The covid-19 pandemic has resulted in unprecedented measures in many parts of the world aimed at preventing the transmission and spread of SARS-CoV-2. While many of these measures, such as social distancing and reduction of mass gatherings, have contributed to the reduction of the disease transmission, the behavioral and psychological consequences of these disruptions may be significant. A new article in JAMA Psychiatry this week discusses many of the psychological challenges generated by covid-19. Based on previous large-scale outbreaks of the Ebola virus disease from 2014 to 2016, we know that anxiety, posttraumatic stress disorder and depression is likely to be common amongst survivors. Data from the covid-19 pandemic already indicates alarmingly high rates of depression and acute stress amongst both survivors and healthcare providers. This is further exacerbated by the fact that many mental health services have been limited or severely restricted due to the closuring of outpatient clinics during the pandemic. However, covid-19 is occurring during an historic period of digital integration throughout society. While screens that offer a constant stream of never-ending news cycles and social media saturation may add represent additional stressors, these same technologies also offer opportunities for timely screening and early intervention by healthcare providers for patients with access. Telemedicine platforms may substantially enhance mental health support structures during this period. Additionally, the use of social media platforms among friends, families, and close contacts may aid in maintaining networks of support and connectedness during prolonged periods of social restrictions. The development of online programs may facilitate remote behavioral interventions. One area not discussed in the article, however, is that of unequal access to online services. High speed reliable internet should not be taken for granted in many parts of the country and around the world. In areas where access to adequate internet services are limited, online mental healthcare may not reach populations most likely to benefit from them. Addressing these disparities should be a priority for public health officials.

A research letter appearing this week in JAMA describes the impact that covid-19 has had on nursing homes. We invited the primary author of the article to summarize the findings. —Brief19

Nursing homes have endured crippling spikes in mortality paired with extraordinary dips in the number of new residents. While residents of nursing homes account for fewer than 1 percent of the US population, they account for over 45 percent of the recorded deaths due to covid-19 so far. The plight of nursing homes has been widely reported in the media, but so far relatively little hard data documenting the extent of mortality in nursing homes has appeared in the medical literature. Why does this matter? In responding to this crisis—or in attempts to minimize it— some are trying to blame a few "bad apple" nursing facilities as the problem, rather than addressing systemic issues in the industry. To understand what is really happening in nursing homes, we looked at mortality and patient census data from dozens of nursing homes in New York City, Detroit, and Cleveland. We found enormous spikes in mortality from all causes coinciding with the overall wave of covid-19 deaths in these facilities in March through May 2020. In New York City, during the peak week, mortality was nearly ten times higher than mortality recorded during the corresponding week in 2019. In Detroit, the mortality was four times higher than normal at the peak. Meanwhile, the city of Cleveland served as a kind of control, as it had a far smaller burden of covid-19 during the period we assessed; correspondingly, we found very little change in nursing home mortality there. The data also show that the curve of mortality in nursing homes mirrored mortality for the entire region in Detroit and New York City, arguing against the few "bad apples" theory. Importantly, mortality rates rocketed to their peak over just 2 to 3 weeks in New York City and Detroit, likely overwhelming the staff at these facilities. In addition to the human toll, this calamity was also accompanied by a significant drop in new admissions and patient census to nursing home facilities. The means that while nursing homes were facing the most harrowing medical crisis in memory, they also were losing revenue desperately needed to invest in PPE, hire additional staff, and obtain other essential supplies. As summarized by my co-author David Grabowski, who spoke today in a House of Representatives hearing on nursing homes and covid-19, "it is time for the federal government to make the necessary investment to mitigate the spread of covid-19 across all US nursing homes. We owe it to our parents and grandparents and the individuals that care for them."

Despite promises from the Trump administration that costs of covid-19 testing and care would be covered by insurers, some patients are finding that they are often stuck holding the bill for costly services. When it comes to testing, official guidance from the Centers for Medicare and Medicaid Services says that insurers must cover "medically necessary" tests. But as more people are being tested when they do not have symptoms, many insurers are beginning to balk at paying for these screening swabs. According to the America's Health Insurance Plans, a national association for health insurers, as more employers are requiring employees to test negative for the virus before returning to work, costs of covering all testing in the next year could reach nearly $45 billion. This could result in substantial costs passed on to the patients now, or in the future via insurance premium increases. Additionally, patients who have long-term complications related to coronavirus infection are finding that the care they have received may not be covered by their insurer, either. Insurers such as Cigna are including continuing care in covid-19 coverage only if complications are explicitly linked to the patient's infection. For many patients, ongoing complications may be multifactorial or may emerge several weeks or months after an initial infection, making the link hard to prove. Patients who were unable to receive coronavirus testing due to limited testing capacity during the initial stages of the pandemic have an even more difficult time linking a subsequent diagnosis to an earlier covid-19 illness. Complicating the situation further, because of the novelty of the virus and the illness it causes, little is known about what long-term complications may be plausibly linked to infection. The Trump administration has not issued guidance to health plans for continuing coverage following infection with SARS-CoV-2, but earlier this week did tell health insurance plans that they can drop benefits related to covid-19 with "reasonable" notice once the public health emergency expires. Similar policy changes previously have required a 60-day notice to patients. NPR, Politico.