COVID-19 FAQs to help you answer client questions

PHIL KAUFFMAN: Good afternoon, everyone. We really appreciate you joining this morning or afternoon, wherever you might be in the country. I'm Philip Kaufmann, chief operating officer for United Healthcare as an employer and individual business. We’ve been doing these COVID seminars for more than a year now and, to be honest, it’s been about four months since our last one. We were hoping that it would be a lot longer before we would all gather again, if not ever, but that’s certainly not where we’re at as a country. We’ve started to hear a ton of questions from all of you around vaccines, their efficacy, different policy provisions to be able to react to, in the environment, obviously, the delta variant, and so we’ve reassembled our team here today to be able to bring you our latest and greatest thinking on those topics. We’ve got Craig Kurtzweil, our VP for center advanced analytics.

We’ve got Dr. Rhonda Randall, our chief medical officer here with us, as well as myself, and our goal today is to guide you through the data and insights that we have at this point, understanding that this is a very fluid and changing environment, as well as to give you some policy updates. This call is being recorded. We will send out a replay through our standard publications. For those of you who might be UMR customers on the phone, your UMR representative can send you the update and then, of course, as usual, our United Healthcare sales and account management teams, who do a wonderful job, are there to support you every step of the way.

A reminder that today we’ve got a lot of different constituencies on the phone, whether you be, you know, a smaller group customer, a larger group, a broker, an employer customer, and, depending on what you’ve bought or purchased from United Healthcare, there could be some nuances in what we cover today. We try to cover that as much as we can, but just keep that in mind, and we’d always suggest reaching out to your United Healthcare rep for additional details. There will be facilitated Q&A time at the end of the call, would encourage you to enter your questions into the chat. We take those chat questions. We try to grab the biggest themes and we cover those at the end of the call. Regardless of whether or not we get to your question today, just want to emphasize that that feedback is really important to us.

We try to make sure all of the questions get into the FAQs that are posted on our respective websites. No call would be complete without our legal disclaimer, which you see here in front of you. I'm not going to read it word-for-word, but just as a reminder, this is intended to provide general information, and we suggest you constitute or check in with your respective legal and medical rep. So, before I pass it over to Craig, just one other comment here. First is that, as usual, I want to thank you, all of you customers, brokers, for putting your faith in United Healthcare. It’s hugely important to us. We take that vote of confidence extremely seriously. I also have two other specific things I want to call today.

The first is I want to thank the providers who are here on the phone today, or those serving providers. They’ve done such a tremendous job helping the United States as a country, as a society to move through this and they have been under an enormous amount of pressure for very extended periods of time. I mean, now north of a year, and so just our shoutout to all of you who might be providers in any way, shape, or form, or are working on the frontlines of this in terms of emergency delivery, we hugely appreciate that.

PHIL KAUFMANN: The other thing, leading into Craig and what he’s going to talk about in data, I just want to really emphasize that you're going to see a lot of data today, some of it’s going to be encouraging, some of it’s going to be discouraging, but we don’t want to lose sight of, and we never do lose sight of the fact that each one of these data points is an individual. This is something that’s impacted families very deeply. We’ve lost loved ones, long COVID, everything else like that. So, we take the individual aspect of this seriously, but we don’t lose light of that in the broad data and patterns that we’re going to tell you but, on the flipside, it’s important for you to see all the data at a macro level. So, I think with that, Craig, let me turn it over to you, and why don’t you get us started.

CRAIG KURTZWEIL: Yeah, thank you, Phil. Couldn’t agree more, you know, we’re, we have all been impacted, and so, yeah, we’ll throw a lot of numbers on the screen, but there’s a person behind each one of those numbers. So, just keep that in mind. As we jump in, we thought it would be good to give a little bit of context operation kind of where we are with the pandemic. We’ll talk through some of the impact of vaccinations and spread of the delta variant as we go through some of the data pieces for this morning. Let’s jump in, into the next view, and we can start to take a look to see what the read of the disease has looked like. I trimmed this map up to look at just the spread of disease since September, and you can click play if you like, ad we’ll start to see that the animation will start to take hold and we can see the spread of the disease in the fall. In the fall months, you can see, as we talked about last fall with the Dakotas being the first, that started to spread over to Michigan, then the whole Midwest started to light up as we got into the post-Thanksgiving period, and then the entire country was lit up as you get into the end of December and into January and, as you start to see, that started to wane down. Vaccines started to roll out and the spread of the disease started to really become much lower than we had ever seen before but, as we started to move into the March and April and now May time periods, you’ll start to see the spread come back and, specifically, starting in Missouri and working its way into Arkansas, Louisiana, and then across the south is where we are today with the spread of the disease. We’ll get into kind of where we are as of this moment but, as you see that spread, you’ll start to see quickly that the game has changed as far as where the disease is today. So, if you don’t mind, let’s jump into the next slide, and we can see in this view, this is where we are as of this morning. So, looking at the current prevalent strain, the most recent seven days, [INDISCERNIBLE 00:02:33]. The first highlighted, Missouri has changed. Missouri was a hotspot three or four weeks ago. That has started to change. You can see that’s starting to turn a little bit lighter shades of orange and yellow. Arkansas, the same thing, parts of Texas, the same sort of thing, that those initial peaks of this wave have started to come down a bit, at least, not that they're dropping, but they're at least starting to level out in some of those states. That’s some of the good news in those states, that it looks like we’re over the hump, so to speak, at least so far. What's the negative news is that the spread is started to continue in the south, in particular. Louisiana has started to level out, but it’s still high, and Florida, Georgia, Alabama, Mississippi, those are the new hotspots as far as the growth and the prevalence of the disease in the most recent seven days. In the next view, I will look to see how does this overlay with vaccinations, and we’re going to talk about vaccines in a lot of different ways, but one simple way to kind of look to see the impact that the vaccines have had is just a simple visualization of the U.S. map, looking at, on the left-hand side, the rate of fully-vaccinated individuals across the country, with the lighter shades being the less vaccinated and the darker shades being the most vaccinated, and that overlay there on the right-hand side with the view of the current prevalence of the disease over the last couple weeks and, basically a mirror image of each other, with those states that are struggling with vaccination rates, also struggling with this initial wave, specifically, of the delta variant. So, definitely having an impact. There’s definitely some connections between those two data points, and we’ll go into more of that a little bit later. We can jump to the next view and look to see. We’ll go back to the slide that [INDISCERNIBLE 00:04:16] as we've been going through the pandemic with a bit of an update. So, this is looking at the cases. On the bar charts, the death and positivity rate is the black line and the orange line, and I would just focus your attention on the far right, as things were looking really good in the early summer months. You can see, over the last three or four weeks, we've started top ramp up significantly, and we’re back to levels that we hadn’t seen since early 2021. What I would also say, we’re going to talk about this in more detail as well as, though we have seen cases started to rise, and rise significantly, over these past four weeks, just know that that black line hasn’t changed much. The mortality rate, there’s still a lot of people suffering and passing away from COVID, but the rate of mortality is, so far, not what we had seen during past waves, at least so far. Next slide. Here, we start to look to see people wanting to start to use a crystal ball to see where are we going, what are the next few weeks, few months going to look like, and the best way that I do that is I leverage data that we’ve seen in other parts of the world and other countries and one of the best barometers for that is looking at the UK, and obviously, the U.S. is very different from the UK as far as the breadth of the geography and the population, but as you see here, there’s a lot of numbers and lines on here, but you can se the dotted lines are what we’re seeing from a case rate and a mortality rate associated in the UK, compared to what we’re experiencing here in the United States and you can see, in the winter months, as we went through that large wave, our curves are not identical, but they're very similar to what the UK experienced and the downturn was very similar as far as timing as well. The UK typically has a sharper peak and a sharper decline, versus our, there’s a little bit less than that. On the right-hand side, you can see where are we today and what we’re [INDISCERNIBLE 00:06:10] looks like we kind of are. You can see that, the red lines, the dotted red line versus some of them, it looks like we are a few weeks behind. This wave started a few weeks earlier in the UK, and now you can see the UK has started to come down pretty dramatically since their peak. We’re a few weeks behind. If we follow the /same trajectory, we might follow the same decline as well. The other piece that I would see is you look at the mortality rates, the black lines, the black solid and black dotted lines, both the UK and the U.S. has not yet seen a dramatic increase relative to the increase that we’ve seen in cases. All right, next slide. So, now we’ll start to look to see what's the status of the various states, and we’ll start with kind of known prevalence. This is the people that have been diagnosed through a test or diagnosis with COVID, and overall, across the United States, about 10-%< 10.5% of the population has been diagnosed with COVID. A wide variety of different states, but most of the states are in that 9-15% range. No matter what really occurred, there’s different strategies and prevention measures. Most states got to that 1-12% range. There are some exceptions on the far right with Hawaii and Vermont, but smaller states with, obviously, very different geographies to manage, but in general, prevalence did not vary significantly across all the different states with all the different strategies that occurred. On the next page, we start to jump into the vaccine variants, and here you’ll see, as we saw on the map, there’s a distinct variety of vaccination levels that are out there. The orange bars in here are looking at the folks that are partially vaccinated, and the green are those that are fully vaccinated, and so you can start to see that there are some states that are in, approaching 80% and there are other states that are well below 50%. In total, we’re at just about 58% across the population has at least a partially vaccinated [INDISCERNIBLE 00:08:10] instead of [INDISCERNIBLE 00:08:13] weeks [INDISCERNIBLE 00:08:14] get there second, as a country [INDISCERNIBLE 00:08:17] be approaching 60% in two to three weeks from where are [INDISCERNIBLE 00:08:21]. On the next page, we add in folks that have had COVID, the known COVID patients, to that map and, on the next page, if you don’t mind, we can start to see that the overall, this now gets us up to about 60% of the population, either having COVID or being fully or partially vaccinated and, obviously, there’s a little bit of overlap in here, right, there are some people that have been vaccinated and have had COVID as well, and we’ll get into some of their stats also, but in total, we know that a good portion of the population has some sort of protection, not complete protection, as we’ll talk about, but some sort of protection, especially around severe illness and death with prior disease or vaccination status but, as you look over to the far right hand side of this chart, you can see the states that are troubling right now from a COVID prevalence rise in the south. Those are the states, on the far right of this chart, that are low when it comes to protection status. All right, in the next view, we’ll start to dive in to see what's changed about this wave, what's different and new about this latest and greatest wave. You can see, in this view, I'm looking at a raw number of cases and these lines are all looking at the cases per 100,000. So, they're a per-capita rate, and what you start to see is that, obviously, all of the age groups have started to ramp up, and in some cases, significantly, but in particular, at the top of this chart on the far right, you can see the younger population. It’s that 18-29 and the 30-39 population, that is increasing the most rapidly, and accounting for, by far, the most amount of cases that are out there. the good news side of that is, if you look at the elderly population, the 65+, the 75+, they're on the bottom of that chart. Ah, that has to do with [INDISCERNIBLE 00:10:12] patient that have [INDISCERNIBLE 00:10:13] person [INDISCERNIBLE 00:10:15]. So, [INDISCERNIBLE 00:10:16] disease in that population [INDISCERNIBLE 00:10:16] as large, and that’s going to come into play when we look at the next couple of slides. On the next slide, we start to focus on mortality, and we have started to see as that’s, the dark purple line. As we started to see vaccination rates uptick dramatically, in that elderly 65+, 75+ population, mortality rates started to decline and decline dramatically. The other lines, if you look at the younger populations, the under-40 population, those lines remain fairly steady. They’ve come down a little bit, but the overall rate of death and the change in the rate of death during this wave has really not changed. It remains very low. I'm not saying, that doesn’t mean that it’s not changing or increasing for some of those populations, but, as you look at it from a 30,000-foot view, the overall rates have not changed dramatically at this point. So, what are we seeing in our data? As we jump forward one more slide, we can start to look at our admissions and start to see, not looking at mortality, but just are they going to the hospital and having a more severe burden of illness and, overall, you can see, there’s lots of different waves on here, but on the far right, we are seeing an increase in people being admitted for COVID. That is evident within this data. The other piece that we've started to see is, though small, those younger age groups in the bottom right there are starting to increase a bit. It’s very low admission rates within that population, but starting to see the first signs of some of those folks now seeing increases in rates of admission, and that potentially could lead to some increases in rates of mortality as well. So, what type of admissions are we seeing? Are we seeing admissions associated with those that are vaccinated for COVID-19? This is an ever-changing science and there’s lots of studies and math that are out there, but I’ll speak to what we’re seeing in our commercial book of business. Over [INDISCERNIBLE 00:12:13], through July, we’re seeing that 99% of the people that are admitted for COVID are the unvaccinated population, and by unvaccinated, I'm looking to sein our claims data, can we nota that, and find that that member has been vaccinated. There are some people that are vaccinated that a claim doesn’t come through, and that’s not included in my math, but 99% of the people that have been admitted do not show a vaccination status in the data that I have access to. That has changed [INDISCERNIBLE 00:12:45] the dark blue [INDISCERNIBLE 00:12:52] it is [INDISCERNIBLE 00:12:52] see the effectiveness start to wane a little bit and the percent of people that are unvaccinated, as far as emissions go, is starting to drop a bit, but it’s still, even dropping, it’s still in the upper 90’s as far as what we’re seeing in our data at this time, and I don't know, Dr. Randall, did you want to add a few comments around what we’re seeing specific to this view?

DR. RHONDA RANDALL: Yes. Thanks, Craig, for sharing all that data. I think there’s, if there’s one slide that you remember that Craig showed you today, I think this is it. This is consistent with external data that we’re seeing as well and all of our market chief medical officers who are speaking to their hospital CMO colleagues across the country, what we are hearing is this is overwhelmingly a serious illness of the unvaccinated. So, you know, to Craig’s point, there may be a couple percentage points here for vaccines that we never got a claim for, but there is a direct correlation between serious illness, hospitalization, and death, and whether or not someone got the vaccine. I think that’s the most important information that you're going to hear today. Thanks, Craig.

CRAIG KURTZWEIL: And, as we start to, double click ahead a little it, the next slide we start to talk in more and more detail about the vaccine and the effectiveness and so, again, this is what we’re seeing just in our claims data, but as we look at those people that are fully vaccinated and start to see what percent of that population has a subsequent COVID-19 diagnosis, the way to read this chart, by the way, is in the January bar are for the folks that were fully vaccinated in January. Since then, what percent of that population has had a subsequent COVID-19 diagnosis, and you can see in January, that was about .3%. As you go into April, when people are just recently vaccinated, it’s well under, basically .05% within that population. So, in total, of all the people that we know of that have been vaccinated, just 0.09% of that population has had a subsequent COVID-19 case but, as you can see in the bar chart, those that are vaccinated earlier, those that were vaccinated in January and in February, that number’s a bit higher as time goes on and you have the vaccination for a longer period of time, we do start to see the total coming down a bit, but we’re still talking about .3, .5, you know, really, really low numbers of vaccinated people having subsequent cases.

DR. RHONDA RANDALL: And, Craig, I’ll add in here too as well, this is the second time we’re receiving a claim with the diagnosis of COVID. So, it’s not necessarily that it’s all reinfection. It’s very likely that a significant amount of this are what was formerly known as long haulers, that we’re referring to today as post-acute sequelae of COVID, or long COVID, I'm going to talk about that later. So, if this is the second time we’re receiving a diagnosis, it could be that that individual never recovered. It could be that they were reinfected, or it could be that they are one of those formerly known as long-haulers, now long COVID.

CRAIG KURTZWEIL: Oh, that’s a good point and, to add on to that a little bit, that some of the folks that have been fully vaccinated and [INDISCERNIBLE 00:16:13] to do [INDISCERNIBLE 00:16:14] so [INDISCERNIBLE 00:16:19] there might not have been any symptoms [INDISCERNIBLE 00:16:23] symptoms and [INDISCERNIBLE 00:16:23] it’s very possible that they did contract COVID but, due to the fact that they didn’t have any symptoms and there’s not a lot of testing, we might not be aware of that either but, again, less symptoms and less severe cases as well and then, finally, another question that we get a lot is what about those folks that had had COVID in the past and what sort of impact does that have in this whole conversation. So, on the next slide, we did a little bit of math to look to see what's happening within that population. So, in total, as we looked at the people that have had COVID in the past, what percent of them had a second claim associated with COVID, and roughly about 2% of the population, and this is, obviously, over 18-20 months, 2% of the population has had a second infection of COVID. Of that population, if you look at the people that have not only had COVID in the past, but also have been fully vaccinated, only 0.07% of that population has contracted COVID again, based on what we’re seeing in the claims data. So, the vaccination having an impact and the combination of prior COVID, and the vaccine appears to even have had a broader impact on that population when it comes to protection. Well, that’s a lot of data. We want to meet, there’s been a lot of questions around what we’re seeing around the pandemic and where we are today, but we wanted to make sure we answered as many of those questions as we can, and we’ll cover some more in the Q&A but, with that, I’ll pass the ball on to talk through some of the more clinical issues with Dr. Randall.

PHIL KAUFMANN: Great, thanks, Craig, and thank you, Dr. Randall, and usually, we would sometimes, you know, save these to the end, but I think, given the relevance, we’re going to just hit these right up front. Dr. Randall, a lot in the news about side effects and, really, that being one of the key reasons that individuals do not want to take the vaccines or are worried about risk. Can you talk about that in general and what you and your team are seeing?

DR. RHONDA RANDALL: Sure. So, I think, as far as side effects of the vaccine are concerned, you know, depending on what those side effects are, allergic reaction, a common side effect of any vaccine, Guillian-Barré can be a side effect of vaccines. We’ve seen a rare condition for individuals who’ve had clotting disorder, predominantly in women ages 18-49, but those are incredibly rare, and generally, you're seeing these in the 1 to 1 in a 100,000, 1 to one in 500,000, one to one in a million, but what's important and what shouldn’t be lost is the rates of these side effects is much higher with the disease itself. So, we all know that COVID can, and any virus can be associated with Guillian-Barré. We know the risks of severe illness requiring hospitalization and death. The clotting disorders have also been well-documented with infection. So, your chances of getting one of those side effects are lower with the vaccine, by a substantial factor, than it is with getting the infection itself.

PHIL KAUFMANN: That’s really helpful. Let’s talk about boosters for a second. You and I have had a dialogue on these several times. I think, organizationally, what we would tell you is we fully expect a situation to evolve next year where at least the most vulnerable portions of the population, if not all the population, may require a booster, but could you say a little bit about, you know, what we’re hearing and seeing right now?

DR. RHONDA RANDALL: Sure, and I'm going to share a little bit of data about what we’re seeing in the delta variant here in just a moment but, as far as a booster’s concerned, breaking news today, if you haven’t heard, the FDA is expected to make a decision under the emergency use authorization as to whether or not a third shot will be available for those who are immunocompromised, and that may happen later this year. You know, so think about individuals who have diseases that impact their immune system. One of the other populations that I haven’t heard talk of, but I will be paying very close attention to as a geriatrician, is the nursing home population. They are, by default, individuals who don’t have a strong immune system. So, those are some populations that we’ll be paying attention to, would likely be the first ones to get a third vaccine or a booster shot, if that’s authorized. As of now, no vaccine is authorized for the booster shot. So, I would discourage, you know, you do hear these anecdotal stories about people who are falsifying the information to go and get a third shot. We don’t want to do that.

PHIL KAUFMANN: I’ll just keep going with this one, Dr. Randall, and you know, you’ve to me before, there's kind of a timeframe in which we might expect vaccines to be approved for kids 12 and under. Could you say a little bit more about that?

DR. RHONDA RANDALL: Sure, there’s actually some really robust trials. So, all three vaccine manufacturers for the vaccines that are emergency use-authorized in the United States: Pfizer, Moderna, and Johnson & Johnson-Jansen, they're all undergoing clinical trials in children today. Moderna and Pfizer, in ages five to eleven, where I'm expecting to hear Pfizer’s results by even the end of next month and the anticipation is that Moderna’s would be the next to follow, later in the fall. J&J’s is phase two trials for the age group, 12-17, and then following that next group down, there are two other cohorts. The next cohort is ages 2-5, and then the third and final cohort is ages six months to two years old. So, we’ll be watching for those. So, I expect that next group of children in the ages of 5-11, that we will have decisions, perhaps by the end of this calendar year, and then beyond that, early in 2022.

PHIL KAUFMANN: Great. You know, long-haulers, we’ve heard that quite a bit. There's a different clinical term that we use for that now. I’ll let you cover that, but if you could talk a little bit what we’re seeing and, you know, the type of work we’re doing to better understand that, as well as help to better manage these individuals through those symptoms.

DR. RHONDA RANDALL: Sure, this is a really important emerging area of research. Many viral illnesses, particularly respiratory viruses can have things that you see afterwards, right, general decondition, some inflammatory disease of the lung that, you know, can often be resolved with several weeks or months of using inhalers and inhaled steroids, for example, but with COVID, in particular, we’re seeing as many as 50 different reported symptoms, that’s now referred to as PASC, or post-acute sequelae, that’s the medical term for long effects, of COVID. The lay term you may be hearing more often now is long COVID, and so we are looking at our claims data, partnering with researchers, partnering with institutions that are starting to really set up best practices for how to identify and support, and we’re hearing from individuals who are suffering with long COVID that, in their communities, they may have difficulty finding someone who believes them. They may be having difficulty finding somebody who has experience treating this, and so those specialized centers are ones that we are working to identify, and then mining through our claims, who’s likely to need additional support, and who may need additional care coordination and those types of referrals. Not everyone who has the post-acute sequelae of COVID has something so serious that it would impact their daily lives or their work, but some of them do. In the range, in the literature, between 5% and 25%, we’re estimating it right around 15% of individuals who have recovered from COVID may have some persistent symptom. Most of them are mild, but some of them can be quite severe.

PHIL KAUFMANN: As we’ve gone through the course of this, we’ve seen really significant improvements in our physicians’ and clinicians’ ability to treat COVID. Could you talk a little bit about that, and it’s been four months since we’ve gotten together and, even since then, there’s been additional movement on really understanding when someone does have COVID, you know, what you should do, when you should be treated, how you should be treated?

DR. RHONDA RANDALL: Sure, and there are very good clinical guidelines now for the treatment of COVID, everywhere from post-exposure prophylaxis to hospitalized patients and those who are seriously ill. There are 11 medications right now that have emergency use authorization for the treatment of COVID at some different point in time. There’s over 600 additional clinical trials going on with medications right now. There is one drug that has been FDA-approved recently for the treatment of COVID, that’s Remdesivir. It goes under the brand name VEKLURY. That is an antiviral. It is only approved for treatment of hospitalized patients. Everyone’s probably also well aware of, quite some time ago, dexamethasone, a steroid that’s been around for a very long time, also shown to decrease mortality in hospitalized COVID patients who require oxygen, and then with the monoclonal antibodies, some of them approved in the outpatient setting, for individuals who are not hospitalized but are at very high risk because of their chronic conditions. Other are approved for those who are hospitalized. So, as far as the t4reatment protocols are concerned, I think, you know, one of the reasons that we’re seeing that death rate come down that Craig showed you, that mortality rate getting lower, testing, testing, testing, testing. We have the ability to do all of the appropriate surveillance testing, contact testing, and testing the symptomatic very quickly, getting an answer, and getting those individuals who are at high risk to treatment quicker, but I will say, with this delta variant, one of the things that we’ve been seeing is that, with the additional rapid spread, you're also seeing rapid progression of symptoms. So, individuals who are getting seriously ill are getting seriously ill quicker. It’s not taking as many days to go from infection to the point where you're showing up in the emergency room.

PHIL KAUFMANN: That’s really helpful. I'm going to go back to something that Craig had presented, and you and I have had a number of conversations on, and I'm going to talk about kids, and then I'm going to pivot that into nursing and pregnant mothers, where we’re getting a lot of questions online on this and, you know, when you think about kids, first of all, a lot of times, you’ll see in these studies, you know, the kids are 0-18, and it’s a pretty wide band and, you know, really, when you think about that, there’s, I kind of break it into there's kind of years 0-10, 0-12, and your 112-18, and, you know, you're 0-12 is really more like a kid and your 12-18, their bodies, physiologically, are going to function much closer to adults and just want to emphasize that, you know, whether the COVID outcomes for, you know, 0-12 continue to be, even with the delta variant, really, really good. They're less likely to get it. they're less likely to show symptoms. They're extremely unusual that they would be hospitalized, and so I know, as everyone thinks about back to school, that that’s on their minds, and so I think that’s important, not to say we aren’t monitoring this very closely week-to-week, and a number of places are and, could that change, absolutely, but, you know, so far, quote unquote, so good, but let’s pivot that into pregnant and nursing mothers and, you know, there’s a lot of questions on, you know, are the vaccines safe in that situation and, obviously, you, just in advance, you know, Rhonda and I always say consult your own physician. You know, every situation’s different, right, that’s important, but at a high level, Dr. Randall, anything you’d like to add there?

DR. RHONDA RANDALL: Sure, I think all, with children in particular, you're right. the data bears out that, on a population level, the older your child is, the closer to age 18, the older someone gets, the higher the risk is that they would have a serious illness were they to contract COVID. The younger your child is, the less likely that is true. So, we’re seeing that younger group have less hospitalizations, lower mortality rates but, you know, to the point when you opened up the call, when one of those cases happened, particularly when it’s a child who didn’t have a chronic disease, and this was completely unexpected, it is avoidable, it’s heartbreaking, and it makes the news. So, until vaccines are approved below the age of 12, what are some things parents can do to help protect their kids? I think the number one thing is get herd immunity in your own household. So, you get vaccinated as a parent, that most of the transmission that happened in children did not happen last year on school campuses. It happened at the home, with close household contacts. So, because, in schools, they're sitting at a predictable desk, they're social distanced, etc., etc. In many cases, they're masking. So, but at home is where most of that transmission from contact tracing occurred. So, if the rest of the family who is eligible to get a vaccine gets vaccinated, you are doing something good to protect your child and then, as far as pregnant women and nursing moms are concerned, I think the good advice is always to be proactive. So, if you're considering getting pregnant and if you're planning your family, it’s important to get vaccinated in advance. That’s the safest time, and more and more emerging data is coming out, showing that the vaccines are safe in pregnant and lactating mothers, but every individual is different, and I’d very much recommend that anyone who’s pregnant has that conversation with their OBGYN.

PHIL KAUFMANN: That’s great, Dr. Randall, just, as usual, really terrific advice and guidance for our listeners today.

PHIL KAUFFMAN: I'm going to pivot into our public policy section and my hope is that we’ll save some time, because I know there’s a ton of questions coming in on the chat, and please continue to send them, and we’d hoped to return to Dr. Randall at the end if we’ve got a little bit more time. I do want to make sure I don’t ignore everything that’s going on in the policy sphere, and so I'm going to pivot into that and talk a little bit about different things that you are facing as a consultant or as an employer and our latest and greatest view on those. So, the public health emergency has been extended to October 17^th.

They typically extend it in 90-day increments. As you think about these extensions, obviously, no one has a full crystal ball, but what I would tell you is I fully expect the public health emergency to be extended into at least the fiurst quarter of next year, if not the first half. So, I don’t see this going away. To some of Craig’s data earlier and, you know, again, we try to stay away from making predictions, but we do expect, given the vaccination levels in the United States, these little, mini waves to continue to break out in the month ahead, you know, depending on different geographies and situations, and so we do think the public health emergency will continue to be extended.

Two key implications of that are, for you, as employers is, number one, testing and testing-related services need to continue to be provided at zero cost share. Number two, the government continues to pay for the actual vaccines themselves. So, either United Healthcare or you, if you're self-funded, you will pay for the administration of the vaccine, but the vaccines themselves will be paid for by the federal government. Whether that changes in the near future, we don’t know, but at least under the emergency health period, that continues to be our expectation. Testing policy is an important one to mention.

As I said before, $0 cost chare for testing, 0$ cost share for vaccines. This is a really important message that we continue to drive out. We don’t want there to be any barriers in front of that. we did, though, want to call out, that some employers have said, or you’ve seen perhaps in the news that, hey, either you need to get the vaccine or we’re going to test you, you know, once a week or once every other week or twice a week. I’d just like to point out that that type of testing would typically not be covered by United Healthcare or the health plan. That’s what we call surveillance testing. It really doesn’t have anything to do with your clinical condition. It has to do with your condition of working.

So, in those situations, those would be, you know, self-pay. You, as an employer, could choose to pay it, or your employee would have to bear the burden, but that isn’t something, typically, that your insurance company would pay for. Mandates continue to be, and local regulations continue to be incredibly dynamic. I will show you a couple of examples of this later on, and so, while, you know, some of the things that, you know, I will tell you in this section, will be national, others, whether you're living in Florida or Texas or California or any other number of states, there are a number of local mandates and regulations apply.

As a reminder, United Healthcare, on your behalf, will work to comply to the best of our ability with all of those local regulations and mandates, however, especially as we head into next year, I do think for those of you who have a national footprint, you should expect, in some of these states, you're going to see very different regulations depending on the state, and so that will likely create some variation for you. We did a webinar last week, which is available via recording, on the transparency and coverage rule and the consolidated appropriations act. Given time, we’re not going to go deep on that today, but I did want to point out that there’s a very deep set of content available. That content is really targeted at self-funded employers.

For those of you who are fully insured or level funded, United Healthcare will largely be complying with all of those on your behalf. Not that you don’t need to be aware of it, but the content of this particular webinar is very targeted at our self-funded customers, and then finally, here, COVID-19 and equal opportunity employment laws and the idea of, like, hey, can I mandate a vaccine or not, can I offer incentives for vaccine, and so I'm going to show you a series of things here on these next slides, and these are word-for-word from the government and, in terms of like what guidance they're putting out there in terms of the equal opportunity conditions.

So, if you go to the next slide, under the Americans with Disabilities Act, can an employer offer an incentive? Yes, yes, you can, and what I would tell you is you need to think about the taxability of the incentive, how you’re providing it, making sure that you provide exceptions, and I’ll talk about a few of those in a second, but yes, and could you do a penalty. A little bit more thin, but yes, check with your legal counsel. There’ll be a lot of local things, regulations that’ll apply. So, it’s complicated, but in theory, the guidance that has been given by the federal government is, yes, you could do a small incentive or penalty, if you choose to do so. I’ll tell you about what we think about that in a second, but I'm going to keep going here for a little bit. On the next slide, could you do an incentive for dependents or spouses of your employees.

The answer, the guidance that is given there is no. As an employer, you only have the right to incentivize your employee, but that doesn’t reach into their dependents. So, just a, and I actually didn’t realize that until I was going deep in the regulations, and I looked at that, that the guidance is out there. So, there’s kind of a limit to, hey, just your employees. If you go to the next slide, it gets into a little bit, okay, how would you respond because of a religious belief, and the guidance there is that, you know, if you did such an incentive, you would need to try to make accommodations for the religious belief, providing reasonable accommodations. So, you know, individuals would be able to say, hey, for religious reason or otherwise, I don’t want to get this and so you, as an employer, would need to be able to make accommodations for them in some other form, and again, just want to emphasize, these words that you see on the screen, these are not our words.

This is direct guidance from the federal government. If you Google this out there, it’ll come up right away, in terms of EEOC guidance. If you Google that, it’ll come out there and you’ll see the whole document. The next one is, and there were a few questions on this earlier, what should an employer do if you're saying, hey, I'm going to mandate vaccines, but an employee says, hey, I'm pregnant, I don’t want to take the vaccine, and again, similar to what you saw in the religious exemptions, the guidance here is that the employer needs to provide reasonable accommodations. Could the employee work from home, have an alternate work arrangement, etc., to be able to fulfill it?

So, there’s a ton of complexity here on mandates and incentives. We tried to do the very best we can to guide you through that. This is a really rapidly evolving space, and if you go to the next slide, this is a really good example of there’s a lot of state-specific dynamics here, and I don’t have the time to go into every state and, by the way, I'm not calling out Texas. I love Texas. I'm just showing you an example of some of the guidances out there, and again, this is exact wording from an order issued by the Texas state governor here, and I'm just going to read a few words of this. Basically, he’s saying, hey, if you're a public or private entity that is receiving or will receive funds from Texas and any taxpayer money, shall not require a consumer to provide or condition to receiving any service or entering a place, documentation regarding the vaccination status for a vaccine administered under EEUA authorization. No consumer may be denied entry into a facility financed in whole or in part by public funds, vaccination status, etc. So, you get the gist here which is, you know, Texas has an order out there saying, hey, you know what, and it’s unclear would this apply to employees, would this apply to just customers, but the vaccination status there and mandating a vaccine might be a lot trickier in that specific situation. So, you know, I’ll end this by emphasizing again that it’s important to speak withy your legal counsel, to understand your local regulations and, in kind of heading down this road, United Healthcare will continue to give you the best advice, you know, from our standpoint, and I will tell you that just globally, we’ve had a lot more employers consider vaccine mandates.

Not as many have made the jump yet. A lot more are considering, though. So, maybe the next time we have this call, we’ll have a different answer. There have been some large ones, obviously. We’ve been very public about that, but it hasn’t been a massive groundswell of tons and tons of employers saying they're going to mandate. Now, if you pivot to the next slide, you know, I've just come through this section. We’ve talked a lot about mandates and incentives for vaccination, and I do want to call out that we’ve done a lot of research and, at the end of the day, there is a very small slice of people who, if they have not had the vaccine yet, that it’s a monetary incentive that’s going to get them to change their mind, but that’s really not the driver. The vast majority of individuals who have been unvaccinated are doing so because, A, they're making a personal choice based on a religious or other belief, or, B, they have concerns about the safety or efficacy, and so those are the two really driving reasons and so, what that says is, you know what, yeah, it’s not that we shouldn’t do incentives or mandates.

Those are important tools in the toolbox. We should consider them. Each situation will be different, but really, if we’re going to make it the last mile here, it’s about education and comfort level, and so what you see here on the screen is kind of over time kind of United Healthcare’s progression on this. We started in January with kind of pre-vaccine, helping people understand it. Mid-March through late April, we were working on first dose, second dose reminders to make sure you completed your vaccination regimen, sending out lots of reminder if we see you haven’t had that second dose. We help vaccine finder for our vulnerable populations. We’re calling them. We’re trying to help them make appointments. I think we helped make appointments for nearly 10,000 people.

So, we’re really pushing that. As we turn the corner into May and July now, we’re saying, hey, people want to see that they’ve been vaccinated. They want to see that record, and I’ll pivot to that in a little bit and like now, maybe do you need to use it in some places. So, the vaccine record becomes important and really tracking that, and then now, entering August, really pivoting into how do we attack vaccine hesitancy and helping, you know, give the really good data and information that was shared by Craig and Dr. Randall and how do we get that out there, as well a many, many other physicians. So, you can see kind of as we move through this over time, we continue to evolve our messaging and, if you go to the next slide, we’ll just show some of the resources here. You don’t need to dig deep on this. I just want to make sure everyone understands that, you know, on behalf of your employees in serving you as a customer, we’re constantly putting out FAQs, checklists, vaccine e-courses, a lot of different content into the space. So, we’re trying to do everything that we can.

There’s always more that we can do, but on some level too, there’s this element of, you know, personal responsibility and kind of breaking through. I don't think, I mean, unless you're really shut down from society, you're not hearing these messages. We will do our part in continuing to reinforce them, but it’s going to continue to be, you know, for that last group of people who don’t want to be vaccinated, we’ll continue to have to work collaboratively with them and I respect, you know, I have friends who are, for very, you know, what I would perceive to be very grounded reasons, are choosing not to do it. That doesn’t mean I don’t try to debate them and say, well, look at this other data here and information that may try to change your mind. So, this is a complex issue. We recognize there are different views.

We’re just trying to do our best to navigate through this, like you all are. As the vaccine has become much more accepted, I'm dure you’ve seen this and, if you go to the next slide, that now this idea of a vaccine pass, and I’ll use New York as an example. New York City announced that, you know, to go to a gym, to eat at a restaurant, starting mid-August, you will need to show proof of vaccination. I did want to emphasize that we show that on our website today. So, we have what's called your employee health record or a member health record. So, you go on there and, if you’ve had the vaccinations and we have the record of that, it will show first and second dose. So, that’s great. We’ve been ahead of the curve on this. We continue to push that. So, you can see that electronically and you wouldn’t necessarily have to carry around your card. Now, some places are evolving to, hey, I want you to show me a QR code, I want you to show it’s validated, and so targeted later this August, I’ll hedge it a little bit, maybe early into September, we will be rolling out where, hey, you know what, I can show you a QR code on my phone, on my digital record.

So, you know, if you're out and you're at a festival or you're at a restaurant, wherever, and it requires it, you don’t have your vaccine card, I can just pick up my phone and I can log on to United Healthcare and there’s my vaccine record right there. Now, we fully recognize that this is a highly politically charged issue. You know, some people really, strongly believe in it and its ability to drive the right behavior. Some people think it’s an incredible infringement on civil liberties. I think our position as a healthcare company is, look, there's a tool here if you want it. We just, you know, we’re recognizing that a lot of places may require it. We just want to make it available. If people want to use it, it’s there. if you don’t want to use it, you don’t need to. As part f this, by the way, there’s the ability to self-report, and we’re working on validation of that, etc. So, if, for whatever reason, we didn’t capture your vaccine record, we would be able to have you self-report it and United Healthcare is in, I’ll call it a privileged position in that, because we’re capturing all the claims of people who have been vaccinated, we do have a very good vaccination record compared to other sources.

So, our data and our information on this may be some of the best that’s out there in terms of have you actually had the vaccine or not. I’ll skip the next slide. I think we’ve largely covered here just this idea that we’re going to try to make the vaccine information that you’ve had as available as possible, and the following in terms of vaccine reporting, I do want to emphasize for larger customers and consultants on the phone, we have provided very robust vaccine reporting. Over 66,000 reports run to-date, talking about, you know, positive viral tests, positive antibody tests, terms of diagnosis, etc., so, costs, fully vaccinated individuals, partially vaccinated, so, all this data will, we continue to evolve these reports all the time with new information. An interesting datapoint for the discussions we’ve had today, and I’ll have Dr. Randall comment on this in a second, we’re having lab core sequence the tests of our member to understand even delta variant versus other, within the data, to really understand that differently.

So, we’re really trying to push the envelope on data here, to what we can deliver to you on your populations. So, okay, a return to health. I don’t want to ignore the fact that, as we go through this, there are other health needs, that behavioral health has been a tremendous, what I’ll call sub-pandemic, underneath the COVID-19 pandemic. So, there's a lot of really significant challenges here. We continue to push on this every way we can. We continue to try to have as large and robust behavioral health networks as possible, lots of different tools for individuals to leverage. We recently announced, for our fully insured population, free access to Peloton digital network for the next year, in terms of like getting access, not just to exercise, but in just general yoga, other healthy tools to kind of staying, you know, active and fit. We’re going to continue to push the envelope here and really recognize the return to health as a big dynamic.

PHIL KAUFFMAN: Jump to it because I know there’s ton of ns. Dr. Randall, let’s start to talk about vaccines and the delta variant and, you know, is there something that we, you know, it kind of comes back into boosters, but we’re getting a lot of questions on this, I mean, does, is the vaccine effective against the dela variant and then boosters and how do we think about that dynamic?

DR. RHONDA RANDALL: That’s a great question. So, stay with me here for a second, because I want to share some important information about the delta variant, in case you're not familiar. You know, everyone’s hearing it’s more transmissible than the wild type, than the original variant that came around, but what does that mean. So, early on, if you were with us, you heard us use a term called R-Nought (R0), that’s the reproductive or transmission number that you look at, and the wild type variant was somewhere in the range of one to three. So, let’s say two. What does that mean? That means that every individual who is sick is likely to infect two other people. Now, the R-Nought with the delta variant is much higher, in the range of five to eight, sometimes even reported as high as nine. That puts it in the range of things like measles, mumps, rubella, chicken pox, right, these vaccines that we’ve had around for a very long time and prevent a significant amount of illness. That means one individual is going to infect five to nine other people. So, that’s why we’re seeing this significant spike in the surge. So, I want to say that. That’s incredibly important. The second thing is, come back to the data you saw that Craig shared. If you are vaccinated, you are very unlikely to get hospitalized or die. Now, more and more data is starting to come out, as the delta variant is now the predominant strain circulating in these areas of spike around the United States, that the vaccines, the three that have EUA, in fact, some data came out today that many of you may have already seen from Mayo Clinic that hasn’t been peer reviewed yet, but it’s a very big study. In general, in a nutshell, when I look at that, here’s the conclusion. The original vaccines, Moderna, Johnson & Johnson and Pfizer, a little less effective of preventing any disease at all. So, your chances of getting a mild symptom, if you get it, are increasing with delta variant versus wild type, but the protection is still good, but where they're still staying really solid is the prevention of serious illness and hospitalization, well upwards of 85-90% in preventing serious illness and hospitalization and, at the end of the day, that’s really what we care about. So, please get vaccinated.

PHIL KAUFFMAN: That’s great, and I continue to emphasize that in the populations that I'm speaking to as well. I’ll hit a couple other quick ones here, some questions around COBRA subsidies, whether we think they’ll be extended. I would be surprised, given the legislative movement between now and then. It’s always possible. Nothing surprises me, I guess, anymore, on some level, but at least as we sit here today, we don’t think that COBRA subsidies will continue to be extended. Now, again, the delta variant really changes that. If you saw that really continued to move across the number of states, maybe that dynamic might change. There are some questions here on, you know, just a little more context on surcharging, similar to tobacco versus incentives for vaccination and I thought that was an interesting question because, actually, the tobacco piece is actually written into the ACA, that you can actually do a surcharge there. There’s nothing there for incentives related to vaccines, which generally makes individuals and health plans more conservative of how we approach this. I do want to address a couple other questions that I've gotten, just kind of related to this, and just to be specific, we, like, for example, the questions come in, hey, Phil, could you differentiate the actual premium amount that you charge somebody based on whether they had the vaccine or not, and the answer to that is no. We think that all the legal guidelines and regulation would not allow us to do that. whatever you do has to kind of fit into that quote unquote incentive bucket. Another question came in and said, hey, would you ever put in a policy that said if you haven’t gotten vaccinated, if you get hospitalized for COVID, all the expenses are going to be on the member and they're going to have, you know, zero coverage for that, and I would just say, similarly, I’ll just say it practically. I don't think that’s a road United Healthcare would go down. I don't think we’d recommend that. This is a really complicated issue, and it’s a complicated disease, and I think that type of an approach probably oversimplifies some of the outcomes and the dynamics behind it but, you know, folks have asked those questions. My recommendation would be that that’s not a good road to go, and I could certainly handle that in more detail with other audiences if you're really interested. There's a question here on the vaccine paths in your system, will it be available for self-funded employer groups via UMR. I don't know that. I'm going to have to take that question back. It will be available for all of our UHC members, and I will look on UMR. Obviously, whenever we develop a web capability or asset, we do try to get it out to all of our populations, but I'm going to have to follow up on that one. Dr. Randall, I'm going to come back to you on this one, and the question is, hey, why is it important that, you know, going back to kind of my comment on surveillance testing and, typically, you know, United Healthcare wouldn’t cover surveillance testing, but why is it important to have a PCP order the test, you know, for COVID, to see, hey, has someone been tested, and maybe in there just give everyone a quick talking point on the at-home test kits and your view on those.

DR. RHONDA RANDALL: Sure. So, the at-home test kits have emergency use authorization. Several of them do. If you do choose one, make sure you choose one that has that authorization. There can always be some bad actors out there. They generally are using a different type of testing to get you that rapid result. It is a good interim step, if you will, if it’s late in the evening and you don’t have access to go get testing at an approved site, for example, but what you don’t have when you do that over-the-counter test is the ability to report those results. So, if your workplace needs it to return to work, if your school needs it to return to school, they're generally not accepting those self-administered over-the-counter tests. So, that’s important, and then the second part of your question around surveillance testing and the need for a physician’s order, you really want to have, you know, and the mass testing sites are falling under a physician’s order as well, right, because they have assigned protocols for who gets tested when and et-cetera, but having that order is important because you want to have somebody to send the results to. You want somebody to have counseling if you're going to need follow-up and treatment, all that contact tracing, and everything that flows through it.

PHIL KAUFFMAN: That’s great. We’re at the end of our time today. I want to remind folks that we are going to make this available via replay, via our regular communications channels. So, look for that. Talk to your United Healthcare rep to try to track that down if you don’t know where, and again, really want to emphasize how quickly and rapidly this environment is evolving. We will try to provide you, either via these sessions or others, the best, latest, and greatest information, and finally, we really appreciate you spending an hour with us today. We hugely appreciate your commitment and support as customers, workers, and consultants, and know that we will continue to do everything on our behalf to really serve you and your members. So, thank you, everybody. Hope you have a great day.