In an address to the country on March 11 about the new coronavirus (COVID-19), President Trump assured viewers that “the virus will not have a chance against us” because we have the “most advanced healthcare” in the world.
Despite this confident declaration, it is becoming increasingly clear that America is ill-equipped to handle this pandemic–not just because of a lack of preventive action taken at the start of the virus, but because our health care system is fundamentally flawed. If we want to be ready for the next epidemic (and there will be a next epidemic) we should be making the following radical changes to our health care system now.
America is ill-equipped to handle this pandemic because our health care priorities as a country are fundamentally flawed.
Build our infrastructure to fight communicable diseases
It seems obvious that in order to fight viruses and other diseases, we need more research, funding, and manpower dedicated to this topic. However, even in the midst of the current pandemic, Russ Vought, acting director of the White House Office of Management and Budget, requested a 15 percent cut of $1.2 billion to the Centers for Disease Control and Prevention (CDC). The message is clear: The government will do everything to help the financial sector, but public health agencies will have to scrape for every dollar they get.
Our health care system also provides few incentives for private companies to develop vaccines and other treatments for communicable diseases. While orphan drugs and gene therapies are being sold at exorbitant prices, and drug companies abuse patent laws to maintain their profits, scientists trying to develop new vaccines struggle for funding.
Gayle Esposito, a patient advocate whose late husband Joe worked as a virologist at the CDC, told me in an email exchange: “I see my husband’s friends and former colleagues in the news commenting on this contagion and think how gutted public health has been as drug companies concentrate on their ‘profitable’ drugs. Many times Joe would tell me that vaccines and antibiotics are not profitable for drug companies so the infrastructure for communicable diseases is always difficult to maintain. I know he would be saying that about this recent pandemic.”
“Public health has been gutted as drug companies concentrate on their ‘profitable’ drugs.”
Gayle Esposito, patient advocate, Mothers Against Medical Error
Give everyone access to affordable care
Health care experts have noted that the lack of universal health care along with high health care costs could pose a dangerous barrier to access for low-income people who become infected with coronavirus. For example, a father and daughter who were put under mandated quarantine later received bills for nearly $4,000 from the hospital. If people are afraid they will be charged surprise bills for coronavirus care, will they seek this care?
Further, government officials have not committed to making a coronavirus vaccine or other treatment affordable for all, which compromises not only the health of low-income individuals, but the health of the entire country. In a meeting in late February, Health and Human Services secretary Alex Azar said, regarding a hypothetical coronavirus vaccine, “We would want to ensure that we work to make it affordable, but we can’t control that price because we need the private sector to invest.” Trusting the market to decide who gets lifesaving medications is the problem with drug prices in America in a nutshell. Our inability to do anything to control drug prices has already killed many people with type 1 diabetes who depend on insulin to survive; now it may result in needless deaths from coronavirus.
There are countless actions the government could take to increase access and reduce the cost of care: Expanding Medicaid in all states, making health coverage universal, regulating drug prices, switching to an “all-payer” plan for hospitals, reforming drug patent laws, and much more. Without available care, more people will avoid seeing a doctor when they have coronavirus, putting them and their communities at increased risk of harm.
Focus on the right kind of prevention
“Prevention” is a buzzword in health care. Theoretically, preventing health problems early can reduce the harm and cost of health problems later. However, not all prevention is equally helpful. As Silicon Valley invests millions in high-tech testing and screening to “disrupt” primary care, states and communities in the US are struggling to fund social services that greatly impact health.
As with public health infrastructure, the lack of funding for “social infrastructure” is coming to a head in this coronavirus crisis. While workers in some European countries can count on keeping their salary when they stay home, not all Americans share that security. About one-quarter of US workers do not have paid sick leave, which means that millions of people have to choose between staying home when sick or making enough money to support their families. Similarly, declining funding for SNAP (food assistance) and other social services has reduced Americans’ trust in the social safety net as a whole. If people do stay home, there is no indication that they will receive help later receive help later to supplement the income they lost.
Improving our social infrastructure, starting with paid sick leave, and expanding income, housing, and food support will be necessary to contain diseases like coronavirus in the future.
Pay attention to value
Lastly, value is an important but overlooked issue in the coronavirus pandemic: Which health care services do we invest in, and how are these allocated? Our health care system is generally a fee-for-service model, which means that health care providers are paid for each service they deliver, rather than a set amount per patient or pay-for-performance model. Fee-for-service gives clinicians the incentive to do more tests and procedures, whether or not they are necessary or beneficial. Hospitals and other health care institutions may make decisions about which health care services to offer based on the potential profitability, rather than patient need.
Intensive Care Unit (ICU) beds are a perfect example of this phenomenon. When hospitals build or expand their ICU, they then have to justify this expansion by filling the beds, even if patients do not need intensive care. A 2017 study found that in one hospital, “over 50% of patients admitted to the ICU had priority ranks suggesting that they were potentially either too well or too sick to benefit from ICU care, or could have received equivalent care in non-ICU settings.”
What does this have to do with coronavirus? When ICU beds are filled with people who do not benefit, it is not only a waste of money, but it leaves less room for incoming coronavirus patients. In a recent Twitter thread, health policy researcher Dr. Aaron Carroll asked hospital workers how many of them had empty ICUs in preparation for coronavirus. Most people responded that their ICUs were not empty, waiting for an influx of new patients; on the contrary, they were as full as ever.
One doctor said, “Our unit hasn’t been even close to remotely empty for two years. We’ve been running average of 66% capacity for at least a year and a half, and haven’t had the staffing for even that. Last month we’ve been close to 80%, and that’s without any Covid patients.” Another responder hit the nail on the head: “The business model of ICUs keeps them full. An empty ICU bed is a huge earning opportunity lost. That’s a big part of our impending problem. No extra bandwidth.”
Similarly, clinicians are working at capacity themselves; a significant portion are burned out on a regular basis. What will happen when clinicians who are already weighed down by exhaustion and moral injury face this crisis?
There is a serious need to lessen the pressure on health care institutions and clinicians to keep doing more, regardless of the need. We need to allocate funding based on value, not volume, and increase our bandwidth to respond to crises that require more of our resources.
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Coronavirus is creating a perfect storm of harm because of systemic flaws in our health care system and social safety net. If we want to reduce this harm, now and in the future, we need to get our health care priorities straight: improving health care access, investing in public health, transitioning to value-based care, and building up our frayed social safety net.