Health Care Reform Articles - March 24, 2020

They Don’t Hide From the Coronavirus, They Confront It

Millions of health care workers are running to where they are needed, sometimes risking their lives.

by Donald Berwick, M.D. - NYT - March 23, 2020

“I’m having flashbacks to the Boston Marathon bombing,” my daughter said.
She was a newly minted physician on the day the bombs went off seven years ago, when the police rolled a man on a stretcher into her hospital’s emergency department. His blood had spilled onto the floor and someone began to wipe it away.
“Don’t bother,” the officer said, “there is a lot more where that came from.” When she tells that story, my daughter always mentions the dread she felt. How many more victims would arrive, and when?
Now, she faces a similar sense of dread, as demand for Covid-19 care could swamp her hospital and patients who could have been saved may die as the ventilator supply runs out.
But along with the fearful memories of the marathon bombing come images of emergency workers running toward the billows of smoke, doing their jobs despite their fears.

As the world writhes in the grip of Covid-19, the epidemic has revealed something majestic and inspiring: millions of health care workers running to where they are needed, on duty, sometimes risking their own lives. I have never before seen such an extensive, voluntary outpouring of medical help at such a global scale.
Intensive care doctors in Seattle connect with intensive care doctors in Wuhan to gather specific intelligence on what the Chinese have learned: details of diagnostic strategies, the physiology of the disease, approaches to managing lung failure, and more. The three-page, single spaced document, full of lessons, circulates immediately and widely through social media platforms, a gem borne of pure, professional commitment. Facebook starts a “COVID-19 USA Physician/APP Group” on March 13. It has 57,000 members on March 15, and 105,000 on March 18.
The Journal of the American Medical Association, even while moving its staff home for social distancing, sets new records for speeding helpful scientific studies, peer reviewed, onto the web. Knowledge grows. One JAMA paper is by a group of Wuhan physicians reviewing patterns and outcomes for 1099 patients, showing surprisingly high rates of severe illness in younger adults. Another is an honest account by physicians in Lombardy of both successes and mistakes as they grapple with unprecedented intensive care demands. A list-serve for hospitals started by the Institute for Healthcare Improvement overflows with questions — “What have you learned about setting up drive-by testing?” “Has anyone found a new source of masks?” — and instant answers from institutions and clinicians.
One anesthesiologist in Valhalla, N.Y., types in a suggestion: “Instead of giving up when the ventilators are all in use, how about asking groups of students or family members who have become immune to the virus to ventilate patients manually, using ‘Ambu bags,’ in shifts even for days at a time?” Clinicians reply, some critical, some supportive, and all trying to find answers.
And city by city, hospitals mobilize creatively to get ready for the possible deluge: bring in retired staff members, train nurses and doctors in real time, share data on supplies around the region, set up special isolation units and scale up capacity by a factor of 100 or 1000. On Tuesday, Mayor Bill de Blasio of New York asks for retired medical personnel to join the city’s Medical Reserve Corps; 24 hours later, 1000 new volunteers have signed up. Northwell Health, a 23-hospital system in New York City, figures out how to add 1,500 beds, if needed, by repurposing space.

Think about such adaptations and agility going on all across our nation and the world. Good people taking the load in a time of crisis, as our president says of the dearth of Covid-19 test kits, “I don’t take responsibility at all.”
We are witnessing professionalism in its highest form, skilled people putting the interests of those they serve above their own interests.
Dr. Roberto Stella, age 67, was president of the medical association in the Varese region of northern Italy. When the supplies of protective equipment ran out, he continued to care for patients. A colleague quoted him: “We have run out of masks,” he said, “but we don’t stop.” Dr. Stella died from Covid-19 a few days after that in a Como hospital.
“How are you doing?” I asked my daughter by phone from the safety of my house. “A little scared,” she said. Then, “Gotta go. …” Patients were waiting.
https://www.nytimes.com/2020/03/23/opinion/coronavirus-doctors.html?referringSource=articleShare

Obamacare Turns 10 Today. Here’s a Look at What Works and Doesn’t.

By Abby Goodnough, Reed Abelson, Margot Sanger-Katz and Sarah Kliff - NYT - March 23, 2020

A pandemic. A Supreme Court challenge (again). A presidential election campaign — this time with attacks from the left as well as the right.
Ever since President Barack Obama signed the Affordable Care Act into law 10 years ago Monday, it has faced legislative, legal and political attacks. The landmark health law, nicknamed Obamacare, has withstood more than 60 votes to repeal it from Republican-controlled Congresses, two Supreme Court decisions, the gutting of one of its main provisions (the tax penalty for not having insurance) and a president who campaigned on promises to get rid of it.
But for all the challenges the law has weathered, no moment has seemed as existential as now. As the coronavirus pandemic tests the American health system in ways few could have imagined, an increasingly conservative Supreme Court is preparing to hear another case, backed by the Trump administration, challenging the law’s constitutionality. At the same time, the left wing of the Democratic Party, a major force behind the law’s passage, has grown impatient with it and is demanding more radical change, to a single-payer, government-run health insurance system.
On the anniversary of the law, veteran health policy reporters at The New York Times looked beyond the political and legal debate to try to answer one question: How has the law worked in its first decade?

It’s greatly expanded coverage.

The law did not achieve universal coverage, but it brought about a historic drop in the number of Americans without health insurance.
When it was passed, nearly a quarter of Americans (22.3 percent) between 18 and 64 were uninsured. By 2016 — just two years after the law’s insurance marketplaces opened and states were allowed to expand Medicaid to more low-income people — that rate had plunged to 12.4 percent. In all, about 20 million more people have coverage now than before the law.
“In addition to making medical treatment available for many who already had chronic and infectious conditions, the A.C.A. offered preventive care to millions of people who otherwise might have become ill,” said John Auerbach, president and chief executive of Trust for America’s Health, a nonpartisan health policy group. “It’s also resulted in improved access to coverage and care for people of color, reducing — although not eliminating — longstanding disparities.”

The biggest advance has been the huge increase in coverage of poor people. The law originally required states to expand Medicaid, the government health insurance program for low-income Americans, with the federal government paying almost all of the bill. In 2012, the Supreme Court ruled that states could not be compelled to do so, and the provision became optional, creating a disparity that remains stark.

Still, all but 14 states have now expanded the program, and the results have been significant: Medicaid enrollment increased by about 13 million, or 34 percent, in the so-called expansion states between 2013 and 2019, according to federal data. The uninsured rate for poor adult citizens with no dependent children — a group that had often been ineligible for Medicaid — plummeted, dropping to 16.5 percent in 2015 from 45.4 percent in 2013, according to the Urban Institute.
Over all, the largest coverage gains under the A.C.A. have been among Hispanic, black and Asian patients — many of the groups that had the highest uninsured rates before the law, the Kaiser Family Foundation found.
For some, the coverage has changed their lives profoundly. Jean Jackson, 64, of Danville, Va., had to retire early from her job as a cooling inspector in 2017 because she had cataracts that made it impossible for her to drive at night, when her shift took place. That left her uninsured until January 2019, when Virginia expanded Medicaid.
By then her cataracts had grown large enough to require surgery. She had them removed within months of getting Medicaid and now can again see well enough to drive after dark, allowing her to volunteer and attend community meetings, activities she said were vital to her well-being.
“It was stressful, yes it was,” Ms. Jackson, who is black, said of not having health insurance. “It was very frightening, not being able to see.”

But for all the success, over the last couple of years, the uninsured rate has started creeping back up. In 2018, 8.5 percent of the population did not have health insurance, up from 7.9 percent the year before, the Census Bureau reported. It was the first increase since the Affordable Care Act passed, and came even as the economy was doing well. Researchers are trying to measure the impact on the uninsured rate of efforts by the Trump administration and Republicans in Congress to undermine the law, including eliminating the mandate requiring most people to have coverage and slashing the budget for marketing and programs that helped people learn about new insurance options.

The slippage has especially hurt children — a recent analysis of new census data by The Times found that the number of children without insurance rose by more than 400,000 between 2016 and 2018.
Now, as the coronavirus sweeps through the country, many state officials are relying on the Affordable Care Act to provide health coverage for residents who have none. On Friday, California became one of the latest states to set up a special enrollment period so people can sign up for insurance on their state-run marketplaces, and the Trump administration is considering reopening enrollment in the larger federal marketplace, which serves most states, for a limited period.

It hasn’t curbed costs enough.

For many Americans, the “Affordable” part of the Affordable Care Act has seemed like an empty promise, as premiums, deductibles and other out-of-pocket costs continue to be an extraordinary burden on millions of households.
But the law has made health care far more affordable in a number of less conspicuous ways.
For Marque Dailey of Dallas, 35, who has multiple sclerosis, the Affordable Care Act was the only way to get private insurance. Before the law, insurance companies were allowed to deny coverage to people like him who had expensive medical conditions, or to charge such a high price that many could not afford the premiums. About half of all Americans had such pre-existing conditions, including high blood pressure or lung disease, that resulted in their being denied or potentially priced out of coverage, according to one federal estimate.
After the law passed forcing insurers to accept anyone without raising premiums, Mr. Dailey was able to enroll in a Blue Cross plan in Texas, which covered his medical care that at times approached $200,000 a year. His income was low enough that he also qualified for generous federal subsidies under the law that kept his monthly premiums at no more than $235, and his out-of-pocket costs capped at around $1,000 a year.
The law has also played an important role in keeping care affordable for the 160 million Americans who get coverage from an employer, including by requiring those plans to cover the children of beneficiaries until age 26.
Before the law, employer-provided plans often set strict limits on what they would pay toward medical bills during a single year and over a lifetime. An estimated 105 million Americans had some sort of lifetime cap before the passage of the health care law.

The A.C.A. outlawed those limits.
That has allowed Erik Westlund and Dr. Christina Cifra, of Iowa City, to afford their 4-year-old son’s care. He has hemophilia and needs a clotting factor that costs roughly $26,000 a month, or $312,000 a year. They are insured, through Dr. Cifra’s job but his more than $1.2 million in medical bills to date would have easily surpassed many employers’ lifetime caps before the A.C.A.
Because such limits are no longer allowed, the family doesn’t have to worry about medical expenses. “We haven’t had any financial challenges, really,” Mr. Westlund said.

Still, health care remains unaffordable for many middle-class people, who don’t qualify for Medicaid or federal subsidies to help buy an individual policy.
The average premium for a midlevel plan for a 40-year-old who doesn’t qualify for a subsidy has climbed to $462 a month in 2020 from $273 in 2014, according to the Kaiser Family Foundation. And the law has done little to address soaring prescription drug costs and staggering deductibles.
“The affordability problem is different from the coverage problem,” said Katherine Hempstead, a senior policy adviser for the Robert Wood Johnson Foundation. “Health care has just become so expensive,” Ms. Hempstead said.

It’s saved lives.

Before the law passed, researchers weren’t sure that having health insurance actually improved people’s health. Of course it made it possible for people to use more health care services. But whether those services really mattered was an unsettled question.

A recent series of persuasive studies has made clear to researchers that Obamacare really did make people healthier.
“At this point now there is enough evidence that we can say confidently that giving people health insurance produces health impacts and positive health changes,” said Benjamin Somers, a physician and researcher at the Harvard T.H. Chan School of Public Health.
A number of small studies that compared states have suggested that expanding Medicaid programs improves health for poor Americans with various ailments: Studies have shown it reduces complications or improves longevity for people with renal disease, cardiovascular disease and heart failure, and after surgery.
Those studies were published in peer-reviewed journals, but they had measurement challenges that caused some scholars to view their conclusions with skepticism.
But, more recently, bigger studies with better data have answered the question more definitively.
“If you put all of it together, it seems like the A.C.A. did have a positive effect on health and caused a reduction in mortality,” said Craig Garthwaite, a health economist at the Kellogg School at Northwestern, who had counted himself a skeptic before seeing the recent results.

The first big study looked at what happened to older low-income adults. It showed that those who lived in states that chose to expand Medicaid coverage were less likely to die than people with similar demographic characteristics in states that chose not to expand.

The second study used an even stronger methodology. Employees at the Treasury Department used tax records to identify Americans who were uninsured, then mailed a letter about health insurance options to a random sample of them. Researchers found less insurance and more deaths in the group that didn’t get a letter. Because that study cut across every state, and because the experiment used a random method of selection, several scholars who had previously been unsure say they are now convinced that the law’s expanded health insurance coverage is making a meaningful difference in physical health.
The new mortality studies measure only death rates. They don’t track the medical care or the health status of the people in the studies, so it’s still unclear precisely how that health insurance matters.
After all, even people without health insurance can go to an emergency room and receive treatment for their most acute problems. And existing networks of free and low-cost clinics have always helped some uninsured people get less urgent care.
One theory is that health insurance makes it easier to get prescription drugs, particularly drugs shown to reduce deaths from cardiac problems. A study from Dr. Somers and his co-authors found that Medicaid expansion led to big increases in prescriptions for this class of drugs.
Another theory is that, even though uninsured people can use the emergency room, insured people are still quicker to seek care there. The difference between waiting hours or days to seek care after showing signs of a heart attack or a stroke could be the difference between life and death.
Jacob Goldin, an associate professor at Stanford, who was one of the authors of the Treasury paper, said he had been surprised by how quickly his paper showed changes from health insurance. They started being able to measure reductions in deaths after just one year, he said, a timeline that may be explained by the emergency room theory.

It’s made insurers richer.

The health care industry supported the law a decade ago because it offered them tens of millions more in paying customers. “These guys supported the A.C.A. for very good and very self-interested reasons,” said Dr. Len Nichols, a health policy professor at George Mason University.

In the early years though, it wasn’t clear that the insurance market created under the law was going to work. Healthcare.gov, the federal online marketplace, got off to a shaky start, with technical issues keeping people from enrolling in plans. Insurers also had difficulty pricing their plans. After decades of carefully selecting whom they insured, insurers were forced to operate under the new requirement to offer anyone a policy, even if that person had a potentially expensive medical condition, without charging a much higher price.
Many insurers suffered heavy losses at first. Some of the biggest players in health insurance abandoned the market. UnitedHealth Group, one of the nation’s largest insurers, bowed out in 2016, citing losses of $1 billion. Lawmakers worried about so-called bare counties, places where insurers would simply refuse to offer coverage because there weren’t enough customers or prices were too high to stay in business.
But while the learning curve was steep, insurers discovered how to prosper. They raised premiums enough to make money and narrowed their networks of hospitals and doctors to reduce their costs. Insurers also latched on to the government’s Medicaid program, which is run by private insurers in most states.
“The individual market remains profitable and stable,” concluded a recent analysis by the Kaiser Family Foundation, which tracked the financial performance of the insurers. Companies, which were once spending nearly every cent of each dollar they collected in premiums on medical claims, were now taking in enough money to have 25 cents left over in the most recent period of 2019.

Here’s its biggest flaw.

When the Affordable Care Act’s architects think about what they wish they had done differently, they often focus on one issue: the deductibles.
Most health insurance plans have deductibles, an amount that patients need to pay before coverage kicks in. The Affordable Care Act, however, allowed insurers to set deductibles significantly higher than those typically faced by Americans who get health insurance at work.
Individual deductibles can go as high as $8,150. For families, the limit rises to $16,300.
The White House and Congress wrote those amounts into the law when they drafted it in order to keep the law’s overall price tag down. Looking back, they question that decision.

“We obviously made a huge mistake,” said Ezekiel J. Emanuel, who advised the Obama White House on health policy at the time. “We were under a lot of pressure to keep the price under a trillion dollars. That was constraining everything we did, from the size of the subsidies to what type of care could have no co-pay.”
Surveys of health law enrollees show that the deductibles are patients’ biggest struggle, more so than concerns about having enough doctors in-network or even the price of the premiums. In interviews, people with coverage through the law said they’re simultaneously grateful to have the peace of mind that comes with health insurance and frustrated that they still can’t afford to see a doctor.

“Because of my experience of being uninsured, I know that my coverage has value even if I never use it,” said Elizabeth Meyer, a contract lawyer in Chicago who has purchased health law coverage since the program began in 2014. “At the same time, any health care I want is still me paying for it on my own.”
Ms. Meyer currently buys a health plan with a $6,650 deductible. She says she now goes to the doctor less than when she was uninsured, because she can no longer ask for a discount her providers typically gave to patients lacking coverage.
Jeremy Kridel, 43, lives in the Baltimore suburbs and buys coverage for his family through the health law marketplace. A federal subsidy brings the premium he pays down to $275 a month, but the plan’s $13,000 family deductible means that the family frequently skips recommended care, including for his son who has autism.
“I feel guilty,” Mr. Kridel, a rabbi, said. “My wife has a lot of damage to cartilage in her knees, but goes as long as she can between sets of shots even when her knees hurt. We know we’re just kicking the can down the road, but we couldn’t afford surgery right now.”

Some of those who worked on the Affordable Care Act say they saw this issue coming, as they were writing the legislation.
“There was an acknowledgment at the time that affordability was likely going to be a concern,” said Frederick Isai, who worked on the law as a congressional staffer in 2009 and 2010. He is now the executive director of the nonprofit Families USA, which advocates affordable health coverage.
Some expected that the health law’s subsidies would be enhanced over time, as legislators often return to make tweaks and adjustments to major legislation. Instead, Republican legislation focused primarily on attempting to repeal the health law and replace it with something else.
The health law’s architects say there is an easy way to address the health law’s large deductibles: pass new legislation that puts more money toward subsidies. Right now, the Affordable Care Act offers premium subsidies to Americans who earn up to 400 percent of the poverty line, about $48,500 for an individual and $100,000 for a family of four.
Subsidies for deductibles go up only to 250 percent of the poverty line, meaning that families like Mr. Kridel’s are excluded.
But more generous subsidies require more government spending at a time when deficits are already ballooning.
So there’s another, harder, way to fix the Affordable Care Act deductible problem: rein in America’s high medical prices. If each doctor visit and hospital stay costs less, then insurers would be able to cover more without asking patients to pay a large share.

“The biggest problem,” said Bob Kocher, a former health policy adviser to President Obama, “is that health care costs have grown relentlessly.”
https://www.nytimes.com/2020/03/23/health/obamacare-aca-coverage-cost-history.html?action=click&module=News&pgtype=Homepage

While working on a book about the failings of the U.S. health care system, this Portland writer got sick

Jennifer Lunden had to take a break from writing, just as her research took on more urgency.

 

 

By Bob Keyes - Portland Sunday Telegram - March 22, 2020

 

  Against her will and despite her best efforts, Portland writer Jennifer Lunden has become pretty good at self-isolation and social distancing these last few months, long before most of us had to.
Lunden, winner of the 2019 Literary Arts Fellowship awarded by the Maine Arts Commission, was deep into writing a book about the health-related costs of capitalism, “American Breakdown: Notes from an Industrialized Body,” when she slipped into an acute relapse of myalgic encephalomyelitis/chronic fatigue syndrome, the illness that made her want to write the book in the first place.
The condition results in extreme fatigue, leaving many people unable to get out of bed or complete simple tasks like taking a shower. The illness was a big part of Lunden’s life when she was younger, back in her 20s. She was flattened by fatigue in 1989, and felt dismissed by her doctor when he told her she was depressed. That set on her on a quest to better understand chronic fatigue and take more control over the physical condition of her life.
She managed well for decades, to the point that chronic fatigue was hardly a factor in her daily life. In 2018, she signed a contract to write a book about her experiences with the American health care system, from her perspective as a dual citizen of the United States and Canada. She was born in the United States, grew up in Canada, and moved to Maine at age 21. Soon after leaving a country with universal health care and moving to one without some form of health care for all, she fell ill with mononucleosis.
That led to the onset of myalgic encephalomyelitis/chronic fatigue syndrome and a 30-year journey into the dark heart of American health care. As she describes it, “American Breakdown” will blend memoir, history, science and social criticism “to explore the health hazards of unfettered industrial capitalism,” told through her experience with chronic fatigue and various chemical sensitivities associated with it.
All was fine until last fall, when she relapsed while she was nearing completion of her first draft. Her condition became so bad she was unable to hold her hands to the keyboard for any length of time. Her writing ground to a halt over the winter. She asked for and was granted an extension by her publisher, and then launched a GoFundMe campaign to help her pay mounting medical bills.
She is feeling better lately, and hopes to return to a full writing schedule in the spring.
As she witnessed the grounding of American society in recent days because of the spread the coronavirus, she felt tremendous empathy for everyone, and couldn’t help but feel some bitter irony. Just as Lunden was feeling like she “had joined life again,” the coronavirus shut down the outside world she was ready to rejoin. Just as she was ready to reengage, if only on a limited basis, she couldn’t.
“This is the best I have felt in a long time,” she said, laughing at the absurdity of it all.
Lunden, 52, understands what it’s like living with uncertainty and fear and the necessity of taking extreme precautions to stay healthy. She knows what it’s like to spend days at home, in isolation. Because of fatigue, she only leaves her Portland home for doctor’s appointments. When the COVID-19 cases began emerging in Portland, she arranged to rent a portable hyperbolic oxygen chamber. She used to go to her chiropractor’s office for treatments, four times a week. Now she is doing them in a portable unit at home.
“It’s scary,” she said. “I’m probably more vulnerable to it than fully healthy people, but it’s scary for all of us. It could hit it any of us and affect any of us. It’s a terrifying feeling.”
The coronavirus notwithstanding, Lunden has been feeling better and is optimistic she will get back to a productive writing routine. She will start with an hour of writing a day, with a goal of getting back to six or seven hours a day. That is what she was doing before the relapse in the fall. “If I can start with an hour a day, that will be enough to make me feel like a writer again,” she said.
In “American Breakdown,” she is writing about the health effects of industrial capitalism on individuals and society. They’re all bad, she said. Americans live with a lot of stress and not a lot of happiness, relative to other industrialized countries. She explores the effects of stress on personal health and the role of capitalism in our stressful lives. “It’s self-evident,” she said. “We are struggling to make a living, and the system isn’t set up in our best interests. It’s set up in the best interests of the corporations.”
As she works her way back to being a productive writer, Lunden is weighing how to handle her relapse in the book. As a writer of nonfiction, her personal story will inform her book. That’s the silver lining of her first-person experience. Her original plan was to finish the book with an optimistic closing chapter about her recovery from her original bout with chronic fatigue and her ability to manage it. “But the relapse is a complicating factor. I might have to write an epilogue or a separate essay to come out when the book is released,” she said.
Her new deadline is February 2021.
One of her physicians, Dr. Sean McCloy of Integrative Health Center of Maine, described chronic fatigue syndrome as “a wastebasket diagnosis. It’s a collection of symptoms, rather than an actual diagnosis,” he said.
For Lunden, it’s been debilitating, he said. “I feel so bad for her. It’s the height of irony that she finally got well enough to write a book about her experience and her condition, and now she has a massive relapse of symptoms so severe that she can’t carry it on anymore,” he said. “It’s sad and ironic.”
McCloy has been working with Lunden since 2006, after she had seen a parade of other doctors who were unable to connect the dots of her condition. He called Lunden “a medical mystery” and an example of someone who was written off by the medical establishment as suffering from depression or anxiety when other explanations demanded exploration.
“It’s a bio-chemical problem,” he said. “Intellectually speaking, these are the most challenging cases for me and my medical practice, because it’s detective work. We have to put all the pieces together to get a complete picture.”
Lunden has a history of toxins in her body, he said. A genetic mutation prevents her body from detoxifying common toxins that we’re all exposed to, things like cigarette smoke, perfumes and scented products. “Because of her issues, her body can’t get rid of that junk,” he said.
As a result of the toxin buildup, Lunden’s mitochondria, the organelles that generate cellular energy, can’t produce enough energy to power her body. At the same time, her brain isn’t producing the serotonin and dopamine required to live “a happy, normal life. So she has literally run out of energy,” McCloy said. “It’s not her fault. She is trying to live a healthy life and is doing all the right things. It’s just that her body won’t let her get better sometimes. Her tank has run empty, in a literal sense.”
Frank Turek, her husband, wondered if his wife would regain the strength to get back to her book. When they met in 2002, Lunden was recovering from her first bout with chronic fatigue syndrome. As a couple, they avoided places with toxic odors out of sensitivity to her condition, but otherwise they lived an active life.
Her setback this fall felt numbing, Turek said. The doctors were flummoxed. He was flummoxed. She had good weeks followed by bad weeks, hope followed by despair. There was an air of general sadness, Turek said.
Lunden couldn’t function and Turek couldn’t do much beyond taking her to her appointments and practical things like shopping for groceries and cooking. Throughout, his admiration of her has grown.
And now with spring, there is hope, he said. “She’s got a strong work ethic, and she is committed to this book. It’s been frustrating, but she’s moving forward.”
https://www.pressherald.com/2020/03/22/while-working-on-a-book-about-the-failings-of-the-u-s-healthcare-system-this-portland-writer-got-sick/

America's extreme neoliberal healthcare system is putting the country at risk 

by Adam Gaffney - The Guardian - March 21, 2020

At the final debate of the Democratic presidential primary on Sunday, Senator Bernie Sanders and Joe Biden clashed on the coronavirus. Sanders contended the pandemic laid bare “the incredible weakness and dysfunctionality” of the US healthcare system, and called for single-payer reform. Biden countered that Italy’s universal system had failed to protect the Mediterranean nation, and asserted that Covid-19 “has nothing to do with Bernie’s Medicare for All”. At first glance, the ex-vice-president seems right: of course single-payer can’t close the door to a novel virus, any more than it can forestall a deadly earthquake or fend off a zombie apocalypse. Nonetheless, a national health program with unified financing and governance – basically the opposite of what we have in America today – is a powerful tool in a health crisis.
The debate over Medicare for All in the age of Covid-19 is complicated by the fact that it is our public health agencies – and not the medical care system – that serve as our first line of defense against novel epidemics. In that regard, we’ve shot ourselves in the foot with a 12-gauge shotgun: year after year of underfunding of our federal, state and local public health agencies has left us ill-prepared for the Covid-19 challenge (as evidenced by the testing fiasco). How we finance medical care, however, is also critical. On the most basic level, containing the coronavirus will require those infected to seek medical care, so that they can be diagnosed and isolated. Fear of devastating ER or hospital bills, however, could keep some home – or at work. As a Taiwan government spokeswoman, lauding her country’s single-payer system for its successful containment of Covid-19, told NBC News, “Taiwan’s health insurance lets everyone not be afraid to go to the hospital. If you suspect you have coronavirus, you won’t have to worry that you can’t afford the hospital visit to get tested.”
On Wednesday, Trump signed into law a bill that would make Covid-19 testing – but not treatment – free. It’s hence inadequate, given the predicted looming surge in hospitalizations from Covid-19 pneumonia. After all, 30 million Americans are uninsured – a number that will surely grow as the economy tanks and millions or tens of millions of Americans lose their jobs. Even more are underinsured, and for these individuals, co-pays and deductibles will only become more unaffordable as disposable income falls and savings dwindle. For both groups, medical bills for an intensive care unit (ICU) stay for Covid-19 could be devastating. People, of course, will also not stop having heart attacks, cancer or traffic accidents during this outbreak – on the contrary, medical needs are likely to rise in the face of a recession, as unemployment and misery takes its toll on the nation’s health. Financial ruin from medical costs – whether it stems from Covid-19 pneumonia or the looming Covid-19 recession – is financial ruin all the same, and will compound the harm of the epidemic.
But there’s more to it than that. We need single-payer not only to protect us from healthcare costs, but to transform our healthcare infrastructure. In recent weeks, you may have heard that the US, despite our high healthcare spending, has fewer hospital beds per capita than many other wealthy nations. You may have also heard in recent years about an epidemic of hospital closures in poorly served rural areas, or the 2019 closure of a major academic safety-net hospital in Philadelphia. These hospitals closed not because they are unneeded, but because they are unprofitable. For the American hospital landscape is shaped by market forces, which largely determine where hospitals grow and where they wane.
At the same time, while our hospital bed supply is relatively low, our ICU bed supply per capita is among the highest in the world. Yet those beds aren’t necessarily where they need to be: a 2010 study in the Journal of American Medical Association, for instance, found large regional disparities in the distribution of ICU beds; the researchers concluded that in the face of a major epidemic, some areas might have empty beds, while others would have too few. Again, this distribution, far too often, is driven by market logic – not health needs.
Finally, healthcare in America is uncoordinated – and ungoverned. Since the epidemic’s onset, hospital and city and state governments have waged “bidding wars” over crucial supplies and ventilators, the New York Times noted. It’s every hospital for itself: some are resorting to pleas to the community for donations of masks; presumably, others are well-stocked – but who knows? “Respirators, ventilators, all of the equipment – try getting it yourselves,” Trump suggested to state governors on Monday, quoted by the New York Times. This is not a healthcare system – it is atomized chaos. For again, in the American way of paying for healthcare, our hospitals (or increasingly, our multi-hospital systems) are silos, some rich and some poor, each fending for themselves, locked in market competition.
This is neither necessary nor rational, leading both to excess and shortfalls, to generous overall health system funding yet care that remains unaffordable for many. A single-payer national health program would allow us to move past the market-driven status quo to remake this chaotic healthcare landscape of simultaneous healthcare plenty and poverty. It would, in short, allow us to begin to plan – not merely for this epidemic, but for the one that follows.
https://www.theguardian.com/commentisfree/2020/mar/21/medicare-for-all-coronavirus-covid-19-single-payer?fbclid=IwAR1X1cyrvoR_B4AvSjmbxkxekes3smHwipdReiDFRxt0S7dZRlASPdNKT4g