WHO has published an annex to the guidance on considerations on adjusting public health and social measures (PHSM). The new annex provides a pragmatic decision process to help countries through adapting PHSM based on epidemiological and public health criteria. According to the 2020 World Health Statistics published by WHO today, the COVID-19 pandemic is causing significant loss of life, disrupting livelihoods, and threatening the recent advances in health and progress towards global sustainable development goals. WHO has joined forces with the United Kingdom to run an awareness campaign named “Stop The Spread” about the risks of inaccurate and false information regarding the COVID-19 pandemic. The Regional Director for the WHO Regional Office for the Americas, Dr. Carissa F. Etienne called on countries to “support their economies while building strong social protection networks and embracing evidence-based public health measures that are essential to saving lives”. In the ‘Subject in Focus’, we discuss newly released WHO guidelines for school-related public health measures.   Read today’s situation report.   View the WHO’s Situation Dashboard for COVID-19 here.

Answers Related to Federal Funding for State and Local Governments
This letter answers questions and answers related to federal funding for state and local governments.

Medicaid
The first set of questions was about the effects of the 2020 coronavirus pandemic on Medicaid. The sharp rise in unemployment caused by the pandemic will increase enrollment in the program. Many of the new enrollees will have experienced sudden declines in income, and some will have become sick because of the pandemic. Some would otherwise have been covered by employment-based health insurance or nongroup coverage subsidized through premium tax credits. Some would otherwise have been uninsured but with too much income to be eligible for Medicaid. Others would have been eligible for Medicaid but nevertheless unenrolled. New enrollees may sign up on their own or be enrolled by providers at the point of service.
 
In addition to health care costs ordinarily covered by Medicaid, states may opt to have the program cover the costs of testing for the disease caused by the coronavirus, COVID-19, for some uninsured people. (The federal government will cover all of those costs.)
 
Later this year, CBO will report updated baseline budget projections for Medicaid that incorporate effects of the pandemic, as well as the increased share of Medicaid expenses covered by the federal government this year (a change put in place by last month’s CARES Act). For the remainder of 2020, CBO expects state governments to pay 35 percent of Medicaid’s costs, on average, for most enrollees; the average in 2019 was 41.5 percent. For other enrollees, adults made eligible for the program by the Affordable Care Act, the CARES Act did not change the share of Medicaid’s costs to be paid by state governments; that share remains 10 percent.
 
Budget Shortfalls
The second set of questions was about the effects of shortfalls in the budgets of state and local governments caused by the pandemic. State and local governments will collect less revenue because of the sudden drop in economic activity and resulting fall in taxable income in 2020. It is unclear how large those shortfalls will be.
 
At the same time, demand for social services provided by state and local governments will increase. In the 2007–2009 recession and subsequent recovery, state and local governments similarly experienced fiscal pressure. They responded mainly by reducing spending on education, health, and social services. Some of those reductions were achieved by cutting public-sector employment.
 
On May 19, CBO will report interim economic projections for 2020 and 2021 that incorporate effects of the pandemic. As part of that work, CBO will provide its usual projection of growth in gross domestic product and its components, including growth attributable to purchases by state and local governments. That projection will take into account the expected effects of the pandemic on states’ budgets.
 
Economic Effects of Federal Funding for State and Local Governments
The third set of questions was about how spending during recessions by state and local governments has affected the economy in the past and how the effects of such spending compare with the effects of other policies that federal lawmakers are considering today.
 
The federal government can boost economic output in various ways, including by providing funds to state and local governments. In the current economic environment, CBO expects, additional amounts of such funding would increase output by reducing the size of tax increases and spending cuts enacted by many of those jurisdictions to balance their budgets. The tax increases avoided and services provided would help residents in the short term. Providing such funds to state and local governments would, however, increase the federal deficit, and in the long term, increased federal deficits tend to slow the economy, in CBO’s assessment.
 
CBO estimates that each additional dollar that was used to fund state and local governments by increasing the federal deficit would increase economic output over the next few years by about as much as would a dollar used to fund some policies recently enacted in the CARES Act. Such policies included funding provided to state governments for pandemic-related expenses and increases in unemployment benefits. The economic effects of increases in unemployment benefits depend on factors such as economic conditions, the type of increase, and the amount of the benefit relative to people’s potential earnings, in CBO’s assessment. The effects of additional expansions of unemployment insurance would therefore differ from those stemming from the CARES Act. For example, as social distancing dissipated, the per-dollar boost to the economywide demand for goods and services would be larger; and as the labor market strengthened, the reduction in the supply of labor per dollar of unemployment insurance benefits would be larger. The net effect on output of such factors would depend on the specific types of additional expansions.
 
Other provisions of the CARES Act, such as increases in federal spending on Medicare, are expected to have larger effects on the economy. Still other provisions, such as business tax provisions and refundable tax credits, are expected to have smaller effects— although the size of the effects would depend on the specifics of the provisions and the corresponding extent to which businesses and households spent the funds they received. And in addition to having different effects on output, policies in the CARES Act are expected to have different effects on other outcomes—such as employment and the distribution of income—and effects that vary by sector of the economy, geographic location, and demographic group.
 
Broadly speaking, CBO expects the CARES Act to support the economy in ways similar to those provided by the American Recovery and Reinvestment Act (ARRA), which was enacted in 2009; the agency’s estimates are informed by research about that experience. That said, stay-at-home orders, other aspects of social distancing, and other factors are expected to lead to some differences in the impact of particular policies in 2020 as compared with 2009.
 
The funding for state governments provided by ARRA for purposes other than infrastructure totaled over $200 billion. In its analysis of ARRA, CBO projected that each dollar of such funding had a two-thirds chance of increasing output by an amount between $0.40 and $1.80 over two years. That estimate used averages of effects from many different uses of the funds. In addition, ARRA provided about $60 billion for spending on infrastructure—specifically, on water, transportation, and housing projects— and CBO projected that each of those dollars had a two-thirds chance of increasing output by an amount between $0.40 and $2.20.
 
Spending for Purposes Other Than Infrastructure. CBO anticipates that the availability of additional funds would both increase states’ net spending for any specified activities and also affect other aspects of states’ budgets. Without further funding from the federal government, states’ tax increases or spending cuts would be larger than they would be otherwise because of fiscal constraints, including requirements to balance their budgets, CBO expects; those actions would result from fiscal challenges arising from the pandemic and also from preexisting challenges, such as unfunded pension liabilities. Such actions would dampen spending by those governments and by households in those states, and more state and private jobs would be lost. Furthermore, many states would probably have to take such steps on an ongoing basis during the next few years.
 
Therefore, federal funding that was provided promptly would probably have a significant effect on output and employment. Such funding could lead states and localities to lay off fewer employees, hire more of them, give them more pay raises, impose fewer pay cuts, purchase more goods and services, spend more on safety-net programs, or impose lower taxes than they would without the funding. But some of the funding would probably be used to replenish or avoid drawing down states’ reserve funds; funding used in that way would not boost the economy in the short term.
 
Spending for Infrastructure. Infrastructure spending directly increases employment because workers are hired to undertake construction projects. It also adds to demand for goods and services through purchases of material and equipment and through additional spending by the extra workers who are hired; that increase in demand leads to further hiring. However, government spending on infrastructure projects could also cause private-sector spending on infrastructure projects to fall. In addition, CBO projects that there is a two-thirds chance that states would reduce spending of their own funds on infrastructure by between $0.20 and $0.80 for each one-dollar increase in federal outlays for that purpose. Also, over the long term, spending on infrastructure can affect productivity, with effects that can differ substantially depending on the type of project.
 
Infrastructure projects often involve considerable start-up lags. Although some projects (such as highway repair and resurfacing) can be implemented relatively quickly, large-scale construction projects generally require years of planning and preparation. For example, building new transportation infrastructure that requires establishing new rights-of-way or developing and implementing alternative energy sources would probably have their biggest effects on output and employment after a few years. Indeed, trying to increase certain types of spending too quickly would raise the risk of making poor decisions about what specific projects should be supported. As a practical matter, the experience with ARRA suggests that the spending of infrastructure funds is slow: By the end of fiscal year 2009, seven and a half months after the legislation was enacted, less than 10 percent of the infrastructure funds provided by ARRA had been spent. Access the document here.

CDC's Laboratory Outreach Communication System (LOCS) (CDC’s gateway to interact with U.S. clinical laboratories). The Laboratory Outreach Communication System (LOCS) is managed by the Division of Laboratory Systems (DLS) in the Center for Surveillance, Epidemiology, and Laboratory Services (CSELS). Currently, LOCS is a functional CDC mailbox (LOCS@cdc.gov) designed to provide updates and answer questions from clinical laboratories through coordination with professional organizations, CDC programs, and state public health laboratories.
 
The mailbox is managed and monitored by DLS staff and is active during regular business hours. Information and updates are sent to clinical laboratories through professional organizations. This system is available to other CDC programs and may also be used during emergency responses to disseminate information in collaboration with CDC’s Joint Information Center in the Emergency Operations Center.

Lab Advisory: CDC Posts Updated Point-of-Care Testing Biosafety Guidelines for COVID-19.  CDC recently updated the Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with Coronavirus Disease 2019 (COVID-19) to provide additional information about point-of-care (POC) testing for SARS-CoV-2. This update includes guidance for a variety of topics:

CMS Issues Nursing Homes Best Practices Toolkit to Combat COVID-19. Today, under the direction of President Trump, CMS released a new toolkit developed to aid nursing homes, Governors, states, departments of health, and other agencies who provide oversight and assistance to these facilities, with additional resources to aid in the fight against the coronavirus disease 2019 (COVID-19) pandemic within nursing homes. The toolkit builds upon previous actions taken by the Centers for Medicare & Medicaid Services (CMS), which provide a wide range of tools and guidance to states, healthcare providers and others during the public health emergency. The toolkit is comprised of best practices from a variety of front line health care providers, Governors’ COVID-19 task forces, associations and other organizations, and experts, and is intended to serve as a catalogue of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19. Press release.

HHS Awards $15 Million to Support Telehealth Providers During the COVID-19 Pandemic
Today, the U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA) awarded $15 million to 159 organizations across five health workforce programs to increase telehealth capabilities in response to the COVID-19 pandemic. These awards demonstrate the Trump Administration’s continued efforts and commitment to building a national telehealth infrastructure.
 
These awards are funded through the Coronavirus Aid, Relief and Economic Security (CARES) Act that President Trump signed into law on Friday, March 27, 2020. HRSA made awards to organizations based on their capacity to implement COVID-19 telehealth activities that train high demand professions across the health care team.
 
These investments will train students, physicians, nurses, physician assistants, allied health and other high-demand professionals in telehealth. This will enable these professionals to maximize telehealth for COVID-19 referrals for screening and testing, case management, outpatient care, and other essential care during the crisis.
 
Additionally, through increased telehealth capabilities from this funding, organizations will be able to maintain primary care services when clinics and medical facilities are not available, especially for COVID-19 positive, quarantined, elderly and other vulnerable populations.
 
HRSA’s Bureau of Health Workforce (BHW) oversees the workforce programs that received awards today. The five BHW programs that received funding are:

“COVID-19: Safely Getting Back to Work and Back to School”
Witnesses appearing before the Senate Health, Education, Labor and Pensions Committee: The Department of Health and Human Services (HHS) is working closely with all of our government partners in this response.  We thank Congress for supporting our efforts through the passage of the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020; the Families First Coronavirus Response Act; the Coronavirus Aid, Relief, and Economic Security (CARES) Act; and the Paycheck Protection Program and Health Care Enhancement Act.  These laws have provided additional resources, authorities, and flexibility. Within HHS, the Centers for Disease Control and Prevention (CDC), the National Institute of Allergy and Infectious Diseases (NIAID), the Assistant Secretary for Health, and the Food and Drug Administration (FDA), along with additional components not represented today, play critical roles in the response to this public health emergency as discussed by the following witnesses:

Access the testimony here.

The U.S. Food and Drug Administration today announced the following actions taken in its ongoing response effort to the COVID-19 pandemic:

Feds to Support COVID-19 Testing Sites in Texas through June 30
In conjunction with U.S. Dept. of Health and Human Services and the state of Texas, the Federal Emergency Management Agency (FEMA) announced today, the seven federally supported COVID-19 Community-Based Testing Sites (CBTS) in Texas will remain open through June 30, 2020. The sites will continue monitoring and testing citizens in an effort to reduce further spreading of the virus.
 
The seven CBTSs, which are federally supported, state managed and locally executed, are located in El Paso County, Dallas County (2), and Harris County (4) are operated in conjunction with HHS and the state of Texas. Read the full release here.

National Institutes of Health: What's New in the Treatment Guidelines (Last Updated: May 12, 2020)
 
New Section of the Guidelines
Antithrombotic Therapy in Patients with COVID-19. COVID-19 has been associated with inflammation and a prothrombotic state, with increases in fibrin, fibrin degradation products, fibrinogen, and D-dimers. Although the true incidence of thrombosis is unknown, there have been reports of increased incidence of thromboembolic disease associated with COVID-19 in patients in the intensive care unit.

A new section titled Antithrombotic Therapy in Patients with COVID-19 has been added to the guidelines to address many questions related to the role of coagulation markers and thrombolytic, anticoagulant, and antiplatelet agents in those with COVID-19. In this section, the COVID-19 Treatment Guidelines Panel (the Panel) provides recommendations on the use of antithrombotic agents for the prevention of venous thromboembolic events in hospitalized patients with COVID-19. In addition, the Panel recommends carefully monitoring, evaluating, and treating hospitalized patients with COVID-19 for incident thrombotic events when indicated.
 
Updates to the Guidelines. Potential Antiviral Drugs Under Evaluation for the Treatment of COVID-19. Throughout the section, study descriptions were updated to clearly indicate a study’s publication status and to provide an assessment of a study’s limitations and results. Data were also updated as needed based on changes to preprints or post-publication changes.
 
The following recommendations were added or revised in this section:

Remdesivir:

Immune-Based Therapy Under Evaluation for Treatment of COVID-19 The following key changes were made to this section:
 
Convalescent Plasma and Immune Globulins:

Interleukin-6 Inhibitors:

Governor Abbott, TDEM Announce Extension of Federally-Supported Community-Based Testing Sites In Texas. Governor Greg Abbott and the Texas Division of Emergency Management (TDEM) today announced that the federal government has extended seven community-based testing sites in Texas through June 30, 2020. These federally-supported, state-managed, and locally-executed sites include El Paso (1), Dallas (2), Houston (2), and Harris County (2). Read the full release here.

Governor Abbott, Texas National Guard Launch Disinfection Mission for Nursing Facilities. Governor Greg Abbott today announced that the Texas National Guard has activated Facilities Disinfection Teams to support Texans in nursing homes and to help limit the spread of COVID-19. These Facilities Disinfection Teams, formed in coordination with Texas Health and Human Services Commission (HHSC), provide a major boost to protecting Texans and limiting the spread of COVID-19. Six teams have already been mobilized to facilities across the state with more coming online.  
 
These Facilities Disinfection Teams consist of Guardsmen from Joint Task Force 176, and each team is equipped with unique supplies such as advanced personal protective equipment, ionized sprayers, and vital oxide. The teams received training from the Texas Military Department 6th Civil Support Team, who specialize in man-made and natural disaster assessment and rapid response in hazardous environments.  
 
The Texas National Guard is currently supporting the fight against COVID-19 in Texas by providing personal protective equipment manufacturing support, food bank support, mobile COVID-19 testing, and points of distribution for essential items. Read the full release here.

Governor Abbott Waives License Renewal Late Fees for Certain Occupational Licenses in Texas. Governor Greg Abbott has waived license renewal late fees that accrued between March 13 and June 15, 2020 for occupational licenses issued by the Texas Department of Licensing and Regulation (TDLR). This waiver applies to licenses associated with a variety of occupations such as barbers, cosmetologists, electricians, speech-language pathologists, and dyslexia therapists. Read the full release here.

Texas Department of Licensing and Regulation (TDLR) Provides Further Clarification of Massage Therapy Services Allowed. Under the Governor’s Executive Order GA-21 (GA-21), massage establishments must remain closed until further notice. GA-21 also prohibits people from providing services which are not designated as essential or re-opened, including massage therapy.
 
GA-21 designates healthcare providers, including physicians and chiropractors, as essential. It does not include massage therapists, unless they are providing services determined to be medically necessary by a physician, chiropractor, or other healthcare provider. Massage therapy that is not medically necessary is still not allowed. If a licensed massage therapist performs a medically necessary massage, they must do so in accordance with the massage therapy laws and rules, including the requirement of a consultation document. A medically necessary massage may be performed in the office of a physician or chiropractor or any other place that is exempt from the requirement for a massage establishment license under Texas Occupations Code §455.155.
 
Please note that GA-21 overrides conflicting local orders, and the ability to provide massage therapy may change as further orders are issued.

GL 20-3004 Emergency Rule for Outpatient Chemical Dependency Treatment Services via Electronic Means to Adolescents and Adults in Chemical Dependency Treatment Facilities (CDTFs) Available Online. GL 20-3004 (PDF) regarding adoption of emergency rules related to CDTFs providing outpatient chemical dependency treatment services via electronic means to adults and adolescents has been posted. The emergency rule permits CDTFs to temporarily provide treatment services via electronic means to clients to reduce the risk of transmission of COVID-19. Contact Health Care Regulation’s Policy, Rules and Training unit with your questions.

HHSC Publishes CMS Notification of More Blanket Waivers for ICFs
CMS is providing more blanket waivers related to care for residents in intermediate care facilities for individuals with an intellectual disability or related conditions. Waivers were issued in the following area:
 
Specific Life Safety Code (New since April 30). CMS is waiving and modifying waivers under §483.470(j) for ICF/IIDs:

Read the waiver details (PDF).

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