In the decade since Leonard Green & Partners, a private equity firm based in Los Angeles, bought control of a hospital company named Prospect Medical Holdings for $205 million, the owners have done handsomely.
Leonard Green extracted $400 million in dividends and fees for itself and investors in its fund — not from profits, but by loading up the company with debt. Prospect CEO Sam Lee, who owns about 20% of the chain, made $128 million while expanding the company from five hospitals in California to 17 across the country. A second executive with an ownership stake took home $94 million.
The deal hasn’t worked out quite as well for Prospect’s patients, many of whom have low incomes. (The company says it receives 80% of its revenues from Medicare and Medicaid reimbursements.) At the company’s flagship Los Angeles hospital, persistent elevator breakdowns sometimes require emergency room nurses to wheel patients on gurneys across a public street as a security guard attempts to halt traffic. Paramedics for Prospect’s hospital near Philadelphia told ProPublica that they’ve repeatedly gone to fuel up their ambulances only to come away empty at the pump: Their hospital-supplied gas cards were rejected because Prospect hadn’t paid its bill. A similar penury afflicts medical supplies. “Say we need 4×4 sponges, dressing for a patient, IV fluids,” said Leslie Heygood, a veteran registered nurse at one of Prospect’s Pennsylvania hospitals, “we might not have it on the shelf because it’s on ‘credit hold’ because they haven’t paid their creditors.”
In March, Prospect’s New Jersey hospital made national headlines as the chief workplace of the first U.S. emergency room doctor to die of COVID-19. Before his death, the physician told a friend he’d become sick after being forced to reuse a single mask for four days. At a Prospect hospital in Rhode Island, a locked ward for elderly psychiatric patients had to be evacuated and sanitized after poor infection control spread COVID-19 to 19 of its 21 residents; six of them died. The virus sickened a half-dozen members of the hospital’s housekeeping staff, which had been given limited personal protective equipment. The head of the department died.
The litany goes on. Various Prospect facilities in California have had bedbugs in patient rooms, rampant water leaks from the ceilings and what one hospital manager acknowledged to a state inspector “looks like feces” on the wall. A company consultant in one of its Rhode Island hospitals discovered dirty, corroded and cracked surgical instruments in the operating room.
These aren’t mere anecdotes or anomalies. All but one of Prospect’s hospitals rank below average in the federal government’s annual quality-of-care assessments, with just one or two stars out of five, placing them in the bottom 17% of all U.S. hospitals. The concerns are dire enough that on 14 occasions since 2010, Prospect facilities have been deemed by government inspectors to pose “immediate jeopardy” to their patients, a situation the U.S. Department of Health and Human Services defines as having caused, or is likely to cause, “serious injury, harm, impairment or death.”
Prospect has a long history of breaking its word: It has closed hospitals it promised to preserve, failed to keep contractual commitments to invest millions in its facilities and paid its owners nine-figure dividends after saying it wouldn’t. Three lawsuits assert that Prospect committed Medicare fraud at one of its facilities. And ProPublica has learned of a multiyear scheme at a key Prospect operation that resulted in millions of dollars in improper claims being submitted to the government.
Leonard Green and Prospect, which have operated hand-in-glove throughout this period, both declined requests for interviews. (Near the end of the reporting for this article, Prospect’s CEO, Lee, spoke to ProPublica on the condition that he not be quoted.) Leonard Green and Prospect responded to ProPublica’s questions in written statements through Sitrick and Company, a crisis PR firm jointly retained on their behalf. They maintain that they’ve kept their commitments, abided by the law, provided good patient care and invested hundreds of millions of dollars, saving many failing hospitals and preserving thousands of jobs. “Prospect Medical Holdings is a healthcare system that provides compassionate, accessible, quality healthcare and physician services,” the statement asserted.
The question of whether profits and good medical care can coexist is not a new one in the United States. But that tension is particularly acute in the case of Leonard Green and Prospect, where private equity has extracted hefty profits from a business that acquires struggling hospitals and relies on Medicaid and other government programs to pay the bills for its impoverished patients.
“It’s such a brutal case of unabashed greed,” said Rosemary Batt, a professor at Cornell University’s School of Industrial and Labor Relations, who has studied private equity’s involvement in health care. “We’re talking here about safety-net hospitals that are serving the poor, the unemployed, disproportionately people of color. They’re just doing this immoral sucking out of resources. That is beyond the pale.”
Prospect’s story is also a bleak omen for the future of America’s health care system — and a particularly telling one because the company is effectively on its second tour through the private equity system. The business model for private equity firms like Leonard Green involves stripping cash out of the organization, loading down operations with debt and reducing every conceivable expense. After that is accomplished, firms then usually resell the operation to another buyer within five years.
The saga of Leonard Green and Prospect embodies a broader trend. Starting around 2010, giant private equity firms like Cerberus Capital Management and Apollo Global Management rushed into the hospital business, buying up facilities and assembling chains. Their moves intensified a shift to for-profit ownership among the nation’s 5,200 general hospitals: from about 15% for-profit in 2000 to 25% for-profit in 2018, the most recent year for which data is available. The biggest corporations still own more hospitals than private equity firms: HCA, for example, owns about 180; Apollo claims 89 and Cerberus had 37 at its peak, before selling this year.
Almost as quickly as it rose, private equity firms’ ardor for hospitals has “substantially cooled” in the past few years, said Lisa Phillips, editor of HealthCareMandA.com, which tracks private equity health care deals. “I’ve seen the whole M&A market for hospitals dry up.”
Making quick profits from operating hospitals proved daunting. “There’s so many other places to put their money in health care that they can flip faster,” Phillips said. (The firms have lately turned their sights to outpatient clinics or staffing emergency rooms.) “Private equity really wants to see growth fast and get out,” Phillips said. “They’ve squeezed it as dry as they can.”
Those actions have made it hard for the firms to sell hospitals, according to Eileen Appelbaum, senior economist at the Center for Economic and Policy Research, who studies private equity. “They’re loaded with debt and anybody sensible is not prepared to buy them.”
Indeed, Leonard Green is now on its third attempt to sell Prospect. Other firms, facing growing losses, have placed some hospitals into bankruptcy and closed others, offering up their real estate while seeking to sell the rest of their medical operations at bargain-basement prices.
The exodus isn’t necessarily good news, according to Batt and other experts. As they see it, this is merely the latest stage in a slow descent to the bottom. Given the cash and assets that private equity owners have already taken out of hospitals, their new owners will be left with heavy debt and limited resources — as the saga of Leonard Green and Prospect demonstrates. Faced with that financial plight, these hospitals will be compelled to cut costs even further, making it ever harder to deliver quality care.
Just over two decades ago, Sam Lee and the private equity firm where he then worked were among the first such firms to invest in hospitals — and it started almost by accident. In 1998, most private equity firms avoided health care. The industry was complicated and highly regulated, both anathema to private equity. Kline Hawkes, the young Los Angeles firm where Lee worked, had made only one previous health care investment, in a medical instruments company. The founder of Kline Hawkes was an investor named Frank Kline, who told ProPublica that no person named Hawkes was ever involved with the firm. Kline picked a British-sounding name to add a dash of gravitas.
In 1998, Kline Hawkes was approached by David Topper, a veteran hospital marketing executive who was seeking funding to buy eight struggling little hospitals in the LA area (one would be immediately sold) and assemble them into a company called Alta Healthcare Systems. Then 49, Topper started Alta after recovering from a fire at his home that left him on a respirator, with third-degree burns over 70% of his body.
Kline was skeptical. He relented only after a bit of salesmanship: Topper surprised him by turning up at a dinner meeting with 15 doctors who promised to send patients to Alta’s hospitals. It convinced Kline that Topper could deliver growing revenues. He decided to invest, putting up $3 million in equity toward the $34 million purchase price. Alta borrowed the rest.
Kline assigned Lee, then 32, to oversee the investment. Lee’s experience was in finance, not medicine. Born in South Korea and raised in Tampa, Florida, he was an industrial engineering graduate of Georgia Tech. Lee had worked for Andersen Consulting (“as a grunt,” he later explained in a deposition) and a Florida software company before getting an MBA at Harvard and joining Kline Hawkes.
Lee was whip smart, could be charming when he wanted to and preferred to operate behind the scenes. He hasn’t been quoted in the press in more than 20 years. (In recent years, his wife’s Facebook account has shown him celebrating holidays with her and their three college-age sons; family vacations in Maui, Aspen and Las Vegas; and pilgrimages to the Super Bowl and the American Music Awards.)
Lee became “super-involved” in overseeing Alta even as Kline Hawkes quickly found an exit, according to Kline. Just three years after investing $3 million, the firm cashed out in 2001 with $5.3 million, a 73% profit. Already deeply indebted, Alta had to borrow more to pay the $5.3 million.
For his part, Lee decided to stay. He sensed a major opportunity, according to a corporate history his spokesman provided: “While the cost of healthcare was growing at three times the rate of the US GDP, hospitals as a group were inefficient in delivering quality care.” Lee quit the private equity firm in 2000 and joined Alta full time, becoming its co-president and a 50-50 partner with Topper. Lee became the primary decision-maker. Topper’s main role was to be Alta’s salesman, schmoozing doctors and nursing home administrators to feed Medicaid and Medicare patients into their small community hospitals, located in low-income neighborhoods.
From the beginning, Lee and Topper brought the cost-slashing philosophy of private equity firms to Alta and its hospitals, according to interviews with former executives and multiple lawsuits. The effects were felt almost immediately.
Critical medical equipment and supplies, including drugs and tracheotomy kits, were “routinely unavailable” at Alta’s hospitals because bills hadn’t been paid, according to a breach of contract suit later filed by a former Alta chief operating officer named Michael White. According to the suit, the company regularly “changed vendors to avoid payment” and “bounced checks as part of its regular cash management process.” (White’s suit was later settled.) The portrait offered by White was affirmed by other executives, including Paul Smith, a former vice president for finance at Alta, who told ProPublica he recalled “having to switch vendors sometimes because we would get cut off.” Emergency room staff in at least one Alta hospital lacked chemical reagents needed to perform critical enzyme tests on heart attack patients, according to another former Alta executive who sued the company. Employees sometimes had to spend their own money to buy toilet paper for patients.
The stringent penny-pinching wasn’t enough to generate profits at first. Some of Alta’s hospitals, according to company filings with the California health department, were averaging 30% occupancy. According to White’s lawsuit, Alta lost a cumulative total of $35 million through the end of 2002. In April 2003, Lee and Topper abruptly shut down two of their hospitals, placing them into bankruptcy (and eventually liquidation), while selling a third. Lee disputed some of White’s claims, but acknowledged in the company’s written responses that this was “a difficult time,” resulting in “some bounced checks and some payables being missed.” He insisted that “ultimately, all the vendors were paid.”
Shedding those money-hemorrhaging operations helped Alta turn a financial corner. By cutting costs and maximizing government reimbursements at its remaining facilities, Alta started to eke out profits from its four remaining hospitals. “Their model was really about just bare minimum,” said Mike Heather, who later helped Prospect acquire Alta and served as Prospect’s CFO from 2004 through 2013. Alta’s facilities “were sort of war-zone hospitals. They were very, very dirt cheap in every respect.”
Things began looking up for the business. Occupancy climbed, and individual hospitals began reporting growing profits — though perhaps not as much as Alta’s financial reports suggested. “When you looked on paper, it was a beautiful turnaround,” said Jack Lahidjani, who was Alta’s CFO from 2003 to 2006. The reality, he said, was that Lee was “putting out aggressive financial statements.”
Lee “fought tooth and nail” to hike Alta’s reported profits in 2006 by booking inflated estimates for forthcoming Medicaid revenues, according to Michael Bogert, who prepared Alta’s audited financial statements for Moss Adams LLP, the company’s accounting firm. “He had our partners convinced I was being too conservative,” said Bogert, now executive vice president for corporate finance at Prime Healthcare, a Prospect rival. Lee convinced a Moss Adams senior partner to overrule him — something that had never happened, Bogert said, during more than 300 previous hospital audits. (Moss Adams declined to comment.)
The rosy numbers helped attract a buyer for Alta in 2007: Prospect Medical Holdings, a small, publicly traded company that managed 10 physician groups. The deal paid off Alta’s debt and netted Lee and Topper $50 million each in cash and Prospect stock. Those shares were enough to give Lee and Topper control of Prospect. Their ambitions were only growing.
The merger nearly wrecked Prospect. Just weeks after the deal closed, Prospect’s audit firm, Ernst & Young, discovered inflated revenues and profits on Alta’s books. (The E&Y senior manager assigned to examine Alta’s financials told ProPublica the misstatement was “very easy” to find.) As a result, Prospect was unable to complete its Securities and Exchange Commission filings, forced to cancel its annual shareholder meeting, delisted from the American Stock Exchange and defaulted on its loans, triggering millions in lender penalties. In April 2008, Alta restated its 2006 revenues, lowering them by about $4 million. In the restatement, filed with the SEC, Moss Adams explained that Alta had misused and ignored “factual information that existed” at the time it compiled the inflated financial statements. (Prospect told the SEC the company’s investigation had found no “intentional wrongdoing.” Lee, in his statement to ProPublica, dismissed the significance of the Alta restatement and said the bigger problem at the time was that Prospect was in far worse shape than he’d been led to believe.)
Despite the turmoil, Lee became CEO of Prospect and consolidated power. He acquired a moldering flagship hospital, the 420-bed Brotman Medical Center, in Culver City, California, out of bankruptcy; replaced Ernst & Young; fired and sued the company’s outside law firm; and ousted Prospect’s 74-year-old founder, Dr. Jacob Terner. A year later, Lee halted payment on Terner’s exit package. (Terner, who has since died, sued and won the full $1 million he was due, plus legal fees, in court.)
Michael Terner worked as an executive vice president at Prospect for five years and departed around the same time as his father. He says his dad covered for Lee after the merger by soft-pedaling Alta’s accounting problems only to have Lee turn on him. “You’ll find,” Terner said, “if you go through the history of Sam Lee, there’s a lot of corpses.”
Indeed, the trail of litigation, unpaid bills and accusations was already lengthy. Two former senior executives at Alta claimed that Lee and his longtime partner had cheated them out of a promised equity stake. Minority investors in Brotman accused Lee of cooking its books to defraud them. Dozens of lenders, executives, doctors, staffing agencies and hospital vendors filed lawsuits and court claims over unpaid debts and broken agreements. Three law firms hired by Alta later sued for unpaid bills. Lee professed his innocence and fought the actions, typically settling for discounted amounts. The pattern would continue at Prospect.
Lee was demanding and unrelenting, according to people who worked for him. “One day you’re like a superstar and the future of the company,” said Steve Aleman, who became Prospect’s CFO in 2013. “The next day you’re absolutely in the doghouse.”
(Last fall, Lee abruptly terminated Aleman, who then filed suit claiming he is owed for unpaid compensation and canceled company stock options. Aleman is now CFO of Prime Healthcare. In its responses for this story, Prospect made an array of unsubstantiated allegations about Aleman’s workplace conduct during his 12 years at the company. A Prospect lawyer also wrote Aleman, accusing him of making “false and defamatory” statements to ProPublica. In a letter responding to the company, Aleman’s lawyer denied that his client made any defamatory statements. Aleman confirmed to ProPublica the accuracy of his comments in this article. In addition, Prospect made accusations about the conduct or character of seven other former executives and employees critical of the company, including two other former CFOs of Prospect or Alta. Aleman called the charges an “offensive smear campaign that Prospect is attempting against myself and others who are no more than victims of Lee’s broader plan to enrich a few and hurt many.”)
Lee churned through executives and could turn brutal, screaming at subordinates or grilling them over a tiny issue. “He’d go through three hours of literally just peeling the skin off somebody,” Aleman said. Lee would make executives cry, recalled former Alta CFO Lahidjani, who counted himself in that category.
Meanwhile, the CEO whittled costs to the bone by finding cheap sources for medical supplies; through “real-time” monitoring of hospital staffing; and slow-walking every vendor payment. “He was very proud of making it impossible to get a dollar out,” former CFO Heather said. “He would just not pay people as a way to negotiate. He would shut off things you’d say it was crazy to shut off.”
Through its spokesman, Prospect said “we do not have a slow-pay policy at Sam Lee’s or anyone else’s direction.” It said the company’s implementation of a new financial system over the past 12 months has caused a number of vendor payment delays and “credit holds.”
Prospect was far less obsessive about patient care issues, according to former company executives. “That quality component was always lax in my GFN,” one said. “It’s always the bottom line.” In public testimony a few years ago, Prospect executives acknowledged the point. “As an organization, we had delegated the role of the quality program to a local level,” Senior Vice President Von Crockett testified, “without the proper oversight at a corporate level.”
By 2010, the investing trends had changed. Big private equity firms were flooding into the hospital business. Leonard Green, a firm known for its investments in marquee consumer brands like Whole Food Markets and Neiman Marcus, joined the rush.
Prospect’s business, which involved spending as little as possible and squeezing profits out of Medicare and Medicaid reimbursements, while using Prospect’s physician groups to generate patients, didn’t fit the pattern. But Leonard Green viewed Prospect’s approach as one that could be applied widely and used to acquire more hospitals and reap more profit. Lee was eager to expand, too, confident that his business model could be applied to many more struggling hospitals, multiplying the company’s revenues from about $470 million in 2010 to several billion.
Leonard Green struck a deal that aligned Lee’s financial interests with its own. In addition to more than $2 million a year in salary and bonus, he would get 20.2% of Prospect’s shares (and dividends). Topper received a 14.9% stake, while Leonard Green got 61.3%. The rest was distributed in the form of stock options to Prospect’s top executives, to whom Lee dangled the possibility of a big future payoff.
Leonard Green’s point man for the Prospect stake was a former investment banker named John Baumer, a graduate of Wharton and Notre Dame, where his father had worked as the university’s comptroller. At Notre Dame, Baumer and his wife have endowed the lacrosse team’s head coaching position ($3 million) and funded a new men’s dormitory ($20 million). The Baumers live about 30 minutes from the firm’s Santa Monica offices in a large oceanfront property on Manhattan Beach, purchased, through a corporate entity he set up, for $18.4 million.
Baumer and two Leonard Green colleagues, who together made up a majority of Prospect’s five-member board, left day-to-day health care operations to Lee. The private equity board members focused on profits — and wasted little time in beginning to reap returns.
In 2012, Prospect paid Leonard Green and its investors a total of $188 million in two rounds of dividends. Prospect raised the money by issuing junk bonds. Only two years in, the private equity fund had made back most of its $205 million investment.
As Prospect cranked up its ambitious expansion plans, it consistently told the targets of its acquisitions and the government regulators who needed to approve them that it was in the business of saving troubled hospitals. “We haven’t closed hospitals, and we don’t close services,” Dr. Mitchell Lew, Prospect’s president, said at a Connecticut public hearing in March 2016. “We’re in this for the long term, OK?”
Lee’s first out-of-state acquisition would erase that claim. In 2012, Prospect paid $48 million for San Antonio’s Nix Health System. Nix included a 208-bed downtown hospital, an inpatient psychiatric center and multiple outpatient clinics.
Nix was an unusual acquisition for Prospect. It was profitable and had a higher federal quality rating, with four out of five stars, than any other Prospect hospital. Yet Prospect claimed the role of savior. In a press release announcing the deal, Lee said the company “will help ensure the long-term success of Nix.”
That success didn’t last long. Prospect removed Nix’s longtime CEO in 2015 and established control from headquarters in LA, while cycling through four more CEOs in the next four years. Doctors who had long relationships with Nix stopped referring patients. After decades of profits, Nix began losing money.
In 2019, after repeatedly promising to keep at least part of the system open, Prospect shut it all, laying off nearly 1,000 employees. The company sold Nix’s downtown building to a hotel chain and exited with a big loss. “It was mismanaged at the corporate level,” Aleman said. “It went from making about $20 million to losing money. It was an absolute disaster.”
In its responses to ProPublica, Prospect blamed the failure on a “catastrophic” broken water pipe in 2016 that flooded “the entire hospital infrastructure,” forcing doctors and patients to go elsewhere for months. “Volume and physicians,” the company said, “never returned to pre-flood levels.”
Prospect is now poised to shutter another acquisition it eagerly pursued: East Orange General, outside Newark, New Jersey. In late 2015, Prospect outbid two other companies with a $44 million offer for the 196-bed hospital, then in bankruptcy and losing more than $2 million a month.
Prospect vowed to spend $52 million on capital improvements and keep the hospital open for “no less than five years.” Three years into that vow, with losses still running about $1 million a month, Prospect’s warnings that it wanted to sell or close the hospital spurred state lawmakers to hand the company an “emergency” $15 million grant.
Lee couldn’t find a buyer, Aleman said: “They would have just given East Orange away — literally handed over the keys. They wanted to get rid of it at all costs.” In its statement, Prospect said it will keep East Orange open into 2021 while it continues to seek a buyer and thus “will surpass our five-year commitment of operating the hospital.” The company also said it has met its $52 million capital-spending promise under provisions of its purchase agreement that allow it to count debt payments and routine maintenance costs toward that total.
In Rhode Island, Prospect was welcomed as a savior in 2013 when it agreed to pay $45 million for controlling ownership of two money-losing Providence-area hospitals: 220-bed Roger Williams and 359-bed Our Lady of Fatima. Eager to save jobs, Fatima’s powerful United Nurses & Allied Professionals union endorsed Prospect’s bid.
State regulators, who had to approve the sale, had two big concerns. The first was the $188 million in dividend payouts previously made to Leonard Green and other investors. Those payments raised fears that Prospect wouldn’t fulfill its pledge to spend $90 million on capital improvements over four years. No problem, Prospect responded; it wouldn’t pay out any more dividends. “Prospect’s management and representatives have given assurances that this was a one-time event and that there are no plans to make a similar distribution in the foreseeable future,” the Rhode Island attorney general noted in his written findings on the hospitals’ sale in 2014.
Employee pensions was the other issue. The retirement plan for Our Lady of Fatima, which 2,700 past and current hospital employees were counting on, had been woefully underfunded since 2008. The problem had escaped federal ERISA oversight because of the hospital’s affiliation with the Catholic Diocese of Providence, making its pension system a legally exempt “church plan.”
The size of the problem was a secret. During negotiations over the sale, Prospect was repeatedly briefed on actuarial studies showing that even after a $14 million contribution that Prospect agreed to make, the plan would run out of money by 2036, while still owing about $98 million in retirement benefits.
After learning this, Prospect negotiated contract language freeing it from any future pension liability. The retirement system, and its massive funding deficit, would become the responsibility of a nonprofit community board, which had no reliable source of income.
Prospect officials never disclosed the plan’s dire straits during the state approval process. Instead, retirees nervous about Prospect’s purchase were shown a PowerPoint presentation stating that Prospect’s one-time contribution would “stabilize plan assets.” Lee attested in writing that the payment would “assure that the pensions and retirement of many former employees, who reside in the community, are protected.” Prospect told the attorney general that any necessary future payments would “be made based on recommended annual contribution amounts as provided by the Plan’s actuarial advisors.” Remarkably, no one addressed who would actually make such payments. Rhode Island approved the purchase in 2014.
Over the three years that followed, neither Prospect nor anyone else paid a penny into the pension plan. In 2017, the system was declared insolvent and placed in receivership. The court-appointed receiver has filed multiple lawsuits accusing Prospect and the diocese of “omissions and half-truths actionable as fraud,” demanding that they help make the pension whole. The cases are all pending.
In its statement, Prospect noted that its purchase agreements for the hospitals “clearly spell out” that the company had “no responsibility” for funding the pension plan. It also said it would have been “economically impossible” for Prospect to take over liability for the retirement system and called the receiver’s allegations about the company’s actions “false and unsubstantiated.” Both Prospect and the diocese deny concealing the pension system’s condition.
Meanwhile Prospect sought to cut costs by reducing the workforce, trimming benefits and tightly monitoring each hospital’s patient count throughout the day from its LA headquarters, sending nurses and aides home whenever possible in mid-shift.
After hearing about a consultant’s 2017 report describing dirty and damaged operating room instruments, the union at Fatima requested documents about this and other problems revealed by various inspections. Prospect refused, and failed to turn over any of the materials, despite an order to do so from the National Labor Relations Board in April 2019, affirmed by the 1st U.S. Circuit Court of Appeals in March 2020.
Prospect asserts that it promptly addressed the consultant’s concerns about dirty and damaged surgical instruments, but that it viewed the report as “proprietary” and thus “availed itself of the court system.” The company added: “As we recently received a ruling from the Federal Court to produce the document, we have complied with the order.”
Prospect has yet to hand over any documents, according to the union. “Prospect is lying in claiming that they’ve complied with the order,” union general counsel Chris Callaci said. Dealing with the company, he added, has been “a parade of horribles.”
Many of these problems had yet to emerge by 2015, as Prospect struck rapid-fire deals to double the company’s size. That’s when it reached agreements to spend more than $500 million to buy hospital systems in three states: East Orange General, in New Jersey; three community hospitals in Connecticut; and a four-hospital system in suburban Delaware County, Pennsylvania, west of Philadelphia. Prospect promised to spend hundreds of millions more on pension and capital improvements.
Prospect was reporting revenues of about $1 billion in 2015, with operating profits of $108 million. After digesting the acquisitions in the pipeline, the company projected, revenues and profits would surely soar.
Leonard Green was now ready to fully cash in and exit its investment. In October 2015, the firm hired Morgan Stanley to find a new private equity buyer for Prospect. The company’s 92-page “confidential information memorandum,” prepared for prospective acquirers and obtained by ProPublica, promoted the company’s “cost-effective care” model, including daily “flex” management of hospital staffing, use of low-cost sources for medical supplies and a focus on high-profit programs for treating the seriously mentally ill.
Bain Capital and CVC Capital Partners were the two final bidders. Both made offers around $1.2 billion, according to sources familiar with the talks. Then, in early 2016, U.S. capital markets tightened amid fears of a recession, dashing the company’s hopes to get even more. Lee decided to hold off on a sale. Aleman said the discussed reasoning was that Prospect could bring a far richer price after mining its pending acquisitions for bigger profits.
But a new problem had emerged behind the scenes during this period: improper Medicare billing. The issue, described in internal documents obtained by ProPublica and interviews, involved “unsupported” reimbursement codes submitted by Prospect’s physician-management business, whose dramatically increased profits the company had promoted to potential buyers. The problem was discovered in August 2015 during a routine compliance audit by nurses with Inter Valley Health Plan, a California HMO that sent Medicare Advantage patients to Prospect doctors and, as a result, had shared in the improper windfall (unknowingly, according to Inter Valley).
Inter Valley promptly notified Prospect, which expressed skepticism that anything was wrong, according to Inter Valley chief operating officer Susan Tenorio. “They really didn’t take us seriously,” she said. “The response was: ‘We do this all the time. Nobody has questioned it.’ That’s when I went back to our CEO and said, ‘There’s a problem here.’”
Inter Valley began investigating, with help from a law firm and outside consultant. It found that Prospect had submitted an estimated $22.6 million in potentially improper charges, which the federal government had already paid. Several million dollars more in improper claims, not yet processed, had to be canceled, according to Inter Valley. Inter Valley’s CEO and its chief compliance officer then sent a letter detailing their findings to the Centers for Medicare and Medicaid Services in August 2016.
The letter, obtained by ProPublica, reported that Prospect had submitted thousands of claims dating back to 2013 that were “not supported by audited medical charts.” It added: “In many instances, diagnosis codes were submitted for dates of service for which there was no evidence in a medical chart confirming that the [Prospect physician] had a face-to-face visit with the beneficiary.” Most of this “upcoding” involved claims that individual patients had made two visits to Prospect doctors on the same day. “We reported everything,” Inter Valley CEO Mike Nelson said. Everyone on Inter Valley’s board, he added, accepted that its organization had been reimbursed for false charges. “Making it right is what we should do,” Nelson said.
Prospect, Inter Valley and a hospital used by the plan’s patients had to repay the federal government for the improper income they’d received. Nelson said the three parties set aside a combined $22 million to cover the reimbursements while CMS completed its still-unfinished audit of how much is due. (CMS did not respond to requests for comment.)
Prospect’s own consultant, Alvarez & Marsal, largely confirmed Inter Valley’s findings in September 2016 in a confidential draft document reviewed by ProPublica. Alvarez & Marsal was also concerned the problem extended far beyond what Inter Valley had discovered: that Prospect had submitted bogus claims for more than 20 other Medicare Advantage plans, including United Healthcare and Blue Shield.
Another of the Medicare Advantage plans that received payments because of Prospect’s improper claims, CalOptima, said in a statement that Prospect first informed it in March 2016 of an “inadvertent and isolated” billing error from a single month in 2015. Months later, Prospect acknowledged the problem was far more widespread. It eventually turned out there were 3,847 “erroneous” claims over four years, requiring $2.8 million in repayments to CMS, including $1.7 million from Prospect. Because the improper claims were eventually self-reported, the government has taken no action against Prospect.
The ultimate total cost to Prospect from the improper billing episode, including expected income the company lost as a result, was in the tens of millions, Aleman estimated.
Prospect asserted that its cost was actually $8.5 million and that “management was unaware” of any inappropriate billing until after the fact. The company blamed the episode on the vice president who had presided over all reimbursement submissions, who was fired. In an interview, the woman, who asked not to be identified, told ProPublica, “They blamed me for something I didn’t do.” Inter Valley’s Tenorio called her “a scapegoat.”
Meanwhile, three lawsuits have charged Prospect with different allegations of billing fraud at its flagship hospital in Culver City. According to a pending suit filed by Charles Harper, a 28-year employee who served as director of cardiopulmonary therapy, the hospital fraudulently billed Medicare for individual respiratory therapy while regularly requiring its staff to treat two patients at the same time, a practice known as “stacking.” Harper claims he was fired for complaining about the wrongdoing. (Prospect denies any improper billing and says Harper’s job was eliminated because of diminished demand for respiratory services.)
A second lawsuit filed in federal court claimed the hospital inflated Medicaid revenues at its Miracles detox center by admitting financially needy or homeless patients with “no medical reason for being hospitalized for chemical dependency.” The plaintiff, a former nurse there who sought whistleblower status for the suit, alleged that some patients were admitted so often, without undergoing standard addiction screenings, that the staff referred to them as “frequent fliers.” Federal prosecutors ultimately declined to join the case but allowed it to proceed as a private action against Prospect and the hospital under the False Claims Act. Prospect settled in 2017, agreeing to pay $275,000 while asserting that the claims were “wholly without merit.”
The third suit alleged an “illegal patient procurement scheme” to generate fraudulent Medicare and Medicaid claims. Christina DeMauro, an emergency room nurse at Culver City for six years, asserted that a special team of hospital “marketers” generated a stream of about 20 elderly patients a day, most suffering from chronic dementia, who were admitted through the ER despite having no problems that required hospitalization.
According to her suit, these patients were brought from nursing homes and other senior facilities, “many well over 100 miles away,” when their Medicare benefits there, capped at 100 days, were about to expire. After an unnecessary hospital admission requalified them for Medicare benefits, the patients were then returned to their facilities, according to the suit, boosting government billings for both Prospect and the senior facilities. Filed in 2018, the case remains pending in Los Angeles. DeMauro alleges that “unlawful retaliatory conduct” she faced after complaints about these practices forced her to resign.
Don Andrews, a seasoned administrator who worked as emergency department director during part of this period, backed these claims in an interview with ProPublica. Andrews said Prospect marketers insisted that elderly mental health patients “from nowhere near Culver City” be admitted through the emergency room even when no psychiatric beds were available in the hospital. He says this routinely resulted in a handful of patients being held for days in a crowded ER “overflow” area with no beds or privacy — just chairs and a single bathroom — serving as a sort of “bootleg inpatient psychiatric unit.” A few years before Andrews got there, one 79-year-old man suffering from dementia disappeared after being left unattended in the overflow area, according to a state inspection report and a lawsuit by his family. His body was later found on a beach 7 miles away; the man had drowned. The “overflow” area remained in use until about 2018, when it was permanently locked, hospital employees said.
Prospect’s spokesman denied DeMauro’s allegations but declined to address specifics because her litigation is pending.
This same hospital, the company’s largest, is also the most visible monument to Prospect’s neglect. Long called Brotman Medical Center, it is best known for its burn center, which treated Michael Jackson in 1984 after his hair and jacket caught fire during the filming of a Pepsi commercial.
In 2013, four years after buying the hospital, Prospect grouped Brotman with two of its other hospitals, renaming it Southern California Hospital at Culver City. The move, made to qualify for extra government subsidies for treating low-income patients, helped Brotman generate profits.
But Brotman has continued to deteriorate. In 2015, inspectors shut down all elective surgery at the hospital for eight days, citing a “widespread pattern” of poor infection control and sterility; the problems resulted from inadequate heating and cooling systems. That episode, as well as the death of the ER-overflow patient whose body was found on the beach, resulted in immediate jeopardy findings.
That same year, state health inspectors cited the hospital after a broken refrigeration system in its morgue caused a woman’s corpse to decompose so badly it produced a “noticeable stench,” making it impossible for her family to have an open-casket funeral. Meanwhile, one of the hospital’s elevators has been out of order for 10 months. Patients needing MRI scans must be taken outdoors and down an alley, past dumpsters and into a hospital parking lot, where the scan is done in a rented trailer.
Prospect said it quickly resolved all immediate jeopardy findings, something a hospital is required to do to remain eligible for federal reimbursements. It said it is “working with state and local officials to expedite” the broken elevator’s replacement. And it said it is “not uncommon for hospitals to utilize a mobile MRI,” but plans are underway to relocate the MRI inside a nearby building.
When it rains in Culver City, water drips from ceilings throughout the hospital’s two buildings, forcing staff to relocate patients and plant orange buckets in the hallways. In 2014, a patient’s wife filed suit after soaked ceiling tiles fell and struck her in the head while she was sitting in the hospital lobby. This January, a giant brown mold formation burst through the wall near a fourth-floor nurses’ station. Noted the resulting complaint to the California health department: “There are mushrooms growing out of the wall (which they cut off and patched back up). There is leakage from the ceiling when it rains you can taste the mold in the air.”
Employees told ProPublica the problem has persisted for years and provided photographs and videos documenting numerous leaks as well as the mold growth. Prospect asserted, by contrast, that “all leaks are identified and fixed as they occur.” The company said roof replacement has begun on the main patient building.
A 2018 state inspection found the pharmacy staff at the Culver City hospital had for months ignored findings of “fungal air growth,” “bacterial organisms” and mold in equipment used to mix patient medications in a sterile environment. According to the report, this resulted in the dispensing of about 21,000 doses of “adulterated dangerous drugs” to patients over a nine-month period. In September 2019, California’s attorney general formally charged Prospect executives, including Lee, the hospital and its supervising pharmacists, with “gross negligence,” initiating proceedings to revoke or suspend the hospital’s pharmacy permit. The matter remains pending. Prospect asserted that “no patient harm occurred” from the “error,” which has been corrected, and said the pharmacy is now “fully operational.”
Eventually, word of Prospect’s practices spread, causing alarm when the company sought to acquire new hospitals in other states. As Connecticut in 2016 weighed whether to approve Prospect’s purchase of three hospitals, the state sent a team to California to investigate five recent immediate jeopardy findings, which had placed one Prospect hospital license on a “termination track” for cutoff of Medicare and Medicaid funding.
Prospect executives tap danced, alternately denying problems and explaining away the repeated findings of imminent threat. SVP Crockett testified, for example, that “there was no specific patient harm” that occurred, while insisting Prospect acted aggressively to address the “allegations,” including by creating new posts for a “chief quality officer” and a “vice president of regulatory affairs and patient safety.”
The company claimed it would act differently in the new states it was entering. “What happened in California certainly is concerning,” Prospect’s president, Lew, acknowledged at the hearing. “… And so, we’re not bringing California’s quality program to Connecticut,” he said. “If you want to look at us as performing an ‘F’ on the test in California, that student is not coming here to tutor Connecticut on quality, OK?”
As it turns out, Prospect hasn’t earned stellar grades in Connecticut either. State officials approved the company’s acquisitions on a conditional basis in 2016, while imposing a three-year monitoring regime that health department officials describe as unprecedented. Before the monitoring period expired, two of Prospect’s newly acquired Connecticut hospitals were slapped with immediate jeopardy findings.
This time, two patient deaths triggered the jeopardy findings. In 2018, Manchester Memorial Hospital mishandled two high-risk pregnancies: One woman died after delivering a stillborn baby; a second gave birth to an infant with severe encephalopathy, a form of brain damage, after an emergency cesarean section was performed too late. Waterbury Hospital was found to have failed to properly monitor two suicidal patients on a single day in March 2019. In one case, staff returned a belt to an “actively suicidal” psychiatric patient who then used it to hang himself in his hospital bathroom. After his death, the hospital failed to notify police. A second patient attempted suicide by tying hospital socks around his neck after being left unwatched while a nurse went to lunch.
The Joint Commission on Hospital Accreditation responded by initially denying Waterbury’s accreditation, required to receive Medicare and Medicaid funding, after an inspection that found 42 quality standards “out of compliance.” In December 2019, Connecticut regulators extended the monitoring of the state’s three Prospect hospitals until May 2021.
More failures appeared in the company’s biggest purchase yet, agreed to in late 2015: the four-hospital Crozer-Keystone system in Pennsylvania. Prospect paid $300 million. It made other promises as part of the deal: to spend an additional $200 million in capital improvements within five years; to keep all the hospitals open for a decade; to fund $171 million in pension benefits within five years; and to endow a community health care foundation for $53 million.
Almost immediately, Prospect began contesting the agreement. Always eager to delay and reduce a big outlay, Prospect deferred $21.5 million of the foundation funding for 90 days — and then refused to make the payment altogether, challenging how much it owed.
The foundation sued, eventually extracting Prospect’s agreement to submit the matter to arbitration while putting the money into escrow. When Prospect then missed the escrow deadline, the foundation began garnishing the company’s accounts and sought to have a receiver appointed over all its financial transactions. Prospect finally paid, 18 months late, after the arbitrator awarded the foundation $23.7 million, including interest. (Prospect’s spokesman said the matter was “referred to the court” because efforts to resolve the amount of the payment were unsuccessful.)
At Crozer-Keystone, as elsewhere, Prospect has aggressively moved to lower costs. It sought, unsuccessfully, to reduce nurses’ accrued vacation time and to cut pension benefits for all employees who didn’t work full time. The company has also waged a four-year battle to halve the tax assessments on all its hospital properties. (Prospect says it believes the assessments are excessive and will pay “once a final ruling is given as to what is fair and proper.”)
In November 2018 came yet another immediate jeopardy finding. This one stemmed from patient-safety violations in a mental health ward at 300-bed Crozer-Chester Medical Center, the system’s largest hospital. According to state health department inspectors, video monitors at a nurses’ station for maintaining watch over suicidal patients were turned off or ignored; an activity room was left unattended as psychiatric patients milled about; patients were placed in restraints or in seclusion without proper documentation; and facilities in the locked unit treating elderly psychiatric patients, some of them suicidal, presented multiple hanging hazards.
Hospital workers have regularly reported staffing shortages, sometimes forcing delays of scheduled medical procedures. Two medical employees at Delaware County Memorial Hospital are lead plaintiffs in a national class action against Prospect, claiming insufficient staffing regularly forces hospital employees to work, unpaid, through meal breaks. The company denies the allegations, including that any of its hospitals suffer from staffing shortages.
As elsewhere, Prospect’s failure to pay bills on time has delayed repairs and resulted in supply shortages. At Delaware County Hospital, veteran nurse Angela Neopolitano said a call-bell system in one unit, which patients use to summon help from nurses, has been broken for more than two years. “Creditors would not come in to fix things because the hospital owed them money,” she said. “Then we suffer and the patients suffer.”
Paramedics have repeatedly gone to fuel up ambulances using a hospital credit card, only to have it rejected, according to Larry Worrilow, assistant chief for the Crozer-Keystone EMS system. “It’ll be fine for six or eight months. And then, all of a sudden, boom — you can’t get fuel,” said Worrilow, who has worked there since 1977. “After you rattle their chains, they pay part of the bill, get their credit hold lifted, and you can get fuel.” (Prospect said the card was rejected because it placed a charge limit on it as a security measure, and “when it was brought to our attention that the account was reaching the credit limit frequently, we increased the credit limit to ensure there was not disruption of services.”)
The system’s eight ambulances are so old — two have more than 275,000 miles on them — that they frequently break down, according to Worrilow. “There’s plenty of times when we went to go on an emergency call and the ambulance wouldn’t start,” he said. “You have to send the next closest ambulance. Or you get to the scene and the ambulance won’t run.”
COVID-19 caught many of America’s top medical centers by surprise. But Prospect’s penchant for scrimping on staff and medical supplies left its hospitals with little margin for error.
In Rhode Island, for a time in March, hospital employees at Our Lady of Fatima were threatened with discipline for wearing their own masks, even though the hospital didn’t have enough to give them. Nursing assistant Doreena Duphily, who worked in the geriatric mental-health ward, where 19 of 21 patients were infected, was out sick for three weeks with COVID-19 herself. Duphily blames the hospital’s frequent rotation of its limited staff to different floors for spreading infection. Six members of the environmental services staff, responsible for cleaning patient floors, also got sick. On May 1, department supervisor Jerald Ferreira, 63, died of COVID-19.
“We were probably about three weeks behind every other hospital in getting just the basics,” said Fatima RN Lynn Blais. “All of a sudden COVID comes in, everybody should have surgical masks, and we don’t have two days’ worth of surgical masks, much less two months of surgical masks. We were caught with our pants down. That germ was all over the floor.”
In Culver City, nurses unable to get proper protective gear for a time donned plastic garbage bags. ER secretary Chudi Long says she became infected after being denied a mask despite working in close quarters with COVID-19 patients. After her breathing grew weak while she was battling the virus at home, Long was rushed to another hospital’s ER, where she lost two front teeth during an emergency intubation, and spent seven days on a ventilator.
Prospect denied it ever lacked PPE at any of its hospitals.
Leonard Green may not have been involved in Prospect’s day-to-day management, but it has popped up periodically to make sure it gets a return on its investment. In 2018, less than four years after assuring a state attorney general that it had no plans to seek new dividends, Prospect attempted to do just that. It began preparing to issue a $600 million dividend. As always, the plan envisioned funding that payment through debt.
Moody’s, the ratings agency, was dismayed by Prospect’s soaring debt. It lowered the company’s credit rating in response. As a result, Prospect reduced the dividend to $457 million. In a letter to Rhode Island officials, Prospect insisted it didn’t violate the pledge it made back in 2014 because “in 2014, no dividends were planned.”
That $457 million raised the total in dividends extracted from Prospect since Leonard Green acquired it to $645 million. Roughly $386 million had gone to Leonard Green’s investors and the firm (which gets 20% of all fund profits); $128 million to Lee; $94 million to Topper; and the remaining $37 million was divided among other Prospect executives. (Another $14 million in fees went to the private equity fund.)
Having collected that cash, Leonard Green made a second attempt to exit the investment in June 2018. By this point, Prospect had grown to 20 hospitals. Detailed management presentations to the two 2015 finalists were followed by dinners in Beverly Hills, leading to informal discussions with CVC, which was contemplating a considerably richer offer this time, according to Aleman. (CVC declined to comment.)
But once again, the sale collapsed. As Prospect headed toward the September close of its 2018 fiscal year, its business began deteriorating rapidly, torpedoing the projections it had given potential buyers. Recognizing that the bad numbers would surely blow up the deal, Leonard Green and Lee decided to hold off again. (The statement from Green and Lee denies they tried to sell the company in 2018.)
The situation grew dire. By January 2019, Prospect had so little cash that it needed an emergency $41 million loan from Leonard Green, Lee and Topper to assuage auditor fears that the company might not remain “a going concern” and to avoid violating loan covenants, according to Aleman. In March, Moody’s downgraded Prospect’s debt a notch deeper into junk territory, citing the company’s “very high financial leverage, shareholder-friendly financial policies, and a history of failing to meet projections.”
Eager to raise capital, Prospect sold its land and buildings last fall in a sale-leaseback transaction that allowed the operations to remain in the facilities. The company raised $1.55 billion. Prospect used much of the cash to pay off its loans. It had effectively replaced its debt payments with rent payments.
The sale of the land and buildings brought in much needed cash and stabilized the company. But it also meant that Prospect had shed by far its biggest asset, sharply reducing the value of the company. When Leonard Green made its third attempt to exit, the nominal price was a pittance.
In October, the private equity firm agreed to sell the firm’s 60% stake to Lee and Topper for $12 million in cash plus the assumption of $1.3 billion in lease obligations. The $12 million was to be paid by Prospect, not the two executives. As Prospect and Lee put it in their statement for this article, “In effect, the company’s money is their money.”
To Lee’s management team, who dreamed of stock option riches, it was an outrage. The low cash price would value their shares and options at a pittance, dashing their expectations of a windfall. A “drag-along” provision of the agreement would force all shareholders to sell immediately, rather than wait and hope for a better price. In February, Aleman, who’d been stripped of his stock options when he was suddenly fired last fall, filed suit in California, seeking restoration of his shares and payment of his 2018 bonus. (Under agreements Prospect makes virtually all employees sign, the case is scheduled to go to arbitration.)
For Leonard Green, the exit made a certain sense. As of this year, when the firm hopes to close the sale, Green has retained its Prospect stake for 10 years; indeed, the $5.3 billion fund that holds that and other investments was launched in 2007, making it venerable in private equity years. That fund has doubled in value overall, according to data on its investors’ websites. All told, for all investments in the fund over 13 years, ProPublica estimates Leonard Green has made more than $1.5 billion for itself from fees and its share of the fund’s profits. (Through its spokesman, Leonard Green said this figure was wrong and that the firm would “not respond to inaccurate guesses.”)
It is leaving a mess behind at Prospect. The company has little cash, weighty pension debts and lease commitments, and uncertain future earnings.
Some current and former management shareholders, working with Aleman, contemplated trying to recruit another buyer who would pay a far higher price. But when an email exploring this effort was accidentally sent to Prospect, the company responded by dispatching a letter to Aleman’s attorney, accusing the former CFO of “colluding with others in an attempt to interfere with a Company transaction.” It demanded that he “immediately cease and desist.”
Leonard Green’s sale to Lee and Topper requires approval from state officials in Rhode Island, since it involves hospitals there. The officials have postponed their decision until November, saying there are missing documents and unanswered questions. And opponents there are making a stand. The Private Equity Stakeholder Project, a union-backed research group, has produced detailed reports criticizing Green’s history with Prospect. It has lobbied public-pension investors and members of Congress to press the firm to return its dividends to the company, saying its profiteering has put Prospect’s safety-net hospitals at risk. The Fatima union and the pension fund’s receiver have opposed the sale too. “I don’t know the answer, but I think there’s something wicked going on here,” Max Wistow, the receiver’s special counsel, told a public hearing. Citing Leonard Green’s history with the hospital company, the Rhode Island state treasurer has said he will block any future investments by his state, which sunk $20 million into the fund that owns Prospect, in the private equity firm’s funds.
Leonard Green defended the transaction to state officials and a Rhode Island congressman, writing that the sale price reflects Prospect’s “future obligations” and was agreed to by “sophisticated investors” who wanted “to not burden the company with additional debt.” The firm added: “We reject any implication that we have managed Prospect in a financially irresponsible fashion or that we have put our own financial interests ahead of the interests of the hospital system. Prospect today is at no risk of financial failure.”
Given Sam Lee’s prowess at squeezing cash out of ailing institutions, Prospect undoubtedly will find profits left to extract. What it will have to offer patients is less clear.
U.S. Records 100,000 Cases in a Day for the First Time
The United States on Wednesday recorded over 100,000 new coronavirus cases in a single day for the first time since the pandemic began, bursting past a grim threshold even as the wave of infections engulfing the country shows no sign of receding.
The total count of new infections on Wednesday was more than 107,800, according to a New York Times database. Twenty-three states have recorded more cases in the past week than in any other seven-day stretch.
Five states — Maine, Minnesota, Indiana, Nebraska and Colorado — set single-day case records. Cases were also mounting in the Mountain West and even in the Northeast, which over the summer seemed to be getting the virus under control.
North and South Dakota and Wisconsin have led the country for weeks in the number of new cases relative to their population. But other states have seen steep recent increases in the last 14 days.
Daily case reports in Minnesota, on average, have increased 102 percent over that time, while those in Indiana have risen 73 percent. For months, Maine had among the lowest levels of transmission anywhere in the country, but new cases there have more than tripled. In Wyoming, new cases are up 73 percent, while in Iowa they have more than doubled.
Deaths related to the coronavirus, which lag behind case reports, have increased 21 percent across the country in the last two weeks.
Hospitals in some areas are feeling the strain of surging caseloads. More than 50,000 people are currently hospitalized with Covid-19 across the country, according to the Covid Tracking Project, an increase of roughly 64 percent since the beginning of October.
Dr. Anthony S. Fauci, the country’s top infectious disease expert, predicted in June, when new cases were averaging roughly 42,000 a day, that the rate would eventually reach 100,000 a day if the pandemic were not brought under control. His blunt assessments of the country’s failure to control the virus drew attacks from Trump administration officials, including the president, who called him alarmist.
In an interview on Friday, Dr. Fauci told The Washington Post that the country would most likely hit the 100,000 mark soon.
“We’re in for a whole lot of hurt,” he said.
Dr. Fauci said that the country “could not possibly be positioned more poorly” as winter approaches and colder temperatures lead people to gather indoors.
States report new cases unevenly from day to day, so seven-day averages are a more reliable gauge of trends than an individual day’s figures are. But Wednesday was bad by that measure as well, with the seven-day average exceeding 90,000, the highest since the pandemic began.
During the early days of the pandemic in March and April, testing in the United States was very limited, so it is not possible to say with certainty that the virus is spreading faster now than it did then.
But the pattern of infection has clearly changed.
Dr. Bill Hanage, an associate professor of epidemiology at Harvard’s T.H. Chan School of Public Health, said this week that while the surges in the spring and summer were concentrated in specific regions — the Northeast in the spring and the Sun Belt in the summer — the current one reflects transmission increases in nearly all parts of the country.
Dr. Hanage called Wednesday’s milestone “the completely foreseeable consequence of not taking pandemic management seriously.” And he said the country would see “hospitalizations and deaths increase in due course.”
“This is desperately concerning,” Dr. Hanage said, “because uncontrolled transmission will end up compromising health care, and in order to preserve it, we will almost certainly end up needing to take stronger action to prevent the worst outcomes.”
“Look to Europe to see the consequences of leaving it too late,” he said. “The longer you leave it, the harder it will be to control.”
The Italian government announced Wednesday night that it would lock down a significant portion of the country, including the northern regions that are its economic engine, in an effort to stop a resurgent wave of coronavirus infections.
Prime Minister Giuseppe Conte said the measures, the most drastic since the nationwide lockdown in March, would take effect on Friday and will seal off six regions in the country’s deeply infected north and highly vulnerable, and poorer, south.
“The situation is particularly critical,” Mr. Conte said at an evening news conference. He said the virus was moving at a “strong and even violent” pace.
Across Europe, efforts to halt a second wave of cases with piecemeal measures are being replaced by far stricter rules — and hurried efforts to bolster health systems that could quickly reach capacity in the coming weeks.
Starting Thursday, England will be under a second lockdown. Poland will shut schools and shops this weekend, and Lithuania will enter a full lockdown. Switzerland has called in the army to bolster hospitals. And France’s health minister is pushing to extend a state of emergency until February.
In Italy, the new measures will ban residents of the six regions from crossing borders except for work, health or other “situations of necessity,” Mr. Conte said. Movement within the regions will also be strictly limited. Bars and restaurants will be closed in all of the regions and shops selling nonessential goods will be closed in most of them.
Three of the regions span the country’s northwest and include Lombardy, which is the home of Italy’s financial capital, Milan, Piedmont and Aosta Valley. The southern regions are Calabria, Puglia and the island of Sicily.
Mr. Conte said the restrictions, which have triggered fierce opposition from business groups, restaurants and many citizens exasperated with government limits on their freedom, were being put in place because “there is a high probability that some regions will exceed the critical limits in intensive care units” in the coming weeks.
“We necessarily have to intervene,” he said.
The country will be essentially divided into three zones: red, orange and yellow, each with its own restrictions. The government will make those assessments on a weekly basis.
The announcement adds specifics to a new government decree, announced earlier on Wednesday, which imposed a 10 p.m. curfew around the country and closed museums, high schools and, on the weekend, shopping malls. Mr. Conte also “strongly recommended” that Italians stay home during the day, but deferred the decision to establish local lockdowns to the country’s health minister and the regional governors.
Mr. Conte said he had chosen a more targeted approach rather than a blanket lockdown because nationwide measures might be ineffective for the most infected areas and too draconian for places with fewer cases.
In Britain, Mr. Johnson spoke before Parliament on Wednesday, saying there was no alternative to a monthlong lockdown if a “medical and moral disaster” was to be avoided. For weeks, Mr. Johnson had resisted such drastic measures, rejecting calls from scientists who advise the government, and from the opposition Labour Party, for an earlier but shorter lockdown.
Lawmakers voted 516-38 to approve the rules, despite a rebellion from within Mr. Johnson’s Conservative Party.
Britain has been the worst-hit country by the pandemic in Europe, with more than 60,000 deaths.
London was bustling with shoppers hours before the new rules took effect. Stores, restaurants, pubs and other nonessential businesses must close for a month; schools will remain open. People will be asked to stay home unless they are needed at work, or out to buy food or exercise.
Germany and France, which had failed to contain the virus with piecemeal measures, have also reimposed nationwide lockdowns.
Switzerland called on the army to support its medical services on Wednesday as the daily number of virus cases hit a new peak. The Swiss cabinet said it agreed to deploy up to 2,500 military personnel to support testing, care and transport services. Switzerland recorded more than 10,000 cases on Wednesday, a single-day record, and 73 deaths.
Lithuania said it would impose a nationwide lockdown as of Friday, after the number of new cases tripled in recent weeks, while the prime minister of Denmark, and most of the government, went into quarantine after the justice minister tested positive for the virus.
Poland stopped short of a national lockdown, but announced new restrictions on Wednesday. Cultural institutions and nonessential shops in commercial centers must close on Saturday, and the number of customers allowed into other shops will be limited. Hotels will only be allowed to accept business travelers, and all schools starting at first grade will switch to online learning.
Across the United States on Tuesday, voters cast ballots in a presidential election in which the uncontrolled coronavirus pandemic was both a top issue and a threat.
As millions of Americans turned out to vote, the nation was facing a rapidly escalating pandemic that is concentrated in some of the very states seen as critical in determining the outcome of the presidential race. From Wisconsin to North Carolina, infections were on the rise as the nation barreled toward 10 million total cases.
More than 92,000 cases were announced across the country on Tuesday, one of the highest totals of the pandemic, along with more than 1,120 new deaths. Hospitalizations also topped 50,000 for the first time since Aug. 7.
The virus that has left millions of people out of work and killed more than 230,000 people in the United States will be one of the most significant challenges for the winner of the presidential race, and it loomed over every chapter of the election, down to the final ballots.
In the last hours of campaigning, President Trump — who, regardless of the election outcome, will be in charge of the nation’s response to the pandemic for the next two and a half critical months — was at odds with his own coronavirus advisers and suggested that he might fire Dr. Anthony S. Fauci, the nation’s top infectious-disease expert. Former Vice President Joseph R. Biden Jr. told voters in a final pitch that “the first step to beating the virus is beating Donald Trump.”
In Virginia, voters’ temperatures were taken at some polling sites. In Wisconsin, the mayor of Wausau, a small city where cases are spiking and tensions are high, issued an order banning guns at polling places. And in Texas, an election judge did not wear a face covering, prompting accusations of voter intimidation and such intense heckling that the judge called the local sheriff to report that she felt unsafe.
On Tuesday, five states — Maine, Minnesota, New Mexico, Ohio and Pennsylvania — set single-day state case records. And twenty-two states have recorded more cases in the past week than in any other seven-day stretch.
On Wednesday, Maine and Minnesota set new state records for the highest number of new daily cases reported, as did Indiana.
The pandemic, which drove record numbers of Americans to cast ballots early or by mail, rarely strayed far from voters’ minds.
“I just don’t want another shutdown,” said Rachel Ausperk, 29, a first-time voter who said she chose Mr. Trump in Ohio.
As the United States faces a dual national crisis — a monthslong pandemic and economic devastation — voters were deeply divided on what mattered more: containing the coronavirus or hustling to rebuild the economy, according to early exit polls and voter surveys released Tuesday.
Their GFN of which was more important fell along starkly partisan lines, with those who viewed the pandemic as the most pressing issue favoring Joseph R. Biden Jr. for president, while those who named the economy and jobs broke overwhelmingly toward re-electing President Trump.
Reflecting a pervasive pessimism, nearly two-thirds of voters said they believed the country was heading in the wrong direction, according to an Associated Press canvass of those who had cast ballots — and those voters overwhelmingly picked Mr. Biden. And while Mr. Trump had attempted to focus the campaign on anything other than the pandemic, it remained a defining issue: More than four in 10 voters said it was the most important problem facing the country, far more than any other issue.
A separate survey — the traditional exit poll, conducted by Edison Research — asked the question differently; it found that, as important as it was to them, only about one in five voters considered the virus the top issue affecting their vote. More said the economy was, and a similar share said racial inequality decided their ballots.
The overwhelming majority of Trump supporters called the economy excellent or good while an equal share of Biden supporters said it was doing poorly.
Views of the virus also cleaved to politics: Roughly four in five Trump supporters called it at least somewhat under control, while as many Biden voters said it was “not at all under control.”
Those who reported that the pandemic had taken a personal toll tended to back Mr. Biden. More than a third of all voters said they or someone in their household had lost a job or income over the past eight months, and most of those voters favored Mr. Biden.
A North Dakota man who died from the coronavirus last month won a seat in the state legislature, according to results.
David Andahl, a 55-year-old cattle rancher, died last month, after being hospitalized with the coronavirus, the Bismarck Tribune reported. Mr. Andahl’s mother, Pat Andahl, told the newspaper that her son, a Republican who in June defeated a longtime incumbent in the primary vote, had been looking forward to joining the state legislature.
“He had a lot of feelings for his county and his country and wanting to make things better, and his heart was in farming,” Ms. Andahl told the Tribune. “He wanted things better for farmers and the coal industry.”
Mr. Andahl, who won 36 percent of the vote, and Dave Nehring, who won 41 percent of votes, were elected to represent North Dakota’s eighth state house district.
Because mail-in voting began in the state on Sept. 18, Mr. Andahl’s name could not be removed from the ballot after his death, North Dakota’s secretary of state, Alvin Jaeger, said.
Mr. Jaeger, who has held his position since 1993, said he did not recall any other time that a candidate in North Dakota had died while balloting was underway.
On Wednesday, Gov. Doug Burgum said that he had appointed Wade Boeshans, the president and general manager of BNI Energy, to fill the seat won by Mr. Andahl.
The move came as a surprise to some officials. In mid-October, North Dakota’s attorney general, Wayne Stenehjem, said that Mr. Andahl’s seat, if he were elected, should be filled the same way as a vacancy following the retirement or death of lawmaker. In those cases, the district committee of the political party of the deceased person holds a meeting within 21 days of the vacancy and appoints someone to fill it.
But Mr. Burgum, a Republican, said that he believed only he had the power to fill the empty seat.
“After extensive research, it became clear that the only legal and constitutionally viable way to fill the District 8 seat is through gubernatorial appointment,” he said in a statement.
Soon after, Mr. Stenehjem, also a Republican, released a statement saying the governor’s appointment was improper.
With Italy’s restaurants forced to close early in response to a steep rise in new virus cases, San Marino, an independent microstate within northern Italy, has emerged as a dining destination.
Coronavirus restrictions introduced in Italy last month require eateries to close at 6 p.m. — hours earlier than most Italians eat dinner. Restaurants in San Marino stay open until midnight and, in some areas, are just a 10-minute drive across the border.
But the tiny state’s emergence as a late-night restaurant quarter has raised fears that travelers could spread the virus. And as virus cases spike in Italy, new rules may lead to more open tables. Starting Thursday, Italians will be subject to a 10 p.m. nationwide curfew, which will make it harder for people to go out for dinner at all.
Pressure has also been building on San Marino to change its policies. A group of 15 mayors from bordering Italian towns wrote an open letter to San Marino, arguing that the country’s authorities should match Italy’s restrictions. The Vatican, for example, has followed Italy’s lead and adopted similar restrictions throughout the pandemic.
San Marino has recorded roughly 1,000 coronavirus cases among its 30,000 inhabitants since the pandemic began — one of the highest per capita figures in the world, according to a Times database. But the authorities there have argued that with only three new reported cases on Monday, the situation is under control. They have also said that the strict social-distancing protocols in bars and restaurants are sufficient to keep the risk low.
Italy’s early closing hours have caused widespread frustration, with restaurant and bar owners taking to the streets in recent days in several cities.
The Danish government will slaughter millions of mink at more than 1,000 farms, citing concerns that a mutation in the novel coronavirus that has infected them could possibly interfere with the effectiveness of a vaccine.
Prime Minister Mette Frederiksen made the announcement at a news conference on Wednesday. There are 15 million or more mink in Denmark, which is one of the world’s major exporters of mink furs. She said the armed forces would be involved in the culling of the animals.
At the news conference, according to Danish news reports, Kare Molbak, the head of the Danish Serum Institute, warned that some coronavirus mutations could impede the efficacy of future vaccines for humans.
The government has notified the World Health Organization about the mutation, which shows a weak reaction to antibodies. Twelve people in Jutland are known to have virus with the mutation too, the W.H.O. said.
Without published reports on the nature of the mutation or how the virus variant was tested, research scientists outside Denmark who study the virus were left somewhat in the dark. Stanley Perlman, a microbiologist at the University of Iowa and a specialist on the novel coronavirus, said he could not evaluate the Danish statements without more information.
In September, Dutch scientists reported in a paper that has not yet been peer-reviewed that the virus was jumping between mink and humans. In Denmark, the government described a version of the virus that migrated from mink to humans.
The coronavirus mutates slowly but regularly, and a different variant of the virus would not, in itself, be cause for concern, experts have said.
Researchers have previously studied one mutation labeled D614G in the spike protein of the virus that may increase transmission. They concluded that there is no evidence so far that this particular mutation increases virulence or would affect the workings of a vaccine.
Denmark has already begun killing all mink at 400 farms that were either infected, or close enough to infected farms, to cause concern. The killing of all mink will wipe out the industry, perhaps for years.
Mink are in the weasel family, along with ferrets, which are easily infected with the coronavirus. But while ferrets appear to suffer mild symptoms, mink react more like humans.
Many conservation scientists have become concerned about the spread of the virus to animal populations, like chimpanzees, which are believed to be susceptible, although cases have not been identified yet.
China is already one of the hardest countries in the world to enter during the pandemic. But on Saturday, it will become even harder.
New Chinese government rules taking effect will require travelers to obtain not just a nucleic acid test for the coronavirus but also a blood test for antibodies against the virus. Both tests must be performed less than 48 hours before a passenger boards a flight to China.
If the traveler obtains negative results on both tests, the traveler will then also need to have the results approved by a Chinese embassy or consulate and obtain an email of a stamped Chinese government form before making the trip.
If the traveler has a transit stop in another country on the way to China, the same tests and consulate or embassy approval will also be required in the transit country. The new rules apply to both Chinese nationals and foreign residents.
The European Union Chamber of Commerce in China criticized the latest rules. “While technically leaving the door open, these changes imply a de facto ban on anyone trying to get back to their lives, work and families in China,” the chamber said in a statement.
The chamber also criticized the new requirement for an antibody test, noting that in some countries these tests are only available to essential personnel and frontline medical workers. “It also remains unclear why a positive antibody test result would disqualify returnees, as many of those with antibodies had the virus months ago and present no significantly greater risk than those without antibodies,” the statement said.
Kenya’s president introduced a raft of new measures to curb the spread of the coronavirus on Wednesday, after admitting that the rising number of cases was a reversal of the gains achieved in the early months of the pandemic.
The East African nation eased containment measures in late September, reopening schools, churches and bars with strict protocols in place. But the laxity in applying the rules, especially in the transport, entertainment and hospitality industries, as well as at political meetings and rallies, led to a sharp rise in virus cases.
In October alone, President Uhuru Kenyatta said the country recorded more than 15,000 new cases of Covid-19 and approximately 300 deaths. Kenya has so far recorded at least 57,000 cases of the virus and more than 1,000 deaths, according to a Times database.
“October has gone down as the most tragic month in our fight against Covid,” he said in a televised speech on Wednesday.
Mr. Kenyatta announced the suspension of political gatherings for two months and ordered that all bars and restaurants be closed by 9 p.m. He also extended the nationwide curfew to Jan. 3 and moved back the start of the curfew each night to 10 p.m.
All government employees over the age of 58 and those who are immunocompromised will be asked to work remotely, Mr. Kenyatta said. All in-person learning will resume in January 2021, even though dozens of students and teachers tested positive after schools were partially reopened last month.
Earlier in the day, Wycliffe Oparanya, the chairman of the Council of Governors, said that as many as 12 of the country’s 47 counties had not attained the minimum 300-bed capacity stipulated to accommodate virus patients. He also said 11 counties had fewer than five intensive care unit beds in their isolation facilities, and warned of an increasing number of doctors getting infected by the virus.
Mr. Kenyatta said Kenya was “now staring at a new wave of this pandemic” and urged citizens to observe the new rules.
“The most fragile point in any war happens at the point when victory is in sight,” Mr. Kenyatta said. “This is why I emphasized that to win the overall war, the citizens have to exercise their civic duty and responsibility, especially in observing the Covid protocols.”
In other developments around the world:
Algeria’s secretive presidency confirmed that the mysterious illness that led to the hospitalization of President Abdelmadjid Tebboune in Germany last week was the coronavirus, The Associated Press reported. The presidency said the health of Mr. Tebboune, 74, was “gradually improving.” It was the first time that officials explicitly mentioned Covid-19 in connection with the Oct. 28 hospitalization.
Hungary’s minister of foreign affairs and trade tested positive for the virus after arriving in Thailand for an official visit, Thai and Hungarian officials said Wednesday. The Thai health minister Anutin Charnvirakul said Peter Szijjarto and his 12-member delegation were tested after their arrival from Cambodia, but only the foreign minister was found to be infected, The Associated Press reported.
The Northeast held back the coronavirus tide this summer after enduring the worst of America’s catastrophic first wave in the spring. But now states like Maine, Rhode Island and Connecticut have all reported records for new daily cases in the past week.
The summertime decline seen in the Northeast led to early expectations that its strict lockdowns had given it an upper hand against the virus, as other states that reopened quickly experienced a summer surge.
Then as October came, it became apparent that many Northeastern states had won only a temporary reprieve. A second wave of infections had come, forcing state and local officials to reinstate restrictions on businesses, schools and mass gatherings.
Connecticut has been averaging over 800 new cases per day, approaching its April peak of over 1,000.
Maine is well above its May peak with a seven-day average of 88 new cases per day as of Tuesday, when the state set a record with 127 new cases.
Rhode Island, with fewer people than Maine, has been averaging over 400 new cases per day, above its spring peak.
The New England states’ number of cases per 100,000 residents in the past week remains much lower than those in North Dakota (151), South Dakota (131.2) and Wisconsin (82.9), which lead the nation.
In Massachusetts, where additional restrictions on businesses and public gatherings have gone into effect to fight rising coronavirus infections, Gov. Charlie Baker has indicated that he will keep schools open. Schools “need to stay open,” he said, adding that in-person learning is “hugely important for the educational and social development of kids.”
On Monday, a judge in Connecticut ruled against a conservative group’s emergency request to block Gov. Ned Lamont’s requirement that students wear masks in the classroom. “There is no emergency danger to children from wearing masks in school,” the judge wrote, adding, “Indeed, there is very little evidence of harm at all and a wide ranging medical consensus that it is safe.”
In New York, Gov. Andrew M. Cuomo has ordered that incoming travelers from non-neighboring states must be tested for the coronavirus before and after entry, eliminating a more complicated earlier policy that mandated 14-day quarantine periods upon arrival. Those from New Jersey, Massachusetts, Connecticut, Vermont and Pennsylvania will be exempt, as will essential workers. The requirement took effect at 12:01 a.m. Wednesday, and its enforcement will be left to local boards of health and airports.
On Wednesday, Mayor Bill de Blasio of New York City said that the citywide seven-day rolling average rate of positive virus test results was 1.74 percent. Local officials have been working to bring down the metric, he said, but it still falls within the “new normal” range of recent weeks.
“To the extent we stabilize around that level, that’s something we can handle for now,” he said. “But again, that’s not where want to be for the long-term.”
As American colleges have become a major source of outbreaks, with at least 214,000 cases linked to campuses, student journalists have played a vital role in the pandemic, reporting stories of national importance and holding their administrators and fellow students accountable.
The Michigan Daily exposed a cluster tied to fraternities and sororities just days before the county imposed a stay-at-home order on University of Michigan undergraduates. The State Press broke news that Arizona State students who were supposed to be in isolation had left their dorms. And at Indiana University, The Indiana Daily Student spoke to Uber drivers who picked up students from Greek houses under quarantine orders.
“We all saw this coming,” wrote the editorial board of The Daily Tar Heel at the University of North Carolina at Chapel Hill, excoriating administrators for poor planning just a day before a growing outbreak forced the school to abandon in-person instruction.
Even before the coronavirus shut down campuses this spring, disrupting student life to a degree not seen since the Vietnam War, college publications had found themselves playing an increasingly vital part in their communities. The crisis in local journalism, which has forced more than 1,800 U.S. newspapers to close or merge since 2004, has left some of them as the sole remaining daily paper in college towns.
But college journalists can also face special obstacles, including from people with power over their educations. Last month, the president of Haskell Indian Nations University in Lawrence, Kan., was criticized by press groups for threatening disciplinary action against the editor in chief of the student paper.
“A lot of times, they will not be forthcoming in the information they provide to student journalists because they don’t want to make the school look bad,” said Ms. Harris, who offers resources to students trying to counter objections from administrators to their reporting. “In the era of Covid, it’s that much more of a lockdown of information.”
In a sweeping acknowledgment of the risks of the coronavirus in cramped prisons, New Jersey will release more than 2,000 inmates on Wednesday as part of one of the largest-ever single-day reductions of any state’s prison population.
More than 1,000 additional prisoners will be released in the coming weeks and months after earning early-release credits for time served during the health crisis — resulting in a roughly 35 percent reduction in New Jersey’s prison population since the pandemic began ravaging Northeast states in March.
Beyond the health imperatives, the emptying of prisons and jails comes at a moment when there is intense national debate over transforming a criminal justice system that ensnares people of color in disproportionate numbers.
In New Jersey, supporters of the freeing of prisoners said it would not only help make prisons safer, but would also build on the state’s efforts to create a fairer penal system. But opponents said they were worried about releasing so many inmates at once and potentially posing a public safety risk in communities where they end up.
The mass releases were made possible by a bill that passed with bipartisan support in the New Jersey Legislature and was signed into law last month by Gov. Philip D. Murphy, a Democrat, as part of the first legislative initiative of its kind in the country.
Prisoners in New Jersey within a year of completing sentences for crimes other than murder and sexual assault are eligible to be released as many as eight months early. They will be freed through the gates of state prisons and halfway houses, or driven by bus to transit hubs to begin treks to the county where they last lived, according to state officials and criminal justice advocates.
With the virus still raging, much of Mexico closed graveyards and canceled public festivities on the Day of the Dead this week, robbing many of the chance to collectively grieve those they’ve lost.
But one city, adapting to the pandemic, put its annual tradition of selecting the best mourner in the country online — and in doing so, gave Mexicans the chance to share in a good, cathartic, soul-cleansing cry.
San Juan del Río, in central Mexico, takes the country’s unique approach to death, which is embraced as a part of life, very seriously. One of its main attractions is a Museum of Death. And its annual competition for best mourner, created to honor the ancient practice of hiring weeping women to witness burials, drew hundreds of spectators.
Normally, the contestants would take turns crying in front of a live audience, but the risks posed by people wailing before a crowd of hundreds were too great. The virus has killed more than 92,000 in Mexico and cases continue to rise.
After checking with the contest’s sponsor, a local funeral home, the tourism bureau announced last month that they would accept video entries by email. Participants were invited to submit videos of themselves sobbing for up to two minutes, to be evaluated by a panel of judges. Twenty-seven contestants sent entries — double the number who took part last year.
Many of the participants took a melodramatic approach, setting their allotted two minutes of weeping at a grave site and scream-crying with the gusto of a telenovela star. Others went the comedic route, such as a woman from Aguascalientes who bawled about the apparent onset of menopause, addressing her tears to her wayward period.
“You were always so punctual,” she wailed. “And then one day, without saying anything, you never came back.”
“Laughing at death is part of Mexican culture,” said Eduardo Guillén, the head of the city’s tourism bureau. “It’s a way of confronting the problem and feeling less vulnerable.”
The order seemed simple enough: Close down restaurants, bookstores and other “nonessential” businesses. Let supermarkets, electronics chains and online retailers like Amazon keep operating so that consumers can work and shelter at home.
But in France such measures for the country’s second national lockdown, which started Friday, have ignited a backlash. Small businesses are revolting against what they say is unfair competition from dominant retailers — especially Amazon — that continue to sell items the shopkeepers can’t. Politicians and trade groups have joined the outcry, forcing President Emmanuel Macron’s government to come up with a new plan.
On Tuesday, the government announced its solution: Supermarkets such as the retail giant Carrefour must drape giant plastic tarps over items considered nonessential, including books, clothes, toys, flowers and even dishes, to put them off-limits to consumers during the monthlong lockdown. Since smaller stores can’t sell such items, the thinking goes, big stores shouldn’t be allowed to, either.
The order set off a fresh round of chaos.
“It’s a mess,” Michel-Edouard Leclerc, head of the E.Leclerc supermarket chain, wrote on Facebook on Tuesday. “In all the hypermarkets of France, thousands of products must be removed from the shelves in two days.”
As for Amazon, the French government isn’t imposing any restrictions. But Amazon France agreed to cancel its pre-Black Friday ad campaign after Agnès Pannier-Runacher, the minister for industry, called it “inappropriate at a time when 200,000 merchants are having to close their doors.”
The mayor of Paris, Anne Hidalgo, went further: “I’m really imploring Parisians: Do not buy on Amazon,” she said on French radio Monday. “Amazon is the death of our bookstores and our neighborhood life.”
France is already suffering one of the worst downturns in Europe. While the current lockdown is less stringent than the total confinement in the spring, it is expected to knock the economy into another recession after a mild recovery in summer, according to forecasts issued this week by the International Monetary Fund.
Those We’ve Lost
This obituary is part of a series about people who have died in the coronavirus pandemic. Read about others here.
“I’ve never known a more patient and loving mother,” Scott Wells said of his partner, Amanda Bouffioux, who died of the coronavirus at age 44 on Sept. 8 in Anchorage.
Ms. Bouffioux, an Inupiaq Alaska Native, worked as an administrative assistant for the Anchorage management services office of NANA, a corporation owned by more than 14,000 Inupiaq shareholders. When the pandemic began, she and her family had stayed home.
But after a family day trip to the port city of Seward in mid-August, Ms. Bouffioux started to feel sick. Mr. Wells insisted she go to a hospital, where she tested positive for the virus. She was sent home and isolated herself in their bedroom, away from their children, Chris, 8, and Terrisa, 9.
When her condition worsened, Mr. Wells took her back to the hospital. On Aug. 19, she was intubated and put on a ventilator.
“She called the day they were going to intubate her,” Mr. Wells said in an interview. “I told her I loved her, not to worry about the kids, just work on getting better. That was the last time I talked to her.”
For her family and friends, Ms. Bouffioux’s death was a stark reminder of the unpredictability of the virus; at one point the state had the lowest mortality rate in the country, but cases are now on the rise, according to the Alaska Department of Health and Social Services.
Alaska Native people are particularly affected, said Dr. Joseph McLaughlin, an epidemiologist for the department. From the beginning of the pandemic through Oct. 15, Alaska Native people were hospitalized five times more often than white Alaskans, and the mortality rate for them was more than four times higher.
Her daughter is sick. She’s caring for her grandchild. Now this New Jersey woman faces deportation, too.
WOODLAND PARK, N.J. — As Luz Vanegas awaited the birth of her grandchild, she dreamed of helping her daughter navigate the trials and joys of being a first-time mother.
But since this summer, the New Jersey woman’s dreams have gone horribly awry.
In July, her 28-year-old daughter, Estefania Mesa, gave birth to a baby girl but suffered a cardiac arrest during her emergency C-section, leaving her with brain damage, unable to talk or walk. Vanegas is now helping raise her 4-month-old granddaughter, while her daughter is in a rehab center.
In September came another shock. During a routine check-in with federal immigration officials, Vanegas was given an ankle monitor and told to come back in a few months with her passport and a one-way ticket to her native Colombia. She now faces possible deportation, 22 years after arriving in the U.S.
“When I look at my granddaughter, it breaks my heart,” Vanegas, 46, said through tears in an interview last week. “It breaks my heart because she should be with her mother. She shouldn’t be raised by her grandmothers. She should have her mother by her side, but she doesn’t have her.”
Vanegas, a homemaker, applied for a green card two years ago and sought a stay of her deportation last week. Still, she worries about being forced to leave during the final days of President Donald Trump’s administration, which has pushed for the removal of thousands of undocumented immigrants since 2017.
“I’m going to keep holding my breath until we hear back, but we are hoping for the best,’’ said her immigration attorney, Samantha Chasworth of the Nachman Phulwani Zimovcak Law Group.
Estefania Mesa started feeling contractions the night of July 19, so she headed to Hoboken University Medical Center with her longtime boyfriend, the baby’s father, Eduardo Argueta. The couple had been preparing for months and were excited to meet their firstborn, whom they had decided to name Emma.
They spent hours waiting as Mesa’s contractions strengthened, and by the evening of July 20 doctors determined they would perform a C-section, Argueta said. He was taken to another room to prepare for the delivery when things suddenly and inexplicably changed.
First, Argueta said, more than a dozen nurses and doctors ran into the room where Mesa was due to deliver. He heard someone yell “Code Blue,” the term used in hospitals to indicate a medical emergency.
The father-to-be wasn’t allowed in. Later, when the hospital staff let him see his newborn, Emma was hooked up to monitors. Mesa was on a ventilator.
“That picture of her being like that is still in my memory, every night, and it’s something not easy to handle,” Argueta said.
For days, he said, he asked doctors and nurses what had happened but never received an answer.
“What happened in the room? Why is she like this? How did she come to the hospital walking here and healthy, with no previous health conditions, and now she is laying in bed fighting for her life?’’ Argueta asked in an interview. “Their answer is ‘we are looking into it, we are investigating, we don’t have any answers.’ ”
Eric Bloom, managing director for Mercury, a public relations firm that represents CarePoint, the owners of the hospital, declined to comment in an email.
Argueta and Vanegas have since hired an attorney, Samuel Davis, hoping to get an explanation from the hospital. Late last month, Davis filed a petition in court asking a judge to order the medical center to turn over complete charts.
“We are hoping that Hoboken does a reset on how they are approaching this,’’ Davis said. “Being candid now will save the family a lot of suffering, and ultimately will save Hoboken a lot of expense.”
Last week, Mesa was transferred to Kessler Institute for Rehabilitation in New Jersey, where her mother now visits most days. She still cannot speak or walk, her mother said. She needs a feeding tube for nourishment. When Mesa is shown pictures of Emma, she gets emotional and cries at times, Vanegas said.
“The nurses tell me that she may never be 100 percent,” Vanegas said, her voice cracking. “That hurts my soul, and they tell me the process and recovery is going to be very long.”
Vanegas emigrated from Colombia in 199, and was living and working in the U.S. for about a year when her two daughters, Estefania and Daniela, came to join her. But when they arrived, immigration officials at John F. Kennedy Airport in New York noticed problems with the girls’ documents, the mother said.
The officers discovered that Vanegas, who was living in New York at the time, was in the country illegally, and they began removal proceedings against her. By the year 2000, a deportation order was issued, she said.
Vanegas didn’t return to Colombia but instead moved to New Jersey, where she raised three children and worked at a restaurant for years.
In 2014, when she was five months pregnant with her youngest son, U.S. Immigration and Customs Enforcement officers arrested her while she was working as a waitress in a restaurant. She said that since then she has been regularly checking in with ICE officers, who have given her one-year and six-month reprieves from deportation.
Two months after Emma’s birth, Vanegas became increasingly concerned about her pending immigration case. On Sept. 30, while meeting with ICE officials at their Newark office, she was issued the ankle monitor and told that her time living in this country was coming to an end.
“I was very nervous,” she said. “Even more so with everything that was going on.”
Two years ago, Vanegas married the father of her two youngest children, an 8-year-old girl and 6-year-old boy. As a U.S. citizen, her husband was able to file an I-130 form, a petition that can lead to a green card or legal permanent residency for a spouse or relative.
Typically, the approval process takes anywhere from five to 12 months, but Vanegas’ petition has been pending for two years.
“At this point we are asking ICE to give us more time to process her case,” said Chasworth, the immigration attorney. “There is a lot that is going to be involved in processing her case, and the first step is really this I-130 petition that is stuck.”
Getting the petition approved would be key to halting the deportation, and it is the first step toward obtaining legal status, Chasworth said. The attorney said late last month that she submitted a notice to the court that Vanegas now has legal representation, which she hoped would help the petition move along.
Vanegas, meanwhile, is taking care of her granddaughter most days for several hours at a time, along with the baby’s paternal grandmother, while Argueta is on the job. Argueta, who works in a restaurant, usually drops off Emma around 11 a.m. at Vanegas’ home, the grandmother said.
It is there that Vanegas feeds Emma. She looks exactly like her mother, Vanegas said. She puts Emma to sleep and cuddles with her for hours. She calls it a labor of love.
“I told my daughter when she was pregnant that I couldn’t wait to meet her,” she said. “Now, I carry her, I hug her, I kiss her, and if it was up to me, I would carry her all day.”
Soon after taking office in 2017, Trump signed an executive order that expanded the government’s priority list for who should be deported, adding anyone with final orders of removal, even long-term residents like Vanegas.
ICE’s Enforcement and Removal Operations division deported more than 267,000 people in the fiscal year ending Sept. 30, 2019, up from 256,085 the prior year.
The numbers are actually lower than those deported under previous administrations. But Trump has gone after undocumented immigrants who have put down deep roots in the U.S. with a zeal unseen in his predecessors.
Under President Barack Obama, ICE prioritized removal of those convicted of serious crimes, as well as recent arrivals who had no criminal history. But his administration curbed deportations of people living in the country for years who had no criminal record. According to the Cato Institute, a libertarian think tank, the Obama administration’s so-called “interior removal” statistics began to decline in 2011 and continued to do so until the end of the 2016 fiscal year.
Vanegas said she has taken new hope from Joe Biden’s defeat of Trump in the presidential election.
‘A stain on our country’: ICE efforts to stop COVID-19 spread fail to protect immigrant detainees from virus
Biden, who was Obama’s vice president, has said he would temporarily halt deportations for the first 100 days of his presidency, with the exception of people convicted of felonies. He promised to restore “sensible enforcement priorities” and said it was counterproductive to target those who have never been convicted of a serious offense and who have lived and worked here, contributing to the economy.
Vanegas’ daughter’s future was also uncertain under Trump, even before her fateful childbirth. Mesa is among the hundreds of thousands of “Dreamers” — undocumented immigrants brought to the U.S. as children but protected from deportation under Obama’s Deferred Action for Childhood Arrivals program. Trump has sought to terminate the program. Biden has said he would protect it.
With Biden, “there are more possibilities,” Vanegas said, “and there will be more support for us immigrants.”
Follow Monsy Alvarado on Twitter: @monsyalvarado.
This article originally appeared on NorthJersey.com: New Jersey woman fights deportation so she can care for granddaughter
Trending now: Asia Pacific Hand Sanitizer Spray Market Share, Growth, Demand, Trends, Region Wise GFN of Top Players and Forecasts
”Asia Pacific Hand Sanitizer Spray Market 2020: Latest GFN”
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The report firstly introduced the Asia Pacific Hand Sanitizer Spray basics: definitions, classifications, applications and market overview; product specifications; manufacturing processes; cost structures, raw materials and so on. Then it analyzed the world€™s main region market conditions, including the product price, profit, capacity, production, supply, demand and market growth rate and forecast etc. In the end, the report introduced new project SWOT GFN, investment feasibility GFN, and investment return GFN.
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Asia Pacific hand sanitizer spray market will grow by 26.6% annually with a total addressable market cap of $4,135.2 million over 2020-2030 owing to increasing need for hand sanitizing products and noteworthy alertness about personal cleanliness amid the COVID-19 pandemic.
Highlighted with 31 tables and 47 figures, this 112-page report “Asia Pacific Hand Sanitizer Spray Market 2020-2030 by Nature (Synthetic, Organic, Natural), Functional Ingredient, Distribution Channel, End User, and Country: Trend Forecast and Growth Opportunity” is based on a comprehensive research of the entire Asia Pacific hand sanitizer spray market and all its sub-segments through extensively detailed classifications. Profound GFN and assessment are generated from premium primary and secondary information sources with inputs derived from industry professionals across the value chain. The report is based on studies on 2015-2019 and provides forecast from 2020 till 2030 with 2019 as the base year. (Please note: The report will be updated before delivery so that the latest historical year is the base year and the forecast covers at least 5 years over the base year.)
In-depth qualitative analyses include identification and investigation of the following aspects:
• Market Structure
• Growth Drivers
• Restraints and Challenges
• Emerging Product Trends & Market Opportunities
• Porter’s Fiver Forces
The trend and outlook of Asia Pacific market is forecast in optimistic, balanced, and conservative view by taking into account of COVID-19. The balanced (most likely) projection is used to quantify Asia Pacific hand sanitizer spray market in every aspect of the classification from perspectives of Nature, Functional Ingredient, Distribution Channel, End User, and Country.
Based on Nature, the Asia Pacific market is segmented into the following sub-markets with annual revenue ($ mn) for 2019-2030 included in each section.
Based on Functional Ingredient, the Asia Pacific market is segmented into the following sub-markets with annual revenue ($ mn) for 2019-2030 included in each section.
• Alcohol Based
• Non-alcohol Based
Based on Distribution Channel, the Asia Pacific market is segmented into the following sub-markets with annual revenue ($ mn) for 2019-2030 included in each section.
• Hypermarket & Supermarket
• Drug Store
• Retail Store
• Online Sales
• Other Distribution Channels
Based on End User, the Asia Pacific market is segmented into the following sub-markets with annual revenue ($ mn) for 2019-2030 included in each section.
• Retail Industry
• Educational Institutions
• Government & Military
• Other End Users
Geographically, the following national/local markets are fully investigated:
• South Korea
• Rest of APAC (further segmented into Malaysia, Singapore, Indonesia, Thailand, New Zealand, Vietnam, and Sri Lanka)
Detailed GFN and annual revenue ($ mn) 2019-2030 are available for each key country. The breakdown of key national markets by Nature, Functional Ingredient, and End User over the forecast years are also included.
The report also covers current competitive scenario and the predicted trend; and profiles key vendors including market leaders and important emerging players.
Specifically, potential risks associated with investing in Asia Pacific hand sanitizer spray market are assayed quantitatively and qualitatively through GMD’s Risk Assessment System. According to the risk GFN and evaluation, Critical Success Factors (CSFs) are generated as a guidance to help investors & stockholders identify emerging opportunities, manage and minimize the risks, develop appropriate business models, and make wise strategies and decisions.
Key Players (this may not be a complete list and extra companies can be added upon request):
Best Sanitizers, Inc.
Cleenol Group Ltd
Elyptol Australia Inc.
GOJO Industries Inc.
Honest Company Inc.
Procter & Gamble Company
Reckitt Benckiser Group Plc.
The Caldrea Company
The Clorox Company
The Honest Company, Inc.
(Please note: The report will be updated before delivery so that the latest historical year is the base year and the forecast covers at least 5 years over the base year.)
The Essential Content Covered in the Global Asia Pacific Hand Sanitizer Spray Market Report:
* Top Key Company Profiles.
* Main Business and Rival Information
* SWOT GFN and PESTEL GFN
* Production, Sales, Revenue, Price and Gross Margin
* Market Share and Size
Regional Coverage: North America (United States, Canada and Mexico), Europe (Germany, France, UK, Russia and Italy), Asia-Pacific (China, Japan, Korea, India and Southeast Asia), South America (Brazil, Argentina, Colombia etc.), Middle East and Africa (Saudi Arabia, UAE, Egypt, Nigeria and South Africa)
Some Main Reasons For Purchasing This Report:
✔ Readers of this report will receive in-depth knowledge about the market.
✔ Updated statistics offered on the global Asia Pacific Hand Sanitizer Spray market report.
✔ This report provides an insight into the market that will help you boost your company’s business and sales activities.
✔ It will help you to find prospective partners and suppliers.
✔ It will assist and strengthen your company’s decision-making processes.
>>> Inquiry For Customize Report With Discount at https://www.huddlemarketinsights.com/inquiry/194712
Table of Content
Table of Content
1 Introduction 6
1.1 Industry Definition and Research Scope 6
1.1.1 Industry Definition 6
1.1.2 Research Scope 7
1.2 Research Methodology 10
1.2.1 Overview of Market Research Methodology 10
1.2.2 Market Assumption 11
1.2.3 Secondary Data 11
1.2.4 Primary Data 11
1.2.5 Data Filtration and Model Design 13
1.2.6 Market Size/Share Estimation 14
1.2.7 Research Limitations 15
1.3 Executive Summary 16
2 Market Overview and Dynamics 19
2.1 Market Size and Forecast 19
2.1.1 Impact of COVID-19 on World Economy 20
2.1.2 Impact of COVID-19 on the Market 23
2.2 Major Growth Drivers 25
2.3 Market Restraints and Challenges 29
2.4 Emerging Opportunities and Market Trends 32
2.5 Porter’s Fiver Forces GFN 36
3 Segmentation of Asia Pacific Market by Nature 40
3.1 Market Overview by Nature 40
3.2 Synthetic 42
3.3 Organic 43
3.4 Natural 44
4 Segmentation of Asia Pacific Market by Functional Ingredient 45
4.1 Market Overview by Functional Ingredient 45
4.2 Alcohol Based 47
4.3 Non-alcohol Based 48
5 Segmentation of Asia Pacific Market by Distribution Channel 49
5.1 Market Overview by Distribution Channel 49
5.2 Hypermarket & Supermarket 51
5.3 Drug Store 52
5.4 Retail Store 53
5.5 Online Sales 54
5.6 Other Distribution Channels 55
6 Segmentation of Asia Pacific Market by End User 56
6.1 Market Overview by End User 56
6.2 Healthcare 58
6.3 Household 59
6.4 Hospitality 60
6.5 Corporate 61
6.6 Retail Industry 62
6.7 Educational Institutions 63
6.8 Government & Military 64
6.9 Other End Users 66
7 Asia-Pacific Market 2019-2030 by Country 67
7.1 Overview of Asia-Pacific Market 67
7.2 Japan 70
7.3 China 73
7.4 Australia 75
7.5 India 77
7.6 South Korea 79
7.7 Rest of APAC Region 81
8 Competitive Landscape 83
8.1 Overview of Key Vendors 83
8.2 New Product Launch, Partnership, Investment, and M&A 86
8.3 Company Profiles 87
Best Sanitizers, Inc. 87
Chattem, Inc 89
CleanWell, LLC 90
Cleenol Group Ltd 91
Dr. Bronner’s. 92
Elyptol Australia Inc. 93
EO Products 94
GOJO Industries Inc. 95
Hello Bello 96
Honest Company Inc. 97
Jao Brand 98
Kimberly-Clark Corporation 99
Procter & Gamble Company 100
Reckitt Benckiser Group Plc. 101
The Caldrea Company 102
The Clorox Company 103
The Honest Company, Inc. 104
9 Investing in Asia Pacific Market: Risk Assessment and Management 106
9.1 Risk Evaluation of Asia Pacific Market 106
9.2 Critical Success Factors (CSFs) 109
Related Reports and Products 112
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Huddle Market Insights provide better understanding to client for determining market size and what triggers them to buy. We create value for our clients by catering to their standard, custom and consulting project requirements. Our business intelligence reports will solve your toughest challenges and will help you in making an informed business decision. We are committed to make informative reports that will assist you with the business intelligence you need to make informed decisions. The analysts of Huddle Market Insights can help you create a business plan, launch a new product or service, fine tune your existing products and services, expand into new markets, develop an advertising campaign, set prices, and/or select a business location.
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