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Advocacy, Equity and Beyond: The End of the COVID-19 Emergency Order

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Mati Hlatshwayo Davis: [00:00:12] Hello, everyone. My name is Dr. Mati Hlatshwayo Davis and I'm the director of health for the city of St. Louis. You're listening to Let's Talk ID. Today I'm so excited to discuss the significance of the COVID-19 emergency order coming to an end. And for as my two inaugural guests, I'm so thrilled to discuss this topic with. Dr. Allison Agwu. Dr. Allison Agwu is the professor of pediatrics and Internal Medicine at the Division of Infectious Diseases, Johns Hopkins University School of Medicine. Thank you for joining us today.

Allison Agwu: [00:00:51] My pleasure.

Mati Hlatshwayo Davis: [00:00:52] Also with us is Dr. Max Brito. He is a professor of medicine at the University of Illinois in Chicago. He also serves as the chief of infectious diseases at the Jesse Brown Veterans Administration Hospital. Welcome, Max.

Max Brito: [00:01:07] Thank you. Glad to be here.

Mati Hlatshwayo Davis: [00:01:09] This couldn't be a more important topic. And at a pivotal time, the COVID-19 emergency federal order is slated to come to an end on May 11th. We all know that this has significant implications at a variety of levels, but I wanted to first ask you all, why do you think it was important for us to even have this emergency order to begin with? And I'll come to you first, Allison.

Allison Agwu: [00:01:37] We reflect back. It seems so long ago, right? But it really wasn't when COVID hit. Right? The pandemic hit and the emergency order allowed us as a country to be able to respond. So everything from vaccines to medications to the capacity to keep people insured on the Medicaid or expanding Medicaid or not kicking people off of Medicaid, even the things that allow people to live, whether it's the pausing evictions or, All of that was enrolled into that emergency order that allowed people to literally survive. Right? Many of those have slowly begun to erode. We know the eviction pause had gone away, but now we're back at the things that the health insurance coverage, the Medicaid expansion, those are the things that are now coming to an end on the 11th that we need to talk about. But it was such a critical part for us to be able to respond the way we did as a nation.

Mati Hlatshwayo Davis: [00:02:26] Exactly. Really good show of leadership here by the government. I'm very thankful that they didn't remove it earlier. We'll talk a little bit about messaging from a federal level and what that means from a health public health, but also for the general public. But couldn't agree with you more that this was pivotal, much needed, and gave us capacity to act swiftly and to prioritize, especially for minorities and disenfranchised communities, to act quickly. So thank you for that perspective. Max. Anything else you would add about the importance of this from the get go?

Max Brito: [00:03:01] Oh, it was really important just for the public. Important translates and the ability of the federal government to have some flexibility in terms of who pays for the vaccines, who pays for the treatments, and having the general public not be burdened by the cost of these medications or these vaccines. As these measures are pulled away, then these medications and these vaccines will enter the general vaccine and medication insurability. So it's going to be going down the same path that every other medication and every other vaccines, which has implications, as you said, for minoritized populations, but also for people who can't afford these things or can't afford the copays or the uninsured, which are a significant portion of the population, as we all know.

Allison Agwu: [00:03:51] And I think it's important to step back and say, while we now are unmasked and running around frolicking and we've forgotten and we have to think about all those numbers and tickers and those numbers were people and those people were more likely to be people with prior illnesses. They're more likely to be black and brown people. We have to underscore that because when Max alludes to we're going to pull away and rely on insurance and all the things those same people are left behind. So I think that's when we say, why are we talking about this? That's the impact. We're now going back to where we are to see those disparities arise or continue to be perpetuated.

Mati Hlatshwayo Davis: [00:04:28] Yes. And this is why you two are my inaugural guests, because that's exactly the issue and what's at stake here for me, You know, I had the flexibility to pick which topic I wanted to lead with. And it was this topic because, listen, we all are highly educated people on this call. Right. I love to remind my staff here at the Health Department that, listen, I've been to school for over 30 years before I even became on faculty, let alone become the director of health. And we didn't have dedicated courses in medicine around what's at stake here. And it is even complex for me. I know it is for you and for Max. That is why this topic is so important to me is because there's a lot at stake. Short term, medium term and long term that is really difficult to wrap your head around. So let me start with just a little bit of background about what that is and looks like we know that there are direct implications on accessibility for vaccines, boosters and COVID-19 testing, but there's direct implications for Medicaid, auto enrollment and coverage in general. Let's talk a little bit about what you think needs to be addressed for public health. And even from a research perspective.

Max Brito: [00:05:41] We're starting off with low numbers of coverage vaccines and coverage of medications for the people like Paxlovid. For example, for the people who get COVID and are at risk of progressing to severe disease. So if we're starting out with low numbers now, imagine what happens when some of these measures are pulled back and all of a sudden people don't have access to to these interventions for free. And so there is a real possibility that we will decrease, especially in the socioeconomically disadvantaged populations that will increase the rates of coverage of vaccine coverage and access to medications against COVID, which are low to begin with. Well, we risk making it worse. So that's, I think, a short term impact of this measure is that, you know, we might see decreasing coverage rates of vaccine and medications.

Mati Hlatshwayo Davis: [00:06:38] Exactly. And so in the short term, we know that the government has made clear COVID-19 vaccines and boosters will still be available for free. But the caveat is, while supplies last. What's important here is once the federal supply runs out, only those with coverage under health insurance, both public and private, will have easy access. Access will be available, but easy access while those not covered. And that's we all know who Allison was talking about likely, who will be, could face challenges. Right. And then when we talk about vaccines, this has implications for children. So there was coverage through vaccines for children program and vaccines will still be covered for those on Medicare Part B without cost sharing, that's a complex thing to know. Medicaid will continue to cover COVID vaccines through September 30th of 2024. When we talk about testing, there will be immediate changes when it comes to home testing. And it's different between Medicare and Medicaid. Medicare will no longer receive free at home tests, while those on Medicaid will be able to access free at home testing through November, a different date than previously stated. And that's before we even talk about what's going to happen with auto enrollment and Medicaid. So it's the complexity from a health literacy position and how we navigate that as leaders, physician leaders, public health leaders and even within our research atmospheres, that's complex. Allison, your thoughts here?

Allison Agwu: [00:08:05] It's already COVID has already been layered with so many of the bizarre political messages and there's so many already in there, and now you add this complexity in a point where people are sick of COVID anyway. My worry is that the people who are highest risk because, you know, we can say we've all had COVID at this point. I know I've had it twice. I've had it. My family, there's this sort of complacency. It's just a cold, etc, etc. Except a thousand people died of COVID last week. Right? So there are people who still have higher vulnerability. You pair that with higher vulnerability, less access to insurance medications, muddy, unclear rules or regulations. And then you just have people just tapping out in general and having increased risk. So I think your points are very well taken in terms of illustrating the impacts on a multilevel perspective.

Max Brito: [00:08:53] Yeah. In terms of messaging, saying that the emergency declaration is over means that in a climate where most people have moved on from the pandemic because that's the reality. I mean, pandemic is, it's not quite over, but people have moved on, as I said in several meetings before it's over where it matters most, which is in the minds of the people.

Mati Hlatshwayo Davis: [00:09:16] Exactly.

Max Brito: [00:09:16] You know, everybody's over that. So if you take away the emergency declaration, if you start saying, well, we're going to go back to where we were at in February, March of 2020, then that has a messaging implications for everything from how the public perceives this and how people pursue care in cases of COVID to funding for COVID to the visibility that that has in terms of research and for clinical care and whatnot. So it is important the psychological effects of this are not to be discounted.

Allison Agwu: [00:09:53] Even the idea of I have some protection because I have COVID and I can't go to work. This whole idea of presenteeism. The emergency is over. There's no space for that anymore. I think we're creating an environment where by saying the emergency is over, not they say that it shouldn't be, we shouldn't be back where we are. But I think some of the messaging is that we can take off all the brakes and there are risks to that. So I think it's what do we alternatively want to say? What should we alternatively be advocating for is where I'm thinking, Mati, that you're taking us. Yes.

Mati Hlatshwayo Davis: [00:10:29] Yes. And again, it's that idea of we all cannot stand the term new normal anymore. But whatever the substitute for that is, is what we're talking about here. Putting my public health hat on, leadership hat. I need to do exactly what Allison is talking about. I need to figure out a way to say you're hearing a lot about a May 11th order, but that's not a light switch being off. Viruses don't prescribe to a date and an announcement.

Mati Hlatshwayo Davis: [00:10:55] And we're still, at least my city, in an environment where transmission is still in the high category, while community levels, because they reflect hospitalizations and deaths, are in a low category. I don't know. You guys may be getting the same texts I do from family members and friends who have COVID. I've had ten in the last two weeks approximately of, hey, I've got COVID now, should I still be taking this or should I still be doing that? What are the current guidelines? So it hasn't left us right? So how do we position ourselves from a messaging perspective is critical here. And one of the reasons why I wanted us to put this out.

Mati Hlatshwayo Davis: [00:11:25] So we're talking a lot about the short term implications here. Can we touch a little bit on the Medicaid issue? Because again, I don't know that a lot of people have the health literacy to understand that Medicaid enrollment was a big part of this. We built in provisions to allow people to get auto enrollment because of this emergency order that occurred during the declaration. And that that will come to an end immediately and that some of those covered may lose Medicaid as well as the Children's Health Insurance Program. This matters. Can we talk a little bit about how you see this playing into maybe your personal or professional roles and where you think IDSA as a society should be positioning ourselves in this conversation? And since both of you were picked because you're fabulous, but also strategically because you sit on the highest boards at IDSA, I'd be very interested to get your take on this. I'll start with you, Max.

Max Brito: [00:12:25] Well, I think the implications are very real - people losing coverage, right? People who were already underinsured to begin with. So we have to at a national level or a society level, we need to be advocating. And that's what we do. We advocate and we have other patients. We want to be in front of legislators. We want to be talking to the communities, to everybody who is a stakeholder in this problem, to try to make sure that our patients are protected. And those patients on which this Medicaid enrollment is pulled continue to have some sort of safety net. And that is a very complex problem. Right, Because that was a problem before the pandemic. It is a problem now through advocacy at the individual level, physicians, nurses, primary care, health care providers are advocating for their patients. But also we as a society advocating on behalf of the larger public in front of legislators. Something that we do at IDSA, we do quite well, I should say.

Mati Hlatshwayo Davis: [00:13:26] Yeah, we do as a matter of priority. And I've been really grateful to see us as a society be leaders in getting these critical statements. You know, updating our own internal and external policies where needed swiftly. I agree with you, Max, that this is something we do well. Allison, your thoughts on this?

Allison Agwu: [00:13:45] You know, I reflect on Ryan White eligibility. I'm an HIV provider, and we used to torture people multiple times a year to provide all their paystubs and had implications for whether or not they were eligible and can continue their Ryan White eligibility, which gives them access to health care. And we heard from clinics that it was burdensome. We heard from patients, it was traumatizing and they simplify that, Right. So what how that eligibility gets done. It's been simplified and it's been met with much appreciation and less burnout from providers and less tense conversations with patients. I think what COVID did and I think we have to think about unintended consequences and this one was a good one. It allowed us to be more humane to our patients. Right?

Mati Hlatshwayo Davis: [00:14:22] Yes.

Allison Agwu: [00:14:23] Right. And we learned we can actually we can do telemedicine. We've been trying to do telemedicine in an effective way for years and couldn't do it. All of a sudden, within two months, we had fully active telemedicine clinics and expanding Medicaid and allowing providers to see patients across different vicinities. These were things that allowed us to literally meet people where they were, which was behind their screens because they couldn't come in. And I think this is one of those, what are we trying to do here? Are we trying to have the people get the coverage they need so they can have the care that they also need to address preventive illnesses to address not just COVID, but everything else? Or what is the end goal here? That's what the advocacy to me is about. Like, can we find a kinder, gentler way to maintain coverage for vulnerable people? That's it. And I think that's the advocacy piece of it.

Mati Hlatshwayo Davis: [00:15:10] I'm through. So that's exactly it. That leads me to my next issue around long term implications is that the asterisks on this is that listen, in the immediate term, outside of auto enrollment, you're not going to see a lot of things dry up the day after. But by around September, or November, there's no guarantee that there will be access to any of the things we've discussed today. And we know from those who keep up with what's happening on the Hill that if Congress doesn't throw money at this, things dry up this fall. Let's talk about the significance of that and who that is going to impact most. And I'm leading here, so I'm gonna go ahead and put my money where my mouth is first, is that the disappointment for me is that we made some of the biggest improvements in the work of disparities where we have seen for decades the same zip codes, the same minoritized and vulnerable communities in a copy and paste fashion, whether we're talking about high blood pressure or diabetes and now COVID, be disproportionately impacted. And we saw the government, because of how serious this pandemic was, do some new and innovative things. We're talking about $6 billion that was prioritized for community based organizations and trusted messengers with thoughtful language to ensure it actually made it to them with ease. Great! But again, it was short term, and now I interact with federally qualified health center leaders who are like, Wow, that was great. We now have all of these additional people we take care of and the money's dried up, right? So what are the implications there? But again, like you said earlier, both of you said earlier this disproportionately will impact those black and brown communities so we could undo and actually worsen the work that we did to bridge the divide for those disparities in COVID. Am I off here or how do you all feel about these long term implications?

Max Brito: [00:17:07] You know, the one good thing about this COVID pandemic is that it highlighted, it showed for everyone to see what we as providers see every day. I mean, the health disparities that not everybody understands or grasps the concept unless you are part of one of these minoritized communities and it put it open for everybody to see as a society. And I'm talking about the larger society, not the society, What is it that we're going to do using this experience? What is it that we're going to do to make some of these changes more permanent, more of these benefits that go on to resolve some of these issues in some of these socioeconomically disadvantaged communities? In this short term, it's going to create a problem because, as you say, some community based organizations, people who counted on this money to employ people, are probably going to have to let people go. They're going to cut on services and you name it. But in the long term, and I agree with Allison and seeing the silver lining here, there were some good things that COVID brought about from telemedicine to seeing patients in an expedited fashion, all of those things. How are we going to capitalize on that? And perhaps as a society, what we should be discussing is how do we come up with ideas that we can bring to legislators who typically rely on us to bring expertise and see if we can formulate them into law and try to see if some of these things could be appropriated. It's a role we play. Expect those emails from IDSA and please respond to them when they call you for legislative action.

Mati Hlatshwayo Davis: [00:18:46] And this is why you're on the board, Max, because you acknowledge the problem, but you immediately come with solutions and a call to arms for all of us. Because you're right, this is what we do best, right? We know what works. We know what we innovated around during the COVID 19 pandemic and knowing that in the long term, these dollars will dry up without intervention. We have the rest of the spring and the summer to really put together thoughtful advocacy around the very initiatives you just stated. So I love that. Allison, your thoughts here?

Allison Agwu: [00:19:25] We started with talking about what the Emergency Preparedness Act did, and it was it was all these things we've been saying was pie in the sky we could never do. It was within months or weeks. It was done, done, done, done, done. And we're talking about the medical aspects of it. But I think the social aspects of it were equally critical, right? The letting having people have food. Right. To support people, because you're right. What do you put forth as what we need? What are the critical things that you actually need? You know, focusing on health coverage. You need people to be able to be covered for the needs that they have. And these are going to have. So whether they're immediate needs like COVID or having a heart attack or how do you get preventative medicine, the public health infrastructure was decimated prior to COVID and that was built up. How do we make sure you solidify funds that that maintains right, where you can have, like you said, community health workers or have the capacity to take care of people within their communities? I think the other piece is the social pieces are probably may or may not want to advocate around them, but they mattered. I mean, food benefits went down. I had a family $600 to $100 within the space of four weeks, within a period of inflation. There's a lot happening and I think there is advocacy around how do we help people live. Many of the things that put people at risk for infectious diseases or social diseases, right? So because you're in poverty, you have this, that and the third and that's why you have this infectious disease. So I think if we can advocate around here is what we need for people to effectively live access food. I'll say all the things that. Maybe we actually get ourselves out of a job because they're less likely to have infectious diseases.

Mati Hlatshwayo Davis: [00:20:56] Come on, Alison. And so is that historically what we've called social and structural determinants of health, or are you thinking beyond or different from that?

Allison Agwu: [00:21:04] It is what we classically call social determinants of health, which is really just social inequities or social determinants of death, really. Right.

Mati Hlatshwayo Davis: [00:21:12] Getting fired up. Love this. Max, did you have anything else to add?

Max Brito: [00:21:16] Not only where these social determinants of health tested, I mean, all the problems came to the surface, but also we realized as a profession, as a profession, that there is a need for more infectious disease providers. We have an issue of workforce that, you know, is championing very efficiently. There are not enough of us to go around. There are not enough doctors to go around. In some communities, this is an area where could also be strengthened. How do we incentivize people to go into infectious diseases or primary care specialties, front line specialties when they're saddled with debt and they can't go into these specialties because they pay a little less? All those things should be part of the discussion. Importantly, how do we use these experiences and these things that we've identified as needs to prepare for the next pandemic? Because we know it's coming and we know it's going to affect disproportionately. We need to use those experiences to inform everything we do going forward.

Mati Hlatshwayo Davis: [00:22:20] Couldn't agree more. And as someone who was charged at a local level with leadership as it pertains to the response to Mpox, we were woefully, woefully unprepared and did not apply the lessons learned from COVID. And so it's important that we do a better job before the next one. Allison, I see you smiling and shaking your heads. Just let it out. Thank you for expressing that.

Allison Agwu: [00:22:47] I feel the same. I feel like we had just gotten out of COVID and we should have had the blueprints already there and we should have been able to launch right in. But, you know, I'll be speaking for my own institution. We couldn't even get the IRB approved quick enough to actually capture it. I'm like, Why is that? When everything was all set up and folks.

Mati Hlatshwayo Davis: [00:23:04] Can't see it, but Max and I are the hands are in the air. We're nodding because we all had similar experiences.

Allison Agwu: [00:23:11] I have that fear because you talked about how we've been documenting decade after decade overlaying hypertension or diabetes with this, where literally the maps look the same, HIV, they look the same. And then we say to ourselves, shocker, COVID. But then we threw a lot of rapid funds. We did lots of things at COVID and said, We know how to do this. And then we were beta tested not two years later and we failed. So what does that mean for the next pandemic that Max, you predicted is coming? Because I agree it's coming, but I don't know that the lessons learned have been solidified to help us in the next phase. And so, I mean, I think that's the piece that gives me angst, like how are we going to actually operationalize it for the next time?

Mati Hlatshwayo Davis: [00:23:54] Exactly. And if you overlay that with multiple adjacent but interlinked crises in gun violence, in behavioral health, in public health, where we lost 38,000 workers at the end of 2021, and this is your enforcement arm, we have a real issue. But like Max said, we have an opportunity around recruitment incentivization and retention efforts. We have to address this in our academic halls around what are we doing in orientation in medical school through dedicated courses, through radical radical adjustment of curricula at every level in health and public health, to make sure that every physician, every researcher and every public health specialist understands what's at stake. And we have a better job of creating the type of policy infrastructure that will then impact future leadership and funding that is necessary. The task is at hand. We just need to heed it. I'm going to end us off with a simple but difficult question. If there was one final call to arms that each of you had for your colleagues listening to this and to anyone else who isn't a colleague but is out there, what do you want to see happen in by way of next steps, whether that is clinically or for public health leaders? What is the call here and how do we advocate not only for ourselves but for the patient populations that we serve? And I'll come to you first, Max.

Max Brito: [00:25:35] We need to get involved. Even before the pandemic, we had seen apathy among health healthcare providers. I'm talking about physicians because that's who we represent. But we not only at IDSA, we not only represent physicians, we represent pharmacists and other, but health care providers. There is a little bit of apathy when it comes. We're very busy and it's apathy in getting involved and getting involved in these things that are not, as you said, that are not in the medical curriculum and should be like teaching people how to advocate for their patients, for themselves and for their patients. And I think the more involved we get and the more of us raise the voice and bring the issues forth. I keep talking about legislators, but it doesn't have to be just legislators, like in international forums. This was a global pandemic advocating for folks in any country, patients in any country, and people affected by health care disparities all over the world. If we don't understand that us as a community, physicians, health care providers need to advocate and get involved, then some of these things are going to keep happening. And we're not going to be effective in taking care of the larger pool of patients. We'll be able to if you practice somewhere that you don't have problems with uninsured and you that's not an issue in your community, then you know it's not going to be an issue for you. But I know for the three of us, this is an issue because we take care of folks who are disadvantaged. We can no longer ignore that this thing happened. And I think we need to raise the voice and we need to have a seat at the table wherever these things are being discussed, whether at the federal level, the state level or at the local level, city level, we need to be involved and we need all of you to get involved. From students to attendings to faculty, everyone needs to get involved and own a piece of advocacy because it's very important for our patients and for our profession.

Mati Hlatshwayo Davis: [00:27:35] Love that. Allison, you're going to bring us home here. Your thoughts?

Allison Agwu: [00:27:39] In addition to all the things we say about COVID to our patients, about avoiding being apathetic and, you know, for vulnerable patients and advising and washing your hands and covering your sleeves and all those things. The silver lining of the pandemic and the response taught me is that the status quo doesn't have to be. And I think for a long time there was this like, well, there's just no money. Oh, I guess we just can't do it. And within, like I said, weeks we saw what happens when you actually put money behind or you actually say there's a different way that it can be done. So I think it does boil down to advocacy. If you've ever been on the Hill, many of the people there have never met anybody that looks like the patients that we take care of, like the millions of people that that that got sick from COVID and died. And it's our job, I think, as doctors, as providers, to bring those people in the room and say they're just not items on a budget. They're actually people whose lives are impacted by what we do and not just by the medicine they get, but their entire lives. Right? So how do we make it better? And we know we can make it better because you did this for us. So give them kudos and say, how can we do more? But I think it's advocacy. It's taking those voices in all the rooms that we actually have privilege of stepping into.

Mati Hlatshwayo Davis: [00:28:51] Oh, I have such pride that we have this platform. I have such gratitude that you two were able to join me. I join you in this call to arms. May we go into every room with intention, at every level, federal, state and local. And let us remember the importance of this, because none of us want the same communities to be in the same positions that we have passively allowed them to be for decades now. Thank you both. This has been Let's Talk ID.

The lifting of the COVID-19 public health emergency at the federal level will have a significant impact on clinical care, public health and research in ID and beyond. In this episode, Mati Hlatshwayo Davis, MD, MPH, director of health for the city of St. Louis, is joined by Allison Agwu, MD, ScM, FIDSA, HIVMA chair-elect, and Maximo Brito, MD, MPH, FIDSA, an IDSA Board member, to discuss the urgency of prioritizing health equity beyond the end of the COVID-19 emergency order.




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