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Takeaway: The incentives to extend the COVID-19 crisis continue to build at the federal level which makes for more bad public health messaging.

Editor's Note: This is a complimentary research note published by Healthcare Policy analyst Emily Evans. CLICK HERE to get COVID-19 analysis and alerts from our research team and access our related webcasts.

Policy Dreams and Public Health Realities - 1 4 2021 8 44 32 AM


The 117th Congress convenes today with both chambers holding very slim majorities regardless of who wins in Georgia on Tuesday. In an earlier time, that balance of power would be interpreted by Members as a mandate for centrism. In this time, however, centrism requires time many Members can ill afford with the realities of the human life span bearing down.

Known by the shorthand PAYGO, one of the rules of the House generally requires legislation that costs money to be offset with provisions that save it. The rules can and are relaxed during emergencies and when the body deems it appropriate to waive the requirements. When functioning under normal conditions, PAYGO requires compromise, astute navigation of the iron triangle of legislators, lobbyists and the bureaucracy and above all, time.

The rules proposed by Speaker of the House Nancy Pelosi and Rules Committee Chairman James McGovern, while leaving the PAYGO rule intact would allow the Budget Committee Chairman to “adjust [a CBO] estimate to exempt the budgetary effects of measures to prevent, prepare for, or respond to economic or public health consequences resulting from the COVID-19 pandemic; and measures to prevent, prepare for, or respond to economic, environmental, or public health consequences resulting from climate change.”

Translated, legislation passed by the House to respond to COVID, which can arguably be most domestic legislation at this point, and climate change, which is probably everything else, may not require budgetary offsets in the form of cuts to Medicare, Medicaid or other big dollar programs.

The Senate, of course, has their own set of rules and it not likely to be as profligate with the U.S. dollar. Given the drubbing House Democrats took in November, they may not either.

The rule change, having reduced one barrier, permits the policy goal of Universal Basic Income to emerge and make common cause with the COVID-19 response. This aspiration has already been evident in the subtext – or in the case of Sen. Bernie Sanders, the text - of the debate over the most recent COVID-19 relief legislation.

Advocates for direct checks, apparently ignorant of the important distinction between operating revenue and capital investment, have nonetheless successful argued that money from the federal treasury was far superior to a reversal of massively damaging COVID-19 response policies that have disproportionately affected the retail, restaurant, travel, arts and entertainment industries with little to no scientific basis.

Like the suspension of the payroll tax, delay of sequestration, the Medicaid enhanced FMAP and a number of other deregulatory measures, the drive toward UBI reduces the urgency to end the crisis at the federal level.

States, of course, take a different view which will make for some very interesting comparisons in the coming months. We hear New Year’s Eve in Florida was a blast.

Policy Dreams and Public Health Realities - 20200103VaccineP3


The durability of the COVID-19 outbreak crisis seems to rest at the moment with a rate of vaccinations perceived to be sufficient to confer widespread immunity on Americans. At an online event at the Harvard Chan School of Public Health, the omnipresent Dr. Anthony Fauci suggested vaccination rates of 75-80% would be necessary to return to “normal” sometime in the fall.

This rate is achievable under certain circumstances. For example, a childhood vaccination program like that for Measles, Mumps and Rubella, which we must note is a requirement to attend school has compliance rates of 87.4% (Colorado) to 99.2% (Mississippi).

Rates for adult immunization are lower. The most common adult vaccination is that for influenza. Rates for persons over 18 range from 35% (Texas) to 50.4% (Wisconsin). For health care workers, compliance is a requirement of employment and rates are higher, 81.5% (Florida) to 97.5% (Washington, DC).

Among populations that can be compelled to take the COVID-19 vaccination are those currently included in the Advisory Committee on Immunization Practices’ group 1a, health care workers and residents of long-term care facilities.

Where is gets difficult to meet Dr. Fauci’s lofty goal is when immunization priorities move to the general population. However, unlike the seasonal flu vaccination, the one for COVID-19 has a lot more going for it. Colleges and universities, prisons and other situations with congregate living arrangements are likely to require it. A record of immunization may be a requirement for international and possibly domestic travel. Health care services may be predicated on compliance. Of course, there are a lot of people who simply wish to avoid getting sick.

Except for congregate living arrangements, other circumstances to compel immunization are more episodic. That could mean that the U.S. reaches the somewhat arbitrary level of 75-80% but over many more months than current consensus suggests.

At that point a paradox may emerge for volunteers. If “normalcy” does not return until 75-80% of the U.S. population take the vaccine, everyone up until that point must continue to adhere to some wacky state level restrictions and there isn’t as much motivation to run down to the pharmacy.

As impossible as it is to imagine, the public health messaging on COVID-19 keeps getting worse. Unless you live in Florida or Texas.


Announcing one’s retirement is normally not considered a power-enhancing move in politics. The United States Senate, the world’s most deliberative body, is different. The sentiment that emerges over a retiring member tends to finally buoy legislation that should have passed months or years ago.

Two retiring Senators, Lamar(!) Alexander (TN) and Pat Roberts (KS) received their parting gifts last week when appended to the COVID-19 relief legislation were two bills for which they advocated.

Alexander’s No Surprises Act resolves the issue of “surprise” medical bills through a dispute resolution process that nobody is going to want to undertake. It also creates mandates for transparency that will layer atop the Trump administration’s already robust efforts.

The highlights of the No Surprises Act are:

  • Holds patients harmless for out-of-network bills by limiting cost-sharing to what would have been required had the physician been in-network.
  • Establishes a dispute resolution process between payers and providers
  • Prohibits gag clauses in contracts between providers and health plans that prevent exchange of information on cost and quality

The law applies to individual, small group, large group and ERISA plans.

The most immediate implications of Alexander’s contribution to the year-end bill is that, for all practical purposes, there is little benefit to being out-of-network unless the provider has sufficient market power to demand it. In most markets, physicians “who nobody asks for by name,” like anesthesiologists and radiologists will find themselves de facto accepting the price offered in the network contract. The alternative is to engage in a time-consuming arbitration process.

For physicians in highly concentrated markets like western North Carolina, anesthesiologists have enough market power to limit or hinder hospital utilization, making their negotiation with payers a bit more balanced.

The elimination of the gag clause holds the most promise. At the moment when employers are required to be more engaged in their employees’ health care and as a greatly diminished benefit cost during COVID inspires deeper analysis, there is no greater catalyst for change than information.

The section-by-section summary can be found here.

Roberts’ National Bio and Agro-Defense Facility Act brings to fruition years of work by Kansas Senator Pat Roberts and others to grant national security status to the food supply. The bill designates the NBAD facility under construction in Manhattan, KS as a National Laboratory. National Laboratories, like Oak Ridge and Laurence Livermore, are protected national security assets. With that brings a level of secrecy that is not possible at private and public research universities.

The bill also raises agricultural and zoonic disease research to higher level. The USDA, whose status as a federal agency has been burnished by Republican control of the White House and Senate, still lags in prestige among the Washington intelligentsia, including researchers at NIH.

Both bills should have been law at least a year ago but their sponsors, having spent a bit of time in government, know the eternal truth of successful politics: patience and persistence are almost always rewarded.