March 10, 2020
The U.S. health care delivery system does not have the capacity to deal with a pandemic like Covid-19. As it spreads throughout the country, it will expose deficiencies in the availability of sufficient primary care, regular and ICU hospital beds, and ventilators. Hopefully, the outbreak will spur Congress to finally develop and fund a plan to create the critically needed reserve capacity.
Coronavirus is spreading rapidly across the U.S. and — like other major epidemics — is shedding a merciless light on the failings of the U.S. health care delivery system
The first is its deficient primary care capability. Many Americans lack access to affordable primary care providers they know and trust, and who know them. In the case of epidemic illness, primary care professionals offer a first line of defense in the form of trusted advice and care that keeps people from flooding emergency rooms and hospital outpatient departments when they don’t need to be there. When individuals who are unlikely to have Covid-19 crowd such facilities, they not only delay care for the truly ill but are much more likely to get infected themselves. And if they have the disease, but it is mild, they pose a risk to other patients and staff. Should an effective vaccine for Covid-19 be developed, primary care providers will also be critical to dispensing it, as they are for all preventive care.
In the absence of a functioning, widely available primary care capacity, the U.S. will have to establish ad hoc systems to advise and treat the many Americans who have Covid-19 related issues — real or feared. The attendant delay and expense may have been avoidable.
Another problem facing the U.S. health care system is its lack of reserve capacity to handle health care crises of the type that the country may now be experiencing. (The source of the high costs of U.S. health care is the inordinate prices charged for using what we have and not an oversupply of resources.) For example, the system’s supply of hospital beds has been declining for the past two decades because of hospital closures and mergers.
Severe flu seasons often stress existing health care facilities. As a physician, one of us (David) has seen the result: Patients lined up on gurneys in frantically busy emergency rooms, and patients overflowing into the halls of hospital floors. The Washington Post recently described how even Boston’s Massachusetts General Hospital, one of the nation’s best hospitals and one of the most prepared, is scrambling to get ready for the epidemic.
Nationally, there is legitimate concern that the nation’s supply of 160,000 ventilators may be insufficient to care for the critically ill victims who are unable to breathe for themselves during a major outbreak. Such patients need intensive care unit beds. The U.S. currently has around 45,000, but in a severe outbreak of respiratory illness, as many as 2.9 million Americans might need ICU care. These issues will be particularly acute in rural areas, where shortages of health professionals and emergency facilities are routine in normal times.
For years, epidemiologists have warned of possibly catastrophic epidemics of new flu-like illnesses — whether swine flu or bird flu or SARS or MERS — but the U.S. delivery system is still not ready. The Centers for Medicare and Medicaid Services does not factor in costs of stand-by capacity in its routine payments to hospitals, which limits the ability of facilities to build and maintain the extra beds and supplies that might be required.
The U.S. needs a much more robust national reserve of health care resources — think of the U.S. strategic petroleum reserve — that it can draw on when the apparently inevitable crisis arrives. Congress would have to appropriate the necessary funds, but it has been reluctant to provide even minimal relief for past epidemics, much less support advance preparedness at the level required.
The current Covid-19 outbreak should trigger a careful examination of the reserve capacity needed to manage an epidemic comparable to the so-called Spanish Flu of 1918, which killed tens of millions of people worldwide and 750,000 Americans. The next step is to determine how to create one. This might begin with a public-private task force, chaired by the secretary of health and human services, that could develop and submit a plan to the White House and the Congress. This plan should also include recommendations for how to protect medical personnel from highly infectious agents like the novel coronavirus and to ensure an adequate supply of health professionals if their ranks are depleted acutely by illness.
Despite the many strengths of the U.S. health care system — especially its care of highly complex, specialized problems – it often falls short on the basics. As Covid-19’s spread continues, it will demonstrate how essential those missing basics truly are.