[Senate Hearing 117-173]
[From the U.S. Government Publishing Office]
S. Hrg. 117-173
EXAMINING OUR COVID-19 RESPONSE:
AN UPDATE FROM THE FRONTLINES
=======================================================================
HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING THE COVID-19 RESPONSE, FOCUSING ON AN UPDATE FROM THE
FRONTLINES
__________
MARCH 9, 2021
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
46-753 PDF WASHINGTON : 2022
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont RICHARD BURR, North Carolina,
ROBERT P. CASEY, JR., Pennsylvania Ranking Member
TAMMY BALDWIN, Wisconsin RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut SUSAN M. COLLINS, Maine
TIM KAINE, Virginia BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota MIKE BRAUN, Indiana
JACKY ROSEN, Nevada ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado MITT ROMNEY, Utah
TOMMY TUBERVILLE, Alabama
JERRY MORAN, Kansas
Evan T. Schatz, Staff Director
David P. Cleary, Republican Staff Director
John Righter, Deputy Staff Director
C O N T E N T S
----------
STATEMENTS
TUESDAY, MARCH 9, 2021
Page
Committee Members
Murray, Hon. Patty, Chair, Committee on Health, Education, Labor,
and Pensions, Opening statement................................ 1
Burr, Hon. Richard, Ranking Member, a U.S. Senator from the State
of North Carolina, Opening statement........................... 3
Witnesses
Shah, Umair, A., M.D., MPH, Secretary of Health, State of
Washington, Tumwater, WA....................................... 7
Prepared statement........................................... 10
Jha, Ashish, K., M.D., MPH, Dean, Brown University School of
Public Health, Providence, RI.................................. 28
Prepared statement........................................... 29
Abraham, Jerry, P., M.D., MPH, CMQ, Director, Kedren Health
Vaccines, Los Angeles, CA...................................... 33
Prepared statement........................................... 35
Summary statement............................................ 39
Fuchs, Mary, Ann, DNP, RN, NEA-BC, FAAN, Vice President of
Patient Care & System Chief Nurse Executive, Duke University
Health System, Durham, NC...................................... 39
Prepared statement........................................... 41
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.
Statement of The American College of Physicians.............. 74
Letter from The American Academy of Family Physicians........ 80
EXAMINING OUR COVID-19 RESPONSE:
AN UPDATE FROM THE FRONTLINES
----------
Tuesday, March 9, 2021
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10 a.m., in Room
106, Dirksen Senate Office Building, Hon. Patty Murray, Chair
of the Committee, presiding.
Present: Senators Murray [presiding], Casey, Baldwin,
Kaine, Hassan, Rosen, Hickenlooper, Burr, Collins, Cassidy,
Murkowski, Marshall, and Tuberville.
OPENING STATEMENT OF SENATOR MURRAY
The Chair. Good morning. The Senate Health, Education,
Labor, and Pensions Committee will please come to order.
Today we are holding a hearing on the ongoing response to
the COVID-19 pandemic with public health experts and those on
the frontlines of our fight against this virus.
Ranking Member Burr and I will each have an opening
statement, and then I will introduce Dr. Shah, Dr. Jha, and Dr.
Abraham; and Senator Burr will introduce Dr. Fuchs.
After the witnesses give their testimony, Senators will
each have 5 minutes for a round of questions.
Before we begin, I again want to walk through the COVID-19
safety protocols in place. We will follow the advice of the
Attending Physician and the Sergeant at Arms in conducting this
hearing. Committee Members are seated at least six feet apart,
and some Senators are participating by video conference. While
we were unable to have the hearing open to the public or media
for in-person attendance, live video is available on our
Committee website at help.senate.gov.
If you are in need of accommodations, including closed
captioning, you can reach out to the Committee or the Office of
Congressional Accessibility Services.
We are all very grateful to everyone, including our
Committee Clerks, who have worked so hard to set up a hearing
like this and help everyone stay safe and healthy during this
pandemic.
Life for families across the country has changed a lot over
the past year, and while we are familiar with the staggering
number of this pandemic, over 29 million infected, over a half-
million dead, the full toll of that loss and so much else
families have gone through--missed birthdays, weddings,
graduations, and even funerals--the fear, the loss, the
isolation we have gone through individually and as a Nation,
and the impact that it is causing on mental health and
substance use, among other issues, cannot be measured.
The true cost of this pandemic so far is unthinkable, and
it should be just as unthinkable that we would do anything
short of everything when it comes to ending this crisis as soon
as possible and rebuilding our Nation stronger and fairer.
I'm glad President Biden has put forward a bold,
comprehensive vision to see our Country through this pandemic,
and we took a critical step toward making that vision a reality
by passing in short order the historic American Rescue Plan,
which provides funding for testing, contact tracing, and
sequencing so we can identify new variants of COVID and slow
the spread; funding for vaccines so we can distribute and
administer them quickly, widely, and equitably, fight
misinformation, promote vaccine confidence, and engage trusted
partners in communities we know are hard to reach; funding to
recruit and train 100,000 new public health workers for these
efforts, and funding to address inequities that have made this
pandemic more deadly for communities of color, to address
mental health, behavioral health, and substance abuse
challenges this pandemic has worsened; to support home and
community-based services that help people with disabilities and
older Americans; and to support community health centers, which
continue to be a lifeline to so many hard-hit and hard-to-reach
communities.
This bill represents important progress, as does President
Biden's announcement that our Country will have enough vaccines
for every adult by the end of May. But we are all well aware
that it is not mission accomplished. We have to roll up our
sleeves, literally and figuratively, and get vaccines in arms.
We have to make sure communities that are often overlooked and
underserved are getting vaccines, and getting answers to
questions people are asking, like when can I get a vaccine,
where do I go for my vaccine, and how do I know the vaccines
are safe and effective.
We have some promising tools here, but we will also still
have work to do to make them accessible to people with
disabilities, people who do not speak English, and people who
do not have Internet or smart phones. We have skilled experts
promoting vaccine confidence, but we still have to engage
trusted community partners as well.
In my home State of Washington, the Pacific Islander
community has been hit harder than anyone by this pandemic, and
while we still don't have good data on the extent of that
problem, it's clear when it comes to vaccinating this community
that we're already behind. That's why when Joseph Seia,
Executive Director of the Pacific Islander Community
Association of Washington State, saw how online booking for
vaccines was missing elders in their community, PICA worked to
set up the first-in-the-nation pop-up vaccination clinic. Seia
told the Seattle Times, ``It's an equity thing. People don't
have technology. People don't have the time. It's essentially
privileged people that are signing up for these appointments,
and the most impacted folks are not able to do it.''
The clinic PICA set up kept things intentionally low-tech
to help prioritize reaching vulnerable seniors. We need to
continue seeking out community partners like that to make sure
we are understanding the challenges they face and working
through them together, because this pandemic will not truly be
over for anyone until we can vaccinate everyone we can. And
even when it ends, we need to make sure nothing like this ever
happens again. So I'll be saying more about how we do that
later this week when I reintroduce the Public Health
Infrastructure Saves Lives Act.
It was hard to imagine when this pandemic began a year ago
where we would be today, but the question before us in this
moment is how soon will students be back in the classrooms? How
soon will those people not already at work be back? How soon
will we be able to visit safely our friends and family for
special occasions and greet them with smiles and handshakes and
hugs?
We all want to get there as soon as possible, but that
starts with the work all of our witnesses are here today to
discuss, and the steps we take right now to support it. I look
forward to hearing from our witnesses about how we end this
pandemic and working with them to get all of our communities
there.
As Ranking Member Burr and I have been talking about since
early in January, COVID-19 has defined this Committee's work
over the last year and in many ways will define it over the
next 2 years. For all of my Committee Members, hearings like
this are just the beginning of our effort to look
comprehensively at the impact of the pandemic we are in the
middle of. I look forward to working with Ranking Member Burr
and every Member of this Committee as we continue those efforts
and work to respond to the COVID-19 pandemic and its aftermath.
Keys to this work will also be helping American workers and
families recover from all impacts of the virus and the dire
economic situation they face, addressing the devastating
impacts of learning loss so many children are facing, and the
symptoms long-haulers continue to fight, and ensuring this
country's response to all the ways this pandemic will stay with
us for a long time, as well as all the things we should be
doing to prepare for pandemics in the future.
I know every single Member of this Committee, no matter how
different our politics or our states, is unified in feeling the
deep loss caused by this crisis, deep gratitude to all of those
on the front lines who are fighting it, and the importance of
responding to this moment by building a stronger, fairer,
better Nation for the people we represent.
I look forward to this hearing and working with all of you
in the days and months ahead.
With that, I will turn it over to Ranking Member Senator
Burr for his opening remarks.
OPENING STATEMENT OF SENATOR BURR
Senator Burr. Thank you, Senator Murray, and good morning
to our witnesses. Dr. Abraham, good to see you, and to our
other witnesses who are joining us virtually.
One year ago today, March 9th, there were 1,020 COVID cases
in the United States and 35 people had died from complications
from the disease. This was still at that time not a threat
based upon what CDC and other agencies said. Since then, 28
million people have contracted COVID-19 in this country, and
more than 514,000 Americans have died from it. Globally, 116
million have contracted COVID and 2.5 million have died from
this once-in-a-century pandemic.
The Committee has an awesome responsibility ahead of it. We
must take stock of lessons learned from the response to the
COVID pandemic and learn together to see what worked, what
didn't work, and what needs to be done to be more prepared in
the future.
We should be proud of the important laws and programs and
policies we have worked on together in this Committee to create
and fund, because so much of it worked exactly as we
envisioned. FDA used its emergency use authority to get
vaccines and therapeutics to Americans in record time, while
maintaining the gold standard of safety and efficacy. The
Assistant Secretary for Preparedness and Response coordinated
with health care providers on the ground to ensure the sharing
of critical information and supplies as quickly as possible
during the response, and coordinated with the NIH and BARDA to
kick our countermeasure development into high gear. Using
BARDA's authorities, Operation Warp Speed developed and scaled
manufacturing for multiple vaccines in record, life-saving
time.
But we should also be humble enough to know that more needs
to be done to be prepared for the future. I hope now that the
partisan spending bill is over, that only had 5 percent of its
funding dedicated to the public health portion of the COVID
response and 1 percent of their massive spending bill dedicated
to COVID vaccines, we can shift our attention back to working
together.
As we start this thorough review process, it's important
that we remember that we are still in the midst of our current
response. But the tools we have today look very different than
where we started over 1 year ago, largely because of the
authorities that we have given to the executive branch. In May
of last year, some experts were predicting that a vaccine could
take years. In partnership with the private sector, we did it
in 10 months. Testing is now widely available, with the FDA
announcing just last week the emergency authorization of
another test that delivers results at home, thanks to the
public-private partnership and leadership from the NIH. Our
doctors and nurses have found new ways to better treat our
sickest COVID patients, improving outcomes with better clinical
practice guidelines, and our state and local officials have led
the charge in tailoring our response to their communities'
needs, as they should.
Alongside our successes, we must acknowledge our failures.
At the beginning of the academic year, just 17 percent of our
Nation's schools had fully returned to in-person learning,
jeopardizing the future and potential of an entire generation
of Americans. Businesses are still closed, with the National
Restaurant Association estimating that 100,000 restaurants will
not ever be back to welcome customers. And the tools we have to
solve these urgent problems, a vaccine, should be reaching more
Americans faster. The CDC stated that we are averaging 2
million shots in arms per day, but this Administration has not
updated its goal to reach 100 million shots in 100 days, which
was already the trajectory when the President took office in
January. Instead, we should set aspirational goals, like we did
with the development of the vaccine, not easily attainable
ones.
When we look at where we are in the response today, the
data shows a significant decline in COVID cases and
hospitalizations. I share this with my colleagues not because
we should let up on our response, but because I believe we are
at the greatest moment, right now, to learn from our progress
and to learn from our failures. The time to capture the lessons
we are learning is now, in real time, and not months down the
road when case levels are low, attention spans are shortened,
and urgency fades.
I remind my colleagues, in the life of BARDA as an
institution, it's been on life support three different times
because Congress lost interest in funding advanced development.
To our witnesses, welcome. Each of you spent the last year
in the thick of the COVID-19 response, 24 hours a day, 7 days a
week. Thank you for your tireless efforts. I hope we can learn
from each of you today about what was most important during the
early days of the pandemic, the strategies that were most
effective at the height of cases and deaths over the holidays,
and the ways your response is changing as the vaccine is made
available to more and more Americans.
Your input is critical as we begin to consider the next
phase of the current response, and as we look to the next
public health threat that we will face. It is not a matter of
if but of when we will need to turn to the tools and policies
we are using today for yet another novel or emerging threat to
our Nation's health and its security. The questions I will
raise with each of you today are what did we get right, what
did we get wrong, and what parts of our response were not part
of the anticipated plan of action originally.
Throughout this year, the Committee has held many
bipartisan hearings and bipartisan briefings, and we spent
countless hours on the phone and in meetings with experts from
around the country. This was a wise decision despite its
logistical difficulties because it allowed us to begin to build
the record necessary to move forward.
This is our first hearing on the COVID response this
Congress, and I look forward to working with Senator Murray to
make these hearings and these conversations a regular practice
of the Committee. I know that we are in the process of securing
administration witnesses for a hearing in the near future, and
I'd like to set the expectation for all of us on this
Committee, on both sides of the aisle, that we should expect to
hear from administration officials on a regular basis just like
we did with the last administration, if not more often. They
have an obligation to be open and transparent with Congress and
the American people about what they are doing, in real time,
and I know all of my colleagues on both sides of the aisle will
join us in this request.
Dr. Abraham, to you and the other witnesses today, thank
you for being here. Please share with us, if you can, those
personal experiences, those personal decisions that you made
that may have gone counter to what the Federal guidelines were
but they were unique to your community in your area, in your
state, in your community health center, and why that decision
was so crucial for you to pivot to something you thought would
work and, in fact, did work.
With that, Madam Chair, I thank the Chair and I yield the
floor.
The Chair. Thank you, Ranking Member Burr.
We will now introduce today's witnesses.
I'm very pleased to start by welcoming Dr. Umair Shah from
my home State of Washington. Dr. Shah was appointed as
Washington Secretary of Health last year and has been on the
front lines of our state's efforts to get vaccines into arms
and to keep families safe. The progress we've seen is
encouraging, especially as new vaccinations per day now outpace
new cases, and cases are down 70 percent from the peak this
winter. I'm grateful to Dr. Shah for the work he's done to help
get us here, the work he continues to do to help us finally end
this pandemic for everyone, and for taking the time to join us
today to share his insights and expertise.
Before his current role, Dr. Shah served for several years
as the Executive Director and Local Health Authority for Harris
County Public Health in Texas, the third largest county in the
Nation. He served a term as President of the National
Association of City and County Health Officials, and he served
as an Emergency Medicine Physician at the Houston VA. Dr. Shah
received his M.D. from the University of Toledo Health Science
Center and completed his residency at the University of Texas
Health Science Center while earning his MPH there.
Dr. Shah, welcome. Thank you for joining us today.
Next I will introduce Dr. Ashish Jha. Dr. Jha is the Dean
of Brown University School of Public Health, and before that he
taught at the Harvard T.H. Chan School of Public Health and led
the Harvard Global Health Institute. Dr. Jha is a renowned
expert on pandemic preparedness whose work has been published
in over 200 research publications. He has led groundbreaking
research on Ebola and been a key advisor to policymakers
looking for thoughtful analysis as they work to respond to
COVID-19.
Dr. Jha received his M.D. from Harvard Medical School,
completed his Internal Medicine training at the University of
California-San Francisco, and completed his MPH and a
Fellowship in General Medicine at Harvard. He was also elected
to the National Academy of Medicine in 2013.
Dr. Jha, I'm glad to have you with us today.
Dr. Jerry Abraham is the Director of Kedren Vaccines at
Kedren Health, a community health center in South Los Angeles,
California, where he also serves as a family medicine
physician. Dr. Abraham has publicly championed the importance
of vaccine equity and how we achieve it, and has worked to make
it a reality in his role leading vaccination efforts in
underserved communities that have been hit especially hard by
this pandemic.
He's a graduate of the University of Southern California's
Keck School of Medicine, where he also completed his family
medicine training. Dr. Abraham, community health centers like
yours are a lifeline to patients across the country and one
that has become all the more important during this pandemic. I
look forward to your testimony about the work happening in your
community and what we can learn from it, so thank you for
joining us.
Now I'll turn it over to Ranking Member Burr to introduce
Dr. Fuchs.
Senator Burr. Thank you, Senator Murray, for the
opportunity to introduce Dr. Mary Ann Fuchs from Durham, North
Carolina. For almost 20 years, Dr. Fuchs has served as Vice
President of Patient Care and System Chief Nurse Executive for
Duke University Health Systems, where she is responsible for
overseeing the nursing practice and ensuring the high-quality
care across the health system.
Dr. Fuchs also serves as the Associate Dean of Clinical
Affairs for Duke University School of Nursing, and serves on
the American Hospital Association COVID-19 Pathways to Recovery
Task Force. In her role as the President of the American
Organization of Nursing Leadership, Dr. Fuchs advocates for
nurses in leadership roles across the country, a position that
has been particularly important during the COVID-19 pandemic,
highlighting the role nurses have played in caring for patients
on the front lines.
Dr. Fuchs earned her doctorate, post-master's certificate,
and master's degree from Duke University, her Bachelor of
Science degree in Nursing from the State University of New York
at Binghamton. Dr. Fuchs is a Fellow in the American Academy of
Nursing, a Fellow in the Wharton Fellows Program and Management
for Nurse Executives, and a Robert Wood Johnson Executive Nurse
Fellow.
Dr. Fuchs, thank you for all the important work you're
doing and what you're doing on behalf of North Carolina and the
country and nurses across the country during this challenging
time. I look forward to hearing your perspective from the front
lines of the fight against the COVID pandemic.
Thank you, Madam Chair.
The Chair. Thank you.
We will now move on to testimony. Dr. Shah, you may begin
your remarks.
STATEMENT OF UMAIR A. SHAH, M.D., MPH, SECRETARY OF HEALTH,
STATE OF WASHINGTON, TUMWATER, WA
Dr. Shah. Good morning, Chair Murray, Senator Burr, Members
of the Committee. Thank you for your leadership and for
inviting me to testify today to share my observations on the
COVID-19 response to date.
Let me start by saying it's far from over, and we need to
stay the course in using every tool available to end it. We're
all tired of the pandemic, but we cannot forget the more than
500,000 Americans who have lost their lives to date. In our
state, in Washington, that means 5,000 Washingtonians whose
lives have been lost.
While we still have a long way to go, it is my hope that
we're on the right road. Let's hope this pandemic is an
inflection point that results in real and sustained change to
protect the safety of all Americans.
My name is Dr. Umair Shah. I have responded to countless
emergencies over the last 20 years, including hurricanes and
tropical storms, infectious disease outbreaks, chemical
incidents, and even global earthquakes. My family and I
experienced firsthand the massive power outage in Texas just a
few weeks back.
I'm a public health professional and medical doctor and
emergency department physician at UCVA Medical Center, taking
care of our Nation's veterans for over 20 years. In late
December, I was honored to be appointed by Governor Jay Inslee
as the Secretary of Health for the great State of Washington,
honored because Washington has been a leader in responding to
this pandemic, and this is a testament to Governor Inslee's
leadership, as well as the work of our state health agency and
countless partners on the ground.
While I'm new to the state role, I've been on the front
lines fighting this pandemic this past year and leading the
public health efforts at Harris County Public Health in Texas;
and as the previous president of HR, I recognize the absolute
importance of what happens in local communities.
That said, I am now a proud member of the Association of
State and Territorial Health Officials, ASTHO, representing the
state public health agencies across the country who served as a
key intersection between the Federal Government and local
communities.
Over this past year we have all witnessed the loss of life,
the impact on countless patients and their families and
communities devastated by COVID-19. Watching this play out, I
have been frustrated by seeing the strain on our public health
system to ramp up epidemiology, surveillance, laboratory
testing, communications, contact tracing, and now getting
vaccines into arms.
I'm here today, though, not to just express frustration but
to work toward solutions. Please refer to my full written
testimony. Today I will touch on two main points.
No. 1, we need the state, of course, using public health
tools to help end this pandemic. And No. 2, public health truly
matters, and there is a cost to chronic underfunding.
With the first point about staying the course, from our
response we remain focused on three things: No. 1, getting
Americans to continue everyday precautions; No. 2, distributing
and administering COVID-19 vaccines; and No. 3, safely
reopening schools and businesses.
Overall, we may see the light at the end of the tunnel due
to vaccines, but we must support preventive measures that have
gotten us to where we are today. We cannot let our guard down
or this pandemic will make us pay yet again. We must emphasize
the importance of following public health guidance, including
wearing masks, watching distance, getting tested, and avoiding
large gatherings.
Secondly, the focus around the country is getting COVID-19
vaccine into the arms of people quickly and equitably. To do
this, we are balancing three legs of a three-legged stool: No.
1, vaccine supply; No. 2, logistics and operations; and No. 3,
vaccine demand.
Currently, our biggest challenge is limited supply, but we
expect this to improve, as you know.
As far as operations go, we are grateful to Congress
working to get resources to support our efforts on the front
lines and within states. As we ramp up supply and capacity, we
must pay attention to the demand as vaccine hesitancy is real,
whether due to mistrust or misinformation.
Third, we all want our schools and businesses to reopen for
in-person learning and get our economy moving ahead, but we
want to do so safely. If communities continue to control the
spread of COVID-19, the road ahead is better than the one we
have been on.
Public health truly matters, and there's a cost of chronic
underfunding. Everyone everywhere, in all communities, should
be able to rely on strong public health systems. This pandemic
has shown the shortcomings of our current system, including
from emergency response. This is due to the fact that we have
not adequately invested in it. We must have a public health
system ready to protect Americans from all hazards, including
pandemics, natural disasters, biological, chemical, nuclear,
and terrorism.
This pandemic has been horrific in so many ways, yet it is
a transformational event. Now is the time to make smart,
strategic, and sustained funding in public health
infrastructure. Making these investments will also address
longstanding health inequities. COVID has not started these,
but it has made them worse. The inequitable distribution of
death and disease means we have seen communities with
disproportionate impacts from this pandemic. This is simply
unacceptable. To reset, reform, and rebuild, Federal
investments must prioritize resource equity, and now is the
time for Congress to act.
We're making progress against COVID-19. We can see the
light at the end of the tunnel, but leaders must stay the
course because there are still threats, including the risk from
COVID-19 variants and COVID-19 fatigue.
Let me close by saying public health is the offensive line
of a football team, and we're not doing enough to invest in
that offensive line. We keep focusing on the quarterback. We
have had an invisibility crisis in public health for far too
long. If nothing changes, we'll get more of the same, systems
without the robust capacity and capabilities to respond to the
next emergency. We are truly at a crossroads. Either we can act
now and invest in public health, or we act later and overspend
dearly to undo that which could have been prevented.
On behalf of the State of Washington, thank you, Senator
Murray, for your leadership, from ASTHO and my colleagues
across the Nation. I appreciate the opportunity to testify
today. We look forward to working with all of you, all of us in
public health, in building safe, healthy, and protected
communities across this great Nation of ours. Thank you.
[The prepared statement of Dr. Shah follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The Chair. Thank you, Dr. Shah.
Now we'll turn to Dr. Jha.
STATEMENT OF ASHISH K. JHA, M.D., MPH, DEAN, BROWN UNIVERSITY
SCHOOL OF PUBLIC HEALTH, PROVIDENCE, RI
Dr. Jha. Good morning, Chair Murray, Ranking Member Burr,
Members of the Committee. It is indeed an honor to be here.
As we heard, we mark a grim anniversary this week, one year
into a global pandemic that has caused unimaginable suffering
and loss. But we also are seeing the beginning of the end of
this pandemic. Infections and hospitalizations are down, more
than 2 million vaccines are going into arms every day, and we
will have enough vaccines for every American adult by the end
of May. This is an extraordinary achievement of what has been a
long and difficult road.
But as you've heard already this morning, the pandemic is
not done with us. There is important work ahead to get back to
a time when Americans feel safe living their daily lives, where
our economy is thriving again.
Let's talk about what remains to be done.
First and foremost, we need to continue to focus on
equitably expanding national and global vaccine supply and
distribution. We are at a time when new variants and strains
pose real risks, and the longer the virus circulates, the more
it will mutate. Our full efforts and attention must be focused
on vaccinating as many Americans as quickly as possible.
We have to do it far more equitably, far more equitably. So
far, vaccinations for people of color has lagged far behind
those of white Americans. We need a renewed strategy that
ensures that those at the highest risk of this pandemic are
getting vaccinated quickly. And Congress should demand that we
systematically collect and publicly report data on vaccinations
by race, ethnicity, age, and income to ensure Americans that
need vaccinations are getting them.
Next, we need an aggressive global vaccination strategy,
because if the pandemic has taught us anything, it's that
viruses don't respect borders. If we continue a slow global
rollout of the vaccine, it is entirely possible that strains
will emerge elsewhere that threaten the efficacy of our current
vaccines and possibly even render them useless. We will then
have to reformulate, retest, and redistribute vaccines, and
revaccinate our population.
At current global vaccination rates, it will take three to
four years to reach widespread global immunity. Now, the Biden
administration has taken important steps, including rejoining
WHO, and Congress has committed funds to COVAX. These are good
things, but unfortunately they are not enough. We need a
strategy that isn't just about more money; it's about
substantially ramping up production of these vaccines. This
will require more global collaboration, and it will require
U.S. leadership.
Next, closer to home, we need to build up more rapid
testing. Some Americans will choose not to get vaccinated, and
vaccines, as good as they are, are not 100 percent effective.
That means we will continue to see some outbreaks of COVID for
the foreseeable future. We need a testing and surveillance
system that can help prevent outbreaks and keep us all safe. In
a world of low transmission and high vaccine coverage, we need
cheap, easy-to-administer tests that are widely available.
These exist today. Now, the FDA should work through the
regulatory challenges to make many more of these tests
available to the American people, and Congress should continue
to make investments to ensure these tests are affordable.
Even with vaccinations and testing, people will get
infected, and some people will get very sick, and we need more
investments in therapeutics, particularly outpatient therapies.
We have identified several good treatments for critically ill
patients, but we have very little to offer to people before
they get very sick. Congress should work with NIH to continue
to support development of new outpatient treatments that can
render this disease far less harmful.
Finally, we need a renewed set of investments in public
health, as you heard from Dr. Shah. This pandemic has shown us
the costs of under-investing in our public health
infrastructure, the economic and human costs, which are not
borne by all of us equally. They are borne by some of us much
more than others. We need a new set of investments in public
health infrastructure that puts equity at the heart of its
mission.
Over the long run, we need to remember that we are entering
an age of pandemics. Infectious diseases caused by pathogens
jumping from animals to humans will become more common as a
result of economic development and climate change, and
globalization means an outbreak anywhere will quickly become an
outbreak everywhere, and that's the world we are looking at.
To conclude, we are at a critical moment in this pandemic.
We can see the time when we get our lives back, but we must do
a few key things: invest in vaccinations, testing,
therapeutics, and public health infrastructure to ensure that
we bring this pandemic to a close, and to ensure that we
prevent the next one. Thank you.
[The prepared statement of Dr. Jha follows:]
prepared statement of ashish k. jha
Introduction:
We mark a grim anniversary this month, one year into a global
pandemic that has caused unimaginable suffering and loss. But, we also
are seeing the beginning of the end of this pandemic. Infections are
down nearly 70 percent since the peak of early January and, while we
must keep wearing masks, keep social distancing, and keep being
careful, data from the past two months suggests that we are turning a
corner in our fight against this deadly pandemic.
As a Nation, our 7-day case average has plateaued and now rests in
the same realm as our mid-summer peak, at just under 60,000 new cases
per day. Accordingly, 7-day average COVID-related hospitalizations and
deaths have decreased by 66 percent and 77 percent, respectively, from
the winter peak. These data reflect a combination of the rebound after
a surge of cases during the holidays, increased national attention to
masking and social distancing, seasonal trends of the virus, a high
level of population immunity, and vaccination efforts ramping up across
the country.
More than 2.1 million shots are now administered every day. Since
December, more than 87 million doses of vaccine have become
vaccinations, and many more are coming. While we began our vaccination
efforts in late December with an average of 228,000 doses administered
per day, the most recent data indicates that we are consistently
administering more than 2 million doses per day, with expected supply
over the next weeks and months likely to increase this number to more
than 3 million doses per day.
Vaccine appointments across the country are scarce and the supply
remains low in comparison to overwhelming demand, but we expect vaccine
supply to far outstrip demand over the next month or so. The Biden
Administration recently announced that all willing American adults will
be able to receive a COVID-19 vaccine by the end of May. This is an
extraordinary achievement on what has been a treacherous road. There is
important work ahead.
First, we must ramp up vaccine supply and distribution efforts
across the country. Though cases, deaths, and hospitalizations remain
at their lowest levels in months, we have entered a plateau phase that,
with the addition of viral variants, poses the potential for further
spikes which could outpace vaccine distribution. The longer the SARS-
CoV-2 virus circulates in our Nation and our world, the more it will
mutate. These mutations are likely to become more dominant over time,
and pose serious risks of rapidly increasing the number of infections,
hospitalizations, and deaths. It is imperative that our full efforts
and attention be focused on vaccinating as many Americans as we can as
quickly as possible over the coming weeks to avoid yet another spike in
COVID-19 cases, hospitalizations, and deaths. Vaccinating all willing
American adults within the timeframe presented by the Biden
Administration mandates that we immediately shift our focus to expand
infrastructure for vaccine distribution and administration. Meeting the
Biden administration goal will require a vaccination rate of 3 million
doses per day through the end of May.
Simultaneously, we must ensure that we substantially improve the
equitable distribution of vaccines. There need not be any tradeoff
between speed and equity. The United States right now does not have the
ability for equitable and widespread distribution of vaccines to reach
all American adults by the end of May--even with expected increases in
supply. Local and Federal leaders must continue to establish more high-
volume mass vaccination sites across the country, and specifically in
communities of color that have been hit hardest by the pandemic. Where
people cannot get to a vaccination site, we must bring the vaccine to
them, with credible community voices addressing concerns. And we must
continue to systematically collect and publicly report data on
vaccinations by race, ethnicity, age, and income to ensure Americans
who need the vaccinations the most are getting them.
Global Vaccination Strategy
Second, there must be an aggressive global vaccination strategy to
match a rapid, equitable distribution model in the United States. Our
Federal Government has both a domestic and global responsibility to
ensure the adequate supply of COVID-19 vaccine. Infectious diseases do
not respect national boundaries, so we must establish a global
vaccination strategy that aims to protect people around the world as an
important mechanism to protect the global economy, global public
health, and in the process, the economy and health of the American
people. A failure to equitably distribute global vaccines may result in
large financial and human costs. Consider the facts: studies suggest an
inequitable vaccination distribution may ultimately result in almost
twice the number of deaths. Failure to employ an aggressive global
strategy will allow more virulent and dangerous strains to emerge. So
far, our vaccine candidates have withstood the emerging strains,
maintaining their efficacy against these new variants of concerns. But
over time, it is possible that strains will emerge that threaten the
efficacy of our current vaccines and essentially, render them useless.
We will then have to reformulate, retest, and redistribute vaccines and
revaccinate our population. Unfortunately, our current global strategy
is neither rapid nor equitable. At the current global rate of 6.39
million doses administered per day, it will take nearly 5 years to
reach widespread global immunity (assuming 75 percent protection with a
2-dose vaccine). An estimated 90 percent of people in low-income
countries will not be vaccinated in 2021. Our government has taken
initial steps to advance an equitable global vaccination process,
including rejoining the World Health Organization and engaging with
COVAX (COVID-19 Vaccines Global Access).
Our government has committed $4 billion to COVAX, with a potential
new pledge of $2 billion through 2021 and 2022. But while these
contributions are substantial, this budget falls far short of global
need. Current estimates suggest that COVAX will secure close to 2
billion doses by the end of the year, with at least 1.3 billion of
those directed toward 92 low-and middle-income nations, covering at
least 20 percent of the participating population. However, this is
nowhere near the 60 -70 percent (or more) of vaccinated individuals
required to achieve global immunity. To meet this goal, COVAX should
instead aim to procure and distribute enough doses to fully vaccinate
four to five billion people by the end of this year. Scaling up its
targets to this level will require substantial additional funding but
money is not the biggest barrier. Limited supplies and manufacturing
capacity will make ramping up global vaccine production a complex
endeavor; it will require more than just relaxing intellectual property
rights or technology transfers. Rather, it will require global
collaboration and solidarity to address challenges at every step of the
supply chain. We will need to work closely with our allies and take an
aggressive approach. It can be done, but we will need U.S. leadership.
Testing
In addition to vaccinations, testing must remain a central part of
our strategy against COVID-19. As vaccinations increase, it is
important to remember that we should not expect to vaccinate 100
percent of Americans. We know some Americans will forgo vaccinations
despite their safety and efficacy.
That means we will continue to see some outbreaks of COVID for the
foreseeable future. For example, more than 90 percent of American
children are vaccinated against measles but the outbreak of over 1,000
measles cases in NY in 2019 highlights what can happen when a disease
finds its way to those who are not vaccinated. In recognition of
imperfect vaccine coverage and the imperfect protection offered by
vaccines, it is important that we build a sustainable viral
surveillance and testing system that can help prevent COVID-19 clusters
and ensure that we can all engage in things we value, such as getting
back to school and work, getting together in large groups, and living
our lives in ways that are safe.
While the United States has substantially ramped up its COVID-19
testing infrastructure over the past year, we are still heavily reliant
on slow and expensive PCR testing. The accuracy of these tests offers
value as we try to curb the pandemic, but in a world of low
transmission and high vaccine coverage these tests are not the proper
tool for surveillance. Instead, we should be looking to cheap, rapid
antigen tests that could be self-administered, cheap, and widely
available. We could imagine using these before large gatherings. They
could be used during the school year, especially next year when many
younger children will not yet be vaccinated. They could be used for
high-risk endeavors, such as when a community comes together to watch a
play in a packed auditorium. These tests ideally would be available
over-the-counter and would make it very easy to continue the simple,
low-level testing needed in a world that is post-pandemic but where
COVID-19 has not been fully eradicated.
Many companies have developed antigen tests that cost less than
five dollars and can return results in less than 15 minutes. The UK has
been a leader in distributing and leveraging these tests, and have
relied largely on Innova Medical Group, a California company who ships
millions of rapid tests a day to Europe but still does not have FDA
approval to distribute tests in the United States. The FDA has been
slow to approve these cheap, rapid antigen tests primarily due to
concerns about accuracy and lack of thorough data, and maintaining the
rigor and high standards of FDA approval are important. However, rapid
tests serve a different role than PCR tests and should be evaluated
accordingly. Accuracy is undoubtedly important for diagnostic tests,
particularly ones used by physicians in a clinical setting. But in the
midst of a pandemic, these rapid tests have shown enough efficacy that,
in combination with their high speed and low cost, would allow them to
play a critical role in keeping our economy open and people safe. It
would be beneficial for the FDA to work through these regulatory
challenges with the recognition that these tests are different from PCR
tests, and offer substantial value despite their reduced accuracy.
Congress, in turn, should make investments to ensure that these
tests are easily available to Americans and that there is effective
messaging on how these tests should be used in the coming months and
years. Doing so would be a valuable step in preparing our Country for
the post-pandemic world.
Therapeutics
Another key element in establishing pandemic resilience is the
development of safe and effective therapeutics, in both inpatient and
outpatient settings. As we continue into the Fall and next Winter, we
can expect to see a rise in cases once more, even as the majority of
Americans are vaccinated. We must ensure these infections do not result
in hospitalization or death. A few promising therapeutics appear to
lower death rates in the inpatient setting, but investment in
developing effective outpatient treatments has been and remains too
limited.
Thus far, in clinical trials, three inpatient therapies have shown
clear promise: remdesivir (likely given early in the disease course),
dexamethasone (for advanced disease) and most recently, interleukin--6
receptor blockers, which are also likely useful in advanced disease. We
still need more inpatient therapies to save our most critically ill
patients.
While effective inpatient therapeutics are important and we are
making progress here, the therapeutic landscape for early outpatient
interventions has been disappointing. If we are able to develop such
therapies, we could dramatically lower the impact of COVID on severe
illness and prevent hospitalizations. So far, the NIH has recommended
monoclonal antibodies as protective therapeutics, but clinical trial
data is still lacking and only a few candidates have presented
promising preliminary results. The FDA has approved Emergency Use
Authorization for select monoclonal antibodies in outpatients:
bamlanivimab (developed by Eli Lilly), casirivimab, and imdevimab (both
developed by Regeneron). Monoclonal antibodies are potentially
important but they must be given as infusions and given early in the
disease course before the patient is hospitalized. These logistics have
created a strange situation. Despite their development and
availability, monoclonal antibodies are largely underutilized. More
concerningly, initial studies suggest the South African and Brazilian
variants of concern may demonstrate escapability from these monoclonal
antibodies, and we do not yet have enough data to determine efficacy
against other new variants. Other companies are developing antivirals
for mild outpatient cases, including Merck's MK-4482 and Synairgen's
SNG001. However, these drugs are still in the initial phases of
clinical trials and we really don't know if they will work.
Members of President Biden's COVID-19 Advisory Board have argued
for a three-pronged approach to ending the pandemic, alongside a robust
vaccination campaign: (1) improve genomic surveillance (2) develop
multivalent vaccines (vaccines which are protective against more than a
single strain of the virus) and (3) develop scalable treatment options
to mitigate severe cases. This last prong is absolutely crucial to
ensuring a stable recovery. Efforts by the NIH's ACTIV program began
far too late, and targeted expensive therapies with limited
applications. We need a renewed focus by the NIH on practical
outpatient therapies (ideally those administered orally) for COVID-19.
To achieve this, we must increase funding for research and development,
scale up recruitment in clinical trials, and rapidly assess which drugs
are safe and effective for use.
Building an Equitable Recovery
As we build robust models of vaccination, testing, and therapeutics
in our recovery, equity must be at the center of our strategies. So
far, there have been clear disparities we are still working to repair.
Investments in our public health infrastructure must be made equitably
to build a healthier society, and Congress has an important role to
play in funding these investments. A comprehensive national public
health system incorporates both disease prevention and health
education, incorporating state, local, and Federal agencies to promote
health, surveil and predict emerging threats, and retain the capacity
to respond to emergencies. The United States Public Health system is
fragmented across local, state, and Federal jurisdictions and
consistently underfunded. In 1969, the Federal Government contributed
almost 50 percent to total public health expenditures. But, by 2013,
that number had fallen to less than 15 percent. The Prevention and
Public Health Fund, established by the Affordable Care Act and designed
to sustain investment in public health at the Federal level, remains at
50 percent of what should have been funded due to the reappropriation
of money to other programs.
This consistent underfunding and underinvestment in public health
is not without its consequences, consequences too often felt by
America's most vulnerable populations. For example, analyses by our
research group show a direct correlation between hospitals where
Intensive Care Units reached capacity due to a larger number of COVID-
19 patients faster, and the social-vulnerability index (SVI).
Underinvestment in public health aligns with structural inequalities
and has left people in these communities, including communities of
color and rural areas, vulnerable to the disparate impact of the
pandemic. Additionally, a lack of data infrastructure has led to
difficulties in collecting data related to cases and deaths by race
early in the pandemic. This issue continues within the vaccine roll-
out. As the Biden administration has prioritized, key changes must be
made to improve the Nation's public health data-collection capacity to
allow us to recognize and improve racial disparities in health.
Public health funding must anticipate rather than react to public
health emergencies. We saw an increase in funding in 2009 during the
H1N1 pandemic, and slight increases in supplementary funding in 2014
and 2016 in response to Zika and Ebola respectively. After these
viruses came under control, investments stopped and there has not been
continued growth in improving our public health systems.
We have built up our public health infrastructure during the
pandemic, and now must continue past the COVID-19 crisis and continue
allocating money and resources to public health agencies. Currently, as
the vaccine rollout continues, Federal and philanthropic efforts are
spending money on vaccine education campaigns, and are funding local
community-based organizations to increase communication and access. We
cannot let these investments stop after the pandemic is over. Giving
community-based organizations and local health departments the money
and resources to continue to engage their constituencies in public
health education will be necessary to reduce the disparities made clear
by the pandemic so we emerge from this crisis a healthier, more
resilient society.
A New Age of Pandemics
Investment in public health infrastructure is all the more
important when we consider that pandemics will start to become
recurring events in our lives. As a result of climate change,
deforestation, agricultural intensification, and globalization,
infectious diseases caused by a pathogen jumping from animal to human
are spreading throughout global society and are increasing in
probability as a consequence of continued development destroying or
diminishing animal habitats. Of all new and emerging human infectious
diseases, 75 percent can be traced to animals, mostly from wildlife.
Additionally, as global travel becomes more pervasive, epidemics
are more likely to turn into pandemics. The number of Chinese
passengers who traveled by air in 2019 was 7 times higher than in 2003,
when the original SARS pandemic hit. World Bank data shows that the
global increase of passengers went from 1.7 billion in 2003 to 4.2
billion in 2018. Thus, it is imperative that we continue to allocate
resources to prepare for this future reality.
Conclusion
We are at a critical point in our response to the COVID-19
pandemic. If vaccine supply projections hold and distribution and
administration efforts are rapidly increased across the country, we
should be able to begin vaccinating the general population by the end
of April or early May. If we accomplish this goal with the speed,
equity, and efficiency required, we should begin to bring the acute
stage of this pandemic to an end by early summer.
While there is much work that remains and we will be combatting
this virus for years, important public health restrictions can begin to
be eased by late spring into summer. From there, we can begin to build
a new normal, that can be even better than where we were before this
pandemic struck. All of this is contingent on vaccinating a vast
majority of Americans, having an effective testing and surveillance
infrastructure that lets us monitor and manage the disease, and
applying some common-sense public health measures that will prevent new
flare ups.
Congress must allocate for key investments, both nationally and
globally, in disease surveillance, stockpiling healthcare supplies,
equitably increasing the capacity and resilience of our public health
infrastructure, just to name a few. Only then will we emerge from this
crisis as an America that is prepared and ready for what the future may
bring.
______
The Chair. Thank you, Dr. Jha.
I will now turn to Dr. Abraham.
STATEMENT OF JERRY P. ABRAHAM, M.D., MPH, CMQ, DIRECTOR, KEDREN
HEALTH VACCINES, LOS ANGELES, CA
Dr. Abraham. Madam Chair Senator Patty Murray, Ranking
Member Senator Richard Burr, Senators, I would like to thank
the Committee for this opportunity to discuss this paramount
issue, the COVID-19 pandemic.
My name is Jerry Abraham, and I'm a family and community
medicine physician, a global injury epidemiologist, and a
medical quality specialist practicing in South Los Angeles. I
provide care to patients at Kedren Health, a federally
qualified health center and acute psychiatric hospital serving
low-income patients, diverse patient populations of South Los
Angeles.
First, on behalf of Kedren and our President, Dr. John
Griffith, we extend the warmest thanksgiving and gratitude to
each of you for inviting us to share our experience and
perspective on the issue of health care service and public
health delivery to underserved populations during this time of
this COVID-19 pandemic.
Before I begin, we at Kedren want to acknowledge the local
leaders who make it possible for our measured success, Governor
Gavin Newsome in the State of California Department of Public
Health, our Los Angeles County Department Board of Supervisors,
our Board of Supervisor Holly Mitchell, our local L.A. County
Board of Supervisors, specifically the city of Los Angeles and
Mayor Eric Garcetti, our Counselor Karen Price, and, of course,
our very own Congressional Representative Maxine Waters, who
represents us here in Washington.
I would also like to begin by thanking the Biden
administration for their leadership in working with physicians
and other providers across the country to address the COVID-19
pandemic. It has made a tremendous difference to have national
leadership, transparency, and communication about the pandemic
and this vaccination effort.
Across this country, the pandemic has exposed deep-seated
divides within our communities. Data from the CDC shows that
Black and Latino populations who contract this disease are
dying at twice the rate of other populations. Nowhere is this
felt more deeply than in South Los Angeles, where we work.
Those living in poorer communities struggle daily with access
to medical care amongst the worst pandemic in over 100 years.
This population is more likely to utilize public
transportation, to struggle with limited access to mental
health services, to have difficulties related to language and
insecurity due to the lack of immigration documentation. They
usually lack medical insurance. Our population suffers from
higher rates of hypertension and diabetes and obesity.
The point is that racial and ethnic, economic, lack of
equitable access to health care and public health, and a whole
raft of other issues related to disparities result in health
outcomes that are different. While it is easy to unmask this
effect related to vaccination rates, the same forces play out
throughout the entire health care system.
But really, why I'm here today is to tell you about the
story of the little Kedren that could, the historically Black
institution from South Los Angeles that started in the `60's by
22 Black psychiatrists when African American individuals in
South L.A. had nowhere to turn when they were in mental health
crisis. That's the place that I work, and that's the place that
answered the call of March 2020 when we knew we had to be a
part of the response of this pandemic.
We became a resource, a safe haven, safe harbor, truly that
light for testing right away for our county and our city. We
knew that testing strategy and contact tracing would be
critical in ending this epidemic. In December, when the FDA
approved Pfizer and then shortly thereafter Moderna and the EUA
was approved, we knew we needed vaccines, and we picked up the
phone and we did what we do best every day, overcoming health
disparities and addressing social determinants of health and
achieving health equity. We called and we asked our department
of public health where are our vaccines, and we worked in lock
step with our local public health jurisdiction to make sure
that we got vaccines.
Our nurses had COVID, our patients had COVID, and we knew
we needed to vaccinate our community now. So we ended up
getting 100 doses. Christmas Eve we started calling. By New
Year's Eve we put 50 doses into the arms of our staff, and the
next day 100, then 150, and today over 52,000 doses into the
arms of people in South Los Angeles.
We said don't give us enough just for us, give us enough
for our brothers and sisters to our right and left, other
health care workers who had nowhere else to turn. And after
that we said give us enough for all of our frail and our
elderly and our vulnerable that needed a vaccine today.
What we do and what we do exceptionally well is we take
down every barrier that stands in the way of our patients and
their vaccines: Internet, email, phone, transportation, I can't
speak English, I cannot walk, I cannot see, hear, talk. None of
those are reasons not to get vaccinated in this country, and we
made sure we broke down every one of those barriers.
What we do exceptionally well, why we're the Center for
Excellence and the exemplary role model is we vaccinate a high
volume of individuals as equitably as we can, and we report
that data back accurately and timely, back to the appropriate
jurisdictions.
No barrier stands in the way with our patients. What stands
in our way is we need more vaccines. We need more hands to
administer them. We're thankful for every volunteer who comes
and helps, over 200 volunteers daily. And we need more
resources, and we're very thankful for the work of Congress and
this Senate in making sure that's achievable.
This is our shot. We must end this epidemic. We must engage
and educate and vaccinate our communities. We can achieve 100
million vaccines and more, as Senator Burr mentioned, and we
will and can get back to work, get back to school, loving our
loved ones and doing all those wonderful things we used to do
before this pandemic, loving and hugging and kissing everyone.
That's the story that we have to tell, and thank you so
much for allowing us this opportunity to be here before you
today. Thank you.
[The prepared statement of Dr. Abraham follows:]
prepared statement of jerry p abraham
Madam Chair Senator Patty Murray, Ranking Member Senator Burr,
Senators, I would like to thank the Committee for this opportunity to
discuss the paramount issue of the day; the COVID-19 Pandemic.
My name is Jerry Abraham, and I am a Family & Community Medicine
Physician, a Global Injury Epidemiologist, and a Medical Quality
Specialist practicing in South Los Angeles. I provide care to patients
at Kedren Health, a FQHC community health center and acute psychiatric
hospital serving low-income, diverse patient populations of South Los
Angeles.
First, on behalf of Kedren Community Health Center and our
President and CEO Dr. John Griffith, we extend the warmest thanksgiving
and gratitude to each of you for inviting us to share our experience
and perspective on the issue of healthcare service and public health
delivery to underserved populations in this time of COVID-19.
Before I begin, we at Kedren want to acknowledge those local
leaders who make it possible for our measured success. Governor Gavin
Newsom and the State of California Department of Public Health, our Los
Angeles County Board of Supervisors, specifically Supervisor Holly
Mitchell, our local LA County Department of Public Health, and many
city of Los Angeles officials including Mayor Eric Garcetti and
Councilor Curren Price and of course our very own Congressional
Representative Maxine Waters who represents us here in Washington, DC.
I would also like to begin by thanking the Biden Administration for
their leadership in working with physicians and other providers across
the country to address the COVID-19 pandemic. It has made a tremendous
difference to have national leadership, transparency, and communication
about the pandemic and the vaccination effort.
Across this country, the pandemic has exposed deep seated divides
within our communities. Data from the Centers for Disease Control and
Prevention (CDC) shows that Black and Latino populations who contract
this disease, are dying at twice the rate of other populations.
Nowhere is this fact more deeply felt than in Los Angeles where
those living in poorer communities in South Los Angeles struggle daily
with access to medical care amid the worst Pandemic in more than 100
years. This population is more likely to utilize public transportation,
to struggle with limited access to mental health services, to have
difficulties related to language and insecurity due to the lack of
immigration documentation, and last, they usually lack medical
insurance. These populations also suffers from higher rates of
hypertension diabetes, and obesity. For example, South Los Angeles has
a rate of diabetes that is three times higher than the rate of diabetes
in other parts of the state. All of these challenges are contributing
to the unequal and uniquely adverse medical outcomes from the Pandemic.
According to recent data released in mid-February by the Los Angeles
County Department of Public Health showed that among those who were
vaccinated with at least one dose, only 5 percent were Black, while 33
percent were white and 23 percent were Latino and 19.1 percent were
Asian. Among Black residents in Los Angeles 65 and above, only 24
percent of Black residents had received at least one dose of the
vaccine compared to 42 percent of white residents 65 and up.
The point is that racial and ethnic, economic, lack of equitable
access to healthcare and public health, and a whole raft of issues
related to disparities have conspired to result in health outcomes that
are different. While it is easy to unmask this effect related to
vaccination rates, the same forces play out throughout the entire
health care system. As the Nation approached 500,000 deaths and
mortality numbers were exceeding 3000 deaths per day, the community in
South Los Angeles had to do something to ensure no one was left behind.
At a time when many had lost hope, Kedren Community Health Center
decided something had to be done to change this dynamic. We needed
action at the local level where people live and work with the full
participation and empowerment of the population. I call this the
``Kedren Miracle'' where a disenfranchised community pulled together
under Kedren Community Health Center to build one of the most effective
vaccination units in this Pandemic which continues to this day to serve
as a model throughout the USA.
Over the last several months, we have been able to transform Kedren
into a COVID-19 vaccination center serving the people of South Los
Angeles. We have worked with the Los Angeles County of Public Health
and received tremendous support from California Governor Newsom's
Administration, including the CalVolunteers program, which has provided
dozens of volunteers to help staff the clinic. We have also received
support from the Americorps, American Red Cross, International Medical
Corps, Salvation Army, Americares, among other official channels for
volunteerism and service--they help us serve over 15,000 members of the
community every week.
During this phase of the vaccination effort, the limiting factor in
our efforts has been vaccine supply. Like many parts of the country,
the demand for vaccine has outpaced supply since the first vaccines
were distributed in December. This has been particularly true in
communities that look like our community, with an overwhelming majority
of people of color, and those who get their health insurance from
Medicaid. Studies have shown that Black and Brown communities have
simply not gotten their fair share of COVID vaccines.
Through our advocacy efforts and by being loud, we at Kedren have
been able to secure vaccines to serve over 15,000 people every week.
That number is increasing, but we still have the capacity to do more.
We stand ready to serve our community, and to help ensure Black and
Brown people in particular don't get left behind when it comes to
getting vaccinated.
Communities like ours are the ones that have been hit hardest by
this pandemic. Residents in the communities around Kedren are far more
likely to have been hospitalized or die from COVID-19 than in most
other parts of the state. We will continue to be more exposed to risk
if we cannot get enough people vaccinated against this deadly disease.
In recent days, the Newsom Administration has adopted new guidance
that will allocate a disproportionate share of the state's vaccine
supply to communities that have higher concentration of high-risk
patients. Using the Health Equity Index to guide vaccine allocations
makes sense. When you fight a fire, you don't just sprinkle a little
water around the entire fire. You aggressively attack the parts that
are burning the hottest and pose the most immediate risk.
That same principle is now driving the Newsom Administration's
approach to vaccine distribution. But it is not enough to just have
vaccine in these areas. We need to make sure we have the people power,
the communications outreach and the infrastructure necessary to get the
shots into arms.
This can't be done by just using apps to make appointments at mass
vaccination sites. While thousands of people have gotten their shots at
mass vaccination clinics like the one at Dodger Stadium in Los Angeles,
if we rely only on these mass sites, we will have distorted and
inequitable distribution of shots. The technology needed to navigate
the state's vaccine appointment system can be confusing in particular
to older patients. The ability to get to these sites requires the
ability to take hours out of your day to be able to sit in line,
limiting opportunities for those who have to work or single parents who
have to care for their children. And of course, it requires use of a
car. Even in Los Angeles, thousands of low-income people do not have
their own car to be able to access a drive-thru mass vaccination site.
Over the next several weeks, it will be essential to build a
network of community-based vaccine administrators. It will be important
to involve physicians and other providers in every single community.
The California Medical Association is working with the state's Third
Party Vaccine Administrator to help build a network of community
physicians and other providers to help the state achieve its goal of
vaccine equity. As vaccine supply becomes less of an issue, it will be
important to make the vaccine available for people in the community
where they live through their local providers.
We also know there are high levels of vaccine hesitancy in our
Black and immigrant communities. There are many historic reasons for
this skepticism which we do not have to go into here. But it does
underscore the added importance of getting vaccine into the hands of
community providers. Many people have a personal relationship with
their local physician or community clinic. When people utilize other
health care services, we need to be able to vaccinate people as well.
If people are in a place they know with a health care professional they
trust, they are more likely to be able to talk through their vaccine
hesitancy issues. Local physicians and others can help advocate for
their patients to be vaccinated, and hear their concerns, while
addressing them with science and compassion.
By late April, we fully anticipate going from a vaccine supply
problem to a vaccine demand problem. If we truly want to bring an end
to this pandemic, we will need a robust, and community-specific
communications and persuasion strategy. Physicians will be an important
part of that outreach, but we cannot do it alone. We need to build
partnerships with trusted community leaders and create a high-touch,
multi-faceted strategy to promote vaccine acceptance.
We have had our share of hiccups over the last several months. It
is no small thing to create a statewide vaccination program for roughly
30 million adults. We know that many of the same problems we've seen in
California are plaguing other parts of the country. Some of this is to
be expected, but that does not mean we should be silent or accepting.
We must continue to push for a faster and more equitable vaccine
distribution at every turn.
We have learned a great deal since vaccinations began in December,
and we share the Biden administration's optimism that we can get
vaccines to those who want and need them by late spring/early summer.
But we are also clear eyed about the challenges that lie ahead. With
continued transparency and cooperation between Federal, state and local
governments, along with health care providers and community leaders, we
can meet those challenges head on and bring an end to this pandemic.
The Kedren Model--The Secret Sauce
Kedren Community Health Center is a federally qualified health
center (FQHC) that provides quality, integrated health and behavioral
health services to children, youth, adults and families irrespective of
immigration status, residency, language, culture, gender, ethnicity,
religion, sexual orientation or one's ability to pay. Annually, KCHC
provides care for more than 100,000 patients. Kedren Community Health
Center is a trusted care provider in South Los Angeles and has worked
to exemplify some of the best practices for distributing the COVID-19
vaccine and breaking down barriers to accessing the COVID-19 vaccine
for vulnerable individuals in South Los Angeles.
For example, one of the biggest barriers cited by patients
attempting to become vaccinated has been the appointment registration
process. Many seniors have had to rely on children, nieces, nephews or
other friends who are more comfortable using the internet to schedule
an appointment. In addition, many vulnerable residents lack access to
reliable broadband or simply do not have the time to wait for
appointments to become available. Kedren Community Health Center.
Adding to the problem and due to the digital divide, many of the local
residents do not have internet access, or own a computer, or even have
access to a smartphone. We worked to develop a simplified system that
allowed both appointed and walk ins, a system that used a combination
of paper and ``point of care'' information collection that could be
entered into the county's online data base later. As a consequence,
Kendren Community Health Center became one of only a handful of country
affiliated vaccination facilities where walk ins are welcome.
Additionally, interpreters for almost every language spoken in
South Los Angeles are available onsite. As of March 5, 2021, more than
12,000 people are vaccinated at our facility each week. One immediate
outcome was that many--many of them Black and Latino healthcare workers
who worked independently or in small practices that were excluded from
that vaccination efforts of the larger hospital system have received
their vaccine doses at Kendren Community Health Center. I would like to
add that although our federally Qualified Health Center accounts for
only a small fraction of the 100's of vaccinating organization in
greater Los Angeles, we routinely account for nearly 10 percent of the
COVID-19 vaccinations given within the county. It doesn't seem possible
that so few can do so much for so many.
We have been relentless in this effort to save lives, much like
Noah gathering people and animals before the great flood, Kendren
Community Health Center has become a beacon for those trying to address
the COVID-19 flood. Organizations such as the Los Angeles County
Department of Public Health, International Medical Corps, AmeriCorps,
the faith-based community, and myriad of other organizations and
donors, many from the community have come to our aid and are providing
surge support and human resources to enhance this vaccination effort.
The result is a small city of vaccinators, with temporary shelters,
stockrooms, endless deliveries of vaccine, needles and medical
commodities. We have been so successful in promoting vaccination
efforts in our community model that we routinely send a fleet of trucks
to other vaccine sites throughout the city to take their unused
vaccines!
Kedren Community Health Center's Framework
Kendren Community Health Center has a robust framework for
distributing COVID-19 vaccine effectively and efficiently to vulnerable
populations, the aged and the disabled. It is a model built on trust at
the most local level of the health system.
Phase 1: Increase vaccination at fixed sites within the
community
Phase 2: Expanding services and recruit additional vaccination
sites
Phase 3: Develop Academic Partners to improve options for
access and quality
Phase 4: Develop mobile vaccination teams for those hardest to
reach
Phase 5: Conduct mass vaccination events uniquely tailored to
the population
I would like to speak to Kedren Community Health Center's Vision
for a future where inequality in medical services doesn't force people
in my community to wait at the end of the vaccine line to ensure their
survival. We are on a mission to get as many people in the life boat as
possible. We are targeting support to drive up vaccinations to over 1
million people in South Los Angeles and beyond this year in an
equitable and culturally focused program able to reach those most at-
risk. Second, we will not let this experience fade. We also have a
dream that we have been able to work in a manner that will contribute
to expanded healthcare infrastructure in our community when the
pandemic subsides. Last, we hope that the heroic work of Kedren
Community Health Center, and the work of our partners, will serve as an
example of others seeking to address the problem of unequal access to
health services in underserved, vulnerable, disabled, minority and at-
risk populations during this Pandemic and beyond.
Thank you for this opportunity to testify before each of you today
on this very important subject. I humbly respect your time and admire
your service to our Nation. I am happy to answer any questions you may
have.
______
summary of jerry p. abraham
Across this country, the pandemic has exposed deep seated divides
within our communities. Data from the Centers for Disease Control and
Prevention (CDC) shows that Black and Latino populations who contract
this disease, are dying at twice the rate of other populations.
Nowhere is this fact more deeply felt than in Los Angeles where
those living in poorer communities in South Los Angeles struggle daily
with access to medical care amid the worst Pandemic in more than 100
years. This population is more likely to utilize public transportation,
to struggle with limited access to mental health services, to have
difficulties related to language and insecurity due to the lack of
immigration documentation, and last, they usually lack medical
insurance. These populations also suffer from higher rates of
hypertension, diabetes, and obesity.
The point is that racial and ethnic, economic, lack of equitable
access to healthcare and public health, and a whole raft of issues
related to disparities have conspired to result in health outcomes that
are different. While it is easy to unmask this effect related to
vaccination rates, the same forces play out throughout the entire
health care system. As the Nation approached 500,000 deaths and
mortality numbers were exceeding 3000 deaths per day, the community in
South Los Angeles had to do something to ensure no one was left behind.
At a time when many had lost hope, Kedren Community Health Center
decided something had to be done to change this dynamic. We needed
action at the local level where people live and work with the full
participation and empowerment of the population. I call this the
``Kedren Miracle'' where a disenfranchised community pulled together
under Kedren Community Health Center to build one of the most effective
vaccination units in this Pandemic which continues to this day to serve
as a model throughout the USA.
Over the last several months, we have been able to transform Kedren
into a COVID-19 vaccination center serving the people of South Los
Angeles. We have worked with the Los Angeles County of Public Health
and received tremendous support from California Governor Newsom's
Administration, including the CalVolunteers program, which has provided
dozens of volunteers to help staff the clinic. We have also received
support from the Americorps, American Red Cross, International Medical
Corps, Salvation Army, Americares, among other official channels for
volunteerism and service--hundreds of servicemembers help us serve over
15,000 members of the community every week--over 52,000 individuals
have been vaccinated at Kedren thus far.
The Kedren Model--The Secret Sauce
Kedren Community Health Center is a federally qualified health
center (FQHC) that provides quality, integrated health and behavioral
health services to children, youth, adults and families irrespective of
immigration status, residency, language, culture, gender, ethnicity,
religion, sexual orientation or one's ability to pay. Annually, KCHC
provides care for more than 100,000 patients. Kedren Community Health
Center is a trusted care provider in South Los Angeles and has worked
to exemplify some of the best practices for distributing the COVID-19
vaccine and breaking down barriers to accessing the COVID-19 vaccine
for vulnerable individuals in South Los Angeles.
Kedren Community Health Center's Framework
Kendren Community Health Center has a robust framework for
distributing COVID-19 vaccine effectively and efficiently to vulnerable
populations, the aged and the disabled. It is a model built on trust at
the most local level of the health system.
______
The Chair. Thank you, Dr. Abraham.
We will turn to Dr. Fuchs.
STATEMENT OF MARY ANN FUCHS, DNP, RN, NEA-BC, FAAN, VICE
PRESIDENT OF PATIENT CARE AND SYSTEM, CHIEF NURSE EXECUTIVE,
DUKE UNIVERSITY HEALTH SYSTEM, DURHAM, NC
Ms. Fuchs. Thank you, Chair Murray, Ranking Member Burr,
and Members of the Committee. I'm honored to represent our many
frontline staff who have worked tirelessly to care for all of
our patients, including those suffering with COVID-19.
Duke University Health System is comprised of a hospital
and health care network that spans the care continuum, and
we're dedicated to providing high-quality patient care,
educating tomorrow's health care leaders, discovering new and
better ways to treat disease, and partnering with our community
to improve health. We appreciate the Committee's leadership in
addressing the current pandemic, and on behalf of Duke Health,
thank you for the critical support Congress has provided over
the last year, including through the CARES Act and subsequent
legislation.
Over the last year, COVID-19 has posed persistent
challenges for the communities we serve, our patients, and our
team members. And as Chief Nurse of our health system, I know
these issues firsthand.
As COVID-19 persisted, I worked with multiple teams to
create new strategies to meet patient care needs, reallocated
internal resources to adapt to influxes of patients, and
quickly pivoted when circumstances changed. We set up new
delivery models and care practices, established testing and
treatment sites, and stood up vaccination sites for employees
and patients. We served our community as a major transfer
center for the sickest patients and provided resources to
skilled nursing facilities in the form of testing, staffing,
and training.
We responded to the ever-changing information by regularly
updating our care, holding town halls and virtual forums for
our employees in the community; and like many health systems,
we were the hub of the COVID-19 response in our community.
This past year has offered us many lessons learned which I
hope can inform the future actions of this Committee. We are
committed to protecting our workforce. We were impacted by a
real and global shortage of N95 masks and other PPE, as well as
stockpiles that contained expired PPE. Our supply chain team
worked around the clock sourcing from around the globe to
ensure we had adequate and effective PPE.
Our workforce must be cared for and offered respite. Caring
for critically ill patients, comforting families with loved
ones suffering in isolation, and fearing bringing the virus
home to our families has taken a significant toll on the mental
well-being of our workforce. We are seeing their exhaustion
compounded by pandemic-related anxieties and increased
responsibilities at home.
In my role as President of AONL, we continue to advocate
for resources to protect the physical and mental health of the
workforce, and we know through a recent national AONL study
that the inability of health care workers is still a major
issue, along with addressing burnout and building resilience.
Duke Health also joins other organizations, including the
AHA and AONL, in supporting the Dr. Lorna Breen Health Care
Provider Protection Act. And before the pandemic, our nursing
workforce needs outpaced our supply. Thus, we continue to
support increased funding for Title 8 Nursing Workforce
Development Programs and support the Future Advancement of
Academic Nursing Act, which would make critical investments in
nursing infrastructure.
COVID-19 has also served as a blunt reminder that we cannot
afford to overlook our public health infrastructure and
workforce. Thanks to a grant from our state, Duke Health's
COVID-19 Support Services Program has been able to assist
community members requiring to isolate or quarantine. Over
30,000 people have been provided relief payments, meals,
supplies, transportation, and medication delivery.
We established a Vaccine Equitable Distribution Committee
to better understand our data and reach marginalized
populations, including those who are disproportionately
impacted by the virus. We have dedicated appointments and
vaccines, and we partner intentionally with community
organizations. This work has improved the rate of African
Americans vaccinated in our community from 8.8 to more than 15
percent today.
The impact of the expansion of telehealth services has
facilitated connection to our communities and demonstrated the
efficacy in delivering care. We want to ensure that telehealth
will remain accessible to more patients on the other side of
this current crisis.
The substantial financial impacts of COVID-19 on hospital
and health systems will also have lasting effects. Systems now
face difficult decisions to reduce cost. Additional support is
needed, including eliminating further reductions in payments
through Federal programs, including Medicare and Medicaid, to
maintain access to care.
In closing, as the number of vaccinations increase, in
combination with continued infection prevention measures, we
need to acknowledge pandemic fatigue, be patient with each
other, and work together to continue to provide the highest
quality care in the safest manner.
Thank you for the opportunity to serve on the witness panel
for this important conversation.
[The prepared statement of Ms. Fuchs follows:]
prepared statement of mary ann fuchs
Chair Murray, Ranking Member Burr, and Members of the Committee, I
am honored to represent our many frontline staff and other team members
who have worked tirelessly to care for all of our patients, including
those suffering from COVID-19. I am Mary Ann Fuchs, Vice President of
Patient Care & System Chief Nurse Executive at Duke University Health
System and Associate Dean of Clinical Affairs at the Duke University
School of Nursing. I also serve as the current president of the
American Organization for Nursing Leadership (AONL), which is the
national professional association of more than 10,000 nurse leaders who
manage and facilitate patient care in all settings across the care
continuum. AONL is the voice of nursing leadership and a subsidiary of
the American Hospital Association (AHA). Thank you for the opportunity
to testify.
Duke University Health System is comprised of a hospital and health
care network supported by outstanding and renowned clinical faculty,
nurses, and care teams. This network is dedicated to providing high-
quality patient care, educating tomorrow's health care leaders,
discovering new and better ways to treat disease through biomedical
research, and partnering with our community to improve health
everywhere. Duke's services span the full continuum of care, from
primary care to medical and surgical specialties and subspecialties,
all dedicated to putting our patients at the forefront of everything we
do.
Founded in 1998 to provide efficient, responsive care, the health
system includes three hospitals--Duke University Hospital on our Duke
University Medical Center campus in Durham, North Carolina, Duke
Regional Hospital, and Duke Raleigh Hospital. In addition to our
hospitals, Duke Health has an extensive, geographically dispersed
network of outpatient facilities that include primary care offices,
urgent care centers, multi-specialty clinics, and outpatient surgery
centers. Duke Primary Care is the largest primary care network in the
greater Triangle, North Carolina area with family and internal medicine
providers and pediatricians in more than 40 locations throughout the
region. Duke Connected Care, a community-based, physician-led network,
includes a group of physicians, hospitals, and other health care
providers who work together to deliver high-quality care to Medicare
Fee-for-Service patients in Durham and its surrounding areas.
The Private Diagnostic Clinic (PDC) is the faculty physician
practice for Duke Health. It is one of the first and largest academic
multi-specialty group practices in the United States. The PDC owns and
operates more than 140 primary and specialty care clinics throughout
central and eastern North Carolina. Through a diverse and integrated
network of Duke providers, patients have convenient, accessible, and
high-quality primary and specialty care close to home.
Duke HomeCare & Hospice offers hospice, home health, and infusion
services. Hospice care is offered to terminally ill patients in their
home, skilled-nursing facilities, assisted-living facilities, and at
our two inpatient facilities located in Hillsborough and Durham, North
Carolina. Home health services are available to patients who are
homebound and in need of nursing services, physical therapy, speech
therapy, or occupational therapy. Infusion services are provided at
home or at work for individuals who need intravenous therapy.
We appreciate the Committee's leadership in addressing the current
COVID-19 pandemic. On behalf of Duke Health, thank you for the support
Congress has provided to hospitals, health systems, and all providers
over the last year. The CARES Act and subsequent legislation
established and added to the Provider Relief Fund, which provided
critical resources to better prevent, prepare for, and treat COVID-19.
As a tertiary and quaternary care center, we put the person who
needs our care at the center of everything we do. Since well before the
arrival of the COVID-19 pandemic, the safety of our patients is and
always has been our first priority. Our hospitals safely manage
infectious diseases every day. And we will continue to provide safe,
effective, patient-centered care in our facilities.
Over the last year, COVID-19 has posed persistent challenges for
the communities we serve, our patients, and our team members on the
frontlines. Below, I address the many ways in which we adapted care for
our community and our patients, many of whom are very sick and require
complex, coordinated care. I will also share our experience standing up
a robust testing program and rolling out a successful vaccine campaign.
I also share some perspectives on the challenges ahead and how to apply
lessons learned to future public health threats.
A View From the Frontlines: Provider Care and COVID-19
As the chief nurse of our health system, and on behalf of the many
nurse leaders on the frontlines of this pandemic, I know firsthand the
issues facing our patients, our nurses and other provider colleagues,
and our health care organizations. At Duke, we provide tertiary and
quaternary services and serve the highest acuity patients. In order to
meet our mission, we need appropriate staffing (nurses, respiratory
therapists, physician staff, others) and equipment (personal protective
equipment (PPE) and other intensive equipment) to best care for our
patients, their loved ones, and each other.
I worked with multiple teams comprised of nurse, physician, and
administrative leaders to create new strategies to meet patient care
needs; reallocated internal resources to adapt to influxes of patients;
and quickly pivoted when circumstances changed. Specifically, our team
developed appropriate staffing models; new policies and procedures in
support of infection prevention for patients, visitors, and staff and
appropriate use and reuse of PPE and supplies; new care models and
patient care practices; established new testing and treatment sites;
and stood up multiple vaccination sites for employees and patients,
among many other things. We also worked in our community in a variety
of ways, including serving as a major transfer center for the sickest
patients, and providing resources to skilled nursing facilities in the
form of COVID testing, staffing, and training to care for that patient
population.
As a team, we responded to the ever-changing information by
regularly updating our policies and procedures, holding weekly town
halls for employees, convening virtual community forums with our
experts to learn more about testing and vaccines, and providing other
outreach--including through print materials and online communications--
to inform our workforce and community about our pandemic response. Like
many health systems, we were the hub of the COVID-19 response in the
community. The vital role health systems played in the response is
something I hope this Committee will consider when drafting future
policy.
At Duke, we are extremely committed to protecting all of our
workforce and have learned so much about this coronavirus since it
first emerged in the United States in early 2020. In the beginning, we
had too little information about the virus and how it is transmitted,
uncertainty that was compounded by a real and global shortage of N95
masks and other PPE, as well as stockpiles that contained expired PPE.
We know that the same challenges were impacting hospitals all over the
country, including those facing additional resource challenges and
workforce shortages.
Very early in the pandemic, we made a commitment at Duke to
universal masking for all our team members, and we later expanded that
to require masks for patients and visitors. Our Supply Chain team
worked around the clock sourcing from around the globe to ensure we had
adequate safe and effective PPE--including surgical masks, gloves, and
gowns--for our teams. Given these challenges, I am proud of our Duke
community and the partnerships across both the health system and
university to help address some of our most pressing needs.
Over a year ago, facing a critical shortage of N95 face masks of
our own, Duke Health research and clinical teams confirmed a way to use
existing vaporized hydrogen peroxide methods to decontaminate the masks
so they can be reused. The process uses specialized equipment to
aerosolize hydrogen peroxide, which permeates the layers of the mask to
kills germs, including viruses, without degrading the mask material. As
a result, the decontamination process allowed for thousands of N95
masks to be reused at all three of our hospitals, easing some of the
shortage and curbing the need for other alternatives using unproven
decontamination techniques. Our experts also provided guidance to other
hospitals and health systems across the country so that they could
develop and implement such procedures.
Recognizing the Mental Health Needs of the Front-Line Workforce
The impact
The pandemic has profoundly affected our health care teams and
clinician leaders, emotionally and physically. Caring for critically
ill patients, comforting families of loved ones suffering in isolation,
and fearing bringing the virus to our families has taken a significant
toll on the mental well-being of our workforce. The unfortunate reality
is physicians and nurses already suffered from high rates of
depression, burnout, addiction, and suicide before the COVID-19
pandemic.
Early on in the pandemic, in my role as president of AONL, we
joined leadership from other national nursing organizations to meet
with the Coronavirus Task Force to collectively advocate for three
priorities: keep our nurses safe; allocate nurses so we have enough
staff to care for our patients and communities; and ensure nurses have
the supplies and equipment they need to treat patients. While we
continue to advocate for resources to protect the physical health of
clinicians and staff, we are also advocating for resources to support
their mental health.
To help shed light on nurse leaders' primary challenges, leading
practices, and areas of support during this pandemic, AONL fielded a
pulse check study of more than 1,800 nurse leaders in July 2020.
Participants included nurses at all leadership levels, mainly in the
hospital and health system setting. The primary challenges identified
were access to PPE and other supplies, communicating and implementing
changing policies, surge staffing, reallocation and training, and
emotional health and well-being. AONL fielded a follow-up study last
month, and while the report is still in development, we do know that
the availability of health care workers is still a major issue along
with addressing burnout and building resilience. These issues are not
specific to nursing and also extend to physicians, respiratory
therapists, transport specialists, and environmental service staff.
I am proud of all our Duke Health team members for their commitment
to our patients and support of their colleagues during unthinkably
challenging professional circumstances, but none of us are immune to
the burdens the pandemic has placed on our mental health. We are seeing
the exhaustion among nurses, first and foremost, followed by the
feelings of being overwhelmed and anxious and having difficulty
sleeping, as many nurses also face challenges of managing other
responsibilities for their families and conducting virtual school at
home. This fatigue and strain, which at times presents as post-
traumatic stress disorder, has been dramatically exacerbated over the
last year.
As a result, we are starting to see more of our skilled workforce
leave or planning to leave, which is also being reported in recent
surveys conducted nationally. This kind of high turnover will have a
significant impact on the future of delivering health care. Compassion
fatigue is just as real and consequential as physical exhaustion, and
while the COVID vaccines bring hope, we are seeing the respect for
frontline workers dwindle as the public tires of this pandemic.
Unfortunately, we also are starting to see an increase in inappropriate
and violent behaviors as a result of the incredible toll this pandemic
is taking on those seeking care in our hospitals and clinics, which is
another complicating factor for our workforce.
Our response and proposed solutions
The constant challenge of caring for COVID patients--by serving as
their family and managing death and dying in addition to intensive
care--means our workforce must be cared for and offered respite. We
provide mental health resources through Duke's Personal Assistance
Service (PAS), which provides assessment, short-term counseling, and
referrals by a staff of licensed professionals to help resolve a range
of personal, work, and family problems. PAS services are available at
no charge to benefit-eligible Duke faculty, staff, and their family
members. Duke also sponsors an emotional support and well-being hotline
and online resources conveniently available to staff, faculty, and our
broader community. In addition, our chaplains provide needed support to
frontline staff in their care settings across the health system.
In addition to supporting the National Academy of Medicine's Action
Collaborative on Clinician Well-Being and Resilience, the AHA and AONL
have developed a number of resources to address burnout and promote
resilience, especially during the COVID-19 pandemic. These include
guides on grieving when there is no time to grieve, embracing
mindfulness, and addressing moral distress. The AHA also created the
Caring for Our Health Care Heroes During COVID-19 resource, which
outlines the ways hospitals and health systems are helping to care for
and support the health care workforce during this crisis. The document
focuses on three areas--mental health, food, and housing--and features
case examples from across the country. It also provides a list of
national well-being programs and resources developed for healthcare
workers.
Further, Duke Health joins other organizations, including the AHA
and AONL, in supporting the Dr. Lorna Breen Health Care Provider
Protection Act, which aims to reduce and prevent suicide, burnout, and
behavioral health disorders among health care professionals. Named for
a physician who led the emergency department at New York-Presbyterian
Allen Hospital, the bill would authorize grants for providers to
establish programs that offer behavioral health services for front-line
workers. In addition, the bill would require the Department of Health
and Human Services to study and develop recommendations on strategies
to address provider burnout and facilitate resiliency, and it would
direct the Centers for Disease Control and Prevention to launch a
campaign encouraging health care workers to seek assistance when
needed. Thank you to Senator Kaine and Senator Cassidy for leading this
effort. I hope this Committee will give the legislation swift
consideration.
Moving forward: Planning for the future from lessons learned
This past year has offered us many lessons learned to better care
for our patients during and after public health crises. We continue to
treat patients who suffer from chronic conditions as a result of COVID-
19 and who will need long-term care in the community. From the early
phases of COVID-19 through recent surges and into the future, we will
continue to see adaptation in the care we provide our patients and the
safety we ensure for our workforce.
The pandemic created regional collaboration between (historically)
competitor health systems, who pulled together above and beyond the
connections that exist in NC, and the state emergency management
collaboratives (RACs) that are in place to address natural disasters
and other emergencies. Health systems like ours began weekly
coordination of our response, sharing supplies and resources and
ensuring access to care and an equal sharing of the burden of COVID
cases. Lessons learned through these efforts could be translated into
mutual aid expectations for any future similar public health crises.
The Hospital at Home program allows us to care for patients at
home. We recently launched this initiative at Duke Raleigh Hospital and
have seen firsthand the benefit of allowing acute healthcare services
to be provided outside of a hospital setting in response to the surging
COVID-19 pandemic. At Duke University Hospital, we are providing
enhanced home care services to COVID-19 positive patients who can be
treated at home and thus provide better access to hospitalization for
more acutely ill patients.
Thanks to a $7.4 million grant from the North Carolina Department
of Health and Human Services (NC DHHS), Duke Health's COVID-19 Support
Services Program has been able to assist individuals and families
required to isolate or quarantine due to COVID-19. The program, which
initially covered three counties and has expanded to nine, has served
approximately 30,000 people through relief payments, food boxes, meals,
COVID supplies, transportation, and medication delivery. Duke has
partnered with 15 minority-led community-based organizations to provide
these much needed services in our community.
At Duke Health, our top priority remains the health and safety of
our patients, their loved ones, and each other. Our planning team has
been diligently coordinating with our state leadership and developing
the proper preparations for administering all three COVID vaccines now
currently available. At Duke Health, we see the vaccine working to
protect our team--with over 70 percent of our team members having been
vaccinated--and in recent weeks we have not seen any COVID-19
infections in vaccinated team members.
As part of our commitment to getting vaccine to those most impacted
by COVID-19, we have established a system-wide Vaccine Equitable
Distribution Committee to better understand our data and reach
historically marginalized populations, including those who are
disproportionately impacted by COVID-19. We have dedicated appointment
blocks and allocation for these populations, and we partner
intentionally with community organizations.
We continue to partner with the community to pilot ``pop-up''
vaccine clinics. Recently, we joined with the Latino Community Credit
Union, La Semilla, El Centro Hispano, Greenlight, and Immaculate
Conception Church through the LATIN-19 initiative to create a vaccine
clinic geared toward the Latino community. We also have partnered with
the Durham Recovery & Renewal Task Force's Faith Leaders Round Table to
hold an event at Nehemiah Christian Center in downtown Durham. We
continue to collaborate with the African American Covid-19 Task Force
and Community Health Coalition, Meals on Wheels, Lincoln Community
Health Center, and additional faith communities to provide vaccine
allocation and transportation for vulnerable communities.
As supply increases and eligibility categories expand, we will
continue to build on the above efforts and develop additional
strategies with the communities we serve. Through this work, the health
system has improved the rate of African Americans vaccinated from 8.8
percent on February 1, 2021, to more than 15 percent today. While we
are still not where we need or want to be, we are making progress and
will continue to do so. All combined, this outreach is just one way to
address the enormous health equity gaps that COVID-19 has exposed. Our
nation's health policies must prioritize addressing these health
disparities so that they are no longer systemic impediments to patient
care and access.
We are following the guidance and direction of our public health
experts, including our infectious disease and infection prevention
colleagues, closely monitoring and adopting new findings, and following
clinical protocols developed by expert scientists and clinicians in
every discipline of care. We will continue to manage the pandemic's
impact on everything we do, while also seeing to the important
challenge of maintaining resilience within our workforce.
Preparing for future health emergencies now means doing all that we
can to ensure a strong, deep, and viable health care workforce in the
future, including our physicians, physician assistants, and especially
our nurses. Even before the COVID-19 pandemic, our nursing workforce
needs outpaced our supply. We are grateful for the leadership of
Senator Burr and Senator Merkley in advancing the reauthorization of
Title VIII Nursing Workforce Development Programs. We were pleased its
reauthorization was included in the CARES Act enacted last March and
thank Congress for supporting legislation to update and improve
programs that help to grow and support the nursing workforce in the
United States.
We continue to advocate for increased funding to the Title VIII
Nursing Workforce Development programs to increase the nursing and
nursing educator workforce. Each year, nursing schools must deny
admission to thousands of potential students because they do not have
enough faculty to teach these aspiring nurses. The Title VIII programs
support nursing schools but also seek to add diversity to the nursing
profession and improve access in health shortage areas. Along with the
broader nursing community, we support the Future Advancement of
Academic Nursing (FAAN) Act, which would make critical investments in
our nursing infrastructure, including underserved areas by supporting
the needs of nursing students, helping retain and hire diverse faculty,
providing resources to modernize nursing education infrastructure, and
creating and expanding clinical education opportunities. These
legislative efforts are essential and will help prepare nursing
students as they transition from the classroom to the frontlines of
patient care. Thank you to Senator Merkley for his leadership
introducing the FAAN Act.
COVID-19 has served as a blunt reminder that we cannot afford to
overlook our public health infrastructure and workforce. At a state
level, and in the absence of a coordinated and consistent public health
infrastructure with sufficient resources, communities, long-term care
facilities, and public health officials turned to health systems and
hospitals to support testing, case identification and contact tracing,
facility interventions in long-term care and communal living
facilities, assistance for historically marginalized communities, and
most recently vaccination at scale in our communities. While health
systems including Duke Health have stepped forward to do this work,
these additional responsibilities have substantially added to the
burden and burnout of our teams and increased financial losses and
challenges. Further ongoing investment in public health infrastructure
is critical.
We appreciate the tremendous and ongoing coordination with our
Governor's Office and NC DHHS to develop a statewide plan to respond in
lockstep to the current pandemic. But because our public health
infrastructure is resourced differently in every county, the local-
level capacity to respond to public health threats varies significantly
across our state. The pandemic has highlighted a critical need to
narrow these gaps in pursuit of a stronger and more coordinated public
health system. In follow-up to legislation enacted by Congress in
December, we are grateful the North Carolina General Assembly approved
a bill last week that will provide $84 million to local health
departments across our state.
As the Trust for America's Health notes, \1\ public health
departments must respond quickly to emergencies while maintaining the
day-to-day work they already do to support healthy communities,
including managing chronic disease and substance misuse. We echo the
TFAH's call for robust funding ``to ensure that all communities are
served by health departments with comprehensive capabilities'' and to
minimize the vulnerabilities recently exposed. We are grateful for
Chair Murray's leadership on legislation that would strengthen the
state and local public health infrastructure. Thank you to this
Committee for its attention to these issues and for seeking policy
solutions that will address workforce needs and provide access to care
for all patients.
---------------------------------------------------------------------------
\1\ https://www.tfah.org/wp-content/uploads/2021/03/Public-Health-
Infrastructure-Fact-Sheet-3-1-21-1.pdf.
As president of the AONL, I served on an AHA task force that
developed a Pathways to Recovery compendium of resources to help inform
hospitals and health systems' work to respond to and recover from the
pandemic. It spans 11 areas, including workforce, testing/contact
tracing, communications (both internal and external), supply chain,
ancillary/support services, plant operations, financial management,
governance, patient experience, transitions in care, and risk
management. It is intended to help hospitals align with where their own
---------------------------------------------------------------------------
communities are in the pandemic.
COVID-19 highlighted the disparities in care and the need for
health equity. In addition to addressing systemic racism within health
care, we recognize the importance of recruiting and retaining a diverse
health care workforce, reflective of the communities we serve. The AHA
and AONL developed resources to help health leaders implement and
foster workforce diversity and inclusion within their organizations.
These tools also address bias and examine how institutionalized and
systemic racism result in inequities in care.
I must also note the impact of the unprecedented expansion of
telehealth services and access to telehealth resources since the start
of the pandemic that has helped us stay connected to our communities.
Our experience, and that of fellow health systems across the country,
has demonstrated the efficacy of telehealth in delivering care in a
public health emergency, and we want to ensure that it will remain
beneficial, acceptable, and accessible to more patients when applied in
the appropriate ways on the other side of the current crisis.
We are grateful that the Centers for Medicare and Medicaid Services
(CMS), through emergency waiver authority, have provided numerous
telehealth flexibilities, and we urge further action by Congress and
CMS to make many of these flexibilities permanent after the pandemic.
In the near term, we support the Temporary Reciprocity to Ensure Access
to Treatment (TREAT) Act (S. 168), introduced by Senator Chris Murphy
and Senator Roy Blunt, that would create Federal uniform licensing for
the duration of the COVID-19 pandemic. We also support changes to
Section 1834m of the Social Security Act to allow more medical
professionals, including, occupational therapists, physical therapists,
and speech-language pathologists, to be able to be reimbursed by
Medicare for their services after the public health emergency ends.
Finally, we urge Congress to address technological, broadband, and
other gaps to access along with any further telehealth expansion
efforts so that the digital divide is not a barrier to quality care.
The substantial financial impacts of COVID-19 on hospitals and
health systems will also have lasting impacts. Systems now face
difficult decisions to reduce costs, potentially limiting support to
health care professionals, further development of needed
infrastructure, and support for their communities. The economic impacts
for patients and those who have lost health care insurance or cannot
afford patient financial responsibilities are further impacting
providers facing financial challenges now due to the COVID-19 pandemic.
Additional support is needed, including eliminating further reductions
in payments through Federal programs including Medicare and Medicaid to
maintain access to care for patients.
In closing, nursing has been ranked the most trusted profession by
Americans for decades, with a large majority of survey respondents
rating the honesty and ethical standards of nurses as high or very
high. Nurses have the skills, expertise, creativity, and unique ability
to problem solve and lead while putting the patient's whole health at
the middle of everything we do. As the spring and summer bring an
increasing number of vaccinations per day, in combination with
continuing to mask and practicing healthy behaviors after receiving the
vaccine, we need to acknowledge pandemic fatigue, be patient with each
other, and work together in being innovative to provide highest quality
care in the safest manner possible. In my role at the AONL and with the
AHA, we will continue to support state efforts to expand scope of
practice laws, allowing non-physicians to practice at the top of their
licenses.
Thank you for the opportunity to serve on the witness panel for
this important conversation. At a recent HELP Committee hearing,
Ranking Member Burr, who has been a great partner for Duke Health and
health systems across North Carolina throughout the challenges of
COVID-19, commented that it would be ``devastating'' if we do not learn
from the lessons of the current pandemic. I wholeheartedly agree. Our
collective weaknesses and failures have rarely been so important to
understand or on such public display--but we have also seen our nearly
unlimited capacity for resilience, innovation, and responsiveness. We
look forward to working with you to apply those lessons, cement our
strengths, and create an even more robust health care infrastructure to
address future challenges.
______
The Chair. Thank you, Dr. Fuchs. And thank you to all of
our witnesses today. We look forward to your responses to our
questions.
We will now begin a round of 5-minute questions, and I ask
my colleagues to please keep track of your clock and stay
within those 5 minutes.
Dr. Shah, for over a year we have been responding to the
greatest public health crisis in over a century. COVID-19 has
pushed our public health system to the brink and underscored a
lack of desperately needed resources. That's why Democrats
included robust funding for vaccines and awareness campaigns,
testing, and public health workforce in the American Rescue
Plan, among other critical public health priorities.
In the all-hands-on-deck effort to end the pandemic, we
must center our response on equity and reach every community.
Populations hardest hit by COVID-19, including communities of
color, tribes, and other underserved populations, must be
prioritized, and outreach efforts and websites and information
tools must be accessible to people with disabilities and
English language learners.
Dr. Shah, can you tell us what is Washington State doing to
make sure things like testing and vaccines are accessible to
everyone?
Dr. Shah. Thank you, Senator Murray, and thank you again to
all of you for your leadership on this issue.
I would say that there are a number of things that we've
been doing, and it starts not just today but starts way back in
the fall. It was really around a number of dialogs and sessions
where we reached 20,000 Washingtonians to also work with them
and learn from them what their prioritization thoughts were.
In addition to that, we have put together, as is in my
written testimony, the Vax Center, which is a public-private
partnership coming together to help with really efficiencies
and numbers, but also a fix, which is really a combination of
dialog sessions and feedback sessions with stakeholders for
equity.
I think the key message is that COVID-19 did not start
these inequities, it has only made them worse. So we have
really an incredible amount of work ahead of us to make sure
that we're really underscoring all the feedback from these
communities and all the people that are impacted
disproportionately by COVID-19, but also addressing them by
giving them a voice in the work that we're doing, and I think
that's critical as well.
The Chair. Okay, thank you very much.
Dr. Abraham, we do have a long history of health inequities
in this country which have only been exacerbated by the
pandemic, as Dr. Shah just said. It is completely unacceptable
that Black people are dying from COVID-19 at 1.4 times the rate
of white people, and that native Hawaiian and Pacific Islander
populations are contracting COVID-19 at over 3 times the rate
of white populations. Despite this, in nearly all states, Black
and Latino people have received a lower share of vaccinations
compared to their share of cases, deaths, and population.
We know vaccinations are an essential tool to end this
pandemic, and they need to reach communities that are hurting
the most. I am impressed with your health center's success in
vaccinating communities of color you serve. Tell us how we can
make sure vaccines and information about them are reaching
communities of color.
Dr. Abraham. Sure. Thank you for that question, Senator
Murray. As Dr. Shah and Dr. Jha mentioned, we have to build
this public health infrastructure yesterday, and we really
needed those networks, and what we have really strong in South
L.A. are networks of Black and brown physicians who knew we had
to work together to race to get our patients vaccinated. So
we've been in close collaboration with the physician community
in South L.A. to figure out how we can better coordinate our
response. We work in lock step.
This whole rollout has been a series of marriages, a series
of marriages between Kedren and our local Department of Public
Health. It has been working in lock step with our state
government and making sure that the supply chain reached
community health centers, FQHCs, to make sure that we get
clinicians and providers access to the essential medicines
because this is what we do every day. We vaccinate our
patients, we care for them, and we educate them. So trust us to
continue to do our job and we will get more of America
vaccinated.
But what we built today really is a revolutionized health
care delivery system. There is an opportunity in this crisis,
and that really is to bring a public health infrastructure that
has been lacking, and we must wed public health and the health
care delivery system together.
The Chair. Thank you very much.
Senator Burr, I'll turn it over to you.
Senator Burr. Thank you, Madam Chair.
All of you have talked about inequities. Let me just put
another one on the table: rural versus urban. It hasn't been
mentioned, and I think you leave out a lot of America when you
don't talk about rural America and how difficult it is to
reach.
Dr. Abraham, it is unbelievably refreshing to hear you say
we just built our system, what we needed. Regardless of what
Washington said, we built what works, and that's what's so
unique about the local communities and the empowerment of those
communities.
Dr. Shah, as I mentioned in my opening statement, we're
closely examining the first year of our response to the novel
coronavirus, and we've seen things we didn't expect. One of the
most obvious recent things, partnership between pharma
companies with each other, an innovator or discoverer and now a
big pharma company that takes on a contract manufacturing role
to finish and fill.
We never dreamed that these things would happen, but
they're happening. Our successes are due in large part to the
ability of state and local public health officials to identify
and address the unique needs of their community during the
pandemic. The way that Raleigh handles COVID-19 in North
Carolina is not the same as Seattle, and we need to address it.
Let me ask you, Dr. Shah, do you agree that state and local
officials should be the leading voices for the needs of their
community as we continue to respond to COVID-19?
Dr. Shah. Senator, thank you for that. Absolutely, state
and local officials have an incredible role to play, and we do
need to lead because we do know our states, we do know our
localities, so absolutely.
That said, we also have a responsibility to make sure that
our Federal partners are also at the table and also leading.
There are certain things that the CDC can do, that the guidance
that allows for consistency across the country is also
incredibly helpful.
I will tell you on the front lines, it has been so
challenging this entire year of up and down, back and forth,
left and right, this and that, to try to fight a pandemic. So
all the tools that we can have, there are roles of government
at the Federal level, the state level and the local level that
all work together so ultimately we are protecting the community
member, and that consistency of either policy or communications
is absolutely critical to the success not just for this
pandemic but in future emergencies.
Senator Burr. Dr. Jha, we have spent millions over the last
decade to set up a surveillance system in the United States as
an early warning system to detect things like this. Hopefully
it would have seen the pandemic earlier, responded to it
faster. Did our surveillance system fail, and what should we
do?
Dr. Jha. Yes. So, Senator, thank you for that question. A
year ago, in January 2020, actually, I wrote a piece in which I
said that I thought the U.S. would have a relatively robust
response to the pandemic because we had such a good
surveillance system. We had great laboratories, great doctors,
great nurses, great hospitals. We do.
It obviously did not work. I think our surveillance systems
are not as robust as we need them to be. We don't do enough
surveillance out in the community. One of the things that we've
learned, for instance, is wastewater surveillance is a very
good way of finding diseases before we start detecting them in
humans. We haven't really made a national effort to do that
kind of surveillance.
There's a whole series of things that are much more public
health and not so much who comes into the doctor's office that
we need to be investing in. And then the other part that really
failed us was the data infrastructure. Even if you could
identify cases or diseases, we could not aggregate it and look
at the broader pattern in individual states, let alone across
the country.
Just yesterday COVID tracking, which was an effort by a
group of journalists, packed up after a year of pulling
together data and making it widely available. That's the data
that we all use as a Nation, was data coming from a group of
journalists.
We need the government to be able to pull together data
across states, do surveillance, and make it available for
policymakers and academics. None of that worked as well as it
needed to.
Senator Burr. Dr. Jha, how can the private sector be better
leveraged and incorporated into biosurveillance systems to
support Federal, state, and local public health decision-
making?
Dr. Jha. Well, the private sector has the tools, right? I
mean, if you think about genomic surveillance, for instance,
there are some fabulous American companies that have that
technology, and the U.S. Government has to partner with them. I
completely agree with the premise of this and your other
question, that so much of the success of this pandemic has come
from the Federal Government, and sometimes state governments,
partnering with the private sector. That's how we have beaten
this thing. And when we think about future investments, that's
the mindset we're going to have to use.
Senator Burr. Thank you, Doctor. Thank you, witnesses.
The Chair. Senator Casey.
Senator Casey. I want to thank Chair Murray, and I want to
start as well by thanking the witnesses for the focus on public
health infrastructure. I want to thank Chair Murray for her
dedication to this issue over time, because we don't talk about
it enough and, frankly, have not moved forward in a manner that
would prepare us for the next pandemic.
I'll start with Dr. Shah. You talked about the need to
build resilience in the public health system, and about the
relationship between both public health infrastructure and
public health preparedness. So I've got a couple of questions.
Do you think it's possible to be as prepared as possible
for a public health emergency without investing in public
health infrastructure?
Dr. Shah. Well, thank you, Senator, for that question. I
will say that it becomes extremely difficult. It's really about
building the capacity not in the middle of the crisis, or not
reactively trying to throw dollars at it, but in advance to
build that capacity so public health can respond. So what Dr.
Jha just mentioned about the surveillance systems, the data
systems, he's absolutely right. These are systems that in
advance of COVID-19, if we had this investment in public health
infrastructure, would have been robust, would have been strong.
Now, we can look back, that's fantastic, but we really need
to be looking forward, and that's really about investing in
systems in a very smart, strategic, and sustainable way.
Senator Casey. Part of that, I guess, is at the local
level, and I guess the follow-up to that is who are the people
you would hire and the other investments you'd make, and what
other resources would be used when we're not in the middle of a
public health emergency, as you suggest, to be prepared for
what's ahead of us?
Dr. Shah. Well, I think we need to be thinking--look, our
department of health in Washington has been stood up for 400-
plus days. I mean, that's remarkable. The same thing in Harris
County down in Texas. The same thing for 300-plus days. We're
talking about a year-plus of response. Public health systems
are fatigued both physically and, honestly, emotionally.
I think the key message is that we need to be thinking
about how do we make smart investments in that workforce so we
support the workforce, we make sure that workforce is both
physically and emotionally and behaviorally supported, but we
should also think about bringing into the workforce the
technology, the logistics, folks that have the cost-
effectiveness, who understand process flow, who have
efficiencies in that. And also, we in public health have to do
a better job of communications. We have to do a better job of
really making sure that we can engage with our communities so
people recognize that we are part of the solution, not part of
the problem.
Senator Casey. Doctor, thanks very much.
I want to move to Dr. Jha regarding children, and I want to
start by thanking him for being such a great communicator at a
time when we needed clear and science-based communication
across the country.
The one issue that relates to our children that has gotten
some attention but probably not enough, that while children are
less likely to become seriously ill from COVID-19 by way of
comparison to adults, they still can spread the virus, and you
and others have spoken about MISC, the multi-system
inflammatory syndrome in children, a very serious condition.
After we prioritized the high-risk populations and are
immunizing now tens of millions of people, once we get to the
immunization of children and teens to reduce community
transmission in cases of this MISC, and we know that all of the
major drug companies are running or plan to run pediatric
vaccine trials, can you speak to the process that's underway
and assess the safety and efficacy of these vaccines for
children and teens as you see it right now?
Dr. Jha. Yes. Senator Casey, thank you. It's a critically
important question because it will make--it's going to be very
hard to reach population herd immunity if everybody under 18 is
not vaccinated. And while the disease does have a much milder
effect on most kids, there are high-risk children with chronic
diseases for whom this can be quite substantial; and then, of
course, we do ultimately want to get kids vaccinated.
I think we can, and I think the question is when are we
going to have the data to feel comfortable about the safety of
these vaccines in children? I do believe we have trials running
by Moderna and some of the others also, for kids 12 and older,
and I expect a lot of that data to be available by mid to late
summer.
The problem will be the younger children and looking for
efficacy, looking to see does the vaccine actually work. When
infection numbers get very, very low, you're going to need very
large trials to prove that the vaccines are effective. We may
need to think about this a bit differently. We may need to say
we want to make sure these things are safe in children and use
that as a bar. But there's a lot of work to be done. We do have
to get our kids vaccinated, and I worry, especially for younger
ones, that it may take a while to have the data to feel
comfortable doing it.
Senator Casey. Doctor, thank you very much.
Thanks, Chair Murray.
The Chair. Thank you.
We'll turn to Senator Cassidy.
Senator Cassidy. Thank you, Madam Chair.
Dr. Jha, there was just an article in the MMWR about the
strong relationship between obesity, even that which people
would think not being very obese but nonetheless is obese, and
its risk factor for hospitalization and death. Now, Dr. Abraham
and I did our training in the same area in South Los Angeles,
and my own medical practice was with the poorly insured in
Louisiana. And as we know, there is more of a risk factor for
obesity in those who are lower socioeconomic regardless of
race.
To what degree do you think we can explain the
disproportionate impact upon some sub-populations relative to
their associated increased risk of having obesity?
Dr. Jha. Senator Cassidy, it's a really good question, and
I think you're absolutely right that we're still really
learning about the impact of obesity on this disease. But no
doubt about it, based on all the data that I've seen, obesity
is a meaningful risk factor for having poor outcomes.
I think if you look at the broader picture of the fact
that, for instance, African Americans have died at much higher
rates of this disease, or Latinos, a lot of it is much higher
rates of infection, which is I think driven by work conditions
and----
Senator Cassidy. That is increased rates of infection, but
we know that there are a lot of folks who are infected and we
don't know that they're infected, correct?
Dr. Jha. Absolutely.
Senator Cassidy. Do you have surveillance testing to
establish that point, or is that intuition?
Dr. Jha. Well, we have very good data that they're
certainly identified far more often as having been infected,
and given that testing rates have often been lower in African
American communities, you'd have to--it stands to reason that
the level of infections in these communities are much, much
higher as well.
Senator Cassidy. That's more of an intuition than actually
having data on that. Everybody respects your intuition, but
it's still an issue there.
Secondly, we are looking at an outcome of prevention of
infection, but it does seem as if there are surrogates for
prevention of infection, specifically the development of
antibody response to vaccination than perhaps the height of the
antibody response. Cannot these surrogate measures be used to
measure vaccine efficacy in children? Obviously, their immune
systems are robust. They typically respond to vaccines better
than those who are older, and yet this vaccine produces good
immunologic response in those who are older. What are your
feelings about using a surrogate as a marker of immunity?
Dr. Jha. It's a great question, Senator Cassidy. As a
physician, you know that the science here is evolving but
getting better. I think the key question you're asking is how
confident are we about the correlates of immunity? How
confident are we that antibody response, or T cells, which we
can also measure, really reflect somebody's immune status? And
my sense is that we're pretty close to that point, but we
haven't really nailed it down.
I can easily imagine, especially as infection numbers get
very, very low into the summer, if we want to measure efficacy
in children or in other populations, we may need to get to
using correlates of immunity as opposed to direct infections,
and that seems to me to be reasonable as long as we've
established that, in fact, those correlates are right.
Senator Cassidy. Dr. Jha, we'll stay with you once more.
Obviously, there's been a lot of concern regarding schools not
reopening.
[Inaudible] heavily favored by teachers' unions than not,
even though CDC continually said that you could safely reopen
taking normal precautions. I am actually associated, or at
least my wife is, with a school that did testing, and we found
that the teachers and the students who were infected typically
brought the infection--in fact, they always brought the
infection into the school. It did not spread within the school.
What are your feelings about the ability of schools to
safely reopen now?
Dr. Jha. Senator Cassidy, I believe, and I've been pretty
vocal in the last several months, that I think most schools in
America can open safely as long as we put in important
mitigation efforts--universal masking, reasonable ventilation,
and I believe testing does add a layer of protection. I have at
this point believed, given how much vaccines we have, that I
think we should go ahead and vaccinate teachers and staff. It
would certainly add a very important layer of protection. But
there's no doubt in my mind that we can get schools open in a
way that will keep kids and teachers and staff safe.
Senator Cassidy. Two more things. Dr. Fuchs, let me just
say thank you for giving a shout out to the Lorna Breen Act.
That is something which I am sponsoring with Tim Kaine, so
thank you for the shout out. We want to take care of our health
care providers.
Dr. Abraham, I did do my training at L.A. County USC, and
the patients you see are my patients as well, and in a sense I
feel as if we're brothers in kind of cheering for the less
fortunate. So thank you for all the work you do.
With that, I yield back.
The Chair. Thank you very much.
We'll turn to Senator Baldwin.
Senator Baldwin. Thank you, Chair Murray. And thank you to
our expert panel today.
Public health experts have warned that the coronavirus
continues to adapt, mutate, and change, and I'm increasingly
concerned about the rise of new and potentially more harmful
variants. This is why I authored the Tracking COVID-19 Variants
Act. It would provide resources necessary to dramatically scale
up our Country's sequencing, surveillance, and outbreak
analytics capacity.
I was proud to see a version of my bill included as part of
the Senate-passed American Rescue Plan, and I look forward to
seeing the President sign that bill into law, hopefully very
soon.
Dr. Shah, many experts have noted that we could see another
spike of new infections due to a rise of variants. What can
states do to respond to these emerging variants, and how will
scaling up our surveillance efforts and our ability to do
genomic sequencing for coronavirus make us better prepared for
the future of this pandemic and future pandemics?
Dr. Shah. Senator Baldwin, thank you for that set of
questions. Let me say that the number-one thing that states can
do is what I said, stay the course. We have to make sure that
those mitigation efforts for prevention, which is really the
robust measures around wearing of masks and making sure that
we're careful as we reopen, that we do so based on evidence and
the best we can for not dialing up too quickly because, as you
know, that can also be challenging when you have to dial back
or if there's another surge.
But the other thing in the State of Washington and one of
the things that I'm really proud of from the Department of
Health standpoint is that we are in the top five in states when
it comes to genomic sequencing when it comes to the variants,
and we have discovered variants in the State of Washington. The
other piece of it is that we've actually invested in more
laboratory capacity in the public health lab at the state level
and working in partnership with the University of Washington.
I think there is something we can do to invest in our own
state public health systems from a laboratory surveillance
standpoint, but also working with our partners in the academic
centers. We need to do a better job and more of genomic
sequencing because, remember, as you said, viruses, this is
what they do. They love to mutate. They love to change. They're
trying to get the next human being to try to figure out how to
infect. So this is what variants do, but our job is to make
sure those public health measures are robust and strong, while
we're also searching and seeking out so we can get data to
individuals, policymakers, and obviously to public health
officials so we can continue to monitor what's happening.
Senator Baldwin. Ideally and pragmatically, what percent of
positive COVID tests should receive genomic sequencing to
really keep on top of or keep close track of emerging variants?
Dr. Shah. This is a tough one, because across the globe
there are certain countries that are doing a better job, in
Europe, for example, the United Kingdom, where it's somewhere
in that 5 to 7 percent range. We're not there. We're obviously
markedly lower than that.
I think it's really about continuing to make sure that we
make progress on it, but we do need to be working with CDC and
many of our partners like APHL, the Association of Public
Health Laboratories, to really learn what exactly the optimal
percentage is.
But it's really not about just a percentage. It's about
making sure it's distributed throughout the country so we have
strong surveillance systems, and then we're also looking and
using those surveillance systems to really discover pockets of
where things are happening across the country.
Senator Baldwin. Thank you.
I know my time is running out, but I did want to ask a
question to Dr. Abraham. Community health centers like the one
you lead play a critical role in providing health services to
underserved populations. In my home State of Wisconsin, there
are nearly 20 federally qualified health centers providing
really important care around the state.
Now, last month the Biden administration established a
partnership with community health centers to expand their role
in COVID-19 vaccinations, and in Wisconsin the 16th Street
Community Health Center in Milwaukee was named one of the
participating sites.
I'm curious to hear from you, are the successes that you're
having at Kedren being replicated at community health centers
across the country, or do you think your experience is unique,
and do you think more needs to be done to help community health
centers in their vital mission in serving the underserved,
especially as it concerns vaccines?
Dr. Abraham. Thank you so much, Senator Baldwin. It also
reminds me of the question that Senator Burr had mentioned
about rural populations, as well.
Community health centers and AFQCs really play a critical
role, whether it's urban underserved Los Angeles, or whether
it's rural parts of this Nation. What we've learned is that the
heroic work at Kedren and the work of partners and public-
private partnerships really is an example for other community
health centers throughout this country, especially where there
is unequal access within those communities, whether they are
rural or urban, anyone who is underserved or vulnerable, those
that are differently abled, minority, or at high risk for any
disease during this pandemic.
What we do is no secret. It's not a magic trick. We just
need more vaccines, more hands, and more resources, and the
more of those that go to the places where we receive our care,
whether those are AFQCs, whether those are small and solo
physician practices, that's how we're going to get everyone
vaccinated. That's what we do every day, COVID or no COVID.
The Chair. Thank you.
Senator Collins.
Senator Collins. Thank you, Chair Murray.
Dr. Jha, I would like to talk with you about the critical
issue of reopening our schools. I've been very concerned about
the fact that so many of our students, particularly in the more
urban areas of the country, still are not back in school.
Maine, I'm pleased to say, is doing a good job in this regard.
Just last week I talked to the head of Maine CDC who made
the point that children are actually safer in schools in many
cases than they would be in their community or in their home
doing remote learning. I have tremendous respect for the CDC,
but I'm very disappointed in its latest guidance on school
reopenings. You have talked about that for some people in
public health, that it did not appear to be particularly well-
grounded in the evidence and science. Similarly, Dr. Allen from
Harvard has questioned the advice on distancing, suggesting
that for children 3 feet might be adequate as long as they're
wearing masks. You've talked also about the need and important
role for ventilation.
Could you please give us your views on schools reopening
and what could be done to expedite reopening of virtually all
schools so that we don't have more and more children falling
behind, additional mental health problems, social development
not progressing, and all of the adverse side effects from
children not being in school?
Dr. Jha. Senator Collins, it's a really good question. It's
a really important question. The effects of children not being
in school over the last year I think have been very
substantial. They have not been borne by everyone equally. I
think children from poorer backgrounds have borne
disproportionately the impact of this. And then let's also be
honest that when kids are at home, the caretaker is often the
mother and therefore has had very negative effects and very
negative labor market effects on women and their ability to
work.
The societal effects here are very, very large, and I think
we need to think about how do we get kids back to school
safely. One of the things I've been frustrated by is we've set
up what I think has been a false dichotomy. We've set up kids'
education versus teacher safety. And the truth is we need both.
We need both if we're going to do this over the long run.
I believe there is a way to get kids back into school full
time now and certainly into the future that keeps teachers and
staff safe and kids learning. And the principles of that in my
mind are--and this is really based on where we are today--right
now you need to have universal masking in school, and you've
got to have pretty high levels of adherence, 90-plus percent.
You're not going to get 100, but you've got to have most people
adhering to that.
Second is ventilation. I really do think that having
reasonable ventilation in schools is critical, and I think most
schools can get that.
Third is I have argued that testing is an important
component of keeping schools safe. You catch outbreaks early.
You offer a level of assurance to everybody that you can do
this.
Last but not least is vaccinations, and I said this to
Senator Cassidy. Given how much vaccines we now have, I believe
it is important to prioritize teachers, and when I say teachers
I also mean other staff in schools.
I did not mention 3 feet versus 6 feet. I did not mention
deep cleaning of surfaces. I think there's a lot that's gotten
us distracted. I think if we focus on these things we can keep
teachers safe, we can keep kids safe and open schools, and I
think we have the ability to do all of this now, not 6 months
or a year from now. That's what we need to focus on.
Senator Collins. I could not agree with you more, and I
hope that school officials, teachers, parents and others will
follow the advice that you just gave. Thank you so much.
The Chair. Senator Kaine.
Senator Kaine. Thank you, Chair Murray and Ranking Member
Burr, and thank you to the witnesses for this important
hearing.
Dr. Fuchs, I want to thank you for your testimony about the
challenges--it's hard to say thank you--about the challenges
that our nursing workforce is facing, mental health challenges.
And you indicated in your testimony that as a result we're
starting to see more of our skilled workforce leave or planning
to leave, which is also being reported in recent surveys. This
kind of high turnover will have a significant impact on the
future of delivering health care.
I want to thank Chair Murray and others. Senator Cassidy
mentioned the Breen Act. You helped put funding into the COVID
bill to start to deal with the mental health needs of our
frontline health care workers and public safety professionals.
But, Dr. Fuchs, what would you suggest to the Committee
that we might want to consider going forward to make sure we
provide resources so that we don't see the kind of high
turnover that you are concerned about?
Ms. Fuchs. Thank you for that question, Senator Kaine. This
actually is a complex issue because, indeed, some of the
factors for individuals may very well be different depending
upon individual situations. But one I would say is that clearly
providing consistent support and education and access to
services I think is extremely important for not just the
nursing workforce but for others. So the acts that you have
sponsored I think will be very helpful.
I think there is a direct need to really study the impacts
of the pandemic on the workforce to be able to really look at
different strategies that may be helpful in addition, and I
think we have to continue to support our workforce. But we're
starting to see now, with patients reentering care facilities,
that the public is stressed, and the public is now acting out
more in addition, and placing largely nurses and those in the
direct care environments in a position to be disrespected and
in more violent situations.
I think that we're going to have to place emphasis on the
support of workplace violence initiatives to be able to support
our staff, amongst other initiatives.
Senator Kaine. Let me ask a question, Dr. Jha, about long
COVID and how we should be thinking about that as we're
thinking about what we need to do. I had COVID in March and
April nearly a year ago, and it was a mild case, thank
goodness. But one of the effects of it was nerve tingling 24/7,
every nerve ending in my body, and a heating pad sensation that
happens about four or five times a day where it just feels like
somebody has turned a heating pad on. It heats up, and then 15
minutes later it goes, then it crops up somewhere else.
These are mild symptoms that don't stop me from working,
and the tingling thing actually helps keep me awake in long
hearings.
[Laughter.]
Senator Kaine. My Governor in Virginia had COVID. Six
months later, no sense of smell. Obviously, there's nothing
wrong with my skin, and there's nothing wrong with his nose.
It's a neurological issue, probably just altered the thalamus
or something like that. But these are not debilitating
symptoms, but many have debilitating symptoms: fatigue, heart
impairment, respiratory problems, brain fog. I did get asked if
I had that and I said no, but my friend said, well, how would
anyone know?
[Laughter.]
Senator Kaine. But as we're thinking about going forward
and the way we look at the health magnitude of this crisis,
there will be a day when the President will declare that the
emergency is over, but there's this huge category of these long
COVID consequences that we still don't completely understand.
Maybe for Dr. Jha, how should we be thinking about that as
we are trying to put together the right plan to take care of
the Nation's health needs going forward?
Dr. Jha. Senator, it's a fabulous question. First of all,
I'm happy to hear that your symptoms are mild. But as you
pointed out, there are people who struggle with substantial
symptoms. I think one of the things that I found most
frustrating over the last year, for people who like to focus on
mortality rates and essentially argued for let Americans get
infected, is that we did not appreciate the effects for the
large number of people who got infected and recovered, didn't
die, thankfully, but had substantial debilitating symptoms.
I would say two or three things. One is, first of all, we
need to really study this much more carefully. We have to apply
science to it the way we do everything else, and NIH I think
has been doing some really good work on building cohorts and
really trying to figure out what are the predictors, how long
do these things last.
Obviously, we need to work on therapeutics to try to
resolve some of these symptoms, address some of these symptoms.
There's some preliminary data that actually vaccinations can
potentially be helpful for long COVID. I don't want to
overstate how good the science on that is, but there is some
preliminary data that it might be the case. I'm hoping that as
more people get vaccinated, that will show up.
The last point I'll say is when our President declares the
public health emergency over, we are going to find a large
number of Americans with substantial disability from this
virus, from this infection, and the cost of that, human and
financial, is going to be long term, and we're going to have to
manage that as a country.
Senator Kaine. Thank you, Dr. Jha.
Thank you, Chair Murray.
The Chair. Thank you.
Senator Murkowski.
Senator Murkowski. Thank you, Madam Chair.
Thank you to all of our witnesses. I really appreciate this
discussion about the mental health side of what we're dealing
with this COVID.
I think last year at this time we were all very keenly
focused on the health impact, what was happening to people who
were coming down with the virus. And then shortly after that we
saw the economic crisis that came following the health. And now
I think we are into this third wave of a crisis, and I think
it's the mental health and behavioral health side of it. You
want to talk about long haul and those long-lasting impacts,
whether it's the impacts on kids, the societal impact that has
been referenced here today, as we think about our providers and
what we need to do to ensure that they have the help and
support, and also recognizing the stigma that attaches.
If you are the mental health provider that says I need
mental health help now--there was an article in the Sunday News
about the doctor who took her own life after dealing with COVID
and then coming back with the stress of handling it all. So I
think we need to be very cognizant of what we're doing to
address the behavioral and the mental health needs of not only
our medical professionals, our children, but at all levels now.
I was looking at a full-page--it was an advertisement but
not really an advertisement. It was an informational piece that
was put out by the Alaska Mental Health Trust Authority, full
page in our newspaper yesterday. But they are partnering with
the State Department of Health and Social Services. They're
bringing together a coalition of health care organizations,
government agencies, social service providers, and community
members, and they call it Crisis Now, and it's a framework for
expanding the behavioral health crisis response. They're doing
it in our larger communities. The big components of it are a
mobile crisis team, a 23-hour and short-term crisis
stabilization center, where those who are experiencing mental
health or substance use emergencies can go for safe care.
The question--and I don't know, maybe this is to Dr. Jha or
to Dr. Shah, maybe any of you--I understand that this Crisis
Now framework is based off SAMHA's National Guidelines for
Behavioral Health Crisis Care model. So the question is whether
or not folks are familiar with these guidelines or if there are
similar models that are being implemented to address the
behavioral needs that we're seeing within the hospitals, and
more particularly in the emergency rooms, because it's in the
emergency rooms that you get them first, and the ability to be
able to respond is perhaps limited.
I throw that out as a jump ball to whomever would receive
it.
Dr. Abraham. Senator, this is Dr. Abraham. I work at an
acute psychiatric hospital. Kedren is a federally qualified
health center that has an outpatient mental health outfit, as
well. One of the things, if you come and visit us in South
L.A., that you'll visibly see is there is joy. There is music,
there is dancing. We're turning the story around. We're at war
with COVID, and we are winning, and that is part of improving
people's mental health.
I'm hoping that with our strategies to really combat this
pandemic, we do get back to work, back to school, back to
loving our loved ones, and I think that has a significant
impact on the burden of mental health both for our workforce
and also the patients and the public that receives the care
that we provide them.
What I've noticed about the over 200 volunteers that come
and show up every day from AmeriCorps and the American Red
Cross and the Salvation Army, they are happy, and they now feel
part of the solution. We are solutions oriented at Kedren, and
we've seen how that has directly impacted people who have been
morally injured by this pandemic, those that are dealing with
the realities of burnout. For health care providers, mental
health care providers who are suffering, this is the antidote,
this is the cure, this is the shot. We say let's get everybody
vaccinated, and we've seen how positively it has impacted our
community.
Senator Murkowski. Thank you, Doctor.
Dr. Shah. This is Umair Shah in Washington. I want to also
give a shout out to Dr. Zink, who is the state health official
in Alaska, and she does a fantastic job.
Senator Murkowski. She's a rock star, really.
Dr. Shah. She is, she absolutely is.
I'm not familiar with that program, but I think one of the
biggest concerns from a patient standpoint is that across the
country we had, prior to the pandemic, some 1 in 10 Americans
had some sort of anxiety disorder or anxiety symptoms, and
during the pandemic that has increased to 4 out of 10. So we've
had an increase in that. And on the provider side we've had
compassion fatigue as well, where there's also been the concern
that even psychiatrists or responders have not been able to
cope with their own challenges from a mental health and
behavioral health standpoint as they're now addressing the
person in front of them.
I will agree with Dr. Abraham that there are moments that
we need to--first of all, we need to support our health care
and public health workforce, absolutely. But there are also
moments that we need to champion. So, for example, in the State
of Washington, we celebrated several weeks ago our millionth
dose. Governor Inslee recognized the millionth dose, which is
Ruby T., a 90-year-old from Eastern Washington who was the
symbolic millionth dose who had received a vaccine, and there
was a big celebration, confetti and things like that. It
brought such an incredible positive uplifting to our own team
at the Department of Health.
I will say that now, as we're closing in on our 2 millionth
dose, actually, this week, in fact we just passed it yesterday,
there are moments of celebration in the midst of this horrific
pandemic. But we do need to not just celebrate. We also need to
support. We need to put the resources in not just for physical
health but really for emotional behavioral health. As you know
just as well as I do that this is what providers are least
likely to come forward and say I've got a problem, I've got an
issue, I've got a challenge, I am burned out, and this is why
we need to be really careful, methodical and forthright in
supporting our health care and public health professionals with
emotional health support.
Senator Murkowski. Thank you.
The Chair. Thank you.
We'll turn to Senator Hassan.
Senator Hassan. Well, thank you, Chair Murray and Ranking
Member Senator Burr. And thank you to all of our witnesses for
your testimony today and for the optimism that you have been
expressing as well. I think it's much needed.
I want to start with the issue of long-term care
facilities. I want to start with a question first to Dr. Shah
and then to Dr. Jha.
In New Hampshire, more than 70 percent of COVID-19-related
deaths occurred within our long-term care facilities. Despite
consistent pressure from me and many of my colleagues, the
previous administration failed to provide the clear and
consistent guidance and resources that these facilities needed
to protect their residents and their staff.
Secretary Shah, moving forward, what steps should we be
taking to better support long-term care facilities and ensure
that they are protecting their residents against COVID-19 and
other infectious diseases?
Dr. Shah. Senator, thank you for that question. I will say
one thing that is absolutely critical, which is that as we are
continuing to prioritize populations for vaccines across the
country, we cannot forget the absolutely critical importance of
vaccinating seniors, those who are older in our communities,
especially in long-term care facilities.
As you remember, in the State of Washington very early on
in this pandemic, we had a long-term care facility where there
were real issues, and that was the first focus across the
country of what we needed to do as a system to respond to the
needs within those long-term care facilities.
I think it's really three-fold. First of all, we have to
continue with the process of vaccinations, and we need to make
sure that the staff and the persons who are within those
facilities are vaccinated. We have to prioritize that.
Fortunately, we have been, but we need to continue to
prioritize that, especially as we have turnover in either staff
or people.
No. 2 is we need to make sure that we have those resources
within those facilities so they also can continue to have all
the protective measures, the personal protective equipment,
masks and hand sanitizers, et cetera, and they have enough room
to be able to cordon off individuals who are sick or have
symptoms, to be able to get them out of that facility, or at
least away from others.
No. 3, which is back to that additional question that I
answered previously around behavioral health, we also have to
be really thinking about the impact on seniors, on those who
are in long-term care facilities by isolation away from
families, away from others who they normally would be relying
on to be able to touch and feel and be a part of a family, and
that is absolutely critical for us to be doing, to make sure
that those resources are also there from a behavioral health
standpoint as we also continue to fight the pandemic.
Senator Hassan. Thank you.
Now I want to turn to Dr. Jha, because outside of
congregate care settings, home health workers face unique
challenges accessing paid sick leave and personal protective
equipment, and many individuals who receive home-based care are
struggling to access vaccines.
Dr. Jha, what steps can we take to improve vaccine
availability for workers and patients across all types of care
settings, including for those who are unable to travel to
centralized vaccine sites?
Dr. Jha. Yes, Senator, it's such an important question, and
there are a couple of components to that. First of all, I want
to talk about home health workers. These are some of the least
well paid people in our society. A lot of them are hourly in
their wages, and the idea that a lot of them have turned down
the opportunity to get the vaccine and we say they're vaccine
deniers or they're being hesitant, we fail to understand that
these people have lives where they can't take time off if they
end up having side effects in a way that I could when I had my
vaccine shot. I could take a day off if I needed it. Many
people cannot.
I think there are some really important issues about
understanding the context in which people are turning down
vaccinations and finding policies as well as really having the
organizations themselves being able to pay people to take that
time off or help them get vaccinated, I think that's a really
important area that has not gotten enough attention, and we've
been quick to dismiss these individuals who work incredibly
hard, often multiple jobs, and get paid so very little.
More broadly, I think right now in terms of getting people
vaccinated across the country, my take is we really need an
all-of-the-above strategy, and I think the Administration has
largely been doing this right. They have large sites, FEMA
sites, that will attract a lot of people and will get a lot of
people through, but there are a lot of home-bound individuals
who can't get to these sites. So that's why we need things like
mobile vans, or we need community-based organizations that know
where these people are and can reach out and connect with them.
My overall thinking on this has been we've got to let
states do a lot of this, and then states have to push this out
to community-based organizations who actually understand the
community at large and can implement a lot of these vaccination
strategies.
Senator Hassan. Thank you very much.
I see that I'm over time, Chair Murray, so I will submit
the rest of my questions for the record. Thank you.
The Chair. Thank you.
Senator Marshall.
Senator Marshall. Thank you, Madam Chair, I appreciate it.
My first question will be for Dr. Abraham. Dr. Abraham,
like you, I'm a physician, oversaw three county health
departments. I volunteered in federally qualified health
clinics. We have 21 in Kansas, very proud of them. And I'm used
to dealing with finite resources, and you are too. I just want
to talk for a second--I wrote an op-ed for the Wall Street
Journal published last night and just kind of talk to you about
how do we save the most lives.
Are you familiar with some of the new studies coming out
saying the effectiveness of one shot of the vaccines? Have you
been following those stories? Well, good.
I think what we're seeing is that one shot of either the
Moderna or the Pfizer vaccine is 75 to 90 percent effective for
one shot. And the other big news is that you can still get the
second shot 12 weeks later and be just as effective and raise
it.
If you have a finite set of number of shots and you're
trying to get to herd immunity as quickly as possible, after
you get the high-risk people who get two shots, let's say
seniors and everybody with diabetes and heart disease--you know
your clinic better than I do--if we would give you the
flexibility of giving everybody one shot now and then coming
back in the next 3 months and picking up that second shot, does
it make sense to you that we could impact a greater number of
folks?
Just a quick example. If I gave you 200 vaccinations and
you had your choice to give 100 people two shots or 200 people
one shot, which would result in the greater number of people
that are effectively vaccinated? And the answer is the latter,
150 people in the latter scenario, the first scenario maybe 90.
What would your thoughts be that you could do with that, if
I could give you the flexibility to do that?
Dr. Abraham. Thank you so much for that question, Senator.
I would gladly take those 200 vaccines and I will make sure
they get into the arms of Americans, and that's what we have to
do. We've got a race against time right now. We don't have a
moment to waste, not a drop to waste of this vaccine. Whichever
vaccine you are offered, whether it's Pfizer, Moderna, or now
Johnson & Johnson, and I'm sure there are many in the pipeline,
we'll see what the technologies bring in terms of updated
versions as we continue to combat variants.
However, I too believe that we must get this vaccine out.
As previously stated, it is not either/or, it is all. My
second-dose patients need their second dose, and they're lining
up outside my gate, and if you get your first dose, we'll do
everything in our power to get you your second dose. But we are
dealing with a rationed, limited supply of these vaccines. But
I do believe achieving that herd immunity as quick as we can is
critical.
To some of the points made earlier about mobile units,
getting those vaccines out to the home-bound, homeless
encampments, to jail populations, there is clearly a critical
use for single-dose vaccines. It is all, not either/or.
Senator Marshall. I visited a federally qualified health
clinic last week in Wichita that has the mobile center, and
we're out there doing it.
I want to turn now and just talk a little bit about the
disparity, about the lack of equality of opportunity for the
vaccines. In Kansas, I'm ashamed to tell you, as of about a
week ago, 10 percent of white Americans already had the vaccine
and 5 percent of African Americans or minorities were
vaccinated, and this was so predictable. I could just bang my
head against the wall what happened. What did we do wrong? We
knew this was going to be the case, that it would be a
challenge, and I knew the places to cure the problems were
federally qualified health clinics and the county health
departments. Those are the ones that can get the vaccines to
those people. Was it that you didn't get the vaccines, or that
people didn't want to get them? I just can't imagine you didn't
give everything you had out.
Did our Governors not make the right choices on where to
distribute the vaccines? Maybe, Dr. Shah, you can tell me. We
know it's been a bad deal. What did we do wrong?
Dr. Shah. Well, Senator, thanks for that question. I will
tell you one of the things that we have to recognize is that
we've also been moving throughout every, if not all, 50 states,
that the vaccines have been going not just in general to the
communities but they're going to specific priority populations.
So health workers, long-term care facilities, and seniors, and
then essential workers. We have to make sure that our
denominator is correct, that we're looking and comparing it not
just to the general population of a percentage of certain
populations within our states but really those who are eligible
for the vaccine.
The reason I bring up that comment is that this is not an
excuse; it's an explanation. We need to be thinking about all
of this information. But as we move into populations, you are
absolutely correct, we need to continue to prioritize equity,
we need to continue to be thinking throughout the system what
can we be doing. And we've been doing that for months.
But I will tell you the challenge has been that these
public health systems and health care delivery systems, whether
it's county health departments, whether it's what's happening
within the health care facilities or community health centers
or pharmacies, that all are ramping up with limited supply. So
as we get more vaccine, we are going to see more logistics and
more operations, but then we've got to shift into vaccine
hesitancy.
This is just continuing to follow and move and evolve as
the vaccine process evolves, as well as the pandemic itself.
Senator Marshall. My time has expired, but I think we got
something wrong. And until we identify what we got wrong, it's
going to be hard to correct. Thank you.
I yield back.
The Chair. Thank you.
Senator Hickenlooper.
Senator Hickenlooper. I appreciate all of your service and
your time on this issue. I mean, COVID and the distribution of
the vaccines has been one of the greatest public health
challenges this country has faced, and it did obviously start
with a lot of bumps in the road, but I for one have been very
impressed that the resolution of a lot of these issues--
obviously, there are 50 different Governors in this country. I
know that too well. I think that the responses and the
evolution of the effort has really been dramatically improved.
Yesterday--you guys have discussed this, the new guidelines
and allowing the fully vaccinated a little more freedom with
still some constraints. I spent a lot of time in small business
and was curious what rays of hope you see for small businesses
and what kind of timeline that looks like, and I'm thinking
specifically of the retail small businesses like cafes, beauty
salons, places where they in many cases have less than 10 and
sometimes have only 2 or 3 employees. What kind of guidelines
and what kind of support do you see helping facilitate them
coming out of this as quickly as possible?
Dr. Shah. Senator, I'm not sure if that question is for me
or for someone else, but I can take a quick stab at it and then
maybe turn it over to my colleagues.
I would just say from the standpoint of what we had been
very, very interested in throughout and supportive of
throughout is to be able to reopen and to reopen safely.
Vaccines provide us that glimpse of hope. And why does it do
that? Because now you have patrons in restaurants and in bars
and throughout different establishments, retail establishments,
who are vaccinated, who have little chance or markedly lower
chance of transmitting to the person next to them in the cafe
or next to them somewhere else.
As we continue to see increases in vaccine rates, we are
going to start to see decrease in transmission, and that's what
vaccines really promise us.
However, we have to continue to be thinking about all those
mitigation efforts that Dr. Fuchs, Dr. Abraham, Dr. Jha
mentioned throughout, that these public health measures cannot
just go away. We have to continue to dial up while we're also
thinking about very carefully what we can dial down. But unless
we do that carefully, unfortunately we can see another surge,
and that's what this virus has taught me this entire year. It
is a super-slick virus that has broken every rule in the
playbook, and if we are not super-smart in response, then
exactly what will happen will be another potential surge.
Dr. Abraham. Senator Hickenlooper, this is Dr. Abraham. I
just wanted to add to that it's critical that we get the
vaccines to where people live, work, and play. And for smaller
businesses, it's impossible to close your doors. How are you
going to send everyone to a vaccination site? How are you going
to wait in line for hours? You may not have PTO or child care
or transportation. Those are all barriers to small businesses
getting their workforce vaccinated. So it's critical that we
take those mobile units, we partner with our roots in the
ground, the network of our business leaders, and let's get to
your business and vaccinate your staff so they can safely
continue the services they provide.
Senator Hickenlooper. I couldn't agree more. I think that,
and being willing to work on weekends, which I see you guys
have made that evolution.
The last thing I'll throw out there just as a concern.
Years and years and years ago, I was a scientist. I got a
master's in geology, did my master's, published a couple of
papers, but I can't ever remember seeing so much distrust of
science. And at a time where it's so important, have you guys--
again, I won't direct this to any one of you; feel free to
chime in. But how do we go about rebuilding trust in science,
especially in terms of rebuilding our public health
departments?
Dr. Abraham. Really quickly, this is Dr. Abraham. I'll just
say we deal with this every day on the front lines. We're
vaccinating over 2,500 people a day. Whether you're Black or
brown, white or yellow, you legitimately have every reason to
have questions. It is your body, your health. What is mRNA?
What is an mRNA vaccine? These are real questions, and you have
every right to ask them. There are questions around health
literacy. There is sometimes a lack of basic science
understanding, and we must meet people where they are.
It's critical to take the time to engage them. We answer
their questions and educate them, and those that are medically
eligible, we've seen that they roll up their sleeves, and let's
not confuse a lack of access for hesitancy, and let's not
confuse not finding parking in South L.A. as I don't have time
for a vaccine or I don't want a vaccine. So those are all
critical issues that we look at, Black and brown vaccination
rates. You've got to start teasing a lot of those things out.
But take time, answer people's questions. Let's be honest
with them. And those who choose to get vaccinated, we will
vaccinate you.
Senator Hickenlooper. Great. Thank you.
I'm out of time. I have more questions, but thank you so
much.
The Chair. Thank you.
Senator Tuberville.
Senator Tuberville. Thank you, Madam Chair. Thank you very
much.
Thanks for all of your service and what you're going
through, a very tough time. What a tough time for the world and
our Country.
I worked in education for the last 40 years, and the last
20 years I saw a huge uptick in mental health problems with our
kids. I don't know whether it has anything to do with drugs--
I'm sure it does--lack of family. But we have a huge uptick.
Now, the question I've got for all of you, if anybody wants
to answer this, we're getting ready, just watching our doctors
and our first responders work for the last year, overworked,
stress, which can cause a lot of problems. Do we have a plan to
help these people that are first responders once, hopefully, we
see the light at the end of the tunnel in this pandemic? Are we
preparing for what we can do for these people who have done so
much for us, and then at the end of the day it's going to hit
us right between the eyes of what the problems they're going to
have?
Dr. Abraham. Dr. Abraham here. I'll answer really quickly.
Thank you for that question, Senator.
As I say, the mantra that we have is more vaccines, more
hands to administer them, and more resources and funding. When
it comes to the hands, there are just not enough health care
workers in our communities. We don't have enough nurses and
doctors and every other health care worker that helps us
deliver essential medicines and health care delivery and public
health in this country.
Part of it is we've got to buildup the workforce because,
myself included, has not taken a day off since the day before
Christmas, and that just can't keep happening. That's not
sustainable. But my colleagues are racing against time in ICUs,
keeping ventilators operating and keeping people from dying.
The least we can do in public health and community health
centers is race against time to get this vaccine out, but it's
not sustainable and we need more health care infrastructure and
more public health and more hands, and that means we do need to
train people to do health work well.
Senator Tuberville. Would anybody else like to answer that?
Dr. Jha. One thing I would just quickly add is during this
last year, what we saw was a pretty unmitigated attack on
health care professionals, people accusing doctors and nurses
of lying about how many cases of COVID there were, a real
turning on these heroes who I think have saved so many lives
across the country.
One of the things we've got to do moving forward is make
sure that we are not doing that moving ahead, that we're not
attacking frontline health care providers as somehow being
dishonest, when I think they have been anything but that.
Then the second is that as we come out of this pandemic, we
really do need to, from a policy point of view, look at our
payment systems that have made it very, very difficult for
primary care practices and independent practices to survive in
this pandemic. We need to find new ways of paying doctors and
nurses and health care providers.
There's a lot of work ahead, but it certainly begins, I
think, by showing people respect and understanding what health
care workers have gone through, and not questioning their
motivations.
Senator Tuberville. Thank you.
Dr. Shah. Senator Tuberville, first of all, I'm from
Cincinnati originally, so I just want to give a little shout-
out to you from that previous job with your career there.
I will say that, in addition to what Dr. Abraham and Dr.
Jha just mentioned, I do think there is an incredible need for
us to invest in that health care and public health workforce
both for more of them and training and support, but also
behavioral health-wise. Your question was are we ready for that
for the future, and my answer is I don't think so. I don't
think we are. I don't think we've done enough. I don't think we
have done enough. I don't think we did enough prior to this
pandemic, I don't think we've done enough during this pandemic,
and I don't think we're doing enough moving forward to make
sure that the health and the health care needs and the mental
health and behavioral health needs of our health care workers
and our public health workers are addressed.
We have not done enough to support it. We've got to do
more. And if we do not get this right, we are going to lose
more people from the health care system and the public health
system, and it's going to be a terrible loss for this country.
Ms. Fuchs. I can't agree enough with my colleagues on the
panel today. This is a big issue, and we are not prepared for
the future workforce for health care. I recently had the
opportunity to speak with both Rear Admiral Mix and Orsega
about the public health workforce and the large gaps in the
numbers of people, in the numbers of nurses that we have
prepared either in the whole workforce or in the Reserves.
This is an extreme area and opportunity for us moving
forward, and then back to the concept of how we're caring for
people within our organizations. Wherever they're delivering
care, we have to have flexible services that meet individual
needs in a place where they can accept and be comfortable with
those resources. That will take a very broad approach that will
require additional sources of resources to be able to impact
our workforce.
Senator Tuberville. Thank you very much.
If I could just make one statement, Madam Chair? I told
this to General Pierre last week, who is over at Operation Warp
Speed. I've been in sales and recruiting all my life. I've
watched how things work. We've got a lot of people that's not
taking this vaccine, and we've got to have a lot more take it,
even when there's more vaccines to be given. We need to come up
with a marketing plan. At the end of the day, when we've got
vaccines and 30, 40, 50 percent of the people will not take it,
we've got to have a marketing plan, television and radio, to go
in and say this is why you've got to take it. We can't just set
back and expect people to take it. It's not going to happen.
I think at the end of the day, probably here in a month or
so, we're going to be at a point where we've got to make a
statement of marketing and getting this thing out to get this
thing behind us.
Thank you very much. Thank you for your service.
Thank you, Madam Chair.
The Chair. Thank you.
Ms. Fuchs. Can I make a comment, please? We need a
sensitive approach to how we educate the American people. We
need to meet them where they're at, as Dr. Abraham has said. We
need to recognize that we have a great opportunity here. As a
nurse on this panel on the front lines of our Country, nurses
are the most trusted professionals as rated by our public for
years, and I don't believe we've taken the opportunity to
really maximize the potential that we have in order to impact
vaccinations. So I look forward to partnering with many to be
able to help in this work in the future.
The Chair. Great. Thank you.
Senator Rosen.
Senator Rosen. Thank you, Madam Chair and Ranking Member
Burr, for holding this really important hearing today.
I just want to thank all of the doctors here for your
compassion during the pandemic, not just you but all of our
health care workforce, all of our first responders who have
gone above and beyond to serve our Nation. We are eternally
grateful for what you have done for those 500,000-plus families
who have lost loved ones alone and just all of it. I'm just so
grateful and I thank you on behalf of our Nation.
It is encouraging to see that 92 million Americans have
been getting vaccinated, about 856,000 so far in Nevada. But
greater access to the vaccine can't come soon enough. Far more
needs to be done. So despite our progress, there have been
challenges with appointment scheduling systems, long lines, too
many individuals in underserved areas and rural communities
being left out, and many Americans still waiting for their
first or second shot as we know that the virus variants
continue to mutate. It's critical that we rapidly review what's
working and make changes to ensure that no one is left behind.
Dr. Jha, from a broad systemic perspective, what do you see
as the long-term changes we need to do to improve vaccine
delivery, especially to our most vulnerable communities? And
then I think part of this would be to address our public health
infrastructure, our data systems, creative ways to meet people
where they're at regardless of their communities. What else can
we do to help you with this?
Dr. Jha. Great. So let me kind of lay out what we know
nationally, and then obviously folks like Dr. Shah can talk
much more about the individual state-level experience.
When we look across the country, we see a lot of variation,
some people doing very well, some states doing very well, and
other states struggling. If you look at what differentiates
states that are doing well from those that are struggling,
keeping things very simple is probably the most important. A
lot of states I think have made this far too complicated and
have made it very difficult for people to sign up, to arrive at
a vaccination place, and the more difficult we make it, the
harder we make it for people with fewer resources, fewer
capabilities, fewer support systems to actually make it through
the system.
We really have to have a ground game where we go out to
people and make this incredibly easy. We've heard some of this
from Dr. Abraham, what he's doing in L.A., but it has got to be
much more about getting out into the communities, and I worry a
lot about the rural areas of the United States because I just
feel like we have not paid enough attention to how we're going
to get vaccines out there.
The problem here is that we're trying to recreate a public
health system that we have hollowed out over the last decade,
and now we find ourselves saying, boy, it would really be
useful if we had a system that had good data, that had a really
terrific workforce that we could plug into, but we don't. And
so we've got to build it for the short run, because vaccines
are a short-term problem and we've got to get people vaccinated
quickly. But then we've got to make sure we don't pull all
those investments away once people are vaccinated and say,
Okay, we're done, we're leaving. We've got to leave a lot of
those resources and infrastructure behind not just for future
pandemics but all the other health crises, opioids and other
things that continue to plague our Nation. We've got to
continue to make investments in those.
I'm hoping that vaccines become really the step that we
need to leave a public health infrastructure that helps us
address all sorts of other public health challenges.
Dr. Abraham. Senator Rosen, I just wanted to add really
quickly--Dr. Abraham here--the digital divide in America, the
digital fortress we've created as barriers to people and their
vaccines, we really need to transform some of the digital
demons that have stalled grandma's shot and train them and
teach them and empower them to be digital angels that actually
help us use these systems. These technologies are supposed to
help us, not harm us, not stand in the way between people and
their vaccines. And we need to understand why we need this
data, and there may be more creative ways to capture it than
having a 65-plus senior in our community fighting with their
computer so that they can get a vaccine.
Senator Rosen. I couldn't agree more.
I just have a few seconds left, so I want to talk quickly
about therapeutics research and access. We know that we're
going to have vaccines, but people will still become ill. So
quickly, I just really want to ask what suggestions do you have
to improve access for COVID-19 therapeutics for our vulnerable
patients, maybe particularly in rural areas or in areas that
are underserved and folks not able to get to a Tier 1 hospital,
perhaps. That's going to be our challenge now as people become
vaccinated.
Dr. Jha. Let me start by quickly saying I think this is an
area--look, we've done a lot of things well. The scientific
community has been extraordinary. The NIH has been
extraordinary. But I would say that therapeutics is one area
where we probably have under-invested. I think there are a
variety of issues. We've done pretty well with inpatient
therapies. We've got monoclonal antibodies, but they need
outpatient infusion, which is very difficult in a lot of
contexts. We actually are under-using them.
I think given the billions of dollars appropriately
invested in vaccines, I would like to see a similar effort for
therapeutics. The virus is not going away, even when most of us
have gotten vaccinated. We'd like to get to a point where if
you got infected, you could take a 5-or 7-day oral course of
something which would dramatically reduce your chances of
getting sick. We don't have that. We got distracted with things
like hydroxychloroquine and all that stuff. We've got to let
science drive this, and we've got to let NIH really--give them
a lot more resources to push new therapies. We don't know which
ones will work, but we've really got to try and put a lot more
effort into this area.
Dr. Shah. The other thing I would just say is we have to
also support our rural systems, to Dr. Jha's point, rural
hospitals, rural health care providers, rural health
departments that are doing an incredible amount of work, both
on the vaccine side but also on the therapeutic side. We need
to make sure we continue to support them because they have
challenges that are quite different than what's happening in
the urban areas. We need to make sure that we're also thinking
about those in a very methodical way.
Ms. Fuchs. I would also add that different innovative
models of care delivery are really important. So the work
that's gone on about hospital-at-home programs or being able to
deliver services from an enhanced home care perspective is some
of the work that we have done in our health system, and we have
seen the ability to treat people at home versus bringing them
into the hospital. So these therapeutics I think have to be
available to be able to be delivered in multiple places.
For example, we believe we can deliver remdesivir in the
patient's home. We're not able to do that right now because of
the restrictions around it. So we have to think innovatively
about how we can deliver care differently to be able to touch
the people wherever they are, and especially in our rural
communities.
The Chair. Thank you.
Senator Rosen. Thank you. I yield back. Sorry, Madam Chair.
The Chair. Thank you very much.
I will turn to Senator Burr.
Senator Burr. Thank you, Senator Murray.
I have one question, and then some comments. And on the
comments, any of you that want to refute what I say, feel free
to do it.
Dr. Jha, some COVID-19 models have started to incorporate
weather patterns into their predictors for the trajectory of
pandemics. Are there other data points or sources of
information that we should be including in our surveillance and
predictive models to provide a better picture of the virus
pathway?
Dr. Jha. Oh, Senator, this is a fabulous question. And let
me say, throughout this entire pandemic, as I have tracked this
pandemic in our Nation, sometimes I look at public health data,
but a large chunk of what I look at is not traditional public
health data at all. I look at Google mobility data. I look at
open-table reservations data, not because I'm trying to get a
restaurant reservation but because it tells us something about
how people are behaving.
We have in the public health world--and this is a broader
societal problem--a not-thought-through how this incredible
proliferation of data that is out there is getting incorporated
and used for public health modeling.
Of course, we need basic laboratory data and all of that,
the standard stuff, but we need a new approach. And it raises a
whole series of questions, Senator, because countries like
China, for instance, use incredible amounts of social-generated
data, but they do it in a way that I think is not consistent
with our values. It's not the way we would want to do it in a
democracy with privacy and security.
We need to find ways--these are policy issues, these are
regulatory issues--where we can access and use these kinds of
data in a way that people feel that their privacy is still
being conserved. We have barely begun to scratch the surface of
this issue.
Senator Burr. Well, I'm delighted to hear you say that
because I think we do have to think outside the box as we talk
about in the future a layered surveillance system, one that
leverages technology, and we've proven in medical research that
you can de-identify data and it can be used and used very
successfully.
A few comments. With the flu every year we flood the zone,
to use a football analogy, as the coach would say. We flood the
zone with vaccines, and we make it as easy as possible, in
large part because we've got unlimited vaccine production. We
never thought about the multi-use manufacturing needs that we
were going to have, and we've got to re-think that, and we've
got to incorporate that into our architecture of the future.
When airlines adopted a mask policy and put HEPA filters in
every airplane, and people started flying with a mandatory mask
and with filtration but no social distancing, we never had an
instance of super-spreader on an airline from the time they
restarted that new system.
I'm not sure why we're so scared on schools. If we've got a
mask and we've got filtration and we've got distancing, which
is the third thing, and the fourth thing is we've got a
population of kids that we have the data that shows they're
less likely to contract, it's just amazing to me that we have
put off so long putting these kids back to school and letting
mothers and fathers go back to work and to resume some normalcy
in their lives.
Three, the vaccine process--I agree with Dr. Jha--we've
made it way too difficult, and I think, Dr. Abraham, you
simplified it where you are. I remember I was in a hospital 1
day that is known for heart bypass surgery. And when they
explained to me what a typical day was like and the first two
operations, they required them to stay inpatient the night
before. My question was why? There's an added expense. And they
made it clear that any missed operation the next day broke
their model of how they reduce cost in health care but make
money at the end of the day.
If you can't assure that your first two people wake up and
show up on time for their pre-op, you've messed up the entire
day of bypass surgery.
Well, any time we have an interruption in the line of
people that are sticking in arms when we've got a limited
number of stickers--Dr. Abraham, I think you alluded to it--we
have missed an opportunity. So we've got to simplify this, as
was said. We've got to make sure that our focus is on sticking
as many arms as we possibly can in a given day with the number
of vaccines that we have, and the system today was not set up
to do it.
We have a limited number of health care professionals that
can do it. This is not new. We identified this in the early
2000's when we started the pandemic legislation with PAHPA and
other things. We identified that we needed a parallel effort to
try to identify a world delivery system, because sticking
people in arms is a very difficult thing in a national and
global picture.
Well, thank God we've had health care professionals that
were retired that have come back to the front lines and
volunteered pro bono to come out and stick people because
they're already trained, and we've got to tap into that supply
even greater.
Either Dr. Jha or Dr. Shah alluded to the fact that we
can't get there if we've got 147 million Americans that aren't
going to be vaccinated because they're under the age of 18. And
I agree totally, as this infection begins to decline, the
pediatric indications that are needed for historical
determination to make safety and efficacy pass the test is
going to be impossible. It will take years, and we really need
to do that population, at least down to an 8-year-old, before
school goes back next year.
I hope that some of the words that you go out and preach
are words that accept the standard that we're going to have to
use technology to close the gap on making those determinations,
which is not the historical model that FDA and others have
used. We're asking Federal agencies, quite frankly, to do
things they haven't done historically, in large measure because
technology gives us the ability to gap that now.
But let me assure all of our witnesses, government is the
last one that will take advantage of it unless it's the medical
community that pushes Congress to make the changes, that pushes
the Federal agencies to make those changes. Partnering with the
private sector is absolutely essential to mapping out the way
to address pandemics of the future, and we are the worst
partner for the private sector, we the government, that exists
in the marketplace. We've got to change that. It can no longer
be that the CDC is in charge of all testing, which is where we
were 1 year ago on March the 9th, and not until we created RadX
over at NIH with Dr. Collins' leadership did they start to
partner with the private sector to bring all sorts of new
testing capabilities both in office and in home, and we're
going to continue to expand on that. But we've got to get
outside of the historical paradigms that exist. Technology,
innovation, and investment are the only way that we will
improve the future, and that's in all aspects of pandemics.
The heroes in this story are the individuals on the front
line. Without them, we'd fail. With them, we have accomplished
something that 12 months ago most people believed we couldn't
do. We've developed three vaccines, and hopefully a fourth very
soon. We have immunized now millions of Americans. And I agree
with the comments that were made, we can't stop looking at
America and saying when are we going to be immunized? Until we
find a way to be the driver of global immunization, then we
will not feel comfortable about where we are.
America needs to open up our schools, we need to open up
our businesses, we need commerce outside of the United States,
and until we find a way to immunize globally, that is not going
to happen at the levels that we've got to get it to. So it's
not just about how do we buy 600 million doses for the United
States which can vaccinate every American. It's how can we use
American assets to leverage manufacturing capabilities, both
here and globally, to where we manufacture cost-effective
vaccines, maybe with U.S. technology, maybe with U.S.
companies, and we leverage the rest of the world to do it.
You'll never get them to do it if we don't display a
willingness to partner between the Federal Government and the
private sector going forward.
Chair Murray, I thank you for this hearing. I thank our
witnesses for their expertise. I'm willing to take any
criticism about my observations from any of you.
The Chair. Well, thank you very much, Ranking Member Burr.
I just have a couple more questions, and I want to again
thank all of our witnesses.
Dr. Jha, if you can just answer me. In December the U.S.
ranked 43rd worldwide in sequencing of coronavirus variants,
which is why I pushed to include $1.75 billion for genomic
sequencing and surveillance activities at the CDC in the
American Rescue Plan. But, Dr. Jha, what do you see as the
biggest challenges ahead in terms of identifying, tracking, and
stopping these emerging variants?
Dr. Jha. Two things, Senator. First, I think your push for
more sequencing was exactly right. It's what we need. I do
believe--look, there's no reason why the U.K. has to be the
global leader in sequencing. We have so much sequencing
capacity in our Country and we just need to be doing a lot more
of it, even a lot more than we have right now.
I remain, as I said in my opening remarks, pretty worried
that we are not taking these variants seriously enough. Within
a year of this disease outbreak, we have seen multiple variants
that challenge our vaccines. None of them will defeat our
vaccines yet. We are on a track for three or four more years
until the world is vaccinated, and the question is how lucky do
we feel that we will not see the rise of a variant that will
make all of our vaccines ineffective.
We need a surveillance program certainly in the United
States that's far more robust. We need a surveillance program
globally that's far more robust. But identifying these variants
isn't enough. We've got to get the world vaccinated, as Senator
Burr said. It is absolutely in our national interest, in our
economic, political, and health interest, to get the entire
world vaccinated as quickly as possible, and we are not on
track to keep the American people safe, but we need to in terms
of getting the whole world vaccinated.
The Chair. Thank you. I'm not for relying on luck myself.
Dr. Abraham, the health care safety net has never been more
important. Millions of people rely on our community health
centers for primary care services. They are really a lifeline
for our families, as you so know, and I was really glad we were
able to secure billions in the American Rescue Plan. That
investment will really help our health centers continue caring
for COVID-19 patients, but we have been solely centered on
COVID-19.
I wanted to ask you, in addition to your work addressing
COVID-19, how have you been able to manage the other primary
care needs of your community throughout this pandemic?
Dr. Abraham. The short answer is it has not been easy. It
has required an all-hands-on-deck approach. Whether you are the
receptionist in our clinic or the medical assistant, every
single person, including the person that wears that business
hat, we've all had to race to help every patient because
despite COVID, our patients still have their needs, their
diabetes, their hypertension, their heart disease, and they
need their refills, and they need access to diagnostics and to
treatments, and we can't delay that because of this pandemic.
That creates a whole other storm.
What we do definitely is we need to have more hands on
deck, more team-based health care delivery. We need more of all
of it, so every dollar that you send from this Act to a
community health center really helps us better care for our
community. It gets more hands hired. It gets more resources,
whether it's getting out into the community, a mobile mammogram
unit, all of those things are required. But they do take
resources, and with more resources we can really do more for
our communities.
The Chair. Thank you, and I think that's one of the things
we have not focused on, that the other cost of this pandemic
has really been all of those other health care needs that we
have not been focused on that have been neglected for a variety
of reasons, including people not going in to get their care,
but also because of the lack of access. So we need to really be
aware of that focus.
I want to thank all of our witnesses today and all of our
colleagues for a really thoughtful discussion. Again, I
especially want to thank Dr. Shah, Dr. Jha, Dr. Fuchs, and Dr.
Abraham for sharing your time and knowledge with all of us and
for the work you are doing on the front lines and for so many
who are working their way through this.
For any Senators who wish to ask additional questions,
questions for the record will be due in 10 business days,
Tuesday, March 23rd at 5 p.m.
This hearing record will also remain open until then for
Members who wish to submit additional materials for the record.
This Committee will next meet on Tuesday, March 15th, in
Dirksen 106 at 10 a.m. for a hearing on the nomination of Julie
Su to be Deputy Secretary of Labor.
The Committee stands adjourned.
ADDITIONAL MATERIAL
Statement from the American College of Physicians
March 9, 2021
The American College of Physicians (ACP) is pleased to submit this
statement and offer our views regarding the response to the public
health emergency (PHE) caused by Coronavirus (COVID-19). We greatly
appreciate that Chair Murray, Ranking Member Burr, and the Health,
Education, Labor, and Pensions (HELP) Committee has convened this
hearing, ``Examining Our COVID-19 Response: An Update from the
Frontlines'', held on March 9, 2021. Thank you for your shared
commitment to ensuring that clinicians have the opportunity to share
their views about the response to the PHE caused by COVID-19. Through
the experiences of its physicians on the frontlines of furnishing
primary care during the COVID-19 pandemic, ACP has consistently
provided input and recommendations to lawmakers surrounding the ongoing
need for personal protective equipment (PPE), increased support for the
frontline physician workforce, adequate funding for COVID-19 testing,
contract tracing, and vaccine distribution, and continued telehealth
expansion. Support for these policies is vital to the pandemic response
effort now after the national PHE comes to an end.
The American College of Physicians is the largest medical specialty
organization and the second-largest physician membership society in the
United States. ACP members include 163,000 internal medicine physicians
(internists), related subspecialists, and medical students. Internal
medicine physicians are specialists who apply scientific knowledge and
clinical expertise to the diagnosis, treatment, and compassionate care
of adults across the spectrum from health to complex illness. Internal
medicine specialists treat many of the patients at greatest risk from
COVID-19, including the elderly and patients with pre-existing
conditions like diabetes, heart disease and asthma.
Personal Protective Equipment
The various coronavirus relief packages, including the recently
enacted American Rescue Plan Act (ARP), H.R. 1319, began and now
continue to provide desperately needed personal protective equipment
(PPE) to frontline physicians, nurses and other health care workers.
The ARP included possible PPE funding in several provisions, including
the use of the Defense Production Act (DPA) for procurement of supplies
and services including PPE. However, ACP members and internists and
other frontline health care workers are still experiencing difficulty
in obtaining some types of PPE. Accordingly, ACP has continued its
financial contributions that will help Project N95 to secure
appropriate inventory levels for PPE, particularly for hard-to-obtain
items such as nitrile gloves.
ACP has partnered with Project N95 since June 2020 to provide PPE
for internal medicine physicians, filling an urgent need for frontline
ACP member physicians during the COVID-19 pandemic. Since the beginning
of the pandemic ACP has been vigorously advocating for the need for
adequate PPE, calling on suppliers and the Federal Government to ensure
the availability of essential PPE to protect frontline physicians. Many
individual physicians, especially those outside of hospitals, had been
closed out of ordering PPE through distributors at reasonable prices
and quantities.
Despite recent reports that U.S. suppliers of N95 respirators have
inventory available, the distribution system in the U.S. is still not
working effectively enough to allow individual physicians to order
high-quality PPE to meet their needs. ACP is continuing to see members
needing to order PPE through our distribution partnership with Project
N95, which is why we continue to provide financial support to Project
N95. The demand crunch has shifted from N95 respirators to nitrile
patient exam gloves, with gloves being the latest example of a product
where the minimum order quantities are so high that only the largest
distributors can easily compete for inventory supplies.
The need still exists for ACP to offer an alternative buying
channel for our members, which we are doing through Project N95, but
the need has declined significantly since last summer. Sales of N95
respirators through ACP declined 50 percent from August to December,
and declined 34 percent from December to January and February. However,
we still have hundreds of members buying through ACP and Project N95.
Support Frontline Physician Workforce
Primary care physicians, including internal medicine specialists,
continue to serve on the frontlines of patient care during this
pandemic with increasing demands placed on them. During the pandemic's
worst months, there was an increasing reliance on medical graduates,
both U.S. and international, to serve on the frontlines in this fight
against COVID-19. Many residents and medical students played a critical
role in responding to the COVID-19 crisis and providing care to
patients on the frontlines. For residents, COVID-19 has inflicted
additional strain on them as they were redeployed from their primary
training programs and put onto the frontlines to care for the sickest
patients, often putting their own health at risk, and many without
appropriate PPE at the time. ACP recommends the following legislation
from the previous, 116th Congress, that should be reintroduced and
passed in the current 117th Congress to assist medical graduates and
the overall physician workforce:
Conrad State 30 and Physician Access Reauthorization
Act, H.R. 2895, S. 948, (116th Congress): This bill allows
states to sponsor foreign-trained physicians to work in
medically underserved areas in exchange for a waiver of the
physicians' two-year foreign residence requirement. It
increases the base number of annual Conrad waivers available to
each state from 30 to 35, with a demand-based sliding scale to
determine the number of available waivers in future years, and
includes a provision to address the current backlog in the
system for physicians on J-1 visas who wish to acquire
permanent residency status (green card).
Healthcare Workforce Resilience Act, H.R. 6788, S.
3599, (116th Congress): This bill would authorize immigrant
visas for health care clinicians, including up to 15,000
physicians who are eligible to practice in the United States or
are already in the country on temporary work visas. The visas
would provide a pathway to employment based green cards. View
ACP's letter of support to Congress for S. 3599 in the 116th
Congress.
The Student Loan Forgiveness for Frontline Health
Workers Act, H.R. 6720, (116th Congress): This bill would
forgive student loans for physicians and other clinicians who
are on the frontlines of providing care to COVID-19 patients or
helping the health care system cope with the COVID-19 public
health emergency.
COVID Testing, Contact Tracing, Treatment and Vaccines
ACP strongly supported several provisions in the American Rescue
Plan (ARP) Act of 2021, H.R. 1319, that directly will help to contain
the COVID-19 pandemic. ACP supported the provisions in the ARP to
provide $49 billion to HHS to detect, diagnose, trace, and monitor
COVID-19 infections, and for other activities necessary to mitigate the
spread of COVID-19. ACP also supported the ARP provisions to require
Medicaid coverage of COVID-19 vaccines and treatment without
beneficiary cost sharing with vaccines matched at a 100 percent Federal
medical assistance percentage (FMAP) through one year after the end of
the PHE. It also gives states the option to provide coverage to the
uninsured for COVID-19 vaccines and treatment without cost sharing at
100 percent FMAP. ACP is pleased that these provisions help cover
vulnerable populations during the PHE caused by COVID-19.
To address current and looming pharmaceutical therapies and vaccine
shortages during a pandemic, ACP recommends that the Federal Government
should work with pharmaceutical companies to ensure that there is an
adequate supply of pharmaceutical therapies and vaccines to protect and
treat the U.S. population. ACP also supports measures to increase
pandemic influenza vaccine and antiviral medications in the Strategic
National Stockpile (SNS) as discussed below to prepare for a future
pandemic. ACP also supports measures to increase domestic production of
vaccines and antiviral medications, including providing liability
protections to decrease barriers to manufacturing while maintaining
protections for individuals injured from the use of vaccines and
antiviral medications.
Accordingly, ACP strongly supported the provisions in the ARP to
provide $7.5 billion in funding for the Centers for Disease Control and
Prevention (CDC) to prepare, promote, administer, monitor, and track
COVID-19 vaccines, and $6 billion to the Department of Health and Human
Services (HHS) to support advanced research, development,
manufacturing, production and purchase of vaccines, therapeutics, and
ancillary medical products utilized for treatment and prevention of
COVID-19. ACP is also appreciative of the $1 billion in the ARP for
vaccine confidence activities to promote education and increase
vaccination rates.
ACP supports requirements that COVID-19 vaccines be provided at no
cost to all patients, regardless of coverage status. ACP supports an
all-hands-on deck approach to administer COVID vaccines, which includes
primary care offices. We urge Congress to work with the administration,
state and local governments, and vaccine distributors to support
physicians who wish to administer the COVID-19 vaccine by ensuring
community-based practices are included in distribution plans. In a
January 2021 survey, 71 percent of medical practices reported being
unable to obtain COVID-19 vaccine for their patients, and independent
medical groups were significantly less likely to have access than those
owned by hospitals or health systems. It is vital that vaccinators
record the vaccine administration data within the patient's medical
record and promptly report to the state's immunization information
system (IIS) or other designated CDC system. Ideally, health IT systems
would automate vaccination data sharing with minimal additional effort
required, including reporting to state IISs and notifying the patient's
primary care team of their vaccination status and other relevant
information.
Continuing Telehealth Expansion
ACP strongly supports the expanded role of telehealth as a method
of health care delivery that may enhance patient-physician
collaborations, improve health outcomes, increase access to care and
members of a patient's health care team, and reduce medical costs when
used as a component of a patient's longitudinal care. Telehealth can be
most efficient and beneficial between a patient and physician with an
established, ongoing relationship and can serve as a reasonable
alternative for patients who lack regular access to relevant medical
expertise in their geographic area. Primary care physicians have had to
convert in-person visits to virtual ones in response to the COVID-19
PHE, and practices are experiencing huge reductions in revenue while
still having to pay rent, meet payroll, and meet other expenses without
patients coming into their practices.
During the Coronavirus pandemic, internal medicine specialists
continue to deliver care to their patients with the expanded
utilization of telehealth made possible by new policies either enacted
by Congress, the U.S. Department of Health and Human Services (HHS), as
well as private payers. However, many of the telehealth flexibilities
and policy changes made by Congress and HHS are due to expire at the
conclusion of the PHE, wherein patients and physician practices would
be expected to revert back to primarily face-to-face services without
any type of risk-based assessment for gradually reopening medical
practices and health systems to care for non-COVID and non-acute
patients. \1\ This quick reversal in policy does not take into account
patients' comfort level in returning to physician offices to seek
necessary care, as well as changes in office workflow and scheduling
practices to mitigate spread of the virus within practices resulting in
substantially lower volume of in-person visits for as long as the
pandemic is with us. Therefore, the quick reversal in policy is not an
effective way to recover from the PHE, nor prepare for possible future
outbreaks.
---------------------------------------------------------------------------
\1\ Doherty R., Erickson S., Smith C., Qaseem A. ``Partial
Resumption of Economic, Health Care and Other Activities While
Mitigating COVID-19 Risk and Expanding System Capacity.'' American
College of Physicians, May 6, 2020: https://www.acponline.org/acp-
policy/policies/acp-guidance-on-resuming-economic-and-social-
activities-2020.pdf.
The College believes that the patient care and revenue
opportunities afforded by telehealth functionality will continue to
play a significant role within the U.S. healthcare system and care
delivery models, even after the PHE is lifted. Please see ACP's
response to the HELP Committee for the Committee's June 17, 2020,
hearing, ``Telehealth: Lessons from the COVID-19 Pandemic'' and more
recently ACP's statement to the House Committee on Energy and
Commerce's March 2, 2021, hearing, ``The Future of Telehealth: How
Covid-19 is Changing the Delivery of Virtual Care''. In order to
address the many barriers to patient access and physician adoption and
use of telehealth prior to the COVID-19 pandemic, and properly assess
how to foster and strengthen longitudinal, patient-centered care
delivery, ACP believes that the following existing PHE flexibilities
and waivers should be continued--and not allowed to expire--to support
making telehealth an ongoing and continued part of medical care now and
in the future, allowing time for further evaluation on which ones
---------------------------------------------------------------------------
should be maintained as is, revised or expanded:
Pay Parity for Audio-Only and Telehealth Services:
The College wholeheartedly supports the Centers for Medicare
and Medicaid Services' (CMS) actions to provide additional
flexibilities for patients and their doctors by providing
payment for telephone services. These changes in payment policy
address some of the biggest issues facing physicians as they
struggle to make up for lost revenue and provide appropriate
care to patients. Primary care services delivered via telephone
have become essential to a sizable portion of Medicare
beneficiaries who lack access to the technology necessary to
conduct video visits. ACP is discouraged to learn that CMS will
not continue coverage of telephone evaluation and management
(E/M) services beyond the PHE, despite mounting evidence about
the effectiveness of expanding coverage for these services.
While ACP has supported the Agency's actions to provide
coverage and payment parity for such telephone services, the
College is very concerned about the impact of reversing these
changes at the conclusion of the PHE. ACP believes that
existing PHE flexibilities and waivers should be continued, and
not be allowed to expire--including pay parity for audio-only
phone calls--to support making telehealth an ongoing and
continued part of medical care now and in the future, allowing
time for further evaluation on which ones should be maintained
as is, revised or expanded. We also urge removal of the
requirement for the use of two-way, audio/video
telecommunications technology so that telephone E/M services
can continue to be provided to Medicare beneficiaries.
COVID-19 Vaccine Counseling: Although most community-
based physician practices are not yet administering COVID-19
vaccinations, many report providing significant counseling and
risk factor reduction services to patients who are concerned
about COVID-19 or who are trying to get vaccinated against the
virus. However, coding and payment has not been made available
to allow physicians to bill for these services. While office
visit E/M visits, telephone E/M, virtual check-ins, and e-
visits have been made available by CMS during the pandemic to
provide for virtual care, these coding options are not
sufficient to meet the current needs. Specifically, the E/M
visits are not available for billing as no diagnoses have been
established to necessitate an E/M visit. Patients are calling
for advice from their doctors, not to set up a visit for a
medical problem/issue they are experiencing. Additionally,
virtual check-ins are an ineligible option as they are for
patients seeking to determine whether an E/M visit is
necessary. In the case of COVID-19 vaccinations, patients are
seeking to understand the risks associated with getting a
COVID-19 vaccine, and where to find a vaccine. These are not
examples of patients checking in with their physician to
understand whether an office visit is necessary. It is merely
for advice and counseling. ACP recommends that Congress urge,
or if necessary, require CMS to make coding and payment
available for time spent by physicians providing counseling
services to patients who are seeking to mitigate their risk for
COVID-19 infection. Specifically, ACP encourages CMS to make
payment and coverage available for CPT code 99401 (Preventive
medicine counseling and/or risk factor reduction
intervention(s) provided to an individual (separate procedure);
approximately 15 minutes), wRVU 0.48. The College believes that
this code adequately describes the resources and physician work
involved in providing counseling and risk factor reduction
services to patients with inquiries about COVID-19. We
encourage CMS to temporarily make payment available for this
code through at least December 31, 2021 and waive the face to
face requirement associated with this service.
Geographical Site Restriction Waivers: ACP strongly
supported CMS' policy changes to pay for services furnished to
Medicare beneficiaries in any healthcare facility and in their
home--allowing services to be provided in patients' homes and
outside rural areas. ACP has long-standing policy in support of
lifting these geographic site restrictions that limit
reimbursement of telehealth services by CMS to those that
originate outside of metropolitan statistical areas or for
patients who live in or receive service in health professional
shortage areas. \2\ While limited access to care is prevalent
in rural communities, it is not an issue specific to rural
communities alone. Underserved patients in urban areas have the
same risks as rural patients if they lack access to in-person
primary or specialty care due to various social determinants of
health such as lack of transportation or paid sick leave, or
sufficient work schedule flexibility to seek in-person care
during the day, among many others. \3\ Accordingly, it is
essential to maintain expanded access to and use of telehealth
services for these communities, as well as rural communities,
and ACP recommends that Congress permanently extend the policy
to waive geographical and originating-site restrictions after
the conclusion of the PHE.
---------------------------------------------------------------------------
\2\ Daniel H, Snyder Sulmasy L. ``Policy Recommendations to Guide
the Use of Telemedicine in Primary Care Settings.'' American College of
Physicians, November 17, 2015: https://www.acpjournals.org/doi/full/
10.7326/M15-0498.
\3\ Webb Hooper M, Napoles AM, Perez-Stable EJ. ``COVID-19 and
Racial/Ethnic Disparities.'' JAMA. Published online May 11, 2020.
doi:10.1001/jama.2020.8598.
Telehealth Cost-Sharing Waivers: ACP appreciated the
flexibility provided by CMS to allow clinicians to reduce or
waive cost-sharing for telehealth and audio-only telephone
visits for the duration of the PHE. At the same time, we call
on CMS or preferably Congress to ensure that they make up the
difference between these waived copays and the Medicare allowed
amount of the service. Many practices are struggling or
closing. It is critical that CMS and other payers not add to
the financial uncertainties already surrounding these
physicians. Given the enormity of the COVID-19 pandemic, cost
should not be a prohibitive factor for patients in attaining
treatment. This critical action has led to increased uptake of
telehealth visits by patients. At the conclusion of the COVID-
19 PHE, ACP recommends that Congress urge, or if necessary
require, CMS to continue to provide flexibility in the Medicare
and Medicaid programs for physician practices to reduce or
waive cost-sharing requirements for telehealth services, while
also making up the difference between these waived copays and
the Medicare allowed amount of the service. This action in
concert with others has the potential to be transformative for
practices while allowing them to innovate and continue to meet
patients where they are. ACP believes that existing
flexibilities and waivers should be continued, and not be
allowed to expire, to support making telehealth an ongoing and
continued part of medical care now and in the future, allowing
time for further evaluation on which ones should be maintained
---------------------------------------------------------------------------
as is, revised or expanded.
Flexibilities in Direct Supervision by Physicians at
Teaching Hospitals: CMS has noted that in instances where
direct supervision is required by physicians and at teaching
hospitals, the agency will allow supervision to be provided
using real-time interactive audio and video technology through
the calendar year 2021. The College welcomes this decision by
the agency to allow attending physicians and residents/fellows
the ability to communicate over interactive systems
asynchronously by waiving the in-person supervision
requirement. This important step promotes efficient patient
care and allows physicians and supervisees to work together
unencumbered by social distancing restrictions. We encourage
Congress to urge, or if necessary require, CMS to maintain
these modifications, and not allow them to expire.
Revised Policies for Remote Patient Monitoring
Services: CMS finalized policy stating that following
expiration of the COVID-19 PHE, there must be an established
patient-physician relationship for RPM services to be
furnished--ending its interim policy permitting RPM services to
be furnished to new patients. The Agency also finalized
policies allowing consent to receive RPM services to be
obtained at the time RPM services are furnished and noted that
practitioners may furnish RPM services to patients with acute
conditions as well as patients with chronic conditions. RPM
services have been a critical component of care, especially
during the COVID-19 pandemic. ACP is pleased to see the Agency
finalized a number of policies that will be beneficial to both
patients and their care teams. These changes expand access to
services at an important time, as patients and their care teams
need additional resources to meet current challenges. These
changes will help relieve physician burden and allow physicians
more time to treat complex patient issues that require more
than remote monitoring. We continue to believe that Congress
should urge, and if necessary, require, CMS to extend the
interim policy to allow RPM services to be furnished to
patients without an established relationship.
Interstate Licensure Flexibility for Telehealth and
Promotion of State-Level Action: ACP supports a streamlined
approach to obtaining several medical licenses that would
facilitate telehealth services across state lines while
allowing states to retain individual licensing and regulatory
authority. \4\ We appreciated CMS' temporary waiver allowing
physicians to provide telehealth services across state lines,
as long as physicians meet specific licensure requirements and
conditions. These waivers offer an opportunity to assess the
benefits and risks to patient care in addressing the pandemic
as well as the ability to maintain longitudinal care for
patients who move across state lines. While these waivers do
not supersede any state or local licensure requirements, they
provide the opportunity to promote state-level action that may
further promote more streamlined licensure requirements across
the country. ACP also supports the Temporary Reciprocity to
Ensure Access to Treatment (TREAT) Act, S. 168, H.R. 708, which
would provide temporary licensing reciprocity for telehealth
and interstate health care treatment.
---------------------------------------------------------------------------
\4\ Daniel H, Snyder Sulmasy L. ``Policy Recommendations to Guide
the Use of Telemedicine in Primary Care Settings.'' American College of
Physicians, November 17, 2015: https://www.acpjournals.org/doi/full/
10.7326/M15-0498.
---------------------------------------------------------------------------
Conclusion
We commend you and your colleagues for working in a bipartisan
fashion to develop legislative proposals to combat the ongoing
Coronavirus crisis--as well as future pandemics--through continuing
innovative policies. We wish to assist in the HELP Committee's efforts
in this area by offering our input and suggestions about ways that
Congress and Federal health departments and agencies can intervene
through evidence-based policies both now and beyond the PHE. Thank you
for consideration of our recommendations that are offered in the spirit
of providing the necessary support to physicians and their patients
going forward. Please contact Jared Frost, Senior Associate,
Legislative Affairs, with any further questions or if you need
additional information.
______
American Academy of Family Physicians
March 9, 2021
Hon. Patty Murray, Madam Chair,
Hon. Richard Burr, Ranking Member,
Senate Committee on Health, Education, Labor, and Pensions,
428 Dirksen Senate Office Building,
Washington, DC.
Dear Madam Chair Murray and Ranking Member Burr:
On behalf of the American Academy of Family Physicians (AAFP) and
the 136,700 family physicians and medical students we represent, I
applaud the Health, Education, Labor, and Pensions Committee for its
continued focus on COVID-19 response. I write in response to the
hearing: ``Examining Our COVID-19 Response: An Update from the
Frontlines'' to share the family physician perspective and the AAFP's
policy recommendations for ensuring that our health care system can
make a complete recovery from the ongoing COVID-19 pandemic.
Family physicians are on the frontlines of the COVID-19 pandemic
screening, diagnosing, triaging and treating patients who are fighting
the virus while continuing to provide comprehensive care to their
patients with ongoing health care needs, including management of
chronic conditions. They are keeping patients healthy and keeping them
out of the hospital and emergency room while many of them have also
provided surge staffing when hospitals have been overwhelmed. The COVID
relief legislation that the Senate passed last week placed a heavy
emphasis on testing, treatment and vaccines to control COVID-19--
primary care is the gateway to all three.
COVID-19 has highlighted the inefficiencies and inequities that
already existed in our health care system. As the pandemic continues,
individuals are struggling more than ever to access the essential
primary health care services they need to stay healthy. Family
physicians are committed to doing everything possible to prevent and
slow the spread of COVID-19 while ensuring that patients get the care
they need. However, they can't do it alone; there are specific actions
that the Federal Government should take now to support access to and
coverage for COVID-19 treatment and prevention.
Recommendations
Equitable Vaccine Distribution--According to a recent
survey, nearly nine in ten primary care clinicians want their
practice to be a COVID-19 vaccination site, only 22 percent are
considered as such by their health department, local hospital,
or health system. \1\ Additionally, independent practices have
had a more difficult time obtaining COVID-19 vaccines for their
patients than those affiliated with a hospital or large health
system. \2\ It is frustrating that primary care has been
overlooked as an outlet for equitable vaccine distribution even
though it is equipped to target those most vulnerable and in
need.
---------------------------------------------------------------------------
\1\ Larry A. Green Center. ``Quick COVID-19 Primary Care Survey.''
Series 26 Fielded February 12-16, 2021. https://
static1.squarespace.com/static/5d7ff8184cf0e01e4566cb02/t/
60368efc6f135d069645fa93/1614188285446/
C19+Series+26+National+Executive+Summary.pdf.
\2\ Medical Group Management Association. https://www.mgma.com/
news-insights/press/nation%E2%80%99s-physician-practicesleft-out-of-
covid-19?utm-source=ga-organic-st-01.26.21&utm-medium=social&utm-
campaign=ga-vaccine-press-release.
While we do not believe legislation is needed to address this
problem, we call on Congress to support Federal, state, and local
efforts to prioritize primary care practices in COVID-19 vaccine
---------------------------------------------------------------------------
distribution.
Disparities in Vaccination Rates--Data indicate that
Black and Hispanic adults under 50, as well as rural residents,
are more likely to report vaccine hesitancy or indicate that
they will not get the COVID-19 vaccine. \3\ However, 85 percent
of individuals across demographic groups report that their
primary care physician or other clinician is the most trusted
source of information about COVID-19 vaccines and they will
rely on them when deciding whether to get the vaccine. \4\, \5\
As trusted members of their communities and the primary source
of comprehensive health services in rural and under resourced
areas, community primary care physicians play an integral role
in ensuring equitable vaccination rates across the state.
According to data from the Medical Expenditure Panel Survey,
primary care physicians provided 54 percent of all clinical
visits for vaccinations, which made them more likely to
administer vaccines than other stakeholders, such as pharmacies
or grocery stores. \6\ As Congress considers policies to reduce
the disparities in COVID-19 vaccine uptake, including investing
in a national vaccine promotion campaign, it is important to
recognize the role of primary care physicians in combating
vaccine hesitancy.
---------------------------------------------------------------------------
\3\ Kaiser Family Foundation. KFF COVID-19 Vaccine Monitor.
February 2021. Available at: https://www.kff.org/coronavirus-covid-19/
poll-finding/kff-covid-19-vaccine-monitor-february-2021/.
\4\ Kaiser Family Foundation. KFF COVID-19 Vaccine Monitor.
December 2020. Available at: https://www.kff.org/coronavirus-covid-19/
report/kff-covid-19-vaccine-monitor-december-2020/.
\5\ Kaiser Family Foundation. KFF COVID-19 Vaccine Monitor.
January 2021. Available at: https://www.kff.org/report-section/kff-
covid-19-vaccine-monitor-january-2021-vaccine-hesitancy/.
\6\ Analysis conducted by the Robert Graham Center. Publication
forthcoming.
Telehealth--Family physicians have rapidly changed
the way they practice to meet the needs of their patients
during the COVID-19 pandemic. About 70 percent report that they
want to continue providing more telehealth services in the
future. Telehealth can enhance patient-physician collaboration,
increase access to care, improve health outcomes by enabling
timely care interventions, and decrease costs when utilized as
a component of, and coordinated with, continuous care. Given
these benefits, patients and physicians alike have indicated
that current telehealth flexibilities should continue beyond
the public health emergency. Congress should act to extend
Medicare telehealth flexibilities and ensure telehealth is
permanently recognized across payers as a valuable modality of
providing primary care services beyond the public health
---------------------------------------------------------------------------
emergency.
Primary Care Workforce--COVID-19 has both highlighted
and exacerbated the physician workforce shortages facing
communities throughout the Nation. It has demonstrated the
urgency of building and financing a robust, well-trained, and
accessible primary care system in our Country. According to the
American Association of Medical Colleges, we will need 52,000
additional primary care physicians by 2025 in order to meet the
health care needs of our growing and aging population and be
prepared to respond to future crises. \7\ Congress should
address the primary care physician shortage by increasing
investments in the Teaching Health Center Graduate Medical
Education (THCGME) program and the National Health Service
Corps, which train and place primary care physicians in
underserved and rural communities.
---------------------------------------------------------------------------
\7\ Petterson, S. M., Liaw, W. R., Phillips, R. L., Jr, Rabin, D.
L., Meyers, D. S., & Bazemore, A. W. (2012). Projecting US primary care
physician workforce needs: 2010-2025. Annals of family medicine, 10(6),
503-509. https://doi.org/10.1370/afm.1431
Mental Health of Physicians--Even prior to the
pandemic, burnout among health providers was a pervasive public
health concern, with some studies reporting burnout in more
than 50 percent of clinicians. According to the American Board
of Family Medicine, primary care physicians have experienced
the highest rate of death (26.9 percent) among health provider
specialties during COVID-19. \8\ Physician burn out during the
COVID-19 pandemic has become worse, negatively impacting
happiness, relationships, career satisfaction, and patient
care. A January 2021 report showed that 47 percent of family
physicians are burnt out, and 20 percent of all physicians are
clinically depressed. \9\ Congress should invest in the mental
health needs of our Nation's doctors, particularly during the
pandemic, and fight the stigma around seeking necessary
treatment by passing the Dr. Lorna Breen Health Care Provider
Protection Act.
---------------------------------------------------------------------------
\8\ Gouda D, Singh PM, Gouda P, Goudra B. An Overview of Health
Care Worker Reported Deaths During the COVID-19 Pandemic. J Am Board
Fam Med. 2021 Feb;34(Suppl):S244-S246. doi: 10.3122/
jabfm.2021.S1.200248. PMID: 33622846.
\9\ Kane, L. (2021, January 22). `Death by 1000 CUTS': Medscape
National Physician Burnout and Suicide Report 2021. Retrieved March 05,
2021, from https://www.medscape.com/slideshow/2021-lifestyle-burnout-
6013456?faf=1#28.
Personal Protective Equipment (PPE)--Access to PPE
has been a continual challenge for primary care providers
during the pandemic. Survey data shows that 1 in 3 primary care
practices are consistently having trouble getting PPE. \10\
Family physicians are on the front lines screening, testing,
and treating patients for COVID-19 in outpatient and inpatient
settings, often at great personal risk. It is imperative during
public health emergencies that health care workers have
adequate protection to decrease personal harm and the spread of
disease. Congress should increase PPE production and stabilize
the supply chain by passing legislation, such as the Protect
our Heroes Act of 2020 and ensure that community-based primary
care physicians are not excluded from PPE distributions from
the Strategic National Stockpile.
---------------------------------------------------------------------------
\10\ Larry A. Green Center. ``Quick COVID-19 Primary Care
Survey.'' Series 20 Fielded September 4-8, 2020. https://
static1.squarespace.com/static/5d7ff8184cf0e01e4566cb02/t/
5f6510dc99d76d706832ba29/1600458973290/
C19+Series+20+National+Executive+Summary.pdf.
Inadequate Reimbursement for Testing--Some primary
care physicians report that payment rates for COVID-19 testing
have dropped so significantly that they do not cover the cost
of the COVID-19 testing supplies, and therefore jeopardizing
access to a tool that is crucial to stopping the spread of
COVID-19. \11\ With new variants of coronavirus emerging,
testing will be especially important. Congress should address
the inadequate reimbursement by clarifying that public and
private payers must reimburse the complete cost of a COVID
test.
---------------------------------------------------------------------------
\11\ Kliff, S. (2021, February 03). Burned by Low Reimbursements,
some doctors stop testing for COVID. Retrieved March 08, 2021, from
https://www.nytimes.com/2021/02/03/upshot/covid-testing-children-
pediatricians.html.
Medicaid Parity--Recent data show that Medicaid
enrollment has increased by more than 6 million since the start
of the COVID-19 pandemic, and trends suggest that enrollment
will continue to increase a result of pandemic-related job
losses. \12\ The demand for primary care physicians in the
Medicaid program is more acute than ever. Inadequate Medicaid
payment threatens access to primary care services in areas
hardest hit by COVID-19, and without proper support during this
public health emergency and beyond, family physician practices
could be forced to close. Congress should ensure Medicaid
beneficiaries have timely access to primary care by raising
Medicaid payments to at least Medicare payment levels.
---------------------------------------------------------------------------
\12\ Corallo, B., Rudowitz, R. (2021, January 21). Analysis of
recent national trends in Medicaid and CHIP Enrollment. Retrieved March
5, 2021, from https://www.kff.org/coronavirus-covid-19/issue-brief/
analysis-of-recent-national-trends-in-Medicaid-and-chip-enrollment/.
We thank you for your leadership and actions to date to help our
Nation combat COVID-19. The AAFP stands ready to partner with you on
additional legislation to recover from the pandemic and improve our
public health preparedness. Should you have any questions, please
contact Erica Cischke, Senior Manager of Legislative and Regulatory
---------------------------------------------------------------------------
Affairs or John Aguilar, Manager of Legislative Affairs.
Sincerely,
Gary L. LeRoy
MD, FAAFP
Board Chair
American Academy of Family Physicians
______
[Whereupon, at 12:14 p.m., the hearing was adjourned.]