The spread of the novel coronavirus has upended life across the Golden State. On March 19, Governor Gavin Newsom issued an order that all individuals living in California were to stay at home except for essential activities like buying groceries or getting necessary health care. Public schools, nonessential businesses like gyms and entertainment venues, and parking lots at many state parks and beaches, are closed.
The health care sector, on the other hand, continues to serve patients while actively preparing for the COVID-19 pandemic. Health experts predict that California’s surge hasn’t come yet. Grant Colfax, MD, director of the San Francisco Department of Public Health, said he expects in a week or two to see a surge in coronavirus patients who need to be hospitalized, Erin Allday reported in the San Francisco Chronicle. Newsom recently increased the estimate of additional hospital beds needed for Californians who become sick with COVID-19 from 20,000 to 50,000.
Here’s what you need to know about how California is adopting policies related to health care coverage, workforce, telehealth, and palliative care to prepare for the COVID-19 pandemic.
Helping Californians Stay Covered
Covered California, the state’s Affordable Care Act health insurance exchange, has opened a special enrollment period to ensure that the newly unemployed don’t get bumped off their health coverage. Californians now have until June 30 to sign up for coverage. The California Department of Managed Health Care and the California Department of Insurance say the enrollment period also applies to health plans purchased by individuals outside the exchange.
State subsidies are available to make health insurance affordable for Californians purchasing coverage through the exchange. According to a Covered California news release, 576,000 consumers earning between 200% and 400% of the federal poverty level receive a monthly average of $608 per household in federal tax credits and new state subsidies. For consumers earning 400% to 600% of the poverty level, the average state subsidy to eligible households is $504 per month.
The state has put a 90-day hold on reviews of Medi-Cal renewals to ensure that individuals already enrolled don’t experience a gap in coverage. The California Department of Health Care Services (DHCS), which administers Medi-Cal, “is seeking to expedite applications for senior citizens and other populations considered vulnerable to the disease,” Cathie Anderson reported in the Sacramento Bee. Medi-Cal enrollment is continuous year-round and is not subject to enrollment periods.
These collective actions are important because being uninsured is “downright dangerous during a public health emergency,” Anthony Wright, executive director of Health Access California, told Sammy Caiola of Capital Public Radio. “In order to get tested and screened you should call your doctor, but that presumes you have a doctor or usual source of care.”
To encourage testing for Californians exhibiting COVID-19 symptoms, Covered California Executive Director Peter V. Lee “stressed that all screening and testing for the coronavirus is free for anyone with coverage, whether through Covered California, Medi-Cal, or employer-sponsored insurance,” Erica Hellerstein reported for CalMatters.
COVID-19 Highlights Workforce Shortages
The crisis has exacerbated the nation’s health care workforce shortage, and California hospitals are bracing for the worst.
Across the country, “hospitals are taking extraordinary measures to bulk up the workforce, from calling on retirees for help to assigning medical students to answer the phones,” Rachel Roubein and Joanne Kenen wrote in Politico. In an attempt to ease the challenges, the Trump administration “announced new rules that would let doctors practice across state lines, without going through layers of recertification and licensing.”
In the meantime, hospitals are working on contingency plans for freeing up their staff in the event of an influx of coronavirus patients. Medical experts are worried about patient-to-provider transmission of the coronavirus. Jenny Gold reported in California Healthline that one case of COVID-19 in Vacaville left more than 200 hospitals workers under quarantine. “It’s just not sustainable to think that every time a health care worker is exposed they have to be quarantined for 14 days,” Jennifer Nuzzo, DrPH, senior scholar at the Johns Hopkins Center for Health Security, told Gold. “We’d run out of health care workers.”
To free up more doctors and nurses, Newsom is exploring the possibility of loosening the state’s “scope of practice” laws, which govern the types of work that licensed health care workers can perform, Sophia Bollag wrote in the Sacramento Bee. “Our staffing is going to require more flex, it’s going to require more capacity as it relates to existing ratios, as it relates to current scope of practice,” Newsom said during a March 23 news conference. He also indicated that “fourth-year medical students and nursing students near the end of their training could be called on to treat COVID-19 patients,” Bollag reported. Retired doctors and those no longer practicing medicine could also be invited back to treat COVID-19 patients.
Amid reports that supply shortages are forcing some health care workers to wipe down and reuse single-use personal protective equipment (PPE), the state released 21 million N95 masks from its emergency reserve. Companies and individuals across the country are stepping up to help. Direct Relief has donated PPE to more than 1,000 community health centers and free clinics nationwide, PG&E is donating nearly one million N95 and surgical masks to California hospitals, and Tesla CEO Elon Musk purchased over 1,000 ventilators to ship to Los Angeles. Bay Area companies Clean360 and Falcon Spirits Distillery pivoted from making soap and spirits, respectively, to making hand sanitizer.
Hospitals in need of PPE can request supplies by filling out a form on the website of Project N95 — a new national clearinghouse for medical equipment. Medical equipment suppliers and government agencies can also visit the website to provide equipment and organize bulk purchase orders.
Those with PPE to donate can learn from this KQED article how to help in the Bay Area and beyond.
Telehealth May Transform How Care Is Delivered
The need for social distancing to slow the spread of COVID-19 has led to a spike in the use of telehealth services, a development that could change the health care landscape forever. Although medical care has been transformed by technology, the adoption of telehealth has lagged, cardiologist Haider J. Warraich wrote in the Los Angeles Times. “One of the main reasons China has been able to slow coronavirus transmission has been because of a dramatic increase in virtual visits,” he wrote. “Supporting telemedicine on a par with [in-person] visits has the potential to protect patients and health care personnel and allow for much more efficiency in the system.”
To that end, the Trump administration announced on March 17 that it would immediately expand Medicare telehealth coverage nationwide to help older Americans access care from home at no additional cost.
To bring telehealth to the 13 million people insured through Medi-Cal, California applied for a federal 1135 waiver that included a request for flexibility for telehealth and virtual communications. Part of the waiver request was approved, but several portions including telehealth are still awaiting approval. In the meantime, DHCS has taken immediate actions to expand telehealth access, requiring Medi-Cal managed care plans (PDF) to pay providers the same rate for telehealth and telephone visits as they do for in-person visits.
Some California hospitals have increased their use of telehealth to curb foot traffic. The American Medical Association reported that 21 Kaiser Permanente hospitals in Northern California serving an average total of 3,000 inpatients per day increased video visits for primary and specialty care by more than 150% in a recent two-week period. UCSF is reaching out to patients with various conditions ahead of their scheduled in-person visits to see if they can convert them to telehealth visits, Jessica Kim Cohen reported for Modern Healthcare.
To stay up-to-date on telehealth policy changes, bookmark the Center for Connected Health Policy’s living document of federal policies and state-specific actions. The California Medical Association compiled a running list of telehealth resources, and the Center for Care Innovations is updating a knowledge center for practicing virtual care during a pandemic.
Care at the End of Life
As more people are hospitalized due to COVID-19, are health care systems, patients, and families prepared for tough conversations and decisions about health care preferences and medical interventions? Now more than ever, it is important for providers to tap into the core tenets of palliative care to guide patients and their families through uncharted waters.
Palliative care is a medical specialty focused on alleviating stress and suffering for people with serious illness, and it is often provided alongside curative care as an extra layer of support. Some experts worry that a longstanding shortage of palliative care specialists “could leave many COVID-19 patients in distress,” Liz Szabo reported in Kaiser Health News.
“This pandemic means that we will be drawn into countless conversations with families who are suddenly having to make difficult decisions about life and death,” Nathan Gray, MD, a palliative care specialist at Duke University Hospital, wrote in a comic book–style story that he illustrated. “As we take stock of masks, gloves, and ventilators, we must also be ready to dig deep into our reserves of patience, communication, and compassion.”
In a Washington Post commentary, Emily Aaronson, MD, an emergency physician and assistant chief quality officer at Massachusetts General Hospital, encouraged families to engage in conversations about end-of-life wishes now. “It’s important that you understand what would be most important to them if they were in the last phase of their life — and what steps you and others will have to take to ensure those needs are met,” Aaronson wrote. “These are conversations designed to guard against regrets.”
Many resources are available to help families and health care providers alike. Aaronson recommended the Conversation Project and Death Over Dinner to facilitate conversations. The Center to Advance Palliative Care organized a COVID-19 toolkit for clinicians, and VitalTalk, a nonprofit organization dedicated to helping clinicians develop communication skills for serious illness, published a guide to difficult conversations about care of COVID-19 patients. This guide was published last week on The CHCF Blog.