Editor's Note -
I'm including the following essay by Ed Yong of the Atlantic in today's posting because it describes how the Coronovirus pandemic in America has laid bare (revealed) the deficiencies of our healthcare system. I use the terms "laid bare", "revealed" or "exposed" rather than "created" because they've been there all the time. All that the pandemic has done is to expose those deficiancies in ways that most of the public cannot ignore! Our job as advocates is to figure out how to most effectively turn that revelation into political and legislative action. The piece is long, but very much worth the time.
- SPC
How the Pandemic Defeated America -
by Ed Yong - The Atlantic - September, 2020
How did it come to this? A virus a thousand times smaller than a dust mote has humbled and humiliated the planet’s most powerful nation. America has failed to protect its people, leaving them with illness and financial ruin. It has lost its status as a global leader. It has careened between inaction and ineptitude. The breadth and magnitude of its errors are difficult, in the moment, to truly fathom.
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In the first half of 2020, SARS‑CoV‑2—the new coronavirus behind the disease COVID‑19—infected 10 million people around the world and killed about half a million. But few countries have been as severely hit as the United States, which has just 4 percent of the world’s population but a quarter of its confirmed COVID‑19 cases and deaths. These numbers are estimates. The actual toll, though undoubtedly higher, is unknown, because the richest country in the world still lacks sufficient testing to accurately count its sick citizens.
Despite ample warning, the U.S. squandered every possible opportunity to control the coronavirus. And despite its considerable advantages—immense resources, biomedical might, scientific expertise—it floundered. While countries as different as South Korea, Thailand, Iceland, Slovakia, and Australia acted decisively to bend the curve of infections downward, the U.S. achieved merely a plateau in the spring, which changed to an appalling upward slope in the summer. “The U.S. fundamentally failed in ways that were worse than I ever could have imagined,” Julia Marcus, an infectious-disease epidemiologist at Harvard Medical School, told me.
Since the pandemic began, I have spoken with more than 100 experts in a variety of fields. I’ve learned that almost everything that went wrong with America’s response to the pandemic was predictable and preventable. A sluggish response by a government denuded of expertise allowed the coronavirus to gain a foothold. Chronic underfunding of public health neutered the nation’s ability to prevent the pathogen’s spread. A bloated, inefficient health-care system left hospitals ill-prepared for the ensuing wave of sickness. Racist policies that have endured since the days of colonization and slavery left Indigenous and Black Americans especially vulnerable to COVID‑19. The decades-long process of shredding the nation’s social safety net forced millions of essential workers in low-paying jobs to risk their life for their livelihood. The same social-media platforms that sowed partisanship and misinformation during the 2014 Ebola outbreak in Africa and the 2016 U.S. election became vectors for conspiracy theories during the 2020 pandemic.
The U.S. has little excuse for its inattention. In recent decades, epidemics of SARS, MERS, Ebola, H1N1 flu, Zika, and monkeypox showed the havoc that new and reemergent pathogens could wreak. Health experts, business leaders, and even middle schoolers ran simulated exercises to game out the spread of new diseases. In 2018, I wrote an article for The Atlantic arguing that the U.S. was not ready for a pandemic, and sounded warnings about the fragility of the nation’s health-care system and the slow process of creating a vaccine. But the COVID‑19 debacle has also touched—and implicated—nearly every other facet of American society: its shortsighted leadership, its disregard for expertise, its racial inequities, its social-media culture, and its fealty to a dangerous strain of individualism.
SARS‑CoV‑2 is something of an anti-Goldilocks virus: just bad enough in every way. Its symptoms can be severe enough to kill millions but are often mild enough to allow infections to move undetected through a population. It spreads quickly enough to overload hospitals, but slowly enough that statistics don’t spike until too late. These traits made the virus harder to control, but they also softened the pandemic’s punch. SARS‑CoV‑2 is neither as lethal as some other coronaviruses, such as SARS and MERS, nor as contagious as measles. Deadlier pathogens almost certainly exist. Wild animals harbor an estimated 40,000 unknown viruses, a quarter of which could potentially jump into humans. How will the U.S. fare when “we can’t even deal with a starter pandemic?,” Zeynep Tufekci, a sociologist at the University of North Carolina and an Atlantic contributing writer, asked me.
Despite its epochal effects, COVID‑19 is merely a harbinger of worse plagues to come. The U.S. cannot prepare for these inevitable crises if it returns to normal, as many of its people ache to do. Normal led to this. Normal was a world ever more prone to a pandemic but ever less ready for one. To avert another catastrophe, the U.S. needs to grapple with all the ways normal failed us. It needs a full accounting of every recent misstep and foundational sin, every unattended weakness and unheeded warning, every festering wound and reopened scar.
A pandemic can be prevented in two ways: Stop an infection from ever arising, or stop an infection from becoming thousands more. The first way is likely impossible. There are simply too many viruses and too many animals that harbor them. Bats alone could host thousands of unknown coronaviruses; in some Chinese caves, one out of every 20 bats is infected. Many people live near these caves, shelter in them, or collect guano from them for fertilizer. Thousands of bats also fly over these people’s villages and roost in their homes, creating opportunities for the bats’ viral stowaways to spill over into human hosts. Based on antibody testing in rural parts of China, Peter Daszak of EcoHealth Alliance, a nonprofit that studies emerging diseases, estimates that such viruses infect a substantial number of people every year. “Most infected people don’t know about it, and most of the viruses aren’t transmissible,” Daszak says. But it takes just one transmissible virus to start a pandemic.
Sometime in late 2019, the wrong virus left a bat and ended up, perhaps via an intermediate host, in a human—and another, and another. Eventually it found its way to the Huanan seafood market, and jumped into dozens of new hosts in an explosive super-spreading event. The COVID‑19 pandemic had begun.
“There is no way to get spillover of everything to zero,” Colin Carlson, an ecologist at Georgetown University, told me. Many conservationists jump on epidemics as opportunities to ban the wildlife trade or the eating of “bush meat,” an exoticized term for “game,” but few diseases have emerged through either route. Carlson said the biggest factors behind spillovers are land-use change and climate change, both of which are hard to control. Our species has relentlessly expanded into previously wild spaces. Through intensive agriculture, habitat destruction, and rising temperatures, we have uprooted the planet’s animals, forcing them into new and narrower ranges that are on our own doorsteps. Humanity has squeezed the world’s wildlife in a crushing grip—and viruses have come bursting out.
Curtailing those viruses after they spill over is more feasible, but requires knowledge, transparency, and decisiveness that were lacking in 2020. Much about coronaviruses is still unknown. There are no surveillance networks for detecting them as there are for influenza. There are no approved treatments or vaccines. Coronaviruses were formerly a niche family, of mainly veterinary importance. Four decades ago, just 60 or so scientists attended the first international meeting on coronaviruses. Their ranks swelled after SARS swept the world in 2003, but quickly dwindled as a spike in funding vanished. The same thing happened after MERS emerged in 2012. This year, the world’s coronavirus experts—and there still aren’t many—had to postpone their triennial conference in the Netherlands because SARS‑CoV‑2 made flying too risky.
In the age of cheap air travel, an outbreak that begins on one continent can easily reach the others. SARS already demonstrated that in 2003, and more than twice as many people now travel by plane every year. To avert a pandemic, affected nations must alert their neighbors quickly. In 2003, China covered up the early spread of SARS, allowing the new disease to gain a foothold, and in 2020, history repeated itself. The Chinese government downplayed the possibility that SARS‑CoV‑2 was spreading among humans, and only confirmed as much on January 20, after millions had traveled around the country for the lunar new year. Doctors who tried to raise the alarm were censured and threatened. One, Li Wenliang, later died of COVID‑19. The World Health Organization initially parroted China’s line and did not declare a public-health emergency of international concern until January 30. By then, an estimated 10,000 people in 20 countries had been infected, and the virus was spreading fast.
The United States has correctly castigated China for its duplicity and the WHO for its laxity—but the U.S. has also failed the international community. Under President Donald Trump, the U.S. has withdrawn from several international partnerships and antagonized its allies. It has a seat on the WHO’s executive board, but left that position empty for more than two years, only filling it this May, when the pandemic was in full swing. Since 2017, Trump has pulled more than 30 staffers out of the Centers for Disease Control and Prevention’s office in China, who could have warned about the spreading coronavirus. Last July, he defunded an American epidemiologist embedded within China’s CDC. America First was America oblivious.
Even after warnings reached the U.S., they fell on the wrong ears. Since before his election, Trump has cavalierly dismissed expertise and evidence. He filled his administration with inexperienced newcomers, while depicting career civil servants as part of a “deep state.” In 2018, he dismantled an office that had been assembled specifically to prepare for nascent pandemics. American intelligence agencies warned about the coronavirus threat in January, but Trump habitually disregards intelligence briefings. The secretary of health and human services, Alex Azar, offered similar counsel, and was twice ignored.
Being prepared means being ready to spring into action, “so that when something like this happens, you’re moving quickly,” Ronald Klain, who coordinated the U.S. response to the West African Ebola outbreak in 2014, told me. “By early February, we should have triggered a series of actions, precisely zero of which were taken.” Trump could have spent those crucial early weeks mass-producing tests to detect the virus, asking companies to manufacture protective equipment and ventilators, and otherwise steeling the nation for the worst. Instead, he focused on the border. On January 31, Trump announced that the U.S. would bar entry to foreigners who had recently been in China, and urged Americans to avoid going there.
Travel bans make intuitive sense, because travel obviously enables the spread of a virus. But in practice, travel bans are woefully inefficient at restricting either travel or viruses. They prompt people to seek indirect routes via third-party countries, or to deliberately hide their symptoms. They are often porous: Trump’s included numerous exceptions, and allowed tens of thousands of people to enter from China. Ironically, they create travel: When Trump later announced a ban on flights from continental Europe, a surge of travelers packed America’s airports in a rush to beat the incoming restrictions. Travel bans may sometimes work for remote island nations, but in general they can only delay the spread of an epidemic—not stop it. And they can create a harmful false confidence, so countries “rely on bans to the exclusion of the things they actually need to do—testing, tracing, building up the health system,” says Thomas Bollyky, a global-health expert at the Council on Foreign Relations. “That sounds an awful lot like what happened in the U.S.”
This was predictable. A president who is fixated on an ineffectual border wall, and has portrayed asylum seekers as vectors of disease, was always going to reach for travel bans as a first resort. And Americans who bought into his rhetoric of xenophobia and isolationism were going to be especially susceptible to thinking that simple entry controls were a panacea.
And so the U.S. wasted its best chance of restraining COVID‑19. Although the disease first arrived in the U.S. in mid-January, genetic evidence shows that the specific viruses that triggered the first big outbreaks, in Washington State, didn’t land until mid-February. The country could have used that time to prepare. Instead, Trump, who had spent his entire presidency learning that he could say whatever he wanted without consequence, assured Americans that “the coronavirus is very much under control,” and “like a miracle, it will disappear.” With impunity, Trump lied. With impunity, the virus spread.
On February 26, Trump asserted that cases were “going to be down to close to zero.” Over the next two months, at least 1 million Americans were infected.
As the coronavirus established itself in the U.S., it found a nation through which it could spread easily, without being detected. For years, Pardis Sabeti, a virologist at the Broad Institute of Harvard and MIT, has been trying to create a surveillance network that would allow hospitals in every major U.S. city to quickly track new viruses through genetic sequencing. Had that network existed, once Chinese scientists published SARS‑CoV‑2’s genome on January 11, every American hospital would have been able to develop its own diagnostic test in preparation for the virus’s arrival. “I spent a lot of time trying to convince many funders to fund it,” Sabeti told me. “I never got anywhere.”
The CDC developed and distributed its own diagnostic tests in late January. These proved useless because of a faulty chemical component. Tests were in such short supply, and the criteria for getting them were so laughably stringent, that by the end of February, tens of thousands of Americans had likely been infected but only hundreds had been tested. The official data were so clearly wrong that The Atlantic developed its own volunteer-led initiative—the COVID Tracking Project—to count cases.
Diagnostic tests are easy to make, so the U.S. failing to create one seemed inconceivable. Worse, it had no Plan B. Private labs were strangled by FDA bureaucracy. Meanwhile, Sabeti’s lab developed a diagnostic test in mid-January and sent it to colleagues in Nigeria, Sierra Leone, and Senegal. “We had working diagnostics in those countries well before we did in any U.S. states,” she told me.
It’s hard to overstate how thoroughly the testing debacle incapacitated the U.S. People with debilitating symptoms couldn’t find out what was wrong with them. Health officials couldn’t cut off chains of transmission by identifying people who were sick and asking them to isolate themselves.
Water running along a pavement will readily seep into every crack; so, too, did the unchecked coronavirus seep into every fault line in the modern world. Consider our buildings. In response to the global energy crisis of the 1970s, architects made structures more energy-efficient by sealing them off from outdoor air, reducing ventilation rates. Pollutants and pathogens built up indoors, “ushering in the era of ‘sick buildings,’ ” says Joseph Allen, who studies environmental health at Harvard’s T. H. Chan School of Public Health. Energy efficiency is a pillar of modern climate policy, but there are ways to achieve it without sacrificing well-being. “We lost our way over the years and stopped designing buildings for people,” Allen says.
The indoor spaces in which Americans spend 87 percent of their time became staging grounds for super-spreading events. One study showed that the odds of catching the virus from an infected person are roughly 19 times higher indoors than in open air. Shielded from the elements and among crowds clustered in prolonged proximity, the coronavirus ran rampant in the conference rooms of a Boston hotel, the cabins of the Diamond Princess cruise ship, and a church hall in Washington State where a choir practiced for just a few hours.
The hardest-hit buildings were those that had been jammed with people for decades: prisons. Between harsher punishments doled out in the War on Drugs and a tough-on-crime mindset that prizes retribution over rehabilitation, America’s incarcerated population has swelled sevenfold since the 1970s, to about 2.3 million. The U.S. imprisons five to 18 times more people per capita than other Western democracies. Many American prisons are packed beyond capacity, making social distancing impossible. Soap is often scarce. Inevitably, the coronavirus ran amok. By June, two American prisons each accounted for more cases than all of New Zealand. One, Marion Correctional Institution, in Ohio, had more than 2,000 cases among inmates despite having a capacity of 1,500.
Other densely packed facilities were also besieged. America’s nursing homes and long-term-care facilities house less than 1 percent of its people, but as of mid-June, they accounted for 40 percent of its coronavirus deaths. More than 50,000 residents and staff have died. At least 250,000 more have been infected. These grim figures are a reflection not just of the greater harms that COVID‑19 inflicts upon elderly physiology, but also of the care the elderly receive. Before the pandemic, three in four nursing homes were understaffed, and four in five had recently been cited for failures in infection control. The Trump administration’s policies have exacerbated the problem by reducing the influx of immigrants, who make up a quarter of long-term caregivers.
Even though a Seattle nursing home was one of the first COVID‑19 hot spots in the U.S., similar facilities weren’t provided with tests and protective equipment. Rather than girding these facilities against the pandemic, the Department of Health and Human Services paused nursing-home inspections in March, passing the buck to the states. Some nursing homes avoided the virus because their owners immediately stopped visitations, or paid caregivers to live on-site. But in others, staff stopped working, scared about infecting their charges or becoming infected themselves. In some cases, residents had to be evacuated because no one showed up to care for them.
America’s neglect of nursing homes and prisons, its sick buildings, and its botched deployment of tests are all indicative of its problematic attitude toward health: “Get hospitals ready and wait for sick people to show,” as Sheila Davis, the CEO of the nonprofit Partners in Health, puts it. “Especially in the beginning, we catered our entire [COVID‑19] response to the 20 percent of people who required hospitalization, rather than preventing transmission in the community.” The latter is the job of the public-health system, which prevents sickness in populations instead of merely treating it in individuals. That system pairs uneasily with a national temperament that views health as a matter of personal responsibility rather than a collective good.
At the end of the 20th century, public-health improvements meant that Americans were living an average of 30 years longer than they were at the start of it. Maternal mortality had fallen by 99 percent; infant mortality by 90 percent. Fortified foods all but eliminated rickets and goiters. Vaccines eradicated smallpox and polio, and brought measles, diphtheria, and rubella to heel. These measures, coupled with antibiotics and better sanitation, curbed infectious diseases to such a degree that some scientists predicted they would soon pass into history. But instead, these achievements brought complacency. “As public health did its job, it became a target” of budget cuts, says Lori Freeman, the CEO of the National Association of County and City Health Officials.
Today, the U.S. spends just 2.5 percent of its gigantic health-care budget on public health. Underfunded health departments were already struggling to deal with opioid addiction, climbing obesity rates, contaminated water, and easily preventable diseases. Last year saw the most measles cases since 1992. In 2018, the U.S. had 115,000 cases of syphilis and 580,000 cases of gonorrhea—numbers not seen in almost three decades. It has 1.7 million cases of chlamydia, the highest number ever recorded.
Since the last recession, in 2009, chronically strapped local health departments have lost 55,000 jobs—a quarter of their workforce. When COVID‑19 arrived, the economic downturn forced overstretched departments to furlough more employees. When states needed battalions of public-health workers to find infected people and trace their contacts, they had to hire and train people from scratch. In May, Maryland Governor Larry Hogan asserted that his state would soon have enough people to trace 10,000 contacts every day. Last year, as Ebola tore through the Democratic Republic of Congo—a country with a quarter of Maryland’s wealth and an active war zone—local health workers and the WHO traced twice as many people.
Ripping unimpeded through American communities, the coronavirus created thousands of sickly hosts that it then rode into America’s hospitals. It should have found facilities armed with state-of-the-art medical technologies, detailed pandemic plans, and ample supplies of protective equipment and life-saving medicines. Instead, it found a brittle system in danger of collapse.
Compared with the average wealthy nation, America spends nearly twice as much of its national wealth on health care, about a quarter of which is wasted on inefficient care, unnecessary treatments, and administrative chicanery. The U.S. gets little bang for its exorbitant buck. It has the lowest life-expectancy rate of comparable countries, the highest rates of chronic disease, and the fewest doctors per person. This profit-driven system has scant incentive to invest in spare beds, stockpiled supplies, peacetime drills, and layered contingency plans—the essence of pandemic preparedness. America’s hospitals have been pruned and stretched by market forces to run close to full capacity, with little ability to adapt in a crisis.
When hospitals do create pandemic plans, they tend to fight the last war. After 2014, several centers created specialized treatment units designed for Ebola—a highly lethal but not very contagious disease. These units were all but useless against a highly transmissible airborne virus like SARS‑CoV‑2. Nor were hospitals ready for an outbreak to drag on for months. Emergency plans assumed that staff could endure a few days of exhausting conditions, that supplies would hold, and that hard-hit centers could be supported by unaffected neighbors. “We’re designed for discrete disasters” like mass shootings, traffic pileups, and hurricanes, says Esther Choo, an emergency physician at Oregon Health and Science University. The COVID‑19 pandemic is not a discrete disaster. It is a 50-state catastrophe that will likely continue at least until a vaccine is ready.
Wherever the coronavirus arrived, hospitals reeled. Several states asked medical students to graduate early, reenlisted retired doctors, and deployed dermatologists to emergency departments. Doctors and nurses endured grueling shifts, their faces chapped and bloody when they finally doffed their protective equipment. Soon, that equipment—masks, respirators, gowns, gloves—started running out.
American hospitals operate on a just-in-time economy. They acquire the goods they need in the moment through labyrinthine supply chains that wrap around the world in tangled lines, from countries with cheap labor to richer nations like the U.S. The lines are invisible until they snap. About half of the world’s face masks, for example, are made in China, some of them in Hubei province. When that region became the pandemic epicenter, the mask supply shriveled just as global demand spiked. The Trump administration turned to a larder of medical supplies called the Strategic National Stockpile, only to find that the 100 million respirators and masks that had been dispersed during the 2009 flu pandemic were never replaced. Just 13 million respirators were left.
In April, four in five frontline nurses said they didn’t have enough protective equipment. Some solicited donations from the public, or navigated a morass of back-alley deals and internet scams. Others fashioned their own surgical masks from bandannas and gowns from garbage bags. The supply of nasopharyngeal swabs that are used in every diagnostic test also ran low, because one of the largest manufacturers is based in Lombardy, Italy—initially the COVID‑19 capital of Europe. About 40 percent of critical-care drugs, including antibiotics and painkillers, became scarce because they depend on manufacturing lines that begin in China and India. Once a vaccine is ready, there might not be enough vials to put it in, because of the long-running global shortage of medical-grade glass—literally, a bottle-neck bottleneck.
The federal government could have mitigated those problems by buying supplies at economies of scale and distributing them according to need. Instead, in March, Trump told America’s governors to “try getting it yourselves.” As usual, health care was a matter of capitalism and connections. In New York, rich hospitals bought their way out of their protective-equipment shortfall, while neighbors in poorer, more diverse parts of the city rationed their supplies.
While the president prevaricated, Americans acted. Businesses sent their employees home. People practiced social distancing, even before Trump finally declared a national emergency on March 13, and before governors and mayors subsequently issued formal stay-at-home orders, or closed schools, shops, and restaurants. A study showed that the U.S. could have averted 36,000 COVID‑19 deaths if leaders had enacted social-distancing measures just a week earlier. But better late than never: By collectively reducing the spread of the virus, America flattened the curve. Ventilators didn’t run out, as they had in parts of Italy. Hospitals had time to add extra beds.
Social distancing worked. But the indiscriminate lockdown was necessary only because America’s leaders wasted months of prep time. Deploying this blunt policy instrument came at enormous cost. Unemployment rose to 14.7 percent, the highest level since record-keeping began, in 1948. More than 26 million people lost their jobs, a catastrophe in a country that—uniquely and absurdly—ties health care to employment. Some COVID‑19 survivors have been hit with seven-figure medical bills. In the middle of the greatest health and economic crises in generations, millions of Americans have found themselves disconnected from medical care and impoverished. They join the millions who have always lived that way.
The coronavirus found, exploited, and widened every inequity that the U.S. had to offer. Elderly people, already pushed to the fringes of society, were treated as acceptable losses. Women were more likely to lose jobs than men, and also shouldered extra burdens of child care and domestic work, while facing rising rates of domestic violence. In half of the states, people with dementia and intellectual disabilities faced policies that threatened to deny them access to lifesaving ventilators. Thousands of people endured months of COVID‑19 symptoms that resembled those of chronic postviral illnesses, only to be told that their devastating symptoms were in their head. Latinos were three times as likely to be infected as white people. Asian Americans faced racist abuse. Far from being a “great equalizer,” the pandemic fell unevenly upon the U.S., taking advantage of injustices that had been brewing throughout the nation’s history.
Of the 3.1 million Americans who still cannot afford health insurance in states where Medicaid has not been expanded, more than half are people of color, and 30 percent are Black.* This is no accident. In the decades after the Civil War, the white leaders of former slave states deliberately withheld health care from Black Americans, apportioning medicine more according to the logic of Jim Crow than Hippocrates. They built hospitals away from Black communities, segregated Black patients into separate wings, and blocked Black students from medical school. In the 20th century, they helped construct America’s system of private, employer-based insurance, which has kept many Black people from receiving adequate medical treatment. They fought every attempt to improve Black people’s access to health care, from the creation of Medicare and Medicaid in the ’60s to the passage of the Affordable Care Act in 2010.
A number of former slave states also have among the lowest investments in public health, the lowest quality of medical care, the highest proportions of Black citizens, and the greatest racial divides in health outcomes. As the COVID‑19 pandemic wore on, they were among the quickest to lift social-distancing restrictions and reexpose their citizens to the coronavirus. The harms of these moves were unduly foisted upon the poor and the Black.
As of early July, one in every 1,450 Black Americans had died from COVID‑19—a rate more than twice that of white Americans. That figure is both tragic and wholly expected given the mountain of medical disadvantages that Black people face. Compared with white people, they die three years younger. Three times as many Black mothers die during pregnancy. Black people have higher rates of chronic illnesses that predispose them to fatal cases of COVID‑19. When they go to hospitals, they’re less likely to be treated. The care they do receive tends to be poorer. Aware of these biases, Black people are hesitant to seek aid for COVID‑19 symptoms and then show up at hospitals in sicker states. “One of my patients said, ‘I don’t want to go to the hospital, because they’re not going to treat me well,’ ” says Uché Blackstock, an emergency physician and the founder of Advancing Health Equity, a nonprofit that fights bias and racism in health care. “Another whispered to me, ‘I’m so relieved you’re Black. I just want to make sure I’m listened to.’ ”
Black people were both more worried about the pandemic and more likely to be infected by it. The dismantling of America’s social safety net left Black people with less income and higher unemployment. They make up a disproportionate share of the low-paid “essential workers” who were expected to staff grocery stores and warehouses, clean buildings, and deliver mail while the pandemic raged around them. Earning hourly wages without paid sick leave, they couldn’t afford to miss shifts even when symptomatic. They faced risky commutes on crowded public transportation while more privileged people teleworked from the safety of isolation. “There’s nothing about Blackness that makes you more prone to COVID,” says Nicolette Louissaint, the executive director of Healthcare Ready, a nonprofit that works to strengthen medical supply chains. Instead, existing inequities stack the odds in favor of the virus.
Native Americans were similarly vulnerable. A third of the people in the Navajo Nation can’t easily wash their hands, because they’ve been embroiled in long-running negotiations over the rights to the water on their own lands. Those with water must contend with runoff from uranium mines. Most live in cramped multigenerational homes, far from the few hospitals that service a 17-million-acre reservation. As of mid-May, the Navajo Nation had higher rates of COVID‑19 infections than any U.S. state.
Americans often misperceive historical inequities as personal failures. Stephen Huffman, a Republican state senator and doctor in Ohio, suggested that Black Americans might be more prone to COVID‑19 because they don’t wash their hands enough, a remark for which he later apologized. Republican Senator Bill Cassidy of Louisiana, also a physician, noted that Black people have higher rates of chronic disease, as if this were an answer in itself, and not a pattern that demanded further explanation.
Clear distribution of accurate information is among the most important defenses against an epidemic’s spread. And yet the largely unregulated, social-media-based communications infrastructure of the 21st century almost ensures that misinformation will proliferate fast. “In every outbreak throughout the existence of social media, from Zika to Ebola, conspiratorial communities immediately spread their content about how it’s all caused by some government or pharmaceutical company or Bill Gates,” says Renée DiResta of the Stanford Internet Observatory, who studies the flow of online information. When COVID‑19 arrived, “there was no doubt in my mind that it was coming.”
Sure enough, existing conspiracy theories—George Soros! 5G! Bioweapons!—were repurposed for the pandemic. An infodemic of falsehoods spread alongside the actual virus. Rumors coursed through online platforms that are designed to keep users engaged, even if that means feeding them content that is polarizing or untrue. In a national crisis, when people need to act in concert, this is calamitous. “The social internet as a system is broken,” DiResta told me, and its faults are readily abused.
Beginning on April 16, DiResta’s team noticed growing online chatter about Judy Mikovits, a discredited researcher turned anti-vaccination champion. Posts and videos cast Mikovits as a whistleblower who claimed that the new coronavirus was made in a lab and described Anthony Fauci of the White House’s coronavirus task force as her nemesis. Ironically, this conspiracy theory was nested inside a larger conspiracy—part of an orchestrated PR campaign by an anti-vaxxer and QAnon fan with the explicit goal to “take down Anthony Fauci.” It culminated in a slickly produced video called Plandemic, which was released on May 4. More than 8 million people watched it in a week.
Doctors and journalists tried to debunk Plandemic’s many misleading claims, but these efforts spread less successfully than the video itself. Like pandemics, infodemics quickly become uncontrollable unless caught early. But while health organizations recognize the need to surveil for emerging diseases, they are woefully unprepared to do the same for emerging conspiracies. In 2016, when DiResta spoke with a CDC team about the threat of misinformation, “their response was: ‘ That’s interesting, but that’s just stuff that happens on the internet.’ ”
Rather than countering misinformation during the pandemic’s early stages, trusted sources often made things worse. Many health experts and government officials downplayed the threat of the virus in January and February, assuring the public that it posed a low risk to the U.S. and drawing comparisons to the ostensibly greater threat of the flu. The WHO, the CDC, and the U.S. surgeon general urged people not to wear masks, hoping to preserve the limited stocks for health-care workers. These messages were offered without nuance or acknowledgement of uncertainty, so when they were reversed—the virus is worse than the flu; wear masks—the changes seemed like befuddling flip-flops.
The media added to the confusion. Drawn to novelty, journalists gave oxygen to fringe anti-lockdown protests while most Americans quietly stayed home. They wrote up every incremental scientific claim, even those that hadn’t been verified or peer-reviewed.
There were many such claims to choose from. By tying career advancement to the publishing of papers, academia already creates incentives for scientists to do attention-grabbing but irreproducible work. The pandemic strengthened those incentives by prompting a rush of panicked research and promising ambitious scientists global attention.
In March, a small and severely flawed French study suggested that the antimalarial drug hydroxychloroquine could treat COVID‑19. Published in a minor journal, it likely would have been ignored a decade ago. But in 2020, it wended its way to Donald Trump via a chain of credulity that included Fox News, Elon Musk, and Dr. Oz. Trump spent months touting the drug as a miracle cure despite mounting evidence to the contrary, causing shortages for people who actually needed it to treat lupus and rheumatoid arthritis. The hydroxychloroquine story was muddied even further by a study published in a top medical journal, The Lancet, that claimed the drug was not effective and was potentially harmful. The paper relied on suspect data from a small analytics company called Surgisphere, and was retracted in June.**
Science famously self-corrects. But during the pandemic, the same urgent pace that has produced valuable knowledge at record speed has also sent sloppy claims around the world before anyone could even raise a skeptical eyebrow. The ensuing confusion, and the many genuine unknowns about the virus, has created a vortex of fear and uncertainty, which grifters have sought to exploit. Snake-oil merchants have peddled ineffectual silver bullets (including actual silver). Armchair experts with scant or absent qualifications have found regular slots on the nightly news. And at the center of that confusion is Donald Trump.
During a pandemic, leaders must rally the public, tell the truth, and speak clearly and consistently. Instead, Trump repeatedly contradicted public-health experts, his scientific advisers, and himself. He said that “nobody ever thought a thing like [the pandemic] could happen” and also that he “felt it was a pandemic long before it was called a pandemic.” Both statements cannot be true at the same time, and in fact neither is true.
A month before his inauguration, I wrote that “the question isn’t whether [Trump will] face a deadly outbreak during his presidency, but when.” Based on his actions as a media personality during the 2014 Ebola outbreak and as a candidate in the 2016 election, I suggested that he would fail at diplomacy, close borders, tweet rashly, spread conspiracy theories, ignore experts, and exhibit reckless self-confidence. And so he did.
No one should be shocked that a liar who has made almost 20,000 false or misleading claims during his presidency would lie about whether the U.S. had the pandemic under control; that a racist who gave birth to birtherism would do little to stop a virus that was disproportionately killing Black people; that a xenophobe who presided over the creation of new immigrant-detention centers would order meatpacking plants with a substantial immigrant workforce to remain open; that a cruel man devoid of empathy would fail to calm fearful citizens; that a narcissist who cannot stand to be upstaged would refuse to tap the deep well of experts at his disposal; that a scion of nepotism would hand control of a shadow coronavirus task force to his unqualified son-in-law; that an armchair polymath would claim to have a “natural ability” at medicine and display it by wondering out loud about the curative potential of injecting disinfectant; that an egotist incapable of admitting failure would try to distract from his greatest one by blaming China, defunding the WHO, and promoting miracle drugs; or that a president who has been shielded by his party from any shred of accountability would say, when asked about the lack of testing, “I don’t take any responsibility at all.”
Trump is a comorbidity of the COVID‑19 pandemic. He isn’t solely responsible for America’s fiasco, but he is central to it. A pandemic demands the coordinated efforts of dozens of agencies. “In the best circumstances, it’s hard to make the bureaucracy move quickly,” Ron Klain said. “It moves if the president stands on a table and says, ‘Move quickly.’ But it really doesn’t move if he’s sitting at his desk saying it’s not a big deal.”
In the early days of Trump’s presidency, many believed that America’s institutions would check his excesses. They have, in part, but Trump has also corrupted them. The CDC is but his latest victim. On February 25, the agency’s respiratory-disease chief, Nancy Messonnier, shocked people by raising the possibility of school closures and saying that “disruption to everyday life might be severe.” Trump was reportedly enraged. In response, he seems to have benched the entire agency. The CDC led the way in every recent domestic disease outbreak and has been the inspiration and template for public-health agencies around the world. But during the three months when some 2 million Americans contracted COVID‑19 and the death toll topped 100,000, the agency didn’t hold a single press conference. Its detailed guidelines on reopening the country were shelved for a month while the White House released its own uselessly vague plan.
Again, everyday Americans did more than the White House. By voluntarily agreeing to months of social distancing, they bought the country time, at substantial cost to their financial and mental well-being. Their sacrifice came with an implicit social contract—that the government would use the valuable time to mobilize an extraordinary, energetic effort to suppress the virus, as did the likes of Germany and Singapore. But the government did not, to the bafflement of health experts. “There are instances in history where humanity has really moved mountains to defeat infectious diseases,” says Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security. “It’s appalling that we in the U.S. have not summoned that energy around COVID‑19.”
Instead, the U.S. sleepwalked into the worst possible scenario: People suffered all the debilitating effects of a lockdown with few of the benefits. Most states felt compelled to reopen without accruing enough tests or contact tracers. In April and May, the nation was stuck on a terrible plateau, averaging 20,000 to 30,000 new cases every day. In June, the plateau again became an upward slope, soaring to record-breaking heights.
Trump never rallied the country. Despite declaring himself a “wartime president,” he merely presided over a culture war, turning public health into yet another politicized cage match. Abetted by supporters in the conservative media, he framed measures that protect against the virus, from masks to social distancing, as liberal and anti-American. Armed anti-lockdown protesters demonstrated at government buildings while Trump egged them on, urging them to “LIBERATE” Minnesota, Michigan, and Virginia. Several public-health officials left their jobs over harassment and threats.
It is no coincidence that other powerful nations that elected populist leaders—Brazil, Russia, India, and the United Kingdom—also fumbled their response to COVID‑19. “When you have people elected based on undermining trust in the government, what happens when trust is what you need the most?” says Sarah Dalglish of the Johns Hopkins Bloomberg School of Public Health, who studies the political determinants of health.
“Trump is president,” she says. “How could it go well?”
The countries that fared better against COVID‑19 didn’t follow a universal playbook. Many used masks widely; New Zealand didn’t. Many tested extensively; Japan didn’t. Many had science-minded leaders who acted early; Hong Kong didn’t—instead, a grassroots movement compensated for a lax government. Many were small islands; not large and continental Germany. Each nation succeeded because it did enough things right.
Meanwhile, the United States underperformed across the board, and its errors compounded. The dearth of tests allowed unconfirmed cases to create still more cases, which flooded the hospitals, which ran out of masks, which are necessary to limit the virus’s spread. Twitter amplified Trump’s misleading messages, which raised fear and anxiety among people, which led them to spend more time scouring for information on Twitter. Even seasoned health experts underestimated these compounded risks. Yes, having Trump at the helm during a pandemic was worrying, but it was tempting to think that national wealth and technological superiority would save America. “We are a rich country, and we think we can stop any infectious disease because of that,” says Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “But dollar bills alone are no match against a virus.”
Public-health experts talk wearily about the panic-neglect cycle, in which outbreaks trigger waves of attention and funding that quickly dissipate once the diseases recede. This time around, the U.S. is already flirting with neglect, before the panic phase is over. The virus was never beaten in the spring, but many people, including Trump, pretended that it was. Every state reopened to varying degrees, and many subsequently saw record numbers of cases. After Arizona’s cases started climbing sharply at the end of May, Cara Christ, the director of the state’s health-services department, said, “We are not going to be able to stop the spread. And so we can’t stop living as well.” The virus may beg to differ.
At times, Americans have seemed to collectively surrender to COVID‑19. The White House’s coronavirus task force wound down. Trump resumed holding rallies, and called for less testing, so that official numbers would be rosier. The country behaved like a horror-movie character who believes the danger is over, even though the monster is still at large. The long wait for a vaccine will likely culminate in a predictable way: Many Americans will refuse to get it, and among those who want it, the most vulnerable will be last in line.
Still, there is some reason for hope. Many of the people I interviewed tentatively suggested that the upheaval wrought by COVID‑19 might be so large as to permanently change the nation’s disposition. Experience, after all, sharpens the mind. East Asian states that had lived through the SARS and MERS epidemics reacted quickly when threatened by SARS‑CoV‑2, spurred by a cultural memory of what a fast-moving coronavirus can do. But the U.S. had barely been touched by the major epidemics of past decades (with the exception of the H1N1 flu). In 2019, more Americans were concerned about terrorists and cyberattacks than about outbreaks of exotic diseases. Perhaps they will emerge from this pandemic with immunity both cellular and cultural.
There are also a few signs that Americans are learning important lessons. A June survey showed that 60 to 75 percent of Americans were still practicing social distancing. A partisan gap exists, but it has narrowed. “In public-opinion polling in the U.S., high-60s agreement on anything is an amazing accomplishment,” says Beth Redbird, a sociologist at Northwestern University, who led the survey. Polls in May also showed that most Democrats and Republicans supported mask wearing, and felt it should be mandatory in at least some indoor spaces. It is almost unheard-of for a public-health measure to go from zero to majority acceptance in less than half a year. But pandemics are rare situations when “people are desperate for guidelines and rules,” says Zoë McLaren, a health-policy professor at the University of Maryland at Baltimore County. The closest analogy is pregnancy, she says, which is “a time when women’s lives are changing, and they can absorb a ton of information. A pandemic is similar: People are actually paying attention, and learning.”
Redbird’s survey suggests that Americans indeed sought out new sources of information—and that consumers of news from conservative outlets, in particular, expanded their media diet. People of all political bents became more dissatisfied with the Trump administration. As the economy nose-dived, the health-care system ailed, and the government fumbled, belief in American exceptionalism declined. “Times of big social disruption call into question things we thought were normal and standard,” Redbird told me. “If our institutions fail us here, in what ways are they failing elsewhere?” And whom are they failing the most?
Americans were in the mood for systemic change. Then, on May 25, George Floyd, who had survived COVID‑19’s assault on his airway, asphyxiated under the crushing pressure of a police officer’s knee. The excruciating video of his killing circulated through communities that were still reeling from the deaths of Breonna Taylor and Ahmaud Arbery, and disproportionate casualties from COVID‑19. America’s simmering outrage came to a boil and spilled into its streets.
Defiant and largely cloaked in masks, protesters turned out in more than 2,000 cities and towns. Support for Black Lives Matter soared: For the first time since its founding in 2013, the movement had majority approval across racial groups. These protests were not about the pandemic, but individual protesters had been primed by months of shocking governmental missteps. Even people who might once have ignored evidence of police brutality recognized yet another broken institution. They could no longer look away.
It is hard to stare directly at the biggest problems of our age. Pandemics, climate change, the sixth extinction of wildlife, food and water shortages—their scope is planetary, and their stakes are overwhelming. We have no choice, though, but to grapple with them. It is now abundantly clear what happens when global disasters collide with historical negligence.
COVID‑19 is an assault on America’s body, and a referendum on the ideas that animate its culture. Recovery is possible, but it demands radical introspection. America would be wise to help reverse the ruination of the natural world, a process that continues to shunt animal diseases into human bodies. It should strive to prevent sickness instead of profiting from it. It should build a health-care system that prizes resilience over brittle efficiency, and an information system that favors light over heat. It should rebuild its international alliances, its social safety net, and its trust in empiricism. It should address the health inequities that flow from its history. Not least, it should elect leaders with sound judgment, high character, and respect for science, logic, and reason.
The pandemic has been both tragedy and teacher. Its very etymology offers a clue about what is at stake in the greatest challenges of the future, and what is needed to address them. Pandemic. Pan and demos. All people.
A Hospital Forgot to Bill Her Coronavirus Test. It Cost Her $1,980.
Ms. Krebs, a lawyer who focuses on insurance issues, had gone to the Valley Hospital in Ridgewood, N.J., with lung pain and a cough. A doctor ran tests and scans to rule out other diseases before swabbing her nose. A week later, the medical laboratory called, telling her it was negative.
Ms. Krebs had a clear memory of the experience, particularly the doctor saying the coronavirus test would make her feel as if she had to sneeze. She wondered whether the doctor could have lied about performing the test, or if her swab could have gone missing. (But if so, why had the laboratory called her with results?)
“When I called the hospital, they said, ‘You did not get a coronavirus test,’” she said. “I told them I absolutely did.”
Across the country, Americans like Ms. Krebs are receiving surprise bills for care connected with coronavirus. Tests can cost between $199 and $6,408 at the same location. A coming wave of treatment bills could be hundreds of multiples higher, especially for those who receive intensive care or have symptoms that linger for months. Services that patients expect to be covered often aren’t.
This patchwork of medical billing is one reason we’re starting something new today: soliciting your medical bills. We’re asking you to send us copies of your bills for coronavirus testing and treatment, so we can understand what costs look like across the country. We want to know how patients are managing their medical bills in the midst of a pandemic. This is part of our larger effort to understand how the pandemic is reshaping American health care.
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Readers’ bills have already shown that surprise medical bills for coronavirus have been in the United States nearly as long as the disease itself.
In late February, an American man and his 3-year-old daughter were hit with medical bills totaling thousands of dollars for care received during a government-mandated quarantine. This was only weeks after Washington State announced the country’s first known case.
“I assumed it was all being paid for,” Frank Wucinski, the patient, said at the time. “We didn’t have a choice. When the bills showed up, it was just a pit in my stomach, like, ‘How do I pay for this?’”
The federal government has since resolved to give Americans special protections against outlandish medical bills. Congress enacted new rules to make the tests a rare oasis within the American health care system — the price had to be public; and co-payments, deductibles or other charges weren’t allowed.
Or at least, Congress tried to. The experiences of patients who had or suspected they might have Covid-19 show how hard it is to write different billing rules for a tiny sliver of the country’s $3 trillion in health spending. Numerous doctor’s offices and hospitals do not post the cash prices for their coronavirus tests, despite the federal requirement to do so. Some patients have encountered unwarranted co-payments as doctors and hospitals have stuck to their regular billing habits. Others have failed to qualify for the protections because they did not receive a coronavirus test as part of their care — or, in the case of Ms. Krebs, had it left off the bill.
“Our system is so complicated,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. “If things aren’t exactly right or weren’t coded correctly, you get thrown into the blizzard.”
The protections that do exist are based on the receipt of something that can be in short supply: a coronavirus test. If doctors can’t obtain a test and turn to other diagnostic methods — testing for other diseases, for example — the patient will have to cover the visit’s cost.
The Trump administration has also set aside an undisclosed sum to pay for uninsured Americans’ testing and treatment, a program that has become increasingly important as millions have lost coverage in the economic downturn. So far, that fund has paid out $348 million to providers, but it is unknown how much money remains or what happens when it runs out.
Billing challenges have persisted, despite these new rules and programs. Many stem from the decision by legislators to condition aid on receipt of a test.
Dr. Kao-Ping Chua, a pediatrician in Michigan, started running into problems in March when he had patients with coronavirus-like symptoms seeking tests. His health system, like many others, required patients to undergo testing for other conditions before coronavirus.
“I had to tell my patients that, if the test I run first comes back positive and says you have the common cold, you’ll have to pay for it,” he said. “But if you test negative, that allows you to get the Covid test, and that waives your cost sharing.”
“I was super scared and worried about Covid, since I never had experienced anything like that before,” he said. A doctor checked his blood pressure, listened to his lungs and took his temperature — but did not administer a coronavirus test. He recalls being told that the emergency room was giving the test only to “critically ill” patients, and he did not qualify.
Mr. Aita, who lost his job at a record store at the start of the pandemic and is uninsured, received a document at the end of his visit estimating he would owe $1,157. If the hospital had tested him for coronavirus, the federal fund could have covered the visit entirely.
Last week, he received a medical bill for the visit that was only $350. He initially thought this was good news — that the hospital had dropped his charge. But when he looked into the issue, he learned this was an additional charge from the doctor who saw him.
“I understood that if it was related to Covid, it would be taken care of,” Mr. Aita said. “It’s a pandemic, I’m unemployed, and now I’m dealing with the stress of this situation.”
A spokesman for Dignity Health, which owns St. Mary’s Medical Center, said the hospital uses C.D.C. protocols to decide who is tested, but he declined to comment on Mr. Aita’s case.
As coronavirus spreads and hospitalizations mount, so will the ranks of those managing unexpected bills.
The Kaiser Family Foundation estimates that a fifth of all coronavirus hospitalizations could result in a surprise medical bill from an out-of-network doctor who became involved in the patient’s care. The nonpartisan foundation also projects that, on average, an American with employer-sponsored coverage would face $1,300 in costs for a coronavirus hospitalization.
Congressional staffers working on the issue say they’ve come across cases in which health providers are not following the new rules on coronavirus billing. The providers are charging patients for services when they shouldn’t, or not posting their cash prices for testing online as they are legally required to.
“Billing offices may just be doing what they’re used to — looking at your card, seeing that it says $30 co-pay and collecting it,” Ms. Pollitz said. “The person at the front desk may not know you got a test. The protections aren’t airtight.”
Congress is currently split over how far to go in protecting coronavirus patients from surprise medical bills. House Democrats have supported mandating that insurers cover all costs related to treatment as part of the HEROES Act, a larger stimulus package.
Senate Republicans introduced their stimulus proposal, the HEALS Act, last week. It does not include a similar mandate.
Two days after I inquired about the case, the Valley Hospital resubmitted her bill with the coronavirus test included. Her insurer, Aetna, reprocessed the bill and confirmed that she would no longer be charged.
“We were trying to come up with extraordinary processes quickly to react to the many changes placed on all of us, including payer requirements of coverage,” Josette Portalatin, an assistant vice president at the hospital, wrote in an email to Ms. Krebs. “We apologize that your lab Covid test was not on your original claim, but happy to report we tracked down the issue.”
https://www.nytimes.com/2020/08/03/upshot/nj-coronavirus-medical-bill.html?action=click&module=Top%20Stories&pgtype=Homepage
How a $175 COVID-19 Test Led to $2,479 in Charges
This article is co-published with The Texas Tribune, a nonprofit, nonpartisan local newsroom that informs and engages with Texans. Sign up for The Brief weekly to get up to speed on their essential coverage of Texas issues.
“I Would Have Signed Anything”
Was the Bill Accurate?
“Testing Should Be Free”
The U.S. Health Care System Is Designed To Fail When It’s Needed Most
Major U.S. Health Insurers Report Big Profits, Benefiting From the Pandemic
Consumers are probably entitled to millions of dollars in rebates under Obamacare rules that cap companies’ profits.
by Reed Abelson - NYT - August 5, 2020
The nation’s leading health insurers are experiencing an embarrassment of profits.
Some of the largest companies, including Anthem, Humana and UnitedHealth Group, are reporting second-quarter earnings that are double what they were a year ago. And while insurance profits are capped under the Affordable Care Act, with the requirement that consumers should benefit from such excesses in the form of rebates, no one should expect an immediate windfall.
But the amounts that insurers are retaining have caught the attention of the Trump administration. The Health and Human Services Department advised companies to consider speeding up rebates, and on Tuesday suggested that they reduce premiums to help consumers through the economic downturn caused by the pandemic.
Just this Wednesday, CVS Health, which owns Aetna, the big insurer, posted much higher earnings. CVS, which also owns a large pharmacy benefit manager and a drugstore chain, said net income for the second quarter reached $3 billion, about $1 billion more than it reported for the same period of 2019, on revenues of $65 billion.
Others had already trumpeted blockbuster results, ensuring that their stocks weathered swings in the markets. Anthem’s net income soared to $2.3 billion for the second quarter, from $1.1 billion in 2019, while UnitedHealth reported net earnings of $6.7 billion, compared to $3.4 billion for the same three months last year.
Although many hospitals have been overwhelmed by the coronavirus outbreaks raging from state to state, insurers have shelled out billions of dollars less in medical claims in the last three months because expensive, elective surgeries have been postponed in many places. Moreover, people have steered clear of doctors’ offices and emergency rooms in fear of contagion.
The companies’ staggering pandemic profits stand in stark contrast to the scores of small medical practices and rural hospitals that are struggling to stay open. And the earnings are putting a spotlight on the big insurance companies at a time when government officials in many states are facing massive budget shortfalls as businesses collapse, unemployment rises and tax revenues plummet. Some states are discussing cutting payments to insurers that offer Medicaid plans to their residents.
“This could tilt the politics against insurers on a whole number of fronts,” said Larry Levitt, the executive vice president for health policy for the Kaiser Family Foundation, a nonpartisan research group.
And in this presidential election year, the companies’ overly buoyant position could also reignite a discussion among Democrats about “Medicare for all,” a proposal that would replace the current private health care system with a government one that guarantees coverage for all U.S. residents.
“We’re looking at the fact that health care can’t be regulated by the marketplace,” said Representative Pramila Jayapal, the Washington State Democrat who is a strong proponent of Medicare for all.
“Who knows what’s going to happen by January?” Ms. Jayapal asked. “It’s entirely possible that everything shifts on health care, within weeks or months after the election.”
Some lawmakers may also try to revive proposals to cap insurers’ profits even more, like one that Senator Elizabeth Warren, the Massachusetts Democrat, has suggested.
“There is that money sitting there,” said Dan Mendelson, the founder of Avalere Health, a consulting firm.
Among the companies with robust earnings is Humana, which reported Wednesday that its net income rose to $1.8 billion for the second-quarter, compared to $940 million for the same three months of 2019. The profits for Cigna, which also owns a large pharmacy benefit manager, were also higher.
Under the federal health care law, insurers are required to use a fixed percentage of the money they take in from premiums for their customers’ medical expenses. The companies must spend at least 80 cents of every dollar they collect in premiums from small businesses and individuals on health care, and 85 cents per dollar for large employers. The remaining 15 to 20 percent is all they are allowed under the Affordable Care Act to spend on administrative costs like overhead and marketing and to keep as profit. Any additional revenues are to be returned to consumers in the form of rebates.
Insurers are currently spending a far lower portion of premium revenue on their customers’ health care costs. CVS said its medical-benefits ratio was 70 percent for the quarter, compared to 84 percent in the same period of 2019.
That translates into millions of dollars that some lawmakers in Congress and advocates say should wind up in the pockets of consumers.
In recent years, insurers have paid out billions of dollars in rebates, said Cynthia Cox, one of the authors of a recent Kaiser Family Foundation analysis that estimated employers and individuals would receive $2.7 billion this year in rebates required under Obamacare. That figure does not include 2020 amounts.
People who had health insurance through the A.C.A. last year could receive an average of $420 a person, she said.
“For any given customer, it’s not going to be a lot of money,” said Mr. Mendelson of Avalere. “It will always feel underwhelming.”
Eventually consumers should get some of this year’s money back. The insurers “are not just able to profiteer,” said Katherine Hempstead, a senior policy adviser for the Robert Wood Johnson Foundation who studies health insurance markets.
Even though the federal government is now encouraging insurers to turn over excess funds to consumers more quickly this year, the Obamacare law gives companies a three-year window to calculate how much to return as a way to offset any mistakes they made in setting rates or if they experienced unexpected expenses.
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“There’s a cushioning effect for swings,” said Mark Hall, the director of the health law and policy program at Wake Forest University.
So no one should count on getting money from this year’s burgeoning insurance profits anytime soon.
And the financial outlook for the year is still uncertain, given the rising number of Covid-19 cases shifting from state to state and the longer term costs of caring for Covid-19 patients, with potentially expensive new vaccines or treatments around the corner. Conversely, the many people who postponed getting medical attention could flock back to doctors’ offices and submit more bills for coverage.
“They don’t actually know what’s coming around the corner,” said Dr. Sanjay Saxena, a managing director for the Boston Consulting Group. “They can’t just write checks and give away the money.”
Insurers say that they are using their financial strength to help customers as well as hospitals and doctors. “From the very beginning, health insurance providers have focused on being part of the solution,” said Matt Eyles, the chief executive of America’s Health Insurance Plans, a trade group. As examples, he cited waiving co-payments for testing and treatment for coronavirus and paying for telemedicine visits, some of which the government has mandated be covered.
The companies also say they are spending billions of dollars on efforts that range from giving small businesses a break on their monthly premiums to paying physicians in advance to help keep practices afloat.
On conference calls with Wall Street analysts, executives were quick to point out steps they have taken to assuage the worries of Americans overwhelmed by the virus outbreaks.
“We took action to commit $2.5 billion in financial assistance to ease the burden of Covid-19 among our members, employer customers, care providers and nonprofit partners,” said Gail K. Boudreaux, the chief executive of Anthem. She listed several initiatives, including giving customers a premium credit and donations to a food charity. “The needs are ongoing, and I’m proud of the way Anthem has responded quickly to provide needed support,” she said.
Nonprofit insurers, including most of the Blue Cross plans offered in individual states, are also experiencing much higher profit margins. While they too are subject to the A.C.A. rules and must pay out required rebates, they can plow any additional surplus into their capital reserves, Mr. Hall said. “They never feel that they have enough reserves, and the regulators don’t really require insurers to spend down their reserves,” he said.
But the companies may have even higher profits than is apparent. Some, like UnitedHealth, have large networks of doctors and other health care businesses, in addition to owning giant pharmacy benefit managers. There are no limits on how much these units can make, and many of the units sell their services directly to the insurer.
The profits being reported don’t “give an accurate picture of how much money they are making for the insurers,” said Michael Turpin, a former insurance executive and an executive vice president at USI, an insurance brokerage. “You’re not going to negotiate with your sister company very robustly.”
Some hospital executives and doctors say that the insurers should do much more. “Everyone should be playing a part as it relates to the pandemic, and insurers are no exception,” said Colleen M. Blye, the chief financial officer for the Montefiore Health System, a large hospital group in the Bronx that has treated more than 10,000 Covid patients.
“The government has been funding the providers significantly,” she said, referring to the $175 billion in funds Congress has allocated to date for hospitals and doctors. “The insurers should be sharing that burden, and they haven’t been.”
Insurers say they have been strong advocates for providers like the hospital systems. “We’ve consistently supported their efforts,” said Mr. Eyles.
So far, investors are not concerned about the political risks of the insurers’ high profits, said Les Funtleyder, who is a health care portfolio manager for E Squared Capital Management, which owns shares of UnitedHealth.
Even if former Vice President Joseph R. Biden Jr., the Democratic presidential candidate, wins in November, he would probably be unlikely to push for anything close to Medicare for all. Mr. Biden favors revamping Obamacare and offering a public option, a government-run alternative to private insurance.
But the calculation could change, depending on his choice of vice president, Mr. Funtleyder said. Senator Warren, who has called for a sweeping health care overhaul, is one of several names on a long list of potential female running mates for Mr. Biden.
“If Warren was vice president, it would definitely spook Wall Street,” Mr. Funtleyder said.
https://www.nytimes.com/2020/08/05/health/covid-insurance-profits.html?referringSource=articleShare
Missouri shows us a lot about health care
No matter how hard they tried, Republican politicians and their allies could not stop Missouri’s voters from expanding access to Medicaid under the Affordable Care Act.
And so did Missouri this week become the sixth state since 2017 — five of them staunchly Republican — where voters took the decision on the expansion of health coverage out of the hands of recalcitrant conservative politicians.
In joining Idaho, Utah, Oklahoma, Nebraska and Maine, the place known as the “Show Me State” showed the electoral power of access to health care and the danger to President Trump and Republicans of their ongoing efforts to repeal Obamacare.
The 53 percent to 47 percent victory to extend health coverage to well over 200,000 Missourians was built on large margins in the Democratic cities of St. Louis and Kansas City. But what should disturb Republicans is that, in suburban areas, including places they had carried in the past, voters supported the referendum or opposed it by much smaller margins than the GOP is accustomed to winning.
Jason Hancock, the Kansas City Star’s lead political reporter, noted that largely suburban Platte County, which narrowly supported Sen. Josh Hawley (R-Mo.) in 2018, gave 61 percent of its ballots to the Medicaid expansion. And while rural Republican counties around the state voted no, the margins against the Medicaid referendum were smaller there than Trump’s advantage over Hillary Clinton in 2016.
“Our rural areas will benefit significantly from this,” said Amy Blouin, executive director of the Missouri Budget Project, which supported the referendum. “We’ve had 10 rural hospitals close in recent years and rural counties are worried about losing more hospitals, which are economic engines for their areas.”
All but 12 states — eight of them in the old Confederacy — have now expanded Medicaid. And the evidence is strong that if their voters were given the chance, they, too, would decide for expansion. In May, the Kaiser Family Foundation (KFF) Health Tracking Poll found that in the states that had not accepted Obamacare’s Medicaid offer (which then included Missouri and Oklahoma), 66 percent favored expansion. “Even in red areas of red states, there is some support for expanding Medicaid,” said Liz Hamel, KFF’s director of public opinion and survey research, noting that the May survey found 37 percent of Republicans favoring the step.
While Missouri is one of the states Trump can still count on against former vice president Joe Biden this November, the health-care issue is clearly hurting the president and his party even among voters who make up the base of the GOP.
“While Trump still has a substantial lead with small-town and White voters, it is significantly less than he won in 2016,” said Geoff Garin, a Democratic pollster. “And his failure to deliver on affordable health care is the number one reason driving those voters away from him. When Trump promised in 2016 to deliver more affordable health care to more people, his voters took that seriously.”
Beyond general dissatisfaction with Trump, health care was far and away the most powerful Democratic issue in the 2018 midterm elections, and it continues to be important in Senate and House races this year. In his campaign to unseat Sen. Steve Daines (R-Mont.), for example, Democratic Gov. Steve Bullock recently ran an ad touting his success in expanding Medicaid and its benefits to “rural hospitals all across Montana.”
Whit Ayres, a Republican pollster, said he was not surprised by the result in Missouri. “The explanation is not complicated: covid-19,” he said. “When thousands and thousands of people are getting so sick with a dastardly disease that we know so little about, it’s not surprising that people will vote for affordable health care — especially when there’s no coherent alternative on the table.”
At some level, Trump seems to understand the costs of having failed to offer that “coherent alternative,” even as he continues to support a lawsuit that would scrap Obamacare altogether. But instead of outlining a policy, he keeps making laughably empty promises. His latest came during a July 19 interview with Fox News’s Chris Wallace, whom he told: “We’re signing a health-care plan within two weeks, a full and complete health-care plan.”
The two weeks expired a few days ago.
Voters may be inured to empty promises, but they take their own and their family’s health care very seriously, especially during a pandemic. If Biden wins in November, one of the reasons will be his pledge to build on the Affordable Care Act. And as Missouri’s voters showed, there will be many grass-roots Republicans quietly cheering him on when he tries to fulfill it.
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