MUST READ POLICY PIECES: This week, the New Yorker published “The Plague Year” by Lawrence Wright, a tour-de-force piece of reporting on the nation’s pandemic response. Having read a great deal of policy-related reporting on the outbreak, I believe this piece (along with this thread of 10 pieces by The Atlantic’s Ed Yong) could serve as the Covid-19 epidemic’s version of The Swine Flu Affair report, which was published two years after the 1976 Swine Flu epidemic and its associated, highly flawed vaccine rollout. You also may find of interest Yong’s look at what’s to come in Pandemic Year 2.
Vaccine Rollout & Prioritization
In the weeks since the authorization and distribution of the first wave of Covid-19 vaccines, we have frequently heard different versions of the adage, “Vaccines don’t stop anything, vaccinations do.” While this is meant to emphasize the need to get the shots into peoples’ arms — see this recent Health Affairs piece coauthored by President-Elect Biden’s appointee to direct the CDC, Rochelle Walensky — and to inject additional urgency into discussions and efforts surrounding vaccine distribution — see, e.g., my Friday discussion with Drs. Dorit Reiss and Scott Knowles — it also tends to downplay what we know from our past pandemic experiences and the science of public health: that vaccination efforts are but one of an array of measures we as a society need to use to contain an outbreak.
Nevertheless, critiquing and suggesting how to refine the Covid-19 vaccine rollout has been a prominent discussion in recent weeks. For example, the incoming Biden administration announced late last week that they will open federally-run mass vaccination sites and diverge from FDA guidance by getting all vaccine doses out for distribution immediately (rather than hold back some doses to ensure those receiving first shots can get their second). This morning, a Politico piece reports significant differences of opinion within the Biden response team about such a plan.
The New York Times published a collection of essays under the theme Four Ways to Fix the Vaccine Rollout. Concepts in two pieces are worth singling out: In “Target Hot Spots” Shan Soe-Lin and Robert Hecht suggest that, after the first phase of vaccinating health care workers, residents of Long Term Care and conjugate settings, and the oldest in our communities and federal and state institutions, we should prioritize getting vaccines into communities where the incidence of new infections is highest. While such an approach diverges from the recommendations of the NASEM and ACIP, and has its own sets of limitations (two the authors don’t mention are inadequate and inequitable access to testing and the overwhelm of many state and local contact tracing systems), the authors feel “hot spotting” vaccines would both be faster, and would “do away with the ugly and unproductive debates in which groups of workers and their unions and employer groups are positioning themselves to get to the front of the queue. It would focus the efforts of state officials on a small number of locations, making it easier to implement. And as trust builds in these communities, mass vaccination will likely snowball and lead more rapidly to the high levels of coverage that we need.”
In the piece, “Don’t Pressure the Vaccine-Hesitant,” authors Peter Doshi and Jennifer Block describe the Covid-19 epidemic as a storm, and the vaccine as protective shelter that can help those who are most vulnerable:
Perhaps a more helpful way to think about restoring public life is to think of Covid as a storm. Most people will ride it out just fine. But the storm poses a real threat to a minority of people, who, because of age or medical conditions or workplace exposure, are particularly vulnerable to its winds. These people are far more likely to have severe complications of Covid-19 that lead to hospitalizations, overwhelmed ICUs and deaths. And these individuals stand to gain the most by the shelter a vaccine hopefully provides. Let’s make sure all of them have easy access to one before attacking those who aren’t sure they want one.
A few more notable recent vaccine policy-related publications:
- This Twitter post from former CDC Director Tom Frieden sharing what he deems four of the “most important, least known documents regarding [COVID-19] vaccination” action, planning, and communication
- Wood & Schulman in NEJM: Beyond Politics: Promoting Covid-19 Vaccination in the United States
Vulnerable Populations in Congregate Settings
Experts, including the NASEM, recommend that vaccinations should be prioritized for people living in congregate and overcrowded settings, including the 2.3 million people in the nation’s prisons and jails, and those living in state institutions. These environments offer “perfect conditions for superspreading events” that also will result in higher community infection rates. According to a recent study, “By summer, infection rates in state and federal prisons dwarfed national rates by a ratio of 5.5 to 1, and, accounting for age, people in prison were dying at three times the rate of society as a whole.” However, the CDC’s Advisory Committee on Immunization Practices has been silent on the subject of incarcerated individuals, and extending access to this population has met with resistance from some politicians and policymakers.
In my COVID-Calls discussion about vaccine policy with Scott Knowles and Dorit Reiss (at around the 55:50 mark), I used the “honey badger don’t care” meme to describe the SARS-CoV-2 virus: the virus don’t care who you voted for, your state, or your immigration status. It just wants to keep living by moving as fast as it can into vulnerable hosts. Therefore, if we want to stop the virus’ spread, it’s important we make sure all our neighbors have access to adequate protection, including vaccines. Some politicians, by trying to distinguish between those who they think do and don’t “deserve” to have vaccine access, are implementing policies that would result in more viral spread. In response to this, Surgeon General Adams recently stated that policies that deny undocumented immigrants COVID vaccine are “not ethically right.”
“Taking Back Control: A Resetting of America’s Response to Covid-19,” an important new report from the Rockefeller Foundation offering guidance on how to safely reopen all U.S. schools this spring through investment in a significant increase in COVID testing and other measures.
Medical Bills & Medical Billing
The COVID-19 relief bill passed in late December by Congress included a provision to protect consumers from “surprise” medical bills. Once the provision goes into effect, patients will be protected from being “balance billed” by health care providers for the difference between the providers’ billing price and the amount the patient’s insurance was willing to pay. According to NPR, this will cover situations when patients “seek emergency care, when they are transported by an air ambulance, or when they receive nonemergency care at an in-network hospital but are unknowingly treated by an out-of-network physician or laboratory.”
Some of these out-of-network surprises have come when people have sought out COVID-19 testing and treatment. According to a report from the Kaiser Family Foundation, “Despite rules requiring that COVID-19 tests be provided without cost sharing, some insured patients have faced unexpected out-of-pocket costs, and some uninsured patients have been left with large bills for COVID-19 treatment even with a Department of Health and Human Services’ (HHS) program in place that is intended to cover those costs. Patients were left with these bills due to gaps in the protections that Congress and the Trump administration put in place early in the COVID-19 pandemic.”
The law also will not protect patients from the high costs of health care, or from being sued for having accrued medical debts. Because of the severe economic disruption caused by the pandemic, resulting in millions of people losing their jobs, many hospitals have suspended their medical debt collection practices, even though a patient’s medical debt may have accrued before the pandemic.
However, some recent articles show that not all hospitals have stopped their aggressive debt collection practices. For example, one hospital in Wisconsin has filed at least 231 claims against consumers for medical debt since the pandemic began. This week, the New York Times reported that one New York hospital system had brought debt collection actions against 2500 patients for medical debt since the pandemic began, and about 5,000 people total in New York state have been sued for medical debt in the last 10 months. According to the Times, these lawsuits “hit teachers, construction workers, grocery store employees and others, including some who had lost work in the pandemic or gotten sick themselves….The cases are rarely contested in court and usually lead to default judgments, allowing hospitals to garnish wages and freeze accounts to extract money, sometimes without the patient’s knowledge.” After the New York Times article was first published, the hospital system “announced it would stop suing patients during the pandemic and would rescind all legal claims it filed in 2020.”
Strengthening Indiana’s Public Health System
IU Fairbanks School of Public Health Dean Paul Halverson and Health Policy and Management Associate Professor Valerie Yeager published the Indiana Public Health System Review last week. A more robust and well-funded state and local public health system will improve our ability to respond to epidemics and to keep our communities healthy. The report’s four overarching recommendations are:
- Create a uniform approach to deliver the Foundational Public Health Services (FPHS) across the state
- Create a district-level mechanism to enable resource sharing among Local Health Departments
- Strengthen the State Health Department’s oversight and enabling capacity to support the local public health delivery system
- Under the auspices of the state board of health, create a multi-disciplinary state-wide implementation committee tasked with executing the recommended implementation steps (outlined further in the report’s 5th section).