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America Is Trapped in a Pandemic Spiral
As the U.S. heads toward the winter, the country is going round in circles, making the same conceptual errors that have plagued it since spring.
Army ants will sometimes walk in circles until they die. The workers navigate by smelling the pheromone trails of workers in front of them, while laying down pheromones for others to follow. If these trails accidentally loop back on themselves, the ants are trapped. They become a thick, swirling vortex of bodies that resembles a hurricane as viewed from space. They march endlessly until they’re felled by exhaustion or dehydration. The ants can sense no picture bigger than what’s immediately ahead. They have no coordinating force to guide them to safety. They are imprisoned by a wall of their own instincts. This phenomenon is called the death spiral. I can think of no better metaphor for the United States of America’s response to the COVID-19 pandemic.
The U.S. enters the ninth month of the pandemic with more than 6.3 million confirmed cases and more than 189,000 confirmed deaths. The toll has been enormous because the country presented the SARS-CoV-2 coronavirus with a smorgasbord of vulnerabilities to exploit. But the toll continues to be enormous—every day, the case count rises by around 40,000 and the death toll by around 800—because the country has consistently thought about the pandemic in the same unproductive ways.
Many Americans trusted intuition to help guide them through this disaster. They grabbed onto whatever solution was most prominent in the moment, and bounced from one (often false) hope to the next. They saw the actions that individual people were taking, and blamed and shamed their neighbors. They lapsed into magical thinking, and believed that the world would return to normal within months. Following these impulses was simpler than navigating a web of solutions, staring down broken systems, and accepting that the pandemic would rage for at least a year.
These conceptual errors were not egregious lies or conspiracy theories, but they were still dangerous. They manifested again and again, distorting the debate around whether to stay at home, wear masks, or open colleges. They prevented citizens from grasping the scope of the crisis and pushed leaders toward bad policies. And instead of overriding misleading intuitions with calm and considered communication, those leaders intensified them. The country is now trapped in an intuition nightmare: Like the spiraling ants, Americans are walled in by their own unhelpful instincts, which lead them round and round in self-destructive circles.
“The grand challenge now is, how can we adjust our thinking to match the problem before us?” says Lori Peek, a sociologist at the University of Colorado at Boulder who studies disasters. Here, then, are nine errors of intuition that still hamstring the U.S. pandemic response, and a glimpse at the future if they continue unchecked. The time to break free is now. Our pandemic summer is nearly over. Now come fall, the season of preparation, and winter, the season of survival. The U.S. must reset its mindset to accomplish both. Ant death spirals break only when enough workers accidentally blunder away, creating trails that lead the spiraling workers to safety. But humans don’t have to rely on luck; unlike ants, we have a capacity for introspection.
The spiral begins when people forget that controlling the pandemic means doing many things at once. The virus can spread before symptoms appear, and does so most easily through five P’s: people in prolonged, poorly ventilated, protection-free proximity. To stop that spread, this country could use measures that other nations did, to great effect: close nonessential businesses and spaces that allow crowds to congregate indoors; improve ventilation; encourage mask use; test widely to identify contagious people; trace their contacts; help them isolate themselves; and provide a social safety net so that people can protect others without sacrificing their livelihood. None of these other nations did everything, but all did enough things right—and did them simultaneously. By contrast, the U.S. engaged in …
1. A Serial Monogamy of Solutions
Stay-at-home orders dominated March. Masks were fiercely debated in April. Contact tracing took its turn in May. Ventilation is having its moment now. “It’s like we only have attention for only one thing at a time,” says Natalie Dean, a biostatistician at the University of Florida.
As often happens, people sought easy technological fixes for complex societal problems. For months, President Donald Trump touted hydroxychloroquine as a COVID-19 cure, even as rigorous studies showed that it isn’t one. In August, he switched his attention to convalescent plasma—the liquid fraction of a COVID-19 survivor’s blood that might contain virus-blocking antibodies. There’s still no clear evidence that this century-old approach can treat COVID-19 either, despite grossly misstated claims from FDA Commissioner Stephen Hahn (for which he later apologized). More generally, drugs might save some of the very sickest patients, as dexamethasone does, or shorten a hospital stay, as remdesivir does, but they are unlikely to offer outright cures. “It’s so reassuring to think that a magic-bullet treatment is out there and if we just wait, it’ll come and things will be normal,” Dean says.
Other strategies have merit, but are wrongly dismissed for being imperfect. In July, Carl Bergstrom, an epidemiologist and a sociologist of science at the University of Washington, argued that colleges cannot reopen safely without testing all students upon entry. “The gotcha question I’ve handled most from reporters since is: This school did entry testing, so why did they get an outbreak?” he says. It’s because such testing is necessary for a safe reopening, but not sufficient. “If you do it and screw everything else up, you’ll still have a big outbreak,” Bergstrom adds.
This brief attention span is understandable. Adherents of the scientific method are trained to isolate and change one variable at a time. Academics are walled off into different disciplines that rarely connect. Journalists constantly look for new stories, shifting attention to the next great idea. These factors prime the public to view solutions in isolation, which means imperfections become conflated with uselessness. For example, many critics of masks argued that they provide only partial protection against the virus, that they often don’t fit well, or that people wear them incorrectly. But some protection is clearly better than no protection. As Dylan Morris of Princeton writes, “X won’t stop COVID on its own is not an argument against doing X.” Instead, it’s an argument for doing X along with other measures. Seat belts won’t prevent all fatal car crashes, but cars also come with airbags and crumple zones. “When we layer things, we give ourselves more wiggle room,” Dean says.
Several experts I’ve talked with have been asked: What now? The question assumes that the pandemic lingers because the U.S. simply hasn’t found the right solution yet. In fact, it lingers because the familiar solutions were never fully implemented. Despite claims from the White House, the U.S. is still not testing enough people. It still doesn’t have enough contact tracers. “We have the playbook, but I think there’s a confusion about what we’ve actually tried and what we’ve just talked about doing,” Dean says. A successful response “is never going to be one thing done perfectly. It’ll be a lot of different things done well enough.” That resilience disappears if we create…
2. False Dichotomies
A world of black and white is easier to handle than one awash with grays. But false dichotomies are dangerous. From the start, COVID-19 has been portrayed as a disease that mostly causes mild symptoms in people who quickly recover, and occasionally causes severe illness that leads to hospitalization and death. This two-sided caricature—severe or mild, sick or recovered—has erased the thousands of “long-haulers” who have endured months of debilitating symptoms at home with neither recognition nor care.
Meanwhile, as businesses closed and stay-at-home orders rolled out, “we presumed a trade-off between saving lives and saving the economy,” says Danielle Allen, a political scientist at Harvard. “That was foolishness of the most profound degree.” The two goals were actually aligned: Epidemiologists and economists largely agree that the economy cannot rebound while the pandemic is still raging. By treating the two as opposites, state leaders rushed to reopen, leading a barely contained virus to surge anew.
Now, as winter looms and the pandemic continues, another dichotomy has emerged: enter another awful lockdown, or let the virus run free. This choice, too, is false. Public-health measures offer a middle road, and even “lockdowns” need not be as overbearing as they were in spring. A city could close higher-risk venues like bars and nightclubs while opening lower-risk ones like retail stores. There’s a “whole control panel of dials” on offer, but “it’s hard to have that conversation when people think of a light switch,” says Lindsay Wiley, a professor of public-health law at American University. “The term lockdown has done a lot of damage.” It exacerbated the false binary between shutting down and opening up, while offering …
3. The Comfort of Theatricality
Stay-at-home orders saved lives by curtailing COVID-19’s spread, and by giving hospitals some breathing room. But the orders were also meant to buy time for the nation to ramp up its public-health defenses. Instead, the White House treated months of physical distancing as a pandemic-ending strategy in itself. “We squandered that time in terms of scaling up testing and contact tracing, enacting policies to protect workers who get infected on the job, getting protective equipment to people in food-processing plants, finding places for people to isolate, offering paid sick leave … We still don’t have those things,” says Julia Marcus, an infectious-disease epidemiologist at Harvard Medical School and regular Atlantic contributor. The country is now facing the fall with many of the same problems that plagued it through the summer.
Showiness is often mistaken for effectiveness. The coronavirus mostly spreads through air rather than contaminated surfaces, but many businesses are nonetheless trying to scrub and bleach their way toward reopening. My colleague Derek Thompson calls this hygiene theater—dramatic moves that appear to offer safety without actually doing so. The same charge applies to temperature checks, which can’t detect the many COVID-19 patients who don’t have a fever. It also applies to the porous and inefficient travel bans that Trump and his allies still tout as policy successes. These tactics might do some good—let’s not conflate imperfect with useless—but they cause harm when they substitute for stronger measures. Theatricality breeds complacency. And by emphasizing solutions that can be easily seen, it exacerbated the American preference for …
4. Personal Blame Over Systemic Fixes
SARS-CoV-2 spread rapidly among America’s overstuffed prisons and understaffed nursing homes, in communities served by overstretched hospitals and underfunded public-health departments, and among Black, Latino, and Indigenous Americans who had been geographically and financially disconnected from health care by decades of racist policies. Without paid sick leave or a living wage, “essential workers” who earn a low, hourly income could not afford to quarantine themselves when they fell ill—and especially not if that would jeopardize the jobs to which their health care is tied. “The things I do to stay safe, they don’t have that as an option,” says Whitney Robinson, a social epidemiologist at the University of North Carolina at Chapel Hill.
But tattered social safety nets are less visible than crowded bars. Pushing for universal health care is harder than shaming an unmasked stranger. Fixing systemic problems is more difficult than spewing moralism, and Americans gravitated toward the latter. News outlets illustrated pandemic articles with (often distorted) photos of beaches, even though open-air spaces offer low-risk ways for people to enjoy themselves. Marcus attributes this tendency to America’s puritanical roots, which conflate pleasure with irresponsibility, and which prize shame over support. “The shaming gets codified into bad policy,” she says. Chicago fenced off a beach, and Honolulu closed beaches, parks, and hiking trails, while leaving riskier indoor businesses open.
Moralistic thinking jeopardizes health in two ways. First, people often oppose measures that reduce an individual’s risk—seat belts, condoms, HPV vaccines—because such protections might promote risky behavior. During the pandemic, some experts used such reasoning to question the value of masks, while the University of Michigan’s president argued that testing students widely would offer a “false sense of security.” These paternalistic false-assurance arguments are almost always false themselves. “There’s very little evidence for overcompensation to the point where safety measures do harm,” Bergstrom says.
Second, misplaced moralism can provide cover for bad policies. Many colleges started their semester with in-person teaching and inadequate testing, and are predictably dealing with large outbreaks. UNC Chapel Hill lasted just six days before reverting to remote classes. Administrators have chastised students for behaving irresponsibly, while taking no responsibility for setting them up to fail—a pattern that will likely continue through the fall as college clusters inevitably grow. “If you put 10,000 [students] in a small space, eating, sleeping, and socializing together, there’ll be an explosion of cases,” Robinson says. “I don’t know what [colleges] were expecting.” Perhaps they fell prey to …
5. The Normality Trap
In times of uncertainty and upheaval, “people crave a return to familiar, predictable rhythms,” says Monica Schoch-Spana, a medical anthropologist at the Johns Hopkins Center for Health Security. That pull is especially strong now because the pandemic’s toll is largely invisible. There’s nothing as dramatic as ruined buildings or lapping floodwater to hint that the world has changed. In some circles, returning to normal has been valorized as an act of defiance. That’s a reasonable stance when resisting terrorists, who seek to stoke fear, but a dangerous one when fighting a virus, which doesn’t care.
The powerful desire to re-create an old world can obscure the trade-offs necessary for surviving the new one. Keeping high-risk indoor businesses open, for example, helps the virus spread within a community, which makes reopening schools harder. “If schools are a priority, you have to put them ahead of something. What is that something?” says Bill Hanage, an epidemiologist at Harvard. “In an ideal world, they would be the last to close and the first to open, but in many communities, casinos, bars, and tattoo parlors opened before them.” A world with COVID-19 is fundamentally different from one without it, and the former simply cannot include all the trappings of the latter. Cherished summer rituals like camps and baseball games have already been lost; back-to-school traditions and Thanksgiving now hang in the balance. Change is hard to accept, which predisposes people to …
6. Magical Thinking
Back in April, Trump imagined the pandemic’s quick end: “Maybe this goes away with heat and light,” he said. From the start, he and others wondered if hot, humid weather might curb the spread of COVID-19, as it does other coronavirus diseases. Many experts countered that seasonal effects wouldn’t stop the new virus, which was already spreading in the tropics. But, fueled by shaky science and speculative stories, people widely latched on to seasonality as a possible savior, before the virus proved that it could thrive in the Arizona, Texas, and Florida summer.
This brand of magical thinking, in which some factor naturally defuses the pandemic, has become a convenient excuse for inaction. Recently, some commentators have argued that the pandemic will imminently fizzle out for two reasons. First, 20 to 50 percent of people have defensive T-cells that recognize the new coronavirus, because they were previously exposed to its milder, common-cold-causing cousins. Second, some modeling studies claim that herd immunity—whereby the virus struggles to find new hosts, because enough people are immune—could kick in when just 20 percent of the population has been infected.
Neither claim is implausible, but neither should be grounds for complacency. No one yet knows if the “cross-reactive” T-cells actually protect against COVID-19, and even if they do, they’re unlikely to stop people from getting infected. Herd immunity, meanwhile, is not a perfect barrier. Even if the low thresholds are correct, a fast-growing and uncontrolled outbreak will still shoot past them. Pursuing this strategy will mean that, in the winter, many parts of the U.S. may suffer what New York City endured in the spring: thousands of deaths and an untold number of lingering disabilities. That alone should be an argument against …
7. The Complacency of Inexperience
When illness is averted and lives are spared, “nothing happens and all you have is the miracle of a normal, healthy day,” says Howard Koh, a public-health professor at Harvard. “People take that for granted.” Public-health departments are chronically underfunded because the suffering they prevent is invisible. Pandemic preparations are deprioritized in the peaceful years between outbreaks. Even now, many people who have been spared the ravages of COVID-19 argue that the disease wasn’t a big deal, or associate their woes with preventive measures. But the problem is still the disease those measures prevented: The economy is still hurting, mental-health problems are growing, and educational futures have been curtailed, not because of some fearmongering overreaction, but because an uncontrolled pandemic is still afoot.
If anything, the U.S. did not react swiftly or strongly enough. Nations that had previously dealt with emerging viral epidemics, including several in East Asia and sub-Saharan Africa, were quick to take the new coronavirus seriously. By contrast, America’s lack of similar firsthand experience, combined with its sense of exceptionalism, might have contributed to its initial sloppiness. “One of my colleagues went to Rwanda in February, and as soon as he hit the airport, they asked about symptoms, checked his temperature, and took his phone number,” says Abraar Karan, an internist at Brigham and Women’s Hospital and Harvard Medical School. “In the U.S., I flew in July, and walked out of the airport, no questions asked.”
Even when the virus began spreading within the U.S., places that weren’t initially pummeled seemed to forget that viruses spread. “In April, I was seeing COVID patients in the ER every day,” Karan says. “In Texas, I had friends saying, ‘No one believes it here because we have no cases.’ In L.A., fellow physicians said, ‘Are you sure this is worse than the flu? We’re not seeing anything.’” Three months later, Texas and California saw COVID-19 all too closely. The tendency to ignore threats until they directly affect us has consigned the U.S. to …
8. A Reactive Rut
In March, Mike Ryan at the World Health Organization advised, “Be fast, have no regrets … The virus will always get you if you don’t move quickly.” The U.S. failed to heed that warning, and has repeatedly found itself several steps behind the coronavirus. That’s partly because exponential growth is counterintuitive, so “we don’t understand that things look fine until right before they’re very not fine,” says Beth Redbird, a sociologist at Northwestern. It’s also because the coronavirus spreads quickly but is slow to reveal itself: It can take a month for infections to lead to symptoms, for symptoms to warrant tests and hospitalizations, and for enough sick people to produce a noticeable spike. Pandemic data are like the light of distant stars, recording past events instead of present ones. This lag separates actions from their consequences by enough time to break our intuition for cause and effect. Policy makers end up acting only when it’s too late. Predictable surges get falsely cast as unexpected surprises.
This reactive rut also precludes long-term planning. In April, Michael Osterholm, an epidemiologist at the University of Minnesota, told me that “people haven’t understood that [the pandemic] isn’t about the next couple of weeks [but] about the next two years.” Leaders should have taken the long view then. “We should have been thinking about what it would take to ensure schools open in the fall, and prevent the long-term harms of lost children’s development,” Redbird says. Instead, we started working our way through a serial monogamy of solutions, and, like spiraling army ants, marched forward with no sense of the future beyond the next few footsteps.
These errors crop up in all disasters. But the COVID-19 pandemic has special qualities that have exacerbated them. The virus moved quickly enough to upend the status quo in a few months, deepening the allure of the hastily abandoned past. It also moved slowly enough to sweep the U.S. in a patchwork fashion, allowing as-yet-untouched communities to drop their guard. The pandemic grew huge in scope, entangling every aspect of society, and maxing out our capacity to deal with complexity. “People struggle to make rational decisions when they cannot see all the cogs,” says Njoki Mwarumba, an emergency-management professor at the University of Nebraska at Omaha. Full of fear and anxiety, people furiously searched for more information, but because the virus is so new, they instead spiraled into more confusion and uncertainty. And tragically, all of this happened during the presidency of Donald Trump.
Trump embodied and amplified America’s intuition death spiral. Instead of rolling out a detailed, coordinated plan to control the pandemic, he ricocheted from one overhyped cure-all to another, while relying on theatrics such as travel bans. He ignored inequities and systemic failures in favor of blaming China, the WHO, governors, Anthony Fauci, and Barack Obama. He widened the false dichotomy between lockdowns and reopening by regularly tweeting in favor of the latter. He and his allies appealed to magical thinking and steered the U.S. straight into the normality trap by frequently lying that the virus would go away, that the pandemic was ending, that new waves weren’t happening, and that rising case numbers were solely due to increased testing. They have started talking about COVID-19 in the past tense as cases surge in the Midwest.
“It’s like mass gaslighting,” says Martha Lincoln, a medical anthropologist at San Francisco State University. “We were put in a situation where better solutions were closed off but a lot of people had that fact sneak up on them. In the absence of a robust federal response, we’re all left washing our hands and hoping for the best, which makes us more susceptible to magical thinking and individual-level fixes.” And if those fixes never come, “I think people are going to harden into a fatalistic sense that we have to accept whatever the risks are to continue with our everyday lives.”
That might, indeed, be Trump’s next solution. The Washington Post reports that Trump’s new adviser—the neuroradiologist Scott Atlas—is pushing a strategy that lets the virus rip through the non-elderly population in a bid to reach herd immunity. This policy was folly for Sweden, which is nowhere near herd immunity, had one of the world’s highest COVID-19 death rates, and has a regretful state epidemiologist. Although the White House has denied that a formal herd-immunity policy exists, the Centers for Disease Control and Prevention recently changed its guidance to say that asymptomatic people “do not necessarily need a test” even after close contact with an infected person. This change makes no sense: People can still spread the virus before showing symptoms. By effectively recommending less testing, as Trump has specifically called for, the nation’s top public-health agency is depriving the U.S. of the data it needs to resist intuitive errors. “When there’s a refusal to take in the big picture, we are stuck,” Mwarumba says.
The pandemic is now in its ninth month. Uncertainties abound as fall and winter loom. In much of the country, colder weather will gradually pack people into indoor spaces, where the coronavirus more readily spreads. Winter also typically heralds the arrival of the flu and other respiratory viruses, and although the Southern Hemisphere enjoyed an unusually mild flu season, that’s “because of the severe precautions they were taking against COVID-19,” says Eleanor Murray, an epidemiologist at Boston University. “It’s not clear to me that our precautions will be successful enough to also prevent the flu.”
Schools are reopening, which will shape the path of the pandemic in still-uncertain ways. Universities are more predictable: Thanks to magical thinking and misplaced moralism, the U.S. already has at least 51,000 confirmed infections in more than 1,000 colleges across every state. These (underestimated) numbers will grow, because only 20 percent of colleges are doing regular testing, while almost half are not testing at all. As more are forced to stop in-person teaching, students will be sent back to their communities with COVID-19 in tow. “I expect this will blow up outbreaks in places that never had outbreaks, or in places that had outbreaks under control,” Murray says. Further spikes will likely occur after Thanksgiving and Christmas, as people who yearn to return to normal (or who think that the country overreacted) travel to see their family. Despite that risk, the CDC recently dropped its recommendation that out-of-state travelers should quarantine themselves for 14 days.
But many of the experts I spoke with thought it unlikely that “we’ll have cities going full New York,” as Bergstrom puts it. Doctors are getting better at treating the disease. States like Massachusetts, New York, and New Jersey have managed to avoid new surges over the summer, showing that local leadership can at least partly compensate for federal laxity. A new generation of cheap, rapid, paper-based tests will hit the market and make it easier to work out who is contagious. And despite the spiral of bad intuitions, many Americans are holding the line: Mask use and support for physical distancing are still high, according to Redbird, who has been tracking pandemic-related attitudes since March. “My feeling is that while things are going to get worse, I’m not sure they’ll be catastrophic, because of situational awareness,” Bill Hanage says.
Meanwhile, Trump seems to be teeing up a vaccine announcement in late October, shortly before the November 3 election. Moncef Slaoui, the scientific head of Operation Warp Speed, told NPR that it’s “extremely unlikely” a vaccine will be ready by then, and many scientists are concerned that the FDA will be pressured into approving a product that hasn’t been adequately tested, as Russia and China already have. Many Americans share this concern. A safe and effective vaccine could finally bring the pandemic under control, but its arrival will also test America’s ability to resist the intuitive errors that have trapped it so far. Vaccination has long been portrayed as the ultimate biomedical silver bullet, separating an era when masks and social distancing mattered from a world where normality has returned. This is yet another false dichotomy. “Everyone’s imagining this moment when all of a sudden, it’s all over, and they can go on vacation,” Natalie Dean says. “But the reality is going to be messier.”
This problem is not unique to COVID-19. It’s more compelling to hope that drug-resistant bacteria can be beaten with viruses than to stem the overuse of antibiotics, to hack the climate than to curb greenhouse-gas emissions, or to invest in a doomed oceanic plastic-catcher than to reduce the production of waste. Throughout its entire history, and more than any other nation, the U.S. has espoused “an almost blind faith in the power of technology as panacea,” writes the historian Howard Segal.* Instead of solving social problems, the U.S. uses techno-fixes to bypass them, plastering the wounds instead of removing the source of injury—and that’s if people even accept the solution on offer.
A third of Americans already say they would refuse a vaccine, whether because of existing anti-vaccine attitudes or more reasonable concerns about a rushed development process. Those who get the shot are unlikely to be fully protected; the FDA is prepared to approve a vaccine that’s at least 50 percent effective—a level comparable to current flu shots. An imperfect vaccine will still be useful. The risk is that the government goes all-in on this one theatrical countermeasure, without addressing the systemic problems that made the U.S. so vulnerable, or investing in the testing and tracing strategies that will still be necessary. “We’re still going to need those other things,” Dean says.
Between these reasons and the time needed for manufacturing and distribution, the pandemic is likely to drag on for months after a vaccine is approved. Already, the event is exacting a psychological toll that’s unlike the trauma of a hurricane or fire. “It’s not the type of disaster that Americans specifically are used to dealing with,” says Samantha Montano of Massachusetts Maritime Academy, who studies disasters. “Famines and complex humanitarian crises are closer approximations.” Health experts are burning out. Long-haulers are struggling to find treatments or support. But many Americans are turning away from the pandemic. “People have stopped watching news about it as much, or talking to friends about it,” Redbird says. “I think we’re all exhausted.” Optimistically, this might mean that people are becoming less anxious and more resilient. More worryingly, it could also mean they are becoming inured to tragedy.
The most accurate model to date predicts that the U.S. will head into November with 220,000 confirmed deaths. More than 1,000 health-care workers have died. One in every 1,125 Black Americans has died, along with similarly disproportionate numbers of Indigenous people, Pacific Islanders, and Latinos. And yet, a recent poll found that 57 percent of Republican voters and 33 percent of independents think the number of deaths is acceptable. “In order for us to mobilize around a social problem, we all have to agree that it’s a problem,” Lori Peek says. “It’s shocking that we haven’t, because you really would have thought that with a pandemic it would be easy.” This is the final and perhaps most costly intuitive error …
9. The Habituation of Horror
The U.S. might stop treating the pandemic as the emergency that it is. Daily tragedy might become ambient noise. The desire for normality might render the unthinkable normal. Like poverty and racism, school shootings and police brutality, mass incarceration and sexual harassment, widespread extinctions and changing climate, COVID-19 might become yet another unacceptable thing that America comes to accept.
8 health systems with strong finances
Here are eight health systems with strong operational metrics and solid financial positions, according to reports from Fitch Ratings, Moody’s Investors Service and S&P Global Ratings.
1. Minneapolis-based Allina Health has an “AA-” rating and stable outlook with Fitch. The health system has a strong financial profile and is the acute care leader in the broad Twin Cities metro area, Fitch said. The credit rating agency said Allina’s proven ability to rebound quickly from operating challenges supports the stable outlook.
2. Children’s Healthcare of Atlanta has an “Aa2” rating and stable outlook with Moody’s. The system has strong operating margins and is the leading pediatric provider in the Atlanta area, Moody’s said. The credit rating agency expects Children’s Healthcare of Atlanta to continue to generate robust margins and maintain exceptional liquidity while undergoing a new campus expansion project.
3. La Crosse, Wis.-based Gundersen Health System has an “AA-” rating and stable outlook with Fitch. The health system has consistently strong operating performance, strong balance sheet metrics and a low debt burden, Fitch said. The credit rating agency said Gundersen’s rating continues to be supported by its leading market position and expanding operating platform.
4. Houston Methodist has an “AA” rating and stable outlook with S&P. The system, which comprises an academic medical center and six community hospitals, has a strong enterprise profile and a history of excellent margins and cash flow, S&P said. The credit rating agency said Houston Methodist is well positioned to withstand the pressures from COVID-19.
5. Indianapolis-based Indiana University Health has an “AA” rating and stable outlook with Fitch. The health system has a solid balance sheet and strong operating cash flow despite short-term pressure from the COVID-19 pandemic. The credit rating agency expects IU Health’s EBITDA margins will range between 12 percent and 14 percent annually when margins recover from the pandemic.
6. Broomfield, Colo.-based SCL Health has an “AA-” rating and stable outlook with Fitch and an “Aa3” rating and stable outlook with Moody’s. The system has a track record of exceptional operations, consistent improvement in unrestricted liquidity levels and significant financial flexibility, Fitch said. The credit rating agency said SCL Health is well positioned to manage the pressures of COVID-19, having built up cash reserves.
7. San Diego-based Scripps Health has an “AA” rating and stable outlook with Fitch and an “Aa3” rating and stable outlook with Moody’s. The health system has a strong balance sheet, strong operations and has maintained a low leverage position, Fitch said. The credit rating agency expects Scripps will continue generating operating levels that are consistent with historical trends following recovery from the pandemic.
8. San Diego-based Sharp HealthCare has an “Aa3” rating and stable outlook with Moody’s and an “AA” rating and stable outlook with S&P. The health system has a healthy financial profile, an excellent balance sheet, a solid business position and is the leading provider in a competitive service area, S&P said. The credit rating agency said the system’s financial performance has remained stable despite COVID-19 and the recession.
More cities and states are opening bars and restaurants despite mounting evidence of potential danger
In New York City, diners will be able to have a meal inside a restaurant at the end of the month, something that hasn’t happened there since the coronavirus pandemic began. In some parts of Florida, bars reopened Monday for the first time since late June.
One decision appears to be riskier than the other, according to an analysis of cellphone and coronavirus case data by The Washington Post.
States that have reopened bars experienced a doubling in the rate of coronavirus cases three weeks after the opening of doors, on average. The Post analysis — using data provided by SafeGraph, a company that aggregates cellphone location information — found a statistically significant national relationship between foot traffic to bars one week after they reopened and an increase in cases three weeks later.
The analysis of the cellphone data suggests there is not as strong a relationship between the reopening of restaurants and a rise in cases, nor with bar foot traffic and cases over time, except for a handful of states.
But like with so much in the pandemic, easy answers can prove elusive.
A study by the Centers for Disease Control and Prevention of nearly 300 adults who tested positive for the coronavirus found that they were more than twice as likely to have dined at a restaurant in the two weeks before getting sick than people who were uninfected. Those who tested positive and did not have close contact with anyone sick were also more likely to report going to a bar or coffee shop. The same effect was not seen in visits to salons, gyms and houses of worship, or in the use of public transportation.
“You’re sitting there for a long time, everyone’s talking,” said Linsey Marr, an environmental engineer at Virginia Tech. “And that’s just a recipe for spread.”
Few states make their contact-tracing data available, but in two that do — Colorado and Louisiana — bars and restaurants are responsible for about 20 percent of cases traced to a known source. San Diego traced nearly one-third of community outbreaks to restaurants and bars, more than any other setting.
But Louisiana’s experience suggests bar patrons contribute more to the spread of the virus than restaurant diners. There have been 41 outbreaks tied to restaurants and the same number of outbreaks associated with bars, but bar outbreaks appeared to result in more infections, with 480 cases traced to those establishments compared with 180 from restaurants.
Marr said indoor dining can be reasonably safe in a restaurant operating at 25 percent capacity and with a ventilation system that fully recirculates air every 10 minutes. New York City’s policy will allow for only 25 percent capacity at first, with a scheduled increase to 50 percent in November if transmission rates remain low.
Still, Marr said, she “will not eat inside a restaurant until the pandemic is over.” As one of the first scientists to begin emphasizing that the virus was spread primarily by air, she has been concerned about indoor drinking and dining since March.
“People go to restaurants to talk,” she said, “and we know that it’s talking that produces a lot — 10 to 100 times more — aerosols than just sitting.”
Other countries facing outbreaks imposed stricter and longer shutdowns on bars and restaurants. Ireland has yet to open its pubs. Countries that did reopen bars and restaurants have, like American states, scaled back in the face of fresh outbreaks.
Researchers at the Massachusetts Institute of Technology say that because U.S. policies vary by state and county, waves of closures and reopenings may have perversely led to more viral spread, as people traveled to enjoy freedoms not allowed closer to home.
The National Restaurant Association argues that restaurants are safe if they follow proper mitigation guidelines and that the industry has been unfairly maligned by the actions of an irresponsible few.
“Bars become particularly risky,” said Larry Lynch, who handles food science for the restaurant trade group. “Anybody who had been in bars knows that conversations get louder, people get closer.”
But, he said, “we haven’t seen … any kind of systemic outbreaks from people going into a restaurant that’s practicing what we ask them to practice.”
Lynch questioned the methodology of the CDC study, noting it covered only 295 people and did not identify the sources of transmission.
The American Nightlife Association, which represents the bar and nightclub industry, did not respond to a request for comment.
Kristen Ehresmann, director of the Infectious Disease Epidemiology, Prevention and Control Division at the Minnesota Department of Health, agreed that when restaurants and bars abide by guidelines designed to reduce transmission, few cases of the coronavirus have been traced to those establishments.
But there are more than a few bad actors, she said: 1,592 cases of covid-19, the disease caused by the coronavirus, have been tied to 66 bars and restaurants in Minnesota. And in 58 other establishments, cases were reported among only staff members, resulting in 240 illnesses. One bar in St. Cloud, Minn., the Pickled Loon, was the only place visited by 73 people who got sick and was one stop among several for 44 other people.
“The bottom line is, we’re seeing a big chunk of our cases associated with these venues, and those cases go on to get other cases in other settings,” Ehresmann said. “We can’t ignore the impact.”
Iowa’s first big spike in coronavirus cases originated in the meatpacking industry. Then, says University of Iowa epidemiologist Jorge Salinas, came bars in college towns such as Iowa City, where he is based.
“It was very clear,” Salinas said. “We reviewed records for patients, and they all shared that common exposure of having been to a bar in the previous five days or so. Usually, the same bars that tend to be very crowded and very loud, rather than a place you just sit down to go and have a beer.”
He said those bars began closing not because of government intervention, but because so many staff members fell ill. By that point, the young people who got infected at bars had begun spreading the virus to an older population through family and work.
After about two months, the outbreak in Iowa City started to burn out. But then college students started returning to campus.
“It’s just a different group of young people but similar exposures — going to bars, hanging out, going to large parties,” he said.
He said an order from Gov. Kim Reynolds (R) closing bars in Iowa City and five other hard-hit counties was welcome but overdue. In the past two weeks, more than 1,000 young people in the region have become infected.
“Unfortunately, it’s late in the game,” Salinas said. “It would have been better if it had been done to prevent this rather than as a reaction to this.”
Politicians who favor an aggressive approach to containing the coronavirus have been hesitant to shut down bars and restaurants. Expanded federal unemployment benefits lapsed more than a month ago. Loans to small businesses are forgiven only if they can keep workers on the payroll, which is usually impossible while running at reduced capacity.
According to the Bureau of Labor Statistics, 2.5 million jobs in bars and restaurants have been lost since February. Although that’s an improvement from the spring, many restaurant owners say they are barely hanging on.
“Winter is coming, and I’m staring down the barrel of the gun of what’s going to happen,” said Ivy Mix, owner of a restaurant called Leyenda in New York and author of the book “Spirits of Latin America.” Even when indoor dining reopens, Mix said she is not sure she and her staff would be comfortable serving enough people inside her Brooklyn restaurant to make a profit.
“This is almost like being thrown a deflated life-jacket — the action and the symbolism is there, but the actual aid is not,” she said.
That’s why she says the only solution is federal legislation introduced by Rep. Earl Blumenauer (D-Ore.) that would issue $120 billion in grants to independent bars and restaurants. A Senate version would cover some chains as well.
“Eleven million people work for these independent restaurants,” Blumenauer said. “If we don’t do something, the evidence suggests that 85 percent of them are not going to survive this year.”
His office estimates that the legislation would more than pay for itself, generating $186 billion in tax revenue and unemployment savings. He said President Trump was receptive in a meeting with supporters earlier this year, but that in recent weeks the administration “has basically shut down meaningful negotiations.”
Arizona reopened indoor restaurants and some bars at the end of August, after a hasty spring reopening and more than 5,000 deaths.
“We really kind of reaped the whirlwind,” said David Engelthaler, a former state epidemiologist now at the Translational Genomics Research Institute. “A lot of that was driven by people going into bars and nightclubs, typically the 20- to 30-year-old set, interacting, socializing like they did prepandemic. And that just supported a kind of wildfire of cases.”
He said he thinks it is probably feasible to reopen restaurants at reduced capacity, but bars are a different story.
“One thing that all bars have in common is that they create a lowering of inhibition, and I think more than anything, this will cause the spread of covid,” he said. “We get more complacent, more comfortable, covid starts spreading.”
With temperatures still regularly topping 100 degrees in Arizona, the appeal of outdoor food and drink is limited. After a rapid May reopening led to a spike in cases and deaths, the state has just begun trying a more cautious approach.
Under Arizona’s new, more deliberate reopening, businesses must apply to reopen and bars must serve food to qualify. But Saskia Popescu, an epidemiologist based in Phoenix, said it is unclear whether those requirements are sufficiently stringent.
“If you put out two items does that count?” she asked. “I just worry that we’re kind of all doing this at once.” She noted that more than 500 new cases a day continue to be reported in Arizona, about the same as during the first reopening: “We’ll see if we learn from our lessons.”
One million Americans lost health insurance last year
Americans became wealthier and more held jobs last year.
Yet at the very same time, one million people lost health insurance. And that number has steadily climbed this year under the pandemic.
A U.S. Census Bureau report released yesterday showed a continued slow erosion of the nation’s insured rate in 2019. The decline of coverage illustrates both the shortcomings of President Barack Obama’s 2010 health-care law and repeated attempts by President Trump and Republicans to undermine it.
“Though the reasons are sharply debated, the new data signifies that the first three years of President Trump’s tenure were a period of contracting health insurance coverage,” Amy Goldstein writes. “The decreases reversed gains that began near the end of the Great Recession and accelerated during early years of expanded access to health plans and Medicaid through the Affordable Care Act.”
Nearly 30 million Americans lacked health coverage in 2019.
The uninsured rate rose to 29.6 million people, totaling 9.2 percent of the population. It has slowly ticked upward since 2016, when 28.1 million people didn’t have a health plan. Between 2018 and 2019, the share of people without coverage increased in 19 states and decreased in just one.
The share of people on Medicare and with employer-sponsored coverage actually increased slightly. That was due to an aging population and last year’s booming economy, which meant more people had workplace plans — still the chief way Americans get their coverage.
The biggest erosions in coverage took place in state Medicaid programs.
Medicaid enrollment fell from 17.9 percent of Americans to 17.2 percent.
One reason for the decline is positive: As poverty rates fell for all major racial and ethnic groups, more people earned too much to qualify for the program. The poverty rate fell to 18.8 percent for Blacks, 15.7 percent for Hispanics and 9.1 percent for Whites.
But other factors were also at play. People no longer face a tax penalty for being uninsured, after Congress repealed it in 2017. Several GOP-led states expanded enrollment requirements. And wide disparities persisted in how states run their programs.
Missouri voters recently approved Medicaid expansion, making the state the seventh to do so under President Trump.
“There is huge variation state-to-state in the ease of enrollment, the administrative process, the mechanisms for verifying eligibility, how hard the state works to sign people up,” said Katherine Baicker, a health economist at the University of Chicago. “All those have big effects on net take-up rates.”
The trickle of coverage losses has become a flood under the pandemic.
Before the coronavirus pandemic upended life, the United States was enjoying a record-long economic expansion. By the end of last year, the unemployment rate was at a 50-year low of 3.5 percent.
“Women outnumbered men in the workforce for only the second time, buoyed by a tight labor market and fast job growth in health care and education,” Amy writes. “Minimum-wage increases were also fueling faster wage growth for those at the bottom.”
But now millions of people have lost their jobs — and, in the process, their health insurance.
“Since March … job losses have disproportionately hit low-income workers and women, many of whom held service-sector jobs that were gutted by shutdown measures to help protect people from infection,” Amy writes. “Nearly 40 percent of households with income below $40,000 were laid off or furloughed by early April, according to the Federal Reserve.”
The Economic Policy Institute has estimated that 12 million people have lost health insurance received through their workplace or that of a family member. Some of those have been able to enroll in Medicaid — its rolls have risen by about 4 million during the pandemic — but others find it unaffordable.
CDC’s Confession That America’s Covid-19 Tracking Failed
In mid-June, the post-coronavirus reopening of America was in full swing, even as the number of new cases was rising fast. The Centers for Disease Control and Prevention (CDC) was key to President Trump’s grand reopening, providing local officials with guidance on how to open up safely. But in private officials admitted the country had failed to track the spread of the deadly virus and that the agency thus lacked the vital information it needed to offer such guidance, Forbes can now reveal.
Disease tracing systems across U.S. states had proven ineffective in furnishing the agency with adequate data on how to curtail the deadly virus, the agency had conceded. The number of people who needed tracking had become simply unmanageable, the CDC said, writing: “Most jurisdictions have been forced to abandon monitoring because the number of monitorees exceeds the capacity. . . . As a result, critical data for CDC to inform and guide public health response to Covid-19 is unavailable.”
The CDC’s admittance of the national failure came in a contract description obtained via FOIA request, from a deal signed off in a bid to fix the problem. The health agency gave Mitre Corp., a much-trusted nonprofit contractor that Forbes recently revealed to be heavily involved in secretive FBI and DHS snooping projects, $16.5 million to build out a different kind of surveillance system, dubbed Sara Alert. The hope was that rather than only work for singular states, it could be a national tool to effectively track Americans exposed to the virus, one that had by then infected 2.5 million in the United States. The Mitre-led project was titled: “Building an Enduring National Capability to Contain Covid-19.”
The confession came a day before President Trump claimed the disease was “dying out,” and a month after he’d unveiled his Opening Up America Again plan. In May, the CDC was offering guidance to states on how to follow that plan, even though it knew it didn’t have the requisite data. Since then, the nationwide reopening has continued apace, despite warnings from the likes of Dr Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, about the risks of opening too soon.
Meanwhile, though they hadn’t openly stated just how ineffective Covid-19 tracing systems had been, CDC officials were stressing why good data on transmission was vital to the country’s response to the pandemic. “I think it’s important that we really have good data at a granular level,” said CDC director Robert Redfield, during a briefing on June 25.
In the same briefing, he noted the agency had handed out $10.2 billion to states “to augment their testing, contact tracing and isolation capability,” whilst bemoaning that “for decades, this nation has underinvested in the core capabilities of public health,” including in data analytics for tracking diseases. CDC has been splashing money on such data analytics tools in its fight against the coronavirus, as Forbes revealed in multiple multimillion-dollar contracts with Palantir, a Silicon Valley giant that has the backing of Trump ally Peter Thiel. But months after signing off on those deals, vital data was still lacking.
President Trump and the CDC are now coming under fire for their push to reopen when they didn’t have adequate information on Covid-19’s spread. Senator Ron Wyden told Forbes it was now clear the health agency was ill-equipped to trace Covid-19 outbreaks, “raising the question of whether the Trump Administration willfully ignored this information while recommending schools and other sectors reopen.”
“As nearly 200,000 Americans have lost their lives, Donald Trump still has no semblance of a national plan to test and trace,” Senator Wyden added.
The CDC hasn’t responded to requests for comment.
Sara to the rescue?
The CDC is now banking on Mitre’s Sara Alert to save the country’s Covid-19 surveillance efforts. Built for free by the nonprofit contractor (one that receives between $1.5 billion and $2 billion every year from Congress), Sara Alert allows public health officials to enroll and monitor individuals and households who are either sick or at risk of being infected. Those who are enrolled are then asked to enter their symptoms daily via text, email, phone or a website. This should help healthcare bodies determine who needs care and who needs to be isolated.
As of July, Sara Alert had only been deployed in a handful of states—including Arkansas, Maine, Pennsylvania and Vermont—and it’s unclear how widely it’s in use today. Nor has any date been set for the national rollout. Mitre had provided neither comment nor updated data at the time of publication.
Those who have put Sara Alert into action have been impressed. They include the Arkansas Department of Health. “This system allows us to more readily identify secondary cases, really establishing a better handle on social clusters, which has been a challenge,” Dr. Mike Cima, chief epidemiologist, told Forbes earlier this year.
Like Dr. Cima, the CDC wants to use Sara Alert in perpetuity for tracking future epidemics. Once refined and scaled out, it will be the de facto national track-and-trace system for diseases, according to the contract description. But before that, a pilot project has to be completed, with an additional five jurisdictions to be added before any national rollout can take place.
Mitre’s been key to various Covid-19 efforts. In March, the DHS Countering Weapons of Mass Destruction office tasked it with developing systems to better support local lawmakers with information on the impact of “non-pharmaceutical” measures like social distancing and mask-wearing. And at the start of this month, HHS Office of the Assistant Secretary for Preparedness and Response handed Mitre a $24.5 million contract for a project entitled: “Strategic Engagement, Education, Outreach and Analytics Support for Covid-19 Convalescent Plasma.” When drawn from those who’ve fought off Covid-19, that plasma contains antibodies that could be transfused to patients who need a boost in fighting the virus. In late August, Trump announced emergency authorization for the use of this plasma to treat infected individuals, in lieu of any vaccine.
The number of infected per day has fallen since peaks of above 70,000 in July, but the figure remains higher in September than in the months leading up to and including June. The Sara Alert should provide better data on just how big a catastrophe Covid-19 has become for the country and how the administration’s response has ameliorated (or exacerbated) the eventual impact.
HENRY KOTULA 