Coronavirus Reveals Flaws in the U.S. Health System

SHANOOR SEERVAI: Hi everyone. Welcome to The Dose. I’m Shanoor Seervai, and today’s podcast is a special episode about the novel coronavirus, or COVID-19. Everyone’s talking about coronavirus. It’s spreading rapidly across the globe. Now, it’s pretty evident at this point that the spread is a “when” not an “if” question. And so I invited two experts to explain just how underprepared our health system in the U.S. is to handle this health crisis. I’m here with David Blumenthal, president of the Commonwealth Fund, and Sara Collins, vice president for coverage and access at the Fund.

David, Sarah, welcome to the show.

DAVID BLUMENTHAL: Thank you. Great to be here.

SHANOOR SEERVAI: So let’s get started just by talking about who is at greatest risk as coronavirus spreads through the United States.

DAVID BLUMENTHAL: Well, the question of risk . . . there are at least two questions of risk. One is risk of being infected and the other risk of having severe consequences if infected. Consequences are obviously severe for older people with what doctors call comorbid illness. That means some coexisting illness like heart disease or lung disease or diabetes or a history of difficulty breathing.

So those are all things that would make people vulnerable to the illness if they get it. Most of the deaths that we’ve been hearing about have been among those people in that category.

SHANOOR SEERVAI: Sara?

SARA COLLINS: The United States is unique. We are much more vulnerable to the kinds of spread of illness that David highlighted, because so many people don’t have health insurance coverage in the United States. About 30 million people are currently uninsured.

Another 44 million people have coverage all the time, are all year long, but they don’t have health plans that keep them sufficiently protected from health care costs. We know from survey data and lots of research that people who are uninsured, who are underinsured are much more likely not to seek care even when they’re quite sick.

SHANOOR SEERVAI: So, because we have a very large section of our population either uninsured or underinsured, what we’re at risk for or what they’re at risk for is being infected, but just trying to go about their daily lives with the infection because they either don’t have health insurance or they can’t afford their out-of-pocket costs, their deductibles, if they were to seek care?

SARA COLLINS: That’s right. So what’s concerning both for people who might become infected and for people that they share a community with, is that people who become infected with a highly contagious virus might not seek care. And as David mentioned, the people who are most vulnerable to this are older people, people with underlying health conditions.

So even if you’re younger and uninsured, you might not get care and it might not affect you very much, but that might have serious implications for someone who’s older who might catch it from you.

DAVID BLUMENTHAL: I’d like to add another point to the underpreparedness of our health care system, and that is that we don’t have adequate primary care in the United States. We have a tremendous deficit compared to other advanced countries of frontline providers who can offer that initial contact with the health care system, where symptom identification can take place, and where screening could happen outside of the crowded and more dangerous setting of a hospital emergency room.

SHANOOR SEERVAI: Part of the weakness or the vulnerability of the health care system is that there just aren’t enough primary care centers. There aren’t enough people with family doctors who they trust who they’re willing to go to see at the sight of the smallest symptom.

DAVID BLUMENTHAL: Access depends on financial access, but also the physical availability of the right kind of care.

SHANOOR SEERVAI: I want to dig into this financial access element because it is the thing that comes up again and again. Health care in the United States is just too expensive, costs are too high. So I wanted to ask you, Sara, who is most impacted by these high costs and how?

SARA COLLINS: The people who are most at risk of having high exposure to health care costs obviously are people who are without insurance coverage altogether and also people who face really high deductibles in their health plans. We know there’s been a trend over the last 10 years, employers and the individual market increasing the amount of cost-sharing that people have in their plans, primarily through the size of deductibles.

SHANOOR SEERVAI: These are the people that you’re talking about with coverage. So who are the people without coverage? What do we know about their demographic?

SARA COLLINS: People who are uninsured are disproportionately more likely to have lower incomes because they’re less likely to have coverage through a job. They are disproportionately Hispanic, and young people are also have a high likelihood of not having health insurance coverage.

This is even after all the expansions of the Affordable Care Act dramatically reduced uninsurance or increased coverage among those specific groups. But they still continue to have higher than average rates of uninsurance.

DAVID BLUMENTHAL: I’d like to go back to the point about employers and employer-sponsored insurance, because there has been a subtle erosion of the value of insurance in the United States. We too often talk about insurance as though, “If you have it, you’re fine.”

I think employers probably should have shared that perception. Employers are very dependent on the health of their workforce. One of the absolute most disruptive things an employer can experience is the presence of this virus in their workforce. Because, as we’ve seen in China, once the virus appears, it becomes necessary to take drastic measures within your workplace. Shutting it down or quarantining parts of it or sending whole blocks of workers home. It turns out there’s a consequence to reducing the quality of insurance over time, and one of those consequences may be greater vulnerability to epidemic illness.

I think employers are going to have to look back at their calculations about whether it was smart economically to reduce the value of their insurance over time.

SHANOOR SEERVAI: Part of the irony in that is that if employers are sending people home or not able to function in the way that they would like to, that hurts their bottom line. That’s why they were providing more skimpy benefits in the first place.

DAVID BLUMENTHAL: Exactly.

SHANOOR SEERVAI: I wanted to speak a little bit more specifically about the groups of people who are likely to be uninsured, without coverage. So if we start with people with low incomes who are living in poverty, we have a public program, correct? Medicaid, which is supposed to provide coverage for people who are too poor or don’t get it from their employers.

SARA COLLINS: That’s right. In the United States, by law, people with incomes under 138 percent of poverty, which is about $30,000 for a family of four, are eligible for Medicaid, but only if their state expanded eligibility for Medicaid under the Affordable Care Act.

Right now, 36 states and the District of Columbia all have expanded their Medicaid programs. Fourteen states — including some of the most highly populated states in the country, Florida and Texas — have not yet expanded. So people in those states who have incomes under poverty do not have access to an affordable source of health insurance right now.

SHANOOR SEERVAI: We’ve seen other changes to the Medicaid program, correct, under this administration?

SARA COLLINS: Medicaid provides very comprehensive coverage to people, very little cost-sharing, and it would protect many people in an epidemic like this who are eligible for the program. But the administration has sought to reduce enrollment in the program through actions like work requirements — requiring people to work or otherwise become engaged in the community — or lose their Medicaid coverage. Those efforts have been stopped by the courts.

The effort to reduce immigrants who are legal enrolled in the program through something called the Public Charge rule, we know that that has also had the effect of putting a chilling effect on enrollment, particularly of children in the Medicaid program.

And in an effort to block grant the Medicaid program, so place a cap on how much the federal government will provide the states for the Medicaid program. All of these efforts have had the effect of reducing enrollment in Medicaid, and we’re seeing what that means in a potential public crisis like this.

SHANOOR SEERVAI: What a block grant means, Sara, is that a state can only get up to a certain amount of money from the federal government for their Medicaid program. So if a state is really badly hit and it needs to draw on the resources of its Medicaid program, if it’s already hit the cap of federal dollars, then the state has to pay for everything.

SARA COLLINS: That’s right. One of the hallmarks of Medicaid is that it has always been flexible. So people who are eligible can become enrolled. The federal government and the states share the cost of the Medicaid program. What it means is that in a crisis, sometimes states and the federal government have worked together to increase coverage for people who might not even be eligible for the program before the crisis, and the federal government was able to put funds into that state to help them cope with a crisis.

But a block grant would prevent that kind of immediate action in the face of a public health emergency.

DAVID BLUMENTHAL: What has happened is that the mesh of the safety net has developed holes, and people can fall through. It used to be that when they fell through, the consequences were mostly to them as individuals.

SHANOOR SEERVAI: Right.

DAVID BLUMENTHAL: Now when they fall through, the consequences are very apparent for all of us. Because the illnesses they may fail to get treated or fail to identify are going to spread to people who have felt in the past that it wasn’t their problem.

SHANOOR SEERVAI: This is making me think of the issue of medical debt. Often people who are worried about how they’re going to cover their costs take out some sort of loan. They borrow money, they take out credit card debt. As you said, the consequences then fall to that individual person where they’re facing a health issue and then they’re also facing a financial crisis.

Now people who are maybe dealing care because they don’t want to deal with that financial crisis, and rightfully so, are actually making the entire population susceptible to a rapidly spreading disease.

DAVID BLUMENTHAL: Exactly. I would also add that one of the worst forms of deductible is the debt you acquired from your last contact with the health care system. Because if you’re already in debt, the prospect of adding to that is particularly intimidating.

We know that debts incurred have long tails in time. It may take months or years before people with major medical debt are able to pay it off. We also know that health care, hospitals and providers have gotten much more aggressive in taking people to court to get unpaid debts paid back. That is also a legitimate source of anxiety for people who are trying to make their way with lower middle income salaries . . .

SHANOOR SEERVAI: Right.

DAVID BLUMENTHAL: . . . and incomes.

SHANOOR SEERVAI: Can we also take a minute to talk about public charge a little more? Because you mentioned that Latinos are more likely to be uninsured than other segments of the population. There’s a lot of immigrants, particularly Latino immigrants, Latinx immigrants who might live in mixed status homes where some of them are undocumented, but some have legal status. My understanding is that public charge and general fear around immigration policy has made people very reluctant from these communities to seek care.

SARA COLLINS: That’s exactly right. That is also a very big risk with the coronavirus right now because a lot of people have been disincentivized to seek coverage through Medicaid. For example, people who would actually be eligible for Medicaid because of this public charge rule, afraid that if they do enroll in the program or even enroll their children in the program, that they’ll put their citizenship status at risk down the road. So that is a very big issue in this current public health crisis.

SHANOOR SEERVAI: So what we know is that the U.S. health system really isn’t prepared to deal with an epidemic that we are likely facing. But I can’t help but wonder, we’re not the only country, dozens of countries are facing this crisis. How are other countries prepared to deal with coronavirus?

DAVID BLUMENTHAL: Well, we know that we are unique in the industrialized world in not having a universal health care coverage system. So financial barriers to access are far, far fewer in almost every other Western country, especially when you compare that to the level of income.

In addition, most other countries in the Western world have much more complete primary care programs and much more organized health care systems. And therefore it is usually the case that, for example, in France or the Netherlands or the United Kingdom or Sweden, that virtually everyone has a doctor who is a first-contact doctor or a primary care clinician who with whom they’re registered and who knows them and who they know. And that creates, as I said earlier, a point of entry with easy access.

So, that is a very strong element in a system for dealing with contagion. It’s not a guarantee of prevention of the spread, but it’s a guarantee that if a test is available, it will be more accessible to people and people will be less reluctant to take advantage of it.

SHANOOR SEERVAI: The 2020 election is getting closer and closer and coronavirus is probably going to come with us into that. We’ve seen in the lead-up that almost all the Democratic candidates have had a perspective on health care that reflects the public concern about health care. As we’re facing both the election and the imminent threat off coronavirus spreading throughout the country, what do you think our next president should be thinking about?

SARA COLLINS: I would argue that maybe the current administration and Congress and the states need to be thinking about this right now. There are things, I don’t think it’s that one needs to accept the fact that we have all these gaps in our insurance coverage. There are things that the administration actually could do proactively.

The Trump administration could turn to the Medicaid program and do what prior administrations have done after the attacks of 9/11, for example, during the Flint water crisis, and Hurricane Katrina. After Hurricane Katrina, the administration encouraged states, they put a program in place very quickly through Medicaid which allowed states to apply and cover people who are not residents of their states. So evacuees from the hurricane. The administration took the lead on that. So they used Medicaid as a way, as a tool in dealing with that particular public health crisis where a lot of people were suddenly in different states and needed access to the health care system.

After the 9/11 attacks, New York City implemented an expedited enrollment program for people who are eligible for Medicaid in the city. They mounted an aggressive outreach and enrollment effort. People, all they had to do is fill out a one-page application. People who were in the program could stay in the program. They didn’t have to recertify.

So there are a number of creative ways that the administration could use the Medicaid program to achieve a number of creative things. The Trump administration could use the Medicaid program in approaching the epidemic. So, it’s an immediate issue for the United States. There are tools that the administration can deploy in order to deal with it and help states get through this.

DAVID BLUMENTHAL: I have another thought and that is based on my training as a physician, that the coronavirus issue is now getting wrapped up in politics. But that’s really regrettable from my standpoint. The best way for any elected official to manage this problem is through managing it competently and in accord with scientific evidence.

From that standpoint, as someone who has always as a clinician, relied on recommendations from the Center for Disease Control and Prevention as reliably based on the best science without attention to political consequences. It’s very disturbing for me to develop doubts about whether that is still the case.

I think one of the lessons of this crisis may be that no one gains in the short term or the long term from trying to impose any political constraints on our nation’s fundamentally critical scientific infrastructure.

SHANOOR SEERVAI: Of course, a crisis is not the time to be learning these lessons. But we should start now before it’s too late. So, thank you both for joining me today. This has been really informative and helpful.

DAVID BLUMENTHAL: Thank you.

SARA COLLINS: Thank you.