One of the many unfortunate developments of the COVID-19 pandemic has been the volume of misinformation, rumors and conspiracy theories that have spread across the globe. During times of crisis, it’s critical that trusted public health leaders step up to discern myth from reality and give communities the information they need to steer them toward making safe and healthy decisions.
In that context, one of the leading public health voices whose presence has significantly grown during the pandemic has been Andy Slavitt, the former acting administrator of the Centers for Medicare & Medicaid Services (CMS) under President Obama. Slavitt, now with nearly 600,000 Twitter followers, has become well-known to the average American who is following COVID-19 developments, both due to his daily tweet threads full of insightful and digestible information around the crisis—often from his conversations with federal officials, providers on the ground, scientists and others—as well as his newly-launched “In the Bubble” podcast that features guests from governors to medical experts to business leaders and others.
Slavitt has spearheaded plenty of other endeavors since leaving the federal government in January 2017 with the change in administrations, including the “United States of Care” health reform group, a venture capitalist firm called Town Hall Ventures that invests in healthcare technology and service companies, and most recently the Medicaid Transformation Project (MTP), an initiative—which he co-leads along with digital health innovation network AVIA—that looks to pinpoint, develop and scale digital solutions to assist Medicaid patients. Slavitt recently spoke to Healthcare Innovation Managing Editor Rajiv Leventhal about wide-ranging COVID-19 issues in the current moment, and the latest developments around the MTP, which just recently released its Phase One Report. Below are experts of that discussion.
[Editor’s note: we have also created a 20-min audio version of the COVID-19-specific questions between Slavitt and Leventhal]
What do you see as the primary reason why this crisis is continuing to hit the U.S. so much harder than most other developed nations?
I think there have been three failures that we really need to deal with. The first one is a failure of leadership and preparation. We failed in January, February and March to take the virus seriously. That only can be done at a federal level, so we have this system of laissez-faire federalism, capitalism and all these other things, and then we have a president who simply viewed this [pandemic] as a political attack. Clearly, that’s the first mistake.
But other countries were also caught by surprise. What they did differently reflects what our second failure is—a significant failure to learn and adapt. When this hit New York hard, one would think that people in Georgia, Florida, Texas, and Arizona would recognize that this could be devastating. Instead of adapting and learning like the rest of the world we did, we had to learn the lesson over and over again.
The third failure is a failure of empathy; a failure of an ability to imagine what this is like for other communities who are getting hit harder. I heard someone say “I don’t know anyone who has been affected by COVID,” and the reason is because you don’t know the people who grow your food, who drive the trucks to distribute your food, or the people in the factories who are putting your food together. This virus has a chance to make disparities worse. All of the things that are at work and making this a very unequal country have come out significantly here. So I believe if we don’t deal with all three of those failures at some level, I don’t think we will get there.
During the lockdown, the president opted to defer to governors in developing plans to reopen their respective states. When you think about our 50-state nation and the different ideologies that exist, is there a federal government strategic path that could overcome the challenge that New York City and Mississippi are essentially two different countries, for all intents and purposes?
This is a 50-state emergency and nobody has the infrastructure except the federal government to do certain things. [But] nobody has the ability at the federal level to do all the nuanced implementations. So, at the federal level, what’s required is a federal plan and leadership. Dr. Deborah Birx put one together, but it wasn’t followed by Trump or by states. It gave states the guidance to know when they should reopen and when they shouldn’t. But the minute it was released, the next day Trump tweeted, “Liberate Minnesota and Michigan.” By their own metrics, these states were not even close to the ability to do that. A little leadership would have gone a long way, but the problem was—and I was talking to the White House at the time—they didn’t want the accountability. They wanted to be able to wash their hands and say, “We’re done, we have done our jobs, now you do yours.” That’s a ridiculous way to govern; you need someone willing to say the buck stops here the entire way.
A lot will vary just because it’s a big geographic country and the virus will not spread evenly to every place at the same time. So you don’t need to monolithically close every school, but you do need to close the schools in areas where there is lots of spread. But if you want to open schools in August and September, the time to decide that isn’t August. Imagine if the president said to the country that if we want schools to open in August, which we all do, then we will have to make tradeoffs. We will have to keep bars closed over the summer. That’s hard, and you have to figure out ways to support that, but there’s no way to open schools safely unless we do that. That’s called leadership; if you want people to sacrifice you need to lead them, you have to paint a picture and tell them what they’ll get for it. That obviously didn’t happen.
From what you’re seeing and hearing, are people putting too much hope in a vaccine solving the problem all at once? Will COVID still be around and still potentially causing health and economic problems well beyond when a vaccine is available?
There has been impressive progress, but if people have in their minds that the vaccine will be like the MMR vaccine—which works in 97 percent of people and you need to get it once—that’s the wrong vision for this vaccine. It’s likely to be more like the influenza vaccine, which you have to get frequently and which works for 40 to 60 percent of people. And by the way, not everyone takes the vaccine, and oftentimes it doesn’t work for the people who need the vaccine the most. There are also long-term consequences to COVID that we haven’t figured out, and it’s unclear how the vaccine interacts there. So the way Americans should look at this is as a tool in the arsenal that can improve our lives, along with other things like monoclonal antibodies, wearing masks, testing, and so forth. There is likely to be a cocktail to things—as well as changes to our behavior—that will be needed to be most effective to get through this. There won’t be a day like June 30, 2021, when things go back to normal, but there will be a gradual improvement over time with continued adjustments.
Are there some promising signs in the way health systems and providers have responded and become more resilient?
I’m hearing two things. One is that the fatality rates of the number of people going on ventilators when this started in the U.S. were around 75 percent, and now it’s about 25 percent. With Remdesivir, proning, and better protocols, this has and will continue to become less fatal. There are obviously a lot of dependencies on peoples’ health and age in that analysis.
Secondly, I’m hearing that we really need to see more data since there are pretty widely disparate outcomes at small hospitals versus large ones. A recent study showed that those with smaller ICUs have significantly worse outcomes than those with very large ICUs. We need to develop more specialization because it’s nice to see the averages improve, but I have been around healthcare long enough to know that the average sometimes isn’t the point. Sometimes the point is you still have a bottom quartile set of results that continue to be very bad. I worry that’s the case here.
A few months ago, if you told experts we’d be conducting upwards of 800,000 tests a day, they probably would have said that’s great. But are we going to run into a testing shortage again, and can you explain the struggles in creating an instant test that’s also accurate?
We have already run into the [shortage]. Backlogs are going from two to three days all the up to eight or nine days. We plateaued, and there’s two sides to the equation—the supply side and the demand side. The supply did grow nicely, but the demand grew massively since the efforts to control the spread and reduce community spread never happened. So now you’re at a point where if you have to wait eight days for a result, it doesn’t even matter since you have no visibility into community spread. We have six or seven times many cases every day as we are able to test for. That is a challenge.
We need a three-prong testing strategy—one for symptomatic people, one for asymptomatic (surveillance testing), and one for entry into schools, buildings and events. We have the first type; we’re launching with SalivaDirect to have more capability to do the second type; and we’re a few months away from this low-cost, home-based paper test that people are hoping to see. The FDA has to get on board with the strategy that we need very low-cost tests, since it’s actually the cadence of testing that matters more. So will we be willing to give up a little on the accuracy side?
In your plan to get things back on track, contact tracing plays a big role. But have cases skyrocketed to a point where contact tracing is just far too difficult?
If you have COVID and I asked you who are all the people you saw in the last 24 hours, you could probably tell me. But if I asked who were all the people you interacted with in the last 10 days, it would be a different story. And I have to do that with every person you interacted with. It’s a geometric challenge, particularly if you are a 27-year-old who went to a bar or a college student who went to a house party with 50 people. Testing matters if you have the ability to contact trace and isolate. If you don’t, then testing doesn’t tell you everything. The idea is to have what people around the world think of as “end-point cases,” meaning what percentage of cases exist where the virus doesn’t spread beyond the person that has it? When you are beating the virus, that number is 70 percent or even higher. When the virus is beating you, that number is in the teens. When you are in the U.S. you don’t even measure that number and it’s probably 2 or 3 percent. Most countries have figured this out.
