Part of the Pandemic Issue of The Highlight, our home for ambitious stories that explain our world.
The flaws in America’s health system have been evident for decades to anyone who cared to look, but the coronavirus pandemic has left no more room for doubt: People will die because the US refuses to treat health care as a public good and a universal right. They already are.
Our decentralized system, with independent providers and many different payers, was not nimble in responding to this stealthy pathogen. These problems weren’t the only reason more than half a million people in the United States have contracted Covid-19 and tens of thousands have died. But America was particularly fertile ground for a virus to run wild.
Only in America could a man and daughter placed under mandatory government quarantine then be hit with a $4,000 hospital bill. Only in America could somebody without health insurance — a situation, all on its own, foreign to other rich countries — receive a bill for Covid-19 treatment that tops $30,000. Only in America would a dying patient ask in his final breaths who will pay for the care that could not prevent his death. The US is the richest country in the world, and yet millions are uninsured or have insufficient benefits. It has fewer hospital beds, doctors, and nurses per capita than its economic peers.
The response to the current pandemic has been portrayed by President Trump and journalists as a war-like mobilization effort. Historically, wars lead to reconstruction. But for decades, the US’s slipshod system has resisted efforts to build a more universal and socialized model, with the government guaranteeing coverage for everyone and overseeing costs for the whole country, as seen everywhere else in the developed world. Even the coronavirus may not be traumatic enough to change that underlying reality.
Nonetheless, the pandemic will leave its mark on US health care long after the immediate threat passes. There is no doubt about that. Vulnerable hospitals are being drained of their reserves, patients are embracing health care from the socially distant safety of home, and Congress and the White House are desperately trying to patch up holes in America’s safety net.
Change is already well underway.
Some hospitals will probably close. A lot of primary care doctors could also be in trouble.
Hospitals of every type — private and public, urban and rural — are paying a heavy price to Covid-19. Not only are they trying to keep their patients and doctors healthy despite a shortage of supplies, but many have canceled or postponed elective surgeries, such as heart surgery or even cancer treatments. Those procedures typically account for much of their annual revenue, and without it, hospitals are laying off staff (temporarily, for now) to keep afloat.
Rural hospitals especially depend on outpatient services for much of their revenue — about three-quarters of it on average, according to a Chartis Center on Rural Health analysis. Most of those services are now on hold. Making matters worse, hospitals in rural communities generally had only a month’s worth of cash on hand for a crisis like this — and the extension of social distancing guidelines until at least the end of April will “increase the likelihood that we will see rural hospitals run out of cash,” the Chartis researchers wrote.
Before Covid-19 reached the US, one in four rural hospitals was already vulnerable to closure. Congress is funneling tens of billions of dollars to hospitals, and elective surgeries will resume at some point. But it still might not be enough to save some of these institutions.
“Even with all of that, there are going to be hospitals that close because of this,” says Susan Dentzer, senior policy fellow at Duke University’s Margolis Center for Health Policy.
The hospitals that will be best positioned to weather the crisis, on the other hand, are larger hospitals and those that are part of a system with several facilities.
“They typically are better capitalized and have more access to capital, have deeper reserves, and have endowments, and investments ... that while currently losing value, will almost certainly rebound,” says Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at the Institute for Public Health at Washington University in St. Louis.
Primary care has also taken a massive, if less-noticed, drubbing during the pandemic, says Andy Slavitt, who oversaw the repair of HealthCare.gov in 2013 and later took over as Medicare and Medicaid administrator for President Obama. Patients are no longer going in for routine check-ups, and doctors aren’t reaping the income they normally would if they perform surgeries at a hospital.
“What happens to the structure of primary care? I fear you could end up with a very different-looking structure, with many [practices] shuttered. Many of them could be bought by insurance companies,” Slavitt says. “I could see a real decimating of independent primary care, and specialists impacted, as well.”
Telemedicine will finally go mainstream
The most obvious effect of the pandemic might paradoxically be the most mundane and the most significant. Telemedicine has struggled for years to realize its full potential, hindered by a combination of bad policies (limited Medicare coverage, states’ restrictions on practicing across state lines) and patients’ attachment to the old-fashioned “laying on of hands” kind of medicine.
But as government officials have sought to keep otherwise healthy seniors away from doctor’s offices and hospitals where they might be exposed to the coronavirus contagion, telehealth has experienced a boom. Those visits surged by 50 percent in March as social distancing went into full effect, and the total number of phone or video interactions is expected to exceed 1 billion total by year’s end. Estimates from 2019 had indicated only about one in 10 Americans were taking advantage of telehealth in the pre-pandemic era.
The Trump administration has relaxed Medicare rules — which previously only covered phone or video calls between doctors and seniors in rural areas — to pay for telehealth visits for all seniors insured through the program. Many private health insurers have done the same, boosting their payments for telemedicine consultations; previously, doctors would often be reimbursed less for virtual visits, discouraging its practice.
“In terms of many of the encounters people need for their daily lives and how many of them can be done through telehealth,” patients will begin to find telemedicine more convenient, says Nancy DeParle, who oversaw Medicare and Medicaid in the 1990s, when the strict rules for Medicare’s telehealth coverage were approved by Congress. “I just don’t see that going back.”
For a permanent paradigm shift, however, insurance companies will have to commit to continuing to covering telemedicine as they are now.
“If providers can get paid for it, then I think it’s reasonable you’ll see a huge bump,” Austin Frakt, a Boston University health economist, says. “It’s more convenient. People like it.”
We’ll invest more in public health preparedness and surveillance
Cuts to the Centers for Disease Control and related surveillance programs that monitor nascent outbreaks around the globe made it harder for the US to anticipate the coming crisis and develop plans to combat it. Congress tends to invest money in preparedness after a crisis like this; after the Zika virus outbreak of 2015, lawmakers set aside more emergency funding so federal outbreak response could launch quickly when the next pathogen arrived on the scene.
But those investments can also be fleeting. Public health tends to be first on the chopping block when the fiscal hawks take power; the cuts under the Trump administration are a grim reminder.
“One would hope that public health will be less of a neglected stepchild in our health care system coming out of this crisis,” says Larry Levitt, executive vice president at the Kaiser Family Foundation. “At least for a while, there may be lasting investments in public health, until memory of the pandemic fades and we go back to underfunding it.”
Slavitt says the US should be investing in a new “sentinel system” that would help to detect emergent outbreaks where they are rising.
“We should end up building some more sophisticated intelligence systems to detect and monitor disease outbreaks,” he says.
The pandemic “is a case study in how it’s detrimental that we can’t do anything close to real-time surveillance,” Frakt says. “I could see movement. It’s very weedy. Nobody is going to go to a presidential debate and talk about how we need better data-sharing. But there are tech nerds who would love to figure this out.”
We could rethink how drugmakers and the federal government handle urgent needs
When Covid-19 appeared on the world stage, it triggered a race to find vaccines and treatments.
Academic researchers and for-profit pharmaceutical companies have rapidly scaled up clinical trials in search of breakthroughs that could alleviate the pandemic’s human toll and allow society to begin returning to normal.
But antiviral (and antibacterial) research investment historically has not been a priority for the major drugmakers whose participation is necessary for the mass production of any new medication. The Wall Street Journal reported Pfizer had to reestablish its antiviral research department for its Covid-19 work because the unit was disbanded in 2009. Novartis ended its antiviral and antibacterial research in 2018. The market has been dominated by Gilead (best known for its hepatitis-C cure) and GlaxoSmithKline.
One systemic review of the last 30 years of antiviral research found “only a few drugs were approved to treat acute viral infections” in that time.
“Antibiotics and antivirals are both areas that haven’t seen a tremendous amount of new drug development because the economic incentives haven’t justified significant R&D in this area,” says Caroline Pearson, senior fellow with NORC-University of Chicago. “I wonder if the FDA might consider new ways to encourage and promote pharmaceutical innovation in areas with high public health value but relatively lower market value.”
Another option, Pearson says, is for Congress to seek to expand federal authorities allowing the government to require drug and device manufacturers to produce drugs and supplies in an emergency.
There will be a push to expand health coverage
The elephant in this proverbial room is America’s embarrassingly high uninsured rate — above 10 percent before the crisis started and significantly higher now that millions are unemployed and losing their health insurance.
This is the fundamental immorality of US health care that the coronavirus has exposed again: How can anybody in the richest country in the world lack financial protection in a medical emergency?
A crisis like a worldwide pandemic historically has been an opportunity to repair such structural problems.
“Many of the biggest coverage expansions both in the US and in similar countries happened in the context of wars and social upheavals, as well as financial crises. One theory is that those circumstances redefine social solidarity, thus expanding views of the role of government,” says Cynthia Cox, director of the Peterson-Kaiser Health System Tracker. “I think one factor that will determine the permanency of these changes is how long this disruption continues. The longer this goes on, the more likely this social solidarity becomes ingrained.”
Targeted fixes passed by Congress now cover the costs of Covid-19 testing and treatment for uninsured Americans, and some health insurers have waived cost-sharing for their customers during the pandemic. But that only raises the question: If those costs should be waived for an acute viral outbreak, then why should somebody diagnosed with cancer or heart disease have to fork over thousands of dollars for the care they need?
If Joe Biden becomes president, empowered with a Democratic Congress, he would likely have a mandate to pass another health reform that patches up holes revealed by the recent crisis. Any legislation would have to be negotiated in Congress, but during the campaign, Biden has proposed a new public insurance option that would be available to uninsured people, people who live in states that don’t expand Medicaid, and people who buy insurance on the Affordable Care Act’s marketplaces. People with employer-sponsored coverage would also be permitted to buy into the new government plan, if they choose.
But any significant expansion of health coverage probably depends on the outcome of the 2020 presidential election.
“The answer to that question,” says Jacob Hacker, a Yale University political scientist who has studied how traumatic social events change political attitudes, “is gonna influence what’s possible in terms of large-scale health policy changes as much as anything else.”
Even if President Trump were to be reelected, it is conceivable that Republicans will have less appetite for their preferred proposals that pare back health coverage. Already, some GOP-led states have put Medicaid work requirements on hold, given the crisis and the surge of Medicaid enrollment resulting from high unemployment.
But more structural changes would require the right political environment. What nobody knows for sure, not even the people who have followed US health policy closely for years, is whether the coronavirus pandemic leads to any permanent political realignment.
“In more normal times, I’m a very staunch ‘nothing ever matters, nothing ever changes’ kinda guy,” Frakt says. “This is such a rare event with no comparable experience in 100 years, and I don’t think it’s fair to compare anything that happened 100 years ago to now. Basically, we don’t know.”
Dylan Scott covers health care for Vox.