state residency, and household size, states can verify this information before or after enrollment or accept an individual’s self-attestation. To expedite enrollment, states can allow for self-attestation for all eligibility criteria, excluding citizenship and immigration status, on a case-by-case for individuals subject to a disaster when documentation is not available.10  Thirteen states have taken up this option in response to COVID-19. In addition, Illinois and Ohio have increased their reasonable compatibility threshold, meaning the state has increased the difference between the amount of reported income and the amount identified through electronic data matches that it allows to determine an individual eligible.

Providing extended time to complete application or provide verification. Florida has extended the timeframe allowed to complete a Medicaid application, providing individuals more time to submit paperwork, while still using the initial application date as the basis for the start date for coverage. Further, eight states have extended the period they provide individuals to verify immigration status. States must verify immigration status prior to determining eligibility; however, they must give individuals who attest to a qualified status a reasonable amount of time to provide documentation.

Elimination or Waivers of Premiums

Seventeen states either eliminated or waived premiums in Medicaid as of May 21, 2020. Prior to the COVID-19 outbreak, four states (CA, MD, MI, and VT) charged premiums to children in Medicaid, and six states (AR, IN, IA, MI, MT, WI) charged premiums or monthly contributions for adults in Medicaid. Three of these states (CA, MD, and VT) suspended premiums for children, and three states (IA, IN, and WI) eliminated premiums for other adult coverage groups in response to the COVID-19 outbreak. In addition, as of 2018, 34 of 45 states that offer a buy-in Medicaid program for working individuals with disabilities charged premiums, and some states charge premiums for children eligible through other disability-based eligibility pathways.11  A total of 16 states (AK, AZ, CA, CO, IA, ID, IL, IN, MD, ME, MN, NC, ND, WI, WY, and WA) report eliminating enrollment fees, premiums, or similar charges that apply to programs for people with disabilities in Medicaid in response to COVID-19, and one state (MO) has waived these premiums for individuals experiencing hardship due to COVID-19. Massachusetts had an existing waiver of premiums for individuals experiencing hardship; it has allowed individuals to self-attest to hardship in response to COVID-19. Under the requirements to access enhanced federal Medicaid funding, states must provide continuous eligibility through the end of the month in which the public health emergency ends. As such, even if a state has not eliminated or waived premiums, it cannot disenroll individuals due to unpaid premiums.

A total of 18 states report eliminating or waiving enrollment fees, premiums, or similar charges in CHIP. In addition, as noted above, Massachusetts had an existing premium hardship waiver, but has newly allowed individuals to self-attest to hardship in response to COVID-19. Prior to the outbreak, 26 of the 35 states with separate CHIP programs charged annual enrollment fees or monthly or quarterly premiums for children. Following this state action, most of these states have eliminated or waived premiums during the public health emergency. However, states vary in how they are implementing these changes and communicating them to enrollees. For example, some states are broadly communicating the change to families and suspending collection of payments, some are only waiving or suspending them for families experiencing hardship, and some are continuing to charge premiums but not disenrolling families due to nonpayment.

Streamlined Enrollment Processes

A total of 23 states have made changes to their Medicaid/CHIP enrollment and application processes as of May 21, 2020, with some states taking multiple actions. These changes include:

Expanded Use of Presumptive Eligibility. Presumptive eligibility (PE) is a longstanding option that allows states to authorize certain qualified entities, like community health centers or schools, to enroll individuals who appear likely eligible for coverage while the state processes the full application. Under the ACA, states were required to allow hospitals to conduct PE determinations regardless of whether the state had otherwise adopted the policy.12  As of January 2020, 31 states were using PE to expedite enrollment for one or more groups. A total of 6 (IL, KS, NE, NM, OR, and WA) of these 31 states have expanded use of PE to allow additional entities to determine PE as part of COVID-19 response, and two states (NE and IL) have extended presumptive eligibility to additional eligibility groups. In addition, seven states (CA, IA, MA, NM, UT, WA, and WI) have extended use of hospital PE determinations to non-MAGI eligibility groups.

Use of a Simplified Application. The ACA required all states to create a single streamlined application for Medicaid, CHIP, and Marketplace coverage and to provide options for individuals to apply for and renew coverage through multiple modes, including online and phone.13  In an emergency, states can adopt a simpler version of their paper or online application. Three states (AZ, KY, and WA) report adopting a simplified application option for Medicaid and/or CHIP to respond to the COVID-19 outbreak.

Promoting Continuity of Coverage. States must provide continuous coverage for Medicaid enrollees throughout the emergency period to receive enhanced federal funding; however, this requirement does not apply to children in CHIP. Some states have taken additional steps to promote continuity of coverage. As of January 2020, 32 states provided 12-month continuous eligibility to children in Medicaid or CHIP, enabling them to maintain coverage even if their households have small fluctuations in income. In response to COVID-19, Missouri, Oklahoma, and Rhode Island newly adopted continuous eligibility for children in Medicaid, and Arizona adopted continuous eligibility for children in both Medicaid and CHIP. In addition, Nebraska extended its continuous eligibility period for pregnant women covered through its unborn child option from six months through the end of the pregnancy period. Further, fourteen states (AZ, GA, IA, IL, KS, NC, NE, PA, RI, TN, UT, VA, WV, and WY) are delaying on acting on changes in circumstances or extending the redetermination period for CHIP populations to provide continuous coverage for enrollees, mirroring the requirements in Medicaid to receive enhanced funding.

Conclusion

In sum, states are taking a range of actions to facilitate access to Medicaid and CHIP coverage in response to COVID-19. Nearly all states (43) have made changes beyond what is required to access enhanced federal funding. The ACA has better positioned state Medicaid and CHIP programs to respond to an emergency such as the COVID-19 outbreak by expanding coverage in many states and establishing streamlined and modernized eligibility and enrollment systems across all states. However, there remains significant variation in eligibility and enrollment policies across states, and states still may face capacity issues as demand grows. The eligibility and enrollment changes states are making can mitigate challenges by enabling people to connect to coverage more quickly and easily and reducing administrative burdens for states. While these changes would increase enrollment and reduce the number of people uninsured, they would also increase state and federal spending for Medicaid coverage. Outside of eligibility and enrollment changes, states also are changing benefits, cost sharing and payment policies to facilitate access to care. Without certainty of additional federal support, many states will need to develop balanced budgets for the fiscal year beginning on July 1 (for most states) that could likely include significant spending cuts, including for Medicaid programs, at a time when demand for services is growing.

Endnotes

  1. KFF, Status of State Medicaid Expansion Decisions: Interactive Map (April 2020), https://modern.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/ ↩︎
  2. KFF, Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2020: Findings from a 50-State Survey (March 2020), https://modern.kff.org/report-section/medicaid-and-chip-eligibility-enrollment-and-cost-sharing-policies-as-of-january-2020-findings-from-a-50-state-survey-tables/ ↩︎
  3. KFF, The Affordable Care Act’s Impact on Medicaid Eligibility, Enrollment, and Benefits for People with Disabilities (April 2014), https://modern.kff.org/health-reform/issue-brief/the-affordable-care-acts-impact-on-medicaid-eligibility-enrollment-and-benefits-for-people-with-disabilities/. ↩︎
  4. Pub. L. 116-127 (March 18, 2020), https://www.congress.gov/116/plaws/publ127/PLAW-116publ127.pdf. ↩︎
  5. Pub. L. 116-136 (March 27, 2020), https://www.congress.gov/116/bills/hr748/BILLS-116hr748enr.pdf. ↩︎
  6. Pub. L. 116-136 (March 27, 2020), https://www.congress.gov/116/bills/hr748/BILLS-116hr748enr.pdf. ↩︎
  7. For state-level income and asset limits, see KFF, Medicaid Financial Eligibility for Seniors and People with Disabilities: Findings from a 50-State Survey (June 2019), https://modern.kff.org/report-section/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-findings-from-a-50-state-survey-issue-brief/ ↩︎
  8. Missouri elects the 209 (b) option to apply Medicaid financial and/or functional eligibility rules to SSI beneficiaries that differ from federal SSI rules. See: KFF, Medicaid Financial Eligibility for Seniors and People with Disabilities: Findings from a 50-State Survey (June 2019), https://modern.kff.org/report-section/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-findings-from-a-50-state-survey-issue-brief/ ↩︎
  9. 42 CFR § 435.945–Eligibility in the States, District of Columbia, the Northern Mariana Islands, and American Samoa; Subpart J—Eligibility in the States and the District of Columbia https://www.law.cornell.edu/cfr/text/42/part-435/subpart-J#subjgrp71 ↩︎
  10. Centers for Medicare and Medicaid Services, COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and Children’s Health Insurance Program (CHIP) Agencies,  https://www.medicaid.gov/state-resource-center/Downloads/covid-19-faqs.pdf ↩︎
  11. KFF, Medicaid Financial Eligibility for Seniors and People with Disabilities: Findings from a 50-State Survey (June 2019), https://modern.kff.org/report-section/medicaid-financial-eligibility-for-seniors-and-people-with-disabilities-findings-from-a-50-state-survey-issue-brief/ ↩︎
  12. 42 CFR § 435–Eligibility in the States, District of Columbia, the Northern Mariana Islands, and American Samoa; Subpart L–Options for Coverage of Special Groups under Presumptive Eligibility https://www.law.cornell.edu/cfr/text/42/part-435/subpart-L ↩︎
  13. KFF, The Single Streamlined Application Under the Affordable Care Act: Key Elements of the Proposed Application and Current Medicaid and CHIP Applications (April 2013), https://modern.kff.org/medicaid/report/the-single-streamlined-application-under-the-affordable-care-act-key-elements-of-the-proposed-application-and-current-medicaid-and-chip-applications/ ↩︎
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News Release

Poll: As States Start to Ease Coronavirus Restrictions, Few Americans Expect to Stay in Hotels or Fly This Summer, Though Most Plan to Visit a Doctor, Get a Hair Cut and Dine Out

Deep Partisan Differences on Almost Every Dimension of Coronavirus: Republicans are More than Three Times as Likely as Democrats to Say Their State is Moving Too Slowly to Ease Restrictions

Published: May 22, 2020

Most of the Public, including Most Swing Voters, Disapprove of President Trump’s Coronavirus Response and Overall Job Performance; President Earns Higher Ratings on the Economy

Even as many states start to lift restrictions on businesses and social gatherings, most Americans are expecting the coronavirus pandemic to upend their summers, with few saying they expect to stay in a hotel (32%), fly (23%), or attend a concert or sporting event (19%) during the next three months, the latest KFF Health Tracking Poll finds.

Larger shares of the public say they are likely to engage in other routine activities, including 82% who say they expect to visit a doctor or dentist in person over the next three months. Most say they expect to attend a gathering of at least 10 people (58%), visit a salon or barber (56%), or eat in person at a restaurant (53%).

Democrats are more wary than Republicans and independents about engaging in most of these activities – just one example of a deep partisan divide that colors Americans’ views about the coronavirus crisis.

“There is one pandemic, but Americans increasingly view both the gravity of it and what should be done about it through red- and blue-colored glasses,” KFF President and CEO Drew Altman said. “It’s a sad comment that partisan division, not national unity, is becoming a defining feature of the American response to coronavirus.”

Fewer than half of Democrats say they expect to attend larger gatherings (43%), visit a barber or salon (43%), or eat at a restaurant (39%) over the next three months, while most Republicans and independents say they are already doing these activities or expect to do them soon.

While minorities across party lines say they would stay at a hotel or vacation rental, fly, or attend a concert or sporting event in the coming months, Republican are more likely than Democrats to say they expect to do each of those activities.

Other examples of the partisan divide include:

  • More than three times as many Republicans (32%) as Democrats (9%) say their state is moving “too slowly” to ease social distancing restrictions and reopen businesses, while Democrats are three times as likely as Republicans to say their state is moving “too quickly” (39% and 13%, respectively). Independents are more evenly split with 28% saying “too quickly” and 22% saying “too slowly.”
  • Democrats (70%) are about twice as likely as Republicans (37%) to say they wear a protective mask “every time” they leave their house and might be in contact with others. Among the public overall, about three quarters of adults say they wear a mask every time (52%) or most of the time (21%).
  • Most people (72%) think President Trump should wear a mask when meeting with other people. This includes a large majority (88%) of Democrats but only about half of Republicans (48%).
  • Two thirds of Republicans either say that the coronavirus pandemic isn’t a major problem (20%) or that the “worst is behind us” (45%), while most Democrats (70%) and half of independents say “the worst is yet to come.” Half of adults overall say “the worst is yet to come,” nearly twice the share (28%) who say “the worst is behind us.”

Most of the Public and Most Swing Voters Disapprove of President Trump’s Coronavirus Response

The public’s rating of President Trump’s job performance on coronavirus has fallen, with slightly more Americans now disapproving (52%) than approving (46%) after tilting positive six weeks earlier. Similar shares now disapprove of President Trump’s performance on health care (51%) and overall (52%). In contrast, most of the public (57%) approve of his performance on the economy.

While most Republicans approve and most Democrats disapprove of President Trump’s performance across the board, independents are conflicted. Most disapprove of his overall performance (54%) and on coronavirus (52%) and health care (51%), but most approve on his performance on the economy (59%).

The crucial group of “swing voters,” who are not yet certain about their presidential vote in November, are also negative in their assessments of President Trump’s presidency. Six in 10 swing voters (59%) disapprove of the president’s overall job performance, and similar shares disapprove of his handling of coronavirus (61%) and health care (58%). Swing voters remain positive in their assessments of his handling of the economy (59% approve).

With less than six months before the 2020 presidential election, the poll finds the economy and health care remain the top two election issues, with roughly equal shares naming the economy (25%) and health care (23%) as the most important issue in their vote for president. The coronavirus pandemic, which affects both health care and the economy, ranks third (17%).

The economy stands out by far as Republicans’ top issue, with 40% saying it is the most important to their vote. In comparison, just 13% of Democrats cite the economy as their top issue, ranking it third behind health care (32%) and the coronavirus pandemic (29%).

Swing voters rank health care (30%) and the economy (25%) as the top issues, followed by the coronavirus pandemic (19%).

Designed and analyzed by public opinion researchers at KFF, the poll was conducted May 13-18 among a nationally representative random digit dial telephone sample of 1,189 adults. Interviews were conducted in English and Spanish by landline (283) and cell phone (906). The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on subgroups, the margin of sampling error may be higher.

KFF will release additional findings from this poll in the coming days.

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Rakesh Singh
KFF

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Craig Palosky
KFF

Also of Interest

COVID-19 in Metropolitan and Non-Metropolitan Counties

Published: May 21, 2020

These slides have been updated as of May 14, 2020. For more information on COVID-19 in rural America, see COVID-19 in Rural America – Is There Cause for Concern?

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COVID-19 Demographics Mortality Public Health

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COVID-19 & PEPFAR: Implications for the Future

Authors: Alicia Carbaugh, Jennifer Kates, and Stephanie Oum
Published: May 20, 2020
Section:
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Issue Brief

Key Points

  • COVID-19 has the potential to deeply impact PEPFAR countries, especially those in sub-Saharan Africa and, as such, affect PEPFAR’s future trajectory.
  • As the largest U.S. global health program, PEPFAR is in a unique position to respond to COVID-19, but the outbreak also raises urgent new questions for PEPFAR, as well as underscores existing challenges.
  • PEPFAR has moved to respond quickly, accelerating prior strategies that could serve to minimize disruption and promote continuity of HIV care, such as multi-month dispensing of antiretrovirals; implementing new strategies, such as telemedicine; and allowing for some program flexibility in reporting requirements, staffing, and funding re-allocation.
  • Despite these steps, there are likely to be additional disruptions and need for further guidance, flexibilities and, potentially, new resources for PEPFAR which, to date, has not received additional support through the emergency measures passed by the U.S. Congress.

Introduction

The potential for the COVID-19 pandemic to significantly affect the health and development of low- and middle-income countries (LMICs), particularly those in sub-Saharan Africa, has serious implications for PEPFAR, the President’s Emergency Plan for AIDS Relief. PEPFAR is the U.S. government’s flagship global health effort, credited with saving millions of lives and helping to change the trajectory of the global HIV epidemic. As of May 17, coronavirus cases have been reported in all PEPFAR countries1 , with cases rising rapidly in some (see Table 1), and many are in lockdown or have instituted other social distancing measures. Most of these countries lack robust health systems and have limited preparedness and readiness capacity to respond to COVID-19. Given PEPFAR’s large country footprint, expertise and country infrastructure, the program is in a unique position to respond to COVID-19.

However, the outbreak also raises urgent new challenges for the program, as well as amplifies existing ones, given the potential for it to halt or even reverse hard-won HIV-related gains and alter the global health landscape. While PEPFAR has taken steps to respond to the outbreak, it is still unclear if these will be enough or if additional measures will be taken. To date, while emergency funding has been provided for certain global efforts and to domestic HIV programs by the U.S. Congress, no new resources have been provided to PEPFAR. As COVID-19 continues to impact the countries within which PEPFAR operates, this issue brief examines the potential implications for PEPFAR, the steps the program has taken to respond to the outbreak, and issues at stake.

Table 1: COVID-19 Cases in 25 PEPFAR Countries

Country

# of COVID-19 Case(as of May 17, 2020)

Angola48
Botswana25
Burundi23
Cameroon3,105
Côte d’Ivoire2,109
Democratic Rep. of the Congo1,455
Dominican Republic12,314
Eswatini203
Ethiopia317
Haiti456
Kenya887
Lesotho1
Malawi70
Mozambique137
Namibia16
Nigeria5,959
Rwanda292
South Africa15,515
South Sudan290
Tanzania509
Uganda227
Ukraine18,291
Vietnam320
Zambia753
Zimbabwe44
Total63,366
NOTES: Includes 25 countries required to develop PEPFAR Country Operating Plans (COPs). Includes confirmed and presumed positive COVID-19 cases.SOURCE: KFF. COVID-19 Coronavirus Tracker.

PEPFAR Snapshot

PEPFAR is funded at approximately $5 billion per year (not including contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria), making it the largest U.S. global health program and largest in the world devoted to a single disease. As of September 2019, PEPFAR is estimated to have provided life-saving antiretroviral medications to more than 15 million people, supported testing services for nearly 80 million, and prevented more than 2.6 million babies from being born with HIV.

While PEPFAR support reaches more than 50 countries, the program focuses most of its efforts on a subset of 25 countries.2  These 25 countries represent nearly 65% of people living with HIV (see Table 2). PEPFAR activities focus on expanding access to HIV prevention, treatment, and care interventions. These include provision of HIV testing, antiretroviral treatment, pre-exposure prophylaxis, voluntary male circumcision (VMMC), condoms, and prevention programming focused on certain populations, including adolescent girls and young women. PEPFAR also provides broader health systems support in countries, including investments in health workforce and laboratory capacity.

While significant progress has been made, prior to the outbreak, only a limited number of PEPFAR’s countries were on target to meet global HIV milestones, including the UNAIDS 90-90-90 targets (by 2020, 90% of people with HIV would know their status; 90% of people diagnosed with HIV would be on treatment; and 90% of those on treatment would be virally suppressed), or PEPFAR’s own goal of achieving epidemic control by 2020 (defined by PEPFAR to be when new HIV infections fall below deaths from all causes among people with HIV). Other challenges facing PEPFAR that pre-date the outbreak include:

  • Concern about U.S. funding fatigue amidst a growing global funding gap;
  • Promise versus reality of domestic resource mobilization;
  • Interdependence of PEPFAR’s and the Global Fund’s successes and donor coordination more broadly;
  • How to optimally reach marginalized populations and those most at risk for HIV; and
  • Converging timelines of the expiration of PEPFAR’s current strategy, the next U.S presidential and congressional elections, and the lead-up to PEPFAR’s next reauthorization.
Table 2: HIV Indicators for 25 PEPFAR Countries
Treatment Cascade
CountryNumber of People Living with HIV(2018)HIV Prevalence(2018)HIV Incidence-to-Prevalence Ratio(2018)HIV Incidence-to-Mortality Ratio(2018)% People living with HIV who know their status(2018)% People living with HIV receiving ART(2018)% People living with HIV who have suppressed viral loads(2018)HIV Incidence per 1000 Population(2018)
Angola330,00028.451.714242–1.01
Botswana370,00020.32.311.249183814.36
Burundi82,00012.030.63–80–0.16
Cameroon540,0003.64.371.047452–1.02
Cote d’Ivoire460,0002.63.670.796355410.7
Democratic Rep. of the Congo450,0000.84.131.16257–0.21
Dominican Republic70,0000.93.921.728256370.26
Eswatini210,00027.33.782.039286818.62
Ethiopia690,00013.281.487965–0.24
Haiti160,00024.631.96758–0.69
Kenya1,600,0004.72.941.268968–1.02
Lesotho340,00023.63.871.298661577.8
Malawi1,000,0009.23.652.049078692.28
Mozambique2,200,00012.66.642.057256–5.25
Namibia200,00011.83.051.519192872.82
Nigeria1,900,0001.56.571.736753420.65
Rwanda220,0002.51.590.869487740.29
South Africa7,700,00020.43.081.889062544.94
South Sudan190,0002.59.931.712416–1.56
Tanzania1,600,0004.64.642.137871621.41
Uganda1,400,0005.73.821.568472641.4
Ukraine240,00015.261.697152480.28
Vietnam230,0000.32.481.01–65–0.06
Zambia1,200,00011.33.891.948778592.97
Zimbabwe1,300,00012.72.931.349088–2.79
Global37,900,0000.84.61.717962530.24
Global Target––<3.0<1908173<1
# Countries Meeting Target––6375410

NOTES: Includes 25 countries required to develop PEPFAR Country Operating Plans (COPs). HIV data is for all ages unless otherwise specified. HIV prevalence data is for adults (ages 15-49). Percentages for the treatment cascade global targets are based on the 90-90-90 global targets.SOURCES: U.S. Department of State, “Where We Work — PEPFAR” webpage, https://www.state.gov/where-we-work-pepfar/. UNAIDS, AIDSInfo database, accessed May 2020. UNAIDS, Global AIDS Update 2019, December 2019. UNAIDS, “Ratio of new HIV infections to number of people living with HIV improving”, April 2020. UNAIDS, “Making the End of AIDS Real: Consensus building around what we mean by epidemic control”, October 2017.

HIV & COVID-19

COVID-19 has introduced particular challenges for the HIV response. First, while there is no evidence that people with HIV are at greater risk of SARS-CoV-2 infection, the virus that causes COVID-19, those with underlying health conditions, including uncontrolled HIV, are at greater risk of developing more severe disease if infected. Second, the very health systems and services that people with and at risk for HIV rely on could be disrupted, potentially affecting access to and continuity of critical medications, care, and other services. Third, lockdowns and other social distancing measures may also affect the ability of those with HIV to access services or exacerbate factors that put people at risk for HIV, including interpersonal and/or gender-based violence (IPV/GBV). New modeling estimates from the WHO and UNAIDS show that there could be half a million additional deaths from AIDS-related illnesses and significant increases in mother-to-child HIV transmission in sub-Saharan Africa if more is not done to mitigate service interruptions.

There are already reports from PEPFAR3  and the Global Fund to Fight AIDS, Tuberculosis and Malaria of interruptions, delays, and other challenges in the HIV service ecosystem in developing countries. These include:

  • Disruptions in supply chains for antiretrovirals, rapid tests, and other key commodities related to HIV services;
  • Reductions in HIV program personnel due to evacuations or redeployment to address COVID-19; and suspension of some prevention services, such as voluntary medical male circumcision;
  • Anticipation of increased use of laboratory facilities and lab staff for SARS-CoV-2 testing, which could impact HIV testing and lab capacity;
  • Lack of personal protective equipment (PPE) for health workers.
  • Concerns that physical distancing measures and health system pressures will prevent people with and at risk for HIV from seeking services, including treatment and testing, and about the potential for clinic closures;
  • Barriers to effective telehealth services, especially for youth; and
  • Concerns about potential food insecurity and resulting poor nutrition, which can negatively affect antiretroviral therapy and can be particularly detrimental to pregnant and breastfeeding women.

PEPFAR’s Response to COVID-19

PEPFAR has identified four key priorities to guide its programming during the outbreak: ensuring continuity of care for people living with HIV, particularly antiretroviral treatment; leveraging PEPFAR’s infrastructure to respond to COVID-19; reducing risk of exposure to staff and clients; and providing program flexibility.

PEPFAR also began providing technical guidance to the field, first released on March 20, and updated regularly. The guidance addresses multiple areas, including: maintenance of antiretroviral treatment; HIV testing; prevention, including provision of PrEP, especially for those who are most vulnerable; particular needs of women, children and families; co-infection/ co-morbidities (e.g., tuberculosis); integration of services, such as HIV and family planning; IPV/GBV; and supply chain challenges and laboratory capacity issues (see Table 3). It provides a number of strategies that can be used by country and regional teams to adapt to the new realities of COVID-19.

Some are strategies PEPFAR has already been working to prioritize and are now being accelerated by the outbreak, such as multi-month dispensing (MMD) of antiretrovirals and health care worker (HCW) task shifting/sharing. These are part of PEPFAR’s larger move to differentiated service delivery, an approach to providing services that aims to meet the diverse needs of clients, while also reducing the burden on health facilities and improving health outcomes. Others are designed to respond to the acute situation of COVID-19 and reduce the risk of transmission, such as encouraging telehealth, cancelation of most in-person activities, and health care worker re-training in Infection Prevention and Control (IPC) and training on COVID-19. The guidance also indicates where flexibilities are permitted, including extensions of reporting periods, and indicates that requests to utilize HIV resources to also respond to COVID-19 can be made.

Table 3: PEPFAR’s COVID-19 Technical Guidance – Summary Of Key Provisions
Program Area/ ActivityKey Provisions
GeneralFacilities should minimize patient contact and reduce non-essential visits.
Clinics to consider staggering appointments and streamlining clinic flow; HIV patients should be seen in clinics that are dedicated for HIV treatment.
Telehealth (e.g., phone calls, SMS, WhatsApp, social media, and other digital platforms) should be used to communicate with HIV clients.
Facilities should maximize 6-month refills for ARVs where stock is available.
Clients should preferably receive drug supplies (e.g., ARVs, PrEP, HIV self-tests, other medicines for chronic conditions) outside of the facility setting (e.g., home deliveries, community or private pharmacies, pop-up pharmacies, automated lockers, or community pickups).
Additional steps should be taken to prepare for clinic closures.
Beyond any Chief of Mission directive, involvement in larger U.S. government COVID-19 response should be based on and limited to the intersection of HIV, HIV/TB, and COVID; PEPFAR Coordination Offices should stay abreast of ways in which PEPFAR program investments are being leveraged for the larger U.S. COVID-19 response and potential adaptations necessary to implement the PEPFAR program safely; PEPFAR Coordination Offices are not responsible for coordinating the larger U.S. COVID-19 response.
Human Resources for HealthPEPFAR-supported health care workers (HCWs) should be prepared to continue to deliver essential HIV services.
Staff should be prepared for task shifting/sharing of essential services where allowed and be prepared to be repurposed or redeployed, including to enable provision of services outside of facilities; staff should work with local governments to allow emergency task-shifting where formal policies are not in place.
Depending on role, HCWs should be trained to screen HIV patients for COVID-19 and refer for testing and treatment based on in-country guidance for COVID-19 cases.
HCWs should receive refresher training in Infection Prevention and Control (IPC) and steps should be taken to protect their safety (e.g., secure authorization from local authorities for continued work, support staff to avoid public transportation, reduce in-person contact).
Limit home visits to those “absolutely essential.”
Direct HCW-patient interactions for HIV services should not take place where routine adequate PPE is not available (e.g., gloves).
HIV TreatmentAccelerate and complete scale up of 3 to 6 multi-month dispensing (MMD) of ARVs, where available.
ARV distribution for all people living with HIV should be decentralized.
Phone or electronic follow-up encouraged to support adherence/assess side effects for those initiating treatment, to continue peer support for youth, and for other purposes related to HIV treatment.
Routine viral load monitoring in stable patients may be delayed.
HIV PreventionPackaging of condoms and lubricants, and at larger than normal quantities, should be supplied to extent possible; distribution points should be modified to reflect social distancing.
PrEP should continue as part of comprehensive prevention; MMD should be allowed.
New VMMCs may be delayed or paused, depending on host government guidance/policies on social distancing; post-operative follow up should continue.
Phone and digital platforms should be utilized for general HIV prevention services, as well as for PrEP and VMMC follow up.
HIV TestingAdapt HIV testing services to host country government directives or policies on social distancing.
Maximize use of self-testing outside of the clinic setting through decentralized distribution approaches (e.g., peer home delivery, private/community pharmacies).
Prioritize clinical-based testing for those most in need (e.g., in antenatal settings, diagnostic testing for individuals presenting with suspected HIV, individuals with TB/STIs/malnutrition; early infant diagnosis (EID) detection, passive partner/index/family testing, in certain key population programs).
Testing should not take place where routine adequate PPE is not available (e.g., gloves).
Recommended recency testing be temporarily paused at health facilities and laboratories.
Shortages of rapid test kits have been reported.
TBPrograms should continue to screen and test for TB in high prevalence areas and consider testing for both TB and COVID-19 in people living with HIV, especially in people presenting with fever and cough.
PEPFAR-supported TB contact investigations should make efforts to use mobile/virtual platforms; community-based testing and active TB case-finding strategies among people with HIV should follow local/national COVID-19 guidance on movement restriction/social distance/continuity of operations; if mobile and virtual platforms cannot be used and it is not safe for HCWs to conduct contact investigations in the community, contact-tracing/case-finding for TB may need to be deferred.
People with HIV should be provided with the full or remaining course of their drugs for TB-HIV or drugs for TB prevention.
Phone consultations for people with HIV-TB should be used, where possible.
Women’s HealthVoluntary family planning services continue as an essential service.
HIV services integrated with contraceptive services should be streamlined to avoid patient visits to facilities or optimally use time when in clinic.
Multi-month provision of oral contraceptives and condoms should be provided and optimal schedules for long-acting contraceptives should be developed between client and provider (note: PEPFAR cannot be used to procure contraceptives; they are made available to PEPFAR-supported programs through collaboration with national family planning programs, USAID, and other donors).
Problems with contraceptive supply chains have been noted; country teams advised to include contraceptives on lists of essential drugs allowed into countries while shipments are restricted; integrating FP and HIV supply chain management and distribution may also help ensure contraceptives are available for HIV-affected populations.
Cervical cancer screening outside of same-day/same-site ART clinical services should be limited; screening done as part of routine ART visit may continue; high-grade lesion treatment can continue.
Maternal Child HealthWomen should follow local/national guidelines for ANC testing; options to limit or reduce time spent in clinic settings should be considered (e.g., providing services in community settings, bundling services); regular retesting for HIV is encouraged, if feasible.
HIV self-testing can be used for pregnant and breastfeeding women; women screening positive should be fast-tracked for confirmatory testing and treatment services.
PrEP should continue to be offered and MMD should be considered.
Consider offering newborn prophylaxis in case of home/community births.
EID should continue as an essential service with proper precautions.
Expand phone/SMS support to mothers and infants.
DREAMSContact with DREAMS participants should be maintained via phone/SMS/WhatsApp/digital platforms, depending on country and local context.
Group-based activities should follow local guidelines for mass gatherings.
Where feasible, facility-based DREAMS services should be offered in community with appropriate social distancing.
IPV/GBVTeams should advocate with host governments to designate child protection and GBV responders; work with local entities and donors to update directories of response services; ensure that PEPFAR staff have information on resources and can support clients experiencing violence.
ChildrenMany stipulations noted above apply to children and the guidance outlines additional recommendations given the special treatment, testing, and prevention needs of children.
Orphans and Vulnerable Children (OVC) activities can continue and can be conducted virtually, including for treatment literacy and adherence support, linkages to food supplementation/assistance, hygiene supplies, and distance learning opportunities; staff encouraged to incorporate COVID-19 prevention messaging and resources, per host country government guidelines, into virtual support to households; enrollment can continue to extent possible and certain populations should be prioritized, including children and adolescents living with HIV; HIV-exposed infants; and infants, children, and adolescents exposed to abuse, harm, or violence.
LaboratorySome countries are experiencing delays for HIV test kits and consumables; orders should be placed at least one month earlier than usual.
Due to recent WHO and FDA guidance on emergency use authorization for HIV viral load, EID, and TB-related instruments for SARS-CoV-2 testing, there is potential for increased demand on diagnostic networks; teams should anticipate increased use of instruments, facilities, consumables, and PPE for COVID-19, HIV, and TB-related testing and prepare for staff diversions or reductions in lab and other staff.
Laboratories should prioritize testing based on local policies and needs; HIV-related testing should be prioritized for certain populations (e.g., EID, viral load services for children and pregnant and breastfeeding women, non-virally suppressed adults).
If HIV and COVID-19-related testing need to be conducted on same instrument, SOPs for testing prioritization should be developed in collaboration with host country government and other stakeholders.
Use of existing national laboratory capacity, systems, and networks for COVID-related testing encouraged; funding dedicated for HIV and TB testing should not be reallocated for COVID-19; any additional costs for COVID-19 testing should be paid using country-specific COVID-19 supplemental funds from other sources.
Supply Chain/CommoditiesCountry programs advised to assess current stocks of antiretrovirals and develop distribution plans with goal to distribute drugs so each client has enough for at least 3 months; PEPFAR working to ensure HIV commodity supplies; USAID coordinating with Global Fund to Fight AIDS, Tuberculosis and Malaria to prevent stock outs; country teams should work with host country governments to ensure MMD policies communicated to providers, facilities, pharmacies, and supply chain actors.
Delays expected for ARVs due to majority of U.S.-FDA approved ARV manufacturers in India; facilities have experienced interruptions due reduced capacity and logistical challenges during lockdown.
Should additional stock be necessary for acceleration of 6-month MMD, teams should notify proper U.S. government staff.
PEPFAR cannot ensure appropriate and adequate supply of PPE; teams asked to seek alternative sources.
NOTE: This table highlights a selection of issues; see guidance for more detail.SOURCE: PEPFAR. PEPFAR Technical Guidance in Context of COVID-19 Pandemic (May 13, 2020).

While the guidance is being regularly updated to address emerging issues, there are potential gaps or questions that exist. For instance, the guidance calls for an acceleration of antiretroviral MMD and, while it notes the challenges in achieving MMD goals for people with HIV in an expedited timeframe, it will be important to monitor how supply chain disruptions, lockdowns/restrictions in movement, and the rapid scale-up will impact MMD across populations and countries. Additionally, the extent to which decentralization and telehealth can be implemented in all settings, especially those with hard-to-reach populations, will be important to assess as well and may require other measures to support continuity of care. The guidance also calls for staff in health care settings to have proper personal protective equipment (PPE), although it does not indicate these can be secured amid shortages and restrictions on purchasing with U.S. assistance dollars.

PEPFAR’s responses also will depend upon host government approaches to COVID-19 mitigation and ensuring the continuity of HIV services during the outbreak. To date, the governments of several PEPFAR countries have issued their own guidance for HIV services amid the pandemic. Further, while PEPFAR has stated that program flexibility is a key goal at this time, there may be a need for more specificity about what is permitted. Finally, as PEPFAR works to maintain its current levels of service, particularly antiretroviral treatment, amid the new challenges of COVID-19, there could be considerable resource implications. While Congress has provided emergency COVID-19 funding to domestic HIV programs, it has not yet provided such funding to PEPFAR.

Questions Ahead

Despite the ongoing uncertainties regarding COVID-19’s impact in PEPFAR countries, it is highly likely that there will be significant implications for PEPFAR in both the short- and long-term. Some of these pre-date COVID-19 but are exacerbated by the outbreak; others are new concerns and challenges. Key questions to consider include:

  • What guardrails and warning systems can be put in place to help ensure the needs of people with HIV, particularly for antiretroviral treatment, are being met in real time as the COVID-19 outbreak worsens?
  • Will additional flexibilities, or clarification about existing flexibilities, be provided, including around the ability to reallocate current budgets?
  • Will additional resources be provided and how far will they go in meeting needs? How will those resource needs be quantified?
  • How will the decentralization of services and responses to COVID-19, including telehealth, carry forward after the pandemic?
  • How can the PEPFAR platform be leveraged to respond to COVID-19 without affecting HIV services? Can marginal investments be made in PEPFAR’s infrastructure, such as its laboratory networks and equipment, that are more cost-effective than building new systems to respond to COVID-19?
  • Will HIV trajectories in PEPFAR countries be impacted? Will ground be lost?
  • Will the larger landscape of HIV donor funding, which was already strained, be further impacted?
  • What does this mean for shifts to domestic HIV funding (which has been an increasing priority for PEPFAR and the U.S. government more broadly)? Are transitions away from PEPFAR funding by countries even more unlikely now, depending on the economic damage done by COVID?
  • How will COVID-19 contribute to and shape PEPFAR’s future role, including tensions between a laser focus on HIV and a broader focus on building health systems in PEPFAR-supported countries?

As the pandemic continues to unfold and health systems are tested and pushed further than most countries have experienced in modern history, the impact of COVID-19 on people with and at risk for HIV, and the programs and systems that serve them, will come into focus, as will the implications for PEPFAR. Should PEPFAR’s early response to COVID-19 be sustained, leveraged, and adequately resourced, it could help to bolster protections for people with HIV during the pandemic and contribute to the broader response in countries. On the other hand, the pandemic could potentially reshape PEPFAR and the broader HIV policy landscape for the years to come.

Endnotes

  1. Of countries receiving PEPFAR funding in 2019. ↩︎
  2. This subset of countries prepare Country Operating Plans (COPs). See KFF’s The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) fact sheet for additional detail. ↩︎
  3. Also based on reports from USAID. ↩︎
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Author: Josh Michaud
Published: May 20, 2020

Sweden’s response to the novel coronavirus has been simultaneously praised and criticized by public health experts. In an article for Foreign Affairs, KFF’s Josh Michaud discusses the merits and risks associated with Sweden’s hands-off approach to the pandemic.

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Impact of Coronavirus on Community Health Centers

Authors: Bradley Corallo and Jennifer Tolbert
Published: May 20, 2020

Background

Community health centers are a national network of safety net primary care providers that fill an important role in national, state, and local responses to the coronavirus pandemic. Health centers primarily contribute to response efforts by providing tests, triaging patients, and reducing the burden on hospitals, although they also play a role in addressing demand for behavioral health services and continuing primary care for patients with chronic conditions. Patients at health centers are disproportionately low-income and people of color, groups especially hard hit by the pandemic. Among the roughly 28 million patients served by health centers, 91% are low-income and 63% are racial or ethnic minorities. Like other outpatient health care providers, health centers are having to adjust to stay-at-home orders, drops in patient visits for non-essential health care, and workforce challenges. This brief presents findings from new data collected by the Health Resources and Services Administration (HRSA) to provide insights into how health centers are adapting their services in response to the pandemic and how coronavirus is affecting their operations and long-term financial outlook with patient visits and revenue from those visits dropping precipitously. (For more detail on the data underlying this Data Note, see the text box at the end of the brief.)

COVID-19 Testing at Health Centers

Nine out of ten (90%) health centers are providing COVID-19 tests, and in 16 states and DC, all health centers are providing tests. Of those that provide testing, the majority (67%) offer walk-up or drive-through testing as of May 8, which can expand access to testing. In the week preceding May 8, health centers reported providing 127,816 tests, with 36,155 patients (28%) testing positive, roughly double the national positive test rate of 13% during a similar period.

People of color represented more than half of all people tested (57%) and confirmed cases (56%) at health centers. Among all individuals receiving tests, 24% were White and 57% were among people of color, including 32% who were Hispanic and 16% who were Black (Table 1). Race/ethnicity was unknown for about 1 in 5 tests (19%) and 1 in 4 confirmed cases (24%). Hispanics made up a higher share of positive tests, compared to their share of total tested patients (42% vs. 32%), while White patients made up a slightly lower share of positive tests compared to their share of total tested patients (19% vs. 24%). The ability of health centers to report testing data by race/ethnicity is important for broader efforts to ensure access to COVID-19 testing for people of color and to address disparities that existed prior to COVID-19 and may be widening due to the pandemic.

Table 1: Share of COVID-19 Tests and Confirmed Cases at Health Centers by Race and Ethnicity, Week Ending May 8, 2020
Race/EthnicityPercent of TestsPercent of Positive Tests
White23.7%19.5%
Hispanic32.2%42.5%
Black15.8%7.0%
Asian1.9%1.1%
American Indian/Alaska Native1.1%0.3%
Native Hawaiian/Other Pacific Islander0.4%0.4%
More than One Race5.9%4.8%
Unknown Race/Ethnicity19.0%24.4%
Total100%100%
NOTES: Persons of Hispanic origin may be of any race. For this analysis, Hispanic patients include those who report Hispanic ethnicity and White, Black, or unknown race. Patients classified as White or Black are non-Hispanic. Other racial categories include both Hispanic and non-Hispanic individuals.SOURCES: HRSA. Health Center COVID-19 Survey. Latest data for the week ending May 8, 2020.

Effects of Coronavirus on Health Center Operations

Despite ramping up testing and virtual visits, health centers are reporting steep declines in patient visits and many staff who are unable to work. Health center organizations reported a 43% drop in the number of patient visits compared to before the pandemic, as many people across the country are avoiding non-essential trips to health care providers. The drop in visits comes even after health centers have been increasing the number of telehealth visits, with health centers conducting roughly half (51%) of visits virtually or over the phone. Additionally, health centers report that 11% of staff are not working due to exposure to the coronavirus, lack of protective equipment, site closures, or family obligations, among other reasons.

There have been 1,954 temporary health center site closures due to repercussions from the coronavirus as of May 8. Most health centers operate multiple service delivery sites – in 2018, 1,362 health centers operated 11,744 sites. The number of temporary site closures likely undercounts total closures, given that more than a quarter of health centers did not respond to the survey and are not included in the total. The survey data also do not provide details on the types of sites that have closed, such as whether the closed sites are brick-and-mortar, mobile vans, or school-based clinics. Still, site closures are occurring in states hard hit by the virus as well as in states less affected. Connecticut, close to the epicenter of the pandemic in the US, has seen nearly three-quarters (73%) of its sites closed, while Kentucky and Mississippi, which had fewer cases, have each seen 49% of sites closed. At least one-third of sites have closed in Nebraska (48%), Kansas (36%), West Virginia (36%), and Michigan (33%).

Figure 1: Percent of Health Center Service Delivery Sites Temporarily Closed due to Coronavirus, as of May 8, 2020

Financial Challenges

Health centers have received $1.98 billion in rapid response grants from the federal government, though more financial support may be needed to sustain services. These grants include $100 million in emergency grant funding and $1.3 billion through the Coronavirus Aid, Relief and Economic Security Act (CARES) that can be used to support response efforts, including buying testing materials and personal protective equipment (PPE), as well as to maintain or increase health center capacity generally. In early May, health centers received $583 million in grants to support COVID-19 testing capacity through the Paycheck Protection Program and Health Care Enhancement Act. All federally-funded health centers received each of these grants through an expedited awards process based on the size of the health center patient population and the number of uninsured patients reported to the Uniform Data System. While this funding is significant in aiding the coronavirus response, the combined $1.98 billion in additional appropriations represents just 7% of total health center revenues in 2018 (the most recent year of data available). Although data on the impact of the pandemic on overall health center finances are not available, the majority of health center revenues (68%) come from patient visits, and the drop in those visits could be contributing to a roughly 30% decrease in health center revenues. Adding to the uncertainty for health centers’ finances is the Community Health Center Fund (CHCF), an important source of federal funding representing $4 billion of the $5.6 billion appropriated to health centers in FY 2019. The CHCF has been extended through November – though it has not been reauthorized longer term as of mid-May 2020.

The effects of patient declines and staffing issues could have major implications for health centers even after the pandemic. Leading up to the pandemic, the two most commonly cited challenges for health centers were financial and workforce issues, both of which have been exacerbated by the economic effects of the coronavirus. The precipitous drop in patient volume has likely led to steep declines in patient care revenue that may contribute to future financial instability. Depending on how long the crisis lasts, some of the temporary site closures and staff reductions could become permanent, further exacerbating long-standing health care access issues in communities served by health centers.

Conclusion

Health centers will continue to play an important role in responding to the coronavirus pandemic and in providing access to care for communities disproportionately affected by COVID-19, especially as job losses mount and the number of people who are uninsured or covered by Medicaid rises. However, key findings from the HRSA survey highlight the significant operational challenges health centers are facing, which threaten their longer-term financial viability. While the emergency federal funding provided so far has aided health centers’ coronavirus response, secure future funding will also be important to maintain the long-term viability of the primary care safety net after the pandemic is over.

About the Health Center COVID-19 Data

In April 2020, HRSA began a weekly, rapid-response survey of all federally-funded health centers to track the impact of the coronavirus on health centers and identify needs for training, technical assistance, funding, and other resources. The survey instrument asks health centers to report on experiences from the previous week. All findings are reported at the health center organization level, although most health center organizations operate multiple clinic sites. Unless otherwise specified, all results discussed in this Data Note report findings at the health center organization (versus site) level. HRSA reports findings from the data as unweighted totals and percentages that do not account for non-responding health centers. The most recent survey data in this report is based on responses from the week ending May 8, 2020, with 1,011 (73%) federally-funded health centers responding to the survey.

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In 18 States, Deaths in Long-Term Care Facilities Account for at Least Half of Their COVID-19 Deaths

Published: May 18, 2020

Source

State Data and Policy Actions to Address Coronavirus

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News Release

As People Lose Jobs Due to the Coronavirus Crisis and Enroll in Medicaid, Survey Finds States Anticipate Medicaid Budget Shortfalls

Published: May 15, 2020

Many states that shared budget projections in response to a new KFF survey of state Medicaid officials report that they expect to see Medicaid budget shortfalls due to rising Medicaid spending and enrollment as people lose jobs amid the coronavirus pandemic and more people enroll in the government health insurance program for low-income people.

KFF conducted the rapid survey of Medicaid directors in all 50 states and the District of Columbia with Health Management Associates (HMA), drawing responses from 38 states. Some states were still in the process of gathering data to understand the implications of the coronavirus at the time of the survey, and did not have updated enrollment and/or spending projections yet for FY 2020 and/or FY 2021.

The survey findings come at a time when Congress is considering an additional increase in the federal match rate available to states for Medicaid. Without additional federal support, state budgets for the forthcoming fiscal year – which begins July 1 for most states – will likely include significant spending cuts, including for Medicaid, at a time when demand for services is growing, the survey suggests.

Overall, nearly all states with enrollment projections and over half of states with spending projections for FY 2020 anticipate growth rates to exceed pre-pandemic estimates for the current fiscal year. Nearly all states with projections anticipate that both enrollment and spending will grow more quickly in FY 2021 than in FY 2020. For most states, the fiscal year begins on July 1.

As a result of the accelerating enrollment and spending, 17 of 19 states that had budget projections reported that a budget shortfall was “nearly certain” or “likely” for the upcoming state fiscal year.  Because Medicaid is financed with a combination of federal and state funds, states would need to make substantial cuts to Medicaid to generate significant state budget savings.

Medicaid is a countercyclical program. During economic downturns more people enroll, increasing program spending at the same time that state tax revenues may be falling. The Families First Coronavirus Response Act (FFCRA) authorized a 6.2 percentage point increase in the federal match rate (“FMAP”) to provide support to state Medicaid programs and fiscal relief for states if states comply with certain maintenance of eligibility requirements that would ensure continuous coverage for current enrollees.

Even with the additional help, state budgets are expected to be severely strained in the coming fiscal year, the survey shows.  Legislation introduced on May 12 in the House would increase the FMAP by 14 percentage points from July 1, 2020 through June 30, 2021. But the future of the legislation, and prospects for additional federal support for states and Medicaid more generally, remain uncertain.

For the full report, as well as other data and analyses regarding Medicaid and COVID-19, visit kff.org.

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Chris Lee
KFF

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This Week in Coronavirus: May 8 to May 14

Published: May 15, 2020

Every Friday, we’re recapping the latest on the coronavirus from our tracking, policy analysis, polling, and journalism. Total coronavirus cases in the U.S. are still climbing, and this week increased by 160,000, bringing the cumulative total of cases past 1.4 million. This week, approximately 10,000 people died from COVID-19 in the U.S., bringing the total to 85,700. Across 36 states reporting this data yesterday, 41% of deaths due to COVID-19 occurred in long-term care facilities.

Meanwhile, since last Thursday, eight more states have allowed some or all non-essential businesses (some with reduced capacity) to reopen since May 7. Restaurants have reopened to dine-in service in 5 states.

Here are more of the latest coronavirus stats from KFF’s tracking resources:

Global Cases and Deaths: This week, total coronavirus cases worldwide passed 4.4 million – with approximately 596,000 new confirmed cases added between May 8 to May 14. There were approximately 33,000 new, confirmed deaths due to COVID-19 worldwide between May 7 and May 14.

U.S. Cases and Deaths: There have been over 1.4 million total confirmed coronavirus cases in the U.S. There were approximately 161,000 new confirmed cases and 10,000 confirmed deaths due to COVID-19 in the United States between May 7 and May 14.

U.S. Tests: There have been almost 10 million total COVID-19 tests with results in the United States — with over 1.9 million added since May 7. 13.9% of the total tests were positive. There have been 30.4 tests with results per 1,000 people in the U.S.

State Reports of Long-Term Care Facility Cases and Deaths Related to COVID-19 (Includes Washington D.C.)

  • Data Reporting Status: 45 states are reporting COVID-19 data in long-term care facilities, 6 states are not reporting
  • Long-term care facilities with known cases: 7,056 (in 41 states)
  • Cases in long-term care facilities: 152,118 (in 38 states)
  • Deaths in long-term care facilities: 30,130 (in 35 states)
  • Long-term care facilities as a share of total state cases: 16% (across 38 states)
  • Long-term care facility deaths as a share of total state deaths: 41% (across 36 states)

State Social Distancing Actions (includes Washington D.C.):

  • Social Distancing: 37 states have eased at least one social distancing measure.
  • Stay At Home Order: Original stay at home order in place in 29 states, stay at home order eased or lifted in 16 states, no action in 6 states
  • Mandatory Quarantine for Travelers: Original traveler quarantine mandate in place in 20 states, traveler quarantine mandate eased or lifted in 3 states, no action in 28 states
  • Non-Essential Business Closures: Original non-essential business closures still in place in 14 states, some or all non-essential business permitted to reopen (some with reduced capacity) in 31 states, no action in 6 states
  • Large Gatherings Ban: original gathering ban/limit in place in 39 states, gathering/ban limit eased or lifted in 10 states, no action in 2 states
  • State-Mandated School Closures: Closed in 7 states, closed for school year in 36 states, recommended closure in 1 state, recommended closure for school year in 6 states, rescinded in 1 state
  • Restaurant Limits: Original restaurant closures still in place in 30 states, restaurants re-opened to dine-in service in 20 states, no action in 1 state
  • Primary Election Postponement: Postponement in 14 states, cancelled in 1 state, no postponement in 36 states
  • Emergency Declaration: There are emergency declarations in all states and D.C.

State COVID-19 Health Policy Actions (Includes Washington D.C.)

  • Waive Cost Sharing for COVID-19 Treatment: 3 states require, state-insurer agreement in 3 states; no action in 45 states
  • Free Cost Vaccine When Available: 9 states require, state-insurer agreement in 1 state, no action in 41 states
  • States Requires Waiver of Prior Authorization Requirements: For COVID-19 testing only in 5 states, for COVID-19 testing and treatment in 6 states, no action in 40 states
  • Early Prescription Refills: State requires in 18 states, no action in 33 states
  • Premium Payment Grace Period: Grace period extended for all policies in 11 states, grace period extended for COVID-19 diagnosis/impacts only in 5 states, no action in 35 states
  • Marketplace Special Enrollment Period: Marketplace special enrollment period in 12 states, no special enrollment period in 39 states
  • Paid Sick Leave: 13 states enacted, 2 proposed, no action in 36 states

NEW: State Actions on Telehealth (Includes Washington D.C.)

38 states have taken action to expand access to telehealth services, such as

  • New Requirements for Coverage of Telehealth Services: Parity with in-person services in 6 states, broad coverage of telehealth services in 6 states, limited coverage of telehealth services in 5states, no action in 34 states
  • Waiving or Limiting Cost-Sharing for Telehealth Services: Waived for COVID-19 services only in 7 states, waived or limited for all services in 9 states, no action in 35 states
  • Reimbursement Parity for Telehealth and In-Person Services: Required for all services in 17 states, no action in 34 states
  • Require Expanded Options for Delivery of Telehealth Services: Yes in 35 states, for behavioral health services only in 1 state, no action in 35 states

Approved Medicaid State Actions to Address COVID-19 (Includes Washington D.C.)

  • Approved Section 1115 Waivers to Address COVID-19: 1 state has an approved waiver
  • Approved Section 1135 Waivers: 51 states have approved waivers
  • Approved 1915 (c) Appendix K Waivers: 42 states have approved waivers
  • Approved State Plan Amendments (SPAs): 32 states have temporary changes approved under Medicaid or CHIP disaster relief SPAs, 1 state has an approved traditional SPA
  • Other State-Reported Medicaid Administrative Actions: 51 states report taking other administrative actions in their Medicaid programs to address COVID-19

Adults at Higher Risk of Serious Illness if Infected with Coronavirus: 38% of all U.S. adults are at risk of serious illness if infected with coronavirus (92,560,223 total) due to their age (65 and over) or pre-existing medical condition. Of those at higher risk, 45% are at increased risk of serious illness if infected with coronavirus due to their existing medical condition such as such as heart disease, diabetes, lung disease, uncontrolled asthma or obesity. Among nonelderly adults — low-income, American Indian/Alaska Native & Black adults have a higher risk of serious illness if infected with coronavirus. In both cases – for race and household income – the higher risk of serious illness if infected with coronavirus is chiefly due to a higher prevalence of underlying health conditions and longstanding disparities in health care and other socio-economic factors.

 

This week’s posts in Coronavirus Policy Watch:  

  • Older Adults Are Hit Hard by COVID-19 – and Also Losing Jobs (CPW Post)

The latest KFF COVID-19 resources:

  • Updated: COVID-19 Coronavirus Tracker (Interactive)
  • COVID-19 Presents Significant Risks for American Indian and Alaska Native People (Issue Brief)
  • Updated: State Data and Policy Actions to Address Coronavirus (Interactive)
  • Updated: Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19 (Issue Brief)
  • Distribution of CARES Act Funding Among Hospitals (News Release, Issue Brief)
  • Eligibility for ACA Health Coverage Following Job Loss (News Release, Issue Brief)
  • How Can Lessons from Medicaid Help Connect People to Unemployment Insurance? (Issue Brief)
  • Global Funding Across U.S. COVID-19 Supplemental Funding Bills (Issue Brief)
  • Opportunities and Barriers for Telemedicine in the U.S. During the COVID-19 Emergency and Beyond (Issue Brief)
  • N. Security Council Works To Find Common Ground On COVID-19, Cease Fire Resolution; WHO’s Nabarro Warns Of ‘Fracture In Global Leadership’ (KFF Daily Global Health Policy Report)

The latest KHN COVID-19 stories:

  • Updated: Lost On The Frontline (KHN, The Guardian)
  • As Congress Weighs COVID Liability Protections, States Shield Health Providers (KHN, Daily Beast)
  • Chasing The Elusive Dream Of A COVID Cure (KHN, Telemundo)
  • Evidence Shows Obama Team Left A Pandemic ‘Game Plan’ For Trump Administration (KHN)
  • Another Coronavirus Casualty: California’s Budget (KHN)
  • In Reversal, Kansas Will Count All Positive COVID Cases, Even Asymptomatic Ones (KHN, NPR)
  • KHN’s ‘What The Health?’: What’s In The Next Round Of COVID-19 Relief? (Podcast)
  • Despite Pandemic, Trauma Centers See No End To ‘The Visible Virus Of Violence’ (KHN)
  • Trump’s Comparison Of COVID-19 Death Rates In Germany, US Is Wrong (KHN)
  • Under COVID Cloud, Prisons In Rural America Threaten To Choke Rural Hospitals (KHN)
  • Returning To Roots, Indian Health Service Seeks Traditional Healers (KHN)
  • Hospital Workers Complain of Minimal Disclosure After COVID Exposures (KHN, The Guardian)
  • Readers And Tweeters: Doctors Chime In On Telemedicine Costs (KHN)
  • Hospital Workers Complain of Minimal Disclosure After COVID Exposures (KHN, The Guardian)
  • As Deaths Mount, Coronavirus Testing Remains Wildly Inconsistent In Long-Term Care (KHN, USA Today)
  • Millions Stuck At Home With No Plumbing, Kitchen Or Space To Stay Safe (KHN)
  • Racial Status And The Pandemic: A Combustible Mixture (KHN, Vice)
  • ‘No Intubation’: Seniors Fearful Of COVID-19 Are Changing Their Living Wills (KHN, Washington Post)
  • Beyond The Glam: Feeding The Coachella Valley’s Most Vulnerable Residents (KHN)
  • Analysis: We Knew The Coronavirus Was Coming, Yet We Failed 5 Critical Tests (KHN, New York Times)
  • How COVID Colors The Salon Experience (KHN, New York Times)
  • COVID Survivors’ Blood Plasma Is A Sought-After New Commodity (KHN, NPR)
  • Keeping The COVID Plague At Bay: How California Is Protecting Older Veterans (KHN, Los Angeles Times)
  • ‘An Arm And A Leg’: Health Care Takes A Financial Hit In The Midst Of Pandemic (KHN)
  • Southwest CEO’s Boast About Airplanes’ Low COVID Risk Flies By Key Concerns (KHN)
  • COVID Bailout Cash Goes To Big Players That Have Paid Millions To Settle Allegations Of Wrongdoing (KHN, Daily Beast)
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