The Commercial Determinants of Three Contemporary National Crises: How Corporate Practices Intersect With the COVID‐19 Pandemic,Economic Downturn,and Racial Inequity

Policy Points

•  The United States finds itself in the middle of an unprecedented combination of crises: a global pandemic, economic crisis, and unprecedented civic responses to structural racism.
•  While public sector responses to these crises have faced much justified criticism, the commercial determinants of these crises have not been sufficiently examined.
•  In this commentary we examine the nature of the contributions of such actors to the conditions that underpin these crises in the United States through their market and nonmarket activities.
•  On the basis of this analysis, we make recommendations on the role of governance and civil society in relation to such commercial actors in a post‐COVID‐19 world.

The united states finds itself amid three concurrent and interrelated crises. First, at the time of writing, the United States has reported more than 27 million confirmed COVID‐19 cases and more than 500,000 Americans have lost their lives. ¹ Second, in part as a consequence of the physical distancing measures enacted to slow the spread of the pandemic, the United States has faced record unemployment, a rise in the number of Americans unable to afford medical insurance, an end to federal support measures, and an uncertain economic outlook. According to the US Department of Labor, more than 50 million Americans have filed for unemployment benefits since the COVID‐19 pandemic started; more than 10 million Americans remain on state unemployment benefits. ² Third, the country is still contending with how to respond to mass civil protests in 2020 unlike any seen in half a century, triggered by the killing of George Floyd at the hands of police in Minneapolis. This civil unrest reflects centuries of structural racism and has brought unprecedented attention to this problem. ³ , ⁴ , ⁵ In each of these three concurrent crises, the pandemic, ongoing large‐scale unemployment, and civil protests, ⁶ the US federal response has been criticized as being delayed and poorly coordinated, involving downplaying the threat posed by the pandemic and building on longer‐term failures by previous administrations to make investments in public goods that may have facilitated a more robust and effective collective response.By contrast, it would appear that some of the largest entities in corporate America have responded more rapidly to each of the ongoing crises than the federal government has. A number of large companies have engaged in activities that responded to needs emerging from the pandemic, such as producing hand sanitizer, ⁷ setting up COVID‐19 testing sites, ⁸ and partnering on contact tracing. ⁹ Most notably, the pharmaceutical sector has contributed to an unexpectedly and unquestionably successful vaccine development process for SARS‐CoV‐2, with almost 200 million shots already distributed. ¹⁰ In response to the economic downturn, many companies have been adapting their business practices to supply essential services in a time of great disruption. For example, food and other essential businesses have largely kept supply chains for essential goods open, ¹¹ through extending working hours, hiring additional staff, and implementing new means of operating. Several large employers have responded to changing circumstance, aiming to keep as many employees working as possible, often through an embrace of remote working and implementing more permanent shifts into patterns of working. ¹² In response to the global protests around structural racism that erupted in 2020, a number of large companies, including Nike, Reebok, Twitter, and Citigroup, have publicly aligned themselves with the Black Lives Matter movement, ¹³ including committing more than a billion dollars in pledged donations. ¹⁴ In a moment of great national turmoil, when government seems not up to the task, private sector actors have appeared, by contrast, to be better positioned to address the three crises of the moment. This plays neatly into a private sector–centric narrative, and there is little question that much good has come from elements of the private sector during this time.It is certainly true that these visible private sector efforts have contributed to helping populations deal with the consequences of an unprecedented global pandemic. But, given the emerging evidence about the populations at risk for COVID‐19, and why that risk exists to begin with, it is legitimate to ask: in the case of COVID‐19, what was the contribution of the private sector in creating the conditions that made us vulnerable to the pandemic and its consequences to begin with? And, by extension, how can private sector actions align with a durable set of solutions to the crises that characterize this moment?We already know that large, consolidated corporate entities, particularly those that manufacture harmful products, can have profound effects on population health. ¹⁵ , ¹⁶ , ¹⁷ The most obvious way in which this manifests is through “market activity,” that is, the direct consequences of manufacturing and marketing particular products. For example, it is easy to recognize that marketing of cigarettes harms health. However, such actors also influence population health through a range of “nonmarket” activities that shape the political, social, and cultural environments that they operate in. ¹⁸ Examples of this activity include political donations, lobbying, corporate social responsibility initiatives, and legal activity. These activities, often seen as intrinsic to corporate practice, support and protect commercial interests, yet do not necessarily promote population health or structures of governance. Bearing this in mind, it is worth understanding how such activities, both market and nonmarket, have contributed to the vulnerability of the United States to the three crises we now face.     

Long COVID and Health Inequities: The Role of Primary Care

Policy Points

• An estimated 700,000 people in the United States have “long COVID,” that is, symptoms of COVID‐19 persisting beyond three weeks.
• COVID‐19 and its long‐term sequelae are strongly influenced by social determinants such as poverty and by structural inequalities such as racism and discrimination.
• Primary care providers are in a unique position to provide and coordinate care for vulnerable patients with long COVID.
• Policy measures should include strengthening primary care, optimizing data quality, and addressing the multiple nested domains of inequity.

The pandemic has highlighted and exacerbated health inequities in both acute coronavirus disease 2019 (COVID‐19) and its longer‐term sequelae. ¹ , ² , ³ , ⁴ Symptoms of COVID‐19 persist in approximately one in 10 patients. ⁵ Acute symptoms include shortness of breath, cough, myalgias, disturbances in the sense of taste and smell, fatigue, fever, chills, and, less commonly, rhinitis and gastrointestinal symptoms. By contrast, the term “long COVID,” coined by patients, refers to both postacute symptoms (lasting more than three weeks) and chronic symptoms (lasting more than 12 weeks). ⁶ Long COVID is a multisystem disease of unknown cause whose manifestations, while partially overlapping the acute presentation, vary widely among patients and are exacerbated by comorbidities and vulnerabilities (Box 1). It occurs in adults who were hospitalized and those who were not ⁶ , ⁷ , ⁸ and (more rarely) in children. ⁹ At the time of this writing, the United States had more than 17 million diagnosed cases of COVID‐19, ¹⁰ , ¹¹ which translates into approximately 1,700,000 people with long COVID. This does not include the likely underreporting of COVID‐19 cases, the proportion of which in one study ranged from one in three to one in 406. ¹² The implications for health services are substantial. Given the heterogeneity in definitions of long COVID and the lack of centralized registries of patients with the disease, those who might suffer from long‐term symptoms might mistakenly be recorded as recovered.Box 1Some of the Many Manifestations of Long COVID ⁶ , ¹³ , ¹⁴ , ¹⁵

Medicare Advantage for Most

Policy Points

• Fixing the ACA requires real cost containment in addition to better subsidies.
• Private Medicare (Medicare Advantage) plans are uniquely empowered to control costs and deliver good care.
• Medicare Advantage plans should serve as the public option on the ACA Marketplace.
• Medicare Advantage plans can also be deployed to voluntarily raise minimum employer‐sponsored benefits and contain their costs.

Covid‐19 highlights one of the major problems with America''s hybrid arrangement for financing health care. While the Affordable Care Act (ACA) improved financial access and reduced racial disparities in coverage, ¹ , ² it has proved inadequate in the face of the pandemic''s disruption of employer‐sponsored insurance (ESI). The number of uninsured persons, almost 30 million in 2019, jumped by 5 million or more in spring 2020. ³ , ⁴ The ACA also cannot do much to control private health care spending. As deductibles and coinsurance rise, tens of millions of insured Americans face a growing share of rising total costs. In 2018, an estimated 42% of those with individual insurance and 28% of those with ESI met the Commonwealth Fund''s definition of underinsurance. ⁵ Decreasing coverage, climbing costs, and the mounting public anxiety about both may well reenergize serious health reform. When the legislative standoff that has blocked improvements to the ACA ends, reform should not only improve enrollment and benefits but actually make care affordable, that is, both adequately subsidize decent coverage and control the total cost of care. Fortunately, the foundation has been laid for ambitious reform without major disruptions.Although the ACA established a framework for achieving near‐universal coverage, premium subsidies have not been adequate, and counterattacks by Republicans have dented the structure. Linda Blumberg and her colleagues at the Urban Institute proposed a package of fixes for the ACA, ⁶ many of which have been incorporated into both HR 1425, the Patient Protection and Affordable Care Enhancement Act, and President‐elect Joe Biden''s campaign proposals. ⁷ The ACA''s expansion of Medicaid eligibility has proven very effective in the 34 states that are participating. ⁸ With sophisticated ballot campaigns for Medicaid expansion in 10 holdout states—some of which have already succeeded—and full federal funding for states newly expanding Medicaid, millions more people would be cut from the uninsurance rolls. ⁹ , ¹⁰ To make the ACA''s Marketplace coverage decent and premiums affordable, Blumberg and colleagues propose increasing the ACA''s premium tax credits so that no household would pay a premium of more than 8.5% of their income for the benchmark plan and increasing that benchmark from covering 70% to covering 80% of expected claims. They would also restore tax penalties for the individual mandate and add a federal reinsurance program, autoenrollment, and a public option.The incremental federal outlays for these fixes would be relatively modest. Blumberg and colleagues estimate that these enhancements (Scenario 4) would have increased 2020 federal outlays by $45.6 billion. ¹¹ The Congressional Budget Office''s projection for HR 1425 is slightly higher, nearly six hundred billion over 10 years. ¹² As Sherry Glied pointed out, “What is impressive is how far these relatively modest proposals could take us . . . bring[ing] the national uninsurance rate among non‐elderly legal residents of the US down to 3.1 percent, counting those eligible for Medicaid as effectively insured.” ¹³ Controlling health care spending is a tougher challenge, one that has eluded US health policy for more than a half century. However, as I describe later, Medicare Advantage could be deployed to invite most privately insured Americans into good, truly affordable coverage without disrupting existing sources of employer funding. To understand how, it is important to recognize that Medicare is no longer simply a public program but a hybrid that includes a robust private segment, Medicare Advantage (MA) health plans. MA plans now cover 36% of beneficiaries, continue to grow rapidly, ¹⁴ and offer many of the advantages of social insurance with considerably more flexibility. They could be adapted to enlarge benefits and provide a peculiarly American response to relentlessly rising health care costs.     

International Collaboration to Ensure Equitable Access to Vaccines for COVID‐19: The ACT‐Accelerator and the COVAX Facility

Policy Points

• Equitable access to a COVID‐19 vaccine in all countries remains a key policy objective, but experience of previous pandemics suggests access will be limited in developing countries, despite the rapid development of three successful vaccine candidates.
• The COVAX Facility seeks to address this important issue, but the prevalence of vaccine nationalism threatens to limit the ability of the facility to meet both its funding targets and its ambitious goals for vaccine procurement.
• A failure to adequately address the underlying lack of infrastructure in developing countries threatens to further limit the success of the COVAX Facility.

ContextSignificant effort has been directed toward developing a COVID‐19 vaccine, which is viewed as the route out of the pandemic. Much of this effort has coalesced around COVAX, the multilateral initiative aimed at accelerating the development of COVID‐19 vaccines, and ensuring they are equitably available in low‐ and middle‐income countries (LMICs). This paper represents the first significant analysis of COVAX, and the extent to which it can be said to have successfully met these aims.MethodsThis paper draws on the publicly available policy documents made available by the COVAX initiatives, as well as position papers and public statements from governments around the world with respect to COVID‐19 vaccines and equitable access. We analyze the academic literature regarding access to vaccines during the H1N1 pandemic. Finally, we consider the WHO Global Allocation System, and its principles, which are intended to guide COVAX vaccine deployment.FindingsWe argue that the funding mechanism deployed by the COVAX Pillar appears to be effective at fostering at‐risk investments in research and development and the production of doses in advance of confirmation of clinical efficacy, but caution that this represents a win‐win situation for vaccine manufacturers, providing them with opportunity to benefit regardless of whether their vaccine candidate ever goes on to gain regulatory approval. We also argue that the success of the COVAX Facility with respect to equitable access to vaccine is likely to be limited, primarily as a result of the prevalence of vaccine nationalism, whereby countries adopt policies which heavily prioritize their own public health needs at the expense of others.ConclusionsCurrent efforts through COVAX have greatly accelerated the development of vaccines against COVID‐19, but these benefits are unlikely to flow to LMICs, largely due to the threat of vaccine nationalism.

A vaccine is viewed as the key to bringing about the end of the COVID‐19 pandemic. The sooner a vaccine is available, the sooner the world can begin to escape the acute phase of the pandemic, suppressing mortality and morbidity caused by infection and restoring a degree of normality to social life and the global economy. Not only is global equitable access to a COVID‐19 vaccine an important public health tool, but it is also necessary to ensure that all countries can discharge their human rights obligations. ¹ In an attempt to accelerate the availability of vaccines and other tools to combat COVID‐19, the World Health Organization (WHO) established the Access to COVID‐19 Tools (ACT) Accelerator, a global initiative designed to harbor international cooperation and knowledge regarding the pandemic. Specifically, the ACT‐Accelerator is focused on accelerating development in four areas, or pillars: diagnostics, therapeutics, vaccines (called COVAX), and health systems strengthening.Although efforts to develop a vaccine are starting to prove successful, with the development of successful candidates from Pfizer, Moderna, and AstraZenica/University of Oxford all receiving emergency regulatory approval in late 2020, key questions remain about which countries will have access to these vaccines, when they will get access, and in what quantities. During the 2009 H1N1 influenza pandemic, procurement of pandemic vaccines was dominated by developed countries, which used advance purchase agreements to reserve doses ahead of production. This severely limited the number of doses available in developing countries. ² In addition to accelerating research and development (R&D) through the ACT‐Accelerator, and in an attempt to ensure more equitable access to vaccines for COVID‐19, the Coalition for Epidemic Preparedness Innovations (CEPI); Gavi, the Vaccine Alliance; and the WHO formed the COVAX Facility in early 2020. The COVAX Facility is designed to address the issues encountered by developing countries during the 2009 H1N1 pandemic by using significant advance market commitments to secure access to vaccines on their behalf. It also encourages multilateral cooperation to increase access to vaccines in all participating countries.This paper argues that the funding mechanism deployed by the COVAX pillar appears to be effective at fostering at‐risk investments in R&D and the production of doses in advance of confirmation of clinical efficacy. Indeed, the development of two vaccine candidates funded by the ACT‐Accelerator is testament to this fact. However, this comes with a caution that the mechanism heavily favors pharmaceutical companies, for which up‐front investment from the COVAX pillar represents a win‐win situation and an opportunity to benefit regardless of whether their vaccine candidate ever goes on to gain regulatory approval. The paper then discusses the COVAX Facility, arguing that, like any multilateral purchasing system, securing a sufficient degree of interest and participation is essential to its success. It argues that the COVAX Facility has so far failed to do this, primarily as a result of the prevalence of vaccine nationalism, whereby countries adopt policies that heavily prioritize their own public health needs at the expense of others, and that its success is therefore likely to be limited. The paper concludes by arguing that the Global Allocation System, designed by the WHO, fails to address the issues experienced by the Vaccine Deployment Initiative during the 2009 H1N1 pandemic, specifically the delays in deploying vaccine in developing countries owing to a lack of preparedness and vaccine utilization infrastructure. It argues that, if these issues are not addressed, the COVAX Facility will fail to secure equitable access to vaccines in developing countries, despite the rapid development of successful vaccine candidates, because the allocation framework will be unable to operate as intended.     

Rapid Transition to Telehealth and the Digital Divide: Implications for Primary Care Access and Equity in a Post‐COVID Era

Policy Points

• Telehealth has many potential advantages during an infectious disease outbreak such as the COVID‐19 pandemic, and the COVID‐19 pandemic has accelerated the shift to telehealth as a prominent care delivery mode.
• Not all health care providers and patients are equally ready to take part in the telehealth revolution, which raises concerns for health equity during and after the COVID‐19 pandemic.
• Without proactive efforts to address both patient‐ and provider‐related digital barriers associated with socioeconomic status, the wide‐scale implementation of telehealth amid COVID‐19 may reinforce disparities in health access in already marginalized and underserved communities.
• To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them.

ContextThe COVID‐19 pandemic has catalyzed fundamental shifts across the US health care delivery system, including a rapid transition to telehealth. Telehealth has many potential advantages, including maintaining critical access to care while keeping both patients and providers safe from unnecessary exposure to the coronavirus. However, not all health care providers and patients are equally ready to take part in this digital revolution, which raises concerns for health equity during and after the COVID‐19 pandemic.MethodsThe study analyzed data about small primary care practices’ telehealth use and barriers to telehealth use collected from rapid‐response surveys administered by the New York City Department of Health and Mental Hygiene''s Bureau of Equitable Health Systems and New York University from mid‐April through mid‐June 2020 as part of the city''s efforts to understand how primary care practices were responding to the COVID‐19 pandemic following New York State''s stay‐at‐home order on March 22. We focused on small primary care practices because they represent 40% of primary care providers and are disproportionately located in low‐income, minority or immigrant areas that were more severely impacted by COVID‐19. To examine whether telehealth use and barriers differed based on the socioeconomic characteristics of the communities served by these practices, we used the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to stratify respondents as being in high‐SVI or low‐SVI areas. We then characterized respondents’ telehealth use and barriers to adoption by using means and proportions with 95% confidence intervals. In addition to a primary analysis using pooled data across the five waves of the survey, we performed sensitivity analyses using data from respondents who only took one survey, first wave only, and the last two waves only.FindingsWhile all providers rapidly shifted to telehealth, there were differences based on community characteristics in both the primary mode of telehealth used and the types of barriers experienced by providers. Providers in high‐SVI areas were almost twice as likely as providers in low‐SVI areas to use telephones as their primary telehealth modality (41.7% vs 23.8%; P <.001). The opposite was true for video, which was used as the primary telehealth modality by 18.7% of providers in high‐SVI areas and 33.7% of providers in low‐SVI areas (P <0.001). Providers in high‐SVI areas also faced more patient‐related barriers and fewer provider‐related barriers than those in low‐SVI areas.ConclusionsBetween April and June 2020, telehealth became a prominent mode of primary care delivery in New York City. However, the transition to telehealth did not unfold in the same manner across communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them.     

Allocating a COVID‐19 Vaccine: Balancing National and International Responsibilities

Policy Points

• In this paper we propose a middle‐ground policy for the distribution of an effective COVID‐19 vaccine, between a cosmopolitan approach that rejects entirely nation‐state priority and unbridled vaccine nationalism that disregards obligations to promote an equitable global allocation of an effective vaccine over time.
• Features of the COVAX partnership, a collaboration among the Global Alliance for Vaccines and Immunizations (GAVI), the Coalition for Epidemic Preparedness Innovations (CEPI), and the World Health Organization (WHO) to develop and distribute COVID‐19 vaccines make it an appropriate framework for a middle‐ground policy.

More than 100 vaccine candidates are now in development to prevent infection from SARS‐CoV2 or serious disease from COVID‐19; many have entered clinical trials; and several are in or ready for Phase III efficacy testing. Two mRNA vaccines have been found to be more than 90% effective based on interim data analysis. The identification and development of vaccine candidates has been an extremely fast process, because of the urgent need for a vaccine to control the pandemic. In addition, when effective vaccines are identified, logistical challenges must be faced, as it will take time to produce enough to cover the world''s population. At least for the first couple of years, the demand will be much higher than the supply, and not everyone who needs a vaccine will get one. Because low‐income countries are likely to lose out in the scramble to get access to the vaccine, there have been calls for global solidarity. For example, the Group of 20 (G20), consisting of countries with the largest economies, issued the following statement: “We will expand manufacturing capacity to meet the increasing needs for medical supplies and ensure these are made widely available, at an affordable price, on an equitable basis, where they are most needed and as quickly as possible.” ¹ But there are worries that these are only empty promises. Even though the G20 statement emphasizes an equitable distribution of medical supplies, it does not actually commit funds to the poorest countries for supplies, including a global distribution of an effective vaccine; it recommends only capacity building and technical assistance and commits only to “mobilize” funds.

We are gravely concerned with the serious risks posed to all countries, particularly developing and least developed countries, and notably in Africa and small island states, where health systems and economies may be less able to cope with the challenge, as well as the particular risk faced by refugees and displaced persons. We consider that consolidating Africa''s health defense is a key for the resilience of global health. We will strengthen capacity building and technical assistance, especially to at‐risk communities. We stand ready to mobilize development and humanitarian financing. ¹

In the race to develop an effective vaccine, many experts have called for a more coordinated global approach, in which individual countries agree to abandon their national interest in securing vaccines for their own populations and hand over the responsibility to distribute the vaccine globally based on need. A group of bioethicists proposed what they term the “Fair Priority Model,” advocating vaccine distribution in three phases. ² The first phase would be devoted to reducing premature deaths and irreversible direct and indirect health impacts; the second to reducing serious economic and social deprivations; and the third to reducing community transmission. They argue that all countries should go through the three phases “approximately simultaneously.” In this model, the distribution principles are based strictly on medical and economic criteria that identify the effects of the vaccine and wealthy countries would not receive the vaccine earlier just because they have the resources to buy it.Another influential approach, proposed by the World Health Organization (WHO), similarly envisages a distribution scheme in which the vaccines are distributed to countries based on the number of high‐risk groups in each country. A country should first obtain enough vaccine to cover frontline health care workers, covering 3% of the highest‐risk individuals first and then continue with other high‐risk groups such as the elderly and people with comorbidities, until 20% of each country''s population has been covered.Both the Fair Priority Model and the WHO proposal seem to disregard the relevance of national borders; that is, all countries should receive a supply of vaccines simultaneously in accordance with country‐independent criteria. Here we argue that both these approaches are untenable and that national governments have both a right and a duty to secure access to a COVID‐19 vaccine for their citizens first. Accordingly, we propose a middle‐ground policy perspective based on two premises: (1) a “cosmopolitan” approach that rejects entirely nation‐state priority is not only unrealistic but also fails to recognize that countries have a legitimate responsibility to give priority to their own citizens and residents; and (2) unbridled vaccine nationalism, without an adequately funded effort to ensure the equitable global allocation of an effective vaccine over time, is unethical and likely to be counterproductive.We present three interdependent arguments for our position. First, we believe that a prioritization framework should include a distribution scheme that can be implemented, rather than one that simply proposes general principles of distribution. Second, any viable prioritization scheme needs to start with nation‐states’ responsibility to secure the health of their populations. Third, appropriate weight needs to be given to national obligations of international assistance for low‐income countries to mobilize resources for health. We argue that the COVAX partnership provides a framework that approximates the right balance between national responsibilities for health and international commitments to global justice.     

COVID‐19: The Time for Collaboration Between Long‐Term Services and Supports,Health Care Systems,and Public Health Is Now

Policy Points

• To address systemic problems amplified by COVID‐19, we need to restructure US long‐term services and supports (LTSS) as they relate to both the health care systems and public health systems. We present both near‐term and long‐term policy solutions.
• Seven near‐term policy recommendations include requiring the uniform public reporting of COVID‐19 cases in all LTSS settings; identifying and supporting unpaid caregivers; bolstering protections for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing barriers to telehealth in LTSS; and providing incentives to care for vulnerable populations.
• Long‐term reform should focus on comprehensive workforce development, comprehensive LTSS financing reform, and the creation of an age‐friendly public health system.

ContextThe heavy toll of COVID‐19 brings the failings of the long‐term services and supports (LTSS) system in the United States into sharp focus. Although these are not new problems, the pandemic has exacerbated and amplified their impact to a point that they are impossible to ignore. The primary blame for the high rates of COVID‐19 infections and deaths has been assigned to formal LTSS care settings, specifically nursing homes. Yet other systemic problems have been unearthed during this pandemic: the failure to coordinate the US public health system at the federal level and the effects of long‐term disinvestment and neglect of state‐ and local‐level public health programs. Together these failures have contributed to an inability to coordinate with the LTSS system and to act early to protect residents and staff in the LTSS care settings that are hotspots for infection, spread, and serious negative health outcomes.MethodsWe analyze several impacts of the COVID‐19 pandemic on the US LTSS system and policy arrangements. The economic toll on state budgets has been multifaceted, and the pandemic has had a direct impact on Medicaid, the primary funder of LTSS, which in turn has further exacerbated the states’ fiscal problems. Both the inequalities across race, ethnicity, and socioeconomic status as well as the increased burden on unpaid caregivers are clear. So too is the need to better integrate LTSS with the health, social care, and public health systems.FindingsWe propose seven near‐term actions that US policymakers could take: implementing a uniform public reporting of COVID‐19 cases in LTSS settings; identifying and supporting unpaid caregivers; bolstering support for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing the barriers to telehealth in LTSS; and providing incentives to care for our most vulnerable populations. Our analysis also demonstrates that our nation requires comprehensive reform to build the LTSS system we need through comprehensive workforce development, universal coverage through comprehensive financing reform, and the creation of an age‐friendly public health system.ConclusionsCOVID‐19 has exposed the many deficits of the US LTSS system and made clear the interdependence of LTSS with public health. Policymakers have an opportunity to address these failings through a substantive reform of the LTSS system and increased collaboration with public health agencies and leaders. The opportunity for reform is now.     

Population Health Science: Fulfilling the Mission of Public Health

Policy Points

• The historical mission of public health is to ensure the conditions in which people can be healthy, and yet the field of public health has been distracted from this mission by an excessive reliance on randomized‐control trials, a lack of formal theoretical models, and a fear of politics.
• The field of population health science has emerged to rigorously address all of these constraints. It deserves ongoing and formal institutional support.

The united states is failing in population health. life expectancy in the United States is falling for the first time since reliable mortality records have been available, and health equity has been on a downward trend for decades. ¹ Why is the United States, among the richest countries in the world, failing to protect the health of its residents? A dysfunctional medical system that pays for sickness rather than wellness is certainly part of the problem, but so is confusion about the role of public health in the United States.     

Effects of the COVID‐19 Emergency and National Lockdown on Italian Citizens’ Economic Concerns,Government Trust,and Health Engagement: Evidence From a Two‐Wave Panel Study

Policy Points

• Preventive measures such as the national lockdown in Italy have been effective in slowing the spread of COVID‐19. However, they also had psychological and economic impacts on people’s lives, which should not be neglected as they may reduce citizens’ trust and compliance with future health mandates.
• Engaging citizens in their own health management and in the collaboration with health care professionals and authorities via the adoption of a collaborative approach to health policy development is fundamental to fostering such measures’ effectiveness.
• Psychosocial analysis of citizens’ concerns and emotional reactions to preventive policies is important in order to plan personalized health communication campaigns.

ContextBecause of the COVID‐19 pandemic, between February 23 and March 8, 2020, some areas of Italy were declared “red zones,” with citizens asked to stay home and avoid unnecessary interpersonal contacts. Such measures were then extended, between March 10 and May 4, 2020, to the whole country. However, compliance with such behaviors had an important impact on citizens’ personal, psychological, and economic well‐being. This could result in reduced trust in authorities and lowered compliance. Keeping citizens engaged in their own health and in preventive behaviors is thus a key strategy for the success of such measures. This paper presents the results from a study conducted in Italy to monitor levels of people’s health engagement, sentiment, trust in authorities, and perception of risk at two different time points.MethodsTwo independent samples (n = 968 and n = 1,004), weighted to be representative of the adult Italian population, were recruited in two waves corresponding to crucial moments of the Italian COVID‐19 epidemic: between February 28 and March 4 (beginning of “phase 1,” after the first regional lockdowns), and between May 12 and May 18 (beginning of “phase 2,” after the national lockdown was partially dismissed). Respondents were asked to complete an online survey with a series of both validated measures and ad hoc items. A series of t‐tests, general linear models, and contingency tables were carried out to assess if and how our measures changed over time in different social groups.FindingsAlthough sense of self and social responsibility increased between the two waves, and trust toward authorities remained substantially the same, trust in science, consumer sentiment, and health engagement decreased. Our results showed that while both the level of general concern for the emergency and the perceived risk of infection increased between the two waves, in the second wave our participants reported being more concerned for the economic consequences of the pandemic than the health risk.ConclusionsThe potentially disruptive psychological impact of lockdown may hamper citizens’ compliance with, and hence the effectiveness of, behavioral preventive measures. This suggests that preventive measures should be accompanied by collaborative educational plans aimed at promoting people’s health engagement by making citizens feel they are partners in the health preventive endeavor and involved in the development of health policies.     

Identifying Opportunities to Strengthen the Public Health Informatics Infrastructure: Exploring Hospitals’ Challenges with Data Exchange

Policy Points

• Even though most hospitals have the technological ability to exchange data with public health agencies, the majority continue to experience challenges.
• Most challenges are attributable to the general resources of public health agencies, although workforce limitations, technology issues such as a lack of data standards, and policy uncertainty around reporting requirements also remain prominent issues.
• Ongoing funding to support the adoption of technology and strengthen the development of the health informatics workforce, combined with revising the promotion of the interoperability scoring approach, will likely help improve the exchange of electronic data between hospitals and public health agencies.

ContextThe novel coronavirus 2019 (COVID‐19) pandemic has highlighted significant barriers in the exchange of essential information between hospitals and local public health agencies. Thus it remains important to clarify the specific issues that hospitals may face in reporting to public health agencies to inform focused approaches to improve the information exchange for the current pandemic as well as ongoing public health activities and population health management.MethodsThis study uses cross‐sectional data of acute‐care, nonfederal hospitals from the 2017 American Hospital Association Annual Survey and Information Technology supplement. Guided by the technology‐organization‐environment framework, we coded the responses to a question regarding the challenges that hospitals face in submitting data to public health agencies by using content analysis according to the type of challenge (i.e., technology, organization, or environment), responsible entity (i.e., hospital, public health agency, vendor, multiple), and the specific issue described. We used multivariable logistic and multinomial regression to identify characteristics of hospitals associated with experiencing the types of challenges.FindingsOur findings show that of the 2,794 hospitals in our analysis, 1,696 (61%) reported experiencing at least one challenge in reporting health data to a public health agency. Organizational issues were the most frequently reported type of challenge, noted by 1,455 hospitals. The most common specific issue, reported by 1,117 hospitals, was the general resources of public health agencies. An advanced EHR system and participation in a health information exchange both decreased the likelihood of not reporting experiencing a challenge and increased the likelihood of reporting an organizational challenge.ConclusionsOur findings inform policy recommendations such as improving data standards, increasing funding for public health agencies to improve their technological capabilities, offering workforce training programs, and increasing clarity of policy specifications and reporting. These approaches can improve the exchange of information between hospitals and public health agencies.     

The Role of Value-Based Payment in Promoting Innovation to Address Social Risks: A Cross-Sectional Study of Social Risk Screening by US Physicians

Policy Points

• One of the most important possibilities of value‐based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. Screening patients for social risks such as housing instability and food insecurity represents an early step physician practices can take to address social needs.
• At present, adoption of social risk screening by physician practices is linked with having high innovation capacity and focusing on low‐income populations, but not exposure to value‐based payment.
• Expanding social risk screening by physician practices may require standardization and technical assistance for practices that have less innovative capacity.

ContextOne of the most important possibilities of value‐based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. However, there is uncertainty about the conditions under which value‐based payment will encourage health care providers to innovate to address upstream social risks.MethodsWe used the 2017‐2018 National Survey of Healthcare Organizations and Systems (NSHOS), a nationally representative survey of physician practices (n = 2,178), to ascertain (1) the number of social risks for which practices systematically screen patients; (2) the extent of practices’ participation in value‐based payment models; and (3) measures of practices’ capacity for innovation. We used multivariate regression models to examine predictors of social risk screening.FindingsOn average, physician practices systematically screened for 2.4 out of 7 (34%) social risks assessed by the survey. In the fully adjusted model, implementing social risk screening was not associated with the practices’ overall exposure to value‐based payment. Being in the top quartile on any of three innovation capacity scales, however, was associated with screening for 0.95 to 1.00 additional social risk (p < 0.001 for all three results) relative to the bottom quartile. In subanalysis examining specific payment models, participating in a Medicaid accountable care organization was associated with screening for 0.37 more social risks (p = 0.015). Expecting more exposure to accountable care in the future was associated with greater social risk screening, but the effect size was small compared with practices’ capacity for innovation.ConclusionsOur results indicate that implementation of social risk screening—an initial step in enhancing awareness of social needs in health care—is not associated with overall exposure to value‐based payment for physician practices. Expanding social risk screening by physician practices may require standardized approaches and implementation assistance to reduce the level of innovative capacity required.     

‘They're getting a taste of our world’: A qualitative study of people with multiple sclerosis' experiences of accessing health care during the COVID‐19 pandemic in the Australian Capital Territory

BackgroundPeople with multiple sclerosis (MS), who are often immunocompromised, require complex care and engage with a variety of health‐care providers to manage their health.ObjectiveTo elucidate people with MS'' experiences of accessing health care during the COVID‐19 pandemic in Australia.DesignA qualitative study involving semi‐structured interviews and thematic analysis.Settings and participantsEight adults with a clinical diagnosis of MS participated in telephone or video call interviews between June and July 2020.ResultsParticipants were aware that having MS made them more vulnerable to contracting COVID‐19. In some cases, usual care was postponed or not sought. Some circumstances warranted the risk of a face‐to‐face consultation. Benefits of telehealth consultations included improved access, convenience and being contact‐free. In comparison with video consultations, those via telephone were considered less personal and limited capacity to read body language, and for physical examination. Most participants hoped to incorporate telehealth into their future health‐care routines.Discussion and conclusionPersonal risk assessment and trust in health‐care professionals are determinants of the mode through which people with MS accessed health care during the COVID‐19 pandemic. Telehealth has been a valuable tool to mitigate COVID‐19 transmission through enabling contact‐free consultations. People with MS may find specific value in video consultations, which enable visualization of physical function. There is a need for training and support for all clinicians to conduct remote consultations.Patient or public contributionThis study was conducted by a team comprised of four people with MS, a neurologist and four health services researchers.     

The Communication Infrastructure as a Social Determinant of Health: Implications for Health Policymaking and Practice

Policy Points

• Persistent communication inequalities limit racial/ethnic minority access to life‐saving health information and make them more vulnerable to the effects of misinformation.
•  Establishing data collection systems that detect and track acute gaps in the supply and/or access of racial/ethnic minority groups to credible health information is long overdue.
• Public investments and support for minority‐serving media and community outlets are needed to close persistent gaps in access to credible health information.

     

A Commons for a Supply Chain in the Post-COVID-19 Era: The Case for a Reformed Strategic National Stockpile

Policy Points

• Reflecting on current response deficiencies, we offer a model for a national contingency supply chain cell (NCSCC) construct to manage the medical materials supply chain in support of emergencies, such as COVID‐19. We develop the following:
  • a framework for governance and response to enable a globally independent supply chain;
  • a flexible structure to accommodate the requirements of state and county health systems for receiving and distributing materials; and
  • a national material “control tower” to improve transparency and real‐time access to material status and location.

ContextMuch of the discussion about the failure of the COVID‐19 supply chain has centered on personal protective equipment (PPE) and the degree of vulnerability of care. Prior research on supply chain risks have focused on mitigating the risk of disruptions of specific purchased materials within a bounded region or on the shifting status of cross‐border export restrictions. But COVID‐19 has impacted every purchase category, region, and border. This paper is responsive to the National Academies of Sciences, Engineering and Medicine recommendation to study and monitor disasters and to provide governments with course of action to satisfy legislative mandates.MethodsOur analysis draws on our observations of the responses to COVID‐19 in regard to acquisition and contracting problem‐solving, our review of field discussions and interactions with experts, a critique of existing proposals for managing the strategic national stockpile in the United States a mapping of the responses to national contingency planning phases, and the identification of gaps in current national healthcare response policy frameworks and proposals.FindingsCurrent proposals call for augmenting a system that has failed to deliver the needed response to COVID‐19. These proposals do not address the key attributes for pandemic plan renewal: flexibility, traceability and transparency, persistence and responsiveness, global independence, and equitable access. We offer a commons‐based framework for achieving the opportunities and risks which are responsive to a constellation of intelligence assets working in and across focal targets of global supply chain risk.ConclusionsThe United States needs a “commons‐based strategy” that is not simply a stockpile repository but instead is a network of repositories, fluid inventories, and analytic monitoring governed by the experts. We need a coordinated effort, a “commons” that will direct both conventional and new suppliers to meet demands and to eliminate hoarding and other behaviors.     

The Role of Primary Care in Improving Population Health

Policy Points

• Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure.
• Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges.
• Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.

     

Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Policy Points

• In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long‐term survival of cancer patients following initial diagnosis. There is also evidence that short‐term (30‐day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower.
• Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed.
• Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care.

ContextThe relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a “must.” For traditional fee‐for‐service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy.MethodsComplementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy‐oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers.FindingsQuality of care as measured in process of care studies and in longitudinal studies of long‐term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range''s lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures.ConclusionsBased on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.     

Chronic and rare disease patients' access to healthcare services during a health crisis: The example of the COVID‐19 pandemic in Turkey

ObjectiveThe restructuring of healthcare provision for the coronavirus disease 2019 (COVID‐19) pandemic caused disruptions in access for patients with chronic or rare diseases. This study explores the experiences of patients with chronic or rare diseases in access to healthcare services in Turkey during the COVID‐19 pandemic.MethodsSemi‐structured interviews were conducted with representatives (n = 10) of patient organisations (n = 9) based in Istanbul. Thematic analysis with an inductive approach was conducted to analyse the responses obtained through the interviews.ResultsThe lack of clinical information at the beginning of the pandemic caused fear among patients with chronic or rare diseases. Patients experienced obstacles in access to healthcare services because of the overcrowding of hospitals with COVID‐19 patients. Some treatment procedures were cancelled or postponed by physicians. Of these procedures, some were medically vital for those patients, leading to or exacerbating further health problems. The most positive measures that patients identified were where the Social Security Institution introduced regulations to facilitate access to prescribed medicine for chronic patients. Information exchange between the doctors and their patients was important to alleviate the uncertainty and reduce the anxiety among patients.DiscussionAccess problems experienced by patients during the COVID‐19 pandemic were a complex mix of factors including shortages and physical barriers, but also perceptions of barriers. The findings of this study show that patient organisations can provide insights on disease‐specific experiences and problems that are very valuable to improve access to healthcare services to achieve the universal health coverage target. Hence, this study emphasises the inclusion of patient organisations in decision‐making processes during times of health crises.Public ContributionRepresentatives of patient organisations participated in the interviews.