Time for a temporarily privatized CDC policymaking process, sponsored and funded by provider & payer organizations, professional societies and states.

Recent efforts by HHS Secretary Kennedy to politicize CDC policymaking leave us without the science-driven process the nation requires. Therefore, while we wait impatiently for the storm to pass, we will need a temporary arrangement where provider and payor organizations, professional societies and states cooperate to establish, fund and delegate some authority to a substitute policymaking process to keep the flame alive and meet urgent needs.

The sudden need

In a Medscape post this week, Dr. Kenny Lin, a family physician and associate director of the Lancaster General Hospital Family Medicine Residency, posed the question “Who Should PCPs Look to for Vaccine Recommendations?“

In our free market system, individual physicians and other private, licensed health care professionals have the primary responsibility for decision-making about medical orders. In our constitutional structure, states bear the primary responsibility for public health. However, in the last century, the federal government has played an important role as a public payor (Medicare and Medicaid), as a funder and executor of basic biomedical and health services research (NIH and AHRQ), and as a source of deep expertise and centralized policymaking and policy advisory services (CDC and FDA). I have previously been critical of the CDC, arguing that it has sometimes strayed from its “lane” as a source of science-based advisory services into the realm of political policymaking. But such criticism was fine-tuning and optimization. As with the vast majority of physicians, I have always had a deep respect for the CDC. The CDC’s Morbidity and Mortality Weekly Report (MMWR) and immunization policy-making processes were formerly recognized as the world’s standard for scientific competence and integrity.

Formerly, sad to say.

This week, HHS Secretary Kennedy fired the CCD Director, Susan Monarez, after she refused to endorse Kennedy’s insistence that vaccine policy should be based on his personal conspiracy theories and misinformation, and not based on science, as interpreted by actual scientific experts. Her firing was accompanied by the resignations this week of four other senior CDC leaders:

• CDC Deputy Director Dr. Debra Houry,
• Head of the CDC National Center for Emerging and Zoonotic Infectious Diseases, Dr. Daniel Jernigan;
• Head of the CDC National Center for Immunization and Respiratory Diseases, Dr. Demetre Daskalakis, and
• Director of the CDC Office of Public Health Data, Surveillance, and Technology, Dr. Jennifer Layden.

These resignations follow a period of crippling budget cuts, firings, limits to CDC’s communications, withholding of previously public sources of data, cancelation of research contracts for mRNA technology, and relentless misinformation and attacks by Secretary Kennedy and other federal officials. Secretary Kennedy recently fired the entire membership of the Advisory Committee on Immunization Practices (ACIP) and replaced them with a group that includes several notorious vaccine “skeptics” — a term that sane-washes their positions as if they might have good faith differences of expert opinion about the interpretation of study results.

Deputy Director Houry wrote “For the good of the nation and the world, the science at CDC should never be censored or subject to political pauses or interpretations.” Dr. Daskalakis wrote that Secretary Kennedy put “people of dubious intent and more dubious scientific rigor in charge of recommending vaccine policy” and “I am unable to serve in an environment that treats CDC as a tool to generate policies and materials that do not reflect scientific reality.” These were principled, conscientious resignations. Our profession owes these people our gratitude.

What to do about it

It was right for those that recognized the attack on the longstanding science-driven CDC policymaking process to first try to resist it and then resort to conscientious resignation. But that leaves the question: what are members of the medical-scientific community to do now that those two lines of defense have clearly failed?

Americans still need to keep the flame of science burning—especially when it comes to healthcare. They need reassurance that science is good, and that truth, evidence and expertise are still important. But on a more practical level, the US population still needs a source of trusted medical-scientific expertise and guidance. Such guidance is sometimes used by individual citizens. More commonly, it is used by physicians, medical leaders of private healthcare provider organizations and health plans, and by state and local public health officials. It would be impractical for each physician, each organization and each state to duplicate the work of gathering and analyzing evidence to support policymaking.

Furthermore, there is value to standardization. We do want healthcare provider organizations to innovate. That implies the existence of intentional, useful variation across organizations. But, for some types of clinical practices, variation is unintentional and not useful. For some clinical topics, the direction of good is toward standardization. Such topics include basic immunization, infection control, public health, preventive services and coordinated management of epidemics. Therefore, for those topics, we need a centralized source of scientific evidence development and science-driven policy development and consensus-building. We need what the CDC was formerly qualified to do.

Therefore, I propose the establishment of a temporary entity to provide the required science-based policymaking process regarding the prevention and control of infectious and chronic diseases, until such time as the CDC can be trusted to do so.

Not just states or regions

Presumably thinking along the same lines, Dr. Robbie Goldstein, Commissioner of the Massachusetts Department of Public Health, organized a recent two-day meeting of a group of public health leaders across eight states in the Northeast to discuss collaboration on public health guidance for vaccinations and implementation of disease-tracking and emergency response services independently of the CDC. The meeting included heads of public health departments from every New England state except New Hampshire, as well as New Jersey, New York and Pennsylvania. Notably, the participants included both Democrats and Republicans. Such an effort is a good way to get a conversation started, but I do not think the target state, even in the interim, should be a process limited to state-level public health officials. And it should not be limited to a particular region of the country. Many of the relevant services are covered by private health plans that are national. Individual physicians look to national professional societies for guidance. Dr. Goldstein implicitly acknowledged this point, saying that states could look to major medical associations to shape their vaccine policy, instead of the CDC.

Not permanent privatization

It is also important to point out that this proposal is not conceding permanent privatization of the CDCs functions. There can, of course, be legitimate discussions about which societal functions should be assigned to the government and which should be handled by the private sector. And there are legitimate discussions about which government functions should be assigned to the federal government vs. states, counties or other local jurisdictions. As a life-long advocate for moderation, I see the allocation of power for specific functions across public vs. private and centralized vs. decentralized dimensions as an interesting optimization problem, not a matter of political doctrine. In other words, we should look at each function and figure out where it should be carried out.

With respect to the general functions of care process design and clinical protocol and guideline development, I would adjust the dial a few clicks toward privatization and decentralization — with more investment by health care provider and payor organizations. But on the more specific topics of infectious disease control and preventive services, I think the optimal place for that to take place is in the federal government — in the CDC. So, I want to make it clear that calling for the establishment of a policymaking process outside the federal government is in no way conceding that their specific functions should be permanently privatized. It is an interim solution. The goal is to serve the continuing need for real science-driven processes while we wait impatiently for the anti-science episode at the CDC to conclude. I hope that happens quickly, but it is unrealistic to expect that to happen within the next few years. That length of time is too long for the nation to go with an anti-science CDC policymaking process, so the private sector and the states need to make alternative arrangements.

Forming an interim privatized policymaking process requires three things: organization, authorization, and funding.

Organization

The new interim process will be a creature of civil society. It will be an “initiative,” a “collaborative,” an “alliance,” a “coalition” or a “committee.” In our healthcare field, we have lots of experience and precedent to draw upon. For example, one of my former clients is the National Comprehensive Cancer Network (NCCN), a not-for-profit “alliance” of 33 of the most respected comprehensive cancer centers in the US. The NCCN brings together oncologists and scientists from the member institutions and other experts and stakeholders to develop what many consider to be the world’s gold standard for detailed expert consensus-based protocols for 67 different types of cancer.

Another exemplar is the Primary Care Collaborative, a “coalition” that includes primary care practices, primary care specialty societies, payer organizations, employers, purchasing coalitions, patient and consumer groups, and technology and pharmaceutical companies. They “convene and unite stakeholders around research, care delivery and payment models and policies.”

There are plenty of other examples, including the Interdisciplinary Association for Population Health Science, the Health Transformation Alliance, the Healthcare Leadership Council, Better Solutions for Healthcare, the Future of Value initiative, the Population Association of America, and too many more to mention.

How do such entities get organized? It starts with individual leaders, thinkers and influencers having conversations with each other. They recognize unmet needs, common themes and opportunities. Such conversations happen in board rooms, in the hallways of conventions, in discussion panels, in podcasts, in viewpoint articles in scientific and trade publications, in LinkedIn posts, etc. Hopefully, this humble post might provide a spark or at least contribute another pixel in a picture emerging in the brains of many people trying to wrap their heads around what to do now that science is being evicted from the CDC and other federal health agencies, such as the FDA, AHRQ and CMMI.

Once there is informal recognition of the need, the formalization of an organizational entity can proceed quickly and easily. It starts with a short slide presentation or whitepaper that gets vetted by leaders of a few well-known organizations. Maybe the American Medical Association (AMA), the American Medical Group Association (AMGA), America’s Health Insurance Plans (AHIP), the National Committee on Quality Assurance (NCQA), Mayo Clinic, Kaiser Permanente, Henry Ford, Geisinger, Blue Cross Blue Shield Association, Aetna, United Healthcare, American Epidemiological Society (AES), the Infectious Disease Society of America (IDSA), etc. I’ve been involved at the birth of a few collaboratives over the years, and my experience is that once a few of the cool kids say they are coming to the party, everyone wants an invitation. Fear of missing out (FOMA) is the starting capacitor for many big motors.

Then, someone writes a charter and some bylaws and files some not-for-profit entity papers and opens a checking account, and someone gets creative with a logo. Copilot AI generated the one above in about 20 seconds.

Sadly, finding a qualified and available set of leaders will be quite easy, since many have recently lost their day jobs.

Authorization

A key step will be for various organizations that tie their own policies to those of the CDC to make changes to their own policies and contracts to unplug the CDC and plug into the interim process. Many health care payers tie their coverage and the associated medical and benefit policies to CDC policies, particularly the policies of CDC’s Advisory Committee on Immunization Practices (ACIP). For example, under the Affordable Care Act (ACA), non-grandfathered plans must cover ACIP-recommended vaccines without cost-sharing. Medicaid expansion plans are required to cover all preventive services specified in the ACA, which includes coverage for all ACIP-recommended vaccines. State-run traditional Medicaid programs are incentivized to cover all ACIP-recommended vaccines without cost-sharing.

Beyond these mandatory public payor requirements, many private commercial health plans voluntarily aligned their medical and benefit policies with CDC guidance. They did so either as a matter of standard practice or simply by routinely citing CDC guidelines in their internal policy documents. This alignment went beyond just ACIP immunization guidance. They also aligned with CDC guidance regarding cancer screening, testing for sexually transmitted diseases, tracking and management of chronic diseases, and more. Private insurers were motivated to align with CDC guidance partly because they had a trusted reputation and doing so reduced their burden of doing all of their own literature reviews and consensus building. They were also motivated to adopt CDC guidance because there was a perception that legal liability would be higher if they adopted unconventional local policies.

Note that the current anti-science corruption of the CDC’s policymaking processes is largely unidirectional — stopping recommendations for things for which there is good scientific support, rather than recommending things for which evidence is weak or absent. Therefore, when private organizations unplug from CDC and plug-in to the interim process, they will generally be deciding to cover things beyond the mandatory minimum, rather than failing to comply with requirements. Of course, if private health plans are too greedy, there could be a race to the bottom, dropping coverage as permitted. But my sense is that the cost differential for the types of services likely to be affected is not sufficient to motivate health plans to move toward the dark side. I’ve been wrong before when betting on health plan morality, but I do think getting the plans to commit to covering the services recommended by the interim process could be doable – as long as it steers clear of costly GLP-1 receptor agonists!

Funding

If large organizations join the coalition supporting the interim process, the cost sharing dues to the member/sponsor organizations could be affordable. A core team of experts would need to be hired. Expert consensus panels would be convened. Literature reviews, meta-analysis, document preparation and publication processes would need to be funded. In this regard, I consider the NCCN to be the existence proof of the economic feasibility of a trustworthy participant-funded organization producing detailed, useful, science-based consensus guidelines. The guideline development processes of many professional societies demonstrate what can be done on an even smaller budget. But in my opinion, all but a few are below the level of quality and rigor that I think is warranted for the interim process I am proposing.

Of course, the level of funding that could be assembled from a coalition of the willing will never be close to replacing the former CDC’s taxpayer-supported budget. The CDC does a lot more than just support policymaking. The coalition cannot be expected to replace the primary data collection, training support and, most importantly the field operations that are part of the crown jewels that are in the process of being squandered.

Making it palatable

The current federal administration proudly acknowledges “retribution” as a campaign promise and tactic. Therefore, the biggest barrier to establishing an interim policymaking entity might be the fear of retribution. There is, unfortunately, an emerging pattern of cowering among leaders of large organizations across civil society. Leaders of some major universities, law firms, technology manufacturers and others have chosen to crouch, flatter and comply. Organizations that sponsor and fund an interim policymaking entity might feel like they have popped their heads out of a foxhole, attracting fire from federal officials. Therefore, to actually get this done, it will be necessary to overcome such fear and make the idea politically palatable. It will be necessary to win at least some bipartisan support, which is not implausible since support for medical science has not traditionally been a partisan issue.

This support can be accomplished by two main methods. First, we will need to communicate the invitation in a way that appeals to the deep, ancient sense of duty and responsibility as professionals who took an oath — as physicians and scientists. Second, we will need to communicate with finesse and a sense of pragmatism. It should take care to minimize the use of partisan rhetoric and inflammatory terminology. In this spirit, the name for an interim entity should avoid being provocative and vulnerable to misinterpretation. Perhaps we should call it something like the “Disease Control Science Committee” — something peaceful, apolitical and humble, but nevertheless staunch in defense of truth and scientific integrity. I asked Copilot AI to draft a seal designed to convey those ideas, and it quickly came up with the one at the top of this post. I think it looks pretty good. I can imagine it on lapel pins given to the members of the committee, who will be proud to wear them because they were selected for their scientific credentials and integrity.