UCSF's Department of Medicine Grand Rounds on November 5, 2020 included (from top left): Dr. Bob Wachter, Dr. Kirsten Bibbins-Domingo, Ezekiel J. Emanuel and Andy Slavitt. Illustration by Molly Oleson; photos from screenshots of live event.

During today’s Grand Rounds, UCSF Department of Medicine Chair and Grand Rounds moderator Bob Wachter called the 2020 presidential election for Joe Biden. Sort of. 

In an unstructured conversation, Wachter and three panelists mused over the confluence of the presidential election, the coronavirus pandemic, and the United States healthcare system. Wachter approached his questions under the “guiding assumption” that Biden would win the presidency and Republicans would hold the Senate, though he acknowledged that neither are certain. 

The three panelists on Grand Rounds included Kirsten Bibbins-Domingo, chair of the UCSF Epidemiology and Biostatistics Department; Ezekiel Emanuel, Vice Provost for Global Initiatives and co-director of the Healthcare Transformation Institute at the University of Pennsylvania; and Andy Slavitt, former Director of the Centers for Medicare & Medicaid Services in the Obama administration and key leader in the implementation of the Affordable Care Act. 

Wachter commenced the conversation by asking panelists for their insights from the election “at a momentous time in health and health care and for our country.”

Emanuel pointed to the passage of several “blue” ballot initiatives in red states (such as the $15 minimum wage in Florida) as signs that “on particular issues, you can get bipartisan majorities, whereas voting for politicians tends to be more polarized,” in part because there aren’t any “compromise candidates.” 

In response, Slavitt said that “’Democrat’ and ‘Republican’ probably officially now don’t mean what they used to mean.” He explained that being a Republican no longer means being in a party of fiscal or military hawks, but rather anti-immigration and populist, while the Democratic party has shifted from the party of union workers to a more educated, institutionalist party. Though Slavitt attempted to be neutral in his descriptions of the parties, Bibbins-Domingo was far more direct, calling out the Republican party for “very clear, racist, polarizing, anti-immigrant messages.”

“It is my concern that the polarization that has been part of the scientific message has really both devastated the communities that are disproportionately affected by our pandemic, but also has harmed our overall pandemic response because we can’t get past that to have people to think in more of a public health collective mindset,” she said. “Every single thing is polarized by racism and other issues.” 

If Wachter is correct in his election assumptions, this is the situation Biden will be stepping into in several months when he takes office. Immanuel, who has been in touch with a key Biden advisor, had some predictions for what Biden will be considering during his time as president-elect.

“You want to hit the ground running on January 20th and be ready to push things forward,” Emmanuel said, believing that vaccine distribution, rebuilding the CDC and “the scientific integrity of  the public health response,” and other familiar issues like testing, PPE, and contact tracing are all likely at the top of Biden’s agenda. 

However, he noted that Biden cannot actually do anything until he takes office, and made a comparison between the current moment and when former presidents Barack Obama and Franklin Delano Roosevelt were preparing to take office during great economic turmoil. “There was preparation on what to do on the day and be sure that you’re ready for that day, and I think the Biden team will do the same thing,” he said. 

Slavitt discussed four “levers of power” at the federal government that Biden can use to shift the tide against the pandemic: executive orders, money (with the consent of Congress), science, and the bully pulpit. 

“The truth is, until we have a reliable vaccine and even after we have one, our communication with one another is our medicine: how we talk to each other, how we communicate, how we decide what values are important to us,” Slavitt said. “People are exporting a lot of sickness and death to other communities. They’re links in a chain that are concentrating this in places where people aren’t paying attention. And so we’ve lost the sense of unity, we’ve lost the sense of empathy.” 

Slavitt then asked the million dollar question: how does a president come into office in a country that is more divided than anticipated and try to get people on the same page? 

His answer? Meeting with governors and other local actors, and going on “listening tours” in communities with low compliance. 

Bibbins-Domingo didn’t seem totally convinced. Discussing the politicization and polarization of mask-wearing, she highlighted the prevalence of strong anti-masking and anti-vaccine sentiments, and pointed out that Biden will be contending with more cases and deaths in January.

Emmanuel felt that changing the narrative of what freedom means in a pandemic will be critical to slowing the pandemic’s spread: instead of viewing freedom as the choice to wear (or not wear) masks, we should think of the freedom people have to live their lives and move around in countries where the virus is under control.

Shifting gears, Wachter asked panelists about the likelihood that Republicans will work with Biden and the Democrats. No one was optimistic. 

Emmanuel and Slavitt both seemed to be of the mindset that the Republicans will be able to be obstructionist if they are able to maintain control of the Senate, with Slavitt noting that “given the divisiveness of the two parties, I wouldn’t be optimistic.” 

Another topic the panelists were not highly optimistic about was the impending Supreme Court case challenging the Affordable Care Act. 

“I do worry about this new composition of the court and its aggressiveness and overturning past precedents,” Emmanuel said. Slavitt foresaw several different scenarios, depending on the  court’s decision on “severability,” meaning how much of the Affordable Care Act the justices decide to throw out. 

“What the court decides is very likely where we’re going to end up. And that’s scary,” Slavitt said. Several panelists believed that larger changes in healthcare in the coming years would be a result of regulatory changes in the healthcare industry and demonstration projects (small pilot programs that demonstrate the need for policy changes), rather than legislative changes.

Bibbins-Domingo also brought up the need for local trust and dialogue between politicians and communities to address the disparities that Covid-19 has exposed, especially in low-income communities of color. She said patterns exist across the country that drive up coronavirus transmission in certain communities, but that passing critical local policy and connecting with community groups (who call out where the government has fallen short) will allow us to have better health outcomes. 

This connection will be critical when it comes to vaccine distribution. Emmanuel believes that “generally, in the country, we don’t have enough visibility into all the steps and all the preparations that have or have not been done to get over the barriers” of distributing a vaccine.

“There are a lot of hurdles that will have to be addressed that have not been well delineated and managed by this administration. That will be different in the new administration,” he said, discussing Biden’s ability to put together a team of competent people and implement practical changes.

See our previous Grand Rounds coverage here

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FREELANCER. Madison Alvarado was raised in the Bay Area and moved to San Francisco after attending undergrad at Duke University. She fell in love with reporting in high school, and after a brief hiatus is eager to continue learning and growing as a storyteller. She has been covering UCSF's Grand Rounds since the summer of 2020.

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