Just 3 months ago (!), there was a debate raging about the future of the US healthcare “system.” Should we overturn Obamacare (the position of the Trump administration), improve Obamacare (the position of most of the Democratic presidential candidates), or replace Obamacare with a truly universal single payer plan (Medicare for All). Very few were arguing for no change at all; despite increases in coverage and some slowing of the rate of growth in healthcare spending following the Affordable Care Act, the US continues to spend more for less results than other industrialized countries.
The global COVID-19 pandemic has led to a temporary pause in this debate. All attention in healthcare is focused on controlling the spread of the virus, finding a vaccine and effective therapies, and repairing the massive financial damage to the industry. But we will eventually have to come back to the discussion about what to do with health care in the US, and the pandemic has dramatically shifted the terms of that discussion. In a few short weeks, a submicroscopic bit of protein-coated RNA has ripped the cover off the US healthcare system and dramatically revealed two of its underlying weaknesses.
The first is the extent to which US healthcare is a massive shell game that is completely supported by cost shifting. Healthcare providers can accept below-cost reimbursement from government payers (Medicaid, and to a lesser extent Medicare) because they can shift those costs onto private payers. This particular shift has been under pressure from employers and private insurers for some time; now, in the face of a massive increase in unemployment and an accompanying increase in people who will rely on Medicaid or be uninsured, this scheme will be tested as never before. Moreover, healthcare providers can accept below-cost reimbursement for many vital services, such as preventive care and mental health care, because they can rely on way-above-cost reimbursement for procedural care. But now that many of those procedures that may be elective or at least less time-sensitive have been delayed due to a severe shortage of supplies such as personal protective equipment (PPE), hospitals and physician practices are losing massive amounts of money. And if there is a persistent change in demand for such lucrative procedures, this second cost-shifting wheel that keeps the bicycle of US healthcare going will also go flat. We’ve never before had this kind of one-two punch before, taking out both means of cross-subsidization that keep the system upright.
The second structural weakness in US healthcare is the shameful lack of investment in public health. This includes not only the traditional public health infrastructure for epidemiology, but everything from preventive care to well-integrated health records to funding on social determinants of health to a national stockpile of supplies and medications that is actually, well, stocked (that is part of the word, after all).
So when we get back to figuring out how to make the US health care system better and more sustainable, we should ask those proposing any of these – or any other – solutions, how their plan will address these fundamental flaws in our current state.