416. How Do You Reopen a Country?

Episode Summary

Executive Summary: The episode examines COVID-19 exit strategies through interviews with Rhode Island Gov. Gina Raimondo, former CDC director Julie Gerberding, IHME’s Chris Murray, healthcare economist Zach Cooper, pharmacist Steve Chen, and economist Steve Levitt. The central tension is reopening safely without adequate testing, tracing, or clear immunity science, and the discussion proposes major testing expansion, pharmacies as testing sites, and incentives to get asymptomatic people tested.

Main Topics: Reopening vs. public health trade-offs (Priority: 5/5): Governor Raimondo frames reopening as choosing among bad options: limiting deaths and virus spread while minimizing economic damage. She stresses the need to reopen quickly but safely, using data-driven thresholds to avoid a full shutdown if cases rise again. Testing as the critical bottleneck (Priority: 5/5): Nearly every speaker agrees that mass testing is the key prerequisite for reopening. The episode details why current U.S. testing capacity is far too low, why supply chains are constrained, and why price incentives and federal coordination may be necessary. Public health strategy: mitigation, recovery, and second-wave risk (Priority: 4/5): Gerberding and Murray explain the pandemic response in phases: early detection, mitigation, and recovery. They warn that a second wave remains likely without robust testing, tracing, and isolation, and that hope alone is not a plan. Role of pharmacies and decentralized healthcare delivery (Priority: 4/5): Steve Chen argues pharmacists are an underused healthcare workforce that could massively expand testing access. He highlights the mismatch between pharmacists’ training and their legal status, especially in states that still bar them from administering COVID tests. Economics of incentives and market failure (Priority: 4/5): Zach Cooper and Steve Levitt argue the testing shortage is a market failure that justifies large public spending. Levitt goes further, suggesting lotteries and cash incentives to induce asymptomatic testing and quarantine compliance. Privacy, civil liberties, and contact tracing (Priority: 3/5): Raimondo supports rigorous contact tracing but says it must be balanced with privacy and civil liberties. She favors opt-in, consumer-friendly approaches and secure data handling rather than intrusive surveillance.

Key Arguments: Gina Raimondo argues reopening decisions must be guided by science, with clear metrics that would allow the state to pause or reverse reopening if infections or hospitalizations rise. Raimondo says Rhode Island’s early shutdown actions helped prevent healthcare system collapse, even if they drew criticism at the time. Julie Gerberding argues COVID-19 requires a three-phase response: early detection, mitigation, and recovery; the U.S. is still in mitigation and not ready for recovery. Chris Murray warns a second wave is a serious risk because most Americans remain susceptible, making testing, tracing, and isolation essential. Zach Cooper argues the testing shortage is a market failure severe enough to justify spending about $250 billion and paying much higher test reimbursement rates. Steve Chen argues pharmacies should be used far more aggressively because they are widespread, well-staffed, and already perform many clinical functions. Steve Levitt argues the main problem is not only test supply but also demand: people need incentives to get tested and stay home if positive. Levitt proposes a large lottery and generous stay-home payments to internalize the externality of asymptomatic infection and make testing attractive. Julie Gerberding says antibody tests are not yet reliable enough to serve as simple “return-to-work” certificates because we do not know whether antibodies guarantee immunity. The episode argues that an exit from lockdown requires not just more tests, but a whole system of rapid, accessible, and incentivized testing plus contact tracing and isolation.

Data Points: Rhode Island first COVID-19 diagnosis: March 1 - Raimondo says Rhode Island was among the first states to see a positive case. States with early cases: one of the first 10 U.S. states - Rhode Island was an early hotspot and had to respond quickly. Rhode Island positive cases: more than 7,000 - Total cases in Rhode Island by the time of the interview. Rhode Island deaths: over 200 - Reported deaths in the state at the time. Unemployment claims in Rhode Island: 170,000 - Reflects the severe economic impact in a state of about 1 million people. U.S. COVID deaths at time of recording: more than 50,000 - Dubner cites the national death toll early in the episode. 1918 influenza deaths worldwide: roughly 50 million - Used as historical comparison for pandemic severity. 1918 influenza deaths in U.S.: around 675,000 - Historical benchmark for U.S. mortality. Modern equivalent of 1918 U.S. deaths: around 2 million - Adjusted for population growth. Rhode Island temporary hospitals: 2 built, 1 more planned; total 1,000 beds - They were built as surge capacity but not needed at that level. Possible hospital-bed need from models: 6,000 to 7,000 beds - Raimondo says this scary projection helped justify extreme measures. Worldwide SARS cases/deaths: about 8,000 cases and 800 deaths - Gerberding references SARS to compare with COVID-19. Global COVID cases/deaths at time of recording: roughly 3 million cases and more than 200,000 deaths - Given as the pandemic scale when the episode aired. U.S. tests per day: around 200,000 - Cooper notes current testing is far below what exit strategies require. Testing capacity target in some plans: 20 million tests a day - Mentioned as an example of the scale some plans imply. U.S. economy losses: $16 to $19 billion a day - Used to argue that testing is economically worthwhile. Cost of a month of shutdown: nearly half a trillion dollars - Derived from daily losses. Proposed federal testing investment: $250 billion - Cooper says this scale of spending could solve many testing-production issues. CMS early reimbursement rate: $30 to $50 per COVID test - Initial payment level before being raised. Later reimbursement rate: $100 per test - CMS increased payment from the initial range. Cooper’s suggested payment rate: $250 to $1,000 per test - He argues the government should pay far more to scale production. Americans living near a pharmacy: 90% within five miles - Chen uses this to argue pharmacies are ideal testing sites. U.S. pharmacies: about 67,000 - Compared with about 5,500 hospitals. U.S. hospitals: about 5,500 - Used to show the relative scarcity of hospital-based testing sites. California pharmacist testing count: 0 - Chen says pharmacists had not yet administered COVID tests in California. Random national testing proposal: 10,000 Americans - Cited as a proposed truly random sample to estimate prevalence. Pregnant women prevalence estimate in New York: about 15% - Used as one of the more reliable prevalence estimates because it is less biased than voluntary sampling. New COVID vaccine timeline discussed: 16 to 18 months - Attributed to the Trump administration’s expectation. Vaccine development norm: about 10 years - Gerberding says typical vaccine development takes far longer. HIV vaccine timeline: after four decades, still none - Used to illustrate that some diseases remain difficult despite scientific effort.

Pivotal Quotes: "There’s no good options. I’m choosing between bad options number one and bad option number two." — Gina Raimondo: Explaining the reopening dilemma facing governors. "Hope is not a strategy." — Chris Murray: Warning that a second wave is plausible without robust testing and preparedness. "We basically need the federal government to set a payment rate for COVID tests that applies to all parties in the healthcare system." — Zach Cooper: Describing how to fix the fragmented and underpowered testing market.

Implications: The episode argues that reopening requires a large-scale public investment in testing, tracing, and incentives, plus broader use of pharmacists and clear legal authority. Without that, states risk reopening too early and triggering renewed outbreaks.