Andy Slavitt

Happy Monday everybody. Thanks for joining us. Jack, first on. No surprise. Good to see you, Jack. Wait just a second for a few more people to join and then we're going to welcome our guest, Andy Slavitt, who is one of the leading experts on healthcare in America, the public health crisis that we face right now, and very much looking forward to getting his thoughts on where we are and where we should go as a country and then give you all the opportunity to ask Andy Slavitt your questions. So there's a question box right here at the bottom and you're welcome to ask Andy Slavitt any question that you'd like to. A couple numbers just to make sure we're all on the same page. Elizabeth, thank you for sending these to me earlier. More than 3 million cases globally. United States, very close to 1 million cases officially reported and we have to caveat these numbers by saying that we've tested so few people in this country, we really don't know what the true number of cases and the true number of deaths are, but comparing the same reported numbers or numbers reported in the same fashion day in and day out gives us an apples to apples comparison. So in the United States, 55,000 deaths so far officially reported and only 5.6 million tests. So nowhere close to the number of tests we need to really understand who has COVID-19 and what we should do to trace their contacts and isolate them to prevent the spread of this. In Texas, 25,000 cases, 661. A big caveat on that number because Texas has tested fewer people per capita than almost any other state. I think there may be one or two states that might rank worse than Texas and yet we just learned today that our governor is going to lift stay-at-home restrictions in the state of Texas starting Friday. And I believe it covers movie theaters, restaurants, malls, and retail establishments. In Texas, you will now be able to on Friday, thanks to the governor, go to a restaurant and eat there, go to a mall, go to a retail establishment, as long as those places maintain 25% or less capacity. Is this a good idea? Doesn't seem to make sense to me if you have tested fewer people than in almost any other state. If this pandemic has not yet progressed fully through the South and the Southwest, at least that's what the public health experts have told us. But I want to make sure we have a chance to ask Andy Slavitt and have him tell us his thoughts on this and answer your questions. Okay, so why don't we just bring Andy on. Andy, I'm going to try to loop you in. Andy Slavitt was the director for the Centers for Medicaid and Medicare in the Obama administration, had a big hand to play in the successful implementation of Obamacare or the Affordable Care Act. And Kano, I'm looking for him and I don't see him on here. Andy, tell us you're there. All right, we'll give Andy a little bit more time. Andy, just wave or make a comment and then we'll bring you on to the program. And again, I want to get to everyone's questions. Andy just authored a letter that was released today. I saw it on NPR that describes steps he thinks this country should take when it comes to contact tracing, when it comes to isolating those who have coronavirus, and then making sure that this ultimately is ready to reopen. All right, Kano, you're going to have to be our guest. I'm looking through the people who are connected. We can have Tim on, which would probably be really good. And Tim can talk about what's going on in her life. We've got Amy O'Rourke on. Let's just bring Amy on, if she's available. Mayday, slow roll. Kano, what are you saying? Okay, she says that Andy's on. We've got to let this invitation to Amy roll through. Yeah, Real Donald says that my hair looks like a Lego piece. It does. This is six plus weeks of no haircut, but we're going to get that done soon. I see Andy Slavitt now. Boom, we're on. Hey. Hey. I think your orientation is to the side. I don't know if you can flip it. There we go. Who cuts your hair? Yeah, right. You made my son laugh at me when you said that about the orientation. I need to get a haircut. Are you cutting your hair? I've gone shaggy, and it's bad. It's just bad. It's not working. The hair grows in directions that I didn't think were possible. I was reading a story in ProPublica yesterday. They interviewed public health experts in Italy and Germany, Spain, Singapore, Taiwan, South Korea, and they were asking for best practices. The short of it is you've got to have just expansive testing. You have to have contact tracing. You have to be able to isolate those who have COVID-19. Then I read a letter that you wrote along with some other public health experts in the United States that basically has some of these same points. You talk about spending $12 billion to stand up a contact tracing workforce, almost $5 billion to use vacant hotels to actually isolate people who don't have a place to go to if they have COVID-19, offering income support to folks. Tell us how you came up with these proposals and what that might look like for America. The first thing is we got together with 16 of the most unimpeachable people. I think 15 unimpeachable people plus me. Gottlieb and I led the letter because I think he's probably one of the most outspoken people on the Republican side. He's the former FDA commissioner, super straight shooter, very reliable source, very nonpartisan. Then we went and got the people, for example, Larry Brilliant, who people might know from the movie Contagion, who was responsible for ending certain outbreaks and the people who were responsible for controlling the HIV epidemic like Asher Holm. Then Republicans and Democrats and healthcare like Bill Frist, Farzad Nasrashiri. We basically said, look, in order to do this, what would it really take? By this, what I mean is, let's talk about what we're aiming at. The idea of eradicating COVID-19 is a job left for people working on a vaccine. We're going to wish them well and stay out of their way. In the meantime, we want to reduce the number of cases and we want to get back to as much of a normal semblance of our life as we can. The way we're going to do that is not because either Donald Trump or whoever our governor is says the economy's open. The reason we're going to do that and the reason that we're going to go back to work and spend money again and employers are going to hire again is when we feel safe. The way we feel safe is when we don't experience COVID-19 as a forest fire, but when we contain it as a series of little campfires. As soon as we see the campfire, we're able to put it out. If we let the campfire get into a forest fire again, then we're going to end up in a situation where people don't feel safe and we're going to have to go backwards again. There's a couple tools to do that, Beto, and you mentioned what a few of them are. One is you have to have a low enough case count. The cases have to be declining, that you're under control and you don't have a lot of community spread. We are not there yet. We will get there, but we're not there yet. The reason we'll get there is because of all the great things that everybody's doing, staying home, which has been absolutely amazing. People have just been unbelievable. I want to talk about that if you give me a second or two later. The other tools you need, you need the ability to do rapid testing so you can see where it's spreading. Then this major thing called contact tracing, which is kind of a foreign idea, except it's how things like the measles and other things have been contained, is you basically say, hey, Beto, if you test positive for COVID-19, we've got to help you figure out who are all the people you came into contact with when you were positive. It's not that easy because you may have seen Amy, and Amy may have gone to a meeting with five of her friends, and those friends may have done something else and something else and something else. It actually takes a fair amount of manpower or person power or legwork to do that and do it right. It takes what we think is going to be about 180,000 people across the country to do this, but if you make that investment, you actually put yourself in a position where people start to feel safe again because they know not that they won't see the bug, but that if it's there, it's going to get contained, and that along with the safe habits that we're starting to employ, masks, social distancing, etc., is really the formula we need. Andy, to put it in perspective in terms of the number of contact tracers we need and the number we have, I think I read that New York is trying to triple the number of contact tracers they have from 50 to 150, and really they're going to need in the thousands or tens of thousands in New York to do proper contact tracing. So do you envision this being a federal program where the federal government hires the contact tracers or a state-by-state effort where it's up to the state governments to get that done? So what we proposed is that it happens at the state level with federal money. So a state like Texas would come to the federal government and say, we project that we're going to have 15,000 cases in the next six months. Here's the work, here's the analysis. And so what we've done is we've basically calculated how many resources you need for every new case. And it turns out, believe it or not, that you need 11 person days for every case. So that's, you know, it's not unimpeachable math. There's some people who get slightly lower numbers and some get higher numbers, but when you ask all the experts, 11 person days, everyone nods their head, say, that should be about right. We'll get more efficient down the road. We can have learnings and lessons and all that. But in order to hire those number of people, we would propose that the federal government would then give a grant like a block grant to a state and the state would use that money to do three things. They would use the money to hire the contact tracers. And these are decent jobs. I mean, they're sort of above, they're sort of like census taker jobs, but a little bit more skilled, but anybody can be trained on them, even me. I could be trained to do this, I believe, although I actually tried and I didn't do a very good job. I did an amateur hour act on it and it's harder than I thought it would be, but people can be trained to do it. In Massachusetts, when they went to hire a thousand people, they got 15,000 applicants in like a couple of days. So people can, people want to do these jobs, I believe. The second thing the money goes for is if you find someone who tests positive and you say, okay, great, you've got to go, so you got to go isolate. But they live in a one bedroom apartment with their grandmother. So where are they going to isolate? So we are putting money, we requested money to take, whoa, by the way, you have no idea what a good test that was. You should be, I should see like applause going on, but it was like a one handed, that all this vacant hotels and motels we have right now to use some of that stock and give people a couple of weeks with cable TV and let them get away if they can't stay at home. And then the third thing is some income replacement because people who are doing this are doing a form of civil service. They're keeping the rest of us safe. And we liken it to jury duty, where if you're going to be missing work and your employer is not going to pay you, then we have to give you something. Otherwise, you're going to say, gosh, I'd love to do my civil duty, but I can't afford to, I got to work. So we put that, we wrapped that, and that's actually a lion's share of the money is the income replacement. How about enforcement of isolation? I remember when you and I talked a few weeks ago, I cited the example from China where if they took your temperature and you had a fever, you immediately had to go get tested. If you tested positive, you could not go home. You were mandated to go to a hotel or a camp or whatever you want to call it, or a hospital. What's the line, the civil liberties line you envision us walking? If I were to test positive, am I mandated to isolate? Does the government check up and make sure that I am? Or do you appeal to my sense of civic duty and say, look, Beto, if you can't isolate at home away from family, then we've got this hotel room and voucher for you, and you can go there. Yeah. I really think it's probably the latter, Beto, but I do think this is a debate and discussion the American public's never had. How do we balance the liberal democracy that we love with the need to be safe and protect ourselves? In my opinion, that's not a debate for the politicians. That's a debate for Americans. And so while I think we would all agree that it would be more effective and safer if you said, oh, I'm taking you to a hotel. You don't have a choice. I think that the reality is that's not how our democracy works, and I don't think that that's the level of support people have. Even if you think about these apps where you could say, I want to know who I've been in contact with, where I've been, use the geotracer function, and all those sorts of things. We did a poll to see how comfortable people were with that, and more than half the people are okay with it. And if you tell people that it's going to get them back to work more quickly, like 60, 65 percent of people are okay with it. But that still leaves 35 percent of the population that's really not okay with it. And, you know, I think this is an opportunity or a moment for unity and not a moment of divisiveness. I think you've been a model of that your whole career, and so I think you'll hopefully relate. It's just that to say we're going to go take a third of the people and say, sorry, I know you don't agree with this, but this is the way it's going to work, that could cause more harm than good. Whereas if you said to people, look, we know you don't want to infect other people. We know you don't want to infect family members, neighbors, and so we're going to help you. We're going to help you figure out who you've been near and help you get into contact with them. And if you don't have a safe place, we're going to help you find a safe place, and we're going to pay for it. I think most Americans would find that something that they would want to do. And if they don't, well, you know what? It's not going to be perfect. We know this isn't going to be perfect. All we can do is increase our odds. I saw a clip of David Katz, Dr. David Katz on Bill Maher, and I don't know if you read his op-ed in New York Times last month, but essentially argues that we shouldn't have the kind of stay-at-home orders, that we need to build up some immunity, maybe not go as far as Sweden has, but have a much more open country and much more open economy right now. And I got to tell you, in watching that and listening to his argument, it wasn't fringe. It wasn't liberation theology a la Trump of liberate your states and dress up in battle gear and take guns to the steps. It was a fairly reasoned and somewhat compelling argument. Let me ask you to respond to that in the context of Texas. Our governor just announced that our state would reopen on Friday in a limited way. Basically, all malls, all retail, all movie theaters, all restaurants can reopen as long as they limit capacity to 25 percent. Is that a good idea? Is begin reopening these states? Or is that a bad idea and instead we need to focus on contact tracing, testing, and isolating? Can the two, are the two mutually exclusive? It's a great question. I mean, look, I don't know David Katz personally, but he's making the easy argument. He's preaching to what people want to hear. We all want to hear we could go back to normal. Great. Someone tell, so if in the absence of information, and look, let's just take a step back. We're in the early stages of a brand new virus that we will understand perfectly well 10 years from now. We'll understand how it spreads. We'll understand who's most at risk. We'll understand all these other characteristics that we don't today. Right now, you can confirm anything you want to believe. You want to believe that it spreads through the air. You can go find 50 studies that say that. You want to go believe that young people can't get sick. You can go confirm it. You want to believe that young people are in peril. You can go confirm that you want to confirm that we'll have a vaccine in six months. I can find you five credible papers or one that says we'll never have a vaccine. I can find 10 credible papers. So we don't know. And so the question is what do we do when we don't know? Well, it's scary because we don't like uncertainty. We get impatient. And, and, and then we try our best to try to work our way through it. I believe that as you said, David Katz, everybody, everybody's motivated by the same thing. Nobody wants, at least as far as I can tell, people don't want people to die. Right. Now there's dumb things and smart things. But I, you know, we, none of us have a monopoly on what those answers are. So there is going to be a period of trial and error of saying, what happens if we try this with the restaurants? Well, maybe that went, maybe when we said you couldn't play in the park, that was too far. And so, you know what, you should be able to play in the park. Over time, I think we're going to learn, but, but here's the, here's the important part of this Texas question you asked, in my opinion, the governor doesn't get to decide. Now the governor can influence people for sure, because people listen to authority, but there's been, there's a poll that we just saw from the Kaiser Family Foundation that shows that even if governors in Georgia and Texas and other places said, go ahead, share popsicles, people, people aren't there. People want, people still value their safety. And so they are, you know, I mean, I was just talking to somebody who called me up to say, you know, we want to do, open up our hotels and all this, and, but we'll, we'll polish them and make sure that there's everywhere, which is good for two purposes, apparently. And, and the, the, the, and they're like, what do you think? I said, well, are you testing everybody that comes into the hotel? And he said, well, well, no. I said, well, then that's all right. Really precariously balanced. You would, you would agree that this is not a smart way to do this. But it's like, it's the so there's a, you don't, if you don't know who's coming into your hotel, that's sick, doesn't matter if it's polished or not, people aren't going to go there. They're not going to stay there. I said, so that we didn't, with all due respect to Trump, he did not decide to close the economy down. We decided to close the economy down and we will start, the economy opens up when what happens when we start spending again, when employers start hiring again, when businesses start investing again, those that's when the economy comes back, the price of oil, you can't magically make it come back up until people start driving again and flying in planes again. So we don't, this narrative that there is that the governor's going to snap their fingers and we're going to have the economy working again. It's really not the case. There has to be really a credible public health plan so that people feel safe going out, businesses feel safe opening, businesses feel safe hiring. And to do that, I think we've got to set, it's sort of conditions on the ground. It's like saying we're going to pull out of Afghanistan on this date versus we're going to pull out of Afghanistan when we, when, when we've got the following conditions on the ground. And I think we're in a situation now where as much as we're impatient, and I don't blame anybody for being impatient. We're not, we're not yet seeing the things that are going to make people feel safe. And as a result, I don't think a whole lot changes, but then again, you know, as I said, there's, there's some things that you probably can open safely and we'll have to just figure what those things are. I'm going to paraphrase some of the questions I just read through them and I won't press on the question so that it pops up. I'll just, I'll just ask him in my own words. We all saw the video from last week of the president musing about injecting disinfectants and the cure of sunlight. And there's an editing of that video that just focuses on Dr. Birx's face. And she seems to be trying to control her response and try to ensure that her face doesn't betray her emotions. You've been in, you know, a top advisory and a top management position within a prior administration. And there's no comparing the two administrations, but what is that person's responsibility when a trusted public leader in a position of power is saying something that is untrue or potentially harmful or even deadly? What could she have done? What should she or Dr. Fauci do? They're in a tough position because they want to continue, I'm assuming, to work towards the public good and the public health. And they want to be able to have the president's trust. How do we balance that within this administration that is being so dangerous right now in the midst of this pandemic? We're really in a tough spot because he really puts experts in a really difficult position. So hydroxychloroquine or whatever, the thing that he was recommending before, doctors were writing about four or five hundred prescriptions a day until the day that he mentioned it at his press conference, doctors wrote 33,000 prescriptions that day. And many of the people that I know that rely on it for their lupus have it on backorder and they still can't get it because we don't produce enough. So like it is funny on one level, right? At one level, it's like hilarious. It really is hilarious that he said that we should inject ourselves with disinfectant. Part of me wants to laugh. But poison control in New York City saw a tripling of the ingestion of poison that day. And so you sit there in your Dr. Birx and you got two things you're trying to that we're all hoping she does. One is set the record straight and two is not get fired. Because I don't think the idea of our best scientists, there's already not quite enough science in the White House as it is. So she's trying to balance those two things. It's almost impossible to do when you work for somebody who and I know this is going to sound critical of the president, but you can't upstage him. You can't you can't prove him wrong. You can't. I mean, with with with President Obama, he would say if I say anything, the slightest bit incorrect, you have to make sure that you correct me. You cannot let that stand. And so he was very different because you'd go into the Roosevelt room, you'd have very you were you were free to argue your point. You didn't always win. We're not as happy with the outcome. But you knew that the president expected you to say what was on your mind. And he didn't see himself in the decision. He didn't. If you said no, you're wrong. He could live with that. Trump is different in the sense that it's got to be his idea. It's got to be something that makes him look good. And if he's already gone out on a limb, it makes it very difficult. So I don't know what I would have done if I were Dr. Birx. I really don't actually think she probably did the perfect thing, which is directed to, you know, not say anything except the way she said it. I'm going to I'm going to combine two questions from Marilat. The first is in anything to the idea that heat cuts down on transmission or the viability of the virus? And then she also asked this question. Why are we not seeing higher numbers in in countries like India and Pakistan? And why, relative to the rest of the world, is United States so much higher? So I'll let you answer those two and then we'll let you go. So in anything to heat, reducing transmission, do we have anything any positive news to look forward to as we approach summer? It's 93 degrees right now here in El Paso. And then why aren't we seeing higher rates of transmission and infection in India and Pakistan? OK, so you're allowing me to make a really important point here, which is the most the answer you should hear most frequently to almost any question is we don't know. Yeah, that's honest. Right. And to the extent that you have a source that you rely on who doesn't start with, I don't know, like to 80 percent of the questions, you might not have the best source. If they then say, well, here's what we think, here's what we've observed, et cetera, et cetera, then fine. So, you know, I have a call many evenings with a number of epidemiologists and clinicians and they don't agree on the question. So first of all, I don't hold myself out as an expert, but I've heard some say that if you have ultraviolet light, it can reduce the are not, which is what we talked about last time I was on the amount of spread by point by a whole half a point. I've heard other people say absolutely not, absolutely not. There's no evidence. And you know what? If I had just talked to one of those two people, they're both highly credible sources. So that's one. The second thing is around around India. And here again, we don't know. But there are a confluence of factors that we haven't yet figured out that have as much to do with the underlying health conditions of the population, the age of the population, the kind of there's a randomness that we don't like to hear about. But, you know, it's entirely possible that when we look back on this three years from now, there were like five super spreaders that vacationed in New York when they could have vacationed in Houston. They just decided to go to New York. And each of them was part of this epicenter that spread this thing really, really, really fast. And we will. So we will go back and try to fit like I try to fit what's happened into the limited data that we have by saying, oh, well, New York didn't start till late. San Francisco started early. That explains it. But the truth is we're trying to fit the narrative to the very limited amount of data we have. Again, I suspect when we go back and look at it later, there will be logical explanations for this stuff. And I could give you four or five logical explanations for India, but there's no point because none of them are you know, they're all they're all speculation. We just have to accept the fact as hard as it is that we have to be patient with the fact that we don't know very much today. It's tough. You know, our we expect answers. We expect the United States to be a leader. We expect to be coming to the aid of other countries are going to be hit much harder by a natural disaster like this one, one that was compounded by some manmade errors, it looks like in this country. But what explains India? What explains China? It's hard for me to to comprehend. But I love your advice and your admonition of don't think that, you know, because we cannot prove any of this stuff yet. So keep an open mind, do those things that we know do work. You mentioned testing, staying at home, washing your hands, keeping six feet away, contact tracing and isolation. Right. Really appreciate the proposal that you all made. And I'm grateful that you joined us today. And I understand you're going to be on the PBS NewsHour tonight. Yeah, on the PBS NewsHour tonight. And I understand, Beto, that you are kind enough to be coming on my podcast soon. Absolutely. That's going to be fun. I'm looking forward to it. I'm looking forward to it. Thanks for joining us. Thanks for doing it. Anytime. Appreciate it. That was that was Andy Slavitt. Our thanks to him for joining us again. I think just one of the the best and brightest leading voices on how this country should respond to this crisis. And, you know, he's good when he begins so many of his answers with we don't really know. I think that admission of ignorance, not on his part, but just on science's part right now, just adds to the credibility when he does come up with something that he really does believe in because he knows it's worked, because he's followed the science and the facts in those places where it's been tried out or tested. So very grateful that he joined us. Quick programming note. Tomorrow, we're going to have Janice Poindexter, who's a transgender victims advocate. I met Janice in Detroit, Michigan, when I was on the campaign trail, and she made such an impression on me. She's such an incredible leader and has done such a great job in focusing attention, including those from public policymakers, on the crimes that are being committed against transgender people in this country, and especially transgender women of color in America. And this is something that I think is so important for us to address. And I thought that as a candidate, I think it now, even though I'm not a candidate. And so I want to make sure that I give her a chance to share what she's working on and then allow you to ask her questions tomorrow. Last thing, and kind of an important thing and a sad thing. We learned yesterday that Memo Garcia, who was shot on August 3rd, 2019, in the El Paso Walmart by a very hateful white nationalist terrorist inspired by the president to come repel an invasion and an infestation of immigrants. Memo Garcia, who had been on life support for nine months at Del Sol Medical Center here in El Paso, supported in the most fierce, awesome, amazing way by his wife, Jessica, and his daughter, Karina, and his son, Memo Jr., Memo, who fought the good fight and lived up to his nickname Tank or Tanque. I mean, he was just the toughest, passed away yesterday. And we just want to send our condolences, our prayers to the Garcia family, to everyone in Memo's life, to the surviving victims of the Walmart massacre, all of whom formed a bond with Memo and his family in the nine months after that shooting. Just want you all to know that we're thinking about you and you're going to be in our thoughts and our prayers forever. And if there's ever anything we can do to help you, we want to do that. So I know a lot of people around the country and a lot of viewers of this show know the story of Memo Garcia. I wanted to share that sad news and just ask you to focus your thoughts and your prayers on Jessica and her kids and that family right now. All right, we will see you all tomorrow. Hope that you continue to stay well, to stay safe, to stay healthy, to stay at home and to stay apart for right now. Much love. See you tomorrow. Bye-bye.