Information As Power

In the JAMA Health Forum, Coleman Drake and I laid out ways that state and federal regulators as well as insurers can optimize the ACA exchanges now and for the 2021 open enrollment period that starts this November to cope with the expected surge in demand.

There are several areas of focus.

First, exchange regulators need to minimize administrative burden for special enrollment periods.  Accepting attestations of changes in circumstances is an immediate and ongoing step that will help people enroll and stay enrolled.  Normal SEPs have significant validation and documentation requirements.  As there have been mass lay-offs and furloughs, not all HR departments will be sending out timely paperwork.  Accepting attestations should be sufficienct.

Next, states that run their own exchanges should be directly linking social service data to both the state based Exchange and Medicaid enrollment portals.  Any data that can be legally shared between eligibilty systems should be shared and pre-populated.  Maryland and Colorado are aggressively linking tax data to eligibility files to maximize the targeting of outreach.  States using Healthcare.gov should be setting up frequent splash pages with ACA explainers and direct links to Healthcare.gov account creation.

The ACA markets are not intuitive.  They are also markets with significant churn.  People, especially individuals who are typically insured by employer sponsored insurance, don’t know how the ACA works.  Aggressive media and communications campaigns employing both paid and earned media by trusted local intermediaries should be implemented to encourage people to look for options on the marketplaces.

Finally, states can work on pricing.  The few states that have not Silverloaded should silver load.  States and insurers should seek to maximize the premium spread between the benchmark and the plans priced below the benchmark.  State regulators should strongly discourage “Silver spam” practices  and strongly encourage insurers to offer plans that are truly meaningfully different.

Optimizing the ACA Exchanges for the unemployedPost + Comments (1)

This is a short cheat sheet of some of the data analysis questions I keep in the back of my head.

1) Lags

COVID has serious lags at all stages of the information flow.

• Multi-day lag from exposure to testing
• Zero to multi-day lag from testing to result
• Negative and positive lag from testing to symptoms
• Zero to multi-day lag from new infection to start of contact tracing and testing
• Week lag from symptoms starting and potential hospitalization
• Week lag from hospitalization to ICU
• Zero to long lag from ICU to death
• Multi-week lag from ICU to discharge
• Significant lags between death and reports of death
• Widely variable death certificate reporting practices

2) Differential impacts

• COVID hits older people far harder
• Non-linear effects
• Massive current racial, ethnic, and economic disparities as a reflection of historical patterns of discrimination and power.

3) Hospital system status

• Overwhelmed hospitals have far higher age adjusted case fatality rates than not overwhelmed hospitals

4) Learning

• We’ve learned a lot over the first four months of the US pandemic and hospital surge
• Dex, proning, remisdivir all seem to help and reduce mortality rates and hospital duration
• We don’t know what long term looks like as we are still in the short term
• We don’t know a lot including how differential factors influence infections and outcomes (esp. with kids)

We should expect a fairly young population to have a far less severe disease course with fewer hospitalizations and deaths than a fairly old population that is identical in all aspects other than age.  We should expect fatality rates to be far lower in regions with significant available and reserve staffed hospital beds then regions that are getting slammed.

Talking Points Memo had a good image of Florida’s positivity rate and case count:

The cases on 6/19 are probably generating hospitalizations at the start of July.   Anything done today won’t show up in death data until after the 4th of July.

These are just some thoughts on how to think through COVID data reporting.

COVID and data analysisPost + Comments (56)

Trying to estimate how much COVID is out there is tough if we assume that there is some spread above zero and also non-universal spread.  We have to estimate the situation from incomplete information.  We have case counts which is a function of who is getting tested with what types of tests at various points in time with various levels of background COVID disease spread.  We have the number of tests and then we also have positivity rates which is merely the quotient of new infections divided by the number of tests administered in a period.  We should assume that testing is non-random in most cases.  We should strongly suspect that people who have already been infected are unlikely to be tested and people who are not symptomatic nor knowingly in recent contact with someone who had been infectious are less likely to be tested than people who have reason to suspect that they might be infected.

We should assume that we’re not testing enough if we are getting 80% positivity rates as there is massive community spread at that point.  We are probably overtesting if we are getting 0.001% positivity rates.

I have a cheat sheet to help me think through the daily reports.

This is not perfect. But as long as positivity rate is going down in the context of flat or increasing testing, community spread is probably going down. If positivity rate is going up, a state or a region might have an upcoming challenge.

My cheat sheet on thinking about COVID spreadPost + Comments (27)

We, as a society had made a collective decision or indecision to resume economic and social activity even before the anti-racism and anti-police brutality focusing event of Mr. Floyd’s murder by cops took place.

I am working with the COVIDExitStrategy.org  to track states progress on meeting the White House gating criteria for re-opening. There are three main areas with six criteria:

• Downward trajectory of Influenza Like Illness within past 14 days
• Downward trajectory of Covid Like Syndromic cases reported within past 14 days
• Downward trajectory of documented COVID Cases within past 14 days
  • OR
• In context of constant or increasing testing, downward positivity rate of tests
• Hospitals have sufficienct non-crisis/non-surge capacity available to treat current patients
• Healthcare workers are well protected.

As of this morning, NO STATE has met all of these criteria.  A few states are close. Yet all states have gone to at least a Phase 1 re-opening even as testing is still insufficienct to meet White House goals much less independent analysts’ predicates for safe re-opening.  Testing and tracing is not widely deployed.

This is the case today.  It was the case yesterday.  It was the case on May 15th.

Yet we have made the societal wide decision that stay at home is over.

Breaking News: Casinos are filled with people choosing not to wear masks, and who generally poorly understand risk https://t.co/fj3DJTCUoB

— Kevin Collins (@kwcollins) June 7, 2020

So what should be communicated for public health in the context of a societal wide decision that first best advice will be blithely ignored?

I think the second best advice is to adopt harm reduction communication.  That means acknowledging that people are going to be protesting and out and about and then offering strategies to minimize the very real risk of COVID spread.  It won’t be perfect, but it will be much better.  It is the same logic of safe injection sites for individuals addicted to injectable opioids and condom distribution to sex workers.

So what is the advice.

1. If you feel like you have symptoms or know you have likely been exposed to someone who is infectious, go get tested and STAY HOME
2. If you have significant risk factors, be aware of them and acknowledge your risk in your decision making.
3. Stay outside
4. Keep moving
5. Keep a mask on and wear it correctly (over the mouth AND nose)
6. Hand hygiene
7. Keep physical distance as much as possible

Almost all of the protests are outside.  Many but not all have significant movement through marches/walks.  The Durham protest I was at on Thursday and the Chapel Hill march that my wife and daughter attended on Saturday were 97% or more masked.  Looking at pictures from other protests, masks are fairly common to very common.

We as a society have made a collective decision to re-engage in economic and social activity despite still having insufficient testing, low contact tracing capacity and a fairly high baseline level of background infections.  The collective socio-political decision is to engage in harm reduction while accepting significant risk of increased deaths from COVID.  Protesting is part of that decision.

Protest and COVID pandemic harm reductionPost + Comments (35)