Commentary: The US healthcare system was ill-prepared in the first place
The COVID-19 pandemic shows the US health care system is underfunded, understaffed and lacked support from the get-go, says an observer.
PHILADELPHIA, Pennsylvania: As the coronavirus pandemic exerts a tighter grip on the world, critics of US President Donald Trump’s administration have repeatedly highlighted the administration’s changes to the nation’s pandemic response team since 2018 as a major contributor to the current crisis.
This combines with a hiring freeze at the Centers for Disease Control and Prevention, leaving hundreds of positions unfilled. The administration also has repeatedly sought to reduce CDC funding by billions of dollars.
Experts agree that the slow and uncoordinated response has been inadequate and has likely failed to mitigate the coming widespread outbreak in the US.
However, it is also important to acknowledge that the US has underfunded its public health system for decades, perpetuated a poorly working health care system and failed to bring its social safety nets in line with other developed nations.
As a result, the country must expect significant repercussions, much of which will disproportionately fall on those who can least afford it.
DECADES OF UNDER-FUNDING
Spending on public health has historically proven to be one of humanity’s best investments. Indeed, some of the largest increases in life expectancy have come as the direct result of public health interventions, such as sanitation improvements and vaccinations.
Even today, return on investments for public health spending is substantial and tends to significantly outweigh many medical interventions. For example, one study found that every US$10 per person spent by local US health departments reduces infectious disease morbidity by 7.4 per cent.
However, despite their importance to national well-being, US public health expenditures have been neglected at all levels. Since 2008, for example, local health departments have lost more than 55,000 staff. By 2016, only about 133,000 full-time equivalent staff remained.
State funding for public health was lower in 2016 to 2017 than in 2008 to 2009. And the CDC’s prevention and public health budget has been flat and significantly underfunded for years.
Overall, of the more than US$3.5 trillion the U.S. spends annually on healthcare, a meager 2.5 per cent goes to public health.
Not surprisingly, the nation has experienced a number of outbreaks of easily preventable diseases. Currently, the US is in the middle of significant outbreaks of hepatitis A (more than 31,000 cases), syphilis (more than 35,000 cases), gonorrhea (more than 580,000 cases) and chlamydia (more than 1,750,000 cases).
Its failure to contain known diseases bodes ill for its ability to rein in the emerging coronavirus pandemic.
FAILURES OF HEALTHCARE SYSTEMS
Yet while the US has under-invested in public health, the country has been spending massive and growing amounts of money on its medical care system. Indeed, the US is spending more than any other country for a system that is significantly under-performing.
To make things worse, it is also highly inequitable. Yet, the system is highly profitable for all players involved.
And to maximise income, both for- and nonprofits have consistently pushed for greater privatisation and the elimination of competitors.
As a result, thousands of public and private hospitals deemed “inefficient” because of unfilled beds have closed. This eliminated a significant cushion in the system to buffer spikes in demand.
At any given time, this decrease in capacity does not pose much of a problem for the nation. Yet in the middle of a global pandemic, communities will face significant challenges without this surge capacity.
If the outbreak mirrors anything close to the situation in other countries, there could be almost six seriously ill patients for every existing hospital bed.
A worst-case scenario from the same study puts the number at 17 to one. To make things worse, there will likely be a particular shortage of unoccupied intensive care beds.
Of course, the lack of overall hospitals beds is not the most pressing issue. Hospitals also lack the levels of staffing and supplies needed to cope with a mass influx of patients. However, the lack of ventilators might prove the most daunting challenge.
LIMITS OF THE OVERALL SAFETY NET
While the US spends trillions of dollars each year on medical care, its social safety net has increasingly come under strain. Even after the Affordable Care Act, almost 30 million Americans do not have health insurance coverage. Many others are struggling with high out-of-pocket payments.
To make things worse, spending on social programmes, outside of those protecting the elderly, has been shrinking, and is significantly smaller than in other developed nations. Moreover, public assistance is highly uneven and differs significantly from state to state.
And of course, the US heavily relies on private entities, mostly employers, to offer benefits taken for granted in other developed countries, including paid sick leave and child care.
But this arrangement leaves one in four American workers without paid sick leave, resulting in highly inequitable coverage. As a result, many low-income families struggle to make ends meet even when times are good.
CAN THE US ADAPT?
The limitations of the US public health response and a potentially overwhelmed medical care system are likely going to be exacerbated by the blatant limitations of the US welfare state.
However, after weathering the current storm, we should expect the US to go back to business as usual relatively quickly. After all, that’s what happened after every previous pandemic, such as H1N1 in 2009 or even the 1918 flu epidemic.
The problems are in the incentive structure for elected officials. Policymakers remain hesitant to invest in public health, let alone revamp the safety net. While the costs are high, particularly for the latter, there are no buildings to be named, and no quick victories to be had.
The few advocates for greater investments lack resources compared to the trillion-dollar interests from the medical sector.
Yet, if altruism is not enough, US citizens should keep reminding policymakers that outbreaks of communicable diseases pose tremendous challenges for local health care systems and communities.
They also create remarkable societal costs. The coronavirus serves as a stark reminder.
Simon F Haeder is Assistant Professor of Public Policy at Pennsylvania State University. This commentary first appeared in The Conversation.