David Brailer | March 16, 2020
People who want to see increased government involvement in health care should be given pause by the coronavirus/COVID-19 pandemic. Americans are facing a mushrooming coronavirus crisis, made worse by the federal government’s bungling of planning, testing, communication and collaboration. Rigid rules, lack of adaptability, conflicting guidance and paralysis deeply undermine the government’s response and its credibility, at a time when both are needed most.
Our elected leaders compounded problems by picking political fights and demonstrating dangerously cavalier behavior. But the problems we see today go much deeper than elected or appointed political leaders. I believe that a future investigation into early coronavirus testing will not show that federal agencies failed to follow rules, but rather that the rules themselves were obsolete and not adequate for today’s challenges. It is a systematic institutional failing that demonstrates the huge downside of having the government too much in control of health care.
There are many committed and passionate public servants and scientists at HHS, CDC, FDA, NIH and in state and local public health departments. They should be praised for their devotion and willfulness, and I have no doubt that they will ultimately get in front of the coronavirus challenge. All of us will be forever grateful to National Institute of Allergy and Infectious Diseases Director Anthony Fauci, MD for his courage, perseverance and unique bedside manner when the patient is the American public. He is one of many public servants at the federal, state and local level who demonstrate resolute competence and professionalism when facing the human race’s microscopic but lethal biological antagonists. These people are the backbone of our public health system and often work without recognition or adequate resources.
Our government has a strong track record of advancing science, epidemiology and old-fashioned isolation-and-case-tracking. These are essential features of our public health capability and the very purpose that many professionals seek careers in health care. But these capabilities are not the only ones we need in a rapid-moving, mobile, information seeking, consumer-driven economy. For years, we have tried to upgrade and integrate the information technology capabilities of the CDC and state and local public health departments so they have seamless information sharing – and are tied into the point of care for rapid situation assessment. This is similar to the top-to-bottom integration of law enforcement after 9/11, under the Law Enforcement Information Sharing Program Exchange Specification (LEXS), except that funding for the public health counterpart to LEXS never seems to be found, leaving it more aspiration than reality. Broadly, our agencies lack the technical ability and often authority to use modern information – geolocation data, credit card data, web search data, etc. – to strengthen case identification and contact tracing, despite that data being used routinely by industry for tasks such as marketing and sales.
Our government challenges go far beyond information technology. As America faces the exponential growth phase of coronavirus, we can’t fight this challenge without relying yet again on the public-private partnerships that undergird health care at the national, state and local level. These relationships – the bedrock of American health care – bring innovation, agility and adaptability, features we don’t often get in government alone. This is nowhere more evident today than in coronavirus testing. As the CDC stumbled around in its early testing, Mayo and Cleveland Clinic rapidly developed their own tests, only to be forced to stand down by government agencies. Now they are unleashed, as is Roche, ThermoFisher, Integrated DNA Technologies, LabCorp and Quest. We will see very rapid scaling of testing, as well as the support component that helps people know where to go, how to prepare, what to expect and how to respond. These kinds of hands-on services are more important than Net-Promoter Scores during times of crisis. They are an essential part of educating and calming an anxious public that is increasingly frustrated and concerned about what is to come and who to rely on.
At the same time, hospitals and health systems are ramping up surge capacity. These are the same hospitals that policymakers regularly scorn for their quality of care risks, health care inflation, fraud and abuse problems, resistance to change, and over-utilization. But policymakers have now removed numerous government rules and gotten out of the way of American hospitals so they can go to work as the front line of protection for people who become ill and need care. And it is shaping up to be a generational fight. After 9/11, there was a huge investment in hospital surge capacity, with whole field hospitals ready to stand up in various parts of the US. While some of that is still in place, it has been slowly defunded as our memory of catastrophe has receded. Moreover, our efforts to shift procedures out of hospitals and to make them more efficient over the past two decades has reduced surge capacity even further. I am certain that our hospitals will stand firm and use their vast resourcefulness to ensure that every American who needs care gets care.
Everyone is looking to telehealth companies like Teladoc, American Well and MDLive to provide care and to keep people away from hospitals and emergency rooms. But this comes after regulators and payors have spent years slow-walking approvals and funding for telemedicine, long after it has proven effective and beneficial. Where would Texas be right now if the state legislature hadn’t forced the Texas Board of Medicine in 2017 to allow telemedicine companies into the state? Texans, and Americans in general, should be glad that Teladoc pushed back against short-sighted interests and made this life-saving capability part of routine care.
And on it goes. Health plans are waiving co-pays and other barriers to testing and are using their considerable public communication and care management capabilities to support their members. Retailers, including Walgreens, Walmart, CVS and others are gearing up for testing and treatment of people with mild illness. Tech companies are rapidly setting up sites to steer people to testing and eventually to help them find available emergency rooms and hospitals. Pharmaceutical companies have launched crash vaccine and treatment development programs. In short, the industrial might of American health care has awoken, and will not relent until we are safely on the other side of this epidemic.
I for one am glad we have such a robust and innovative private sector in health care. I feel indebted to the clinicians and leaders who work passionately every day to keep us a step ahead of illness and disease. I am grateful for the innovators and mavericks and relentless leaders who don’t take no for an answer and who don’t wait to be told what to do. Without these people, we would still be waiting for a government agency to give us a test, to offer us treatment or to support our care — all while it worries about political infighting, top-down budgets, arcane rules and overlapping authorities.
Over the next few weeks, we will face a once-in-a-century fight for the health and wellbeing of our citizens and our nation. When it is done – and we will put it behind us – we will then ask what we learned and what we should do differently next time. I hope this includes an exploration of how much we benefit from our America’s unique public-private collaboration and how we can make it stronger and deeper in the future.
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