The Covid-19 coronavirus exposed weaknesses in the US health system

The international response to the novel coronavirus has laid this bare: America was less prepared for a pandemic than countries with universal health systems.

There is a real concern that Americans, with a high uninsured rate and high out-of-pocket costs compared to the rest of the world, won’t seek care because of the costs. Before the crisis even began, the United States had fewer doctors and fewer hospital beds per capita than most other developed countries. The rollout of Covid-19 testing has been patchy, reliant on a mix of government and private labs to scale up the capacity to perform the tens of thousands of tests that will be necessary.

“Everyone working in this space would agree that no matter how you measure it, the US is far behind on this,” says Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation.

People need to go to the doctor and get checked if they have Covid-19 symptoms, yet Americans may avoid medical care, even for serious conditions, because of the costs. Hospitals will need rooms for the people who require close monitoring in a clinical setting, and ICU beds and ventilators for patients who take a turn for the worse and require mechanical support to keep their bodies functioning.

Kaiser Permanente medical workers take swabs from people for the coronavirus at a drive-through testing facility in San Francisco, California on March 12, 2020.
Josh Edelson/AFP via Getty Images

But none of those units are sitting empty right now — they already have non-coronavirus patients who need them and will continue to need them through the crisis. New York Gov. Andrew Cuomo said Sunday that nearly 80 percent of New York City’s intensive care units were already filled, even with the Covid-19 outbreak still expanding.

By any of these metrics on pandemic preparedness, America trails most of the rest of the developed world.

“The U.S. performs worse than average among similarly large and wealthy countries across nearly all measures of preparedness for a pandemic,” Cynthia Cox, director of the Peterson-Kaiser Health System Tracker, told me. “The coronavirus outbreak is already exposing inefficiencies and inequities in our health system, and it is likely to put much more strain on the system in the coming weeks.”

And the slow start to testing in the US is only going to exacerbate those problems.

Testing is important not only because it gets people diagnosed and on an appropriate treatment if they do have an infection. It also establishes how widespread a virus actually is. Experts know the size of the problem, they know the rate at which people are being hospitalized or dying, and they can follow its movements. That leads to a more informed response.

But the United States has faltered in rolling out coronavirus tests, putting us far behind our economic peers in tracing the outbreak. A manufacturing problem with the test kits that were initially sent out in the field, and a delay in approving commercial tests, set the nation back in stopping or slowing down Covid-19.

Christina Animashaun/Vox

“The testing failure is putting additional strain on our already challenged health system,” Cox said. “The combination of all of these factors will make the U.S. worse off than similar countries.”

Universal health care is not a perfect treatment for emergencies like this. Italy has a universal health care system, a federalized national health insurance program similar to Canada’s, but an uncontained outbreak has still forced the country to lock itself down as cases and deaths continue to pile up.

Nevertheless, other countries are still generally better prepared for a pandemic than the US is, and we are seeing right now the consequences of that gap.

For the time being, US politicians are proposing to make American health care more like these other nations: making care free or cheap at the point of service, either by having the government cover more of the cost or by mandating private insurers cover services related to the outbreak.

They are, however, only a temporary patch on these structural problems.

Why America is less prepared for a pandemic than other countries

On many measures, the United States has one of the worst health systems among developed economies. A bigger share of the population lacks health insurance. We carry more medical debt. We die more often from preventable causes. The weaknesses in this system, which already puts the US behind its peers on many health outcomes, are exposed in an outbreak.

And the biggest single problem, the one most unique to the American system, is costs.

Americans face higher out-of-pocket costs for their medical care than citizens of almost any other country, and research shows people forgo care they need, including for serious conditions, because of the cost barriers. Patients here are much more likely than those in most other countries to say they had a cost-related barrier to getting medical care: 33 percent in America vs. between 7 percent (Germany) and 22 percent (Switzerland) in other developed economies. Americans are more likely to say they struggled to afford or couldn’t afford medical bills and that their insurance plan had refused to cover some of their medical claims.

Peterson-Kaiser Health System Tracker

We know Americans delay care as a result of these cost barriers: in 2019, 33 percent of Americans said they put off treatment for a medical condition because of the cost; 25 percent said they postponed care for a serious condition. A 2018 study found that even women with breast cancer — a life-threatening diagnosis — would delay care because of the high deductibles on their insurance plan, even for basic services like imaging.

Those cost barriers hit patients at several points in a pandemic situation. First, they might be wary about going to the doctor at all because they are afraid they can’t afford the check-up or any testing. But then if they do get a Covid-19 diagnosis and require hospitalization, they have the bills from the hospital, the doctors they see, and any treatment they receive to worry about.

In America, and only in America among developed countries, do patients risk thousands of dollars in medical bills by seeking help in a crisis. Some Americans have already been billed nearly $4,000 over a government-imposed quarantine, as the New York Times reported.

Making matters worse is our system’s health care infrastructure, built on top of this fractured payer system. There are capacity shortages that put us at further disadvantage in a time of pandemic, when they are most needed.

Hospital beds, for example, will be necessary for Covid-19 patients with more serious symptoms. America has fewer hospital beds per capita than most other countries in the developed world.

Peterson-Kaiser Health System Tracker

A potential shortage of hospital beds is compounded by the fact that the US has higher rates of hospitalizations for chronic conditions that, with proper management, shouldn’t require the patient to go to the hospital. Those conditions include congestive heart failure, diabetes, and asthma. Researchers think a lack of access to primary care, and the high costs of seeking even this routine care compared to other countries, drive potentially preventable hospitalizations in the US.

That means our hospitals are already taking in patients they wouldn’t have to if the system functioned better, and now they will have to accommodate an influx of Covid-19 patients.

We have fewer doctors per capita too: 2.6 per 1,000 people, well below the comparable country average of 3.5 and lower than every country tracked by Peterson-Kaiser except for Japan. Experts blame the high cost of a medical education in the US, inextricably linked to America’s world-leading health care prices, for much of that shortfall.

And, likely as a result, Americans struggle more than people in most other places to get a same-day or next-day appointment with their doctor.

Peterson-Kaiser Health System Tracker

Take these structural problems together with America’s slow start to testing for coronavirus, and we are far behind where we should be.

“A failure to widely test and slow the spread means that we could have large spikes in the number of people who need medical care all at once, putting exceptional strain on our health system,” Cox told me. “By not acting quickly enough to prevent spread, our health system will be under greater, more concentrated strain.”

Many countries with universal health care are doing better than the US, but some have problems too

Countries with universal health care are testing more people and seem to be faring better with Covid-19 death rates than the United States. More centralized planning is an asset in a crisis.

Taiwan has seen a remarkably low level of coronavirus cases despite high traffic with the Chinese mainland. As Vox’s Kelsey Piper reported:

As of March 10, Taiwan has just 45 coronavirus disease (Covid-19) cases, and only one death. Health experts do not expect that Taiwan is overlooking many cases, either. That’s many fewer than its neighbors like Japan and South Korea and one of the best containment track records in the world so far. The Netherlands, with a comparable population, has five times as many cases despite having much less frequent direct travel with China.

In Taiwan, with its single-payer health program, every citizen has their digital medical records loaded into the same system. In the coronavirus outbreak, the country has added travel records to that online medical file, so every doctor can check whether their patients have visited an area affected by the outbreak.

And by getting jumpstarted on their response, those countries are able to lower the burden on their health systems. The primary goal with the coronavirus outbreak at this point is to slow the spread so health care providers aren’t overrun: to flatten the curve in this chart so patient needs don’t exceed the system’s capacity.

Christina Animashaun/Vox

So even though, as you may have noticed above, countries like Canada and United Kingdom have about the same number of hospital beds as the United States does, they should be better positioned to mitigate the outbreak. They are already testing a lot more people. More testing allows them to take smarter protective measures, because they have a better idea of the scope of the pandemic, which helps to reduce the burden on their health system during the worst peak of the outbreak.

But even universal health care cannot fully prepare a country for the unpredictable movements of a pandemic virus. Italy, with a national health service that provides care to each of its citizens, has seen its coronavirus situation spin quickly out of control. On Monday, the country decided to close its borders in a desperate attempt to stem the crisis.

As Vox’s Julia Belluz reported, there are competing theories for the problem. Perhaps the aggressive testing had just made the scale of the problem clear earlier than in other places. It’s hard to say for sure. Or:

Another is that intense spread of the virus in the hospital system, before doctors realized there was a problem, may have amplified the outbreak. Some 10 percent of medical workers in Lombardy have been infected, according to a March 3 Washington Post report, and health workers account for 5 percent of those infected in the country. (Bolstering this explanation: The WHO-ECDC joint mission report suggests Italy should work on its infection prevention and control measures in hospitals.)

There’s also speculation about whether Italy’s burden is particularly severe because of the country’s aging population. Covid-19 is known to hit the elderly particularly hard. That, along with the fast rise in confirmed cases, has tested the limits of the health system.

And yet, Italy still has more hospital beds per capita and doctors per capita than the United States, according to OECD and World Bank estimates. As experts worry whether Italy shows a glimpse of what’s to come in America, it’s worth remembering their health system still had a bigger capacity to handle a surge in patients than the US system currently does.

But the point is, pandemics are unpredictable. Their spread and containment depends a lot on human factors that even the most well-designed health system, or pandemic response plan, can’t fully anticipate.

And if the pandemic does overcome a country’s best preparedness efforts, some other countries could conceivably be at a deeper disadvantage than the US.

Patients who develop pneumonia because of Covid-19 may require mechanical ventilators. The Johns Hopkins Center for Health Security reported in 2018 that Canada, Australia, and New Zealand (each with their own version of national health insurance) had fewer ICU beds with mechanical ventilation capability per capita than America does, though we too are not equipped to handle a crisis on the scale of the Spanish flu.

Nevertheless, “these numbers suggest that the capacity of other countries to provide ventilation therapy might be significantly lower than our own,” the Johns Hopkins experts wrote.

For now, US officials want to temporarily make our health care more like other places

America’s fractured health system has made it more vulnerable to coronavirus. And in response, members of Congress and state governors keep proposing to make our health care more like other countries’ systems — at least during this emergency.

Some states are doing what they can to lower those burdens. New York Gov. Andrew Cuomo announced last week he would require insurers and Medicaid in New York to cover treatment and testing cost-free with an emergency declaration. States have some discretion with what their Medicaid programs cover, and more states are taking their own actions: California Gov. Gavin Newsom issued a similar order in the last few days.

Members of the National Guard attend the opening of a drive-through coronavirus mobile testing center in New Rochelle, New York, on March 13, 2020.
Spencer Platt/Getty Images

States are limited in what they can do, though ERISA, the federal law regulating the large employer health insurance plans that cover about 100 million Americans, is a barrier to state officials who want to do more. Cuomo’s order, for example, noted it applied to private health plans regulated by the state — the plans available to small businesses or individuals — but not the self-funded employer plans covered by ERISA. It’s another way a more decentralized health system complicates the response to an outbreak.

Rep. Ruben Gallego (D-AZ) announced last week he would introduce a bill that would make Medicaid cover testing for and treatment of Covid-19 for every American, no matter how they get their insurance. This would be an important change to US health care: The federal government would assume responsibility for medical care for every American under these particular circumstances.

And the Trump administration appears to see a need to do something drastic, too, even if experts don’t think some of their proposed actions will have a significant effect.

Vice President Mike Pence, for example, said Covid-19 testing and treatment would be treated as an “essential health benefit” (a standard established by the Affordable Care Act) to cover everyone’s care. But that change would actually not apply to the self-funded plans, nor to Medicare, as Nicholas Bagley, a law professor at the University of Michigan, wrote for The Incidental Economist:

Even if they did, insurers can (and do!) impose cost-sharing for EHBs, and could do so for a COVID-19 test. It’s a completely meaningless statement.

Though that may be, Pence’s statement still reflected a real need to put at least a temporary patch on our health system. Everybody seems to agree on that.

But these problems don’t go away when the coronavirus disappears. They are still there, if treated less urgently than in a crisis, affecting the lives of millions of Americans every day.

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