‘Life’ After the Pandemic
In this essay I try to project or imagine what life will be like in specific terms after the Covid pandemic subsides or disappears.
Assumptions about The Covid-19 Virus
The Coronavirus ravages the world and continues its deadly and dangerous path in the United States. Now, President Trump and much of the White House staff have become infected and/or hospitalized. The virus has spiked in a significant number of states in the Mid-West, in southern states and on the west coast. Surges have occurred in places where the economy has been opened and safety guidelines have been ignored. Nevertheless, Covid-19 is still only partially understood. The medical community, epidemiologists included, admits that they cannot completely explain how the virus is transmitted. It is still not known why some people get sicker than others, and if there is any immunity possible for survivors. What is known is that its initial stages can last up to a month or longer, and, even then, death is possible. Recent experiences show that a survivor can contract the virus again. Though earlier consider less vulnerable, victims among children and young adults have become significant statistics. Long term effects on survivors include impacts on the heart, lungs, kidneys and other organs that may be experienced by many millions and could be life-long. The Coronavirus is a pre-existing condition.
There is no universally accepted protocol of therapeutics for infected Covid patients, though some have been found more effective than others. Meanwhile, a world-wide search for a safe vaccine continues, with some efforts entering final stages of testing. Even if a safe vaccine were available, initial supplies would not be available to all Americans as are yearly flu vaccines. Those who do not initially receive the vaccine, and there will be millions, will either be potential victims or transmitters. New surges have been projected. My assumption is that virus will be around for a long time and continue to be a threat to lives everywhere. That assumption also includes a projection that its effect on the economy will be negative and disastrous for the foreseeable future.
Assumptions About The Economy
Though there has been some recovery, much of the economy is experiencing a prolonged recession/depression. Small businesses have been hard hit. A large number of them will never re-open or will later fail, for lack of available credit or from a lack of customers to allow them to be profitable. The latter condition the result of FDA guidelines related to the pandemic. Small family-owned farms have been will be absorbed by large corporate farms of will disappear forever. Some of the under-financed and no longer competitive larger businesses have and will continue to file for bankruptcy or will sell to cash-rich economic giants and investors. Well known large retailers have followed this trend, and are particularly notable among long established brand names, such as J.C. Penny and Brooks Brothers. Especially hard-hit sectors include the hospitality businesses, real estate, airlines, as well as other industries that provide goods and services to them. Some of this long-term trend is the displacement of workers as the result of the increasing use of sophisticated technology, e.g. artificial intelligence, in many industries that depend on repetitive tasks. Business failures and bankruptcy have been going on even before the pandemic, in part because of competition from on-line retailing. Big oil corporations are threatened because of large debts used to expand. Under the present White House Administration, federal bail-outs are and will continue to be inadequate or unavailable to finance the return the economy to pre-Covid-19 conditions.
A Possible Future Economy
The future of small business operations and even the large ones depends on the innovative thinking of the investment community. The new trend, far from a solution, is for the buying up of brand names and selling to retailers of unrelated products. Nevertheless, there Is and will continue to be a market for mechanic-run auto garages or the neighborhood florist or cheese emporium, local bars, local breweries, small liquor stores. It is not only conceivable but an ongoing trend that investors collaborate with each other and have the vision and credit to create profitable ‘cooperatives’ or national corporations of small and large businesses that will sell franchises to former owners and managers. In fact, these former owners and managers could be cooperative stockholders, as is the case with fast food restaurants. This could be the future structure of our economy.
A reordering of the economy can be achieved by the creation of new jobs and by changes in the way people work, especially remotely, by both the private sector and government. Unknown but subject to possible major changes include office building construction and space use; the repurposing of shopping malls as on-line purchasing and small business failure increase. Major job creation might occur by way of government funded and widespread infrastructure maintenance and new construction. New and extensive measures to protect the environment and reduce global warming and the expansion of high-speed internet and free access to computers for those in poverty are also job and business opportunities. In a post Trump era, all of this could take place under the umbrella of a domestic federally organized domestic ‘Marshal Plan’. There are precedents for this kind of plan in the federal recovery program to restore the economy during the 1930s worldwide depression, the rebuilding of Europe after WW II, and the economic recovery program by the Federal Reserve in 2007. Under the umbrella of a ‘Marshal Plan’ for the United States that that includes the active participation of the private sector and encompasses all parts of the economy, there would be more available credit and human resources. Fears of ‘socialism’ would have to be suspended to pave the way for a comprehensive rebuilding of the economy.
In order for this new economy to function globally, commercial relations with highly developed countries, like China, for example, will have to be revived. Characterizing China as an economic rival and a security threat will have to be superseded by an organized system of many partnerships in a global economy. Conditions that prevent technological ‘stealing’, currency manipulation, and national credit investments in competitive business that underprice American industries will have to be neutralized. If there is to be a new “Marshal Plan” for not just the US but also for the planet, it will rest on the availability of credit and the managing of all global economic relationships.
Inequity
The pandemic has painfully exposed the inequities of our current brand of capitalism. The long-prevailing poor, historically without jobs, residents of towns without industry that have fled, the working poor, people of color that are victims of systemic racism, and the struggling middle class are too often locked out of available standard medical care, high standard public education, affordable housing, and a social safety net that enables them to survive economically. These groups represent a substantial percentage of Covid-19 victims. Over the last 30 years, there has been a major shift from a broad industrial base to a service economy that has produced low wage and hourly jobs with limited benefits. The United States has monetized every facet of the economy. Jobs have been outsourced to cheaper labor markets. The US economy has been measured by return on investment, stock prices as well as investor dividends. The previous standard was the quality and quantity of goods produced. This has resulted in making ordinary living expensive beyond the means of an average family. Though originally designed to make up these wage gaps and provide subsistence living, federal programs like food-stamps and Medicaid have never resolved these differences. Providing assistance for of these groups is viewed by ‘conservatives’ as functions for which the central government should not be responsible. Meanwhile, compensation for the upper 1% is now hundreds of times more than wage workers.
CEO and senior managers’ salaries should be capped and dividends investment taxes monitored. Taxes and tax havens and government subsidies to big business will have to be revised, regulated and loopholes closed. Under a government-sponsored domestic Marshal previously described, infrastructure projects that also deal with environmental rebuilding, and the reordering the economy in a digital world by way of public-private part these positive ways to create an equitable country for everyone. The potential for change is very largely dependent on future administrations, the prevalence of long term thinking, and a belief that all things are possible.
The Social Safety Net
Considerations of expanding or replacing the social safety net have been a political football for generations. They have been based on the division of society into two general halves. Those that can afford their lives and do not require direct government subsidy in some form. The other half are those who cannot afford the “American dream’ and do require federal intervention. The majority of the population falls into the latter category. The two major components of the social safety net issue are income and medical insurance. No raising of national average hourly wages can provide a family in the latter group to live in standard housing, assure standard education for their children, and meet monthly demands on their incomes. A rise of hourly wages, say to $15/hour, cannot meet that standard. Those from the ‘affordable’ populations are also subject to emergency health problems, being fired and too old to find a comparable job, and own real estate with prices out of reach for the average wage earner. The once 2020 presidential hopeful, Andrew Yang, proposed that the government provide a minimum monthly income subsidy of $1,000. Those who laughed at this seemingly outrageous proposal will now have to face the realities that even an average income is impossible to predict and that any emergency will force these families into bankruptcy. Instability in the markets and failed businesses during the pandemic have led to layoffs and firings. This idea of a guaranteed minimum income has been considered by European countries and has gained attention by American economists and others as a viable solution for those who cannot afford today’s capitalism. A guaranteed annual income for middle class and the working poor may be an inevitability and a way to avoid political pressure for equity under the current capitalist system.
Medical Insurance
The inadequacies of the Affordable Health Act and medical care, in general, have been laid bare during this emergency. Though Medicare-for-all was laughed at for being what conservatives criticized as socialism begins to have appeal as a result of the current crisis. For individuals and family to avoid treatment for the virus as impractical for lack of available and affordable insurance is a national embarrassment. This paper falls short of the requisite knowledge about affordability and economic impact for some programs like this on the growing national debt. But the idea that everyone should have health insurance makes convincing practical sense. A counter argument is that this single-payer idea requires that individuals give up their private insurance provided by their employers. Employment is so unpredictable that tying medical insurance to an employer is impractical and disastrous to those who are laid off. Something radical, as suggested, has to take the place of the now very complex and expensive medical insurance matters.
Medical Care in the 21st Century
Is complex and broken. Aside from the realities that rich hospitals can provide modern medicine to its patients and poorer and smaller ones cannot, medical services are, nevertheless, uneven and short of trained and available medical personnel. In more stark terms, there is the unavailability of hospitals and physicians in small towns, rural areas, and sparsely populated places. There is a doctor shortage nation-wide, in part because of the cost of education, but, mostly, as the result of low fees provided by Medicare and Medicaid. Physicians do not get rich as they once did 30 or more years ago. Specific organizations to the pandemic is the inadequacy and shortage of effective public health organizations, the defunding of CDC and, in other cases, the disbanding of organizations responsible for pandemic response and tracking of possible effects of spreading diseases and viruses. Finally, there is the rise of medical corporations and expanding university medicine that have bought up smaller and/or individual practices. Family physicians and specialists do not practice any more in hospitals and have been replaced by hospitalists whose treatment protocols dominate those ordinarily provided by the patients’ personal doctors. Medical care is rapidly being taken over by corporate America and ruled over by Medicare-Medicaid and individual private medical insurance companies that count pills and approve medical procedures. Treatment of patients by contract hospitalists, in conjunction with a shortage of nurses and now the widespread use of nursing aides, is spotty and below the standards of preceding decades. The bottom line of profit is the primary measurement of profitable busines and medical practices. Medical record keeping, even in this advanced digital age, is incomplete, inaccurate in too many cases, and without standards that enable the sharing of patient data. Medical privacy legislation, such as HIPPA, makes this even more difficult. The cost of and availability of drugs is dependent on the cost of development and market demand, and, unlike other countries that negotiate drug prices within a system of universal medical care, their cost, even with insurance subsidies, is inordinately high. They may be out of reach to those with inadequate or no insurance and low incomes. The cost of drugs needs to be negotiated and tracked. Concurrently, economic risks of development that are reflected in costs to the patient need to be transparent. The participation of so-called discount companies that act as middle-men and women to pharmacies needs to be investigated as part of lowering consumer costs. Finally, the Covid-19 pandemic has exposed the realities that hospitals are not capable of keeping regular patients and medical personnel safe from infection. Hospitals may also be the centers of the spread of the virus’ and other kinds of infections as medical personnel return to their homes, families. Revising the operation of nursing homes, where virus spread is serious, seem to ration nursing care and access to physicians. Nursing home disciplined regulation is part of this enormous project to revolutionize Medical care and to keep their residents safe.
The severe recession/depression, as a direct result of the pandemic, has devastated the entire medical provisioning system. Individual physicians or those unaffiliated with hospital corporations and academic support systems will not be able to weather the loss of income needed to pay for space, salaries, liability and insurance, and record keeping. Private hospitals have been exposed to all of their weaknesses of outdated or lack of equipment, the cost of personnel, and the scarcity of in-house physicians and specialists that are staff.
What happens now? There are three very pressing issues to which creative ideas need to be quickly and comprehensively focused. Universal medical insurance has been discussed earlier. The first is the establishment of public health systems, connected to state health departments, that are universally available to all citizens. As a part of that system, well-funded research on health threats as serous is intricately tied. Second, is the availability of physicians and a system of different levels of hospital care. These vary from the most complex hospitals with a full array of services, to well-staffed clinics that can refer sicker patients to satellite mini-hospitals and that collaborate formally with more sophisticated and fully serviced hospitals. Second, this entire system of public health and more sophisticated and available medical facilities, working together especially in rural and remote areas, must operate in an actively managed environment, capable of responding to emergencies and are clean to avoid the spread of infections. Finally, there must be modern tuition financing schemes, perhaps public-private, for medical schools to minimize student debt, and that is federally guaranteed. The conditions for this medical school finance system must include the training of more primary care physicians and a system for deploying them to areas without them. As selective as medical schools are, attending should not be akin as belonging to an exclusive country club with a $100,000 or more, outrageous entry fee. The practice of medicine must be a public service system.
In another time, this discussion would be labeled as ‘sky-bluing’. And, if not, subject to that accusation of ‘socialized medicine’. This set of ‘revolutionary’, but certainly not unique, ideas about the future of medical care inevitably have many, many downsides, besides the obvious political ones. The politics of the right that fuel fears of socialism taking over the US are considerable and influential. Capsulated in these proposed schemes is the inevitable bureaucracy that will be employed to create and manage each and every aspect. The way to destroy all of these ideas is to create ‘pill counters’ and politically motivated managers. Today, they form the bulwark of private socialized medical system that, in the end, does not work effectively, affordably, or humanely. One of the available models of how to undertake and successfully turn this system around can be found in the many logistical disciplines that manage the military, from procedure writers to the architects of war games, to the running a military campaign. This military precedent snuffs out the claim that these new medical schemes “will never happen”. We do not and should have a professional civil service as often painted about Great Britain to replicate the discipline used by the military. The informal one in this country was FDR’s “brain trust”. It was made up of experts that had to use every kind of method to make economic recovery from the “Great Recession possible and to run and manage the task of creating a war time economy. During the LBJ era, attendant to the “Great Society”, civil service salaries were increased to compete with those in private industry. Civil servants were recruited from many of the elite universities and colleges and from graduate courses in business and management. These two management examples were temporary. Instead universities will have to create course work for the training of a new class of public-private managers. Tied to this, the federal government will have to create a more remunerative pay system to attract the best talent.
The Power of Big Everything
The inevitable consequence of these ideas is limiting severely individual entrepreneurship and innovation. More significant, to make these radical ideas work is to enable large, well-funded, cash-rich corporations to expand their power and influence. The definition of a monopoly has to be modified, in order for new capitalism to be created. A corollary to the private sector bigness is that these recommendations also demand a significant growth in the federal bureaucracy. How to mitigate these downsides requires talents beyond this writer. One not very well understood idea is that these systems could be broken down into semi-independent public-private organizations that follow the goals and mitigate the operations of the larger public bureaucracy. It makes good sense that a special class of private and public bureaucrats, as described in the previous section, be educated and coached to deal with the interstices between big and smaller. How to avoid the inevitable crushing force of multi-layered, interlocking bureaucracies is one of the central problems that stands in the way of effective outcomes for the implementation of these ‘radical’ proposals.
Technology
For all of the attention given to the negative side effects of technology, the US is far behind the achievements of Estonia. Every aspect of daily life there is digitally recorded and shared, including medical, banking, licensing, and personal data collected by government and the private sector. Almost all purchases eliminate the uses of cash and use bank cards instead. In this country such a system is not understood and is suspect. The image of ‘big brother’ who rules everything in kingly fashion easily comes to mind. Such a project would be greeted by claims that such a system threatens privacy and freedom. But the Estonians have built into their system many layers of security to ensure that this outcome does not happen. We have so much talent in this country to achieve same result, if only the politicians and many political tribes that fear change would see the benefits and participate. Almost everything is possible, as proved by the many innovations that have been created in the US to make life easier and safer.
The pandemic has exposed the shortcomings of technology use and efficiency. Federal government systems are old and subject to breakdown. The tracking of accurate statistics regarding virus infections and deaths has been made very difficult, because there are conflicting methods in the states for accounting cases loads and for data collection. To complicate this shortcoming, the federal government has shifted reporting of cases from one agency to another. There is no agency that has been designated for coordinating upgrading existing and installing new technology. And information technology management is inconsistent across bureaucracies, lacking also management at the highest levels of government.
Security of information and information systems has become a major concern. The discovery of Russian intervention in our elections has made this concern acute. This reality has caused concern about the protection of all personal information that the social media and internet retailers collect and, in some notable instances, sell. While there is no magic bullet to constrain foreign intervention and the use of personal data, it is still possible to mitigate and/or eliminate these practices. Under the bright light that has been shined on the social media, lackluster attempts have been made to correct their practices and business models. A large part of solving these problems is the lack of knowledge in Congress and the federal bureaucracy to pinpoint and correct these problems by way of Congressional hearings and managing the federal response to these problems. There is a general attitude that these matters are overwhelming to the point where imposing regulations and/or controlling the power of great corporations seems impossible. But, in truth, nothing is impossible if we consider Estonia’s accomplishments as a template.
Medical record keeping defects have also been exposed by the pandemic, previously described. But this global problem can be seen locally. Two years ago, I was hospitalized after a serious road accident. The first hospital where I was a patient was a nationally known trauma center. My vital signs were written down on a sheet of paper on a clip board, instead of entered into an IPad that is connected to the hospital’s computer system. When I was transferred to a rehabilitation hospital, owned by a national hospital corporation, my patient records were not transferred either digitally or on paper, resulting in the interruption and poor management of my drug therapies. It was not uncommon for my vital statistics to be written on the sleeves of the medical technologists. Medical care there was substandard and was rendered by very few nurses and poorly trained nurse-assistants. One physician hospitalist covered the entire rehabilitation/nursing home hospital and was available only by schedule. When I subsequently visited my Internist, those records were not accessible through the Med-Star hospital system. I concluded from that experience that the medical care system, in particular managed by national hospital corporations, as I experienced them, is broken and seemingly beyond even minimal repair. Physician friends of mine have the same experience and share my conclusion.
The revolution of medical care that has taken place by the purchasing of both small and large hospitals is in need of another revolution, by way of a complete transformation of management and consistent government inspection and regulation. To assure that this occurs, and as another way to increase employment nationally, a cadre of medical care managers has to be educated and deployed in large numbers to correct the deficiencies of record keep and patient management.
Conclusion
What I have imagined demands a revolution and a sea-change in legislative thinking, as well as the strategies of concerned non-governmental organizations. A comprehensive domestic ‘Marshal Plan’ is one template for managing change. The costs to carry out these ideas will be very high. In the trillions over many decades. Inevitably, taxes will have to be raised, and how much depends on other strategies to revise the tax code; close unnecessary tax loopholes closed; and reduce or eliminate unnecessary industry subsidies to big businesses as required. An essential component is a new kind of management and oversight system are especially trained private civil servants and private sector mangers. Political opposition to what can be seen as a turn form capitalism to socialism aside, the time is right for this kind of change to be regarded as necessarily practical. This is because all of the problems cited here have been exposed by the bright light of the pandemic, in particular the personal social and economic suffering caused by its impact. It is an international embarrassment for the richest country in the world to have experienced the problems discussed here, and to ignore them by the usually politically convenient incremental changes.
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