The COVID-19 pandemic has unmasked chronic shortcomings of the U. S. health care system that have exacerbated the challenging situation the nation faces in trying to recover from the most severe pandemic in more than a hundred years. The pandemic became a triple crisis—the pandemic itself, the resultant economic downturn, and underlying systemic racism. This crisis calls for reflection on how these long-term problems can be dealt with in order to move past recovery to an improved system. Pressing issues must be addressed involving medicine, public health and health policy.
Markers of the Devastating Impact of the COVID pandemic in the U. S.
Nine months into the pandemic in this country, these markers document their scope and unparalleled impacts:
• More than 14 million confirmed COVID-19 cases, with 275,000 deaths, projected by the University of Washington’s Institute of Health Metrics and Evaluation to exceed 410,000 by early 2021.
• Many patients not wanting to go near an ER, hospital or doctor’s office for fear of exposure to the virus.
• Temporary closure of almost 2,000 low-cost and free health clinics, with others worried about their financial viability.
• Almost one in ten health workers lost their jobs in the first two months of the pandemic.
• Primary care physicians in smaller independent group practices, already in short supply, faced with such a large drop in patient volume that they had to consider closing their practices.
• By June, 2020, almost 600 front-line health care workers had died of COVID-19.
• Hospitals postponing elective treatments and procedures, resulting in precipitous drops in patient flow and revenue.
• Closure of many psychiatric beds in order to expand the number of beds for COVID patients, thereby further stressing mental health care.
• Nursing homes, the original epicenter of the pandemic, being pressured to discharge patients to relieve pressure on crowded hospitals.
• By September, with tens of millions of Americans out of work, almost one in four households were food insecure.
• Public health and infectious disease experts sidelined and marginalized by the anti-science Trump administration.
• Absence of any evidence-based national health policy within the Trump administration, including failure to invoke the Defense Production Act to build a National Strategic Stockpile of Critical Supplies such as personal protective equipment, face masks, and test kits.
• Profiteering, even to the point of fraud, by opportunistic traders and middlemen for coronavirus face masks and COVID test kits
Transformative Changes over the Last 50 Years that impair our recovery from the pandemic
These six major changes have greatly impacted medical practice and our health care system, which together have contributed to decreasing access to affordable care, compromised quality of care, and made us more vulnerable to pandemics.
Rise of the medical-industrial complex
In their 1970 book, The American Health Empire: Power, Profits and Politics, John and Barbara Ehrenreich described the growth of technology and its products after World War II, the replacement of physicians by hospitals at the center of the new system, and the increasing threat of institutionalized medicine to the hallowed doctor-patient relationship.
Ironically, the passage of Medicare and Medicaid in 1965 opened up new opportunities for corporate investment across much of the health care enterprise, including hospitals, nursing homes, clinical laboratories, and even the insurance industry.
Commodification of health care services
Health care became big business as a commodity for sale on a largely deregulated market, with corporate stakeholders vying for profits for themselves and their Wall Street shareholders.
According to the 2016 annual survey by the Commerce Department, for- profit ownership of facilities across the health care system had reached these numbers, higher than many of us might realize: Hospice 63%; Nursing homes 65%; Home care 76%; Dialysis centers 90%; SurgiCenters 95%; and Free-standing Lab/Imaging Centers 100%. Privatization of Medicare and Medicaid has sacrificed the social contract established in 1965 as private insurers reap a bonanza that now accounts for more than one-half of their net revenue. They increase their profits by upcoding diagnoses, claiming payment for conditions for which treatment was not given, and successfully lobbying Congress for large overpayments over many years.
Growth of investor-owned care
Since the 1980s, investor-owned chains have grown across most parts of the medical-industrial complex ranging from acute care and rehabilitation hospitals to psychiatric hospitals and nursing homes. In every instance, they bring higher costs and worse quality of care than their not-for-profit counterparts. When private equity is involved, volatility results as venture capital firms acquire facilities, seek a maximal investor return over a 3 to 5-year timeline, load facilities with excessive debt that often makes default or bankruptcy likely as a profit-taking strategy. As a result, many hospitals, nursing homes and other facilities end up being closed, with a loss of essential community services.
Decline in sovereignty and clinical autonomy of physicians
The above five system changes have had a major impact on physicians and medical practice. Today, as hospital systems buy up physician practices, they employ two-thirds of U. S. physicians, often under productivity-based contracts that reward them for providing a higher volume of services and ordering more expensive tests. Further instability of relationships between hospitals and physicians occur when insurers purchase their own clinics.
Physicians today have to cope with different and changing policies of more than 1,000 private insurers concerning restricted networks, pre-authorizations, and other requirements related to reimbursement. A 2016 study found that U. S. physicians in ambulatory practice are now spending twice as much time each day on EHR/desk work than with patients, leaving less face-to-face time with patients and lower practice satisfaction.
Directions toward a ‘New Normal’ in U. S. health care
As noted, medical practice, health care, public health and health policy have been diverted over the last several decades from their original, service-oriented missions to adapting to their corporate overlords, as enabled by powerful Wall Street interests. Health care reform has become an urgent need, raising the question of how the medical profession can play a leading role.
If we can agree that health care is a human right and essential need and not a privilege based on ability to pay, the following directions give us a roadmap to providing the best possible care for individuals and populations in this country.
1) Establish universal coverage
2) Expand primary care
3) Restore independent, small group practice
4) Strengthen evidence-based evaluation of health care services
5) Rebuild public health
Single-payer Medicare for All, as framed by House Bill 1384 now in the House, would bring us a mechanism to meet all of the above needs through a new system of national health insurance (NHI). Yes, it would eliminate the private health insurance industry, but that industry has had a long run as an enormous profit-driven industry that fights against any reforms that would reduce its size or profits. Employer-sponsored health insurance, by far the largest part of the industry, involving about 150 million Americans in past years, has proven to be too expensive and volatile to be relied upon, even before the pandemic struck. Today, with more than one in ten U. S. businesses planning to lay off workers during the last 3 months of 2020, often with loss of insurance, the circumstances for them have become dire.
The COVID pandemic has shown how the private health insurance industry is more of a problem than an asset. Taiwan has had national health insurance for the last 20 years, and was able to control the pandemic much earlier with far fewer lives lost and less disruption to their economy than the U. S. Their system achieves much better health outcomes than ours, and its electronic information system facilitated a strong, coordinated approach to widespread testing, rapid results, quarantine, and effective contact tracing. In late October, despite its population density and proximity to mainland China, Taiwan had experienced just 550 confirmed COVID-19 cases with 7 deaths.
Hopeful Signs within the medical profession favoring reform
Although most medical organizations in the U. S. have long opposed national health insurance, there has been a sea change in that pattern with the endorsement of Medicare for All by the American College of Physicians in 2019. The American Medical Association and the American College of Radiology have withdrawn from the “Partnership for America’s Health Care Future,” an industry front group formed to fight coverage expansions like Medicare for All. The Hawaii and Vermont State Medical Associations have endorsed Medicare for all. More recently, the California Medical Association added equity and social justice to its mission statement.
The AMA and its House of Delegates have overwhelmingly voted for the first time to adopt policies that name and act on racism as a public health threat and launched a Health Equity Center. The AMA elected its first black president in 2019.
As physicians become more stressed and frustrated under the grip of their corporate employers, many have come to seriously consider the advantages of independent private practice under NHI. Not surprisingly, younger physicians are much more receptive to NHI than their older colleagues.
Other medical and health care organizations have long supported universal coverage under NHI, including Physicians for a National Health Program (PNHP) the American Public Health Association, National Nurses United, and others. In the midst of this pandemic, further support for NHI is coming from Public Citizen and a number of new coalitions.
A new day exists with the recent 2020 elections that returned Democrats to the White House together with a majority in the House and possibly a 50-50 split in the Senate depending on the outcome of the two January Senate runoffs in Georgia. This brings new opportunities to reform health care rather than incremental patches to a broken system.