H1N1 Vaccination: The Difference Between the Obama Administration Being At Fault and Being Responsible

The Disease Management Care Blog has pointed out twice (here and here) that the Obama Administration's health care chops will be tested by H1N1. The President can't blame a lack of any warning, the prior Republican administration, absent regulations or an unfunded infrastructure. While moving virus from eggs to humans is very complicated, this is a public health effort that risks falling short across the entire system bandwidth of health care - most visibly the part owned by the Federal government.

Of course, there is no underestimating the capacity of loonies on the left or the right and the middle to refute the same technology that conquered small pox and polio. The community-dwelling DMCB personally discovered this nuttiness is not confined to distant enclaves and AM radio. The astonished DMCB ran into one urbane and educated colleague who, over a glass of Toasted Head, serenely discounted the research on vaccines. No amount of explanation could get past his blinkered anti-science puritanism.

Whatever. Americans still have the right to make bad decisions.

What the DMCB worries about, however, is that those who correctly decide to get the vaccine won't be able to get it, those unable to get the vaccine will get ill, those who are ill won't be able to get to a physician, those unable to get to a physician will overwhelm emergency rooms, and those in the emergency rooms will overwelm the hospitals. It won't necessarily by the White House's fault, but given their leadership and visibility in this area, they will be held responsible.

Fairly or not, the risk is that opponents of health reform will use a failed vaccination campaign to impugn the Obama Administration's competence in managing the nation's health. The DMCB wonders if this could reduce the odds that legislation will be passed.

H1N1: The Obama Administration's Coming Katrina?

In a prior post, the Disease Management Care Blog noted that the Obama Administration’s health care chops would depend on its response to the H1N1 (Swine Flu) virus. So far, it’s been lucky: a serious pandemic has yet to land on U.S. shores. With the coming arrival of fall, however, luck may be running out.

According to this New England Journal of Medicine article, planning is furiously underway. It looks like the patchwork of emergency rooms, public health clinics and primary care providers are being geared up to give the vaccine. Individual clinics are anticipating the coming demand based on the Centers for Disease Control's (CDC's) emerging two shot vaccine recommendations that assign priority to the pregnant, children, young adults and adults up to age 50 years with a chronic illness.

This may look good on paper, but the DMCB worries that this public health campaign is vulnerable to one of two extremes. One is high numbers of persons refusing to be vaccinated because of the fear of side effects. The other is high numbers of persons demanding the two shots and over-running our decaying primary care network. Over the last decade, most primary care sites have reduced overhead to a minimum and have neither the personnel or the resources to take on a new crush of persons demanding the two Swine Flu shots.

For more insight on this, the DMCB turned to one of its primary care colleagues, who, unlike the apparent healthcare experts writing in the New England of Journal, has a real grip on the reality of what could happen this fall:

'I hear rumors that the government is going to pay for the vaccine but the cost of administering the shot (including storing the vaccine and covering the cost of the nurses to administer it) is supposed to be covered by private insurance. We haven’t heard if the insurance payers we deal with will provide first dollar coverage or if they’ll transfer some of that cost through a co-pay or other forms of co-insurance. We also still have no idea about the distribution channels and we don’t know how the vaccine supply will be shared with physicians’ offices, Department of Health clinics or pharmacies. Our small primary care office is terrified of the burden that will be imposed by having giving two more shots to our population with a short lead time. We already have full schedules for the fall season and will have difficulty processing the 1200+ extra contacts and associated paperwork. We are a tiny office that normaly gives 600-700 flu shots a year.'

By the way, the primary care physician had a particularly novel idea. It’s built on the common sense observation that lay people can be trained to give shots.

'My solution: Train census takers to give shots or better yet, put a shot giver on every Fed Ex and UPS truck. Those guys are the best logistical wizards on the planet. You could even get a tracking number and find out where your flu shot is!! They know where everyone lives. My UPS guy knows that if I am not a work to drop by my house. Talk about a neural network.

Readers may think this is naive, but the DMCB points out that the circumstances of the coming H1N1 pandemic may warrant out-of-the-box thinking. This is the Obama Administration's chance to show that it is different - that it is able to come up with non-FEMAoid approaches. Are there plans to involve the public schools? Why can't Visiting Nurse Associations be contracted to set up vaccine stations in our nation's post offices? Or maybe when the Administration isn't pillorying the insurance industry, it is working with it to reduce the out of pocket financial barriers that patients may be facing?

And, in case sizable numbers of persons refuse to be vaccinated for H1N1, check out this thought:

How about a variation of the Cash for Clunkers Program. I call it Shekels for Shots program. At first glance, this may sound silly, but if a voucher not only provides first dollar coverage of the shot for particularly vulnerable persons, but gives them a meaningful cash rewards, the population will be vaccinated and we’ll have another stimulus!!

The DMCB says the traditional response to H1N1 so far does not bode well for the Administration. If the story being told above is typical of many other primary care providers, H1N1 could turn out to be the Obama Presidency’s Katrina.

How Well the Administration Does with H1N1 Swine Flu Has Implications for the Success of Healthcare Reform

In a prior post, the Disease Management Care Blog warmed up to the idea of unleashing the heavy hand of government in another area of public health. The topic of sugared beverages is relatively narrow and, what's more, taxation is the one thing that government does well.

Not long after the keyboard cooled off over that posting, the DCMB became aware of another proposed $1.5 billion government foray. This one is far more expansive. The H1N1 Influenza A Swine Flu emergency has prompted the White House to request an additional $1.5 billion in supplemental funding from Congress. The number is apparently based on the cost of vaccine, the purchasing of anti-viral drugs and first responder protective gear as well as supplemental funding going to the State and other local agencies.

This, thinks the DMCB, will be the defining moment for the idea of expanded Federal involvement in health care. This is big and very visible. If the Administration appears competent and does this right (or if they're lucky), momentum for reform will grow. If the government proves impotent in changing the course of this emerging epidemic (or if they're unlucky), second thoughts will emerge and public support for health reform could wane signficantly.

Good scenario: The Centers for Disease Control, in partnership with pharma, makes good progress in developing a vaccine. Enough anti-viral treatment medications are available to patients who need it. Hospitals and clinics reasonably keep up with the additional demand for services. Public health messaging has the three C's: consistentcy, calmness and correctness. If the virus turns out to have mild symptoms for a vast majority of cases and dissipates, count the Administration lucky. The public credits the Administration for a job well done.

Bad scenario: Whether deserved or not, the public perceives that an effective vaccine's arrival is being delayed. The Administration fails to 'play well' with pharma, who distrust the Democrats. What's more, finger-pointing develops over who is to blame. Reports of shortages of anti-viral drugs begin to pepper the evening news. Patients can't get appointments and there is the spectacle of people outside emergency rooms waiting to be seen. In the meantime, the more nimble local health resources (small physician offices and retail clinics for example), supported by commercial insurers, come through in providing all the necessary care without the special involvement of the Feds - who are a dollar short and a day late. The messaging confusingly varies between CDC, the White House and the States. Too many people with the virus die. Bad luck, the virus turns out to be the mean species originally seen in Mexico with the twin features of high transmissibility and higher than normal lethality.

The DMCB thinks the odds may be slightly tilted toward bad scenario. However, it thinks and hopes there will be good luck (from a prior post, here's why). Despite the best efforts of the most competent government in the world, it takes a long time to develop and test a vaccine, demand for anti-viral drugs currently in the pipeline may outstrip supply and anyone feeling unwell will clog the healthcare system no matter what the messaging is. The good luck news is that the disease so far is appearing to be relatively mild for the patients we know about, the actual number of H1N1 cases is still relatively low and may stay that way.