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Bioethics Forum Essay

Cracks in the System: Lessons Learned from the Covid-19 Pandemic

The United States leads the world in coronavirus cases and deaths. Although many people have called out the inadequacies of our health care system, Covid-19 has exposed the most significant shortcomings. The need for change can no longer be ignored. Here are three lessons from this pandemic that should be leveraged for change.

  1. All Americans Should Be Guaranteed Health Care

The U.S. health care “system” is a patchwork that even under normal conditions leaves far too many citizens without adequate coverage of health care expenses and unable to afford costly premiums, deductibles, and copays. The Congressional Budget Office’s interim economic projections predict a peak unemployment rate of 15.8%, almost 25 million people in the third quarter of this year. Because most people in the U.S. obtain their health insurance through employment-based programs, millions more will be left without health coverage. This number would be added to the 28 million Americans who were uninsured prior to the pandemic. Although the federal government is reportedly covering Covid-19 testing costs, no requisite funding for care related to Covid-19 treatment has been offered. Nor is there coverage for the many U.S. citizens with non-Covid-19 related health care needs who are uninsured and ineligible for Medicare or Medicaid.

Tragically, there are reports of patients’ final breaths expressing concern over their family’s financial well-being rather than saying goodbye. Many hardworking people will find themselves with medical debt and lack of income, having been forced out of “non-essential” work  to assist the greater community in flattening the curve through social distancing. The individual costs of this public emergency are not borne equally. Those living day-to-day in low-wage jobs will carry most of this enormous economic burden.

Gaps in coverage will remain in all states regardless of Medicaid expansion. The current federal stimulus packages offer no additional health coverage to those in need. The inequities of the U.S. health care system are well known, but Covid-19 has revealed just how incapable it is in the face of a public health crisis. While federally-guaranteed health care coverage would not have prevented this pandemic, it would have reduced the burden the pandemic placed on millions of people living in the U.S., and ultimately improved the rate of economic recovery.

  1. Racial and Socioeconomic Disparities Require Aggressive Intervention

Disparities within the U.S. health care system and beyond are well described. The gap between rich and poor continues to widen.  Awareness of the impact of race on health and health-related outcomes is increasing. Yet change has been painfully slow. The rapid spread of Covid-19 has made it impossible to ignore the existence of these disparities.

Economically disadvantaged people have been disproportionately impacted by the pandemic. School cancellations prove trying for the affluent, but are potentially disastrous for low-income families. Worsening food insecurities, lack of childcare, and the inability to stay home highlight some of the challenges faced by low-income families. The need for continued income forces many poor workers to put themselves at increased risk of infection in low-wage jobs deemed essential. Social distancing is actually a luxury that many people do not possess within the confines of crowded living conditions. Undocumented immigrants are at particularly high risk, both in detention centers and in the community.

People of color have been hit especially hard by Covid-19. Racism has resulted in poor health outcomes, especially for African-Americans. The higher prevalence of hypertension and diabetes represents a partial explanation for why African-Americans have significantly higher rates of ICU admissions and deaths from Covid than Caucasian patients.  Across the country, triage policies  have inadvertently played a role. Triage policies, developed in case demand for medical resources exceeds supply,  allocate limited resources to those with the greatest likelihood of survival based on objective data. The aim is to avoid implicit bias in decision-making, but an unintended consequence of triage implementation may be to further exacerbate health disparities, since the poorer baseline health of many African-Americans may lower their likelihood of surviving  coronavirus.

Triage algorithms are not the problem, however. They are a symptom, highlighting the imminent need for aggressive intervention to both improve the health of marginalized groups and invest in systemic policy to target structural racism and the disenfranchisement of the poor and other oppressed groups. Rectifying injustices, both within the health care system and society, is of the utmost importance.

  1. Federal Leadership and Preparation are Critical

The threat from infectious disease is not new. Warnings about the need for pandemic planning have been sounded for years from the World Health Organization and other experts. Yet, the federal government was slow to respond. Delays in testing prevented early containment. Lack of available personal protective equipment, including an inadequate federal stockpile, placed health care workers at excessive risk, beyond what is required by duty and the Hippocratic Oath. Ventilator and PPE shortages  forced governors of some states to compete against one another for supplies. Notably, the competition for critical supplies has been global, and poorer countries are losing out.

The uncoordinated, state-by-state approach in responding to Covid has been less effective and less fair than a nationwide response would have been. The degree of suffering could have been lessened. We must take what we’ve learned and immediately start preparation at the federal level for the next pandemic. Covid-19 will not be the last, and will likely not be the worst, pandemic. An effective and fair response requires clear and consistent messaging from experts in the field; redundant supply chains for PPE, essential medications and medical supplies; national and regional databases to monitor available hospital beds, ICU beds, and ventilators; an enhanced federal stockpile of essential medical equipment; and a national distribution system for scarce supplies.

The Covid-19 pandemic has laid bare the weaknesses and injustices in the U.S. health care and public health systems. It is imperative that we learn from our failures and use this opportunity to strengthen our health care and public health systems and eliminate disparities–and improve our response to the next crisis.

Emily Berkman is pediatric intensive care physician and bioethicist at Seattle Children’s Hospital and the University of Washington School of Medicine. Douglas Diekema is a pediatric emergency medicine physician and bioethicist at Seattle Children’s Hospital and the University of Washington School of Medicine.




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