Rethinking U.S. Health CareThrough The Lens of COVID-19
By Ray Dorsey and Susan Dentzer
COVID-19 has exposed the shortcomings of the U.S. health care system. Never before have hospitals, physicians, nurses, administrators, medical staff, and many others worked so hard to address a public health emergency. Never before have medical centers and physician practices lost more money or health care workers more jobs.
Similarly, the loss of nearly 30 million jobs across the U.S. economy has demonstrated the limitations of employment-based health insurance. Although many employers have maintained health insurance for furloughed employees, that may not continue. Consequently, 25 to 43 million Americans could lose their employer-sponsored health insurance.1 Medicaid enrollment could increase to 90 million.2
The novel coronavirus has also shown the fallacy of the disease-focused orientation. In a large New York City cohort, the most common co-morbidities among patients hospitalized with COVID-19 were hypertension, obesity, and diabetes.3 These are not only modifiable, but almost entirely preventable, conditions that predispose individuals to higher death rates.
The pandemic has again highlighted the country’s enormous health disparities. According to the Centers for Disease Control and Prevention, one third of individuals hospitalized are African-American.4 Yet, African-Americans make up only 18% of the population in these communities and just 13% of the overall U.S. population.
Finally, the pandemic has revealed the shortcomings of the public health system. At the federal level, almost every aspect of the response from viral testing to distributions of masks has been delayed, insufficient, or both. Many inadequately funded state and local health departments are left struggling to formulate plans for widespread testing and contact tracing — the principal strategies available to re-open local economies while still preventing and containing new outbreaks.
In this pandemic, the U.S. has fared worse than most countries despite spending vastly more on health care (Table). The U.S. has adopted some helpful countermeasures. These include using telemedicine, increasing home care options, empowering clinicians, and reducing administrative burden. However, all of these changes are temporary, required a public health emergency to occur, and highlight the fragility, not the resiliency, of our current health care system.
The future may hold even greater challenges and opportunities. Losses to medical centers are likely to continue in the short run and to far exceed funds available from taxpayers. Motivated by both clinical needs and economic survival, hospitals and clinics will attempt to re-open. But the mix of insurance coverage for patients will likely be less favorable, and the financial pressures will mount.
In a cruel irony, some revenue sources that maintain the health care system may be lessened because the pandemic has halted so much of everyday life. The demand for services due to car accidents and sports injuries will likely be reduced. And in the worst irony of all, many patients may have fared far better than expected in the absence of care. Previous temporary reductions in the availability of cardiologists, for example, have been associated with increased survival among patients with heart failure.5
Now, though, may be the opportune time for fundamental transformation. The last two months has seen more change in health care delivery than the previous two generations. We are in the midst of a great societal re-set that will affect everything from education to work to recreation. And in less than six months, we have national elections that will determine our leadership and future direction.
Among those directions is a migration to patient-centered, rather than institution-centered, care. Medical centers still make more money when patients are hospitalized than not. They make more money if patients come to their clinics because they can levy facility fees and conduct diagnostic testing and procedures. Because many insurers still pay less for virtual care, medical centers receive more if patients come to them instead of clinicians connecting to patients. It will be difficult, if not impossible, to square the old medical center business model with a new world brought it by COVID. More patients will lack health insurance, and regardless of insurance status, many will want and have more options to obtain care either virtually or closer to home.
Before the pandemic, the “gig” economy was already driving demand for health insurance options that were uncoupled from employment. Now, with unemployment at Depression-era levels and prospects for economic recovery uncertain, achieving universal health insurance that is separate from employment should also have its moment. Medicare for All, a Medicare buy-in for those age 55 or younger, expanded eligibility for Medicaid and Affordable Care Act coverage, or some other guaranteed public option should all be on the table in the policy debates ahead.
We can also change our disease-orientation to a health promotion one. The decline in cigarette smoking is one of the great public health accomplishments in recent times, has saved millions of lives, and prevented likely thousands of deaths from COVID-19. Approaches that led to smoking’s fall could be applied to reduce heart disease, obesity, diabetes, and many preventable chronic conditions that plague 130 million Americans and consume the vast majority of U.S. health care spending.
Finally, we need to address disparities in health care and outcomes. In the long-term, we can direct reductions in health care expenditures to providing greater social support and economic opportunities for those that need them. In the short-term, many communities need more culturally appropriate care, free of unconscious bias, from more clinicians that they trust. Beyond disparities in care, African-Americans, Hispanics, and other minorities are bearing a large burden of lay-offs. The latter, including those in health care, are occurring even though few were in leadership positions with responsibility for foreseeing potential crises or developing organizations with the resilience to withstand them.
COVID-19 has allowed us to see what we knew, or should have known, all along. We have outstanding and dedicated clinicians, health care workers, and public health leaders, all working in compromised systems. The perverse incentives, misguided orientation, and fundamental flaws that plague them are costing us lives and money. In a final cruel irony, a pandemic may turn out to be just what is needed to change our system for the better.
Ray Dorsey, MD, MBA, is David M. Levy Professor of Neurology and Director of the Center for Health Technology at the University of Rochester Medical Center. Susan Dentzer is Senior Policy Fellow at the Robert J. Margolis Center for Health Policy at Duke University.
ACKNOWLEDGEMENTS
The authors thank Madeleine Coffey, BA for her assistance in the preparation of this post.
References
1. Garrett B, Gangopadhyaya A. How the COVID-19 Recession Could Affect Health Insurance Coverage. Washington, DC: Urban Institute; 2020. https://www.rwjf.org/en/library/research/2020/05/how-the-covid-19-recession-could-affect-health-insurance-coverage.html. Published May 4, 2020. Accessed May 17, 2020.
2. Health Management Associates. COVID-19 Impact on Medicaid, Marketplace, and the Uninsured, by State. https://www.healthmanagement.com/wp-content/uploads/HMA-Estimates-of-COVID-Impact-on-Coverage-public-version-for-April-3-830-CT.pdf. Published April 3, 2020. Accessed May 17, 2020.
3. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775
4. Centers for Disease Control and Prevention. COVID-19 in Racial and Ethnic Minority Groups. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html. Updated April 22, 2020. Accessed May 17, 2020.
5. Jena AB, Prasad V, Goldman DP, Romley J. Mortality and treatment patterns among patients hospitalized with acute cardiovascular conditions during dates of national cardiology meetings. JAMA Intern Med. 2015;175(2):237‐244. doi:10.1001/jamainternmed.2014.6781
6. Health spending (indicator). Organisation for Economic Cooperation and Development (OECD). Accessed May 17, 2020. doi: 10.1787/8643de7e-en
7. Mortality Analyses. Johns Hopkins Coronavirus Resource Center. https://coronavirus.jhu.edu/data/mortality. Updated May 16, 2020. Accessed May 17, 2020.
