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Mar 27, 2020

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TOUGH CHOICES — Now comes the hard part: figuring out who gets saved.

It's the cruel calculus facing American hospitals as Covid-19 cases skyrocket, our executive health editor Joanne Kenen writes. A shortage of ventilators, hospital beds and other life-saving equipment is forcing providers to develop plans that would help them determine who goes to the front of the line for treatment. There is no uniform, national legal or ethical framework guiding such triage decisions. The American health care system is entirely unprepared to make such moral calls.

No one has been denied a ventilator yet, the White House has said, though triage and ventilator rationing could happen soon. And as a very, very last resort, New York might someday face turning to a lottery system for equipment in very specific cases. These would be situations where a small number of ventilators are left and several people with the same risk of recovering need one.

The state's procedures, written by a panel of doctors, ethicists, religious leaders and other experts in 2015, indicate that during a crisis like this, "random selection (e.g., lottery) methods" would be fairer than treating patients on a first-come, first-served basis, which could discriminate against poorer patients with less access to information.

A look at Italy reveals that we may not be terribly far off from rationing care.

There's a lot that can go wrong. Remember Obamacare's "death panel" rumors? In Texas there's a court battle over whether a hospital must keep caring for an infant on life support. Now many of the country's hospitals may have to make those decisions daily as patients gasping for breath threaten to overwhelm them.

Who makes the call? Bioethics experts suggest hospitals create response teams with doctors separate from the ones actually caring for patients, protecting the bedside clinician from the ethically fraught, and hauntingly emotional, burdens that Italian doctors have carried.

It's not just hospitals, either. Nursing homes, home health care companies and even hospices are designed to handle patients with conditions like cancer, disability and dementia — not a highly contagious and lethal disease.

Older and critically ill patients are likely to move further down the priority list. One Italian medical association issued guidelines that prioritized younger patients over older ones, but also looked at factors like additional health problems that might limit a person's life expectancy. Providers may look at factors such as the person's role in society — first responders and health care workers may get priority — or whether they have kids to care for.

WHAT WE'RE WATCHING: President Donald Trump is expected to announce Tuesday whether he will move forward with his plans to try to end the nation's coronavirus lockdown, as the White House's aspirational 15-day effort to slow the spread of the virus comes to an end, a senior administration official said.

While America largely stays put, Trump will travel to Norfolk, Va., on Saturday as part of a sendoff for the hospital ship USNS Comfort as it leaves for New York City.

PRESIDENT PELOSI? Boris Johnson already has Covid-19. What if Trump gets it? And then Vice President Mike Pence? And then — she's third in line for the presidency — House Speaker Nancy Pelosi? And then Chuck Grassley, who, as president pro tempore of the Senate, is fourth in line? None of them is exactly young and vigorous. For a gerontocracy, coronavirus could be an extinction-level event.

When asked about the coronavirus contingency planning, one administration official familiar with the matter told our Daniel Lippman that government continuity plans are "being worked constantly" and called the topic "one of the most serious issues in government." A senior White House official declined to comment on the issue but added that "continuity of government protocols are always in place, for every administration." But it's notable that the administration has neither gone out of its way to obviously separate Trump and Pence — remember Dick Cheney's "secure, undisclosed location" during terror alerts after 9/11? — nor announced a specific "designated survivor," the way the British government said Foreign Secretary Dominic Raab would play that role, even before Johnson got sick.

One thing the administration is clearly not doing well is separating the leadership at the top. At times crucial figures practice social distancing — during some, but not all, recent briefings, for example. But then, today, many of them gathered around the Resolute Desk — barely six inches apart, much less the recommended six feet — for the signing of the rescue bill. "I would leave that up to the doctors," a senior Trump administration official told Lippman. "I'm sure they're extremely mindful of it."

But how mindful are they being, really? A former U.S. government official said: "Of course there are continuity of government plans on the books. Whether or not they're adhering to them right now is an open question."

Welcome to POLITICO Nightly: Coronavirus Special Edition, a nightly intelligence brief from our global newsroom on the impact of the coronavirus on politics and policy, the economy and global health. Check out this video from your host. Reach out: rrayasam@politico.com and @renurayasam.

TRUMP RAGES AT GM, STRIKING FEAR IN C-SUITES — Trump finally invoked the Defense Production Act today, allowing him to force General Motors to make ventilators. But not before he raged at the automaker in a series of angry tweets, slamming GM for allegedly overpromising on ventilator production while asking for "top dollar." He called out the company CEO, Mary Barra, directly. "Always messy with Marry B," he tweeted. Trump also slammed Ford over ventilators. Our chief economic correspondent Ben White writes us:

It's never been easy to be a big company CEO in Trump's America given the president's hot temper and itchy Twitter finger. In the coronavirus era, it's even harder. The GM and Ford tweets illustrate how any company — even iconic American brands like Harley Davidson — can swiftly wind up in Trump's crosshairs. Corporate executives across the country are wrestling with excruciating decisions on furloughs and layoffs. They also must now quiver in fear of a Trump attack that could activate his legion of online super fans to support boycotts and advocate stock sales. GM shares dropped over 5 percent today.

They also must navigate various pieces of the congressional rescue package while wondering if they might suddenly have to shift into different areas of production if Trump does decide to wield the DPA more broadly.

So pity the poor CEO.

EXPERT INSIGHT — Reporters from across our newsroom weighed in on the state response to the pandemic, whether Congress will return for another aid package, long term economic impact, Trump's promise to reopen the economy and more.

A message from PhRMA:

In these unprecedented times, America's biopharmaceutical companies are coming together to achieve one shared goal: the eradication of COVID-19. We are working with governments and insurers to ensure that when new treatments and vaccines are approved, they will be available and affordable for patients. Explore our efforts.

China File

BACK TO NORMAL? Our colleague David Wertime writes us from San Francisco:

China, the place where (all the evidence suggests!) Covid-19 started, has a dilemma. After months of enforced lockdown and economic and personal strain, Chinese life is normalizing. Students in Sichuan, Liaoning and Anhui provinces are returning to school. Epicenter Wuhan is seeing what state media call "an orderly return to the city." Most are clocking into work, albeit behind masks.

Is this safe? No one's sure of Covid-19's capacity for a second outbreak, particularly given what NPR calls "a spate of mysterious second-time infections" in Wuhan. There's no verifying China's official Covid-19 infection numbers, given local officials' propensity to juice their stats. But Beijing appears confident enough to open things up, surely knowledgeable that a fresh outbreak would be tragic and politically ruinous.

That means Beijing will try for its propaganda win right now. Communist Party Chairman Xi Jinping appears in People's Daily headlines schooling the G20 on proper Covid-19 handling and instructing President Trump that Covid-19 "knows neither national borders nor race" on a call. Chinese social media shows images of tragedy and fumbling abroad, from a procession of coffins in Italy to New York City's infection stats to video of a weeping French cashier forced to report to work without a mask. A recent, cruelly ham-handed ban on foreigners traveling to China will lower the number of imported cases — and make a point about which shoe is on which foot now.

GLOBAL LESSONS — Reporter Ryan Heath led a Global Translations Virtual Briefing with David on the latest coronavirus developments from around the world and the lessons we can learn from them. And catch Ryan's rundown of the best practices of countries worldwide in fighting the virus.

WHERE THE CURVE IS FLATTENING — With cases of coronavirus surging around the world, regular people and policymakers alike want to know: Where are the new hotspots? And which countries are doing the best job in controlling outbreaks? Using global data from Johns Hopkins University, POLITICO explored two new ways to track countries that are succeeding — or failing — in "flattening the curve."

Chart of top doubling rates by country

THE FDA & AGENCY IQ: The ground below our feet is shifting by the second. And the FDA is at the epicenter of the federal government's response to the COVID-19 pandemic. POLITICO's newest division, AgencyIQ, is providing around-the-clock coverage of the developing public health crisis for regulatory professionals in the biopharmaceutical and in vitro diagnostic (IVD) communities. AgencyIQ's full suite of research and analysis is available in the COVID-19 Resource Center , which addresses important topics ranging from development pathways available to companies bringing new medical products to the public to the impact of FDA's efforts to accelerate the introduction of a vaccine for the novel coronavirus. If you are monitoring this situation at a micro level, check it out here.

Talking to the Experts

What will be the lasting impact of the coronavirus outbreak on how we use technology?

"The need for trusted, centralized information repositories — globally, nationally, and locally. We should be running new experiments on directing small business stimulus. We should be learning how to prepare for the next pandemic. Making our society resilient will require the development and deployment of many new technologies, because the baseline [response] of shelter in place crushes the economy, especially and massively for the working class." — Reid Hoffman, partner at Greylock Partners and co-founder of LinkedIn as told to technology reporter Steven Overly

"We're seeing people turn to modern takes on old tech: phone calls, FaceTime, VC [video conferencing], and chat are seeing a spike in usage and new creative uses. This will persist, likely even beyond this current situation. It seems that we're still a bit too early for VR [virtual reality] to break through to fill part of this communication gap, but it's possible it may quicken demand. Looking at the work-from-home trends generally, the biggest thing is that it turns out offices aren't strictly required for work. They are, however, important for socializing. It all comes back to connecting to your community." — Steve Huffman, chief executive officer and co-founder of Reddit as told to technology reporter Cristiano Lima

"Until now, everybody's point of reference for high-speed broadband networks was the one-way delivery of video services such as Netflix. Henceforth, broadband will be recognized for what it is: a critical two-way connection that can no longer be considered a luxury." — Tom Wheeler, former Federal Communications Commission chairman, as told to Steven.

Nightly Number

$11 trillion — That's the worth of the U.S. mortgage finance system, which could collapse if the Federal Reserve doesn't step in with emergency loans to offset a coming wave of missed payments from borrowers crippled by the coronavirus pandemic. Congress did not include relief for the mortgage industry in its $2 trillion rescue package — even as lawmakers required mortgage companies to allow homeowners up to a year's delay in making payments on federally backed loans.

Palace Intrigue

WILD GOOSE CHASE? Trump's all-out push to advance unproven coronavirus treatments is deepening a divide between the White House and career health officials, who are being pulled away from other potential projects to address the president's hunch that decades-old malaria medicines can be coronavirus cures, Sarah Owermohle and Dan Diamond report. "Everyone is getting ahead of their skis here," said one senior Health and Human Services official involved in drug policy. "All this buzz is confusing the American public, it's confusing doctors. There's a ton of people involved in front-line response in the government ... who are getting pulled into meetings to discuss this when the data doesn't support it."

Turning to Congress

BREAKING DOWN THE $2T — After plenty of back and forth between Democrats and Republicans, the new $2 trillion bill Congress passed today touches on nearly every aspect of American life. Eugene Daniels breaks down the details in a video with congressional reporter Kyle Cheney. Since you asked us: People receiving Social Security benefits won't see those payments boosted by the stimulus but they will receive the same one-time checks based on income built into the package.

Oversight under fire in Trump signing statement — Trump intends to ignore provisions in the newly passed coronavirus relief bill aimed at shoring up Congress' oversight of the massive rescue program. In a signing statement issued shortly after he approved the bill, Trump says he'll be the last word on whether this provision is followed.

TUNE IN TO POLITICO DISPATCH: Our POLITICO Dispatch podcast takes you behind the scenes at POLITICO, where journalists break news, work sources and pull back the curtain on politics and policy. Fast. Short. Daily. Subscribe and start listening today.

2020 Watch

HOW CORONAVIRUS SAVED SANDERS 2020 — The pandemic is extending the life of Vermont Senator Bernie Sanders' campaign and creating the prospect of a new back-end Super Tuesday, senior politics editor Charlie Mahtesian tells us. Joe Biden has a nearly insurmountable delegate lead in the race for the Democratic Presidential nomination. But the virus has effectively ended campaign and in-person fundraising events and delayed primaries as states push back nominating contests — many are now piled up on June 2. That's stalled Biden's momentum, forcing him to struggle to stay in the headlines as he's confined to his Delaware home — and alleviating some of the pressure on Sanders to drop out.

"It's dramatically altered the dynamics of the race," Charlie tells us. "No presidential nominee has ever had to struggle so hard to maintain their relevance and capture the spotlight."

Both parties continue to insist they still plan to hold their nominating conventions — it's hard to imagine how a virtual convention would look, but equally hard to conceive of holding an event when mass gatherings are banned.

Around the Nation

SLOWDOWN SHOWDOWN — State governors and Trump are headed for a showdown if the White House forges ahead with a gradual lifting of a lockdown based on the local severity of the outbreak, according to health care reporter Dan Goldberg. Public health experts say that small-bore loosening of restrictions could create new localized clusters that would extend the pandemic.

Minnesota Gov. Tim Walz has started conversations with his counterparts in North Dakota and Wisconsin about an upper Midwest pact to ensure that their states are in sync on rules around social distancing. That effort follows Connecticut, New Jersey, New York and Pennsylvania joining last week to announce the closure of bars, movie theaters, malls and bowling alleys — all to try to avoid a patchwork of lockdowns.

Parting Words

SORRY, NOT SORRY — Republican Kentucky Rep. Thomas Massie isn't sorry for forcing members of Congress to travel back to Washington to vote on a $2 trillion coronavirus rescue package. In a phone interview with Betsy Woodruff Swan, the Kentucky Republican said he was just standing up for the Constitution and pushed back against criticism that he endangered his fellow members of Congress. "These are people that make $174,000 a year and they expect the person at Kroger's that bags groceries to go to work, they expect the truck drivers bringing produce to their grocery stores to go to work, they expect all these other people to work," he said. "But how is it that they've decided that people with the best health care in the world, which they all get, that they can't come to work?"

A message from PhRMA:

In these unprecedented times, America's biopharmaceutical companies are coming together to achieve one shared goal: the eradication of COVID-19. The investments we've made have prepared us to act swiftly:
· Working with governments and insurers to ensure that when new treatments and vaccines are approved, they will be available and affordable for patients
· Coordinating with governments and diagnostic partners to increase COVID-19 testing capability and capacity
· Protecting the integrity of the pharmaceutical supply chain and keeping our plants open to maintain a steady supply of medicines for patients
Explore our efforts.

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