S1E4 / Our Health System’s in Trouble / Andy Salvitt & Dan Diamond

I'm Dr. Celine Gounder.

And I'm Ron Klain.

And this is Epidemic. Today is Friday, March 20th. In this episode, we're going to speak with Dan Diamond, a leading health journalist, on what's going on right now in our health system and in Washington.

And we'll hear from Andy Slavitt, who oversaw Medicare, Medicaid. He understands how this is going to hit our healthcare system and our senior citizens.

Finally, we'll field a couple listener questions.

Joining us today is Dan Diamond. Dan is one of the nation's leading health journalists. He covers health and things going on in Washington for Politico. Thanks for joining us, Dan.

Ron, I'm thrilled to be here.

So Dan, there's coronavirus relief coming through Congress. What does phase 2 of the bill look like?

The Phase 2 stimulus package includes a lot of different ideas that just a few weeks ago would have been seen as an impossibility. The idea for some paid sick leave, waiving of some mortgage payments— these are things that, that it's unbelievable to see this happen, but perhaps less unbelievable given the circumstances that we're finding ourselves in.

So, Dan, let's play this out though. So Phase 2 signed by the president starting to get things out there, but then Congress is quickly moving on to a much, much larger package, phase 3, that may be as much as $1 trillion in aid. Give us the big picture of what people are going to see if Congress acts on this trillion-dollar package.

One of the biggest concerns, Ron, is just the cratering of industries like the airline industry or small businesses. So that's a major focus, just keeping businesses that otherwise are going to see massive hits in operations. And Treasury Secretary Steve Mnuchin has issued dire warnings in trying to negotiate this package. He has told people on the Hill that unemployment could get to 20%. President Trump has walked that back, saying that's unlikely. But when you start doing the math, it's clear that the damage is real and the unemployment numbers are rising. The speed also here is notable in that this potentially $1 trillion package could get passed in the next 2 weeks. Compare that to what was happening with the stimulus during the Great Recession 12 years ago, and the pace is so much faster now, perhaps because it needs to be.

So we talk about phase 3, this trillion-dollar package. It's got 3 big parts to it. Some of it's direct aid to people. People are going to start to get checks in the mail. Another big part of it is lending to small businesses, businesses with less than 500 employees, They'll be able to borrow money to meet payroll. But the third part, the more controversial part, is industry aid, what we used to call bailouts. Is that going to happen? What kind of strings will there be on that?

So, Ron, I think what makes these bailouts both controversial and not is that Republicans are embracing the idea. The airline industry, for instance, asking for direct support to keep their operations open. Cruise lines, hotels, other industries that have traditionally been Republican donors and now have Republican lawmakers acting on their behalf. The issue though is whether these industries should be at the front of the line. Hospitals, for instance, are also asking for direct support, given that their volumes are going to surge and that they need either relaxing of some of the restrictions around their bonds or other direct financial boost to absorb the patients who are now coming. And to see the cruise industry, for instance, get more prioritization in this moment, perhaps because President Trump has been close to that industry, that's caused a lot of concern among Democrats that I've talked to, and the fear that hospitals, which are about to get creamed, should be moved to the front of the line if there's going to be any financial bailout.

So, Dan, let's move to the other end of Pennsylvania Avenue, to the executive branch, to the White House. There's been obviously a lot of criticism of how the Trump administration has handled the response, but some suggestions they're getting better now. How do you think they're doing? Are they learning as they go along?

Well, I hope they're doing better because the first couple weeks were abysmal, and I think we're seeing the fallout of that in the failure to have testing around the country, the the supply shortages that are hitting. Certainly, Ron, Celine, no one was expecting this sort of disruption 2 months ago, but the ability of the White House to get ahead of the problem just wasn't there. And that is now hitting the administration in so many different ways, from short-term strategic thinking to long-term planning. There's just a lot of chaos depending on who I talk to. The White House has improved. The president has made this a priority in the past week or so in a way that he had not for the first 2 months. But there, there are still warring factions within the White House, different teams that aren't seeing eye to eye, resources that are being fought over, and general confusion over who is leading this effort at a time when Americans are deeply concerned.

Yeah, I mean, one more question on that. I mean, obviously, from my perspective, having been in charge of one of these responses. There was no question when we did the Ebola response who was in charge, who was responsible. That was me. Now we read that Jared Kushner has one task force and Vice President Pence has a different one. Ambassador Birx obviously is an important figure. Secretary Azar, he's saying that it's not the government's responsibility to deal with a lack of supplies in the hospitals. Who really is in charge and why can't these people get their act together?

I don't remember that sort of discord when trying to understand the Ebola response, which granted was a different time, a different issue, not changing American life the way that the coronavirus threat is. But the amount of feuding that I've reported on at Politico, that other outlets have picked up on too, that has continued and been magnified at moments when I think Americans would want public officials to agree on a shared strategy and, and not be caught up in who is top of the heap. With the task force, and the Jared Kushner one especially, that team has some similarity to the efforts to fix healthcare.gov years ago when that Obamacare website crashed and techies and government officials got together and rapidly tried to come up with a solution. There's an argument that a similar approach needs to happen now overnight as the US is trying to catch up with its testing gaps. The challenge is a lot of those people aren't government officials, and if they're not acting with the full support of government, it can create more confusion as other teams also are trying to think about testing resources and supply chains. And there's no clarity in who ultimately gets final say on some of these things, perhaps outside of the president and Vice President Mike Pence., and they have not always had an ability to rein in all the disparate efforts happening across the federal government.

So, Dan, I understand another problematic feud is between Seema Verma and Alex Azar. Can you comment on how that's also complicating the response here?

Celine, the two officials, Azar, the health secretary, and Seema Verma, the Medicare/Medicaid chief, have been at war for the past year. Those wars have been private, not public. But Azar is the health chief. Verma is technically his deputy but has her own giant portfolio and her own relationship with the White House. Last year, it got so bad between them that the White House was thinking about replacing one or both of them. There just wasn't clarity on whether they could even work together. Secretary Azar led the White House task force on coronavirus for about a month. In that time, Seema Verma wasn't part of the task force. She wasn't as looped in on the White House effort. And for the person in charge of Medicare and Medicaid, two programs that are set to be hit by coronavirus-related demand, for that person not to be intimately involved in the response, that was a big issue, Verma and her team and supporters thought. That's also changed dramatically in the past few weeks after Mike Pence took over the task force operations He is a longtime backer of Verma. She reported to him in Indiana. She was his top Medicaid consultant. Her role the past few weeks has been much bigger because of the new leadership. And it's those sorts of fights and those sorts of bureaucratic battles that in normal times might be a sideshow, might be an interesting story. In the middle of a crisis moment, it makes it that much harder to figure out how the government is responding if there are these deep-seated issues preventing people from working together.

Fascinating.

And, you know, just for our listeners, coming up later in this episode, we're going to talk to Andy Slavitt, who had Seema Verma's job in the Obama administration. So we'll get his perspective on this, too. Dan, let's talk about where we go from here in terms of what the administration needs to do next. Clearly, what's really getting on people's minds right now, in addition to these economic issues, is this crisis we're facing in our hospitals. What do you think the administration's focused on to address this most immediate, most crucial pain point?

Well, Ron, I know that they're trying to both find supplies that might be in the system, encourage philanthropy, and gin up whatever additional material can be directed to hospitals. The authorization too of defense production capabilities might be a way to get some of those material into the hospital system in the weeks and months to come. But in the meantime, there are effectively rationing measures being proposed. The CDC put out new guidance on what health workers should even be wearing and using. I've talked to doctors and hospital administrators who say that they're now preparing to reuse protective equipment that they probably shouldn't, but it is that dire on the front lines. And this just speaks to deeper issues with planning. Why were there not further efforts weeks ago to get ahead of this issue? Why was there not a crisis moment reached in mid-February after seeing what had happened in China and protecting that it could happen here in the States, to just get those plants up and running then so we wouldn't be in shortage mode now?

Well, and the reality is that we're already reusing personal protective equipment. We've already in some hospitals run out of N95 respirator masks. You know, a key piece of that is that we need to be diverting people away from the health system who don't really need to be there, so that's people who might be mildly ill with coronavirus. I understand that some of the restrictions on telehealth are currently being loosened. What does that look like, and what is that going to mean for how doctors can care for their patients moving forward?

So, Celine, we've had a generally pessimistic conversation, and the nation's mood is understandably very down in recent days. I do think this is a sliver of a good news story. CMS has relaxed a lot of regulations around telehealth. That lots of people wanted to see changed for years. Medicare patients now can use Skype to connect with their doctors and get a virtual checkup that will be covered by the Medicare program. For a long time, that was not allowed, or there, there were very tight restrictions on what could be done. And this moment is forcing now a reliance on that technology to both protect patients, protect the provider, and also to fray the demand on the system. It's only in operation for this crisis. It's like a waiver of regulations for now, but I wouldn't be surprised to just see momentum build, and when we get through this, to have that be the new normal, have more telehealth operations.

Well, Dan, thank you so much for joining us.

Ron, I'm glad to be here. I just wish it was for a happier story.

So we're very fortunate to be joined today on The Epidemic Podcast by Andy Slavitt. There are few living people in the world who know as much about how the healthcare system works, how things get paid for, as Andy. He, in the Obama administration, was in charge of the entire Medicare and Medicaid system, the Children's Health Program as the director of something called CMS. He's been a longtime expert in our healthcare system and how it works. And as we face this challenge from the coronavirus, he is the person we most wanted to have on this program to share with you his insights. So thanks for joining us on the podcast, Andy.

Thanks, Ron. So kind of you. Nice to talk to you and nice to talk to you, Celine.

Yeah, welcome and thank you for joining. Andy, I'm a healthcare worker and me and my colleagues, we're really worried about the surge in patients we expect to see in the coming weeks. What do you think this is going to mean for us?

Well, first of all, the country is going to end up owing the healthcare workforce tremendous gratitude throughout this process and when this is all done. I think it's important for everyone to recognize you're operating without a real roadmap and we're grateful and we need to, we need to commit back to you as a healthcare workforce some important things. We need you to stay safe. We need you to stay sane. We need you to be sure that you're not getting exposed and have prioritization when it comes to testing. I think Ron has been saying it quite loudly, that means getting more resources. And then to allow you guys to make the decisions that you're best positioned to make, which is what are the things that can be put off and what are the things we have to deal with now? And, you know, you're going to be making those decisions every day and people like you in every community in this country.

So, Andy, I want to get into some of the nitty-gritty of how this is all going to work out. And we hear political leaders saying that the testing should be free. When people say testing should be free, how is that going to work? Who's actually going to pay for it? In what sense will it be free?

Right. So let's think about 3 things we're going to need. We're going to need testing. We're going to need therapeutics. And eventually, soon, hopefully, around the corner, we're going to need a vaccine. And, you know, in this country, as we well know, 60 to 70% of us who are, you know, with good insurance, who are middle class and above, have good access to healthcare, will be able to get those things. And so what we really need is a solution for the uninsured, and the federal government needs to get to work and make sure we're putting money to it and getting money to hospitals. So that everybody knows that they can get their testing paid for. Then we've got to get on to how we pay for therapies, and then we're going to have to get on to how we pay for vaccines, because in this country, we are only going to be as strong as our weakest link. And if we're only giving some people access to the medical care they need and others who can't get it, then that puts us all at risk.

So Andy, there are two particular patient populations I'm really concerned about, in part because they actually constitute, I don't know, somewhere around 25-30% of the patients I care for where I work in New York, and that's people without insurance and in particular people who are not citizens. And, you know, some of them are afraid because of the public charge rule, which without getting into too many details for our listeners, basically is a disincentive for people who who might want to apply for a visa or a green card in the US, it's a disincentive to accessing public services. So what are we going to do for that group?

Well, you're right. We need to begin to think systematically about high-risk populations and how to meet them where they are. And so it feels like mobile testing is going to have to be a part of the solution. Going into communities with buses and using some of the innovative kinds of things that I know you've been thinking about around telemedicine and other ways of getting testing to people. But, you know, in this country, we tend to do a pretty good job of thinking through how to help the 80%, and we drop off pretty significantly when it comes to people who are lower resource, don't have insurance, et cetera. So those are important focal points. Obviously, there's other groups that may even have insurance but are, you know, at risk and people we should be focused on. We talked about frontline healthcare workers, first responders, people who are working in elder care facilities and nursing homes. You know, sadly, in these situations, you do have to prioritize. I think as we get testing capability out and we get the ability to treat these populations, We can't forget that there's many people that don't have the choice to self-isolate. They have to go to work every day because they get paid by the hour, and we have to do our best to keep them healthy.

So, Andy, I want you to put your, uh, old hat on as someone running CMS. Obviously, we know this is going to hit the elderly very, very hard, and that's going to have a huge impact on Medicare. A lot of people don't know that Medicaid also pays for a lot of the nursing home care in America, so this is going to be a real challenge for Medicaid too. If you were running those programs today, what would you be thinking about right now about its impact on Medicare and Medicaid? And what should those two programs be doing to get ready for the influx of costs and complexity they're about to face?

The first thing is people, many people don't know that CMS is in, is in charge of nursing home quality and inspection, as well as laboratory quality and inspection. And I think there is a, If you think about the worst-case scenarios, there are many people who are sick and, you know, the flu would, would probably kill them anyway if it ravaged nursing homes. And nursing homes and elder care facilities have very poor infection controls. So the lion's share of energy has to be around getting to those nursing homes and nursing home facilities The second thing that I think would be important to focus on is the biggest need right now, I believe, is to get money into states. Biggest need beyond getting our testing capacity where it should be. And the primary mechanism the federal government uses to get money to states is the Medicaid program through a matching program. And so I would be focusing pretty hard on making sure that the Medicaid program, which is our safety net program, was doing the job that it needed to do for the people that were going to need it the most. And it will give governors a lot more wiggle room to be able to maneuver to execute whatever they need to do locally. And so that's, I think, you know, a second, a second thing that I really, really hope happens. But, you know, as you said, you know, in some larger existential way, when you're sitting there in the Department of Health and Human Services, What do you think about every day? You know, you think about the 130 million Americans that are on low incomes or on fixed incomes that are relying on our programs and making sure they have appropriate access to the care that they need. That means organizing and pulling together a lot of different things. It means coordinating across government agencies. It means coordinating on housing and other kinds of things. And I really miss the days and hope we get back to the days when we have a really organized, disciplined team led out of the White House that has a chain of command and a structure that allows us to serve up those priorities, make decisions on them quickly, and move quickly.

So, Andy, let me ask you a follow-up to that. If your mom or dad, someone listening to us, their mother or father's in a nursing home right now, what questions should that person ask the nursing home about how prepared it is for the onslaught of coronavirus? What, what should they be looking for? What can they do? What can they ask? What should they think about?

Yeah, so I think the first thing to make sure is that you understand what the infection control policies are and procedures are inside that nursing home. And remember, nursing homes have to have infection control policies. You may have a parent that lives in an elder care facility, senior housing, some other communal housing where there are no requirements and no regulations. So the first thing to do is just make sure your parent is safe and that they are in a setting that, that respects the infection control policies that are often hard to do in communal living situations. And if they're not, that means making sure that you are moving into a safe setting or to your house if you can. One thing that is critical to this, if nobody is tested positive in a nursing home, is to make sure that the nursing home is strictly limiting visitors into the nursing home and that their visitation policy is consistent with not having someone introduce anything into the system that would put anybody in there at risk. And that means they may tell you that, you know, you may need to talk to your parents or see your parents or your grandparents by video or by phone or not see them or see them in some safer setting where you keep a distance and you don't see other people. And, you know, that's, that's one of the adjustments that we need to make. But if your nursing home has people coming in and out of it, including people who are working and working there and traveling and delivering food and all that, that's That's the kind of thing that should make you talk to the people who run the nursing home and really question that. And then just make sure they're taking your, your mom or dad's temperature every day, and that if they spike a fever, that you are aware of it instantly and you can act on it.

Andy, my last question for you: Is there anything else we can do to build more resilience into the system? Because we know we're going to see more pandemics in the future.

Well, you know, I thought that when we dealt with the last several pandemics, it felt like we touched the hot stove of what could happen if you're not prepared. And it feels like this administration has repeatedly had to touch the hot stove over and over again and continue to burn them, burn their fingers every single time. But What appears obvious is that having some simple things can really make this go a lot differently. You want to be South Korea and not Italy. I think we have, quite frankly, lost our chance to be South Korea, and now we just have to get as close to that as possible and pray that we're not Italy. That just means a lot of preparation. It means a lot more infrastructure. It means a lot more spending on public health. It means that when we're spending money on things we don't see, that doesn't mean that they're not valuable. It means that there are things that are keeping us safe and healthy, just like we invest in our military, even though we don't deploy them every day. We need to be investing in public health and in infrastructure, and then a decision-making apparatus and chain of command that allows us to move quickly in a crisis. I am hopeful now that when we do come out of this, and we will come out of this, that it will sear into people's memories and that it won't be as quickly forgotten as other kinds of things are. And if that's the case, then we'll have a Congress that allocates a lot more money, we'll have an administration that leaves an infrastructure in place, maybe required by Congress, and we'll have a public health system that is much more alert and much more intelligent about discovering and acting on these things as they pop up.

My thanks to Andy for joining us today. It's a pleasure to have you on, and I'm sure we're going to have you back as this progresses and as the complexity and cost of this just escalates week by week.

Thanks, Andy, for joining us on Epidemic.

Thank you, and thanks both for what you're doing and making sure the public's hearing these things.

Every week we answer a few listener questions on the podcast. Record an audio file on your phone with your question and then email that to us at hello@justhumanproductions.org. That's hello@justhumanproductions.org. Our first question this week comes from Amy Bennett.

Hello, my name is Amy from McKinney, Texas.

My question is, what are the risks of contracting the virus via mail or via deliveries of groceries or prepared food from restaurants?

Thank you. Amy, the risk of getting coronavirus from mail delivery or from food delivery is quite low. Unless your mail carrier sneezed or coughed on your package just before you went to pick it up, it's very low risk to get coronavirus that way. As for food, again, you know, people who prepare your food have to continue to abide by the public health regulations in terms of washing hands, wearing hairnets, and and all of that sort of thing, we really don't see transmission of coronavirus by food. I'd be more concerned again about face-to-face transmission with the person actually delivering the food to you. So our next question comes from Stephanie Corcoran in Weston, Massachusetts.

Hi, Dr. Gounder. My name is Steph, and I live outside of Boston in Massachusetts. I have a question that I'm guessing is on a lot of parents' minds right now. With the number of recent school closures announced in our area for a minimum of 2 weeks, should parents limit their children's exposure to all other children, or are playdates and neighborhood interactions in fact okay? Should we be sheltering in place as families? Thanks for keeping us so informed and safe.

So Steph, I think the whole purpose of social distancing is that we want to reduce transmission, and transmission can occur among kids just as it can among adults.. And while kids have milder cases of coronavirus, we are in fact learning that especially kids under 5 can have serious cases. And even if they have no symptoms at all, they can still transmit to others within the home. So really, you know, playdates are probably not a great idea at this moment. Really try to think about it as a bubble of your family. You don't want anybody going in or out of that bubble. And that's going to be the best way to really tamp down transmission in the community at this point.

You know, Celine, back when we were managing the Ebola epidemic in West Africa, countries over there tried school closures, and it didn't really stop the spread of the disease for exactly the reason you're talking about. If you close the schools, but then the kids all play together and hang out together, go to the playground, you're not really doing much to slow the spread of the disease. And indeed, as I drive around my neighborhood here in Maryland, I see closed schools and I see playgrounds full of kids playing basketball, playing football, interacting with one another. And so it's important if we're going to pay the price of taking kids out of school that we get the value from that. The value from that is really engaging in social distancing, really keeping kids from interacting with other kids. That's the only way we're going to slow the spread of this disease. Our next question comes from Julia Renard. From Washington State.

Hi, Celine and Ron. This is Julia in Seattle. I have been fascinated in the work that they've done on genetic analysis and mutation rates of the virus. I'm curious if you feel that this is important new work in understanding transmission and spread patterns of a virus And how important would it be to expand this testing to understand this more broadly? Thank you very much for the great work. Look forward to the next episode. Bye. So, Julia, that's a great point. There's a researcher by the name of Dr. Trevor Bedford at Fred Hutchinson Cancer Research Center, which is affiliated with the University of Washington, and he's done some really seminal work looking at how the genetics of the virus shift as it transmits and spreads through a population. That research really allows us in a different way to analyze how quickly the virus is spreading, how it may be changing over time, and it really complements the shoe leather epidemiology that we do, which is where we literally go person to person and, and try to figure out how it's spreading on that level. And then the other piece of it is we do want to know how the virus may be changing over time. We actually don't think it's going to become more virulent over time. Usually viruses become less virulent as they mutate. Adapt to the host, but it may be helpful in terms of figuring out how we may need to design our vaccines. So understanding how the virus is changing is really essential to vaccine development, and then also in terms of drug development. So this kind of research is really important. Our final question is from Dr. Melanie Hogan in Gainesville, Florida.

Hi, this is Melanie Hogan. I'm a general internist and primary care provider in Gainesville, Florida. My question is, when are we going to have a unified, single message about how we as healthcare providers and the public are going to respond to the coronavirus? I ask because I feel like I'm getting different messages from different places— my state health department, the CDC, the World Health Organization. It would be great if we could have a unified message, and I think that would help the public as well.

Thank you. Well, Dr. Hogan, that's a great question, and first of all, I thank you and all the medical professionals who listen to this podcast for being on the front lines as we fight this epidemic. Your bravery and your willingness to serve all of us is a real credit to our country and to you. You know, I think the question you present is a very, very difficult one. Now look, this is a complicated, big country. Our federal government has some powers. The governors have powers. The local governments have powers. And our healthcare system is largely in private hands. So this is always going to be a pluralistic system. But in a crisis, it is important for there to be leadership, for there to be clear messages coming from those at the apex of that system. And that's the people in Washington and Atlanta at the CDC. Is really at the end rolls up to the White House and this coronavirus task force that President Trump has put in charge. And I think the fact that the messages are inconsistent, that they are changing all the time, leaves people confused. Look, it is difficult to engage in the kind of social distancing practices and all the kinds of things people need to do. But it's impossible to get that done if people are hearing mixed and confusing messages. And that's one of the challenges right now. The Trump administration needs to get its act together. It needs to get a grip on these messages, and it needs to communicate clearly and consistently about them.

Thanks for calling. Epidemic is brought to you by Just Human Productions. Today's episode was produced by Zach Dyer and me. Our music is by the Blue Dot Sessions. If you enjoy the show, please tell a friend about it today. And if you haven't already done so, leave us a review on Apple Podcasts. It helps more people find out about the show. You can learn more about this podcast, how to engage with us on social media, and how to support the podcast at epidemicpodcast.com. Epidemic.fm. That's epidemic.fm. Just Human Productions is a 501(c)(3) nonprofit organization, so your donations to support our podcasts are tax deductible. Go to epidemic.fm to make a donation. Also, starting next week, we'll be releasing Epidemic twice a week on Tuesdays and Fridays. But producing a podcast costs money. We've got to pay Zac, so please make a donation to help us keep this going. Also check out our sister podcast, American Diagnosis. You can find it wherever you listen to podcasts or at americandiagnosis.fm. On American Diagnosis, we cover some of the biggest public health challenges affecting the nation today. In season 1, we covered youth and mental health. In season 2, the opioid overdose crisis. And in season 3, gun violence in America. I'm Dr. Celine Gounder.

And I'm Ron Klain.

Thanks for listening to Epidemic.