Category: Blog

Across the United States, Pride festivals provide opportunities for members of the LGBTQ community to celebrate their identities, receive free HIV testing, and other HIV prevention resources. This past summer, the COVID-19 pandemic had forced many cities in the United States to cancel their pride celebrations to reduce the spread of the coronavirus. While these state and municipal stay-at-home orders were needed to protect the public from COVID-19, the resulting loss of Pride events that provide the public with free HIV testing and PrEP advocacy may contribute to a potential increase in HIV cases.

HIV disproportionally affects members of the LGBTQ community in the United States, especially Black and Latinx members. According to the Centers for Disease Control and Prevention (CDC), one in six of all gay or bisexual men in the United States will contract HIV in their lifetime. When looking at the health risks by race, the CDC estimates that 1 in 2 Black men, one in four Latinx men, and one in eleven white men who identify as gay or bisexual will contract HIV in their lifetime. For transgender women,  the CDC estimates that 14% of all transgender women in the United States live with HIV. When analyzing the data by race, the CDC approximates that 44% of Black transgender women, 26% of Latinx transgender women, and 7% of white transgender women live with HIV.

Free HIV testing at Pride events have been shown to be an important strategy to promote HIV prevention in LGBTQ community, especially for those who lack access to healthcare. A study conducted by the CDC surveyed participants who were getting tested for HIV at Pride events held in thirteen separate cities in the United States. Among the participants tested at the Pride events, 11.9% had never been tested for HIV and 21.7% had not been tested for HIV for more than twelve months prior to the event. When analyzing the participants who tested positive for HIV, 84.4% stated that they were unaware of their HIV infection. Overall, the study found that free HIV testing in nonclinical settings like Pride events are an extremely useful strategy to promote HIV prevention among groups who lack access to healthcare and/ or fear societal stigma.

Some public health organizations have emphasized the importance of at-home HIV testing and prevention during the COVID-19 pandemic. For example, the non-profit organization Greater Than AIDS created an online platform to link people with participating local health agencies and community-based organizations in order to obtain free or reduced cost at-home HIV tests. Other efforts include the U.S. Department of Health and Human Service’s (HHS) Ready Set PrEP program. Pre-Exposure Prophylaxis (PrEP) is a daily pill that studies have shown to reduce the risk of contracting HIV by more than 90%. The Ready Set PrEP program works to provide free PrEP medication from participating pharmacies or by mail to individuals without insurance.

COVID-19 is a pressing public health issue in the United states. The total reported COVID-19 cases in the United States have reached the millions and the total reported COVID-19 related deaths are nearing 250,000. Yet, COVID-19 is not the only public health crisis that the United States faces. In 2018, an estimated 36,400 new HIV infections occurred in the United States. Currently, 1.2 million Americans live with HIV and about 14% of those people do not know they have the virus and need testing. While HIV prevention outreach like Pride events have been limited during the COVID-19 pandemic, public health organizations are trying to work around this obstacle. By expanding access to free at-home HIV testing and distribution of PrEP, public health officials may continue to be effective at reducing the spread of HIV.

As most Americans fixate on the surging COVID-19 cases and deaths, health care experts are growing weary of “an imminent mental health surge” in the United States. Over the past nine months, COVID-19 has affected Americans of all ages in every facet of daily life disrupting employment, education, religious practices, recreational activities and relationships. The staggering amount of death experienced in the nine months since the World Health Organization declared the virus a pandemic is devastating. In the United States, the number of deaths currently attributed to COVID-19 is nearly 4 times the deaths of Americans killed during the entirety of the Vietnam War which spanned two decades. This magnitude of death combined with an upheaval of normal grieving processes due to social distancing measures has significantly altered the ways in which individuals and families cope with grief, compounding their already disrupted daily lives. 

A recent study, conducted this year by scientists at the Journal of Affective Disorders, showed a global increase in the prevalence and severity of anxiety and depression and increases in post-traumatic stress disorder and substance abuse. Of central concern is the transformation of normal grief and distress into prolonged grief and major depressive order and symptoms of post-traumatic stress disorder. Indicators of prolonged grief disorder include at least six months of intense longing, preoccupation, or both with the deceased, emotional pain, loneliness, difficulty reengaging in life, avoidance, feeling life is meaningless, and increased suicide risk. These conditions, once established, could become chronic and may lead to substance use disorders. While prolonged grief affects approximately 10% of bereaved individuals, experts believe is an underestimate for grief related to deaths from COVID-19. Measurements estimate that each COVID-19 death leaves an estimated nine family members bereaved. This approximation projects over two million bereaved individuals at the current COVID-19 death count. Mental health experts warn this level of  bereavement, triggering new mental health disorders and intensifying existing mental health disorders, has the potential to overwhelm the American healthcare system beyond its capacity. 

America’s infrastructure for mental health and addiction services was fragmented, overburdened, and underfunded even before the COVID-19 crisis. An online survey of 880 organizations that provide behavioral-health services revealed that the pandemic has forced practices to reduce services, provide care to patients without sufficient protective equipment, lay off and furlough employees, and risk untimely closures. This reduction in services further burdens individuals with serious mental illness from receiving treatment and/or medication for their conditions, including those who are experiencing such symptoms for the first time. Alarmingly, mirroring COVID-19 itself, experts anticipate that a mental health surge will disproportionately affect Black and Hispanic individuals, older individuals, lower socio-economic groups of all races and ethnicities, and health care workers. 

Each day, as the United States continues to report record breaking COVID-19 cases, mental health care experts are certain the second wave of the COVID-19 pandemic is imminent. Experts suggest immediate emergent funding for mental health programs; widespread screening to identify those at the highest risk; availability of primary care clinicians and mental health professionals trained to treat those with prolonged grief, depression, traumatic stress, and substance abuse; and a diligent focus on families and communities to creatively restore the approaches by which they have managed tragedy and loss over generations. To further mitigate the threats of a mental health care disaster, states like Connecticut, are reaching out to the Centers for Disease Control and Prevention for grants to support expanded mental health resources after experiencing increases in both the use of the state’s suicide hotline and suicide rate amid the COVID-19 pandemic. 

Even as mental health care experts rush to mitigate the potential devastation of a second wave, it is clear that the havoc from COVID-19 will be felt for generations to come. The tremendous loss of life and the disruptions to all aspects of everyone’s lives reminds us of our fragility and how important it is and it will be to provide adequate mental health protections as an integral part of the healing process.

Currently, there are over 11.8 million active cases and 253,600 COVID-19 related deaths in the United States. Since the onset of the pandemic, the Trump Administration has repeatedly downplayed COVID-19, denounced mask-wearing mandates, and refused to order a nationwide shutdown. Moreover, the current administration has been criticized for false claims that physicians are financially benefiting from the increase in COVID-19 cases. For instance, at a Michigan rally, President Trump stated that “our doctors get more money if somebody dies from COVID.” He then criticized the United States’ method of reporting COVID-19 deaths by stating deaths are characterized differently in other countries if a patient has multiple causes of death. However, this is misleading because the World Health Organization dictates that COVID-19 deaths should “not be attributed to another disease (i.e. cancer) and should be counted independently of preexisting conditions that are suspected of triggering a severe course of COVID-19.”

The interpretation of the administration’s unsubstantiated statements is that physicians and hospitals are incentivized to over-report COVID-19 deaths in order to receive additional federal funding supplied by the Coronavirus Aid, Relief, and Economic Security Act (CARES). The term “upcoding” is used when providers fraudulently request reimbursements for services they did not provide to patients. Upcoding violates the False Claims Act (“FCA”) which prohibits providers from intentionally making false claims to federal healthcare programs. Penalties for violating the FCA include fines triple the amount of the claim plus $11,000, criminal prosecution, and imprisonment.

Unjustified claims against COVID-19 reporting reveal a general misunderstanding of how the U.S. healthcare billing system functions. Insurance companies and payor systems, including Medicare, require physicians to bill for various services provided to the patient throughout their treatment. Therefore, providers are compensated for treating COVID-19 related symptoms regardless if the patient dies from a pre-existing condition. Since reimbursements are not increased based on cause of death, providers have no financial incentive to over-report COVID-19 deaths.

The CARES Act increased physician and hospital reimbursements by 20% in an effort to assist hospitals with the increased costs related to COVID-19. Medicare has estimated the cost of treatment for an inpatient with COVID-19 to be around $13,000. If the patient requires a ventilator, the cost of treatment increases to roughly $39,000. The reimbursements that insurance companies pay out is split between the physicians and hospitals. Physicians are reimbursed for services rendered to patients, while hospitals are reimbursed for the use of equipment, nurse and staffing salary, laboratory services, and various treatment related services. Although hospitals stand to receive additional financial compensation, these institutions are not “financially benefiting”. The additional funds are allocated to cover the increased cost of resources needed for treating COVID-19 patients in addition to providing personal protective equipment (PPE) to employees. The additional money from the CARES Act also allows hospitals to hire additional nurses and staff. Furthermore, while the federal government has provided aid in supplying expensive medical equipment, the increase in cases have left many hospitals needing to purchase additional ventilators. The CARES Act reimbursement enables hospitals to purchase additional necessary equipment required to treat COVID-19 patients and PPE to protect hospital staff from contracting the virus.

Although data shows reimbursement rates for COVID-19 patients are higher, there is no evidence suggesting provider upcoding or other fraudulent over-reporting of COVID-19 deaths. Unsubstantiated claims against physicians and other providers gravely undermines the ethics and hard work of many American frontline workers and lends itself to the fear that surrounds the impact of COVID-19 in the US.

---

The start of the holiday season—the busiest travel period in the United States—is just weeks away. Though the number of Americans taking to the skies this Thanksgiving is sure to be less than the 26 million travelers who passed through Transportation Security Administration checkpoints last year, passenger volume is nonetheless expected to surge.

However, potential travelers will have to weigh the risks of a COVID-19 resurgence against the range of travel options in an industry that remains largely outside the scope of any federally mandated COVID-19 safety regulations. The reticence to issue firm federal regulations to keep both passengers and workers safe has been a familiar narrative during this health crisis, and the airline industry has arguably been one of the most scrutinized segments of travel.

This unprecedented public health crisis begs the question: who is responsible for regulating passenger safety on airplanes as it pertains to COVID-19?

This is not a novel question. On March 14, 2020, in the early stages of the COVID-19 outbreak in the U.S., the Director of the Centers for Disease Control and Prevention (CDC) Dr. Robert Redfield issued a No Sail Order for all cruise ships operating within the United States, effectively shutting down cruise lines until further notice. In the No Sail Order, the Director rooted his decision in scientific information about the transmission of COVID-19 and on the powers granted to him as the CDC Director in 42 CFR § 71.32(b). Dr. Redfield justified issuing this federal mandate as he determined that the scope of this pandemic “cannot be controlled sufficiently by the cruise ship industry or individual state or local health authorities.”

However, the federal government has enacted no other substantive regulatory measures on other sectors of the travel industry during the course of the COVID-19 crisis. Instead, the CDC has opted for issuing non-binding COVID-19 safety guidelines for different industries, leaving sectors, such as the airline industry, to individually self-regulate.

The result of this recommended guidelines approach is a wide array of safety policies that differ between airlines with no legal mechanism for enforcement, meaning that the repercussions for consumer noncompliance extend only as far as what is within the company’s power to implement (e.g. denying service, customer banning, etc.). Furthermore, this range of options forces the consumer to compare health and safety measures between available choices or settle for the only option available to them.

Opponents to national standards often cite a disdain for government regulations as a driving factor for inaction. The Department of Transportation (DOT) recently denied a petition requesting the implementation of a nationwide mask policy for airports and air travel under their rule making powers found in 5 U.S.C. § 553(b)(3)(B). In DOT’s response, General Counsel Steven Bradbury stated his reasons for the denial being that guidelines recommending masks already exist, most air carriers have enacted mask policies, and DOT “embraces the notion that there should be no more regulations than necessary.”

Similarly, the New York Times reported that the CDC drafted a mandate last month that would require masks on all commercial and private transportation. The mandate was rooted in the CDC’s quarantine powers found in 42 USC § 264, 268, and was backed by the Secretary of Health and Human Services (HHS) Alex Azar II. However, the White House reportedly blocked the mandate, instead deferring to state and local authorities to issue their own guidance; Vice President Pence “declined to even discuss [the mandate]” with the White House Coronavirus Task Force.

This vacuum of federal safety regulation has led to a patchwork of self-regulation between industries and state officials attempting to establish legal standards to allow for enforcement of these standards. Some states, such as Virginia, have taken it upon themselves to codify CDC guidelines to provide legal standards for businesses and individuals alike whereas other states continue to pass the responsibility of public safety off to industries and individuals.

For interstate industries such as airlines, differing state and company standards are not sufficient to effectively manage the risks COVID-19 presents. Yet, a path toward the creation of national safety standards and a means of enforcement does exist. The CDC, DOT, HHS, and the president are provided various statutory powers while Congress has the ability to pass legislation—similar to some legislation passed at the state level—to create a national set of safety standards for certain industries.

As we approach the 2020 holiday travel season amidst the backdrop of a global pandemic, it is abundantly clear that the airline industry and the American people would be better served by a set of national safety regulations for air travel. The implementation of national safety regulations will provide the airline industry with means of legal enforcement for noncompliance, restore confidence in air travel, and provide airlines the best guidance from health experts to ensure consumer safety.

As the October deadline for states to submit their COVID-19 vaccine distribution plan to the CDC approaches, public health officials across the country are feeling the pressure. Questions about storage, dosing, and the uncertainty of an authorized supplier continue to plague immunization managers. While it is a virtual certainty that frontline healthcare workers will be among the first to receive the vaccine, the distribution scheme beyond the folks in scrubs becomes a delicate ethical question.

In early October, the National Academy of Medicine revealed its recommendations for this very dilemma in a report commissioned by the National Institutes of Health and the U.S. Centers for Disease Control (CDC). The framework in the report recommends a four-phase distribution plan prioritizing health care workers and first responders as well as older adults and those with pre-existing conditions as predictable initial recipients. However, it also makes novel use of the CDC’s Social Vulnerability Index (SVI) to ensure equity in vaccine allocation. The SVI uses U.S. Census data to map fifteen social factors—including poverty and crowded housing—which are then used to estimate the type and amount of a resource needed by a certain community. 

While a valuable assessment tool for analyzing community vulnerability, some argue the SVI Is not robust enough, failing to capture rates of pre-existing health conditions known to increase the risk of mortality for COVID-19, and the capacity of community healthcare systems. In order to more accurately and comprehensively assess vulnerability, the Surgo Foundation created the COVID-19 Community Vulnerability Index (CCVI). The CCVI expands on the SVI foundation to offer a six-theme calculation for community vulnerability, which policymakers can rely upon when making decisions about where to direct resources.

Understanding COVID-19’s specific relationship to community vulnerability is essential. On a national level, the virus consistently has a disparate impact along race and class lines, as well as on individuals with intellectual and developmental disabilities.

Various state guidance publications all spell out a version of the same vague plan, deferring to CDC guidance and prioritizing “high risk” groups. Given that the CDC has the greatest influence over how vaccines are used and distributed by health departments in the U.S., it should promote and incorporate the robust analytical framework created by the Surgo Foundation as a socioeconomically conscious improvement on existing CDC guidance. Presently, the CDC includes the Surgo Foundation’s work in its COVID-19 Research Guide as a secondary data and statistics source.

The CCVI could be used to create community risk profiles and to overcome the infrastructure barriers to health access, like the strictures on telemedicine implementation in rural communities. Whatever needs are addressed by use of the CCVI, COVID-19 has exposed the inequity of the systemic healthcare structure in the U.S. as more dire than previously thought, and only an equitable approach to distribution will bring equitable relief.

2020 has undoubtedly become the year for telemedicine. The COVID-19 pandemic has created unprecedented demand for virtual visits to support the continued need for timely, safe care while avoiding in-person contact. By offering many ambulatory care services, telemedicine protects both patients and healthcare providers by reducing possible exposure to COVID-19. Federal policymakers temporarily relaxed regulations that impede telemedicine utilization and expanded Medicare coverage of remote appointments to encourage this shift, which is so popular among patients and providers that the technology changes may become permanent. Yet, despite these efforts, some patients continue to face barriers to telemedicine due to disparities in digital access and “unread[iness]” to use the requisite technology. As policymakers consider permanent use of telemedicine, they must address these barriers to ensure that those with much to gain from virtual care are not left behind.

            The amended rules implemented by policymakers made telemedicine visits easier to obtain, but also assumed that individuals have access to technology that enables home video visits. According to an August study of Medicare beneficiaries, 26.3% of beneficiaries (approximately fifteen million people) had neither a home computer with a high-speed internet connection nor a smartphone with a wireless plan, making telemedicine video visits unlikely for those individuals. Furthermore, this technology gap disproportionally impacts low-income individuals, persons eighty-five years or older, and people of color—all of whom form a vulnerable population in terms of their health and economic characteristics. The ability of individuals in these groups to access care was already a concern pre-COVID, and the shift to a virtual system may widen existing disparities in access to care. One solution from a study authored by Health Policy Researchers at the University of Pittsburgh and Harvard Medical School, proposed to expand the Federal Communications Commission’s Lifeline program, which provides phone or internet service at a reduced-cost. Lowering the cost of virtual care, however, will not be enough. As telemedicine utilization rises, the issues contributing to the technology gap must be addressed.

            Even if the technology gap was mitigated, there are additional barriers that may prevent a person from engaging with telemedicine. The ability of some individuals to use telemedicine enabling technology prevents many people from accessing virtual care. To have a successful video visit, individuals need to know how to get online, use audiovisual equipment, and communicate without in-person social cues. A study conducted by medical researchers affiliated with the University of California, San Francisco indicated that, of Medicare beneficiaries age sixty-five and older, 38% of these individuals were “unready” to have video visits, largely stemming from inexperience with technology, and 20% were “unready” due to difficulty hearing, difficulty communicating, or dementia. Similarly, this accessibility gap disproportionately impacts people of color, low-income individuals, and persons eighty-five years or older.

Live closed captioning during virtual visits and digital literacy programs during may help make telemedicine more accessible. Recognizing the need for accommodations in virtual visits is crucial to safeguarding equity in the telemedicine boom. Telemedicine will likely become an increasingly important aspect of health care delivery as the COVID-19 pandemic continues. By developing policies that recognize and bridge the digital divide, policymakers would ensure that the virtual migration does not worsen existing disparities and inequity in health care and improve access to telemedicine.

---