Dr. Anthony Fauci, the nation’s top infectious disease expert, said he and his family are getting death threats because people don’t like what he says about COVID-19.
“Getting death threats for me, and my family, and harassing my daughters, to the point where I have to get security is just — I mean, it’s amazing,” Fauci said during an interview with CNN’s Sanjay Gupta on Wednesday.
“I wouldn’t have imagined in my wildest dreams that people who object to things that are pure public health principles, are so set against it and don’t like what you and I say, namely in the world of science, that they actually threaten you.”
He noted that crises like COVID-19 has brought out the best of people but also the worst of people.
Fauci’s notoriety has been elevated by COVID-19, as he is often on TV offering a blunt portrayal of the state of the pandemic in the U.S.
Fauci, 79, is one of the world’s most respected infectious disease experts, having advised six presidents on HIV/AIDS, Ebola, Zika and other health crises. He has earned a reputation for being blunt and willing to correct the president.
Fauci also reflected on what he says is a degree of “anti-science” sentiment in the U.S. that is making it difficult to get people to do things to slow the spread of COVID-19 like wearing masks.
“There is a degree of anti-science feeling in this country, and I think it is not just related to science. It’s almost related to authority and a mistrust in authority that spills over,” he told Gupta.
“Because in some respects, scientists, because they’re trying to present data, may be looked upon as being an authoritative figure, and the pushing back on authority, the pushing back on government is the same as pushing back on science.”
He said the scientific community should be more transparent and reach out to people to underscore the importance of science and evidence-based policy.
“I know when I say that if we follow these five or six principles, we can open up we don’t have to stay shut…There are some people that just don’t believe me or don’t pay attention to that. And that’s unfortunate because that is the way out of this,” he said.
President Trump has repeatedly undermined Fauci, questioning the White House coronavirus task force member on Twitter and in interviews with the media.
Over the weekend, Trump tweeted out a video of a portion of Fauci’s testimony explaining why the U.S. has recorded more cases than European cases and called it “wrong.” Trump has falsely claimed several times that the U.S. has more cases because it is doing more testing.
Trump has also retweeted multiple messages that question Fauci’s expertise, including one last week that said he had “misled the American public.”
The tweet Richard Costigan posted July 23 was bluntly honest: “We tried our best to limit exposure to #COVID19 but we slipped up somewhere.”
Costigan tweeted while waiting anxiously in the parking lot of a hospital outside Sacramento. The veteran Republican political consultant had just dropped his wife, Gloria, off at the emergency room. He wasn’t allowed to go in with her.
His thoughts traveled back to the small family gathering they had attended in Georgia nearly two weeks before with their 23-year-old daughter, Emma, and 17-year-old son, Andrew. They had planned it so carefully. Nobody wanted to get Gloria’s 88-year-old mother sick.
But here they were, Costigan’s wife battling for breath in the ER, and Costigan sitting in his car coughing.
The family’s journey since then has been one of sleeplessness, pain and worry about the future. And it’s one that Costigan, who worked as deputy chief of staff for Republican Gov. Arnold Schwarzenegger, is taking to social media and his 4,400 Twitter followers.
Looking back, Costigan, 54, doesn’t think he and Gloria, 53, contracted the virus on their separate flights to Georgia, where the family owns a home. The flights were nearly empty and the passengers and crew wore masks, he said.
In Georgia, the family continued its regimen of social distancing and wore masks whenever they left the house — protocols they had followed for months at home in California. And when they gathered with their relatives on that sunny Saturday in July, they were careful to space the chairs 6 feet apart in the backyard.
But they didn’t wear masks, he said, and family members went in and out of the house to grab drinks and use the restroom. “We thought we’d done everything right, and we screwed up,” Costigan said in a July 29 phone interview. “We made a big mistake.”
Now seven of the 10 family members who attended that backyard gathering are sick. Emma and Andrew don’t have any symptoms but haven’t been tested. Exactly who introduced COVID-19 to the group is unclear. No one showed signs of sickness at the time. The first person to become sick was Gloria’s sister, then her niece — then her mom.
Gloria Costigan became sick after they returned to Sacramento, spent a night in the hospital, needed an oxygen machine at home and developed COVID-related pneumonia. By Saturday, however, she no longer needed supplemental oxygen.
Costigan’s reputation as a straight shooter, respected and liked by both Democrats and Republicans, could help change minds about the virus, said Barbara O’Connor, emeritus director of the Institute for the Study of Politics and Media at California State University-Sacramento.
“I think that Richard is being very honest about what’s going on,” said O’Connor, who has known Costigan for decades. “It’s not political. It’s really human.”
Lawmakers who have responded on Twitter with messages of support include state Controller Betty Yee, and state Sens. Richard Bloom and Steve Glazer, all Democrats. Sen. Richard Pan (D-Sacramento), a physician who chairs the Senate Health Committee, has texted well wishes to Costigan.
For his followers, Costigan’s chronicles of the virus remain grim.
“I can’t go very far without needing to lay down,” he wrote in a July 25 tweet. “Been sleeping constantly last two days and the joint pain is intense.”
In another tweet two days later, the symptoms were the same:
Gloria’s 88-year-old mom is at home with a cough, he said.
Costigan talked to California Healthline about his family’s disease odyssey and what he hopes people will take away from his COVID-19 Twitter chronicles. The interview has been edited for length and clarity.
Q: You have tweeted in such detail about the horrible symptoms you experienced. How do you feel now?
My ribs just hurt with the coughing and the fatigue, and my joints hurt. I have the sweats and vivid dreams. I sleep on the floor because it’s more comfortable than the bed.
This thing just hits like a ton of bricks. It’s also the nervousness of it. How long is it going to last? Who are we going to expose to it? I just don’t know what the end game is.
Q: What is it like at your house now?
I wear a mask inside, Gloria wears a mask inside, and Andrew wears a mask. Gloria is sleeping in Emma’s old bedroom, I’m in our bedroom, and Andrew stays upstairs. When I’m hacking, you can see the spit come out. I’m worried about getting pneumonia. That’s something I’m worried about giving to my kid. It’s not just COVID.
Our daughter can only stand on our front porch. She delivers food to us. She puts it by the door, rings the bell and stands 6 feet back.
Q: You suspect you got COVID from the family gathering in Georgia. How do you trace it to that event?
When we looked at everybody that was at the gathering, we were trying to figure it out. It started with my sister-in-law getting sick. Out of 10 of us, seven of us are sick.
We never thought of our family being the one to harm us. Sometimes, you can’t control your anger. You want to be mad at someone. Gloria and I just decided we’re not going to blame anyone. We just don’t know who had it.
Q: How has this experience been so far for you and your family?
It’s been a bizarre week. I went to Kaiser Thursday night. You drop your significant other off. You can’t go in. Off they go to the tented area and I wait in the parking lot. She is admitted. Her oxygen levels are low. She gets a CT, she gets a shot in her stomach for possible blood clots. She gets out Friday and they send oxygen tanks to your house. … She’s in her early 50s and doesn’t have any health issues [otherwise].
Saturday, my son is doubling over in pain. I end up in the ER with my son, and I start coughing. I’m getting the side eye from everyone. Thankfully, he had a kidney stone.
Q: What kind of precautions have you and your family taken these past few months?
We hadn’t been anywhere for months. It was: Stay home. Work from home. No school.
Going to the store was extremely stressful. You go to the store, mask up, glove up, you bleach your shoes when you come home, spray down your car, wash your hands, use a towel to dry your hands, the towel goes straight into the washing machine.
Our son got frustrated with us because we wouldn’t let him see his friends. He saw photos of friends of his partying at Folsom Lake. We were the hardcore parents.
Q: In posts on social media, you are asking people to wear a mask. Why do you think it’s become a political issue?
I’ve been taking flak from friends of mine because I’ve been posting “wear a mask.” Wearing a mask — somehow it has become a freedom issue. It’s not a grand conspiracy. Wearing a mask is a simple thing to do to prevent someone else from getting sick. I do not understand how this has turned into a political issue. The government has a role to play. This is a health care crisis.
Q: How do you move forward in this pandemic?
We’re locking down. Nobody is coming into our circle. I don’t want it again. To see my wife this way is hard.
I want folks to realize this thing is non-discriminatory. It doesn’t matter who you are.
[Readers’ Note: This is the first of two articles on the Future of Hospitals in Post-COVID America. This article
examines how market forces are consolidating, rationalizing and redistributing acute care assets within the
broader industry movement to value-based care delivery. The second article, which will publish next month,
examines gaps in care delivery and the related public policy challenges of providing appropriate, accessible
and affordable healthcare services in medically-underserved communities.]
In her insightful 2016 book, The Gray Rhino: How to Recognize and Act on the Obvious Dangers We Ignore,
Michelle Wucker coins the term “Gray Rhinos” and contrasts them with “Black Swans.” That distinction is
highly relevant to the future of American hospitals.
Black Swans are high impact events that are highly improbable and difficult to predict. By contrast, Gray Rhinos are foreseeable, high-impact events that we choose to ignore because they’re complex, inconvenient and/or fortified by perverse incentives that encourage the status quo. Climate change is a powerful example
of a charging Gray Rhino.
In U.S. healthcare, we are now seeing what happens when a Gray Rhino and a Black Swan collide.
Arguably, the nation’s public health defenses should anticipate global pandemics and apply resources
systematically to limit disease spread. This did not happen with the coronavirus pandemic.
Instead, COVID-19 hit the public healthcare infrastructure suddenly and hard. This forced hospitals and health systems to dramatically reduce elective surgeries, lay off thousands and significantly change care delivery with the adoption of new practices and services like telemedicine.
In comparison, many see the current American hospital business model as a Gray Rhino that has been charging toward unsustainability for years with ever-building momentum.
Even with massive and increasing revenue flows, hospitals have long struggled with razor-thin margins, stagnant payment rates and costly technology adoptions. Changing utilization patterns, new and disruptive competitors, pro-market regulatory rules and consumerism make their traditional business models increasingly vulnerable and, perhaps, unsustainable.
Despite this intensifying pressure, many hospitals and health systems maintain business-as-usual practices because transformation is so difficult and costly. COVID-19 has made the imperative of change harder to ignore or delay addressing.
For a decade, the transition to value-based care has dominated debate within U.S. healthcare and absorbed massive strategic, operational and financial resources with little progress toward improved care outcomes, lower costs and better customer service. The hospital-based delivery system remains largely oriented around Fee-for-Service reimbursement.
Hospitals’ collective response to COVID-19, driven by practical necessity and financial survival, may accelerate the shift to value-based care delivery. Time will tell.
This series explores the repositioning of hospitals during the next five years as the industry rationalizes an excess supply of acute care capacity and adapts to greater societal demands for more appropriate, accessible and affordable healthcare services.
It starts by exploring the role of the marketplace in driving hospital consolidation and the compelling need to transition to value-based care delivery and payment models.
COVID’s DUAL SHOCKS TO PATIENT VOLUME
Many American hospitals faced severe financial and operational challenges before COVID-19. The sector has struggled to manage ballooning costs, declining margins and waves of policy changes. A record 18 rural hospitals closed in 2019. Overall, hospitals saw a 21% decline in operating margins in 2018-2019.
COVID intensified those challenges by administering two shocks to the system that decreased the volume of hospital-based activities and decimated operating margins.
The first shock was immediate. To prepare for potential surges in COVID care, hospitals emptied beds and cancelled most clinic visits, outpatient treatments and elective surgeries. Simultaneously, they incurred heavy costs for COVID-related equipment (e.g. ventilators,PPE) and staffing. Overall, the sector experienced over $200 billion in financial losses between March and June 20204.
The second, extended shock has been a decrease in needed but not necessary care. Initially, many patients delayed seeking necessary care because of perceived infection risk. For example, Emergency Department visits declined 42% during the early phase of the pandemic.
Increasingly, patients are also delaying care because of affordability concerns and/or the loss of health insurance. Already, 5.4 million people have lost their employer-sponsored health insurance. This will reduce incremental revenues associated with higher-paying commercial insurance claims across the industry. Additionally, avoided care reduces patient volumes and hospital revenues today even as it increases the risk and cost of future acute illness.
The infusion of emergency funding through the CARES Act helped offset some operating losses but it’s unclear when and even whether utilization patterns and revenues will return to normal pre-COVID levels. Shifts in consumer behavior, reductions in insurance coverage, and the emergence of new competitors ranging from Walmart to enhanced primary care providers will likely challenge the sector for years to come.
The disruption of COVID-19 will serve as a forcing function, driving meaningful changes to traditional hospital business models and the competitive landscape. Frankly, this is long past due. Since 1965, Fee-for-Service (FFS) payment has dominated U.S. healthcare and created pervasive economic incentives that can serve to discourage provider responsiveness in transitioning to value-based care delivery, even when aligned to market demand.
Telemedicine typifies this phenomenon. Before COVID, CMS and most health insurers paid very low rates for virtual care visits or did not cover them at all. This discouraged adoption of an efficient, high-value care modality until COVID.
Unable to conduct in-person clinical visits, providers embraced virtual care visits and accelerated its mass adoption. CMS and
commercial health insurers did their part by paying for virtual care visits at rates equivalent to in-person clinic visits. Accelerated innovation in care delivery resulted.
THE COMPLICATED TRANSITION TO VALUE
Broadly speaking, health systems and physician groups that rely almost exclusively on activity-based payment revenues have struggled the most during this pandemic. Vertically integrated providers that offer health insurance and those receiving capitated payments in risk-based contracts have better withstood volume losses.
Modern Healthcare notes that while provider data is not yet available, organizations such as Virginia Care Partners, an integrated network and commercial ACO; Optum Health (with two-thirds of its revenue risk-based); and MediSys Health Network, a New Yorkbased NFP system with 148,000 capitated and 15,000 shared risk patients, are among those navigating the turbulence successfully. As the article observes,
…providers paid for value have had an easier time weathering the storm…. helped by a steady source of
income amid the chaos. Investments they made previously in care management, technology and social
determinants programs equipped them to pivot to new ways of providing care.
They were able to flip the switch on telehealth, use data and analytics to pinpoint patients at risk for
COVID-19 infection, and deploy care managers to meet the medical and nonclinical needs of patients even
when access to an office visit was limited.
Supporting this post-COVID push for value-based care delivery, six former leaders from CMS wrote to Congress in
June 2020 calling for providers, commercial insurers and states to expand their use of value-based payment models to
encourage stability and flexibility in care delivery.
If value-based payment models are the answer, however, adoption to date has been slow, limited and difficult. Ten
years after the Affordable Care Act, Fee-for-Service payment still dominates the payer landscape. The percentage of overall provider revenue in risk-based capitated contracts has not exceeded 20%
Despite improvements in care quality and reductions in utilization rates, cost savings have been modest or negligible. Accountable Care Organizations have only managed at best to save a “few percent of Medicare spending, [but] the
amount varies by program design.”
While most health systems accept some forms of risk-based payments, only 5% of providers expect to have a majority (over 80%) of their patients in risk-based arrangements within 5 years.
The shift to value is challenging for numerous reasons. Commercial payers often have limited appetite or capacity for
risk-based contracting with providers. Concurrently, providers often have difficulty accessing the claims data they need
from payers to manage the care for targeted populations.
The current allocation of cost-savings between buyers (including government, employers and consumers), payers
(health insurance companies) and providers discourages the shift to value-based care delivery. Providers would
advance value-based models if they could capture a larger percentage of the savings generated from more effective
care management and delivery. Those financial benefits today flow disproportionately to buyers and payers.
This disconnection of payment from value creation slows industry transformation. Ultimately, U.S. healthcare will not
change the way it delivers care until it changes the way it pays for care. Fortunately, payment models are evolving to
incentivize value-based care delivery.
As payment reform unfolds, however, operational challenges pose significant challenges to hospitals and health
systems. They must adopt value-oriented new business models even as they continue to receive FFS payments. New
and old models of care delivery clash.
COVID makes this transition even more formidable as many health systems now lack the operating stamina and balance sheet strength to make the financial, operational and cultural investments necessary to deliver better outcomes, lower costs and enhanced customer service.
MARKET-DRIVEN CONSOLIDATION AND TRANSFORMATION
Full-risk payment models, such as bundled payments for episodic care and capitation for population health, are the
catalyst to value-based care delivery. Transition to value-based care occurs more easily in competitive markets with many attributable lives, numerous provider options and the right mix of willing payers.
As increasing numbers of hospitals struggle financially, the larger and more profitable health systems are expanding their networks, capabilities and service lines through acquisitions. This will increase their leverage with commercial payers and give them more time to adapt to risk-based contracting and value-based care delivery.
COVID also will accelerate acquisition of physician practices. According to an April 2020 MGMA report, 97% of
physician practices have experienced a 55% decrease in revenue, forcing furloughs and layoffs15. It’s estimated the
sector could collectively lose as much as $15.1 billion in income by the end of September 2020.
Struggling health systems and physician groups that read the writing on the wall will pro-actively seek capital or strategic partners that offer greater scale and operating stability. Aggregators can be selective in their acquisitions,
seeking providers that fuel growth, expand contiguous market positions and don’t dilute balance sheets.
Adding to the sector’s operating pressure, private equity, venture investors and payers are pouring record levels of
funding into asset-light and virtual delivery companies that are eager to take on risk, lower prices by routing procedures
and capture volume from traditional providers. With the right incentives, market-driven reforms will reallocate resources to efficient companies that generate compelling value.
As this disruption continues to unfold, rural and marginal urban communities that lack robust market forces will experience more facility and practice closures. Without government support to mitigate this trend, access and care gaps that already riddle American healthcare will unfortunately increase.
WINNING AT VALUE
The average hospital generates around $11,000 per patient discharge. With ancillary services that can often add up to
more than $15,000 per average discharge. Success in a value-based system is predicated on reducing those discharges and associated costs by managing acute care utilization more effectively for distinct populations (i.e. attributed lives).
This changes the orientation of healthcare delivery toward appropriate and lower cost settings. It also places greater
emphasis on preventive, chronic and outpatient care as well as better patient engagement and care coordination.
Such a realignment of care delivery requires the following:
A tight primary care network (either owned or affiliated) to feed referrals and reduce overall costs through
better preventive care.
A gatekeeper or navigator function (increasingly technology-based) to manage / direct patients to the most
appropriate care settings and improve coordination, adherence and engagement.
A carefully designed post-acute care network (including nursing homes, rehab centers, home care
services and behavioral health services, either owned or sufficiently controlled) to manage the 70% of
total episode-of-care costs that can occur outside the hospital setting.
An IT infrastructure that can facilitate care coordination across all providers and settings.
Quality data and digital tools that enhance care, performance, payment and engagement.
Experience with managing risk-based contracts.
A flexible approach to care delivery that includes digital and telemedicine platforms as well as nontraditional sites of care.
Aligned or incentivized physicians.
Payer partners willing to share data and offload risk through upside and downside risk contracts.
Engaged consumers who act on their preferences and best interests.
While none of these strategies is new or controversial, assembling them into cohesive and scalable business models is something few health systems have accomplished. It requires appropriate market conditions, deep financial resources,
sophisticated business acumen, operational agility, broad stakeholder alignment, compelling vision, and robust
Providers that fail to embrace value-based care for their “attributed lives” risk losing market relevance. In their relentless pursuit of increasing treatment volumes and associated revenues, they will lose market share to organizations that
deliver consistent and high-value care outcomes.
CONCLUSION: THE CHARGING GRAY RHINO
America needs its hospitals to operate optimally in normal times, flex to manage surge capacity, sustain themselves
when demand falls, create adequate access and enhance overall quality while lowering total costs. That is a tall order requiring realignment, evolution, and a balance between market and policy reform measures.
The status quo likely wasn’t sustainable before COVID. The nation has invested heavily for many decades in acute and
specialty care services while underinvesting, on a relative basis, in primary and chronic care services. It has excess
capacity in some markets, and insufficient access in others.
COVID has exposed deep flaws in the activity-based payment as well as the nation’s underinvestment in public health.
Disadvantaged communities have suffered disproportionately. Meanwhile, the costs for delivering healthcare services
consume an ever-larger share of national GDP.
Transformational change is hard for incumbent organizations. Every industry, from computer and auto manufacturing to
retailing and airline transportation, confronts gray rhino challenges. Many companies fail to adapt despite clear signals
that long-term viability is under threat. Often, new, nimble competitors emerge and thrive because they avoid the inherent contradictions and service gaps embedded within legacy business models.
The healthcare industry has been actively engaged in value-driven care transformation for over ten years with little to
show for the reform effort. It is becoming clear that many hospitals and health systems lack the capacity to operate profitably in competitive, risk-based market environments.
This dismal reality is driving hospital market valuations and closures. In contrast, customers and capital are flowing to
new, alternative care providers, such as OneMedical, Oak Street Health and Village MD. Each of these upstart
companies now have valuations in the $ billions. The market rewards innovation that delivers value.
Unfortunately, pure market-driven reforms often neglect a significant and growing portion of America’s people. This gap has been more apparent as COVID exacts a disproportionate toll on communities challenged by higher population
density, higher unemployment, and fewer medical care options (including inferior primary and preventive care infrastructure).
Absent fundamental change in our hospitals and health systems, and investment in more efficient care delivery and
payment models, the nation’s post-COVID healthcare infrastructure is likely to deteriorate in many American communities, making them more vulnerable to chronic disease, pandemics and the vicissitudes of life.
Article 2 in our “Future of Hospitals” series will explore the public policy challenges of providing appropriate, affordable and accessible healthcare to all American communities.
Nearly a third of the laid off workers who were able to go back to their previous jobs have been laid off again, according to a Cornell survey released Tuesday.
The survey was conducted by RIWI from July 23 to Aug. 1, as a slew of states experiencing major COVID-19 outbreaks slammed the breaks on their economic reopenings and reimposed social distancing restrictions.
Danielle Goldfarb, head of global research at RIWI, said it was a sign that a second wave of layoffs was well underway.
“Official and private sectors jobs data have not yet picked up the significant share of American workers that have already been re-laid off,” said Goldfarb.
“Since the impact is actually worse in states that have not seen COVID surges, these data indicate a systemic problem and a much deeper recession than the mainstream data suggest,” she said.
The survey found that about 37 percent of people who were not self-employed were laid off after the pandemic struck in March, but over half (57 percent) had been called back to work since then.
But of those, 31 percent had been laid off again and another 26 percent had been told there was a possibility they would lose their jobs.
A deeper dive into the data, however, suggested that the second round of layoffs may be less about the resurgence of the virus than the loss of aid. It found only small differences in “healthier” states, those not experiencing a surge, than in places with new outbreaks.
One possible reason for the additional layoffs are problems with businesses that had remained afloat with the help of forgivable loans from the federal Paycheck Protection Program (PPP).
The funds, which started rolling out the door in April, were supposed to be enough to cover eight weeks of salary and expenses.
“The RIWI dataset output clearly shows that a substantial portion of the job growth experienced in May and June resulted from anomalies associated with PPP requirements, as opposed to underlying economic strength,” said Daniel Alpert, a senior fellow and adjunct professor of macroeconomics at Cornell Law School.
Congress has made scant progress in negotiating a new COVID-19 response bill which is expected to include an extension of the PPP and may allow businesses to apply for a second loan.
The survey was completed by 6,383 respondents, though some questions had smaller samples because they were only applicable to some people.
The margins of error for the survey questions ran from plus or minus 1.5 percent to plus or minus 3.9 percent.
The lapse of enhanced jobless benefits amid a record-breaking crush of applications is exposing the flaws and shortcomings of how the U.S. provides unemployment insurance.
The economic toll of the coronavirus pandemic has torn holes in a federal safety net woven by individual systems for every state plus the District of Columbia, Puerto Rico and the Virgin Islands. More than 30.2 million Americans were on some form of unemployment insurance as of mid-July, with the Labor Department reporting a growing number of new applications in subsequent weeks.
Friday’s expiration of a $600 weekly add-on to state benefits plunged those vulnerable Americans into financial peril.
Congressional Democrats and Trump administration officials are now deadlocked over negotiations for a broader coronavirus relief package that’s expected to include some form of federal unemployment benefits.
But short-staffed unemployment offices across the U.S. grappling with outdated technology and unprecedented demand would face challenges from implementing a scaled-down or more complicated approach to the weekly payments.
Economists and labor market experts also warn that any solution that emerges from the negotiations would take weeks, if not months, to get up and running, risking a potentially catastrophic fiscal cliff for tens of millions of U.S. households.
“You ought to be able to deliver the program that’s on the books,” said Douglas Holtz-Eakin, former director of the Congressional Budget Office and a White House economist under former President George W. Bush.
“The states, collectively, seem to have not kept up the systems and we now have a big problem because of that,” he added.
The unprecedented size and speed of the pandemic-driven economic collapse has posed a brutal challenge for state unemployment agencies. After 10 years of steady economic expansion, the labor market quickly went from the lowest unemployment rate in 50 years to the highest level of joblessness since the Great Depression.
New claims for unemployment benefits were averaging roughly 200,000 nationwide a week before the pandemic — a manageable level for state agencies that had largely been neglected during the longest stretch of growth in modern U.S. history. But the coronavirus lockdowns spurred 3.3 million new claims between March 15 and March 22, a then-record that would be doubled the following week. Before the COVID-19 outbreak, the previous record was 695,000 from the first week of October 1982.
A little more than four months after the pandemic hit, state agencies are now processing roughly 2 million new claims a week for both unemployment insurance and Pandemic Unemployment Assistance (PUA), a program designed to cover those who don’t qualify for typical benefits.
“On some level, you can’t really blame states for not being prepared for that level of onslaught,” said Michele Evermore, senior policy analyst at the National Employment Law Project.
“Usually, you see the recession starting up and state agencies say ‘You know, this looks like a recession here, so let’s start to staff up.’ This came on all at once, so we’ve had these neglected, antiquated systems and then there’s all these other stressors.”
The U.S. economy has been in recession since February, according to the National Bureau of Economic Research.
Processing the massive surge of unemployment claims on shoddy technology would have been hard enough for states. Adding enhanced benefits and PUA claims to the mix strained state agencies even more.
“It took time to upgrade those systems. It took time to hire and train new staff who could deal with the volumes of the calls, and all in a pandemic, when face-to-face contact and training and being together in office were not possible,” said Julia Pollak, labor economist at job recruitment and posting company ZipRecuriter.
“So it’s easy to see in hindsight why it all fell apart.”
Enhanced unemployment benefits are among the biggest obstacles to reaching a deal on what’s likely to be the last coronavirus relief package before the election. While President Trump and Republicans are divided over how and whether to extend the federal boost, Democrats are largely united behind extending the benefits and reducing them gradually along a curve tied to the unemployment rate.
Speaker Nancy Pelosi (D-Calif.) has called for including such a mechanism, known as an automatic stabilizers, in the coronavirus package being negotiated.
Rep. Don Beyer (D-Va.), vice chair of the Joint Economic Committee, introduced a separate bill designed to tackle economic downturns beyond the coronavirus recession. His measure would establish a six-tier system for reducing the federal benefit in line with a state’s unemployment rate.
The approach was endorsed by former Federal Reserve Chairman Ben Bernanke, who oversaw the central bank’s response to the Great Recession, and his successor, Janet Yellen.
“Every time you get close to a cliff and there’s a political battle and political price to be paid, probably by both sides, rather than just saying ‘This is what’s needed,’ let’s kick it in,” Beyer said in an interview.
“We talked to economists all across the country and virtually everyone we talked to said this makes the most sense.”
But Republican lawmakers and right-leaning economists have pushed back on efforts to codify mandatory spending and make decisions now about what will be needed to mitigate future crises.
“It’s hard for me to understand why it’s appropriate now to anticipate the economic conditions in the future and tie the hands of future elected representatives of Congress,” Holtz-Eakin said.
“It forked out $2.3 trillion in [the CARES Act] across the board in ways that got to small businesses, to households, to the employed, the unemployed. If you’re going to have one in 100-year events, that’s how you deal with them,” he added.
Republicans have instead proposed replacing the flat $600 weekly boost with a percentage of the worker’s pre-pandemic earnings in addition to what is prescribed by each state. While the wage-replacement is more tailored, Evermore warned that making the necessary calculations for each claimant could overwhelm an already teetering system.
“If you told states that they had to do a percentage replacement — oh, my gosh, that’s a recipe for crashing everything,” she said.
Roughly 40% of Americans have postponed getting medical care due to the coronavirus outbreak. That number has stayed around 40% in all 12 weeks of the Census Bureau’s Household Pulse Survey.
Why it matters: Hospitals and doctors started rescheduling surgeries and other appointments as early as mid-May, and many patient volumes are mostly back to pre-pandemic numbers, Axios’ Bob Herman writes.
But this data suggests there is still a major backlog of Americans who need care — a phenomenon that existed well before the pandemic.
President Trump said in an interview with “Axios on HBO” that he thinks the coronavirus is as well-controlled in the U.S. as it can be, despite dramatic surges in new infections over the course of the summer and more than 150,000 American deaths.
“They are dying, that’s true. And you have — it is what it is. But that doesn’t mean we aren’t doing everything we can. It’s under control as much as you can control it. This is a horrible plague,” he told Axios’ Jonathan Swan.
Reality check: The U.S. is averaging roughly 65,000 new cases and 1,000 deaths per day, Axios’ Sam Baker writes. The virus has already killed nearly 150,000 Americans, and it spread largely unchecked through almost the entire country throughout June and July.
The big picture: In the interview, which took place last Tuesday, Trump returned to familiar themes and areas where the U.S. really has made significant progress. He cited the dramatic increase in ventilator production, the ramp-up in testing and treatment that has reduced the overall fatality rate from the virus.
Yes, but: He painted a far rosier picture of the pandemic than most data would support.
On testing, Trump said, “You know there are those that say you can test too much” — a view that no experts have advocated.
The U.S. is experiencing long turnaround times for coronavirus testing, as Trump acknowledged, because of the high demand for testing. But that is largely a function of the country’s high caseload and the number of people at risk of infection.
He also returned to his mantra that “because we’ve done more tests, we have more cases.”
The cases the U.S. has, we would have had with or without testing. We know we have them because of testing, but the massive outbreak here would be a massive outbreak whether we chose to know about it (through testing) or ignore it by not testing.
As the influenza pandemic swept across the United States in 1918 and 1919, masks took a role in political and cultural wars.
The masks were called muzzles, germ shields and dirt traps. They gave people a “pig-like snout.” Some people snipped holes in their masks to smoke cigars. Others fastened them to dogs in mockery. Bandits used them to rob banks.
More than a century ago, as the 1918 influenza pandemic raged in the United States, masks of gauze and cheesecloth became the facial front lines in the battle against the virus. But as they have now, the masks also stoked political division. Then, as now, medical authorities urged the wearing of masks to help slow the spread of disease. And then, as now, some people resisted.
In 1918 and 1919, as bars, saloons, restaurants, theaters and schools were closed, masks became a scapegoat, a symbol of government overreach, inspiring protests, petitions and defiant bare-face gatherings. All the while, thousands of Americans were dying in a deadly pandemic.
1918: The infection spreads.
The first infections were identified in March, at an Army base in Kansas, where 100 soldiers were infected. Within a week, the number of flu cases grew fivefold, and soon the disease was taking hold across the country, prompting some cities to impose quarantines and mask orders to contain it.
By the fall of 1918, seven cities — San Francisco, Seattle, Oakland, Sacramento, Denver, Indianapolis and Pasadena, Calif. — had put in effect mandatory face mask laws, said Dr. Howard Markel, a historian of epidemics and the author of “Quarantine!”
Organized resistance to mask wearing was not common, Dr. Markel said, but it was present. “There were flare-ups, there were scuffles and there were occasional groups, like the Anti-Mask League,” he said, “but that is the exception rather than the rule.”
Alma Whitaker, writing in The Los Angeles Times on Oct. 22, 1918, reviewed masks’ impact on society and celebrity, saying famous people shunned them because it was “so horrid” to go unrecognized.
“The big restaurants are the funniest sights, with all the waiters and diners masked, the latter just raising their screen to pop in a mouthful of food,” she wrote.
When Ms. Whitaker herself declined to wear one, she was “forcibly taken” to the Red Cross as a “slacker,” and ordered to make one and put it on.
The San Francisco Chronicle said the simplest type of mask was of folded gauze affixed with elastic or tape. The police went for gauze masks, which resembled an unflattering “nine ordinary slabs of ravioli arranged in a square.”
There was room for creativity. Some of the coverings were “fearsome looking machines” that lent a “pig-like aspect” to the wearer’s face.
The penalty for violators was $5 to $10, or 10 days’ imprisonment.
On Nov. 9, 1,000 people were arrested, The San Francisco Chronicle reported. City prisons swelled to standing room only; police shifts and court sessions were added to help manage.
“Where is your mask?” Judge Mathew Brady asked offenders at the Hall of Justice, where sessions dragged into night. Some gave fake names, said they just wanted to light a cigar or that they hated following laws.
Jail terms of 8 hours to 10 days were given out. Those who could not pay $5 were jailed for 48 hours.
The ‘mask slacker’ of San Francisco is shot.
On Oct. 28, a blacksmith named James Wisser stood on Powell and Market streets in front of a drugstore, urging a crowd to dispose of their masks, which he described as “bunk.”
A health inspector, Henry D. Miller, led him to the drugstore to buy a mask.
At the door, Mr. Wisser struck Mr. Miller with a sack of silver dollars and knocked him to the ground, The San Francisco Chronicle reported. While being “pummeled,” Mr. Miller, 62, fired four times with a revolver. Passers-by “scurried for cover,” The Associated Press said.
Mr. Wisser was injured, as were two bystanders. He was charged with disturbing the peace, resisting an officer and assault. The inspector was charged with assault with a deadly weapon.
In Los Angeles, ‘To Mask or Not to Mask.’
That was the headline for a report published in The Los Angeles Times when city officials met in November to decide whether to require residents to wear “germ scarers” or “flu-scarers.”
Public feedback was invited. Some supported masks so theaters, churches and schools could operate. Opponents said masks were “mere dirt and dust traps and do more harm than good.”
“I have seen some persons wearing their masks for a while hanging about their necks, and then apply them to their faces, forgetting that they might have picked up germs while dangling about their clothes,” Dr. E.W. Fleming said in a Los Angeles Times report.
An ear, nose and throat specialist, Dr. John J. Kyle, said: “I saw a woman in a restaurant today with a mask on. She was in ordinary street clothes, and every now and then she raised her hand to her face and fussed with the mask.”
In Illinois, the right to choose, and to reject.
Suffragists fighting for the right to vote made a gesture that rejected covering their mouths at a time when their voices were crucial.
At the annual convention of the Illinois Equal Suffrage Association, in October 1918, they set chairs four feet apart, closed doors to the public and limited attendance to 100 delegates, the Chicago Daily Tribune reported.
But the women “showed their scorn” for masks, it said. It’s unclear why.
Allison K. Lange, an associate history professor at Wentworth Institute of Technology, said one reason could have been that they wanted to keep a highly visible profile.
“Suffragists wanted to make sure their leaders were familiar political figures,” Dr. Lange said.
‘Four weeks of muzzled misery’
San Francisco’s mask ordinance expired after four weeks at noon on Nov. 21. The city celebrated, and church bells tolled.
A “delinquent” bent on blowing his nose tore his mask off so quickly that it “nearly ruptured his ear,” The San Francisco Chronicle reported. He and others stomped on their masks in the street. As a police officer watched, it dawned on him that “his vigil over the masks was done.”
Waiters, barkeeps and others bared their faces. Drinks were on the house. Ice cream shops handed out treats. The sidewalks were strewn with gauze, the “relics of a torturous month,” The Chronicle said.
The spread had been halted. But a second wave was on the horizon.
By December, the San Francisco Board of Supervisors was again proposing a mask requirement, meeting with testy opposition.
Around the end of the year, a bomb was defused outside the office of San Francisco’s chief health officer, Dr. William C. Hassler. “Things were violent and aggressive, but it was because people were losing money,” said Brian Dolan, a medical historian at the University of California, San Francisco. “It wasn’t about a constitutional issue; it was a money issue.”
By the end of 1918, the death toll from influenza had reached at least 244,681, mostly in the last four months, according to government statistics.
1919: A new year
In January, Pasadena’s city commission passed a mask ordinance. The police grudgingly enforced it, cracking down on cigar smokers and passengers in cars. Sixty people were arrested on the first day, The Los Angeles Times reported on Jan. 22, in an article titled “Pasadena Snorts Under Masks.”
“It is the most unpopular law ever placed on the Pasadena records,” W.S. McIntyre, the chief of police, told the paper. “We are cursed from all sides.”
Some mocked the rule by stretching gauze across car vents or dog snouts. Cigar vendors said they lost customers, though enterprising aficionados cut a hole in the cloth. (They were still arrested.) Barbers lost shaving business. Merchants complained traffic dropped as more people stayed home.
Petitions were circulated at cigar stands. Arrests rose, even of the powerful. Ernest May, the president of Security National Bank of Pasadena, and five “prominent” guests were rounded up at the Maryland Hotel one Sunday.
They had masks on, but not covering their faces.
The Anti-Mask League.
As the contagion moved into its second year, so did the skepticism.
That board’s decision led to the creation of the Anti-Mask League, a sign that resistance to masks was resurfacing as cities tried to reimpose orders to wear them when infections returned.
The league was led by a woman, E.J. Harrington, a lawyer, social activist and political opponent of the mayor. About a half-dozen other women filled its top ranks. Eight men also joined, some of them representing unions, along with two members of the board of supervisors who had voted against masks.
“The masks turned into a political symbol,” Dr. Dolan said.
On Jan. 25, the league held its first organizational meeting, open to the public at the Dreamland Rink, where they united behind demands for the repeal of the mask ordinance and for the resignations of the mayor and health officials.
Their objections included lack of scientific evidence that masks worked and the idea that forcing people to wear the coverings was unconstitutional.
Repeal came a few days later on Feb. 1, when Mayor Rolph cited a downturn in infections.
But a third wave of flu rolled in late that year.The final death toll reached an estimated 675,000 nationwide, or 30 for every 1,000 people in San Francisco, making it one of the worst-hit cities in America.
Dr. Dolan said the story of the Anti-Mask League, which has drawn renewed interest now in 2020, demonstrates the disconnect between individual choice and universal compliance.
That sentiment echoes through the century from the voice of a San Francisco railway worker named Frank Cocciniglia.
Arrested on Kearny Street in January, Mr. Cocciniglia told the judge that he “was not disposed to do anything not in harmony with his feelings,” according to a Los Angeles Times report.
He was sentenced to five days in jail.
“That suits me,” Mr. Cocciniglia said as he left the stand. “I won’t have to wear a mask there.”
After two hours of sleep a night for four months and seeing a member of his team contract the virus, Joseph Varon, MD, is growing exasperated.
“I’m pretty much fighting two wars: A war against COVID and a war against stupidity,” Dr. Varon, MD, CMO and chief of critical care at United Memorial Medical Center in Houston, told NBC News. “And the problem is the first one, I have some hope about winning. But the second one is becoming more and more difficult.”
Dr. Varon noted that whether it’s information backed by science or common sense, people throughout the U.S. are not listening. “The thing that annoys me the most is that we keep on doing our best to save all these people, and then you get another batch of people that are doing exactly the opposite of what you’re telling them to do.”
In an interview with NPR, Dr. Varon said he has woken up at dawn every day for the past four months and has headed to the hospital. There, he spends six to 12 hours on rounds before seeing new admissions. He then returns home to sleep two hours, at most.
He said his staff is physically and emotionally drained.
UMMC nurse Christina Mathers spoke with NBC News from a hospital bed in the segment, noting that she had recently tested positive for COVID-19 after not feeling well during one of her shifts. “All the fighting, all the screaming, all the finger pointing — enough is enough,” Ms. Mathers told NBC. “People just need to listen to us. We’re not going to lie. Why would we lie?”
Ms. Mathers has worked every other day since April 29, according to The Atlantic, which created a photo essay of Dr. Varon and the UMMC team at work.