vox--2020-02-10--Why Angela Merkel’s successor resigned

Why Angela Merkel’s successor resigned

German Chancellor Angela Merkel ’ s chosen successor resigned Monday , shaking up German politics and throwing Merkel ’ s legacy into question .
Annegret Kramp-Karrenbauer , the minister of defense , took over as leader of the Christian Democratic Union ( CDU ) in late 2018 .
She was widely seen as Merkel ’ s preferred candidate , and potentially next-in-line to become chancellor when Germany votes in federal elections in 2021 .
Kramp-Karrenbauer ( also known as AKK ) said Monday she would step down as CDU leader after a controversial election in the German state of Thuringia @ @ @ @ @ @ @ CDU voted with the far-right , anti-immigrant , anti-Islam Alternative for Deutschland ( AfD ) to install a member of the smaller , pro-business Free Democrats as state premier .
The move shunted aside the more popular left-wing leader .
But even more significantly , it defied a ban on the CDU working with the growing far-right faction .
The CDU ’ s decision to join forces with the AfD in Thuringia wasn ’ t just verboten — it revealed the cracks within the CDU under AKK ’ s leadership and her weakened @ @ @ @ @ @ @ foreshadows an uncertain future for the party and Germany after Merkel leaves power next year .
Germany ’ s politics have become more and more fragmented , with groups on both the right ( AfD ) and the left ( the Greens ) challenging the traditional establishment parties — the center-right CDU and the center-left Social Democrats ( SPD ) — and their two-party dominance .
This has complicated governance , especially on the state and local levels .
The Thuringia election illuminated this crisis as it pushed Merkel ’ s CDU to @ @ @ @ @ @ @ cooperate with the far-right AfD to bolster its political power .
“ A lot of political commentators have said the ‘ dam has been breached , this is a turning point , we should never cooperate with the AfD , ’ ” Sudha David-Wilp , a senior transatlantic fellow at the German Marshall Fund , told me .
“ But they are faced with reality , on the conservative side of the aisle , that nearly a quarter of the voters in Thuringia and some other states , like Brandenburg , have voted @ @ @ @ @ @ @ Though the state premier in Thuringia , Thomas Kemmerich , has since resigned , it has sparked a national political crisis .
Merkel , who was on a state visit in South Africa at the time of the election , also condemned the alliance , calling it “ unforgivable ” and “ a singular process that broke with a fundamental conviction of mine and my party ’ s , namely that you don ’ t win majorities with the help of Alternative für Deutschland.
” AKK will take the fall for Thuringia , @ @ @ @ @ @ @ uncertain Merkel has served as leader of the CDU for nearly two decades ; she came to power as Germany ’ s chancellor in 2005 .
She is , as Vox has previously written , a “ boringly stable leader.
” In more than a decade in power , Merkel helped make Germany a powerful force within the European Union and effectively managed one of the strongest economies in Europe even as the continent weathered an economic crisis .
Her biggest challenge came around 2015 , where Merkel welcomed about 1 million refugees @ @ @ @ @ @ @ Germany .
The political crisis in Germany today stems , in part , to backlash from this policy .
But , at the same time , Merkel weathered the political pushback and was seen by many as a champion of human rights and democracy in an increasingly volatile world .
But as her party started to struggle in elections , Merkel stepped down as leader of the CDU in 2018 , saying that though she would remain in power as chancellor she would not seek reelection in 2021 .
Kramp-Karrenbauer , a Merkel @ @ @ @ @ @ @ , and many saw her as Merkel ’ s preferred choice to carry on her centrist legacy and stable leadership within Europe .
But AKK ’ s 14-month tenure , which began in December 2018 , has not been smooth .
She has not yet quite emerged from Merkel ’ s shadow , David-Wilp told me .
“ Mini-Merkel , ” as she is known , has also proven to be a bit more conservative than her predecessor , particularly on social issues like gay marriage , and has made some high-profile gaffes @ @ @ @ @ @ @ leader , the CDU has struggled in state elections , which is usually a bad omen for any party .
When the CDU in Thuringia defied Kramp-Karrenbauer and voted with the AfD to install a state premier , it showed the shortcomings of her leadership and proved she did not have full control over the party on such a significant issue .
“ The AfD stands against everything that we in the CDU stand for , ” AKK said as she announced her plans to step down .
“ Any form of rapprochement @ @ @ @ @ @ @ Merkel is likely to play some role in choosing AKK ’ s successor , but divisions are already emerging between more traditionally conservative CDU leaders and those more closely mirroring Merkel ’ s centrism .
But the whole Thuringia affair points to a more serious problem that won ’ t go away with the departure of AKK .
The AfD has surged in recent years and is now the largest opposition party in Germany ’ s Bundestag ( the CDU and the center-left SPD are in a grand coalition ) .
It is @ @ @ @ @ @ @ Germany .
Germany ’ s politics are in a state of upheaval The AfD spun off as a protest party in 2013 , mainly in response to the eurozone economic crisis .
But the party began to embrace a more anti-immigrant , far-right platform in the wake of Merkel ’ s refugee policies .
It has capitalized on those fears to become a serious political force .
At least some of the AfD ’ s support comes from conservative voters who ’ ve abandoned the mainstream parties , and the CDU hasn ’ @ @ @ @ @ @ @ with this or how to stop AfD ’ s momentum .
Especially on the local level , as Thuringia ’ s election showed , some CDU members seem open to working with the AfD , both as a way to stay in power and to figure out how to actually get stuff done in Germany ’ s increasingly fragmented political landscape .
Attempting to bring the far-right into the mainstream has failed in places like Austria , but Germany ’ s history makes this political gambit even more sensitive .
What has complicated @ @ @ @ @ @ @ of the Greens , a left-wing party that ’ s pro-immigrant , pro-Europe , and pro-environment .
The party had a historic victory in the European elections in 2019 , coming in second in Germany , and it ’ s currently challenging Merkel ’ s CDU for dominance .
The popularity of the Greens , alongside the growth of the AfD , highlights the hollowing out of the center that ’ s happening not just in Germany but across Europe .
Voters are rejecting the traditional center-left and center-right establishment parties .
This @ @ @ @ @ @ @ Spain , and in Ireland , which just saw the radical , left-wing Sinn Fein achieve a historic result .
This makes the inevitable departure of Merkel all the more worrying .
The German chancellor for a decade was a steadying hand across Europe ; after Trump ’ s election in the US , she was cast into the role of defender of liberal democracy .
Merkel ’ s impending exit comes as Europe prepares for an uncertain time .
The European Union is set to begin tough negotiations with the United Kingdom @ @ @ @ @ @ @ and the EU are on the verge of a potential trade war , and the potential reelection of Donald Trump could put even more strain on NATO and traditional Western alliances .
Germany ’ s own political chaos could make all of this much more complicated .

German Chancellor Angela Merkel’s chosen successor resigned Monday, shaking up German politics and throwing Merkel’s legacy into question.
Annegret Kramp-Karrenbauer, the minister of defense, took over as leader of the Christian Democratic Union (CDU) in late 2018. She was widely seen as Merkel’s preferred candidate, and potentially next-in-line to become chancellor when Germany votes in federal elections in 2021.
Not anymore.
Kramp-Karrenbauer (also known as AKK) said Monday she would step down as CDU leader after a controversial election in the German state of Thuringia last week. There, the center-right CDU voted with the far-right, anti-immigrant, anti-Islam Alternative for Deutschland (AfD) to install a member of the smaller, pro-business Free Democrats as state premier.
The move shunted aside the more popular left-wing leader. But even more significantly, it defied a ban on the CDU working with the growing far-right faction.
The CDU’s decision to join forces with the AfD in Thuringia wasn’t just verboten — it revealed the cracks within the CDU under AKK’s leadership and her weakened control over the party. It also foreshadows an uncertain future for the party and Germany after Merkel leaves power next year.
Germany’s politics have become more and more fragmented, with groups on both the right (AfD) and the left (the Greens) challenging the traditional establishment parties — the center-right CDU and the center-left Social Democrats (SPD) — and their two-party dominance. This has complicated governance, especially on the state and local levels.
The Thuringia election illuminated this crisis as it pushed Merkel’s CDU to cross the once-unimagined prospect of having to cooperate with the far-right AfD to bolster its political power.
“A lot of political commentators have said the ‘dam has been breached, this is a turning point, we should never cooperate with the AfD,’” Sudha David-Wilp, a senior transatlantic fellow at the German Marshall Fund, told me. “But they are faced with reality, on the conservative side of the aisle, that nearly a quarter of the voters in Thuringia and some other states, like Brandenburg, have voted for the AfD in state elections.”
Though the state premier in Thuringia, Thomas Kemmerich, has since resigned, it has sparked a national political crisis.
Merkel, who was on a state visit in South Africa at the time of the election, also condemned the alliance, calling it “unforgivable” and “a singular process that broke with a fundamental conviction of mine and my party’s, namely that you don’t win majorities with the help of Alternative für Deutschland.”
AKK will take the fall for Thuringia, but Germany’s post-Merkel future is uncertain
Merkel has served as leader of the CDU for nearly two decades; she came to power as Germany’s chancellor in 2005. She is, as Vox has previously written, a “boringly stable leader.” In more than a decade in power, Merkel helped make Germany a powerful force within the European Union and effectively managed one of the strongest economies in Europe even as the continent weathered an economic crisis.
Her biggest challenge came around 2015, where Merkel welcomed about 1 million refugees from Syria and the Middle East to Germany. The political crisis in Germany today stems, in part, to backlash from this policy. But, at the same time, Merkel weathered the political pushback and was seen by many as a champion of human rights and democracy in an increasingly volatile world.
But as her party started to struggle in elections, Merkel stepped down as leader of the CDU in 2018, saying that though she would remain in power as chancellor she would not seek reelection in 2021. Kramp-Karrenbauer, a Merkel ally, won a close leadership contest, and many saw her as Merkel’s preferred choice to carry on her centrist legacy and stable leadership within Europe.
But AKK’s 14-month tenure, which began in December 2018, has not been smooth. She has not yet quite emerged from Merkel’s shadow, David-Wilp told me. “Mini-Merkel,” as she is known, has also proven to be a bit more conservative than her predecessor, particularly on social issues like gay marriage, and has made some high-profile gaffes. Meanwhile, bereft of a dominant leader, the CDU has struggled in state elections, which is usually a bad omen for any party.
When the CDU in Thuringia defied Kramp-Karrenbauer and voted with the AfD to install a state premier, it showed the shortcomings of her leadership and proved she did not have full control over the party on such a significant issue.
“The AfD stands against everything that we in the CDU stand for,” AKK said as she announced her plans to step down. “Any form of rapprochement with the AfD weakens the CDU.”
Merkel is likely to play some role in choosing AKK’s successor, but divisions are already emerging between more traditionally conservative CDU leaders and those more closely mirroring Merkel’s centrism.
But the whole Thuringia affair points to a more serious problem that won’t go away with the departure of AKK. The AfD has surged in recent years and is now the largest opposition party in Germany’s Bundestag (the CDU and the center-left SPD are in a grand coalition). It is also represented in every state legislature in Germany.
Germany’s politics are in a state of upheaval
The AfD spun off as a protest party in 2013, mainly in response to the eurozone economic crisis. But the party began to embrace a more anti-immigrant, far-right platform in the wake of Merkel’s refugee policies. It has capitalized on those fears to become a serious political force.
At least some of the AfD’s support comes from conservative voters who’ve abandoned the mainstream parties, and the CDU hasn’t quite figured out how to deal with this or how to stop AfD’s momentum. Especially on the local level, as Thuringia’s election showed, some CDU members seem open to working with the AfD, both as a way to stay in power and to figure out how to actually get stuff done in Germany’s increasingly fragmented political landscape.
Attempting to bring the far-right into the mainstream has failed in places like Austria, but Germany’s history makes this political gambit even more sensitive. What has complicated this even more is the phenomenal rise of the Greens, a left-wing party that’s pro-immigrant, pro-Europe, and pro-environment. The party had a historic victory in the European elections in 2019, coming in second in Germany, and it’s currently challenging Merkel’s CDU for dominance.
The popularity of the Greens, alongside the growth of the AfD, highlights the hollowing out of the center that’s happening not just in Germany but across Europe. Voters are rejecting the traditional center-left and center-right establishment parties. This splintering is happening in Italy, in Spain, and in Ireland, which just saw the radical, left-wing Sinn Fein achieve a historic result.
This makes the inevitable departure of Merkel all the more worrying. The German chancellor for a decade was a steadying hand across Europe; after Trump’s election in the US, she was cast into the role of defender of liberal democracy.
Merkel’s impending exit comes as Europe prepares for an uncertain time. The European Union is set to begin tough negotiations with the United Kingdom over its post-Brexit relationship. The US and the EU are on the verge of a potential trade war, and the potential reelection of Donald Trump could put even more strain on NATO and traditional Western alliances. Germany’s own political chaos could make all of this much more complicated.


vox--2020-02-10--Trump is running on criminal justice reform but just praised China’s execution of drug dealers

President Donald Trump is campaigning on criminal justice reform efforts that reduce sentences for nonviolent offenders , while suggesting he ’ d like the American justice system to work more like ones in authoritarian countries where drug dealers are executed after “ fair but quick ” trials .
If those two things sound hard to square with each other , that ’ s because they are .
But the contrast serves as an especially stark illustration of the incoherency at the core of Trumpism .
Just days after his Super Bowl ad and State of the Union speech highlighted his @ @ @ @ @ @ @ effort to reduce prison sentences at the federal level , Trump on Monday said the best way to further reduce the quantity of fentanyl in the US is to follow China ’ s lead .
“ States with a very powerful death penalty on drug dealers don ’ t have a drug problem , ” Trump said during a White House event with governors .
“ I don ’ t know that our country is ready for that , but if you look throughout the world , the countries with a powerful death @ @ @ @ @ @ @ fair but quick trial , they have very little if any drug problem .
That includes China.
” It should be noted that Trump ’ s claim about China and other authoritarian countries having “ very little if any drug problem ” is false .
Records from the Chinese government indicate that there are more than 2.5 million officially registered drug users in the country , and that the total has increased significantly in recent years .
( The real numbers are likely much higher since not all drug users have registered with @ @ @ @ @ @ @ in China in spite of the harsh punishments Trump alluded to .
The Guardian reported in late 2017 that China “ executes more people every year than the rest of the world combined , although the exact figure is not published and considered a state secret.
” And the Chinese government executes people for nonviolent crimes , including , as Trump mentioned , drug dealing — and in some cases carries out executions in public .
( Draconian measures taken by President Rodrigo Duterte in the Philippines have similarly failed to stamp out @ @ @ @ @ @ @ those who watched Trump ’ s Super Bowl ad , seeing him laud countries that are remarkably harsh with drug offenders might seem off-key .
That ’ s because the Super Bowl ad highlighted Trump ’ s June 2018 decision to pardon Alice Marie Johnson , who at the time was serving a life sentence in prison after she was convicted of conspiracy to possess cocaine and attempted possession of cocaine .
Fast-forward eight days , and now Trump seems to be suggesting people like Johnson should be executed .
But Monday wasn @ @ @ @ @ @ @ commended the Chinese government for its tough approach to drugs .
Speaking to mayors at the White House late last month , the president sounded the same note : Notably , in both instances Trump portrayed the suppression of individual rights and due process that ’ s part of the Chinese system as if not an improvement over the American system , then at least not significantly worse than what we have here .
And Trump has also congratulated the Philippines ’ Duterte for doing an “ unbelievable job on the drug problem @ @ @ @ @ @ @ has resulted in thousands of deaths .
Even Pompeo ’ s State Department acknowledges that China ’ s justice system is nothing to emulate Beyond the specifics of what Trump thinks about how drug dealers should be dealt with , it ’ s bizarre to see the president of the United States praise the criminal justice system of a country where a million people are locked away in internment camps .
Trump doesn ’ t have to take it from me .
His own State Department ’ s website notes that “ [ @ @ @ @ @ @ @ be opaque and the interpretation and enforcement of local laws arbitrary .
The judiciary does not enjoy independence from political influence.
” And with regard to drugs in particular , State notes that “ [ p ] olice regularly conduct unannounced drug tests on people suspected of drug use and have been known to enter a bar or nightclub and subject all patrons to immediate drug testing.
” A politicized judiciary selectively enforcing laws and executing people for nonviolent crimes might sound bad to Americans who are mostly unaccustomed to such things .
@ @ @ @ @ @ @ tried to hide his affinity for authoritarian rulers or for the death penalty — not just for drug crimes but for other ones as well .
The jarring thing in this instance , however , is that as part of his efforts to win support from more than 6 percent of black voters in 2020 , Trump is simultaneously pushing contradictory notions — that leniency for nonviolent offenders is good , and that nonviolent offenders should in some instances be put to death .
In that way Trump ’ s comments about criminal @ @ @ @ @ @ @ manifested itself with regard to entitlement programs , which Trump is proposing to cut while at the same time telling people he will never cut them .
The news moves fast .
To stay updated , follow Aaron Rupar on Twitter , and read more of Vox ’ s policy and politics coverage .

President Donald Trump is campaigning on criminal justice reform efforts that reduce sentences for nonviolent offenders, while suggesting he’d like the American justice system to work more like ones in authoritarian countries where drug dealers are executed after “fair but quick” trials.
If those two things sound hard to square with each other, that’s because they are. But the contrast serves as an especially stark illustration of the incoherency at the core of Trumpism.
Just days after his Super Bowl ad and State of the Union speech highlighted his support for legislation that makes a modest effort to reduce prison sentences at the federal level, Trump on Monday said the best way to further reduce the quantity of fentanyl in the US is to follow China’s lead.
“States with a very powerful death penalty on drug dealers don’t have a drug problem,” Trump said during a White House event with governors. “I don’t know that our country is ready for that, but if you look throughout the world, the countries with a powerful death penalty — death penalty — with a fair but quick trial, they have very little if any drug problem. That includes China.”
Trump suggests he'd like to model American criminal law on drug dealing on authoritarian systems like China, where dealers are executed: "Countries with a powerful death penalty, with a fair but quick trial, they have very little if any drug problem. That includes China." pic.twitter.com/9WprysjJAX — Aaron Rupar (@atrupar) February 10, 2020
(Trump made a number of other eyebrow-raising comments during the event, including saying of the coronavirus that “a lot of people think that goes away in April with the heat” and claiming the European Union “was really formed so they could treat us badly.”)
It should be noted that Trump’s claim about China and other authoritarian countries having “very little if any drug problem” is false. Records from the Chinese government indicate that there are more than 2.5 million officially registered drug users in the country, and that the total has increased significantly in recent years. (The real numbers are likely much higher since not all drug users have registered with the state.)
Drugs are prevalent in China in spite of the harsh punishments Trump alluded to. The Guardian reported in late 2017 that China “executes more people every year than the rest of the world combined, although the exact figure is not published and considered a state secret.” And the Chinese government executes people for nonviolent crimes, including, as Trump mentioned, drug dealing — and in some cases carries out executions in public. (Draconian measures taken by President Rodrigo Duterte in the Philippines have similarly failed to stamp out drug use there.)
But for those who watched Trump’s Super Bowl ad, seeing him laud countries that are remarkably harsh with drug offenders might seem off-key. That’s because the Super Bowl ad highlighted Trump’s June 2018 decision to pardon Alice Marie Johnson, who at the time was serving a life sentence in prison after she was convicted of conspiracy to possess cocaine and attempted possession of cocaine. Fast-forward eight days, and now Trump seems to be suggesting people like Johnson should be executed.
But Monday wasn’t the first time Trump has commended the Chinese government for its tough approach to drugs. Speaking to mayors at the White House late last month, the president sounded the same note:
And they’ve put in very strong penalties, and their penalties are really strong. You want to talk about penalties? Those are strict. (Laughter.) And their court cases go slightly quicker than ours. (Laughter.) Like — like one day. One day. They call them “quick trials.” They go quick. (Laughter.) They go so quick, you don’t know what happened. (Laughter.) Ours take 15 years; theirs takes one day. But he was — he’s been terrific on that. And we’re seeing a tremendous — a tremendous difference in the fentanyl.
Notably, in both instances Trump portrayed the suppression of individual rights and due process that’s part of the Chinese system as if not an improvement over the American system, then at least not significantly worse than what we have here. And Trump has also congratulated the Philippines’ Duterte for doing an “unbelievable job on the drug problem,” even though his violent crackdown has resulted in thousands of deaths.
Even Pompeo’s State Department acknowledges that China’s justice system is nothing to emulate
Beyond the specifics of what Trump thinks about how drug dealers should be dealt with, it’s bizarre to see the president of the United States praise the criminal justice system of a country where a million people are locked away in internment camps.
Trump doesn’t have to take it from me. His own State Department’s website notes that “[t]he Chinese legal system can be opaque and the interpretation and enforcement of local laws arbitrary. The judiciary does not enjoy independence from political influence.”
And with regard to drugs in particular, State notes that “[p]olice regularly conduct unannounced drug tests on people suspected of drug use and have been known to enter a bar or nightclub and subject all patrons to immediate drug testing.”
A politicized judiciary selectively enforcing laws and executing people for nonviolent crimes might sound bad to Americans who are mostly unaccustomed to such things. Trump, however, hasn’t tried to hide his affinity for authoritarian rulers or for the death penalty — not just for drug crimes but for other ones as well.
Trump downplays the role that high-powered guns play in mass shootings: "Mental illness and hatred pulls the trigger, not the gun."
He then proposes an expansion of the death penalty, to be administered with as quickly as possible. pic.twitter.com/xrKO3hKLs0 — Aaron Rupar (@atrupar) August 5, 2019
The jarring thing in this instance, however, is that as part of his efforts to win support from more than 6 percent of black voters in 2020, Trump is simultaneously pushing contradictory notions — that leniency for nonviolent offenders is good, and that nonviolent offenders should in some instances be put to death. In that way Trump’s comments about criminal justice echo a dynamic that has also manifested itself with regard to entitlement programs, which Trump is proposing to cut while at the same time telling people he will never cut them.
The news moves fast. To stay updated, follow Aaron Rupar on Twitter, and read more of Vox’s policy and politics coverage.


vox--2020-02-10--What we know (and don’t know) about the Nevada caucus “tool”

Here we go again !
Fresh off the unmitigated ( and still unfolding ) disaster that was the Iowa Democratic caucuses , Nevada will soon kick off caucuses of its own .
After understandably scrapping its plans to use an app made by Shadow Inc. , the company behind Iowa ’ s fated caucus app , the Nevada State Democratic Party is now scrambling to come up with a solution before the early voting period begins on February 15 .
Exactly what that solution might be remains a mystery to the greater public .
Multiple reports say the party is @ @ @ @ @ @ @ iPad “ tool , ” which , the party told volunteers , is not an app — despite its app-like properties .
But the state party has yet to confirm this or much of anything else .
Nevada ’ s secrecy is not a good sign , given how tight-lipped its Iowa predecessors were .
The caucus process differs depending on the state ( and political party ) that does them .
Nevada has been the third in the country to hold its Democratic nominating contest since 2008 .
Then-Sen. Harry Reid argued @ @ @ @ @ @ @ of America ’ s population than Iowa ( the first caucus ) and New Hampshire ( the first primary ) did and so should have the chance to be an influential part of the presidential nominating process .
This year , Nevada ’ s Democratic caucus will be held on February 22 , with early voting taking place February 15-18 .
This is the first time the caucus has had early voting , allowing registered Democrats to make their choice in person at any early voting location in their county .
( While @ @ @ @ @ @ @ voters , Nevada has same-day voting registration . )
On February 22 , caucus-goers will report to their precinct and stand on the side of the room designated for the candidate they prefer .
If a candidate doesn ’ t get a certain threshold of support — typically 15 percent , depending on the number of delegates at stake — they ’ ll be considered non-viable and their supporters will have to “ realign ” to a viable candidate ( or not vote at all ) .
There will also be paper ballot @ @ @ @ @ @ @ are anything like Iowa ’ s , will come in handy .
Once that ’ s all figured out , voters pick delegates to represent their selections at conventions .
In the event of a tie , the delegate will be decided by a drawing of playing cards .
Yes , that ’ s right : In Vegas fashion , whichever group picks the highest card wins the delegate .
If the groups pick the same card , the winner is chosen according to the card ’ s suit ( spades being the @ @ @ @ @ @ @ and finally clubs ) .
The candidate who gets the most delegates — not the one who gets the most votes — is considered the winner .
This year is the first to allow for early voting , the hope being that the option will increase participation among potential voters who can ’ t make the February 22 event .
Early voters will submit their top three to five choices on a paper ballot .
If a voter ’ s first choice doesn ’ t meet the threshold , their vote will be @ @ @ @ @ @ @ their list .
The new rules also limit the number of realignment rounds to one .
Also , precinct chairs will have to submit both the raw vote totals as well as the delegate counts to party headquarters , much like Iowa ’ s precinct chairs did .
That means they ’ ll report three sets of numbers : the first round of votes , the votes after the realignment , and the number of delegates awarded .
In previous contests , precinct chairs simply reported the number of delegates won .
While @ @ @ @ @ @ @ several new steps to the reporting process .
These complications are likely why state party leaders planned to use a new smartphone app to help chairs report all those extra numbers .
While Iowa had used a ( different ) app in 2016 , this year would have been Nevada ’ s first caucus with one .
Nevada paid Shadow at least $ 60,000 to develop the app — and recommended the company to the organizers of the Iowa caucuses .
In the original Nevada plan , the app would send early votes @ @ @ @ @ @ @ with the in-person caucus totals .
The app would then calculate the combined results and report them back to the state party headquarters .
Similar to the Iowa caucus , there would be phone and paper backups in place , according to the Reno Gazette-Journal .
The smartphone app is dead .
Long live the iPad “ tool.
” In the wake of the Iowa caucus , Nevada quickly distanced itself from Shadow , saying it would not be using its apps and was “ currently evaluating the best path forward.
” But @ @ @ @ @ @ @ what that path was .
News outlets reported Saturday that the party was demonstrating a “ caucus tool ” to be preloaded onto iPads distributed to precinct chairs .
Preloading the tool sounds like a good idea , considering how many Iowa chairs had difficulty downloading their apps onto their mobile devices , let alone actually running them .
The tool , assuming it works as intended , will give chairs the early voter numbers so they can integrate them into the vote totals .
According to the reports , the party stressed @ @ @ @ @ @ @ but rather a tool .
The difference between an “ app ” and a “ tool ” remains unclear .
And assuming the reports are true , the iPads that the tool will be installed on will not be able to connect to the internet .
This should make it harder for any would-be hackers to infiltrate the devices and influence the caucus results .
Which , one long week ago , before the caucuses began , was the biggest source of concern about online voting tools .
We don ’ t know @ @ @ @ @ @ @ such as who developed it and what , if any , cybersecurity tests it ’ s been put through .
Even volunteers complained about how little information they were given by the party thus far .
This might be because the party itself doesn ’ t know what the procedure will be .
According to the New York Times , it ’ s still testing out various “ backup plans.
” The Nevada State Democratic Party did not respond to requests for comment , but told CBS News that it has 3,000 volunteers @ @ @ @ @ @ @ statement did not , CBS noted , have any information about the non-app tool .
Nevada might have learned a few lessons from Iowa regarding which app vendors to trust , but it doesn ’ t appear to have learned that transparency is an essential part of the democratic process .
Open Sourced is made possible by Omidyar Network .
All Open Sourced content is editorially independent and produced by our journalists .

Here we go again!
Fresh off the unmitigated disaster that was the Iowa Democratic caucuses, Nevada is kicking off caucuses of its own. After understandably scrapping its plans to use an app made by Shadow Inc., the company behind Iowa’s ill-fated caucus app, the Nevada State Democratic Party came up with a last-minute replacement — just in time for the early voting that began on February 15.
The replacement is a “tool” — reportedly (and, again, understandably) party leaders intentionally stayed away from calling it an “app” — which involves party-distributed iPads equipped with “caucus calculators” accessed through a simple Google form.
How Nevada’s Democratic caucuses work
The caucus process differs depending on the state (and political party) that does them. Nevada has been the third in the country to hold its Democratic nominating contest since 2008. Then-Sen. Harry Reid argued that his state better reflected the diversity of America’s population than Iowa (the first caucus) and New Hampshire (the first primary) did, so should have the chance to be an influential part of the presidential nominating process.
This year, Nevada’s Democratic caucus will be held on February 22, with early voting taking place February 15 to 18. This is the first time the caucus has had early voting, allowing registered Democrats to make their choice in person at any early voting location in their county. (While the caucuses are considered closed to non-affiliated voters, Nevada has same-day voting registration.)
On February 22, caucus-goers will report to their precinct and stand on the side of the room designated for the candidate they prefer. If a candidate doesn’t get a certain threshold of support — typically 15 percent, depending on the number of delegates at stake — they’ll be considered non-viable and their supporters will have to “realign” to a viable candidate (or not vote at all). There will also be paper ballot backups — which, if the caucuses are anything like Iowa’s, will come in handy.
Once that’s all figured out, voters pick delegates to represent their selections at conventions. In the event of a tie, the delegate will be decided by a drawing of playing cards. Yes, that’s right: In Vegas fashion, whichever group picks the highest card wins the delegate. If the groups pick the same card, the winner is chosen according to the card’s suit (spades being the highest, then hearts, diamonds, and finally clubs).
The candidate who gets the most delegates — not the one who gets the most votes — is considered the winner.
What changed in 2020
This year is the first to allow for early voting, the hope being that the option will increase participation among potential voters who can’t make the February 22 event. Early voters will submit their top three to five choices on a paper ballot. If a voter’s first choice doesn’t meet the threshold, their vote will be awarded to the next viable candidate on their list. The new rules also limit the number of realignment rounds to one.
Also, precinct chairs will have to submit both the raw vote totals as well as the delegate counts to party headquarters, much like Iowa’s precinct chairs did. That means they’ll report three sets of numbers: the first round of votes, the votes after the realignment, and the number of delegates awarded. In previous contests, precinct chairs simply reported the number of delegates won. While this increases transparency, it also adds several new steps to the reporting process.
These complications are likely why state party leaders planned to use a new smartphone app to help chairs report all those extra numbers. While Iowa had used a (different) app in 2016, this year would have been Nevada’s first caucus that uses one. Nevada paid Shadow at least $60,000 to develop the app — and recommended the company to the organizers of the Iowa caucuses.
In the original Nevada plan, the app would send early votes to precinct chairs that would be combined with the in-person caucus totals. The app would then calculate the combined results and report them back to the state party headquarters. Similar to the Iowa caucus, there would be phone and paper backups in place, according to the Reno Gazette-Journal.
The smartphone app is dead. Long live the iPad “tool.”
In the wake of the Iowa caucus, Nevada quickly distanced itself from Shadow, saying it would not be using its apps and was “currently evaluating the best path forward.” But it didn’t say much about what that path was. News outlets reported Saturday that the party was demonstrating a “caucus tool” (the party discouraged volunteers from referring to it as an app, presumably due to the term’s new negative connotations) to be preloaded onto iPads distributed to precinct chairs. Preloading the tool sounds like a good idea, considering how many Iowa chairs had difficulty downloading their apps onto their mobile devices, let alone actually running them.
On February 13, a memo from the state party went out to campaigns that shed a little more light on the process: The tool is, in fact, a “caucus calculator” — accessed through a Google form — that would help precinct chairs figure out which candidates met the threshold and how many delegates to award the ones who did. The process sounds very similar to the functions of the app it replaces. The party said it consulted with the Democratic National Committee, the Department of Homeland Security, and Google to ensure security from potential hackers, which was, once upon a time, the primary concern about the caucus apps.
Chairs will have to report their results either through a phone hotline or by taking a photo of their reporting sheets and texting them to the party headquarters.
On February 19 — three days before the caucus is set to begin — the Nevada State Democratic Party released training guides showing precinct chairs how to operate the iPad tool:
Yes, the instructions include steps such as “open iPad case,” but, considering Iowa’s issues with some precinct chairs being entirely unfamiliar with smartphone apps, it’s probably a good idea to not assume any prior knowledge. Nevertheless, those familiar with Google Forms will feel right at home:
Chairs will also be completing a paper “math poster” worksheet that will require them to do the same basic math the iPad tool is supposed to do for them.
The most complicated part of the process — calculating re-aligned early voting results — still remains a bit of a mystery; the guide simply tells chairs to click “next” and the new totals will automatically appear, apparently distributed by the tool behind the scenes:
Once again, it looks like we’ll just have to hope the tool works as required come caucus night.
Update February 22, 2020, 4:40 pm: This post has been updated to add new details about the caucus tool and process.
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vox--2020-02-10--10 questions about the coronavirus outbreak, answered

The coronavirus outbreak , centered in China , keeps evolving at a dizzying speed .
With the case toll rising steeply — reaching over 40,000 on February 10 — and face masks flying off store shelves , it ’ s no wonder questions and fears are swirling about 2019-nCoV , as the virus is known .
For most people in the US , there ’ s no reason to worry : Ninety-nine percent of cases are happening in China .
But that may shift in the coming weeks as more outbreaks are detected in other countries .
Here are answers @ @ @ @ @ @ @ new coronavirus and its risks .
1 ) What is this new coronavirus , and what are the symptoms ?
Coronaviruses are a large family of viruses that typically attack the respiratory system .
The name comes from the Latin word corona and the Ancient Greek korōnè , meaning garland , or wreath , because of the spiky fringe encircling these viruses .
Most infect animals , such as bats , cats , and birds .
Only seven , including 2019-nCoV , SARS , and MERS , are known to infect humans .
@ @ @ @ @ @ @ bats to civet cats to humans in China ; MERS evolved from bats to camels to humans in the Middle East .
No one knows where 2019-nCoV came from .
For now , the new coronavirus is believed to have made the leap from animals in Wuhan , China , a city of 11 million , late last year .
But researchers are still trying to suss out its precise origins .
As for symptoms : Two of the seven coronaviruses that infect humans , SARS and MERS , can cause severe pneumonia @ @ @ @ @ @ @ than 30 percent of cases , respectively .
But the others lead to milder symptoms , like a common cold .
At the moment , we know 2019-nCoV can kill — but it ’ s not clear how often or how its fatality rate compares to SARS and MERS .
According to the Centers for Disease Control and Prevention , most patients start with a fever , cough , and shortness of breath .
An earlier report , published in The Lancet , provided more detailed information .
It looked at a subset @ @ @ @ @ @ @ 2019-nCoV in Wuhan .
The most common symptoms were fever , cough , muscle pain , and fatigue ; less common were headache , diarrhea , and coughing up mucus or blood .
All had pneumonia and lung abnormalities on CT scans .
As for the disease severity : 32 percent were admitted to an ICU , and 15 percent died .
By January 22 , most ( 68 percent ) of the patients had been discharged from the hospital .
By February 10 , the WHO said 80 percent of patients have @ @ @ @ @ @ @ 3 to 5 percent need intensive care ; and 2 percent have died .
At the same time , there ’ s also evidence of asymptomatic cases .
And it ’ s possible that as we learn more , 2019-nCoV will seem more like the flu than like SARS .
That ’ s because infectious diseases typically look more severe when they ’ re first discovered , since the people showing up in hospitals tend to be the sickest .
Already , the new virus appears to be less deadly than both SARS @ @ @ @ @ @ @ yet know how exactly 2019-nCoV spreads , but we do have a lot of data on how MERS , SARS , and other respiratory viruses move from person to person .
And that ’ s mainly through exposure to droplets from coughing or sneezing .
So when an infected person coughs or sneezes , they let out a spray , and if these droplets reach the nose , eyes , or mouth of another person , they can pass on the virus , said Jennifer Nuzzo , an infectious disease expert and senior @ @ @ @ @ @ @ Health Security .
In rarer cases , a person might catch a respiratory disease indirectly , “ via touching droplets on surfaces — and then touching mucosal membranes ” in the mouth , eyes , and nose , she added .
That ’ s why hand-washing is an important public health measure — all the time , and especially in an outbreak .
3 ) Should I travel while this outbreak is going on ?
Both the CDC and the State Department have issued their highest-level travel alerts for China , advising Americans @ @ @ @ @ @ @ .
( These advisories are likely to change as the outbreak evolves , so keep checking them . )
And that ’ s not only because there ’ s a risk of catching this new virus .
Right now , numerous airlines are canceling or scaling back flights to China , in part because of decreased demand .
“ I ’ m more concerned about the unpredictability of the [ outbreak ] response at this point , ” Nuzzo said .
“ It would not be fun to go to China and get @ @ @ @ @ @ @ , you ’ ll be subject to additional screening.
” But people worried about travel should remember that these advisories focus on China , where the epidemic is currently playing out .
Of the cases right now , 99 percent are in mainland China .
And more than half of those are in Hubei .
“ The risk of acquiring this infection outside of Hubei and , truly , outside of China is remarkably low , ” said Isaac Bogoch , a professor at the University of Toronto who studies how air travel @ @ @ @ @ @ @ new coronavirus infection .
People with the virus have been detected in other countries , which is the reason the WHO declared the outbreak a public health emergency .
But to date , those have mainly been travelers from China and their close contacts .
“ So if people are traveling [ anywhere outside of China , ] your risk is close to zero percent , ” Bogoch said .
What if you have to travel and you ’ re seated near someone who is sick ?
That ’ s not time to @ @ @ @ @ @ @ been some work looking into the risk of acquiring infectious diseases through air travel , ” Bogoch said .
“ The risk of acquiring a respiratory infection through air travel is still extraordinarily low.
” The risk does go up if you happen to be seated within six feet of a person with a respiratory infection .
But even there , simple proximity doesn ’ t necessarily mean you ’ ll catch anything .
Instead , the more infectious the person is , and the longer you sit near them , the higher @ @ @ @ @ @ @ not near the person for very long , or they ’ re not very infectious , the risk is lower .
And again , it ’ s unlikely that sick person has the coronavirus .
4 ) I ’ m still worried about the new coronavirus .
What should I do to protect myself ?
Buy a mask ?
In the US , the risk to the public is currently deemed low .
And just about every health expert Vox has spoken to has said there ’ s little evidence to support the @ @ @ @ @ @ @ in the general population .
Masks are only useful if you have a respiratory infection already and want to minimize the risk of spread to others , or if you ’ re working in a hospital and are in direct contact with people who have respiratory illnesses .
( Plus , there are reports of runs on masks and other supplies health workers need to stay safe . )
That ’ s why the CDC advises against the use of masks for regular Americans .
“ The virus is not spreading in the @ @ @ @ @ @ @ director of the CDC ’ s National Center for Immunization and Respiratory Diseases , reasoned in a press briefing on January 30 .
But people are hoarding them anyway , and for the wrong reasons .
The best thing you can do to prevent all sorts of illnesses , Messonnier said , is “ wash your hands , cover your cough , take care of yourself , and keep alert to the information that we ’ re providing.
” 5 ) What about the cases of people spreading the virus before they show @ @ @ @ @ @ @ ?
The best evidence that the virus can spread before a person has symptoms came from Germany .
But there were problems with the initial analysis .
The outbreak there was first identified in Bavaria on January 27 , when a German businessman was diagnosed .
He had been in meetings with a female colleague who was visiting from Shanghai and had the virus but didn ’ t know it .
The woman , according to a New England Journal of Medicine case report , only began to feel symptoms — such as @ @ @ @ @ @ @ left Germany , and days after meeting with the German businessman .
This suggests she may have transmitted the virus to the man before knowing she was sick .
If this were true , it ’ d throw a wrench in the attempts to stop the virus from spreading , since it suggests people who don ’ t even know they ’ re infected can spread the disease .
But it turns out the researchers published this report without having spoken to the woman .
And within days of the report , the @ @ @ @ @ @ @ public health agency — wrote a letter to NEJM about an error in the study , according to Science ’ s Kai Kupferschmidt , who broke the story .
The public health researchers followed up with the woman and found out she actually did have symptoms while in Germany .
She “ felt tired , suffered from muscle pain , and took paracetamol , a fever-lowering medication , ” Kupferschmidt explained .
This doesn ’ t mean that we won ’ t still find out people can spread the virus asymptomatically .
More @ @ @ @ @ @ @ believe it will .
However , Bogoch said , “ even if there have been cases of asymptomatic transmission of this infection , those will be typically rare cases , and with just about every other respiratory tract infection known to humankind , those are not the people who are driving an epidemic.
” 6 ) Is this going to become a deadly pandemic ?
While there are cases in at least 25 other countries , they haven ’ t yet turned into local outbreaks .
So for now , the CDC and @ @ @ @ @ @ @ .
Very soon , though , health experts may determine that there are enough cases in China to officially call the outbreak an epidemic .
And if the disease continues to spread locally in other countries , it could turn into a pandemic ( which is defined as an epidemic that ’ s spread to two or more regions of the world ) .
On February 10 , the WHO ’ s director general , Dr. Tedros Adhanom Ghebreyesus , flicked at that possibility .
He noted there were cases outside of China @ @ @ @ @ @ @ onward transmission from people with no travel history to China.
” These “ could be the spark that becomes a bigger fire.
” But a disease can spread widely , and become a pandemic , without being particularly severe .
And no one knows yet what a 2019nCoV pandemic would look like — mostly because we don ’ t yet know how lethal this disease is .
If you take the current number of deaths and divide it by the number of known cases , “ the case fatality is 2 percent — @ @ @ @ @ @ @ 3 percent in the early days , ” said University of Michigan ’ s Howard Markel , who studies outbreaks .
“ And if it goes really , really low , we ’ ll probably say — like we did in Mexico in 2009 with swine flu — that it ’ s something very similar , if not less deadly , [ to ] regular seasonal flu.
” So once more of these mild cases are discovered , this virus could look a lot less deadly .
“ We live [ with ] @ @ @ @ @ @ @ viruses , ” Nuzzo said , “ some of which are even more transmissible than the estimates people have come out with for this one — but they don ’ t make the headlines.
” 7 ) Is my city at risk of an outbreak ?
Some of the best research on that question comes from Bogoch and his colleagues .
They ’ ve done studies in the past couple of weeks on the cities most vulnerable to novel coronavirus infections .
What ’ s the big takeaway ?
It ’ s really @ @ @ @ @ @ @ most at risk .
The researchers — from the University of Oxford , University of Toronto , and London School of Medicine and Tropical Hygiene — used 2019 data from the International Air Transport Association to find all the cities in China that received at least 100,000 airline passengers from Wuhan during February through April .
They then modeled how the disease could spread from those cities if they experienced local outbreaks .
Here are 15 of the top 50 destinations that might see outbreaks ( also pay attention to the IDVI — @ @ @ @ @ @ @ .
It ’ s a measure of a country ’ s ability to manage an infectious disease .
Scores closer to zero mean they ’ re less prepared . )
“ By no means would anybody be surprised if there are more cases exported to Europe and the US , ” Bogoch said .
“ But the places that are going to have the greatest volume and number of infections exported would be to East Asian and Southeast Asian centers.
” 8 ) So what might happen next ?
If China contains the @ @ @ @ @ @ @ countries don ’ t blow up , we might see the case count start to fall and the public health emergency fizzle out .
But there are already so many cases across China , as well as the very real possibility that the virus is circulating , undetected , in countries with weak health systems , that the possibility of containment is looking less likely by the day .
If 2019nCoV is not contained , “ if it continues to accelerate , we very well may have a pandemic , ” said Tony @ @ @ @ @ @ @ Institute of Allergy and Infectious Diseases .
That would mean more sickness and deaths not only in China , but also in other countries around the world , as cases grow from one-off travelers or small clusters to full-blown outbreaks .
In this scenario , he added , “ you don ’ t try to control [ the virus ] because it ’ s already everywhere.
” So public health officials would move from attempting containment of the virus to mitigating its impact — setting up hospitals to isolate and care for patients @ @ @ @ @ @ @ ” ( like canceling public events ) , and coming up with triaging protocols for the many people who might need hospital care .
But again , even if this virus moves around the world , it may not be very deadly .
In the best-case scenario , this outbreak might look more like H1N1 swine flu .
When H1N1 was first recognized in 2009 and spread around the world , there were major concerns about its lethality .
US schools closed , people from North America were quarantined when they arrived in @ @ @ @ @ @ @ Not only did those measures fail to contain the virus , Nuzzo said , it turned out H1N1 wasn ’ t all that deadly .
“ Now we ’ re still living with that virus — it ’ s one that circulates with every flu season , ” Nuzzo explained .
9 ) How is the world responding to this crisis ?
On January 30 , the WHO declared the outbreak a global public health emergency .
Though it advised countries not to put in place travel or trade restrictions against China , @ @ @ @ @ @ @ have already sealed their borders .
Meanwhile , the US government dramatically escalated its response — issuing its highest-level travel advisory , quarantining citizens evacuated from China , and temporarily banning foreign nationals who have recently been to the East Asian country from coming in .
These extreme measures can be explained , in part , by all the unknowns related to this virus : leaders are taking extreme precautions for fear 2019nCoV is very deadly and can spread very far .
The measures can also be explained by the fact that we @ @ @ @ @ @ @ responses .
So countries can basically do what they want in response to pandemic threats without getting penalized , even if the WHO advises against whatever actions they ’ re taking .
The most dramatic — and unprecedented — response is currently playing out in China , where more than 50 million people are under quarantine .
“ China has implemented the most extensive cordon sanitaire [ or quarantine ] in the history of humankind , ” Lawrence Gostin , a global health law professor at Georgetown University , told Vox .
“ @ @ @ @ @ @ @ fear and panic .
They ’ ve violated human rights.
” Authorities there have also censored information and silenced the whistleblowers who tried to sound the alarm sooner than Chinese authorities were willing .
But again , because of the weakness of global health law , the international community has remained mostly silent about these potential human rights abuses .
10 ) How might this end ?
There are a few ways this outbreak could end , as my colleague Brian Resnick explained .
Perhaps public health measures — identifying cases fast , @ @ @ @ @ @ @ stop the spread of this coronavirus .
( That ’ s what stopped the spread of SARS in 2003 . )
Because this is a zoonotic disease , meaning it came from an animal , finding and eliminating that source would also help .
Or maybe a vaccine or antiviral will be invented quickly to curb a broader epidemic ( though that ’ ll likely take years ) .
The coming seasons of warmer weather could also play a role in at least slowing the virus down .
“ Coronaviruses are winter viruses @ @ @ @ @ @ @ the weather is warm and moist , these viruses don ’ t spread as well as when the weather is cold and dry.
” Finally , there ’ s the possibility the virus will simply die out .
“ Disease outbreaks are a bit like fires , ” Resnick wrote .
“ The virus is the flame .
Susceptible people are the fuel .
Eventually a fire burns itself out if it runs out of kindling .
A virus outbreak will end when it stops finding susceptible people to infect.
” A SARS-like @ @ @ @ @ @ @ and made its way to the United States .
Vox ’ s Julia Belluz explains what ’ s known and what ’ s next .
Subscribe to Today , Explained wherever you get your podcasts , including Apple Podcasts , Google Podcasts , Spotify , Stitcher , and ART19 .

Editor’s note, April 2: There have been significant developments in the coronavirus pandemic since this story was last updated. Here is our latest information on the big questions about the coronavirus, as of this writing. For our most up-to-date coverage, visit our coronavirus hub.
The coronavirus outbreak, which began in China, keeps evolving at a dizzying speed. With the global case toll rising steeply, face masks flying off store shelves, borders around the world closing, and meetings, cruise itineraries, and the global economy upended by the virus, it’s no wonder questions and fears are swirling about Covid-19, as the disease is known.
On March 11, the WHO declared the outbreak a pandemic, a new disease that has spread around the world. Many countries have seen reported cases of the virus rise within their borders — and that includes the US.
“We will see more cases, and things will get worse,” Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told members of the House Oversight Committee on March 11. “How much worse … will depend on our ability to do two things: to contain the influx in people who are infected coming from the outside and the ability to contain and mitigate within our own country.”
Spread of the virus and the slow rollout of testing mean reported case numbers are changing quickly. Meanwhile, outbreaks have been surging in South Korea, Italy, and Iran. With the new virus continuing its tour around the world, here are answers to your most burning questions.
1) What is this new coronavirus, and where did it come from?
Coronaviruses are a large family of viruses that typically attack the respiratory system. The name comes from the Latin word corona, for crown, and the ancient Greek korōnè, meaning garland or wreath, because of the spiky fringe encircling these viruses. Most coronaviruses infect animals, such as bats, cats, and birds. Only seven, including Covid-19, SARS, and MERS, are known to infect humans.
SARS is thought to have evolved from infecting bats to civet cats to humans in China; MERS evolved from bats to camels to humans in the Middle East. No one knows precisely where Covid-19 came from, though a leading hypothesis is that bats were once again the original source: They spread the virus to another animal species, possibly a pangolin, where it jumped to humans.
2) What are the symptoms and death rate?
Two of the seven coronaviruses that infect humans, SARS and MERS, can cause severe pneumonia and even death in 10 and more than 30 percent of cases, respectively. But others lead to milder symptoms, like a common cold. The most common symptoms of Covid-19 are fever and dry cough.
No one knows the precise incubation period for the virus, but symptoms can show up anywhere from one day to two weeks after exposure, according to a WHO report on China’s response.
At the moment, we know Covid-19 can cause pneumonia and that it too can kill — but while it seems to be less deadly than SARS and MERS, it’s not yet clear by precisely how much.
Some of the best evidence on the question comes from a February 16 China Center for Disease Control report looking at the outcomes of the first 72,314 patients with confirmed or suspected Covid-19 in mainland China. It’s the largest such analysis to date, and it found an overall case fatality rate of 2.3 percent — lower than both SARS and MERS. (The case fatality rate, or CFR, is the proportion of deaths a disease causes within a group of people who have the disease.)
The researchers also discovered a huge variation in the case fatality rate by age group. In short, the virus appears to be deadlier in people with each passing decade. You can see the trend in this graph:
Overall, the researchers characterized 81 percent of the cases as mild and 19 percent as severe or critical.
One major caveat, though: This data comes from mainland China. And the case fatality rate has been different outside of China.
At the same time, there’s also evidence of asymptomatic cases. And it’s possible that as we discover more of these cases, Covid-19 will look less deadly. That’s because infectious diseases typically look more severe when they’re first discovered since the people showing up in hospitals tend to be the sickest. Disease modelers who account for this under-counting of cases currently estimate an overall case fatality rate of just over 1 percent.
As for symptoms: Fever, dry cough, and fatigue are more common, while thick mucus from coughs, shortness of breath, sore throat, and headache are less common, according to China’s data.
But the picture might change as data on symptoms emerge from other countries. For example, a yet-to-be published German paper looked at some of the country’s earliest confirmed Covid-19 patients. Researchers found symptoms in this small sample often resembled a cold. So only two of the nine patients had a fever, and seven had a cough, but just as common were symptoms like stuffy nose, runny nose, and sneezing.
3) What should I do if I think I have Covid-19?
If you’re in a high-risk group — over the age of 60 with an underlying health condition — seek medical treatment immediately, and let your hospital or health care provider know you suspect Covid-19 before showing up.
Otherwise, stay at home and call a health professional, Vox’s Umair Irfan explained: “They will work with your local health department and figure out whether you need to get tested or get treatment. Doctors and health officials advise not to go to the emergency room if your symptoms do not appear to be life-threatening.” There’s a good chance you’ll recover with nothing more than rest and fluids. But you will need to self-isolate while sick to avoid spreading the disease to others, including any people in your home. Here’s how to do it.
The CDC and the WHO recommend several basic measures to help prevent the spread of Covid-19: Wash your hands often for at least 20 seconds.
Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
Clean and disinfect frequently touched objects.
Practice social distancing, and stay home when you are sick.
Contact a health worker if you have symptoms; fever and a dry cough are most common. Guidance may change. Stay informed, and stay safe, with Vox’s coronavirus coverage hub.
And if you are healthy, here are some ways you can help vulnerable people in your community.
4) How do coronaviruses spread?
We don’t yet know exactly how SARS-CoV-2 — the virus that causes the Covid-19 disease — spreads, but we do have a lot of data on how MERS, SARS, and other respiratory viruses move from person to person. And that’s mainly through exposure to droplets from coughing or sneezing.
So when an infected person coughs or sneezes, they let out a spray, and if these droplets reach the nose, eyes, or mouth of another person, they can pass on the virus, said Jennifer Nuzzo, an infectious disease expert and senior scholar at the Johns Hopkins Center for Health Security. In rarer cases, a person might catch a respiratory disease indirectly, “via touching droplets on surfaces — and then touching mucosal membranes” in the mouth, eyes, and nose, she added.
There’s also emerging evidence showing that SARS-CoV-2 may spread through poop — known as the “fecal-oral” route of disease transmission. Researchers are on the lookout for potential airborne transmission, too, and there’s a lot of speculation about whether inanimate objects — like door handles — can pass on the virus.
In the case of airborne transmission, a person would get infected by directly inhaling droplets suspended in the air from an infected individual. With “fomites” — objects that can transmit infections — droplets from an infected person would end up on surfaces another person touches. “So far, there is no conclusive evidence of that,” wrote Megan Murray, a Harvard Infectious Disease specialist, in a coronavirus explainer, “although that is challenging to prove one way or the other.”
What we do know: More and more research is piling up to suggest people who have only mild symptoms, or no symptoms at all, can test positive for Covid-19 disease. The virus also appears to be present in the body at very high levels early on in an illness, when people are still going to work or traveling.
“We still don’t know to what extent people without symptoms can infect,” Nuzzo cautioned. And Isaac Bogoch, a professor at the University of Toronto told Vox, “even if there have been cases of asymptomatic transmission of this infection, those will be typically rare cases, and with just about every other respiratory tract infection known to humankind, those are not the people who are driving an epidemic.”
Even so, if this virus can spread from people with no or mild symptoms, it might help explain why it’s so contagious. Researchers currently believe one person with Covid-19 generally infects two to more than three others, which would make the new coronavirus more transmissible than seasonal flu, SARS, and MERS. That’s why social distancing measures are so important.
5) What should I do to protect myself? Buy a face mask?
In the US, just about every health expert Vox has spoken to has said there’s little evidence to support the use of face masks for preventing disease in the general population.
Masks are only useful if you have a respiratory infection already and want to minimize the risk of spread to others, or if you’re caring for someone who is sick or working in a hospital in direct contact with people who have respiratory illnesses. (Plus, there are reports of runs on masks and other supplies that health workers need to stay safe. If they can’t get them and start walking off the job, we’re all in trouble.)
Related How soap absolutely annihilates the coronavirus
That’s why the CDC advises against the use of masks for regular Americans. The best thing you can do to prevent all sorts of illnesses, CDC’s Nancy Messonnier said, is “wash your hands, cover your cough, take care of yourself, and keep alert to the information that we’re providing.”
Individuals at a higher risk of developing severe disease — the elderly, people with underlying health conditions — should take additional precautions: avoiding crowds and contact with people who are sick, and stocking up on medicines and groceries, Messonnier said.
6) Is this a deadly pandemic?
The WHO has officially declared the outbreak a pandemic, with the disease in more than 100 countries and major epidemics in several regions of the world.
That means containing the virus — fully halting its spread — is no longer the goal but rather mitigation of fast spread and harm reduction.
Keep in mind, the p-word doesn’t say anything about the severity of Covid-19. A disease can spread widely and become a pandemic without being particularly severe. And no one knows yet what the ultimate effects of this pandemic will look like — mostly because we don’t yet know precisely how lethal the disease is.
There was a time when it seemed possible that China might contain the virus and the outbreaks outside of China would fizzle out, spelling the end of this public health emergency.
But there are now so many around the world, and the very real possibility that the virus is circulating, undetected, in even more countries — especially those with weak health systems — that containment appears out of reach.
This means we’re likely to see more sickness and death in many countries as cases grow from one-off travelers or small clusters to full-blown outbreaks.
In this scenario, the NIH’s Fauci said, “you don’t try to control [the virus] because it’s already everywhere.”
Health officials are now in the mitigation phase of the response strategy. This involves a focus on social distancing to slow the speed of the outbreak and avoid overwhelming health systems. It also involves ramping up public health communications to inform the public about the disease, testing of potential cases to find sick people and their contacts, and capacity in hospitals.
So hospitals need to be ready with Covid-19 protocols so the disease doesn’t spread from them, and health care workers need to be protected with access to protective equipment such as face masks so they can keep doing their jobs. Countries also need plans in place for maintaining supply chains and carrying on with travel and trade.
The slow rollout of testing in the US, in particular, has made slowing the spread of the virus more difficult.
An investigation led by the Atlantic and independent researchers found that a little more than 7,000 people in the US had been tested as of March 11 — putting the US far behind other developed countries. (The Covid Tracking Project team is now gathering test counts daily.)
Slowing epidemics is critical in preventing more deaths, as it reduces stress on hospitals and health centers, which can only treat a certain number of patients at a time. That’s why “flattening the curve” of the pandemic through social distancing measures is so important.
As Eliza Barclay and Dylan Scott wrote for Vox: “A disastrous inundation of hospitals can likely be averted with protective measures we’re now seeing more of — closing schools, canceling mass gatherings, working from home, self-quarantine, self-isolation, avoiding crowds — to keep the virus from spreading fast.”
In the best-case scenario, which has become less likely, this outbreak might look more like H1N1 swine flu. When H1N1 was first recognized in 2009 and spread around the world, there were major concerns about its lethality. US schools closed, people from North America were quarantined when they arrived in other countries, flights were canceled. Not only did those measures fail to contain the virus, Nuzzo said, but it also turned out H1N1 wasn’t all that deadly.
“Now we’re still living with that virus — it’s one that circulates with every flu season,” Nuzzo explained.
7) Are there any places I shouldn’t go during this outbreak?
The CDC has issued its highest-level travel alerts for Italy, Iran, South Korea, and China, advising Americans to avoid traveling in these places for the moment. These are the countries with the largest known coronavirus outbreaks. On March 11, President Donald Trump issued a ban on travel from most of Europe for 30 days.
But just because a country you plan to visit isn’t on the list right now doesn’t mean it won’t be there tomorrow. The outbreak is evolving rapidly, and these advisories are likely to change in the coming days, so keep checking in with the CDC. This map and list of travel restrictions from the Council on Foreign Relations is another good resource.
As Nuzzo told Vox: “I’m more concerned about the unpredictability of the [outbreak] response at this point. It would not be fun to go to China and get stuck there somehow. And coming back, you’ll be subject to additional screening” or quarantines.
What if you decide to travel and you’re seated near someone who is coughing or sneezing? That’s not very reassuring, but it’s not time to panic, either. “The risk of acquiring a respiratory infection through air travel is still extraordinarily low,” Bogoch, who studies how air travel influences the dynamics of outbreaks — including the new coronavirus infection.
The risk does go up if you happen to be seated within six feet of a person with a respiratory infection. But even there, simple proximity doesn’t necessarily mean you’ll catch anything. Instead, the more infectious the person is, and the longer you sit near them, the higher your risk. If you’re not near the person for very long or they’re not very infectious, the risk is lower.
Also keep in mind: The travel warnings are not entirely driven by the risk of catching this new virus. Airlines have been canceling or scaling back flights, trains have been halted, and countries have been imposing quarantines on travelers and citizens.
8) How is the world responding to this crisis?
On January 30, the WHO declared the outbreak a global public health emergency, and about a month later said it had become a pandemic.
A dramatic — and unprecedented — response played out in China, the country with the most Covid-19 cases. “China has implemented the most extensive cordon sanitaire [or quarantine] in the history of humankind,” Gostin told Vox. “They’ve restricted movements, caused fear and panic. They’ve violated human rights.” But they also managed to get more control over the outbreak, and cases are now declining.
Italy has adopted quarantine measures that are similar to China — first locking down some 16 million people in the country’s north, where the virus has been spreading, and then extending restrictions on movement to the entire country.
Some governments have so far been able to halt the spread of coronavirus within their borders, seemingly through quick action. In Taiwan, a small island close to mainland China, testing for Covid-19 began in late December, even as China was just beginning to discover cases and ramp up its response. The Taiwanese government also emphasized public education about curbing the disease’s spread. Taiwan has only reported one death from the virus, as of March 11.
In recent weeks, the US government dramatically escalated its response: issuing its highest-level travel advisories, quarantining citizens evacuated from China, and banning foreign nationals who have recently been to China from coming in, as well as travelers from Iran. On March 11, Trump announced a 30-day travel ban from most of Europe to the US (excluding the UK).
The CDC warned, on February 25, there may be a lot more to come; “disruption to everyday life might be severe.” This means Americans can expect more cancellations, quarantines, and social distancing efforts. (To read more about those, see this explainer.)
The severe measures can be explained by the fact that there’s still a lot we don’t know about this new virus and health officials are taking drastic actions. There’s also no enforceable international law governing outbreak responses, so countries can basically do what they want in response to pandemic threats without getting penalized, even if those actions are proportional or science-based, and the WHO is advising against them.
9) How might this end?
There are a few ways this outbreak could end, as Vox’s Brian Resnick explained. Perhaps public health measures — identifying cases fast, putting infected people in isolation — will slow the spread of this coronavirus. (That’s what stopped the spread of SARS in 2003.)
“If we slow it so that infections happen over 10 or 12 months instead of over one month, that’s going to make a big difference as far as how many people seriously infected, how many people may end up hospitalized, and how many they end up dying,” said Tara Smith, a Kent State University epidemiologist. “We talk about it as ‘flattening the epidemic curve’ — so that it’s not a big, sudden peak in cases, but it’s a more moderate plateau over time.”
Because this is a zoonotic disease, meaning it came from an animal, finding and eliminating that source would also help.
Or maybe a vaccine or antiviral will be invented quickly to curb a broader epidemic (though a vaccine is expected to take at least a year).
Related A simple guide to the vaccines and drugs that could fight coronavirus
The coming seasons of warmer weather could also play a role in at least slowing down the virus. “Coronaviruses are winter viruses,” Fauci said. “When the weather is warm and moist, these viruses don’t spread as well as when the weather is cold and dry.”
Covid-19 could also keep spreading at a high rate and become endemic — regularly infecting humans, like the common cold.
Either way, “it’s going to have tremendous — really negative and lasting effects — for the most vulnerable people who are either medically or economically vulnerable in our society,” Angela Rasmussen, a Columbia virologist, told Vox.
Correction March 3: A graphic in this piece previously misstated the percentage of cases in China that were not linked back to the Wuhan area. The graphic has been updated with the correct figure, 14 percent.
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vox--2020-02-10--These New Hampshire primary voters will truly be first in the nation

A handful of New Hampshire primary voters will truly be first in the nation : Three rural New Hampshire towns — Dixville Notch , Millsfield , and Hart ’ s Location — will open their polls at 12:01 am on Tuesday , February 11 , and they ’ ll likely report their informal results within the hour .
These are the very first New Hampshire residents to cast their day-of primary ballots in the 2020 Democratic primary , and their midnight voting honors a tradition that ’ s been around for years .
New Hampshire has long prized its position @ @ @ @ @ @ @ , timing that allows it to claim that it is “ first in the nation , ” even though its election is now preceded by the Iowa caucuses .
The midnight voting tradition boasts its own set of unique quirks : The towns holding these votes are so small that they ’ ve historically been able to tally up the ballots and announce the outcomes shortly after the polls open .
In Dixville Notch and Millsfield , there will be wooden ballot boxes where people will be able to drop their submissions .
@ @ @ @ @ @ @ specially timed votes , all three places are required to have 100 percent voter turnout , something that ’ s typically unheard of in most elections .
By opening their polls at midnight , the trio of towns are also continuing a custom that ’ s been increasingly celebrated over the years : Millsfield held the first-ever midnight vote in 1936 , something it initially did in order to become the first place in the US to report out its results to the press and broader public .
“ [ Genevieve Nadig ] @ @ @ @ @ @ @ country in an attempt to upstage Massachusetts , ” Millsfield ’ s chief elections officer Wayne Urso told Vox .
It ’ s worth noting , however , that while much will be made of these very early returns , these votes are not expected to be predictive of the state ’ s broader outcome , given the size of the voting pool .
In the past , a string of Dixville Notch results for the Republican primary has coincided with the eventual nominee that ’ s picked by the GOP , though @ @ @ @ @ @ @ Nate Silver concluded that the town ’ s votes had no predictive effect .
What these votes do represent is the desire to preserve a time-honored custom in a state that highly values such traditions , not least its own established role in the primary calendar .
New Hampshire has long prized its first in the nation status , and these traditions are just another part of it Ultimately , this midnight practice is one that ’ s stuck around because of what it represents for each of these towns .
Dixville Notch @ @ @ @ @ @ @ s North Country that ’ s close to the Canadian border , has been the focus of extensive media attention for its famed midnight vote , even though its proceedings will feature just five people this year .
“ The midnight vote to Dixville is what snow is to New Hampshire , or what the Boston Red Sox are to Fenway Park , ” developer and Dixville voter Les Otten told Vox .
“ These things have become synonymous with each other.
” This year ’ s midnight vote was nearly canceled because @ @ @ @ @ @ @ that was necessary , a challenge that emerged in the wake of scrutiny about voters ’ residencies from state election officials in 2016 .
Otten , however , became the town ’ s much-needed fifth resident and will be among the handful of people dropping their ballot at the Balsams Resort on Tuesday .
Meanwhile in Millsfield , voters are set to gather at the local tavern , while in Hart ’ s Location , they ’ ll huddle at the town hall .
In the past , presidential candidates including the late @ @ @ @ @ @ @ as key campaign stops , though fewer have passed through this cycle .
Regardless of the attention they get , though , these towns are as determined as the state itself to maintain their positions in the primary .
“ While there are practical reasons , there ’ s also the reason of some local pride ... of saying ‘ Let ’ s get our mark on the election earlier than anyone else , ’ ” Millsfield ’ s chief elections officer Urso said .

A handful of New Hampshire primary voters were truly first in the nation: Three rural New Hampshire towns — Dixville Notch, Millsfield, and Hart’s Location — opened their polls at 12:01 am on Tuesday, February 11, and reported their informal results within the hour.
These New Hampshire residents were the very first to cast their day-of ballots in the 2020 Democratic primary, and their midnight voting honors a tradition that’s been around for years. New Hampshire has long prized its position as the first primary in the country, timing that allows it to claim that it is “first in the nation,” even though its election is now preceded by the Iowa caucuses. The midnight votes take this custom one step further, enabling these towns to claim they are first in the state.
The limited pool of early votes was ultimately distributed across a wide spectrum of candidates: Sen. Amy Klobuchar currently leads with eight votes, followed by Sens. Elizabeth Warren and Bernie Sanders, who picked up four votes each. Former New York Mayor Mike Bloomberg also did well in Dixville Notch specifically, where he won three of the five residents’ votes as a write-in candidate, winning both the Republican and Democratic primaries.
It’s worth noting, though, that these votes should not be taken as predictive of the rest of the state or country’s outcomes. In the past, the Dixville Notch results for the Republican primary were known for matching up neatly with the eventual nominee that’s picked by the GOP. A 2008 analysis by FiveThirtyEight’s Nate Silver, however, concluded that the town’s votes had no predictive effect.
Rather than serving as a harbinger of some kind, these midnight votes are simply the continuation of a historic tradition that boasts unique quirks: The towns holding these votes are so small that they’ve historically been able to tally up the ballots and announce the outcomes shortly after the polls open.
In Dixville Notch and Millsfield, where participation included no more than 30 voters, there were wooden ballot boxes where people were able to drop their submissions. And in order to hold these specially timed votes, all three places featured 100 percent voter turnout, something that’s typically unheard of in most elections.
By opening their polls at midnight, the trio of towns are continuing a custom that’s been increasingly celebrated over the years: Millsfield held the first midnight vote in 1936, something it initially did to become the first place in the US to report out its results to the press and broader public.
Genevieve Nadig “organized the first midnight vote in the country in an attempt to upstage Massachusetts,” Millsfield’s chief elections officer Wayne Urso told Vox.
What these votes ultimately represent is the desire to preserve a time-honored tradition in a state that highly values such practices, not least its own established role in the primary calendar.
New Hampshire has long prized its “first in the nation” status, and these traditions are just another part of it
Ultimately, this midnight vote has stuck around because of what it represents for each of these towns.
Dixville Notch, a town in the state’s North Country that’s close to the Canadian border, has long been the focus of extensive media attention for its famed midnight vote, even though its proceedings featured just five people this year.
“The midnight vote to Dixville is what snow is to New Hampshire, or what the Boston Red Sox are to Fenway Park,” developer and Dixville voter Les Otten told Vox. “These things have become synonymous with each other.”
This year’s midnight vote was nearly canceled because the town almost missed the required five-person threshold, a challenge that emerged in the wake of a review of voters’ residencies by state election officials in 2016. Otten, however, became the town’s much-needed fifth resident and was among the handful of people dropping their ballot at the Balsams Resort on Tuesday.
In Millsfield, voters gathered at the local tavern, while in Hart’s Location, they huddled at the town hall.
In the past, presidential candidates including Sen. John McCain have frequented these towns as key campaign stops, though fewer have passed through this cycle.
Regardless of the attention they get, though, these towns are as determined as the state itself to maintain their positions in the primary. “While there are practical reasons, there’s also the reason of some local pride ... of saying, ‘Let’s get our mark on the election earlier than anyone else,’” Urso said.
Ella Nilsen contributed reporting to this article.


vox--2020-02-10--Utah’s plan to send patients to Mexico to buy cheap medicines is an indictment of US health care

The insurance plan for Utah government employees decided two years ago it had to do something to curb prescription drug costs .
Its solution ?
Pay for workers to travel to Canada or Mexico to buy the same medications they ’ d been getting in the United States , just at much lower prices .
Today , the Utah insurer is saving hundreds of thousands of dollars a year on drugs for a handful of patients who need expensive medicines and make the trip abroad to get them .
It ’ s not as much as they were originally hoping @ @ @ @ @ @ @ plus a $ 500 bonus is still a worthwhile deal for the state to make .
Medical tourism is hardly a new phenomenon .
Eight percent of Americans said in a 2016 Kaiser Family Foundation poll that they had purchased prescription drugs outside of the United States .
US government surveys have estimated between 150,000 and 320,000 Americans annually name health care as their reason for traveling abroad .
Lower costs are usually their motivation .
But to see it so deliberately deployed by a major health insurer as a cost-saving measure is @ @ @ @ @ @ @ heard stories of individuals or informal groups of patients crossing the border to buy cheaper drugs , it has not typically been a sanctioned part of the American health insurance system , ” Caroline Pearson , senior fellow at NORC-University of Chicago , told me .
“ The Utah ... example is the only case that I am aware of.
” Employers and health insurance plans are always looking for ways to cut costs , of course .
That ’ s why they create provider networks in the first place .
Some employers @ @ @ @ @ @ @ geographic area to high-quality health centers in the interest of lowering costs — according to the Kaiser Family Foundation , 16 percent of employers have utilized these so-called “ centers of excellence ” and of those firms , about one in five will pay for travel and lodging expenses .
” This is just the natural extension , I suppose , ” Walid Gellad , director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh , said .
“ It is really something that they ’ re paying people @ @ @ @ @ @ @ for it , but paying people to do it.
” In brief , here is how the Utah government employee program works : • Patients taking one or more of 13 specialty drugs are eligible to participate • They can travel to Vancouver , Canada , or Tijuana , Mexico , to buy their prescriptions • They still make their usual copayments only • The state health insurance plan covers the cost of their airfare , transportation to and from the airport , and lodging if necessary • The state will also pay @ @ @ @ @ @ @ the trip The health insurer works with a Mexico-based pharmacy to arrange the purchases and coordinate travel .
From a great Salt Lake Tribune story on the program : Of course , the only reason it ’ s worth going through all this trouble for the patients and their insurer is drug prices in the United States are so much higher than anywhere else , including Mexico and Canada .
Here are the international price comparisons for the arthritis medication Humira , one of the 13 drugs that qualify for the Utah program @ @ @ @ @ @ @ : So you can see why Utah ’ s insurance plan is eager to find cheaper prices for these drugs .
But it turns out they really needed the $ 500 cash incentive to get people to take advantage of it .
According to the Tribune , the state insurance plan actually already had a longstanding policy to cover travel costs for patients who journeyed to Tijuana to have certain procedures done ( to the same hospital where they now go to get prescriptions filled ) , but nobody took them up on @ @ @ @ @ @ @ in cash that seemed to make the difference .
It ’ s important to maintain some context here : Only 10 patients have actually made the trip to Mexico to buy cheaper drugs ( though , remember , these are specialty drugs for expensive conditions — they are by definition pretty rare ) .
So it ’ s not as if Utah is suddenly sending people in droves across the border .
The relatively low uptake means the state has saved “ only ” $ 225,000 through the program , not the $ @ @ @ @ @ @ @ per the Tribune .
Still , whatever savings there are can be used to lower premiums for everybody .
This is not a sustainable model for curbing health care costs .
There are concerns , like making sure the medications bought in Mexico are safe to use .
Gellad pointed out to me that one of the eligible drugs , Enbrel , can increase the risk of infection , so putting those patients on a plane to travel abroad is a risk to be wary of .
But this might be the best @ @ @ @ @ @ @ the US gets its house in order .
Throughout the Tribune ’ s story , consultants who advise employers on international medical tourism are quoted .
There aren ’ t many specifics , but there is clearly a whole cottage industry out there to help US patients find cheaper health care abroad .
It is a subtle , or not so subtle , indictment of our current health system .
This story appears in VoxCare , a newsletter from Vox on the latest twists and turns in America ’ s health care debate @ @ @ @ @ @ @ your inbox along with more health care stats and news .
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The insurance plan for Utah government employees decided two years ago it had to do something to curb prescription drug costs. Its solution? Pay for workers to travel to Canada or Mexico to buy the same medications they’d been getting in the United States, just at much lower prices.
Today, the Utah insurer is saving hundreds of thousands of dollars a year on drugs for a handful of patients who need expensive medicines and make the trip abroad to get them. It’s not as much as they were originally hoping for, but enough that paying airfare plus a $500 bonus is still a worthwhile deal for the state to make.
Medical tourism is hardly a new phenomenon. Eight percent of Americans said in a 2016 Kaiser Family Foundation poll that they had purchased prescription drugs outside of the United States. US government surveys have estimated between 150,000 and 320,000 Americans annually name health care as their reason for traveling abroad. Lower costs are usually their motivation.
But to see it so deliberately deployed by a major health insurer as a cost-saving measure is unusual.
”While we have long heard stories of individuals or informal groups of patients crossing the border to buy cheaper drugs, it has not typically been a sanctioned part of the American health insurance system,” Caroline Pearson, senior fellow at NORC at the University of Chicago, told me. “The Utah ... example is the only case that I am aware of.”
Employers and health insurance plans are always looking for ways to cut costs, of course. That’s why they create provider networks in the first place.
Some employers will also send patients outside of their geographic area to high-quality health centers in the interest of lowering costs — according to the Kaiser Family Foundation, 16 percent of employers have utilized these so-called “centers of excellence” and of those firms, about one in five will pay for travel and lodging expenses.
”This is just the natural extension, I suppose,” Walid Gellad, director of the Center for Pharmaceutical Policy and Prescribing at the University of Pittsburgh, said. “It is really something that they’re paying people to do this — not just paying for it, but paying people to do it.”
In brief, here is how the Utah government employee program works:
Patients taking one or more of 13 specialty drugs are eligible to participate
They can travel to Vancouver, Canada, or Tijuana, Mexico, to buy their prescriptions
They still make their usual copayments only
The state health insurance plan covers the cost of their airfare, transportation to and from the airport, and lodging if necessary
The state will also pay the patients $500 cash for making the trip
The health insurer works with a Mexico-based pharmacy to arrange the purchases and coordinate travel. From a great Salt Lake Tribune story on the program:
Flying from Salt Lake City to San Diego International Airport takes about two hours. At the base of the baggage claim escalator in San Diego, Javier Ojeda greets first-time patients with a name placard and a driver. “We never leave [patients’] side,” said Ojeda, general manager of Provide Rx, the pharmacy that works with Hospital Angeles to obtain and dispense specialty drugs for U.S. patients. Provide Rx also makes all travel arrangements, including a motor service staffed by bilingual drivers, who escort patients out of the airport and into a van for the short drive south.
Of course, the only reason it’s worth going through all this trouble for the patients and their insurer is drug prices in the United States are so much higher than anywhere else, including Mexico and Canada.
Here are the international price comparisons for the arthritis medication Humira, one of the 13 drugs that qualify for the Utah program, via a report from House Democrats:
So you can see why Utah’s insurance plan is eager to find cheaper prices for these drugs. But it turns out they really needed the $500 cash incentive to get people to take advantage of it.
According to the Tribune, the state insurance plan actually already had a longstanding policy to cover travel costs for patients who journeyed to Tijuana to have certain procedures done (to the same hospital where they now go to get prescriptions filled), but nobody took them up on it. It was the $500 in cash that seemed to make the difference.
It’s important to maintain some context here: Only 10 patients have actually made the trip to Mexico to buy cheaper drugs (though, remember, these are specialty drugs for expensive conditions — they are by definition pretty rare). So it’s not as if Utah is suddenly sending people in droves across the border.
The relatively low uptake means the state has saved “only” $225,000 through the program, not the $1 million they were hoping for, per the Tribune. Still, whatever savings there are can be used to lower premiums for everybody.
This is not a sustainable model for curbing health care costs. There are concerns, like making sure the medications bought in Mexico are safe to use. Gellad pointed out to me that one of the eligible drugs, Enbrel, can increase the risk of infection, so putting those patients on a plane to travel abroad is a risk to be wary of.
But this might be the best of a bunch of bad options until the US gets its house in order.
Throughout the Tribune’s story, consultants who advise employers on international medical tourism are quoted. There aren’t many specifics, but there is clearly a whole cottage industry out there to help US patients find cheaper health care abroad. It is a subtle, or not so subtle, indictment of our current health system.
This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.
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