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December 23, 2020
Building Back Better
Michelle M. Mello
Alan B. Cohen
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President-elect Biden will take office during a staggering new wave of COVID-19 infections, hospitalizations, and deaths. Fighting the pandemic is his most urgent domestic priority. Mr. Biden has taken promising early steps by convening a highly qualified new Coronavirus Task Force populated with physicians and other scientists and a Special COVID Transition Team to coordinate efforts with state and local health officials. As these teams begin their work, we offer six important actions they should pursue:
The Centers for Disease Control and Prevention (CDC) must regain its stature as the preeminent national leader of public health efforts and a place where science drives policy. Trump Administration officials’ systematic undermining of the work of career scientists has profoundly shaken public faith in the agency and its recommendations, and has left state and local departments of public health unsupported. Similarly, President Trump’s barefaced pressure on Food and Drug Administration (FDA) leaders to approve COVID-19 countermeasures led to emergency use approvals of therapeutics whose safety and efficacy were subsequently cast into doubt, along with public concerns (probably unfounded, but not unreasonable) about the safety of vaccines. President-Elect Biden should reassure the public that scientists are back in the driver’s seat by publicly committing to a hands-off relationship with the FDA and CDC, declaring that no political influence will be brought to bear on decisions or timelines regarding product approval and disease control guidance. He also should restore regular press briefings from FDA and CDC directors, and welcome departed scientists back to their agency jobs.
The Trump administration took a decidedly federalist approach to containing the spread of COVID-19, pushing much of the responsibility down to the states where pandemic responses varied widely. Although there are legal obstacles preventing national mask mandates and federal closure of businesses and schools within a state, there is a clear need for a more vigorous federal role in community mitigation. President-Elect Biden should convene a summit of all state and territorial governors, along with the District of Columbia mayor and tribal leaders to present and share the best evidence about the effects of stay-at-home orders, business closures, school closures, and mask orders and the experiences of states with such interventions. The summit also should facilitate states working together (aided by the CDC) to craft a common framework for what businesses and services will be open and permissible, based on uniform criteria. There are existing compilations of state orders that could inform the summit, but additional information tools should be developed to help each community know its status in a standardized way. While hotspots require a different level of interventions than lower-risk areas, it is difficult to justify not imposing evidence-based interventions when key trigger criteria are met, such as low hospital capacity and high death rates. Conditioning federal COVID-19 aid dollars on states’ adherence to the terms of this framework would provide political cover for state officials who face resistance at home, as would engaging Republican opinion leaders to vocalize support for the framework once the danger of retaliation from President Trump has passed.
The Trump Administration’s initiative to stimulate development of COVID-19 vaccines, Operation Warp Speed, will go down in history as a remarkable success story. Although not all of the vaccine frontrunners participated, there is little doubt that the federal government’s massive investment in vaccine research and its commitment to purchase millions of doses of successful vaccines hastened the beginning of the end of the pandemic. Now, President-Elect Biden should pivot this initiative to focus on vaccination rather than vaccines, provisioning it with the same generosity and pragmatism that he would a war plan. States are well into devising their vaccine distribution plans and have received expert recommendations on allocation, but desperately need additional federal dollars to make it happen. Congress approved nearly $9 billion in its year-end stimulus bill, but there is concern that additional funds will be needed for logistical and technical support to ensure that vaccination efforts reach—and are accepted by—communities of color, other disadvantaged persons, and rural populations. The federal government should publicly report weekly on vaccination uptake in each state, focusing assistance on states and communities lagging behind. Finally, enlisting influential voices from the right may help message the importance of vaccination to persons who identify as Republican, as illustrated by the recent statement by Sen. Mitch McConnell.
One of the most urgent national priorities for restoring civil life and stabilizing family income—bringing kids back to school—has also been one of the most egregiously neglected areas of the federal pandemic response. CDC guidance has lacked credibility (as well as specificity) because of political meddling. To an astonishing extent, school reopening decisions have been led by educators left largely alone to manage enormously complex judgments and plans. Further, where federal guidance has emerged on issues like in-school mitigation measures, it has not been accompanied by the funding required to implement them in resource-poor districts. President-Elect Biden should immediately task his COVID-19 experts with synthesizing what has been learned about successful strategies for school reopening and devising a plan to make those strategies accessible to every school district in the US. Because educators and families deserve the best available knowledge about the actual risks of reopening, a national data collection effort should be launched to assess outcomes of reopening plans with various features. New, more detailed, evidence-based CDC guidance should be issued that more pragmatically confronts the need for screening testing in schools. Finally, to ensure equity in school reopening, President-Elect Biden should double down on his pledge to work with the Congress for further aid to schools, as the funds in the current economic relief bill likely fall short.
The pandemic has created a policy window for President-Elect Biden to pursue an idea that he has long endorsed: that every American worker should have access to paid sick and family leave. Congress passed the Families First Coronavirus Response Act in the spring of this year providing COVID-19-related paid leave to many (though not all) workers, but these benefits will expire on December 31, 2020. Whether or not they are renewed, President-Elect Biden should springboard off this legislation to push for permanent benefits that reach all workers. Ample evidence from the pandemic demonstrates the importance of paid sick leave for fighting disease, and adds to the mountain of other research showing its benefits. Before Americans forget how others’ access to sick leave affects them personally and this policy window slides shut, the Biden Administration must act.
Despite the shocking nature of the COVID-19 escalation in spring 2020, this type of epidemic was foreseeable—and, indeed, foreseen. Yet, emergency preparedness playbooks developed under the Bush and Obama administrations were tossed aside. These plans should be reviewed for immediately actionable interventions, and then updated with lessons learned during the COVID-19 pandemic. Updates should include a plan for restoring the necessary federal infrastructure for effectively governing pandemic response, replenishing and clarifying the role of the Strategic National Stockpile, and funding private-sector partnerships that will enable local public health departments to rapidly scale up testing and contact tracing during future outbreaks.
Many more actions will be necessary to stop the pandemic’s advance, but these six actions are among the most urgent requiring immediate attention.
The authors thank Nicole Lurie for helpful comments on an earlier draft of this post.
 Kingdon JW. Agendas, Alternatives, and Public Policies. New York: Little, Brown and Company, 1984.
Michelle Mello is professor of law at Stanford Law School and professor of medicine in the Center for Health Policy/Primary Care and Outcomes Research in the Department of Medicine at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. She is the author of more than 200 articles on medical liability, public health law, the public health response to COVID-19, pharmaceuticals and vaccines, biomedical research ethics and governance, health information privacy, and other topics. The recipient of a number of awards for her research, Mello was elected to the National Academy of Medicine at the age of 40. From 2000 to 2014, she was a professor at the Harvard School of Public Health, where she directed the School’s Program in Law and Public Health. Mello teaches courses in torts and public health law. She holds a JD from the Yale Law School, a PhD in Health Policy and Administration from the University of North Carolina at Chapel Hill, an MPhil from Oxford University, where she was a Marshall Scholar, and a BA from Stanford University.
Alan B. Cohen became editor of The Milbank Quarterly in August 2018. He currently is a research professor in the Markets, Public Policy, and Law Department at the Boston University Questrom School of Business, and professor of health law, policy and management at the Boston University School of Public Health. He previously directed the Scholars in Health Policy Research Program and the Investigator Awards in Health Policy Research for the Robert Wood Johnson Foundation. Earlier in his career, he held faculty positions at Johns Hopkins University and Brandeis University, and spent 8 years at the Robert Wood Johnson Foundation. He is a member of the National Academy of Social Insurance. He received his BA in psychology from the University of Rochester, and his MS and ScD in health policy and management from the Harvard School of Public Health.
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