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 floundering; less 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.

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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.  

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.

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.

Robots
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 workers, Amazon 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.

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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. 

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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.    

There Will Be Consequences

Crises -- like our current COVID-19 pandemic -- force people to come up with new solutions.  They slash red tape, they improvise, they innovate, they collaborate, they cut corners.  Some of these will prove inspired, others will only be temporary, and a few will turn out to be misguided.  We may not know which is which except in hindsight.

I covered some of these in a previous article, but let me highlight a few:

• Hospitals: we're building new hospitals, such as in convention centers, to address the expected shortage of beds.  Hospitals are also coordinating where to send which types of patients.
• Testing: we're creating drive-through testing centers in parking lots and elsewhere.
• Telehealth: we've loosened the restrictions on telehealth, improving reimbursement and rules about when it can be used.
• Coverage: we're trying to ensure that deductibles/copayments do not pose barriers to people getting tests and treatment, even for those without insurance.
• Clinicians: we're looking for clinicians everywhere we can -- allowing licensed ones from other states to practice, letting people who were health care professionals in other countries practice here, calling retired ones back into service even if their license had expired, even letting almost-graduated medical professionals start practicing.  
• FDA approvals: The FDA is using its "emergency use guidance" authorization to start allowing use of drugs and other treatments much quicker, and with much less evidence, such as for hydroxychloroquine, diagnostic testing, and ventilators. 

This is certainly not a complete list, and people are still developing new ones.  Kudos to all the people working long hours to try to do what is necessary, even if it means doing things that are unconventional.  We are not in conventional times.    

That being said, we should not ignore the fact that these solutions will have consequences, and some of those may not be good ones.  I'll quickly discuss a few of the things that could result in problems:

Networks

When I read about these new hospitals, I immediately think, hmm, I wonder whose networks they're in, and what the payment rates for them will be.  Same for hospitals cooperating about which hospitals do which patients, or for the new drive-through testing centers.

So is this field hospital in-network? Photo: AFP/Bryan R. Smith

I.e., I may want to go to an in-network hospital, but get sent to some other hospital, possibly one of the new, a jury-rigged ones.  Am I going to get billed out-of-network charges? 

Similarly, it's great that so many healthcare professionals are flowing to where the needs are, but I suspect that most of the "new" ones are not credentialed/considered in-network for most health plans,  What will they charge, and will those charges be considered out-of-network?

I think networks should be a thing of the past, but we can't ignore that they do still exist.

Licensure

Some of the health care professionals who are being recruited to start practicing in order to help out aren't licensed in that state.  Aside from the network problem discussed above, that means that patients may end up getting some portion of their care from clinicians who have not demonstrated to their state's licensing bodies that they are qualified to do so.  

Many will prove to be eminently qualified, but a few may not, especially as the surge of COVID-19 patients overwhelm parts of the health care system.  Mistakes will be made, some care will be substandard, and when this is all over some injured parties may seek remedies via medical malpractice or other lawsuits.  Those without current "proper" licensure would be an obvious target.

I personally do not think our current system of licensing for health care professionals is particularly effective, nor appropriate for today's connected world, but I am not enough of a libertarian to believe that there shouldn't be any kind of licensing.  

Coverage

It is understandable that during a pandemic we can't afford to let cost be a barrier to necessary testing, and it's only compassionate that we don't want treatment to be unaffordable for COVID-19 patients, but it creates inequities for patients with other conditions.

The health plans that are waiving deductibles and copayments for COVID-19s are essentially unilaterally revising their contracts during the contract year.  There are other patients with critical needs who may not think COVID-19 patients should get such preferential treatment, and it's hard to say they're wrong, especially since coronavirus coverage may increase everyone's premiums.

Moreover, since we have not had anything like universal testing, there are COVID-19 patients who have never actually tested positive for it.  When it comes to covering COVID-19 preferentially, how do we distinguish those patients from others who might have had similar symptoms and treatments?  We're not even counting deaths accurately.

Safety

Maybe hydroxychloroquine will be the solution some believe it will be.  Maybe GM, Ford, and others can make ventilators just as well as their usual manufacturers.  Maybe the new coronavirus tests will each prove equally accurate.  But, chances are, some of the shortcuts the FDA is allowing will result in some harm.  

The FDA has sometimes been criticized for taking longer to approve new drugs, treatments and devices than other countries, but, in this crisis, it is understandably taking actions at what is, for it, a breakneck pace.  But we should not be naive; the normal FDA review processes are in place for reasons.  Even if there are not always perfect, they serve as guardrails for patient safety -- and we're now removing some of those guardrails.  

There will be some patients who suffer, perhaps even die, as a result of some of these shortcuts.  Who will we blame?  

Privacy

Telehealth companies have spend many years trying to make their platforms HIPAA-compliant and, ideally, integrated with other health platforms.  Now, though, we're using FaceTime, Skype, Zoom, and other video platforms to do telehealth, even though some of these (I'm taking to you, Zoom!) have prioritized ease-of-use over privacy, much less adherence to HIPAA.   

This is a time for telehealth, but when this is all over we may wonder whether the cost to our privacy was worth it.

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There is nothing about the current pandemic that allows us to be business-as-usual.  It's natural in a crisis to focus on the short-term problems, especially when there are so many and they are so big.  Each of the solutions being developed is being done with good intentions to address immediate problems.  But it's not too early to be thinking about what the longer-term implications of these solutions might be.  

Crises demand action, but actions have consequences.