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Anxiety over coronavirus grows on Capitol Hill
Pressure is mounting on congressional leaders to cancel votes and restrict activity in the Capitol to avert a coronavirus outbreak.
Several lawmakers appearing at the recent American Israel Public Affairs Committee (AIPAC) and Conservative Political Action Conference (CPAC) gatherings in the Washington, D.C., area interacted with individuals who have since tested positive for the highly contagious virus.
Both Sen. Ted Cruz (R-Texas) and Rep. Paul Gosar (R-Ariz.) said over the weekend they would self-quarantine after coming into contact with a person at CPAC who had tested positive.
Cruz, who had a brief interaction and shook hands with the individual, said he is not showing any symptoms of coronavirus, but would remain in Texas “out of an abundance of caution.”
Gosar, a dentist, said both he and his staff came in contact with the individual. The congressman said he would shut down his Washington office this week and follow Congress’s “tele-commute plan.”
Over the weekend, Congress’s medical office sent lawmakers an update on the CPAC encounters that supported the self-quarantines and suggested the chances of transmission were low.
“The public health authorities assessed each person’s contact with the ill individual,” reads the notice, which was obtained by The Hill. “The overall findings are considered to be a “low risk” to acquire SARS-Cov-2 (coronavirus) infection and they were advised on courses of action specific to their unique level of exposure.”
Others are taking self-imposed precautions, as well.
Rep. Liz Cheney (R-Wyo.), the third-ranking House Republican, opted to skip a leadership retreat on the Eastern Shore of Maryland over the weekend, with a spokesperson citing a need to protect “people in our families who are particularly vulnerable,” Politico reported.
As of Monday morning, more than 500 patients in the United States had been diagnosed with the virus across 34 states, according to a tally being kept by The New York Times.
Senate and House lawmakers were expected to travel back to Washington, with votes still scheduled for Monday afternoon and evening. And lawmakers across the country were boarding planes Monday morning to return to the nation’s capital, including those from coronavirus hot-spots like Seattle.
But a sense of anxiety permeated Capitol Hill, where many lawmakers — including the top three Democratic leaders — are in their 70s and 80s, travel constantly around the country for district visits and campaign events, and meet regularly with constituents and other interest groups.
“I don’t see how you keep asking a large group of elderly folks to fly on planes back and forth over the next few weeks,” said one House aide who’s been monitoring the situation on Capitol Hill.
Added a GOP lawmaker: “The most vulnerable population are people over 70 … which is all of the Democrat leadership and most chairman, and a third of the U.S. Senate.”
Still, many leaders and rank-and-file lawmakers believe closing the Capitol at this moment could send the wrong message to an already jittery public, setting off a wave of panic. On Monday, the Dow Jones industrial average tumbled more than 1,600 points on falling oil prices related to the coronavirus outbreak.
“Business should carry on,” the GOP lawmaker said.
A second staffer said that while leaders have given no signal of shuttering the Capitol, individual lawmakers are making their own contingency plans.
“Many offices including ours are preparing for some kind of total office building shutdown, shifting to telework, etc.,” the aide said.
Last week, the top congressional leaders received a partially classified briefing on the threat to the Capitol complex.
Afterward, Speaker Nancy Pelosi (D-Calif.) said the Capitol Police assured the lawmakers that the Capitol is well-secure, while the message from the Capitol physician’s office largely related to simple precautions related to personal hygiene, like washing hands and sneezing into tissues. Around the Capitol, illustrated signs have popped up in the bathrooms instructing visitors on proper hand-washing procedures.
“It’s not about testing everybody who comes into the building. That’s not realistic,” Pelosi said last Thursday. “But it is also, hopefully, that the message that goes out more globally is that people will be more responsible about their own preventative measures.”
She added: “Some of that sounds very basic and mundane, but it does prevent the spread.”
House Democratic leaders are expected to huddle Monday afternoon, ahead of the evening’s votes, where the coronavirus issue will almost certainly be front and center. Meanwhile, leadership offices are reaching out to members to encourage preparations in the event the Capitol is closed down.
“Offices are putting together emergency telework plans … and assessing IT needs, and encouraging off site meetings or phone calls,” said a third staffer.
Coronavirus and Healthcare Reform
At this writing, the number of COVID-19 cases worldwide has reached 100,000 with 3,500 deaths. These numbers will be higher by tomorrow.
What does this have to do with U.S. healthcare reform? A lot.
Two current background articles drive home the point that a well-functioning public health system is critical for responding to a pandemic like 2019 coronavirus disease (COVID-19), especially in its early phases. And it means that the healthcare system – including a robust public health infrastructure — should be about health, not just about profit and greed.
Let’s Put This in Context: Is COVID-19 “Just Another Flu”?
WHO reports that annual cases of influenza A and B worldwide range from 3 to 5 million, causing 290,000 to 650,000 respiratory deaths. That’s a lot more than COVID-19, at least so far. So what’s the big deal?
The big deal is that, This Is Not a Competition, not an either-or between influenza virus and coronavirus. Otherwise this would be like asking, Would you rather be killed by an airplane crash, by tobacco-related cancer, or by pollution-related pneumonia? The answer is, of course, none of the above.
What these types of deaths and illness have in common is being in part preventable by known public health measures, with different interventions needed for each one. Likewise, influenza A and B deaths are in part preventable. Prevention relies on the elaborate and sophisticated worldwide influenza vaccine program. It includes monitoring influenza strains alternating between Northern and Southern hemispheres, annual adjustment of vaccine components, production, distribution, and public messaging.
But unlike influenza, currently COVID-19 is not preventable, since vaccine development and testing will take a year or more. And WHO is modeling that COVID-19 is at best only partially containable by general non-pharmaceutical measures. For example, one worst-case model of the pandemic estimates that two-thirds of the world’s population could be infected, once it runs its course. This has epidemiologists scrambling to calculate the actual transmissibility and actual mortality rates so as to refine predictions more accurately and to help plans for mitigating its spread.
So, no, COVID-19 is not “just another flu,” as the President implied in a March 4 off-the-cuff interview. COVID-19 is to be sure, a “flu-like illness,” but it has unique (as yet not fully characterized) epidemiologic characteristics, and it requires a completely different public health strategy, at least in the short- and medium-term. The President is reckless to minimize either disease – both diseases are widespread and lethal — especially since proper public messaging is a key to rallying a coherent response by individuals, communities, and nations.
How Bad Could It Be? Comparison to 1918 Spanish Flu
Could the COVID-19 pandemic wreak the same devastation as the 1918 Spanish flu? Spanish flu eventually infected 500 million people worldwide, effectively 25 percent of the total global population. And it killed up to 100 million of them. “It left its mark on world history,” according to University of Melbourne professor James McCaw, a disease expert who mathematically modelled the biology and transmission of the disease, and who was quoted today by the Australian Broadcasting Company (ABC).
What SARS-CoV2 (severe acute respiratory syndrome-corona virus strain 2), the agent that causes COVID-19 disease, has in common with the H1N1/Spain agent is novelty, transmissibility, and lethality. Novelty means that it is antigenically new, so that no one in the world is already immune or even partially cross-immune. Transmissibility means it’s easily spread by aerosol (coughing) or surface contact (hand to nose). Lethality means its significant death rate.
On the one hand, Dr. McCaw hopes that public health measures against COVID-19 will be more effective than in 1918. For one, experts and the general public now know about viruses. In 1918, virology was in its infancy.
“We’re not going to see that sort of level of mortality, that mortality was driven by the social context of the outbreak,” predicts Dr. Kirsty Short, a University of Queensland virologist, also quoted by the ABC. “We had a viral outbreak, at the same time as the end of a world war.”
In addition, modern medicine means much better care is available now than it was then. “We’ve already got a lot of scientists working on novel therapies and novel vaccines to try to protect the general population,” Dr Short says.
Professor McCaw points to an apparent initial success in Wuhan Province. “What’s happened in China gives very clear evidence that we can get what’s called the ‘reproduction number’ under one. So at the moment in China, on average, each person infected with coronavirus is passing that infection on to fewer than one other person. If people hadn’t changed their behaviour, we would have expected somewhere around the millions of cases in China by now instead of the comparatively small number of around 100,000.” So, he says, it looks like the transmissibility of coronavirus can be significantly modified through social distancing and good hygiene.
On the other hand, best-case calculations from these Australian epidemiologists appear to discount other factors that could actually worsen the pandemic in 2020 compared with 1918 – rapid international travel and higher concentration of people in urban centers.
Both Dr. Short and Professor McCaw admit that in the early days of a pandemic accurate predictions remain difficult to make.
Nevertheless, they both make clear that in battling the coronavirus, the national and international public health systems – and the public’s trust in them – will be key.
Public Health Approach Is the Key
The importance of public health actions is underscored by a second report today by two experts from the Center for Strategic and International Studies, a Washington think tank.
Samuel Brannen and Kathleen Hicks write in Politico.com,
Last October, we convened a group of experts to work through what would happen if a global pandemic suddenly hit the world’s population. The disease at the heart of our scenario was a novel and highly transmissible coronavirus. For our fictional pandemic, we assembled about 20 experts in global health, the biosciences, national security, emergency response and economics at our Washington, D.C., headquarters. The session was designed to stress-test U.S. approaches to global health challenges that could affect national security. As specialists in national security strategic planning, we’ve advised U.S. Cabinet officials, members of Congress, CEOs and other leaders on how to plan for crises before they strike, using realistic but fictional scenarios like this one.
Here are their conclusions:
- Early and preventative actions are critical. They praise bipartisan Congressional support, including $50 million allocated to the CDC Infectious Diseases Rapid Response Reserve Fund, the passage of the 2019 Pandemic and All-Hazards Preparedness and Advancing Innovation Act, and the continuation of the Global Health Security Agenda.
- Communication is vital—but a decline in trust makes it harder. A critical ingredient for addressing pandemics is public order and obedience to protocols, rationing, and other measures that might be needed. Today, public trust in institutions and leaders is fragile, with routine evidence of intentional disinformation by foreign actors and elected officials alike. Misstatements about science are particularly damaging to the credibility of scientists and health officials seeking to guide response to the pandemic. Amid the hyperpartisanship of the current U.S. political environment in a presidential election year, politicization of the coronavirus outbreak could undermine public health efforts.
- International cooperation is also key. A virus knows no borders, as we have already seen with the real-world outbreak, and here a concerning change is heightened mistrust among countries. In the midst of trade tensions, fraying of international relationships, increased meddling by one country in the internal politics of another, and growing military tensions in hot spots around the globe, organizations such as the World Health Organization are increasingly caught in the middle, unable to play their intended neutral function.
- The private sector will be vital to managing the outbreak. There’s a good reason the President gathered pharmaceutical executives on Monday, March 2. The U.S. federal government is rightly at the center of the response to this likely pandemic, but it is the private sector that holds the bulk of the technological innovation to producing treatments and cures. One bit of good news on this front: There is already in place a highly effective public-private partnership structure in the Coalition for Epidemic Preparedness Innovations, which is making important contributions in the current race for a vaccine.
- The principal conclusion of our scenario was that leaders simply don’t take health seriously enough as a U.S. national security issue. Congress holds few hearings on the topic, especially in the defense committees, and the White House last year eliminated a top National Security Council position focused on the issue.
Healthcare Reform: We’re All in This Together
The impending epidemic of coronavirus in the U.S. also brings up important practical questions in the whole healthcare system, as reported in, for example, the New York Times and Kaiser Family Foundation.
Who will have access to testing? Who will pay? Will copays designed to keep patients with trivial illnesses from overutilizing the health system now backfire by delaying their testing and care? These kinds of questions are not at issue in countries with universal access.
However, even those countries will struggle to cope with the pandemic. For example, the United Kingdom faces a shortage of intensive care unit beds after a decade of downsizing its bed capacity.
This drives home the point that public health infrastructure is necessary but not sufficient for managing a pandemic. Namely, the U.K.’s bed shortage shows that public health is but one component of the broader task of maintaining a nation’s strategic risk preparedness. Calculating the surge capacity of inpatient beds for an unexpected pandemic emergency should not be left just to hospital administrators. This is also why the President should restore both bio-preparedness positions dropped by him in 2018 from the National Security Council and the Homeland Security Department.
Conclusion: Right, Privilege or, Rather, Social Contract?
Is healthcare a right or a privilege? The coronavirus tells us, Neither. Instead, this virus reminds us that healthcare is better framed as part of the social contract, the fundamental duty of governments to their citizens to defend them from clear threats, both currently present and foreseeable, not only military, but also economic, cyber, and in this case biological. Can Americans and their leaders put aside petty polemical bickering over healthcare reform and recognize the healthcare system for what it is, part of the backbone of a healthy, resilient nation?
Caught in the crossfire of payer-provider strategies
https://mailchi.mp/9e118141a707/the-weekly-gist-march-6-2020?e=d1e747d2d8
The aggressive push among insurers to purchase physician practices—one that mirrors the vertical integration strategies pursued by hospital systems over the past few years—has some asking what the end game looks like for health plans.
A recent investigative piece from Kaiser Health News shows where this payer-physician integration might lead. Focused on the activities of UnitedHealth Group in the New Jersey Medicaid market, the article describes a move by the company’s insurance subsidiary, UnitedHealthcare, to shift the Medicaid beneficiaries it covers in its Medicaid managed care plan into physician practices owned by its sister subsidiary, Optum.
That effort is the target of a lawsuit brought by some physician practices in the state, who allege they are losing patients as a result of an attempt by UnitedHealthcare to “narrow” its physician networks by terminating their contracts. It’s an obvious, and clever, strategy on the part of the insurer, which likely hopes to capture savings and generate greater revenue by integrating insurance and provision of care.
But as the piece describes, it’s proving significantly disruptive to the care of many patients, who are losing access to physicians with whom they’ve built relationships with over time. Insurers have pursued these strategies less aggressively in their commercial and Medicare businesses, turning instead to referral management tactics like specialist steerage, mandatory pre-authorizations, and discounted rates instead of shifting primary care patients care.
But, as in many other aspects of care, it may be easier to implement such aggressive “management” techniques in the low-income population, because patients have so few alternatives to care. As vertical integration strategies play out on both the hospital and insurer sides of the industry, it’s worth paying attention to how “grand strategy” of the sort depicted in our map above plays out on the ground, in the lives of individual patients.
The Velvet Rope Economy: How Inequality Became Big Business
https://mailchi.mp/9e118141a707/the-weekly-gist-march-6-2020?e=d1e747d2d8
FROM THE GIST BOOKSHELF
Feed your head—read this.
Income inequality has become a central topic in our national political debate in the wake of the financial crisis. The gap between the “haves” and “have nots” has grown steadily, and addressing that gap has become a key priority for a new generation of politicians, economists, and policymakers. But inequality has also become a lucrative business opportunity in many parts of the economy, a phenomenon that New York Times economics reporter Nelson Schwartz entertainingly (and unsettlingly) describes in his new book, The Velvet Rope Economy: How Inequality Became Big Business.
Based on a series of Times articles by Schwartz from the past several years, the book describes life on both sides of the “velvet rope”: how services have become faster, better, and higher quality for those with the ability to pay extra, and how the rest of us are getting left behind. He describes how the familiar amusement-park “Fast Pass” approach has pervaded other parts of our lives, from school sports to social services to travel, and yes, to healthcare.
Across the economy, businesses increasingly cater to the top tier of customers, providing privileged access, concierge services, and special perks. As Schwartz describes it, “This pattern—a Versailles-like world of pampering for a privileged few on one side of the velvet rope, a mad scramble for basic service for everyone else—is being repeated in one sphere of American society after another.”
It’s a phenomenon we see in healthcare every day, as rural hospitals are shuttered, access to care is restricted for Medicaid patients, and wait times for new primary care appointments soar to six weeks or more, while concierge physician practices and cash-based, on-demand services proliferate. Most troubling, in Schwartz’s view: this intentional, class-based separation causes those on one side of the “velvet rope” to misunderstand, and even denigrate, those on the other.
That aptly describes our current political dynamic—Schwartz provides a useful (and highly readable) window into how businesses seek to profit from that division. Worth a read.
Health plans ramp up physician practice acquisitions
https://mailchi.mp/9e118141a707/the-weekly-gist-march-6-2020?e=d1e747d2d8
Health systems and private equity firms aren’t the only ones aggregating physician practices—many large insurers are rapidly acquiring or affiliating with physician groups, especially to support their Medicare Advantage (MA) strategies.
As the map below shows, most insurers are focusing this vertical integration in states like Florida, Texas, and California—places where they also have large populations of MA beneficiaries. Astonishingly, UnitedHealth Group—through its Optum division—is likely the largest employer of physicians in the US, employing or affiliating with 50,000 physicians—roughly 5,000 more than HCA Healthcare and nearly double the number of Kaiser Permanente. The number of Optum-controlled physicians has increased rapidly in recent years, the result of many large-scale deals, including the $4.3B acquisition of DaVita Medical Group.
When it comes to leveraging this growing physician network, United is setting its sights well beyond Medicare Advantage, as demonstrated by its recent introduction of Harmony, a commercial narrow network health plan in Southern California based almost exclusively on a network of Optum physicians.
Meanwhile, Humana’s physician strategy has focused more on affiliations with non-traditional groups serving MA patients, including Iora Health and Oak Street Health—though Humana also has two large primary care groups, Conviva and Partners in Primary Care, the latter of which just secured a $600M private equity investment to expand.
Notably absent from this map is Aetna, which has been pursuing a different strategy, focused around steering its MA population to its advanced practice provider-run HealthHUBs in CVS pharmacies.
This trend of insurer acquisition of physicians is obviously worrisome for health systems, as the health plans they negotiate with for payment are now directly competing with them at the front end of the delivery system.
