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Policy Primer: Telehealth (2021)
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Summary

The most fundamental concern of modern healthcare is not reimbursement, but supply. Today’s healthcare market is crippled by government regulation and a command/control structure which slows the market’s natural tendency toward innovation, investment, and scale. Many of these concerns may not be addressed in our lifetime. However, we can start by controlling costs that focus on innovation, new delivery systems, licensing restrictions, and the decertification of state-sanctioned monopolies. By addressing supply concerns today, we can begin to develop opportunities for medical service providers to expand outside of the prevailing third-party insurance model, which has reigned for the last 80+ years.

Telehealth Initiative

“Despite per capita expenditures exceeding those of any other country, the U.S. healthcare system has problems with access, cost, and quality. These deficiencies have proven refractory despite the efforts of policy experts and politicians and the desires of an increasingly concerned public.”

This is the opening statement of a 2018 Mercatus working paper by Jeffrey Flier, Distinguished Service Professor at Harvard University, and Jared Rhoads, Research Project Manager for the Dartmouth Institute for Health Policy. Their sentiments echo problems that have been addressed repeatedly in the media, in academia, and in the household budgets of Americans for more than a decade. While the healthcare market seems ripe for innovation and growth, the shift has been slow, failing even to keep up with those advancements in technology and communications which might best serve patients and practices.

As many states have expanded Medicaid over the last decade, a significant question was never answered. How are patients and payors going to address the inevitable increase in the per-service cost of healthcare? For every dollar used for patient coverage under the Medicaid system, there is an increase in the demand for medical services. As demand increases alongside Medicaid spending, and supply remains unchanged, the per-service costs of healthcare necessarily increase for all payers, whether they be patients who pay cash, insurance companies who are renegotiating rates, or the states via Medicaid reimbursements. In other words, for every dollar spent in the Medicaid system, service costs will increase at some point in the supply chain – this is how economics works. It’s quite simply a question of supply and demand.

The supply of service providers, however, is not so easily addressed. The short/mid-run horizon of accessibility remains unyielding for two reasons. First, training new medical personnel is a costly and time-consuming activity. This is what economists refer to as “highly inelastic supply.” It is challenging for a medical service provider to simply expand operations like, say, a restaurant might do during the busy hours of the day. In effect, this inelastic supply of healthcare providers exacerbates the rising costs caused by the increase in demand. One solution for this problem is to employ those innovations, such as telehealth, which allow providers to increase their efficiency and decrease the time and opportunity cost of each service. To illustrate, remote patient monitoring technologies have been shown to decrease the intermittence of emergency department visits by patients with one or more chronic conditions. Remote patient monitoring allows providers to triage these particularly demanding cases without overwhelming emergency room staff and facility limitations.

Public policy is the second reason for a hesitant and unyielding supply curve. Often, legislative and regulatory restrictions hinder the healthcare market’s ability to innovate and build high-efficiency platforms which will positively affect the supply of service providers or make services more efficient to perform.

The outcome of the Virginia Institute’s Healthcare Freedom Initiative is ultimately to create an atmosphere where the per-service cost of healthcare can moderate over the short term. An appropriate state-level healthcare policy must necessarily focus on the realities of the supply of medical services to improve accessibility. For more than a decade, the conversation has centered on payment methodology – i.e., private health insurance, Medicaid/Medicare, single-payer, etc.  Health insurance, however, is correlative to neither healthcare nor health outcomes. Health insurance, healthcare, and health are three very different matters that need to be attended to as such. This initiative addresses outcomes related to the accessibility of healthcare directly. In following these policy recommendations, the state can better achieve its objective of improved societal health outcomes by strengthening relationships between doctors and their patients.

Telemedicine Deregulation 

For telemedicine to expand, three policy avenues require considerable improvement.

The first is the geographic limitations of medical licensure, which has a direct effect on the supply of professionals within a state. Every doctor who receives a degree from Johns Hopkins University or the University of West Virginia is qualified to be licensed in every state in the nation. In fact, licensure requirements vary only marginally from state to state. Telemedicine can provide an untapped supply of medical professionals, as well as a way for in-state practitioners to streamline their operations by utilizing telehealth as an innovative and agile triage for their patients. Inherent to telehealth is the distinct benefit of shrinking the world of medicine.

Secondly, the Commonwealth of Virginia currently mandates that private insurers reimburse telemedicine companies at parity with similar in-person services. This means that private insurance companies must pay the same rate for similar services regardless of whether they are offered in-person or via telecommunications technologies. These types of mandates prevent cost savings from being passed on to the consumer, in this case insurance companies; cost savings that may go a long way to developing the infrastructure necessary for telehealth services to develop into their fullest potential. Recent research performed by both the Rand Corporation, a nonprofit think tank, and Teledoc, a telehealth provider, found the per-service savings are often as high as 45 percent. Telemedicine’s ease of use does tend to increase service utilization over the short-term, which generally moderates to a 13 percent increase in service usage. This represents massive potential savings to healthcare consumers and payors, including the state.

Thirdly, during the COVID-19 pandemic, numerous temporary regulatory waivers have been granted, allowing the expansion of telehealth to meet both the increased demand for medical services as well as the need to maintain social distancing, particularly at the doctor’s office. These waivers were largely effective, but their temporary nature disincentivizes further investment into current and new technologies. The Virginia Institute for Public Policy supports a “fresh start” for COVID-19 related telehealth waivers, allowing many of these critical provisions to become permanent. As Virginia clarifies the stability of telehealth offerings within the medical service offerings in the Commonwealth, it will draw investment to develop these services as well as their necessary peripheries (broadband access, for instance).

Policy Recommendations

The key elements of the Virginia Institute for Public Policy’s Healthcare Initiative include:

  • The removal of restrictions on telemedicine services within Virginia’s healthcare markets, including geographic licensure barriers, and opening the language for Virginia’s regulatory and statutory codes in such a way as to allow the market to innovate as freely as possible in the future.
  • Address liability concerns in the case of telehealth facilitators providing consumers with appropriate recourse in those rare cases of medical malpractice.
  • Sunset Virginia’s Certificate of Need program, in its entirety, within three years to remove hindrances to the competitive development of medical service capacity.
  • Provide budget-neutral (or positive) tax incentives for healthcare businesses to enter and develop the telemedicine market in a competitive and consumer-focused atmosphere.

FAQs 

Q. How will the adoption of telemedicine affect Virginia’s budget?

A. There is a common misconception specific to healthcare that the more supply is available, the more demand there will be for medical services. This is, of course, irrational. Numerous studies have shown that, following the adoption of telehealth and telemedicine service modalities, the utilization rate increases approximately 13 percent, but the cost savings to payers is between 40 to 45 percent. Much of these savings occur within the realm of long-term care for those patients who have one or more chronic conditions. Not only does the use of telehealth and telemedicine eliminate unnecessary trips to the emergency department, but the efficacy of these services often decreases the morbidity rates for these patients.

To state this simply, the reimbursement of telehealth delivery modalities by Medicaid/Medicare will create a net-savings to Virginia’s healthcare budget.

Q. What is the difference between telehealth and telemedicine?

A. This question has very different answers depending on whom you ask. From a regulatory standpoint, telehealth is an umbrella term that includes any medical service offered via the medium of telecommunications technology. In contrast, telemedicine includes only those services that currently have an in-person counterpart – dermatological or behavioral health visits, for instance. Within the Code and regulatory language, both terms are essential to provide new space for innovation, which may develop as investment grows in the medical telecommunications markets.

Q. What is keeping telehealth from being used today? Can’t we just call our doctors and have a visit over the phone?

A. There are multiple concerns that keep us from simply engaging in telehealth with our doctors today. First, oftentimes third-party payors like insurance companies or Medicaid/Medicare refuse to reimburse for services offered via telehealth, despite these services usually being considerably less expensive. The solution to this problem is often patients communicating with their insurance companies to make it clear that telehealth service would make their lives easier and less costly. Secondly, and most concerning, health care legislation at the state and federal level is often written from the perspective that everything is illegal until sanctioned by the law. This is not only irresponsible but is also completely unreasonable in a free country. This rhetorical direction has been embedded in the law for well over fifty years and will take some time to unknot, but we must continuously work to “move the ball down the field,” so to speak. Opening legal avenues for innovations like telehealth and telemedicine gives us opportunities to begin to turn the tide against the use of command-and-control language in the Code. 

 

What is the Tuesday Morning Group?

The Tuesday Morning Group (TMG) coalition is a joint project of the Virginia Institute for Public Policy, a 501(c)3, and Tertium Quids, a 501(c)4.

Established by the late John Taylor, co-founder of the Virginia Institute for Public Policy, in December of 2001, the TMG coalition has proven a phenomenal success in Virginia.

Today, TMG is recognized as one of the largest state coalitions with over 1,000 activists representing more than 250 organizations.

The political leanings of the TMG coalition is about 70% conservative, 30% libertarian, and 100% free market. Guest speakers have included presidential candidates, governors, state legislators, and members of Congress, as well as nationally-recognized, issue-specific scholars and experts.

To get involved or for more information, please visit our Tuesday Morning Group page here.  You can also click here  to view or download our TMG Handout (2021).

“Will Virginia Reject American Federalism?”

By Michael C. Maibach

During the 1788 New York ratification convention, anti-federalists opposed the new Constitution “for lack of a Bill of Rights”.  Alexander Hamilton replied, “The Constitution is itself in every rational sense, and to every useful purpose, A BILL OF RIGHTS” (Federalist #84).  Indeed, it was written to safeguard liberty against the worst form of tyranny, the tyranny of the majority about which Plato, Aristotle, and Montesquieu warned, as did Tocqueville five decades later.

The American Left (no longer worthy of the term “liberal”) has always chaffed against the Founders’’ “checks and balances” within Madison’s “compound republic” (Federalist #51).   If the mission of the Left can be summarized, it is “Tear down every rafter in the Constitutional edifice until all the protections for minority rights and diversity of regions and political thought are gone.”

In 2006 wealthy Californians launched a cynical attempt to remove one of the load bearing pillars of our Constitution – the Electoral College – by way of a National Popular Vote Interstate Compact.  They aim to convince state legislatures to enact their Compact until states representing 270 Electoral College votes sign on, the number needed to elect a President.  Already 15 entirely “blue” states have enacted the Compact for a total of 196 Electoral votes.  Now those Californians have convinced Sen. Adam Ebbin (D) and Del. Mark Levine (D) to advance their model legislation in the January 2021 legislative session in Richmond.  There are five major reasons why this legislation must be defeated:

NPV COMPACT:  A CONSTITUTIONAL ASSAULT

The NPV Compact is a Constitutional assault on three fronts.  First, the State Compact Clause (Article I) reads “No state shall, without the consent of Congress, enter into any Compact with another state…”  The NPV cabal has not sought Congressional approval for their illicit state Compact.  Second, the NPV cabal has not attempted to use the Constitution’s amendment process to achieve their goal as they know 38 states will never agree to this radical change to how we elect our Presidents.  Third, the Framers considered three other ways to elect our President – election by Congress, by state governors, and by a national popular vote. All three were rejected for an Electoral College, what is today a Presidential election in each of our 50 states.  Once agreed in Philadelphia, 13 state ratifying conventions voted to adopt our Constitution as written, including an agreed amendment process.  The manner of electing our President was a keystone in the document’s architecture, one that must not be altered absent agreement with the requisite 38 states.  It was the states that created our Constitution, the Constitution did not create the states.

NPV COMPACT:  CONTRARY TO THEIR OATH’S “SACRED PROMISE”

The dictionary defines an oath as “A solemn promise, often invoking a divine witness, regarding one’s future actions or behavior.”  Members of the Virginia legislature and the Governor affirm this oath of office:  “I do solemnly swear I will support the Constitution of the United States, and the Constitution of the Commonwealth of Virginia… to the best of my ability, so help me God.”   The NPV Compact is an un-Constitutional state compact (its name alone confirms this), a cynical attempt to change the Constitution without the votes of 38 states.

Moreover, the Commonwealth Constitution provides that only Virginia residents are entitled to vote for Virginia’s elected officials.  Yet the NPV Compact would mandate turning the votes of Virginians over to the voters of other states to decide for whom Virginia’s 13 Presidential Electors will cast their votes!  Can Virginia legislators who support the NPV Compact legislation tell the citizens who elected them that they are living up to their oath of office?

NPV COMPACT:  AN AFFRONT TO THOSE THEY REPRESENT

A Virginia legislator or Governor who supports the NPV Compact defies the Constitution and offers a civic afront to the citizens of our state.  They are saying, “Regardless of how the majority of Virginians vote, I favor allowing citizens of larger states to decide how our Electors shall vote –  none of whom elected me, none of whom pay my salary, and to none of whom have I given an oath of office.”

NPV COMPACT:  ONLY NORTHERN VIRGINIA WILL MATTER

The population of “Northern Virginia” has exploded along with the US government and the high-tech industry.   Today NoVA accounts for 67% of the state’s population!   If the NPV Compact were in place, future Presidential candidates would only visit major metropolises like New York, Miami, Houston, Chicago, LA County… and the DC metro area.  Virginia legislators who favor the NPV Compact are saying to the rest of the state – “You will no longer matter.”  Will downstate legislators and the Governor support this unlawful Compact and then explain this additional affront to those who elected them and pay their salaries?

NPV COMPACT:  A FEDERAL GOVERNMENT TAKE-OVER OF PRESIDENTIAL ELECTIONS

In 2020 the vastly different and swiftly changing elections laws of our 50 states have whipsawed our national elections. Over 30 states require photo IDs to vote, the rest do not.  Until 2020 only seven state had 100% mail-in voting, now officials are finding boxes full of ballots all over the place and recounts abound!   With Covid we saw 44 states change their voting laws and systems, often without public hearings. We are now witnessing the bitter harvest of election dysfunctions.  Too many Americans today no longer feel that our elections are “fair and transparent”.  This is a real threat to our ability to govern ourselves with good will and a sense of democratic justice.

Along comes the NPV Compact to heap upon our civic environment even more disruption and cynicism.  It says, “regardless of how your state votes, those states with the most voters will forever rule this Nation.”  Nine US states are home to 50% of our citizens.  LA County has more people than 41 of our states!  The “national popular vote” scheme aims to turn farmers and rural Americans into modern day serfs, feeding the major cities who will forever rule them.  Gone will be the quaint Iowa Caucuses and New Hampshire Primaries.  Want to alienate Americans more than they are now in this republic?  Support the NPV Compact!  And with all of the differences among our 50 state voting systems, the NPV Compact will naturally lead to calls to “nationalize our election laws” by placing the US government in charge of the voting systems of our 50 states.  In turn, this will place a future American President in charge of their own re-election machinery.  Stunningly unwise!

Yes, the Left seeks to take down the US Constitution, pillar-by-pillar.  And they understand that taking down the Electoral College is actually the swiftest way to take down the entire Republic.

 

Michael C. Maibach is a Distinguished Fellow on American Federalism at Save Our States, Managing Director of the James Wilson Institute, and the first American to be elected to public office under the age of 21 in US history.  www.SaveOurStates.com

Documentary Rebuts Claim That the Electoral College is Racist

Original article posted with permission from Save Our States.

Staff – Sept 03, 2020

Critics of the Electoral College Paint a False Narrative for Partisan Purposes.

Today, Save Our States, a non-partisan nonprofit, responded to critics who allege the Electoral College is racist. In a soon to be released documentary, “Safeguard: An Electoral College Story,” the group shows that the Electoral College serves to protect and promote minority voices.

In the wake of George Floyd’s death, Americans have grappled with race relations. Many communities, especially big cities, have experienced unrest. Some activists and politicians are now arguing that the way we elect our president is a product of racism and hurts black voters.

Prominent civil rights leader Vernon Jordan, who as president of the National Urban League in the 1970s was a vocal defender of the Electoral College, argues this is untrue, “For blacks, abolition of the electoral college would severely limit our political leverage in national elections.”

This issue has come to the forefront as the presidential election approaches and with voters in Colorado about to vote on a “National Popular Vote” (NPV) ballot measure. This effort – openly described as an“end-around” of the Constitution is endorsed by Rep. Alexandria Ocasio-Cortez and funded by George Soros. NPV would essentially give away Colorado’s voice in presidential elections, as voters there would be drowned out by those in bigger states like California or New York.

In a compelling new documentarySave Our States shows the flaws of NPV and the need for the Electoral College. “Safeguard: An Electoral College Story” explains how the American Founders established the Electoral College as part of a system of checks and balances, allowing the people of each state to have a voice in presidential elections. “Safeguard: An Electoral College Story” – will be released nationally and internationally on September 8, 2020. The film will be made available on Amazon Prime (an audience of 120 million viewers), iTunes and other platforms. The film will be submitted to multiple film festivals.

“Attacking the Electoral College as racist makes for a good talking point, but bad history. The constitutional system has helped to moderate our politics, forcing political parties to reach out to new voters. Support for the Electoral College by figures like John F. Kennedy and Vernon Jordan remind us how the system has benefitted minority voters,” writes Trent England, Executive Director of Save Our States.

Trouble Brewing in the Housing Market?

Just this last week, a number of interesting news stories crossed my desk. Two in particular stood out – the Trump administration’s newest moratorium on evictions, and the Federal Reserve’s purchasing $1 trillion worth of mortgage bonds. Now, I don’t think there is any question as to why the feds have chosen this path; times are hard for some people and the feds don’t want them to get harder. The question is, what problem does this solve? The answer: it doesn’t solve any problems. As Thomas Sowell was quoted recently, “There are no solutions, there are only trade-offs; and you try to get the best trade-off you can get, that’s all you can hope for.”

The real question is, then, “what are the trade-offs for these policies?”

Well first, the administration’s moratorium certainly provides some much sought after breathing room for America’s renting population. The Aspen Institute estimates that between 30 and 40 million people are at risk of being evicted: that is quite the number. What happens, however, to the landlords when their troubled but legally protected tenants stop paying rent until the end of the year?

Consider the following: a reasonable percentage of at-risk renters cease paying rent for the next 4 months. Due to this, the less financially prepared property owners must choose to foreclose rather than to continue to deal with the mortgage that many are using the rent to pay. January 2021 comes along, renters are no longer protected, and the houses they live in are now bank-owned assets which will undoubtedly be sold at auction after the tenants are evicted en masse. Potentially millions of rental properties may end up in just such a circumstance, and the potential of a sudden decrease in rental supply could very well mean higher rents in 2021. Will this policy truly help America’s renters, or will the trade-offs come back to bite even those that are not currently “at risk”?

Beyond this, what happens to all those mortgage-backed bonds that are being held by the Federal Reserve if mortgages go belly-up like they did after the 2008 recession? Mortgage delinquency peaked in 2010 at 9.3% as we began the agonizing process of digging ourselves out of a politically driven recession with the same political burdens slowing down our efforts. This last August, mortgage delinquency had reached 8.2% at the same time that the Fed was approaching $1 trillion in what some might consider toxic securities; incidentally, that is approximately 30% of the American housing market. I can only imagine that among the threats of continued lockdowns, a flagging service industry, and the administration’s short-run compassion, we may see considerable difficulties in the new year vis a vis 2008.

This does not address all of the potential trade-off for these policies, but this is what you need to be thinking about when you read the news on new economic programs, public welfare spending, and public policy more generally. It should always be your very first question: “what are the trade-offs?”

Should Government Officials Drop in on Homeschooling Families?

June 17, 2020, article republished with permission from CATO Institute.

By Neal McCluskey

A couple of days ago Cato’s Center for Educational Freedom hosted a discussion on one of the hottest topics in education: homeschooling. The issue is in the front of many people’s minds because COVID-19 forced just about every child in the world to school at home. But people have been debating the right degree of parental and government control of education for centuries, and the debate specifically concerning homeschooling reached peak heat last month with a Harvard Magazine article pondering “a presumptive ban on the practice.” Our event featured Elizabeth Bartholet, the Harvard professor who called for the presumptive ban; Cato adjunct scholar and homeschooling advocate Kerry McDonald; historian and Messiah College professor Milton Gaither; and me, serving as both a panelist and moderator.

Homeschooling: Protecting Freedom, Protecting Children

In my opening remarks I endeavored to quickly work through a libertarian thought process on the role of government vis‐​à‐​vis homeschooling, with an emphasis on the difficulty of fitting children into a basic libertarian framework. That basic framework is grounded in freedom for people whom we assume are capable of self‐​government – typically adults. For at least some amount of time—we can debate how long for any given person—children cannot make many informed decisions for themselves, nor can they defend themselves against abuse or neglect. Someone else controls them.

In light of that, the homeschooling debate is more complicated than simply concluding that parents should be able to do whatever they want with their children. Few people, for instance, would disagree that government should stop child abuse or neglect. Of course, the norm for dealing with criminal activity, as I explained in my remarks, is for someone to suspect a crime is occurring, an investigation to occur, and if an investigation provides sufficient evidence for government to intervene, alleged perpetrators are charged and tried, with their innocence assumed unless they are proven guilty.

That said, our event was intended to discuss difficult issues from multiple perspectives, hopefully with all involved trying to understand how reasonable people could hold opinions different from their own. With such a discussion as a goal, and knowing that there have been very rare, but also very devastating, cases of isolation and abuse of children under the guise of homeschooling, in my remarks I said that it “may” be reasonable to “maybe” annually have some government official drop in unannounced on homeschooling families to briefly check in on children.

Many people heard this and thought that I was asserting that such a policy should be implemented. That was not my intention – I wanted to offer food for thought, and perhaps something that could spur a search for common ground.

So where do I stand? Again, the legal norm is suspicion, investigation, and trial with a presumption of innocence. That remains the best approach because a government empowered to inspect our homes and families without probable cause is a dangerous, insufficiently constrained government. The same presumption of innocence and due process should apply to how we deal with potential educational neglect, which I define as failure to educate a child to read, write, and calculate – the building blocks a child needs to become self‐​governing and access more expansive education.

I also, though, believe that we need to spend more time and effort thinking about how we can protect children from abuse and neglect. This may well mean reforming child protective services, encouraging communities to pay closer attention to families that appear to be isolated or in crisis, and maybe just discussing abuse more to raise the public consciousness. And we must remember that children are not adults—many cannot defend themselves or self-govern—rendering the policy framework we use for them more complicated than simply letting people do as they want as long as they do not forcibly impose things on others. No matter what, someone other than the child is imposing on them.

Relax Pharmacy Regulations to help with COVID-19 Testing and Treatment

March 27, 2020 article republished with permission from Mercatus.org

By James Broughel and Yuliya Yatsyshina

One of the most urgent challenges facing policymakers managing the current COVID-19 public health crisis is how to ramp up diagnostic testing on a mass scale. Companies such as Walgreens, CVS, and Target have already started working with the federal government, as their locations are well-suited to become testing sites. As a result, pharmacies and pharmacists themselves are likely to become instrumental in testing for COVID-19 in the coming weeks and months. However, certain regulatory restrictions on pharmacists should be relaxed so that they can practice to the full extent of their training and abilities.

The Importance of Testing

The president has declared a national emergency and the federal agencies and state governments overseeing the response to the pandemic have recommended or required that citizens stay at home, practice social distancing, and, in some instances, self-isolate, self-quarantine, or shelter in place. To-date, authorities have offered little guidance as to when these recommendations will expire. Without reliable information about how many people are infected with COVID-19 as well as the rate at which the disease spreading, it is likely that policymakers currently have no clear sense of when to recommend a return to normalcy. Critical data required to inform such decisions will only emerge once large-scale testing is implemented.

Tragically, the federal government botched its early response to the crisis. Among other things, the first COVID-19 tests distributed around the country by the Centers for Disease Control and Prevention (CDC) produced unreliable results. Furthermore, commercial labs and public health officials in the states couldn’t get initial approval to perform their own tests (though in some cases, they tested anyway). These failures, largely a result of inflexible regulations, have contributed to delaying the rollout of testing in the United States. Even now that many legal barriers to testing have been removed, shortages of supplies could be hampering the scaling up of testing.

This is a particularly unfortunate outcome because the experience of other countries suggests that testing on a large scale has been a key ingredient of an effective response to the pandemic. Testing, when combined with practices such as isolating infected individuals and using contact tracing methods to identify who else may have been exposed to the virus, has shown promising results in places such as South Korea and Singapore. Testing to confirm that those who are exhibiting no symptoms or who were previously ill are in good health could also potentially speed the transition back to normalcy.

The effectiveness of mass testing is powerfully illustrated by the experience of Vò, a small town that reported Italy’s first death from COVID-19. The town’s 3,300 or so residents were tested and retested as part of an experiment rolled out by the University of Padua, with assistance from the government of the Veneto Region and the Red Cross. Residents were tested regardless of whether they were exhibiting symptoms. Those who were confirmed as infected were quarantined. The second round of testing revealed that the number of infected residents had dropped from 3 percent of the population to nearly zero, and Vò eventually reached zero new cases within a few weeks. Notably, this outcome differs dramatically from the experience of other parts of northern Italy, which has been one of the regions of the world most affected by COVID-19.

The Role that Pharmacists Can Play

At the time of this was written, 579,000 COVID-19 tests had been administered in the United States. If the disease continues to spread exponentially, testing will have to keep up with that pace of growth. Meeting that goal is going to be a significant challenge, as laboratories are already facing shortages of testing equipment. Another challenge is going to be finding safe places where potentially infected individuals can be tested without infecting others and healthy individuals can be tested without getting infected themselves. A role for pharmacies is thus quickly becoming apparent.

Massachusetts, for example, set up one of America’s first drive-through testing facilities in a pharmacy parking lot. Other states, such as Michigan and Pennsylvania, are following suit. Major drug store chains have publicly committed their support for the fight against COVID-19.

Pharmacies are well positioned to become testing sites because of their geographical coverage across the country. There are more than 309,000 employed licensed pharmacists in the United States and its territories, and 90 percent of Americans live within five miles of a pharmacy. Many pharmacies have adequate parking, which makes them well suited for drive-through testing. Some pharmacies even have drive-through windows. The familiarity patients have with pharmacists could prove important if sick individuals are more comfortable driving to their local pharmacy than going to a doctor’s office or a hospital.

Pharmacists can be of critical assistance in triaging the coming avalanche of patients seeking diagnostics and care. Pharmacists could test patients for COVID-19 and, if the results return positive, give directions for home care if the illness is mild. If the illness is severe, pharmacists could direct patients to designated facilities for their particular area. Even if results were to come back negative, the pharmacist would save the patient from having to visit another venue of care, thereby freeing up time for other medical professionals to focus on more urgent cases. Should patients suffer from other minor ailments, pharmacists could also provide treatment (though this might require legal changes in many jurisdictions; to be discussed later in this brief).

Pharmacists’ training makes them capable of providing this kind of basic medical care. It takes about eight years to obtain a doctor of pharmacy degree, a regular requirement for a pharmacist license. This time includes three to four years of undergraduate prerequisite work and four years of additional professional study. The COVID-19 test is relatively simple and usually involves taking swabs from a patient’s nose or throat. This is a task well within the capabilities of a pharmacist to perform. Although for now the analysis of the swab is likely to take place off site at a lab, in the future this work could potentially be done on site. Indeed, rapid-turnaround COVID-19 tests are currently being developed and, in some cases, undergoing FDA approval. Moreover, pharmacists themselves stand ready to assist, as identified by a recent call by the American Pharmacists Association for expanded pharmacist services to combat COVID-19.

Policy Recommendations

Fortunately, there are not many laws standing in the way of pharmacists and pharmacies immediately assisting in testing efforts for COVID-19. Personnel working at testing sites set up near pharmacies should be able to collect specimens from patients and send those specimens to laboratories for analysis without facing significant legal hurdles. These laboratories, however, do need government approval to operate, and indeed this has been one of the central bureaucratic hurdles that has hampered the US government’s response to the crisis.

These same restrictions also affect pharmacists with respect to performing laboratory testing for other ailments. For several decades, many pharmacies have been allowed to perform low-risk health tests thanks to the Clinical Laboratory Improvement Amendments of 1988 (CLIA). Even in ordinary times, pharmacies can obtain CLIA waivers and perform tests related to such ailments as influenza, strep throat, human immunodeficiency virus, and other medical conditions.

Currently, however, the percentage of pharmacies holding CLIA waivers varies enormously across states. One study finds the percentage of pharmacies possessing CLIA waivers to be between 0 and 60 percent, depending on the state, with a median percentage of 19.56 percent. One reason for the disparity across states is varying state and local regulations, which include restrictions related to testing procedures, licensure of the personnel conducting tests or overseeing a lab, phlebotomy requirements, and waste disposal requirements.

Allowing pharmacists to perform tests in ordinary times would better prepare them for crises like the current pandemic. Moreover, as CLIA waivers have increased, pharmacists and lab technicians have been able to incorporate basic testing into their existing workload without needing to work more hours. Pharmacist testing has an additional benefit of potentially reducing the time between symptom development and treatment. Thus, ensuring that CLIA-waived COVID-19 tests quickly become available should be a top priority of the US Department of Health and Human Services.

When pharmacists are testing for an ailment, they are usually qualified to treat similar conditions as well. Florida recently passed a law that allows pharmacists to test and treat for influenza and strep throat. These kinds of changes are likely to alleviate some of the stress on the medical system as pharmacists take on the burden of handling some of the more routine cases. However, Florida’s reform remains far from ideal, in part because it requires a licensed pharmacist to have in place a collaborative agreement with a supervising physician, which can act as a disincentive for many pharmacists.

Idaho is perhaps the model state in this regard, as Idaho allows pharmacists to prescribe autonomously if a pharmacist identifies a medical condition as a result of a CLIA-waived test, as well as under a number of other routine situations, all without a collaborative agreement with a physician in place. Idaho also allows for substitution of therapeutically equivalent drugs without express physician authorization (but with notification to the physician). As more states like Idaho and Florida allow for basic testing and prescribing authority for pharmacists, colleges of pharmacy are likely to respond by updating curricula, thereby enhancing preparedness for future pandemics.

Many states are relaxing other kinds of regulations as a result of the COVID-19 pandemic. Massachusetts has allowed pharmacies to produce hand sanitizer and mandated that insurers cover certain telehealth services. Some states are now accepting out-of-state medical licenses or embarking in reciprocity agreements with other states with regard to medical licenses. Again, Idaho has a reciprocity law for pharmacists that could serve as a model in this regard.

Relaxing restrictions on telepharmacy could also yield beneficial outcomes. Currently, most tests for COVID-19 have a relatively long turnaround time, often requiring patients to wait at home for results. When results become available, tested individuals could have a consultation with the pharmacist on the phone or via video conferencing platforms such as Skype or Zoom. Not only is this convenient for the patient, it also encourages social distancing. Currently, there is a debate taking place about take-at-home COVID-19 tests. If these tests become common, relaxing telepharmacy rules could enable pharmacists to provide remote instructions to patients administering their own tests. Telepharmacy reforms have also been known to increase access to pharmacies among underserved populations, such as rural populations.

Importantly, as pharmacists take on additional responsibilities, they will likely need to rely more on pharmacy technicians to pick up more routine tasks. However, many states have restrictions in place that mandate a maximum ratio of technicians that can work with each pharmacist. Notably, many states have no ratio requirements, and some states even have provisions in place that allow technicians to work remotely, suggesting that some restrictions on pharmacy technicians can be relaxed or lifted altogether.

In short, pharmacists could readily play a role in ramping up COVID-19 testing and treatment, and eventually, when available, providing the vaccine. Relaxing state phlebotomy laws could yield additional benefits, as drawing blood may be necessary in efforts to search for antibodies for COVID-19. Any restrictions on the ability of pharmacists to immunize using FDA approved vaccines should also be reconsidered.

Conclusion

As pharmacies and pharmacists become instrumental in COVID-19 testing, any related regulatory restrictions at the state and federal level should be reconsidered. States should make it easier for pharmacies to obtain CLIA waivers, pharmacists should have the ability to prescribe in low-risk situations, regulations should be amended to make it easier for pharmacists licensed in one state to practice in another state, and the use of telepharmacy should be encouraged. Restrictions on pharmacy technicians and the ability of pharmacists to vaccinate are also areas where liberalization could prove beneficial. Combined, these reforms are likely to improve the public’s access to testing and treatment for COVID-19 as well as a variety of other medical conditions. Equally important, these reforms can enhance preparedness for future pandemics.

Spaced Out, Hidden, Here Come the 2020 Tax Hikes

Stephen D. Haner, Senior Fellow for State and Local Tax Policy at the Thomas Jefferson
Institute for Public Policy, brings us a list of the tax hikes coming to Virginia as early as July 1st of this year.

Highlights include: big increases in state and regional gasoline taxes, double the cigarette tax, and authorization to impose a 5-cent tax on plastic bags. Read the full Jefferson Journal article here.

A Letter to the President of the Virginia Institute

The Importance of the Freedom Caravan

Saturday, April 25, 2020

Dear Lynn,

I have seen our freedoms disappear over the years. The inception of our country was spurned on by our founding father’s revolts against King George’s policies, and they fought relentlessly for the rights and freedoms we now possess in our constitution. This month, we were witness to another tyrannical government in the form of our governor and his administration.

I believe we as citizens of this great nation have a responsibility to stand against the tyranny designed to destroy our state and country. This notion is shared with hundreds of patriots I spoke with on Wednesday, at the rally point near the Capitol in Richmond. These patriots came from all over Virginia to voice that the “free enterprise system is the most productive supplier of human needs and economic justice,” therefore meaning we must open Virginia for business as soon as possible. If we are to survive as a state and nation, we must take a stand against our governor to protect the constitutional values that are under fire.

To not attend the rally on Wednesday out of fear of COVID-19 or government reprisal was not an option. It was an opportunity to peacefully object to the government overreach that is plaguing Virginia today. My hope is that our governor and his administration will view the assembly on Wednesday as leaders of conservative groups that represent thousands of votes this November, and as a peaceful message to reopen the state so that we, as a state and nation, can become economically viable again.

Lynn, I could not begin to tell you how many people commented on the Thomas Jefferson quote on the little blue truck. Thank you for your support!

“When government fears the people, there is liberty. When the people fear the government, there is tyranny.”- Thomas Jefferson

Regards,

Major Mansfield