A chance to think through where we stand in the fight against COVID-19

The legislation passed by the Senate Tuesday, and likely soon to make it through the House, offers a good chance to think through where we stand in the fight against COVID-19, and where our government’s response stands.

The bill’s main purpose is to “top up” the Paycheck Protection Program enacted in last month’s CARES Act to help small businesses stay afloat. The $350 billion appropriated for that program have been spent in just a few weeks, and this bill adds another $320 billion and adds a little bit more structure to the program’s design. It then appropriates $75 billion to support hospitals in this emergency — reimbursing expenses related to COVID-19 and making up some lost revenue. And it provides another $25 billion for testing needs, including money to the states and to HHS to support research, manufacturing, deployment, and administration of testing.

On the whole, it would be fair to say this bill is necessary but far from sufficient. It’s necessary because the needs it sets out to address are very real and the funding it provides will be useful. It is far from sufficient not so much because it doesn’t provide enough money to meet these needs (although in the cases of both economic relief and testing it is grossly insufficient on that front too) but because the broader understanding of the problem to be solved that is implicit in the bill is dangerously behind the curve. The bill is basically conceived as a patch to the CARES Act, which was enacted on March 27 — nearly a month ago. And in the national catastrophe we’re living through, a month is a very long time.

A month ago, the basic question was how to make a hard economic pause sustainable for a time while mobilizing to respond to the peak of the crisis. That’s what the CARES Act sought to help do, and it has helped. That question is still with us of course, but by now we are also necessarily asking ourselves how to effect the gradual soft start that needs to follow the hard pause.

We need to do that not because the pause was a mistake but because it is necessarily temporary. Its purpose is not to wait out the virus but to help the health system avoid being utterly overwhelmed and to enable our society to live with the virus relatively safely while our biomedical enterprise finds the most effective ways to fight and beat it. The balance of safety and activity required to do that could not have been achieved by gradually ramping down from normal life, because the risks involved would have been too great and in the process we would likely have overwhelmed the health system in many places. So it needs to be achieved by gradually ramping up from a near-shutdown of social and economic life that lets us get through the peak of this first wave of the pandemic and prepare the resources needed for the ramp-up. We have achieved that shutdown, we are beginning to reach that peak in some places, and we need to be preparing ourselves for that ramp-up.

The “debates” we are having over lockdowns and liberation right now are mostly a distraction from this process. The people involved in them paint their opponents as either calling for long-term lockdowns until a vaccine comes or treating the virus as just another seasonal flu and demanding a sudden, total end to the national mobilization to respond to it. It doesn’t help that the president can be found embodying both caricatures at different times, as the obligations of governing and the pleasures of cynical populist politics compete to define his crude conception of a job he has managed not to understand even after three years of doing it. The fact is that almost no one really holds either of those two views, and those few who express them seem to do it mostly to strike a pose.

The “hard pause, soft start” view of the purpose of intense social-distancing policies is not an ex post facto redefinition but has at least implicitly been the aim of these policies throughout the five or six weeks since they were broadly enacted. (And it has sometimes been made explicit too, here’s how I put it a month ago myself.) The core reason why a hard shutdown is not sustainable beyond the near term is not that people are mad as hell and screaming to reopen right now. Very few people are doing that, and huge majorities say they prefer to hold out until they see a reason to feel safer, even after things reopen. But the fact is that the arrangements involved in enabling most people to stay home are inherently untenable even in the medium term. They involve some people (who sustain our hospitals, core public services, and supply chains) taking big risks so that other people can take minimal risks. And they involve holding out — many people doing without paychecks, many property owners doing without rent and mortgage payments, many businesses doing without revenue.

That holding out can be sustained by massive government support for a short time, but there is no way to keep the economy on hold with such support in the medium term. The government can’t actually substitute for the economy. And so we need to gradually restart what is paused, but to do it in a way that moderates the risk of the virus and makes it possible for us to live with it while the fight to end it continues.

The bill going through Congress this week patches up the effort to sustain the hard pause, but it does awfully little to help the effort to enable the soft start.

That effort would require, first of all, a much greater investment in testing, tracing, and containment. This has become increasingly clear; it is basically the view of everyone who has looked at it. And given that this bill actually does fund testing, it is hard to imagine why it does not fund far more of it, and why it makes no effort to establish some framework for a massive mobilization of testing to enable a gradual return to work.

There are a variety of plausible frameworks out there, and they are pretty similar to one another. My AEI colleague Scott Gottlieb and a team of other public-health experts have proposed one approach. A team of economists, public-health experts and others brought together by the Safra Center at Harvard have proposed another. There is a lot of common ground among such proposals, and they all call for much greater testing and containment capacity — including the necessary workforce for contact tracing and massively greater infrastructure for ongoing testing. Developing that capacity will be difficult, and will require in particular some novel kinds of engagement by employers. But it will also require funding. If we don’t want to end up spending hundreds of billions of dollars every few weeks on more patches to support an essentially unsustainable economic freeze, then we need to start spending more modest but still very significant amounts on the mobilization of such testing, tracing, and containment work. That obviously should have been in this legislation but wasn’t.

That effort would also require a much more intense and urgent focus on the development of treatment options for COVID-19. A vaccine is probably a year or more away, but treatment that makes the worst cases less bad need not be nearly so far away. And America’s uniquely capable pharmaceutical R&D enterprise, made possible by our uniquely commercial and innovative health sector, is likely to be where such progress comes from. China’s rigid and repressive regime has inflicted this nightmare on the world through its unwillingness to acknowledge the scope of the problem early on, and America’s innovative and creative society will end this nightmare for the world through its capacity for scientific and technological ingenuity.

But there is a role for government in enabling the mobilization required for that to happen quickly. The National Institutes of Health, in particular, is well positioned to break down some of the barriers to cooperative innovation posed by the usual protocols of corporate, academic, and public medical research. The agency even already has the statutory authority to take on that role — I wrote about what that might look like a few weeks ago at The Atlantic. And the NIH has lately begun such an effort, announcing a first step just last Friday. But it needs more resources from Congress to do that: nothing on the scale of the financial bailouts, but much more than this new bill has made available.

Treatments that could make the worst cases of COVID-19 much less bad are really the only plausible near-term game-changers. They would dramatically transform how we think about and deal with the virus, and make it much easier for us to live with it until a vaccine is available. Since living with it until a vaccine is available needs to be the goal of the policy response at this point, advancing treatment options needs much greater emphasis from policymakers. Getting to an effective treatment this summer rather than next winter, for instance, would make a difference on a scale that we can barely fathom. This calls for more than just including a vague reference to “treatment” on a list of things HHS can do with a paltry sum it is granted in this bill.

We are at a dark and difficult hinge-moment in our struggle against this virus. It does look like some parts of our country may be reaching the peak of this initial outbreak, but that means we are living through a very difficult phase. About 15,000 Americans have died from this virus in just the past week. And yet it is precisely now that we need to be thinking about how to start returning to work.

Doing that thoughtfully and safely means being ahead of the curve just a bit. This latest legislative effort, useful and necessary though it is, suggests that Congress and the administration are still behind the curve. That needs to change, and fast.

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