Broad Coalition of Health Industry Groups Calls for Obamacare Expansion
Hospitals, doctors, insurers and employers say the Affordable Care Act can help the country achieve universal coverage
by Reed Abelson - NYT - February 10, 2021
In an unusual display of unity, groups representing nearly all the major players in the American health care system — hospitals, doctors, insurance companies and employers — are joining forces to urge Congress to embrace President Biden’s broad vision of building on the Affordable Care Act to reach the long elusive goal of universal coverage.
The coalition is composed of eight powerful industry groups, including America’s Health Insurance Plans, the American Medical Association and the U.S. Chamber of Commerce. It released a detailed set of proposals on Wednesday morning, including an increase in the federal subsidies available to help people afford coverage and a three-year re-establishment of the generous match in federal funding to states to entice more of them to expand their Medicaid programs. The coalition also urged the government to spend more money on enrolling people in plans offered by the insurance markets established under the law, efforts that were slashed by the previous administration.
“While we sometimes disagree on important issues in health care, we are in total agreement that Americans deserve a stable health care market that provides access to high-quality care and affordable coverage for all,” the coalition said in a joint statement.
Some of the proposals, including increases in federal subsidies, are already being discussed as part of a broad Covid-19 relief bill and have long been on a list of proposals made by the groups to Congress.
The decision to work together was fueled by the pandemic, the coalition said, and by the need to address “longstanding inequities in health care access and disparities in health outcomes.” Millions of Americans lost their insurance during the downturn, and the virus has disproportionately affected communities of color, which have experienced high numbers of cases and deaths.
The recommendations signal a strong show of support for the beleaguered health care law, which had been under fierce attack not only from Republicans under the Trump administration but from progressive Democrats who have urged replacing it altogether with a government-run “Medicare for all” system.
While the hospitals, the doctors and the insurers, which benefit when more people have coverage, had previously united to fight the attempts to repeal Obamacare by the Republicans in 2017, the new coalition also includes the Chamber, which had not been a proponent of the law.
“We have always believed that there are better approaches to expanding health care coverage and lowering costs than the A.C.A., but it is the law of the land and as such we want it to function as smoothly and efficiently as possible,” Neil Bradley, the executive vice president and chief policy officer for the Chamber, said in an emailed statement.
Given the election of Mr. Biden and the change in the composition of Congress, “we now have an opportunity to see something actually happen,” said Chip Kahn, the president of the Federation of American Hospitals, which represents for-profit hospitals and, along with the American Hospital Association, is a member of the coalition. In addition to the American Medical Association, the American Academy of Family Physicians is also a member of the coalition.
“This is a very specific set of proposals for the A.C.A. framework to meet its aspirations,” Mr. Kahn said.
The coalition now estimates that 29 million working-age people remain uninsured, and it says that the proposed measures are a way to achieve near-universal coverage.
“We worked hard with all of the partners in the coalition to put forth recommendations to get us to where we need to a pathway to really expand coverage,” said Justine Handelman, a senior vice president for the Blue Cross Blue Shield Association, which is a member of the coalition.
Employer groups, which include the American Benefits Council, are particularly supportive of temporary measures that would help people retain their job-based coverage during the pandemic. The coalition is calling for higher subsidies under COBRA, the federal law that allows people to retain employer-provided health benefits after leaving a job, so that people can afford to keep those job-based plans or so the federal government can provide direct loans to employers.
“It’s really all about the existing system and figuring out the gaps and issues,” said Jeanette Thornton, a senior vice president at America’s Health Insurance Plans. All of the recommendations are “about filling those gaps,” she said.
https://www.nytimes.com/2021/02/10/health/ACA-obamacare-expansion.html?searchResultPosition=3
Envision or perish — why we must start imagining the world we want to live in
“Where there is no vision, the people perish.” These words from the Old Testament Book of Proverbs are uncanny in their present-day relevance. As we are reeling from a pandemic, with the raw wounds of racism uncovered, an unraveling economy and unprecedented threats to our democratic system, imagining the world we want to live in may seem like a luxury. But in reality, there may be no task more important for our time.
For months and years, it seems that we have been locked into reactivity. We are worn down by the compulsion to respond to each new terrible thing, ready to expire from outrage fatigue.
Nobody should have been surprised at what unfolded at the Capitol on Jan. 6. It had been building for months, and the dynamic is well-known. Ours is not the first country to be pushed by a far-right nationalist populist movement fueled by white supremacy, racism and economic inequality toward neo-fascism. Fortunately, the center held this time.
While there may be better governance and incremental gains under centrist Democratic leadership, the most intractable underlying dynamics will go largely unaddressed. With our economic and financial systems hard-wired to reward those at the top at the expense of everybody else, it will take more than good will and tinkering to wrest control of the country from the top 1 percent and redirect it toward meeting common needs.
Yet the darkest days can offer unexpected opportunities — if we are willing to move beyond the realm of reactivity, fear and damage control, and start having compelling conversations about the world we want.
When Congress reconvened to continue the vote after the attack on the Capitol, Sen. Ben Sasse, a Republican from Nebraska, focused his remarks not on the events in the Capitol building, but on neighborhoods across the country. He spoke of our desire to be good neighbors to each other, saying, “The center of America is not Washington, D.C. The center of America is the neighborhoods where 330 million Americans are raising their kids and trying to put food on the table and trying to love their neighbor. That’s the center of America.”
What if we raised up the stories of our neighborhoods — what makes them whole and what allows them to thrive?
Building prosperous local economies
One community group in a mixed neighborhood in Philadelphia offers a remarkable example of what is possible when a group of people envision the community they want, and work together to make that dream a reality. Germantown Residents for Economic Alternatives Together, or GREAT, has captured the imagination and commitment of a growing group of neighbors.
In reality, the economic interests of small town and rural white folks are closely aligned with those of urban and poor minorities.
Together they have created opportunities for neighbors to get to know each other, taken the time to hone a stunning set of core values, set up a mutual aid fund to help meet COVID-related needs, and developed projects to share time, talents and needed items. GREAT has also taken on the challenge of gentrification and predatory home-buying — steadily building up a core of connected and engaged community leaders who are ready to take on ever larger challenges.
“I belong to a couple of other organizations with structures and titles, and GREAT is like a breath of fresh air,” said Dionne Chambers, a long-time Germantown resident, who has become deeply involved with GREAT over the last several years. “It’s so organic. It’s about good people getting together and making sure that everybody participates and everybody’s vision is part of the mission. As we start a new project on wellness, we’re asking what wellness looks like and means to the community. We make sure everybody’s voice is heard, so there’s a place for them, and a way to put their passion into action.”
While GREAT has a clear vision of the power of good neighbors, activist and author Judy Wicks has long had a vision of the power of good business. Starting in 1983 with a little Philadelphia restaurant, the White Dog Café, she began to see the potential of sourcing locally, and building up a network of mutually supportive farmers and food businesses. She went on to found Fair Food Philly, then the Sustainable Business Network of Greater Philadelphia, followed by the nationwide Business Alliance for Local Living Economies.
In a new project, All Together Now Pennsylvania, Wicks is working to knit together what appear to be intractably divided rural and urban communities across the state. Moving beyond local food systems, her vision includes increased local self-reliance in fiber, energy and building materials as well. She sees this as a way to build prosperous regional economics that serve everyone, while helping prepare communities to withstand climate change.
Her goal is not to search for common political ground, but to build on a shared need for livelihood and food, as well as the potential of mutually beneficial economic relationships. The growth of profit-maximizing multinational corporations that have hollowed out rural economies and depressed wages everywhere — along with the divisions that have been whipped up between working people — are benefiting nobody but the owning elite. In reality, the economic interests of small town and rural white folks are closely aligned with those of urban and poor minorities.
“I believe that the meeting place of the political right and left is community self-reliance,” Wicks said. “Local economies can merge the right’s emphasis on individual self-reliance with the left’s focus on collective endeavors.”
Reimaging Appalachia
Not far away, in a region of the country whose wealth has been extracted for more than 200 years for the benefit of others, a group of citizens have gathered to form ReImagine Appalachia. They are working to envision a new economy that is centered on creating local wealth — as well as one that is good for current workers, communities, the environment and everyone in the next generation. Consisting of over a hundred groups in western Pennsylvania, West Virginia, southern Ohio and Kentucky, they are developing a plan to direct public investment toward good jobs that prioritize coal workers, build career ladders and expand opportunity — not to mention a sustainable economy.
“We actually need coal workers to help us build the 21st century that we want to live in,” said Amanda Woodrum of Ohio Public Policy. “That means work laying rail, for instance, or building out electric vehicle infrastructure for a more sustainable transportation system. That means work modernizing the electric grid.”
The political advances made by Medicare for All and the Green New Deal show that our country is opening again to vision, if we become bold enough to reach out to those who don’t already agree.
Coal-fired power plants, with all their infrastructure, could be repurposed into eco-industrial parks that share energy — including renewables — and other resources. Meanwhile, a civilian conservation corps could put people to work repairing the damage from a century of extraction, restoring forests and wetlands, promoting local farmers and soil health. This would all contribute toward reducing the region’s carbon footprint, and help win over folks who traded in their Bernie signs for Trump ones.
“What the people of Appalachia respond to is sort of a willingness to change and blow up the existing political system,” Woodrum said. “I think the idea of the New Deal that works for us does that.”
On a national level, we have seen how the emphasis on a Green New Deal can bring climate, justice and labor issues together, as well as groups working on those issues. For example, the youth climate group, Sunrise Movement, spent years honing their vision before it was catapulted onto the scene in the halls of Congress in 2018. Since then, they have been cultivating that vision among youth across the country, then doing the hard work — first with Sanders and then the Biden campaign — that has played such a significant role in President Biden’s climate plan.
The Nordic example
As we think about moving forward as a nation, perhaps we can also learn from the example of Norway and Sweden in the 1920s. Poverty was widespread at the time and political polarization was growing, with Nazis at one end and revolutionary communists at the other. The democratic socialists believed they would swing a critical mass to their side by offering a vision of what Sweden and Norway would look like if there were major change. Good health care could be taken out of the market system and made available to all; slums could be replaced by decent housing and everyone could continue with schooling as far as they wished to go. The government could adopt full employment with generous pensions.
Affordable childcare could be provided, enabling parents to enter the workforce. Welfare for the poor could be replaced by the right to a decent livelihood for all who could work. Taxation and other means could re-configure the income pyramid from high inequality to relative equality. The result of all these changes would be more individual freedom for everyone, and more democratic decision-making, too.
Not surprisingly, a majority of working and middle-class people in both countries were attracted to those visions, and the lure of the Nazis and radical communists steadily weakened. Many upper middle-class people took a wait-and-see attitude, thinking the scheme of the democratic socialists sounded impractical, but they were outnumbered. Once the new systems were up and running (first in Sweden, then in Norway), many of the holdouts came to see the wisdom of the vision. By the 1950s, the severity of political polarization had dropped hugely. Although the economic elites still wanted more profits and the workers wanted more say, there was general agreement about the direction in which they were headed.
Of course, progressives and the left in Sweden and Norway had an advantage over the United States in making such a big change because they were starting from a place of ethnic homogeneity. On the other hand, when the Scandinavians were advancing their vision, skeptics could claim that no country had ever had such a just and democratic system! They also had fewer resources and a smaller internal market than the United States. What they did then is what we could do now: make the most of what we have instead of letting the economic elite name the game.
“A Huge Potential for Chaos”: How the COVID-19 Vaccine Rollout Was Hobbled by Turf Wars and Magical Thinking
by Katherine Eban - Vanity Fair - February 5, 2021
One Pandemic, Two Task Forces
On January 5, 2021, the day before an angry mob invaded the U.S. Capitol and called for him to be hanged for disloyalty to the president, Vice President Mike Pence convened his long-suffering COVID-19 task force at the White House to address a vaccine rollout that had devolved into chaos. On the agenda was a long list of concerns, from expanding eligibility for the shots to releasing second doses, which until then had been held back.
Among those in attendance were the task force’s coordinator, Dr. Deborah Birx, and the director of the Centers for Disease Control and Prevention, Dr. Robert Redfield. But the person most responsible for the rollout, the secretary of health and human services, Alex Azar, was missing. Azar, along with the secretary of defense, was in charge of Operation Warp Speed, the federal government’s vaccine development and rollout program. So where was he?
Sixty miles away, it turned out, inside a secure situation room at Camp David. There, Azar and a small group of top aides and military members of Operation Warp Speed were busy conducting their own analysis of the rollout’s problems. At least one blindsided White House task force member was “shocked” upon learning of the separate meeting.
The bureaucratic brinkmanship of the dueling meetings would be laughable if the stakes weren’t so high. Three weeks after the first vaccines rolled out of warehouses, the distribution effort was failing to live up to the Trump administration’s extravagant promises. Too few people were getting the shots, and states were ending each day with unadministered doses that had to be discarded, owing to the onerous refrigeration requirements.
The Camp David group determined that the states were adhering too religiously to the CDC’s guidelines for who was eligible to be vaccinated first, according to one person present. The solution the group arrived at was to tap pharmacy chains to order and administer the vaccine. As part of this effort, the military performed a “geospatial analysis” to identify the 19,000 pharmacies that were the closest to population centers.
Weeks later President Joe Biden’s incoming administration began phone calls with those pharmacies and discovered that they had little understanding of how patients would flow through their systems. “They were begging us for answers,” said one member of Biden’s White House COVID-19 team. “There was a concept to use pharmacies. There wasn’t any plan to exercise against that concept.” That revelation, among others, led Biden to declare former president Donald Trump’s vaccine rollout plan a “dismal failure.” Administration officials vowed to start from scratch in redesigning it.
As officials from the Trump and Biden administrations point fingers, a Vanity Fair investigation, encompassing interviews with more than 20 people with knowledge of Operation Warp Speed’s activities and a review of dozens of internal emails and documents, indicates that the rollout was plagued by turf wars and infighting, Trumpian overpromises, a culture clash between military and public health officials, and a blinkered military focus on delivering vaccines to states instead of vaccinations to individual citizens. The failure to plan for the “last mile” has left Americans desperately navigating a chaotic online wilderness to score elusive vaccination slots in a maddeningly uneven rollout that changes from hour to hour and county to county.
“They had a theory of the case. They had press releases,” as the Biden team member put it. “They did not have a plan to deliver 600 million shots in record time.”
Paul Mango called that characterization a “bunch of bullshit.” Mango, the former HHS deputy chief of staff for policy under Azar, played a central role in coordinating Operation Warp Speed. He also defended the program’s handling of the pharmacies. “We reviewed their business plans. We visited their CEOs.”
But Mango also embodies the laissez-faire ideology that infused the vaccination effort, just as it had the Trump administration’s decision to scrap a proposed national testing plan. “We’ve inoculated more citizens than any country in the world,” Mango told Vanity Fair. “For the Biden team to say, ‘We have to start from scratch,’ their task should be to avoid creating a mess with their authoritarian impulses.”
Unlike many of the career health officials they worked with or oversaw, some political appointees within Operation Warp Speed held an ideological belief that the federal government should limit its role to empowering the private sector, handing off responsibility for actual vaccinations to the states. The program’s mantra—“federally assisted, state managed, locally executed”—was adhered to so slavishly that urgent requests for direct federal assistance to states for vaccinations, from increased funding to additional manpower, were rebuffed, Vanity Fair has learned.
General Gustave Perna, who headed Operation Warp Speed’s logistics, prioritized two key metrics for success, say two people involved in the program: to ship out vaccines within 24 hours of the Food and Drug Administration authorization and to develop a regular cadence for vaccine deliveries to the states. But his definition of mission accomplished didn’t seem to involve actually getting people vaccinated. In one tense meeting between Perna and the CDC, Perna’s staff had to explain to the four-star general that the CDC defined success by two entirely different metrics: the uptake of the vaccine and the elimination of the pandemic, said someone present at the meeting.
Perna retained laser-like focus on what was called the N-hour sequence: the plan to move out the vaccine within 24 hours of its being authorized by the Food and Drug Administration. Perna “talked about how it would look” on TV, said one CDC official. “He really thought that would be the most important thing to build vaccine confidence.” The emphasis on the N-hour sequence led to days of phone calls and tabletop exercises. “It took up tons of staff time,” said the CDC official.
General Perna declined to be interviewed, but an HHS official said, “General Perna and OWS leaders contend that the unparalleled expertise of the health care community and scientists, military planning and logistics capability, American industrial ingenuity, and academic innovation enabled success and strengthened every step” of what continues to be a “complex, unprecedented, and herculean operation.”
Inside the CDC the prevailing wisdom on vaccine administration, built from hard-earned experience, was to underpromise, given everything that could go wrong, and then hopefully over-deliver. Redfield urged the White House and Secretary Azar to promise a more modest and achievable vaccination goal of 4 million doses by year-end, Vanity Fair has learned. He was rebuked by both Azar and Trump himself, who claimed to have better information and told him he didn’t know what he was talking about, said someone familiar with the exchanges. The number they insisted on was 100 million. In the end Redfield’s instincts proved accurate. By January 2, U.S. states had administered 4.2 million doses.
Azar declined to be interviewed for this story, but a former senior administration official said he never heard any point of difference between Redfield’s numbers and Azar’s, and that Azar was “meticulous” about getting accurate numbers from Operation Warp Speed planners and conveying them to the public.
By almost all accounts the Warp Speed program succeeded phenomenally in its central goal: to fund and support the development of COVID-19 vaccines, a process that usually takes years but was accomplished within 10 months of the pandemic’s onset. The program’s officials held weekly phone calls with state governors and sent out strike teams to states that were struggling with their rollout planning. But Operation Warp Speed’s failure to prioritize the administration of vaccines became a growing topic of concern at White House task force meetings, said several people familiar with the discussions.
Based on past experience, public health officials expected distribution planning to take up a significant amount of their time. But officials at the CDC said they were restricted from discussing distribution plans with the states until very late in the game, and were told by Operation Warp Speed officials that any operational details were “close hold.” And from the program’s formal launch on May 15 to the start of the vaccine rollout seven months later, just one of the roughly dozen Operation Warp Speed board meetings addressed distribution, according to two participants.
In response, a former senior administration official said, “The only role that the board played was to get barriers out of the way for the scientists and logisticians, to make sure they get what they need to be successful.”
To Ashish Jha, dean of the Brown University School of Public Health, the insistence on offloading responsibility to the states looks less like a reasoned plan than a deliberate evasion tactic. “It’s very clear that the feds really didn’t know or care whether states were going to be able to do this or not. If states can’t do it, we can always blame them. And that has been the strategy from the very beginning.”
In retrospect the FedEx trucks rolling to the rescue out of vaccine warehouses, duly captured by news cameras in accordance with General Perna’s wishes, call to mind U.S. tanks rolling into Baghdad in 2003—a declaration of victory, followed by mayhem.
All of the Credit, None of the Blame
In late April, HHS Secretary Alex Azar had a telling encounter in the West Wing with President Trump’s chief of staff, Mark Meadows. The two men had just left a COVID task force meeting in which the fledgling Operation Warp Speed program was discussed, and Azar was feeling bullish.
“This vaccine program is the way we need to do it,” he said.
Meadows, who had seen his share of reputations rise and fall in Trump’s orbit, wasn’t so sure. “You’re not going to get the credit for this, and you’re going to get the blame,” he told Azar, according to a former senior administration official. Azar responded, “I am completely fine with that.” To which Meadows, wearing a frown, said, “This may not be a good gamble on your part.” (Meadows did not respond to a request for comment.)
As it happened, according to several people who worked on the vaccine rollout, Azar’s gamble was that he could achieve the opposite effect: all of the credit, with none of the blame.
A lawyer by training, who had previously served at Health and Human Services under President George W. Bush, Azar was feared by subordinates as a formidable bureaucratic infighter. He surrounded himself with loyalists and was skilled at leaving paper trails against those who crossed him, according to a former HHS official, who described his leadership style as “ultra paranoid.”
A former senior administration official said of Azar, “It wasn’t about getting the credit. It was: Americans are dying every day. That was his guiding light.” Regarding his leadership, the official added, “He built a very strong team. That’s what any good executive would do.”
On January 29, Azar was put in charge of the White House COVID-19 task force, but within a month, control was turned over to Vice President Pence. The memory of that reversal shaped Operation Warp Speed, as Azar worked to design a program that could not be wrested from his grasp, said several people involved in the program.
As the secretive $15 billion program rumbled to life, with a central goal of developing a COVID-19 vaccine in record time, Azar moved swiftly to consolidate control, holding meetings that excluded the leaders of the agencies under the Health and Human Services umbrella, from the CDC to the Centers for Medicare & Medicaid Services. “He owned Warp Speed. He shoved everyone out of this,” said one former senior HHS official, adding, “He was the one who said [the states] didn’t need money to do this.”
Operation Warp Speed was supposed to be jointly run between the Defense Department and HHS, with an advisory board that included the CDC director, Dr. Redfield, and Dr. Deborah Birx, the coordinator of the White House COVID-19 task force. But most major decisions were made without any input from the board, said several program participants. “It’s part of the positioning the secretary has prioritized,” said one participant, “to get the credit for it, and anything else that goes wrong he can Teflon it off.”
“Rapidly Mashing Together Two Cultures”
Azar exhibited a tendency to side with the program’s military members against health officials from his own agencies. As military officials flooded into the Hubert H. Humphrey Building, where HHS is headquartered, the offices there began to look “like an armed camp,” said one Trump administration official who worked on the program. Top officials traded copies of a book called Freedom’s Forge: How American Business Produced Victory in World War II, which celebrated collaborations between the Pentagon and private companies.
At an early meeting Perna directed the participants—drawn from different backgrounds and from different agencies—to look at their government badges, which bore different logos. “We’re now one team,” he said, according to a meeting attendee, who added, “The CDC never bought into it.”
In a May 27 email to Operation Warp Speed officials, Dr. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, acknowledged the tensions between military and public health officials: “Part of the struggle here is rapidly mashing together two cultures. I am hoping that a joint work plan will go a long way to setting up swim lanes, timelines and deliverables.”
But the culture clash wasn’t so easily resolved, in part because it stemmed from a fundamental disagreement over the core mission. Were they trying to deliver vaccines to states or inject them into arms?
To officials at the CDC, creating a credible last-mile plan was an obvious imperative. Such a plan would have given the states detailed instructions on how to reach eligible vaccine recipients, how to formulate and deploy effective messaging, and how to enlist and assemble a force of vaccinators. It would be up to each state to tweak those instructions based on individual circumstances, but a clear blueprint needed to be in place, along with ample financial support.
More than a month before Operation Warp Speed was formally announced, CDC officials worked through Easter weekend to assemble a preliminary last-mile plan. But it soon became clear that their belief in its importance was not shared by Azar and his Pentagon allies. Dr. Messonnier, who had previously incurred the president’s wrath in late February when she warned Americans at a press conference that the COVID-19 virus would soon disrupt everyday life, was again sounding the alarm. She “warned and warned and warned” about the difficulties of forming a credible rollout strategy, said Dr. Rick Bright, then the head of the Biomedical Advanced Research and Development Authority, the government’s central incubator of new therapeutics. Others heard from Dr. Messonnier that the CDC was getting little support and being kept out of discussions and meetings.
To the political appointees and their Pentagon allies, these complaints from career officials sounded like unimaginative bellyaching. The CDC “strongly preferred public sector input over private,” said Paul Mango. As one Operation Warp Speed team member told him, “This is their Super Bowl. They’re not acting like it.”
In May, Dr. Redfield asked Operation Warp Speed officials for $5.35 billion for states to build their last-mile capacity. It wouldn’t be his last request. He asked again repeatedly through September, each time running up against the same obstacle: Secretary Azar’s office didn’t think that the states needed the money.
On June 5, a CDC team traveled from its headquarters in Atlanta, Georgia, to Washington, D.C., to brief Operation Warp Speed officials on their view of the essential components of a successful vaccination plan. What they heard back was dismaying. “They told [us] their task was to pick up the vaccine and put it in the trucks and drive it to state health departments and drop it off,” said one of the CDC team members.
When Dr. Birx asked the officials leading Operation Warp Speed more granular questions about the distribution and administration of vaccinations, she was rebuked, said someone familiar with the exchanges. “If you’re questioning my judgment, maybe you should do this,” one told her.
“A Vaccine World and a Vaccination World”
By June, concern was growing in the larger vaccination community that no credible plan to distribute vaccinations had been established. On June 27, Dr. Bruce Gellin, the president of global immunization for the Sabin Vaccine Institute, urgently emailed Paul Mango, requesting a meeting with Secretary Azar. “My mantra when I ran the National Vaccine Program Office was that there was a vaccine world and a vaccination world—and there wasn’t an arrow that connected the two,” he wrote. “From what I can tell, OWS is mostly focused on the vaccine part but has little insight into our national immunization program. I worry that there is a huge potential for chaos if, as it seems, the wheel is going to be reinvented on the fly.”
Before long Gellin scored an invitation. On July 15, he was invited to join a vaccine consultation panel that HHS established to presumably get expert input and loop in key experts who could help disseminate critical information. “Producing a vaccine is one piece of the task—but another equally critical component is ensuring public understanding, acceptance, and participation in any eventual vaccine campaign,” the invitation stated.
But Gellin soon came to believe that the panel’s principal function was to create a facade of “famous people” in the vaccine world, who would serve as “external validators” for any Operation Warp Speed vaccine. In biweekly Zoom calls that allowed for limited discussion, the group was briefed by various Warp Speed officials. “It was a seminar series,” said Gellin.
As states began work on their individual rollout plans, military officials headed down to CDC headquarters in Atlanta and took over a conference room. They brought their mission-driven culture with them, erecting a poster outside the conference room that read, “Winning Matters,” and touted “300 Million Doses of Vaccine January 2021.” The expectations were “unrealistic,” said one CDC official. “We counseled Perna that we should be planning a much slower rollout. These vaccines are complicated. It’s intimidating. States were likely going to want to start slow.”
But the warning fell on deaf ears. On October 8, at a discussion sponsored by Goldman Sachs, Azar dangled the idea that it was possible to have 100 million doses of the vaccine by year-end, a number that the White House supported. Said one former HHS official of Azar: “He just lies. The biggest lie is that he had it under control. He oversold it.”
A former senior administration official said that Azar’s projections related to doses produced, not administered, adding, “Whatever he said had been vetted by the Warp Speed team because he strived for transparency and accuracy.”
As late as December, shortly before the Pfizer vaccine was authorized by the FDA on an emergency basis, one participant recalled an Operation Warp Speed planning meeting where the distribution plan was outlined. “They showed how the vaccines were going to leave the warehouse, have a military escort. We’re going to add vaccines, kits, gloves. Then we’ll ship it wherever the states tell us,” said the former HHS official. “That’s where the presentation ended. You can’t say, ‘My job ends here.’ When you’re running an operation this large, you want to get shots in arms.”
Paul Mango defended the planning, saying that it was “all based on the fundamental belief that local leaders are best positioned to execute. It guided our whole process. We’re going to provide you the vaccine for free, all the accoutrements; we are going to distribute to precisely the place you want it; and all you need to do is tell us where.”
But by mid-December, as vaccines landed in hospitals and storage depots, the majority of states faced an almost immediate tangle of problems: too few vaccinators; in some cases, too few interested patients; threadbare public health departments, depleted by months of pandemic crisis; I.T. systems that were crashing in real time. Though several states—notably West Virginia and Connecticut—pulled off efficient and well-organized rollouts, they were the exceptions.
The Biden administration has moved swiftly to get more shots into arms. This week it announced that the Federal Emergency Management Agency would provide $1.7 billion and 600 workers to 27 states and territories, support the deployment of thousands of National Guard troops to help with vaccinations, and build new community vaccination centers that would be substantially staffed and funded by the Department of Defense.
Meanwhile, Dr. Redfield, who departed as CDC director on January 20 and returned home to Maryland, still has not been able to get a vaccination appointment for himself or his wife, who, like him, is 69 years old. He chose not to jump the line when the vaccine was offered to him as part of his federal job. “We’ve tried,” he told Vanity Fair. “Maryland is in the second week of 65 and over, [and there is] nothing available to sign up for.”
With more than a thousand Americans dying each day from COVID-19, the frozen sign-ups and stuttering rollout have life-and-death consequences. “When you have a policy where only a few states can succeed,” said Dr. Jha, “the problem is not that you have 47 failing states. It’s that you have a failing federal government.”
https://www.vanityfair.com/news/2021/02/how-the-covid-19-vaccine-rollout-was-hobbled?
Primary Care Doctors Are Left Out of the Vaccine Rollout
In the rush to immunize people against Covid, federal and state health officials have overlooked the role of doctors, physicians say.
by Reed Abelson - NYT - February 10, 2021
Primary care doctors have grown increasingly frustrated with their exclusion from the nation’s vaccine rollout, unable to find reliable supplies for even their eldest patients and lacking basic information about distribution planning for the shots.
“The centerpiece should be primary care,” said Dr. Wayne Altman, the chairman of family medicine at Tufts University School of Medicine who also sees patients in Arlington, Mass. State officials there are using Fenway Park and Gillette Stadium as mass vaccination sites, rather than ensuring practices like his can inoculate patients who are at high risk from the coronavirus.
“If you distribute the vaccine to all these practices and let them go at their pace, it would accelerate this rollout dramatically,” Dr. Altman said.
There are roughly 500,000 primary care doctors in the United States, who have traditionally administered nearly half of all adult vaccinations, inoculating their patients against pneumonia, flu and other infectious diseases. While most physician offices can’t handle storage for the Pfizer-BioNTech vaccine because of its need for special freezers, doctors say they could easily administer the Moderna vaccine with adequate storage measures as well as some of the others likely to become available soon.
“We’re ready,” said Dr. Elizabeth Kozak, an internist in Grand Rapids, Mich. She was approved in early January to deliver the Moderna vaccine. “We haven’t seen a thing, but we’re ready.”
Federal and state officials have focused most of their efforts on large vaccination sites, and are still setting priorities for frontline workers, teachers and people 65 and over. They also are relying on the big drugstore chains, like CVS or Walgreens. As part of that strategy, the Biden administration announced last week that it planned to distribute an additional million doses of vaccine to 6,500 pharmacies this week.
The administration has promised to give states three weeks’ notice about how many doses they expect, which should help with distribution plans. While supplies are not expected to increase significantly until April, the administration has talked about being able to vaccinate 300 million Americans by the end of the summer.
With the current supply, Dr. Carlos Portu, an internist in Naples, Fla., likens his patients’ efforts to find the vaccine to “whack a mole”; availability pops up, on a website or on Facebook, only to disappear very quickly.
His elderly patients struggle to check the website of their local Publix supermarket at 6 a.m. every day to try to find an appointment. Some may not even be able to remember their email address, let alone know how to refresh their web browser frequently enough to land a spot.
“We vaccinate every single year millions of Americans for influenza,” Dr. Portu said, adding, “It’s a shame we haven’t been given a seat at the table.”
Dr. Farzad Mostashari, a former Obama administration official whose company, Aledade, works with primary care doctors like Dr. Portu, has witnessed the struggle to get his own parents vaccinated.
“We need to use the systems people use normally,” he said. “A big part of that is going to be primary care doctors’ offices. They know how to give vaccines and have the trust relationship.”
Federal officials say they understand the critical role physicians play, especially in persuading Black and Latino patients who may be hesitant to get the vaccine.
But the largely first-come first-serve system, which heavily relies on someone’s ability to sign up for the vaccine by navigating a complicated website or driving to where doses are available, is reinforcing many of the country’s inequities. In many cities, individuals from wealthier, largely white neighborhoods, are taking up more than their representative share of the limited supply of the vaccine.
“Primary care doctors have been a loud and frequent voice in the conversation we have had on a path to equity,” said Dr. Cameron Webb, an internist who is now a senior policy adviser for Covid equity to the White House. He pointed to the administration’s recent efforts to supply vaccines to federally qualified health centers, which serve individuals who are likely to be at the highest risk from the virus and those who live in the most vulnerable areas. “It’s a critical component to our strategy.”
Despite their eagerness to participate, only one of five primary care physicians said they were giving the vaccine to their patients, according to a survey conducted in mid-January by the Larry A. Green Center with the Primary Care Collaborative, a nonprofit. Given the widespread shortages of supply, many could not get the vaccine, and a third of them reported they had not been in contact with their local health department.
Dr. Katelin Haley, a family medicine doctor in Lewes, Del., is one of the lucky few who just received 240 doses of the vaccine and will be immunizing patients this week. Her staff had been checking every day with the state to see when they could expect a shipment. “Chasing the vaccine has been almost a full-time job,” she said.
While Dr. Haley, who also works with Aledade, is sympathetic to the state’s struggle to get adequate supplies of the vaccine, she thinks practices like hers need some of the doses. “It’s a delicate balance to address the state’s needs and the individual practice’s needs,” she said.
Some physicians, like Dr. Altman, have received small amounts of the vaccine but they do not know when they may have enough to immunize all of the patients who qualify. In late January, Dr. Altman and his staff vaccinated 200 patients in the practice’s parking lot, in spite of the frigid weather. “Patients were literally in tears, they were so grateful for our efforts,” he said.
The Trump administration left it up to the states to determine how they distributed the vaccines, and the states, and even local communities, are taking different approaches. “So much of whether primary care is leveraged depends on the state,” said Ann Greiner, the chief executive of the Primary Care Collaborative.
Although the demand for vaccines is currently outstripping supply, relying on primary care doctors to vaccinate the public when supply begins to outpace demand later in the year is essential, said Dr. Asaf Bitton, a primary care doctor who is the executive director of Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health. Their involvement will be critical to overcoming vaccine hesitancy and reaching herd immunity.
While some conversations are beginning to take place, “they should have been starting to happen six months ago,” he said.
In other countries, like England and Israel, where primary care is more central to the overall delivery of health care, doctors are playing an important role in getting the public vaccinated, said Dr. Ezekiel J. Emanuel, a professor of medical ethics and health policy at the University of Pennsylvania and a member of the coronavirus task force set up by President Biden before he took office.
“We don’t exactly have that system in America,” he said, adding that he and his colleagues advised the incoming president of the need for a hybrid approach.
Doctors may also be in the best position to persuade patients who are hesitant to get the vaccine, by being able to talk with them one-on-one and even by making sure to offer the shot as part of a routine visit. A recent Kaiser Family Foundation survey found eight out of 10 people are likely to rely on the advice of a doctor, nurse or some other provider in deciding whether to get immunized.
“We can’t have one or two strategies for vaccine distribution,” said Dr. Evan Saulino, a family physician in Portland, Ore., who has talked to patients, including those who are Black or Spanish-speaking, who are not sure they want the vaccine. Some of his patients are distrustful of the government and may not want to get a shot from someone in uniform. One person he spoke with would not go to the drugstore but might consider being inoculated at his clinic.
Dr. Kozak, the internist from Michigan, agreed, saying doctors like her could focus their attention on people who can’t easily navigate the current set up. “We might not be able to do the numbers but we are able to do the more fragile and vulnerable populations,” she said.
https://www.nytimes.com/2021/02/10/health/covid-doctors-vaccine.html?referringSource=articleShare
No comments:
Post a Comment