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Williamson Explains Medicaid Expansion to Joint Committee

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Staff Report

MONTGOMERY–On Tuesday, Dr. Don Williamson, the interim director of Alabama Medicaid, spoke to the Permanent Joint Legislative Committee on Medicaid Policy explaining how the expansion of Medicaid would affect the state.

Williamson explained the expansion programs: costs, benefits, problems along with upcoming changes to Medicaid and healthcare insurance will have a direct effect on how Medicaid is handled moving forward.

Speaking of the Supreme Court ruling regarding the Affordable Care Act, Williams said, “The individual mandate (which says citizens must be covered by some sort of healthcare insurance or face a federally imposed penalty in the way of a tax) remains because that has a role in what happens to individuals who need Medicaid. The healthcare exchanges remain because individuals are going to be driven to the exchange to purchase insurance to comply with the individual mandate.”

Maintenance of effort requirement for states, both for the child health insurance program and for Medicaid remains intact. It freezes those activities that Medicaid has been engaged in and that Childhood Insurance has been engaged in as of March 23, 2010. That means that Alabama can not impose an asset tax for Medicaid, cannot create a waiting list for AllKids and cannot roll back enrollment for AllKids because these programs were all in effect on March 23, 2010.

“That is the floor that we have to build up from. If we are going to comply with federal law we cannot go below it,” said Dr. Williamson.

The calculation of income to qualify for Medicaid will change to the MAGI system (Medicaid Adjusted Gross Income). This sees that all states will calculate Medicaid the same way which means Alabama will have to change its enrollment process.

“That’s going to cost some money, we are going to raise that if we have to borrow, steal or talk to some other states that have developed some enrollment programs and see if we can cannibalize them especially if they are in the public domain,” said Williamson.

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The MAGI number is reached by disregarding 5 percent of an individual’s income, in essence changing the multiplier from 133 percent to 138 percent of the federal poverty level to qualify for Medicaid.

He said that there is no deadline for the Medicaid expansion. “Alabama could choose to expand Medicaid today, it could choose January 1, it could choose 2014, it could choose to expand Medicaid presumably in 2016. But for whatever time we choose not to expand Medicaid after 2014 we are losing 100 percent money for each of those years,” said Williamson. Federal dollars will fully fund any Medicaid expansion 100 percent for the first 3 years. This will decline gradually and in 2020 will reach the set rate of federal funding at 90 percent with a 10 percent state matching funds.”

Dr. Williamson warned the legislators of two impending problems with or without the expansion. He said that because of proration he has cut physician payments by 10 percent but that the legislature had passed a bill requiring the rate to be raised by 10 percent beginning October 1, 2014.

Williamson said that the first problem will arise as a result of federal program designed to raise physician payments to Medicare rates for two years. Medicaid currently pays approximately 78-79 percent of the Medicare rate. This will result in a substantial raise for primary care physicians beginning in January 1, 2013.

He said that these rates will only be paid for two years “so that is going to be an issue beyond 2013.”

The second problem he raised regarded Disproportionate Share Hospital (DSH) payments that cover unpaid medical bills to hospitals that were incurred by the uninsured.

Currently there is an estimated $11.3 billion of DSH money in the Medicaid program nationwide. That will decline by 61 percent beginning in 2014 and stabilizing in 2019. Williamson said that the reason this cut was made was because the American Medical Association determined that if all patients would be covered by some type of insurance there would no longer be a need to provide the supplemental payments to hospitals.

“There are today in Alabama persons who are eligible for Medicaid but have never enrolled,” said Williamson. The problem he says is that when the healthcare exchange is put into effect many of those people will realize that they qualify. But because they met the qualifications before the expansion they will fall into the category of the old Medicaid match of a 68/32 because they are not “newly” qualified.

These people would include women that are not pregnant and children that have never been sick. “The good news is that these kids will be fairly inexpensive. They haven’t had a reason to go to the doctor. They just, for whatever reason, have not got insured,” said Williamson. Estimates claim that this could increase the nationwide Medicaid population by up to 10 percent, without the expansion. Since Alabama has the most constricted plan in the country, Williamson doesn’t think the number should be small.

Based on the Kaiser Foundation Report, Williamson’s anticipation is that the expansion could increase the number of eligible Medicaid participants by 57 to 75 percent.

According to Dr. Williamson’s assumptions the expansion would lead to an estimated 351,000 to 456,000 new enrollees. Williamson estimates that there are 244,000 currently uninsured that would become eligible. He also estimates that there are another 100,000 people either currently insured or already eligible for Medicaid who will come to the Medicaid program when enrollment is opened under the expansion.

“The biggest portion of that will be people who are currently insured in small business and then small businesses find that it is cheaper to drop insurance, pay the penalty and for those people to be covered under Medicaid,” said Williamson. “It will be the shifting from the small private market into the Medicaid market.” The current penalty is estimated at $2,000 per FTE.

Senator Greg (R-Montgomery) Reed asked, “According to our conversation the other day, doesn’t this create a hole for the lowest income working people in the state of Alabama that are being disenfranchised by the definition of this?”

“I think you are exactly right, the Affordable Care Act closed one hole and that was the hole around Part D Medicare but the Supreme Court ruling has opened another hole. It is quite possible that in a number of states those people who are most in need of insurance and are financially least able to acquire the insurance are going to be the one’s left uninsured,” said Williamson.

When the exchange goes into effect the rules of the insurance market will change. There will no longer be small group rates or any risk-based ratings, it will now go to universal issue with community rating. With that change Williamson believes that there will be double digit increases in both the small group model market and the individual market and beginning January 1, 2013.

When asked what the the expansion could mean to Alabama’s economy, he said, “Alabama Medicaid is matched at 68/32. So, you think that for every dollar you put in you get three back. So, you would think that $100 million translates into $300 million. But if you look at our program that is really not how it works. If we put $600 million in we get $5.4 billion back, that is a 9-1 match. So that $100 million would probably, when you filter it through the multipliers, CPE, and all of those, you are not talking about $300 million, you may be talking about $600 million, you may be talking about $700 million, and that is a real number.”

Committee members were asked their thoughts after the meeting adjourned:

“I think the real essence of providing quality healthcare to all of the citizens of Alabama is so important that I think members of the legislature and members of the Medicaid Task Force will take this study to heart and will do the right thing because if you have a healthy public then you have a real healthy workforce. That workforce will be more productive and companies will be more productive. This is the beginning of a very lengthy process. This is a learning process, a lot of information came in today that will be helpful as we make decisions. It is always important to remember we are here to serve the people and this is a peoples issue. I believe in doing what is right by the people of Alabama,” said Senator Billy Beasley (D-Clayton).

“This meeting was another meeting that was educating us, giving us the facts and figures and what we are up against in terms of the decisions that we need to make. Personally, I feel that everybody should have access to affordable healthcare and that we should do everything that we can. It is a win-win situation. When you have a healthy population, you have a productive population. Also, when people have access to healthcare in the beginning they can get preventive healthcare and not wait until they get to a chronic stage which causes the amount of money that they are spending to increase. If they don’t have that coverage they are going to wait until it becomes critical and go to the emergency room where the costs are astronomical,” said Senator Vivian Figures (D-Mobile).

“This is most important issue we face. Medicaid and its impact on the people of our state and the economy can not be understated. Medicaid expansion is the biggest economic opportunity since our nation decided to build roads and bridges. Its impact on the people will be substantial and if we do the work we need to do to expand Medicaid for all who need to be included then this will increase prosperity and healthcare across our country,” said Representative Ron Scott (D-Fairfield).

“I think the meeting was very helpful to everyone who attended. Of course legislators, but also policy groups and advocates… everyone who was present. Dr. Williamson’s ability to get into the fine dilemmas of Medicaid has once again surfaced. He is the right man for this much needed job. These meetings are going to arm us with the knowledge and tools we need for the structural changes that have to occur in Medicaid. There are urgencies we must face in the next sixty days before the fiscal year ends but we are looking at a new design to Medicaid. We are looking at a new delivery system for people on Medicaid. We are going to look at eligibility and enrollment changes and systemic changes to a system that historically has not had change. For thirty years people have been sitting on the same pew, well, we are here to say that the church services has just changed. These meeting are being instrumental in the education necessary to move forward to properly run the $5 billion dollar healthcare system,” said Representative Greg Wren (R-Montgomery)

Williamson is preparing economic impact numbers for the possible expansion’s impact on Alabama’s economy.

The next committee meeting is scheduled for September 12.

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Black people over-represented among COVID-19 patients, deaths, UAB doctor says

Eddie Burkhalter

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Contrary to rumors, black people aren’t immune to the COVID-19 virus, and in some places in the U.S., black people are not only getting the deadly virus in larger numbers but are more likely to die from it, said a physician at University of Alabama at Birmingham.

Dr. Selwyn Vickers, Dean of UAB School of Medicine, was speaking during a Facebook live video on Saturday, the first in what’s to be a series of discussions with faith leaders and physicians on the COVID-19 crisis, organized by UAB and the Housing Authority of the Birmingham District.

Vickers said in Milwaukee and Michigan, two places that, unlike most others in the U.S. currently, are keeping track of the racial makeup of COVID-19 patients, black people are overrepresented among the virus’s patients.

“In Milwaukee, which is 26 percent African American, 50 percent of the COVID-19 cases happen to be African American,” Vickers said.

What’s even more troubling, Vickers said, is that even though whites and other races make up 50 percent of Milwaukee’s the COVID-19 cases, black people make up 80 percent of the city’s deaths from the virus.

“You can hypothesize that they may have some of these chronic illnesses. You could also worry that they just don’t get access. They don’t get to the hospital as early, and so it’s probably multiple reasons,” Vickers said.

In Michigan, where just 14 percent of the population is black, nearly 35 percent of the COVID-19 cases are among people, Vickers said.

Even more concerning, he said, is that even though only 14 percent of the population is black, 40 percent of the deaths are among black people.

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While the Centers for Disease Control and Prevention does typically track detailed data during a viral outbreak, including the racial makeup of patients, the CDC is not currently releasing such data for COVID-19.

Five members of Congress wrote a letter to the U.S Department of Health and Human Services on March 27 urging the CDC to collect and report data on race among COVID-19 cases.

“The C.D.C. is currently failing to collect and publicly report on the racial and ethnic demographic information of patients tested for and affected by Covid-19. Our concerns echo those from some physicians: that decisions to test individuals for the novel coronavirus may be ‘more vulnerable to the implicit biases that every patient and medical professional carry around with them,’ potentially causing ‘black communities and other underserved groups … [to] disproportionately mis[s] out on getting tested for Covid-19,” the letter reads.

Vickers also dispelled a rumor that kids can’t get COVID-19.

“Kids can get it, and young people have died from it,” Landers said, adding that a young person was treated at UAB for COVID-19. “Kids probably more often are carriers. They don’t often get very sick, but they carry the virus, and they can spread it.”

What makes COVID-19 so difficult to treat, compared to the regular seasonal flu, VIckers said, is that “there is no therapy we have right now.” There are clinical trials in the works, and some drugs are being used, but it’s not yet clear how well they’re working.

And unlike the regular seasonal flu, COVID-19 is much, much deadlier because it attacks the lower respiratory system, Vickers said. Patients with the novel coronavirus are more likely to be placed on ventilators.

“We have about 60 patients in the hospital who have the diagnosis of coronavirus. If we had in this season 100 patients with the flu in the hospital maybe five or 10 might be on a breathing machine,” Vickers said.

With the 60 patients UAB may have at any given time, nearly half of them are on a breathing machine, he said.

“So consequently now, there are a number of deaths, well over 60,000 deaths, in the world. There are 8,000 deaths in America and those numbers will continually climb,” Vickers said.

The best way to prevent yourself from getting COVID-19 and form helping spread it to others, is to keep at least six feet of distance from others, Vickers said, and suggested limiting interaction with others to groups of less than five.

“Keeping a distance, covering your mouth and nose with the mask, and trying to make sure every time you touch something clean your hands, Vickers said.

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What you need to know about Alabama’s stay-at-home order

Eddie Burkhalter

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Gov. Kay Ivey and the Alabama Department of Public Health issued a statewide stay-at-home order Friday. Here’s what you need to know.

What is the bottom line?

Stay at home if at all possible.

“The default position for everyone is they need to stay at home. We need to stay at home if at all possible,” State Health Officer Scott Harris said.

When does it start?

The order goes into effect at 5 p.m. on Saturday, April 4.

How long does it remain in effect?

The order is to remain in effect until Thursday, April 30 at 5 p.m., but it could be extended.

Why are we doing this?

By following these guidelines, you’re protecting the people who work in your community in essential functions. You’re also protecting yourself and the health care workers like nurses and doctors in the community so they won’t get sick.

Staying at home protects all of us, and it protects our hospitals from being overwhelmed by a surge of COVID-19 patients. Hospitals’ ability to care for those who are most vulnerable depends on not being overwhelmed.

What will happen if I don’t follow the order?

Not following the order can result in misdemeanor charges, fines and jail time, enforceable by all law enforcement agencies statewide.

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Can I still go to the grocery store?

Yes. Buying food — whether from a grocery store or from another store or restaurant (take-out or delivery) — is considered an essential activity and is allowed.

What are “essential activities”? 

  • You can still leave your home to obtain necessary supplies such as: Food, pet food, distance learning and educational materials, supplies needed to work from home, prescriptions and medical supplies, fuel and supplies for vehicles.

For what other reasons can I leave home?

  • Dental, medical, or surgical procedures, government-funded benefits, automobile repairs.
  • Services to care for people with physical, intellectual, or developmental disabilities, or substance-use disorders. Educational services and services to maintain a person or pet’s health and safety.
  • To take care of a family member, friend or pet in another home, to donate blood, or take a family member, friend or pet to places allowed in Ivey’s order.

Are religious services exempted?

Some religious services are exempted:

  • You can leave home to attend a religious service, wedding or funeral, as long as 10 or fewer people are present and six-feet of distance is kept between people, and drive-in religious services.

What about my job?

Ivey’s order allows people to leave home to:

  • Work at an essential business.
  • Maintain the value of a business.
  • Work to enable people to work or shop remotely from home, or buy products through drive-by, curbside, or door- to-door delivery.
  • Work that does not require any regular interaction within six feet of another person.

What about getting outside for a while or leaving home during an emergency like severe weather?

People can still leave home to:

  • Engage in outdoor activities as long as 10 or fewer people participate and stay at least 6 feet from one another.
  • To take shelter if required by an employer of essential business, or if a person’s home is unsafe or at risk of becoming unsafe.
  • Fulfill the direction of a police officer or court order.
  • To see a family member

What’s closed under this order?

All non-essential businesses, which include:

  • Night clubs, bowling alleys, movie theaters and auditoriums, arcades, concert venues, tourist attractions, race tracks, bingo halls and casinos.
  • Athletic facilities including gyms, spas and spectator sports.
  • Close-contact businesses such as barbershops and salons, massage therapy and tanning salons.

What about restaurants? 

Dine-in is prohibited at all restaurants and bars, but take-out and delivery remain open.

Are there more exemptions?

Yes, but as State Health Officer Scott Harris said, the default assumption should be to stay at home unless you are engaging in essential activity.

“It’s not a list of things to look for and see if you can figure out a way to not keep yourself at home,” Harris said. “We need Alabamians to make sure that they stay at home. Things will look a lot different in our state in the next two or three weeks if we can just get people to see that and to agree to do that.”

Can I read the full order?

Yes, a copy of the full stay-at-home order is available here.

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Alabama Power working with UAB, Alabama Productivity Center to aid health care workers

Bill Britt

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Families across the state are under a stay-at-home order. Imagine a family of four stuck at home. Mom and Dad go to the garage to clean the clutter of boxes that have accumulated over the years, they turn on the lights, they don’t even think about where the energy came from, it’s automatic. A teenage daughter plugs in her smartphone after texting distant friends all day, where does the charge come from, does she care? A son still on his game console late into the night isn’t thinking about the power that enables his game, he just wants to play.

Now think about a medical professional caring for a COVID-19 patient in an ER, she needs a face-shield. It should be there, but maybe it’s not.

Alabama Power keeps the lights on, so the house is illuminated, the smartphone charges and the game console keeps humming, but recently the company stepped out of its usual role and is now making medical face shields in a partnership with The Alabama Productivity Center, and the UAB School of Engineering.

An email from within the Alabama Power Company landed in Scott Bishop’s inbox two weeks ago. Bishop is a team leader at APC’s Technology Application Center. “I received an email that asked did we know anyone who could do 3D printing to make headbands for face shields,” said Bishop.

Bishop knew immediately that within the companies network, there were resources with 3D printing capabilities that could possibly make medical face shields.

“In our network of people, some of those resources reside at UAB and the productivity center,” said Bishop. “So we looked at our capabilities and we had a printer and UAB had printers and so did the productivity center,  so we started printing headbands for UAB Hospital.”

From that initial email, a small network is now producing 100 face shields a day with more production ramping up as the days go by.

“Healthcare workers’ faces have been reported to be the body part most commonly contaminated by splashes, sprays and spatter of body fluids,” notes the National Center for Biotechnology Information.

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As a PPE, face shields play an essential role in keeping healthcare workers safe when dealing with infectious deceases like COVID-19.

What started as a project to manufacture headbands has grown to crafting the full face shields.

Last week, the Alabama Productivity Center took to Twitter to showcase the face shields.

“Thank you to all of our partners and volunteers for helping out producing these shields! We have more & more request for the need of these shields. Please DM us if you can help! Here is what the final product looks like. #COVID19 #3DPrintedFaceShield.”

As part of the Culverhouse College of Business at UA, the Alabama Productivity Center is known as a premier source of innovative sustainable solutions to improve efficiency, effectiveness and profitability of Alabama business and industry.

APC offers student internships with businesses throughout the state giving students ability to explore career options, understand the nature of the industry world, and acquire valuable skills not taught in the classroom. Most students are juniors, seniors or graduate students with majors such as engineering, operation management, information technology, marketing and other disciplines, according to information provided by the university.

The UAB School of Engineering spread across five academic departments, provides undergraduate students with a solid foundation in engineering. With more than 15 graduate degree programs and tracks to choose from at the master and Ph.D. level, as well as a variety of certificate programs, UAB offers highly adaptable programs that range from traditional M.S./Ph.D. pathways to online master of engineering degree tracks for working professionals, according to the school curriculum.

Justin Koch at the UAB School of Engineering and Jody Beck at the Alabama Productivity Center are leading the charge at their respective institutions efforts to produce face shields.

UAB Hospital is supplying materials for the face shields; the teams at Alabama Power, UAB and UA are donating their time.

Alabama Power’s TAC facility serves as a demonstration and test facility that investigates ways to reduce production costs, improve energy efficiency and productivity while addressing environmental concerns.

“I look at it from our group’s perspective; we are helping our customers,” Bishop said. “In this case, our customer is the hospital’s staff. We are still helping our customers, just in a different way.”

“The Alabama Productivity Center, a non-profit organization, is an outgrowth of a 1983 joint venture of the University of Alabama and General Motors to save a Tuscaloosa GM plant from closing,” according to the center’s website. “The positive experience utilizing university faculty and students to save Alabama jobs led to the establishment and sponsorship by Alabama Power Company and the University of Alabama.”

“Safety has always been our top priority,” said APC spokesperson Katie Bolton. “As the pandemic has unfolded, this is one of the small ways we can take something that’s important to us and use our resources to help provide some safety for the frontline healthcare workers,” she continued. “We want these important health care workers to return home to their family’s and loved ones safely. That’s part of Alabama Power’s core value system.”

These types of private, university and state partnerships are increasingly becoming the backbone to fighting the COVID-19 pandemic.

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Opinion | It’s make or break time: The math behind social distancing

John Atkinson

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John Atkinson is the public relations and marketing director at East Alabama Medical Center.

On March 31, EAMC’s Chief of Staff Michael Roberts, M.D. used the Penn Medicine CHIME tool to look at where East Alabama Medical Center—and its collective communities—stand regarding the COVID-19 coronavirus and social distancing.  After sharing the resulting data with his colleague, Ricardo Maldonado, M.D., infectious disease specialist, the two knew it was make or break time.

“Social distancing is the number one denominator,” says Dr. Roberts, EAMC’s chief of staff.  “If we do a poor job of that—50 percent or less—then we’re in a situation where our hospital simply cannot handle the influx of ICU patients we will see or the number of ventilators we will need, and many people will die as a result. This includes even those without COVID-19 because we simply will not have the staff and equipment to keep up.”

When asked recently by a local official what percentage he thinks we are at currently, Dr. Roberts hesitated before answering. “I don’t know if I can put a number on our current performance,” said Dr. Roberts. “The website unacast.com recently gave the state of Alabama a grade of ‘D’ on social distancing, representing only a 55 percent decrease in non-essential visits. Lee County was a little better with a grade of ‘B minus,’ and Chambers County received a ‘D.’ If we really want to save lives and return to a sense of normalcy, we need to shoot for an ‘A,’ with 75-100 percent social distancing—not just in Lee County, but in all of the surrounding areas.”

Dr. Maldonado agreed, and did not mince words. “If we are not pro-active today, we won’t see light anytime soon.”

75 or 100 Percent

Looking at the social distancing percentages, if 75 percent of people comply, the peak number of COVID patients at EAMC at one time would be 74, with 28 of them in ICU and 21 of them on ventilators.  Those numbers are manageable, but the problem is that the peak is not until June 15, meaning that the 75 percent of people doing the right thing will have to do it for more than two more months.  “And that only gets us to the peak,” states Dr. Roberts. “We would still have COVID-19 in the community.”

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Using the following assumptions: population of 180,000, first hospitalization on March 16 and 64 patients currently hospitalized, the predictive modeling clearly shows that 100 percent social distancing is by far the best option.  Hopefully, the “stay at home” order put in place by Governor Kay Ivey, effective Saturday, is the catalyst to reach that 100 percent mark.

“Likely have thousands of cases in our area”

Some people point to the number of confirmed cases in the community and believe the situation is not so dire. Dr. Maldonado says that does not paint an accurate portrayal.  “The number of positive cases does not tell us the number of people with COVID-19 infection,” says Dr. Maldonado. “We are testing less than 100 a day while we get almost 1,000 calls daily at 528-SICK. If we tested all 4 million people in Alabama at once, we could then know how many have it,” he says, followed by a disclaimer.  “Even if we did that, the next day, the number could multiply by 2 or 3 easily. The number of reported cases is just the tip of the iceberg.”

Dr. Maldonado goes on to say that 20 percent of adults will need to be hospitalized, “but this calculation does not include children who are likely the ones that have only mild symptoms or no symptoms at all; and they will continue to infect other people.”

The bottom line, says Dr. Maldonado, is that “we likely have thousands of cases in our area if we include children. Each person can infect between two and three, or much more in large gatherings that include handshakes and touching.”

“The only real option”

Dr. Maldonado, who has 16 years of infectious disease experience, including 11 years at EAMC, says there is no time to waste. “We can see the top of the peak in less than three weeks if we practice 100 percent social distancing starting right now!  That means businesses can open back up sooner, people can spend time with friends and loved ones, and churches can meet sooner. The only real option—where this lasts the least amount of time and where the least amount of people die—is when we see 100 percent of our community practicing social distancing.”

What exactly is Social Distancing?

The term social distancing has been used a lot, but what exactly does it mean to practice social distancing.  Here are the key things to know:

  • Stay inside your home as much as possible.
  • If someone in your home shows symptoms of COVID-19 (cough, shortness of breath, fever of 100 or more), isolate them immediately and do not allow any non-family members into the house.
  • If you go outside to exercise or for other reasons, stay a minimum of 6 feet away from anyone and do not touch surfaces that others may have touched.
  • Use hand sanitizer before going back into your home. Or, wash your hands immediately inside your home and then sanitize your door and faucet handles.
  • Limit outings to food, healthcare, pharmacy and gas.
  • In those settings, stay a minimum of 6 feet away from anyone and do not touch surfaces that others may have touched.
  • Use hand sanitizer after opening doors, touching grocery carts, handling money of any form, and any surfaces that others may have touched.
  • Do not touch your face with your hands, especially your eyes, nose or mouth.
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