When Might You Get the COVID-19 Shot?

0 (6s):
The vaccine rollout in the United States has been a dismal failure thus far. You've got to have a good flow and you've got to be able to expeditiously get it into people's arms once it gets to the place that it has been distributed to. We're not pleased with the rate of distribution, so we're going to supplement the hospitals with additional networks. I'm giving us a C minus to D plus on distribution of the vaccine so far.

Terry Wilcox (33s):
As COVID-19 spreads across the US, a bumpy vaccine rollout slowly continues. Today we take a look at the ongoing vaccine distribution efforts, why it's slow, and some of the bright spots. Welcome to the Patients Rising podcast. I'm your host, Terry Wilcox, Executive Director of Patients Rising, a hundred thousand members strong organization of patients with chronic illness. Today I'm joined by my rockin cohost, who in his early teenage years fronted a rock and roll band, he's Dr. Bob Goldberg, Co-founder of the Center for Medicine in the Public Interest. Now, Bob, are you currently booking for any post COVID-19 wedding gigs?

Dr. Bob Goldberg (1m 16s):
Yes. My bid to play with the inaugural was canceled, but I just want to warn people, unlike the vaccine, listening to our band would lead to serious side effects, including loss of appetite, nausea, and dizziness. So Terry, instead of hearing me sing, I would encourage our audience to join us and listen, as we discuss the latest breaking healthcare news coming out of our nation's Capitol and around the world. Every week we pull back the curtain of Washington DC to explain how ongoing health policy discussions and debates will impact the millions of Americans living with chronic disease. And with President Joe Biden now inaugurated and in office, the focus we'll certainly turn to COVID, the vaccine, and access to care.

Dr. Bob Goldberg (2m 1s):
Look, Terry, 2020 was shaped largely by healthcare concerns and the government response to those things. And I think 2021 will be more of the same.

Terry Wilcox (2m 9s):
That's right. And President Biden has an ambitious health plan, particularly for tackling Covid. Now last week he outlined his proposal called the American rescue plan. And if passed by Congress would give new direct relief checks to families and businesses. It also calls for increased funding to expand COVID-19 testing in vaccine manufacturing and delivery.

Dr. Bob Goldberg (2m 31s):
Delivery is key. Terry, just last week, we looked at States that were doing it poorly like New York and some States that are getting the job done and getting the vaccine out to lots of people very quickly like West Virginia and South Dakota. And county by county, health officials, volunteers in the private sector are redoubling their efforts.

Terry Wilcox (2m 52s):
President Biden has said he has an ambitious goal of 100 million shots in 100 days, but to get there, something is going to have to change in these vaccine roll up plans.

Dr. Bob Goldberg (3m 4s):
Understatement of the year. And there's a lot of moving parts in getting the vaccine into people and to give us a look into the pandemic readiness of the United States and our scorecard on vaccine distribution. This week, I spoke with Tevi Troy. Tevi is a friend of mine, also the former Deputy Secretary of Health and Human Services under George W. Bush, where he led pandemic response and preparedness.

Terry Wilcox (3m 30s):
I'm really looking forward to hearing that conversation, Bob. That will be up shortly, but first this week's healthcare news headlines.

Robert Johnson (3m 40s):
In your health news, a new president means a new approach to the nation's COVID-19 response. Joe Biden wasting no time outlining plans to fight the deadly virus issuing ten directives, among them orders to produce more medical supplies, speed vaccinations, improve testing, and safely reopened schools. It was a year ago yesterday that the first Corona virus case in the U S was confirmed by the CDC. Since then, more than 400,000 Americans have died, millions have been sickened. With President Biden's plan on the table, attention turns to Congress where the money to fund a strategy must be approved. Even his own party is struggling to find a way to afford the new administration's $1.9 trillion COVID package.

Robert Johnson (4m 23s):
The working deadline to pass the latest request is March 14th. That's 53 days into the president's 100 day COVID battle plan. There's worrisome news from more than a dozen States now reporting they are low on vaccine doses, even as they're working to ramp up the pace of vaccinations. Among those sounding the alarm Colorado, Oregon, Minnesota, and Michigan. A new study reports cancer patients are at increased risk of severe illness from COVID-19 infections even if their cancer is in remission. It reveals that among 4,800 people who tested positive for the virus, cancer patients were much more likely to need hospitalization and intensive care.

Robert Johnson (5m 4s):
Their chances of dying from the infection also were much higher. Finally, the outgoing Surgeon General, Jerome Adams, will stay on as an advisor to the new administration, at least for now. He resigned his post when Trump left office, but has been invited to help with the transition. No word on whether he'll be offered a permanent position elsewhere in the federal government. That's your health news update for this week. I'm Robert Johnson.

Terry Wilcox (5m 35s):
This week, President Joe Biden was inaugurated and several cabinet positions are in the process of being filled. One face will be familiar, especially to listeners of our podcast. Dr. Janet Woodcock will serve as Acting Commissioner of the Food and Drug Administration during President Biden's transition into office. Now, Dr. Bob, you interviewed her on a past episode on drug safety, which our listeners can go back and listen to at any time. So what are your thoughts on this move?

Dr. Bob Goldberg (6m 2s):
Well, having followed Dr. Woodcox career and been involved in some initiatives that she began at FDA, I think this is great. Whether she stays there full-time or wants to still remains to be seen, but it is a good sign that the Biden administration is taking seriously many, if not all of the reforms that Dr. Woodcock and Scott Gottlieb and Steve Hahn implemented under the 21st Century Cures Act. So fingers crossed, but to me, it's a great appointment.

Terry Wilcox (6m 33s):
Great. I couldn't agree with you more. I think that's a great, I mean, she would be a great appointment. It's an excellent transition appointment obviously.

Dr. Bob Goldberg (6m 40s):
I like her. So I don't know if I'd want her to be in there or should I just be a good steward of the public trust and say, go for it. But either way, we wish her the best.

Terry Wilcox (6m 51s):
So let's talk a little bit about HHS and CMS. I mean, there was a lot that went on in that agency throughout the Trump administration. I mean Seema Verma did a great deal. As a matter of fact, Joshua Cohen wrote a piece in Forbes this week. I think it was titled something like HHS regulations with enduring impact on pricing and reimbursement, et cetera. She really went for it in that space with what she did with Medicaid, best price, which was right there at the end price, transparency, all of those different things. Do you think any of this will have a lasting impact or do you think it'll just be railroaded when the Biden team comes in?

Dr. Bob Goldberg (7m 32s):
Well, it's not so easy to undo regulations. You've got to formulate new regulations and issue a comment period and send it out to review. I don't think there's any one particular thing that the administration will focus on. Again, my guess is that a lot of the attention will be on re-introducing a Medicare price control bill and Covid. And you're right. I mean, Seema Verma accomplished a lot. It was a very busy CMS. Some of it was very good. And as you said, some of it was horrible. It took them time to get their act together. You know, my big concern always is that someone from ICER are going to sneak in and be involved in setting policy.

Dr. Bob Goldberg (8m 13s):
That's what keeps me up at nights, apart from watching Netflix.

Terry Wilcox (8m 18s):
No, I agree with you a lot on that. That's one of my biggest concerns with this administration is ICER creep. There's a lot of pro ICER voices in the mix. That's something we definitely want to do some education on and outreach on. I think that it's going to be key for patients that there's advocacy in place to speak to that. But like you said, that's not going to be the first focus. A lot of it's initially obviously going to be, I mean, let's talk about the fact that he wants to give a hundred million vaccine shots in a hundred days. Is that what it is a hundred million in a hundred days?

Dr. Bob Goldberg (8m 52s):
So that's it. Let me see. Here's my math. So you divide 100 into a hundred million. That's 5 billion vaccines a day, right? No, wait a minute. You know what? My math is, forget it, I didn't do well in math.

Terry Wilcox (9m 5s):
No, a hundred million in a hundred days. That's a little less than a third of the population. I mean, that's

Dr. Bob Goldberg (9m 12s):
It's not 5 billion?

Terry Wilcox (9m 13s):
It's not 5 billion, Bob.

Dr. Bob Goldberg (9m 13s):
But it's a lot.

Terry Wilcox (9m 14s):
It is a lot.

Dr. Bob Goldberg (9m 16s):
Yeah, but listen, they're not going to reach that goal. If you have states like California saying, well, we're not going to distribute the vaccine because of the allergic reactions. I mean, can't, you do both, can't you monitor adverse events, which are minimal below that of other vaccines and continue to immunize people, particularly in a state like California, where, as we've said before, you have fewer beds per a hundred thousand people than Poland, and the transmission rate for a number of reasons, including the mutation of the virus has gone out of control. Why would you do that? There's always going to be give and take with the States. That's just the way of our government, but somebody's got to call California to account for what they're doing.

Terry Wilcox (9m 58s):
Well, and I also think there needs to be more voices out there like Patrick Kennedy, who recently, I think it was a republished piece stating that at risk populations need to be a priority beyond the vaccine and also criticizing ICER's, you know, methodology within that piece. So I think that's something that there are champions of patient access on both sides of the aisle. And I think that's one of the things that advocates need to be aware of and need to fight for and to support those members who are pro-patient.

Dr. Bob Goldberg (10m 34s):
Yes, absolutely. And meanwhile, you know, there are more vaccines that will be approved. So manufacturing and supply, is not going to be the problem. It's going to be distribution. J and J has a vaccine coming out, AstraZeneca.

Terry Wilcox (10m 49s):
Yeah, they both have vaccines coming out, but I just read a headline earlier this week that, you know, of course you get Anthony Fauci to weigh in,

Dr. Bob Goldberg (10m 57s):
Oh no

Terry Wilcox (10m 57s):
It's like, those are months away.

Dr. Bob Goldberg (11m 0s):
Well, then he said it would be in a week or so. So it's hard to follow

Terry Wilcox (11m 5s):
Hard to follow

Dr. Bob Goldberg (11m 6s):
Fauci's statements

Terry Wilcox (11m 7s):
What exactly is the case? I have to say, it's hard to follow. It's sorta like the market, you know, it's up and down. So, I want to talk a little bit about the successes and the failures, or less than successes I'll say. I don't want to go calling a state a failure.

Dr. Bob Goldberg (11m 26s):
Well there's been some failures.

Terry Wilcox (11m 27s):
There have been. Nine States from the most recent article I read, and this was published over the weekend, but more than 31 million COVID-19 vaccine doses have been distributed to the States and other jurisdictions in the United States, but only 12.2 million or 39% have actually been administered, and that was according to the latest data over the weekend from the CDC, nine States have managed to administer more than half of the doses they received. That's North Dakota, West Virginia, South Dakota, Connecticut, Texas, Louisiana, Kentucky, Colorado, Montana, and Washington DC.

Terry Wilcox (12m 7s):
So North Dakota and West Virginia are leading the nation among that. And this compares, I say, this, this is a comparison, Alabama and Georgia have only administered 23% of their doses. And five other States have administered 30% or less. So there's the low end of the high end of what I just talked about. A lot of it, they say, has to do with States, not relying on hospitals as much. Some are relying on hospital systems and others are choosing to use Walgreens, CVS, some even the National Guard and you know, and stadiums and places like that to administer it. What are your thoughts? Have you read anything around this?

Dr. Bob Goldberg (12m 46s):
Well, I can just tell you from New Jersey, there actually was an article in the Wall Street Journal about this a couple of days ago. I border on Essex County. I live in Union County. They've actually done a very good job of getting the vaccine out and they've, you know, used the playbook of the other States that have been successful. So, you know, they've relied upon a combination of volunteers, law enforcement's been involved. They haven't just limited to Walgreens. They've made it available to local pharmacies. As in West Virginia, they've done a good job of making sure that there aren't any of these so-called vaccine deserts, where, you know, you have a bunch of vaccines available in one part of the County and then not another.

Dr. Bob Goldberg (13m 27s):
That's why I'm thinking, ultimately, it's going to be on a County by County basis that I'm hoping that the additional funding that the Biden Administration is making to support those efforts will help amplify it. I think we blew it on the testing in terms of CDC thinking the only one to do it. And then we blew it on the allocation. And both of those, we lay at the door of CDC. And CDC was not set up and not equipped to fully deal with pandemic response. They were more interested in other things, including behavioral health and changes in eating and to lose weight and stop smoking, and less on the pandemic planning. That's the meat and potatoes of dealing with a situation such as this.

Dr. Bob Goldberg (14m 9s):
Secondly, their allocation regimen, you know, was designed to appease the social justice movement and not deal with the highest risk patients regardless of race or locality. If you're older than 75, you are at the highest risk possible, and other States have done this, Israel has done this as I've mentioned, and I firmly believe this is the way to go until proven otherwise.

Terry Wilcox (14m 34s):
Well, I'm going to say a couple of things. Virginia is not on this list on either end, but we have vaccinated all of our teachers. Meanwhile, our students are not in school. Okay. That's all I'm going to say on that. Everybody knows how I feel about that so I don't have to rant. But one of the States on there that hasn't gotten a lot of press was Colorado. And one of the things that I found with all of the ten or so States that I listed, that they all have in common was that they started preparation for this distribution back in the summer. And Colorado, as a state, did bring hospital systems, emergency management, technology leaders, and everyone together and created kind of a whole state approach. But one rule that they had was that all vaccine providers in the State must administer doses they've received within 72 hours.

Terry Wilcox (15m 23s):
If they don't, the State steps in and moves the unused doses somewhere else. So that's a plan that's worked for them. It's gotten people vaccinated. They said, okay, you have 72 hours to use these. You don't get any more. We're taking them away and we're moving them to a place who's ready to distribute them.

Dr. Bob Goldberg (15m 38s):
Yeah. In, in Israel, the same thing is if you don't use it, you lose it. And if you lose it, then text messages go out from the particular clinics to everybody in a specific radius and say, we've got extra vaccines, come and get it. We haven't been doing that, Colorado has. And I think we're going to learn a lot of, I mean, one of these days we will do a retrospective on the show because there are a lot of valuable lessons in terms of the nuts and bolts of not just dealing with a pandemic, but dealing with continuity of care that we can learn from this experience.

Terry Wilcox (16m 10s):
Yeah. I mean, every State sort of has a different take like West Virginia had backed away from the federal standardized program because more than 40% of their pharmacies are not chain affiliated. So they wanted to prioritize the existing relationships they have and use other means that work for their State to get the vaccinations to the people in their State. I'm very excited to hear your interview with Tevi.

Dr. Bob Goldberg (16m 34s):
Yeah. I'm, I'm mixed for two reasons. Well, three. First of all, I've worked with him for a number of years. Second he's written two books on the issue of preparedness and the role of the President in responding to these kinds of issues. And thirdly, he is the first Yankee fan that we've had on the podcast. So with that introduction, here is my interview with Dr. Tevi Troy, the former Deputy Secretary of the U.S. Department of Health and Human Services. He's an expert in pandemic preparedness, biodefense, presidential leadership, and he's going to tell us what Americans who are eagerly awaiting the vaccine should demand to see in the upcoming months. Welcome Tavi and hoping we get to see pictures and catches report normally this year.

Dr. Tevi Troy (17m 19s):
Amen to that, Bob, I am just hoping for a much better 2021 than we had 2020.

Dr. Bob Goldberg (17m 24s):
In 2014, you wrote a very interesting editorial in the Wall Street Journal where you wrote that the failure thus far, this is for a Ebola, confront and a fight of Bola comes from the shortfalls in three areas, gauging the true scope of the outbreak, deploying therapeutics to effectively combat the virus and delivering medical equipment and personnel. And that fixing these limitations should be the priority in dealing with this epidemic, and the next one. So starting with the pandemic in hand, what grade would you give the federal government's ability to solve the problems you identified back then and why?

Dr. Tevi Troy (18m 2s):
That's a good question, and I think I would amend what I wrote in 2014 a little bit to say that the three lines of defense that we have against pandemics are number one international monitoring, number two tracking, tracing, isolating, and testing of people when they have a disease in the country so we can find where they are and stop them from spreading, and number three is deploying of countermeasures to help address the problem. I think on the first one international monitoring, we failed and I put some of the blame, large part of the blame, on the Chinese government for not being forthcoming with us. Perhaps we shouldn't have been, I guess, suckered by them, or we should have been more attuned, but after the SARS outbreak, when they really messed up and they were not forthcoming with the information, we had indications, including in subsequent flu outbreaks, that the Chinese were being a much more honest and open about these kinds of things so we thought that they were going to give us true and honest information and they did not, but that's on us as well.

Dr. Tevi Troy (18m 57s):
So I would give us a C to C minus on that. The second is track trace, test, isolate, F minus on that complete disaster. I think our testing system did not work at all. I think CDC was arrogant in saying that they were the only ones who could develop a test. And I think FDA kind of enabled the arrogance by telling other entities that we're trying to develop tests, stop what you're doing. So I think we did an awful job on that and we haven't been able to track the virus appropriately as a result since that moment. So that was really bad. And then I'm going to have to give a split grade on the third one, which is storing and deploying of countermeasures. So I identified in my book, "Shall We Wake the President" in 2016 that we did not have countermeasures for coronavirus.

Dr. Tevi Troy (19m 41s):
I specifically said that it's a warning. I said, it's something we have to address. And when I say countermeasures, I mean, either an antiviral or a vaccine, we have neither for coronavirus. We have both for flu. We have both for flu, we do better on flu. So F on preparation for coronavirus in terms of having that. On the second part of the grade, I think we kind of get an A, maybe even an, A plus on developing a vaccine in record time, nine months. Unbelievable. Astounding. Usually takes four to five years if you're lucky, and often the federal government is kind of not paying enough attention to develop the countermeasures that we need such as I was saying earlier with my 2016 warning. So it was clear we had the technology in 2016 to do this. We just didn't do it.

Dr. Tevi Troy (20m 22s):
So A in developing the vaccine. And then I'm giving us a C minus to D plus on distribution of the vaccine so far. So split grades on number three, but I think that's in line with all the categories that they're laying out for the vaccine when I'm in Maryland and you've got category one, one, a one B, one C, then there's two. And so I'm in category three, but I might as well be in category 12 because of all the other letters. So split grades on the development of a vaccine, poor grades on the other two aspects.

Dr. Bob Goldberg (20m 52s):
Just a quick follow-up, the public health community writ large, which include both state and local health departments and officials and the CDC in recent years have shifted away from the traditional mission of public health, which is to, you know, prevent, avoid, identify, isolate, et cetera, and focused on, for example, you know, the CDC's budget for pandemic prevention was gutted even as the budget for projects on environmental health, you know, tripled. So I'm wondering if that's a, not that it was the particular reason, but the underlying infrastructure itself wasn't oriented culturally or administratively to do pandemic response.

Dr. Tevi Troy (21m 36s):
It's a great point, Bob and our friend, Doug Badger has been talking about this, that the CDC stopped orienting itself towards the prevention of communicable diseases, which is its mission, the Centers for Disease Control. That is what it is supposed to do. It it's supposed to save us from communicable diseases. And instead it has been focused on behavior modification. Maybe people are eating too much sugar or they're having sodas or whatever it is that they're doing, that the CDC doesn't like it, and they focus too much attention on that and not enough on their core mission. And I think that's a problem and I'd love to see the Biden administration address it. I don't know if they will, but some administration has to address it at some point in the future.

Dr. Bob Goldberg (22m 13s):
The successful rollout in the state levels in countries like Israel, they basically have gone by age group. And CDC, I saw the slide presentation, I mean there were several slides about social justice, and I'm obviously all for social justice as I'm sure you are, but the allocation of these vaccines led to a situation where, for instance, if you worked at Crate and Barrel in some urban areas, you got the vaccine over my father who is 95 years old and lives by himself, again, not to put the blame on a particular mindset, but you know, going forward it was just one more complication that we didn't need.

Dr. Tevi Troy (22m 55s):
I agree. And I think you can't put the blame on a particular mindset. You've got to focus on mitigating the risk and the way you mitigate the risk is by two things, one hit the most vulnerable, and two get it out as quickly as possible. The governor of New York, Governor Cuomo, I think made a horrific decision among his many horrific decisions, but when he said that he was going to fine entities that gave the vaccine to people who were not according to the prioritization chart, and as a result people were throwing out vaccines so that they would not get fine. You've got to get it out as fast as possible. My brother lives in Israel and he is like you and me, healthy and in his fifties, and he is not a top priority person, but when a clinic had excess doses at the end of the day, they sent out a text message to people saying anybody who is nearby, come by and get it, and they stood in line and the people who got there got it.

Dr. Tevi Troy (23m 44s):
And that's why Israel is at 20 plus percent and counting because they prioritize getting the vaccine in the arms of people. Even if it doesn't necessarily adhere to certain social justice concerns,

Dr. Bob Goldberg (23m 55s):
You mentioned your book, excellent book, "Shall We Wake the President, Two Centuries of Disaster, Management from the Oval Office",. We will link to it on the podcast website. You concluded that turning the president into a nation's help desk is a waste of time and authority and ineffective. I'm wondering, I mean, it seemed to me that your description of that responsibility characterizes the response to every pandemic or every disaster starting with swine flu, and of course, you were there during hurricane Katrina. In my opinion, President Trump's leadership style may have contributed to his defeat if not the perception of the poor response, but what should presidents do differently?

Dr. Bob Goldberg (24m 36s):
And why does this help desk idea where everything's going to get done through the White House isn't the best way to deal with pandemics?

Dr. Tevi Troy (24m 44s):
Look, Bob, the president needs to prioritize and delegate. That's what they need to do. There are things that the presidents are good at and they're supposed to do, and only the president could do. And there were plenty of other things that all different levels of the federal government and state level government and the local government should be doing. And I think if you put it all on the president, he's not Superman. He's not going to put on a cape. He's not going to distribute the vaccine personally to different people. He's not going to develop the vaccine. He is in charge of communicating and telling the nation what we're facing and making sure that people are appropriately worried, but not panicking. That I think is a good use of the president's time. The president can also direct resources within the federal government. He can say, we're going to push aside certain pesky regulations to get work speed going.

Dr. Tevi Troy (25m 28s):
The famous idea on the presidency is that the power of the presidency is the power to convene. The president can convene people and get them to talk about stuff, people who might not get together otherwise. So there are things the president can do, but there are also things the president can't do. The president doesn't develop the tests. He doesn't develop the vaccines. He doesn't put the shot in the arms of people. And this whole notion of the president as superhero who handles everything is misguided and dangerous.

Dr. Bob Goldberg (25m 52s):
I've read your book, reread it twice, it's another great book, "Fight House: Rivalries in the White House from Truman to Trump", and just want to tell the audience sort of the general theme and they should buy the book because you point out that the fights over control over policy and getting the president's ear is in fact, the process. But the process is decided by what the president wants it to look like and feel. So I'm wondering whether there's a better way for these processes to unfold for pandemics versus say, passing a trade bill or dealing with a tax policy.

Dr. Tevi Troy (26m 28s):
Yeah, you raised a good point, Bob, because I think in a pandemic or an emergency situation, you need to go faster. You may perhaps circumvent the process. If you circumvent the process as I lay out in the book, as I lay out in Fight House, you are more likely to lead to conflict. So sometimes people will put their own personal beliefs or their egos aside for the disaster. But as I show in Fight House, that's not always the case. And I think that maybe presidents need to think about how they can do things faster when necessary while at the same time, maintaining clear and deliberate processes that allow all the voices within their White House to be heard when time permits.

Dr. Bob Goldberg (27m 6s):
You worked in the Bush White House for awhile, did you get a sense that President Bush used certain processes for certain issues and let the dust settle on their own.

Dr. Tevi Troy (27m 17s):
Here's what I think, the President, his most precious commodity is time. The President's time is the most valuable resource in a White House, in an administration. He only has four years and the possibility of renewing it for one more term for eight years. And that time runs out very rapidly. And I think the President devotes more time to an issue or to a process in times of emergency. So I remember distinctly in Katrina, the President said at one point, we're canceling the weekend. So that automatically gives you 48 additional hours of time. And the President can look at issues and make decisions and have decision-making meetings, policy time meetings, and the like, and I think by devoting additional presidential attention and putting other presidential activities aside during crisis, you can get more done.

Dr. Tevi Troy (28m 9s):
Now that doesn't mean that the other activities, whether it's welcoming a sports team for winning a championship or going out on the road to speak to the various States, or promoting certain programs, those are all valuable, but when a disaster strikes, sometimes you have to put those things aside and focus on getting more decisions made and more resources directed towards the disaster.

Dr. Bob Goldberg (28m 31s):
So, we have a new President coming in and like many new presidents, they are trying to do everything at once. In this particular case, setting aside the whole impeachment issue. resident Biden wants to deal with immigration and Covid and climate change. I mean, what advice would you give to President Biden about the kind of processes that he should use and how we should allocate his time to each?

Dr. Tevi Troy (28m 57s):
Yeah, look Bob, you know as well as I, Management 101 is if you have too many priorities, you have zero priorities. And I know there's a lot going on with the country. And I know there are a lot of problems, but the President needs to be able to focus on a few number of items and not just say everything is a priority. And I would focus on the issues where the American people are hurting. Right? We have an economic crisis that is facing us right now as a result of the pandemic. And we have a health crisis as a result of the pandemic. And I would make every day about those two things, focus on those things. And I understand that Democrats are very concerned about climate change. People are, everyone's concerned about climate change, but you've got to focus on the immediacy of the now. Right now people are dying because of COVID, right now people are losing their businesses and going bankrupt because of the COVID related activity or non-activity.

Dr. Tevi Troy (29m 45s):
And I think that's gotta be the absolute number one focus for the Biden administration for the first hundred days. Now when you were one-on-one with the President, I mean, how did you respect or address the fact that you had a limited amount of time and what was your approach? Look, there is a time tested thing called the White House Policy Process. As Deputy Assistant to the President for Domestic Policy, I was in charge of the domestic policy process, and it's really like a station map or conductor where you're managing various policy trains. Some need to move faster and get to the President sooner. Some can take more time. Some are more contentious, some can be solved at a level below the President, some require the President's attention and only the President's attention.

Dr. Tevi Troy (30m 26s):
And you just needed to manage those things. You worked closely with the staff secretaries office, which had to approve every piece of paper that went in front of the President. In Fight House, I have some amusing stories about people who tried to get around the staff secretary, like this guy, Bob Hartman, who would take pieces of paper that went into the President's inbox. If he didn't like them, he'd leak them to Evans and Novak, the political columnists, and if he wanted to get something himself in there, he'd skip the staff secretary process and just shove it in the box. Well, I never took the Hartman approach. I think you need to go through the process and it is set up for that. It is not a democratic approach. Is that a Republican approach? It's the White House approach. And that is the way you prepare the President best for the decisions he needs to make.

Dr. Bob Goldberg (31m 5s):
I did have my one minute with the President. It wasn't in the oval office, at a fundraiser, and the only thing I could think of asking him was because he was President of the Texas Rangers was, Hey, Mr. President, what about the Souza trade? And he looked at me and he looked at the secret service guys. There's always one person here trying to push the sore spots.

Dr. Tevi Troy (31m 26s):
What's interesting about that is my experience with the President when I was working inside the government is never had a conversation with him like that. I didn't talk to him about the external things. I didn't talk to them about my family. I didn't talk about my baseball interests. None of that stuff came up. We were talking about the business at hand while he was President, but after he was no longer President, I went to visit him in Dallas and we had the most wonderful conversation about books and about arts and about articles I was writing and articles other people were writing and what my family does, his family does, and it was really interesting to see the contrast between the very correct relationship you have with him when he is in the White House and you need to get the people's business done. And then the relationship you can have afterwards when your two friends talking over, over his desk with his feet up on the desk, and he's joking around about people.

Dr. Bob Goldberg (32m 12s):
We've covered the gamut in this interview. I just have one more question. That is, are you writing another book or do you plan to write another book?

Dr. Tevi Troy (32m 19s):
I do plan to write another book. It actually will touch on some of the things that we've talked on here, but I'm not ready to disclose what the subject of the book is here on the open world of podcasting, but I am playing around with it.

Dr. Bob Goldberg (32m 30s):
First of all, thank you for joining us, you underscored the fact that the mundane aspects of public health should not be left to the delivers a public health. There has to be a presidential led, highly precision focused effort to change the paradigm, because as you pointed out in your journal article, there's one pandemic and there's going to be a next one. So if we haven't learned in the past, I hope we learn about what to do in the future. And I think that you're one of the individuals in the country that people should go to, to figure out what we should do better the next time around. So I hope we have you back on the show that hopefully by that time, you know, Yankee stadium and other stadiums will stop being epicenters of immunization and be epicenters of the Yankees cruising to a world championship.

Dr. Tevi Troy (33m 18s):
As you know, I'm a Yankee fan like you, and I want this podcast to be enjoyed by all people. But I do hope that from a health perspective, we are comfortable having maybe not 50,000 people in the seats in April, but you know, maybe 25,000 people sometime in mid summer. And maybe there are the playoff season. We can have 50,000 people enjoying baseball and all the other great cultural offerings in America.

Terry Wilcox (33m 50s):
This episode of the Patients Rising podcast is brought to you by Patients Rising Concierge, a new service from Patients Rising that helps patients and caregivers find the resources they need to find stability and support throughout their healthcare journey. From finding a professional advocate, to help with insurance challenges, to legal and tax counsel, to local caregiving resources and so much more, our team is standing by to help you navigate the healthcare system and connect you to the services you need. To learn more, visit patientsrisingconcierge.org or email us at askusanythingatpatientsrising.org.

Terry Wilcox (34m 37s):
Thank you for bringing us that conversation, Dr. Bob. Up next, our monthly legal segment with Shelly Rosenfeld, Co-director of the Disability Rights, Legal Centers, Cancer Legal Resource Center. Now this week, she provides some resources for caregivers navigating time off and understanding caregiver duty. Take a listen.

Shelly Rosenfeld (34m 59s):
Today I wanted to talk about the really important topic of caregivers. I'm a lawyer, but just a reminder that what I'm sharing today doesn't count as legal advice. It's general information. So let's get to it more than 40 million Americans who serve as family caregivers, and often they're unaware of the services and resources available to support them. So today I thought it's a great opportunity to talk about the legal rights of caregivers to take time off work, avoid discrimination, and to learn about other caregiver resources available. As you may have experienced when a person is sick, it is extremely helpful to have someone advocate on your behalf.

Shelly Rosenfeld (35m 44s):
Here's a tip, know your duty. There is generally no legal requirement to become a caregiver, regardless of whether the person who is ill is a family member or a close friend. You don't generally have to be someone's caregiver, but once you begin to act like their caregiver, you have a duty to do so responsibly. So are parents required to take care of their adult children? A parent has a duty to take care of their minor children. A parent's duties to take care of their child ends when their child reaches the age of maturity, which is usually age 18 in their state, however many States have laws that require a parent to continue their parental care.

Shelly Rosenfeld (36m 29s):
If the child has a disability that causes him or her to be unable to take care of themselves. So are adults required to take care of their aging parents? Adult children do not have a legal duty to care for their parents. However, many States have what's called filial responsibility laws that require adult children to financially support an aging parent in need of financial or general support or to potentially reimburse the state for services used by the aging parent. For questions about filial responsibility laws in your state contact the CLRC. Here's another tip. There are workplace protections which exist for caregivers.

Shelly Rosenfeld (37m 11s):
The American with Disabilities Act or ADA is a law that protects people with disabilities. And in some instances, caregivers. Many people with cancer do not consider themselves disabled. It's important to note that the definition of disability is different in various legal contexts. The ADA's definition of disability has three parts. First is that the person has an impairment. Second is that the impairment limits a major life activity. And third, the limitation is substantial. Cancer can be a disability under the ADA, but it is determined on a case by case basis.

Shelly Rosenfeld (37m 52s):
It's not just a cancer illness itself that is considered, but also the side effects of the treatment. Here's how the ADA applies to caregivers. The ADA prohibits private employers with 15 or more employees from excluding or denying equal jobs or benefits because of a relationship or association with an individual who has a disability, which can include cancer or the effects of cancer. Caregivers should therefore not be treated differently or have their employment terminated by an employer based on the knowledge that the caregiver has an association with a person with a disability.

Shelly Rosenfeld (38m 36s):
Now we're going to discuss another federal law, commonly known as FMLA. That stands for the Family and Medical Leave Act. It allows qualified employees to take up to 12 weeks of unpaid leave at once or in shorter blocks of days or even a few hours within a 12 month period. The law applies to patients and caregivers of a spouse, child, or parent with a serious health condition. The caregiver and/or patient is often required to get medical certification from a healthcare professional, stating that the caregiver's services are needed. A person can take FMLA time from work to care for themselves, or a covered family member.

Shelly Rosenfeld (39m 21s):
People that qualify as a covered family member are parents or a person acting as a parent, minor children or adult children who are incapable of self care because of a mental or physical disability and spouses. If the person is a covered family member, a caregiver can take time off from work under FMLA to care for them. Many resources are available in different States to navigate this process. These are some of our favorite national caregiving resources, but please feel free to contact us and we can search for local resources for you. The American Cancer Society, Cancer Support Community, and Caregiver Action Network.

Shelly Rosenfeld (40m 4s):
Today, we learned about how the ADA and FMLA laws can serve the caregiver who helps the person with cancer. This is Shelly Rosenfeld. Know your rights. The cancer legal resource center is just a click or a phone call away.

Dr. Bob Goldberg (40m 23s):
Now, if anyone else out there has a policy issue impacting you or a loved one, we want to hear about it. You can become a patient correspondent by mailing me and Terry at podcast@patientsrising.org.

Terry Wilcox (40m 37s):
Thank you for joining us for today's episode. We hope you're enjoying the show and finding it useful to you. If you are, we would be so grateful if you could take a moment to let us know what you think of the show by leaving us a rating and a review. Thank you to Shake it up fan who recently gave us a five star review and said, "the best, some of the best information around and valuable, very useful." Thank you so much. Shake it up fan. That really makes what we do so worth it.

Dr. Bob Goldberg (41m 6s):
Terry, if Shake it up fan contacts us, I will play at her wedding, her bat mitzvah, whatever.

Terry Wilcox (41m 12s):
I love Skate it up fan

Dr. Bob Goldberg (41m 15s):
No, that's the right. We shouldn't punish them for the great review, but look, you know, we did create this show so that patients everywhere could sift through all the information and get really, really straight talk on the impact of health policy to you. And we're not here to push a particular set of ideas or agenda, but to make sure that you have the information you need to make your life more enjoyable and disease free. So make sure to subscribe to the podcast, as always it's free, and you'll get the latest episodes delivered straight to your phone as soon as they're available.

Terry Wilcox (41m 49s):
Speaking of new shows, we'll be right here again next week for another new episode. Until then for Dr. Bob and everyone at Patients Rising, I'm Terry Wilcox, keep your distance and stay healthy.