Monday, May 25, 2020

The 2020 COVID-19 Election

Many believe that the 2020 Presidential election will be a referendum on how President Trump has handled the coronavirus pandemic.  Some believe that is why the President is pushing so hard to reopen the economy, so that he can reclaim it as the focal point instead.  I fear that the pandemic will, indeed, play a major role in the election, but not quite in the way we're openly talking about.

It's about there being fewer Democrats.

Now, let me say right from the start that I am not a conspiracy believer.  I don't believe that COVID-19 came from a Chinese lab, or that China deliberately wanted it to spread.  I don't even believe that the Administration's various delays and bungles in dealing with the pandemic are strategic or even deliberate.

I do believe, though, that people in the Administration and in the Republican party more generally may be seeing how the pandemic is playing out, and feel less incentive to combat it to the fullest extent of their powers.  Let's start with who is dying, where.

The New York Times put it bluntly: The Coronavirus Is Deadliest Where Democrats Live, as illustrated with their map:
Coronavirus cases in counties won by Clinton in 2016 on left, in counties won by Trump on right; larger bubble means more cases. Data is as of May 21, 2020. By Jugal K. Patel for The New York Times
The article explains:
The devastation, in other words, has been disproportionately felt in blue America, which helps explain why people on opposing sides of a partisan divide that has intensified in the past two decades are thinking about the virus differently. It is not just that Democrats and Republicans disagree on how to reopen businesses, schools and the country as a whole. Beyond perception, beyond ideology, there are starkly different realities for red and blue America right now.
Potential explanations for the differences include population densities, loci of international travel, and proportion of minority populations.

Nor is it necessarily true that the current trends will remain; coronarvirus is starting to surge in rural areas.  A Washington Post analysis indicates: "Rural counties now have some of the highest rates of covid-19 cases and deaths in the country, topping even the hardest-hit New York City boroughs and signaling a new phase of the pandemic."  

It's not only about red states versus blue states; it is also about who is dying in each.  People of color have been impacted much more.  African-Americans are dying at almost three times the rate of whites or Latinos; in Kansas, the rate is seven times, and five times in Michigan or Missouri.  And not all states are reporting deaths by race, so the problem may be understated.  Latinos and, to a lesser extent, Asian Americans have also been hit harder than whites.


APM Research Lab estimates (as of May 20):

If they had died of COVID-19 at the same rate as White Americans, about 12,000 Black Americans, 1,300 Latino Americans and 300 Asian Americans would still be alive.

Some of this has been attributed to underlying health and/or living conditions, but a new study found that, even controlling for differences in age, sex,income and chronic health problems, African-Americans are hospitalized with COVID-19 at nearly three times the rate of white or Latino patients. Co-author Stephen H. Lockhart told The New York Times:  "The important thing we found in this study is that even when we were accounting for all those things, race mattered."  

There's an economic toll as well -- as shocking as the jobless rates are generally, they are worse for minorities, and minority-owned businesses are being hit hardestThis may be due, in part, because such businesses had a much harder time obtaining PPP loans.

Certainly not all minority voters vote Democrat, but African Americans tend to overwhelmingly do so and Latino voters also do, although not quite as monolithically.  A disease like COVID-19 that disproportionately impacts minorities hurts Democrats more than Republicans, whether outright through fatality or just in reducing turnout.   

Turnout by minority votes has long been a problem.  Going to a polling place during a pandemic will be problematic for some voters, and if you are a voter who is in a higher risk group -- such as African-American, it may be particularly so.  Many states are pushing for mail-in voting for any resident as a way to assuage such concerns, a tactic that President Trump fiercely opposes.  He cites potential for "massive fraud," although no evidence exists for this and many states, including ones controlled by Republicans, have allowed it without problems.  

The opposition to mail-in voting is less about safeguarding the integrity of the election and more about trying to control who ends up voting. 

Our reactions to the pandemic are very much splitting along party lines.  For example, wearing a face mask, as public health officials urge, is now seen as a political statement.  That brought North Dakota Governor Doug Burgum, a Republican, to tears in a recent press conference:

President Trump's 2016 election hinged on razor thin margins in a few swing states. No matter the impact of COVID-19, he isn't likely to win in hard-hit blue states like New York, California, or Massachusetts, but it might well make the difference in swing states like Michigan, Pennsylvania, or Wisconsin, and could even make a difference in purple states like Illinois, New Jersey, or Minnesota.  How many fewer Democrats able/alive to vote would it take?

The strategy is not without risks.  Polls show voters give former Vice President Joe Biden a wide lead on ability to deal with the pandemic, and support for Trump among senior citizens -- which had supported Trump in 2016 but who now at greatest risk of contracting and dying from COVID-19 -- is weakening.  Statements from Republicans like Texas Lieutenant Governor Dan Patrick suggesting seniors were willing to die from COVID-19 as a trade-off for restarting the economy don't help.

Let me be clear: I'm not saying President Trump or other Republicans want minority voters to die, and certainly not that they are intentionally trying to make that happen.  But, from a political standpoint, the pandemic is currently is hitting his supporters less hard, and there's a political calculation may come with that.  Democrats cannot be blind to that.  

COVID-19 is the biggest health crisis in a hundred years.  It has caused perhaps the greatest economic crisis in ninety years.  It would be unfortunate if we allowed it to also cause perhaps the biggest political crisis in our nation's history.  

Monday, May 18, 2020

Home, Sweet Work

If you're lucky, you've been working from home these past couple months.  That is, you're lucky you're not one of the 30+ million people who have lost their jobs due to the pandemic.  That is, you're lucky you're not an essential worker whose job has required you to risk exposure to COVID-19 by continuing to go into your workplace.  
What's interesting is that many of the stay-at-home workers, and the companies they work for, are finding it a surprisingly suitable arrangement.  And that has potentially major implications for our society, and, not coincidentally, for our healthcare system.

Twitter was one of the first to announce that it wouldn't care if workers continued to work from home.  "Opening offices will be our decision, when and if our employees come back, will be theirs," a company spokesperson wrote in a blog post.  "So if our employees are in a role and situation that enables them to work from home and they want to continue to do so forever, we will make that happen."

Other tech companies are also letting the work-from-home experiment continue.  According to The Washington Post, Amazon and Microsoft have told such workers they can keep working from home until at least October, while Facebook and Google say at least until 2021.   Microsoft president Brad Smith observed: "We found that we can sustain productivity to a very high degree with people working from home."  

The tech industry, of course, had been famous for its unconventional workplaces, with open architecture, free/low cost food, games, rowdy atmospheres, and, more lately, futuristic buildings.  It also led to concentrations of talent in areas like Silicon Valley or Seattle, with corresponding soaring housing costs and commuting sagas.  

José Cong, a tech talent acquisition advisor, told The Wall Street Journal that, when it comes to increased remote work, the pandemic "is going to be the gasoline on the fire."  

It's not just corporate benevolence or concerns about public health.  It's also about the money.  Short term savings in office energy use/upkeep and business travel, and longer term savings in real estate costs, make work-at-home attractive to companies.  Entrepreneur Hiten Shah told Cat Zakrzewski of The Washington Post: "Everyone's doing the math.  Once you follow the money, it points to the fact that this is inevitable...The cost savings are just ridiculous comparing to have an office and all the things that come with that."  

Tech may have gotten most of the work-at-home press, but the trend is broader than that.  For example, think also about IT more broadly, customer service, HR, or finance.  Nationwide Insurance moved 98% of its jobs to work-from-home due to the pandemic, and doesn't see any reason to move them back.  CEO Kirt Walker told Fortune: "We've tracked all of our key performance indicators, and there has been no change.  We keep hearing from members, 'if you hadn't announced you were all working from home, we never would have known."  

He sees the change as part of a historic, permanent mindset shift: "We think the world is changing. We’ve got to take cost out of the system. We want to enable sustainable growth."

There are real questions about the shift.  "Companies will have to find ways to build culture remotely, which is really tough to do," tech analyst Gene Munster told the WSJ.  Zoom calls are all well and good, but "People like to come in and collaborate with and work with their folks," said Jennifer Christie, Twitter's chief human resource officer.  Professor Andrew Hargadon told The Post, "there’s still value in being together in person.  Those accidental interactions in elevators and cafeterias or when grabbing coffee can still spark ideas."  

In The WSJ, Rachel Feintzeig raises another consideration: when home is work, how do we separate home life from work life?  Harvard Business School Professor Leslie Perlow noted: “You can’t get away from your family, can’t get away from your work.  You have no excuse ever. Where can you be?”  

In her NYT op-ed, Jennifer Senior predicts: "But over the coming months, I suspect that those of us who spent most of our careers in offices will grow to miss them."  She mentions the camaraderie, the intellectual stimulation, even the prospect for romance as reasons.  

There are further ripple implications.  Business Insider reported how suburban office parks were already becoming more deserted, posing problems not just for their commercial real estate owners but also for the cities and municipalities that relied on tax revenue from them -- not to mention for the restaurants and other small businesses that served all those workers.  

We've seen a urban-suburban competition for jobs, but now that fight has a new contender -- workers' homes -- and no one yet knows all the implications of that shift.  

Healthcare is less able than most industries to work from home, but it is doing its best through increased use of telehealth.  Its problem is that its revenues are built around patients coming in for visits/treatments/procedures, and most aren't.  As a result, telehealth notwithstanding, hospitals say they are losing billions of dollars, and healthcare workers are, for the first time in decades, undergoing massive layoffs -- well over a million in April alone.  

When we think about all those deserted office parks and buildings, think also about hospitals and medical office buildings.  The healthcare system will need fewer of them both from the demand side -- patients preferring to use telehealth -- and from the supply side -- healthcare professionals able to do more remotely.  Mei Kwong, executive director of the Center for Connected Health Policy, warns of a long transition, telling mHealth Intelligence: "It’s going to take some time to sort things out...It’s going to get interesting."

"Interesting" indeed.

This pandemic will not last forever.  Ready or not, we're already starting to reopen major parts of the economy.  Perhaps the sudden, massive work-from-home experiment will soon be just a memory, and we'll all end up back to our offices.  

But that's a sucker's bet.  The prudent business leader would seriously consider, as Mr. Walker said, that this is part of a once-in-a-generation/once-in-a-lifetime, permanent shift.  The prudent business leader would evaluate how much of their business could be done from home (or other settings), and how to best support that shift.  The prudent business leader would be trying to drive and support the changes, not react to them.

The question is, how many such prudent business leaders there are in healthcare?

Monday, May 11, 2020

Keep Petri Dishes in the Lab

COVID-19 is changing the landscape of our healthcare system, and, indeed, of our entire society, in ways that we hadn't been prepared for and with implications that we won't fully grasp for some time. 
As we grapple with how to reshape our healthcare system and our society in the wake of the pandemic, though, I worry we're going to focus on the wrong problems. 

Take, for example, nursing homes, prisons, and the meatpacking industry. 

Anyone who has been paying attention to the pandemic will recognize that each of these have been "hot spots," and have been called "petri dishes" for coronavirus (as are cruise ships, but that's a different article).  These institutions aren't the only places where masses of people congregate, but they seem to do so in ways that create fertile territories for COVID-19.  And that's the problem.

We knew early on that nursing homes were going to be a problem.  We knew COVID-19 was a problem in Wuhan, but that was far away -- until a few cases emerged in late February in a skilled nursing home in King County, Washington.   We know now that these were not the first cases, nor the first deaths, but we were stunned by how quickly it spread in that facility.  By mid-March experts were already calling nursing homes "ground zero," and that has been proven right. 

It is now estimated that as many as a third of all U.S. coronavirus deaths have come from nursing home residents or workers.  That is (as of this writing) almost 30,000 deaths, and over 150,000 cases. 

It took us longer to realize that prisons were also going to be a problem, although it shouldn't have.  The U.S. incarcerates far more people -- absolute numbers or per capita -- than any other country, and many of those institutions are overcrowded, dangerous, and less than sanitary.  Worse yet, they are disproportionately populated by people of color, who have been found to be disproportionately impacted by COVID-19.  It was a disaster in waiting and the disaster didn't wait. 

COVID-19 is "spreading like wildfire" in several prisons; one prison in Ohio has found eighty percent of inmates -- that's 2,000 people -- have tested positive.  Seventy percent of inmates in a California prison tested positive.  The Marshall Project estimates over 20,000 cases have been identified among prisoners nationwide.  States that are aggressively testing are, no surprise, finding mass infections in their prisons, including among the staff. 

Meatpacking also took us by surprise.  States that thought they were successfully avoiding the pandemic suddenly had major outbreaks tied to meatpacking plants, including ones in Iowa, Nebraska, Minnesota, and South Dakota.  Meatpacking plants across the country started to close, promoting the President to invoke the Defense Production Act to keep them open, despite the ongoing concerns from workers.  Plants are continuing to close despite the order.

Samantha Gillison described the dangerous working conditions of meatpacking plants in Think, and concluded:
But no one really paid attention to the brutal working conditions until it turned out that they also make the people who work there particularly susceptible to being infected with COVID-19.  
The fact that these jobs tend to be low wage ones, often filled by immigrants and definitely with no work-from-home options, add to the risk. 
There are things that can be done to mitigate the spread even in these three industries, starting with much more testing, but the very nature of each industry makes them susceptible to this and other public health hazards:

Nursing homes: Nursing homes (and their cousins, assisted living and other congregate care facilities) are the stepchildren of our healthcare system.  They're generally crowded, understaffed, underpaid, without sophisticated personal protective equipment (PPE), and not well-versed in nor well regulated on infection control measures.   According to the CDC, out of 4 million nursing home residents each year, there are typically between 1 to 3 million serious infections every year, with some 380,000 deaths from them.  That's without a pandemic. 

We can, and we should, address the pay and safety issues inherent in the nursing home model, but those are bandaids.  The model itself is the problem.  Too many people who are in nursing homes and other facilities are there because they lack the resources -- financial, family, support options -- to stay in the community.  We need to invest in developing and supporting a 21st century approach to aging in place. 

Prisons: We may still use term "correctional facilities," but at best it is ironic: few get "reformed."  We imprison far too many people, for far too long, especially for substance abuse or mental health issues that in other countries would merit treatment and support.  Worse yet, after leaving prison many find that their lives can never be normal again, shut out of many professions, living options, even voting.  We say we're addressing criminal justice problems but we're actually creating  significant socioeconomic, racial/ethnic public health problems.

Norwegian prison cell.  Credit: Stringer/Reuters
Other countries - take, for example, Norway -- manage their society in ways that result in far fewer people being locked up and in safer conditions when they are.  Certainly the U.S. can do better than we are.   

Meatpacking:  We like our meat and we like it cheap, so as a result much of it is raised under horrific conditions and processed under equally bad ones.  We should be willing to pay more for more humane conditions for the animals and much safer conditions for the workers, and find ways to automate much more of the work.  If that means our meat consumption drops and our meat budget rises, well, how many lives is that worth to us?

As Ms. Gillison wrote: "Industries famously don't regulate themselves, and the meatpacking industry isn't going to be an outlier...Things won't get better until there is the real political will to change how the meatpacking industry handles worker safety."  Do we have that will?  
It's not going to be enough to try to minimize the pandemic in these industries; in each case, the pandemic isn't the problem, but rather is the result of the problem.  We need new models for these industries that take advantage of available technology and safeguards, reimagining them for the 21st century...and, along the way, making us all safer.  

I'm all for petri dishes to help find new drugs or to teach science, but not as places to live or work.

Monday, May 4, 2020

Healthcare Starts to Zoom Along

A year ago, if you'd used or even heard about Zoom, you were probably in the tech industry.  Today, if you haven't used Zoom, your friends or colleagues must not like you very much.  COVID-19 has made most of us homebound most of the time, and video services like Zoom are helping make that more bearable.

And, thankfully, healthcare is finally paying attention.

Zoom was founded in 2011, poking along under the radar for several years, overshadowed by competitors like Skype or WebEx.  For the entire month of May 2013 it only had a million meeting participants.  Even by December 2019 it could boast "only" 10 million daily users.

Then -- boom -- COVID-19 hits and people start staying at home.  Daily users skyrocketed to 200 million in March and as many as 300 million in April (well, not quite).  Daily downloads went from 56,000 in January 2020 to over 2 million in April.  Zoom is now used by businesses and families alike, drawn by it simplicity and ease of use. 

By all rights, we should be using WebEx for business video calls and Skype for personal ones.  Both had been around longer, offered credible services, and still exist.  But both were acquired along the way, WebEx by Cisco, and Skype ultimately by Microsoft.  As with its acquisition of Nokia, once acquired Microsoft didn't quite seem to know what to do with it.  Each left openings that Zoom plunged through when the pandemic hit.

Zoom's success has not gone unnoticed.  Google introduced Hangouts in 2013, Duo in 2016, Meet in 2017, with Hangouts and Meet aimed primarily at businesses using its G Suite.  Late last month Google announced it was making Meet available for free to anyone with an email account.  Google claims Meet now has 100 million daily users, up 30 times since January. 

Meanwhile, Microsoft had been pushing its business collaboration service Teams, and in COVID-19 times is now trying to broaden its reach to consumers, extending Teams to its consumer Office 365 subscription service.  While Microsoft insists Skype is booming, with over 40 million daily users, it looks like Teams is the future.  A spokesperson told VentureBeat:
For now, Skype will remain a great option for customers who love it and want to connect with basic chat and video calling capabilities.  With the new features in the Microsoft Teams mobile app, we see Teams as an all in one hub for your work and life that integrates chat, video calling, [and the] ability to assign and share tasks, store and share important data with your group, [and] share your location with family and friends, whereas Skype is predominantly a chat and a video calling app platform.  
Then there is Facebook.  Last month it launched Messenger Rooms, which allows for up to 50 people at a time on a video conference call.  It is a direct response not only to Zoom but also to life in a COVID-19 world.  CEO Mark Zuckerberg said: "Video presence isn’t just about calling someone.  It is starting to be a fundamental building block of a private social platform with lots of new use cases."  The service is free and does not include time limits.  

Credit: TechCrunch
Zoom gave competitors some openings.  Its security measures left something to be desired (although Zoom claims to have now addressed), allowing "Zoombombing" to become a thing.  Google, Microsoft, and Facebook have all stressed the security features of their video platforms; e.g., Microsoft's new Teams ad emphasizes its security.

Healthcare hadn't ignored video conferencing.  Let me rephrase that: video conferencing hadn't ignored healthcare, with companies like TelaDoc, AmWellDoctors on Demand, and MDLIVE doing their best to make telehealth a standard part of healthcare.  With certain exceptions like Kaiser Permanente, though, telehealth seemed like healthcare's stepchild, beset by reimbursement issues, licensing restrictions, and simple inertia.   

As recently as last year, it was estimated that only 1 in 5 physicians used telehealth, and even that reflected dramatic growth.    Only one-third of hospitals had a telehealth option.  But the coronavirus pandemic changed all that.  Any kind of "elective" visits or procedures were limited; The Commonwealth Fund found that in-person ambulatory visits dropped 70% from mid-February to mid-April.  

HHS has actively promoted telehealth, along with many private health insurance companies.  Not having potentially sick people come into offices, exposing both other patients and healthcare workers, seems like a very prudent thing during a pandemic, and as both clinicians and patients get used to telehealth visits, many believe they will persist after the pandemic.

Zoom saw the potential in healthcare long before COVID-19, introducing Zoom for Telehealth (now Zoom for Healthcare) in 2017.  It offers "HIPAA/PIPEDA enabled plans" for healthcare organizations, and claims customers such as Phoenix Children's Hospital and Magellan Health, although one suspects that not all patients who are using Zoom to communicate with their physician are doing so with a Zoom for Healthcare platform. 

Similarly, Google specifically mentions "hospitals supporting patients via telehealth" as one of the uses for Meet, and Microsoft boasts that "Microsoft Teams can help healthcare providers conduct virtual visits," enabling "simple, secure collaboration and communication with chat, video, voice, and healthcare tools in a single hub."  That new Teams ad includes a healthcare customer as one of its four featured Team clients:

Not to be left out, Epic is reminding customers that its EHR can also be used to provide video visits with patients, a service it had previously rolled out with several telehealth vendors, including AmWell.  Epic is now working with Twilio to build its own telehealth solution. 

Stay-at-home restrictions are already starting to be lifted (even if it is not clear we're ready), allowing more of us to get out more often, even for healthcare services.  We'll be able to see our friends and family again, go back to work (although whether we'll give up remote work remains to be seen), and start using the healthcare system in-person again.  It's possible that Zoom has reached its zenith already, and the competition between it, Facebook, Google, Microsoft is a zero-sum game on a declining customer base,

But I don't think so.  We've now seen more of the world that broadband promised us over a decade ago, and we like it.  With healthcare, though, all too often it is about the money, not our convenience or preferences.  I just hope that healthcare learns its COVID-19 Zoom lesson. 

Monday, April 27, 2020

After the Flood

I keep thinking about the COVID-19 pandemic as a flood. 

You know the water is rising, you usually know how high it will get and even when, but there's just not much you can do about it.  You can put in levees or floodwalls, maybe throw up some sandbags, but for big floods the water is going to have its way.  It creeps up and subsumes everything in its path.  Inevitably, the waters do recede, but leave their mark.  Some things survive, some are badly damaged, some are simply swept away. 

Looking at the coronavirus statistics every day is like watching the water rise, and I wonder what our healthcare system will look like once the pandemic flood subsides.

Before the current pandemic the U.S. already had plenty to be unhappy with about its healthcare system.  It cost too much, it delivered care unevenly, its focus seemed too oriented to profit instead of to quality, and, most importantly, it didn't actually seem to be keeping us healthy.  No one seemed happy about it -- not patients, not clinicians, not even the army of administrators who have infiltrated it.  But, we assured ourselves, at least it would be there for me/us if I/we had a health crisis.

That seems like wishful thinking now.  As Dr. Siddhartha Mukherjee wrote in What the Coronavirus Crisis Reveals About America Medicine, in the wake of this pandemic "the medical infrastructure of one of the world’s wealthiest nations fell apart, like a slapdash house built by one of the three little pigs."  

Credit: CNN
We can't get enough essential personal protective equipment (PPE).  We can't accurately test sufficient numbers of people.  We're overwhelming the healthcare system in hot spots.  Our health care heroes -- doctors, nurses, first responders, and the myriad of workers who support them -- are working long hours, putting themselves at greater risk, and struggling to figure out how to best help patients.

The pandemic is wrecking havoc on our healthcare system.  Costs for PPE are skyrocketing.  We're having to reconfiguring health care facilities to reduce risks of exposure. The weaknesses of our supply chains have been exposed.  Many parts of our healthcare system are working past peak capacity, while others have been idled. Deferral of most "elective procedures" have made very clear how much our health system is dependent on them; even in a pandemic, many hospitals are being forced to cut staff as a result.

Already vulnerable hospitals have become even more vulnerable.    Nursing homes are struggling to absorb new costs to deal with COVID-19, and we're realizing that their very nature makes them petri dishes for such a pandemic.  Many primary care physician practices are flounderingless than half think they can stay open for another month.  Private equity firms that had bought up hospitals and specialty practices are rethinking their investments. 

People like to point to telehealth as one innovation that the pandemic has spurred.  Patients and physicians who had previously never tried it are now becoming fans.  Regulatory barriers and reimbursement limitations are being addressed.  Almost half of physicians now report using telehealth, drive largely due to COVID-19 concerns. 

Still, though, whether telehealth advances persist after the pandemic subsides remain to be seen.  We're still struggling with reimbursement, the inter-state licensing issues have not gone away, and the relief from HIPAA requirements is not permanent. 

People rebuild in flood plains even after being hit by a flood; we may be stupid enough to try to go back to the healthcare system we used to know once we lose our alarm about COVID-19.  That would be stupid.  As Dr. Mukherjee put it: "Medicine needs to do more than recover; it needs to get better."

Here are a few thoughts about how:

Telehealth:  It's the 21st century; time to bake telehealth fully and firmly into our healthcare ecosystem.  Just as retail and offices are unlikely to return to pre-pandemic norms, relying more on virtual options, healthcare must as well.  

Supply chain: We're still going to import some healthcare supplies from abroad.  But we do need to spread our dependencies over more options, including more domestic options, and ensure that they have the ability to scale up when needed.  

Nursing homes: Nursing homes/assisted living facilities weren't a great option for residents' health even before the pandemic, and the pandemic has exposed what a terrible option they are during such outbreaks.  We need 21st solutions for supporting people in staying safely at home.  

Unnecessary procedures: We've known for decades that too many of our health care services are unnecessary and sometimes inappropriate.  We've taken a meat-axe to them during the pandemic, chopping needed services as well as unnecessary ones.  The post-pandemic period should be the time to finally take a hard look at what we really should be doing to/for patients.

Infrastructure: We have too many buildings for what should be an increasingly virtual system.  The buildings we do have need to be more nimble, as the scramble for ICU beds has shown.  Our systems need to produce data that is more shareable, searchable, and real-time.  And we have too many layers of bureaucracy that add to costs but not to outcomes.   

Public Health: It is usually only visible during public health crises, but public health needs to be seen as an ongoing investment not just in managing such crises, not just in avoiding them, but also in improving our health.  It should be the base of our healthcare system, not an adjunct to it.
Credit: MGMA
Right now, we're still watching the water, hoping it is no longer rising and waiting for it to recede.  Right now we know there is damage to our healthcare system, but not how bad it will be.  Right now, we're more focused on establishing the "new normal" for our daily lives, but not what the new normal for our healthcare system should be.  

As hard as it is to think past the pandemic, we must.  Returning to something that resembles "normal" is way too low a bar when it comes to health care.  Pandemics like this only come along perhaps once in a century, so we have a unique opportunity to, as Dr. Mukherjee says, make our healthcare system better.  We mustn't miss it.  

Monday, April 20, 2020

Hiding Our Heads in the Sand

There are so many stories about the coronavirus pandemic -- some inspiring, some tragic, and all-too-many frustrating.  In the world's supposedly most advanced economy, we've struggled to produce enough ventilators, tests, even swabs, for heaven's sake.

I can't stop thinking about infrastructure, especially unemployment systems.

We'd never purposely shut down our economy; no nation had.  Each state is trying to figure out the best course between limiting exposure to COVID-19 and keeping food on people's tables.  Those workers deemed "essential" still show up for work, others may be able to work from home, but many have suddenly become unemployed.

The U.S. is seeing unemployment levels not seen since the Great Depression, and occuring in a matter of a couple months, not several years.  As of this writing, there are over 22 million unemployed; no one believes that is a complete count (not everyone qualifies for unemployment), and few believe that will be the peak.

Many unemployment systems could not manage the flood of applications.

It's not surprising.  Any system might struggle to handle such sudden increases in volume.  Some seemed purposefully intended to fail (that'd be you, Florida!).  Not having robust enough systems might have seemed a viable political strategy when unemployment was low, but less so with such widespread unemployment.

The word that has been repeatedly used to describe unemployment systems is "antiquated."  Many are still mainframe systems based on COBOL, dating as far back as the 1960's.  COBOL was a very popular language in its day and is still in widespread use, but it is not the language of choice in modern systems.  It's hard to even find COBOL programmers anymore.

New Jersey Governor Phil Murphy lamented: “We have systems that are 40 years-plus old, and there’ll be lots of postmortems.  And one of them on our list will be how did we get here where we literally needed COBOL programmers?"  Cybersecurity expert Joseph Steinberg told CNN: "Governors should not have to think about computer systems during a pandemic, and we should have systems that if there are emergency situations, should not make the emergencies worse."

Amen to that.

And, let's be fair: it's not just state unemployment systems dependent on COBOL; many key federal systems are as well, including some used by the IRS, HHS, Treasury, and DoD, not to mention many banking systems.  The systems needed to produce those promised stimulus payments and small business loans are not easily adapted.  Former IRS Commissioner John Koskinen told The Washington Post: "The IRS systems are still hard-coded.  It’s not just a keystroke to go into the code and make the change and hope you’ve made it correctly."

There had been precious little money spent on upgrading the systems to more modern architectures, or even to retaining the programmers who could keep them running.  When making budget decisions, it often seems like there will always be time to modernize...until there isn't.  Like in a pandemic.

Michele Evermore of the National Employment Law Project told Vox: "It’s really not a sexy item to fund UI [unemployment insurance] administration.  The only times any improvements have ever happened with UI has been because a recession exposed holes in the coverage."  We've found the holes now, and they are big ones.

But we should not be surprised.  We're a nation that likes to push its problems into the future.  All that emergency COVID-19 spending?  Trillions of dollars of deficit spending, on top of existing annual trillion dollar deficits, deficits that some future generations will have to deal with.

We're a nation that tends to underfund public pensions, at the local, state, and federal levels.  We're a nation whose infrastructure -- e.g., roads, bridges, railroads, dams, water and sewer systems-- is rated D+ by the American Society of Civil Engineers.   And, as the COVID-19 pandemic is making so very evident, we're a nation that has been extremely shortsighted in funding public health.

A new report from the Trust for America's Health minces no words.  President and CEO John Auerbach charges:
COVID-19 has shined a harsh spotlight on the country’s lack of preparedness for dealing with threats to Americans’ well-being.  Years of cutting funding for public health and emergency preparedness programs has left the nation with a smaller-than-necessary public health workforce, limited testing capacity, an insufficient national stockpile, and archaic disease tracking systems – in summary, twentieth-century tools for dealing with twenty-first-century challenges.
Public health contact tracing.  Credit: The Daily Iowan
Similarly, Julie Bosman and Richard Faussett warned in March: "A widespread failure in the United States to invest in public health has left local and state health departments struggling to respond to the coronavirus outbreak and ill-prepared to face the swelling crisis ahead."  The Association of Schools and Programs in Public Health claims we have a shortage of 250,000 public health workers -- you know, the kind of people we need now to do hot spot analysis and contact tracing.

Tom Frieden, formerly of the CDC, warns: "We need an army of contact tracers in every community of the US to be ready to find every contact and warn them to care for themselves and stop spreading it to others."  Unfortunately, as Brian Castrucci of the de Beaumont Foundation told Time: "We waited until the house was on fire before we started interviewing firefighters."  

Oh, now we're seeing why we need to invest in public health.  Now we see why we need to invest in better UI systems.  Now we see why things like the federal emergency stockpile and the Defense Production Act are important.  It's not like we didn't know that pandemics could happen and how devastating they could be; we just chose to not be prepared.

We've been hiding our heads in the sand.

We'll get through this pandemic.  Not all of us, and not without too many of the rest us suffering in many ways.  We're told that we're probably not going back to "normal," at least not anytime soon, that we'll have to adjust to a "new normal."  I just hope that the new normal includes a more clear-eyed perspective on being prepared for when pandemics and other catastrophes do strike. 

We may never be fully prepared for when emergencies do hit, but we certainly can do better than we've done so far with this one.

Monday, April 13, 2020

Wait -- Robots Work But I Get Paid?

We're not through the COVID-19 pandemic.  We're probably not even near the end of the beginning yet.  That hasn't stopped many pundits to start speculating about how our society (and our healthcare system) are likely to be permanently changed as a result, such as continued reliance on telecommuting and telemedicine. 

OK, I'll play too: I believe we need to greatly expand the role of robots, and begin something that resembles Universal Basic Income (UBI).  They're not the only changes that may result, but they are two that should.

We've been seeing robots infiltrating the workforce for many decades, such as in manufacturing but also in many other industries.

Still, though, as our economy pares down to "essential businesses" during the pandemic, I've been alarmed at how many of the jobs remain done by humans.  Not just healthcare workers on the front lines but also all those people doing the cleaning for essential businesses, all those people in the supply chain of food and other vital materials, all those people making deliveries, all those first responders, all those people all those people keeping the power on, the water running, and the internet streaming, among others.  And so on.

We're already seeing reports of positive tests for COVID-19 in grocery workersAmazon employees,  meatpacking workers, not to mention first responders and healthcare workers.  The trucking industry fears the impact.  Garbage collection was already a not very desirable job and carries the risk of COVID-19 infection as well.  At some point, we run the risk that we won't have enough essential workers.

Thus, robots.

An article last month in Science Robotics noted: "As epidemics escalate, the potential roles of robotics are becoming increasingly clear."  The authors cited four key areas where robots could make a key difference in a pandemic:

  • clinical care (e.g., telemedicine and decontamination), 
  • logistics (e.g., delivery and handling of contaminated waste),  
  • reconnaissance (e.g., monitoring compliance with voluntary quarantines), 
  • continuity of work and maintenance of socioeconomic functions  
Disinfecting robot.  Credit:UVD Robots
Indeed -- but I believe that even those areas do not go nearly far enough.  Professor Richard Pak, an automation expert, told The New York Times: "Pre-pandemic, people might have thought we were automating too much.  This event is going to push people to think what more should be automated."  AMP Robotics CEO Matanya Horowitz pointed out the obvious advantage of robots: "They can't get the virus."

If some jobs are truly "essential," the current pandemic highlights the risk that there may not be enough people to do them, at least not safely.  We should be making every effort to identify if/how more of them could be done by robots.  It'd be a big investment to make, but that investment would pale next to the costs of the current shutdown to our economy.

Universal Basic Income
This idea has been floating around for several years, largely by tech futurists worried about what happens when robots do, in fact, take a significant number of our jobs.   It was the centerpiece of Andrew Yang's presidential campaign, and brought him more ridicule than respect. 

Illustration by Anna Parini for The New Yorker
Now this idea seems prescient, as job losses soar past the levels of the last Recession and could exceed the joblessness of the Great Depression.  No one knows how long the economy will persist in shutdown mode, nor even exactly how we'll emerge from it.  Many experts caution we may never go back to "normal," especially not until there is a proven vaccine.

State employment programs vary widely in terms of which workers are covered, how much benefits are, or for how long.  Those programs have been overwhelmed, both by the huge, sudden increase in volume and by the antiquated systems they use (let's put it this way: these are the salad days if you happen to know COBOL). 

Congress belatedly responded to the employment crisis by throwing money at the problem in three separate bills, each costing more than ten times the prior bill.   The bills tried to expand paid sick leave, give loans to businesses that do not lay off their workers, beef up state unemployment benefits, and make direct payments to most Americans (a very limited UBI program!), as well as, of course, providing subsidies to big businesses.

Despite all that, few believe the trillions of dollars are nearly enough, especially if the shutdown continues into or even past this summer.  For example, the small business loan program, designed to help small businesses keep their workers, has been beset with problems -- neither banks nor small businesses knew what to do -- yet is reportedly already running out of money. 

Other countries address unemployment by directly subsidizing the majority of workers' paychecks, thus limiting unemployment and making restarting the economy quicker.  It is an idea that has been argued even by some conservative Republicans here.  It is much simpler, and more direct, than the various programs Congress has enacted.

When people can't work, or we don't want them to work, we should have a uniform national income support system already in place, one that allows people to pay their bills, without them having to jump through a variety of hoops that will end up stymieing too many of them. 

Ours is a federal system, which specifically reserves rights to the states, but in times of a national or even regional emergency like a pandemic, it's crazy that we have to wait until the crises hits, then rely on the federal government to belatedly respond with (borrowed) largesse squeezed through a crazy-quilt of programs. 

Some believe the COVID-19 crisis could be the crisis that helps bring about MedicareForAll, but I think the economic crisis it is causing may prove to be an even more powerful impetus to create a federal income entitlement program.  We just have to decide if it this should be an true, always-on UBI program (remember those robots!), or one aimed solely at reducing lost employment income. 
A year ago -- heck, six months ago -- each of these were issues that we knew might someday be important, but we thought we had time to think about.  We are out of time.  It is time for action.