with Alexandra Ellerbeck

It’s been a year, readers.

I expected to spend 2020 writing about topics like drug prices, insurance reforms, the opioid epidemic and health policy fights in the election. Instead, I spent most of the year trying to understand and explain one particularly pernicious virus — and the havoc it wreaked on the United States. 

I wrote a lot about the coronavirus. Far more than any other topic, in fact:

  • We sent you 206 editions of Health 202 this year: 141 of them – nearly 69 percent – were focused in some way on the coronavirus.
  • Between March 7 and the end of June, we took a break from the topic on just four occasions.
  • In the months of April and May, every single Health 202 led with the coronavirus.
Thank you for sticking with us through it all.

We tried all year to bring you the newest and smartest reporting on the pandemic, even as scientists’ and researchers’ understanding of the novel coronavirus evolved. Our Washington Post colleagues contributed immensely, providing in-depth reporting on everything from testing to vaccines to state shutdowns and more.

And while the pandemic raged, all the other issues we normally cover were still in the background. The nation elected a new president who will shift the government’s approach to health policy. The opioid crisis raged on — and may have worsened. The Supreme Court considered whether Obamacare is constitutional yet again. 

We definitely didn't predict a pandemic back in January – but we didn't downplay the virus, either.

Our first Health 202 about the coronavirus was on Jan. 23, with this headline: “Coronavirus may not get as bad as SARS, but U.S. officials are on alert anyway.” I wrote this:

Is this new coronavirus a SARS redux? It’s too early to say, but the virus does appear to be spreading rapidly.

More than 500 people — most of them in Wuhan, China — have been sickened by the illness, and at least 17 have died, according to the latest figures. So far, the new coronavirus appears to be less deadly than the variety that caused the 2003 severe acute respiratory syndrome (SARS) epidemic, which sickened more than 8,000 people and killed about 800, but little is known about how contagious this new virus is.

But we readily admit we weren’t always spot on about everything. 

Part of that is because we — and the experts we talk to — can’t see into the future. And while we try to include historical perspective, that's not always a predictor of how events will unfold. That was apparent in the case of vaccine development, which moved much faster than most had predicted based on timelines for past vaccines.

A Twitter follower recently suggested that news outlets could increase trust in journalism by doing a year-end listicle of stories where they were wrong. That’s not a bad idea, considering Americans’ trust in media has declined over the past two decades. 

So we’re taking her advice. Here are a few Health 202s that didn’t age so well:

Jan. 9: “A cancer-free ‘RBG’ looks likely to stick around through the November election.”

“Liberals fearing yet another Supreme Court vacancy for President Trump to fill have some cause for relief: It doesn’t appear that Justice Ruth Bader Ginsburg is going anywhere anytime soon,” I wrote.

Uh — not so much. Justice Ginsburg died in mid-September, setting up a worst-case judicial scenario for Democrats in the waning months of the Trump administration. The Senate confirmed Trump nominee Amy Coney Barrett just weeks later, putting a conservative majority on the court, probably for years to come.

Jan. 22: “The Supreme Court may have saved Trump from himself on Obamacare.”

I wrote this

“Now President Trump is almost certainly off the hook for coming up with an Obamacare replacement before the November election. That’s a political plus for him, despite the president's recent frustrations over polls showing voters don’t tend to trust him on health-care issues. …

“The Supreme Court turned down a chance yesterday to quickly decide a lawsuit that could dismantle the 2010 health-care law and its provision of coverage for millions of Americans.

The Supreme Court announced six weeks later it would hear the case, setting off a huge ad blitz by Democrats who capitalized throughout the election cycle on the administration-backed threat to the Affordable Care Act.

The court heard the case one week after the election. While deeply skeptical questions from the justices calmed the fears of liberals that they might strike the whole law down, the court’s decision to consider the law gave Democrats tons of ammunition in an election that Trump ultimately lost.

March 12: “Number of U.S. coronavirus deaths will depend on how many older people are exposed.”

Here's what I wrote:

Could tens of thousands of Americans die of the coronavirus? Maybe, if the elderly aren’t sufficiently sheltered from it. … That will likely be the key factor in keeping the fatality rate from skyrocketing in the U.S., since the covid-19 has proved especially deadly for those over 80 while rarely killing children, young adults or even those in middle age.

It's clear that the elderly have accounted for a huge portion of the covid-19 death toll. An estimated 40 percent of deaths were to residents of long-term care facilities, and 80 percent of all fatalities were among people age 65 and older.

But deaths in the tens of thousands? If only. By The Post's count, 306,000 people in the United States have died of covid-19, 11 months after the first case on U.S. soil.

Sept. 8: “Most Americans won’t be allowed to get a coronavirus vaccine as soon as it’s approved.”

I wrote this: 

The most likely scenario to play out is that the Food and Drug Administration would grant initial approval to vaccinate just front-line health workers, those older than 65 and those with underlying medical conditions, two industry vaccine experts tell me. It would come in the form of an emergency use authorization — a shortcut for the government to approve medicines and treatments in dire circumstances — as large clinical trials continue.”

The FDA did indeed grant emergency use authorization to Pfizer’s coronavirus vaccine. That occurred last week. 

As broadly predicted, the first groups to get vaccinated are front-line workers. The FDA has also recommended that those in long-term care facilities be at the front of the line, and that older people and those with underlying medical conditions be prioritized. 

But the EUA itself is much broader than just the highest-risk groups. It allows the vaccine to be used on anyone 16 or older. The FDA is expected to authorize Moderna’s vaccine for those 18 and older by the end of the week.

Ahh, oof and ouch

AHH: Relief checks may be back in the stimulus package, while aid to states and cities is out.

Congressional leaders are nearing a deal on a roughly $900 economic relief package that could be finalized by the end of the week.

“The package emerging is expected to include hundreds of billions of dollars in aid for ailing small businesses and jobless Americans; tens of billions of dollars in aid for other critical needs, such as vaccine distribution and schools; and a one-time check of between $600 and $700 for millions of Americans below a certain income threshold,” Jeff Stein, Mike DeBonis and Seung Min Kim report.

The bill is also expected to include a new round of funding for the Paycheck Protection Program, $300 per week in supplemental unemployment benefits and $25 billion to provide emergency rental assistance that can cover past and future rent payments.

State and local funding relief appeared to have fallen out of the deal on Wednesday along with a liability shield that Republicans had pushed for to protect businesses from coronavirus-related lawsuits. Slashing state aid provides more money for stimulus checks, but it comes as states and cities are facing a major budget crunch that could force some to cut services, including for health care.

Lawmakers are aiming to pass the bill alongside a $1.4 trillion government funding bill, which must pass by Friday. 

OOF: A top Trump appointee pushed for a “herd immunity” approach to covid-19.

Paul Alexander, who served as a science adviser to top Department of Health and Human Services spokesman Michael Caputo, repeatedly urged health officials to allow the coronavirus to spread freely among young people. 

“There is no other way, we need to establish herd, and it only comes about allowing the non-highrisk groups expose themselves to the virus. PERIOD,” Alexander wrote in July to Caputo and six other senior officials, according to emails obtained by the House Oversight Committee and shared with Politico.  “Infants, kids, teens, young people, young adults, middle aged with no conditions etc. have zero to little risk….so we use them to develop herd…we want them infected… ."

Alexander also pushed for HHS and Centers for Disease Control and Prevention communications to be more favorable to the president, according to emails obtained by the House Oversight Committee and shared with Politico

Politico's Dan Diamond writes: “Senior Trump officials have repeatedly denied that herd immunity — a concept advocated by some conservatives as a tactic to control Covid-19 by deliberately exposing less vulnerable populations in hopes of re-opening the economy — was under consideration or shaped the White House's approach to the pandemic.”

But officials said that they understood Alexander’s recommendations to have backing from the White House. HHS has distanced itself from Alexander since he left the agency in September, and a spokesperson from the agency said that the demands for herd immunity did not shape department strategy. Caputo also left the agency that month. 

Public health experts have overwhelmingly rejected a herd immunity strategy that relies on natural infection rather than vaccines, arguing that it would lead to too many preventable deaths.

OUCH: The coronavirus pandemic is killing young Americans at historic rates.

While the largest burden of the coronavirus has fallen on the elderly, public health officials have downplayed the risk of the virus to the young to potentially deadly consequence, according to an op-ed in the New York Times co-written by Rochelle P. Walensky, Biden’s pick to lead the CDC.

Walensky, writing along with Jeremy Samuel Faust and Harlan M. Krumholz, physicians at Brigham and Women’s Hospital and Yale, respectively, cites research showing that July may have been the deadliest month for young adults in modern American history.  A study published in the Journal of the American Medical Association found that 16,000 adults between the ages of 25 to 44 died that month, compared to an average of 11,000. Between March and July, there were almost 12,000 excess deaths in this age group.

“For too long, the message has been repeated — by us and our colleagues, by government officials and the public — that Covid-19 is dangerous for the old and that younger people do well,” the physicians write. “But what we believed before about the relative harmlessness of Covid-19 among younger adults has simply not been borne out by emerging data.”

Deaths among adults between the ages of 25 to 44 account for fewer than 3 percent of covid-19 deaths, but as the virus surges across the country, thousands of younger people are dying. Because young, healthy people are low on the priority list for a vaccine rollout, it may be all the more important to stress that they are at risk and need to continue wearing masks and social distancing. 

Vaccine latest

The Pfizer vaccine supply contains additional doses, potentially expanding the nation’s quantity by millions.

After pharmacists began to notice that vials of the vaccine contained more than the expected five doses, the Food and Drug Administration granted them permission to draw an additional sixth or seventh dose from each vial.

“That means the supply of remaining vaccine could be up to 40  percent greater, though the drugmaker cautions that it’s uncertain how many extra doses are available,” Fenit Nirappil reports.

Meanwhile, the Trump administration is negotiating with Pfizer for additional coronavirus vaccine doses after turning down an opportunity earlier this year to double its purchase of 100 million doses. Pfizer has warned that other countries have rushed to purchase the supply and the United States may have to wait until summer to receive additional doses.

Vice President Pence, second lady Karen Pence and Surgeon General Jerome Adams are expected to receive the vaccine live on camera Friday.

UC Davis Health received its first shipment of the Pfizer-BioNTech vaccine on December 15, with emergency department employees receiving the first doses. (The Washington Post)

In other vaccine news, a health-care worker in Alaska had a serious, nonfatal allergic reaction after receiving the Pfizer vaccine, Lena H. Sun and Joel Achenbach report. The case echoes similar situations in the United Kingdom last week. British authorities have counseled that anyone with a history of anaphylaxis, a type of life-threatening allergic reaction, consult with a doctor before receiving the vaccine. The CDC has issued somewhat more narrow guidance, urging people who have had such severe reactions in response to other vaccines to get counseling on the risks versus benefits.

More in coronavirus

  • The National Football League says it plans to invite health-care workers to who have received the coronavirus vaccine to February’s Super Bowl, Mark Maske reports.
     
  • Record numbers of coronavirus patients are pushing hospitals to the brink, and with cases surging across the country, the health-care system can't transfer excess capacity among regions, Brittany Shammas, Ariana Eunjung Cha, Ben Guarino and Jacqueline Dupree report. One public hospital in Los Angeles warns that it is a step away from crisis triage levels, at which it will be forced to discourage people from coming to the hospital altogether. 
     
  • Biden and Vice President-elect Kamala Harris met virtually with governors on a Zoom call to discuss the coronavirus response, ABC News reports. Biden reiterated his plan to ask people to wear a mask during his first 100 days in office and told state leaders he wanted to work with them on delivering vaccines free and equitably. 
     
  • Kyle McGowan, a former chief of staff at the CDC, and his deputy, Amanda Campbell — both young Republicans and Trump appointees — are going public with their frustration over political interference in the health agency during the pandemic, the New York Times’s Noah Weiland reports.

Elsewhere in healthcare

National health-care spending continued to grow steadily in 2019, before the pandemic.

Health-care spending increased by 4.6 percent in 2019, similar to the growth rate of 4.7 percent in 2018. The overall share of health spending in the national economy also remained relatively stable, according to an analysis published in Health Affairs. The data only includes expenditures through 2019 and does not capture the impact of the coronavirus pandemic.

The United States spent $3.8 trillion on health care in 2019, accounting for 17.7 percent of the nation’s gross GDP. 

Spending on hospital care and physician and clinical services increased in 2019, primarily driven by people using more services, and to a lesser extent by increasing prices and changing demographics, such as an increase in older adults. 

The increased spending on medical services was offset by a decline in the net cost of health insurance, which can largely be explained by the suspension of the insurance tax in 2019.

While finalized numbers are not available on health-care spending in 2020, experts predict that the nation may see a decline for the first time in years because of the suspension of elective procedures during the pandemic.

The New York Times’s Sarah Kliff writes that the decline in medical spending in 2020 is hitting hospitals unevenly, with those caring for the poor and vulnerable at a breaking point while wealthier hospitals are weathering the storm. The inequalities are already apparent as some wealthier hospitals are better able to attract traveling nurses compared to their rural counterparts.

Sugar rush

Kartik Chandran, a professor at Columbia University's engineering school, discusses the impact of wastewater sanitation. (Columbia Engineering)