Preview

The United Kingdom has become the first Western country to authorize a coronavirus vaccine, green-lighting the Pfizer/BioNTech for emergency use. The first shots could be deployed by early next week, as shipments come in from a factory in Belgium. Pfizer’s vaccine will probably get the go-ahead from the U.S. next week.

The British priority order for deployment of the vaccine, which will be in short supply until the manufacturing ramps up, begins with nursing home residents and their carers, followed by citizens over 80, and frontline healthcare workers. That’s similar to the priority order for the U.S., which a CDC panel announced yesterday. The panel put healthcare workers first, followed by nursing home residents and personnel.

One reason that healthcare workers need to take priority here is that they’re currently overloaded from caring for over 100,000 COVID patients. Capacity is on everyone’s minds, as the system nears that fateful decision to decide who to care for. One way hospitals are coping is by literally accepting fewer COVID patients for admission (a “hospital-at-home” program has been initiated in several areas). Another way is the increase in mobile hospital units in parks and other offsite locations, or repurposing space within the hospital. But capacity is not the only issue; there’s also staffing.

There are increasingly not enough nurses to staff beds in the Kansas City metro area. Staff is running out in San Diego. And obviously, every time a healthcare worker contracts the disease—they are constantly around the virus and PPE can only do so much—that becomes one fewer staff member, especially if they get sick. (North Dakota for a time was trying to get positive-testing workers to come in if they were asymptomatic.) There are often traveling nurses that pick up shifts, but when everyone needs them, that doesn’t stretch as far. Some states, like Maryland, are frantically recruiting medical professionals and developing emergency academic programs to rush through students.

What you won’t hear quite as much about is the lack of medical professionals and locations before the crisis hit. It sneaks into this Washington Post report, as Jean Ross of National Nurses United dares to mention it: “She said many nurses across the country were already spread thin before the pandemic arrived, which she blamed on hospital administrators who are ultimately driven by financial interests.”

That is a reality in this country, where hospital coverage is uneven and staffing is motivated by concerns other than caring for patients. Nursing labor fights habitually include patient ratios, as nurses are routinely expected to care for more patients than they can handle at one time. And money plays a role in how many beds a hospital administers and how many people they have on the floor.

This story out of California is instructive. The state has long lagged the rest of the country and the world in hospital beds per 1,000 residents, with only 1.8 as of 2018. This is a deliberate design, to limit patient stays. It sounds like making, say, a restaurant with only 6 tables, forcing waitstaff to keep turning them over, would not be lucrative. But healthcare is a different kind of market.

Long-term hospital stays are the most expensive to manage for a hospital, relative to their cost to the patient or insurance company. Outpatient care is much more lucrative, because it reduces labor costs, physical real estate, supplies, everything. This “just-in-time” kind of logistics just destroys preparedness. Just as retailers don’t want to hold inventory because they’d have to pay for storage, hospitals don’t want to hold patients. Therefore the excess capacity is rooted out of the system, both in terms of beds and staff.

Then there are the “unprofitable” hospitals and unprofitable services. If you aren’t doing a bunch of elective surgeries, if you’re just the source for healing in communities that aren’t terribly dense, it doesn’t make financial sense. Rural hospital closures have reached new heights, forcing people to travel 50, 75 miles or more to see a doctor.

But the staffing shortages are almost worse. There’s a deliberate shortage keeping doctors out of the profession, through American Medical Association accreditation. Bringing in foreign doctors would sharply reduce costs, but also cut the salaries of the wealthiest people in healthcare. Nursing staffing is controlled by cost-conscious hospitals.

The concern with this approach was always a disaster that would magnify the shortages. That’s where we are right now, with deadly consequences. The drive has been to reduce the cost of health care, not by cutting administrative bloat or the price of treatments and medical devices, but by cutting staff and capacity. That only works outside of a catastrophe.

There was lots of coverage of the bipartisan “deal” on COVID relief, and the usual suspects saying that Democrats should “take” said deal. I hate to be a broken record on this stuff, but there is no deal. There’s a set of numbers on a paper created by a small minority of Senators, which bears no resemblance to the priorities of the guy who gets to decide what the Senate votes on. That guy, Mitch McConnell, has still, in nine months, not sat down to negotiate with anyone over a follow-up package after the CARES Act. He or his staff was not present at the Pelosi-Mnuchin talks, he was not part of appropriations discussions, he was not party to this bipartisan deal. And until he does anything approaching a negotiation, there’s not going to be any bill. Whether Jerome Powell likes the bipartisan package does not matter.

McConnell released his own proposal yesterday, which doesn’t give any new money in unemployment payments, doesn’t give any money to state and local governments, doesn’t give any money for transit, doesn’t give any new stimulus checks, and only extends the two expiring unemployment programs, the lifeline for 12 million people, by one month. It’s essentially the same proposal he’s put up in the Senate like 6 times. He’s not interested in a deal.

The one notable addition here is $31 billion for vaccine development and distribution, about the level Chuck Schumer has said was necessary. As I’ve said, getting the vaccine to people is an economic stimulus beyond all others, worth literally trillions of dollars. If McConnell is willing to put that forward, I’d take the vaccine money tomorrow, passing it as an emergency supplemental with the omnibus spending bill that has to happen by next week. What matters in the long-term above everything else is getting that vaccine out.

Lack of economic relief in the pandemic is literally killing people. (Vox)
Steve Mnuchin, of course, thinks everything’s rosy. (U.S. News and World Report)
The post-vaccine future is bright but scarring now could hamper recovery. (New York Times)
One in six deaths in Vermont from COVID attributable to one Genesis Healthcare nursing home. (The Intercept)
The Cherokee Nation has had one of the best COVID responses. (Stat News)
Small Business Administration data finds that large businesses were favored in the small business grant program. (Washington Post)
California Democrats can’t stop eating out. I’ve been to a restaurant for in-person outdoor dining once in nine months, vote for me! (New York Magazine)