One recent Friday night, we huddled with our colleagues in the pouring rain at a movie theater parking lot– our cars packed with supplies for our mobile vaccine clinic— trying to find someone who wanted an extra dose of Pfizer’s COVID-19 vaccine before it expired. Five months ago, we would have been inundated with people desperate for that extra dose. But that has changed now that the most willing and able segments of the population have largely been vaccinated.
Amidst this backdrop of slowing vaccination rates in the U.S. and many miles to go before reaching all of those willing to be vaccinated, the CDC has released updated recommendations for mask wearing that we believe to be premature and contrary to the ethic and mindset of public health. Buoyed by mounting evidence supporting the effectiveness of vaccines, the CDC— cheered by the Biden administration— gave fully vaccinated Americans the green light to ditch their masks. As fully vaccinated public health nurses who are as excited as anyone about the vaccines’ real-world effectiveness, we nonetheless find ourselves again asking: what are they thinking?
To be clear, we do not question the evidence showing that all COVID-19 vaccines currently approved in the U.S. are safe and effective. We also crave good news, hope, and allowing the bottom half of our faces to see the light of day. We have also appreciated the Biden administration’s commitment to “following the [biomedical] science” in pandemic policymaking. Our concerns lie with the timing of the recommendation; the lack of regard for social science demonstrating the importance of public policy in influencing community norms and human behavior; and the blatant disregard for health equity. That the nation’s preeminent public health institution has fallen prey to the individualistic mindset that typifies American society, as CDC director Dr. Rochelle Walensky stated herself on Sunday regarding this “science-driven individual assessment” of risk, is frustrating, to say the least.
Currently, only one-third of the U.S. has been fully vaccinated. The news media has been full of accounts of many sub-groups who stubbornly defend their right to refuse a COVID vaccine, but the majority of those in the U.S. who remain unvaccinated belong to communities that have been unable to access a vaccine due to difficulty navigating online appointment scheduling, inability to take time off of work, poorly translated informational resources, or being ineligible due to age restrictions or other medical contraindications. Universal mask-wearing has been a critical stopgap measure to protect these at-risk populations until the majority of Americans are vaccinated. The CDC’s recommendation is therefore not only premature: it sends the message to individuals and other governmental entities alike that we don’t need to care about our neighbors.
John Maynard Keynes, the famous British economist, was born and raised in Cambridge, England, and taught at King’s College. He died in 1946. He is widely recognized today as the father of Keynesian economics that promoted a predominantly private sector driven, market economy, with an activist government sector hanging in the wings ready to assume center stage during emergencies.
Declines in demand pointed to recession. Irrationally exuberant spending signaled inflationary increases in pricing, eroding the value of your money. Under these conditions, Keynes encouraged the government and central bank to adjust fiscal and monetary policy to dampen the highs and lows of the business cycles.
Keynesian economics were popularized in America in the 1930’s by a University of Minnesota economist who would go on to become Chairman of Economics at Harvard. For this, he is often referred to as “The American Keynes”, and was highlighted this week in the New York Times by Nobel economist, Paul Krugman, for his association with another tagline, “Secular Stagnation.”
When that economist, Alvin Hansen, first described the condition, he was working on FDR’s Social Security Plan. He defined it as “persistent spending weakness even in the face of very low inflation.” Krugman’s modern-day description? “What we’re looking at here is a world awash in savings with nowhere to go.”
Krugman is not the only economist sounding the alarm. Larry Summers, Harvard economist and Treasury Secretary under Bill Clinton, recently wrote, “The relevance of economic theories depends on context.” On the top of his list of current environmental concerns restricting investment and growth is the strong belief that the number of available workers is in steep decline.
Just days ago the CDC added fuel to the fire when they reported a 2020 birth rate in the U.S. of 55.8 births per 1,000 women ages 15 to 44. That was 4% lower than in 2019, and the lowest recorded rate since we started collecting these numbers in 1909. Our lower birthrate is further aggravated by declines in numbers of immigrants and a flattening of the movement of women into the workforce. Add to this the general aging of our population. To put it in perspective, Americans over 80 now outnumber Americans 2 and under.
Those of us of a certain age remember the Timex slogan that bragged about its watches’ durability: “It takes a licking and keeps on ticking.” A recent article about our military, of all things, made me wish we had a healthcare system that prized that kind of durability.
I can never resist analogies between the U.S. healthcare system and the U.S. military system. They’re both huge, they’re both wildly expensive, they both rely on a combination of high tech and front-line people, and they both protect us from threats. In some ways, both are the best in the world, and, in other ways, both have weaknesses that are embarrassing. And, as I wrote last year, both are often still fighting the wrong wars.
Ms. Herz notes how Americans love innovation, but:
This mythos informs a narrative that what is valuable is The New—the upgrade to something bigger, badder, and sexier…What the United States needs to reinvigorate its defense base, compete with China, and win the global economy must be more innovation.
Except the United States does not suffer from a lack of innovation; it suffers from a lack of resilience.
But these systems can be tuned to reflect and address key concerns.
What follows is a list of ten separable concerns, and responsive design strategies. The concept of separation of concerns in technology design offers a path to better health policy. Because each concern hardly interacts with the others, any of them can be left out of the design in order to prioritize more important outcomes. Together, all of them can maximize scientific benefit while enhancing social trust.
An inspector should be assured that a vaccine certificate was not tampered with and that it was issued to the presenter. This need not imply any privacy risk, or even need a network connection. One such method for authenticating vaccine credentials adds a human-recognizable and machine-readable face photo to a standard 2D barcode. It works with paper as well as mobile phone presentations.
The digital divide
For this concern, paper credentials have equity and privacy advantages. Equity, because paper is cheap and well understood. Privacy, because there is no expectation that a person must unlock and show a mobile phone. Digitally signed certificates that also include a photo, like #1 above, can be copied for convenience without risk of fraud.
Mothers deserve more than a day of recognition this year—they deserve the whole month, and more. The pandemic has been particularly hard on women, especially poor women and women of color.
To demonstrate the appreciation mothers deserve this Mother’s Day, we should get them something they really need: health care. To improve maternal health, we should look to the Medicaid program, long a pathway to accessible, quality health care for low-income Americans. Medicaid is especially important for mothers; it covers close to half of all births in the U.S.
Now, states have the opportunity to do even more for moms.
The American Rescue Plan signed into law in March gives every state the option to extend Medicaid maternity coverage for up to 12 months postpartum, a significant increase from the current limit of just 60 days. Illinois has already announced it will extend postpartum coverage; other states should follow. Extending the guaranteed coverage period will increase access to postnatal care during this ‘fourth trimester’ to ensure that women can access treatment for common conditions like postpartum depression as well as preventing organ prolapse or hemorrhage. Not only mothers will benefit. Parental insurance is associated with better health for children, including a lower risk of adverse childhood experiences.
In addition, the American Rescue Plan offers an opening to expand Medicaid with even more federal funding than is currently available through the Affordable Care Act. The 12 states, mostly in the South, that have not expanded their Medicaid programs are leaving hundreds of thousands of women without the support they deserve.
Expanding Medicaid programs will provide robust access to health care to more women and reduce maternal morbidity and mortality, which has reached crisis proportions among many women of color. Black and Indigenous women are more likely than other women to die during pregnancy, childbirth, and the postpartum period. According to the CDC, the maternal mortality rate is 2.5 times higher for Black women than white women. Disparate access and uneven quality of care, higher rates of chronic illness, and racism all play a part in that grim statistic.
The disproportionate burden of maternal mortality and adverse outcomes from childbirth has long-lasting effects on mothers and their children. Black newborns have an increased risk for long-term complications resulting from pre-birth complications. They may also face generational poverty and trauma in the long run if they are born to a mother who dies during childbirth.
In the second half of the 19th century, Emily Dickinson wrote a short poem that could easily have been a forward looking tribute to two American Presidents – one from the 20th, the other the 21st century.
Dickinson’s poem “A WORD is dead” is hardly longer than its title.
“A WORD is dead
When it is said,
I say it just
Begins to live
She certainly was on the mark when it came to President Franklin Delano Roosevelt’s signature legislation. FDR’s New Deal, extending from 1933 to 1939, ultimately came down to just three words – the 3R’s – Relief , Recovery, and Reform.
He promised “Action, and action now!” This included a series of programs, infrastructure projects, financial reforms, a national health care program and industry regulations, protecting those he saw as particularly vulnerable including farmers, unemployed, children and the elderly. And he wasn’t afraid to make enemies. Of Big Business, he said in a 1936 speech in Madison Square Garden, “They are unanimous in their hate for me – and I welcome their hatred.”
But he was also a political realist. And by his second term of office Justice Hughes and his Conservative dominated Supreme Court had begun to undermine his legislative successes and were threatening his signature bill- the Social Security Act. So FDR compromised, and in the face of withering criticism from the AMA, postponed his plans for national health care.
Unlike medical meetings, rendering Beethoven’s Ninth Symphony isn’t easy on Zoom, so the local orchestra has been furloughed and their members work for Uber. The opera house wants to reopen, preferably before we reach the elusive herd immunity threshold. They mandate vaccinations for their artists, not least because the performers can keep their masks off. Should they extend this requirement to their patrons?
Vaccine passports, proof of immunity against SARS-CoV-2, to work, dine, fly or watch shows, are controversial. Opponents say they blithely disregard decency, are operationally onerous, and hurt liberty. Worryingly, they create a caste system, which wouldn’t be as concerning if based on just immunology. Such a two-tiered system could sadly mirror societal inequities because it’s the poor who may disproportionately be left unvaccinated. Supporters of vaccine passports further the very structural disadvantages they seek to end.
When arguments are too compelling they likely betray an obvious simplicity. Too often arguments against mandates assume they’d be a government fiat. The opponents recline on the country’s inherently liberal streak conjuring visions of rugged individuals fighting unelected bureaucrats. They say with undisguised pride “this isn’t who we are. We’re the US, not New Zealand. We can’t be controlled.”
This narrative is so tightly embedded in right-of-center discourse that it’s now folklore bordering on an Ayn Rand fairy tale. The narrative is nonsense. The state is too incompetent to either govern adeptly or tyrannize efficiently. Case-in-point: CDC’s easily forgeable paper vaccine certificate. If the state were serious about prying on people’s antibodies, it’d have made the immunosurveillance digital.
The obsession with big government should be antiquated. By censoring content, Facebook and Twitter showed that freedom can more efficiently be curtailed by the private sector. Bottom-up censorship is arguably more powerful than top-down censorship because it has buy-in from a segment of the market. It may very well be the private sector which demands vaccine passports, which begs two questions – why and why not?
Since I first heard about them, I have been fascinated, and dismayed, by the concept of “million dollar blocks.” For those of you unfamiliar with the term, it doesn’t refer to, say, Beverly Hills, Chicago’s Gold Coast, or Manhattan’s Hudson Yards — areas where the wealthy congregate. No, it refers to city blocks for which society spends over a million dollars annually to incarcerate residents of that block.
I, of course, have to think about the healthcare parallels.
The concept dates back many years, credited to Eric Cadora, now at Justice Mapping, and Laura Kurgan, a professor of architecture at Columbia University, where she is the Director of the Center for Spatial Research (CSR). The power of the concept is to use data visualization to illustrate the problem.
Here, for example, is CSR’s map of Brooklyn for prison spending:
CSR describes the findings as follows:
The maps suggest that the criminal justice system has become the predominant government institution in these communities and that public investment in this system has resulted in significant costs to other elements of our civic infrastructure — education, housing, health, and family. Prisons and jails form the distant exostructure of many American cities today.
Virtual-first primary care company Firefly Health is becoming a health plan! Backed by a $40M Series B, CEO Fay Rotenberg and Executive Chairman Jonathan Bush stop by to explain how they’re providing “half-price healthcare that’s twice as good.” (Or, as only Jonathan can put it: “we’re a bloat-less Kaiser.”) All kidding aside, some big-name health innovation investors are not only behind this raise (Andreessen Horowitz led, F-Prime Capital and Oak HC/FT dipped back in), but also this idea to wrap a benefit around Firefly’s digitally-driven comprehensive care model. Already in-market, the new benefit-plus-care product is aimed squarely at mid-sized/small, fully-insured employers – shops with 50-500 employees which, right now, have limited options for dramatically changing their healthcare spend or being able to build out their own benefits the same way large self-insured employers can.
Fay and Jonathan get into the details about how they’re extending their “Marie Kondo-ing” of healthcare delivery – which has thus far netted some pretty impressive health outcomes, cost savings, and a 92 Net Promoter Score – into healthcare financing.
BONUS: Tune in around 25:30 and stick around for a few minutes as Jonathan weighs in on the health tech funding boom, how it compares to the EMR arms race days of ole, and whether or not he thinks he can beat Glen Tullman’s $14.5B valuation if/when Firefly goes public. HA!
In the fog of the Covid pandemic, many are wondering what ever happened to prior vocal support for universal coverage and Medicare-for-All. Expect those issues to regain prominence in the coming months. A bit of recent history helps explain why.
The January 6th insurrection, followed by the past weeks two mass shootings, have served to remind our citizens that we must address a range of issues while continuing to confront the pandemic threat.
Modern civilized societies rely on a double-armed approach to maintain order, peace and security. The first arm is laws. But laws are of little value without even and unbiased enforcement.
The second guardrail of civility is culture. MIT professor Edgar Schein described it this way: “Culture has three layers: the artifacts of a culture — our symbols and signs; its espoused values — the things we say we believe; and, most important, its underlying assumptions — the way things really are.”
In the Senate chamber this week, and in Republican controlled state houses across the nation, Americans witnessed a colossal collision of reality and ideals in the form of new Jim Crow laws to suppress minority voting rights, and refusal to address gun violence. In the wake of a constant stream of racial animus and mass shootings, this lethal epidemic demands a response as well.
Were these the only flashing alerts signaling danger ahead, that would be enough to cause sleepless nights. But unenforced or unevenly enforced laws, and value dissonance in America, do not occur in isolation, but are supported by an even more erosive underpinning – greed-induced economic inequality.