Note: This is a rough transcript of episode 12 of Health Savings News and has been lightly edited for clarity. Copy may not be in its final form.
Hello, and welcome to Health Savings News: the podcast about healthcare costs in America and how to save money on the often expensive care all kinds of people need. I’m your host, Evan O’Connor, joined by retired doctors, Rich Sagall and Mike Woods.
Hello as well.
Each episode we discuss healthcare costs in America, offer tips for saving money, and relevant news that affects and reflects the expensive landscape of healthcare in America. This week’s topic is COVID-19. Despite claims of the contrary — whether from internet op-eds or from the President of the United States — the COVID-19 pandemic is ongoing and continues to affect our lives. More than 400 people are dying from this one preventable disease every week. At the time of recording, over 25,000 people are in the hospital with COVID-19, and most insurers stop waiving cost sharing for COVID hospitalizations over a year ago. The available reported infection rates are likely many times higher in reality, as they do not include rapid tests taken at home — which has increasingly been the case since exhausting federal funding made communities lose availability of free and accessible PCR testing. Even with the relatively low rate of fatal illness, a third to a half of people infected can develop long term disability, vascular damage, or organ system complications that we haven’t fully realized the scope of — which will inevitably result in higher healthcare costs. United States relaxed pandemic precautions early in response to business demands, political pressure, and public in patients rather than scientific evidence, creating multiple overlapping risks and dilemmas for those still at higher risk.
Yeah, let me pipe in here and give you the context of today’s podcast. As Evan said, the president and others have declared that the pandemic is over. I disagree. All that’s really happening now is that the rates of COVID infections are dropping. However, I think they’re almost certainly going to spike again, and whether the spike is as high as the recent one from Omicrom BA.4 and BA.5 depends on a number of factors that we’ll be discussing in the podcast. One is the nature of whatever new COVID variant develops. And the second is related to our ongoing response to it, both individually and as a nation.
I’ve talked to a couple of friends who live in other countries, and they were amazed that the politics involved in COVID response in this country. In Australia and Germany, the scientists really decide what was going to happen, not the politicians or the business people. Going back to your point, Mike, why do you think there’s going to be another spike?
Well, first of all, I actually still think that the COVID is a pandemic. And the major reason is because there are way too many people susceptible to COVID infections who may eventually get the disease and cause a spike in the infections again. And COVID is not going away anytime soon. I actually agree that it’s going to probably become a seasonal epidemic similar to the flu, but an epidemic is basically a surge in a particular disease. Now, how quickly this is going to happen really, again, depends on the nature of the new variants and how we’re going to respond to it.
I think before we go any further, we need to define a few terms. According to the CDC, an endemic refers to the amount of disease that’s present in the community all the time, it’s also called a baseline presence. An epidemic is an increase, often sudden, in the number of cases of a disease above what’s normally expected for the population in a specific area. And a pandemic is an epidemic that is spread over several countries, continents, or effects the entire world.
I guess I have to Mike’s point, there really is no way to anticipate when the next wave will begin to rise. Throughout the pandemic, we’ve been surprised by what’s becoming the dominant variant. I know Mike’s probably going to talk about the Bivalent booster coming up, and the bivalent booster is a really good thing and it is going to protect a lot of people, but it’s also just kind of our best guess that these are the strains that will continue to affect people the most. And it could be a newer one or an older one that we’re just not anticipating coming to dominance.
Exactly like the flu shot. The flu shot’s the same way.
You pick what you think might be the flu strain going around that year. Sometimes you’re right, sometimes you’re not. And that’s just the way it works out. Let’s go over some of the reasons why we think that surges are actually going to occur. Probably the most important thing to understand about the human body when it comes to immunity is that immunity wanes over time. So even though 95% of people age 16 and over have some form of COVID antibody — either from vaccination or prior infection — those levels vary significantly over time. For example, a vaccine rarely offers a long term immunity. So when you first immunized with a vaccine, you build up antibodies which protect against infection. However, these can begin to wane as soon as one to two months after the immunization. The primary reason for most immunization is to build up the body’s ability to respond to an infection once it’s entered the body by reengaging the immune system against that particular infection. That long-term type immunity met last much, much longer; in most case it’s years, although it varies from person to person, vaccine to vaccine and variant to variant. Now the same is true of most infections as well. Having had an infection, you develop the same same similar types of immune response, but that immunity also wanes over time — and this is especially true in the current COVID environment where new variants are developing all the time that are somehow resistant to previous infection immunity that was built up. And the last point is that there are so many people in our country that either respond poorly to vaccines or don’t develop any protective immunity at all. For example, elderly, a lot of people with certain severe long term illnesses, and people with suppressed immune systems through disease or chemotherapy.
It’s important also to note, Mike, that for normal healthy people, there isn’t much you can do to build your immune systems or to make it stronger, except vaccinations.
Yes, I agree. This will be the topic, obviously of another podcast in the future, but there are so many products out there that claim to boost the immune system but none of those really actually work. You know, your immune system is boosted one infection at a time or one vaccination at a time. There really are no shortcuts.
So, Mike, what are some of the consequences for people with this waning immunity?
Well, it means over time that even though at this point we may be seeing a decrease in infection, that protection is going to decrease over time. For COVID specifically, this means as time goes on, everybody will become increasingly susceptible to new or re-infections. The further you get from your last immunization, booster, or episode of COVID. And even though for the moment protection against severe disease has persisted, this may be affected too over the long term. And unfortunately, COVIDs going to stick around long enough that we might be able to see that effect.
Why do you think some people continue to either refuse or avoid getting the vaccines?
It’s a tough question. There are some people that were afraid of the new technology with the mRNA vaccine, and there is now a way around that that I can discuss later. Some people just are not convinced of the need to prevent the disease of this magnitude or have just not invested in trying to protect other citizens and are really only concerned with their own risk.
It’s probably worth noting that there’s also been wide dissemination of misinformation. Up to 40% of the deaths the first year of the pandemic were avoidable just because of how much misinformation and who was pushing that misinformation. And I think those are things worth mentioning in talking about why people refuse the COVID vaccine in particular.
Yeah. One question based on the statistic that I just gave is, you know, why is non immunization a factor when, you know, 95% of those 16 years old and older do have some antibodies? You know, so you’re saying “95% of us seem to have protection,” but again, the key there is the protection goes way over time. Plus there are many unvaccinated out there who have not had COVID and they are much more susceptible to infections and they are at the highest risk for hospitalization and death, which is a shame since most of this would be prevented by vaccination, even though who are unvaccinated and have had a COVID infection are much more susceptible to newer variants. Especially the new omicron BA.4 and BA.5 variants which will be protected against with the new by valent vaccination again, if they choose to get it, which unfortunately a very significant percentage of the 20% of unvaccinated people still claim that they have no intention of getting the vaccines. So the bottom line is, is that as time goes on, more people become susceptible to the virus and increase the opportunity to spread the virus.
I think we need to look at the reasons why people become vaccine refusers. I think that some people don’t believe the science and other people who may believe the science don’t like being told what they have to do. And I think, as Mike pointed out, refusing to be vaccinated is really a selfish act because when you get vaccinated, you’re helping those that cannot develop immunity to not get the disease.
The next point in line about creating surges, I have to admit that this happened to me as well, but I use the term COVID fatigue. I think it’s just a less urgency felt about the COVID due to constant exposure to COVID in our lives and in the media. This has really resulted in the pandemic slipping into the background for a lot of people.
I’ve actually heard this kinda referred to as a pandemic nihilism where it’s portrayed where it just doesn’t matter that there’s a pandemic going on. What would you say the consequences of this falling off people’s radar or just something people don’t care about?
Yeah. Well, aside from those who are refusing an avoiding vaccine, a lot of people that have this fatigue are just really not motivated to do some of the excellent new preventive measures that have been developed with the immunization. For instance, there’s a new Novavax vaccine that doesn’t use the messenger RNA technology that a lot of people were concerned about. And were deferring the vaccine because of it. Because it does not have any mRNA components, It is now more appealing to those who are afraid of that technology. However, we’re still seeing a situation where not a lot of people are getting it, even though they had stated that that was really their only objection to it. Now there’s been a recently approved bivalent Omicron-containing booster. That to me is an actual game changer because number one, it protects against the two Omicron variants that are around right now causing infection BA.4 and BA.5. It also has components of the original infection, which has still been offering protection to a lot of people. The second thing I think that’s really significant about that is it shows how quickly the new vaccine development techniques have been able to produce a timely vaccination to strains currently going on with the omicron. I think that’s a big, big factor. The other problem is obviously that COVID fatigue has really resulted in a significant reduction of the use of the perfected protective measures that we all know work really well, such as face masls, social distancing, and situational isolation after exposure or with symptoms. As Evan mentioned, you know, the CDC no longer recommends mandatory use of protective measures and even in a lot of places they cannot be legally enforced even though we know that face masks work, they are primarily effective in preventing infection from spreading. So unfortunately, people are really left with a poor option, which is, even though face masks are poor for protection from catching the virus, it’s really the only option available to people who need to be or want to be around others. Although it’s not really unique, COVID does have a very significant propensity to develop new variants quickly. So usually when the new variants develop, which in the case of COVID is in the spike proteins, there’s a chance that previous infections with other variants will not offer any protection whatsoever. This is actually happened with BA.4 and BA.5 mutation. From personal experience. I know the same is true of protection from vaccinations. I was fully vaccinated and, boy, I really got pretty sick from co COVID after Omicron showed up.
I myself, if I ever had COVID, it would’ve been in February 2020 where there was a week where my partner was very sick from a dog show. My partner breeds standard poodles, and a lot of people from that dog show got really sick. We know at least one person who passed away. And I did get mildly sick after taking care of my partner for a full week, but it was very quick for me. Since then I’ve been– since, you know, March 2020, I’ve been– I don’t go in public without a mask, even if I’m outside in a populated area. It’s becoming cooler weather, I’m definitely going to start double-masking again when I go to the grocery store. My brother and his wife and their three month old son all just had COVID a week ago. And my brother and his partner — who is a healthcare professional and a teacher — are fully vaccinated; they’re boosted. My three month old nephew is not, clearly, because he’s not old enough.
My family’s been fortunate, only my adult son got COVID and we are fully back vaccinated and boosted, but we’re not sure that we weren’t liable for spread because people can have the disease and have no symptoms. Can you talk about how that fits into the overall picture, Mike?
Yeah. One of the big problems with COVID recently has been asymptomatic spread. COVID-19 is probably the most contagious virus that’s ever existed. So it spreads so easily, and that is causing a big problem because many people who are affected with COVID never developed symptoms and even those who develop symptoms eventually may not develop them for up to two weeks after exposure and also be contagious during that time. So there’s a huge number of people out there that could be spreading COVID with absolutely nobody knowing about it.
Are there seasonal aspects to this risk?
Yeah, I mean, Evan talked about him personally. He’s saying now that it’s that the weather’s becoming cool, he’s going to, you know, start double-masking and that really very much has a basis in reality. For instance, you know, once the weather does get cool like this, let’s say in the late fall and the winter and early spring, people spend much more time indoors, the days are shorter, so people are outside less often where it’s less difficult to spread the infection. Also if you think about it during these times, this is when most of the major holidays occur when family and friends are gathering together in large groups. So if you put this together with the relaxed attitude toward preventive measures, I think this is another one of those things that’s really inviting a COVID spike.
You can go back and check previous spikes. They definitely line up to be roughly two weeks after major holidays and times of gathering.
One of the few things that is positive about the COVID epidemic is more people were taking precautions in general and other diseases such as the flu was markedly decreased in incidents last year.
That was more 2020; last year they jumped back up again. But yeah, in 2020 there was I think a single flu death in the U.S.
I read the same thing. Yeah.
And I think it comes down to in 2021 there was a more relaxed approach to preventive measures, which probably resulted in the increase in the flu as well. Yeah, I mean, even traveling these days is a risky procedure. So with all the periods of asymptomatic spread, it’s easy to see how travel can spread COVID through communities and other countries. If you figure that a person can spread COVID for two weeks and they’re on an extended trip where they can spread COVID to any number of locations and, you know, certainly another reason why the pandemic is easily prolonged.
And we’re seeing travel spreading other diseases that were not normally found in certain regions.
Yeah, like monkeypox is the most recent one.
How about COVID testing? Is that still worthwhile?
Yeah, it’s definitely worthwhile, but unfortunately it’s becoming significantly underused. As Evan pointed out that COVID tests are, although still available, are not as easily accessible, which means in a lot of cases we’re kind of stuck with the rapid test. And even though places where people gather, like camps and cruise ships or vacation spots require negative COVID testings, most of the time they’re kind of stuck with the accepting the less accurate rapid screening tests. But the other problem is most places where people gather, even in large numbers, like in sports stadiums or concert arenas or something, none of these situations are requiring any proof of either vaccination or negative test. So they’re very, very significant super spreaders. And I’m sure you could see statistics as well with a bump in COVID numbers after a big event such as that, even though things like airplanes, you still, you do need proof of vaccination or a negative test. Most of the means that people travel together in large groups like trains or buses, et cetera, most of those aren’t requiring any evidence that they’re not sick either. And the final thing is that the most concerning thing about relying solely on the home testing is that really has a very high significant false positive and false negative result.
So I guess I can’t speak to the false negative of the rapid test, but I know that the false positives is something like 15 to 20%, which is alarming for people who get those. And you want more false positives and false negatives, clearly, with a screening test like that. I have a friend who is very scientifically-minded and knows exactly the difference between the rapid and the PCRs, and essentially what the rapid tests is just checking if there are any anomalies in the sample, and the PCR test is checking for a specific genetic anomaly, and that’s why one is more accurate than the other.
Yeah, I apologize, I probably should have looked at the percentage of false negatives, but a false positive, I hate to sort of put it this way, but it’s more of a personal annoyance than it has a significant effect on the epidemic. It’s truly the false negative results that have the most significant impact on the epidemic because there’s a lot of people out there who had a negative COVID test that are running around completely unaware that they are actually spreading the virus.
Right. We’re using a screening test to make diagnoses, and that’s not what they’re designed for. A screening test is designed to have false positive and then you would do a confirmatory test to make sure and rule out whether, determine whether the positive is a true positive or false positive. But we are just using the screening test as a diagnostic and that’s not appropriate.
Yeah, unfortunately, the, the other necessary qualification of a screening test is there has to be a very low number of false negatives, because you know, if you’re testing for cancer, you really don’t want to miss any. You know, you take the risk of having too many people panic for a while, but you have the reassurance that somebody with cancer’s not going to slip through. That’s not true with a COVID test. It’s just got a too too high a false negative rate.
Speaking to tests and their importance. When I said earlier that PCR tests are no longer accessible to a lot of people, there are still venues where people can get a PCR test, but mostly those people have to be insured now. Millions of people lost their jobs in 2020, and not only did a quarter of those people who lost their jobs due to the pandemic not have employer provided health insurance prior to being laid off, as many of 56% of those who remain unemployed lost their health insurance along with their jobs. Of those who are still unemployed, 81% remain uninsured. Most are no longer receiving routine care or taking prescribed medications, and nearly half of delayed planned medical procedures, are not seeking treatment for chronic conditions, or have stopped receiving mental health treatment. People without health insurance have been at higher risk of dying due to COVID-19 throughout the pandemic. Their chances of getting sick and not having access to testing increases the likelihood of future outbreaks. Even insurance can reimburse for rapid tests bought at a pharmacy, but for the millions of new and existing uninsured and underinsured Americans there are no guarantees for covering the costs that can be tens of thousands of dollars for hospitalizations — hundreds of thousands for complex cases. Is there anything the two of you are particularly concerned about as doctors?
Yeah. You know, there’s a big concern that hasn’t been talked about very much, and that’s drug resistance. We hear about it a lot with bacterial infections like MRSA and pseudomonas and other bad infections, but drug resistance does occur with viruses as well. So as far as I’m concerned, it’s only a matter of time before COVID becomes resistant to some of the current treatments such as the antiviral drugs and monoclonal bodies. So, you know, the longer COVID hangs around, the higher the risk becomes of severe infection from that viral antiviral treatment resistance. And because these are only used on people at the highest risk, there’s really going to be a lot of severe infections that are going to be happening once this happens. Unfortunately, there are fewer antiviral drugs around than antibiotics, so it’s really difficult to find backup options for antiviral medications. And just like antibiotics and development of new antiviral drugs is a very slow and difficult process. For instance with antibiotics, there’s really not been a significantly new antibiotic group developed in like 30 years. So if that happens, we are really going to fall behind on the COVID epidemic.
As a physician, my concern is a little bit different and I’m concerned about two things. One is the lack of understanding of how the scientific process works and how medicine works. People criticizing Dr. Fauci and others for the recommendations they made early in the COVID pandemic, when as we learned more, we discovered certain things we thought were true or not. I’m also concerned about the selfishness of people. I’m sure everyone’s heard the vaccine and preventive measures are not as much, not so much when you getting it as prevents you spreading the disease to other people who may be immunologically compromised. And that concerns me, the selfishness…
I guess, as not a physician, the thing that worries me the most is people being left behind, which we have a couple episodes coming in a few weeks that kind of get further into that. But even earlier this year, the CDC had described the deaths of disabled people and patients with chronic illnesses as quote, “really encouraging” in terms of how well things are “returning to normal.” Ignoring the hundreds of people who are dying each week and the disabilities that COVID can lead to itself, the portrayal of deaths of vulnerable people as “hopeful” or “reassuring” is thoughtless and harmful dismissal of human lives. During the worst moments of the pandemic some states, cities, and individual hospitals responded to the shortage of workers, protective equipment, ventilators, and hospital beds by explicitly ruling out treatment for people with certain preexisting conditions — devaluing the lives of disabled and chronically ill people while prioritizing “healthier” people. Federal health and civil rights officials in the United States ultimately ruled these policies to be unacceptable discrimination on the basis of disability, but it’s illustrative just how easily vulnerable people can be systemically dehumanized and denied healthcare. COVID-19 is disabling, debilitating and deadly, and the updated guidelines continue to relax precautions not out of interest in public health, but for the sake of the economy. Workers who have lost their job, can’t work due to unsafe conditions, or are no longer able to work due to long COVID are overlooked or erroneously blamed for an unwillingness to work. The push from across the political spectrum to abolish the simplest of mitigations or vaccination requirements are based on optimistic predictions and the desire to win support from a pandemic-weary public. The COVID-19 pandemic could have been a catalyst for the kind of healthcare reform the United States needs. The universal access to COVID-19 prevention, testing, and treatment was essentially a “Medicare for all for COVID” model. Instead of increasing access to universal care for other conditions, the plan instead is to fold COVID-19 care into the existing framework of profit-based insurance. By 2023, testing vaccines and treatment will be subject to superfluous prior authorizations, time-wasting appeals, and potential for Long COVID conditions to not be covered under COVID-19 requirements if a patient’s only diagnosis came from an at-home rapid test, which we’ve discussed. The messaging at this point seems to be, “if you’re healthy and you have good health insurance, there’s almost no reason to worry.” But there are 26 million uninsured patients in the United States and 133 million Americans — nearly half of the United States population — suffer from at least one chronic illness. Especially since COVID-19 can lead to chronic illness — and if you develop a disability that leave you unable to work — you can lose your health insurance. No one is exempt from these risks, vaccinated, unvaccinated, young, elderly, healthy, or the medically vulnerable. In a society that has all been embraced “Everyone will catch it eventually” the goal needs to be to be infected with the SARS-CoV-2 coronavirus as few times as possible. Each infection comes the risk of immune, vascular, and organ damage that medicine doesn’t fully comprehend yet. To protect yourself and those around you wear masks in public shared indoor spaces and outdoor gatherings, get vaccinated as frequently as necessary, and respect the boundary set by immunocompromised people.
Just to sum up, I mean, I’m all for being optimistic, but the future of COVID is a big unknown because we have no idea what the severity of illness will be or the infectivity of future COVID variants. My suggestion is just prepare for the worst and take all the measures that we need to do that. And we’ve already talked about that. We really, really need to get people vaccinated. I don’t know how to go about it and, and I think most people are stymied by how to get those who will accept the personal risk of not being immunized and are not motivated by the greater good who refuse the appropriate use of proactive measures and or refuse of war to defer COVID vaccination. I don’t know how to do that and I think a lot of people don’t either, but those are the two key elements going forward of what’s going to make a significant impact on the COVID pandemic.
I have three quick points I’d like to make. One is people should realize that we’re never going to get rid of this COVID. It’s always going to be around because it has reservoirs that are non-human so other animals can harbor the virus and spread it back to us. Two, I think an advantage or a good outcome from this is telemedicine has become more important and more accepted because it’s more convenient for the physician, more convenient for the patient, and it’s safer when people are sick. And the third point is that I think there’s been some expansion in those on the healthcare team that can make certain diagnoses. Pharmacists have been able to give many immunizations now, which they couldn’t do five years ago, 10 years ago. They’ve even in some areas, been able to make a diagnosis and prescribe the Paxilovid. So I think that’s a, that’s a step in the right direction.
To me, the most depressing thing of all is I have no question in my mind that people in general especially those who deny science and will not use vaccine or protected measures, have been responsible for making this much worse than it could have been had everyone responded appropriately when the pandemic first arrived.
The last segment of each episode, we suggest some of the culture, art, entertainment, and social causes we’ve been engaged with to each other and our listeners. I’ve been listening to the podcast of The Dose from the Commonwealth Fund, a foundation dedicated to healthcare for everyone. hosted by Shanoor Seervai, the show asks what can the United States do differently when it comes to healthcare? It features engaging conversations with leading and emerging experts. They cover topics such as the nursing crisis, biases in medical care, and why drugs cost so much. I listened to their most recent episode in preparation for today’s COVID-19 recording. Other podcasts I listened to in preparation for today, I’ve already mentioned, but I want to shout out again: Movement Memos from Truthout, a nonprofit news organization, and the podcast Death Panel.
Thank you so much for joining us for this episode of Health Savings News. Please subscribe, rate, and review us on Apple Podcast or wherever you’re listening to the show, it really does help. You can follow @NeedyMeds on Twitter, Facebook, Instagram, LinkedIn, YouTube, and you can follow @HealthSavingPod (no S at the end of saving) on Twitter for updates specific to this podcast and send questions, comments, and topic suggestions to email@example.com. Our music is composed by Samuel Rulon-Miller. His music can be found at musicisadirtyword.bandcamp.com. The Health Savings News podcast is produced by me, Evan O’Connor. All the sources we used in our research can be found in the episode’s podcast description on our website or your podcast app of choice. Health Savings News is not intended to substitute for professional medical, financial, or legal advice. Always seek the advice of a qualified healthcare professional, or appropriate professional with any questions. Views expressed on Health Savings News are solely those as the individuals expressing them. Any views expressed do not necessarily represent views in Health Savings News, other contributors, the NeedyMeds organization, or staff. Thanks again for listening. See you in two weeks with our next episode.