Every Friday, we’re recapping the latest on coronavirus from our tracking, policy analysis, polling, and journalism. Total cases in the U.S. are still climbing, and surpassed 1.2 million this week. Approximately 76,000 have died in the U.S. from COVID-19. Meanwhile, since last Thursday, actions to ease social distancing requirements went into effect in 28 states and 14 states extended social distancing measures. One of the most notable updates to our data trackers was that 33 total states are now reporting 25,000 across 6,000 LTC facilities. Two weeks ago, only 6 states reported this data.

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

Global Cases and Deaths: This week, total cases worldwide passed 3.85 million – with approximately 591,000 new confirmed cases added between April 30 and May 7. There were approximately 36,000 new confirmed deaths worldwide between April 30 and May 7.

U.S. Cases and Deaths: There have been over 1.26 million total confirmed cases in the U.S. There were approximately 188,000 new confirmed cases and 13,000 confirmed deaths in the United States between April 30 and May 7.

U.S. Tests: There have been approximately 8.1 million total COVID-19 tests with results in the United States — with over 2 million added since April 30. 15.4% of those tests were positive.

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. For both 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 socioeconomic factors.

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

• Social Distancing: 28 states have eased social distancing measures: Alabama, Alaska, Colorado, Florida, Georgia, Hawaii, Idaho, Indiana, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, and West Virginia. 14 states have extended social distancing measures: Arkansas, Illinois, Maryland, Michigan, New Hampshire, New Jersey, New Mexico, New York, Oklahoma, Oregon, Rhode Island, Tennessee, Vermont, and Washington
• 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 22 states, some or all non-essential business permitted to reopen (some with reduced capacity)  in 23 states, no action in 6 states
• Large Gatherings Ban: original gathering ban/limit in place in 40 states, gathering/ban limit eased or lifted in 9 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 35 states, restaurants re-opened to dine-in service in 15 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 Reports of Long-Term Care Facility Cases and Deaths Related to COVID-19 (Includes Washington D.C.)

• Data Reporting Status: 43 states are reporting COVID-19 data in long-term care facilities, 8 states are not reporting
• Cases in long-term care facilities: 127,693 (in 37 states)
• Deaths in long-term care facilities: 24,869 (in 33 states)
• Long-term care facilities as a share of total state cases: 15% (across 37 states)
• Long-term care facility deaths as a share of total state deaths: 38% (across 33 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: 38 states have approved waivers
• Approved State Plan Amendments (SPAs): 29 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

This week’s posts in Coronavirus Policy Watch:   

• At-Home SARS-CoV-2 Diagnostic Tests Could be a Breakthrough, But What Are the Limitations? (Blog)
• What We Can Learn from HIV in Communicating about COVID-19 (Blog)
• Lifting Social Distancing Measures in America: State Actions & Metrics (Blog)
• When Will The Unemployed Go Back To Work? Many Laid Off Workers Expect To Get Jobs Back In The Short-Term But Experts Caution About Long-Term Unemployment (Blog)

The latest KFF COVID-19 resources:

COVID-19 in the United States

• Low-Income and Communities of Color at Higher Risk of Serious Illness if Infected with Coronavirus (Issue Brief)
• COVID-19: Who Is Most At Risk of Serious Illness? (Video)

• COVID-19 Quiz (Quiz)
• Key Questions About the New Increase in Federal Medicaid Matching Funds for COVID-19 (Issue Brief)

• Key Questions About the New Medicaid Eligibility Pathway for Uninsured Coronavirus Testing (Issue Brief)
• How Are States Supporting Medicaid Home and Community-Based Services During the COVID-19 Crisis? (Issue Brief)
• How Publicly-Funded Family Planning Providers are Adapting in the COVID-19 Pandemic (Issue Brief)
• Updated: FAQs on Medicare Coverage and Costs Related to COVID-19 Testing and Treatment (Issue Brief)

• Drew Altman: Reopening is a Risk for Republican Governors (Blog, Axios)

• Pandemic Exacerbating Humanitarian Crises, Interrupting Aid Supply Chains, U.N. Agencies, Charities Say (KFF Daily Global Health Policy Report)

Trackers and Tools

• COVID-19 Coronavirus Tracker – Updated as of May 8, 2020 (Interactive)
• State Data and Policy Actions to Address Coronavirus – Updated as of May 7, 2020 (Interactive)
• Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19 – Updated as of May 7, 2020 (Issue Brief)
• COVID-19 and Related State Data (State Health Facts)

The latest KHN COVID-19 stories:

• Updated: Lost On The Frontline (KHN, The Guardian)
• Trying Out LA’s New Coronavirus Testing Regime (KHN, Washington Post)

• Looking For A Path To Reopen, Employers Weigh COVID Testing Of Workers (KHN, Time)
• Reopening In The COVID Era: How To Adapt To A New Normal (KHN)
• How The Pandemic And An Anti-Vax Health Official Are Roiling A Montana Community (KHN, Daily Beast)
• Economic Blow Of The Coronavirus Hits America’s Already Stressed Farmers (KHN)
• KHN’s ‘What The Health?’: Blowing The Whistle On Trump Team’s COVID Policies (Podcast)
• Eerie Emptiness Of ERs Worries Doctors As Heart Attack And Stroke Patients Delay Care (KHN, NPR)
• When Prisons Are ‘Petri Dishes,’ Inmates Can’t Guard Against COVID-19, They Say (KHN, NPR)
• Always The Bridesmaid, Public Health Rarely Spotlighted Until It’s Too Late (KHN, NPR)
• COVID-Plagued California Nursing Homes Often Had Problems In Past (KHN, KPCC)
• As COVID-19 Lurks, Families Are Locked Out Of Nursing Homes. Is It Safe Inside? (KHN, CNN)
• Palliative Care Helped Family Face ‘The Awful, Awful Truth’ (KHN, NPR)
• Testing In California Still A Frustrating Patchwork Of Haves And Have-Nots (KHN, NPR)
• As Lawmakers Reconvene, Not Everyone Agrees On COVID-Only Agenda (KHN)
• Viral Post Alleging Obama-Era Device Tax Caused Current PPE Shortage Is Way Off (KHN)
• Listen: A New Hope In The Battle Against COVID-19 (Podcast)

The first SARS-CoV-2 diagnostic test with a home collection option by LabCorp received emergency use authorization (EUA) from the Food and Drug Administration (FDA) on April 21, 2020. LabCorp is initially prioritizing healthcare workers and first responders and then expects to make the tests available more broadly. On May 8, 2020 the FDA granted a second EUA to Rutgers’ RUCDR Infinite Biologics for an at-home test using a saliva-based specimen. At-home tests may be a promising avenue to get more people tested in a timely manner and also reduce the risk of exposure in health care settings. An at-home SARS-CoV-2 test would not be the first at-home test for an infectious disease. For several years now, Americans have been able to purchase at-home sexually transmitted infection (STI) tests from online sellers, and experiences with these tests can offer some lessons on the challenges that we might anticipate with the widespread adoption of at-home SARS-CoV-2 testing.

Before the Food and Drug Administration (FDA) authorized any at-home tests for SARS-CoV-2, several companies began development of at-home diagnostic tests. A few of the companies that were already offering at-home tests for STIs and other conditions (e.g. Nurx and Everylywell), jumped on the opportunity to develop and distribute at-home diagnostic tests soon after the FDA issued a policy to accelerate approval of diagnostic tests for COVID-19 in the early days of the outbreak. However, on March 20, 2020 the FDA clarified that test self-collection and at-home tests were not authorized under the initial policy, so these companies subsequently discontinued the distribution of at-home tests, with some redirecting their tests to hospitals and healthcare providers or providing them though clinics (Table 1).

Among the issues that have arisen are state level restrictions on at-home tests, accurate reporting of results to public health authorities, the ability of individuals to safely and correctly collect their own samples, as well as affordability and coverage. Lessons learned from at-home STI testing products highlight other logistical hurdles that could make the mass distribution of an at-home SARS-CoV-2 test challenging.

• State policies blocking at-home testing: Existing state direct-to-consumer testing laws currently limit at-home testing in New York, New Jersey, and Rhode Island (which has been a barrier to the availability of STI at-home STI testing in those states). Many of these laws only allow tests to be ordered by licensed physicians and not consumers. LabCorp states that their new FDA-authorized at-home SARS-CoV-2 diagnostic test is not available in Maryland, New Jersey, New York, or Rhode Island, states with large numbers of COVID-19 cases and deaths.
• Public health surveillance: The Coronavirus Aid, Relief, and Economic Security (CARES) Act requires every laboratory that performs or analyzes a test that is intended to detect SARS-CoV-2 or to diagnose a possible case of COVID-19 to report the test results to HHS. COVID-19 was also added to the Centers for Disease Control and Prevention’s (CDC) list of national notifiable diseases on April 5, 2020, which often prompts states or local jurisdictions to mandate reporting through law or regulation. Syphilis, chlamydia, gonorrhea, and chancroid are also national notifiable diseases. Most STI home-testing companies have individuals send in their samples, the lab reports the results of the test back to the individual, and the companies report the results to public health agencies that report to the CDC. OraSure Technologies, a company that is currently working on an at-home rapid diagnostic test for SARS-CoV-2 with federal support, has been offering a rapid at-home HIV test that provides the results to individuals without the need to send back a specimen to the lab. It has been up to the individual to contact a provider to confirm the HIV test results and that provider then reports the confirmatory results to the CDC. To keep track of how many people have been tested for SARS-CoV-2 and the prevalence of the virus in the community, at-home testing companies that run the results will need to be required by law to report the test results to public health agencies. However, if a test is developed and approved that provides results at home, unless there is a system of consumers to easily report the test results to public health agencies, we won’t get a full picture of test results and the number of community infections.
• Home specimen collection: Many at-home STI tests are FDA-approved laboratory tests and are often sent to labs accredited by the College of American Pathologists (CAP) and certified under the Clinical Laboratory Improvement Amendments (CLIA). The Centers for Medicare & Medicaid Services (CMS) regulates all laboratory testing (except research) performed on humans in the U.S. through the CLIA. While there is concern that self-collected specimens may be more prone to variability and error in the collection (leading to inaccurate results), a systematic review and meta-analysis of self-collected vs. clinician-collected vaginal swabs and urine samples for chlamydia and gonorrhea found self-collected samples to be similarly accurate and a good option for those that otherwise might not be tested. Nasal swabs, particularly of the nasopharynx, the hard to reach cavity between the nose and the throat, may be more challenging to self-collect than those collected by a health care provider. Some companies are proposing saliva tests, which may make self-collection easier. Some companies proposing saliva tests, like the newly approved test from Rutgers’ RUCDR Infinite Biologics, may make self-collection easier.
• Cost and Coverage: Historically, few at-home STI tests few accept private insurance or Medicaid. However, the Families First Coronavirus Response Act (P.L. 116-127), and the CARES Act require private insurance, Medicare, Medicare Advantage plans, Medicaid, and the Children’s Health Insurance Program to cover (without cost-sharing or other cost-containment measures) a SARS-CoV-2 test if the test has received an EUA from the FDA or if it is FDA-approved. LabCorp’s test received an EUA from the FDA on April 21, 2020. However, in addition to the costs of STI test kits ($24-$522), some companies charge a consultation fee that ranges from $10-$99 that is not covered by insurance. A few companies like Nurx accept private insurance in 28 states and DC and Medicaid in California, Illinois, and Texas, but consumers with insurance must still pay $75 for the kit contents and the processing. The FDA-approved LabCorp SARS-CoV-2 test costs $119 and as of April 30, 2020, they say they can file your insurance or utilize federal funds to cover the upfront cost of this test. Home-testing companies, however, historically have not accepted insurance for their other diagnostic tests, so a mechanism to charge insurers would need to be developed and implemented to make these tests more widely accessible once they are approved, particularly to low-income individuals.

Using platforms with these ready at-home tests is an attractive avenue to ramp up testing and reduce exposure of health care workers and individuals in the community. Because asymptomatic people may need diagnostic testing multiple times after potential exposure, an at-home test would be a convenient way to do broad scale testing. However, in addition to the many concerns about the accuracy of the tests, there are still challenges in assuring that individuals can easily and accurately collect their own specimens, and receive the financial protections that federal law now provides. Finally, there are not yet systems in place to assure that if rapid result at-home tests are approved, the results can be reported to public health agencies to be included in surveillance statistics and allow for contact tracing for people who test positive.

Source

State Data and Policy Actions to Address Coronavirus

Among non-elderly adults, American Indian/Alaska Native and Black adults are more likely than Whites to be at higher risk of serious illness if infected with the new coronavirus — chiefly due to a higher prevalence of underlying health conditions and longstanding disparities in health care and other socio-economic factors, according to a new KFF analysis. People in lower-income households are also at higher risk.

The analysis finds that the share of non-elderly adults at higher risk of serious illness is 34 percent among American Indian/Alaska Natives and 27 percent among Blacks, compared to 21 percent of Whites. Asian adults are the least likely to be at higher risk of serious illness if infected (12%).

The analysis also finds that more than one in three (35%) non-elderly adults with household incomes below $15,000 are at higher risk of serious illness if infected with coronavirus, more than double the rate found among adults with household incomes greater than $50,000 (16%). Here again the higher risk arises due to a higher prevalence of underlying health conditions among non-elderly people with low incomes.

The new analysis builds upon previous work by KFF examining how many people in the U.S. are at higher risk of developing serious illness from coronavirus. The findings comport with emerging data on COVID-19 cases and deaths that suggest that serious illness from the disease is disproportionately affecting people in communities of color, due to the underlying health conditions and economic challenges faced by such groups.

Also available is a new short animation that examines the populations at higher risk for serious illness if they are infected with the coronavirus that causes COVID-19.

For the full analysis, and other KFF data and analyses related to COVID-19, visit kff.org.

The number of confirmed cases of coronavirus in the U.S. has steadily climbed and is now the highest in the world. The Centers for Disease Control and Prevention (CDC) and state and local governments continue to release data about the characteristics of people who have developed serious illness when infected with coronavirus, as well as the number of hospitalizations and deaths due to COVID-19. These emerging national and state-level data suggest that serious illness resulting from coronavirus disproportionately affects people in communities of color, due to the underlying health and economic challenges that they face. Similarly, adults with low incomes are more likely to have higher rates of chronic conditions compared to adults with high incomes, which could increase their risk of serious illness if infected with coronavirus.

To provide greater insight into the characteristics of people at greater risk of illness if infected with the novel coronavirus, we build on a prior analysis of higher risk adults in the U.S. to break down these numbers by race/ethnicity and household income in 2018. Our definition of higher risk includes: non-elderly adults between the ages of 18 and 64 with heart disease, chronic obstructive pulmonary disease (COPD), uncontrolled asthma, diabetes, or a body mass index (BMI) greater than 40, following the risk factors identified by the CDC. See Methods for more information.

Key Findings

Our prior analysis found about one in five adults (21%) ages 18-64 have a higher risk of developing serious illness if they become infected with coronavirus, due to an underlying health condition. This analysis finds:

• More than one in three (34%) American Indian/Alaska Native non-elderly adults are at higher risk of serious illness if infected with the coronavirus; this share is greater than all other racial and ethnic groups (Figure 1).

• More than one in four (27%) Black non-elderly adults are at higher risk of serious illness if infected with coronavirus, compared to about one in five (21%) White adults.
• Asian non-elderly adults have the smallest share (12%) of adults at higher risk of serious illness among the racial and ethnic groups included in this analysis.
• More than one in three (35%) non-elderly adults with household incomes below $15,000 are at higher risk of serious illness if infected with coronavirus, compared to about one in seven (16%) adults with household incomes greater than $50,000 (Figure 2).

Discussion

Most people who are infected with the novel coronavirus are not expected to become seriously ill, however, about one in five non-elderly adults (21%) have an underlying medical condition which puts them at higher risk of serious illness if they get infected. Among people ages 18-64, American Indian/Alaska Native and Black adults are more likely than White adults to be at a higher risk of serious illness due to underlying health conditions and longstanding disparities in health care and other socio-economic factors. Even though the shares of Hispanic and Native Hawaiian or Pacific Islander nonelderly adults at higher risk for serious illness if infected are similar to that of White adults, these groups face disparities in other health, social, and economic factors that may contribute to barriers to health care associated with coronavirus. Although our analysis finds Asian adults are the least likely to be at higher risk for serious illness, this finding may mask subgroups of Asian adults who may be at higher risk.

A larger share of non-elderly adults with lower household income than higher household income have a greater risk of serious illness if they are infected with coronavirus. This is principally because of underlying health conditions that are more prevalent among non-elderly adults with low incomes. People with low incomes who work in jobs such as grocery story workers, delivery drivers or home health aides that are defined as essential may put themselves at higher risk of contracting coronavirus than others who are able to shelter in place and follow guidelines for social distancing.

Lack of health insurance could pose challenges to people seeking treatment for COVID-19, which could disproportionately affect non-elderly adults with low incomes and people in communities of color. On April 24, 2020, the Paycheck Protection Program and Health Care Enhancement Act was signed into law, adding an additional $100 billion to the Provider Relief Fund, with funding to reimburse providers for treating uninsured patients with COVID-19. However, the large number of providers and services which are eligible for reimbursement could drain available funds, raising questions about coverage for the uninsured, and the costs of their care when such funds are no longer available.

Federal and state governments are strengthening their efforts to collect and report data by demographics on coronavirus testing, hospitalizations, and deaths. Even so, efforts to analyze these data are limited by the large number of missing responses, and limited surveillance in certain communities. Comprehensive nationwide data, broken down by race and ethnicity and income, are needed to understand how COVID-19 is affecting communities in the U.S. and how best to target coronavirus testing and other resources accordingly.

How many adults in the United States are at a higher risk of serious illness if they are infected with coronavirus and who are they? Watch this two minute video to get informed about these highest-risk populations.

As we, and others, navigate how to communicate about COVID-19 and the urgent public health issues it brings, there is much that can be learned in looking at HIV messaging and how it has evolved.

Below are some of our observations from KFF’s more than two decades of experience running large-scale public information campaigns about HIV and other communicable diseases that have bearing in this new environment.

1. Don’t overlook the basics. In a rapidly changing environment where scientific advances are coming fast, it is important not to lose sight of the basics. Even after more than three decades into the HIV epidemic, we still see a need to cover fundamentals, like how HIV is – and is not – transmitted and that testing is the only way to know if you (or someone else) has it. As the COVID-19 conversation shifts to testing, treatment, and vaccines, there will still be a need for reinforcing messaging about frequent handwashing, not touching your face, and physical distancing.
2. Focus on normalizing, not moralizing. Blame and shame are terrible public health motivators. In fact, they can have the opposite effect. We have seen the stigma around HIV keep people from taking the very actions needed to stem the epidemic, like getting tested or using protection. Despite best efforts, COVID-19 infections will happen. Some individuals – for reasons beyond their control and not for lack of effort – will be at greater risk. Effective messages empower.
3. It can be hard to assess personal risk. There is a tendency to look for what makes us different from those who are affected. In HIV, one of the greatest barriers to reaching even those at higher risk is a sense that “it can’t – or won’t – happen to me.” The reality, of course, is that if you are exposed and not protected, there is a chance you will get infected. That’s true for any virus. First person, relatable stories can be effective in breaking down this misconception.
4. Asymptomatic people are a key audience. As with HIV, not everyone with COVID-19 displays symptoms right away, or at all. Messaging needs to highlight risk, and need for prevention, even when symptoms are not visible.
5. Responsibility lies with everyone. Collective action and social solidarity are critical to confronting COVID-19. The burden cannot fall only on those who are positive – or symptomatic. Sheltering in place relies on those who may be at lower risk staying home to protect the broader community and frontline workers. Just as an effective HIV response includes messaging both for those who are negative about what they can do to stay that way, as well as for those who are living with HIV, so too must COVID-19 communications.
6. Acknowledge disproportionate impact without furthering stigma. While every community has experienced some type of fallout from COVID-19, emerging data indicates that Black and Latinx people are disproportionately impacted. These are some of the same populations most affected by HIV. While it is important to shine a light on communities carrying the heaviest burden, it must come with an understanding of why it is happening (lack of health care access, structural racism, social networks, etc.), which are many of the same issues that drive other health disparities, including HIV.
7. Watch out for unintentional stigma. Most Americans carry some type of risk and many will test positive for COVID-19. They need to be encouraged – and supported – in sharing this information, without fear of judgement about how it happened, even as we continue to educate about prevention. Preserving confidentiality, when possible, is important.
8. Don’t message in a vacuum. Life circumstances bring different challenges. Sheltering in place will come with economic uncertainty for many. Those struggling with mental health issues may feel increased stress/isolation/anxiety. The most effective messaging reflects and responds to the real-life issues people face. In communicating about HIV, we often are addressing challenges that go beyond the doctor’s office.
9. Look ahead to messaging about living with COVID-19. COVID-19 is going to be part of our lives for a long time and we need to talk about not just how to survive it, but how to live with it. There has been a huge shift from the early days of the HIV epidemic when it was a death sentence to now, where it is a treatable, manageable condition. While we maintain urgency, it is also important to convey hope.
10. Connect to resources. To be successful, messaging needs to connect back to concrete actions, including local resources where people can get help. Geo-based, mobile-friendly locators that direct people to testing, treatment, and access to care in their areas will be critical. These tools will need to be developed for COVID-19, as they have been for HIV, and promoted widely.

While much remains unknown about what our future with COVID-19 looks like, and even as we still are learning about the disease itself, what we have learned from messaging about HIV can offer a useful roadmap.

Since the early 1990s, KFF has produced some of the largest, most successful HIV public information campaigns on HIV, many with leading media, both here and abroad. In 2009, we launched Greater Than AIDS, a social impact response that works in partnership with health departments and other community allies to reach those most affected with life-saving information. In 2019, Greater Than AIDS media messages generated more than 360 million impressions and 15.4 million video views.

With so much information coming out daily about the coronavirus and COVID-19, it’s hard to keep up, but important to know the facts.

Test your knowledge, and share this quiz with family, friends and colleagues.

Family planning providers, including community health centers, free-standing women’s health centers, health departments, and Planned Parenthood clinics are significant sources of care for contraceptive and STI services for low-income and uninsured individuals. Medicaid, the Title X Family Planning Program, and Section 330 of the Public Health Service Act (PHSA) provide support to more than 10,000 safety-net clinics across the country that provide reproductive health services to low-income women, men, and teens. These safety-net clinics have had to find ways to continue providing quality family planning services while also following the social distancing rules during the coronavirus pandemic. Some of the common changes reported by clinics and recommended by organizations (e.g., CDC, NFPRHA, FPNTC, ASCCP, UCSF’s Beyond the Pill, and the Reproductive Health Access Project) during this time apply throughout the delivery system, while others are specific to family planning care.

• Shift to telehealth – Many safety-net clinics are shifting to telehealth when possible. According to HRSA’s survey of health centers on April 24^th, more than half (54%) of health center visits were conducted virtually during the prior week. The range was considerable however, from clinics in Louisiana reporting that roughly two-thirds (64%) of visits were conducted virtually, compared to about one-third in neighboring Mississippi (38%). For many providers, this is a major new undertaking, as only a small fraction of family planning services were previously provided via telehealth. For example, Planned Parenthood announced that they will offer telehealth services in all states, including contraceptive counseling and prescriptions, sexually transmitted infections (STIs) and HIV care, emergency contraception, and other services. Telehealth services have required significant up front investment from providers for technology, training, and to ensure regulatory compliance. To make it easier for safety-net providers to offer telemedicine during the COVID-19 outbreak, however, many state Medicaid programs have issued guidance expanding coverage and access to telehealth services, and waiving potential penalties for HIPAA violations for the duration of the emergency.
• Contraception services – Many family planning clinics are trying to continue providing the full range of contraceptive services but must balance decisions about staffing, services, hours, and space with needs for care. This includes whether to initiate a new contraceptive method, how to address maintenance such as routine Depo-Provera injections, or support discontinuation when patients seek it, such as LARC removal. In several states, women can obtain oral contraceptive prescriptions for 12 months, which reduces the need for in-person visits.
• Extending use of LARCs – While most LARC products are FDA-approved for three to ten years, research has found that some are effective at preventing pregnancy for longer, up to 12 years in the case of the copper IUD. To reduce the need for in-person appointments, some clinicians are advising patients that they can continue with their current LARC method longer than the official recommendation without greatly risking unintended pregnancy.
• STI treatment – CDC has recommended prioritizing patients with STI symptoms, those reporting contact with STIs, and individuals at greater risk for complications. Some clinics are offering at-home chlamydia and gonorrhea tests through a telehealth appointment and then an at-home test kit using urine collection or a home swab, which can be returned to a clinic for testing.
• Self-administered injectable contraception – While a subcutaneous Depo-Provera injection has been available for years and was designed for self-injection, it is not formally approved by the FDA for at-home use, which is considered off label use. In light of the pandemic, rather than medical staff administering injections at the clinic every 12-15 weeks, which is usual clinical practice, NFPRHA has released guidance on offering subcutaneous Depo-Provera that individuals can self-inject at home.
• Deferral of non-urgent services – State orders have outlined that non-essential services be delayed until the emergency response is over, which could include a wide range of services such as preventive well woman visits but also certain follow up services for cervical cancer, as recommended by ASCCP.
• Curbside services – Some clinics are offering curbside services that may include a packet with condoms, at-home STI testing kits, medication pick-up, or drive-up injectable contraception administration.

Some of these changes may be temporary, but some, such as greater use of telemedicine, which can give patients more autonomy in their reproductive health care, may endure longer-term. Over time, we will gain a better understanding of the scope and scale of these changes as well as their impact on access and quality. Provider finances and the type of regulations the states adopt after the emergency eases will also have implications on how and whether clinics will continue to offer services like telemedicine care after the pandemic emergency subsides. In the recent past, some family planning providers have faced a unique set of funding challenges. The network of providers receiving federal Title X funds shrunk considerably in the past year, with 26% of clinics leaving the network, including all Planned Parenthood clinics. These departures were triggered by major changes to the program, issued by the Trump Administration in Spring 2019, that prohibited Title X -funded clinics from making abortion referrals and required complete physical separation of abortion services. Six states (WA, OR, UT, ME, VT, HI) no longer have any Title X-funded clinics. While many states were able to offset the loss with state funds, the looming fiscal crisis puts the continued availability of these dollars in question.

Now, during the pandemic emergency, many clinics are experiencing lower patient volume and staffing shortages. Rising unemployment means that safety-net clinics may see an increase in patients in the near future as people lose employer-sponsored insurance. This will likely be a combination of uninsured patients without a source of payment as well as some with Medicaid coverage, particularly in expansion states, which could bring in additional revenue.  In non-expansion states, Medicaid family planning programs could provide another revenue source for clinics by extending coverage for family planning services to individuals who do not qualify for full scope Medicaid coverage. While some providers will obtain short-term assistance from the recently enacted COVID-19 relief laws, this support will likely not be sufficient to meet long-term financial needs. For millions of low-income people, their need for timely sexual and reproductive health will continue, but the extent to which many of the providers that have been serving them will have access to resources they need to keep their doors open is not clear.

There has been a lot of focus on the impact of COVID-19 on people in nursing homes, but less attention so far paid to seniors and people with disabilities receiving long-term home and community-based services (HCBS), who also face serious issues. Some news reports recently have emerged about outbreaks in group homes for people with developmental disabilities and the impact on people who receive and those who provide home care. HCBS help with tasks such as bathing, dressing, and preparing meals. Medicaid is the primary payer for these services, financing 59% of HCBS (Figure 1). Over 2.5 million people received services through Medicaid HCBS waivers offered in all 50 states and DC in FY 2018. People receiving HCBS may be at increased risk of adverse health outcomes from COVID-19 due to older age and/or chronic illness as well as from unmet daily needs due to workforce and medical supply shortages during the crisis. Maintaining and potentially expanding HCBS during the public health emergency is critical to prevent increased need for nursing home care.

States are using a previously little-known Medicaid authority, Section 1915 (c) waiver Appendix K, to make temporary changes to their HCBS programs to respond to the COVID-19 emergency. States can use Appendix K to ensure that current HCBS enrollees continue to receive needed services, support providers, and cover additional people during the emergency. As of April 30, 2020, CMS has approved Appendix K authority in 182 waivers across 37 states.

Most states with Appendix K approvals to date are temporarily adopting or modifying policies to ensure that current waiver participants remain enrolled in coverage and maintain access to services during the emergency (Figure 2). For example, nearly all Appendix K approvals allow virtual eligibility assessments and service planning meetings, and most extend due dates for eligibility reassessments. These changes are important to continuity of care and do not require substantial new funding. Similarly, many approvals permit remote services at home or otherwise expanding the settings where services can be provided to account for social distancing. Approvals also enable waiver enrollees to receive services beyond the typical limits when necessary to address health and welfare during the emergency. Fewer states are using Appendix K to add new services to the waiver benefit package, such as home-delivered meals, medical supplies or equipment, or services specific to the COVID-19 emergency, such as wellness counseling, changes which likely would require additional funding.

Many states with Appendix K approvals to date also are taking steps to support existing HCBS providers and expand the provider pool (Figure 2). For example, many approvals authorize making retainer payments to support the financial survival of providers who are temporarily unable to offer services as usual due to the crisis and temporarily modify provider qualifications to ensure an adequate workforce at a time when the health care system is strained to meet increased service needs and to account for providers who may be unable to work because they are ill. Like the most frequently adopted policy changes supporting enrollees, these actions do not require substantial new funding to implement. By contrast, fewer states are using Appendix K to temporarily increase provider payment rates to account for higher costs, such as personal protective equipment or hazard pay, during the emergency.

Few states with approvals to date are using Appendix K to serve more people in their HCBS waivers during the public health emergency. Many people on waiver waiting lists are at increased risk of coronavirus infection themselves or at increased risk of having unmet daily needs due to a caregiver’s infection. However, states are likely hesitant to commit additional funding as their budgets come under increased strain. Two states to date have temporarily increased the total number of people served under one of their waivers during the emergency (Maryland and Utah). A small number of states have temporarily increased cost limits or functional need criteria to expand the definition of who is eligible for the waiver during the emergency.

Overall, states’ use of Appendix K to temporarily adopt HCBS policies to respond to the COVID-19 emergency is limited, due to state budget constraints. The 6.2 percentage point increase in federal Medicaid matching funds recently enacted in the Families First Coronavirus Response Act is designed to help states facing increased costs during the emergency but likely is inadequate to encourage states to make even temporary changes during the emergency that require new funds. It remains to be seen whether additional legislative efforts will make more federal funding available to states to support current and expanded HCBS efforts to address the effects of the COVID-19 pandemic.