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Without modern medicine, COVID-19 would be a ghastlier plague. Some enter the hospital with pneumonia from the novel coronavirus and do well with extra oxygen alone, administered using a cannula placed in the nostrils or a plastic mask held over the face with an elastic band. After some days, the virus mercifully relents. Unfortunately, for others, it gains the upper hand, and fierce countermeasures are required. When the diaphragm tires, and the lungs fill with fluid, we place a breathing tube through the mouth and vocal cords down into the trachea, permitting artificial respiration via a breathing machine, or ventilator. Complications can then arise, organs often fail, and metabolism goes awry. Close and meticulous management by a team in the intensive care unit (ICU), where I work, can save the lives of some, but not all, of those facing this illness.
Yet addressing the COVID-19 pandemic requires more than the exertions of health care professionals, or the workings of advanced medical technology. It necessitates political transformation. Years of underfunding of our public health infrastructure have left us ill prepared for the outbreak of this novel respiratory virus, even though such an outbreak was entirely predictable, and indeed predicted. Our privatized, fragmented health care financing system, meanwhile, leaves more than 100 million Americans liable to potentially ruinous health care costs, compounding the human tragedy. Meanwhile, mass incarceration, xenophobic policies, and a paltry social safety net put the most vulnerable amongst us at greatest risk of harm. Ventilators are needed, but ventilators cannot fix this. Transformative social change is needed to mitigate the impact of this pandemic and of those pandemics to come. The following statement from Physicians for a National Health Program (PNHP), which I lead, outlines the steps our nation must undertake to control the COVID-19 epidemic and combat the deep social inequalities it will intensify.
—Adam Gaffney, MD, MPH
Eight Needed Steps in the Fight Against COVID-19:
Physicians for a National Health Program Statement
COVID-19 cases have been identified in all fifty U.S. states, a surge of hospitalizations is underway in some cities, and nearly seven thousand patients have died. Meanwhile, unprecedented public health measures undertaken to slow the spread of the outbreak look certain to provoke a recession, with job losses for millions or tens of millions of workers. The nation is facing this outbreak and the looming recession with a dangerously fragmented and privatized health system. At the start of the crisis, 30 million people were uninsured and 44 million more underinsured, around one in three Americans went without needed medical care because of costs, and medical bankruptcies were commonplace. These problems will worsen as the economy spirals downward and hospitalizations rise.
Since its founding in the late 1980s, Physicians for a National Health Program (PNHP) has called for a single-payer, expanded and improved “Medicare for All” reform to ensure that everyone in the nation has health insurance that would: eliminate cost barriers that keep our patients from needed care; improve health outcomes; and free physicians to focus on patient care, not wasteful billing and clerical activities that sap needed time and resources. The COVID-19 crisis intensifies the urgency of such reform. It also calls for additional measures to fully protect all of our patients, including the most disadvantaged. We present, below, recommendations for measures needed to minimize hardship and loss of life during the COVID-19 pandemic and its aftermath.
1. Immediately protect patients from medical costs due to COVID-19
Recently passed legislation eliminated cost sharing for COVID-19–related diagnostic testing and provided coverage of testing for the uninsured. However, it did not expand coverage of treatment, leaving tens of millions of Americans at risk of financial disaster in the face of illness. Even those with insurance who are treated at an in-network hospital are likely to be stuck with thousands of dollars in copays and deductibles. For the uninsured (or the insured who are treated “out-of-network”), costs are likely to rise to tens, or even hundreds of thousands of dollars.
PNHP calls on Congress and the president to immediately enact legislation providing full coverage for all COVID-19-related care for everyone in the United States. Such a measure would protect patients who are infected, and ensure that those with symptoms do not delay seeking testing and care.
2. Implement universal coverage through a Medicare for All reform
Covering the costs of COVID-19 related care is not enough. In the impending recession, millions will lose jobs, income, and health insurance, exacerbating the health care cost crisis. Some, including those with severe COVID-19 infections, will require costly long-term care. Medicare for All reform would guarantee coverage for everyone in the United States; eliminate cost barriers for needed care, whether for COVID-19 or other conditions; and ensure that precious health care dollars are spent on care—not wasteful bureaucracy, corporate profits, or unnecessary, but lucrative interventions. Such reform is needed now more than ever.
3. Restore our public health infrastructure
Public health agencies are our first line of defense against novel epidemics. However, chronic underfunding of our federal, state, and local public health agencies impeded the response to this outbreak, exemplified by the ongoing diagnostic testing fiasco. Funding cuts have forced state and local public health agencies to eliminate 50,000 positions, a 20 percent decrease in the frontline workforce for fighting epidemics. The shortfall in resources has led some local public health authorities to give up on the case identification and contact tracing efforts that other nations have successfully employed to control spread of the epidemic.
PNHP calls for increased federal funding to raise the share of national health expenditures devoted to public health and prevention from 2.5 to 5.0 percent. Bolstering the public health infrastructure is vital to combat the current pandemic and to address other public health needs.
4. Protect incarcerated patients
Our nation’s densely crowded jails and prisons, which house the largest incarcerated population in the world, put inmates, staff, and communities at grave risk of COVID-19. Outbreaks are already being reported among this uniquely vulnerable population.
In addition to guaranteed health care access for the incarcerated population, PNHP joins other groups in calling for measures to reduce the at-risk population: the release of persons in pretrial detention or incarcerated for technical violations of parole or probation; stopping arrests for low-level offenses; early release where possible, especially for persons at increased health risk due to advanced age (a group known to have a low risk of re-offending) or comorbidities.
Universal coverage via Medicare for All would also ensure that individuals have adequate health care access in their communities after release from incarceration.
5. Protect immigrant patients
The Trump administration’s public charge rule, which imposes penalties on immigrant families for enrolling in social programs like Medicaid, will lead many to avoid needed testing or treatment for COVID-19, even though such care is technically exempt from the rule. Meanwhile, immigrants and asylum seekers in Immigration, Customs, and Enforcement (ICE) detention facilities are at serious risk from a COVID-19 outbreak; such facilities are crowded and are often in remote locations with limited accessibility to medical care.
PNHP urges the federal government to rescind the public charge rule and joins other human rights organizations in calling for ICE to release asylum seekers and immigrants held in administrative detention, and to ensure secure travel and continuity of medical care for released individuals. Additionally, PNHP calls for a universal Medicare for All coverage expansion to cover all U.S. residents regardless of immigrant status.
6. Stabilize hospital financing while protecting patients from hospital costs
In the face of the coronavirus threat, hospitals across the country have canceled elective procedures and stockpiled supplies, leading to falling revenue and rising costs. For some hospitals, particularly smaller rural hospitals, the coronavirus crisis could lead to closure. In response, recent legislation provided almost $100 billion in relief to the nation’s hospitals.
Our nation can ill afford hospital closures, particularly at this moment. However, reform is also needed in how hospitals are paid to ensure their stability in the face of future crises, and to protect patients, who have faced lawsuits, wage garnishment, and home foreclosures as a result of hospital efforts to recoup medical debt. Hospital associations, meanwhile, continue to spend precious resources lobbying against public insurance expansions. PNHP hence calls for action from the nation’s community hospitals, the American Hospital Association (AHA), and the federal government.
Hospitals must end all lawsuits against patients for medical bills, including those hospitalized for COVID-19. The AHA should cease spending member hospitals’ funds on lobbying efforts against Medicare for All and other coverage expansions. In particular the AHA should withdraw from, and stop contributing to, the Partnership for America’s Healthcare Future, a dark-money lobbying group.
Finally, PNHP calls on the federal government to take action. It should replace hospitals’ current per-patient payment system with global budget funding similar to how fire departments are paid. This would free up substantial funds that hospitals currently spend on administration, which could be redirected to patient care—including for infectious disease–related surges. Global budgets would also ensure that hospitals are not dependent on lucrative elective procedures for their financial stability and that hospitals caring for disproportionate numbers of poor and poorly insured individuals have adequate resources.
Finally, such a reform of hospital financing should include separate and dedicated funding for new hospital infrastructure, to ensure that an adequate and equitable supply of infrastructure—including hospital beds, ICUs, and a reserve supply of emergency equipment and protective gear—are available throughout the nation. Until then, the federal government should take direct action and provide necessary funding to procure needed personal protective equipment for the nation’s hospital workers.
7. Ensure that pharmaceuticals and vaccines—including for COVID-19—are affordable for the public
A recent bill signed into law by President Trump provided needed funds for the development of drugs and vaccines for COVID-19. However, the new law will not ensure that patients could afford the newly developed therapeutics.
The current crisis underlines the need for the comprehensive pharmaceutical reform policy advocated by PNHP. We call for increased public drug R&D, including publicly financed clinical trials. However, publicly developed therapeutics—including for COVID-19—should remain in the public domain, and be available to patients without charge. Additionally, prescription drug supply chains are threatened by the COVID-19 crisis, which could lead to shortages of essential medicines. The United States should establish public drug manufacturing capacity as one backup to address such shortfalls.
8. International considerations
Every nation faces major challenges fighting COVID-19. Some current U.S. policies hinder other nations’ responses to the pandemic, and the global cooperation vital to containment. PNHP hence recommends easing or ending international sanctions that disrupt nations ability to respond to COVID-19. Additionally, the United States should eliminate intellectual property constraints like patents and trade agreement that might restrict the low-cost production and distribution of essential drugs and vaccines, including those developed from publicly funded research. Finally, we call for an end to the racist and xenophobic rhetoric that sows division and undermines cooperation.
The steps outlined above focus on public health and medical measures. With recession on the horizon, however, additional measures are needed to ameliorate impoverishment and social dislocation. Mass unemployment and economic privation will harm the nation’s health unless sweeping measures to strengthen the social safety net are enacted. Such steps go beyond the scope of this document, but are critical for protecting the health and welfare of our patients.
There is much uncertainty in how severe the COVID-19 outbreak will ultimately prove to be in the United States. The rapid rise of cases and deaths, however, gives little reason for optimism. While no single policy could have prevented this outbreak, a robust, adequately funded public health infrastructure and adherence to science-based policy—together with a universal publicly funded national health program with unified financing and governance—would be powerful tools to control it. Change is sorely needed: to protect our patients during this pandemic, and other threats that will follow.
Adam Gaffney, MD, MPH, is Instructor in Medicine at Harvard Medical School, a pulmonologist and critical care physician at the Cambridge Health Alliance, and president of Physicians for a National Health Program. His writing about health, policy, politics, and history has appeared in The Washington Post, The Guardian, Salon, and The New Republic, among many other publications. He tweets @awgaffney.
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