How Should the U.S. Government Respond to COVID-19?

Update: On March 18, the working group published a blog post responding to the Families First Coronavirus Response Act, which has passed Congress and been signed into law, and making recommendations for additional legislation.

Read a press release about the proposal.

Read the full text of the proposal on Health Affairs Blog.

What are the most immediate and pressing needs for the federal government to address?

First of all, a massive testing apparatus stood up very quickly so that we can get a handle on what’s going on around us. Then, at the same time, we need to be able to put in place economic protections for the many people that are being displaced by this, many of whom are either infected or exposed to infected people, and for whom protections are not ordinarily provided by their employer, insurer, or society.

How did the group of experts that you assembled decide what was most pressing and what could be left out of your stimulus proposal?

I first want to say that this was a truly collaborative effort. You can go back to my original tweet of last Sunday and see what I was saying as one naive person, just seeing it from my perspective. I personally did a lot of organizing but, in terms of the content, we assembled a team of amazingly talented people with legislative, subject matter, and executive branch experience who could help guide us in our proposals and tell us what can be done and what, quite honestly, is not in the responsibility or remit of the federal government or even state governments. I don’t want to even suggest that I made any of those decisions. The group worked as a collaborative team in which each person took responsibility for a collection of ideas that were submitted from a collection of experts that we sought advice from.

We parceled it out. We had a team of three medical students at Harvard and two law students at Yale, who did a tremendous amount of the groundwork and kept the wheels on the wagon. We were basically concatenating information in real time over about a 48-hour period coming in from about 50 folks across the nation.

We organized it, and we made some decisions about where different things fit in our own organizational structure. Individuals took responsibility for each category. Then we worked collaboratively to make sure that everybody, including our colleagues here at the law school and elsewhere, felt that we weren’t stretching beyond what is possible. We weren’t just thinking pie-in-the-sky: “It would be nice to have this.” We were thinking what is possible through legislation, regulation, or executive orders.

Why did the group conceive of it as a stimulus as opposed to just emergency measures?

This was my perception of what was going to happen. I thought that [last] Monday the market was going to plummet a lot, and that the president would start talking about stimulus and bailouts. I felt that it would be morally offensive if we were talking about a stimulus bill or a bailout bill for industry without actually looking at it from the point of view of healthcare and the needs of individual people. I started using that term mostly as a reflection of what I thought politically was starting to be bandied about, almost immediately.

And it has been; people have continued to talk about various bailout bills. People have continued to talk about stimulus bills. I think we’ll see pretty soon exactly what a final bill will look like coming out of the House and Senate. I just wanted to make sure that public health and healthcare were first and foremost, not an afterthought.

How did you think about the long-term priorities to include?

We didn’t think about anything truly long-term. Our goal was to address the current pandemic and its effects, but we also have to recognize the fact that one of the long-term effects of this pandemic has to be, how do we not let this happen again? We didn’t address things like Medicare for All, which are worthy topics. We didn’t address things like how do you deal with the uninsured and the underinsured in this country. We really kept it very narrow to specifically this crisis.

How confident are you in the way the federal government is reacting at this point? Did the announcement this morning about stepping up testing reassure you at all?

Until I see that the testing has been really augmented substantially… I want to see it. I tweeted something out two weeks ago where I turned out to be half right. I said the numbers were going to start to explode in the United States over the next few days as we expand testing. While that was right, the magnitude of the expansion of testing was so different from what I anticipated that we’re two weeks behind where I thought we would be. Part of that was my own naivete about how long it would take to stand up a lab. Part of it was also the failure of the CDC to have prepared the state departments of public health for augmented testing. I think what we’re witnessing now is a slow, but very steady, ramping up. I have a lot more faith today, partly because they’re reporting more numbers, that we’re getting closer and closer to the numbers we want to see. We’re still an order of magnitude away from what I would consider to be the minimally adequate level of testing

A week ago you wrote for Yale Insights about the kind of information that we could gain from testing—how quickly it’s spreading, who is communicable, etc. How far do you think we are from having enough testing to be able to make those kinds of determinations?

For the type of information I would like to see, we’re over a month away. Just being able to do testing of everybody that has symptoms would be a really great first step. There are estimates by some people that there are a million people infected in the country, or three million people. Certainly, there’s probably a few hundred thousand people with some type of symptoms, even if it’s really a cold or an unrelated infection. There are a lot of people with symptoms for who it would be good to know if they have this. It would really help us a lot epidemiologically. It would help us make decisions for the community if we had that type of information. That’s just one step. We’re not even close to that yet.

Then the next step is how we get to do some types of surveillance testing and prevalence testing where we go into communities that might not even be infected. For instance, if schools were still operating or if we could have done this two weeks ago, it would’ve been really nice to be able to test all the kids in the school if that was what was felt to be necessary to know where we stand. It would also tell us a lot about the disease incidence versus the infection incidence in the population. It may be that for every 10 children infected, less than one shows any symptoms. Those are things that we would like to know. We don’t have those answers yet, and we won’t have that for a while.

A lot of ordinary life came to a stop suddenly in the last couple of days—schools closed, people working at home, the NBA suspended. Would you want to hazard a guess as to when ordinary life will return on some level, based on what we’ve seen in other countries?

Ordinary life, I think, is a long way off. I think that in three or four weeks, we will have so much more information available that we will begin to change the way we’ve responded. We may decide, for instance, that schools are going to stay shut down. We may find in three weeks that this is a lot less lethal than we thought it was going to be. It’s still going to be way, way, more lethal than the flu. At least it’ll make people a little calmer if we find out that the fatality rate is 0.7% and not 3.4%. We may find that we know how to manage it quicker. We may find some novel treatments that work and that help mitigate the infection itself. There are so many things that could happen over the next few weeks. Once we have adequate testing, once we have, let’s say, half a million people documented and we start to see outcomes on a much more global scale, we’ll do a lot better.

That’s three or four weeks before we have that knowledge. Then, presumably, there would be some weeks after that where we’re all still holed up?

I think there’s a very high likelihood that real normal life is going to be months away for us. I think that’s a very, very, high likelihood for now. But the fear should abate and freedom of movement will return for many, even as we may still emphasize social distancing as a critical measure of protection to the public.

Do you have an expectation either way about the effect of warming weather?

I personally am in the camp that believes that there will be decreased spread during warmer weather, and that there’ll be sort of a smoldering. There will be a number of cases at that point, but it’ll be much less than we’re going to see over the next three to six weeks. That is just a guess based on the history of coronaviruses, the history of flus, the history of colds. This is a completely novel virus, and I could be proven wrong completely.