On Friday, March 20, Michael Leavitt participated in an interview-style webinar sponsored by the Washington, D.C.-based Alliance for Health Policy, “a non-partisan, not-for-profit organization dedicated to helping policymakers and the public better understand health policy.” The Alliance has been sponsoring a series of policy-focused webinars around the COVID-19 pandemic.
Leavitt, who served three terms as governor of Utah, served in the cabinet of President George W. Bush, as Administrator of the Environmental Protection Agency, and as Secretary of Health and Human Services. He is now chair of the Board of Managers at the Leavitt Partners consulting firm, based in Salt Lake City. In the webinar, Leavitt spoke with Sarah J. Dash, M.P.H., the Alliance’s president and CEO.
Early on in the webinar, Dash asked Leavitt, “You have an incredibly unique vantage point, as a former governor and a former HHS secretary, and in fact, you’ve led through pandemics yourself. Can you explain to us the different roles of the federal and state governments in responding to outbreaks like this?”
“Yes,” Leavitt responded. “May I say that I think we have to start by making an acknowledgement that we have all now begun to make, and that is that pandemics are a unique emergency? We’ve become accustomed to government playing a role in an emergency, whether it’s a tornado or hurricane or terrorist event—we’re able to deploy as a federal government, to the scene, with many different resources, most of which come from the states. As we look at what a federal government has to deploy, most of those [resources] tend to be people from states not directly engrossed in the event itself. With a pandemic, everything is happening at the same time everywhere, and that makes this a uniquely local emergency. That being said, it’s important to acknowledge that there’s a role for everyone, especially the federal government.”
Per that, Dash asked, “What are the roles of the federal government?”
“First of all, vaccine,” Leavitt responded. “We have great hopes of being able to develop vaccines and medicines that in fact diminish the symptoms or in some ways bring about healing. The federal government has that role. There is the capacity of the federal government to collect and spread risk through tax dollars. We’re seeing now work on the third supplemental appropriation to respond; only the Congress, only the federal government can do that. There’s the collection of data and the providing of information that has to come through the aggregation of data that’s collected at the local level; no one would have that capacity other than the federal government, to be able create those kinds of data standards and aggregate data and information. The federal government has supplemental assets that can be deployed in a time of emergency, including the military. So there is a very distinct federal role.”
That said, Leavitt went on to say that “Anyone who believes that the federal government can come to their rescue through its deployment, would be somewhat disappointed, I think, because that has to be done for the most part by state and local governments, who have resources on the ground; and the job of the federal government, in my view, is to meet its unique roles in being able to support what’s happening on the ground. Let’s take school closures as an example. The thing about a pandemic is that it unfolds differently in different regions of the country at the same time, so we do see different responses being taken by governors and by local mayors and county commissions, who have a view through their public health officials what should be done in those areas. There may be schools that do a soft close, schools that close for a long time, schools that have limited schedules. It depends on the nature of what’s happening; and my advocacy is for them always to make decisions based on local health officials’ advice.” Leavitt emphasized that, in this situation, “there’s a role for everyone,” down to the individual family level, in terms of individuals and families stocking up appropriately on food and over-the-counter medications and sheltering in place when required to do so by authorities.
Asked about some of the very major challenges facing U.S. society right now, Leavitt told Dash that “I do think we ought to acknowledge that what is happening among the American people, is nothing short of historic. People are responding; this is hard—it’s not something people would choose. However, we’re seeing such a profound response, with businesses working from home, with entire professional sport leagues and entertainment venues closing, with families making preparations; this is a profound response, and it will save lives. So I think we can acknowledge, and I think should, that there are so few times in a country’s history, when people pull together in a way that provides a sense of unity. It’s inspiring, I think, that we have government working together. To say three or four months ago that Congress would work together to create a common product, that would have been unlikely. So I think that spirit is very much alive.”
Levels of coordination
When Dash asked about what types of inter-agency coordination need to take place inside the federal government right now, Leavitt said that “I think this is the reason that the President chose to place the Vice-President at the top of the multi-agency task force; that was an important symbol—to say that the entire executive branch was going to work together in a full-government response. There’s not an area of the federal government that’s not required: if you’re in Labor, you’ve got a job; if you’re in Commerce, you’re working on the balls of your feet; if you’re at HHS, you’re working day and night; if you’re the Department of Ed, you’ve got problems you have to deal with; if you’re at State, you’re working with other governments; if you’re at Treasury, you’ve got all kinds of new regulations and demands put forward; if you’re Energy, you’re worried about the energy supply. Every department of the national government has a role here; so without that level of coordination, it would be difficult to function.”
Meanwhile, he noted that one of the complexities involved in situations like this one is that “It’s often difficult to collaborate across line items, even within a budget. So for those who are listening, who have some influence on the way legislation is written for appropriation, keep that in mind. There’s a need for federal agencies to work together; but at points in time, they also have to contribute jointly to projects that can be for the common good.”
What about public-private partnerships? Dash asked. “I think people are innovating right now, because that is not an area that’s particularly strong,” Leavitt said. “I’ve been on a number of different large video conferences where people are struggling to come up with information that allows them to model what their new future looks like. All of us have come to the conclusion that we’re going to have to operate in an environment we’re not accustomed to. What does that look like? People are struggling to know even what to do. I was talking to a friend of mine who runs a small shop at a golf course. And he was saying, I don’t know what to order, or whether I should order anything. Giving people assumptions and the degree of certainty possible, is an important role that policy makers and those who serve the public, should keep in mind.”
Are there policy and other changes taking place right now that might take hold over a longer period of time, beyond this immediate crisis phase? “Generally, when you study pandemics, as I have,” Leavitt responded, “you begin to realize that pandemics are reshaping events—the economics of a nation, of the world, become reshaped. The politics are affected; the sociology is affected; business practices are affected. I’ve already done three video conference meetings this morning, and it’s working out OK. We’re learning to use that technology in a way we haven’t done as much before; we’re learning to use that technology, we’re learning new skills. I think it’s likely we’ll go through some rough economic times in the next few months, and as we do, we’ll be reminded about getting back to basics. During times of prosperity, we begin to feel a little bit too much entitled; I think our attitudes will be adjusted as well.”
What about the role of HHS, and the military? Dahs asked. “I think it’s important to keep in mind the construct of the way things operate in public health,” Leavitt replied. “The federal government has taken a significant role in the past two decades, mostly because the states have seen Medicaid expenditures going up so dramatically that one of the areas they’ve had to cut back on is public health, and therefore the federal government has had to help. The effect of that, we’re seeing. But public health is both constitutionally and practically, very much a local function. There are city and county public health functions, governed by the state. Public health is at its root a state function. Similarly, CDC has been given some policy role, but for the most part, it has been to offer guidance to the states and to provide policy coordination. So the role between governors and HHS is very important. And there are times when the federal government is acting as primary and times when the federal government is acting as secondary. When secondary, the role of the federal government is to provide assistance; when primary, to offer guidance. One primary area involves the development of standards of data; another would be the approval of vaccines and medications. So the relationship has to be both pliable and efficient, because it’s not a single relationship, it goes both ways. There are primary relationships for both, and secondary for both.”
All that said, Leavitt noted that one area in which changes taking place right now will last, is that around telehealth/telemedicine. “There’s a need for telemedicine, for example,” in the current situation, he noted. “And literally yesterday, the president, HHS and CMS—announced that they’ll clear a whole series of questions around payment for telemedicine. That’s a very important development. And you’ve asked about changes that will occur during this pandemic that we won’t go back on. This is one of them. There’s been a need for us to clear a pathway for physicians to operate across state boundaries; that’s been cleared out now. And I don’t think we’ll ever go back; we’ll see telemedicine become a much greater part of American medicine.”