Health policy is always a matter of life and death — and even more so during a pandemic. This week, health economist Vivian Ho grapples with some of our moment’s big questions:
How is Texas doing with its vaccine rollout? What’s baked into our state’s unusual choice to prioritize people over 65 or with underlying conditions, rather than teachers and other frontline workers? How fair has it been so far? And what does it mean that even the Centers for Disease Control and Protection’s data isn’t good enough to answer basic questions about reopening safely?
At Rice University, Ho is the James A. Baker III Institute Chair in Health Economics, and she directs the Baker Institute’s Center for Health and Biosciences. She is also a professor at Baylor College of Medicine, and was recently elected to the National Academy of Medicine, one of the highest honors in the field.
This interview has been lightly edited for length and clarity.
Could you start with an overview? Where are we with COVID-19 right now?
In the U.S., the cases do seem to be on the decline, which is a good sign, and in Texas, they are decreasing as well.
However, I look at the Harris County numbers quite a bit. Last I checked, they were stalled at a little over 2,000 cases per day, which I find quite disconcerting. I was hoping that now we’ve gotten well beyond the holidays, that there would have been less mixing of people who don’t normally don’t see each other, so that we would start seeing a decline.
One of the metrics I use is an email from METRO. Anyone who has a METRO bus pass gets an email every day telling how many cases Metro has had. If there are no cases you don’t get an email.
Starting, I think, around Dec. 21, there’s been an email almost every day, Monday through Friday. I think I had a break of one day, but then they popped right back up again in my inbox. And even worse, it used to be one or two cases in each notification. Now it’s regular to see five new exposures on a day.
What about the vaccine rollout? How is Texas doing, compared to other states?
Texas is relatively OK. We’re not at the top of the list. Our percentage of the population that’s been vaccinated isn’t double-digit yet, but we’re very close.
It’s been quite a slow rollout all over the country. But we are doing somewhat well compared to the other big states. It’s harder for big states: They have to come up with a coordination plan, send it out, and then it can run smoothly or it can go badly depending on which county you’re in. Compared to Florida, California and New York, I think Texas is doing relatively well.
We seem to have a distinction. Many other states have chosen to prioritize teachers and maybe some other frontline workers, whereas Texas has chosen to prioritize the elderly and people under 65 with a health risk. There’s really not a good way to argue that one solution is consistently better than the other.
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In Texas, we really don’t want to overburden our healthcare system. We vaccinate the people who are most likely to get severely ill, and then we can avoid hospitalizations.
Some of the other states are receiving tremendous pushback from teachers. Teachers say, ‘We’re not going to go back into the classroom unless we’re vaccinated.’ That creates restrictions so that the state has to vaccinate them. Then out of fairness, there are many other frontline workers who suffered terribly under the pandemic, so they’re sometimes vaccinated first, too.
As an economist, how do you see the trade-offs in those approaches?
I think Texas’s approach is better in terms of economic return. First of all, because you avoid hospitalizations, you avoid the cost of paying for all those hospitalizations. That saves money for the federal and state governments, and it may eventually lower insurance premiums. (Laughs.) Well, those premiums never go down. But maybe they won’t rise as quickly.
Unfortunately, with that approach, there is higher burden on frontline workers and their employers. If employers are providing them health insurance, then employers have to pay the costs if they get sick.
There’s also another economic advantage of Texas’s vaccinating the elderly population. A lot of them have been very, very sensible up until now, and have stayed away from all sorts of economic activity that they would normally do. After being vaccinated, they’re going to feel more comfortable going out and doing some things that they weren’t doing before.
I’m very curious to see what happens on Valentine’s Day. I think by that time, a fair number of seniors will have gotten both shots and will decide to go out to a restaurant.
Experts still don’t know if a vaccinated person could contract the virus and spread it on to someone else without knowing it. I’m really hoping that that that doesn’t turn out to be the case.
Because if the elderly are going out again, we could see an increase in income for restaurant workers, which would would be a good sign all the way around. They also would feel more comfortable going back to the hairdresser and doing all these these things that all of us have been missing.
The elderly population’s income, of course, is extremely unequal. But there’s a large proportion of elderly who have significant incomes and haven’t been spending them. So if they’re out and they’re spending, that’s a big boost to a part of the economy that hasn’t seen much activity.
And then there are travel agents. Some elderly people have already started booking their trips for 2021, as long as they’re refundable. They are ready to go.
So we’re unleashing the partying seniors? I’ll have to check out restaurant parking lots at 6 p.m. on Valentine’s Day.
(Laughs.) And then we’ll cross our fingers and hope there’s not an increase in cases associated with that. That would be very good news.
You follow statistics as closely as anyone I know. What do you think about the general state of U.S. stats on COVID?
Unfortunately, we’ve been functioning on an incredibly low amount of data relative to what we could have. At the Baker Institute, the law firm Baker Botts gave us pro-bono assistance in submitting an expedited Freedom of Information Act request to the CDC back in the summer.
Wait: To get data from the CDC, you had to file a Freedom of Information Act request? The CDC wouldn’t just release it?
Yes. The data was protected. The CDC case reports are a large data set of supposedly every single case report of COVID in the country. And although other large government data sets are open — you can go to the Census Bureau and click “download” right away — it’s more challenging for healthcare data. There are more issues of privacy, so they want to be very careful who they’re making this data available to.
Of course, we also had some restrictions under the previous administration. It wasn’t so friendly about sharing data. But I have to say, the week we submitted that Freedom of Information Act request, a woman at the CDC got on the phone with us and was quite helpful. I think a number of employees realized it’s important to get the data out. They were not allowed to say anything publicly about this, but if someone goes in and submits this legal request, then it’s “Well, we have to respond. So I guess we will.”
After we got on the phone, she sent the data to us within hours. But unfortunately, it was a really large data set with mostly missing fields. It was 2 million records, but the records had no information in them.
What kind of information was missing? What fields were blank?
It was huge. It was very common to have missing information on race or ethnicity. The county of where exposure occurred was missing most of the time.
At least we had the state that the report came from. So we counted the number of cases relative to what the New York Times was counting. The New York Times was quite accurate because they were looking at daily postings, down to the county level, all over the country.
Hardly anything was coming in from Texas. For the time period we were looking at the CDC records for Texas had 5.5% of cases relative to what the New York Times was counting.
What does that mean, 5.5% of cases?
If you divided the CDC’s count of Texas cases from late spring until the end of summer by the number of Texas cases the New York Times was counting, you got 5.5%.
That really means that over late spring and summer, 95% of case reports from Texas never made it to the CDC. It was mind-boggling.
We’d thought that we were going to collect this data so we could give guidelines to Texas policymakers — you know, “these things are safe” and “these things are not safe.” But how can you even do that if you have no information?
Texas was one of the worst. Some states were much better. Utah was pretty good. Minnesota, Michigan and surprisingly New Mexico had good data. So we were able to analyze a few states and just characterize the nature of the outbreak.
We had data that were similar to what you would have seen in other reports for you know, certain states or local areas. For example, it was clear that the Hispanic population had many more cases relative to their representation in the population distribution. It was clear that a lot of the case exposure was people ages 20 to 39 — that was the highest. It was clear that a good portion of the work that the exposure was either at work or at home.
The missing data frustrates me so much. The CDC case reports actually asked whether you had been on an airplane. They asked, what county you live in? Also, if you had done domestic travel in the last 14 days, and if so, which states?
If that information had been complete, you would have been able to calculate the rates of cases at most major airports in the country. You could line up the county information with the location of the airports and say, “Well, is it safe to fly or not?”
But here we are. The latest information I’ve seen about whether it’s safe to fly came from a story of a flight from Dubai to New Zealand. I’m speechless: That’s more than a 12-hour flight. I don’t care how safe it is, or unsafe it is, to be on a 12-hour flight. But a lot of us care whether it’s safe or not to be on a two- or three-hour flight, right? And we still don’t know.
The airlines would have appreciated that. I mean, they can get up and say, “Well, we’re sanitizing our airplanes every time after people get off.” But if we had CDC numbers, we would actually know how dangerous this is or whether it isn’t.
What else could we figure out if we had better data?
The case report form did ask: Have you been at work? Were you exposed at work? And if so, it had a blank for what type of work. It could distinguish between health care workers and others — we’ve had good data on health care workers — but the CDC form also specifically asked, “Are you a grocery store worker?” We would really have benefited from knowing how many of these cases resulted from people being in grocery stores, in restaurants or bars, and being in work areas where there are many people not wearing a mask.
You really want to distinguish those from places where exposure is not much of an issue. My guess is, if you walk into most small businesses, or most small retail stores, there are many fewer people and they’re all wearing masks, and so it’s not an issue.
Having that work data would tell you, do we need a full shutdown of the entire local economy? Or could we get by with just shutting down restaurants and bars and recommending curbside delivery for lots of items?
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Over the holidays, a former student — he’s now a medical student — said, “Hey, I’ve got some time. Maybe I could write a short paper.” And I said, “Please look in the research data for me. Can you find the number of cases that were bar exposures?” He found case studies that show virus outbreaks in bars. But there are no studies of a county or a state saying the percent of virus cases that resulted from bars.
Here’s the reason I want to know that: Certainly if you read the Chronicle, you’ve seen that some places are running full tilt in the middle of the night. If we knew that most of the cases in Houston were resulting from just small businesses, it might have made sense policy-wise to pay those bar owners not to open. The cases that resulted from their opening would result in such substantial health care costs in terms of hospitalizations, that in these extreme circumstances, we’re better off doing something like telling bar owners, “Not only do you get a PPP loan, but we’re going to make it super easy for you to apply.”
That didn’t happen, because we had no information. There are all sorts of things we could have done in terms of economic incentives.
We could also have determined that it’s okay for various other workplaces to stay open.
So if we don’t know where the outbreaks come from, we don’t know what to target when we’re deciding what to close or reopen?
Exactly.
Do other countries do a better job tracking that sort of thing? Should the U.S. be looking at data from Israel or South Korea?
That’s a really good question. Early on, our understanding of what happens in restaurants and some of these other situations came from epidemiological papers about outbreaks in South Korea and China.
The problem is, those countries control the virus so effectively, they can’t do the epidemiological studies anymore. It’s like, there’s no virus to study.
Here we have plenty of virus to study, but we’re not tracking it?
Exactly. We have so much to study, and there’s just no information.
The other thing is, if you Google “COVID-19 case report form,” you’ll find different case report forms for different states and even different counties. There should be a federal mandate that says, “This is the CDC’s case report form. Everybody has to use it.”
I looked at some of the forms. Some of the differences were interesting, It was like, “Oh, that was a good idea to ask whether you’d been sleeping with someone the night before.” But it’s important that we decide on just one form, so that we get more data. That really has to happen before the next pandemic.
The only other solution I can think of is, experts in artificial intelligence could take the different forms, then aggregate all the information and get it working together. It’s a shame that we just can’t get some of the very top worker from Google, or Amazon or Microsoft t work on these things.
And boy, they would have been great in terms of vaccine distribution too, wouldn’t they?
Do you have a sense of how vaccine is being rolled out in the different states? There are a lot of questions about equity. Are Black and Mexican-American people getting as much vaccine as you would expect, given their exposure and death rates?
I don’t think there’s a single state that has vaccinated people of color in proportion to how much they’ve suffered from this pandemic. Even just in proportion to their part of the population, it is not happening.
Some states are doing better than others. Texas is taking this approach of delivering to large vaccine hubs. In a way, that’s great. When you’re getting a lot of vaccines to the city of Houston and Harris County, they make sure that they put vaccine hubs in all parts of the city and county where it’s easier for people of color and lower-income people to get access. That part, I think, is terrific. And also the vaccine programs at federally qualified health care centers.
The part I’m not so happy with is, a lot of these vaccines went to large hospital health care systems because it was easy for the state to do that. And yes, they are vaccinating lots of people.
But there’s a backdrop to this in terms of people of color. We know that a lot of them are uninsured — Texas has the highest percentage of uninsured people in the population — so they don’t have a primary care provider at a major hospital system, and they’re going to be left out. So because of that, you’re getting a population at a disadvantage.
Let me be sure I understand what’s going on: The hospitals call their qualified patients to make appointments? Those appointments aren’t open to anybody who’s not already a patient, who just walks up, even if the person meets vaccine criteria?
That is correct. You have to get an appointment.
Any of the major healthcare systems in Houston now have electronic medical records. You log on to what’s called MyChart, and the first page you see says, “We have COVID vaccines, but there is a line.” So you sign up online or call your primary care provider, and they put you on the waiting list. Lots of people are getting vaccinated that way, which is really good news.
But here’s something else I’m quite concerned about: Fewer vaccines have been going to independent physician practices that are not part of a hospital system. Many of them are two- and three-person practices, but some are big as Kelsey-Seybold. I was checking this morning: Kelsey-Seybold has received only 2,000 doses total from the state.
The problem is, this system starts making it look as though a hospital system is a better place than these independent practices to have your primary care provider. The independent practices have already been hurt the most during the pandemic because they saw that drop-off in patients who were too afraid to go to the doctor.
Other research I’ve done has shown that these independent practices actually have lower spending per patient on an annual basis than practices where the physicians’ salary is paid by the hospital. And we couldn’t find any difference in the quality of care delivered. I’d be okay with higher cost if it means better quality — but I couldn’t find a quality difference.
So favoring physicians in hospital systems leads to higher costs in the long run, and higher insurance premiums.
We all know that insurance premiums are going up. Before the pandemic, everyone was concerned about the high cost of insurance. And a lot of the reason why health insurance is expensive is because health care is expensive. All of that is going to come back when economy opens back up. You’ll sit there and look at your paycheck, and find out how much more your employer is going to charge you for your employer-provided insurance.
This is what a lot of health economists are already talking about: “What’s the post-pandemic scenario?”
What else are health economists and policy people thinking about? What’s the most interesting stuff you’ve read lately?
JAMA, the Journal of American Medical Association, just came out with an editorial this week, talking about concerns about consolidation of medical practices. A month after the pandemic hit, we were all told about the drop-off in in patients going to see their doctors. Everyone has been saying consolidation is going to increase and that consolidation is going to increase prices.
So small practices, with one or two doctors, were hit hardest by the pandemic? And fewer will survive?
They will not be able to survive. Hospitals are large enough to be able to negotiate a better price with insurance companies. If you’re a two- or three-person practice, you can’t get a good price.
The large hospitals also have financial reserves, so if there’s some problem, they can get through it. But lots of the small practices didn’t have enough in reserve for the pandemic. So those doctors join bigger practices or work for hospitals. That’s consolidation. Consolidation makes things worse.
The larger practices are able to charge high prices: Unless patients have a high-deductible health plan, they usually pay just a relatively small copay, so they don’t notice they’re going to a higher-cost provider. It’s not a competitive market. It’s far from that.
The JAMA editorial was written by Leemore Dafny, a professor at Harvard Business School, who grew up in Houston. She says we have to stop this consolidation and maybe unwind some of it.
Currently, large hospital systems do these all-or-nothing deals. They’ll say to the insurance company, “Look, if you’re going to our main facility in the Texas Medical Center, you also have to include in your contract all of our other hospitals in the surrounding areas — The Woodlands, Conroe, Clear Creek — even if they have really high prices compared to their local competitors.”
This leads to higher prices. Dafny is recommending substantially more employment in the Department of Justice and the Federal Trade Commission. My understanding is that their number of employees actually dropped under the Trump administration, at the same time as we’re really concerned about sort of unfair business practices by the large tech groups.
They’re going after Facebook and Google. And we want to say, “Wait a minute, there’s this health care problem, too, that’s costing us a lot of money.”
Economists are really concerned about it. We’ve been concerned about it for years. It has not received as much attention as it should because it’s hard for the normal consumer to see what’s going on. It’s all hidden in your insurance plan.
I recognize we have to get through COVID first. But there will be a post-COVID period, and it’s going to be very expensive. We have to do everything we can to make sure that it doesn’t get out of control.
lisa.gray@chron.com, twitter.com/LisaGray_HouTX
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