Trimestrale di cultura civile

The Value of Coordinated Management

Experiencing the pandemic has put unprecedented strain on the US public health system. There is an ongoing strong debate in the nation, focusing on the causes and on the steps to be taken to start the necessary change of direction. An extensive reflection, where science and politics are being involved. The pillars of the US healthcare are under discussion.

A particular focus is on the actual lack of interest of the federal government in public care: its underlying deficiency is its most obvious trait. Now everybody is waiting to understand the direction that the new Administration is going to take. Now a coordination work is really urgent. However, it is unthinkable –also for historical and cultural reasons– for the country to move towards universal health care models.

In less than a year, the Covid-19 pandemic has infected almost 10 million Americans, and caused the death of more than 240,000 (at the end of November, ed.). These numbers account for more than twenty percent of the cases and deaths worldwide, an especially tragic figure given that the United States has only four percent of the world’s population. What accounts for the disproportionate impact of the pandemic in the United States? Part of the answer is rooted in the inadequate response of the Trump Administration, which has consistently minimized the danger presented by the virus, politicized key public health measures (such as wearing masks), and failed to develop a national pandemic response. At the same time, however, part of the answer is rooted in the nation’s public health system, which is under-financed, under-resourced, and lacks needed political influence.

In this article, I look first at the roots of the American public health system, a history and an evolution that explains much of the nation’s inadequate pandemic response. In addition, however, I consider as well the ways that the Trump Administration bungled the pandemic response, making an effective public health response nearly impossible. I conclude with some suggestions as to how President-Elect Joe Biden can fashion a more effective response going forward.

The Roots of a Public Health Crisis
By international standards, the United States is a relatively young country, founded in the late 18th century, following a war that resulted in independence from the British Empire. The nation’s founding fathers fiercely debated the appropriate division-of-power between the various levels of government, with those concerned about excessive central authority (such as Thomas Jefferson) battling those who argued for a strong national government fueled by powerful executive branch (such as Alexander Hamilton). Following the Presidential election of 1800, however, won by Jefferson, the nation for more than a century sharply limited federal power, delegating nearly all authority over the economy and the social welfare system to the state and local governments. In this context, nearly every local community developed its own department of public health, focused on the non-medical determinants of health, using their regulatory authority to encourage cleaner streets, safe food, working sewage systems, and workplace safety, while also serving as first responders to epidemics of infectious disease. More than two centuries later, the nation’s 3000 local health departments remain the core of its public health system.

Over time, however, the state and federal governments gradually increased their role in the public health and health care systems. The first key moment was in the 1930s, during the economic depression, when President Franklin Roosevelt engineered a dramatic expansion of federal power, overcoming political and legal challenges, enabling the federal government to become the engine for most economic and social welfare policy. Importantly, however, Roosevelt did not seek a significant expansion of the federal health agenda, instead deferring to hospitals and other health care providers who preferred private sector autonomy. Roosevelt’s focus instead was a pension program for the elderly and a cash assistance program for certain segments of the poor.

Shortly after World War Two, however, President Harry Truman advocated for a significantly expanded federal role in health care, trying (and failing) to get national health insurance, but having more success in using federal power to grow the nation’s hospital and medical research industries. In the post-war “era of optimism,” federal authority soon became grounded in the assumption that clinical medicine could conquer all disease, and that federal dollars and federal resources more generally should be used to support improved medical technology and improved access to such technology for all Americans.

There was, to be sure, a growing federal role in public health as well, most notably found in the Centers for Disease Control (CDC), which was officially created during the Truman Administration, in 1946, and which over time became a strong voice and resource for local and state health departments (and indeed for public health agencies around the world). But the core of the US public health system remained the state and local agencies, which were of quite varied sizes and capabilities. Moreover, as the nation’s health care bill escalated dramatically, the proportion allocated to public health began a steady decline, as U.S. health care spending was focused on clinical and acute care medicine as opposed to prevention and public health. As a result, by the early part of the 21st century, the United States was spending far more than any other nation in the world on medical care, but it had a public health system that was under-financed, under-resourced, and without clear lines of authority over emergency response activity.

There were, to be sure, additional reasons why public health became the step-child of the medical care system, explanations rooted in the very nature of the public health enterprise. For example, public health activities are invisible when successful (clean water and safe food are assumed and expected) but visible and scary during a crisis (excess lead in the water and illness caused by unsafe food). Once the crisis ends (the food contamination is found and fixed) the clamor for public health activity ends. In addition, there is in the United States a growing distrust of government and of science, and public health is a governmental activity rooted in science. It is also hard to quantify the return-oninvestment of many public heath activities. Citizens also often resent public requirements that are viewed as in conflict with individual rights (seat belt laws, no smoking rules, mask requirements during a pandemic), especially given the cultural inclination toward individualism in the United States, which contrasts sharply with the greater social solidarity in many other nations. Finally, the influential and highly prestigious interest groups that do well in the medical care system (hospitals, doctors, insurers, pharmaceutical companies) might support public health activities in the abstract, but fight fiercely to protect their own financial resources against efforts aimed at redistribution.

In this context, most “health reform” efforts in the United States are targeted at providing individuals with greater access to affordable insurance (and thus medical) coverage, surely a desirable goal, but one which again prioritizes medical care over public health. In 2010, for example, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA), commonly known as Obamacare, which was primarily designed to reduce the number of uninsured (and under-insured) Americans, through a variety of strategies, including expanding the nation’s public insurance programs (especially Medicaid), and also ensuring more affordable access to private insurance (though a combination of subsidies and regulatory requirements on insurers). While the law continues to be politically controversial (not a single Republican voted in favor, and President Trump has tried for years to repeal and/or undermine its key provisions), it so far has survived such efforts. Indeed, the ACA today provides insurance coverage to more than 25 million Americans and insurance security to tens of millions more, especially those with pre-existing medical conditions. But the law has not had much of an effect on rising health care costs, nor has it significantly increased funding or other resources for the public health community. 

The U.S. Response to Covid-19
The Covid-19 virus first appeared in Wuhan, China, in late 2019. By early 2020, the virus had spread globally, moving rapidly from Wuhan to northern Italy and then on to the United States and the rest of the world. By late November 2020, the worldwide toll was more than 50 million infected and more than 1.3 million killed, with 20 percent of that total concentrated in the United States, which had 10 million infected and more than 240,000 dead. There was, however, extraordinary variation in the cross-national impact. For example, while the United States has had 3039 cases per 100,000 population, Italy has had 1551, Germany has had 821, and New Zealand has had 40. In addition, while the United States has had 72 deaths per 100,000 population (and Italy has had 69), Germany has had 14, and New Zealand only 1.

There are many potential explanations for the cross-national variation, but the argument here is that the United States, under the Trump Administration, has done particularly poorly on the key pandemic response tasks. The overarching problem is that federal officials have not implemented a coordinated and comprehensive pandemic response, and have instead delegated to the sub-national governments (and to the private sector) the task of leading the country through this public health (and economic) crisis. While such an approach may be consistent with much of U.S. public health history, it is at odds with the response needed during a crisis, and at odds with the U.S. response to other recent infectious disease break-outs, such as Ebola and SARS.

Consider, for example, six key tasks that every nation needs to perform, and the United States performance to date on each.

Monitoring the path of the outbreak, so as to implement an appropriate data driven response
The U.S. scorecard on this task is mixed, as several University-based institutions (at Columbia, Johns Hopkins and elsewhere) have teams of superb infectious disease modelers, and these researchers have done an excellent job of tracking the path of the outbreak across the country, providing warning signals for policymakers and others. At the same time, however, these modeling efforts are led by these separate private institutions, without the kind of needed central coordination that can be supplied only by the federal government.

Producing and distributing the needed goods and services
Here the scorecard also is mixed. The good news is that hospitals and their affiliated health care workers have performed heroically in the face of the pandemic, as have medical researchers in both the public and private sectors. Hospitals created special Covid-19 wings, re-deployed physicians and other health care workers to pandemic-related tasks, and implemented new safety protocols quickly and efficiently. Meanwhile, pharmaceutical companies and academic researchers developed and tested new treatments, and engaged in an extraordinarily rapid (and likely successful) effort to develop an effective vaccine.

At the same time, however, the supply chain for needed personal protective equipment (masks, face shields, protective gowns) was inadequate to meet the need. Hospitals had spent years shifting to “just-in-time” supply closets, and thus had to procure needed equipment rapidly and efficiently, and had trouble doing so. And, unfortunately, the federal government did not take the lead in coordinating the purchase of such equipment (often from abroad) or its distribution. The result was a mass scramble for supplies, with state and local governments competing with each other, while hospitals and other health care providers engaged in bidding wars, a process that was particularly problematic for safetynet facilities that serve large numbers of the poor. President Trump also was overly reluctant to employ the Defense Production Act, which grants him the authority to order private industry to produce needed goods in a national emergency.

Communicating with the larger population to both explain what is happening, and why, and also to engender trust and compliance with needed behaviors
During the height of the first wave, in the Spring of 2020, President Trump became the nation’s lead communicator on the path of the virus, and the actions needed to get it under control, as he held news conferences nearly every night for weeks. Unfortunately, the President often misstated facts about the seriousness of the virus, regularly minimized the scale of the crisis and falsely promised it would be ending soon. He also promoted ineffective treatments (such as hydroxychloroquine) while downplaying (and politicizing) the need to wear masks. Perhaps most dangerously, he refused to let public health scientists be the chief pandemic communicators. Indeed, and to the contrary, he, instead challenged the need for many public health interventions, thereby encouraging his supporters, who were predisposed to distrust government and science, to view the pandemic as a political conspiracy rather than a public health crisis.

Regulating behavior as appropriate, by imposing limits on travel, closing businesses (or limiting their hours), requiring people to wear masks when in public places
For more than 200 years, state and local governments have served as the core of the nation’s public health system. Responding to a global pandemic, however, requires a national (indeed global) response. Federal officials should have put in place the measures needed to ensure an effective early warning system, an adequate supply of personal protective equipment, needed hospital surge capacity, and an intergovernmental compact with state and local governments on who would do what. Instead, President Trump delegated to those state and local officials the task of leading the pandemic response.

The lack of federal leadership has led to extraordinary variation in response by state (indeed by community). One problem is that some state and local political leaders parroted President Trump’s disdain for science and public health, thereby undermining their own public health professionals. At the same time, many of the local agencies are inadequately funded and understaffed. Indeed, by 2018, there were 56,000 fewer public health workers than there were a decade before. So, when the virus arrived, most local agencies were ill-equipped to conduct needed diagnostic tests, to isolate the infected, to determine who had contact with the infected, and to provide support to vulnerable populations.

Subsidizing businesses and individuals that suffer significant economic distress due to the pandemic, such as those who lose their jobs or their businesses due to the pandemic
The economic lockdowns imposed in response to the pandemic have imposed significant economic distress for millions of Americans. In response to this crisis, in late March, 2020, Congress enacted the Coronavirus Aid, Relief, and Economic Security Act (known as the CARES Act), which provided $2.2 trillion in assistance for the newly unemployed, health care providers, state and local governments, and others adversely impacted by the pandemic.

This Act was an excellent first step toward subsidizing those businesses and individuals that suffered economic distress during the pandemic.

By early Fall 2020, however, the pandemic continued to wreck havoc on the American economy, but the President and the Congress could not agree on a second economic stimulus bill, leading to renewed fiscal distress for individuals, small businesses, health care providers, and state and local governments. The deadlock was exacerbated by the Presidential election, which took place in early November. And in the immediate aftermath of that election, the legislative deadlock continues.

Reducing the disparities by focusing policy assistance to those groups most at risk (the elderly, those with underlying medical conditions, the poor)
In the United States, persons over the age of 65 account for more than 80 percent of the deaths due to Covid-19. The disproportionate impact of the virus is also felt among those with underlying medical conditions, along with those in the African-American and Latinx communities. Without a national pandemic response plan, the effort to respond to the disparities based on age, underlying medical condition, and race, has again devolved to state and local governments, who have had mixed (but generally inadequate) responses.

Responding to the Covid-19 Pandemic: Next Steps
The United States, along with much of the globe, is in the midst of a second wave of the Covid-19 virus. At the same time, there are two reasons to be optimistic about the pandemic response going forward. First, Pfizer and other pharmaceutical companies have developed what seem to be effective vaccines. Second, President-Elect Joe Biden, who takes office in mid-January 2021, seems likely to implement a strong and aggressive national pandemic response plan, which will include a massive scale-up of testing, a public health jobs corps which could include up to 100,000 individuals, and federal oversight of the distribution of the vaccine. Perhaps most importantly, however, President-Elect Biden is communicating a very different message about the virus than his predecessor, insisting that policy be guided by science rather than politics, and by noting that in order to stabilize the American economy, we first need to get control of the virus.

To be sure, there will be difficult days before the virus is under control. The surge in cases and deaths will not end soon. Moreover, the recent election demonstrated again how divided the nation is, as President-Elect Biden’s victory was narrower than expected, and the Republicans are likely to retain control of the Senate. In this divided government, it will be difficult to get a second comprehensive economic stimulus bill enacted, and without such legislation, pandemic fatigue and politics more generally will complicate the response effort.

At some point in the next year or so, however, there will be an effective and widely distributed vaccine, and the nation will again be able to return to some sense of normalcy. We cannot forget, however, the need for a strengthened public health system, led with strong federal leadership. In my view, we need a new and empowered voice for public health, which can be best accomplished by creating a new cabinet-level position for a secretary of public health systems. Indeed, it will take strong national leadership, billions of dollars, and a 21st century Marshall Plan to create the public health system we need. The new secretary of public health systems should be the person who leads that effort!

 

Michael S. Sparer, J.D., Ph.D. is Professor and Chair in the Department of Health Policy and Management at the Mailman School of Public Health at Columbia University. He studies and writes about the politics of health care, with a particular emphasis on the health insurance and health delivery systems for low-and-middle income populations, both in the United States and globally.

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