"President Trump marshaled the full resources of our federal government from the outset. He directed us to forge a seamless partnership with governors across America in both political parties," said Vice President Mike Pence, during his speech at the Republican National Convention on Aug. 26.

This article was published on Thursday, August 27, 2020 in Kaiser Health News.

By Jon Greenberg, PolitiFact and Amy Sherman, PolitiFact and Victoria Knight

Vice President Mike Pence portrayed his boss, President Donald Trump, as a leader who has reached out across the aisle to help during the coronavirus pandemic.

“President Trump marshaled the full resources of the federal government and directed us to forge a seamless partnership with governors across America in both parties,” Pence said during his speech Wednesday night at the Republican National Convention.

Clearly, the federal government has provided supplies and funding to states led by both parties in response to the pandemic, and Pence himself has held regular conference calls with governors in both parties. But Pence was speaking about the actions of Trump, not his own.

Pence’s comments ignored Trump’s multiple feuds, frequently with Democratic governors, about state-federal responsibilities and the pandemic response.

A Trump campaign spokesperson sent us a list of dozens of teleconferences and meetings that Trump or Pence had with governors, including Democrats such as New York’s Andrew Cuomo and Michigan’s Gretchen Whitmer. In March, Trump sent a letter to governors thanking them for “stepping up to help America confront this unprecedented global pandemic.” The campaign pointed to actions by administration officials to brief governors about making available supplies, such as testing swabs, utilizing the National Guard, and reopening state economies.

Trump Argued With Governors Over COVID-19 Supplies, Tests

Early in the pandemic, Trump traded barbs with governors, especially over where the responsibility lay in securing medical supplies for the states.

After declaring a national emergency over the health crisis on March 13, Trump directed governors to order their own ventilators, respirators and supplies, saying the federal government is “not a shipping clerk.” Governors in both parties shot back that Trump’s stance, and the lack of coordination from Washington, left states bidding against one another and the federal government for access to critical equipment.

Cuomo said it was akin to competing on eBay with all the other states plus the Federal Emergency Management Agency.

Whitmer and Maryland Gov. Larry Hogan, a Republican and then chair of the National Governors Association, were among those pleading for better coordination from FEMA to ensure that supplies were distributed based on need.

“The lack of any centralized coordination is creating a counterproductive competition between states and the federal government to secure limited supplies, driving up prices and exacerbating existing shortages,” they wrote in a joint March 30 op-ed in The Washington Post.

A couple of days earlier, Trump said during a White House briefing that governors should be “appreciative” toward him and the federal government.

Speaking of Pence, Trump said: “He calls all the governors. I tell him — I mean, I’m a different type of person — I say, ‘Mike, don’t call the governor of Washington. You’re wasting your time with him. Don’t call the woman in Michigan.’” On Twitter, Trump said Whitmer was “way in over her head, she doesn’t have a clue.”

In April, Trump said that testing “is a local thing” and that states should turn to commercial labs for help. After he was blasted by governors from both parties, Trump said the federal government would step up efforts to get testing supplies.

Governors also called on Trump early on to enact the Defense Production Act, a law that gives the president authority to expedite the supply of materials for national defense, in order to ramp up production of personal protective equipment and COVID-19 testing supplies. While the president did eventually invoke the act to produce ventilators and medical equipment, he delayed efforts to do so and did it sparingly. Washington Gov. Jay Inslee and Arkansas Gov. Asa Hutchinson called for him to broaden its use.

Trump’s justification for slow-rolling the act was that he didn’t want the government to intervene in the private sector.

“You know, we’re a country not based on nationalizing our business,” Trump said at a coronavirus task force press briefing on March 22. “Call a person over in Venezuela, ask them how did nationalization of their businesses work out? Not too well.”

In April, Trump said that Georgia Gov. Brian Kemp, a Republican, had reopened Georgia “too soon.” In May, he criticized Pennsylvania Gov. Tom Wolf, a Democrat, for keeping parts of his state closed that Trump said were “barely affected.”

Trump said in mid-April that it was up to him — not the governors — to decide when to reopen states on lockdown.

Some Governors Bypassed the Federal Government to Work Together

Frustrated with the responses from the Trump administration, some governors teamed up with one another to get needed supplies.

In May, a coalition of governors from seven Northeastern states, including New York, Connecticut, New Jersey, Rhode Island, Pennsylvania and Delaware, joined together to buy personal protective equipment and ventilators and create a unified reopening strategy.

As late as July, some governors were calling on the feds for help and not getting what they needed. There were shortages of testing supplies, as well as personal protective gear. Washington state asked for 4.2 million N95 respirators. It received a bit under 500,000. It asked for about 300,000 gowns. It got about 160,000.

On Aug. 18, a bipartisan group of governors — five Democrats and five Republicans — announced they would be partnering with the Rockefeller Foundation to create a national testing strategy in the absence of federal action. The 10 states are Louisiana, Maryland, Massachusetts, Michigan, Ohio, North Carolina, Utah, Arkansas, Rhode Island and Virginia. Their goal is to buy and deploy 5 million COVID-19 antigen tests.

Feuds Between Trump Administration and States Continue

The Trump administration sought to pressure states to reopen schools for in-person instruction. In July, Trump threatened to cut off funding if schools didn’t reopen.

This summer, the Trump administration reduced the federal share of National Guard assistance to the states to help with pandemic response, despite pleas from governors in both parties. An Aug. 3 memo said that the federal government would no longer continue to pay for 100% of the tab for most states and that it would be reduced to 75% as of Aug. 21.

And when the CDC unveiled new testing guidelines that downplayed the need to test people who don’t show symptoms — about 40% of those infected — Cuomo and California Gov. Gavin Newsom said that they wouldn’t follow it. Asymptomatic people are thought to be significant spreaders of the virus. Both governors at times praised certain responses by the Trump administration to help their states respond to the pandemic.

Our Ruling

Pence said, “President Trump marshaled the full resources of our federal government from the outset. He directed us to forge a seamless partnership with governors across America in both political parties.”

Trump and top administration officials have communicated with governors of both parties for months in meetings, phone calls and written communication. But Pence’s comment ignores that Trump has feuded with governors over state-federal responsibilities, supplies and policies for shutting down or reopening. Trump also has suggested a lesser role for the federal government and said that the handling of COVID-19 should be left to the states.

We rate this claim Mostly False.

However, those executive orders are far from being implemented, and multiple experts told us it’s unlikely the measures would pass along drug-pricing discounts to a majority of Americans.

This article was first published on Wednesday, August 26, 2020 in Kaiser Health News.

By Victoria Knight

President Donald Trump has long considered lowering the high cost of prescription drugs to be one of his signature issues, and it is likely to be a talking point he relies on throughout the upcoming campaign.

During his afternoon speech Monday ― delivered on the first day of the Repubublican National Convention after delegates had unanimously renominated him to seek reelection ― he returned to this theme.

“Now, I’m really doing it,” he said, referring to a series of four executive orders he issued in July. These orders touched on a range of issues, including insulin prices and drug importation. He focused on two specifically.

“But the fact is that we signed a favored nations clause and a rebate clause, and your numbers are going to come down 60, 70%,” he said.

However, those executive orders are far from being implemented, and multiple experts told us it’s unlikely the measures would pass along drug-pricing discounts to a majority of Americans. And the text of one, the favored nation executive order, has not yet been made public ― making it hard to know how exactly the initiative would work.

“Details are a bit murky,” Matthew Fiedler, a health care fellow with the Brookings Institution, wrote in an email.

We checked in with the White House to find out more details about the favored nation order and when the text might be released. However, we did not get a response. Still, we decided to dig in.

What We Know

The favored nation executive order was supposed to match U.S. prices for a certain class of drugs with the lower amount paid in certain European countries, which negotiate drug prices. It reportedly would have applied only to drugs covered by Medicare Part B ― those that patients receive at their doctors’ offices, such as infused cancer drugs ― but not those purchased at the pharmacy counter. Drug companies criticized the executive order, and the Trump administration offered to consider an alternative plan if the firms offered it by Aug. 24. So far, the industry has not made a counter offer.

A spokesperson for PhRMA, the lobbying group that represents major drugmakers, said in a statement that “the most favored nation executive order is an irresponsible and unworkable policy that will give foreign politicians a say in how America provides access to treatments and cures for seniors and people struggling with devastating diseases.” The group did not confirm on the record whether an alternative drug-pricing plan had been discussed with the White House.

The Trump administration floated a similar idea in 2018, which met with swift criticism from some of its usual supporters, such as Americans for Tax Reform, a right-leaning advocacy group that opposes tax increases. The criticism was marked by TV ads warning that this approach to drug costs was a step toward socialism. We found that claim to be Mostly False. The Centers for Medicare & Medicaid Services estimated at that time the resulting savings from such a plan would be 30%, but it was never enacted.

Multiple experts questioned Trump’s claims about how much costs would come down as a result of the more recent proposal.

That’s in part because the full text of the executive order has not been published, and so classifying the president’s statement as true “requires a leap of faith,” said Benedic Ippolito, a resident scholar who studies health care costs at the American Enterprise Institute.

Ippolito allowed that because some drug prices in other countries are far below those in the U.S., a reduction of 60% or 70% could be plausible for an individual product. But, in order for that to happen, the policy would have to be implemented.

Seeing this 60% to 70% decrease “relies on the idea that this policy ever happens. And I think there is reason to be very skeptical there,” Ippolito wrote in an email.

Rachel Sachs, an associate professor of law at Washington University in St. Louis, who has analyzed the drug-pricing executive orders, agreed there’s no solid foundation to support those percentages.

“I don’t know about the 60 or 70%,” she said. “I don’t know what he’s talking about.”

Another executive order attempted to address the rebates paid to pharmacy benefit managers within Medicare by directing that these payments instead be used as discounts for beneficiaries within the Part D program, the plans that pay for prescription medications.

However, experts pointed out that those discounts usually go toward lowering insurance premiums for seniors. Without applying the discount there, premiums would likely go up. And, in order to keep premiums down, the federal government would need to spend more on subsidies.

Analyses from the Congressional Budget Office and other groups predicted that Trump’s rebate proposal would lower drug prices for some seniors, but would also increase federal spending and increase seniors’ premiums.

There is also a stipulation in the text of the order, which says the order cannot be implemented if it leads to increased government spending or higher premiums for beneficiaries. Thus, it’s unclear how such a proposal would be implemented.

“The executive order on the rebate is internally contradictory, which makes you wonder how they can do this,” said Sachs.

Why It Matters

Trump is likely to continue saying he has reduced drug prices, not only during the Republican National Convention but for the remainder of the 2020 campaign.

Trump likes to present proposals in the works as having been implemented, and we’ve fact-checked him twice before on similar drug-pricing statements.

In May 2019, he claimed he brought down drug prices for the first time in 51 years, which we found to be Mostly False. And in early August of that year, we fact-checked a claim about another of his drug-pricing executive orders that inflated his efforts to reduce insulin prices, which we also found to be Mostly False.

This time, Trump referenced two different drug-pricing executive orders. While it is true that he signed both of them (though the text of only one is publicly available), experts have expressed skepticism about whether these proposals will be implemented, as well as whether they would lower drug prices significantly for Americans.

And this isn’t the first time Trump has made this promise to the American people.

“He promised to lower drug prices as part of his campaign in 2016 and has done absolutely nothing of substance about drug prices at all while he’s been in office,” Aaron Kesselheim, a professor of medicine at Harvard, wrote in an email.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

As COVID-19 continues to spread, an increasing number of rural communities find themselves without their hospital or on the brink of losing already cash-strapped facilities.

This article was published on Wednesday, August 26, 2020 in Kaiser Health News.

By Sarah Jane Tribble Jerome Antone said he is one of the lucky ones.

After becoming ill with COVID-19, Antone was hospitalized only 65 miles away from his small Alabama town. He is the mayor of Georgiana — population 1,700.

"It hit our rural community so rabid," Antone said. The town's hospital closed last year. If hospitals in nearby communities don't have beds available, "you may have to go four or five hours away."

As COVID-19 continues to spread, an increasing number of rural communities find themselves without their hospital or on the brink of losing already cash-strapped facilities.

Eighteen rural hospitals closed last year and the first three months of 2020 were "really big months," said Mark Holmes, director of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill. Many of the losses are in Southern states like Florida and Texas. More than 170 rural hospitals have closed nationwide since 2005, according to data collected by the Sheps Center.

It's a dangerous scenario. "We know that a closure leads to higher mortality pretty quickly" among the populations served, said Holmes, who is also a professor at UNC Gillings School of Global Public Health. "That's pretty clear."

One 2019 study found that death rates in the surrounding communities increase nearly 6% after a rural hospital closes — and that's when there's not a pandemic.

Add to that what is known about the coronavirus: People who are obese or live with diabetes, hypertension, asthma and other underlying health issues are more susceptible to COVID-19. Rural areas tend to have higher rates of these conditions. And rural residents are more likely to be older, sicker and poorer than those in urban areas. All this leaves rural communities particularly vulnerable to the coronavirus.

Congress approved billions in federal relief funds for healthcare providers. Initially, federal officials based what a hospital would get on its Medicare payments, but by late April they heeded criticism and carved out funds for rural hospitals and COVID-19 hot spots. Rural hospitals leapt at the chance to shore up already-negative budgets and prepare for the pandemic.

The funds "helped rural hospitals with the immediate storm," said Dr. Don Williamson, president of the Alabama Hospital Association. Nearly 80% of Alabama's rural hospitals began the year with negative balance sheets and about eight days' worth of cash on hand.

Before the pandemic hit this year, hundreds of rural hospitals "were just trying to keep their doors open," said Maggie Elehwany, vice president of government affairs with the National Rural Health Association. Then, an estimated 70% of their income stopped as patients avoided the emergency room, doctor's appointments and elective surgeries.

"It was devastating," Elehwany said.

Paul Taylor, chief executive of a 25-bed critical access hospital and outpatient clinics in northwestern Arkansas, accepted millions in grants and loan money Congress approved this spring, largely through the CARES (Coronavirus Aid, Relief and Economic Security) Act.

"For us, this was survival money and we spent it already," Taylor said. With those funds, Ozarks Community Hospital increased surge capacity, expanding from 25 beds to 50 beds, adding negative pressure rooms and buying six ventilators. Taylor also ramped up COVID-19 testing at his hospital and clinics, located near some meat-processing plants.

Throughout June and July, Ozarks tested 1,000 patients a day and reported a 20% positive rate. The rate dropped to 16.9% in late July. But patients continue to avoid routine care.

Taylor said revenue is still constrained and he does not know how he will pay back $8 million that he borrowed from Medicare. The program allowed hospitals to borrow against future payments from the federal government, but stipulated that repayment would begin within 120 days.

For Taylor, this seems impossible. Medicare makes up 40% of Ozarks' income. And he has to pay the loan back before he gets any more payments from Medicare. He's hoping to refinance the hospital's mortgage.

"If I get no relief and they take the money … we won't still be open," Taylor said. Ozarks provides 625 jobs and serves an area with a population of about 75,000.

There are 1,300 small critical access hospitals like Ozarks in rural America and, of those, 859 took advantage of the Medicare loans, sending about $3.1 billion into the local communities. But many rural communities have not yet experienced a surge in coronavirus cases — national leaders fear it will come as part of a new phase.

"There are pockets of rural America who say, 'We haven't seen a single COVID patient yet and we do not believe it's real,'" Taylor said. "They will get hit sooner or later."

Across the country, the loss of patients and increased spending required to fight and prepare for the coronavirus was "like a knife cutting into a hospital's blood supply," said Ge Bai, associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore.

Bai said the way the federal government reimbursed small rural hospitals through federal programs like Medicare before the pandemic was faulty and inefficient. "They are too weak to survive," she said.

In rural Texas about two hours from Dallas, Titus Regional Medical Center chief executive Terry Scoggin cut staff and furloughed workers even as his rural hospital faced down the pandemic. Titus Regional lost about $4 million last fiscal year and broke even each of the three years before that.

Scoggin said he did not cut from his clinical staff, though. Titus is now facing its second surge of the virus in the community. "The last seven days, we've been testing 30% positive," he said, including the case of his father, who contracted it at a nursing home and survived.

"It's personal and this is real," Scoggin said. "You know the people who are infected. You know the people who are passing away."

Of his roughly 700 employees, 48 have tested positive for the virus and one has died. They are short on testing kits, medication and supplies.

"Right now the staff is strained," Scoggin said. "I've been blown away by their selflessness and unbelievable spirit. We're resilient, we're nimble, and we will make it. We don't have a choice."

Sarah Jane Tribble: sjtribble@kff.org, @SJTribble

Oxford signed an exclusive vaccine deal with AstraZeneca that gave the pharmaceutical giant sole rights and no guarantee of low prices.

This article was published on Tuesday, August 25, 2020 in Kaiser Health News.

By Jay Hancock

In a business driven by profit, vaccines have a problem. They're not very profitable — at least not without government subsidies. Pharma companies favor expensive medicines that must be taken repeatedly and generate revenue for years or decades. Vaccines are often given only once or twice. In many parts of the world, established vaccines cost a few dollars per dose or less.

Last year only four companies were making vaccines for the U.S. market, down from more than 20 in the 1970s. As recently as Feb. 11, Dr. Anthony Fauci, the government's top infectious disease expert, complained that no major drug company had committed to "step up" to make a coronavirus vaccine, calling the situation "very difficult and frustrating."

Oxford University surprised and pleased advocates of overhauling the vaccine business in April by promising to donate the rights to its promising coronavirus vaccine to any drugmaker.

The idea was to provide medicines preventing or treating COVID-19 at a low cost or free of charge, the British university said. That made sense to people seeking change. The coronavirus was raging. Many agreed that traditional vaccine development, characterized by long lead times, manufacturing monopolies and weak investment, was broken.

"We actually thought they were going to do that," James Love, director of Knowledge Ecology International, a nonprofit that works to expand access to medical technology, said of Oxford's pledge. "Why wouldn't people agree to let everyone have access to the best vaccines possible?"

A few weeks later, Oxford—urged on by the Bill & Melinda Gates Foundation—reversed course. It signed an exclusive vaccine deal with AstraZeneca that gave the pharmaceutical giant sole rights and no guarantee of low prices—with the less-publicized potential for Oxford to eventually make millions from the deal and win plenty of prestige.

Other companies working on coronavirus vaccines have followed the same line, collecting billions in government grants, hoarding patents, revealing as little as possible about their deals—and planning to charge up to $37 a dose for potentially hundreds of millions of shots.

Even as governments shower money on an industry that has not made vaccines a priority in the past, critics say, failure to alter the basic model means drug industry executives and their shareholders will get rich with no assurance that future vaccines will be inexpensively available to all.

"If there were ever an opportunity" to change the economics of vaccine development, "this would have been it," said Ameet Sarpatwari, an epidemiologist and lawyer at Harvard Medical School who studies drug-pricing regulation. Instead, "it is business as usual, where the manufacturers are getting exclusive rights and we are hoping on the basis of public sentiment that they will price their products responsibly."

In the United States and other developed nations, the solution to drug-company reluctance was to shower them with billions of dollars in public funds to persuade them to help. The Trump administration has announced deals worth more than $10 billion with seven companies to try to turn basic research—often funded by the government—into effective, widely distributed vaccines—but with no guarantee they would be widely affordable or available.

That approach has driven up stock prices in the past four months and enriched drug executives betting with somebody else's money.

AstraZeneca stock and options owned by CEO Pascal Soriot have increased by nearly $15 million in value since early April, according to calculations by KHN based on company disclosures. The stock hit an all-time high in July. The stock market value of Novavax, a biotech that never recorded a profit in more than two decades, soared tenfold to $10 billion after a nonprofit and the Trump administration agreed to give it $1.6 billion to make a vaccine.

Companies "say we have to charge high prices because we are taking a risk," said Mohga Kamal-Yanni, an independent consultant on global health based in the United Kingdom. "Actually, the public is taking the risk. The public is paying for the cost of research and development and probably the cost of manufacturing as well."

Moderna, another company working on a vaccine candidate, received nearly $1 billion from the U.S. government to pay essentially all costs to research the product and get it approved by regulators. It's using a vaccine designed in large part by the National Institutes of Health and academic scientists using federal grants.

If the vaccine works, the company gets an additional $1.5 billion to cover 100 million doses, a deal that U.S. Rep. Lloyd Doggett, a Texas Democrat, likened to giving taxpayers "the privilege of purchasing that same vaccine that we already paid for."

That deal comes to $15 a dose. Moderna told Wall Street analysts it might charge as much as $37 a dose for smaller-volume contracts.

"This is greedy, and the taxpayers who have funded all of this should have expected better negotiation on the part of the U.S. government," said Margaret Liu, a globally respected vaccine scientist who once worked for Merck and is now chairperson of the International Society for Vaccines.

The U.S. Health and Human Services Department "conducted extensive market research and price analysis" to ensure prices are fair, said a senior HHS official who asked for anonymity. "We are prohibited from disclosing price discussions and details."

Even if Moderna distributed a successful vaccine at a loss to make it widely available, it would reap enormous benefits because government support would have helped validate its technology for future products, Liu said. Moderna did not respond to requests for comment.

Nonprofits such as Oxfam and Doctors Without Borders have been pressuring drug companies to change for years. Exclusive patents and high prices that sometimes make lifesaving medicines unaffordable in rich countries often render them completely unavailable in the poor world, they argue.

One workaround has been enormous private and government subsidies, including from the U.K., the United States and the Gates Foundation, to promote developing-nation vaccines through the Geneva nonprofit Gavi, formerly known as the Global Alliance for Vaccines and Immunization.

The Gates Foundation helped launch another non-governmental organization, the Coalition for Epidemic Preparedness Innovations, in 2017. CEPI was created to fight something exactly like the coronavirus: potential infectious threats ignored or slighted by pharmaceutical companies.

CEPI's early principles of "equitable access" drew praise from reformers. The group asked for public data disclosure from drug-company grantees, "transparent" accounting to show true vaccine cost and the right to step in and take over a vaccine project if the developer failed to deliver.

The pharma industry immediately objected. Even though they were bankrolled by public money, drug companies were "concerned about the precedent that could be set if they allowed an outside entity, in this case CEPI, to set [the] price of a product unilaterally," CEPI reported in February. The nonprofit backed down, removing most references to prices in a new policy that Doctors Without Borders called "an alarming step backwards."

The original policy was intended to be "interim," and CEPI's "commitment to equitable access as a principle is the same," said spokesperson Rachel Grant.

Some thought the worst infectious disease crisis in a century, along with the enormous public investments, would change industry behavior.

Governments could have demanded transparency and low prices. They could have offered developers cash prizes for vaccines that would have incentivized science but let the public retain the marketing rights, said Love, of Knowledge Ecology International.

Agreement by researchers to publish the virus genome in January set the stage for global scientific cooperation, many believed.

"The full sequence was shared with the world without any strings attached," said Manuel Martin, a U.K.-based adviser to Doctors Without Borders on access to medical innovations.

The World Health Organization set up a "COVID-19 Technology Access Pool" to promote the sharing of patents and other knowledge. Oxford stepped forward and said it would offer nonexclusive, royalty-free licenses for its vaccine, meaning multiple parties could sell it at a low cost.

"I personally don't believe that in a time of pandemic there should be exclusive licenses," Adrian Hill, director of Oxford's Jenner Institute, which is developing the vaccine, told The New York Times in April.

Instead, little has changed. No vaccine maker has offered open licenses, although NIH is sharing key technology it developed with multiple vaccine companies. Governments are signing lucrative deals with manufacturers to ensure vaccines for their own populations. WHO has made no announcements about contributions to its COVID-19 shared technology pool since it launched in May, patent experts said. WHO officials did not respond to a reporter's queries.

After Oxford announced the exclusive AstraZeneca deal, the company said it would sell vaccines at no profit—but only during the pandemic. Johnson & Johnson's pledge to earn no vaccine profit is similarly limited.

With financial information kept confidential, no one will be able to confirm whether the vaccines are truly being sold at cost. And if vaccine immunity is only temporary and endemic coronavirus strains require regular shots for years, the companies will make plenty of money down the road, critics say.

Under its deal with AstraZeneca, Oxford will receive no royalties during the pandemic but could make millions after it ends through a web of patents including those held by Vaccitech, a for-profit spinoff. Vaccitech's ownership includes a 50% stake held directly or indirectly by Oxford and 5.25% each owned by Hill and Jenner's other top vaccine scientist, Sarah Gilbert, U.K. regulatory filings show.

The potential for vaccine profits at Vaccitech was first reported by The Wall Street Journal.

Pharma company officials say that only decades of industry research could have made it even possible to produce a coronavirus vaccine at the present speed.

"The federal government cannot research, develop and manufacture vaccines and other new treatments on its own," said Andrew Powaleny, a spokesperson for the Pharmaceutical Research and Manufacturers of America, a lobbying group. Large and early government investment "is a well-accepted approach to addressing public health crises," he said.

Many argue that a health crisis is not the time to worry about overpaying for vaccines or backing some candidates that won't deliver. Getting a good vaccine as quickly as possible requires spreading bets, they say.

"Spending some extra billions on vaccines is the right choice when human life is at stake and trillions in economic loss is at risk," said Edward Scolnick, a top scientist at the Broad Institute and former head of research for Merck. He owns no stock in Merck or other pharma companies, he said.

Oxford backed off from its open-license pledge after the Gates Foundation urged it to find a big-company partner to get its vaccine to market.

"We went to Oxford and said, Hey, you're doing brilliant work," Bill Gates told reporters on June 3, a transcript shows. "But … you really need to team up." The comments were first reported by Bloomberg.

AstraZeneca, one of the U.K.'s two major pharma companies, may have demanded an exclusive license in return for doing a deal, said Ken Shadlen, a professor at the London School of Economics and an authority on pharma patents—a theory supported by comments from CEO Soriot.

"I think IP [intellectual property, or exclusive patents] is a fundamental part of our industry and if you don't protect IP, then essentially there is no incentive for anybody to innovate," Soriot told the newspaper The Telegraph in May.

Some see the Gates Foundation, a heavy funder of Gavi, CEPI and many other vaccine projects, as supporting traditional patent rights for pharma companies.

"[Bill] Gates has staked out this outsized role in the vaccine world," Love said. "He has an ideological belief that the intellectual property system is a wonderful mechanism that is necessary for innovation and prosperity."

The Gates Foundation requires all its grantees to commit to making products "widely available at an affordable price," a spokesperson said.

Oxford officials, including Hill and Gilbert, did not respond to requests for comment. AstraZeneca, for its part, would set a "reasonable" post-pandemic price and is "committed to ensure equitable access, globally" in the meantime, a spokesperson said. The company has signed deals with CEPI, Gavi and the Serum Institute of India to bring more than a billion doses to low- and middle-income countries, he said.

If nothing else, governments and vaccine makers should be open about their relationships, including making contracts public, said Duncan Matthews, a patent law professor at the Queen Mary University of London.

"We simply don't know what's in these deals," he said. "The biopharma industry is applying old rules of commercial confidentiality in a situation that is unprecedented."

Jay Hancock: jhancock@kff.org, @JayHancock1