with Paulina Firozi

U.S. hospitals are on the hook starting this week to pay back billions in federal loans that helped tide them over when they had to scale back services amid the pandemic’s initial surge in the spring.

But hospitals say the repayments, which are to be docked from their regular Medicare payments until they're fully paid back, could put rural and low-income-serving facilities underwater particularly in areas where the coronavirus continues to surge.

“We’re in the midst of these surges and it isn’t reasonable,” Chip Kahn, president of the American Federation of Hospitals, told me. “You’re going to kill those hospitals.” 

Hospitals are furiously lobbying lawmakers to include loan relief in the next coronavirus relief package. 

There's a protracted and dramatic battle on Capitol Hill over what a fifth relief bill should look like. The legislation remained stalled over the weekend as Hill Democrats and Republicans argued over how extensive and costly it should be. Democrats rejected an offer by the White House last week for a short-term extension of expiring unemployment benefits, instead demanding a broad bill that includes aid for local governments and schools. 

House Speaker Nancy Pelosi (D-Calif.) and Treasury Secretary Steven Mnuchin said yesterday they remain far apart on a deal, despite meeting almost daily for the past week. “I’m not optimistic that there will be a solution in the very near term,” White House Chief of Staff Mark Meadows said on CBS.

If and when a deal does emerge, lobbyists and aides say it probably will contain some loan relief for hospitals.

Congress probably won’t entirely forgive their loans, which span tens of billions of dollars. But there’s a good chance it will delay when hospitals have to start repaying them, spread out the repayments over a longer time, reduce the loan interest rate — or some combination thereof.

“I think there is clearly consensus there needs to be additional relief for hospitals,” said Tom Nickels, executive vice president for the American Hospital Association.

The funds were provided via the Cares Act, the initial bill Congress passed in March to respond to the pandemic. Health providers — mainly hospitals — were eligible to apply for a $100 billion pool of loans. They were allowed to get a loan equaling half of the money they'd been paid by Medicare in 2019, through what’s known as the Medicare Accelerated and Advance Payment Program. 

More than half of the AHA’s 5,000 member hospitals received loans through the program, Nichols said, although he didn’t have a precise count. The program is separate from a $175 billion provider relief fund (we’ve written about that here and here), which distributed funds to hospitals, doctors offices, clinics and other providers that don’t have to be paid back.

Hospitals argue they’ve suffered more than other businesses — and even other health providers — under the pandemic.

Not only did they have to suspend nonelective services during much of the spring, but they also had to spend extra cash preparing for a possible surge of covid-19 patients. That surge transpired in some areas — first in the Northeast and then in the South and West — but not in other areas of the country.

“Hospitals got a triple whammy,” Kahn said. “In almost all jurisdictions across the country the electives were shut down, you were then required to surge up in terms of capital changes, buying a bunch of [personal protective equipment] in preparation for a surge. Three, you were hit by covid cases.” 

Nor could most hospitals apply for small-business loans through the Paycheck Protection Program, since they typically employ more than 500 people. Lawmakers recognize they’re in a difficult situation and feel it’s a priority to prevent job losses in that sector, a congressional aide involved in the discussions told me.

“I think hospitals and other providers have a compelling argument to make,” the aide said.

Without the Cares Act funding, hospitals would have been operating at a loss of 15 percent in the year’s second quarter, according to an analysis commissioned by the AHA. Even with the extra help, their operating margins were minus-3 percent and could sink to minus-11 percent by the end of 2020 if cases keep increasing across the country, the analysis says.

The effects are most acute for rural hospitals, which have been struggling financially for years. In the past four years, nearly 50 rural hospitals have closed across the nation, according to the North Carolina Rural Health Research and Policy Analysis Center.

Both parties have demonstrated willingness to ease the repayment requirements.

Neither party appears interested in entirely forgiving the loans, as the AHA is requesting. But House Democrats and Senate Republicans have both proposed measures providing relief.

A $3 trillion relief bill passed by House Democrats would recoup the loans with just 25 percent of hospitals’ Medicare payments instead of 100 percent, thus spreading out repayments over a longer time. It would also lower the interest rate to 1 percent instead of 10 percent and give hospitals an additional year before repayments begin.

The $1 trillion Heals Act, proposed by Senate Republicans, doesn’t spread out the payments, but would delay the repayment period by five months and delay the start of interest accruing by six months.

A measure from Sens. Jeanne Shaheen (D-N.H.) and Michael Bennet (D-Colo.), which is backed by the FAH, would go further than either of those by allowing the government to forgive balanced owed by hospitals in cases of financial hardship.

“Providers in New Hampshire have furloughed hundreds of workers and facilities are teetering on the edge of shutting down,” Shaheen said in a statement. “This would be a health care crisis during normal times, but in the middle of a public health emergency of this nature, it’s dangerous and unsustainable.” 

Ahh, oof and ouch

AHH: President Trump keeps promising a health-care overhaul, but no plan has come to fruition.

In a July 19 interview, the president told “Fox News Sunday” anchor Chris Wallace that he would be “signing a health-care plan within two weeks, a full and complete health-care plan.” Now that two weeks have passed, there’s no sign that the administration has designed any such replacement for the Affordable Care Act. 

“Repeatedly and starting before he took office, Trump has vowed that he is on the cusp of delivering a full-fledged plan to reshape the health-care system along conservative lines and replace the central domestic achievement of Barack Obama’s presidency,” Anne Gearan, Amy Goldstein and Seung Min Kim report

“Trump’s latest promise comes amid the outbreak of the novel coronavirus, which has infected millions, caused more than 150,000 deaths and cost Americans their work and the health benefits that often come with jobs. His vow comes three months before the presidential election and at a time when Trump’s Republican allies in Congress may least want to revisit an issue that was a political loser for the party in the 2018 midterm elections.”

Trump repeated the pledge on Friday, telling reporters at an event in Belleair, Fla.: “We’re going to be doing a health-care plan. We’re going to be doing a very inclusive health-care plan. I’ll be signing it sometime very soon… Might be Sunday. But it’s going to be very soon.”

Sen. Lindsey Graham (R-S.C.), a close Trump ally, said Trump’s “fairly comprehensive” plan will come in the form of an executive order. “He’s pretty excited about it,” Graham said.

OOF: Deborah Birx warned the U.S. has entered a “new phase” of the pandemic and urged people to take heath precautions as deaths sharply rise.

“I want to be very clear: What we’re seeing today is different from March and April,” Birx, who is overseeing the White House coronavirus response, told CNN. noting that cases are increasing in rural and urban areas. “It is extraordinarily widespread.”

Birx did not rule out an estimate from former Food and Drug Administration commissioner Scott Gottlieb that virus deaths could top 300,000 by the end of the year, saying “anything is possible.” Such an outcome would be far less likely, Birx said, if people practiced social distancing and avoided large gatherings.

“The seven-day average for new coronavirus-related deaths rose in nearly half of the states over the past week, pushing the national death toll past 150,000 and prompting health experts to warn that the trend is unlikely to reverse anytime soon,” our colleagues Derek Hawkins and Marisa Iati write.

“Numerous states reported record daily fatalities in recent days, including California, which reported 219 on Saturday, according to tracking by The Washington Post. Florida reported a record 257 deaths on Friday, and seven-day averages for new deaths reached new highs in states across the South, the West and the Midwest.”

A report from Johns Hopkins University declared this week: “Unlike many countries in the world, the United States is not currently on course to get control of this epidemic. It’s time to reset.” 

“It comes at an unnerving moment in which the economy suffered its worst collapse since the Great Depression, schools are rapidly canceling plans for in-person instruction and Congress has failed to pass a new emergency relief package,” Joel Achenbach, Rachel Weiner and Chelsea Janes report

The virus is spreading across the country, taking hold and spreading especially where people let their guard down. “When communities tighten up, by closing bars or requiring masks in public, transmission drops,” Joel, Rachel and Chelsea write. “That has happened in some Sun Belt states, including Arizona, Florida and Texas, which are still dealing with a surge of hospitalizations and deaths but are finally turning around the rate of new infections.” 

OUCH: A coronavirus vaccine may not be a neat ending to this crisis. 

Public health experts are worrying that there’s too much hope riding on the potential vaccine. 

“The confident depiction by politicians and companies that a vaccine is imminent and inevitable may give people unrealistic beliefs about how soon the world can return to normal — and even spark resistance to simple strategies that can tamp down transmission and save lives in the short term,” Carolyn Y. Johnson reports. “…As the plotline advances, so do expectations: If people can just muddle through a few more months, the vaccine will land, the pandemic will end and everyone can throw their masks away.”

But experts say it’s going to be a long road ahead. Once there is a safe and effective vaccine, it could still take months or years to reach enough people to make the world safe. Deploying the vaccine will test supply chains, distribution networks and global cooperation, as well as public trust.

“For those who do get a vaccine as soon as shots become available, protection won’t be immediate — it takes weeks for the immune system to call up full platoons of disease-fighting antibodies. And many vaccine technologies will require a second shot weeks after the first to raise immune defenses,” Carolyn adds. 

“Immunity could be short-lived or partial, requiring repeated boosters that strain the vaccine supply or require people to keep social distancing and wearing masks even after they’ve received their shots. And if a vaccine works less well for some groups of people, if swaths of the population are reluctant to get a vaccine or if there isn’t enough to go around, some people will still get sick even after scientists declare victory on a vaccine — which could help foster a false impression it doesn’t work.”

In the states

Coronavirus cases are surging in San Francisco, which was early in the effort to flatten the curve. 

It was one of the first metropolitan areas in the country to shut down to curb the spread, Heather Kelly and Rachel Lerman report. Now as cases rise there, it’s a cautionary tale for government and health officials. 

“Its progressive residents generally have been inclined to follow the rules, and there’s a high level of trust in public health officials, local governments and the fast-changing science,” they write. “But now, more than four months after the region put some of the nation’s first shelter-in-place orders in effect, the Bay Area is experiencing a surge in cases and counties are rolling back reopening plans.”

Medical experts are pointing fingers at a growing sense of complacency. Contact tracers say people are contracting the virus after gathering with others indoors. Heather and Rachel add: “Many people who live here say they are worn out — that a hermitlike existence is impossible for months on end. Tired of being stuck at home, friends and families are starting to gather again, and some parents are letting their children use still-closed playgrounds, ducking under the caution tape that has been wrapped around jungle gyms since March.” 

The debate about reopening schools

Single parents are facing a fall of remote education, but there are difficult choices and few child-care options ahead. 

Single parents are “often the sole breadwinner in their homes, so cutting back hours or taking a leave of absence isn’t feasible. Some say they are simply out of options,” the Wall Street Journal’s Lauren Weber reports

There were more than 11 million families led by single parents of children under 18 in 2019, according to the Census Bureau. For single mothers, in particular, the current reality makes them vulnerable to falling behind economically. 

Lauren adds: “Researchers who examined the effects of the pandemic on gender equality found that, despite short-term economic pain for all workers, married women stand to reap some long-term benefits if household work is distributed more evenly between men and women and if employers begin providing more telecommuting and flexible work options to all employees. But many single mothers won’t experience these gains, says Titan Alon, an economist at the University of California, San Diego who co-wrote the research.” 

  • More: An Arizona superintendent told The Post’s Eli Saslow that the prospect of reopening schools safely is a “fantasy. Kids will get sick, or worse. Family members will die. Teachers will die.”

Coronavirus latest

Here are a few more stories to catch up on after the weekend:

The hardest hit: 
  • For many Americans, daily life has become a twist of navigating calls and applications for unemployment benefits. It’s about figuring out how to make due when a broken unemployment system and the pandemic are upending people’s lives, Kyle Swenson reports. He writes about three people in Washington, among the hundreds who have waited months for unemployment payments.
  • The coronavirus has officially killed more than 150,000 people in the United States, and in recent weeks, Hispanics and Native Americans have made up an growing proportion of covid-19 deaths, Reis Thebault and Alyssa Fowers report.

Sugar rush

The Fix’s Amber Phillips breaks down how President Trump’s rhetoric about voting has gotten more extreme as he has sunk in the polls. (The Washington Post)