April 15, 2020

My 3^rd ICU Covid-19 patient is not doing well;  I can now get testing and millions of unemployed will lose their health insurance.

My third Covid patient ICU patient is not doing well.  He is intubated. For the past two weeks I speak to family members every night around 7pm giving them an update. (The ICU staff calls me as I am the primary care physician). Every Covid-19 death is a tragedy; these deaths were largely avoidable. But this patient, who is only 38 year years old, is especially painful for me.  I spoke with him the day before he was hospitalized. He called me about symptoms that were likely Covid-19, but he said he was feeling much better. In a familiar Covid-19 scenario, the next day he had trouble breathing, was hospitalized and has been intubated on a ventilator ever since.

I am now able to order Covid-19 tests. Of course, nothing is that simple. There are false negatives.  But I do feel that I am making a little progress: yesterday I was able to order the Covid-19 test for someone who had been exposed to the virus and was coming down with symptoms.

By now the (barest) outline of how the United States will emerge out of this totally avoidable human tragedy is becoming clear. The two main questions that remain are.

(1) Will the executive branch of the federal government be held to account for its sheer incompetence, brazen mendacity, and obvious authoritarian tendencies? Will Congress assert its authority and pass significant legislation checking the executive branch? Thus far Congress has been on the sidelines and Fauci is doing a balancing act, And this includes issues like the false hope spread about hydroxychloroquine.

At this time, it also appears that the important recommendations of Scott Gottlieb and Mark McClelland, two excellent health policymakers who served under Republican Presidents, for a strong federal response will not come to pass. States will do their best to respond and many will do just fine; though the political polarization even to Covid-19 will stop for example NY and Florida from working together. (Partisanship, Health Behavior, and Policy Attitudes in the Early Stages of the COVID-19 Pandemic)

(2) Will we, similar to what occurred in the aftermath of the Great Depression, be able to take this unique once in a century opportunity to address the gross inequities in our health system? These will come into sharp relief as millions of people, especially the young, lose their health insurance and are unable to buy it. The Trump administration’s unrelenting opposition to “Obamacare” could become an obstacle for millions of uninsured people in the coronavirus outbreak, as well as many who are losing coverage in the economic shutdown.  Health Coverage for the unemployed will be harder to come by in some states.

It is not just the young but as we already know, Covid-19 discriminates: the “pre-existing health conditions” that put a person at risk of severe disease and death from COVID-19 are over-represented in communities of color and poor communities as a result of long-term disinvestment and neglect.

The answers to this “once in a century opportunity” are completely dependent on citizen group mobilization and the extent to which groups such as the hospital industry, health professionals small business groups and unions see it in their interest to collaborate.

‘Ask Nurses and Doctors’ (AND) is doing its part by working with health professionals in competitive Congressional districts organizing for election of incumbents and/or candidates who prioritize universal coverage; we are also organizing in swing states such as Florida and Michigan to help elect a Democratic President.   This once in a century opportunity is dependent on policymakers coming up with feasible ideas that can be quickly implemented. Akin to what the states of Mass. and Washington are doing. In essence, the initiatives use traditional public health measures for a debilitated public health system. I will summarize what I and other colleagues are calling Community Centered Population Health (CCPH) – as our response to this once in a century opportunity. CCPH is community centered (not patient centered) health care that links public and personal health with community health workers as the first line.

Read more here  and here.

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