Perfect prescription for inequity: The intersection of COVID-19 and the U.S. health care system
The COVID-19 pandemic is a perfect prescription for exacerbation of current, and creation of new, inequities in our health care system. When we get to the other side, the pandemic will leave unprecedented devastation in its wake, including a disproportionate toll on the aged, those with preexisting conditions, minorities, the poor, the incarcerated, essential workers, healthcare workers, and Native American populations (Woolhandler & Himmelstein, 2020; Bibbins-Domingo, 2020). The existing inequities in the U.S. health care system, including barriers to and social determinants of care, were addressed in the 2020 American College of Physicians’ “Better Is Possible” policy papers (Doherty et al., 2020). In the face of the COVID-19 pandemic, this prescient call to action and offer of systemic solutions is more relevant than ever.
Inadequate personal protective equipment and infection control procedures will have a disproportionate impact on health care practitioners, including those with underlying preexisting conditions, which will increase risk of poor outcomes, including hospitalization and death (Ranney, et al., 2020). Concerns about data inadequacies that will underestimate the impact of the pandemic on traditionally marginalized populations must be addressed (Osuji, 2020). This is a moment we cannot ignore.
Additional inequities that have been created or exacerbated in the face of COVID-19 are daunting and innumerable. Front and center is the increased clinical and economic risk of frontline and essential workers in health care and other industries. Many of these low-wage earning individuals are fearful of taking unpaid leave and job loss when they or others they care for are ill. Lack of provision of safe working environments in health care has resulted in several thousand Occupational Safety and Health Administration complaints (Vaidya, 2020). Reports of sanctioning of health care and other workers who are speaking out by their employers is alarming (Stone, 2020). Structural inequities in health care environments which perpetuate lack of diversity, equity, and inclusion, are magnified (Singiser, 2020).
So, how do we gain ground on the inadequate health care system structures that have teed up the astounding and unacceptable outcomes we have seen during this pandemic? In January 2020, the American College of Physicians (ACP) put forth a series of policies, creating a vision for systematic reform of the U.S. health care system. The plan ensures access to health care for all by addressing the inadequacies that created a system that leaves many behind by undervaluing public health and primary care, fostering barriers and discriminating against vulnerable populations, spending too much on administration, and creating perverse incentives. It includes policies that put forth solutions to ensure access to equitable care for all, achieved by overlaying the current employer-based insurance system with a public option, or through a single-payer system, addressing inadequately funded and structured public health systems, addressing social indicators of health, improving health for all, with lower costs and better outcomes (Doherty, 2020).
Our health care system is in critical condition and in need of a rapid, and comprehensive response. Now is not the time for bitter partisanship, but is the time for the communities in health care to work together to address the variety of existing, amplified, and new inequities, created in the face of COVID-19.
While we were woefully unprepared to address the acute consequences of the impact of the first wave of COVID-19, we must be better prepared to address the next waves, as well as the predictable exacerbations of chronic diseases, and the mental health and sociobehavioral consequences that will disproportionately impact traditionally marginalized communities.
We must also use this opportunity to restructure our health care leadership to create a more just, equitable, diverse, and inclusive environment for the benefit all in health care — and especially for our patients.
DARILYN V. MOYER
MD, FACP, FIDSA, FRCP-E
EVP/CEO of the American College of Physicians and Adjunct Professor of Medicine at the Lewis Katz School of Medicine at Temple University.
Bibbins-Domingo, K. (2020) This Time Must Be Different: Disparities During Covid-19. Annals of Internal Medicine, 173(3). https://doi.org/10.7326/M20-2247
Doherty,R., Cooney, T.G., Mire, R.D. & Engel, L.S. (2020) Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians. Annals of Internal Medicine, 172(S2). https://doi.org/10.7326/M19-2411
Osuji,C. (2020, April 29). High Rates of coronavirus among African Americans don’t tell the whole story. The Philadelphia Inquirer. https://www.inquirer.com/opinion/commentary/coronavirus-black-americans-racial-disparities-testing-data-20200429.html
Ranney, M., Griffeth, V. & Jha, A.K. (2020) Critical Supply Shortages- The Need for Ventilators and Personal Protective Equipment during the COVID-19 Pandemic. The New England Journal of Medicine. 382(e41). https://doi.org/10.1056/NEJMp2006141
Singiser, D. (2020, April 27). Supporting Frontline Women Amid Covid-19. The Hill. https://thehill.com/opinion/healthcare/494741-supporting-frontline-women-amid-covid-19
Stone, W. (2020, May 29). An ER Doctor Lost His Job After Criticizing His Hospital On COVID-19. Now He’s Suing. NPR. https://www.npr.org/sections/health-shots/2020/05/29/865042307/an-er-doctor-lost-his-job-after-criticizing-his-hospital-on-covid-19-now-hes-sui
Vaidya, A. (2020, April 29). OSHA Investigates surburban Atlanta hospital after nurses’s death. Becker’s Hospital Review. https://www.beckershospitalreview.com/nursing/osha-investigates-suburban-atlanta-hospital-after-nurse-s-death.html
Woolhandler, S & Himmelstein, D. (2020) Intersecting U.S. Epidemics: COVID-19 and Lack of Health Insurance. Annals of Internal Medicine, 173(1). https://doi.org/10.7326/M20-1874