The Collision of COVID-19 and the U.S. Health System
Authors: Sue S. Bornstein, Ryan D. Mire, Eileen D. Barrett, Darilyn V. Moyer, Thomas G. Cooney
Journal: Annals of Internal Medicine (2020)

Ideas and Opinions2 June 2020The Collision of COVID-19 and the U.S. Health SystemFREESue S. Bornstein, MD, Ryan D. Mire, MD, Eileen D. Barrett, MD, MPH, Darilyn V. Moyer, MD, and Thomas G. Cooney, MDSue S. Bornstein, MDTexas Medical Home Initiative, Dallas, Texas (S.S.B.)Search for more papers by this author, Ryan D. Mire, MDHeritage Medical Associates, Nashville, Tennessee (R.D.M.)Search for more papers by this author, Eileen D. Barrett, MD, MPHUniversity of New Mexico School of Medicine, Albuquerque, New Mexico (E.D.B.)Search for more papers by this author, Darilyn V. Moyer, MDAmerican College of Physicians, Philadelphia, Pennsylvania (D.V.M.)Search for more papers by this author, and Thomas G. Cooney, MDOregon Health & Science University and Portland Veterans Affairs Medical Center, Portland, Oregon (T.G.C.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-1851 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail The coronavirus disease 2019 (COVID-19) pandemic is wreaking havoc and causing fear, illness, suffering, and death across the world. This outbreak lays bare the fault lines in our society and highlights that the United States could have been better prepared for the pandemic had we a more equitable and just health care system.As leaders in the American College of Physicians (ACP), we have helped develop ACP's wide-ranging policies on health care in the United States. The College has adopted a “health in all policies” approach, integrating health considerations into policymaking across sectors to improve the health and health care of all communities and people, which we believe, if enacted, would have enabled the United States to more effectively respond to the COVID-19 pandemic. In January 2020, ACP released a series of far-reaching position papers on ACP's vision for the U.S. health care system (1). As background to these papers, ACP posed a question: What would a better health care system be like for all Americans? In response, we proposed ways to achieve improved access to care, decrease per capita health care costs, and reduce complexity of our health care system. Here, we focus on key recommendations from ACP's position papers that can advise how to act now and in the future in service to patients, our peers, and the profession.Universal Coverage and AccessBefore the COVID-19 pandemic, at least 30 million Americans were uninsured and many more underinsured (2). Although most U.S. workers have employer-based insurance, those covered decreased from 67.3% in 1999 to 55.9% by 2017, while increasing deductibles and copays were adding to the financial burden in accessing care (3). More than 36 million Americans have filed for unemployment since March 2020. For most, losing a job means losing employer-based health care. Those who lose coverage can purchase insurance, but this is often prohibitively expensive. The $2 trillion CARES Act (Coronavirus Aid, Relief, and Economic Security Act) did not include insurance subsidies for the unemployed, mandates that companies receiving government assistance provide health care coverage for workers who get laid off, or requirements that Affordable Care Act exchanges reopen enrollment (4).Equitable access to health care depends on having a robust primary care system. The pandemic highlights the need for increasing investment in primary care, which serves a particularly critical role during crises. Primary care provides a sentinel surveillance system, first-line response, and mitigation of the burden currently placed on our nation's overrun emergency departments and hospitals. Robust primary care with universal coverage can be a tool for health justice that can reduce morbidity and mortality, particularly in currently and historically marginalized patient groups. The COVID-19 pandemic has underscored the adverse effects of our current system on primary care: In a recent survey of primary care practices, 76% reported severe or close-to-severe strain on their practice (5).The American College of Physicians envisions a health care system where everyone has coverage for and access to the care they need, at a cost they and the country can afford.To achieve this vision, the ACP recommends the following policies:The American College of Physicians recommends that the United States transition to a system that achieves universal coverage with essential benefits and lower administrative costs.a. Coverage should not be dependent on a person's place of residence, employment, health status, or income.b. Coverage should ensure sufficient access to clinicians, hospitals, and other sources of care.c. Two options could achieve these objectives: a single-payer financing approach, or a publicly financed coverage option to be offered along with regulated private insurance.The American College of Physicians supports greater investment in primary care and preventive health services, including support for the unique role played by internal medicine specialists in providing high-value primary, preventive, and comprehensive care of adult patients.As described in the January 2020 ACP position papers, universal coverage would reinforce our increasingly underfunded safety net and ensure all Americans have accessible, affordable, and comprehensive health care. The continued trajectory of increasing per capita spending on U.S. health care threatens the stability of our current system when we can least afford it.In comparison to countries with nationally coordinated systems of health care that have successfully limited spread of the virus, such as Australia, New Zealand, and Taiwan, the U.S. response to COVID-19 was delayed, uncoordinated, and less effective (6, 7). Methods employed by New Zealand and Taiwan, including tracking travel and contact history for every patient, timely mass testing, and early restriction of activity, could have been replicated in the United States if it had a robust system for primary care and national coordination under a universal coverage model.Socioeconomic Inequalities and Race- and Ethnicity-Based MarginalizationPrior pandemics disproportionately affected groups that have been marginalized and excluded on the basis of socioeconomics, race, and ethnicity. The COVID-19 pandemic is no exception. Across the United States, deaths from COVID-19 are disproportionately high in African American, Latinx, and Native American communities (8, 9). These same groups have the highest rates of low health literacy (10). Racial and ethnic minorities make up a significant percentage of “essential workers” with a greater risk for exposure to the virus. Similarly, immigrants who work in places like meatpacking factories and the incarcerated population face higher risk. Social distancing is more difficult in areas with high population density, multigenerational households, or high reliance on public transit.Public policies that relieve environmental, geographic, occupational, educational, and nutritional inequities must be implemented to reduce disparate health outcomes and engender trust in the health care system.The American College of Physicians envisions a health system that ameliorates social factors that contribute to poor and inequitable health (social determinants); overcomes barriers to care for vulnerable and underserved populations; and ensures that no person is discriminated against based on characteristics of personal identity, including but not limited to race, ethnicity, religion, gender or gender identity, sex or sexual orientation, or national origin.We believe more than ever that better is possible. The COVID-19 pandemic has further demonstrated that the status quo is unacceptable and strengthens our resolve to help shape a better health care system for all Americans. This pandemic has ripped the seams of the U.S. health care system wide open, thrusting front and center our health care inequities and injustices. The bigger challenge moving forward is how we can take the lessons learned from this time of great suffering and fear to create an equitable and just system of care for all.References1. Doherty R, Cooney TG, Mire RD, et al; Health and Public Policy Committee and Medical Practice and Quality Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: a call to action by the American College of Physicians. Ann Intern Med. 2020;172:S3-S6. [PMID: 31958804]. doi:10.7326/M19-2411 LinkGoogle Scholar2. Gunja MZ, Collins SR. Who are the remaining uninsured and why do they lack coverage? Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2018. The Commonwealth Fund. 28 August 2019. Accessed at https://bit.ly/3e9HRuU on 10 April 2020. Google Scholar3. Coverage at work: the share of nonelderly Americans with employer-based insurance rose modestly in recent years, but has declined markedly over the long term. Kaiser Family Foundation. 1 February 2019. Accessed at https://bit.ly/2RkXMN5 on 10 April 2020. Google Scholar4. Hohmann J. The Daily 202: Losing a job can also mean losing health coverage, adding to anxiety amid coronavirus pandemic. Washington Post. 3 April 2020. Accessed at https://wapo.st/2JJAMDs on 11 April 2020. Google Scholar5. Lewis C, Seervai S, Shah T, et al. Primary Care and the COVID-19 Pandemic. Commonwealth Fund To the Point [blog]. Posted 22 April 2020. Accessed at https://bit.ly/2X5hGOj on 15 May 2020. Google Scholar6. Nunn G. Coronavirus: How Australia's ‘suppression' approach is rapidly flattening the curve. The Independent. 22 April 2020. Accessed at https://bit.ly/366vdJH on 15 May 2020. Google Scholar7. Ing-Wen T. President of Taiwan: how my country prevented a major outbreak of COVID-19. TIME. 16 April 2020. Accessed at https://bit.ly/2X4mdAC on 15 May 2020. Google Scholar8. Scott D. Covid-19's devastating toll on black and Latino Americans in one chart. Vox. 17 April 2020. Accessed at https://bit.ly/2WDgFht on 16 May 2020. Google Scholar9. Klemko R. Coronavirus has been devastating for the Navajo Nation, and help for a complex fight has been slow. Washington Post. 16 May 2020. Accessed at https://wapo.st/2WCXK6u on 18 May 2020. Google Scholar10. Wolf MS, Serper M, Opsasnick L, et al. Awareness, attitudes, and actions related to COVID-19 among adults with chronic conditions at the onset of the U.S. outbreak: a cross-sectional survey. Ann Intern Med. 2020;173:100-9. [PMID: 32271861]. doi:10.7326/M20-1239 LinkGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Jonathan R. Dreazen, MDWorknet Occupational Medicine10 June 2020 Universal Healthcare, a dream deferred I have personal experience with the issues of our US healthcare system. My younger daughter in 2009, without health insurance, developed a herniated disc which required discectomy and fusion. I paid her hospital bill and she paid the rest of her cost (doctor care, MR scans, etc). She was unable to get health insurance (pre-Obamacare) and in 2010 developed benign intercranial hypertension requiring a shunt. She is still paying off the hospital bill of $76,000. My other daughter, who was in England holding a visa and thus insured by NHS, develped stage 3 cervical cancer. She was treated as she would have been in the US and was released from care 5 years later with no debt. So the American in England received excellent care with no debt and the American in the US who did not have health insurance in paying off a debt. What is wrong with this picture? Is not adequate healthcare a basic right of citizenship? Kevin Sheng-Kai Ma, Alice Shin-Yi TsaiDepartment of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.25 June 2020 Integrating Travel History via Big Data Analytics Under Universal Healthcare Framework for Disease Control and Prevention in the COVID-19 Pandemic To the editor: We read with great interest the article by Bornstein et al. on “The Collision of COVID-19 and the U.S. Health System”[1]. In this letter we reported Taiwan’s experience of disease control and prevention in the COVID-19 Pandemic by Big Data-driven Universal Healthcare. Big data analytics has facilitated healthcare quality promotion by analyzing electronic medical records, socio-demographics, and environmental factors, to optimize treatment decisions [2,3]; moreover, its roles in predicting and tracking emerging infectious diseases, including the coronavirus pandemic, have also been proposed [3,4]. In countries offering universal healthcare systems (UHS), claimed healthcare informatics of payers could serve as an abundant source of massive database due to universal coverage. This indicates that the intersection of public health policies and technology could bring about additional benefits of healthcare reform through integrated real-time data analytics [5]. Take Taiwan for example, cloud computing-based healthcare databases within the UHS have been part of its critical national infrastructure. Such platform has allowed healthcare providers to query travel history on a real-time basis, as well as manage the allocation of personal protective equipment. Collected data of beneficiaries (> 99.5% of all residents) regarding medical records, lab data, images, and prescriptions from all healthcare providers during the past 24 years are retrievable [6]. As data analytics and cloud technology allow for both personalized medicine and public health policy-making, Taiwan authorities have been allowed to adopt low stringent level strategies as opposed to lockdown policies among other high income countries [7]. Remarkably, the utilization of UHS databases may realize cost-effective and efficient solutions to epidemic prevention in the early outbreak. After the severe acute respiratory syndrome outbreak in 2003, Taiwan CDC (TCDC) commenced transferring real-time infectious disease registry data to this monitoring system, and since 2016 real-time analytics were enabled via cloud computing, concatenation of intramural data on all severe influenza cases was practiced. Therefore, alerts were indicated prior to the official recognition of COVID-19 outbreak [3, 4], which travel history databases were subsequently concatenated to trace the source. Inauguration of such travel history tracking system would involve data transfers as well as managerial issues including ownership and governance, which interdepartmental communication would be more efficient within a single-payer UHS. For instance, the tracking system in Taiwan was co-operated by the Immigration Agency and TCDC, which the traveling history of beneficiaries and their corresponding history of contact were retrievable with insurance or passport numbers. As the UHS provider, government also gave access of the above information to healthcare providers external to the universal insurance plan, including dental, aesthetic, or physiotherapy clinics, as well as nursing home and blood donation sites, to reduce iatrogenic viral exposure and postponed care. During the era of healthcare reform, we advocate for integrative systems that promote not only accessible healthcare services, but cost-effective tracking of potent factors for the emergence of diseases, so as to achieve pandemic management. Reference [1] Sue S. Bornstein, MD; Ryan D. Mire, MD; Eileen D. Barrett, MD, MPH; Darilyn V. Moyer, MD; and Thomas G. Cooney, MD. The Collision of COVID-19 and the U.S. Health System. Ann Intern Med. doi:10.7326/M20-1851 [2] Kevin Vigilante, Steve Escaravage, and Mike McConnell. Big Data and the Intelligence Community — Lessons for Health Care. N Engl J Med 2019; 380:1888-1890 [3] Olson SH, Benedum CM, Mekaru SR, et al. Drivers of emerging infectious disease events as a framework for digital detection. Emerg Infect Dis. 2015 Aug; 21(8): 1285–1292. [4] C. Jason Wang, Chun Y. Ng, Robert H. Brook. Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing. JAMA. 2020;323(14):1341-1342. [5] Jaime S. King. Covid-19 and the Need for Health Care Reform. DOI: 10.1056/NEJMp2000821 [6] NHCC [National Health Command Center]. Taiwan Centers for Disease Control. Updated February 1, 2018. Accessed May 6, 2020. https://www.cdc.gov.tw/En/Category/MPage/gL7-bARtHyNdrDq882pJ9Q [7] Jonathan Schwartz, Chwan-Chuen King, Muh-Yong Yen, Protecting Healthcare Workers During the Coronavirus Disease 2019 (COVID-19) Outbreak: Lessons From Taiwan’s Severe Acute Respiratory Syndrome Response, Clinical Infectious Diseases, , ciaa255, https://doi.org/10.1093/cid/ciaa255 Author, Article, and Disclosure InformationAuthors: Sue S. Bornstein, MD; Ryan D. Mire, MD; Eileen D. Barrett, MD, MPH; Darilyn V. Moyer, MD; Thomas G. Cooney, MDAffiliations: Texas Medical Home Initiative, Dallas, Texas (S.S.B.)Heritage Medical Associates, Nashville, Tennessee (R.D.M.)University of New Mexico School of Medicine, Albuquerque, New Mexico (E.D.B.)American College of Physicians, Philadelphia, Pennsylvania (D.V.M.)Oregon Health & Science University and Portland Veterans Affairs Medical Center, Portland, Oregon (T.G.C.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-1851.Corresponding Author: Sue S. Bornstein, MD, 3111 Beverly Drive, Dallas, TX 75205.Current Author Addresses: Dr. Bornstein: 3111 Beverly Drive, Dallas, TX 75205.Dr. Mire: 4230 Harding Road, Suite 601 East, Nashville, TN 37205.Dr. Barrett: Department of Internal Medicine, University of New Mexico, 1 University of New Mexico, Albuquerque, NM 87131.Dr. Moyer: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.Dr. Cooney: Department of Medicine OP30, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098.Author Contributions: Conception and design: E. Barrett, S.S. Bornstein, T.G. Cooney, D.V. Moyer.Drafting of the article: E. Barrett, S.S. Bornstein, T.G. Cooney, R.D. Mire, D.V. Moyer.Critical revision for important intellectual content: E. Barrett, S.S. Bornstein, T.G. Cooney, R.D. Mire, D.V. Moyer.Final approval of the article: E. Barrett, S.S. Bornstein, T.G. Cooney, R.D. Mire, D.V. Moyer.Administrative, technical, or logistic support: S.S. Bornstein.Collection and assembly of data: S.S. Bornstein, T.G. Cooney.This article was published at Annals.org on 2 June 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byImpact of COVID‐19 pandemic on the medical activities of the Directorate of Health and Hygiene, Vatican City StateAccelerating action on cervical screening in lower- and middle-income countries (LMICs) post COVID-19 eraRacial and Ethnic Differences in COVID-19 Outcomes, Stressors, Fear, and Prevention Behaviors Among US Women: Web-Based Cross-sectional Study 15 September 2020Volume 173, Issue 6 Page: 484-485 Keywords COVID-19 Fear Forecasting Health care Health care policy Health economics Health systems strengthening Patients Racial and ethnic issues Vision ePublished: 2 June 2020 Issue Published: 15 September 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...