COVID19 will likely rear its horrible head again next year if it follows the pattern of previous pandemics as many experts believe. So, once we’re past our panicked response to the height of this year’s epidemic, we need to honestly and quickly address what we did wrong to make sure we respond more effectively in the next round. But, do we even have the infrastructure or governance tools to mount a more effective response the next time?
What Went Wrong?
Despite decades of warnings about the risks of cross-species epidemics, we mounted only half-hearted efforts to plan for the worst-case outcomes one could cause.
First and foremost, we, as a society, lacked the imagination to believe something like this could occur. Or, perhaps, this was just plain hubris. Of course, this couldn’t happen to us. The U.S. is home to some of the most highly regarded healthcare providers in the world, and we’re a leader in new health technologies.
Beyond that, we have consistently ignored the increasing number of our very real failures to respond to other health crises we have faced as a nation. The very immediate and painful failures in response to the COVID19 pandemic are not outsized, nor are they unusual. Although somewhat different, the last several years have seen similar failures of epidemic response to opioid abuse, obesity, suicide, and gun violence. And, we have also failed with each. But why?
Everyone’s in Charge and No One’s In Charge
Unlike issues in our broader healthcare system, we don’t lack planning or strategies for anticipating and responding to epidemics. It’s just that most aren’t worth the paper they’re written on and need to be scrapped and entirely re-worked.
Federal, state, local agencies, and providers have been planning, gaming, assessing preparedness, and practicing pandemic and other emergency responses at least since 9/11, SARS, swine flu (H1N1), and scares about bird flu (H1N1). The federal government created the Strategic National Stockpile in 2003 precisely in response to these concerns. We’ve had global pandemic surveillance programs in place in both the CDC (Centers for Disease Control) and (until recently) in USAID (U.S. Agency for International Development) for more than a decade.
At the federal level, we also have strategies and plans throughout federal agencies, raising the specter that, as with so much of the U.S. healthcare system, everyone is in charge, but no one is in charge. As stated with Dr. Suess-like clarity in the 2019-2022 National Health Security Strategy put out by the HHS Assistant Secretary for Preparedness and Response (ASPR):
“Ensuring a health-secure nation is a collective responsibility among federal, state, local, tribal, and territorial (SLTT) governments and public and private partners, non-governmental organizations, academic, professional associations, communities, volunteers, families, and individuals.”
All that is missing from that statement is the family dog. At a minimum, the U.S. Health and Human Services Agencies, Homeland Security Agencies, Defense Department, Veterans Administration, Agriculture Department (USDA), Department of Education, Environmental Protection Agency, State Department, and Occupational Safety and Health Administration (OSHA) all have plans. Just at the federal level, these include (at a minimum): Department of Health and Human Services Pandemic (Influenza) Plan; National Health Security Strategy; National Biodefense Strategy; U.S. Health Security National Action Plan; and, Global Health Security Agenda.
These federal plans are in addition to state, local, and hospital system pandemic preparedness plans. We’ve also had an ongoing assessment of each state’s ability to respond in this kind of crisis with measuring and reporting through the National Health Security Preparedness Index, which has been published annually for the last five years.
There has been near-continuous monitoring of U.S. and global threats and warnings from numerous experts that a deadly pandemic could emerge at any time. Before the Trump administration discontinued funding for the program, the USAID PREDICT program worked across the globe to identify and monitor zoonotic illnesses that had the potential to jump species and fuel a human epidemic. The program identified at least 1,000+ diseases. This effort was in addition to ongoing monitoring by the CDC in the U.S. and internationally. Just within the CDC monitoring includes the Laboratory Response Network (LRN) of 130 certified laboratories and reporting by local public health departments primarily focused on flu surveillance.
Our approach fails to consider and plan for the loose, private structure of the healthcare industry in this county.
But, this disjointed, multi-agency approach fails in one important way. Any response to an emergency like an infectious disease outbreak demands rapid action and military precision in coordination. We are a country with varied, broadly dispersed, and fragmented healthcare resources and decision making. If plans don’t include explicit mechanisms to corral key actors in advance, we lose critical time for our response. And, federal plans, and even to a large degree, state plans, lack those decisive mechanisms and decision making authority.
This is why the administration’s restructuring of the NSC office for global pandemics was potentially so disastrous. And, the administration’s government-wide efforts to “streamline” and restructure agencies involved in this kind of response, their minimizing of the role of the federal government in providing coordination and direction, and their drive to privatize solutions have magnified existing weaknesses. This includes shifting the National Stockpile between multiple agencies, which only added to the confusion and lack of preparation. The net result is that not unlike what we confronted with the 9/11 attacks, this disjointed approach increased risks that we would miss emerging threats or fail to mount a timely and adequate response.
If we don’t change our approach to these issues, this will not be the last time we face this kind of crisis.
Who Really Has Authority?
Though the public may clamor for the federal government to step in and exercise persuasive authority in a crisis like the COVID19 pandemic, national emergency response law and regulation generally does not grant that level of authority. Instead, those laws, our system of governance, and our healthcare system mostly delegate responsibility for an emergency response to our governors, local health authorities, and healthcare providers.
Existing law and health emergency response plans and strategies assume that the federal government performs a coordinating role, facilitating and providing technical support and some minimal funding for states and local governments. It does not direct.
The failed nationwide Medicaid expansion mandate reminded us that the states are not required to even participate in many federal programs. That includes pandemic planning. Each may also have its unique way of approaching the issue as is evidenced by the lack of a consistent approach to stay-at-home orders. A review of the most recent National Health Security Preparedness Index 2019 Summary of Key Findings shows this kind of wide variability in the state by state capabilities and readiness to respond to the kind of crisis we currently face.
The federal government’s ability to respond early and aggressively to an epidemic is limited mainly to ongoing, standardized health monitoring (testing and reporting through established, certified labs and local health departments) overseen by or certified by the CDC, risk monitoring, facilitating federal-state-local collaboration and development of planning frameworks and standards, maintenance of the strategic stockpile for emergency response, and shared funding and Hospital Preparedness Grants for specific activities. This limited capability leaves the federal government mostly dependent on states and local governments to carry out many of the actions necessary to respond to the urgent circumstances we are currently experiencing.
Even within the best run organization, these competing responsibilities, unclear lines of authority, and voluntary participation would be a recipe for mixed results. In the case of a country of 50 States, the District, and 16 territories, it is an invitation to disaster.
Plans Don’t Reflect the Real World of American Healthcare
Most plans that are in place also assume the American healthcare system has capabilities it does not have and can respond in ways for which it is ill-equipped. The issues we’re seeing in creating surge capacity and exponential increases in demand for supplies and equipment are Exhibit-A.
IP capacity has been significantly reduced and restructured over the last 30-40 years as more and more care has moved to outpatient settings, physician offices, and homes. Additionally, within hospital systems, capacity has been rationalized across facilities to limit the need to invest in high cost, specialized services in every facility. Although many hospitals retain unstaffed capacity, many newer facilities do not. And, even those that do have closed wings or other unused beds can’t always quickly shift that capacity for other uses, particularly if it requires the physical isolation of patients.
Though many plans anticipate the need for IP surge capacity, mechanisms to quickly and easily create it are weak at best, as the experience in New York is demonstrating. The plans that are in place also rely heavily on individual hospitals and states to quickly build and staff new capacity when needed. This is even more unrealistic since, as we are seeing now, many hospital systems simultaneously experience cash flow issues because of the need to limit elective procedures during an epidemic. Expecting individual hospitals or hospital systems to respond quickly to create new capacity in these circumstances fails to recognize the constraints under which many providers operate.
Most provider organizations operate under lean staffing models, making it challenging to support physical surge capacity even if brought online quickly. Additionally, it is a regular and ongoing challenge to recruit enough staff (particularly nurses) to fill open positions that exist even under normal operations. Few emergency response plans anticipate and include mechanisms to deliver additional staff to support surge capacity.
Most hospital systems utilize just-in-time inventory management systems. They don’t hold excessive levels of equipment and supplies, making it difficult to respond quickly to significant, rapid increases in needs. Additionally, most systems either use distributors/intermediaries or maintain shared services organizations that are responsible for sourcing and delivering those supplies. And, just like the hospitals they serve, most of those companies employ just-in-time inventory systems as well as having dispersed supply chains based on strategic sourcing principles to help reduce costs and drive asset efficiency. Anticipating that hospitals and health systems can respond to rapid, dramatic changes in demand for essential equipment and supplies is simply not realistic.
Reference labs and related services are used throughout the healthcare system to increase efficiency and rationalize capacity. This approach is, even more, the case for small rural and suburban providers. Many of the pandemic response plans assume the ability to identify and test for risks in the broader population quickly. But, as the COVID19 testing disaster has shown, they fail to address where and how that capacity will become available other than through the paltry 130 existing CDC-certified testing facilities that cover a population of almost 350 million. The CDC touts the fact that it tested more than 67,000 Zika virus specimens, a number far fewer than the millions needed to respond in an actual epidemic.
The financial state of rural and safety-net hospitals is precarious at best. At the same time, many of the pandemic and health emergency response plans assume these hospitals are the first line of defense. Without additional supports and emergency funding, many may not have the financial ability to respond to a significant, but temporary, increase in demand. Again, except as anticipated in state-level emergency planning, federal plans are mostly silent on the issue of how these facilities will have the resources to respond in this kind of crisis.
Hospitals and health systems are primarily independent businesses. Except for the 20% that are publicly owned and operated, we have limited ability to mandate their participation in any planned response. As noted previously, the largely voluntary nature of most plan elements magnifies the problem.
Private sector partners can’t pivot on a dime to shift manufacturing, retool machinery, or source products from closer in locations. As is the case with other parts of the healthcare value chain, most manufacturers have moved to just-in-time inventory and production practices. They have also rationalized capacity across a global supply chain, which may provide some flexibility in sourcing products, but becomes a challenge when borders are closed during an epidemic.
Making Sure People Can Get the Care They Need
But, even where authority is clear and realistic about how the industry works, existing plans fail to recognize problems with access to and financing of care. Our high uninsured rates, insurance that relies on employment, and high out-of-pocket costs make people reluctant to seek care even when they have coverage. When combined with the lack of paid sick leave for many individuals, we risk that people spread disease by continuing to work when sick or waiting to seek care until their illness is acute. The lack of clear sources of funding for the care needed during an epidemic also puts additional strains on the healthcare system just at the time when their resources are severely strained by increased demand.
The existing tools to address this issue are only half helpful. The federal government does have the authority to ease access to coverage by waiving some Medicaid and Medicare requirements during a declared national emergency. But, there is no automatic funding mechanism to support those changes, and final decision-making authority still rests with the states. This approach leaves a patchwork of coverage and no precise mechanism to ensure states can support these added costs and that providers, who are already stretched thin, will be paid.
Americans Are Not Healthy
Finally, let’s be really clear. Americans are unhealthy relative to other developed countries, and that increases clinical risks and the acuity of illness. Planning should, but doesn’t reflect that. As we’ve seen in this response, modeling is often based on the experience of other countries. Because of that it seriously underestimates the potential acuity of those infected, their need for care, and the demand that places on caregivers and system capacity.
What Do We Need to Do?
So, what are we supposed to do about all this?
First, we need to get realistic about the risks we face from a reoccurrence of COVID19 and, god forbid, the emergence of a new disease. If you think the COVID19 pandemic is like a 500-year flood that’s unlikely to occur again anytime soon, think again. Take a look at the graphic below from the World Health Organization Global Pandemic Monitoring Board. This chart is just a high-level cataloging of infectious diseases that the organization is currently monitoring.
So, assuming that this is not the last time we will deal with SARS-CoV-2, or the next pandemic threat, what are some of the things we can do, short of some sort of unlikely radical restructuring of our entire democracy and healthcare system?
1. Streamline responsibility at the federal level. We don’t need more plans. We need clear accountability and less confusion.
2. Engage the healthcare and manufacturing industry in crafting new plans that realistically reflect their capabilities and needs.
3. States should consider designing and adopting a common “Model Pandemic Response Law” (similar to what they do in the insurance industry) that standardizes state-level activities, including mutual aid, information sharing, region-wide planning, and implementation. States should assume they will be the first line of defense and must work collaboratively to meet their needs.
4. Standardize planning and response to implement surge capacity both nationally and at a state and local level. It should be clear who is responsible for identifying a need, maintaining capabilities to respond, and implementing that response. Planning should recognize that most states will not have the capacity to meet these needs without federal assistance.
5. Strengthen state and local surveillance, with consistent, standardized methods of collection, monitoring, and reporting. Programs should include a massive expansion of lab certification for testing and tracking, including engagement and certification of expanded private sector participants.
6. Consider “Pandemic Response Certification” for provider organizations, which would be responsible for rapid response and coordination in a community or region. Certification should be similar to what we do for trauma certification, requiring that designated facilities meet specific criteria, maintain ready capacity, and act in a coordinating role.
7. Require that all hospitals and health systems include planning and investment in pandemic response capabilities as part of their Community Benefit Plans.
8. Establish a real and functioning federal-level ready reserve corps of health professionals as was approved in 2010, and as envisioned by Senate Bill 2629 – the United States Public Health Modernization Act.
9. Pre-certify private sector partners, including manufacturers, as essential for pandemic and public health emergency response, allowing for rapid implementation of purchasing and procurement of needed resources.
10. Replenish the national stockpile and establish a transparent, multi-state framework and decision-making process for deploying resources in a national emergency.
11. Modify the Social Security Act to include an automatic funding mechanism for payments through Medicaid and Medicare for epidemic-related health care costs. Changes should also allow for direct payment (similar to disproportionate share – DSH) for hard-hit providers on the front-lines of any response.
Finally, as I’ve pointed out in earlier posts, we must address the severe misalignment of our health policy and resources. This current crisis should be a wake-up call that we need to start thinking about a lot more than just covering the uninsured. We need to re-think our approach to how we deliver health in America.
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