Monday, July 6, 2020

Michigan groups sue to "Stop the Hamster Wheel" - Medicaid hearings that are never resolved due to lack of adequate funding

A press release from three legal advocacy groups, Including Michigan Protection and Advocacy Services (MPAS), alleges "Systematic Due Process Violations in Michigan Medicaid Program":

...Lansing, MI – Medicaid recipients have long had rights to “fair hearings” to challenge actions affecting their benefits. According to a new lawsuit, however, recipients in Michigan cannot get relief from those hearings, even when they win.

The suit, filed by attorneys for Michigan Protection & Advocacy Service, Inc. (MPAS), the National Center for Law and Economic Justice (NCLEJ) and Legal Services of South Central Michigan (LSSCM), says that the administrative law judges (ALJs) presiding over fair hearings lack the power to order the agency to grant the benefits it had wrongfully denied. All they can do is send the case back to the agency to “reassess” the recipient. And when the agency comes back with the same decision on reassessment—as it often does—all the recipient can do is ask for another fair hearing, where the same thing will happen again. This is the Michigan Medicaid “Hamster Wheel”: recipients run and they run and they run, but they never get anywhere.

Named Plaintiff Kevin Wiesner lives with various disabilities, and he relies on Medicaid-funded community living supports (CLS) to stay in the community. In 2019, he challenged the CLS budget provided by Washtenaw County Community Mental Health (WCCMH), and the ALJ held in his favor in every respect: The budget was insufficient to meet Kevin’s medical needs, it had been insufficient since at least 2015, and at least a certain, specific amount was required to make it sufficient. But the ALJ did not—because he said he could not—order a budget of that amount. Instead, he told WCCMH to “reassess” Mr. Wiesner’s needs. To no one’s surprise, WCCMH’s “reassessment” ignored the ALJ’s determination and denied Mr. Wiesner any increase at all.

“For more than 50 years, the Constitution and federal statutes have guaranteed public benefit recipients the right to an impartial determination of their benefits,” said Ed Krugman, a senior attorney at NCLEJ, “The Michigan Hamster Wheel makes a mockery of that right. Kevin Wiesner fought for the services he needs, and he won, but he got precisely nothing. That is a travesty.”

“The Medicaid Fair Hearing System is supposed to give recipients the right to challenge actions that negatively affect their benefits,” said Kyle Williams, legal director for MPAS. “If administrative law judges are only allowed to order reassessments, they can never win those challenges, because the reassessment decision is ultimately in the hands of the agency that took the negative action in the first place.”

Nick Gable, attorney for LSSCM, offered a similar thought. “The Medicaid fair hearing “Hamster Wheel” has been a problem for years, to the point that appeals challenging personal care or home and community-based support services denials are rendered futile. A legal challenge to the Hamster Wheel is overdue.”

The suit names WCCMH, Community Mental Health Partnership of Southeast Michigan, their directors, and Michigan Department of Health and Human Services Director Robert Gordon as defendants. The requested relief seeks to end the practice of ALJs remanding cases without ordering specific relief for Medicaid recipients.

Michigan Protection and Advocacy Service, Inc. (MPAS) is the independent, private, nonprofit organization designated by the governor of the State of Michigan to advocate and protect the legal rights of people with disabilities in Michigan.

Since 1965, the National Center for Law and Economic Justice (NCLEJ) has worked with low-income families, individuals, communities, and a wide range of organizations to advance the cause of economic justice through litigation, policy work, and support of grassroots organizing around the country.

Legal Services of South Central Michigan provides free legal advice and representation to low-income individuals, families, and older adults.

For more information, contact:

Mark McWilliams

or Edward P. Krugman

Kerry Kafafian [ ], Kevin's mom, is also willing to provide more information about the lawsuit.

Tuesday, June 30, 2020

Troubled times: law enforcement, severe mental illness, and other disabilities

Susan Werner - Did Trouble Me on YouTube

As we experience the Covid-19 pandemic, political unrest, and economic uncertainty, we frequently hear the expression “During these troubled times…” or something equivalent. Whether it is used in an ad for anti-anxiety medication or to promote a candidate in a seemingly distant election, many people with severe mental illness and those with severe intellectual and developmental disabilities (IDD) and their families experience “troubled times” as the norm. Untroubled times are a welcome relief, while waiting for troubles that may be just around the corner. 

In the recent Black Lives Matter upheavals following the horrific video-recorded killing of George Floyd in Minneapolis, a demand to “Defund the Police” has been pushed to the forefront of news coverage. There are varying interpretations of what this means. However one interprets the phrase, there is a lot to be gained from examining the role of law enforcement in the lives of people with mental illness and other disabilities, the allocation of taxpayer funds in this regard, and whether there are more effective ways to use the money that might produce better results for everyone concerned. Police departments, like public schools, are often called on to solve societal problems that they have no control over, such as poverty, the lack of medical and mental health care, and homelessness. The neglect of these problems through years of de-funding programs that might have shored-up our system of care and services to people with with mental illness and intellectual and developmental disabilities (IDD), has led to law enforcement taking on responsibility for problems where others have failed to have an impact. It is hard to believe that most police officers want this responsibility, nor are they very good at solving these types of societal problems.

Severe mental illness often leads to police involvement when a person with untreated mental illness is perceived as acting irrationally or in a threatening manner toward others. People with severe IDD and their families experience similar situations to that of people with severe mental illness and their families. [See "Michigan’s mental health system is failing many with severe autism", 5/16/19 from The DD News Blog for some examples.]

The Treatment Advocacy Center (“Eliminating barriers to the Treatment of Mental Illness”), distributes a Research Weekly that recently looked at the “Role of Law Enforcement in Mental Illness Crisis Response". Its recommendations show how shifting funding from law enforcement to better care and treatment for people with severe mental illness would relieve law enforcement of taking on responsibilities better left to the mental health system and divert people who are unnecessarily forced into the criminal justice system into more appropriate and effective treatment.

Here are excerpts from from the Research Weekly: "Role of Law Enforcement in Mental Illness Crisis Response":
“The Treatment Advocacy Center has been calling attention to the need to transform law enforcement’s role in communities for more than 20 years, starting with the work of our founder Dr. E. Fuller Torrey. Our research expertise includes the role of law enforcement in mental illness crisis response and how people with severe mental illness are overrepresented in the criminal justice system.

"What follows is a compilation of data and information on these important topics: ..”
"Approximately one in four fatal police encounters involve an individual with severe mental illness, according to our 2015 report, Overlooked in the Undercounted. This means that people with mental illness are 16 times more likely to be shot and killed by police, compared to people without mental illness. Reducing the disproportionate volume of contacts between law enforcement officers and people with severe mental illness is the single most immediate, practical strategy to reduce fatal police encounters for individuals with mental illness. Furthermore, there is currently no national government database collecting information regarding arrest-related deaths, let alone the role of mental illness or race disparities in these encounters."

"The role of law enforcement in mental illness crisis response is an enormous portion of department resources and budgets. Responding to and transporting individuals with mental illness occupies more than one-fifth of law enforcement officers’ time, according to our 2019 report, Road Runners . This outsized role is a result of the overrepresentation of people with mental illness within the criminal justice system, the length of time mental health crisis service calls take, the long distances law enforcement must travel to find available mental health resources and the time officers must wait while transporting individuals in crisis to an emergency department."


"The lack of appropriate mental health treatment services in the community was the most prominent factor contributing to law enforcements’ outsized role in mental health crisis response, according to a thematic qualitative analysis of our 2019 law enforcement department survey results . Survey respondents felt that many of the time and resource issues surrounding psychiatric transports are due to an inadequate supply of beds in the community for individuals to receive treatment. As with any other illness, severe psychiatric diseases have a variable illness course, with waxing and waning symptomology and resulting needs for the individual suffering. Therefore, a full continuum of psychiatric care, including outpatient, crisis, and acute care, as well as longer-term and residential-type beds, is needed for a functioning psychiatric system. Few communities in the United States have such a robust mental health care system in place."

"As municipalities continue to examine the role law enforcement plays in our society, these data and resources can serve to inform evidence-based policy decisions.

Elizabeth Sinclair Hancq
Director of Research
Treatment Advocacy Center

Monday, June 1, 2020

Michigan Update on Covid-19 Policies and More...

The ARC Michigan is the largest organization in the state advocating for people with developmental disabilities. As the parent of two sons with profound intellectual and developmental disabilities (IDD), I often disagree with the policies the organization has promoted over the years that ignore the real-life consequences of severe disabilities on the individual and his or her family. Along with many other disability advocacy organizations, the Arc attempts to promote public acceptance of disabled individuals by painting a rosy and unrealistic picture of life with a disability and applies it to all who fall under that category. I do give them credit, however, for making available information that individuals and families need to participate in effecting change in government policies.

The ARC Michigan e-newsletter update has timely information on legislation, other state and national policies, and recent court decisions affecting people with IDD. The archives for the newsletter are available on the website. You can also sign up to receive the newsletter by e-mail.

This is from the May 29, 2020, Government Affairs Update from RWC Advocacy, A Governmental Affairs Law Firm in Lansing, Michigan:

Emergency Authorities & COVID-related Legislation

The Michigan House of Representatives has yet to take action on Senate Bill 690, which provides $523 million in supplemental appropriations for Fiscal Year 2020 from the federal coronavirus relief fund for various purposes, most notable of which is the inclusion of a $3/hour increase for direct care worker wages. [emphasis added] We can likely expect the supplemental to move the first week of June.

[This appears on page 11 of the bill: DEPARTMENT OF HEALTH AND HUMAN SERVICES

Section 451. (1) From the funds appropriated in part 1 for pay enhancement for direct care workers, the department of health and human services shall provide sufficient funding to increase the wages paid to direct care workers described in subsection (2) by $3.00 per hour above the rates paid on March 1, 2020 retroactive to April 1, 2020 through September 30, 2020.
(2) The direct care wage increase shall be provided to direct care workers employed by the department of health and human services, its contractors, and its subcontractors who received a state-funded wage increase in April 2020. The total combined increase from the April 2020 wage increase and the wage increase outlined in this section shall be $3.00 per hour and shall be in effect from April 1, 2020 to September 30, 2020.
(3) A direct care wage increase of $3.00 per hour shall be provided to direct care workers employed by skilled nursing facilities, retroactive to April 1, 2020 and shall continue until September 30, 2020.
(4) Contractors and subcontractors receiving funding to support these pay enhancements shall be required to provide documentation of the wage increases provided pursuant to this section to the department of health and human services.
(5) Any payment enhancement above the hourly rate in effect on March 1, 2020 shall be of no effect in determining any employee's average compensation as provided by any contract or other provision of law...]


[The bill is 18 pages long and contains funding information on many other departments of state government. To find out more, read the bill.]

Stay Home, Stay Safe 

On Thursday, May 21, Governor Whitmer announced that she signed another iteration of the Stay Home, Stay Safe order – Executive Order 2020-96 – reaffirming the measures set forth in the previous order but taking the following new actions:
  • Repeal of Executive Orders 2020-17 and 2020-34, which imposed a prohibition on elective dental, medical and veterinary services statewide, beginning on Friday, May 29 at 12:01 a.m.

  • Allowing statewide reopening of auto showrooms, by appointment only, on Tuesday, May 26.

  • Allowing statewide retail, by appointment only, starting on Tuesday, May 26. Stores will be limited to 10 customers at any one time.

  • Allowing statewide gatherings of 10 people or less are allowed, but necessary health and safety measures should be used.
...Executive Authority Lawsuit

Judge Cynthia Stevens issued a ruling in the Michigan Court of Claims on Thursday, May 21 in Michigan House v. Whitmer upholding the Governor’s authority to declare a state of emergency under the Emergency Powers of the Governor Act of 1945. However, the judge also ruled that the Governor could not declare a state of emergency and disaster declaration under the Emergency Management Act of 1975 without legislative intervention.

[The Governor also has authority under the Emergency Powers of Governor Act of 1945 that does not require the intervention of the legislature.]

See more about Medicaid funding and the legislative attempt to direct funds from recent federal legislation to help the state get through the financial disaster that the corona virus has created.

Friday, May 29, 2020

Washtenaw County Democratic Party Special Education Summit, 6/18 @ 6-8 pm

from the Washtenaw County Democratic Party:

Special Education Summit, K-12
June 18 @ 6:00 pm - 8:00 pm

The Washtenaw County Democratic Party is working hard to tighten our connection to the community and serve as a bridge between politics and people. Since parents have started crisis schooling, many of the gaps in our education system have been exposed. What does the “sense of urgency” in our response say about our commitment to educational equity? The WCDP’s Dems Care has organized the Special Education Summit to address this question. This event will include a number of speakers as well as several breakout panels with experts in the field. These panels include:

  • The Tea Room: Open discussion for parents
  • How Stuff Works: IEPs during COVID-19, summer resources and services
  • Advocacy is Self-Care: Special education advocacy
  • Big Changes: Social-emotional support, advice for families with students who were in self-contained classrooms
  • Ally/Working with Families and Intersections: How to support non-parent allies including teachers, social workers, and service providers
More information is forthcoming including a link to the Zoom meeting.

Wednesday, May 27, 2020

Parenting a child with severe autism during a pandemic

This is an NPR interview with Feda Almaliti, the mother of a 15-year-old son with severe autism. Feda is also the Vice President of the National Council on Severe Autism and has written articles for the NCSA Blog and the Autism Society San Francisco Bay :

'He's Incredibly Confused': Parenting A Child With Autism During The Pandemic  

May 22, 2020
Heard on All Things Considered 
by Courtney Dorning and Mary Louise Kelly 

Here are some excerpts from the interview: 

"'Muhammed is an energetic, loving boy who doesn't understand what's going on right now. He doesn't understand why he can't go to school. And school is one of his favorite places to go. He doesn't understand why he can't go take a walk in the mall when that was one his favorite things to do. He doesn't know why he can't go to the park, why he can't go down to the grocery store,' Almaliti says. 'So he's incredibly confused, in this time when we're all confused, but he really doesn't understand it.'"

..."It's the unknowing. ... We don't know when it's going to end. We don't know what's going on, and to deal with autism at home makes it even harder. The only support that I get to get through it is through fellow autism parents. We have Zoom calls, and we try to find humor in this thing. ... We're just trying to lean on each other to get through. Because I can't do it alone. Nobody can."...

"...I almost feel like nobody hears us. Because my son doesn't really talk. He doesn't talk. And I'm supposed to be his voice. And no one's listening to what's going on for our families. You know, no one gets that we are just as vulnerable as coronavirus people. The coronavirus is going to come and go. Autism is here to stay." ...

..."We desperately need extra help to get through this. And I firmly believe that autism support workers, aides, their teachers and caregivers are as essential as nurses and doctors and should be given the same accommodations. People don't understand that for our families, caregivers are our first responders. Special needs schools are our hospitals. Our teachers are our ventilators. And we can't do this without them."

More articles by Feda Almaliti:

Three Strikes... and He's Out?
May 23, 2020 [Reprinted from
a 2018 blogpost at Autism Society San Francisco Bay Area]

What happens when the regular world has had enough of my son's autism 
..."Inclusion is a hot topic in disability circles, but when our kids can’t play by society’s rules, inclusion can truly suck. Instead of some fantasy of joyful acceptance, we get black-listed. Over and over and over. How I dream of places, spaces and programs fully accepting of our special children. Autism-friendly rules, not 'If you act autistic you’re out' rules."

"...At Autism Society San Francisco Bay Area’s Summer Pool Parties we make sure an autistic kid can be him or herself. Where they can chew on pool noodles, bellow and flop around, and no one judges them. So here we are, me in the burkini and Mu in his element. A place, however small, where everyone with autism belongs... on the VIP List. If only the rest of the world were so accommodating."

Inclusion Sucks. Or, Why My Son with Severe Autism Has Nowhere to Swim this Summer 

May 22, 2020

"An autism mom stuck at home with her son on a hot summer day meditates on the smallness of his world when inclusion is the only option. ...Of course my pool predicament is a microcosm of a bigger problem: disability-friendly day programs, jobs, housing, and therapeutic care—vital lifelines for parts of our population—are at risk given the direction of federal policy. The trendy mantra is 'community integration' while options for the severely disabled slowly disappear into the black hole of red tape and de-funding."...

..."They say, 'Why maintain an autism day program when Joe could just go to the local Y?' or 'Why have sheltered workshops when Sam can get a competitive job at Safeway?' Please tell me, what are these people smoking and in which smoking lounge can I find them? Have they ever tried caregiving for someone like my son?

"So let's make a deal. Let's ensure inclusion and integration for all those who want it. And let's support acceptance of all, including acceptance of alternative options for the Muhammeds of our world. Don't let narrow ideology throw our babies out with the bath, or, er, pool water. It's just common sense. In the meantime if you'll invite us over for a swim, we'd appreciate it."

Monday, May 25, 2020

Michigan voter information - the Secretary of State's Website is the most reliable source

Last week, Michigan was the subject of a tweet storm between President Trump and Jocelyn Benson, the Michigan Secretary of State. As the dust settled, it turned out the President’s assertions were without merit and the original tweet was deleted, but the odor lingered of a grossly misleading accusation - that the Michigan Secretary of State was implicated in voter fraud. 

I looked to for an accurate account of what happened. is a “nonpartisan, nonprofit 'consumer advocate' for voters that aims to reduce the level of deception and confusion in U.S. politics.” It is a project of the Annenberg Public Policy Center of the University of Pennsylvania. 

According to this article at, “Trump’s False Tweet About Michigan Absentee Ballot Applications” by D’Angelo Gore, 5/20/20:

“President Donald Trump erroneously tweeted that Michigan’s Democratic secretary of state was 'illegally' sending 'absentee ballots to 7.7 million people' for this year’s primary and general elections.

“The state said it will send absentee ballot applications — not actual ballots — to all registered voters, who may want to vote by mail.”

The article confirms that Benson’s Republican colleagues in Iowa, Georgia, Nebraska, and West Virginia have also mailed absentee ballot applications to voters and there is nothing illegal about it.

“The National Conference of State Legislatures says that all U.S. states allow qualified voters to vote by absentee ballot, and five states (Utah, Colorado, Hawaii, Washington and Oregon) currently conduct all their elections primarily by mail. Michigan is one of 34 states that do not require an excuse from those who want to vote by absentee ballot, according to the NCSL." [emphasis added]

The President deleted his original tweet and replaced it with one that claimed incorrectly that sending out ballot applications is illegal. He also threatened to withhold unspecified federal funds from Nevada and Michigan for sending out “illegal” ballot applications.

Furthermore, “Election experts previously told us that fraud via mail-in ballots is more common than in-person voting fraud, but still rare. Plus, a recent study by Stanford University’s Democracy & Polarization Lab found that neither the Democratic or Republican parties would benefit from an entirely vote-by-mail system.”

Putting all this aside, the Michigan Secretary of State Website has tons of information on voting. Here are some excerpts that tell you who can vote, where to vote, and how to vote;

How does one register to vote and who is eligible to vote?


You can register to vote through Election Day.

You must be:
  • A Michigan resident (at the time you register) and a resident of your city or township for at least 30 days (when you vote)
  • A United States citizen
  • At least 18 years of age (when you vote)
  • Not currently serving a sentence in jail or prison

[Note that a person under guardianship as determined by a Probate Court is not disqualified from voting. My husband and I are plenary co-guardians for our two sons who have profound developmental and Intellectual disabilities. If we thought they had opinions on who they would like to vote for, we would be happy to facilitate that. But they are unable to communicate or give any indication that they understand the concept of voting, so we will not do that. If we did, I think one could easily question whether we were having them express their own thoughts and opinions, or just giving ourselves two extra votes based on our own opinions.]

Check to see if you are registered to vote

[Michigan does not register voters by political party. If you vote in a primary election to choose a candidate for a political party, you must pick which party primary you want to vote in. You may not split your vote between parties.]

Frequently asked questions about voting



Do I need to show identification in order to vote?

Michigan does have a voter identification requirement at the polls. Voters are asked to present an acceptable photo ID such as a Michigan driver's license or identification card. Please note that voters who do not have an acceptable form of ID or failed to bring it with them to the polls still can vote. They simply sign a brief affidavit stating that they're not in possession of a photo ID. Their ballots are included with all others and counted on Election Day….

Can Michigan residents in jail or prison still vote?

Michigan residents confined in jail or prison who are awaiting arraignment or trial are eligible to vote. However, residents who are serving a sentence in jail or prison after conviction cannot vote during the period of confinement. When residents are released from jail or prison after serving a sentence, they are free to participate in elections without restriction.

Can voters be challenged based on home foreclosures?

The compilation of home foreclosure information alone does not provide sufficient reason to challenge a person's voting status. In fact, the Michigan Republican and Democratic parties are in agreement that so-called foreclosure lists do not provide a reasonable basis to challenge voters.

How does the voter ID requirement affect me if I vote with an absent voter ballot?

If obtaining your absent voter ballot in person, you will be requested to show photo ID. If you are not in possession of photo ID, you can simply sign an affidavit stating you are not in possession of photo ID. This requirement does not apply if requesting your ballot via mail. 

Does Michigan allow early voting?

Michigan Voters can cast absentee ballots beginning 45 days prior to Election Day. These ballots are tabulated on Election Day.

For more information and answers to questions, see Michigan Election and Voter Information

Future Scheduled elections: 

Primary elections: August 4, 2020
General election: November 3, 2020

Saturday, May 23, 2020

Covid-19 Transmission: the risks and how to avoid them

When it comes to Covid-19 and the global pandemic, we are constantly advised to “follow the science” without considering what that means exactly. There are many variations of the definition of science. Here are parts of a definition from  that go a long way to describe what I refer to as “science”:

“...systematic knowledge of the physical or material world gained through observation and experimentation”…”knowledge, as of facts or principles; knowledge gained by systematic study”

Add to that this excerpt from : “..the state of knowing : knowledge as distinguished from ignorance or misunderstanding”. This covers the territory for me.

“Science” is not static. A body of knowledge about a new human virus changes with time as we get to know more and more about it. What we do about it is sometimes based on misleading and incomplete information. Combined with wacky conspiracy theories and unproven assertions of fact, the public response to the presence of the virus can veer into irrationality.

Early on in the pandemic, medical authorities recommended that masks should be worn by front-line medical workers, but were not necessary for average citizens without symptoms to contain the spread of the disease. This was based partly on a shortage of masks for medical workers who were most at risk of coming into contact with people who were contagious and falling ill because of it. As the shortage of masks eased and more studies came out about the value of masks in controlling previous epidemics, the recommendation changed to encourage the use of masks by everyone who was in a situation where strict social distancing could not be observed, and, finally, everyone out in public should wear a mask because many people can be contagious with the virus before they experience symptoms. Many others transmit the virus without ever knowing they have it.

For some, this seemed like a betrayal. People we are supposed to trust told us one thing and then recommended the exact opposite a few weeks later. “Science” does not offer certainty or necessarily comfort for people who are confused and fearful. But scientific knowledge, even as it changes, usually gives us the best chance to protect ourselves and our fellow citizens - in other words, to do the right thing.


“News” about Covid-19 that is more than two weeks old may be out of date. But this article, "The Risks - Know Them - Avoid Them", 5/6/2020, that appeared as a blog post by Erin Bromage, an Associate Professor of Biology at the University of Massachusetts, Dartmouth, functions as a little instruction manual for understanding the virus that causes Covid-19 and what we can do to avoid infection and prevent its spread. This is especially relevant as states remove restrictions on activities that have helped to contain the virus.

Here at two things from Bromage’s blog post to keep in mind when you read the article:

“As states reopen, and we give the virus more fuel, all bets are off. I understand the reasons for reopening the economy, but I've said before, if you don't solve the biology, the economy won't recover. “ [emphasis added]


“Remember the formula: Successful Infection = Exposure to Virus x Time”

Highlights from “The Risks - Know Them - Avoid Them”

Based on infection dose of other Corona viruses, “Infection could occur, through 1000 infectious viral particles you receive in one breath or from one eye-rub, or 100 viral particles inhaled with each breath over 10 breaths, or 10 viral particles with 100 breaths. Each of these situations can lead to an infection.”

Sources of Infection

"A Bathroom: Bathrooms have a lot of high touch surfaces, door handles, faucets, stall doors. So fomite [objects or materials that are likely to carry infection] transfer risk in this environment can be high. We still do not know whether a person releases infectious material in feces or just fragmented virus, but we do know that toilet flushing does aerosolize many droplets. Treat public bathrooms with extra caution (surface and air), until we know more about the risk...."

A Cough: A single cough releases about 3,000 droplets and droplets travels at 50 miles per hour. Most droplets are large, and fall quickly (gravity), but many do stay in the air and can travel across a room in a few seconds."

"A Sneeze: A single sneeze releases about 30,000 droplets, with droplets traveling at up to 200 miles per hour. Most droplets are small and travel great distances (easily across a room)."

"A breath: A single breath releases 50 - 5000 droplets. Most of these droplets are low velocity and fall to the ground quickly. There are even fewer droplets released through nose-breathing. Importantly, due to the lack of exhalation force with a breath, viral particles from the lower respiratory areas are not expelled."

"Speaking increases the release of respiratory droplets about 10 fold; ~200 virus particles per minute. Again, assuming every virus is inhaled, it would take ~5 minutes of speaking face-to-face to receive the required dose.

Who is contagious?

“Symptomatic people are not the only way the virus is shed. We know that at least 44% of all infections--and the majority of community-acquired transmissions--occur from people without any symptoms (asymptomatic or pre-symptomatic people). You can be shedding the virus into the environment for up to 5 days before symptoms begin.”

“The amount of virus released from an infected person changes over the course of infection and it is also different from person-to-person. Viral load generally builds up to the point where the person becomes symptomatic. So just prior to symptoms showing, you are releasing the most virus into the environment. Interestingly, the data shows that just 20% of infected people are responsible for 99% of viral load that could potentially be released into the environment.”

Where are you most likely to contract the virus?

“We know most people get infected in their own home. A household member contracts the virus in the community and brings it into the house where sustained contact between household members leads to infection."...

“But where are people contracting the infection in the community? I regularly hear people worrying about grocery stores, bike rides, inconsiderate runners who are not wearing masks.... are these places of concern? Well, not really. Let me explain….”

Bromage gives excellent explanations with references to relevant studies of outbreaks that show where an invidual is most at risk to contract the virus. 

“The reason to highlight these different outbreaks is to show you the commonality of outbreaks of COVID-19. All these infection events were indoors, with people closely-spaced, with lots of talking, singing, or yelling. The main sources for infection are home, workplace, public transport, social gatherings, and restaurants. This accounts for 90% of all transmission events. In contrast, outbreaks spread from shopping appear to be responsible for a small percentage of traced infections.”

…”Basically, as the work closures are loosened, and we start to venture out more, possibly even resuming in-office activities, you need to look at your environment and make judgments. How many people are here, how much airflow is there around me, and how long will I be in this environment. If you are in an open floorplan office, you really need to critically assess the risk (volume, people, and airflow). If you are in a job that requires face-to-face talking or even worse, yelling, you need to assess the risk. “

Most importantly, “… if you don't solve the biology, the economy won't recover. “

Read “The Risks - Know Them - Avoid Them” by Erin Bromage to see all the graphics accompanying the article, references to studies, and information about the author.