As I recently wrote here, and spoke about here, bans on elective surgery invoked by governors across the country in response to the COVID-19 pandemic have caused many people to suffer and even possibly face fatal consequences due to delays in necessary medical care. But there are other reasons why the public health emergency has the potential to generate secondary public health crises.
In some cases people are avoiding doctors’ offices and emergency rooms because they worry about handling the expense at a time they have seen their income, and perhaps their savings, vanish during the current economic shutdown. In other cases, people–particularly those with vulnerabilities–avoid medical care out of fear they might get exposed to the virus in the process.
Fear among vulnerable patients that they may contract and succumb to a COVID-19 infection is completely understandable. It is less understandable, however, when this fear makes parents forgo taking their children to the doctor’s office for routine vaccinations against diseases which are far more deadly and contagious, as the Wall Street Journal reported May 8. The timing of certain immunizations in children can be crucial. Forgoing or even just postponing them can have serious consequences.
Despite the fact that family practice and pediatrics offices have employed social distancing strategies to minimize the risk of COVID exposure to parents and their children if they come in for their scheduled vaccinations, the Journal reported:
The immunization rate for all recommended childhood vaccines declined about 40% in the U.S. from late February through mid‐April, according to Physician’s Computer Co., a provider of electronic health‐record systems. The data are based on vaccines administered by more than 1,000 pediatricians in 40 states who use PCC’s record system.
Concerns about a drop in the vaccination rate in association with the pandemic were also published by the Centers for Disease Control and Prevention.
This is particularly unfortunate considering that children appear relatively spared by the COVID pandemic. According to the CDC, as of May 3 less than two percent of confirmed COVID-19 cases were among patients under age 18. The cases are almost always mild. The CDC report states, “In the U.S., as of April 2, 2020, there have been three deaths among children with laboratory‐confirmed SARS‐CoV‐2 infection that have been reported to CDC, but the contribution of SARS‐CoV‐2 infection to the cause of death in these cases is unclear.” The fatality rate among adults under age 50 is likewise extremely low.
Meanwhile, diseases like measles and polio are much more deadly and contagious. Measles can lead to pneumonia, along with brain swelling and secondary permanent neurologic sequelae, such as vision and hearing loss and cognitive impairment. Measles can also be fatal. Complications of polio include paralysis. Parents must consider risks such as these when they fail to get their children vaccinated.
The World Health Organization reported 140,000 deaths from measles occurred globally in 2018, most under the age of five. Even polio virus, thought to be largely eradicated, is showing traces of a comeback, with worldwide reported cases increasing from 28 in 2018 to 163 in 2019.
It’s not only measles that poses a threat. Rotavirus, which can cause severe gastrointestinal illness in children is also a part of the standard vaccination package, as is immunization against Bordetella pertussis, the cause of “whooping cough.” Some vaccinations may protect against problems that can develop down the road. An example is the immunization for human papilloma virus (HPV), which can be a cause of cervical, anal, penile, and throat cancers in adults.
The Wall Street Journal article quoted one pediatrician as saying, “The numbers will tell you it’s guaranteed that some American kid today is going to die in 10 to 20 years of HPV as a result of Covid.”
It would be a great tragedy to see new pandemics, from pathogens previously believed to have been defeated, arise from the ashes of the current pandemic.
Public health experts should inform political leaders as well as the public about the dangers of COVID-19 and the best ways to avoid them. But policymakers and the public should also be told about trade‐offs, as well as the relative risks faced by different demographic groups. Policies and personal decisions should be based on reason, not fear.
A photo of the pharmacy kiosk at 2196 East Camelback Road in Phoenix, Arizona
Among the many new realizations derived from the COVID-19 pandemic is how telemedicine has been underutilized and can be a great way to bring health care to millions of people to whom access is otherwise difficult or unavailable. As I discussed at length in this and other podcasts, the practice of telemedicine across state lines faces state‐based licensing barriers, preventing patients from benefitting from the free trade of professional health services across state lines, denying them access to quality care from across the nation.
Similarly, state laws stand in the way of the development of telepharmacy. Last month, lawmakers in Florida passed HB59, which would permit pharmacy kiosks outside of hospitals, nursing homes, and correctional facilities. It awaits the governor’s signature. This will enable people in rural or remote areas as well as localities underserved by brick‐and‐mortar pharmacies to pick up and pay for their prescriptions and also consult, using the touch screen monitor, the on‐call pharmacist who is supervising the transaction. This technology is not new. It has been used by students at Arizona State University since 2014.
With the advent of the COVID-19 pandemic and the need for social distancing comes a new appreciation for pharmacy kiosks, as customers can pick up their prescriptions privately, away from crowds, in much the same way they perform transactions at ATM machines.
The Phoenix metro area has several kiosks operated by a retailer named SpotRx, manufactured by a company called MedAvail. SpotRX stocks the kiosks with medications and staffs them with a team of pharmacists who practice remotely. Because of concerns that the Arizona summer heat might harm drugs within the kiosks, most of them are kept in lobbies or entry‐ways of buildings, although some are kept in the waiting rooms of medical clinics, and some SpotRx kiosks are inside Sam’s Club big box stores. An outdoor kiosk is maintained on a shady area of the Arizona State University campus in Tempe, AZ.
Unfortunately, residents of several states are legally blocked from availing themselves of this technological advance.
The present public health emergency shines a light on many of the ways the health care sector lags far behind other sectors of the economy in using new technologies to serve their customers. State lawmakers should learn from this and remove regulations that keep the health care sector, in many ways, stuck in the 20th century.
Reuters reported the other day that the savings from forgone health care and claims due to people sheltering in place is enough to pay for the cost of full coverage for COVID-19 care that many insurers are offering:
“The costs from COVID-19 are going to be actually very small and more than outweighed by the deferral of elective procedures. The net impact is going to be positive for them,” said Jeff Jonas, portfolio manager with Gabelli Funds…
The largest U.S. for‐profit hospital operator, HCA Healthcare Inc, said it has seen a 70% drop in outpatient surgeries so far in April compared with a year ago, while inpatient admissions declined 30%…
Health plans and employers who provide insurance have seen an overall decline in healthcare use of about 30% to 40% excluding COVID-19 patients, according to Tim Nimmer, the global chief actuary at Aon, a benefits company that advises large corporations and health plans.
“For each month that this goes on, we are expecting about 1.5% to 2% in annual costs to be reduced,” Nimmer said. “The number one issue is how long will this go on.”
As for what health insurers will do with the money they’re saving, the ACA’s “medical loss ratio” provisions require that if insurers (large‐employer plans) spend less than 80 percent (85 percent) of premium revenue on claims, they have to refund that money to enrollees. Since insurers are spending far less than expected on claims, we can expect the ACA will require them to send lots of rebate checks to enrollees.
But do we need government regulation to ensure that insurers return such windfalls to their enrollees? Consider what’s happening in the auto insurance market.
Similar to health insurers, auto insurers are saving money because people are driving less. The Wall Street Journal reports, “Allstate Chief Executive Tom Wilson said mileage was down ‘an unprecedented’ 35 percent to 50 percent across the U.S. since mid‐March, including in states without shelter‐in‐place restrictions.” (That latter part provides a helpful reminder that government affects pandemic response only at the margin.) Less driving means fewer accidents, so claims have likewise fallen as much as 40 percent.
What are greedy insurance companies doing with those windfall profits? They are issuing refunds.
Policyholder‐owned American Family Mutual Insurance is refunding $200 million to policyholders. Publicly traded Allstate is refunding $600 million to customers. American Family COO Telisa Yancy explained, “It is real dollars we expected to pay out this year and no longer have to pay out. We are sharing it back right now when our customers probably most need it.” The WSJ reports, “Wall Street analysts believe many will follow suit…for reasons including competitive pressure.”
Darn those greedy insurance companies.
Governments often fail because they tend not to learn lessons. They make similar mistakes over and over for reasons described in this study.
The FDA botched its COVID-19 response by using its regulatory powers to monopolize the development of virus tests. I have not heard any apologies for the failure or that any officials have been fired. As a Wall Street Journal investigation of HHS leadership suggests, the gross testing failure has led to lots of finger pointing, but not institutional reforms.
After the testing debacle, one might think that federal leaders would hesitate to impose further one‐size‐fits‐all solutions for COVID-19. But no—the Wall Street Journal reports that House Democrats want to require OSHA “to order all companies to implement comprehensive plans to protect workers who continue in their jobs during the pandemic. The new, emergency standard would have to be issued within seven days after any legislation is signed into law.”
Thus, in seven days federal bureaucrats would apparently write‐up a Giant Safety Plan to impose on millions of businesses in hundreds of industries across our huge and diverse nation. That makes no sense.
Federal policymakers seem to have little comprehension that their actions often sideline the vast brain power and innovation that lives outside of Washington. At the stroke of a pen, federal regulations nullify the experimentation, dynamism, and speed that America’s private sector can mobilize to solve problems.
As they consider imposing COVID-19 safety regulations, policymakers should ponder the pro‐active steps that businesses are already taking or actively considering, as discussed in another Wall Street Journal article. Businesses are separating workspaces, taking temperatures and screening health at work entrances, testing employees before they get to work, closing lunch rooms, installing workspace partitions, adjusting shifts, modifying production lines, changing entrances and exits, closing facilities and tracing contacts if workers test positive, placing materials down rather than handing them to others, sanitizing workspaces, having safety experts instruct workers, spacing bathroom urinals, wearing electronic bands to alert workers if others are too close, and providing masks, gloves, and hand sanitizer.
A central plan quickly thrown together in Washington could not impose a “best” way for millions of businesses to install these sorts of changes. Every business is unique. Here are some reasons why allowing businesses to address their own safety challenges is superior to top‐down federal mandates:
Trial‐and‐Error. The Journal story puts a negative spin on diverse business approaches to safety as a “patchwork” and “ad hoc.” But anyone who studies innovation knows that trial‐and‐error processes are crucial to economic and societal improvements. Private institutions change direction all the time as they try different things and receive feedback from stakeholders. To discover the best ways to adjust each workplace for COVID-19, businesses need the freedom to experiment and to change course.
Government regulations undermine the steady improvements that are the hallmark of markets and free societies. Imposing COVID-19 safety regulations would reduce business incentives to implement new and better approaches. The question around every workplace would change from “Are we doing this safely and can we do it better?” to “Are we conforming to the OSHA rules?”
Horizontal Learning. Volkswagen is reopening some of its European factories after making 100 workplace changes. VW has been flooded with requests from other businesses about the safety procedures it is using, and so the company has posted its ideas online. American businesses are also studying Chinese businesses that were able to open safely. This sort of horizontal learning is superior to the often‐ill‐informed edicts from Washington. Similarly, horizontal sharing of resources during crises is better than vertical intervention, as discussed here.
Costs and Benefits. In theory, federal bureaucrats are supposed to design regulations by comparing the costs and benefits of various possible rules, but the process is a crude way of making decisions in an economy, even after rules have been studied for years. In the current crisis, regulators would have little time to even try and make balanced decisions. Business leaders know their own facilities, employees, and customers, and they can make better reopening decisions based on their local knowledge.
Flexibility. The nature of the COVID-19 threat will change over time. Scientists may learn more about virus transmission on surfaces and in the air. Drugs may be developed to reduce the health risks. New safety approaches and technologies may be developed. As such, businesses need the freedom to adjust their safety procedures over time. Regulations would lock‐in rules that may be quickly outdated as conditions change.
When it came to dealing with an unexpected surge in infections and deaths from SARS‐CoV‐2 (the virus causing COVID-19 symptoms), federal and state policymakers understandably sought guidance from competing epidemiological computer models. On March 16, a 20‐page report from Neil Ferguson’s team at Imperial College London quickly gathered enormous attention by producing enormous death estimates. Dr. Ferguson had previously publicized almost equally sensational death estimates from mad cow disease, bird flu and swine flu.
The New York Times quickly ran the hot news about this new COVID-19 estimate:
The report, which warned that an uncontrolled spread of the disease could cause as many as 510,000 deaths in Britain, triggered a sudden shift in the government’s comparatively relaxed response to the virus. American officials said the report, which projected up to 2.2 million deaths in the United States from such a spread, also influenced the White House to strengthen its measures to isolate members of the public.
A month later that 2.2 million estimate was still being used (without revealing the source) by President Trump and Doctors Fauci and Birx to imply that up to two million lives had been saved by state lockdowns and business closings and/or by federal travel bans.
The following summary of the Ferguson/Imperial College report provides clues about how the model came to generate such dramatic conclusions:
In the (unlikely) absence of any control measures or spontaneous changes in individual behavior, we would expect a peak in mortality (daily deaths) to occur after approximately 3 months. In such scenarios, given an estimated R0 of 2.4, we predict 81% of the G.B. and U.S. populations would be infected over the course of the epidemic… In total, in an unmitigated epidemic, we would predict approximately 510,000 deaths in G.B. and 2.2 million in the U.S., not accounting for the potential negative effects of health systems being overwhelmed on mortality.
This worst‐case simulation came up with 2.2 million deaths by simply assuming that 81% of the population gets infected –268 million people– and that 0.9% of them die. It did not assume health systems would have to be overwhelmed to result in so many deaths, though it did make that prediction.
Neither the high infection rate nor the high fatality rate holds up under scrutiny.Read the rest of this post »
The Food and Drug Administration’s cumbersome and ossified approval process for drugs and tests stands out as a major cause of the federal government’s failure to quickly and effectively respond when the the COVID-19 virus first attacked. And one thing upon which all policymakers agree is that abundant testing—both for the presence of active infection and for evidence of previous infection and possible immunity—is crucial to ending this crisis.
As I have written here, on February 29 the FDA began to loosen these regulations, particularly regarding approval of tests, and allowed academic and commercial labs more freedom to produce and distribute them without having to follow normal FDA approval protocols. Finally, on March 16, the FDA delegated authority to the states to approve COVID-19 tests that may be used within their borders. The FDA should have also granted states this same authority to approve drugs that may treat the infection.
While the FDA has approved only a few antibody tests (which provide evidence of previous infection), many have been approved by state governments and have already been deployed. For example, an antibody test manufactured by California‐based Premier Biotech has been used by researchers at Stanford University and the University of Southern California to detect large segments of the populations of Santa Clara and Los Angeles counties who have already been infected by the virus.
In exercising the authority delegated to him by the FDA, Maryland Governor Larry Hogan announced yesterday that he purchased 500,000 tests from South Korea, a country that set an example of efficient and accurate testing when the virus attacked. The governor set the wheels in motion to purchase the tests from South Korea shortly after the FDA delegated authority to the states in mid‐March. It culminated in a chartered Korean Airlines flight that carried the test kits to the Baltimore‐Washington International Airport yesterday. The governor plans to deploy these kits to reach his state’s goal of testing 10,000 Marylanders per day.
Ironically, perhaps due to nationalist impulses, President Trump criticized Governor Hogan’s move. The president contended the governor should have used the tests available at federal laboratories—even though the governor was acting in accordance with administration policy. This was not the first time during this crisis that the president or his administration have transmitted mixed messages to the public.
One of the first questions that should have been asked in late February when it was discovered that the de facto CDC‐monopoly on COVID-19 testing was a fiasco was: Why not use the tests already successfully in use in other countries? As I wrote last month, a good policy reform that should emerge when this crisis passes would be for the FDA to grant reciprocal approval to all drugs and tests that are already approved and in use by a list of similar countries—and not just in time of emergency. That way the people won’t get deprived of drugs and tests to which they have a right.
In the meantime, states should continue to exercise their newly‐delegated power to decide on the tests that may be run within their borders and resist relinquishing this power once the crisis is over.
COVID-19 statistics that are easiest for reporters to find and explain are often the ones we keep hearing about in daily news reports. A perennial favorite is the John Hopkins University graphical database which is constantly updated to add up the cumulative number of “confirmed” cases, deaths and recoveries since January 21 for separate countries and the world.
To switch the focus from these familiar multi‐month totals to what is happening now, however, I built this simple graph of daily new deaths and daily new confirmed cases. It does suggest recent flattening, though professional optimism about reaching a peak is partly based on key states rather than national totals.
The cumulative data we see repeatedly in the daily news is not always the data we need. “Confirmed cases” in the John Hopkins data means cases that were tested. This makes it sensitive to the intensity of testing and also limits the count to those sick enough to be tested. It also exaggerates the apparent death rate by excluding the majority of COVID-19 infections, those having mild or no symptoms.
The “number recovered” would ultimately add up to 99% of infections if 1% died. Yet the number recovered seen in the John Hopkins site always remains very low. That is because states don’t keep track of what happened to every sick person, and nobody knows about the vast majority who recover at home.
As these cumulative multi‐month totals go, the most relevant one is missing. That would be “active” cases – all those infected minus those who recovered or died. But the published numbers don’t tell us how many Americans are now or ever have been infected, nor how many recovered. Compared with confirmed cases and recovered cases, death numbers are more meaningful and solid (despite ambiguity about attributing death to COVID-19 despite underlying conditions).
Cumulative totals include old history. The numbers we need would tell us whether or not the rate of change is slowing for new deaths. New deaths are a good proxy for new cases (as the graph shows), and also for new hospitalizations with a lag. But death figures are clearer and easier to track.
The Murray Model I discussed on April 6 updates a model‐built epidemic curve with actual daily deaths by state. It has already reduced mid‐range estimates COVID-19 total deaths from about 81,000 to 61,000. But the model’s highest estimates more than double that figure, and even the mid‐range curve (which fits best so far) can rise or fall with new data. The main point is that I do believe the model’s focus on real‐time death data is the best single indicator we have right now or will have later without a lot more testing, including random samples and testing for immunity.