Post #1320: More crisis standards of care? Yawn.

Posted on November 11, 2021

Source:  Colorado Department of Health, accessed 11/11/2021

“Vaccine hesitancy” gets my vote for the most misleading phrase in the popular press of late.

I don’t perceive the least bit of hesitancy or ambiguity among those who refuse to get a COVID-19 vaccine.  How does “hell no, I won’t get vaccinated under any circumstances” get characterized as “hesitancy”?

I blame liberals.  Liberals remain the naïve children of the Enlightenment.  Despite strong evidence to the contrary, they cling to this crazy belief that people are, at heart, fundamentally good and reasonably rational.  That they will, by and large, make informed choices for the benefit of themselves and society at large.  Within that fictional world-view, those who turn down a free, more-or-less harmless shot that reduces odds of an early death and could end the pandemic for society at large — those people must merely have different values and beliefs.  Perhaps they’ve assessed the facts differently, and have some reasonable doubts or fears regarding the efficacy of the vaccine or likelihood of true side effects.  And so they hesitate to get vaccinated.

In this liberal fantasy world, the unvaccinated are just unenlightened, or have made alternative, rational choices. They hesitate to get vaccinated.  Perhaps they can be led to see the light with proper guidance and education.

But back in the real world, nope, they’re just stupid and stubborn.  No amount of appeal to reason can fix that.  So if you want to get the entire population vaccinated, you’re going to have to resort to some level of coercion.

It’s actually completely unfair to blame “liberals” for this wishy-washy misleading term for the unvaccinated.  The true story is that “vaccine hesitancy” has been a term-of-art in public health circles for decades.  The earliest Wikipedia page on it (under the current Wikipedia page on vaccine hesitancy) dates back to 2007.  A quick search using date ranges on Google shows that the phrase appears to have emerged in the 1990s (and/or any references to it prior to 1990 aren’t captured by a Google search).

The true story isn’t that “vaccine hesitancy” is some polite new buzz-phrase, cooked up by the liberal media.  It’s just a mis-application of a bit of standard public health jargon. 

That said, surely we need something that’s a more accurate description of the current circumstances.  “Hesitancy” just doesn’t cut it.

At the very least, it should be “vaccine refusal”.  Just to make it clear that these people have been given a choice, and they’ve turned it down flat.  And that they own the consequences of their decisions.

Colorado declares crisis standards of care for hospitals.  Nobody notices.

But why bother with the whole vaccine thing, at this point?  I mean, everything’s OK, right?  More-or-less?

Well, no.  That brings me to crisis standards of care.  That’s the formal, legal declaration  by the governor of a state that, owing to a shortage of hospital beds, physicians may triage patients/allocate hospital care based not on need, but on likelihood of survival.  It provides the legal cover for physicians to allow individuals to die for lack of hospital care, because there simply aren’t enough hospital beds (or ICU beds or respirators or whatever) to meet current demand.

The potential for governors to invoke crisis standards of care has been on the books for years.  It’s a reasonable and rational part of medicare emergency preparedness.  It went hand-in-hand with pre-established CDC rules for the substitution of sub-standard PPE for normal hospital PPE in the event of a shortage. Rules that (I believe) were never invoked prior to the COVID-19 pandemic.

When Alaska and Idaho made formal declarations of crisis standards of care, that made the news.  It was judged to be a fairly significant event, that a U.S. state had reached the point of letting people die for want of hospital beds.

Only in Alaska was the effect of the hospital bed shortage obvious enough to be clearly visible on a graph (Post #1269).  You can see that in the two-month-old graph below.  Cases spiking (red), admissions declining (yellow).  In Idaho, by contrast, they largely managed to slough the problem off onto hospitals in eastern Washington.

Source:  CDC COVID data tracker, accessed 9/19/2021.

But at least that made the headlines.

Now it’s reaching the point that when another Western state runs out of beds, people hardly notice.  And the case in point today is Colorado.  They declared something like crisis standards of care last week.  And if my wife hadn’t picked up on it, based on a single New York Times article, I surely wouldn’t have noticed.  Near as I can tell, that’s the sole reference in mainstream media.

Running out of hospital beds has become the new normal.

There’s an oddity, in that the wording of the Colorado executive order is different from others.  (I’d better provide a link to the actual executive order, because in the nut-o-verse this has been characterized as requiring hospitals to refuse admission to unvaccinated individuals.  Whereas the actual executive order says nothing of the sort.)

It says ” … Order authorizing the Colorado Department of Public Health and Environment (CDPHE) to order hospitals and freestanding emergency departments to transfer or cease the admission of patients to respond to the current disaster emergency due to coronavirus disease 2019 (COVID-19) in Colorado.”

And, to be clear, it not only empowers the Colorado DPHE to stop admissions at some hospitals, it requires other hospitals to take those admissions if DPHE so directs it.  In effect, it gives the Colorado DPHE the right limit admissions and to re-allocate hospital admissions across the entire Colorado hospital system.  Not just to deny admission to certain hospitals, but to require other hospitals to accept those admissions.

If you read further, you’ll see that this particular language is taken directly from Colorado state statute.  And, as an extra for experts, this is all to get around the requirements of EMTALA, the Federal law that prevents hospitals from “dumping” undesirable (that is, uninsured) patients.  Hence the “transfer or admission” phrasing of the executive order.  The oddity of phrasing doesn’t necessarily reflect a different view of how best to triage patients.  It’s an artifact of how Colorado state statutes were written, and in turn, how the Federal EMTALA law was written.

Just to be completely clear, the declaration doesn’t even mention COVID-19 or vaccination status.  (So the claims in the nut-o-verse that this requires hospitals to deny treatment to the unvaccinated are completely fictional).

In fact, the bulk of the document pertains to insurance issues.  (Only in America, right?)  It notes that hospitals cannot take a patient’s insurance status into account, and that patients will still be insured even if sent out-of-network on an emergency basis under the provisions of this law.

But at this point, I need to cease ragging on Republican governors.  Because, despite the surge in cases, and the fact that Colorado hospitals are full, the Democratic governor of Colorado won’t do anything more than issue this order allowing the state health department to transfer cases across hospitals.  Mask mandates appear to be local-option only.  Near as I have been able to tell, bars and indoor restaurant seating remain open with no restrictions.

With that, about half the people in Colorado report wearing masks now.  That’s unchanged since the first of September.  So a little thing like running out of hospital beds doesn’t seem to be enough to affect behavior there.

Source:  Carnegie-Mellon University COVIDcast.

In any case, unlike Alaska at its peak, there’s no indication of any outright denial of hospital care yet, in Colorado.

Source:  CDC COVID data tracker accessed 11/11/2021


Coda:  An un-funny anecdote about Medicare Durable Medical Equipment.

Or:  Why COVID-19 in Colorado is distinctly different from COVID-19 in Louisiana.

I used to be a self-employed consultant in the area of health economics.  One day I was tossed the following problem:

In the Medicare program, at that time, there was a more than five-fold difference across the states in spending for home oxygen.  Worse, there was no indication of any difference in need for home oxygen.  There was almost no difference in prevalence of the main disease for which these rentals would be authorized (Chronic Obstructive Pulmonary Disease (COPD), which used to be called emphysema.)

That sort of thing is a big red flag for Medicare.  When they see massive differences in service use or spending, and no differences in the underlying health of the population, they immediately investigate for waste, fraud, and abuse.  In this case, my client — a manufacturer of oxygen concentrators — was rightly worried that this was going to affect his business.

At first, the Government’s case looked pretty good.  The scatterplot of oxygen use against COPD prevalence showed only a weak association.  There really was a lot of spending variation that appeared unrelated to prevalence of the relevant illness.  In particular, prevalence of illness did nothing to explain the high spending outliers.  (That is, the dots net the top of the graph below.)

Next, that spending variation was large.  The high-spend states really did out-spend the low-spend states by a factor of five or more.

But somewhere along in this process, I managed to recall that the Denver Broncos used to play in Mile High Stadium.  And then it all fell into place.  Those states at the bottom of the list all have one thing in common:  They are Mountain region states.  There isn’t much oxygen there.

When I arranged the same set of states by mean elevation above sea level, I got a much more orderly plot.  Suddenly, those big outliers made sense.

Medicare was supplying a lot of oxygen in those states because Mother Nature wasn’t.  Here’s a quantitative estimate of the impact of elevation on the amount of oxygen available (the partial pressure of oxygen).


If you live in Aspen, CO, you’re missing about one-quarter of your oxygen, compared to life at sea level.  If your lungs are healthy, you’ll soon get used to it.  But if you’ve got COVID, and your blood oxygen saturation starts to fall, you’re going to be a lot worse off in Aspen than you would be at sea level.

And so, my guess is that for a given population of individuals severely ill with COVID-19, a higher fraction of them are going to require an inpatient level of care in Colorado, compared to (say) the U.S. Gulf Coast states.  That’s because a critical deciding factor is their 02 blood saturation levels.

The upshot is that COVID is different in Colorado.  Not because the disease is different, or the people are less healthy.  There’s just less oxygen there.