Q&A with Professor David Cutler: How COVID-19 Will Impact Our Society and Healthcare
Updated: Jul 15, 2020
By: Audrey Jones, PRIMO, Harvard College '22
On Tuesday June 16th, we heard from our first speaker, Professor David Cutler, who generously shared his time and thoughts about the impact of COVID-19 on society and the healthcare industry. Professor Cutler is the Otto Eckstein Professor of Applied Economics in the Department of Economics and holds secondary appointments at the Kennedy School of Government and the T.H. Chan School of Public Health. He served on the Council of Economic Advisers and the National Economic Council during the Clinton Administration and has held positions with the National Institutes of Health and the National Academy of Sciences. His research focus is in healthcare economics. This virtual speaker series event was conducted via a Q&A forum, moderated by Ph.D. student Masha Kuznetsova. Below are some highlights from this engaging event.
The first set of questions revolved around how COVID-19 has, almost overnight, changed the practice and structure of healthcare systems. When stay-at-home orders were implemented across the country, they challenged one of the foundational features of traditional medicine: the idea that if you wanted to see a doctor, you went to the doctor's office. “For years and years,” Professor Cutler observed, “people have been saying why don't we use telemedicine...why do I have to physically go to the doctor's office, especially when I'm sick.” As fears of catching and spreading COVID-19 rose, “total visits plummeted by about 70% [and] 15% of the visits became telemedicine visits.” Telemedicine quickly became an acceptable form of care, and Medicare began reimbursing charges for these visits more broadly.
But with the embracing of telemedicine came questions about its future in medical care. Since people were not visiting hospitals, emergency rooms, and doctors’ and dentists’ offices as frequently, medical practitioners were renting spaces that largely stayed empty. Would this change persist into and impact the post-pandemic era? And if so, what type of downsizing and restructuring would need to occur in response to that change? Would smaller medical practices, whose profit margins are narrow to begin with, be co-opted into larger, more corporate forms of medical care in order to be financially sustainable? And how would we, as a society, react to these structural changes if they did happen -- would we appreciate the efficiencies of technology and consolidation or would we miss the more personalized approach of smaller doctor offices?
In short, Professor Cutler questioned, “what is COVID going to mean for how we actually practice medical care in the future?”
The answers to those questions are complicated by the social issues that the U.S. is struggling with. For example, as people lose their jobs due to social distancing, they will lose their employer-based health insurance too. While many have alternative sources of insurance, such as Medicaid, the type of care offered is, Professor Cutler noted, not always the same and in some cases is inferior. As a result, some individuals may avoid going to the hospital out of fear that they will not be covered by insurance. Here, too, is where the gaps in U.S. healthcare compared to the broad access in other countries becomes evident.
Professor Cutler observed that “infectious disease outbreaks are times where you really miss not having universal insurance coverage because in an infectious disease situation, we're only as strong as the weakest link.”
In a pandemic, everyone who is symptomatic should receive appropriate care. But if what is appropriate is not affordable, then, Professor Cutler explained, “you’ve got a bunch of weak links in your chain.” Individuals who are sick and unable to afford care may end up not being treated or isolated and will instead transmit infectious diseases, an impact which would harm society at large. Societal issues also exacerbate these affordability challenges. Professor Cutler pointed out that we have a “doctor's office centered model more than a community care centered model. And that's a real problem when you've got people in the community who aren't that plugged in and are afraid to go to the emergency department...we need to care for people and there are a lot of things working against that.”
Another set of questions focused on how to reopen safely while COVID-19 cases are still very much a presence in our society. Professor Cutler pointed out several baseline challenges the U.S. is facing in this regard: 1) the U.S. did not put into place robust plans for testing, tracing, isolating, and treating when the pandemic first hit, and it continues to struggle with implementing optimal plans; 2) there are few historical precedents and experiences to draw on in making decisions; and 3) given the state of politics in our country, it is hard to definitively ascertain how much our government can and is willing to support people when they’re not at work (or are not able to work because of social distancing regulations). Therefore, when looking at reopening, there are many complex factors to contend with, and Professor Cutler observed that perhaps it was best to focus on two well-established approaches: 1) keep elderly people and other high risk groups as safe as possible through encouraging limited contact with the broader community and 2) engage in massive testing and contact tracing as well as isolating those who have tested COVID-positive in order to contain community spread.
But even employing such a “massive public program” would carry risk, and assessing these risks is exactly the issue Harvard is facing as well when considering how to bring students back to campus during the fall. Interestingly, part way through the Q&A, students in attendance were asked if they had to choose between returning to campus under pre-pandemic conditions (everything being normal with no social distancing restrictions, PPE, etc.) or to proceed in the fall as they had during the latter part of the spring semester (remote learning and non-residential), which would they choose? While students might have missed being on campus and interacting with friends/teachers/mentors, they unanimously chose the remote learning option, tacitly acknowledging that returning to campus without significant public health regulations would not be responsible nor mindful of the broader community. However, when asked the more nuanced question of whether they thought it would be a good idea to have only one cohort return to campus e.g. the first-years, the answers were more mixed. This balancing of risk factors is, Professor Cutler explained, difficult to do and even more so in this instance because not all outcomes can be measured with certainty e.g. how do you adequately measure the loss of educational value from not being on campus?
A final set of takeaways centered around a potential vaccine for COVID-19. First, Professor Cutler recommended that if pharmaceutical companies did develop a safe and effective vaccine, they should take a more altruistic stance with respect to its pricing, ideally “at the cost of producing it.” While such a position could result in the loss of profits, by making the vaccine more widely and equitably available, they could also create positive public perceptions about the pharmaceutical industry at a time when pharmaceutical companies’ reputations are mixed at best. And on a practical level, if the pharmaceutical industry did try to charge exorbitant prices for the vaccine, it might encounter challenges on the validity of their vaccine patents (since these companies might have used government funding and/or resources). Second, Professor Cutler queried whether enough of the population would agree to get vaccinated, thereby resulting in herd immunity. Indeed, he asked, “suppose a vaccine came out today and the U.S. said everyone should get vaccinated -- what percentage would get it?” He posited that, unfortunately, a portion of the population might hesitate to get vaccinated because of their general distrust of government, partisan politics, or their susceptibility to the proliferation of conspiracy theories about the nature of vaccinations. That hesitation could serve to hinder the attainment of herd immunity.
Before the speaker event concluded, Professor Cutler encouraged students to educate themselves on COVID-19 from reputable sources such as the Johns Hopkins Coronavirus Resource Center and the Harvard T.H. Chan School of Public Health. In addition, he advised following the Twitter accounts of reputable scientists and accounts that they follow as good ways to source reliable information. He told students that he would follow up after the event with more resource links.
Overall, this was an extremely informative and engaging event, and all the students expressed appreciation for Professor Cutler’s insights.
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