On September 4, 2019, hackers infiltrated the networks of Austin-based software company SolarWinds. Five months later, the hackers injected a malicious code known as SUNBURST within the SolarWinds Orion network management platform, which allowed the hackers to scan protected user data. By December 12, 2020, Solarwinds became aware of the infiltration and worked to respond in concert with U.S. government officials and agencies. 

But by then, the damage was done.

On January 5, 2021, the Cyber Unified Coordination Group (UCG)—a task force that includes the FBI, CISA, ODNI, and NSA—released a statement saying that 18,000 public and private sector customers had been affected by the breach, including government agencies such as the Departments of State, Defense, Energy, Treasury, and Commerce, as well as major companies including Microsoft, Lockheed Martin, Visa, and Mastercard. Microsoft President Brad Smith would later tell 60 Minutes that “from a software engineering perspective, it’s probably fair to say that this is the largest and most sophisticated attack the world has ever seen.”

The Biden administration attributes the attack to the SVR, Russia’s Foreign Intelligence Service, but officially, the Russian government claims no responsibility. Nevertheless, on April 15, 2021, the Biden administration announced measures against the Russian government in response to the SolarWinds hack (as well as Russia’s continued occupation of Crimea and interference in U.S. elections). These new measures include sanctions against individuals and entities, the expulsion of officials from Russia’s diplomatic mission in the United States, and a U.S. Treasury directive that “provides authority for the U.S. government to expand sovereign debt sanctions on Russia as appropriate.”

The implications of this hack will take years to fully comprehend. According to Brandon Wales, the Acting Director of CISA, a “strategic recovery” from the breach could take federal agencies between 12 to 18 months. And an analysis from BitSight and Kovr estimates “the insured losses to be $90,000,000, which includes incident response and forensic services for companies who were impacted by this incident and have cyber insurance coverage.”

Ultimately, the most significant consequence of the SolarWinds breach is that it revealed how deficient America’s cybersecurity strategy is. And worse, now our adversaries know this too.

The Biden administration has signaled its intent to make cybersecurity a national priority due to several breaches in recent years. On April 12, 2021, President Biden nominated Chris Inglis to be White House National Cyber Director and Jen Easterly to be the director of the Cybersecurity and Infrastructure Security Agency (CISA). Biden is also expected to issue several cyber-focused executive orders in the coming weeks.

On February 21, 2021, during an appearance on CBS’s Face the Nation, Biden’s National Security Advisor Jake Sullivan hinted that America’s response to the suspected Russian government-backed attack, which Sullivan said would happen within “weeks, not months,” will include a “mix of tools seen and unseen.” Now that the U.S. government has announced certain economic and diplomatic measures against Russia, The New Center wanted to provide a brief overview of what other options it might pursue.

“Seen Elements”

• Internal: Reviewing and overhauling U.S. cybersecurity infrastructure and policies in order to better anticipate and respond to future cyber attacks.

• Diplomatic: Establishing a more robust international cyber framework through engagement with allies and adversaries.

• Commercial: Mandating cyberthreat information-sharing between the public and private sector and holding companies liable for failing to enact appropriate cybersecurity standards.

“Unseen Elements”

• Covert Action: A counterattack on Russian critical infrastructure akin to the Stuxnet computer worm used to damage Iran’s nuclear program. Much like the “Operation Olympic Games” campaign from which Stuxnet originated, this action would likely not be acknowledged by the U.S. government.

On April 13, 2021, the Office of the Director of National Intelligence released the Annual Threat Assessment of the U.S. Intelligence Community. The report outlines a wide range of threats that the United States and its allies will likely have to contend with in the coming year. 

Below, The New Center provides summaries and key insights from the report, which focuses on major geopolitical trends, transnational issues, and regional conflicts and instability. If you want to do further reading on some of these challenges, we also link to papers from The New Center’s foreign policy series.

Major Trends

China

China’s goal is to expand its global economic and political influence at the expense of the traditionally U.S.-led international order. It seeks to achieve this goal through fortifying its military, nuclear, and space capabilities, strengthening its cyber-attack and cyber-espionage capabilities, and engaging in economic diplomacy (i.e., the Belt and Road initiative). China is beginning to test the reach of its growing influence by meddling in Hong Kong’s democratic process, threatening Taiwan’s pro-independence faction with forced reunification, and making expansive territorial claims across the South China and East China Seas.

Russia

Even though Russia believes it is beneficial to engage with the United States within areas of mutual interest, it still seeks to undermine U.S. influence not only within what it considers its own ‘sphere of influence’ but also around the world. Much like China, Russia is bolstering a wide range of capabilities to advance its interests against those of Western nations. Its global engagements—ranging from support for the Cuban and Venezuelan governments to interventions in Syria and Libya—demonstrate a desire to be a key player on the world stage. At the same time, Russia must contend with growing domestic political dissent, which it seeks to stifle through methods such as public assassinations, the most recent attempt being the poisoning of opposition activist Alexey Navalny in 2020.

For more information on the challenges President Biden may face in Europe and Eurasia, read The New Center’s February 2021 primer, “Foreign Policy Challenges Facing The Biden Administration: Europe and Eurasia.”

Iran

Iran’s top priorities are ensuring regime stability, building deterrence capabilities against adversaries, and increasing its influence in the region. Iran has solidified its deterrence capabilities through conventional and unconventional military weaponry. It is also expected to increasingly use cyber warfare operations to target adversaries through a low-cost, high-yield method. Beyond that, Iran will continue to seek influence in the Middle East region by funding and arming militias and insurgencies in Afghanistan, Iraq, Lebanon, Pakistan, and Yemen, as well as providing direct support in conflicts such as the Syrian Civil War. Regarding its nuclear program, Iran is expected to continue to violate the terms set forth under the JCPOA (such as enriching uranium at higher levels) if it does not get sanctions relief, but these violations are likely intended to draw the U.S. back to the negotiating table.

North Korea

For North Korea, no amount of international pressure seems to be effective at preventing the regime from developing the nuclear and ICBM capabilities it believes necessary to deter threatening actors such as the United States and South Korea. Its resilience in the face of a global sanctions regime means that it has made significant progress on its conventional military capabilities, long-range missile capabilities, and cyber warfare program—all of which pose a growing threat to the United States and its allies.

Transnational Issues

COVID-19 Pandemic and Diseases

COVID-19 continues to be a public health risk that will disrupt our economy and way of life until vaccines and therapeutics have been sufficiently distributed across the globe. The social and economic effects of the pandemic are also inducing food insecurity, internal conflicts, and migration. Some governments struggling to contain their COVID-19 cases and deaths are reconsidering global cooperation on transnational security and diplomatic issues in favor of tending to their own populations; others, such as Russia and China, see ‘vaccine diplomacy’ as an avenue to cultivate more soft power.

Climate Change and Environmental Degradation

2020 was the hottest year on record, and with greenhouse gas emissions increasing, climate change and environmental degradation will only continue. Weather events will become more frequent and intense, displacing populations, threatening critical infrastructure, and increasing conflict over water, food, and other resources. Air pollution brought on by environmental degradation will lead to more premature deaths due to related health issues such as heart disease, lung cancer, and pneumonia.

For more information on the breakthrough technologies the U.S. can invest in to combat climate change, read The New Center’s May 2019 report, “Double Down on Federal R&D for Breakthrough Energy Technologies.”

Emerging Technology

The scale of research and development (R&D) funding that has been poured into emerging technologies in recent years has led to significant advances in the fields of computing, biotechnology, artificial intelligence, and manufacturing. While the widespread proliferation of breakthrough technologies can be a social good, the assessment notes that certain technologies in the hands of actors such as Russia and China can increase their military and economic edge at the expense of our own.

Cyber

Cyber threats from nations such as Russia, China, Iran, North Korea, and independent actors are expected to become increasingly prevalent. Adversaries will seek to collect intelligence, damage critical infrastructure through cyberattacks, and, in the case of recent U.S. presidential elections, damage social cohesion by exploiting existing societal rifts. Beyond focusing attacks on enemies abroad, regimes will also utilize cyberspace at home to maintain regime stability, control their own populations, and stifle dissent.

For more information on how the U.S. can tackle its persistent cyber vulnerabilities, read The New Center’s March 2020 report, “Cybersecuring America.”

Foreign Illicit Drugs and Organized Crime

Although travel restrictions instituted to stop the spread of COVID-19 temporarily curtailed the flow of foreign illicit drugs (such as cocaine, fentanyl, heroin, marijuana, and methamphetamine) into the United States from Mexico, drug trafficking remains a critical threat to the American population, particularly as overdose deaths have increased each year since 2018 according to the Centers for Disease Control.

Migration

Despite COVID-19 travel restrictions, migration and refugee flows are expected to continue increasing. While Europe has experienced a decrease in migration from the Middle East and North Africa since 2015, the United States will see a surge of migration not only because of the new presidential administration but also due to long-standing criminal and economic issues in Central America now coupled with hardships brought on by COVID-19.

Global Terrorism

Terrorist organizations such as ISIS, Al-Qa’ida, and Hizballah continue to present risks to American security interests both at home and abroad. However, ISIS and Al-Qa’ida’s operational capabilities have weakened. Instead, Domestic Violent Extremists (HVEs) and Homegrown Violent Extremists (DVEs) now represent the most salient domestic threat.

Conflicts and Instability

Afghanistan

Although President Biden has announced the withdrawal of U.S. combat troops by September 11, 2021, there is little prospect of conflict ending within Afghanistan soon. The Afghan government, while it has secured major cities, has been ineffective in holding territory. This, in turn, has encouraged Taliban forces to sideline a peace process in favor of attempting to secure a military victory.

India-Pakistan

Tensions between India and Pakistan remain high, but are unlikely to develop into an outright war between the two powers except in the event of critical flashpoints such as “violent unrest in Kashmir or a militant attack in India.”

Middle East

Long-standing conflicts across the Middle East—including those in Iraq, Libya, and Syria—have little chance of short-term resolution in the face of continued domestic upheavals, terrorism, Iranian diplomatic machinations, and the economic consequences of COVID-19.

For more information on the challenges President Biden may face in the Middle East, read The New Center’s February 2021 primer, “Foreign Policy Challenges Facing The Biden Administration: Middle East.”

Asia

Myanmar’s democratic transition has been stunted by a military coup. Now, protesters are being met with a deadly crackdown by Myanmar’s military as it attempts to secure control.

Latin America

Nations across Latin America—including Honduras, Nicaragua, Columbia, Guatemala, Peru, and Venezuela—will likely see further instability this year as a result of tense election cycles, persistent crime and drug trafficking, and deteriorating economic conditions.

Africa

The African continent is expected to face increased conflict this year. Ethiopia’s Tigray crisis, Sudan’s intragovernmental power struggles, and Somalia’s raging civil war will plague East Africa. West Africa, the Sahel, and portions of Eastern and Southern Africa are expected to experience heightened terrorist activity as a result of “conflicts, undergoverned spaces, the marginalization of some communities, and persistent communications connectivity.” Upcoming elections across Sub-Saharan Africa are also likely to foster increased tensions.

For more information on the challenges President Biden may face in Africa, read The New Center’s February 2021 primer, “Foreign Policy Challenges Facing The Biden Administration: Africa.”

On January 6, 2021, a large mob attacked the United States Capitol building in an attempt to stop the counting of state electoral votes that would certify Joe Biden as President.

Law enforcement ultimately subdued the rioters, and Joe Biden was certified as the next president, but not before five people, including one police officer, were killed. In the aftermath of the January 6 attack, law enforcement has charged a growing list of over 270 people with various crimes, including entering a restricted building or grounds, disorderly or disruptive conduct, assault, and theft of government property.

During a Senate Judiciary Committee hearing on March 2, 2021, FBI Director Christopher Wray said that the attack on the Capitol “was criminal behavior, plain and simple, and it’s behavior that we, the FBI, view as domestic terrorism.”

The U.S. government has a clear definition of domestic terrorism and the FBI Director explicitly called the siege a domestic terrorist attack. Despite this, not a single perpetrator will be charged with domestic terrorism because the United States doesn’t classify “domestic terrorism” as a crime.

However, if any of these individuals demonstrated links to a Foreign Terrorist Organization (FTO) and had a clear political or ideological motive, law enforcement could charge them with terrorism. In the absence of these criteria, an individual who perpetrated an attack in the United States would need to be charged with a related crime, which may not carry the same weight as a terrorism charge.

The United States has been plagued with several high-profile domestic terror events in recent years, including a shooting at a synagogue in Pittsburgh, Pennsylvania in 2018, a shooting at a Walmart in El Paso, Texas in 2019, and, most recently, the siege on the U.S. Capitol in 2021.

Lawmakers on both sides of the aisle have advocated for measures to address perceived gaps in domestic terror tracking and prosecutorial capabilities. In 2019, former U.S. Senator Martha McSally (R-AZ) and Congressman Adam Schiff (D-CA) introduced bills in the House and Senate that would criminalize domestic terrorism. Most recently, during FBI Director Wray’s March 2 testimony to the Senate, Senator Lindsey Graham (R-SC) said, “I don’t know if we should have [a domestic terrorist list] or not…but I think it’s time to think about it.”

Broader prosecutorial and classificatory mechanisms are opposed on several grounds. In a statement submitted in September 2019 to the Senate Committee on Homeland Security and Governmental Affairs, the ACLU argued that the FBI and other law enforcement agencies already had all of the tools and authorities they needed to successfully counter threats of domestic terrorism and that expanded authorities would only serve to further target historically marginalized communities and individuals with controversial beliefs.

New measures are also criticized on the grounds that they may violate First Amendment rights. During a January 2020 hearing before the House Committee on Financial Services, the former head of the Justice Department’s National Security Division Mary McCord testified that “hateful speech, even if abhorrent to the majority of the population, is protected by the First Amendment, as is assembling with others who share the same hateful views. Unless an organization engages solely in unprotected activity, such as committing crimes of violence, any designation of a U.S. organization would likely run afoul of the First Amendment.”

The ability to designate groups in the United States as terrorist organizations and prosecute them for domestic terrorism might also contribute to growing political polarization. 

Lawmakers could potentially target groups simply because of their message and political leaning and not because of the real danger they may pose to our national security. This is not unprecedented; while still in office, former President Donald Trump tweeted that “The United States of America will be designating ANTIFA as a Terrorist Organization.” And in Montana, a group of lawmakers introduced a bill in February 2021 that would designate ANTIFA as a domestic terrorist group, though it is not expected to pass.

Terrorism expert Brian Michael Jenkins instead advocates for “efforts against the violent extremists to be done within the ordinary criminal code…Put aside the political pretensions; don’t give them that. These are crimes—murder, assault, willful destruction of property—deal with it on that basis.”

In the October 2020 Homeland Threat Assessment, the U.S. Department of Homeland Security identified lone offenders, Domestic Violent Extremists (DVEs), and foreign terrorist-inspired Homegrown Violent Extremists (HVEs) as the “primary terrorist threat inside the United States” that will “drive an elevated threat environment at least through early 2021.”

Countering this threat should be a top priority for the Department of Homeland Security and other law enforcement agencies. But changes shouldn’t be made hastily, and they certainly shouldn’t come at the expense of historically marginalized communities, First Amendment rights, and desperately needed national and political unity.

This publication originally appeared on RealClearPolicy on March 18, 2021.

Image: Drew Angerer / Getty Images

In mid-February 2021, a severe winter storm hit Texas and neighboring U.S. states, bringing record-low freezing temperatures, snow, sleet, and ice. Storm warnings were issued before the weather turned, but no amount of advisories could have prepared Texans for what was to come.

At the height of the storm, PowerOutages.US reported that over 4.5 million homes and businesses in Texas had lost power. And it could have been so much worse; according to the Electric Reliability Council of Texas (ERCOT), the power grid was “4 minutes and 37 seconds away from a total collapse,” which would have sent the entire state of Texas into total blackout.

The storm also disrupted food and water supplies across the state, leaving about 12 million people on “boil water” notices and grocery stores unable to stock shelves to meet the growing demand for emergency supplies. AccuWeather estimates the total economic damage caused by the storm to be between $45 and $50 billion. And dozens of Texans have died so far due to hypothermia, carbon monoxide poisoning, house fires, untreated medical conditions, and winter weather accidents, alongside other reasons attributable to the storm. Still, officials will not know the full extent of the storm’s far-reaching effects for months to come.

Satellite images of Houston, Texas, on February 7, 2021 (top), and February 16, 2021 (bottom), depicting the extent of electricity loss. Source: National Aeronautics and Space Administration.

Although the severity of the storm was unpredictable, the response from political leaders in Texas and Washington has unfortunately been utterly predictable. In an interview with Fox News host Sean Hannity, Texas Governor Greg Abbott claimed that the state’s widespread outage “shows how the Green New Deal would be a deadly deal for the United States of America.”

Many Democrats, for their part, echoed White House Press Secretary Jen Psaki who said that “it was failures in coal and natural gas that contributed to the state’s power shortages.” 

In reality, the kind of energy sources Texas was using is the least relevant aspect of this crisis. It was the power grid—the whole system for transmitting and distributing energy—that led Texas to the brink of disaster. According to Dan Woodfin, a senior director at the Electric Reliability Council of Texas (ERCOT), “nuclear units, gas units, wind turbines, even solar, in different ways—the very cold weather and snow has impacted every type of generator.” Generators were impacted because they were not adequately “winterized,” meaning they lacked defenses against harsh winter weather conditions.

How Texas Generates Its Electricity. Source: Niall McCarthy, Statista.

In the aftermath of the February 2021 storm, Governor Greg Abbott announced that the state had “already begun the process to make sure that events like this never happen in Texas and that starts with reforming the agency in charge of electric reliability in Texas, which is ERCOT…I’m asking the Legislature to mandate the winterization of generators in the power system. I’m calling for the funding needed to ensure that this winterization and modernization occurs.”

But if history is any guide, the Texas legislature may not heed the Governor’s call for more investments in grid resiliency and winterization. Texas lawmakers faced a similar choice following the winter storm that hit Texas and other Southwestern states between February 1-4, 2011. During the storm, a total of 4.4 million people lost electrical power. In the aftermath, the Federal Energy Regulatory Commission and the North American Electric Reliability Corporation released a report on what caused the widespread outages, one of the reasons being that “the lack of any state, regional or Reliability Standards that directly require generators to perform winterization left winter-readiness dependent on plant or corporate choices.” Many of the recommendations in the report were either not implemented or were released as “best practices,” meaning power generators were not mandated to follow any new winterization procedures.

This isn’t just a Texas problem. Even at the federal level, legislators have ignored the threat of widespread power grid failure for years. In 2008, the Commission to Assess the Threat to the United States from Electromagnetic Pulse (EMP) Attack released a report detailing how critical national infrastructures might be affected by an EMP attack. The report warned that:

“Electrical power is necessary to support other critical infrastructures, including supply and distribution of water, food, fuel, communications, transport, financial transactions, emergency services, government services, and all other infrastructures supporting the national economy and welfare. Should significant parts of the electrical power infrastructure be lost for any substantial period of time, the Commission believes that the consequences are likely to be catastrophic, and many people may ultimately die for lack of the basic elements necessary to sustain life in dense urban and suburban communities.”

Though the report was focused on an EMP attack, its recommendations could easily apply to any unforeseen attack or weather event that could jeopardize the electric grid. But according to some of the original members of the EMP Commission, lawmakers have not, as of 2015, implemented any major recommendations from the Commission, leaving America vulnerable to what the authors believe to be a “civilization killer.”

What happened in Texas was clearly not the result of an EMP attack. But whether it’s an EMP attack or a severe winter storm, the outcome is the same: an event disrupts the nation’s power supply, and ordinary Americans have to fight for their lives to survive. And things will only get worse unless we invest in what is needed to make our grid more resilient.

Thus, the choice for lawmakers is clear: prioritize bolstering our national power grid or continue to knowingly put millions of American lives and livelihoods at risk.

On January 28, 2021, the New York State Attorney General Letitia James released a report detailing her office’s investigation into how New York State nursing homes responded to COVID-19. The report found that nursing homes failed to comply with infection protocols, lacked the personal protective equipment needed to keep residents and staff safe, and did not conduct enough testing to properly track the spread of the virus. Most notably, nursing homes and the New York State Department of Health (DOH) appear to have undercounted total nursing home deaths by about 50%.

The OAG report identifies guidance issued by the New York State DOH on March 25, 2020, which prohibited nursing homes from refusing to admit patients based on a confirmed or suspected COVID-19 diagnosis, as a potential cause for the increased infection rates and deaths of nursing home residents, writing that “the peak single day in reported resident COVID-19 deaths was April 8, with 4,000 reported deaths occurring after that date.”

The March 25 guidance from the NYS DOH, which was later rescinded, drew widespread criticism, to which New York State’s Governor Andrew Cuomo responded by saying that “the policy that the [New York] Department of Health put out was in line directly with the March 13 directive put out by (Centers for Disease Control and Prevention) and (Centers for Medicare and Medicaid Services).” 

The original CMS and CDC guidance, issued on March 13, 2020, stated that “a nursing home can accept a resident diagnosed with COVID-19 and still under transmission-based Precautions for COVID-19 as long as the facility can follow CDC guidance for Transmission-Based Precautions. If a nursing home cannot, it must wait until these precautions are discontinued.” The guidance included a note that said, “nursing homes should admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was/is present. Also, if possible, dedicate a unit/wing exclusively for any residents coming or returning from the hospital.”

Ultimately, states had the authority and the ability to decide against sending COVID-19 patients back to nursing homes if they did not think the nursing homes were equipped to handle them. And many states, including Massachusetts and Connecticut, interpreted the federal guidance in this way. But other states, including New York, New Jersey, and California, did not, and instead felt they needed to mandate nursing homes accept COVID-19 patients.

The confusion stemmed from a single problem: the difference between federal laws, guidance, and regulations. According to the Department of Health and Human Services (HHS), federal laws are used by government agencies as the basis for publishing regulations, which “[hold] the force and effect of law, and [establish] requirements.” Agencies will then use guidance to clarify regulations and explain how an agency should interpret them; however, “compliance with Guidance and Guidelines is voluntary unless the Guidance or Guidelines are incorporated into a regulation, or become a term and condition of an agreement.”

Different state interpretations of federal nursing home guidance were a recipe for confusion in the midst of a pandemic that has claimed the lives of at least 152,000 nursing home residents and staff to date—about 35% of all COVID-19 deaths in the United States.

The CDC can take one simple step to end this confusion. Moving forward, all nursing home policies released by the CDC and CMS that specifically pertain to COVID-19 should be clear and codified regulations, rather than just guidance, so that they become legally binding. 

Early in the pandemic, when information was scarce and incomplete, perhaps guidance was the best the CDC could offer. But moving forward, the pandemic stands a much better chance of being contained with more consistent and binding directives.

To learn more about COVID-19 in nursing homes, read The New Center’s issue brief, “COVID-19 in Nursing Homes: How Could We Let This Happen?” from June 2020.

With so much noise surrounding the 2020 election, it’s easy to forget that this process hinges on one central question: what does it take for a candidate to go from president-elect on November 3rd to officially being sworn in on Inauguration Day?

Our election system functions in two tracks: one being the official electoral process, and the other being the behind-the-scenes process that allows a candidate to smoothly transition from president-elect to officially being in power on January 20th. Check out this infographic from The New Center so you know what to expect next.

At this moment in American history, when the far right and far left seem to have so much influence in American politics, people often wonder: What happened to the political center?

To find the political center in America, you first need to know where to look. That’s why The New Center recently commissioned a poll from HarrisX and the Society of Presidential Pollsters to identify where the center lies for the American public on today’s most salient policy challenges and ideological, values-driven debates.

Our poll found that voters tend to have very nuanced views on many issues at a time when our political system increasingly demands that elected officials embrace rigid views completely out of step with most Americans. And given the inability of Washington to reflect the public’s nuanced views, it’s no wonder that 70% of the respondents polled believe that Congress is not working, and 83% of respondents believe that the system of creating bipartisan legislation in Congress has broken down.

To find out more about where Americans place themselves on a variety of critical policy issues, read our poll findings above or download them below.

Although there is so much we still do not know about COVID-19, public health officials and doctors were sharing the same urgent message from the beginning of the outbreak in early 2020: The older you are, the more likely you are to die if you contract the disease.

And yet, somehow, America allowed its nursing homes to become the epicenter of the worst COVID-19 outbreak in the world. According to data analysis from The Foundation for Research on Equal Opportunity, over 40% of those who have died in the U.S. from COVID-19 have been residents or workers in nursing homes or long-term care facilities. On this episode of Centering on Coronavirus, Policy Analyst Aleksandra Srdanovic interviews Gregg Girvan, a Health Care Policy Expert at the FREOPP, on how the high death toll amongst nursing home residents has profound implications for the way we’ve managed the coronavirus pandemic.

For more insights on the impact of COVID-19 on nursing homes, you can read The New Center’s issue brief “COVID-19 in Nursing Homes: How Could We Let This Happen?”

Transcript:

Gregg Girvan: My name is Gregg Girvan. I am the research fellow at the Foundation For Research on Equal Opportunity. I perform a lot of the data analysis that we do, especially on the healthcare side. We had several projects going on even before the coronavirus came onto the scene. Essentially, I dive deep into the different issues with a lot of different aspects of healthcare policy. We’ve been working quite a bit on doing a country by country comparison of healthcare systems. It’s been an ongoing project we’ve been working on for quite a while now, but obviously when the coronavirus hit, we definitely pivoted toward that. And that’s been what we’ve been talking about.

A lot of people are now familiar with our work, given that they’ve seen our comprehensive plan on reopening the economy. Even despite the coronavirus pandemic and this sort of FREOPP plan that we have that has gotten a lot of attention, we were really the first ones to ask the question, if we don’t have an effective treatment, if a vaccine doesn’t come on the scene anytime soon, if at all, and if we have trouble with other things like scaling up testing, what do we do then? Do we just remain locked down, or do we find in the data and what we know about the virus, a way or ways to selectively reopen in certain ways so that we can get as many people as possible back to school, back to work, and still protect those who are most vulnerable.

Out of that plan that we’ve been talking about for a couple of months now, it began to emerge in the data that the nursing home crisis was really starting to become a real problem. When you discover that well over 40% of people have died from the virus so far are nursing home and assisted living residents, and yet they only comprise 0.6% of the population, that gives you a very clear indication that this is an extraordinary problem within nursing homes, but it also informs how we reopened the rest of the economy. It tells us that maybe sort of the optimistic view here is that the fact that so much of the problem is concentrated in nursing homes means that it may not be the same danger or threat to those outside of nursing homes, including those who are elderly, as we perhaps thought before. 

Aleksandra Srdanovic: On the topic of nursing homes, you’ve brought up that statistic of these nursing home and assisted living facility residents accounting for over 40% of deaths. We knew pretty early on into the pandemic that the disease would be particularly deadly for older people with underlying health issues, which of course describes a lot of people who live in nursing homes. I’m wondering if you think local or federal government entities acted too late to protect them. Or do you think that they took action, but it was just inevitable?

Gregg Girvan: Well, there is certainly the thought out there that these particular places were vulnerable prior to the pandemic. And we look at just the hundreds of thousands of people, nursing home residents, who are affected every year by any number of different bacterial or viral pathogens. And this is a pretty common problem just outside of there being the coronavirus. There’s certainly the thought out there that this was a vulnerable population to begin with.

That being said, what we kept hearing as this became a larger and larger problem in the United States was that we have to institute these lockdowns and we have to engage in social distancing and all these other different pandemic tactics that were from this previous playbook for influenza type viruses, where we needed to shut things down in order to prevent our hospitals from being overrun. That was really the main focus was to make sure that hospitals were able to handle the influx of patients that were going to come in, that we’re going to have to take up those ICU beds.

When the original plans were being drawn up by federal state, local governments to deal with the crisis, the focus was completely on hospitals. And unfortunately, that meant that these other areas like nursing homes and assisted living facilities did not get prioritized like our hospitals did. And there was good reason to prioritize the hospitals. And certainly in certain urban areas like New York City, where there was a huge spike in the number of patients and the number of hospitalizations. But it’s become clear looking back that this was an area where really all levels of government, federal, state, local government did not measure up in terms of being able to protect those who truly are the most vulnerable.

You have to think if you look at the people that are in nursing homes and their levels of need, you talked about the comorbidities that these people had. These are people that need a tremendous amount of help. They have a high prevalence of cardiovascular disease, diabetes. You can imagine among this pandemic with people who, for instance, are diabetic and they need to leave their nursing home to have dialysis. You think about the danger that presents for that individual with the coronavirus and this increased likelihood that they would become infected simply because they have to leave the nursing home and undergo dialysis.

And then you look the other way where you have a lot of these healthcare workers in nursing homes that don’t live at the facility obviously, they have lives outside of the facility and oftentimes they would get infected, they’d be asymptomatic and they’d bring the virus right into the nursing home where, because of the congregate nature of nursing homes, where oftentimes residents are sharing a room, sometimes there’s even up to four in one large room, or up to four that are sharing a bathroom, for instance.

And then combine that with the fact that these facilities have had difficulties in the past with infection control and then layer on top of that, the fact that you have an elderly population that has a lot of these comorbidities. It was really a perfect storm for widespread infections and a high fatality rate. This is obviously something that we’re going to have to reckon with as the pandemic one day eventually dies down and we’re looking back and assessing all of this. It’s pretty clear that our model for protecting really the most vulnerable among us, pretty much failed. And we’ve got to make some major changes in order to protect residents from the next pandemic.

Aleksandra Srdanovic: I think that the general perspective on how the federal government states approached the nursing home has been negative. But do you think that there’s any states whose policies have been particularly successful at preventing the spread? Have you found some states that have lower rates of cases and deaths in nursing homes or that have been particularly unsuccessful, or do you think it’s pretty much the same across the board?

Gregg Girvan: Well, for sure, there have been problems with this particular population since the pandemic began pretty much across the United States with certain exceptions. There are a few states, for example, the ones that come to my mind are states like Alaska and Hawaii that haven’t had really any fatalities, or they’ve only had some in the single digits. A part of that simply has to do with the fact that those are populations that are more remote, they’re more removed from where the epicenters of the virus have been.

Contrast that with essentially New England, if you look really far along the I-95 corridor from basically Maryland up through Massachusetts, you’ve had a really high rate of infection and high fatality rates, especially in nursing homes. And part of that simply has to do with the fact that that’s where the epicenter of the virus has been, and the population is more dense there, so you’re going to have more nursing homes there. And on top of that, you’re just going to have the people in closer proximity to one another, so there’s that factor.

If you look at other states though, that do have higher levels of population, for instance, you have a state like Texas or Florida, those couple states have done a reasonably better job of keeping the virus out of their nursing homes. Part of that has to do with the fact that very early on, they made a conscious decision to not send those residents [who had gone to hospitals] back to the nursing home before they were completely clear of the virus.

Then you look at other States like New York, under Governor Cuomo’s orders, you look at a state like Michigan that is still doing this. They are still taking patients that were in nursing homes, they’re treating them in the hospital, and then out of fear that their hospitals would be overrun, that they would not have enough beds, they’re sending these individuals back to the nursing home before they’ve been completely clear to the virus, before they’ve fully recovered. And it’s pretty clear that that has yet another way that the virus has spread throughout these facilities.

A lot of these state governments that have had these orders in the past, or still have them in place now, will say, “We have procedures in place to separate those individuals and to keep them separate from the rest of the nursing home population.” But the fact is there are a lot of nursing homes that were not even equipped to do that and yet they were still being forced to take these patients back into nursing homes.

Really, the first thing that has to be done in order to address the crisis in nursing homes is these orders need to be rescinded. It’s very clear looking at the data that the rate of hospitalizations has for the most part across the country, been on the decline. There are a few states, a few localities where there’s an uptick as testing has increased as the states have opened up. But for the most part, the rates of hospitalizations have been on the decline and there is plenty of capacity in hospitals. These orders need to be rescinded, and that’s first and foremost.

States like Texas and Florida never had those orders in place, and rightly so in order to prevent the infections from starting from those individuals being returned to the nursing home. It’s policies like that that have helped states like Texas and Florida. As I said, going forward, these orders need to be rescinded, but on top of that, there needs to be better protocols put in place for infection control. We need to ensure that these facilities have adequate personal protective equipment for the staff as well. That’s something that, again, we prioritized for hospitals and made sure that we ramped up PPE capacity for hospitals, but nursing homes really became an afterthought. And there are plenty of nursing homes, according to the data that we’ve seen, that either don’t have enough PPE right now, or they don’t have enough to handle a surge in cases within their facilities. Those are some of the things that state and local governments really need to focus on.

Aleksandra Srdanovic: It seems like those reforms are very COVID focused, like providing PPE and making sure that they have these infection protocols in place. But a lot of the issues that the states have had with their COVID-19 policies, it seems like have been exacerbated by a lot of underlying and longstanding issues in how nursing homes are run and regulated, namely underfunding, and it seems like there’s lapses in state inspections and there’s inadequate training for staff. So I’m wondering, what are some of the broader and long term reforms that you feel like are necessary to ensure that these nursing home residents have better living conditions once COVID-19 has passed?

Gregg Girvan: Sure. Aleksandra, you bring up a really good point here. And that is that the problems that we’re seeing in nursing homes in relation to the coronavirus and really in relation to any major disease outbreak is the fact that this has been a longstanding problem and a structural problem that has really been multiple decades in the making. This is also something that I’ve written about recently, where really, you look at the business model of nursing homes, and it really lends itself to the problems that you’re seeing right now, especially in terms of understaffing and in terms of not having adequate infection controls and PPE storage.

What you have to understand is: what is the business model? How are these nursing homes really being run? The idea is to follow the money, as with so many other things. That it’s really about where the money is coming from in order for these nursing homes to operate. Really in this country, most people don’t realize that the oversize role that Medicaid plays in paying for residents in nursing homes.

For nursing home residents, you basically have two subsets of populations. One is those who are going to nursing homes for a specified shorter duration of time in order to recover from a major surgical procedure, say a hip replacement. These people are in there for post-acute care as they call it. These individuals, when they’re elderly, age 65 or older, Medicare is paying for those individuals. And Medicare pays at a much higher reimbursement rate than Medicaid does.

Contrast that with the second subpopulation, and these are the individuals that are in long term care facilities and nursing homes for a longer period of time or indefinitely. And these are individuals that are not necessarily there because they’ve had a surgical procedure or something to that effect, they’re there because they need assistance with what we call activities of daily living or ADLs. And these are things that we often take for granted in our normal, everyday life. But they’re things like walking, dressing, eating, getting in and out of bed, so what they call transferring. These particular individuals need assistance with those kinds of activities, they can’t do them on their own anymore.

These individuals typically are in these facilities fees and are being paid for by Medicaid. And this really has a lot to do with just the way that the Medicaid law has been written over time. And what we find is when nursing homes or when long term care was originally made part of a Medicaid, or it being a service reimbursed by Medicaid, they were just for nursing homes. That was the only thing Medicaid would reimburse for back in the early 1970s. There became what we call institutional bias, where people were getting long term care services and nursing homes only in, really in what we call institutional settings. These are settings that are higher levels of care, and they look a lot more like hospitals, if you look at just the way they’re structured physically.

The thing to remember is that with Medicaid, they’re getting paid at a much lower reimbursement rate. What these nursing facilities often have to do is they have to increase their mix of Medicare patients or patients who are paying through long term care insurance, or simply paying out of pocket in order to cover the residents that are paying through Medicaid, because the Medicaid reimbursement rates often don’t even cover their cost of care.

Nursing homes, because they have such a high level of Medicaid patients on average, 62% of nursing home residents are on Medicaid. When you look at that fact, you could see how they operate on pretty razor thin margins. Then if you layer on top of that  the coronavirus pandemic and how that’s affected that case mix, you still have a lot of these people in there who are on Medicaid, but because the hospitals have been closed to non-elective procedures, the number of residents that are paying through Medicare that are just there for post-acute care has decreased rapidly because nobody’s having those surgical procedures done with the hospitals being closed down. They’re only starting to reopen in certain places now. So that’s a major revenue stream that the nursing homes have also lost out on, on top of the fact that nobody wants to live in a nursing home right now. Understandably so, given the crisis that’s been going on.

Prior to the pandemic, you have a very tenuous and very shaky business model to begin with that has just been blown apart by the pandemic. Going forward, what is this going to look like? What is long term care going to look like? And the answer is we don’t know for sure, but looking at how things are breaking down right now, it’s pretty clear that the demand for living in a nursing home is going to go down even further. The problem again, is that there are certain ways in which the Medicaid Laws are written that’s still biased toward placing people in nursing homes.

They’ve done quite a number of things over the years with Medicaid waivers to try to encourage people to receive these kinds of services in their home or in the community and in a lower impact settings so that they could still receive these services in the community, but not be as intense. But that being said, a lot of those waivers have waiting lists, and there just isn’t enough room for a lot of those people to pull down those services in Medicaid so they still end up in a nursing home anyway, and looking forward, we really have to deal with that. That’s going to be a structural problem that has to be dealt with and reformed one way or another.

We definitely need to introduce more flexibility into the Medicaid programs so that these individuals, at least for now, can seek long term care services in other settings, other than nursing homes. We don’t even know how many nursing homes are going to be around really after the pandemic sort of fizzles out. We just don’t know how many are going to survive, there’s probably going to be a lot of consolidation in the industry as well.

Really, what we need to do is we need to be thinking more holistically and from a 30,000 foot view and say, “How are we going to provide these services to individuals and how are we going to pay for it?” Because clearly the model that we have now is not sustainable. We need to find ways to encourage people to save for this, to increase their uptake of long term care insurance. It’s easier said than done because of the market power so to say that Medicaid has in long term care, but that is going to have to change because of what’s going on on the ground.

Aleksandra Srdanovic: That’s a really fascinating point that you make about the funding structure. I think a lot of people probably don’t know how much of an impact that has on how these nursing homes are run. Thank you for diving deep into that. I think those are all the big points that I wanted to cover with you on my end, unless you think that there’s anything that we missed that you thought was really insightful or important to bring up?

Gregg Girvan: The last thing that I would mention is the fact that throughout this whole thing, it’s been very difficult to obtain data as somebody who works with this on a daily basis. It’s been difficult to find what’s been going on in certain states and even in States like Michigan, where again, they still have these orders in place to send recovering patients back to nursing homes, and yet, you can’t even get accurate numbers from the state in terms of how many people are infected, how many fatalities have happened in these different facilities.

Now, CMS is really trying to obtain this data. And in early May, they put that into place where all the nursing homes that we’re receiving either Medicare or Medicaid funding were required to report to CMS on data points, such as the ones I’ve mentioned. And the thing to remember about that is that that rollout has been shaky. It’s been… The data that they have out right now is not accurate, or at least that the level of accuracy that we want to see. We’ve been diving into this data, and for instance, there have been nursing homes that somehow reported that they had five, six, 700 fatalities in their nursing homes. And yet these are nursing homes that may only have a hundred or 150 that’s to begin with.

Some of the data has not been released to the public properly, so we just have to wait for that and wait for those corrections in order for us to give a better idea, or at least for that comprehensive nationwide reporting to give us some clearer pictures, but we should be getting better updates in the coming weeks as we go.

That being said, again, at the Foundation for Research on Equal Opportunity, we’ve been going really state by state and finding this data. And again, most underappreciated fact or statistics in this whole pandemic is the fact that again, over 40%… according to our calculations, over 42% of people who have died from the virus have died in nursing homes, and they only make up 0.6% of the entire US population. And because of that, we know that we can take steps to reopen the economy, to reopen schools, because it’s a much less significant threat to those populations than it is to say folks in nursing homes.

This is really the most under-appreciated statistic, and once people really understand that it will help to inform the policy decisions that we make going forward so that we can still protect the most vulnerable without completely wrecking the economy with tens of millions of that are unemployed. These are things that we can prevent to begin to repair the country.

Aleksandra Srdanovic: Right. Thank you so much, Gregg. I really appreciate you taking the time. This has been really insightful.

Gregg Girvan: Absolutely. Well, it was my pleasure. Thank you for having me.

This transcript has been edited for length and clarity.

In the wake of the brutal killing of George Floyd in Minneapolis, Americans across the country and across the political spectrum are calling for reforms that combat racial bias in our justice system and change the way we police our communities. Although many cities have already announced significant reforms to the rules governing their local police forces, the U.S. Congress is still debating a variety of proposals.

The New Center’s Criminal Justice Reform Tracker will keep a running tally of the various criminal justice and police reform bills and resolutions that are being introduced, and most importantly which are garnering bipartisan support.

With Republicans controlling the Senate and Democrats controlling the House, votes from both parties will be needed to turn any of these ideas into law.

Update: In the month following calls for action after the killing of George Floyd, Congress introduced 61 bills specifically related to changes to the U.S. criminal justice system. Only 16% of bills (10 bills) garnered bipartisan support, meaning they have both Republican and Democratic co-sponsors. 97% of the bills that have been introduced are stuck in committee.

The only successful House bill, the George Floyd Justice in Policing Act of 2020 introduced by Representative Karen Bass, has been placed on the Senate Legislative Calendar, while the Senate has so far voted against opening debate on the JUSTICE Act originally introduced in the Senate by Senator Tim Scott.

Congressional Bills

Congressional Resolutions

Last updated on July 06, 2020

On this episode of Centering on Coronavirus, The New Center interviewed Greg Burel, the former Director of the Division of the Strategic National Stockpile. Mr. Burel served in this capacity for 12 years, from March 2007 up until his retirement this January. Today, he serves as president at Hamilton Grace, a consulting firm focused on preparedness and response. 

Aleksandra Srdanovic: So I thought to frame the discussion, it’d be worthwhile to address the current narrative around the Stockpile. Since the onset of the pandemic, there’s been criticism of the shortages of supplies in the stockpile and its inability to meet requested needs from states. So I’m wondering, given this criticism, what exactly is the Stockpile’s role in a crisis like this, and how would you rate its performance in carrying out that mission?

Greg Burel: So I’ve actually published quite a bit on this that you might want to go take a look at, the most recent was an op-ed in The Hill. But, the Strategic National Stockpile was established a little over 20 years ago now with a mission to be able to respond to chemical, biological, radiological and nuclear events that were either tied to individually acting terrorists or terrorist cells, all the way to a state actor. 

The primary purpose is to store the drugs and materials that you need to respond to even large scale terrorist events, but more focused on sort of a regional response. So we think about the theoretical bioterror attack on, maybe, Washington, D.C., New York City, and some other city at the same time, and we’re prepared to respond to those with a variety of materials that nobody else could move as quickly as we could to the area to cover all the people that might need to be taken care of, and in many cases to move the material from us to those locations where there is no other source for that kind of material, because it’s very unique in terms of drug product and so on. There is no commercial market for most of the things that one stocks to deal with bio-terror events, or chemical nerve agent attacks, or large scale radiation releases, or in the worst case, a nuclear detonation. 

In 2005 or 2006, the Bush administration was trying to get better prepared for potential pandemic influenza events. So there were some supplemental appropriations from Congress that allowed us to build some stock of antivirals and personal protective equipment designed to respond to a pandemic influenza event. When we looked at models that suggested what we would need to deal with a 1918-type event in today’s United States population, the numbers of things that you might have to have are staggering. And there would really be no way even with almost unlimited funds to stock those and manage that material. 

So, we used most of the material that we purchased for pandemic influenza in fighting the 2009 H1N1 pandemic influenza. Congress never gave us additional funds to revive that material. So, what I would say in terms of narrowing this down for you, the Stockpile was intended to respond to chemical, biological, radiological, and nuclear events. Over time, because it’s clear that one of the most capable medical logistics institutions around, we’re saying what we call at this point mission gallup. So, we went from a plan to be able to respond to CBRN in multiple cities simultaneously based on data that can’t be disclosed, to being asked to be engaged in a response to natural events, to being asked to be engaged in response to emerging infectious disease, and we’ve never seen a commensurate increase in funds to do that. 

So, based on all of those factors, I think that what the Strategic National Stockpile had, at the beginning of this, was a limited quantity of specific material that could be used to respond to a pandemic or any other emerging infectious disease. Our plan has been always, because we’ve not been able to secure additional funding from the Congress, to get really ready in those areas as we would like-to be able to draw from the private sector supply chain at the time of an event. We’ve done that very successfully as well, for example, when we had to prepare on the fly for Ebola. But the reality is, the money is not there to be prepared as we should be for pandemic emerging infectious disease. 

I would say that the Stockpile’s response has been outstanding based on what it has and the funds it’s received to be prepared for this. But I think what this raises is, if the nation expects the Strategic National Stockpile to continue to grow its mission, and it expects it to be prepared for these kinds of events, then it’s going to have to fund it to be able to do that.

AS: You suggested that [the Strategic National Stockpile] had some mission creep and it expanded into other areas aside from chemical, biological, nuclear incidents. So, would you say that it’s more of an issue of, the SNS just really needs more funding from Congress, or do you think that it would be better suited to have a more contracted mission or to have some internal reorganization?

GB: Congress has to fund it. SNS is fully capable of executing the mission that it needs to execute, whether it’s where the mission currently sits, really built around CBRN, or if you really want to expand it and make it do all of these other things. SNS is fully capable of doing that. And I would say it’s more capable than any other organization, not just because I worked there, but other government people will tell me, “SNS can do things that nobody else can do.” People look to us from, even, DOD to help support their mission requirements in many spaces. And the Strategic National Stockpile is the envy of the world. People are routinely coming to the SNS asking us, “How do you do this? How would we set this up in another country?” And so on. I don’t think there’s any benefit really from reorganization.

It needs more funds, and it would be nice if there were some additional authorities. So, for example, the issue here is not necessarily that the SNS didn’t have what it needed, although we would love to have seen the SNS have more material. But the reality is, the normal operating medical supply chain in the United States runs on a very lean, just-in-time paradigm. And while that does a great job of optimizing for the best value, the best profitability, the least funding that’s needed to do that, what it does is it sub optimizes that entire system to be prepared for anything. So if we have just enough of, let’s say, whatever drug it is in the supply chain, all the way from the manufacturer to the point that it would be dispensed to someone to cover a 30-day requirement for the entire United States, you can see there’s no flexibility.

Let’s exacerbate that a little bit. Probably 90% or [more] pharmaceuticals and a similar range of medical surgical supplies like gloves, gowns, face shields and so on, are made outside the United States. Any geopolitical problem can disrupt that supply chain. A number of years back, there was a longshoreman strike on the West Coast, and there were many container ships sitting off the coast with gloves, gowns, and they couldn’t make port and drop those off. So, it’s a combination of factors and to fix this problem. 

First, the normal operating supply chain is going to have to create some flexibility in itself. Because it shouldn’t have been necessary with four or five cases in Washington state for Washington state to come ask the federal government for help.

Secondly, states and locals, well, primarily state public health, has to be better funded. Because state public health needs to be prepared to respond to it’s piece of this. The Strategic National Stockpile, even when we think about it in terms of CBRN, was always instead intended to supplement and resupply states just like the rest of the disaster response mechanisms in the United States are. The federal government is never supposed to be the first responder. The problem is, because there isn’t funding for public health as it should exist at the state and local level, they’re not prepared to be the first responder and the second responder either. So when you get back to the Strategic National Stockpile, it has to be funded if you want it to do this. But realistically, if we said that to respond to a 1918 type flu, you would need 3.7 billion N95 masks in stock, and that’s not realistic.

So everybody has to give a little in this. The supply chain has to be more flexible. We’d have to encourage manufacturing to come back into the United States so that we’re not reliant on easily disrupted supply chains from other nations. And I wouldn’t say everything, but there has to be a higher manufacturing capability in the US. And then, those government agencies that are responsible really, and they should be the fall back, on this kind of thing, have to be funded in such a way that they can have a valid way to deal with these things.

AS: Do you have any thoughts on how Washington could ensure that we augment some of these supply chains so we’re making more of these products at home, or just making importing it easier? A followup to that being, in the wake of a lot of previous pandemics, the American public and Congress became really focused on public health preparedness, but obviously as these threats recede, so too does the attention and the funding. Do you have any strategies or ways do you think that we could prevent that from happening again? Or making public health preparedness more conscious in people’s minds?

GB: I think the only way that you’re going to get manufacturing to increase in the United States is if you see, at least initially, some government incentives to bring that manufacturing back. The reality is that the cost to manufacture these products in the US is significantly higher than it is to manufacture them in foreign nations. You can get into all of the why’s and wherefores and politics and goods and bads about that whole thing. But, in reality, it costs more to make these in the US. A company that attempts to make product like this solely in the United States is, on price, always going to compete poorly with somebody that’s bringing in most of those from foreign sources. There are actual real examples of this out there; there is a company in Texas that has a great desire to make a lot of N95s, and they do have a number of customers and they make N95s. But the reality is, their product is significantly higher priced than their nearest competitor’s.

So if people are buying on price alone, which tends to be the case with this kind of thing, then they’re going to be driven away from that higher priced product, simply because it’s higher priced. Not because it’s a better product, but only because it’s made in the US. There’s going to have to be some kind of government incentive somewhere to bring that manufacturing back on shore, or at least a bit of it. Maybe that takes the form of tax incentives, maybe it takes the form of some relaxation of whatever stricture is causing some of the additional costs. There are risks associated with that as well. But, another thing that could be done is to fund the Strategic National Stockpile with, say, a special reserve fund that’s just designed to say, “We want to be able to have another 5 million masks a day manufactured in the United States.” So we put out a contract that we’re not really buying masks, but were buying capacity, and funding the cost to build that capacity. So, there are some potentials to think about there.

To your second question, I think that your articulation of the problem is very clear, and I would’ve said it the same way. Public health has often been, and frankly, much emergency response in general has been a matter of, if there is an event, we throw tons of money at that event. Typically, it’s too late at that point for that money to make a difference in that event. But we beat our chest and say, “This will make a difference in the future.” But the reality is, as we move further away from that event and it recedes in the mind, less and less money is available.

When I look at the supplemental funds that have been awarded under CARES [the Cares Act of 2020] and that we expect to see more of under other acts, the reality is that money is good to get a start on what you need for the future. If you don’t make that a regular investment, you’re going to have the same problem we have here. You’re going to buy this stuff, and it’s going to be used for an event, and you’re going to have no way to replace it. Or you’re going to buy this stuff, and it’s going to sit on the shelf for five or six years until the next event pops up, and then we’re going to get complaints because, “the mask is out of date” or “the drug is out of date” or whatever it is. Well, if you’ve got no money to rotate it after that initial investment to buy it, it was potentially a huge waste.

So, I think that’s a problem, but it’s a problem that affects the state and local level as well. After 9/11, a huge amount of money got poured into public health preparedness as well as other emergency preparedness across the country. And then you can look at the funds that were provided in subsequent years, and the further you moved away, those funds were diminished. This is something that has got to be at the forefront of the mind for forever. To suggest how to change that, I think, is difficult, because this has been the pattern of emergency response and public health preparedness in the United States for hundreds of years.