Public Health and Covid-19

Background

The COVID-19 pandemic is a public health crisis of proportions and complexity not seen in over a century. The highly contagious and dangerous virus has caused hundreds of thousands of deaths in the U.S. and millions worldwide. The COVID-19 pandemic has created dual crises in health and economic security, and it has also profoundly affected other aspects of Americans’ lives, for example, the ability to vote safely.

The COVID-19 health crisis

COVID-19 has profoundly negatively affected the health of Americans, particularly older adults. Research has shown that adults age 60 and older, especially those with preexisting medical conditions, are more likely to have severe—even deadly—infections than other age groups. According to the Centers for Disease Control and Prevention, eight out of ten COVID-related deaths have been among those age 65 and older. Much of this is due to systemic challenges in the provision of long-term services and supports and health care.

Long-term care (LTC) settings: COVID-19-related mortality has been especially high among those living in the nation’s LTC facilities. Data show that 2.1 million Americans, or 0.62 percent of the U.S. population, reside in nursing homes and assisted living facilities. Nevertheless, those residents have accounted for nearly 40 percent of all U.S. deaths due to COVID-19.

LTC facilities should held accountable for any failures to ensure the health, safety, and quality of life of residents (see also Quality, Consumer Rights, and Emergency Preparedness in all Long-Term Services and Supports Settings). If they haven’t yet, these facilities should put in place measures to minimize disease transmission through the use of personal protective equipment, physical distancing requirements, and regular testing of residents, staff, and visitors. Families need greater transparency about COVID-19 cases within the facility and about treatment and discharge decisions. Care facilities must be held accountable when residents are harmed, neglected, or abused.

Social isolation and loneliness are significant problems that contribute to worse health outcomes for older adults under normal circumstances (see also Social Isolation). The pandemic has exacerbated these challenges. As such, outreach efforts to break isolation for older adults are important, particularly for older adults who live in long-term care settings During periods of required physical distancing and stay-at-home orders brought on by COVID-19, social isolation and loneliness became new or worsening problems among  many older adults. This perhaps was the worst for those living in nursing homes, which became, in many cases, completely closed to outsiders. Many experts believe that extensive social isolation in locked-down nursing facilities has contributed to worsening dementia, overall declining health, and increased deaths. This has made planning how and when to reopen to visitors particularly difficult, as facilities must balance different types of risk. They need to combat  social isolation while maintaining the safety of the facility during a pandemic.

Some LTC facilities are attempting to combine best practices for infection control with vigorous support of virtual visitation options like video visits and telehealth options (see also Long-term Services and Supports). This, of course, requires staff who know how to use and clean tablets and other tools, and who are trained in how to facilitate engagement between residents and would-be visitors. In the community, older adults who are isolating or keeping physical distance from others can also use virtual visits. However, to do so, they must  have knowledge, ability, tools, and infrastructure.

Health care utilization: COVID-19 has had enormous impacts on the U.S. health system as a whole. Providers have had to focus on treating those with the virus. Further, some people have forgone medical care to avoid risk of exposure to the virus. The resulting decrease in utilization as well as the supply of health services has caused worsening health outcomes for those with chronic or other conditions. This means an overall weakening of the health system, lack of trust in the quality of services available, and increases in all causes of mortality, not just limited to COVID-19.

Telehealth services: Digital access to health care via telehealth has become increasingly important as people continue to try to minimize their exposure to possible infection by avoiding in-person encounters. High-speed internet access enables connection to telehealth services. It allows people to interact with their health care team safely from home, improving accessibility and, some argue,  potentially quality of care as well. It can also enable individuals to remain safely in the community (see also High-Speed Internet Services). As access to telehealth is expanded, it is important to collect data on its use, cost, and quality. It is also important to recognize and address that some people do not have the internet access necessary to engage in telehealth. Congress enacted an Emergency Broadband Benefit to improve the affordability of high-speed internet service during the pandemic, but some households, particularly those in rural areas, do not have the infrastructure necessary to get broadband service. Others may not have the necessary technology (e.g., a tablet, smartphone, or computer) or sufficient ability and comfort in using the technology. Even if they have the necessary technology, they may require assistance to use it.

Vaccine distribution challenges: The weakening of the overall health system also has had impacts on the access to and distribution of COVID-19 vaccines. The system faces many challenges in ensuring that the authorized COVID-19 vaccinations are distributed quickly and equitably. The federal government is responsible for overseeing vaccine allocation to the states and assisting in the distribution. States are responsible for funding and organizing the distribution of vaccine doses to providers and creating public service messaging about the vaccine and how to obtain it. All parts of the process have faced challenges, which slowed initial access to the vaccines.

Crisis standards of care: In 2020, the COVID-19 pandemic caused critical shortages of medical supplies and care. Under circumstances like these, doctors and hospitals are forced to decide who gets potentially lifesaving treatment and who does not.

The COVID-19 pandemic revealed the critical role and responsibility policymakers have to plan and implement strategies to do everything possible to avoid the emergence of shortages when there are severe outbreaks of highly contagious diseases such as COVID-19.

Some organizations, states, and federal agencies have developed resources and guides for hospitals and systems to address these challenges. Federal health agencies, including the Department of Veterans Affairs and Department of Health and Human Services, have also published guidance that includes approaches for allocation of scarce resources during a pandemic.

These guidelines typically employ a utilitarian approach. They seek to maximize overall health by directing care toward those most likely to receive the greatest benefit from it. If a hospital had only one ventilator, for example, it would go to the patient who is more likely to survive. It would not go to whichever patient was first admitted, and it would not be assigned via a lottery system. The guidelines also often prioritize the health of front-line health care workers to maximize the number of lives saved.

The process for developing guidelines for these profoundly difficult decisions requires a thorough ethical, clinical, and legal analysis. The process should be transparent and include genuine public outreach, education, and engagement in order to establish public trust. It is equally critical that the guidelines include protection for groups that often face discrimination including older persons, persons with disabilities, those with lower incomes, the uninsured, and other historically disadvantaged racial and ethnic groups. There are already racial, ethnic, and socioeconomic disparities in care. Therefore these protections are essential in ensuring no group is disproportionately harmed by these policies and guidelines. Transparency is important in the logic, reasoning, and analysis behind the guidelines. Finally, the guidelines should be updated and revised in line with advances in clinical knowledge and changes in societal norms. Feedback from clinicians and the public is also essential.

The Office for Civil Rights at the Department of Health and Human Services, which enforces several anti-discrimination laws in health care facilities that receive federal funding, issued a bulletin emphasizing the need for protection against discrimination for certain groups. This included older adults and those with disabilities. Specifically, it said medical care should not be denied based on stereotypes, assessments of quality of life, or judgments about a person’s relative “worth” due to age or the presence or absence of disabilities.

The COVID-19 Economic Crisis

In addition to the profound loss of human life, COVID-19 has engendered an economic crisis that has disproportionately affected people with low incomes and people of color. This disruption continues to significantly affect the U.S. economy. It also threatens to destabilize the world’s interdependent economy in ways never seen before.

The full impact of the crisis on the economy and how long it will last remain unclear. Public health measures required to slow the spread of COVID-19 (physical distancing, stay-at-home orders, and the like) have contributed to widespread unemployment. Job losses have hit older workers particularly hard. Unemployment in the U.S. has risen to levels not seen since the Great Depression. And the security of retirement savings has been threatened by the volatility in the stock market (see also Employment).

Unemployment insurance and other benefits: Currently, only one-third of people out of a job receive unemployment insurance. Benefit calculation formulas leave many people with only a small fraction of their previous earnings. Households with low incomes and low wealth have been especially hard-hit by the pandemic. In addition, essential workers who are unable to work from home face heightened risk for contracting COVID-19. At the beginning of the pandemic, Congress put in place enhanced unemployment benefits that substantially increased the benefits displaced workers could receive. These measures also extended unemployment benefits to independent contractors and others who previously did not qualify for unemployment. However, that program has now ended. Displaced workers are attempting to access the unemployment insurance system as well as training and job counseling programs to tide them over during periods of unemployment. Paid sick leave, family leave, and flexible work arrangements have become more important than ever (see also Job-Protected Leave). With the economic downturn, food insecurity has increased, especially among Black and Hispanic/Latino older adults (see also Food and Nutrition Assistance Programs). Widespread job loss is likely one of the largest reasons for this increase. Strengthening the nutrition safety net is critical to meet the rising need.

Worker safety: The pandemic has also called attention to worker safety (see also Protections for Workers). As many as 20 million adults age 55 and older have jobs that require them to leave home. This puts them at risk of exposure to the virus. There are currently no solid guidelines or requirements for employers to provide access to personal protective equipment, implement sanitation strategies to prevent disease spread, facilitate physical distancing, or accommodate remote work where possible.

Housing: The deep recession that followed the pandemic has made it difficult for many renters and homeowners to pay for housing. Given the rise in unemployment, many people in the U.S. are experiencing severe financial distress and have lost or are at risk of losing their housing. Housing stability during major emergencies or crises, such as pandemics or other public health emergencies, natural disasters, and severe economic downturns, has come to the fore (see also Home Mortgage Lending). Many people, especially older adults, find themselves in need of financial assistance to help pay for their housing cost, protection against eviction and foreclosure during the crisis, and a reasonable repayment period once the crisis has ended (see also Home Mortgage Lending and Housing for displaced residents).

Student loans: Likewise, many student loan borrowers have had difficulty repaying their student debt. During the pandemic, Congress and the U.S. Department of Education provided relief for borrowers of student loans owned by the federal government (see also Student Loans). Relief included automatically deferring payments, waiving interest accrual, and suspending collections. But those who have privately-held student loans have not enjoyed the same relief.

Credit scores: Likewise, throughout the pandemic many people have been at risk of severe damage to their credit because they have been unable to pay all their bills. One proposed solution has been to restrict or suspend negative credit reporting during major crises for all borrowers when credit may be weakened through no fault of the consumer (see also Consumer Credit). Many are also in need of easy access to credit reporting so that they can monitor changes in their credit rating and take action as needed.

Price-gouging and product-hoarding: At the start of the COVID-19 pandemic, some sellers attempted to profit from the scarcity of essential services and products such as masks and hand sanitizer. This has happened in other declared emergencies, such as natural disasters (see also Price-Gouging and Product-Hoarding).

Other impacts of the COVID-19 pandemic:

Along with impacts on health and the larger economy, COVID-19 has also severely impacted the everyday rights and protections that older adults benefit from daily.

Civic rights and voting: The primaries and general election held in 2019 and 2020 demonstrated that many voters would like options for voting that are not in person and will take advantage of such options when they are provided (see also Voting). Absentee and mail-in voting for that election cycle accounted for just over half of all votes cast in the 37 states and the District of Columbia for which data are available. That is double the number of votes cast that way from each of the previous two election cycles.[1] Voting access and safety issues during the COVID-19 pandemic were especially important for older adults, particularly those from historically disadvantaged groups who were disproportionately affected by the virus. About 46 percent of voters used alternative methods that did not require them to appear in person to cast their ballots for the 2020 general election. Many cited the COVID-19 pandemic as the cause.[2] These elections highlighted the vital importance of supporting the ability of all Americans to exercise their right to vote, including during public health crises, natural disasters, and other emergencies.

Assistance during emergencies: COVID-19 has also once again demonstrated the importance of disaster planning at every level of government. It is particularly important that the needs of older adults, people with disabilities, and caregivers are addressed in the disaster planning process (see also Disaster Planning and Recovery). Older adults and others who have trouble navigating systems are often left behind in emergencies. Clear directions to the public about where to access services and assistance are critical during such times.

Travel: The safety and reliability of public transportation systems during public health crises such as the COVID-19 pandemic have become an issue of great concern (see also Community Transportation). Many essential workers, those who cannot work from home, or others who have no other means of transport continue to rely on public transportation to get to work. They need to feel safe doing so. Travel more broadly has also become dangerous given COVID-19. The need to ensure the safety of various forms of travel has been heightened. For many older adults, travel is important as a way to encounter new experiences, visit with friends and family, and obtain necessary medical care (see also Travel Protections). Additionally, many people have had to cancel travel plans due to the pandemic, increasing the need for consumer protections regarding refunds or vouchers for missed or canceled plans.

 

[1] https://www.pewresearch.org/fact-tank/2020/10/13/mail-in-voting-became-much-more-common-in-2020-primaries-as-covid-19-spread/

[2] https://www.pewresearch.org/politics/2020/11/20/the-voting-experience-in-2020/

PUBLIC HEALTH AND COVID-19: Policy

PUBLIC HEALTH AND COVID-19: Policy

Crisis standards of care

Policymakers and health care administrators must conduct adequate emergency preparedness planning to avoid scarcity of medical equipment, supplies, and personnel that result in the need to make determinations of who gets care and who does not.

They should also develop guidelines for the allocation of scarce resources. The process should be transparent and include broad input and genuine public outreach, education, and engagement in order to establish public trust.

If policymakers design guidelines for the allocation of scarce health resources in times of emergency, the guidelines must be transparent. These guidelines must not discriminate against older adults, people with disabilities, people with lower incomes, the uninsured, and individuals from other historically disadvantaged groups.

Decisions concerning whether an individual is a candidate for treatment must not be based on age, race, disability, income, or other nonclinical factors, but on an individualized clinical assessment of the patient and their circumstances using the best available objective medical evidence.

Coordinated emergency and crisis planning

Policymakers should collaborate to identify, develop, fund, and implement timely, effective response plans for national, state, and local public health crises. These plans should be designed to adequately protect the health and welfare of vulnerable populations such as older adults and people with disabilities during a public health crisis (see also Disaster Planning and Recovery).

Governments should develop strategies designed to meet the health care needs of people affected by declared emergencies. Such strategies should, at a minimum, finance health care for the uninsured for a reasonable period of time. They should ensure the availability and accessibility of needed services and equipment.

Policymakers should create and implement a national response plan for national public health emergencies. The plan should include acquiring and distributing necessary equipment and supplies. Federal and state governments should work cooperatively to address the emergency and avoid unnecessary competition for goods (see also Price-Gouging and Product-Hoarding).

Communicable diseases

Health care providers and individuals should be educated about behavioral risk factors for contracting and spreading serious communicable diseases. These include diseases such as tuberculosis, hepatitis, HIV/AIDS, and COVID-19. Health providers should recognize the importance of taking sexual histories and discussing HIV/STD prevention with patients age 50 and older. Programs should teach all individuals who know or have reason to believe that they may be infected to protect others from infection. They should advise those whom they know to be at risk to seek testing. The outcome of such tests must be confidential, consistent with public health responsibilities, and subject to the requirements of confidentiality standards.

Health care providers, businesses, schools, organizations, and individuals should ensure that they are educated about behavioral risk factors for contracting and spreading serious communicable diseases.

Vaccines

All levels of government should:

  • direct sufficient financial and technological resources toward the timely development and manufacture of safe, effective, and affordable vaccines;
  • during vaccine shortages, federal and state governments should develop transparent, nondiscriminatory, evidence-based guidelines for vaccine allocation that maximize overall public health and protect those at highest risk of harm;
  • provide funding to ensure that key public- and private-sector health care personnel are adequately prepared to respond to public health crises relevant to their areas of practice.
  • federal and state governments should adopt policies that ensure that vaccines have appropriate clinical evidence of safety and efficacy, are allocated equitably, and are widely available; and
  • public officials and other stakeholders should employ targeted, evidence-based outreach strategies to build public trust and help individuals make informed decisions about FDA-approved vaccines.

During vaccine shortages, federal and state governments should not adopt policies that allocate vaccines solely on the basis of age.