In one of his last political rallies in Charlotte, North Carolina on March 2, President Donald Trump assured his enthusiastic audience about the coronavirus pandemic, that “the United States is, right now, ranked by far No. 1 in the world in preparedness.”
He went on: “We know what we are doing as we have the greatest health system on earth.”
Despite Trump’s early confidence, it has become increasingly clear that the United States public health system is in fact, poorly-prepared to handle the covid-19 pandemic.
In part, that is because of Trump’s slow initial response to the crisis. But, underlying that, some experts say, the coronavirus has exposed a fundamentally flawed health system that is under-equipped, underfunded and undermanned.
“ The public health system that we needed to be ready for this crisis simply wasn’t in place,” said Jose Szapocznik, a public health scientist at the University of Miami.
Far from being the No. 1 in the world for preparedness, the United States has long ignored massive deficiencies in its public health system that have led it to be No 1 in the world only in terms of cost, while lagging behind the rest of the world in terms of quality of outcome, he said.
Instead, “we have the worst and most expensive outcomes in the developed world,” said Szapocznik.
"Like the crash of 2008"
“I think this is a moment when all the different pieces in the delivery system that were papered over in the good times are all coming back to haunt us,” said Dr Vikas Saini, president of the Lown Institute, a nonpartisan think tank in Massachusetts that advocates for health care reform.
“ It’s like the run up to the crash of 2008. People were talking about it, but most people thought it was fine,” he said.
Many political commentators and activists have been quick to single out the U.S. privately-run health insurance system as the culprit, arguing that the coronavirus epidemic would have been better handled by a universal, ‘Medicare-for All’ healthcare system such as that advocated by Democratic party presidential candidate, Bernie Sanders.
But experts point to the unfolding mess in Italy, Spain, France and the United Kingdom, which are among the countries worst impacted by the covid-19 disease, and all have large government-run health systems.
“This is not a matter of (insurance) coverage. Nobody is being turned away from treatment. This is about the provision of services, like testing kits to identify cases of infection,” said Szapocznik.
Public health experts from Bill Gates, the billionaire founder of Microsoft on down, have been warning for years that the U.S. health system was ill-equipped for a major pandemic, citing a host of issues from a lack of hospital beds and medical professionals, to a patchwork system that lacks centralized control and is instead fragmented from state to state.
The U.S. health system is a patchwork of responsibility divided between the states and the federal government, creating conflict and confusion at the best of times. A widely criticized lack of speedy and decisive political leadership from the White House only made things worse.
As a result, the response to the spread of the virus has varied widely, with some states taking drastic, pro-active measures to quarantine residents, while others have resisted limiting movement to avoid shutting down the economy.
“The central government has been slow because our leadership minimized the problem and was not willing to jump in with both feet,” said Dr David Blumenthal, president of the Commonwealth Fund, a 100-year-old private foundation headquartered in New York that seeks to promote improvements to the quality of the health care system.
“The president was not willing to influence the production and allocation of supplies,” he added.
Instead, the obtaining of supplies was left to state governors leading to a bidding war for vital items such as ventilators, masks and other protective equipment which has driven up prices due to a global shortage.
According to some reports, a lack of coordination resulted in a huge number of masks manufactured in the United States being sold to foreign buyers.
To make matters worse, despite the existence of a ‘Strategic National Stockpile’ of medical supplies, the White House was slow to get those goods moving, and, worst of all, the stockpile did not have enough of the items most needed, while some were past their expiration date.
Military to the rescue
Eventually, under pressure from some governors, Trump summoned the U.S. military to the rescue to build ‘pop-up’ field hospitals, as well as mobilizing two U.S. Navy hospital ships sent to the ports of New York and Los Angeles.
The use of the military to respond to the coronavirus, makes some experts ask the question, why is health care not a national security issue, on a par say with the war on drugs or terrorism?
The White House famously eliminated the office for Global Health Security and Biodefense at the National Security Council last year, folding it into another directorate, although some officials say the relevant expertise was not lost due to the restructuring.
“We maintain an army of two million people. It’s prepared for war,” said Szapocznik. “However, we don’t think about it that way for public health. In this war, we need an army too, an army of health workers,” he said.
Much of the essential supplies, such as ventilators and protective hospital gear is manufactured abroad. “Would we outsource airplanes for the Airforce?” asked
Szapocznik. “We should look more at the Armed Forces as our model,” he added.
Similarly, in the early days of the coronavirus as global petroleum prices began to tumble, one of Trump’s first actions was to order U.S. energy officials to purchase large amounts of oil to prop up the U.S. oil and gas industry in order to fill up the Strategic Petroleum Reserve, the nation’s emergency supply.
“One for all, and all for one”
But, tackling the virus itself, got less attention. In fact, experts argue that the decision by the president not to use his full authority to impose a nationwide ‘stay-at-home’ quarantine has fueled the patchwork approach, allowed the virus to spread.
The problem is the virus doesn’t respect borders, experts say. “If one state doesn’t do it, you are going to be fighting a losing battle, like walking a treadmill,” said Blumenthal.
The only way to defeat the virus is: “all for one and one for all,” he added.
Test kit catastrophe
Perhaps the biggest institutional failure is the slow distribution of test kits to identify people with the virus. It has been widely reported that the Centers for Disease Control (CDC) - long regarded as an exemplary government agency and a global leader the fight against infectious diseases – made a series of catastrophic errors.
Instead of adopting one of the test kits already being used in other countries, it decided to make its own. But it didn’t work. Instead, the government was obliged, late in the day, to turn to the private sector to produce kits.
On top of that, the government did not have teams ready to go out into the field and find infected cases and trace the history of contact with other potential victims.
“ This is epidemic 101, bread and butter public health,” said Blumenthal, noting that it is a widely used practice for other illnesses, such as sexually transmitted diseases and tuberculosis.
Blumenthal and others say the issue of test kits illustrates a key vulnerability of the nation’s public health system. “ 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,” he said.
In that sense, the private insurance system does make the United States more vulnerable to the spread of the coronavirus, even if it is not completely at fault.
“The health of one of us affects all of us,” said Saini, from the Lown Institute, which was founded by Nobel Peace Prize winner, Dr. Bernard Lown who invented the defibrillator and co-founded International Physicians for the Prevention of Nuclear War.
“If people can’t afford insurance they will continue to spread the virus. You can’t nip it in the bud if you can’t get people into the system (for treatment),” he said.
The fact that health insurance is tied to a person’s employer also creates more problems when, as was reported on Thursday, a sudden surge of 6.6 million people applied for unemployment benefits, bringing the two-week total to nearly 10 million.
Cost of care
The coronavirus has also exposed other structural issues such as the cost, capacity and quality of care of the U.S. health system.
“There won’t be enough beds, or doctors and nurses for everyone who needs hospitalization,” said Cynthia Cox, vice-president at the Kaiser Family Foundation, a non-profit organization focusing on national health issues. States like New York have appealed to retired physicians and nurses to rejoin the workforce, as well as graduating medical students early to reinforce hospitals.
Cox noted that the United States has fewer beds per capita than any other developed country, due to a mix of government efforts to reduce costs and industry efforts to maximize profits.
At the same time, the United States has fewer physicians per capita than other countries, in part because of lobbying by the American Medical Association to limit numbers. While the AMA says this is necessary to ensure quality control, critics say there is also a financial reason to keep salaries high.
As a result, the United States spends about 18 percent of GDP, on health expenditures – more than twice the average among developed countries.
Experts say that is also because other countries dedicate more resources to preventive care, working at a community level to provide cheap drugs, as well as food and housing, to catches illnesses early before they require expensive hospital treatment.
Despite all the inherent weaknesses of the public health system in the United States, at the end of the day, most experts agree that in the case of covid-9, most of the issues now being dealt with could have been avoided if the federal government had responded quicker. The slow response created a domino effect.
“ The reason we need ventilators is because we failed to contain the epidemic. South Korea contained the epidemic and they don’t need ventilators,” said Szapocznik.
“That’s the really gross failure here. The government didn’t pay attention to the first signs of the epidemic,” he added.