Donald Trump, the CDC and much of the rest of the federal government have demonstrated sustained incompetence on getting testing going…
The obvious answer is to enlist the adult film industry in returning the economy to normalcy. The industry has operated a testing system successfully for years to stave off threats of infections from HIV and other sexually transmitted diseases.
I went on to describe the PASS system that had operated successfully for a decade, with frequent testing and follow-up. I encouraged employers to do something similar.
Employers haven’t really taken this on, but one sector of the economy is not only adopting this approach but taking it to the next level. Some high-end private colleges and universities are determined to return to campus this fall. Online classes are ok but they are a very poor substitute for the in-person experience and are frankly not worth the tuition.
Unlike some of our red state governors, certain college presidents are taking a cold, hard look at what it will take to make it happen. They aren’t relying on science and public health experts, not wishful thinking. And they have come to the same conclusions that the porn kings did.
Here’s what Colby College is doing (emphasis mine). They expect to spend $10 million this year.
Colby’s testing program… will require the participation of all members of the campus community—students, faculty, and staff. Students will be tested prior to arrival with test kits provided by Colby, and all community members will be tested three times during the opening weeks of the semester. Thereafter, everyone will be tested twice per week, a rate that scientific models have demonstrated will greatly limit the spread of the virus by detecting infections in individuals prior to them becoming contagious. To put this in perspective, we expect to administer roughly 85,000 tests in the first semester alone, a number that almost equals the total number of tests administered in the entire state of Maine since the start of the pandemic.
…Test results will be returned to the individual and the College within 24 hours, allowing for any required mitigation efforts to be instituted quickly. We have leased additional housing for quarantine and isolation of students, who will be provided with a range of support services, including facilitating their coursework, attention to medical and mental health, and food delivery.
Brandeis will provide high-frequency, mandatory COVID-19 testing to all on-campus community members…All students living in campus residence halls will be tested upon their arrival to campus, and students living off-campus will be tested at a designated time before the start of the fall term. There will also be mandatory testing multiple times per month for all students, faculty, and staff who either live on campus or who come to campus several times per week, whether or not they are symptomatic. This will enable us to quickly identify and contain any instances of infection on our campus. Those coming to campus less frequently will also be tested, though not as frequently.
Testing is part of broader plans, but it is the core and let’s us know they are dead serious. Both of these schools are working with the Broad Institute for testing.
Interestingly, some other colleges are wavering on testing or throwing in the towel with a move to online only. Good luck with that.
Purposeful –aiming to meet the objective of educating children in person while keeping them and staff members safe
Timely –coming at the end of the school year, with updates promised over the summer
Evidence based –relying on the latest medical and public health guidance and the experience of schools abroad
Appropriately detailed –with enough specifics to guide decisions that need to be made now without being overly prescriptive
Circumscribed –acknowledging and accounting for issues of racism and disparities without purporting to solve every problem
Balanced –recognizing that we are living in the real world (such as it is!) and that COVID-19 is part of it. None of the measures (hand washing, masks, staying home when sick, social distancing) on their own will prevent the spread, but taken together they have and will
I’m not an easy grader, so my A for this assignment is real. I have publicly criticized Massachusetts’ reopening plan and its testing plan for being vague, non-evidenced based, and irrational. Privately, I’ve admonished the local school system for its defeatist attitude toward COVID-19.
The plan doesn’t set a cap on the number of students in classrooms
COVID-19 testing is not mandated
Daily temperature checks are not required
It mandates only 3 feet of social distancing even though officials have been telling us 6 feet
Superintendents need to develop 3 sets of plans (in person, hybrid, virtual)
No clear guidance on whether state should go back to in-person classes when school reopens
Doesn’t adequately address challenges of urban schools that serve children from disadvantaged backgrounds and have limited space
Racism is not connected to students’ mental health in the plan
It doesn’t say how many students can ride the bus
People don’t like the idea of wearing masks all day
The report itself anticipates and addresses these criticisms. The Globe notes some but not all. Here is the reasoning
Number of students isn’t capped because the relevant constraints are adequate space between desks and proper behavior. If a room is larger it can accommodate more students. The report encourages use of new spaces like libraries and cafeterias
No one in the country (or world?) is seriously suggesting testing all school age kids. It’s expensive, slow, unpleasant, impractical and unnecessary. Maybe there will be cheap, spit tests at some point. They can be used if the need is real
Daily temperature checks produce too many false negatives and false positives, offering a false sense of security and causing students to miss school when they don’t need to. These checks are good for other illnesses, like the flu where fever is a good indication of active infection, but it’s of limited use for COVID-19
There’s no magic in 6 feet. Three feet seems to work fine in other countries’ schools, especially in combination with other measures, like wearing masks. Schools with 3 feet of distance abroad have not had outbreaks. Kids aren’t going to be safer out of school
Superintendents need to develop plans for different scenarios. Of course they do! If they just developed one plan it would have to be for remote instruction only. Is that what we want?
Of course the guidelines can’t be definitive in June about whether students can go back in September. But the goal is to get as many back as possible. To make that happen requires everyone to behave well over the summer (adults, especially!)
Although the plan isn’t going to eliminate disparities or solve racism, there are extra funds to help all schools and especially those with extra needs. And the best way to reduce disparities is with kids in school. Disparities widen (as I’m sure they did this spring) when normal routines are thrown off. For extra space, the guidelines suggest working with local community centers, libraries, etc.
Kids will need to wear masks on the bus. If the bus is crowded then buses will need to be added or kids will need to get to school in other ways. They can keep windows open, too.
It’s true that people don’t like wearing masks all day. The guidelines call for mask breaks and make special mention of how to work with people with breathing or communication problems. If we all behave there’s a good chance we can take our masks off sooner rather than later.
Notably, these guidelines are endorsed by people who know what they’re talking about and have children’s interests at heart. The healthy approach is to work within the guidelines to plan a return to in-person classes this fall. We should continue to challenge the guidelines and expect them to be updated as we learn more and as the situation on the ground evolves.
Meanwhile, we can all contribute to a safer back-to-school scenario by continuing to follow public health guidelines that are knocking the virus down in Massachusetts. The lower the level of community spread, the safer any reopening plan will be.
COVID-19’s impact on the United States and its healthcare system is unprecedented. In this piece, I make four predictions for what the next phase will bring. Each has important strategic implications for healthcare companies and investors.
Here’s what I expect:
Treatment, not testing will be key to reopening the economy
Hybridization (virtual/in-person mix) will be the new reality
Public health post-COVID-19 will be like security post-9/11
The federal government will grow even more powerful relative to everything else
Treatment, not testing will be key to reopening the economy
It is accepted wisdom among public health experts and many others that the widespread availability of COVID-19 testing is a necessary condition to reopen the economy. It says so on the roadmaps of California, Massachusetts, the federal government, and many companies and institutions. It makes great sense: once we can see the problem clearly we can prevent infections from spreading. Other countries that are reopening –like Germany and Singapore—make extensive use of testing and contact tracing. This, we’re told, is the way things will be until a vaccine is introduced in a year or so.
Here’s the problem: progress on ramping up testing has been slow, even in Massachusetts where I assumed it would go fast. Despite lots of announcements of new capacity coming online I haven’t seen anything that makes me think there will be a breakthrough. Consider, also that effective testing for COVID-19 can’t be a one-time phenomenon. People will need to be tested over and over.
Meanwhile, with the worldwide deluge of patients, doctors are figuring out how to treat them. We might not have a vaccine in a year –or ever (unfortunately), but treatments are improving now, through experimentation, physician insight, and good luck. There is early promise from Gilead’s remdesivir; other drugs will be useful, too. But it’s not just drugs, it’s also non-drug adjustments such as how to optimize use of mechanical ventilation for these patients and even when to turn them onto their stomachs. As another example, I received firsthand reports from frontline Italian physicians who hypothesize that the coronavirus attacks the cardiovascular system first, and that is where to focus to address the root cause in a straightforward way. These are just things I’ve been privy to; certainly there are thousands of other investigations going on around the world. Some will work, and soon. These innovations can be additive or multiplicative, even if they’re not a miracle cure.
Bottom line, I think it’s likely that COVID-19 will become a manageable disease within a few months or even a few weeks, and that’s what will enable us to start to go back to work and school and to start flying again with an acceptable level of risk. For better or worse, it’s also more consistent with how the American healthcare system works: treat the sick.
It would be so much better to have ample testing in place before trying to reopen. Until we get there the US will suffer from higher disease burden, greater cost, higher inequities, and more skittishness about public gatherings compared to other countries. Yet as a whole we will figure out how to make do without the testing capacity that everyone wants.
Hybridization (virtual/in-person mix) will be the new reality
When COVID-19 hit, telemedicine made more progress in one week than it had in the past 10 years. Suddenly patients were scared to come to the office or hospital (and doctors/nurses/staff were afraid of the patients), reimbursement with in-person visits was equalized, and cross-state licensing restrictions were eased. People are getting accustomed to online meetings, online socializing, online schooling, and online shopping. Some of it –like convenience, immediacy—they like. Other parts –such as the difficulty building new, trusting relationships and absence of physical contact, and difficulty interacting with groups or teams—they don’t.
The pandemic will be with us for a while, which means people will have plenty of time to get used to being remote, understand better how to make it work, and won’t always default to the old ways. This is true even for some older Americans who thought they’d be able to ride out their careers or lives without jumping into the digital waters.
There has been a gradual shift to online over the past couple of decades, but the pandemic changes things. Now, we realize that we may have to suddenly revert to a remote world at any time, so we had better be ready for it. Social distancing is likely to be required to some degree over the next couple years, which means offices, factories, schools and entertainment venues won’t be able to return to their previous density. We can expect to see a rotation of remote and in-person staff and students –instead of total shutdowns. And kids may not like it, but there will be no excuse for another snow day!
Health status and age will play important roles in how hybridization is realized. Older people and those with conditions making them vulnerable may find that they have to spend more time in the digital world than their younger and healthier peers, because it’s not safe for them to show up in person. Ageism and discrimination against people with disabilities is already a major problem. It will become much more so in a COVID-19 influenced economy, especially during a recession where the job market favors employers.
For healthcare delivery and clinical trials, it is likely that more routine interactions will be conducted online rather than the office, and that the home will become even more attractive for recovery, aging and research. Providers will make greater use of nurse practitioners and physician assistants as front-line representatives, for triage, follow up and care coordination. It’s more straightforward to standardize protocols and supervise staff in the digital realm, plus it’s cheaper. We will also see a rise in asynchronous interactions, which are often more effective and efficient than as live video call. With the right leadership, these changes can also facilitate an increase in value based and evidence based cared.
The current situation has very negative consequences for the health of people with chronic and even acute conditions, who are avoiding the doctor and hospital at all costs. Meanwhile, providers face financial ruin as patients stay away. It has to be addressed, and hybridization is the way to do it.
Public health post-COVID-19 will be like security post-9/11
After 9/11, security came to the fore. Suddenly there was visible security at airports, in office buildings, and throughout public spaces. New physical and digital surveillance technologies and practices were introduced and there was massive hiring of security guards, analysts, etc.
Now that COVID-19 has struck, we can expect public health to be similarly elevated. It will become a pervasive part of our economy and society. Expect temperature –and maybe face mask and hand washing– checks at the office, school, and any public venue. Contact tracers may call or visit our homes or scrutinize our cellphone records. Event managers and employers will need to hire a health team and devise a health/safety plan to prevent outbreaks and provide confidence.
New products and tools will be needed to sanitize surfaces, detect pathogens in the environment, and monitor outbreaks. Sick leave policies will need to be revised and enforced. New cultural norms will be established –for example on the wearing of masks, shaking hands, what personal space means. Mental health needs must also be recognized and addressed in the adult and pediatric populations.
It won’t be enough to pursue these approaches privately. Local, state, and federal agencies will have to invest in order to deploy a comprehensive strategy to protect and reassure the public.
The new public health approach will dovetail with existing post 9/11 security measures and infrastructure. For example, the Red/Orange/Yellow/Blue/Green threat level developed for terrorism is actually more suitable to viral dangers. There will also be opportunities to redefine and expand the corporate wellness industry, which at last will be able to demonstrate a robust return on investment.
Federal government will grow even more powerful relative to everything else
The federal response to the pandemic has been problematic. The US had time to prepare after observing China and Europe, but largely failed to do so. States complain that there’s been little federal response or coordination and that they have been left to fend for themselves. The underlying reasons and political elements can be debated elsewhere.
Somewhat paradoxically, the pandemic has strengthened the federal hand relative to others. Consider:
With interest rates near zero, the federal government is easily able to borrow $2+ Trillion for the CARES Act
The Federal Reserve has propped up the stock and bond market with its promise to buy essentially anything, including non-investment grade securities
States are facing huge drops in revenues thanks to the shutdown of the economy. They need to balance their budgets and don’t have the borrowing powers of the feds. They also have to beg the federal government for assistance with the current crisis
The completely unprecedented surge in unemployment is leading to dependency on programs such as SNAP and Medicaid that are primarily funded at the federal level
Many industries –think travel, tourism, restaurants—are essentially shut down and need a bailout to restart
Colleges and universities, are hamstrung by having to close their campuses -possibly through the fall semester as well—and the question of whether domestic and especially international students will return
The healthcare delivery system is suffering from a huge disruption as essentially all resources are diverted to COVID-19 or idled
The broad implications of this sudden swing will play out over time and will be affected by the November elections (assuming they occur on schedule). The pandemic really does place the country at a crossroads. The conditions are ripe for further dividing the nation along various fault lines (rural/urban, nationalist/globalist, etc.) or for bringing us together. We may also see blocs of states ally more formally to coordinate with one another and attempt to shift the balance of power. Meanwhile, it is notable that this federal power expansion, involvement in the economy and massive increase of borrowing are occurring under ostensibly conservative leadership.
One near-term result is that the country has jumped much closer to the left-wing policies of Bernie Sanders and Andrew Yang than would have seemed imaginable in February. Everyone will be covered for COVID-19, whether directly through their insurance plans or through federal subsidies to providers, and the $1200 stimulus checks with the president’s signature are like Yang’s Universal Basic Income.
Massive unemployment will shift millions of people to Medicaid, so we may have Medicaid for All rather than Medicare for All. (This is actually a better idea, in my view.) I think we’ll see the holdout states finally accept the Affordable Care Act’s Medicaid expansion now that their backs are to the wall. And I also expect the COVID-19 experience means the Supreme Court will decline to strike down the Affordable Care Act, even though that won’t be the explicit rationale.
The situation is fluid and each of these predictions is subject to change. But I wanted to get some thoughts down while they were fresh, with the goal of spurring conversation and debate. In addition, I hope that clients will find this thinking useful as they determine what to do next and make longer term strategic and investment plans.
In this edition of #CareTalk, Carecentrix CEO John Driscoll and I discuss the impact of COVID-19 in the US and around the world. John retracts his earlier claim that the feds are doing a good job, and we go on to discuss the fact that we’re all in this together, universal coverage is a sensible policy, science matters, and government can help.
We agree with Tony Fauci, who said, “If it looks like you’re overreacting, you’re probably doing the right thing,” and we also look for signs of hope on the horizon (or just over it).
The COVID-19 coronavirus provides a valuable lens for viewing our healthcare system, society, and politics. Teachable moments like these are a rare occurrence, and I’m cautiously optimistic that people will take a fresh look at how they view the world.
Here are some lessons I see from the emerging crisis:
We are all in this together. The virus affects the whole society. You can’t wall yourself off from it or blame it on “losers.” If we’re going to prevail we’ll all need to pull together, not pit ourselves against one another or allow our politicians to fan the flames.
Universal coverage is a sensible policy. It seems crazy to people from other countries that Americans would hesitate to get tested for coronavirus because they were worried about how they would pay for the test or treatment. It is crazy, but true. And never mind the fact that many can’t take sick leave.
Science matters. The Administration has been systematically undermining scientists in and outside of the government. Climate change is a great example –where it’s convenient to believe what suits one’s politics, and the consequences won’t show up for a while. When it comes to corona, the problem is here now –or will be within weeks. Dissing the scientists and experts won’t work well. The public -for the most part– gets it.
Government can help. In 2018, Trump dumped the head of global health security from the National Security Council and disbanded his team, “at a time… the country [was] already underprepared for the increasing risks of pandemic or bioterrorism attack.” CDC funding is being cut dramatically and local and state public health services have been starved for resources for years.
The Emperor has no clues. Trump’s visit to the CDC was an embarrassment, in which he played his usual game of attacking politicians and the press, while showcasing his own narcissism. Maybe those who laughed it off or cheered it on in other circumstances will be more concerned when it has real implications for their health. In any case, Presidential quotes like the following should be wearing a bit thing: “I like this stuff. I really get it. People are surprised that I understand it. Every one of these doctors said, ‘How do you know so much about this?’ Maybe I have a natural ability. Maybe I should have done that instead of running for President.”
Next time I’ll write about some of the lessons that we may soon learn, about the virus, about democracy, and about the health of our society.