Policy

Background

• The US response to COVID-19 has been primarily decentralized, led by governors, mayors, and local health departments

• This disjointed response is by design, as Federalism, the division of power between a national government and states, is a fundamental feature of US public health authority

• A Federalist response presents challenges to an effective, unified pandemic response

Challenges presented by Federalist Response

• Some states have independently acquired essential equipment or collaborated with neighboring states to reopen, but more cohesive response needed

• Divided Federalist response creates challenges when timely, efficient, unified response required

• Challenges from federal government’s response include uneven assistance to states, funding and supply delays, inconsistent messaging, and insufficient testing

• Federal agencies (such as the DHHS, FEMA, and the CDC) have limited ability to mandate a centralized course of action; the power to quarantine lies primarily with state/local jurisdictions

• The Surgeon General has the authority to prevent the spread of disease between states and from other countries

• The CDC is responsible for hard science, data collection, and surveillance rather than enforcing public health measures, resulting in responses that vary by state

• Different approaches to stay-at-home orders and re-opening strategies in neighboring cities and states compromise effective response when some areas are more lax than others

• The historical state flexibility in health policymaking has resulted in certain communities, such as poor African American families in the deep South, experiencing poorer health and more comorbidities that may exacerbate COVID-19 disease severity; pre-existing regional economic disparities may also result in different economic outcomes of pandemic responses

Recommendations to Improve Response

• For effective pandemic response, the federal government should make a robust set of pandemic response guidelines to prevent wide variation of regional responses

• Federal standards for local stay-at-home orders should be data-driven, based on case numbers, transmission rates (as determined by the CDC), and the status of bordering states; this would trigger states to enact protections supported by federal funding

• Medical supply distribution should be systematized with clear, data-driven guidelines for allocation; FEMA and the CDC may work to establish an online portal for state supply requests to help map need and response more effectively

• Epidemic data collection should be standardized, enabling timely and coordinated choices regarding re-opening; COVID-19 outcomes should be tracked by race/ethnicity and household income to target resources exhibiting health disparities

• Support for underresourced hospitals, especially rural hospitals, is needed; direct funding infusions may help short-term and expansion of Medicaid eligibility may help long-term

Conclusions

• These recommendations retain federalist flexibility by allowing state actions beyond federally established minimum standards, and most do not require congressional action

• Such changes require enhanced coordination and cooperation between all levels of government

• Implementing national guidelines for state-level pandemic response and providing a uniform baseline of healthcare access will improve equity and help protect the nation’s health

This article analyzes the different types of contact tracing that can be done and summarizes the potential risks of implementing digital smartphone tracking.

Types of tracking

• Manual vs digital:

  • Manual tracking is done by the health department who calls patients to ask about known contacts and then notifies known contacts.

  • Digital tracing, such as through apps by Apple and Google, notifies users through proximity and alerts them if they have been near a person diagnosed with COVID-19. There are privacy measures in place. The diagnosed person is not revealed to anyone else and individuals have the decision to download the app.

• User controlled vs centralized approaches:

  • User controlled: People receive notification about proximity to others but may choose if they use to report to health authorities.

  • Centralized approach: The federal government uses surveillance methods to determine who is infected and consequences. Examples of different countries’ methods are below.

    • China: scores individuals on infection risk and does not permit people with higher scores to enter public facilities, work, or travel

    • South Korea: uses law enforcement and fines against those who violate quarantine or social distancing

Considerations

Digital tracing cannot replace public health strategies. Reasons include lack of the entire population using apps or phones, lack of data for the effectiveness in contact tracing from these apps and potential for this information to be abused, such as requiring smartphone app information before employees are allowed back at work. It is premature to mandate digital tracking over current public health strategies like wide scale population testing, manual tracing and quarantine.

Introduction

This study assessed the association between the stay-at-home orders issued by the governors of 42 states, with the hospitalization trends due to COVID-19 in those states.

Methods

Four states met the inclusion criteria for this study - Colorado, Minnesota, Ohio, and Virginia - these being states which had stay-at-home orders, and 7 consecutive days of cumulative hospitalization data prior to the issuing of the stay-at-home orders and data for at least 17 days following the order. These states were observed from March 10, 2020 to April 28, 2020.

Results

In all four states, the cumulative hospitalizations up to and including the median effective date (hypothesized to be 12 days, meaning that is the time when an association between stay-at-home orders and hospitalization rates would become evident) favored an exponential function. But after the median effective date, observed hospitalization growth rates in all four states deviated from the exponential function and were slower than anticipated.

Discussion

There are many factors which could have contributed to this deviation. These factors include factoring in the median incubation period for symptom onset and time to hospitalization to the median effective date; factors that decreased the spread of the virus and thus hospitalizations - school closures, social distancing guidelines, and pandemic awareness in general; and economic insecurity and loss of health insurance due to the pandemic resulting in less hospital use.

Objective:

This correspondence provides a description of the Commonwealth of Massachusetts’ efforts through the Manufacturing Emergency Response Team to open new supply chains for needed medical supplies and equipment that have faced shortages due to the COVID-19 pandemic.

Background:

• The COVID-19 pandemic has led to shortages of many types of medical supplies and equipment including swabs, personal protective equipment (PPE), ventilators, and others

• Increased use and demand for these products coupled with the destabilizing effects of the pandemic on society and the global economy have disrupted normal supply chains for these products and have resulted in shortages of such supplies

• Shortages of these supplies compromise the efforts of clinicians and public health officials to conduct COVID-19 testing and provide care for patients with COVID-19

Methods:

• The Massachusetts Technology Collaborative (MassTech) established the Manufacturing Emergency Response Team (M-ERT) to help open up new supply chains for medical supplies facing shortages

• MassTech assembled the M-ERT group with volunteers from university research and development and engineering departments, manufacturing companies, and health care institutions

• The M-ERT convened three times per week to assess supply needs and establish new supply chains. The group faced the challenges of determining what materials were needed most urgently, what capital and resources would be needed to produce such materials, and how to test these materials to ensure that they comply with FDA regulations. The M-ERT addressed each of these challenges as follows:

  • What supplies were needed urgently:

    • The M-ERT consulted purchasing officials at Beth Israel Deaconess Medical Center and other institutions to assess levels of demand for supplies

    • The team is currently assessing amounts of PPE and other materials that will be needed in Massachusetts throughout the coming year

  • Capital and resources required:

    • Volunteer leaders became experts in specific product areas and remained in contact with manufacturers to understand current guidelines and address barriers

  • FDA compliance:

    • Frequent discussion with the FDA to develop and share repository of information on emergency policies and regulations

    • The M-ERT partnered with organizations to establish complex testing for fabrics, gowns, face shields, masks, and swabs

• The need for nasopharyngeal swabs was addressed by exploring 3D printing and other manufacturing processes, performing testing, and carrying out clinical validation at Beth Israel Deaconess Medical Center under protocols approved by an institutional review board

Results:

• The M-ERT’s efforts and testing approaches for nasopharyngeal swabs have led to new FDA registration of at least four types of nasopharyngeal swabs that may be 3D printed at a potential rate of millions of swabs per day

• The Commonwealth of Massachusetts has placed strategic orders for goods, including 3 million gowns, to enable Massachusetts-based supply chains established through the work of the M-ERT to become permanent

• Manufacturers also sell products directly to healthcare organizations, first responders, and other groups

Discussion:

• The M-ERT has helped develop domestically-produced supplies of nasopharyngeal swabs, face shields, isolation gowns, face masks, and sanitizers

• The M-ERT has accelerated production of new ventilators, is helping to establish a domestic source for ventilator filters, and created a plan for rapidly servicing ventilators

• The M-ERT has established a trusted supply chain for needed medical supplies by facilitating communication between manufacturers, engineers, regulators, health care providers, and other buyers

• This supply chain has allowed the Commonwealth of Massachusetts to provide supplies for COVID-19 testing and patient care as well as COVID-19 protection for health care workers

• Similar partnerships may be possible in other states to ensure that health care providers, first responders, and other have the supplies required to respond to the COVID-19 pandemic

COVID-19 is creating many problems in the healthcare system due to the fee-for-service payment model of the healthcare system. These issues include: decrease in elective procedures, decrease in ancillary services (ex: imaging), decrease in patients coming to the hospital in general because they want to avoid COVID-19 patients. The result is that health systems are laying off physicians and other healthcare workers to reduce expenses. Physicians in independent practices report negative financial effects as well. In the Coronavirus Aid, Relief, and Economy Security (CARES) Act, the federal government designated funds for financial losses hospitals and physicians may be experiencing. However, the designation of the $30 billion is based on Medicare spending and largely ignores physicians and hospitals whose reimbursement is less associated with the Medicare program.

Private insurers are absent in attempting to stabilize the healthcare delivery system. They are not maintaining their anticipated flow of funds to hospitals and thus are contributing to the risk of a financial meltdown.

These issues outline a flaw in the fee-for-service model. Hospital systems like Kaiser Permanente, which uses a different delivery system, are less affected by COVID-19 than those who use a fee-for-service model. The author argues the US should move towards a population-based payment system where the contributions of all payers should be separated from the services they receive.

Money is a major factor in people choosing to get tested and seek treatment for COVID-19. Although the Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security (CARES) Act have been passed to assist with testing costs and vaccines, there are still gaps in the system. The author outlines three suggestions for additional policies to ensure affordable health care for all Americans.

1. Freeze people’s insurance status as of April 1, 2020 to keep people within their plan, even if they are no longer with their employer or if they cannot pay the premium.

2. Secure coverage for people who have lost their jobs with expansion of ACA market-place plans and Medicaid. Employ something like the disaster Relief Medicaid program, a temporary public health insurance program created for New Yorkers after the 9/11 attacks. This short term program helped New Yorkers access coverage at a critical time and gave a grace period to find another plan.

3. Address issues with out-of-pocket expenses, which are not covered under the FFCRA or CARES. Eliminate bills from out-of-network providers that exceed in-network costs, especially due to staffing shortages and triage protocols in network.

The Trump administration has decided state governors should determine when they open up their states. They published a set of guidelines to open up in stages, outlined below. Changes to each stage are bolded.

Criteria to fill before opening:

• Symptoms: downtoward trajectory of influenza-like illnesses reported and downward trajectory of covid-like syndromic cases reported within a 14-day period

• Cases: downward trajectory of documented cases within a 14-day period or downward trajectory of positive tests as percent of total tests within a 14-day period

• Hospitals: treat all patients without crisis care and robust testing program for at risk healthcare workers

General guidelines:

• Individuals: Continue practicing good hygiene. Stay home if you feel sick.

• Employers: Develop policies regarding social distancing, protective equipment, temperature checks and sanitation. Monitor workforce for symptoms. Develop policies for workforce contact tracing after employee COVID+ test.

Phase one: applicable to states who pass the gating criteria.

• Individuals: Vulnerable individuals (elderly and immunocompromised) should continue shelter in place. Everyone should maximize physical distance from each other in public. Avoid socializing in groups of more than 10. Minimize non-essential travel.

• Employers: Encourage telework. Return to work in phases. Close common areas where people will congregate. Create special accomodations for employees who are vulnerable. Minimize non-essential travel

• Schools and organized activities should remain closed.

• Visits to senior living centers and hospitals should be prohibited.

• Large venues like sit-down dining, movie theaters, sporting venues, places of worship can operate under strict physical distancing protocols.

• Elective surgeries can resume.

• Gyms can open if they adhere to physical distancing and sanitation protocols.

• Bars should remain closed.

Phase two: for states with no evidence of resurgence in cases and satisfy gating criteria a second time

• Individuals: Vulnerable individuals should continue shelter in place. Everyone should maximize physical distance from each other in public. Avoid socializing in groups of more than 50. Non-essential travel can resume.

• Employers: Encourage telework. Close common areas where people will congregate. Create special accomodations for employees who are vulnerable. Non-essential travel can resume.

• Schools and organized activities can reopen.

• Visits to senior living centers and hospitals should be prohibited.

• Large venues like sit-down dining, movie theaters, sporting venues, places of worship can operate under moderate physical distancing protocols.

• Elective surgeries can resume.

• Gyms can open if they adhere to physical distancing and sanitation protocols.

• Bars may operate with limited standing-room occupancy.

Phase three: for states with no evidence of resurgence and satisfy gating criteria a third time

• Individuals: Vulnerable individuals can resume public interactions but should continue practicing social distancing. Everyone should minimize time spent in crowded places.

• Employers: Resume unrestricted staffing of worksites.

• Visits to senior living centers and hospitals may resume.

• Large venues like sit-down dining, movie theaters, sporting venues, places of worship can operate under limited physical distancing protocols.

• Gyms can open if they adhere to standard sanitation protocols.

• Bars may operate with increased standing-room occupancy.

In light of the COVID-19 pandemic supply and demand is a major concern, with hospitals in certain areas of the nation already or on their way to becoming overloaded. WFBH’s executive medical director of general medicine and hospital medicine shared services, Dr. Huang’s, discussion on this issue could not be more timely.

Main points

• The U.S. healthcare system is inefficient

• Mergers are a solution to this problem, they:

  • Utilize resources in a more plausible manner

  • Improve patient outcomes

  • Create more efficient operational systems

• Based on a study by Drs. Noether and May from Charles Rivers Associates, “non-federal mergers for a six-year period (2009 to 2014)…[lead] to a cost saving of 5.8 million dollars at each hospital.”

• Implementing “queuing theory,” developed by Dr. Anger Krarup Erlang, can allow hospital administrations to have efficient flow by matching supply with demand and scheduling elective procedures smartly

  • Artificial intelligence can help bridge the gap and allow for effective implementation of queuing theory

  • Machines learn algorithms and are easily able to adapt to the rapidly changing environment of hospitals and correctly assessing patients needs

Description of the power of the government on public health measurements during the COVID-19 Pandemic:

Schools and Businesses

• • Health authorities have well-established power to order a shutdown of places where people congregate.

  • Courts may closely scrutinize determinations for private organizations, whose operations are central to the exercise of particular constitutional rights (eg,houses of worship,abortion providers,and firearm retailers), as being nonessential

  • Federal power to close businesses is limited to preventing the interstate spread of disease. For example: the president could order transportation companies to limit travel across states.

Bans on Gatherings

• • Despite the first amendment protecting Free speech, religion and assembly, the decision to ban gatherings does not single out a specific group. Therefore, the supreme court justifies “content-neutral” restrictions when it’s for public interest.

Curfew

• • Local governments can establish a curfew as long as they are not arbitrary or discriminatory.

  • Curfews are being utilized in cities/towns whose states have not imposed stay-at-home orders.

Stay-at-home Orders

• • Long term mandatory stay-at-home orders over large geographic areas are untested in court.

  • Because of the large scale of the pandemic, health authorities should provide evidence based criteria for implementing the Stay-at-home orders and have clear indications when it will be eased or lifted.

  • If possible, distancing should be sought through volunteerism to keep public trust.

Quarantine for Travelers

• • Some states (specific states not indicated) have mandatory quarantine for travelers or returning residents entering the state. Especially if coming from high COVID-19 mortality areas.

  • Orders require travelers to stay home for 14 days while being monitored. They are not allowed to go out for food or other necessities.

  • This quarantine could be challenged in the courts

Travel Restrictions

• • Congress has the authority to restrict travel between states and territories to prevent a contagious disease.

  • Presidential authority is uncertain, and to impose a large-scale domestic travel ban, the president would need more legislative authority than current statutes provide.

Sanitary Cordons

• • No city or state has erected a sanitary cordon, prohibiting exit from an area of active SARS-CoV-2 contagion or a reverse cordon that completely prohibits entry from zones of substantial transmission

  • Modern courts have not reviewed sanitary cordons

CDC recommends everyone wear a cloth face mask when around others such as when going out in public. The cloth mask is designed to protect other people from your transmissions and is not a substitute for other protective measures like hand washing and keeping 6 feet away from others. There are 3 models of cloth face masks the CDC has uploaded tutorials on, which can be made from cloth, old t-shirts or bandannas.

CDC is expected to recommend people in areas of high-community transmission wear simple cloth masks or face coverings when in public, a major reversal of prior CDC recommendations. These simple cloth masks are different from N95 masks worn by medical professionals, which are in short supply.

Why is this being recommended?

• This recommendation seeks to reduce transmission of the virus from people who have been infected but are asymptomatic.

• Recent evidence has shown that asymptomatic transmission is a more significant contributor to SARS-CoV-2 spread than initially considered.

• These masks are not to protect the wearer but to prevent viral transmission to others.

The CDC expected to announce this policy change in the coming days, and the WHO is considering adopting a similar measure. In addition, the US government is considering distributing cloth masks to residents of heavily-hit areas. It is recommended that these be used in addition to, not instead of, current CDC recommendations, including regular hand-washing and physical distancing of 6+ feet.

Review by Rohin Gawdi on 4/2/20.

What is included (from Vox)

$500 billion for emergency loans to large businesses

Increased unemployment insurance: $600/week for 4 months, in addition to what the state already pays to unemployed citizens

$150 billion to boost the healthcare system

$150 billion to state and local governments

A $1200 one-time direct payments to citizens making $75,000 or less annually

$367 billion available for loans to small businesses (this could include small hospitals and private practice doctors)

Healthcare-specific funding and policies (from Modern Healthcare)

$200 million to aid the CMS in making alterations to Medicare and Medicaid, to make healthcare more accessible in this time

$11 billion towards diagnosing, treating, and creating vaccinations for COVID-19

$80 million to aid the FDA to expedite the approval of therapeutics and vaccinations for COVID-19

$16 billion towards the Strategic National Stockpile and $1 billion for the Defense Production Act to combat the medical supply shortage incurred by COVID-19

Private health insurers are required to cover all COVID-related treatments

Hospitals will receive a 20% add-on in payments for every COVID-19 patient treated in-patient

$200 million for increased hospital surge capacity

$1.3 billion for community health centers

$4.3 billion in additional funding to support the CDC’s efforts surrounding COVID-19

$200 million to aid the Federal Communications Commission initiative of standardizing telehealth services

$45 billion for the Federal Emergency Management Administration

$20 billion to the Department of Veteran Affairs

Reviewed by Shaleen Thakur on 3/30/20.