The 2019 novel coronavirus (COVID-19) “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,” according to Sue S. Bornstein, MD, FACP, lead author of the American College of Physicians (ACP) article, “The Collision of COVID-19 and the US Health System,” published in the Annals of Internal Medicine.1
In January 2020, ACP published a series of position papers that asked readers to envision what a better health care system in the United States would look like.2 The ACP responded with ways to achieve access to care, decrease health costs per capita, and reduce the complexity of the health care system. And then the COVID-19 epidemic hit the United States.
“This widespread public health crisis has wreaked havoc on patients and left many health care systems unable to provide much needed care,” said Dr Bornstein. “Enough is enough. The time is now to address our system’s shortcomings and enact real change.”
Although the government implemented the Coronavirus Aid, Relief, and Economic Security (CARES) Act, it did not include insurance subsidies for the unemployed. Prior to the endemic, approximately 30 million Americans were uninsured or underinsured, and since March 2020, more than 36 million Americans had filed for unemployment. “For most, losing a job means losing employer-based health care,” they noted.
The authors also reaffirm that the pandemic highlights the need for increasing investment in primary care, which provides a first-line response and mitigation of the crowded 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,” noted the authors. “In a recent survey of primary care practices, 76% reported severe or close-to severe strain on their practices.”
To achieve the ACP’s vision for a more inclusive health care system, they recommend:
- The Unites States transitions to a system that achieves universal coverage with essential benefits and lower administrative costs.
- Coverage should not discriminate based on a person’s place of residency, employment or health status, or income.
- Coverage should ensure sufficient access to all forms of care both primary and specialty.
- Options for universal coverage could include a single-payer financing approach or a publicly financed coverage option to be offered with regular private insurance.
- The ACP supports greater investment in primary care and preventive services, including support for internal medicine specialists.
Across the United States, deaths from COVID-19 have been much higher among black, Latinx, and Native American communities; the same groups have the highest rates of low health literacy, noted the report. Racial and ethnic minorities also make up a significant percentage of essential workers who may be at an increased risk of exposure to the virus. Social distancing is more difficult in areas with high population density, multigenerational households, and high reliance on public transit, the report said.
In light of this, The ACP “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.”
Countries with nationally coordinated systems of health care that have successfully limited spread of the virus, noted the authors. Australia, New Zealand, and Taiwan, for example, mitigated the virus by tracking travel and contact tracing for every patient, timely mass testing, and early restriction of activity. “Had the United States had a robust system for primary care and national coordination under a universal coverage model, outcomes of the pandemic may have been different,” they stated.
“As physicians on the front lines of the COVID-19 pandemic, we believe more than ever that better is possible,” said Thomas Cooney, MD, MACP, a senior author on the paper and Chair of ACP’s Health and Public Policy Committee. “We must take the lessons learned of healthcare inequities and injustices and move forward to create a more equitable and just system of care for all.”3
1. Bornstein SS, Mire RD, Barrett ED, Moyer DV, Cooney TG. The collision of COVID-19 and the U.S. health system [published online June 2, 2020]. Ann Intern Med. doi: 10.7326/M20-1851.
2. Doherty R, Cooney TG, Mire RD, et al. Envisioning a better U.S. health care system for all: a call to action by the American College of Physicians [published online January 21, 2020]. Ann Intern Med. doi.org/10.7326/M19-2411.
3. ACP Leaders Suggest Using “New Vision” to Guide U.S. Health Care Reform During and After COVID-19 Pandemic [news release]. American College of Physicians newsroom; June 2, 2020. https://www.acponline.org/acp-newsroom/acp-leaders-suggest-using-new-vision-to-guide-us-health-care-reform-during-and-after-covid-19. Accessed June 5, 2020.