Even before the global COVID-19 pandemic, scholars, healthcare experts and everyday citizens were already turning their attention to some of the deep flaws in the American healthcare system.
It is well-known, and well-documented, that healthcare in America is expensive, broken and riddled with inequality. Anne Case and Angus Deaton, authors of the recent book, Deaths of Despair and the Future of Capitalism, summarize the state of our for-profit, employer-based system: “We believe that the healthcare system is a uniquely American calamity that is undermining American lives…[It’s] a leading example of an institution that, under political protection, redistributes income upward to hospitals, physicians, device makers and pharmaceutical companies while delivering among the worst health outcomes of any rich country.”
But if anything, the pandemic is shining an even brighter light on these flaws, any one of which could stymie progress for those recovering from childhood adversity and trauma. Pew Research reported in March that an estimated 33 million Americans do not have paid sick leave. A little more 27 million Americans – 8.5 percent of the population – don’t even have insurance. While Blacks are minorities in most major cities, they have had disproportionately high COVID-19 infection hospitalization and death rates in New York, Georgia, Illinois and Michigan. And now that elective surgeries have been put on hold, and provisions to provide urgent medical care without regard to profit have expanded, the profit motive is hurting hospitals more than ever.
At the same time, however, COVID-19 has some experts wondering if the day of reckoning has finally arrived. Is it possible, they ask, that America can use the collective trauma of this moment to make healthcare more equitable?
In an April article in STAT News, Julia Marcus and Dr. Joshua Barocas express hope for such a transformation. “In the past two weeks, the nation has adopted new policies to protect the health of vulnerable populations – policies that public health professionals and advocates have been pursuing for decades.
“We are finally protecting workers. For the first time, the federal government is providing paid sick leave so more employees do not have to choose between their paychecks and their own health. [It’s not nearly enough, but it’s a start.] Some states have reopened health insurance exchanges under the Affordable Care Act, and others are expanding Medicaid, broadening access to health care as unemployment skyrockets and the markets collapse.”
Marcus and Barocas name other positive changes such as the increased use of telehealth, which vastly broadens access to services; health insurance reimbursement for remote care; lifted restrictions on methadone and buprenorphine (drugs for opioid use disorder); and policies that extend to the criminal justice system, allowing the release of nonviolent offenders in some states to reduce the overcrowding that boosts transmission of COVID-19.
The authors express hope that the rapid transformation of the healthcare system to meet the needs of the most marginalized will be hard to reverse. But other public health experts aren’t as optimistic about America’s potential for holistic, systemic change.
“I tend to take a long view of our society,” says Jennifer Malat, first author of the 2017 paper, “The effects of whiteness on the health of whites in the USA.” “And one of the things about the U.S. that has been consistent is that we provide all things unequally.” Indeed, the main point of her paper is that even socially disadvantaged whites who could benefit from expanded Medicaid, for example, view anything that might help Blacks and Latinos as unfair, so they tend to actively disapprove of such measures. “So I don’t see any reason to be optimistic that that will be over,” Malat says. “Historically, when resources are scarce, those with the most power take action to maintain resources for themselves.”
The absence, too, of a sustained and honest conversation among white people, in particular, about the combined impact of race and capitalism, as well as the ways in which privilege and ignorance have shaped modern practices and beliefs, are likely to persist, she says. “We have a lot of white people who wouldn’t agree with the premise that the system distributes resources based on race.”
Philip Alcabes, director of the public health program at Hunter College, in New York City, is also skeptical that our society is ready for system-wide change. He explained his position in a webinar he produced in mid-April, along with Distinguished Professors of Public Health at Hunter College David Himmelstein and Steffie Woolhandler, on the impact of COVID-19 on American healthcare.
“It is always the case that economic disadvantage produces more vulnerability to disease, and perhaps especially so in an outbreak,” Alcabes said. “Unless there are some specific measures taken by policy makers to provide extra protection to the poor and working classes, these groups will suffer more. Our leaders haven't done very much to reduce vulnerability. Given the political situation these days, I don't feel optimistic that that is going to change.”
Himmelstein agreed that the pandemic has exposed the economic disparities in our culture. “[It] has highlighted the mismatch between who do valuable work and who reap financial rewards in our society,” he said. “Many of those whose work has been deemed ‘essential’ are low-paid, or even minimum-wage workers, while the super-rich are generally not needed. So yes, the pandemic has made the class stratification in society both more visible and visibly irrational.” But he is slightly more optimistic than Alcabes about what might come next. “I am hopeful that this will lead to change going forward.”
Malat actually shares Himmelstein’s hope that the pandemic could force some kind of reckoning on the issue of income inequality, despite her belief that the racial disparities are too entrenched to change. “There are some reasons for optimism,” she says, pointing to the attention that’s been paid to low-wage workers like healthcare grocery store and delivery workers. Things only change when there’s a demand for change, she explains, and the pandemic seems to be creating that kind of pressure.
Whatever happens on the racial and economic fronts, Woolhandler is convinced that one outcome of the pandemic could very likely be the destruction of employer-based health insurance. “Employer-based healthcare is like an umbrella that melts in the rain with 22 million people out of work,” she explained during the webinar. As of May 1, that number had expanded to 30 million.
In a subsequent email exchange, she elaborated on what she sees as the inevitable result of millions of people continuing to join the ranks of the unemployed. “U.S. health financing will shift away from employer-based healthcare simply because employment is shrinking. Over the long term, many Americans may become disenchanted with the employment-based, private-insurance paradigm. With good political leadership, this disenchantment could, and should, be turned into political momentum for a Medicare-for-All reform.”
Comments (0)