On April 15, the Department of Justice announced that it had reached a $41 million settlement with two Florida healthcare providers—a lab and a pain relief center, both subsidiaries of Surgery Partners—and two of its former executives over fraudulent billing claims because for half a decade patients suffered unnecessary urine drug tests solely for the purpose of getting reimbursements under Medicare and Medicaid.

However, on April 10, five days before that settlement was announced, another arm of the Trump Administration, the Department of Health and Human Services, gave Surgery Partners roughly $45 million total from the CARES bailout, per its filings with the Security and Exchange Commission.

The $41 million that Surgery Partners’ subsidiaries paid on April 15 to settle serious federal fraud allegations had been essentially erased the week earlier—all with taxpayer dollars.

“You have the federal government on the one hand accusing a company of cheating the government and then you have, [on] the other hand the government giving money to that same company,” says Philip Mattera, Research Director at Good Jobs First, a non-profit organization tracking recipients of CARES funds. “At the very least, it’s unseemly.”

It’s also not uncommon. Good Jobs First found dozens of health care providers and nursing homes that received bailout funds under the CARES Act after reaching settlements on federal fraud allegations within the last decade—some worth hundreds of millions of dollars.

William M. McSwain, U.S. Attorney for the Eastern District of Pennsylvania, called the allegations “the type of conduct that must be rooted out of our health-care system.” But even as the settlement was made public, HHS was propping up those same companies with taxpayor funds.

Nursing homes need to be a priority when personal protective equipment (PPE) is being distributed, and these facilities also need to be required to have a nurse on staff 24 hours a day.

“It’s absolutely critical to have registered nurses 24 hours a day in nursing homes,” said Toby Edelman, senior policy attorney at the Center for Medicare Advocacy, in Washington. “Right now, the only federal requirement is a registered nurse for 8 consecutive hours a day, but people get sick in the middle of the night.” Without a nurse on duty for nursing home workers to consult, “we’re not going to get good care for people,” she said. “It is way past time to have nurses in nursing homes.”

“The federal government, whose prompt response was so desperately needed, failed to surmount the challenge and make PPE a priority for nursing homes,” said Michael Wasserman, MD, a geriatrician and president of the California Association of Long Term Care Medicine. The nursing home industry “had the ability to leverage their assets to acquire PPE, but many chose to wait for a government response which didn’t happen … As a clinician, I don’t care who takes responsibility for the acquisition of PPE, but without PPE, COVID-19 cannot be stopped.”

Wasserman and Edelman were speaking at a roundtable hosted by the House Democratic Caucus Task Force on Aging and Families. Task force members also heard from Chris Brown, a certified nursing assistant working at a nursing home. “I find the work to be very rewarding but to be truthful, I face many challenges on the job, and many of these challenges existed before COVID-19,” said Brown.  Brown said nursing home workers are being paid “poverty wages” and often don’t get sick leave. “If I become sick, how can I take care of somebody? And who will take care of me? I have to choose between having the lights on and protecting my health.”

Wasserman worried about nursing homes allegedly dumping vulnerable residents in order to make room for more profitable COVID-19 patients. “I was worried that this type of behavior could and would occur, so when the story came out, it didn’t surprise me,” he said. “The bad apples highlight a couple of fundamental problems in the industry …. Surveyors can only do so much after the fact; we need to work to prevent this type of behavior” from occurring in the first place.

In addition, “medical directors have been kept out of medical management and decision making. We need to make sure the medical director is fully engaged,” said Wasserman. They’re critically important because “unless you have clinical leadership in the building calling this out, the facilities manage to come up with reasons and excuses for why they’re doing it. We need to be calling it out and recognizing that staff and facilities are under tremendous financial pressure and that drives a lot of this type of behavior.”

A striking bipartisan consensus arose in the Senate Judiciary Committee last month on the fact that the Trump administration hasn’t done its part to assure businesses and schools on how they can open responsibly, leaving many unsure how to proceed and worried about the consequences if they get it wrong.

The committee focused primarily on the question of whether to give businesses immunity from lawsuits over COVID-19. That wouldn’t be a good idea. But luckily, the hearing unearthed the real remedy to reassure businesses that it’s safe to reopen: giving them clear federal rules that will protect both well-meaning business owners and the ability to hold bad actors accountable.

David Vladeck, a law professor at Georgetown University who once headed the Bureau of Consumer Protection in the Federal Trade Commission, testified to the Judiciary Committee that companies generally are not vulnerable to negligence lawsuits if they can show they reasonably followed government safety regulations. As a result, he said, “the best way to reduce liability is for agencies to step up and issue guidelines.”

Lindsey Graham, the South Carolina Republican who chairs the Senate Judiciary Committee, asked every witness in Tuesday’s hearing — a group that included advocates for business, labor, and academia — whether “the country would be better off” if OSHA issued industry-specific guidelines about how businesses should protect workers and customers. The witnesses all said yes. (The labor representatives added, however, that it also mattered whether anyone would enforce those rules.)

Given how easy it is to transmit the coronavirus, it would be hard for plaintiffs to definitively establish where they or a deceased family member caught COVID-19, let alone that it resulted from a business’s negligence. Even if someone wanted to try to make such a claim, many lawsuits would be blocked either by state laws that route injury complaints through the workers’ compensation insurance system or by employment agreements that require workers to go to arbitration rather than the courts.

It would be terrible for Congress to reduce the threat of lawsuits for employers in egregious situations. The prospect of being sued for negligence helps to hold companies accountable for public-health and safety regulations that the government can’t enforce through inspections alone.

The Trump administration has refused or declined to institute a comprehensive national framework for responding to COVID-19 including buying and disseminating virus tests.  Dr. Anthony Fauci, the nation’s top infectious disease expert, again expressed alarm at the increasing rate of infections after the country continues to discover more than 50,000 new cases per day.  Fauci warned that the country was still “knee-deep in the first wave” of the pandemic, as U.S. deaths passed 130,000 and cases neared three million.

As the United States passes three million cases, most cities and states are still struggling with testing. Sites in New Orleans have run out of tests five minutes after doors open. In Phoenix, where temperatures have topped 100 degrees, residents have waited in cars for as long as eight hours to get tested.

America’s health care workers are dying; medical personnel account for as many as 20% of known coronavirus cases in many places. “Lost on the Frontline,” a collaboration between KHN and The Guardian, has identified 765 such workers who likely died of COVID-19 after helping patients during the pandemic.

As much as $273 million in federal coronavirus aid was awarded to more than 100 companies that are owned or operated by major donors to President Donald Trump’s election efforts, according to an Associated Press analysis of federal data. Many were among the first to be approved for a loan in early April, when the administration was struggling to launch the lending program. Churches connected to President Donald Trump and other organizations linked to current or former Trump evangelical advisers received at least $17.3 million in loans from a federal rescue package designed to aid small businesses during the coronavirus pandemic. Those receiving loans include City of Destiny, the Florida church that Trump’s personal pastor and White House faith adviser Paula White-Cain calls home, and First Baptist Dallas, led by Trump ally and senior pastor Robert Jeffress. City of Destiny got between $150,000 and $350,000 from the Paycheck Protection Program, or PPP, and First Baptist Dallas got between $2 million and $5 million, according to data released by the Treasury Department on Monday.  Nearly 90,000 companies in the program took the aid without promising on their applications they would rehire workers or create jobs.

The video of a nursing home resident punching his roommate taken inside the Westwood Nursing center in Detroit has increased the push for video monitoring in nursing homes. The 75-year-old man is recovering after the assault from 20-year-old Jadon Hayden. Michigan Senator Jim Runestad is now preparing a petition calling for nursing homes to allow patients to install cameras in their rooms, it is what he says – right now only five other states allow.  Runestad says Senate Bill 77 would establish that a nursing home patient – their family or advocate – would be allowed to monitor their own private room with a camera – under certain conditions… essentially the family would pay for and oversee the cameras.

“It’s just unbelievable how often this happens across the country and our state,” he said.

“This is a huge, huge problem,” said Sen. Jim Runestad (R-White Lake). Senator wants bill for video cameras inside nursing home room for senior safety, “I have literally watched dozens, hundreds, maybe thousands of videos (like) that online,” said Runestad.

Runestad says at the very least, allowing cameras inside patients’ rooms would deter bad or neglectful behavior and at the very best, give families some assurance that their loved one is getting the care they need.

“You have to require these nursing homes to allow the family to put the camera in,” he said.

Runestad is starting a petition drive calling on nursing homes, fellow legislators and governor Gretchen Whitmer to show their support – adding that it’s long past time we do something to protect our seniors from abuse.

“What we have now I believe is going to solve 90 percent of the problems if we get this passed,” he said.

The U.S. death toll from the coronavirus pandemic exceeds 130,000, as surging infection rates in the country overstretch hospitals. The U.S. is adding more than 50,000 new cases every day. Officials in states with surging coronavirus cases issued dire warnings and blamed outbreaks on reopenings as the weekly average for daily new cases in the United States reached a record high for the 27th straight day.

At least 60,000 residents and workers have died from the coronavirus at nursing homes and other long-term care facilities for older adults in the United States. The virus has infected more than 300,000 people at some 12,000 facilities. Covid-19, the disease caused by the coronavirus, is known to be particularly lethal to adults in their 60s and older who have underlying health conditions.  In 24 states, the number of residents and workers who have died accounts for either half or more than half of all deaths from the virus.

While 11 percent of America’s cases are in nursing homes, deaths account for more than 43 percent of fatalities.

Infected people linked to nursing homes also die at a higher rate than the general population. The median case fatality rate — the number of deaths divided by the number of cases — is 17 percent, significantly higher than the 5 percent case fatality rate nationwide.

Some states, including South Carolina, regularly release cumulative data on cases and deaths at specific facilities.

Trump continues to dismiss the severity of the coronavirus pandemic in the United States, downplaying the impact of the disease and saying “99 percent” of the positive cases were “totally harmless.” His flippant remarks about a virus that has already claimed 130,000 lives is shocking and perplexing.

Congress launched an investigation into the ongoing COVID-19 crisis in nursing homes, requesting information from both the federal government and five national for-profit operators in the industry. The action comes after the subcommittee held a hearing on COVID-19 in nursing homes in which both frontline workers and academics described the problem as systemic.  The probe focuses on five major nursing home owner/operators: Genesis HealthCare (NYSE: GEN), The Ensign Group (Nasdaq: ENSG), Life Care Centers of America, Consulate Health Care, and SavaSeniorCare. (Data indicates over 500 deaths of caregivers and residents at SavaSeniorCare facilities, including in one facility where 98 percent of residents were infected).

“The only thing COVID did was rip the doors open,” Chris Brown, a CNA working in Chicago, said during the hearing, testifying that staffing and PPE shortages were a problem in nursing homes prior to the pandemic. “It blasted the doors open of a system that was already failing.”

Atlanta-based SavaSeniorCare is targeted in the congressional investigation because of their long history of problems including a pending Medicare Fraud case in Tennessee.  Rubin Schron expanded his interests with the $1.3 billion acquisition of about 175 nursing homes from Mariner Health Care, Inc., which were subsequently leased to and operated by SavaSeniorCare.  SAVA operates 209 SNFs and five ALFs in 21 states with a total of 24,908 beds as of December 31, 2017, making it one of the largest SNF operators in the United States. Mr. Schron effectively owns most of the equity in Sava through Cammeby’s outstanding loans to Sava.

The former Mariner properties are master leased to SAVA subsidiaries and each property, in turn, is subleased to separate entities, subject to an operating lease. After Tony Oglesby’s sudden death, Jerry Roles took over as the CEO of SAVA. The rest of the management team includes Tim Schindler (President and Chief Operating Officer since May 2017) and Kevin Seramur (Executive Vice President and CFO)
and Stefano Miele (Executive Vice President, General Counsel and Secretary).

SavaSeniorCare is a named party in ongoing litigation focused on violations of federal law. Cases of note include United States ex
rel. Hayward v. SavaSeniorCare, LLC, alleging that SAVA knowingly and routinely submitted false claims to Medicare for
rehabilitation therapy services that were not medically reasonable or necessary. In addition, SAVA and related entities were defendants in a previously settled lawsuit alleging that SAVA and other parties took illegal kickbacks to refer their residents to Omnicare for pharmacy services. The United States entered into a settlement agreement with SAVA, and other related parties. The settlement agreement required the defendants to pay a sum of $14.0 million to the United States. Somehow they keep operating…

Annaliese Impink, corporate counsel for the national for-profit chain said:

“While we will likely cooperate, we are weighing our options and will determine our next steps.”

Sava has 13 nursing homes across Georgia and 4 in South Carolina. At Roselane Health and Rehabilitation Center in Marietta, 99 residents have tested positive for COVID-19 and 14 died. At Sandy Springs Health and Rehabilitation, 66 have tested positive and 13 have died, according to the Georgia Department of Community Health. Sava nursing homes in other states have also had major outbreaks and large numbers of deaths, including almost all of its facilities in Maryland and Michigan, according to federal data. At one Pennsylvania facility, 173 residents were infected, and 48 died.

“We know that this is an unsettling and scary time for our residents and the community,” SavaSeniorCare Consulting LLC Chief Experience Officer Annaliese Impink wrote in a statement emailed to 7 On Your Side. “We understand and greatly appreciate family members’ concern for their loved ones and are doing everything in our power to keep our residents safe and protected.”

SavaSeniorCare Administrative Services LLC, the company that issued the statement, provides management services to nursing homes, and is based in Atlanta.

The Centers for Medicare & Medicaid Services announced plans today to end the emergency waiver and resume requirements for all nursing homes to submit staffing data through the Payroll-Based Journal (PBJ) system. Providers must have second-quarter staffing numbers to the Centers for Medicare & Medicaid Services by Aug. 14. Meanwhile, staffing data submitted for the end of 2019 will be captured for public posting and ratings.

CMS recommends that first-quarter data be submitted but does not require it.  Industry apologist Steven Littlehale, chief innovation officer at Zimmet Healthcare Services Group advises not to submit the staffing data.

“While Q1 data will not be used in Five-Star, if you choose to submit it, it will be publicly accessible and be possibly used by others,” Littlehale cautioned. “I would be careful in sharing data externally that isn’t required, but keep meticulous documentation on your staffing and all your attempts to provide appropriate staff to your residents. Secondly, COVID-19 hit our nation hard, but not equally. Certain markets were severely hit, while others had no cases. Five-Star doesn’t adjust for these geographic variances.

Many families are asking themselves that question since COVID-19 policy has prevented families from visiting nursing homes.  Many families have no idea what’s happening to their loved ones.  They fear abuse and neglect.

One example is a family in NY who had photos showing Gloria Caldaroni-Ford’s mother Donata in her nursing home, with bruises under her eyes, a huge knot on her head and a big cut on her nose.

The incident happened before the COVID-19 pandemic. Caldaroni-Ford says her family only learned about the injury when they came to visit her mom the next day. The aide accused of causing her mother to fall was charged for not following procedure and for failing to report what happened.

“It is so important you don’t assume everything is okay behind closed doors,” Caldaroni-Ford said.

Advocates and experts agree that cameras should be allowed in rooms so families always have eyes on their loved ones.

Just three months ago, The Washington Post published the below article. At the time, confirmed COVID deaths had not even reached 8,000 yet.  It is interesting to take a step back this Fourth of July and look back for a minute.  Stay safe out there.

“By the time Donald Trump proclaimed himself a wartime president — and the coronavirus the enemy — the United States was already on course to see more of its people die than in the wars of Korea, Vietnam, Afghanistan and Iraq combined.

The country has adopted an array of wartime measures never employed collectively in U.S. history — banning incoming travelers from two continents, bringing commerce to a near-halt, enlisting industry to make emergency medical gear, and confining 230 million Americans to their homes in a desperate bid to survive an attack by an unseen adversary.

Despite these and other extreme steps, the United States will likely go down as the country that was supposedly best prepared to fight a pandemic but ended up catastrophically overmatched by the novel coronavirus, sustaining heavier casualties than any other nation.

It did not have to happen this way. Though not perfectly prepared, the United States had more expertise, resources, plans and epidemiological experience than dozens of countries that ultimately fared far better in fending off the virus.

The Trump administration received its first formal notification of the outbreak of the coronavirus in China on Jan. 3. Within days, U.S. spy agencies were signaling the seriousness of the threat to Trump by including a warning about the coronavirus — the first of many — in the President’s Daily Brief.

And yet, it took 70 days from that initial notification for Trump to treat the coronavirus not as a distant threat or harmless flu strain well under control, but as a lethal force that had outflanked America’s defenses and was poised to kill tens of thousands of citizens. That more-than-two-month stretch now stands as critical time that was squandered.

Trump’s baseless assertions in those weeks, including his claim that it would all just “miraculously” go away, sowed significant public confusion and contradicted the urgent messages of public health experts.

“While the media would rather speculate about outrageous claims of palace intrigue, President Trump and this Administration remain completely focused on the health and safety of the American people with around the clock work to slow the spread of the virus, expand testing, and expedite vaccine development,” said Judd Deere, a spokesman for the president. “Because of the President’s leadership we will emerge from this challenge healthy, stronger, and with a prosperous and growing economy.”

The president’s behavior and combative statements were merely a visible layer on top of deeper levels of dysfunction.

The most consequential failure involved a breakdown in efforts to develop a diagnostic test that could be mass produced and distributed across the United States, enabling agencies to map early outbreaks of the disease, and impose quarantine measures to contain them. At one point, a Food and Drug Administration official tore into lab officials at the Centers for Disease Control and Prevention, telling them their lapses in protocol, including concerns that the lab did not meet the criteria for sterile conditions, were so serious that the FDA would “shut you down” if the CDC were a commercial, rather than government, entity.

Other failures cascaded through the system. The administration often seemed weeks behind the curve in reacting to the viral spread, closing doors that were already contaminated. Protracted arguments between the White House and public health agencies over funding, combined with a meager existing stockpile of emergency supplies, left vast stretches of the country’s health-care system without protective gear until the outbreak had become a pandemic. Infighting, turf wars and abrupt leadership changes hobbled the work of the coronavirus task force.

It may never be known how many thousands of deaths, or millions of infections, might have been prevented with a response that was more coherent, urgent and effective. But even now, there are many indications that the administration’s handling of the crisis had potentially devastating consequences.

Even the president’s base has begun to confront this reality. In mid-March, as Trump was rebranding himself a wartime president and belatedly urging the public to help slow the spread of the virus, Republican leaders were poring over grim polling data that suggested Trump was lulling his followers into a false sense of security in the face of a lethal threat.

The poll showed that far more Republicans than Democrats were being influenced by Trump’s dismissive depictions of the virus and the comparably scornful coverage on Fox News and other conservative networks. As a result, Republicans were in distressingly large numbers refusing to change travel plans, follow “social distancing” guidelines, stock up on supplies or otherwise take the coronavirus threat seriously.

“Denial is not likely to be a successful strategy for survival,” GOP pollster Neil Newhouse concluded in a document that was shared with GOP leaders on Capitol Hill and discussed widely at the White House. Trump’s most ardent supporters, it said, were “putting themselves and their loved ones in danger.”

Trump’s message was changing as the report swept through the GOP’s senior ranks. In recent days, Trump has bristled at reminders that he had once claimed the caseload would soon be “down to zero.”

More than 7,000 people have died of the coronavirus in the United States so far, with about 240,000 cases reported. But Trump has acknowledged that new models suggest that the eventual national death toll could be between 100,000 and 240,000.

“This has been a real blow to the sense that America was competent,” said Gregory F. Treverton, a former chairman of the National Intelligence Council, the government’s senior-most provider of intelligence analysis. He stepped down from the NIC in January 2017 and now teaches at the University of Southern California. “That was part of our global role. Traditional friends and allies looked to us because they thought we could be competently called upon to work with them in a crisis. This has been the opposite of that.”

This article, which retraces the failures over the first 70 days of the coronavirus crisis, is based on 47 interviews with administration officials, public health experts, intelligence officers and others involved in fighting the pandemic. Many spoke on the condition of anonymity to discuss sensitive information and decisions.

Public health authorities are part of a special breed of public servant — along with counterterrorism officials, military planners, aviation authorities and others — whose careers are consumed with contemplating worst-case scenarios.

The arsenal they wield against viral invaders is powerful, capable of smothering a new pathogen while scrambling for a cure, but easily overwhelmed if not mobilized in time. As a result, officials at the Department of Health and Human Services, the CDC and other agencies spend their days scanning the horizon for emerging dangers.

The CDC learned of a cluster of cases in China on Dec. 31 and began developing reports for HHS on Jan. 1. But the most unambiguous warning that U.S. officials received about the coronavirus came Jan. 3, when Robert Redfield, the CDC director, received a call from a counterpart in China. The official told Redfield that a mysterious respiratory illness was spreading in Wuhan, a congested commercial city of 11 million people in the communist country’s interior.

Redfield quickly relayed the disturbing news to Alex Azar, the secretary of HHS, the agency that oversees the CDC and other public health entities. Azar, in turn, ensured that the White House was notified, instructing his chief of staff to share the Chinese report with the National Security Council.

From that moment, the administration and the virus were locked in a race against a ticking clock, a competition for the upper hand between pathogen and prevention that would dictate the scale of the outbreak when it reached American shores, and determine how many would get sick or die.

The initial response was promising, but officials also immediately encountered obstacles.

On Jan. 6, Redfield sent a letter to the Chinese offering to send help, including a team of CDC scientists. China rebuffed the offer for weeks, turning away assistance and depriving U.S. authorities of an early chance to get a sample of the virus, critical for developing diagnostic tests and any potential vaccine.

China impeded the U.S. response in other ways, including by withholding accurate information about the outbreak. Beijing had a long track record of downplaying illnesses that emerged within its borders, an impulse that U.S. officials attribute to a desire by the country’s leaders to avoid embarrassment and accountability with China’s 1.3 billion people and other countries that find themselves in the pathogen’s path.

China stuck to this costly script in the case of the coronavirus, reporting Jan. 14 that it had seen “no clear evidence of human-to-human transmission.” U.S. officials treated the claim with skepticism that intensified when the first case surfaced outside China with a reported infection in Thailand.

A week earlier, senior officials at HHS had begun convening an intra-agency task force including Redfield, Azar and Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases. The following week, there were also scattered meetings at the White House with officials from the National Security Council and State Department, focused mainly on when and whether to bring back government employees in China.

U.S. officials began taking preliminary steps to counter a potential outbreak. By mid-January, Robert Kadlec, an Air Force officer and physician who serves as assistant secretary for preparedness and response at HHS, had instructed subordinates to draw up contingency plans for enforcing the Defense Production Act, a measure that enables the government to compel private companies to produce equipment or devices critical to the country’s security. Aides were bitterly divided over whether to implement the act, and nothing happened for many weeks.

On Jan. 14, Kadlec scribbled a single word in a notebook he carries: “Coronavirus!!!”

Despite the flurry of activity at lower levels of his administration, Trump was not substantially briefed by health officials about the coronavirus until Jan.18, when, while spending the weekend at Mar-a-Lago, he took a call from Azar.

At the time, Trump was in the throes of an impeachment battle over his alleged attempt to coerce political favors from the leader of Ukraine. Acquittal seemed certain by the GOP-controlled Senate, but Trump was preoccupied with the trial, calling lawmakers late at night to rant, and making lists of perceived enemies he would seek to punish when the case against him concluded.

In hindsight, officials said, Azar could have been more forceful in urging Trump to turn at least some of his attention to a threat that would soon pose an even graver test to his presidency, a crisis that would cost American lives and consume the final year of Trump’s first term.

But the secretary, who had a strained relationship with Trump and many others in the administration, assured the president that those responsible were working on and monitoring the issue. Azar told several associates that the president believed he was “alarmist” and Azar struggled to get Trump’s attention to focus on the issue, even asking one confidant for advice.

Within days, there were new causes for alarm.

On Jan. 21, a Seattle man who had recently traveled to Wuhan tested positive for the coronavirus, becoming the first known infection on U.S. soil. Then, two days later, Chinese authorities took the drastic step of shutting down Wuhan, turning the teeming metropolis into a ghost city of empty highways and shuttered skyscrapers, with millions of people marooned in their homes.

“That was like, whoa,” said a senior U.S. official involved in White House meetings on the crisis. “That was when the Richter scale hit 8.”

It was also when U.S. officials began to confront the failings of their own efforts to respond.

Azar, who had served in senior positions at HHS through crises including the 9/11 terrorist attacks and the outbreak of bird flu in 2005, was intimately familiar with the playbook for crisis management.

But doing so would require assets that would elude U.S. officials for months — a diagnostic test that could accurately identify those infected with the new virus and be produced on a mass scale for rapid deployment across the United States, and money to implement the system.

Azar’s team also hit another obstacle. The Chinese were still refusing to share the viral samples they had collected and were using to develop their own tests. In frustration, U.S. officials looked for other possible routes.

A biocontainment lab at the University of Texas medical branch in Galveston had a research partnership with the Wuhan Institute of Virology.

Kadlec, who knew the Galveston lab director, hoped scientists could arrange a transaction on their own without government interference. At first, the lab in Wuhan agreed, but officials in Beijing intervened Jan. 24 and blocked any lab-to-lab transfer.

There is no indication that officials sought to escalate the matter or enlist Trump to intervene. In fact, Trump has consistently praised Chinese President Xi Jinping despite warnings from U.S. intelligence and health officials that Beijing was concealing the true scale of the outbreak and impeding cooperation on key fronts.

The CDC had issued its first public alert about the coronavirus Jan. 8, and by the 17th was monitoring major airports in Los Angeles, San Francisco and New York, where large numbers of passengers arrived each day from China.

In other ways, though, the situation was already spinning out of control, with multiplying cases in Seattle, intransigence by the Chinese, mounting questions from the public, and nothing in place to stop infected travelers from arriving from abroad.

Trump was out of the country for this critical stretch, taking part in the annual global economic forum in Davos, Switzerland. He was accompanied by a contingent of top officials including national security adviser Robert O’Brien, who took a trans-Atlantic call from an anxious Azar.

Azar told O’Brien that it was “mayhem” at the White House, with HHS officials being pressed to provide nearly identical briefings to three audiences on the same day.

Azar urged O’Brien to have the NSC assert control over a matter with potential implications for air travel, immigration authorities, the State Department and the Pentagon. O’Brien seemed to grasp the urgency, and put his deputy, Matthew Pottinger, who had worked in China as a journalist for the Wall Street Journal, in charge of coordinating the still-nascent U.S. response.

But the rising anxiety within the administration appeared not to register with the president. On Jan. 22, Trump received his first question about the coronavirus in an interview on CNBC while in Davos. Asked whether he was worried about a potential pandemic, Trump said, “No. Not at all. And we have it totally under control. It’s one person coming in from China. . . . It’s going to be just fine.”

The move by the NSC to seize control of the response marked an opportunity to reorient U.S. strategy around containing the virus where possible and procuring resources that hospitals would need in any U.S. outbreak, including such basic equipment as protective masks and ventilators.

But instead of mobilizing for what was coming, U.S. officials seemed more preoccupied with logistical problems, including how to evacuate Americans from China.

In Washington, then-acting chief of staff Mick Mulvaney and Pottinger began convening meetings at the White House with senior officials from HHS, the CDC and the State Department.

The group, which included Azar, Pottinger and Fauci, as well as nine others across the administration, formed the core of what would become the administration’s coronavirus task force. But it primarily focused on efforts to keep infected people in China from traveling to the United States even while evacuating thousands of U.S. citizens. The meetings did not seriously focus on testing or supplies, which have since become the administration’s most challenging problems.

The task force was formally announced on Jan. 29.

“The genesis of this group was around border control and repatriation,” said a senior official involved in the meetings. “It wasn’t a comprehensive, whole-of-government group to run everything.”

The State Department agenda dominated those early discussions, according to participants. Officials began making plans to charter aircraft to evacuate 6,000 Americans stranded in Wuhan. They also debated language for travel advisories that State could issue to discourage other travel in and out of China.

On Jan. 29, Mulvaney chaired a meeting in the White House Situation Room in which officials debated moving travel restrictions to “Level 4,” meaning a “do not travel” advisory from the State Department. Then, the next day, China took the draconian step of locking down the entire Hubei province, which encompasses Wuhan.

That move by Beijing finally prompted a commensurate action by the Trump administration. On Jan. 31, Azar announced restrictions barring any non-U.S. citizen who had been in China during the preceding two weeks from entering the United States.

Trump has, with some justification, pointed to the China-related restriction as evidence that he had responded aggressively and early to the outbreak. It was among the few intervention options throughout the crisis that played to the instincts of the president, who often seems fixated on erecting borders and keeping foreigners out of the country.

But by that point, 300,000 people had come into the United States from China over the previous month. There were only 7,818 confirmed cases around the world at the end of January, according to figures released by the World Health Organization — but it is now clear that the virus was spreading uncontrollably.

Pottinger was by then pushing for another travel ban, this time restricting the flow of travelers from Italy and other nations in the European Union that were rapidly emerging as major new nodes of the outbreak. Pottinger’s proposal was endorsed by key health-care officials, including Fauci, who argued that it was critical to close off any path the virus might take into the country.

This time, the plan met with resistance from Treasury Secretary Steven Mnuchin and others who worried about the impact on the U.S. economy. It was an early sign of tension in an area that would split the administration, pitting those who prioritized public health against those determined to avoid any disruption in an election year to the run of expansion and employment growth.

Those backing the economy prevailed with the president. And it was more than a month before the administration issued a belated and confusing ban on flights into the United States from Europe. Hundreds of thousands of people crossed the Atlantic during that interval.

While fights over air travel played out in the White House, public health officials began to panic over a startling shortage of critical medical equipment including protective masks for doctors and nurses, as well as a rapidly shrinking pool of money needed to pay for such things.

By early February, the administration was quickly draining a $105 million congressional fund to respond to infectious disease outbreaks. The coronavirus threat to the United States still seemed distant if not entirely hypothetical to much of the public. But to health officials charged with stockpiling supplies for worst-case-scenarios, disaster appeared increasingly inevitable.

A national stockpile of N95 protective masks, gowns, gloves and other supplies was already woefully inadequate after years of underfunding. The prospects for replenishing that store were suddenly threatened by the unfolding crisis in China, which disrupted offshore supply chains.

Much of the manufacturing of such equipment had long since migrated to China, where factories were now shuttered because workers were on order to stay in their households. At the same time, China was buying up masks and other gear to gird for its own coronavirus outbreak, driving up costs and monopolizing supplies.

In late January and early February, leaders at HHS sent two letters to the White House Office of Management and Budget asking to use its transfer authority to shift $136 million of department funds into pools that could be tapped for combating the coronavirus. Azar and his aides also began raising the need for a multibillion-dollar supplemental budget request to send to Congress.

Yet White House budget hawks argued that appropriating too much money at once when there were only a few U.S. cases would be viewed as alarmist.

Joe Grogan, head of the Domestic Policy Council, clashed with health officials over preparedness. He mistrusted how the money would be used and questioned how health officials had used previous preparedness funds.

Azar then spoke to Russell Vought, the acting director of the White House Office of Management and Budget, during Trump’s State of the Union speech on Feb. 4. Vought seemed amenable, and told Azar to submit a proposal.

Azar did so the next day, drafting a supplemental request for more than $4 billion, a sum that OMB officials and others at the White House greeted as an outrage. Azar arrived at the White House that day for a tense meeting in the Situation Room that erupted in a shouting match, according to three people familiar with the incident.

A deputy in the budget office accused Azar of preemptively lobbying Congress for a gigantic sum that White House officials had no interest in granting. Azar bristled at the criticism and defended the need for an emergency infusion. But his standing with White House officials, already shaky before the coronavirus crisis began, was damaged further.

White House officials relented to a degree weeks later as the feared coronavirus surge in the United States began to materialize. The OMB team whittled Azar’s demands down to $2.5 billion, money that would be available only in the current fiscal year. Congress ignored that figure, approving an $8 billion supplemental bill that Trump signed into law March 6.

But again, delays proved costly. The disputes meant that the United States missed a narrow window to stockpile ventilators, masks and other protective gear before the administration was bidding against many other desperate nations, and state officials fed up with federal failures began scouring for supplies themselves.

In late March, the administration ordered 10,000 ventilators — far short of what public health officials and governors said was needed. And many will not arrive until the summer or fall, when models expect the pandemic to be receding.

“It’s actually kind of a joke,” said one administration official involved in deliberations about the belated purchase.

Although viruses travel unseen, public health officials have developed elaborate ways of mapping and tracking their movements. Stemming an outbreak or slowing a pandemic in many ways comes down to the ability to quickly divide the population into those who are infected and those who are not.

Doing so, however, hinges on having an accurate test to diagnose patients and deploy it rapidly to labs across the country. The time it took to accomplish that in the United States may have been more costly to American efforts than any other failing.

“If you had the testing, you could say, ‘Oh my god, there’s circulating virus in Seattle, let’s jump on it. There’s circulating virus in Chicago, let’s jump on it,’ ” said a senior administration official involved in battling the outbreak. “We didn’t have that visibility.”

The first setback came when China refused to share samples of the virus, depriving U.S. researchers of supplies to bombard with drugs and therapies in a search for ways to defeat it. But even when samples had been procured, the U.S. effort was hampered by systemic problems and institutional hubris.

Among the costliest errors was a misplaced assessment by top health officials that the outbreak would probably be limited in scale inside the United States — as had been the case with every other infection for decades — and that the CDC could be trusted on its own to develop a coronavirus diagnostic test.

The CDC, launched in the 1940s to contain an outbreak of malaria in the southern United States, had taken the lead on the development of diagnostic tests in major outbreaks including Ebola, zika and H1N1. But the CDC was not built to mass-produce tests.

The CDC’s success had fostered an institutional arrogance, a sense that even in the face of a potential crisis there was no pressing need to involve private labs, academic institutions, hospitals and global health organizations also capable of developing tests.

Yet some were concerned that the CDC test would not be enough. Stephen Hahn, the FDA commissioner, sought authority in early February to begin calling private diagnostic and pharmaceutical companies to enlist their help.

FDA leaders were split on whether it would be bad optics for Hahn to be personally calling companies he regulated. When FDA officials consulted leaders at HHS, they understood it as a direction to stand down.

At that point, Azar, the HHS secretary, seemed committed to a plan he was pursuing that would keep his agency at the center of the response effort: securing a test from the CDC and then building a national coronavirus surveillance system by relying on an existing network of labs used to track the ordinary flu.

In task force meetings, Azar and Redfield pushed for $100 million to fund the plan, but were shot down because of the cost, according to a document outlining the testing strategy obtained by The Washington Post.

Relying so heavily on the CDC would have been problematic even if it had succeeded in quickly developing an effective test that could be distributed across the country. The scale of the epidemic, and the need for mass testing far beyond the capabilities of the flu network, would have overwhelmed the plan, which didn’t envision engaging commercial lab companies for up to six months.

The effort collapsed when the CDC failed its basic assignment to create a working test and the task force rejected Azar’s plan.

On Feb. 6, when the World Health Organization reported that it was shipping 250,000 test kits to labs around the world, the CDC began distributing 90 kits to a smattering of state-run health labs.

Almost immediately, the state facilities encountered problems. The results were inconclusive in trial runs at more than half the labs, meaning they couldn’t be relied upon to diagnose actual patients. The CDC issued a stopgap measure, instructing labs to send tests to its headquarters in Atlanta, a practice that would delay results for days.

The scarcity of effective tests led officials to impose constraints on when and how to use them, and delayed surveillance testing. Initial guidelines were so restrictive that states were discouraged from testing patients exhibiting symptoms unless they had traveled to China and come into contact with a confirmed case, when the pathogen had by that point almost certainly spread more broadly into the general population.

The limits left top officials largely blind to the true dimensions of the outbreak.

In a meeting in the Situation Room in mid-February, Fauci and Redfield told White House officials that there was no evidence yet of worrisome person-to-person transmission in the United States. In hindsight, it appears almost certain that the virus was taking hold in communities at that point. But even the country’s top experts had little meaningful data about the domestic dimensions of the threat. Fauci later conceded that as they learned more their views changed.

At the same time, as the president’s subordinates were growing increasingly alarmed, Trump continued to exhibit little concern. On Feb. 10, he held a political rally in New Hampshire attended by thousands where he declared that “by April, you know, in theory, when it gets a little warmer, it miraculously goes away.”

The New Hampshire rally was one of eight that Trump held after he had been told by Azar about the coronavirus, a period when he also went to his golf courses six times.

A day earlier, on Feb. 9, a group of governors in town for a black-tie gala at the White House secured a private meeting with Fauci and Redfield. The briefing rattled many of the governors, bearing little resemblance to the words of the president. “The doctors and the scientists, they were telling us then exactly what they are saying now,” Maryland Gov. Larry Hogan (R) said.

That month, federal medical and public health officials were emailing increasingly dire forecasts among themselves, with one Veterans Affairs medical adviser warning, ‘We are flying blind,’” according to emails obtained by the watchdog group American Oversight.

Later in February, U.S. officials discovered indications that the CDC laboratory was failing to meet basic quality-control standards. On a Feb. 27 conference call with a range of health officials, a senior FDA official lashed out at the CDC for its repeated lapses.

Jeffrey Shuren, the FDA’s director for devices and radiological health, told the CDC that if it were subjected to the same scrutiny as a privately run lab, “I would shut you down.”

On Feb. 29, a Washington state man became the first American to die of a coronavirus infection. That same day, the FDA released guidance, signaling that private labs were free to proceed in developing their own diagnostics.

Another four-week stretch had been squandered.

One week later, on March 6, Trump toured the facilities at the CDC wearing a red “Keep America Great” hat. He boasted that the CDC tests were nearly perfect and that “anybody who wants a test will get a test,” a promise that nearly a month later remains unmet.

He also professed to have a keen medical mind. “I like this stuff. I really get it,” he said. “People here are surprised that I understand it. Every one of these doctors said, ‘How do you know so much about this?’ ”

In reality, many of the failures to stem the coronavirus outbreak in the United States were either a result of, or exacerbated by, his leadership.

For weeks, he had barely uttered a word about the crisis that didn’t downplay its severity or propagate demonstrably false information. He dismissed the warnings of intelligence officials and top public health officials in his administration.

At times, he voiced far more authentic concern about the trajectory of the stock market than the spread of the virus in the United States, railing at the chairman of the Federal Reserve and others with an intensity that he never seemed to exhibit about the possible human toll of the outbreak.

In March, as state after state imposed sweeping new restrictions on their citizens’ daily lives to protect them — triggering severe shudders in the economy — Trump second-guessed the lockdowns.

The common flu kills tens of thousands each year and “nothing is shut down, life & the economy go on,” he tweeted March 9. A day later, he pledged that the virus would “go away. Just stay calm.

Two days later, Trump finally ordered the halt to incoming travel from Europe that his deputy national security adviser had been advocating for weeks. But Trump botched the Oval Office announcement so badly that White House officials spent days trying to correct erroneous statements that triggered a stampede by U.S. citizens overseas to get home.

“There was some coming to grips with the problem and the true nature of it — the 13th of March is when I saw him really turn the corner. It took a while to realize you’re at war,” Sen. Lindsey O. Graham (R-S.C.) said. “That’s when he took decisive action that set in motion some real payoffs.”

Trump spent many weeks shuffling responsibility for leading his administration’s response to the crisis, putting Azar in charge of the task force at first, relying on Pottinger, the deputy national security adviser, for brief periods, before finally putting Vice President Pence in the role toward the end of February.

Other officials have emerged during the crisis to help right the United States’ course, and at times, the statements of the president. But even as Fauci, Azar and others sought to assert themselves, Trump was behind the scenes turning to others with no credentials, experience or discernible insight in navigating a pandemic.

Foremost among them was his adviser and son-in-law, Jared Kushner. A team reporting to Kushner commandeered space on the seventh floor of the HHS building to pursue a series of inchoate initiatives.

One plan involved having Google create a website to direct those with symptoms to testing facilities that were supposed to spring up in Walmart parking lots across the country, but which never materialized. Another centered on an idea advanced by Oracle chairman Larry Ellison to use software to monitor the unproven use of anti-malaria drugs against the coronavirus pathogen.

So far, the plans have failed to come close to delivering on the promises made when they were touted in White House news conferences. The Kushner initiatives have, however, often interrupted the work of those under immense pressure to manage the U.S. response.

Current and former officials said that Kadlec, Fauci, Redfield and others have repeatedly had to divert their attentions from core operations to contend with ill-conceived requests from the White House they don’t believe they can ignore. And Azar, who once ran the response, has since been sidelined, with his agency disempowered in decision-making and his performance pilloried by a range of White House officials, including Kushner.

“Right now Fauci is trying to roll out the most ambitious clinical trial ever implemented” to hasten the development of a vaccine, said a former senior administration official in frequent touch with former colleagues. And yet, the nation’s top health officials “are getting calls from the White House or Jared’s team asking, ‘Wouldn’t it be nice to do this with Oracle?’ ”

If the coronavirus has exposed the country’s misplaced confidence in its ability to handle a crisis, it also has cast harsh light on the limits of Trump’s approach to the presidency — his disdain for facts, science and experience.

He has survived other challenges to his presidency — including the Russia investigation and impeachment — by fiercely contesting the facts arrayed against him and trying to control the public’s understanding of events with streams of falsehoods.

The coronavirus may be the first crisis Trump has faced in office where the facts — the thousands of mounting deaths and infections — are so devastatingly evident that they defy these tactics.

After months of dismissing the severity of the coronavirus, resisting calls for austere measures to contain it, and recasting himself as a wartime president, Trump seemed finally to succumb to the coronavirus reality. In a meeting with a Republican ally in the Oval Office last month, the president said his campaign no longer mattered because his reelection would hinge on his coronavirus response.

“It’s absolutely critical for the American people to follow the guidelines for the next 30 days,” he said at his March 31 news conference. “It’s a matter of life and death.”