Los Angeles Times - 18.03.2020

LATIMES.COM/OPINION WEDNESDAY, MARCH 18, 2020A

OP-ED

O

n Tuesday, it was elec-

tion day in three states,

including Illinois. But

you could also have

gone to the polls more

than two weeks earlier in Illinois, on

March 2.

Like the District of Columbia

and 37 other states, including Arizo-

na and Florida, Illinois allows its

citizens to vote on or before election

day, in person or with a mail-in/

drop-off ballot. In California, many

voters get up to 11 days to vote at the

polls and nearly a month to vote by

mail. Colorado, Hawaii, Oregon and

Washington have all-mail voting

systems. The voters in those four

states get their ballots two to three

weeks before an election.

These various early voting rules

are meant to make it more conven-

ient to cast a ballot. The idea is to in-

crease participation in the demo-

cratic process and to decrease long

lines at the polls. It’s all good, except

when early voting works against its

own goals of perfecting democracy:

A lot can happen in a race just be-

fore election day, so early voting can

mean wasted votes.

The crucial Super Tuesday pri-

maries this year were proof of that.

All the voting states but one, Ala-

bama, had some form of early vot-

ing that day. Democratic primary

voters who cast their ballots as late

as the weekend before March 3

would have seen major candidates

drop out of the race afterthey

voted. If they chose Pete Buttigieg,

Amy Klobuchar or Tom Steyer, they

essentially voted in vain. Illinois

voters who showed up very early on

March 2 to vote could have wasted

their votes on Klobuchar or Eliza-

beth Warren.

It doesn’t have to be that way.

Ranked-choice voting could have

maintained the advantages of early

voting, without the downside.

Under a ranked-choice system,

first-choice votes for those Super

Tuesday candidates who dropped

out before election day would have

gone to voters’ second-choice can-

didate, then to their third-choice

candidate if their second-choice

candidate was eliminated, and so

on until the votes landed on a candi-

date who won at least 15% of votes

and therefore qualified for a share of

Democratic delegates.

If your heart was with Buttigieg

but you also preferred Michael R.

Bloomberg to the rest of the field,

you could have ranked Buttigieg

first, Bloomberg second and in-

stead of your vote not counting once

Buttigieg dropped out, it would

have shored up Bloomberg.

In a general election, where

there are usually fewer candidates,

ranked choice still fortifies your

vote: If your first choice is elimi-

nated because the candidate re-

ceives the fewest first-preference

votes, the vote goes to the second

pick, and so on until only two candi-

dates are left standing. The highest

vote-getter of the top-two candi-

dates wins.

In 2020, five states (Alaska, Ne-

vada, Hawaii, Kansas, Wyoming)

are using ranked choice for presi-

dential nominations in major party

caucuses or primaries. Currently,

Maine is the only state to use ran-

ked-choice voting for all its state

and federal elections with the ex-

ception of presidential primaries (it

will be implemented for primaries

in 2024).

Ranked voting is much more

common in municipal elections.

Eighteen towns and cities, includ-

ing Berkeley, Oakland, Minneapo-

lis, San Francisco and St. Louis,

have ranked-choice voting. Cam-

bridge, Mass., has used it since 1941.

New York will adopt it in all city pri-

mary and special elections begin-

ning in 2021.

Ranked choice’s superiority is

perhaps most clear in situations

like this year’s Super Tuesday,

where early voting combined with a

big field. But it has other advan-

tages: It can prevent “vote-split-

ting” in races with multiple candi-

dates from one party. For state and

local elections, it can replace win-

nowing caucuses and primaries,

saving money and time, but still giv-

ing voters the same level of choice. It

helps grass-roots candidates; they

often lose supporters who fear

throwing away votes on a little-

known newcomer. And it encour-

ages civil campaigning because

candidates are not only vying for

base support but also seeking to ap-

peal to supporters of candidates

who could get eliminated early.

We should all want to maximize

participation in our democracy.

Early voting gets us part of the way

there. More states should add

ranked-choice voting to the effort.

Sean McMorrisis the Los

Angeles/San Gabriel Valley chapter

leader of RepresentUs and an

organizing and policy consultant

for California Common Cause.

Ranked

choice, so

no vote

is wasted

By Sean McMorris

point to the bumbling Trump,

who, announcing the national

emergency last week, said he had

just uttered “two very big words.”

Sunday night, Los Angeles

Mayor Eric Garcetti went a step

further than the governor, order-

ing the closure of bars, movie

theaters, gyms and fitness cen-

ters until March 31. Restaurants

may operate only in takeout

mode.

Before his order took effect,

the bars and restaurants along

Washington Boulevard near the

Venice Pier were hopping. Some-

one — I would love to know who

— had posted bright orange

warnings on telephone poles:

“Coronavirus spreads BEFORE

YOU CAN SEE SYMPTOMS.

Don’t take a chance.”

Another sign warned the

many younger people who seem

to be in denial: “Coronavirus? I’ll

be fine,” it said. But a chart on

the flier dispelled that statement,

showing that younger people

transmit the virus, while older

people die from it. “Brunch,” said

the flier, “can wait.”

Indeed, by Monday afternoon,

the street was dead. Bars and

restaurants were shuttered.

And what about in Nunes

country? Are residents following

their congressman’s advice or

that of public health officials?

Shortly before lunchtime on

Monday, I reached Dean

Ametjian, a partner in the Tulare

Golf Course in the Central Valley.

OK, so may-
be Rep. Devin
Nunes doesn’t
want you dead.
But he sure
seems willing to
put your health
in jeopardy out
of fealty, I assume, to President
Trump, who up until this week
seemed hellbent on minimizing
one of the greatest health crises
in our lifetimes.
If Trump has worried mainly
about the economy, and not the
rapid, uncontrolled spread of a
deadly virus that he downplayed
until far too late in the game, well
then, so has his most loyal aco-
lyte.
“It’s a great time to go out and
go to a local restaurant,” the
Tulare Republican told Maria
Bartiromo of Fox News on Sun-
day morning. “Likely you can get
in easily.” Nunes also urged folks
to go to “your local pub.”
At virtually the same mo-
ment, Dr. Anthony Fauci, direc-
tor of the National Institute of
Allergy and Infectious Diseases
at the National Institutes of
Health, was saying on national
television that he, personally,
would stay away from restau-
rants.
“I just wouldn’t because I
don’t want to be in a crowded
place,” Fauci said on “Face the
Nation.” “I have an important job
to do. I don’t want to be in a situa-
tion where I’m going to be all of a
sudden self-isolating for 14 days.”
Also on Sunday, after a fifth
person in the area tested positive
for the coronavirus, Fresno
County health officials declared a
state of emergency.
That did not stop Nunes from
telling a local radio station, ac-
cording to the Fresno Bee, that
instead of panic-buying toilet
paper at Costco, people should
“go to McDonald’s, go to Taco
Bell, go to Denny’s.”
Nunes is surely not alone in
dispensing bad advice. But he
stands as a shining example of
how not to talk to the public
during a health crisis.
I cannot put it better than the
Bee did Sunday in an editorial:
“Devin Nunes might want to
think twice before he tries to be a
doctor.”
On Sunday afternoon, Gov.
Gavin Newsom spoke knowl-
edgeably about coronavirus and
its spread, urging people to stay
out of bars and restaurants not
just for the sake of their health,
but also to slow the spread of a
disease likely to soon wreak
havoc on the nation’s already
overloaded health system. On
Monday, he went further, urging
all theaters, gyms and health
clubs to shut their doors and
asking restaurants to close ex-
cept for takeout.
It was a refreshing counter-

Ametjian, whose grandfather

built the golf course in the early

1950s, told me the operation is

not just a golf course, pro shop

and restaurant, but an impor-

tant gathering place for local

farmers, who stop in for meals on

their way to and from work.

I asked Ametjian how he was

feeling about the conflicting

directives from officials like

Nunes and Newsom.

Forget about feeling the Bern.

Was a hospitality business owner

like Ametjian feeling the whip-

lash?

“I’m a supporter of Nunes,”

Ametjian told me. “I’m not going

to bash him or Newsom.”

Diplomacy aside, Ametjian

said he has decreased the capac-

ity of his restaurant, and if the

sun is out, he’s urging people to

sit on the patio, because “the

virus does not do well in sunlight

and open air.” Someone might

want to tell the virus that. But

he’s also offering curbside pickup

for farmers who want to safely

grab a meal.

“We are doing everything we

can to keep this virus at bay,” he

said, “but we are a tight-knit

community. When you tell far-

mers they can’t mingle or con-

verge, they are going to do it no

matter what — whether at their

house or in their garage or in a

public bar. You are not going to

keep those people away from

each other.”

A few minutes after we hung

up, Fauci was back on television

standing shoulder to shoulder

with the president and other

government officials who have

become a familiar presence on

our TV screens in the last week.

(Why don’t these people take

their own damned advice and

stand a few feet apart?)

As reporters pressed for an-

swers about whether bars and

restaurants should stay open,

Fauci held up a copy of new

guidelines from the Centers for

Disease Control and Prevention,

“15 Days to Slow the Spread,”

which recommends Americans

severely curtail contact with

others.

“The small print here, it’s

really small print,” said Fauci,

whose subversiveness is telling.

“In states with evidence of com-

munity transmission,” he read,

“bars, restaurants, food courts,

gyms and other indoor/outdoor

venues where groups of people

congregate should be closed.”

That would certainly include

California, the most populous

state in the country.

Putting such potentially life-

saving information in small print

is as good a metaphor as we’re

going to get for this adminis-

tration’s bungled response to the

coronavirus crisis.

We don’t need two big words

when two small ones will do: Stay

home.

@AbcarianLAT

Devin Nunes’ bad advice

A CORONAVIRUSwarning sign on a pole at Washington Boulevard and Pacific Avenue in

Venice. By Monday afternoon, the area was dead. Bars and restaurants were shuttered.

Robin AbcarianLos Angeles Times

ROBIN ABCARIAN

A

s a physician, wait-
ing for the worst of
coronavirus to hit, I
see a lot to fear. It
seems increasingly
likely that this will be one of the
most significant pandemics in
modern human history, and that
it will change our approach to
healthcare going forward. But
not all of its legacy will be nega-
tive. Here’s one thing I hope will
come out of the crisis: an in-
creased reliance on telemedicine,
something that should have
happened long ago.
A few months ago, when I was
between jobs, I took a part-time
job in a rural hospital serving a
county of more than 150,000 peo-
ple. On the verge of bankruptcy,
the hospital was unable to at-
tract many specialists to join its
ranks, and in desperation, had
turned to telemedicine to cover
many services. So, for example, if
a patient was rushed to the emer-
gency room after a stroke, there
was unlikely to be a neurologist in
the room. Instead, a neurologist
would assess the patient on a
mobile screen from far away, with
local nursing staff and doctors
aiding him or her.
I had been skeptical of
telemedicine going in. Physical
exams are the bedrock of how
doctors and nurses assess pa-
tients. We look patients and their
loved ones in the eye, palpate
sore spots with our fingers and
offer comfort with a hand on a
shoulder. Physical contact, I’d

always thought, was at the heart

of how doctors and patients

communicate.

It was with this skepticism

that I found myself next to a

young man who’d been brought

to the emergency room after

attempting to take his own life.

Again. This time, instead of see-

ing a psychiatrist in person, he

saw one on a screen with wheels.

The psychiatrist was in some

distant location, but she had

been in touch with the local doc-

tors and had access to his medi-

cal records. Despite her physical

remoteness, she connected with

him, and he opened up. She knew

of all the local resources to refer

him to, and at the end of her

conversation, she had developed

a real rapport with him.

After the visit ended and the

nurse wheeled the monitor out of

the room, I asked the young man

what he thought, and to my

surprise, he told me he was more

comfortable with this than an

in-person visit.

He wasn’t the only one —

many patients say they prefer a

virtual doc to one sitting across

from them.

Over the last few decades,

medical care has been trans-

formed by technology. Whenever

a new drug becomes available, or

a medical procedure is approved

by the FDA, the medical commu-

nity is quick to deploy it. Yet,

when it comes to how we see

patients, our current practices

haven’t changed much since the

time of Hippocrates. If a patient

is sick, he or she either has to

come see us in clinic, urgent care,

the emergency room or the hospi-

tal. Despite the internet trans-

forming every aspect of our lives,

from how we find love to how we

order groceries, the way we deliv-

er medical care has stagnated.

In the United States, not only

are doctors often inaccessible for

those living in rural areas, hospi-

tals everywhere have huge econo-

mic challenges. One healthcare

executive jokingly told me his

hospital made more money from

its parking lots than its clinics.

The response to COVID-

might help change that. One of

the main reasons China has been

able to slow coronavirus trans-

mission has been because of a

dramatic increase in virtual

visits. In fact, China has moved

half of all medical care online,

allowing patients to consult with

their doctors and get prescrip-

tions from the comfort of their

homes. Hospitals have been

notorious petri dishes for deadly

bugs since long before COVID-19,

and this pandemic has brought

that risk into crystal-clear focus.

On Tuesday, Medicare

announced that it will greatly

expand coverage for telemedicine

visits, previously sharply re-

stricted. And at a White House

briefing, the government an-

nounced it was urging states to

similarly expand Medicaid cov-

erage to include telemedicine

visits by Skype, FaceTime or

other platforms. Some insurers

have also said they will cover

telehealth visits at parity with

in-person visits.

These measures are com-

mendable, but policies need to be

put in place to ensure that the

expansion of telemedicine is not

temporary. Of course, in-person

visits will still be necessary in

many cases. But supporting

telemedicine on a par with such

visits has the potential to protect

patients and healthcare person-

nel and allow for much more

efficiency in the system.

That said, physicians and

nurses will need high-quality

training to provide compassion-

ate and thorough care to a pa-

tient from across a computer

screen. Technology that allows

patients to be “examined” re-

motely needs to be better studied

and made more accessible. And

since the backbone of tele-

medicine is reliable high-speed

internet, Congress should con-

sider Elizabeth Warren’s plan to

bring broadband internet to the

remotest parts of this country, to

ensure broad access to these

services.

This week my team converted

most of our clinic visits from

face-to-face to virtual visits.

Some were over the phone, oth-

ers were over video, often with a

family member present. While

there were some patients who

still needed to be seen in person,

we were able to minimize the risk

of viral transmission not only for

patients, but also for valuable

members of our clinical team.

Even before this crisis, as part

of my job at the Veterans Affairs

Health System in Boston, I often

consulted with patients I had

never seen as part of an “E Con-

sult” system. While I was initially

nervous when I first started

doing this, it allowed me to ex-

pand my footprint far beyond

what I could manage if I were

seeing every patient in person.

At some point, I fervently

hope the coronavirus will be a

thing of the past. But I hope it

leaves behind a legacy. I hope it

changes how well we wash our

hands, how well we fund public

health and how well we protect

the healthcare workers caring for

our sickest patients. And, most of

all, I hope it pushes us to em-

brace telemedicine.

Haider J. Warraichis a

cardiologist at VA Boston

Healthcare System, Brigham

and Women’s Hospital and

Harvard Medical School, and

author of “State of the Heart —

Exploring the History, Science

and Future of Cardiac Disease.”

I was a skeptic, but telemedicine works

One good thing that could

come out of this crisis is a

broader acceptance of

virtual consultations.

By Haider J. Warraich