Editor's Note -
Check out this 11 minute video about the causes of high health care costs in America from CNBC.
Not too bad, considering the source.
-SPC
Disease took my brother. Our health-care system added to his ordeal.
by Karen Tumulty - Washington Post - March 11, 2022
As a child, Pat could multiply three-digit numbers in his head, but social interactions mystified him and making friends did not come naturally. Our father was in the Air Force, and we moved almost every year; at each new school, the bullies quickly found him. Yet no one who knew him could ever remember seeing him angry or bitter. He assumed the best of people, no matter how many times they betrayed that trust; I don’t think he was capable of a mean-spirited act.
As an adult, Pat was proud and protective of his independence. But when he reached his early 50s, his health began to fail. My brother found himself up against not just disease but a broken medical system. Pat’s journey became a story of the best and worst of health care in this country, and it reveals the real-life consequences when health-care policy is treated like a football by two political parties.
None of which our family would have anticipated back in 2007, when Pat, who had always been fit, began having bouts of fatigue and a fluctuating appetite. Then came more alarming signs: His blood pressure crept up to 150/90; his urine turned brown and foamy.
At the time, Pat was unemployed, having been laid off from his $9-an-hour position as an administrative assistant. That job hadn’t paid benefits; nor had the one before it. So he had bought a series of high-deductible, six-month medical insurance policies that promised “the peace of mind and health care access you need at a price you can afford.”
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A skimpy plan was indeed the only policy he could afford — and it turned out to be a big mistake. Though Pat had faithfully kept up the premium payments for more than six years, his insurer began denying his claims a few weeks after a biopsy in July 2008 showed his kidneys were failing.
The company, a subsidiary of Assurant Health, cited a technicality: Each successive six-month policy treated Pat as a new customer. In digging through Pat’s records, it noticed some abnormal bloodwork from the previous December, eight months earlier. Though at the time the test result was inconclusive, the insurer deemed it evidence that Pat had a “preexisting condition,” meaning his policy wouldn’t cover it.
At that point, Pat was facing more than $14,000 in bills from hospitals, doctors and labs — and those were just to figure out what was wrong with him. Dealing with his condition going forward was going to be unimaginably expensive; newer drugs that his specialist thought might help him the most could cost up to $10,000 a treatment; even the older ones could run $500 a month. “Cancel that policy,” the billing coordinator at the doctor’s office advised me. “Your brother is wasting his money on premiums, and he’s going to need it.”
Suddenly stranded with no coverage at all, Pat had plenty of company in our home state of Texas, which, then as now, led the country in both the highest number and the highest percentage of its residents who are uninsured. (The rate was 18.4 percent in 2019, twice the national average.)
Texas’s Medicaid program — which the state has chosen not to expand, despite the incentives offered by the Affordable Care Act — is notoriously stingy; a non-disabled adult without children, such as Pat was, could not qualify if he earned more than $2,274 a year. The offerings of the state’s high-risk pool, for those who are hard to insure, was not only twice as expensive as a typical medical policy, but Pat would have had to wait a year to join with a preexisting condition.
Peter Smolens, his kidney doctor, assured us he would keep treating Pat even if he couldn’t pay — as Smolens did with 10 percent of his other patients. A social worker in his office made countless phone calls seeking forbearance from other providers. (One radiologist gave him a $22 hardship discount off a $626 tab, adding: “We are happy that we could be of assistance to you and your family in this time of need.”) Knowing that creditors could come after his one-bedroom condominium, his 2003 Saturn Ion and his $36,000 in savings, Pat began paying off bills in bits and pieces as best he could: $51.89 a month to one hospital, $76 to another, monthly installments of $4.78 to $111.89 on six different sets of laboratory charges.
I also did research into Assurant Health, and discovered regulators in Connecticut had imposed a record $2.1 million in penalties on two of its subsidiaries for allegedly engaging unfairly in a practice called “postclaims underwriting” — combing through short-term policyholders’ medical records, as they had with Pat’s, to find pretexts to deny their claims or rescind their coverage. We had canceled Pat’s useless policy, but I nonetheless lodged a complaint with the Texas Department of Insurance. In reply, Assurant maintained it had done nothing wrong, but it offered to cover the bills it had rejected the previous year — which it claimed was a gesture of beneficence that nodded to “the extraordinary circumstances involved.”
These practices were common at the time. Insurers argued they were necessary to prevent fraud — specifically, people buying policies only after they learned they are sick. That clearly was not the case with Pat, but that didn’t seem to matter in the case of Assurant’s decision not to cover his care.
One of the more popular provisions of the Affordable Care Act did away with insurance company exclusions for preexisting conditions. Barack Obama’s administration also significantly curtailed short-term plans, such as the junky one Pat naively bought, by prohibiting them from being purchased for more than three months. They were available as a stopgap for people who, say, were briefly between jobs. But for the longer term, the idea was to steer people toward the more comprehensive coverage offered on the ACA’s government-run insurance exchanges for those who do not receive insurance through their employer. As Pat’s experience showed, diagnosing and treating an unexpected illness is not something that can be wedged neatly into six-month increments.
After Donald Trump was elected, Republicans fell short in their efforts to repeal all of Obama’s signature legislative achievement, but they managed to undercut it where they could — including by issuing new regulations that allowed health insurance companies to once again sell short-term policies, renewable for up to three years. The policies were not required to cover preexisting conditions or offer a full array of benefits. Trump Health and Human Services Secretary Alex Azar conceded that short-term insurance “may not be the right choice for everybody,” but insisted, “we believe strongly in giving people options here.”
Assurant Health, the parent company of Pat’s former insurer, meanwhile, got out of the business of selling individual health policies in 2016, after failing to find a buyer for that part of its operation. Its questionable business model was a casualty of the ACA. As Crain’s Chicago Business noted: “Regulators routinely found that Assurant Health failed to pay or unreasonably denied medical claims.”
While Pat’s medical bills mounted and his kidneys continued to fail, he managed to find a job answering queries that came into a text-messaging service, which paid $1,257 a month, but it didn’t offer health coverage. He was almost out of options when he discovered a county program available to low-income people. It operated much like a health maintenance organization, negotiating prices with health-care providers and then billing clients on a sliding scale according to income.
For Pat, it cost only about $40 a month. But the system was complicated, especially for someone with Asperger’s, and he often got confused navigating between his kidney specialist, who prescribed tests and medications, and the county program, which had to approve them. As Smolens, his doctor, told me: “The fact is, for guys like Pat, it requires a lot more work to do the same sorts of things” that would be easily dealt with if he had insurance. At one point, Pat had a bad reaction to steroids and was taken by ambulance to a hospital that was not a participant in the county program. The result — including a pile of bills and a short, unhappy stint for Pat in a group home — was a bureaucratic, emotional and financial nightmare.
While this was going on, I was living in D.C. and covering the ongoing national debate over health-care reform for Time magazine, as I tried to help out as my brother’s long-distance case manager. I thought I was something of an expert on health-care policy; I had even moderated a presidential candidate forum on the issue in 2007.
But experiencing firsthand what so many other families were going through gave me a different understanding of the unending hurdles and real-life stakes that underlie the heated political battles raging around the subject. I wrote about Pat’s ordeal in a March 2009 cover story for Time that carried the headline “So You Think You’re Insured? (Think Again.)”
The January 2014 opening of the health insurance marketplaces created by the Affordable Care Act, though beset by technology glitches, was a godsend for Pat. Along with nearly three-quarters of a million other Texans, he signed up during the enrollment period; government subsidies made a “silver” plan affordable, and his options more flexible, though there were bumps from year to year as several companies dropped out of the marketplace.
But while he no longer had to worry about how to pay for his treatment, even the best care was not enough to hold back the progression of the kidney disease, a condition known as glomerulonephritis. By the end of 2016, he had end-stage renal disease, which meant he needed dialysis.
At this point, Pat encountered yet another paradox of the health-care system. End-stage renal disease is one of only two conditions that make people automatically eligible for Medicare, with no waiting period, regardless of their age. (Pat was 62.)
That meant he was already covered by Medicare and a supplemental policy eight months later, when another, even greater medical calamity struck: In early September 2017, Pat suddenly lost control of his car and crashed it. He was taken to an emergency room, where a scan revealed a baseball-size brain tumor. Surgery and a biopsy produced a diagnosis of Stage 4 glioblastoma; his doctors told me he could expect no more than a year to live. I scrambled to find him a new living situation, a comfortable apartment in Patriot Heights, a retirement community that also offered a separate skilled nursing facility and was near the medical center where most of his specialists practiced.
Pat was now caught: The fact that he was also undergoing dialysis made him ineligible for clinical trials that might have given him a better chance against the glioblastoma; that he had cancer meant he was no longer eligible to stay on the waiting list for a kidney transplant. My gentle, sweet brother accepted this new turn in his life as he had every other one, starting a regimen of radiation and chemotherapy without a trace of anger or despair. It helped enormously, however, that his Medicare coverage allowed all of us to concentrate on getting him what he needed, rather than worrying about how and whether he was going to pay for it.
For reasons the doctors couldn’t explain, Pat lived years longer than anyone thought possible. And he lived fully. He enjoyed raucous gatherings with our large extended family in San Antonio, and looked forward to visits from my brother Mike, who lives near Dallas. Pat’s new home was truly a community, one where he learned everyone’s life story and was greeted like the mayor when he entered the dining room. His fellow aging baby boomers were appreciative of his encyclopedic knowledge of ’60s and ’70s rock-and-roll.
The Patriot Heights staff was indulgent of — and more than a little amused by — his quirks and his routines; how he wanted four packets of honey with his coffee, his juice with and not before his meal, a serving of exactly eight grapes. Pat loved his Wednesday morning Bible study group, where he always volunteered to read aloud the epistle of the week, especially the ones by the apostle Paul, known for their comfort and righteousness. Physically, he was doing well enough to regain his driver's license, which restored a measure of his independence.
But in late 2020, doctors told us that his cancer, which had been stable for more than two years, was coming back. Over the next year, Pat endured a second brain surgery; a craniotomy to relieve a subdural hematoma that he suffered in a fall; and another fall that broke his hip, which required a partial replacement. And yes, Pat also caught covid.
After many trips to the hospital and several stints in nursing care, he was able to return to his apartment but required 24-hour caregivers — something he was able to afford thanks to a modest inheritance from my parents and a bit of savings of his own. But he lost the ability to walk and began suffering small seizures, which required frequent trips to the emergency room. He also began losing track of people’s names, something that really bothered a man who had always been proud of his remarkable memory.
Medicare paid for nurses to visit, and on Feb. 7, one of them called me to say that Pat had told her something I never expected to hear from him: He wanted no more treatment, and wished to be placed in hospice care. She then put him on the phone, and he repeated his wishes to me.
The end for him came gently 10 days later. It was a gift to all of us that he made this decision himself, that he could determine when the medical care that had prolonged his life had begun to make it unbearable.
At his memorial service, the Rev. Linda Gwathmey, a Patriot Heights resident who had led Pat’s Bible study group, read from 2 Timothy 4:7, a passage where Paul, in prison and near death, writes that he has given God and his fledgling church his best effort.
“I think Patrick was a little like Paul here. He was tired, he was depleted, he knew death was approaching, and he thought it might be soon,” she said. “Patrick, like Paul, fought the good fight, finished the race and kept the faith.”
We will miss him every day, but we are left with the soft light of Pat’s spirit, which we had never seen more clearly than in those final, borrowed years of his life. Rest in peace, big brother.
https://www.washingtonpost.com/opinions/2022/03/11/health-insurance-obamacare-karen-tumulty-brother/
Envision Healthcare Hits the Skids
Backed into a corner financially, the private equity–owned physician staffing company could put doctors and patients at risk.
Envision Healthcare—the private equity–owned emergency medicine group with some 70,000 health care professionals staffing 540 health care facilities in 45 states—is in serious financial trouble. Creditors have lost confidence in its ability to repay its huge debt. Envision’s $5.3 billion first-lien term loan, due in 2025, was trading in distressed-debt territory at the beginning of March 2022, at 73 cents on the dollar; and its senior unsecured note due in 2026 was trading at 53 cents on the dollar.
How did this happen to the largest U.S. physician staffing firm, owned by Kohlberg Kravis Roberts (KKR), one of the most financially successful private equity firms in the world? How can KKR extricate itself and protect its investment? And what happens to its doctors and patients?
Private equity firms like to boast about their closely guarded “secret sauce” recipe for how they buy a company, load it with debt, introduce new high-tech practices that increase efficiency and revenue, and exit at a profit. But KKR and Envision demonstrate these assertions are empty. KKR acquired Envision in 2018 in a leveraged buyout that burdened the company with billions in debt. But KKR’s plan for paying off the debt and garnering a high return for its investors was purely low-tech.
Envision’s emergency room doctors do not belong to any insurance network. This let Envision send surprise medical bills to patients even when the hospital was in the patient’s insurance network. Loading patients who sought emergency care with often unpayable medical debt was KKR’s secret sauce. It was as simple as that.
Envision’s reliance on surprise billing became clear by mid-2019. As public anger rose, Congress focused on the two largest physician staffing companies engaged in this tactic, KKR’s Envision and TeamHealth, owned by Blackstone. Both houses of Congress introduced a joint, bipartisan bill to ban surprise medical bills that was expected to pass by the end of that year. (It would take a bit longer.)
Financial markets understood that, if the surprise-billing ban passed, Envision would not be able to pay off its debts. Envision’s first-lien term loan, the most secure debt held by creditors, quickly tanked to 50 cents on the dollar. When House members introduced a competing, PE industry–friendly alternative, stalling the effort, Envision’s debt recovered to around 70 cents, and hovered there through the first half of 2020.
Envision’s debt, however, still traded below 80 cents, which is considered distressed-debt territory. With the outbreak of the COVID-19 pandemic in March 2020, Envision’s finances were further strained, as elective surgeries and ER visits were curtailed throughout the country. The company faced the pandemic without any help from KKR’s deep pockets. It cut salaries of doctors and administrators, laid off clinical staff, and cut other costs at its emergency rooms nationwide. By April 2020, just two years after KKR acquired it, Envision was in bankruptcy talks with creditors and financial consultants.
But Envision avoided bankruptcy thanks to a bailout from the CARES Act (estimated by Axios to be $100 million) and the drawdown of its entire $300 million revolving line of credit with Credit Suisse—a provision included in Envision’s filing following the 2018 buyout. By mid-2020, its term loan was trading above 80 cents.
Congress continued its efforts to rein in surprise medical bills, and finally passed the No Surprises Act as part of the December 2020 omnibus spending bill, with the ban to take effect on January 1, 2022. But the bill included a provision allowing providers to take their case for higher pay to arbitration, which private equity–owned health providers favored.
However, while many viewed the final No Surprises Act as a victory for private equity, a close reading of the arbitration provision suggested otherwise. When the Biden administration’s Department of Health and Human Services wrote the regulations to implement the act, they hewed closely to the intent of Congress. While arbitrators determining payments can consider mitigating facts such as the doctor’s level of training or sickness of the patient, they are expected to start negotiations from the median in-network rate for a specific service in a specific region, not from the amount billed for physician services by the PE-owned staffing company. This allows for exceptions, but holds down health care and premium costs.
The ultimate outcome remains uncertain. In February 2022, a Texas federal judge struck down the rule requiring arbitrators to use in-network bills as a starting point. Patients are still protected from receiving surprise medical bills. But without this anchor, providers may receive outsized payments for services, driving up overall health care costs.
Loading patients who sought emergency care with often unpayable medical debt was KKR’s secret sauce.
Despite this potential lifeline, the value of Envision’s debt continues to get hammered and its financial troubles persist. Envision’s current credit agreement allows it to transfer between $2 billion and $2.5 billion of assets to an unrestricted subsidiary. The company is in talks with Apollo Global Management, HPS Investment Partners, and Pacific Investment Management Company (PIMCO) to raise new capital in a deal that would shift some assets, presumably the most valuable ones, away from the existing creditors.
Drawing on lessons from other PE-owned companies facing financial distress—like Nine West, J. Crew, and Sears—KKR will likely emerge unscathed by dividing Envision into two companies, one with the valuable assets and the second with the remaining assets. For example, after the leveraged buyout of Nine West, Sycamore Partners immediately moved the most valuable brands out of the reach of creditors, leaving all of the original debt on Nine West. It paid itself a $40 million dividend, sold the better brands, and pocketed the proceeds. Nine West, meanwhile, filed for bankruptcy in 2018, laid off its workers, and closed all its stores.
Following suit, KKR may divide Envision’s assets, with “Bad Envision” holding the least profitable assets and the debt, while “Good Envision” gets to make a clean start and raise new debt to pay off creditors holding the debt of Bad Envision, at significantly less than 100 cents on the dollar.
Bad Envision, now left holding the debt, will need to engage in drastic cost-cutting to service debt and stave off bankruptcy. Even without the specter of bankruptcy, Envision physicians are under pressure to meet corporate performance metrics. According to a December 2021 California lawsuit filed by physicians at an ER facility, Envision’s corporate management has “profound and pervasive” control over its doctors. It determines pay and staffing, work schedules, patient volumes, and internal standards for treatment. Envision pits physician performance against the standards, “with the intention of modifying and interfering with” the physicians’ judgment of how best to treat patients.
The situation at Bad Envision can be expected to be even worse, with understaffing to save money imposing costs on both doctors and patients.
HCR ManorCare provides a disturbing preview of what may happen. PE firm Carlyle acquired the chain of over 500 nursing homes in 2007 for $6.3 billion, with $4.8 billion in debt. In 2011, Carlyle sold off the chain’s real estate to Healthcare Properties (HCP), a real estate investment trust, for $6.1 billion, pocketing more than $1.3 billion on the deal. Carlyle’s sale-leaseback arrangement unfairly burdened ManorCare with unaffordable rent payments. By 2012, unable to make these payments, ManorCare began laying off hundreds of employees. HCP responded to ManorCare’s decline by retaining its own “good performing” assets and spinning off ManorCare’s bad ones into a new REIT called Quality Care Properties (QCP). QCP sued Carlyle for back rent payments, and in 2018 ManorCare filed for bankruptcy. Between the time ManorCare’s real estate was split in two and the time of its bankruptcy, investigators had cited the chain for thousands of health code violations, as exposed in an investigative report by The Washington Post. Health code violations increased by 25 percent to 2,000 per year, almost all related to understaffing. Serious health code violations posing “immediate jeopardy” rose 29 percent.
Similarly, Bad Envision may find itself hurtling toward bankruptcy while understaffing emergency rooms to fend off that outcome, turning life-threatening emergencies into deadly ones for some patients. Congress was right to put an end to surprise medical bills; now it must act quickly to prevent KKR from extricating itself from a bad financial situation of its own making at the expense of Envision’s doctors and patients.
https://prospect.org/health/envision-healthcare-hits-the-skids/
Groups Reject Biden Rebrand of Trump's Medicare Privatization Ploy
Can Public Health Be Saved?by James Hamblin - NYT - March 13, 2022
At the end of February, the Centers for Disease Control and Prevention issued a consequential turn in its mask guidance. The new recommendations meant that most of the country could stop requiring masks indoors — largely passing the decision on to local authorities, many of whom had already decided to roll back mask mandates. This was greeted with a mix of contempt and indifference. Depending on whom you ask, it was either too late (Masks? What masks? Fire Fauci.) or too soon and too cavalier. A unifying thread was that the C.D.C. is wrong, its rules are politically motivated and it needs to do … better.
As of this January, trust in the C.D.C. had plummeted. At the beginning of the pandemic, 69 percent of Americans believed what they heard from the agency, according to an NBC News poll. Now that has fallen to 44 percent. The numbers for Dr. Anthony Fauci have also substantially declined, despite his decades of government service under seven presidents and attempts to remove himself from political rhetoric.
Without this foundational trust, contempt for guidelines trickles down to anyone tasked with applying the rules. Retail workers, teachers and flight attendants asking people to wear masks end up serving as a proxy target for a deep-seated rage against the science.
To understand how the public health establishment has fallen, and what might be done to redeem it, one needn’t look far back. While the Trump administration may have created a new level of distrust by directly undermining experts, the issues are more deeply ingrained and something a changing of the guard alone couldn’t fix.
No moment in the pandemic underscores this better than July of 2021. You were there. It was great. The long-awaited — if regrettably nicknamed — “hot vax summer” was nearing a premature peak. It was a fleeting period of blissful ignorance. Many vaccinated people had stopped wearing masks after the C.D.C. told them they didn’t have to in most settings. Cases of Covid-19 had dropped, and the number of vaccinated Americans was growing. The long-promised return to normalcy was supposedly finally imminent.
Americans had been assured as much before. But this time, the United States had a new president who promised to follow science and surrounded himself with an esteemed team of doctors. Most notable was the chief of infectious diseases at Massachusetts General Hospital, Rochelle Walensky, whose appointment to lead the C.D.C. was greeted by resounding praise in the public health community. Under Donald Trump, the agency’s pandemic response had been defined by shortages and chaotic messaging. But that was finally over.
Then, the new hope crumbled. Leaked internal C.D.C. information suggested that vaccinated people who were infected with the new Delta variant might be able to spread the virus by way of breakthrough infections.
Americans squinting over their sunglasses weren’t sure what to make of the news. Immunologists had long mentioned the potential for post-vaccination infection, though it was unclear how often it would actually happen. Now the agency apparently had changed its recommendation on masks for the vaccinated based on data that the infections could be more common and consequential than originally thought. This had the potential to upend President Biden’s promise to end the pandemic. Yet the first word the public heard on the data was from a leaked presentation, devoid of context. This seemed the inverse of the candor and transparency Americans had been promised.
“I think there was a shortsighted hope that messaging that vaccines were perfect would ensure people get vaccinated,” said Julia Raifman, an assistant professor of health law, policy and management at Boston University.
By the height of the Delta surge, some 2,000 Americans were dying each day. Then during the Omicron wave in early 2022, the United States would see an even more severe wave of illness and death. Amid all of this, the public has received few news conferences from agency experts, instead parsing cryptic guidance on their own, amid news of testing shortages and reports of the C.D.C. withholding Covid data.
Many politicians and pundits actively work to highlight such failures as proof that nothing the agency says is to be trusted. Others are spreading outright falsehoods in bad faith. “It’s disgraceful, and it’s shameful, and it’s killing people,” said Dr. Francis Collins, former director of the National Institutes of Health. “Politicians and media and social media personalities who are distributing misinformation have blood on their hands.”
Some leaders brazenly do the opposite of what the C.D.C. recommends. In Florida, mask mandates have been banned, and the state is defying medical consensus by recommending that healthy children not be vaccinated against Covid. The overall effect can erode a common factual basis for reality, leaving many people believing that everything is simply a matter of opinion.
No country in the world has had a perfect pandemic response. America is not alone in its struggles to develop and communicate effective policies. But one of the few constants of the pandemic is the fact that countries with high levels of social cohesion and trust in leadership fare better than those without it. The authority of the public health establishment lies in its trustworthiness among the public. Without that, it is ineffective. The Biden administration seemed to understand this and has made real attempts to restore the public trust that was lost under Mr. Trump. But America’s public health apparatus remains beleaguered.
How could it be that this happened, since it seemed all the best people were in place?
***
For all the blame placed on Mr. Trump for his failed pandemic response, many of the same issues of distrust and confusion have plagued the Biden administration, for nearly opposite reasons.
Under Mr. Trump, the silencing of health officials was overt. The administration blocked some C.D.C. officials from television interviews and reportedly reviewed C.D.C. reports and in some cases, requested word changes. Dr. Robert Redfield, the agency’s director at the time, and the coronavirus response coordinator, Dr. Deborah Birx, seemed to struggle to avoid contradicting Mr. Trump. The image of Dr. Fauci chuckling and cupping his head with his hand as the president spoke of the “Deep State Department” during a coronavirus briefing became indelible.
By contrast, Dr. Fauci has told me, President Biden is far more interested to hear from him and the other experts on the team. And the administration’s messaging is confident, concise and unified. There is very little daylight between what Dr. Fauci says and what Mr. Biden and Dr. Walensky say and what Jeff Zients (Dr. Birx’s successor) and Surgeon General Dr. Vivek Murthy say. This is, theoretically, ideal.
And yet the system is struggling. Public distrust, uncertainty and skepticism are at a low ebb. The generous read on the situation is: When leaders attempt to follow science earnestly — and wait for consensus among people who think in nuances — they risk being slow to respond and vague in advice and conclusions. The less generous read is that politics and science have melded so completely that the result has been neither scientifically nor politically effective.
“I think the administration has been thinking: ‘We want to speak with one voice. We don’t want to confuse people. We don’t want mixed messages,’” said Dr. Thomas Frieden, a former director of the C.D.C. who dealt with outbreaks such as Zika, H1N1 influenza and Ebola during his tenure. “‘So, all of the briefings will be from the White House.’ The problem is, then you don’t get the granular briefings you need.”
In the attempt to have a cohesive message, there appear to be delays and failures to say anything at all. Whatever the intent, the effect has left Americans feeling uncertain of whom to trust, at best. At worst, lied to. The issues go beyond messaging, to failures to update basic definitions or policies that could easily — instantly — be carried out.
For example, the definition of “fully vaccinated” has not yet been changed to include booster shots, even months after the C.D.C. recommended them for everyone. It can be argued there’s a political benefit to not doing so: If the definition were updated, the administration would no longer be able to tout the success of 65 percent of people being fully vaccinated. Suddenly that number would drop to around 44 percent. (The C.D.C. says people who have gotten their booster are considered “up to date.”)
Other decisions have been similarly vexing. During the Omicron surge, the administration maintained a travel ban against South Africa for weeks despite the fact that the virus was already in the United States. And for months there was persistent hesitation to acknowledge the usefulness of N95 masks and rapid tests, coinciding with a national shortage of both.
In isolation, any of these decisions might be dismissed as an earnest oversight. The agency is small, understaffed and underfunded. But taken together, there is a pattern of alignment between health information and political expediency. This approach may placate people in the short term, but it makes the crisis of trust only worse with time.
It is not too late for the Biden administration to make lasting changes expressly aimed at stopping the decline in trust. But it must act now. Because there is a real chance that America’s public health institutions will slide further into the realm of serving political agendas.
The situation could be far darker if another president came to office who proudly derided expertise and silenced agencies when their message became inconvenient. It’s not so hard to imagine that a second term for Donald Trump, for example, could see requirements of total fealty from scientists.
It doesn’t have to be this way. There are real steps that the government can take to rebuild public trust.
***
No system of public health is perfect. But protecting science from politics as best as possible, without siloing it into obscurity, is a good goal and would go a long way to healing many of the divisions over public health that we’ve seen during this pandemic. In a hypothetical world, a president could assure Americans that everything is fine and churches could be packed by Easter. Then, a C.D.C. director could step to the podium to tell the public: “Well, I’m not sure they will be. Here are the numbers we have ….” And the public would be able to draw their own conclusions.
In any crisis, serious disagreement over values and priorities is inevitable. How many lives saved should justify, say, closing schools? Is preventable illness acceptable as long as our hospitals are not overcrowded? There is no single correct answer when choosing between losses that people value differently. Trust in a system does not mean always agreeing that the correct decision has been made but that decisions were made in good faith, transparently, taking all perspectives into account. We haven’t had enough of this in the pandemic.
This process cannot happen without a baseline of evidence and facts, from which people can agree or disagree about policy. A good example is weather. Meteorologists say that a hurricane is approaching the coast. Local leaders advise people to take precautions, maybe to shelter in place or evacuate. Some will decline to do so. But it’s not because they don’t believe in hurricanes or think the meteorologists are trying to fool them.
Similarly, people should be able to trust that a deadly virus is spreading and evolving, and agree on the numbers of cases and the potential consequences of various policy approaches, and then disagree about what approach to take. As it is, science and policy are packaged together. This causes situations in which people who disagree with a policy like school closures are accused of dismissing the seriousness of the virus altogether.
A healthy distance between the C.D.C. and other political leaders would allow the agency to quickly and transparently communicate information to the public, even when it’s politically inconvenient. When health agencies, scientists and politicians appear to be working as one, especially in a highly polarized political climate, people can dismiss the messages altogether. “For the people to whom the Biden White House is anathema, you basically get them to turn off to C.D.C.,” Dr. Frieden said.
One of the key steps to take, according to Dr. Frieden, would be freeing up the C.D.C. to do independent briefings. “If you look at H1N1, Ebola or Zika, we were giving nearly daily press conferences,” he said. “It hurts the public to not hear regularly from C.D.C.”
And not just the C.D.C. — Americans should hear from, and be heard by, all involved in a pandemic response and bear witness to a transparent process of decision-making. Even when it gets messy, the end result will feel less like a decree from an ivory tower and more like the imperfect product of continuing dialogue. The new mask guidelines in February may have felt too abrupt to some because the C.D.C. hadn’t yet explained the imperfection of relying on case numbers alone to define risk calculations; its new community-based guidance now includes the share of hospital beds being used and hospital admissions, in addition to case numbers.
Inevitably, pundits and political opportunists would attempt to paint disagreement as conflict, and changes in guidance as hypocritical contradictions. This could lead people to believe that no one knows what they’re doing, and so you may as well eat horse paste. This effect is not insurmountable. But it requires active work to earn trust and retain credibility.
To ensure that this kind of separation between politics and health can happen regardless of the presidential administration, new measures may need to be enacted. For example, Congress could move agencies like the C.D.C. and the Food and Drug Administration outside of the Department of Health and Human Services to allow for more independence. This has been called for many times over the years, and the case is only growing clearer. Within that arrangement, it may also be possible to limit the influence of any given president over public health, for example by requiring congressional approval of C.D.C. directors, possibly for a term that does not coincide with presidential terms.
And though communication lies at the heart of rebuilding public trust, the agencies must also have timely and credible — ideally impeccably vetted and contextualized — information to communicate. This means expanding them significantly, possibly via a mandatory funding stream that can allow for long-term planning and independence from political whims. In 2021, the C.D.C.’s discretionary funding was $7.1 billion, equal to roughly 1 percent of the funding for Department of Defense. Having just witnessed how costly a pandemic can be, we should take this moment to treat public health as a matter of national security and provide the agency the tools and personnel to live up to its own advice on crisis communication: “Be first, be right, be credible, express empathy, promote action and show respect.”
Absent this, Americans are witnessing what happens. Regular cycles of panic and confusion have worn everyone’s patience to the bone.
And this virus is not going away; there will be more surges. And there will be other pandemics. Our system has proved to be unprepared to deal with them. Investing in rebuilding sources of information is the only way forward.
https://www.nytimes.com/2022/03/12/opinion/public-health-trust.html?referringSource=articleShare
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