The head of the World Health Organization said Monday that allowing the novel coronavirus to spread in an attempt to reach herd immunity was “simply unethical.”
The remark was a sharp rebuke of the approach amid mounting new infections around the world. Recent days have seen the most rapid rise in cases since the pandemic began in March.
“Never in the history of public health has herd immunity been used as a strategy for responding to an outbreak, let alone a pandemic,” WHO Director-General Tedros Adhanom Ghebreyesus said at a Monday media briefing. “It is scientifically and ethically problematic.”
In a public health context, herd immunity typically describes a scenario in which a large enough share of the population is vaccinated against a disease to prevent it from spreading widely, thereby providing default protection to a minority of people who have not been vaccinated.
But as there is still no vaccine for the coronavirus, achieving herd immunity in the current environment would require a large number of people to contract the virus, survive covid-19, and then produce sufficient antibodies to provide long-term protection.
While the scientific community has roundly rejected herd immunity the approach, public interest in it has waxed and waned amid pressure to reopen schools and economies.
Last month, President Trump appeared to praise the idea during a town hall in Pennsylvania.
“You’ll develop herd — like a herd mentality,” he said. “It’s going to be — it’s going to be herd developed — and that’s going to happen.”
British Prime Minister Boris Johnson’s government initially expressed interest in the theory before backtracking amid public outcry over the dangers of letting the virus spread. Johnson himself was hospitalized with a severe case of covid-19, which he said could have killed him.
Tedros, noting that there had been “some discussion” about the concept recently, told reporters Monday that allowing people to be exposed to a deadly virus whose effects are still not fully known was “not an option.”
“Most people who are infected with the virus that causes covid-19 develop an immune response within the first few weeks, but we don’t know how strong or lasting that immune response is, or how it differs for different people,” he said.
Though rare, there are multiple documented instances of people being infected for a second time after recovering from covid-19. An 89-year-old woman in the Netherlands died after being infected with the coronavirus for a second time, Dutch news reported Monday.
Antibody studies suggest that less than 10 percent of people in most countries have contracted covid-19, Tedros said, which is nowhere near the majority that would be needed for herd immunity.
With the “vast majority” of the world’s population susceptible, letting the virus spread “means allowing unnecessary infections, suffering and death,” he said.
Just in the last four days, Tedros said Monday, the global coronavirus count has continued to break its daily record for the number of new confirmed infections.
“Many cities and countries are also reporting an increase in hospitalizations and intensive care bed occupancy,” he added.
Tedros has urged governments to pursue comprehensive plans that include widespread testing, social distancing, and other preventive measures, such as face-mask wearing, alongside a global push to develop a vaccine. The WHO is spearheading an effort to distribute coronavirus vaccines equitably once they are available, which Trump declined to join.
What is the probability of testing positive for Covid-19 before you get symptoms? Scientists really don’t know.
Vice President Mike Pence has not tested positive for SARS-CoV-2, the virus that causes Covid-19. But he’s been in close contact, in recent days, with people with confirmed Covid-19 infections. And he debated Sen. Kamala Harris last night. Was this a good idea?
In a word: No. Per the Centers for Disease Control and Prevention’s own guidelines, Pence should have been quarantining, not debating, even if he’s testing negative. (That said, CDC director Robert Redfield had cleared Pence to debate.)
Since the Trump administration’s actions over the last 11 days have muddied the message from public health experts, let’s be clear: A negative test is not an all-clear for doing risky activities during the pandemic.
Scientists don’t yet understand exactly when a person who is infected with the coronavirus will start testing positive for the virus. There are situations when a person could test negative, actually be infected, and also be contagious. It’s also possible — since this virus multiplies itself exponentially in the body very, very quickly — that someone could test negative in the morning (and not be contagious), but by the afternoon test positive (and be very contagious).
Confusing? Yes, it is. But the bottom line is that Covid-19 diagnostic tests (both the slower, more common, viral genetic test — called RT-PCR— and the more rapid viral protein test, called an antigen test) are most useful, and most accurate, when used on people experiencing symptoms.
“One of the huge gaps now in the data is: What is the probability of testing positive before you get symptoms?” Benny Borremans, a disease ecologist at UCLA, says. Right now, scientists just don’t know for sure.
Why testing is less accurate before symptoms begin
There are several reasons scientists are unsure about when in an infection people will start testing positive for SARS-CoV-2. To understand why, and to make this less confusing, it’s helpful to think through all the things that have to happen for a Covid-19 test to come back positive.
First, the virus needs to take its time to establish itself in a person’s body. This is called the incubation period, and it can take upward of two weeks. On average, this happens in about five or six days. During the incubation period, a person might not test positive for the virus because there’s not enough virus in their body to detect in a test.
“The virus particles, day by day, will multiply,” Muge Cevik, a virologist and physician at the University of St. Andrews, says. “The virus needs to reach a threshold for the PCR [i.e. viral genetic] tests to pick it up.” PCR is the more common Covid-19 diagnostic test because it requires a lower threshold of the virus to test positive; rapid antigen tests would require a higher level of virus to register a positive test.
Testing positive should coincide with being contagious. But not always.
Generally, a person can start being infectious for the virus around two days before they start to show symptoms, in what’s known as the presymptomatic phase.
And, generally — but not always — scientists would expect that if a person is contagious, they’d test positive. After all, if they’re spewing enough virus out to get another person sick, they’re probably spewing enough virus out for a diagnostic test to pick up on.
But there are a few wrinkles here: When exactly a person makes the jump from testing negative and being non-infectious to testing positive and being infectious is hard to predict.
“If everything works as it should, the test should be positive if you are infectious at the very moment of the test, as there must be virus present then,” Justin Lessler, an epidemiologist at Johns Hopkins University, says. “However, you could easily test negative then become infectious a day, or even hours, after the test.” Unless you’re testing every hour, it’s impossible to get a fine-grained view on when the infectious period truly begins. (Also possible, but probably rarer: A person tests positive before they start to be contagious.)
Even if a person is contagious, they may not test positive. It could come down to where the sample for testing was taken from.
In general, “we consider the gold standard to be the nasopharyngeal swab,” Bobbi Pritt, the director of clinical microbiology at the Mayo Clinic, says. “That’s the deep nasal swab that goes all the way back into the back of your nose. Whereas other specimens — like a throat swab or just the very outer edge of your nose, like right inside your nostril — that’s not going to contain as much virus.”
Early on in the infection, a person who is incubating the virus is expected to test negative. Over the summer, Johns Hopkins researchers — including Lessler — published a paper estimating the likelihood of a false negative test in the first few days after being exposed to the virus. On the first day, they found the chance of a false negative is near 100 percent. No test is going to find the virus so early. Through the first four days, that rate drops to 67 percent on day four, on average, but with a very large range of error. On the day people first reported symptoms, there’s still a significant false negative rate, at 38 percent.
What does this all add up to? “What we’re saying is don’t test anyone in less than four days after exposure,” Cevik says. It’s not going to tell you much about the person’s status. Or if a person is tested in that time, they ought to be retested a few days later.
“In general, five to eight days after exposure is the best time to test,” Cevik says. “Or day three after symptom onset.” That’s when the genetic RT-PCR tests are most likely to reveal a true positive.
Because nothing about Covid-19 can be simple, here’s another thing to consider: The antigen tests that produce quick results have a shorter window in which you’d expect a person would test positive.
They are also slightly less accurate. But if used correctly, they can be very useful: They’ll test positive in the window when a person is most likely to be contagious. With repeated use, scientists hope these quick tests could help stop outbreaks from growing out of control.
The White House, on the other hand, has been using another rapid test, Abbott’s ID Now, to screen asymptomatic people. We just don’t know how good these tests — or any tests, for that matter — are at screening asymptomatic, or presymptomatic, people. “The FDA would be the first ones to tell you that they don’t know how the test is going to perform in that population,” Pritt says.
A negative test without symptoms might not mean much. Keep your mask on.
Here’s the bottom line: “We don’t know when one will test positive pre-symptom onset for PCR or antigen tests,” epidemiologist A. Marm Kilpatrick writes in an email. If you have symptoms, you’re likely to test positive the day you start feeling ill, but not guaranteed. The first few days after starting to feel sick, you have a very high probability of testing positive.
We could learn more in the months ahead about testing asymptomatic and presymptomatic people with studies following people after they have been exposed to the virus, and testing them repeatedly over a few weeks to determine the likelihood of testing positive before symptoms begin. “We have a lot of data from symptom onset onwards, but we don’t have data in terms of pre-symptoms,” Cevik says.
This is why testing is no replacement for other Covid-19 mitigation measures, like quarantining people exposed to the virus, mask-wearing, and social distancing.
“Testing negative is not like a passport for people to go out and do whatever they want to do,” Cevik says. If you might have been exposed to the coronavirus, like Vice President Pence was, you should quarantine for two weeks, regardless of what your test says.
A new wave of Covid-19 cases is building across the United States, a harbinger of difficult winter months ahead.
America is now averaging nearly 48,000 new confirmed cases every day, the highest numbers since mid-August, according to the Covid Tracking Project. More than 34,500 Americans are currently hospitalized with Covid-19 in the US, up from less than 30,000 a week ago. Nearly 700 new deaths are being reported on average every day, too — and while that is down from August, when there were often more than 1,000 deaths a day, deaths are going to eventually start increasing if cases and hospitalizations continue to rise. It’s a pattern we have seen before.
Public health experts have been warning for months that fall and winter could lead to a spike in Covid-19 cases. Why? Because the best way to slow down the coronavirus’s spread is to keep your distance from other people and, if you are going to be around others, to be outside as much as possible — and both become harder when the weather gets cold.
We may now be seeing those predictions start to come true. The US already has more than 7.7 million confirmed cases and 214,000 deaths. Both numbers will continue to climb.
Eight months into the pandemic, America’s failures to contain Covid-19, and states’ eagerness to reopen even if they haven’t gotten their outbreaks under control, is once again leading to a surge in cases and hospitalizations.
Covid-19 cases are rising everywhere across the country
Earlier in the year, there was limited value to discussing “waves” because some states would have a decline in cases while other states were experiencing surges. What distinguishes this autumn wave is that it seems to be happening everywhere.
Case numbers are up in the Northeast, the Midwest, and the West. The South appears to be, at best, plateauing at a level even higher than that which the Northeast endured during the worst of New York’s outbreak.
What’s so worrisome is that no one state or region can be blamed for this new wave. Just 13 states have seen their number of new Covid-19 cases drop over the last two weeks, according to Covid Exit Strategy. Cases are up in all the others.
Raw case numbers can, of course, obscure important differences in population; 100 new cases means something different for California than it does for Wyoming. Experts will use another metric — new cases per million people — to gauge how saturated a given state is with Covid-19.
The goal would be to have fewer than 40 new cases per million people. But just three states — Maine, Vermont, and New Hampshire — meet that threshold. Meanwhile, North Dakota (627 cases per million), South Dakota (596), Montana (474), and Wisconsin (434) are some of the states seeing very high levels of new infections.
As Vox’s German Lopez reported this week, just one state — Maine — meets all of the benchmarks established by experts for a state to consider its Covid-19 outbreak contained. And yet, most states have reopened many of the businesses that were closed in the spring: 40 or so states have reopened restaurants, bars, gyms, movie theaters, and nonessential retail.
“Part of the problem is America never really suppressed its Covid-19 cases to begin with,” Lopez wrote, explaining why experts were anticipating a new surge in cases. “Think of a disease epidemic like a forest fire: It’s going to be really difficult to contain the virus when there are still flames raging in parts of the forest and small embers practically everywhere. The country always risks a full blaze with each step toward reopening and with each failure to take precautions seriously.”
Too many Covid-19 tests are coming back positive right now
Another closely watched indicator for renewed Covid-19 spread is the percentage of coronavirus tests that come back positive. The number of tests being conducted doesn’t actually tell you all that much; if a high percentage of them are positive, that suggests that many others aren’t being caught at all and the virus could continue to spread unchecked.
So while the US is now averaging nearly 1 million tests every day, that is not quite the triumph it might sound like (or President Donald Trump would like to believe it is). The country’s positive test rate is 5 percent, right at the threshold experts say would reflect adequate testing. Ideally, it would be even lower, 2 percent or less.
But even with that passable national positivity rate, most states are still not conducting nearly enough testing. Here are the 10 states with the highest positive test rates, according to Covid Exit Strategy:
Idaho (25 percent)
South Dakota (20.6 percent)
Wisconsin (19.5 percent)
Iowa (17.1 percent)
Kansas (16.1 percent)
Wyoming (15.5 percent)
Utah (14.7 percent)
Nevada (14.4 percent)
Indiana (13.6 percent)
Alabama (13.3 percent)
It’s really only a handful of better-performing states — namely, New York, with more than 115,000 tests conducted per day and a 1.2 percent positivity rate — that’s keeping the US’s overall positive test rate from looking a lot worse.
America has never had a cohesive Covid-19 testing strategy. Since February, there have been regular supply shortages delaying test results. States have been fighting each other for precious testing resources. Contact tracing has not been a priority for the federal government, and most states have still not hired nearly enough people to perform that work.
Wealthy countries like Germany and South Korea have used effective test-trace-isolate programs to keep their Covid-19 outbreaks in check. The US, meanwhile, is still struggling to perform enough tests or scale up its contact tracing capabilities. Just 11 states, plus the District of Columbia, could realistically expect to perform adequate contact tracing, according to Covid Exit Strategy, considering their positivity rate.
Without improvement in both of those areas, it will continue to be difficult for the US to contain the coronavirus before a vaccine becomes available.
More Americans are being hospitalized with Covid-19 too
Both case numbers and the positive test rate can be a little deceptive, depending on how many tests are being performed. They suggest what’s happening on the ground — in this case, Covid-19 is spreading — but they do have their limitations. There is some truth to the president’s claim that more tests will mean more cases, though that is not a reason to stop testing.
Hospitalizations, on the other hand, are more concrete. If more people are developing symptoms severe enough to warrant being hospitalized, that is a strong indicator that the real number of people being infected with Covid-19 is growing, regardless of whether they are getting tested.
And after a dip in September, the number of Americans currently in the hospital with Covid-19 is higher than it’s been in a month. That trend has been seen across the country.
The worry becomes that if hospitals take in too many patients, they’ll have to turn other people away, or that overwhelmed staff and facilities could lead to some patients receiving substandard care. According to Covid Exit Strategy, 20 states currently have reduced ICU capacity that puts them in a danger zone; 21 states have an elevated occupancy rate in their regular hospital beds.
Wisconsin,where the number of hospitalized Covid-19 patients has risen over the last month from about 300 to 876 today, recently established a new field hospital on its state park fairgrounds over fears that the state’s hospitals wouldn’t have enough beds given the recent surge in cases.
Fortunately, hospitals have gotten much better at treating Covid-19. They have proven treatments, like remdesivir and dexamethasone, that reduce the length of hospital stays and reduce mortality in patients with severe symptoms. They have learned techniques like putting patients on their stomach to improve breathing. Hospitals that have endured multiple spikes of Covid-19 cases report patients in the later waves are spending less time in the hospital and dying less frequently.
Nevertheless, more people developing severe symptoms, as we are starting to see, will inevitably lead to more deaths. Over the summer, people wondered why deaths were falling while cases and hospitalizations rose — until deaths did start to increase. There is a long lag between cases rising and deaths rising, because it can take a month or more between when a person first contracts Covid-19 and, if they die, when their death is reported.
That’s why these new Covid-19 trends in the US are so worrisome. Cases are rising, as are hospitalizations. It could be only a matter of time before deaths start to spike as well.
An otherwise healthy 25-year-old Nevada man is the first American confirmed to have caught COVID-19 twice, with the second infection worse than the first.
He has recovered, but his case raises questions about how long people are protected after being infected with the coronavirus that causes the disease, and potentially how protective a vaccine might be.
“It’s a yellow caution light,” said Dr. William Schaffner, an infectious disease expert at the Vanderbilt University School of Medicine in Nashville, Tennessee, who was not involved in the research.
Respiratory infections like COVID-19 don’t provide lifelong immunity like a measles infection. So, Dr. Paul Offit, an infectious disease expert at Children’s Hospital of Philadelphia, said he’s not at all surprised people could get infected twice with the coronavirus, SARS-CoV-2.
It’s too soon to know whether the man from Washoe County, Nevada, who had no known health problems other than his double infection, was highly unusual or if many people could easily get infected more than once with SARS-CoV-2, Schaffner said.
“There’s hardly an infectious disease doctor in the country who hasn’t encountered a patient who thinks they’ve had a second infection,” he said. “Whether that’s true or not, we don’t know. There are lots of respiratory infections out there.”
How rare is he?
There have been at least 22 documented cases of reinfection worldwide since the start of the pandemic, but it’s unclear how many cases there have actually been, and how common it may be among people who don’t even know they’re infected.
“It could be a one in a million event, we don’t know,” said Akiko Iwasaki, an immunologist at Yale University and an investigator with the Howard Hughes Medical Institute, who wrote a commentary with the study.
With millions of people infected, it’s hard to know if case studies like the new one represent very rare events or the tip of an iceberg, she said. “It’s possible that the vast majority of people are completely protected from reinfection, but we’re not measuring them, because they’re not coming to the hospital.”
Also, many people don’t know they are infected the first time, so it’s hard to say whether they’re getting re-infected.
In one of the recent cases, a Hong Kong man only knew he was reinfected because it was caught during a routine screening when he returned from outside the country, months after he had cleared an infection and tested negative.
One reason there may not be more documented cases of reinfection: It’s tough to prove, said Mark Pandori, a pathologist at the University of Nevada, Reno School of Medicine, and senior author on the new study.
His team coordinated early in the pandemic with members of the Washoe County Health District to look for repeat infections. They had the benefit of sequencing equipment on campus, as well as microbiologists, he said. And they got lucky finding someone who had been tested both times he was infected and cleared in between.
Why his infection was worse the second time remains unclear, said Pandori, director of the Nevada State Public Health Laboratory. “I can’t tell you if it tells us anything in particular about the biology of this virus.”
The man caught a slightly different version of the virus the second time, according a genetic analysis of the man’s infections. It’s possible the second version was more dangerous, though there is no evidence of that, or that it was just different enough that his body didn’t recognize it, the paper said.
Implications for vaccination
Iwasaki said the study raises questions about how long immunity lasts after a natural infection. Protection with a vaccine is likely to be quite different, she said.
“Vaccines can be designed to induce much higher levels of antibody and much longer lasting immunity,” she said. Just because the natural infection doesn’t give you protection doesn’t mean the vaccines cannot. It’s a separate issue.”
Offit, also a vaccine expert at the Perelman School of Medicine at the University of Pennsylvania, said he expects protection from vaccines will likely last at least a year or two.
The protection provided by infection or vaccination isn’t 100% perfect until the day it disappears completely, he said. Instead, protection fades gradually, so someone exposed to a huge dose of the virus might get re-infected within months, while others could be protected for years, Offit said.
It’s also possible the Nevada man has an undiagnosed problem with his immune system. “He probably should be seen by an immunologist,” Offit said.
The length of time an infection will be protective remains one of the key open questions about the virus.
Infected twice, two months apart
The Nevada man, considered an essential worker, started feeling ill in late March, with a sore throat, cough, headache, nausea and diarrhea. His workplace had been hit with an outbreak early in the pandemic, before safety measures like masks could be put in place, said Heather Kerwin, senior epidemiologist at the Washoe County Health District and a co-author on the paper.
He went for testing on April 18 and his infection with the coronavirus was confirmed.
On April 27, he reported his symptoms had all resolved and he felt fine, but at the time, employees were required to test negative for COVID-19 twice before they would be allowed back to work, Kerwin said. So he remained isolated at home.
A month later, he began feeling poorly again. At the same time, there was an outbreak where one of his parent’s, also an essential worker, was employed, Kerwin said.
On May 31, he went to an urgent care center, reporting fever, headache, dizziness, cough, nausea and diarrhea. On June 5, he went to see a doctor who found his oxygen levels dangerously low and had him hospitalized. Again, the man tested positive for the virus, even though he still had antibodies to the virus in his bloodstream, Kerwin said.
Genetic differences between the viruses responsible for each of his infections suggested he was infected two separate times. The virus doesn’t mutate quickly enough within a single person to explain the differences between the two infections, the researchers found.
A parent living with the man also caught COVID-19 and was diagnosed on June 5.
Mark Pandori, pathologist
The paper reports it’s possible the man was reinfected because he was exposed to a higher dose of the virus the second time, perhaps from the family member.
His cough lingered and he suffered from shortness of breath and mental fog, and was on oxygen for six weeks after the second infection, Kerwin said. He has now fully recovered.
Reinfections imply so-called herd immunity cannot be obtained just through natural infection. If natural infection protects for only a few months, then it will be impossible for enough people to be protected simultaneously to reach herd immunity.
The moral of the case study, said co-author Pandori, is even people who already have been sick with COVID-19 need to protect themselves by wearing a mask, avoiding large gatherings, washing hands frequently and maintaining social distance.
“You’re not invulnerable to this,” Pandori said. “In fact, you could get it worse the second time.”
For its first 208 years, the New England Journal of Medicine has never endorsed a political candidate. But this week the journal published an editorial outlining its political position in the upcoming Presidential election, signed unanimously by all editors who are US citizens.
The editors did not explicitly endorse former Vice President Biden, but rather offered a scathing condemnation of the current administration’s performance during the COVID pandemic:“Reasonable people will certainly disagree about the many political positions taken by candidates.
But truth is neither liberal nor conservative. When it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.” (Formally endorsing Biden last month, Scientific American also made the first political endorsement in its 175-year history.)
Much of the media coverage of the NEJM statement has centered on the question of whether medicine should involve itself in politics, or “live above it”.
Medicine has been drawn into political disputes before, but now the nature of the involvement has changed. In the past, debates largely centered around regulation, payment or policy—but now the science itself has become a fundamentally political issue.
The very nature of the coronavirus has become a matter of political belief, not just an indisputable scientific fact.
Public trust in both scientific institutions and the government, and their ability to work together, has been damaged. We fear this will lead to poorer health outcomes regardless of who wins the upcoming election.
The D.C. Health Department is trying to jump-start contact tracing efforts around the White House’s coronavirus outbreak. Tracing has been inadequate so far even as cases spread deeper into the city, Axios’ Marisa Fernandez writes.
The big picture:The White House has decided not to move forward with recommended public health protocols of contact tracing and testing since President Trump tested positive for the virus.
The state of play: Tracing has been done for people who had direct contact with Trump, White House spokesman Judd Deere told the Washington Post.
On Capitol Hill, there’s also no formalized contact tracing program in place, even as lawmakers themselves test positive.
Two infected staffers in Rep. Doug Lamborn’s (R-Colo.) office were told to not disclose to roommates they may have been exposed, WSJ reports.
The bottom line:The White House’s refusal to contact trace is “a missed opportunity to prevent additional spread,” Emily Wroe, a co-leader of a contact-tracing team at Partners in Health, told Nature.
The quarantining of most of the Joint Chiefs of Staff, coming on the heels of President Trump’s COVID-19 diagnosis, is raising fears that U.S. adversaries might seek to exploit a perceived weakness.
Few expect any sort of overt military action, but there are other ways to wreak havoc on the United States.
Chief among them is disinformation. Experts have been warning ever since Trump tested positive for the coronavirus last week that disinformation is likely to kick into overdrive.
Now, with six of the seven members of the Joint Chiefs of Staff waylaid at home, warnings are being amplified about the national security implications of the growing COVID-19 outbreak among U.S. leadership.
“All these kinds of things are just a huge distraction for us where our national security apparatus is consumed with matters domestic and internal,” former Director of National Intelligence James Clapper said at a Washington Post event after news broke of the Joint Chiefs quarantining. “So this is an ideal time for adversaries, particularly in adversary intelligence services, to look for ways to further confuse us, to distract us.”
Adding that “you can bet particularly our good friends the Russians are doing this,” Clapper warned of them “further sowing seeds of disinformation.”
“They will appeal to all the various tribes and continue to capitalize on the polarization in this country,” he said. “So it is a vulnerable time, and it’s an opportunity for them while we’re not looking and not being alert to further sow seeds of disinformation, casting doubt, discord, distrust in the country.”
The quarantining of top military officers stems from the Coast Guard’s No. 2 admiral contracting COVID-19. The Coast Guard announced Tuesday that its vice commandant, Adm. Charles Ray, tested positive for the coronavirus on Monday after feeling mild symptoms over the weekend.
The test result came after Ray met with most of the Joint Chiefs of Staff at the Pentagon on Friday.
That put Joint Chiefs of Staff Chairman Gen. Mark Milley into quarantine, as well as the chiefs of the Army, Navy, Air Force, Space Force and National Guard. The vice chairman, Gen. John Hyten, was also in the meetings and is quarantining.
The only member of the Joint Chiefs who didn’t meet with Ray was Marine Corps Commandant Gen. David Berger, who was traveling.
Berger’s deputy, Gen. Gary Thomas, met with Ray instead and went into quarantine Tuesday. The Marine Corps announced Wednesday evening that he has tested positive for the virus.
Gen. Paul Nakasone, commander of U.S. Cyber Command and director of the National Security Agency, also met with Ray and went into quarantine.
It’s unclear exactly where Ray caught the virus, but his schedule within the incubation period included a visit to the White House, which is now considered the epicenter of a coronavirus outbreak that includes Trump himself.
Ray — along with Milley, Defense Secretary Mark Esper and other top defense officials — attended a White House ceremony for Gold Star families on Sept. 27.
The event happened the day after Trump announced he was nominating Amy Coney Barrett for the Supreme Court, a gathering for which several attendees have since been diagnosed with COVID-19.
Since Trump’s diagnosis, the Department of Defense has sought to allay any national security concerns.
When Trump’s positive test was first announced last week, the Pentagon insisted there has been “no change to DoD alert levels.”
After news broke Tuesday of the Joint Chiefs quarantining, chief Pentagon spokesman Jonathan Hoffman reiterated that “there is no change to the operational readiness or mission capability of the U.S. Armed Forces.”
“Senior military leaders are able to remain fully mission capable and perform their duties from an alternative work location,” Hoffman said in a statement.
The military chiefs are well-equipped to work from home, and besides Ray and Thomas, none have tested positive for the virus yet.
But the development has raised questions about whether adversaries will try to take advantage of the situation nonetheless.
After the military quarantines were revealed, House Armed Services Committee Chairman Adam Smith (D-Wash.) said “the national security implications of the president’s recklessness cannot be overstated” even though the military “can still operate while leadership is quarantined.”
“Since announcing that he tested positive for the virus, the president’s antics have been downright reckless and harmful,” Smith said in a statement. “Our adversaries are always looking for any weakness to exploit. President Trump’s pathetic attempts to exude strength aren’t fooling anyone — Americans know he is weak and so do those who wish us harm.”
Rep. Jackie Speier (D-Calif.), another senior member of the Armed Services Committee, questioned why so many senior military leaders were meeting in person in the first place, as well as attending a White House reception in which they were pictured maskless.
“What if the Joint Chiefs’ responsibilities cannot be done remotely while they are isolating?” Speier wrote in a series of questions on Twitter. “How many other senior military leaders have tested positive? Why weren’t we safeguarding the health of senior military leaders like the natural security asset that it clearly is?”
Barry Pavel, senior vice president and director of the Atlantic Council’s Scowcroft Center for Strategy and Security, stressed that there is “no degradation in operational command and control” from the Joint Chiefs quarantining.
But, he added, adversaries such as Russia and China could misperceive that the United States is distracted and decide to act. For example, he cited concerns about China moving against Taiwan or Russia trying to grab more territory.
Pavel also listed what he called Russia’s “non-kinetic war” against the United States in the cybersecurity, influence and disinformation realm.
“This is a KGB officer’s most wildest dream coming true almost on a daily basis,” he said. “And so I think it’s a big threat. Who knows what proportion of our current public divisions are sown by Russian influence and bots or are just part of our current division. I don’t know the answer to that question. But they’re certainly right now exploiting it.”
To diminish those concerns, Pavel said, the Pentagon should keep emphasizing its military readiness, as well as demonstrating it by taking actions like publicizing a previously planned exercise.
“It’s probably a good idea to keep repeating those messages,” he said, “to be reiterating those messages, sending them publicly, privately, by third parties and through various forms of military activity so adversaries have no misunderstanding about our readiness and capabilities despite the chairman being quarantined in his quarters.”
The undercurrent of the VP debate is the age and health of the two men vying for the presidency.
The two remaining presidential debates, scheduled for October 15 and 22, are in question due to President Trump’s positive COVID-19 and quarantine status, making the vice presidential debate this Wednesday at 9 p.m. even more important than VP debates of past elections.
The undercurrent in the debate consists of the ages of challenger Biden, who is 77 and turning 78 before the end of the year, and Trump, 74, who has been hospitalized for COVID-19 and was released from Walter Reed Army Medical Center on Monday afternoon. Trump has said he plans to debate Biden on October 15.
This VP debate is big, said Paul Keckley, a healthcare policy analyst and managing editor of the Keckley Report.
“The reason is not so much the two are debating,” Keckley said. “We have a 77- year-old challenger and a 74-year-old incumbent. Voters are expecting the odds are one will become disabled and the vice president is going to step in. That’s the undercurrent of this debate.”
Healthcare is an obvious dominant theme Wednesday night beyond the health of the two men seeking the presidency.
It is expected that Biden’s running mate, Kamala Harris will challenge Vice President Mike Pence on his role heading the coronavirus task force when close to 7.5 million people in this country have been infected with COVID-19 and more than 200,000 have died.
Pence will likely challenge Harris on her support for Medicare for All before she backtracked to support Biden’s public-private option for healthcare coverage.
Pence and Harris are expected to lay out the healthcare plans of their respective Republican and Democratic nominees less than four weeks before the election, in a way the lead candidates failed to get across during the first presidential debate that presented more chaos than clarity.
TRUMP AND BIDEN PLANS
Trump and Biden differ fundamentally on whether the federal government should be involved in the business of providing healthcare coverage.
Trump’s guiding principles rest on the pillar of state autonomy as opposed to a federalized healthcare system and Biden’s maxim that healthcare is a right, not a privilege.
Trump believes that private solutions are better than government solutions, according to Keckley. He is much less restrained on private equity and the Federal Trade Commission’s scrutiny of vertical integration. States become the gateway to the market as private solutions are sold to states as innovation.
Trump’s other concept is that the door to engaging consumers in healthcare is price transparency. His view is that price transparency will spawn consumer engagement.
Centers for Medicare and Medicaid Services Administrator Seema Verma, who was appointed by Trump in 2016 based largely on the recommendation of Pence, is instituting a rule, starting January 1, 2021, requiring hospitals to have price transparency for 300 shoppable services. Hospitals are being required to make their contract terms with payer accessible.
This is separate from CMS’s interoperability rule aimed at payers that also goes into effect on January 1.
Trump believes healthcare is a personal responsibility, not a public obligation. To Trump, healthcare is a marketplace where there are winners and losers, according to Keckley.
Biden has a more developed policy platform on making healthcare a universal right, starting with strengthening the Affordable Care Act that was passed while Biden was vice president during President Barack Obama’s terms.
Biden wants to increase the eligibility for tax subsidies in the ACA up to 400% of the federal poverty level, which would expand access to subsidized health insurance.
He also wants to reduce the affordability threshold for employer insurance. Currently, if employees pay more than 9.7% of their adjusted income for their workplace coverage, they can seek a plan in the ACA marketplace. Biden would lower that eligibility for ACA coverage to 8.5%, opening the door for many more consumers to be insured through the ACA, at a lower cost.
Biden would also lower the age of eligibility for Medicare from 65 to 60.
For companies such as manufacturing and transportation, in which individuals can retire after 30 years of service, this lets them into the Medicare system earlier to fill that gap between retirement and Medicare eligibility.
Biden’s public option would create insurance plans that would compete with private plans.
The other factor to watch on the Biden side, Keckley said, is his clear focus on equity and diversity in healthcare.
AFFORDABLE CARE ACT
Biden wants to strengthen Obamacare while Trump is actively pursuing a repeal of the law through the Supreme Court.
President Trump’s debate prep and the White House Rose Garden event announcing the nomination of Judge Amy Coney Barrett to replace the late Supreme Court Justice Ruth Bader Ginsburg, border on the definition of super spreader events.
The Justices, perhaps with the addition of Trump’s pick, Amy Coney Barrett, if there are enough Republican senators well enough and in attendance to vote for confirmation, are scheduled to hear oral arguments in the case brought by 18 GOP-led states on November 10, the week after the election.
Senators must be present to vote, and Republicans, who have a majority of 53 to 47 seats, need a four-vote majority. Two Republican senators – Susan Collins of Maine and Lisa Murkowski of Alaska – have said they wouldn’t vote on a nominee prior to the election. Vice President Mike Pence could cast the deciding vote in a tie.
Three Republican senators have tested positive for the coronavirus. Sens. Mike Lee of Utah and Thom Tillis of North Carolina, who sit on the Judiciary Committee, tested positive for COVID-19 days after attending the White House Rose Garden event on September 26. Republican Sen. Ron Johnson of Wisconsin is now the third to test positive, though he did not attend that event.
There was a lack of social distancing and mask wearing at both the Rose Garden nomination and at a meeting between Trump and staff for debate prep. Twelve people in Trump’s inner circle, including his wife Melania, former New Jersey governor Chris Christie and White House Press Secretary Kayleigh McEnany, have tested positive since attending.
Senate Majority Leader Mitch McConnell wrote in an email to GOP senators obtained by CNN that he needs all Republican senators back in Washington by October 19.
COVID-19
Trump announced in a tweet Monday that he would be leaving Walter Reed later in the afternoon, saying he felt “really good!” and adding, “Don’t be afraid of Covid. Don’t let it dominate your life. We have developed, under the Trump Administration, some really great drugs & knowledge. I feel better than I did 20 years ago!”
Trump has been criticized for leaving the hospital on Monday to take a drive-by ride to wave to supporters. Attending physician Dr. James Phillips called the action “insanity” and “political theater” that put the lives of Secret Service agents in the car with him at risk.
Trump has downplayed the virus in an effort to reopen the country and the economy, and has put the blame on China, where the coronavirus originated.
Trump told Biden during the debate, “We got the gowns; we got the masks; we made the ventilators. You wouldn’t have made ventilators – and now we’re weeks away from a vaccine.”
Biden puts the blame squarely on Trump for delaying action to stop the spread.
Biden said during the debate: “Look, 200,000 dead. You said over seven million infected in the United States. We in fact have 5% or 4% of the world’s population – 20% of the deaths. Forty thousand people a day are contracting COVID. In addition to that, about between 750 and 1,000 people, they’re dying. When [Trump] was presented with that number he said ‘It is what it is’ – what it is what it is – because you are who you are. That’s why it is. The president has no plan. He hasn’t laid out anything.”
Biden said that back in July he laid out a plan for providing protective gear and providing money the House passed to get people the help they need to keep their businesses open and open schools.
Under Trump’s Administration, Congress passed $175 billion in provider relief funds for hospitals, small businesses, individuals and others – $100 billion from the CARES Act and $75 billion from the Paycheck Protection Program and Healthcare Enhancement Act.
MEDICAID EXPANSION
CMS Administrator Seema Verma was healthcare advisor to Pence while he was governor of Indiana. Her consulting firm, SVC, Inc., worked closely with Pence to design Indiana’s Medicaid expansion under the Affordable Care Act. They developed a unique Medicaid expansion program called Health Indiana Plan 2.0, which mandated low income adults above the poverty level pay monthly premiums for their healthcare.
Members who did not pay faced being disenrolled for six months.
As administrator, Verma has initiated similar work requirements for Medicaid coverage nationwide.
While as governor Pence implemented Medicaid expansion, as vice president he has supported torpedoing the ACA, and has pushed the Graham-Cassidy plan for healthcare reform that would have replaced the ACA.
DRUG PRICES
Neither Trump nor Biden has taken on the pharmaceutical industry in a meaningful way, though both have voiced a strong belief that drug manufacturers are egregious to the system, according to Keckley.
“Both camps are saying, we’re really going to take them on,” he said.
During the debate, Trump said he was cutting drug prices by allowing American consumers to buy drugs from Canada and other countries under a favored nation status.
“Drug prices will be coming down, 80 or 90 percent,” Trump said during the debate, telling Biden he hadn’t done anything similar during his 47 years in government.
If Trump gets a second term, there will likely be more industry folks in his circle, following up on his first term of stacking his cabinet with business people.
Biden would be more likely to lean toward a blend of public health officials and industry executives. There would be more of a spotlight on wealth creation in healthcare and executive pay.
In the $1.1 trillion world of prescription drugs, the United States makes up 40% of the market.
“We’re the hub of the prescription drug industry,” Keckley said.
President Donald Trump spent three days in the hospital. He arrived and left by helicopter. And he received multiple coronavirus tests, oxygen, steroids and an experimental antibody treatment.
For someone who isn’t president, that would cost more than $100,000 in the American health system. Patients could face significant surprise bills and medical debt even after health insurance paid its share.
The biggest financial risks would come not from the hospital stay but from the services provided elsewhere, including helicopter transit and repeated coronavirus testing.
Trump has praised the high quality of care he received at Walter Reed National Military Medical Center, and has played down the risk of the virus. “Don’t be afraid of Covid,” Trump tweeted on Monday, before returning to the White House. “Don’t let it dominate your life.”
Across the country, patients have struggled with both the long-term health and financial effects of contracting coronavirus. Nearly half a million have been hospitalized. Routine tests can result in thousands of dollars in uncovered charges; hospitalized patients have received bills upward of $400,000.
Trump did not have to worry about the costs of his care, which are covered by the federal government. Most Americans, including many who carry health coverage, do worry about receiving medical care they cannot afford.
For some Americans, the bills could start mounting with frequent tests. Insurers are generally required to pay for those tests when physicians order them, but not when employers do.
The Trump administration made that clear in June, when it issued guidance stating that insurers do not have to pay for “testing conducted to screen for general workplace health and safety.” Instead, patients need to pay for that type of testing themselves. Some might be able to get free tests at public sites, and some employers may voluntarily cover the costs. Others could face significant medical debt from tests delivered at hospitals or urgent care centers.
COVID tests can be expensive. Although they typically cost $100, one emergency room in Texas has charged as much as $6,408 for a drive-through test. About 2.4% of coronavirus tests billed to insurers leave the patient responsible for some portion of payment, according to the health data firm Castlight. With 108 million tests performed in the United States, that could amount to millions of tests that leave patients responsible for some share of the cost.
Marta Bartan, who works as a hair colorist in New York City, needed a coronavirus test to return to her job this summer. She received a $1,394 bill from the hospital running the drive-through site where she was tested.
“I was so confused,” said Bartan, who is contesting the bill. “You go in to get a COVID test expecting it to be free. What could they have possibly charged me $1,400 for?”
The bills for the typical American would continue at the hospital, with the routine monitoring that any patient would receive and the drugs provided in the course of care.
Remdesivir, a new coronavirus treatment created by Gilead, costs $3,120 when purchased by private insurers and $2,340 with public programs like Medicare and Medicaid.
Trump also received an experimental antibody treatment from Regeneron. It’s currently available to clinical trial participants or to those granted a “compassionate use” exemption. In either situation, the drug would typically be provided to the patient at no charge. This will most likely change, however, when the treatment finishes trials and hits the commercial market. These types of drugs are hard to manufacture, and other monoclonal antibodies cost thousands of dollars.
Health economists are only starting to understand the full costs of coronavirus treatment, just as scientists are mapping out how the disease works and spreads. They do have some early estimates: The median charge for a coronavirus hospitalization for a patient over 60 is $61,912, according to a claims database, FAIR Health
That figure includes any medical care during the hospital stay, such as an emergency room visit that led to admission or drugs provided by the hospital.
For insured patients, that price would typically be negotiated lower by their health plan. FAIR Health estimates that the median amount paid is $31,575. That amount, like most things in American health care, varies significantly from one patient to another.
In the FAIR Health data on coronavirus patients over 60, one-quarter face charges less than $26,821 for their hospital stay. Another quarter face charges higher than $193,149, in part because of longer stays.
Many, but not all, health insurers have said they will not apply copayments or deductibles to patients’ coronavirus hospital stays, which could help shield patients from large bills.
Uninsured patients, however, could be stuck with the entire hospital charges and not receive any discounts. While the Trump administration did set up a fund to cover coronavirus testing and treatment costs for the uninsured, The New York Times has reported that some Americans without health insurance have received large bills for their hospital stays.
The biggest billing risk for a patient receiving treatment similar to Trump’s would probably come from helicopter rides to the hospital.
Air ambulances are expensive and often not in major health insurance plans’ networks. The median charge for an air ambulance is $38,770, according to a study in the journal Health Affairs published this year. When the helicopter trip is out of network — as about three-quarters of them are — patients are left with a median charge of $21,698 after the insurance payout.
Taking two helicopter rides, as Trump did, could plausibly result in more than $40,000 in medical debt for patients without access to their own aircraft (though of course most people do not leave the hospital by helicopter).
The financial consequences of a coronavirus hospitalization could be long-lasting, if a new Supreme Court challenge to the Affordable Care Act is successful. That case argues that all of Obamacare is unconstitutional, including the health law’s protections for preexisting conditions. The administration filed a brief in June supporting the challenge.
The Supreme Court hears that case on Nov. 10. If the challenge succeeds, COVID-19 could join a long list of preexisting conditions that would leave patients facing higher premiums or denials of coverage. In that case, coronavirus survivors could face a future in which their hospital stays increase their health costs for years to come.
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HENRY KOTULA 