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.

COVID-19 DEATHS PER 100,000 PEOPLE OF EACH GROUP, REPORTED THROUGH MAY 19, 2020.  Source: APM Research Lab

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 hardest.  This 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.  

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.  

Shutterstock/KornT

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.

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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?

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.

Credit: NASH JONES / KUNM

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. 

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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?  

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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.

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, AmWell, Doctors 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.