Archive for the ‘State News’ Category

Seven Days

Tuesday, October 27th, 2020

A diversion

How about a break from anything having to do with COVID-19 or the election? Would you like that? Then let me tell you a story.

Long ago, in a galaxy far away, a 23-year-old, newly-minted, Infantry 2nd Lieutenant airborne ranger with my name spent two-plus years in a little country in Southeast Asia called Vietnam. I think if Donald Trump had foregone the fake bone spurs and taken his chances over there he might have learned a lot.

But that’s another story, and not the point of this one. Couldn’t help myself.

Three months before rotating home to the U.S., I had been pulled from the field, that is, taken out of the jungle, and given a staff job on Firebase Vegel in northern South Vietnam.

With two months to go, I decided to begin keeping a Short-timer’s Calendar.

My Short-timer’s Calendar consisted of the centerfold of the June, 1971, Playboy magazine. My Battalion Commander, Lt. Colonel  Bulldog Carter (that’s right, Bulldog), and my partner, Buck Kernan (who went on to become a Lieutenant General, like his father before him), marked up the luscious photo into 60 puzzle-like areas numbered from 60 down to one. The trajectory of the progression became increasingly lascivious.

Thereafter we held a nightly, candle-lit ceremony in the bunker occupied by Buck and me.

But before I describe the ceremony, I have to tell you about the Macadamia nuts.

During Vietnam  the army  allowed soldiers a ten-day R&R (Rest and Relaxation) vacation. As a two-year guy I got two of them, which I spent in Honolulu, Hawaii, with my wife, Marilyn. One day, during the second R&R, we went to the PX (Post Exchange) at Scofield Army Barracks to pick up a couple of things. While we were there we bought a large bottle of Macadamia nuts for me to take back to Vietnam. In Vietnam, little things became luxurious delicacies.

Back to the ceremony.

Our bunker had a single bunk bed. There was only one bed, because Buck and I took 12-hour shifts in the Op Center keeping the world safe for democracy. One of us would end his shift, wave to the other and crash into the bed.

Every night, at 2000 hours, 8:00 pm to you, the three of us would gather in the bunker. There was a small table to the side of the bed.  I had pinned the centerfold to the wall above the table. At the appointed hour, I would light two candles and place them on each side of the table under the pin-up. I would open the bottle of Macadamia nuts, which occupied a special spot in the center of the table, and hand each of my comrades one nut, taking one for myself. We would then have a moment of quiet reflection, after which I would, with a red marker purloined from the Op Center, X-out the next descending number on Miss June.

We would then eat the nuts.

We did that all the way down to ONE! On that night, we held a special ceremony, inviting the Battalion XO, the other six staff officers and the Battalion Sgt. Major into the bunker, which became almost as crowded as the stateroom scene in Night at the Opera. We gave everyone a Macadamia nut that night, and, in a service worthy of priestly ordination, I passed the bottle of Macadamia nuts to Buck, who, because he still had six weeks to go, later on would replace my centerfold with his centerfold and continue the tradition. We retired my centerfold to a place of prominence on the side wall of the Op Center, where Bulldog could see it every day all day. Six weeks later, Buck’s would be hung beside it.

The next day, I choppered south, boarded a chartered Pan Am plane with about three-hundred other happy guys and flew home to what we called “the world.”

OK. Break’s over

If it weren’t so stupidly tragic and delusional, one might be forgiven for viewing Donald Trump’s campaign swan song as comical. “We’ve turned the corner.” “It will go away.” “On November 4th, you won’t hear about it anymore.” And the list goes on.

But if you really want to know how we’re doing, there are, actually, reliable places to look. Johns Hopkins Coronavirus Resource Center and the New York Times COVID Tracker, for example.

And now there is this website, which tracks the Rt factor for each state, daily. Rt represents the effective reproduction rate of the virus calculated for each locale. It lets us estimate how many secondary infections are likely to occur from a single infection in a specific area. Values over 1.0 mean we should expect more cases in that area, values under 1.0 mean we should expect fewer. As of today, only one state, Mississippi, of all places, is below 1. You can see what infection rates are like today, two weeks ago, one, two and three months ago. It confirms what all of us, except the aforementioned Mr. Trump, his minions and cult-like followers, know to be true.

If we’ve “turned the corner” it is only to enter Dante’s Ninth Circle of Hell. You remember that one, don’t you? It’s the final, deepest level of hell, reserved for traitors, betrayers and oath-breakers. Up until now, it’s most famous occupant had been Judas Iscariot.

Up until now.

And finally…

Seven days to go.

The number seven comes up a lot in Roman Catholicism. There are seven Cardinal Virtues, called by the church, “Gifts of the Holy Spirit.” They are wisdom, understanding, counsel, fortitude, knowledge, piety, and fear of the Lord.

There are seven Corporal Works of Mercy. They are feed the hungry, shelter the homeless, clothe the naked, visit the sick and imprisoned, bury the dead, and give alms to the poor.

And there are seven Spiritual Works of Mercy. They are instruct, advise, console, comfort, forgive, and bear wrongs patiently.

Judge, now Justice, Amy Coney Barrett is a devout Roman Catholic. I’m sure she is also a very smart person and probably a pretty good lawyer, too.

But for a month now, I’ve been bothered by something about her, and with seven days to go, I’m bothered even more.

For the life of me I cannot get over that, at her super-spreader Rose Garden introduction and follow-on reception in the White House, she did not wear a mask to protect herself and others. I understand everyone else who attended had swallowed the Kool-Aid, but she should have known better. And last night, in the White House Blue Room and outside on its balcony, she was still unmasked.

There are only three possibilities for this behavior.

  1. She doesn’t believe masks protect us and others from the virus, which I don’t believe for a minute;
  2. She is ignorant about masks and doesn’t understand their importance, which I don’t believe for a second;
  3. She was influenced by Trump’s behavior, as well as that of everyone else’s, and just went along to get along.

I’m voting for door #3, and that is a scary thought for our future.

Seven days.

 

 

It’s Been Quite A Week — Here Are Some Things You Might Have Missed

Saturday, October 24th, 2020

From the Department of There’s No Accounting For Stupidity

Since 1980, the population of Idaho has grown from about one million to nearly 1.8 million, considerably outstripping the rate of growth of its neighbors Montana and Wyoming. Over the last 14 days, all three states have seen large spikes in Covid-19 cases, according to the New York Times’s Covid Map and Case Count. And they’re not alone. All the Midwest and Pacific region states are seeing similar surges. Their governors are faced with balancing increased restrictions with the personal freedom inherent in pioneering individualism.

Nowhere did this daunting task become more evident than Thursday in Idaho, a state that has seen a 55% rise in cases in the last two weeks and where, minutes after hearing local hospitals were approaching full capacity necessitating moving patients to Seattle, of all places, the regional health board voted to repeal the local mask mandate.

The regional board, composed of seven appointed members with no requirement to have any medical experience, voted 4-3 to end the mandate. Health District epidemiologist Jeff Lee had just finished describing how the state’s hospitals were becoming “overwhelmed” by the surge in cases. For example, even after doubling up patients in rooms and buying more hospital beds, the hospital in Coeur d’Alene had reached 99% capacity. But, not to worry, it’s just an eight hour, 493 mile ambulance ride from Boise to Seattle.

“We’re facing staff shortages, and we have a lot of physician fatigue. This has been going on for seven months — we’re tired,” Lee said.

He introduced several doctors who testified about the struggle COVID-19 patients face, the burden on hospitals and how masks reduce the spread of the virus. But that didn’t matter to the Board’s majority who just did not see the sense in masks, no matter what the experts said.

To put a period on the “Health” Board’s meeting, member Allen Banks got to the heart of the matter by denying the existence of Covid-19. Lecturing the medical professionals who testified, he said, “Something’s making these people sick, and I’m pretty sure that it’s not coronavirus, so the question that you should be asking is, ‘What’s making them sick?”

That penetrating question came from a gentleman with a Ph.D. in chemistry from the University of Colorado, who for 30 years has worked in medical research in biotechnology and pharmaceutical development.

Dr. Banks would make a wonderful addition to the White House Coronavirus Task Force.

How cold is cold enough?

Have you stopped to consider the logistics of delivering upwards of 200 million doses of a future Covid-19 vaccine? That’s a lot of syringes. If you laid them end to end they would stretch from the North Pole to the South Pole, about 13,000 miles.

And the vaccine would have to be kept cold, very cold. Just how cold you ask? Try minus 103 Fahrenheit. That’s nearly four times colder than your home freezer, colder even than Antarctica in the dead of winter.

This is a complex challenge. For months, manufacturers, federal and state governments, and large health care systems have been quietly planning how to navigate this ultra “cold chain” that stretches from vaccine manufacturers to hospitals, nursing homes, doctors’ offices, and many far-flung clinics. Now that Pfizer has announced it plans to apply for emergency-use authorization designation in late November for its vaccine currently in Phase 3 trials, solving the cold problem becomes more urgent.

The nation’s governors wrote the Trump Administration last Sunday expressing concerns about the supply of ultracold freezers and dry ice — already experiencing shortages. Pfizer says it has developed specially designed, temperature-controlled shipping packages, using dry ice, to keep its vials at roughly minus 103 below Fahrenheit for up to 10 days. But what happens if the doses are not used in ten days? This is what is confounding the governors.

This issue is even more difficult than it appears, because the vaccines of both Pfizer and Moderna, another leading vaccine developer in Phase 3 trials, require two shots within 21 and 28 days, respectively. The situation is eased somewhat, because Moderna’s vaccine, at around minus 4 Fahrenheit, does not require the same ultra-cold storage temperature as Pfizer’s.

Might be a good time to buy stock in a maker of dry ice.

High Deductibles: Another nail in the rural hospital coffin

Since 2010, more than 130 rural hospitals have closed, 15 thus far in 2020. One mostly overlooked reason is the health insurance deductible. Depending on the plan (employer-sponsored, ACA Marketplace, etc.) a family deductible can range from $0 (but the out-of-pockets are huge) to well over $8,000.

Families in rural communities often face deductibles in the $2,000 to $4,000 range. And when family members require hospitalization, it often happens they cannot pay the deductible. Rural hospitals are forced to eat this less than tasty bill, send it to a collections company, or set up a payment plan with the patient. They prefer the payment plan route, but this significantly delays getting the money, and the bill is often reduced because of the patient’s economic circumstances. So, the hospital goes further in the red and its patients go further in debt. The pandemic has only exacerbated this problem.

Just another example of our nation’s dysfunctional health care “system.”

How to get rid of an irritating federal employee

Despite a great swath of the public thinking otherwise, federal employees can be fired, although it is true that this happens rarely. Of the 2.1 million federal employees about 10,000 are terminated annually, according to the Merit Systems Protection Board (MSPB).

Firing a federal worker is similar to what would occur in the private sector, with one twist. In both settings, best practice recommends, and the federal system requires, the three step verbal warning, written warning, termination process. The twist comes after that. Federal employees can appeal to the MSPB, and the appeals can take a long time to adjudicate.

This past week, the Trump administration threw an interesting log on the fire when the President issued an Executive Order stripping long-held civil service protections from employees whose work involves policymaking. This will affect tens of thousands of workers, and will reduce them to being, for all practical purposes, “at will” employees, meaning they can be fired for cause or not for cause at a moment’s notice.

Under this order, federal scientists, attorneys, regulators, public health experts and many others in senior roles would lose rights to due process and in some cases, union representation, at agencies across the government.

These are not politically appointed employees who require confirmation to their positions, whom the president can terminate or have terminated by whim. Rather, they are professionals who serve as a cadre of subject-matter experts for every administration. I will let you consider the possible ramifications of this Executive Order, which to me seem profound. The Order, while not affecting a majority of the government, could upend the foundation of the career workforce by imposing political loyalty tests.

It is possible, with less than two weeks before election day, this may be more symbolic than real, because the Order requires agencies to indicate employees who would be affected by 19 January 2021, a day before the next inauguration. If Joe Biden wins the election he would be unlikely to follow through on the president’s order. But if Donald Trump is re-elected, this tectonic Order will monumentally reshape the federal service.

Think about that. Please.

 

 

 

 

Sisyphus Must Have Felt Like This

Wednesday, September 16th, 2020

The COVID-19 boulder, full of facts, lies, information, misinformation, disinformation, and just plain delusional thinking keeps rolling back down the mountain. Try as we might, it’s certainly difficult to make sense of COVID-19. But we keep trying, anyway. As in:

Unions during COVID-19

I have written previously about the perplexing case of union participation in America. In 1960, about a third of hourly workers belonged to unions. In January of this year, the BLS reported that number had dropped to 10.3%. Yet, in the same press release, the BLS reports:

Nonunion workers had median weekly earnings that were 81 percent of earnings for workers who were union members ($892 versus $1,095).

Right now we won’t get into why this puzzling paradox exists, except to say we now have another log to throw on the pyre.

A new study authored by researchers at George Washington University, the University of Pennsylvania Perelman School of Medicine and the Boston University School of Medicine, published in Health Affairs, found that having a unionized workforce at a nursing home greatly reduces the likelihood that residents or staff will die from COVID-19. From the study’s Abstract:

Health care worker unions were associated with a 1.29 percentage point mortality reduction, which represents a 30% relative decrease in the COVID-19 mortality rate compared to facilities without health care worker unions.

The study analyzed data from more than 300 nursing homes in New York from March 1 through May 31. The authors conclude the unionized health care workers in the nursing homes were able to negotiate for more PPE, higher pay, and better working conditions.

During the pandemic, New York has suffered nearly 7,000 nursing home deaths, more than any other state except New Jersey.

My take on this? If you have loved ones who may be headed for a nursing home, it might be a good idea to ask if the staff is unionized.

Avoiding medical care during COVID-19

Since early in COVID-19, we’ve known that many people, fearful of the disease, have put off getting routine, or, in some cases, emergency medical care. What we have not known is what demographic groups are doing that and to what degree. Now, the CDC has put a full stop period to that issue.

In its 11 September weekly Morbidity and Mortality Report, the CDC published a comprehensive analysis concluding 40.9% of U.S. adults delayed or avoided medical care as of June 30. This includes urgent or emergency care (12%) and routine care (32%). Regarding what population segments are doing this, the study had this to say:

The estimated prevalence of urgent or emergency care avoidance was significantly higher among the following groups: unpaid caregivers for adults versus non-caregivers (adjusted prevalence ratio [aPR] = 2.9); persons with two or more selected underlying medical conditions† versus those without those conditions (aPR = 1.9); persons with health insurance versus those without health insurance (aPR = 1.8); non-Hispanic Black (Black) adults (aPR = 1.6) and Hispanic or Latino (Hispanic) adults (aPR = 1.5) versus non-Hispanic White (White) adults; young adults aged 18–24 years versus adults aged 25–44 years (aPR = 1.5); and persons with disabilities§ versus those without disabilities (aPR = 1.3).*

So, Mary, taking care of her aged mother at home, foregoes either emergency or routine care at nearly three times the rate of Sarah, her next door neighbor who is not burdened with an aged relative, because she doesn’t want to bring COVID-19 home to Mom. Even more troubling is that people with two or more co-morbidities forego care at nearly two times the rate of people without such underlying conditions.

The CDC’s paper advises that, “… urgent efforts are warranted to ensure delivery of services that, if deferred, could result in patient harm.”

Enough said.

*By way of example for the statistically challenged, an adjusted prevalence ratio of 2 means that the prevalence of cases among a study group is 2 times higher than among the control subjects. It’s calculated through a series of regression analyses. There. Now you know.

U. S. life expectancy

COVID-19 has sucked all the air out of any national attempt at healthcare reform, while revealing in sharp detail the foundational flaws in the current system. Eventually, however, America is going to have to confront this issue in a meaningful manner. Healthcare cost in America is still twice the average of all 37 member countries of the Organization for Economic Cooperation and Development (OECD), and Americans still have poorer health and lower life expectancy than the average of the member countries (78.7 versus 79.5)

In its latest Health At A Glance publication, the OECD updated its life expectancy data, as shown here:

There are many cracks in our healthcare house that Jack built. Ignoring them is not a strategically viable plan for improvement, improvement that all citizens deserve.

To quote the venerable A. E. Housman, “Terrence, this is stupid stuff.” Another example of our woebegone healthcare system.

Trump’s Nevada rally

Last night, during an ABC-TV Town Hall Meeting President Trump once again pilloried cities and states run by Democrats and blamed their leaders for any problems with the response to COVID-19.

A little contextual background is required here. On 14 April, Trump asserted “absolute authority” to control the nation’s response to the pandemic, saying, “When somebody is president of the United States, your authority is total.” He made it clear he would be in charge and the states would have to fall in line.

Two days later, he reversed himself on a call with all the governors, telling them, “I’ve gotten to know almost all of you, most of you I’ve known and some very well. You are all very capable people, I think in all cases, very capable people. And you’re going to be calling your shots.”

Since then, he has repeatedly repeated the “You’re on your own” line. The result, of course, has been that we have seen 51 different plans and approaches  with varying degrees of success.

Nevada, one of the “you’re on your own” states, is still in the midst of a tough fight against the disease with a Daily Positivity Rate of 7.1% and a Cumulative Positivity Rate of 10.2% as of 10 September.

On 24 June, Nevada Governor Steve Sisolak imposed certain restrictions, among them the requirements that all Nevada residents wear masks when in public and that no more than 50 people, socially distanced, congregate in one place.

Enter Donald Trump and his the-sky-is-the-limit indoor rally of last Sunday evening at Xtreme Manufacturing in Henderson, Nevada. Fire officials estimated the size of the crowd was 5,600 people, nearly all of whom were maskless (except for the people right behind Trump who were constantly on full TV view).

Just as we saw in Tulsa after his previous rally, we’ll probably see a spike in cases in Nevada in two to three weeks.

Beyond the nonchalant and willful endangerment to peoples’ lives, what bothers me most of all about this event is Donald Trump’s cavalier and metaphorical raising high of his two middle fingers to Nevada’s scientifically-based efforts to keep its citizens alive. After repeatedly telling the nation’s governors they should do what they think they need to do to combat COVID-19, this “law and order” president, without compunction of any kind, imperiously violates the law while telling his large crowd Nevada’s Governor Sisolak is “a hack” and “weak.”

Allow me to close with Joseph Welsh’s question to Senator Joe McCarthy on 9 June 1954: “Have you no decency, sir?”

 

Important COVID-19 Workers’ Compensation Questions

Wednesday, May 13th, 2020

Economic chickens are coming home to roost all over America. Except for the one percenters, and I may be wrong about them, everyone is feeling it, the pain. Biomedical devastation is leading us to places we have never imagined, let alone seen. In the quiet little room called workers’ compensation where I have sat for some number of years, there are questions that are going to need answering. Let’s look at a few of them.

But first, a little background. A week ago we wrote about a recent National Council on Workers’ Compensation (NCCI) analysis of workers’ compensation cost projections due to COVID-19. NCCI’s analysis projected a best case scenario, in which loss costs increase $2 billion, and a worst case scenario, in which they increase $81.5 billion, or 250% more than current total loss costs. Willis Towers Watson also released a scenario-based analysis that suggested pretty much the same thing.

On 8 April, the California State Assembly Insurance Committee asked the the California Workers’ Compensation Insurance Rating Bureau (WCIRB) to project loss costs if conclusive (rebuttable) presumptions were provided to front line workers, something Governor Gavin Newsom actually did through Executive Order one month later, so the “if” became a “done.” Later in April, the WCIRB released the requested report and concluded:

…the cost estimates in this Research Brief are presented as a range of potential impacts based on varying assumptions of the number of COVID-19 claims filed. On this basis, the WCIRB estimates that the annual cost of COVID-19 claims on ECI (Essential Critical Infrastructure) workers under a conclusive presumption ranges from $2.2 billion to $33.6 billion with an approximate mid-range estimate of $11.2 billion, or 61% of the annual estimated cost of the total workers’ compensation system prior to the impact of the pandemic.

Note two things. First, for perspective, if California were a country, it would have the fifth largest GDP in the world. Second, regardless, the WCIRB’s best case scenario is $.2 billion more than NCCI’s best case scenario for all 38 states where it provides ratemaking services.

Clearly, whatever scenario happens, workers’ compensation losses are going to be cataclysmic.

So, about those questions:

  1. Who’s going to pay for all of this? In normal times, the answer is obvious: Employers and insurers (when losses exceed an employer’s liability). But if we know one thing for sure, these are not normal times. So, who takes the hit?
  2. What about secondary chronic conditions the virus has been shown to cause in some people? Many survivors of SARS (Severe Acute Respiratory Syndrome) suffered crippling ailments for more than a decade. We’re already seeing COVID-19 survivors come home from hospital with severe, possibly persistent, chronic conditions. Are these conditions covered by the initial claim? I can see the plaintiff’s attorney now. “Your Honor, but for the COVID-19 occupational disease, poor John here would never have immediately lost kidney function requiring dialysis three times per week, and would be the picture of health.”
  3. How will COVID-19 claims impact experience modification, which affects an employer’s premium for three years? It is only logical that if loss costs increase by billions in one year, an employer of essential workers, say a hospital, will see its experience modification factor take off like a SpaceX rocket. That is a recipe for economic doom and disaster beyond what we’re already seeing.
  4. What happens when an essential worker who has contracted COVID-19 and filed a claim infects other family members, or the neighbor next door, for that matter? Would they be covered by the claim, or by health insurance if they happen to have it? Keep in mind, job losses due to COVID-19 are now in excess of 20.6 million. Many have lost not only a job, they have also lost the health insurance the job provided. The Kaiser Family Foundation has said, “26.8M would become uninsured after losing job-based coverage during the coronavirus if they don’t enroll in other coverage.” Consequently, this question is very important, because workers’ compensation health care is totally free, unlike employer-based and nearly all other insurance options that all come with deductibles and co-pays.

Meanwhile, back at the California Workers’ Compensation Insurance Rating Bureau, the organization has submitted a proposed rule to deal with number 2, above. It wants to exclude COVID-19 loss costs from the calculation of experience modification. Specifically, the proposed rule says:

Claims directly arising from a diagnosis of Coronavirus disease 2019 (COVID-19), reported with a catastrophe Number 12 pursuant to the Uniform Statistical Reporting Plan, shall not be reflected in the computation of the experience modification.

The proposed rule would also reclassify workers now working remotely from home as clerical – 8810, which is the lowest premium rate possible.

Let’s suppose for just a moment that the WCIRB’s proposed rule is approved, and California’s employers are off the hook with respect to experience modification. This presents another question: Will other states do the same? All of them? Some of them? None? Whatever happens, it seems to me we need a nationally consistent approach. Wouldn’t you agree?

Finally, this all leads back to the first question: Who’s the guy at the end of the line left holding the bill for COVID-19 claim costs?

How Are States Handling Workers’ Compensation During COVID-19?

Monday, May 11th, 2020

Last week we wrote about Governor Gavin Newsom’s Executive Order implementing a workers’ compensation rebuttable presumption for all essential workers who contract COVID-19 in California.

To review, a rebuttable presumption means an essential worker who contracts COVID-19 does not have to prove work-relatedness. The burden is on the employer to prove the disease was not caused by work.

Writing that other states have also taken action, I noted those actions varied widely across the country. But the monumentality of COVID-19 requires more on this topic. Just what are other states doing? Specifically.

Thirty-nine have either done nothing or have legislation pending. That is, they have taken no action via Executive Order, as Newsom did, or have yet to enact legislation. The District of Columbia is also in this group. Neither, have any of these states declared COVID-19 an occupational disease, although it obviously can be one.

The other 12 states have taken the following actions:

Akaska: On 9 April, Alaska Governor Mike Dunleavy signed legislation declaring a rebuttable presumption for first responders and other health care workers.

Arkansas: On 21 April Governor Asa Hutchinson issued an Executive Order creating a rebuttable presumption for first responders, other health care workers and National Guard personnel assigned to COVID-19 duties.

Florida: The state published a Memorandum saying first responders and health care workers “would be eligible for workers’ compensation benefits under Florida law.” Given the torment COVID-19 is causing throughout society, this is pretty wimpy, don’t you think?

Illinois: On 16 April, Governor J. B. Pritzker issued an Executive Order declaring a rebuttable presumption for first responders and other health care workers. Then, under intense pressure from the business and insurance communities, Pritzker, whose family owns the Hyatt hotel chain, rescinded the order. Obviously, a stand-up guy. So, I guess you could say Illinois now belongs in the camp of the other 38 states that have done nothing.

Kentucky: On 9 April, Governor Andy Beshear issued an Executive Order similar to Newsom’s, creating a rebuttable presumption for all essential workers who contract COVID-19. The business community isn’t happy, but, unlike Pritzker, Beshear has not changed his position.

Michigan: On 30 March, the Workers’ Disability Compensation Agency declared an Emergency Rule creating a rebuttable presumption for all First Response Employees, a term, as Michigan defines it, that includes just about everyone in health care.

Minnesota: On 7 April, Governor Tim Walz signed legislation establishing a rebuttable presumption for first responders, health care workers, correctional officers and child care workers.

Missouri: The Department of Labor and Industrial Relations issued an emergency rule, effective 22 April, declaring a rebuttable presumption for first responders, but, not, perplexingly, for other health care workers exposed to COVID-19. First responders are defined as “a law enforcement officer, firefighter or an emergency medical technician (EMT).”

New Mexico: On 23 April Governor Michelle Lujan Grisham issued an Executive Order creating a rebuttable presumption for state-employed first responders and volunteers to the health care system fighting the disease. Private sector employees are not covered.

North Dakota: On 25 March, Governor Doug Burgum issued an Executive Order creating a rebuttable presumption for all first responders and health care workers. On 16 April, he issued another one to cover funeral directors.

Utah: On 22 April, enacted legislation creating a rebuttable presumption for all first responders.

Washington: On 5 March, Governor Jay Inslee issued an Executive Order  creating a rebuttable presumption for first responders and other health care workers. The order also applies if the workers are merely quarantined.

The majority of states not listed here have some kind of legislation filed awaiting legislative action. But as anyone who has ever wandered the halls of a state capital watching the sausage being made knows, it doesn’t mean a thing until the Governor in the corner office signs it.

Time is wasting.

 

More COVID-19 Quick Takes

Thursday, May 7th, 2020

Workers’ compensation and the disease

COVID-19 is presenting some interesting and perplexing issues for workers’ compensation. Among them are:

  1. Claims adjusters and Nurse Case Managers are far more familiar with injury claims than disease claims. Occupational disease claims are fuzzy, and work-relatedness is often difficult to determine. A broken arm on the shop floor is ever so much more cut and dried. Yesterday, Governor Gavin Newsom made this moot for California by signing an Executive Order that will make it easier for essential workers who contract COVID-19 to obtain workers’ compensations benefits. His order is in effect for 60 days and is retroactive to 19 March. Note Bene – his order establishes a rebuttable presumption and covers all workers deemed essential during the crisis; e.g., grocery workers, among others, as well as first responders and all health care workers. A rebuttable presumption means an essential worker who contracts COVID-19 does not have to prove work-relatedness. The burden is on the employer to prove the disease could not have been caused by work. California is one of a number of states that have taken action addressing workers’ compensation coverage for essential workers.
  2. But not all states have taken action in the same way. In fact, approaches vary considerably. Two issues treated differently among the states are: first, whether to establish a rebuttable presumption as described above; and, second, just who is essential. Some states say that while a number of occupations have been determined to be “essential” during COVID-19 (see Grocery Workers, above), only first responders and health care workers are essential enough to qualify for workers’ compensation if they come down with the disease. Labor unions say this is an issue of fairness, but since when has workers’ compensation been equally fair in all states? Consider loss of function awards, which vary tremendously across the nation.
  3. NCCI has jumped into the COVID 19 what if debate and projected various loss cost scenarios for the workers’ compensation insurance industry. All scenarios show increased losses, and some of the them are downright grim. In the worst case, 50% of all workers are infected and 60% of all claims are paid, in which case losses increase $81.5 billion, or 250% more than current total loss costs. Ouch! In the best case NCCI presents, there is no rebuttable presumption, only first responders and health care workers are eligible for workers’ compensation benefits, only 5% of them become infected, and only 60% of the claims are paid, which results in an increase in loss costs of $2 billion. The best case scenario is is not going to happen. See 1, above.
  4. And what about the poor employers and insurers who are going to foot the bill? Specifically, what about experience modification? One can almost say COVID-19 comes under the heading: An Act Of God. But the claims are going to be paid, so how does a confused insurer account for that in  the premium it’s going to drop on the head of John Q. Employer with a loud and painful thud?

Update on Long Term Care Facilities

I’ve addressed LTCFs here, here  and here, pointing out that there is no coordinated national reporting of LTCF COVID-19 cases or deaths. “One would think this cries out for federal data tracking conducted in a consistent manner across the nation.” Doesn’t seem to have happened yet.

The logical entity to track this is the Centers for Disease Control and Prevention (CDC), and maybe it is. But, then again, maybe it isn’t, because it won’t say. Yesterday, two Senate Democrats — Ron Wyden of Oregon and Bob Casey of Pennsylvania — called on the Trump administration to close this gap and commit to a timeline to release the information.

“There have been no signs that the Trump administration has an effective plan to address the tragedy that is taking place in America’s nursing homes,” they said in a joint statement.

It’s logical to assume that a disproportionate number of deaths would occur in LTCFs. The vulnerable elderly, many, perhaps most, with a number of comorbid underlying conditions, are packed together and present a breeding ground for the virus. Early on, this should have been apparent to the CDC. Why its talented scientists didn’t dive into this from Day 1 is beyond me.

We’ll continue to follow this.

Are We Learning From History, Or Repeating It?

Throughout history, infectious diseases have crippled societies. They have stymied progress and, in the best cases delayed, in the worst reversed, economic development and prosperity.

How have societies handled infectious disease pandemics throughout history, and are our actions in the midst of COVID-19 any better?

It’s true that our science puts us a quantum leap ahead of historical societies in terms of searching for therapies and a vaccine. Oh, the vaccine will happen, but between now and then are we dealing with our current infectious disease problem better than our ancestors?

Actually, no. Societies have long known that when a killing disease strikes on a grand scale the best thing to do is stay far away from other people. Quite literally, head for the hills. Trouble was, that wasn’t always possible due to urban densities and economic privation. Today, densely packed areas, especially cities, are the immediate hot spots, the poor and African Americans are disproportionately infected, and our mitigation efforts are the same as time immemorial.

Tomorrow, we’ll take a look at the history of pandemics, their societal effects and how we can learn from them as we move through and, we fervently hope, leave behind the scourge of COVID-19.

 

 

Direct Care Workers: Health Care’s Essential Underbelly

Wednesday, April 29th, 2020

First, an update

Yesterday, we wrote about Long Term Care Facilities (LTCF) and the sad COVID-19 experience of Massachusetts’ nursing homes. As of this morning, 303 of the Commonwealth’s 386 nursing homes have had at least 2 cases, for a total of 10,031 cases statewide. Fifty-six percent, or 1,632, of all the Commonwealth’s COVID-19 deaths have happened to nursing home residents or staff.

Governor Charley Baker is a former CEO of Harvard Pilgrim health Care, one of the Commonwealth’s leading HMO  health care plans. So, it’s a given that Baker knows health care. But, even with that background, he, like all our governors, has been living through the tortures of Tantalus as they attempt to work with the administration in all things COVID-19.

Today, the governor announced he’s sending $130 million to help nursing homes deal with the crisis. He’s also enlisting 120 nurses to respond lickety split to nursing home emergencies. Moreover, his administration will be auditing LTCFs for compliance with new care criteria including mandatory testing of staff and residents, a 28 point infectious disease checklist, and PPE requirements. This is all good, but one hopes reality is not that this particular horse has escaped the barn and is now grazing four pastures over.

And what about those caregivers?

They call it “Direct Care.” The care that Certified Nursing Assistants (CNAs), home health aides, and personal care attendants provide America’s elderly and disabled. You’ll find them in nursing homes, residential care homes, hospitals, and plain, ordinary, everyday homes, the kind you and I live in. And they are essential workers.

All told, there are more than 1.3 million of them in the U.S., and the Bureau of Labor Statistics (BLS) projects the direct care industry will grow more than any other over the next decade, with a compound annual growth rate of 4.0. And they are essential workers.

They are also the least compensated workers, by far, in the health care sector. Here’s a graph from the BLS to illustrate the point:

The direct care workers are the pink dots. The isolated pink dot on the lower right refers to Certified Nurse Assistants. According to the Paraprofessional Health Institute (PHI):

The median hourly wage for home care workers in the U.S. is $10.49—a wage that, when adjusted for inflation, has remained virtually stagnant for the last 10 years. In turn, the median annual income for home care workers, most of whom work part-time or only during part of the year, is $13,800.[1]

Twenty-three percent of direct care workers live below the federal poverty line (FPL), as opposed to 7% of the rest of the population (which is abominable in its own right). Some of them might be caring for your parents or grandparents right now. Yes, they are essential workers.

Fifty-two percent of home care workers and 39 percent of nursing assistants rely on some form of public support, such as food and nutrition aid, Medicaid, or cash assistance. Moreover, because of low pay and irregular hours, it’s difficult for direct care workers to qualify or pay for employer-based or individual health coverage. Neither can they afford to stop working during COVID-19. They need the money, such as it is – and they are essential workers.

And what about direct care workers who are immigrants? Researchers from Harvard Medical School studied this in their June 2019 paper, “Care for America’s Elderly and Disabled People Relies on Immigrant Labor.” 

They wrote:

Using nationally representative data, we found that in 2017 immigrants accounted for 18.2 percent of health care workers and 23.5 percent of formal and nonformal long-term care sector workers. More than one-quarter (27.5 percent) of direct care workers and 30.3 percent of nursing home housekeeping and maintenance workers were immigrants. Although legal noncitizen immigrants accounted for 5.2 percent of the US population, they made up 9.0 percent of direct care workers. Naturalized citizens, 6.8 percent of the US population, accounted for 13.9 percent of direct care workers. In light of the current and projected shortage of health care and direct care workers, our finding that immigrants fill a disproportionate share of such jobs suggests that policies curtailing immigration will likely compromise the availability of care for elderly and disabled Americans. (emphasis added)

Nearly 15% percent (14.9%) of the foreign born workforce are college graduates, compared with 8.4% of the native born direct care workforce.

Many foreign born direct care workers are in the country with Temporary Protected Status (TPS), a status provided to nationals of certain countries, ten of them, experiencing problems that make it difficult or unsafe for their nationals to be deported there. In 2018, The Trump administration attempted to terminate the Temporary Protected Status for workers from a number of the designated countries, but courts have enjoined that for now. Nonetheless, that can’t be doing the workers’ mental health much good at the moment. And they are essential workers.

Nobody’s attacking direct care workers during COVID-19. They wouldn’t dare. After all, they are essential workers. But, if we ever get out of this healthcare fiasco, I don’t think it’s a wild stretch of the imagination to think if Donald Trump continues his  fervent anti-immigration polemic direct care workers will be marginalized even more than they already are.

They deserve better. They are essential.

 

At The Heart Of COVID 19: Fear

Thursday, April 16th, 2020

 

“One fear creates a dereliction, which brings a greater fear, and there comes a point where the fear is too great and the human spirit just gives up…” – Wolf Hall, by Hilary Mantel.

“We have to remember the enemy is the virus. Not one another.” – Michigan Gov. Gretchen Whitmer.

The protests are ramping up. Over the last two days groups demanding governors reopen state economies have gathered to protest stay at home orders.

Protesters in Michigan, Kentucky, Ohio, Utah, North Carolina and Virginia have made their presence felt and voices heard. Timed to coincide with governors’ daily press briefings on COCVID 19, to varying degrees of success they tried to drown out the gubernatorial updates.

By far, the largest protest was yesterday in Lansing, Michigan where, for five miles, thousands of vehicles blocked traffic going into or out of the city. They also blocked all traffic heading to Sparrow Hospital, which meant hospital workers were denied access to the most important jobs in the nation: Treating COVID 19 victims. And, to make a bad situation worse, many, perhaps most, of the protesters were unmasked, standing around as if they’d never heard the term, “social distance.”

Here’s a pretty alarming photo from Ohio:

And this from Michigan:

Yes, those really are automatic weapons in the hands of angry protesters. People, this is a bad combination.

What in the name of Galen is going on here?

How about fear and insecurity?

When I was a commander in Vietnam, training, and lots of it, kept my unit alive. We trained for everything imaginable, and when bad things happened, we were scared, but prepared. Running toward danger is not an intuitive response. Training takes over in those situations. Here, in the midst of COVID 19, no one has any training, and that includes most of the health care workers on the front lines fighting this entirely new disease. Everyone is making it up as they go along, and our health care workers…excuse me, our health care heroes… are learning new things every day aimed at keeping people alive.

Americans have no training or experience to guide them through the stay at home period, however long it turns out to be. And so, they fearfully worry. About themselves, their kids, their parents and grandparents, and their jobs. Many of those jobs could be gone forever, and this scares them to their core. That, along with the open-ended nature of the stay at home orders, leads to fearing the worst.

People are looking for something to believe in, some hope, someone to blame, so, when right wing rabble rousers stoke their fears…

Defusing this growing powder keg starts at the top. The nation’s governors, with some notable exceptions, have stepped up and are doing all they can to keep their citizens alive. They have to, because Donald Trump and his administration have performed so poorly during the crisis. It is unfortunate, indeed, that the president cannot help himself from fanning the flames of his base. Yesterday’s protests were replete with Trump and MAGA hats, as well as, ironically, protesters calling the stay at home orders “tyranny.”

The protests without social distancing or masks are going to result in more infections and deaths. That is a terrible thing. And so unnecessary.

Governor Kristi Noem’s Magical Thinking

Tuesday, April 14th, 2020

Once more unto the Covid 19 breech, dear friends, once more.

Ever been to South Dakota? Beautiful place. Miles and miles of rolling prairies. Postcard worthy. Home to Mount Rushmore, the Crazy Horse Memorial, and the Black Hills.  Remember the three-season HBO series Deadwood? The real city of Deadwood is in South Dakota, although how a place with 1,300 people gets to be a city is beyond me. But that’s rural America for you.

South Dakotans are hardy souls, rugged individualists. They have to be; there are less than 885,000 of them all spread out over 77,000 square miles. That’s about 11 people per square mile.

With about 182,000 people, Sioux Falls is the most populous city in South Dakota. Virginia-based Smithfield Foods, the city’s fourth largest employer, is the third largest pork processor in the country, producing 18 million food servings a day. Two days ago, Smithfield announced it was closing down and ceasing operations indefinitely after more than 300 of its 3,700 workers tested positive for COVID 19. More than 550 independent family farmers supply the plant. This is a huge blow to Sioux Falls and South Dakota, as well as a kick in the gut to the nation’s food supply and supply chain.

This morning, Sioux Falls Mayor Paul TenHaken gave a passionate press briefing about the current situation and the horror he sees coming if drastic mitigation efforts don’t happen. The Mayor reported that in the last three days, the number of COVID 19 cases have been 149, 182 and 218, respectively. He would like to issue a stay at home order. Trouble is, the South Dakota legislature has stripped him of much of his authority to do so. He has to “request approval” from the legislature, which requires a seven-day notice period. Today, he made his request, and the earliest his order can take effect is 21 April. In the Mayor’s words, “This is crap. A shelter-in-place order is needed now. It is needed today,”

The Mayor is taking his action, the only action he can take, because the state’s governor refuses to issue such an order.

Which brings us to Governor Kristi Noem and her magical thinking.

Noem did, by Executive Order, compel everyone over the age of 65 to stay at home, except for essential travel. That’s only 14% of the state’s population. For everyone else, well, they can do what they want. She acknowledges her action could result in around 70% of South Dakotans contracting COVID 19, but she said it is not up to government to tell people how to behave. “The people themselves are primarily responsible for their safety,” she said. “They are the ones that are entrusted with expansive freedoms.”

As we have just seen in Sweden, this type of governing puts one firmly on the path to doom.

It appears Noem may be the only person in South Dakota who actually believes this idiotic laissez faire attitude is correct. Mayors like Sioux Falls’s TenHaken and Rapid City’s Steve Allender have joined with 160 county and city leaders who have petitioned her to declare a statewide public health emergency. In addition, more than 30,000 front-line health care workers have sent their own petition to Noem demanding she order people to stay at home.

Thus far, Noem seems to be an “n” of one. Drastic mitigation, Noem said disparagingly, reflected a “herd mentality.” It was up to individuals — not government — to decide whether “to exercise their right to work, to worship and to play. Or to even stay at home.”

So, what happens when, not if, the rancid COVID 19 flower blooms in South Dakota in the next week of two?

Among 44,000 cases in China, about 15% required hospitalization and 5% ended up in critical care. In Italy, the statistics so far are even more dismal: More than 50% of infected individuals have required hospitalization and about 10% have needed treatment in the ICU.

Nearly half the population of South Dakota lives in cities. That’s about 431,000 people. New York’s experience showed us COVID 19 spreads much more readily through densely packed populations. Consequently, it is logical to presume the cities of South Dakota are where it will strike more fiercely. If, because of Noem’s inaction, COVID 19 infects only 10% of that population, more than 43,000 cases will happen. If only 20% of those cases require hospitalization, the state will need 8,600 hospital beds.

As of 2019, South Dakota had 2,735 hospital beds; Sioux Falls,1,159. According to the 2019 State Physician Data Workforce Report, South Dakota has 240 doctors per 100,000 people, or about 1,920 in the entire state. The number of ICU beds is unknown.

South Dakota could be in for a monumentally rough ride.

 

 

CoVid 19 Quick Takes

Friday, April 3rd, 2020

 

Quote of the day: “To put it bluntly, the U.S. economy went from full speed to full stop — and millions of workers were not wearing seat belts.” – Josh Lipsky, director of global business and economics policy at the Atlantic Council, a nonpartisan think tank.

 

Keeping up with all things CoVid 19 is like swimming through Semolina. It takes a lot of fortitude and stamina. But here goes, anyway.

The states versus the nation

Examining the national response to CoVid 19….no, wait, we don’t have a national response. We have close to 60 responses, one for each of the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands and the other US territories. If you don’t think they’re all on their own, just ask Andrew Cuomo. He said yesterday that none of the governors were currently screaming for states rights. They all want help, they all want national leadership, and they want it yesterday, maybe last week. Look at Ron DeSantis, Governor of Florida. For weeks, under withering criticism and through the debacle of Spring Break on the beaches, he refused to issue a Stay At Home order. Said the state didn’t need it. His excuse? The White House hadn’t told him to do it. But yesterday it did, so he did. Well, actually, the White House “recommended” it. DeSantis made a point of saying he “cleared it with the President.”

Contrast DeSantis’s actions with those of Mario Cuomo, Jay Inslee, Gavin Newsom, JB Pritzker, Gretchen Whitmer, Janet Mills, Charley Baker, and Mike DeWine. They’ve all been on their own, but they’ve been decisively responsible, and their constituents will one day thank them.

Every governor is reacting, and reacting is the right word, differently. It’s like watching an Athenian Trireme in the Mediterranean with all 170 oarsmen rowing at different speeds.

Don’t believe me? Let’s look at Stay At Home orders. Here’s a New York Times map showing state Stay At Home orders from 30 March, four days ago:

And here’s the same map as of yesterday, four days later:

The nation’s Governors are all having to act like European Prime Ministers, many of whom have issued travel restrictions and sealed borders. A week ago, Rhode Island’s Governor Gina Raimondo began letting New Yorkers into her state only if they would self-quarantine for 14 days, and she had the National Guard at the border to enforce the order.

All Governors would like their constituents to view them as Horatius At The Bridge, but Covid 19 is likely not the particular bridge they would have in mind. They need national leadership, not national cheerleading. Absent that, they’ve been forced to step into the void, some, like DeSantis, very reluctantly.

Trouble coming for the southeast

Vann R, Newkirk, II, has a terrific piece in this week’s The Atlantic looking at the public health difficulties facing young people, made even more severe by CoVid 19, in America’s southeastern states. Newkirk says:

So far, about one in 10 deaths in the United States from COVID-19 has occurred in the four-state arc of Louisiana, Mississippi, Alabama, and Georgia, according to data assembled by the COVID Tracking Project, a volunteer collaboration incubated at The Atlantic….The coronavirus is advancing quickly across the American South. And in the American South, significant numbers of younger people are battling health conditions that make coronavirus outbreaks more perilous.

Some context is needed. A new study by the World Health Organization (WHO), endorsed and published by the National Academies of Science, Engineering and Medicine ranks America at or near the worst in just about every mortality rate category you can think of when compared with the other 16 wealthiest countries. U.S. Health in International Perspectives: Shorter Lives, Poorer Health paints a grim picture that should concern us all.

Now, look at the health of people in the deep south, particularly young people, who, according to a new study by the Kaiser Family Foundation, have more comorbidities than young people anywhere else in the country. Those comorbidities put them at much greater risk of becoming seriously ill if they contract CoVid 19.

According to Newkirk:

If you define Oklahoma as part of the South, southern states fill out the entirety of the top 10 states in percentage of population diagnosed with hypertension by a doctor. Southerners are more likely to suffer from chronic diseases than other Americans—even as Americans are more likely to suffer from chronic diseases than citizens of other countries with comparable wealth.

Imagine you have a big barrel full of apples. Inside that barrel is a smaller barrel with apples your farm stand might label “seconds.” Inside that “seconds” barrel is a third and smaller barrel with apples your farm stand wouldn’t ever sell. The third barrel is health in the deep south.

The USNS Comfort

Remember this photo?

That’s the USNS Comfort, the 1,000 bed ship Donald Trump, to great fanfare, sent to New York to help with the serious hospital bed shortage, getting worse every day.

I’m guessing not too many people knew that the Comfort’s orders prohibit treating CoVid 19 patients. As President Trump said when he sent her on her way, “By treating non-infected people remotely on the ship, it will help to halt very strongly the transmission of the virus.” Note the words, “non-infected.”

So far, the Comfort has taken in three of New York’s patients. It’s kind of a Catch 22 thing. The ship can only take patients not infected with CoVid 19, but without sufficient testing, the ship’s clinicians won’t know if anyone actually has the disease, or not. Result: three patients. “If I’m blunt about it, it’s a joke,” said Michael Dowling, the head of Northwell Health, New York’s largest hospital system.

And finally – Getting back to the deep south

The American Association of Medical Colleges is out with its 2019 State Physician Data Workforce Report,

This annual report examines the supply of physicians in the United States. It documents the number of physicians per 100,000 inhabitants of every state. I’m proud, (I think) to report my home state, the Commonwealth of Massachusetts, takes the Gold Medal with 449.5 doctors per 100,000 people. On the other end of the scale, coming in at Number 50, is Mississippi with 191.3. I would love to know what goes on in Mississippi. It seems to be at or near the bottom of anything you can name.

Here are how all the southern states rank:

State                                MDs/100K                       Rank

Mississippi                       191.3                                50

Oklahoma                        206.7                                48

Arkansas                          207.6                                47

Alabama                           217.1                                43

Texas                                224.8                                41

Georgia                            228.7                                39

South Carolina                 229.5                                38

Kentucky                          230.9                                36

Tennessee                        253.1                                29

North Carolina                255.0                                28

Louisiana                          260.3                                27

Florida                              265.2                                23

Given that New York, which is begging for retired clinicians and clinicians from other states to come and help with its CoVid 19 fight, and given that New York, with 375.1 doctors per 100,000 people, ranks Number 3 on the list, just behind Massachusetts and Maryland, how do you think a state like poor Mississippi is going to fair when the full weight of this virus lands on it with a loud thud?

I hope all of you hermits have a safe weekend!