Unlike many developed nations, the United States does not provide a universal healthcare service. Instead, citizens must acquire health insurance policies to protect themselves against the potential of unexpected and substantial costs incurred from treatments which could put some in precarious financial positions.
For many Americans, health insurance is provided through their employment, called employer-sponsored insurance. This system, which ties health care to employment, is fraught with problems, especially for the most vulnerable members of society. In this twisted logic, it is often those most at risk of serious health problems who are the least likely to receive adequate healthcare.
As it stood before the COVID-19 pandemic, 87 million Americans were uninsured or underinsured, meaning they have inadequate protection against healthcare expenditures.
Not only is this insurance-based healthcare system systematically unfair and complicated, it is also extremely expensive. According to Alison Galvani, Director of the Yale Centre for Infectious Disease Modelling and Analysis, Americans pay more for healthcare than any other developed nation. In 2019, the OECD reported that healthcare costs made up 17% of US GDP. These costs have considerable financial and medical implications. It is estimated that around 500,000 Americans file for bankruptcy each year due to healthcare-related debt. More troublingly, around 30,000 Americans die annually as they are unable to afford doctor’s fees. Many asthma sufferers do not use their inhalers as they can’t afford the dosage; some even go for years without primary care and end up in an Intensive Care Unit (ICU). This, in turn, results in greater healthcare expenditure for the individual, their insurer, or the government.
In essence, Galvani’s study on the flaws of the US healthcare system demonstrates that it is expensive, inefficient, very inequitable and does not cover everyone. Such sentiments are beginning to take hold of the American public as faith in their costly and convoluted healthcare system wanes.
Covid-19: A broken system pushed to its limits
According to the Johns Hopkins Coronavirus Research Centre, more than one-fifth of global COVID-19 cases have been registered in the United States. The current pandemic has further pushed the already flawed US healthcare system into a state of disarray and potential disaster. The key aspects of the pandemic’s impact on the system are as follows: economic crisis and unemployment, extreme shortages and racial disparities.
Economic crisis and unemployment
The economic crisis prompted by the pandemic has had a serious impact on the US healthcare system. Between February and April, the unemployment rate more than quadrupled to reach a record high; causing more than 26 million Americans to claim unemployment benefits. As many Americans’ health insurance is covered by their employers, many of these 26 million will have lost their health coverage; leaving them unable to pay extortionate healthcare costs. A nurse at a New York hospital reported the ‘next-level heartbreak’ of hearing a dying patient use his last words to ask, "Who’s going to pay for this?".
According to a 2019 report, 30% of Americans delay medical treatment due to cost every year, including 19% who delay treatment for serious conditions.
In the context of the pandemic this could mean many people not getting tested and some delaying getting healthcare support, consequentially harming their own health as well as potentially spreading the virus. As Adam Gaffney, an ICU medic, pointed out ‘it’s hard to fight an epidemic if people are afraid to go to the doctor’.
Since hospitals and healthcare services are run as businesses, they have been financially impacted like many other sectors of the economy. Although the pandemic has seen a surge in health treatments to combat the virus, there has also been a significant decline in non-essential treatments such as physical therapy, cosmetic surgery and orthopaedic procedures. These treatments have the highest profit margins and therefore generate much-needed revenue for healthcare practices. As a result of this shortfall in income, hospitals and health services are having to make serious cuts.
In what many see as a policy of profits over people, hospitals have laid off medical workers in their thousands – including those working on the frontline. It was predicted that 60,000 family practices would be closed by summer and innumerable emergency doctors and physicians would stop being provided with benefits, including paid time off. As one nurse from Wisconsin stated, "[the] bottom line has always been at the very forefront", but the pandemic is further preoccupying healthcare professionals with the need to be frugal. In response to the health sector crisis, Congress has allocated a sum of $100bn to ease the financial burden on hospitals.
Shortages: choosing who lives and who dies
The current cuts in the healthcare system have not only led to fewer jobs and increased strain on workers but also shortages of supplies. These shortages have been exacerbated by the consistent disinvestment and cuts made by the government which have decimated public health agencies. Now 6 months into the COVID-19 crisis, reports from the frontline in the US reveal that there is still an extreme shortage of Personal Protective Equipment (PPE), forcing doctors and nurses to reuse single-use masks, some even resorting to wearing bin bags as overalls. Some reports have suggested that many organisations are forced to source the necessary equipment through back channels and the black market. In New York and New Jersey, some hospitals resorted to turning equipment such as anaesthesia and sleep apnoea machines into make-shift ventilators to combat severe shortages. Furthermore, there is a scarcity of painkillers and sedatives for those in pain from the ventilators, as well as a lack of dialysis machines to tackle COVID-induced kidney failure.
In order to deal with these vital shortages, some hospitals have needed to set up triage committees, which have been labelled as ‘death panels’. These committees discuss matters of bioethics and determine whether a patient has a higher ‘survivability’ than another. However, since the Trump administration failed to establish a federal commission on bioethics to provide national guidelines for COVID-related triage, the decision on who should live has been left to states, hospitals and individual groups. As the president of a New York bioethics thinktank has suggested, these triage plans led by ‘heartbroken health professionals’ are likely to cause tremendous suffering and PTSD.
Racial disparities
Much like in the UK, the covid-19 pandemic has not proved to be a ‘great leveller’ affecting all of society equally. It has instead revealed all kinds of inequalities that exist in our societies, and this is certainly the case for the US. Statistics from the pandemic have revealed significant racial disparities in COVID-19 cases and deaths:
African Americans constitute 13% of the US population but 20% of Covid-19 cases and more than 22% of COVID deaths
Hispanic persons constitute 18% of the population and 33% of new COVID cases
Some reports state 30% of reported deaths are from African American populations
The reasons for these figures lie behind the intrinsic racial inequality that exists in the US and the long-standing failure of the health system to care for persons of colour.
For example, it is more likely that persons of colour have low-paid jobs which cannot be performed remotely, and which therefore require them to maintain high levels of social contact. At the beginning of the pandemic, 30% of White Americans said that they could easily work from home, compared to only 20% of African Americans and 16% of the Hispanic community. In addition, many of the hospitals on the verge of bankruptcy serve poorer and non-white communities in less affluent areas; some of which are now closing due to financial issues.
A case for Medicare for all?
There can be no doubt that such immense strain on America’s healthcare system has laid bare its weaknesses for everyone to see. As Kelly Coogan-Gehr of National Nurses United stated, "everyone’s seeing that it’s in the interest of all Americans that everyone gets the healthcare they need when they need it". In support of this, a poll has discovered that more than 40% of Americans claim the pandemic has increased their likelihood of supporting a universal care policy where healthcare is provided by the government, such as Medicare for All. Polls show that over two-thirds of Americans support the expansion of Medicare – a government-financed health insurance system targeted at elderly and disabled citizens.
In this way, the pandemic could lead to incremental changes that see the unlinking of employment and health insurance, thereby making the system far more equitable. This being said, healthcare providers have been purported to generate more than $180bn in profits a year, providing CEOs with large reward packages. Therefore, they will likely put up a fight against those trying to end the status quo. Nevertheless, as the long-time universal healthcare advocate Bernie Sanders has suggested, this is a hopeful time which provides an opportunity to "reassess the foundational institutions of US society and build a better future".
Take a look at our US Politics section for more insightful resources.