Living in a Covid‐19 World

To say that we live in uncertain times would be a gross understatement. As the June 2020 issue of the Quarterly goes to press, the United States is reeling from the one-two punch of the lethal COVID-19 pandemic and its shock to the economy, the likes of which we have not seen, respectively, since the 1918-1919 influenza pandemic and the Great Depression of the 1930s. Either calamity alone would be devastating, but together they appear almost apocalyptic. Just five months ago, few could have imagined the magnitude of the tragic loss of life and the crippling economic effects wrought by the pandemic. Since then, nation after nation has struggled to control the rapid spread of the virus and its consequences. Some (e.g., China, South Korea, Germany) have fared better than others (e.g., Italy, Spain, France), owing in large part to the speed with which civic leaders responded to the crisis. The United States unfortunately failed to take prompt action despite adequate warning of the imminent danger.1, 2 The price for this indecision and delay is that COVID-related deaths are rapidly approaching 100,000,3, 4 and unemployment figures have already exceeded 36 million.5, 6 Compounding the problem has been the federal government's insistence on ignoring sound scientific evidence, choosing instead to engage in combative political discourse, finger pointing, and irresponsible advocacy of unproven cures.7-9 If not for exemplary leadership at state and local levels of government from a bipartisan group of governors and mayors, the death toll likely would be far greater and the economic damage more severe.10 It is unclear how long the COVID-19 pandemic will persist and how far-reaching its effects will be. One thing is certain, though: the epidemic has exposed glaring weaknesses in our nation's health care system, not only its inadequacy to respond to emerging public health threats but also its inability to deliver health care effectively and equitably to all citizens. These inconvenient truths have long existed, but the current crisis has deepened the political divide and led to a tug of war between politicians and scientists over control of the narrative. Misinformation abounds regarding the virus, its origins, preventive measures to contain it, and the prospects for cures and vaccines. Equally damaging is the false dichotomy that permeates the public debate over whether it is more important to restore the economy or mitigate the pandemic. The enormous political and economic pressure to “re-open” the country to commerce and “normal” activity has caused virtually all states to relax “stay-at-home” orders and other restrictions intended to control the virus’ spread.11 However, public health experts remain concerned that these activities may generate new surges in the numbers of confirmed cases, hospitalizations, and deaths. There is no denying that we now live in a COVID-19 world—one fraught with constant uncertainty about personal safety as well as our collective health and economic well-being. Those affected the most by the pandemic—low-income individuals and communities of color—also are the most disadvantaged by poverty and other social determinants of health.12 As we begin to chart a path toward recovery, we need to recognize the interconnection between health equity and economic security. Economic recovery in the absence of an equitable health care system will only perpetuate longstanding historical injustices. However, a reformed health care system that truly embraces and pursues equity in health outcomes will serve the needs of all Americans and instill hope in the future. This transformation will take time, effort, and resources, and it will test the patience and resolve of many as they adapt to living in a COVID-19 world. What, then, might this journal do in the present situation? Throughout its history, the Milbank Memorial Fund has been dedicated to connecting leaders with the best available evidence and experience. In that same spirit, the Quarterly has been committed to applying the best empirical research to practical policymaking regarding population health. We intend to pursue that goal in the current crisis, publishing original research and insightful perspectives that advance knowledge in the field and serve the public interest. This month, we will announce a call for papers regarding policies and practices as they relate to the COVID-19 pandemic, with an eye toward improving future decision-making and avoiding the mistakes and pitfalls of the recent past. Stay tuned—details to follow. This issue of the Quarterly contains a mix of articles, some targeted to the COVID-19 pandemic and others spanning our ongoing areas of editorial interest. In “Detailing the Primary Care Imperative”—the third installment in our Milbank Classics series—James Perrin celebrates the enduring wisdom of Barbara Starfield, Leiyu Shi, and James Macinko in their 2005 landmark article, “Contribution of Primary Care to Health Systems and Health.” Perrin emphasizes the important characteristics of primary care—first contact care, holistic person-focused care over time, comprehensive care, and coordinated care—that emerged from this work and have become ingrained within primary care medical homes across the nation. He critically examines the progress made by the United States in the years since the 2005 publication, citing notable improvements but also pointing out the lingering weaknesses and obstacles to fulfillment of Starfield's original vision for primary care. In two complementary Milbank Quarterly Perspectives, Nason Maani and Sandro Galea explore the long-term negative effects of the United States’ failure to invest in the nation's infrastructure to address both population health and public health. In “COVID-19 and Underinvestment in the Health of the US Population,” they identify the underlying conditions of the US population that have made Americans particularly susceptible to the spread of the virus, including inequitable socioeconomic conditions, long-entrenched racial and ethnic divides, poor treatment of marginalized populations, and a mismatch between health care needs and access to care. In “COVID-19 and Underinvestment in the Public Health Infrastructure of the United States,” the authors examine trends in public health funding, noting the chronic underfunding of state public health departments and reductions in federal funding of public health in favor of commitments to build hospital infrastructure and support biomedical research. These trends, they assert, have hampered the nation's ability to respond appropriately to the COVID-19 crisis. To counter these problems, they call for a sustained federal commitment for a centrally coordinated and accountable public health infrastructure coupled with acknowledgment by policymakers that social determinants are the foundational causes of health and that the health of all citizens is a public good that can lead to economic security. As states look for novel ways to provide affordable health insurance to their citizens, several are implementing initiatives that test the concept of a “public option” to compete with private insurance within the Affordable Care Act marketplaces. In a new Milbank Quarterly Perspective, Michael Sparer evaluates reform efforts in two states: Washington state, which enacted a “public option,” and New Mexico, which failed in its effort to enact a Medicaid buy-in. Sparer compares the two approaches, finding that federal funding remains central to expanded coverage and that the line between the ACA public expansion and the commercial marketplaces has become blurred, posing significant challenges to state policymakers. He contends that Washington state's initiative will be important to follow as a redefined “public option” that potentially might serve as a politically viable model for health reform. The 2020 Democratic presidential election campaign stirred contentious debate over potential health reform—pitting single payer Medicare for All plans against incremental changes to the Affordable Care Act. With Joe Biden as the presumptive Democratic nominee, the likely path for Democrats will be modest and incremental. In a new Milbank Quarterly Perspective, Tsung-Mei Cheng draws upon the work of her late husband and health policy collaborator, Uwe Reinhardt, with particular attention to possible lessons for the United States from Germany's all-payer health care system. The Perspective is a tribute to the legacy of Reinhardt, who for more than four decades illuminated the fields of health economics and health policy with his penetrating insight and witty commentary that always offered object lessons for policymakers and researchers alike. In a sweeping review, Cheng defines all-payer systems and their advantages, compares health care spending in the United States with that in several other nations, provides a detailed description of Germany's all-payer system, and concludes with lessons for the United States. Both she and Reinhardt believe that Germany's system could serve as a model to help bend the cost growth curve and expand coverage, while also creating a kinder health care system for all Americans. In an original research article, that also is the subject of a Milbank Quarterly in Conversation podcast this month (see https://www.milbank.org/quarterly/milbank-quarterly-podcast/), Emilie Courtin and colleagues address the question of “Can Social Policies Improve Health? A Systematic Review and Meta-Analysis of 38 Randomized Trials.” Their comprehensive review and meta-analysis of these experiments in the United States find suggestive evidence of health benefits associated with investments in early life, income support, and health insurance policies. However, many of the studies are underpowered to detect health impacts and are at risk of bias. They recommend that future social policy experiments be better designed to measure and evaluate health outcomes. How to prioritize interventions with intertwined threats and costs poses great challenges for decision makers in large urban counties. In “Which Priorities for Health and Well-Being Stand Out After Accounting for Tangled Threats and Costs? Simulating Potential Intervention Portfolios in Large Urban Counties,” Bobby Milstein and Jack Homer use County Health Rankings data for a predefined peer group of 39 urban counties to identify cross-impacts among threats to health and well-being. Adding appropriate time delays, they develop a dynamic model of these cross-impacts and simulate each of the counties over 20 years to assess the likely impact of 12 potential interventions for outcomes that include years of potential life lost, the fraction of adults in fair-poor health, and total spending on urgent services. The combined portfolio of interventions yields improvements by year 20 that are considerably greater than those at year 5. Poverty reduction and social support are the most highly ranked interventions. They suggest that a significant concentration of resources in a regional portfolio ought to go toward these strongest contributors for equitable health and well-being. In a rapidly changing health care environment, primary care leaders need training to enhance their practice-level leadership skills. In “Leading Innovative Practice: Leadership Attributes in LEAP Practices,” Benjamin Crabtree and colleagues review the literature on leadership from the perspective of complex adaptive systems, and identify nine leadership attributes thought to support practice change. They apply these attributes to practices that rank high on a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see whether and how the attributes manifest in high-performing innovative practices. All nine attributes identified from the literature are evident and seem important during a time of change and innovation. The authors argue that complexity science offers a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. Policymakers need to evaluate integrated care programs to identify and manage conflicts and tensions between a program's aims and the context in which it operates. In “Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts,” Gemma Hughes and colleagues report on a systematic review of literature covering integrated care strategies and concepts. Their analysis includes comparing heterogeneous strategies and concepts, developing a taxonomy of the literature, and generating a new interpretation of those strategies. Common across empirical and conceptual work is a concern with unity in the face of fragmentation. However, the authors find that integrated care programs do not necessarily lead to intended changes in experiences and outcomes, which they attribute, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other. They conclude that models of integrated care need to be valued for their heuristic rather than predictive powers. Community-engaged research (CEnR) aims to engender meaningful academic-community partnerships to increase research quality and impact, and to improve individual and community health through the uptake of evidence-based practices. In “Measuring Community-Engaged Research Contexts, Processes, and Outcomes: A Mapping Review,” Tana Luger and colleagues describe a mapping review aimed toward helping partnerships find and select measures to evaluate CEnR projects and characterize areas where further development of measures is needed. The authors identify multiple measures of context (factors to support effective academic-community collaboration), process (measures of group dynamics and trust), and outcomes (impacts such as benefits and challenges of CEnR participation). They find substantial variation in how academic-community partnerships conceptualize and define even similar domains. They advocate a hybrid approach in which partnerships discuss common metrics and develop locally important measures to address CEnR's multiple goals. The Flint, Michigan, water crisis—a manmade tragedy that exposed thousands of children and adults to excessive lead levels in the city's drinking water—has been well documented. A major factor explaining why the crisis unfolded as it did is the complexity of the laws regulating how government agencies maintain and monitor safe drinking water. Peter Jacobson and colleagues analyze “The Role of the Legal System in the Flint Water Crisis” by examining the legal arrangements governing public health and safe drinking water, and the degree of legal preparedness among governmental officials. Their analysis reveals flaws in both the legal structure and the implementation of the laws that failed to stop the crisis while simultaneously exacerbating it substantially. They recommend that policymakers examine the legal framework in their jurisdictions and take appropriate steps to avoid similar disasters. Precision medicine depends on new technologies that measure specific biomarkers, which theoretically will lead to more accurate diagnosis and targeted treatment. Owing to the disruptive nature of these technologies, they often require radical changes to clinical practice and service organization. In “Personalized Medicine, Disruptive Innovation, and 'Trailblazer' Guidelines: Case Study and Theorization of an Unsuccessful Change Effort,” Alex Rushforth and Trisha Greenhalgh describe a case study of an attempt by academic researchers to radically change asthma management in the United Kingdom using a precision medicine biomarker. The authors employ a wide-ranging data set that includes documents, interviews, and ethnographic observation. They find that, despite efforts by the academic researchers to engage in clinical guideline development for primary care clinicians, practitioners working outside tertiary referral centers do not accept the vision of precision medicine as inscribed in the guideline for various reasons. They believe that “trailblazer” guidelines, based on new, disruptive technologies, may catalyze practice change only in a limited way for interested individuals and groups, and that, in the absence of broader professionally led change efforts, may be strongly resisted. In closing, we wish to inform readers that scholarly opinions will no longer appear in the print edition of the Quarterly. All opinions will appear exclusively on our website (https://www.milbank.org/quarterly/the-milbank-quarterly-opinions/). We invite you to visit the website, where you will find recent opinions by contributing writers Lawrence Gostin, Sara Rosenbaum, and Joshua Sharfstein as well as guest opinions by Sherry Glied and others on various topics of interest.