04.06.2020
Scrabble, Virginia — My neighbor on the farm across the road and I had a conversation on the shore of his pond yesterday. We kept a safe distance from each other, but enjoyed sitting in the warm sun together and comparing notes, including on the rate at which various trees and shrubs have bloomed this Spring. Some of his forsythia were just beginning to bloom, while on the other side of the pond, the yellow flowers had all fallen off the forsythia and the trees were turning green. “Being out here every day this month, “ he said “I have for the first time watched the full blossoming cycle of the red bud trees. It’s fascinating to watch the emergence as they move from tiny growths on the branches to full blown vibrant arrays of pinks and reds.”
We also talked about the other thing we have all watched bloom, from hundreds infected in a city most people had never heard about, to a full on global pandemic striking hundreds of thousands. “What if we had acted on the early warning signs when it was just emerging,” he asked, “would we have still wound up with hospital beds in Central Park in Manhattan?”
What-if alternative history exercises are usually only useful as sensitivity analyses, reminding us that the present and the future were not and are not pre-ordained, that minor changes at the right time can have monumental results. Some historians will debate such What-ifs as whether Hitler had been killed in World War I would that have prevented WW II and the Holocaust, some arguing the Great Man Theory and others taking the side of inevitable historical trends. Alternative Historian Jeff Greenfield brought a richly detailed insider’s expertise to his What-if stories about the 1968 and 2000 elections. In the latter, President Al Gore pays attention to warnings from his Security and Counter-terrorism Coordinator about an impending al Qaeda terrorism, but some of the 9–11 attack still occurs. We will never know. That’s the thing about What-ifs.
We can, however, do analysis of the facts as they are before us on this arrow of time and history. If we had acted on the Wuhan warnings, we could have had more testing earlier and perhaps contained the virus better, as other nations have done. We would still, however, have probably exceeded our capacity for respirators and for hospital beds. Why in the richest country in the world are there not enough hospital beds and people are in make shift hospital tents in Central Park?
Why? Because we as a nation decided to eliminate excess hospitals and excess hospital beds over the last twenty years as a matter of policy. Hospitals were closed, others closed wings. Insurance companies and Medicare/Medicaid saw excess beds as unnecessary overhead, to be cut in a cost consultant’s campaign of efficiency. It is akin to the manner in which such consultants effectively eliminated empty seats on US passenger flights (until the plague, of course. Now, planes are flying almost empty of passengers, if they fly at all.)
Efficiency, of course, is generally a good thing, but not always one to be mindlessly praised on an alter of gold by private equity players and management consultants. Sometimes excess capacity or preparedness measures are, or should be, a cost of doing business. We should have adopted a national policy that gave us surge capacity in hospitals in case of disasters with high casualty hospitalization rates, or in case of, uh the plague. Those who argued for such preparedness were drowned out by the cost cutting consultants.
Maybe the better debate would have been to ask not whether we should have maintained some excess capacity, but rather what budget was going to pay for it. If the Center for Medicare/Medicaid did not want to pay, if Blue Cross, United and Cigna wanted to save on overhead costs, perhaps it would have made sense to have Homeland Security or the Public Health Service budget carry the cost.
We see the same kind of penny-wise/pound foolish thinking when it comes to another security issue related to health, cyber security. Hospitals do not have the funds, they say, to pay for effective IT security. Government and insurance cost regulators won’t let them charge more and without more funds, they cannot afford what have become “table stakes” (ugly term) for managing any corporation or institution, effective software to prevent hacking. Thus, we have witnessed hospitals close temporarily when hit by a ransomware cyber attack. There have been medical devices taken over by hackers’ bots.
Most companies, ones that do not have their customer on life sustaining machinery, have been able to do a far better job of securing their networks than hospitals. The reliably secure companies are spending about ten percent of their computer and IT budget to secure their networks. Hospitals average around three percent. The results are easily predicted.
We learned the hard way in the World Wars that not having excess military capacity in peacetime is a dangerous risk. So it is with excess medical capacity. Even after this plague passes, or fades into a new normal, we will need excess hospitals and bed capacity for when the next disaster or pandemic strikes. If we will not pay for that out of the health care insurance pocket, then pay for it out of the Homeland and FEMA budgets. Take the closed hospital wings and entire hospitals that were shuttered and get them ready so that they can be reopened quickly when needed. Then, create a data base of doctors and nurses, retired and active, who can be re-purposed in an emergency as part of a National Medical Emergency Corps. Pay and train them the way we do the military reserve forces.
Excess capacity is not always a bad thing, for when you see a problem emerging, you can activate that capability. Then it is not excess, it is prudential.
Notes from the Rapp 