By LEV FACHER @levfacher MAY 19, 2020
WASHINGTON
— In the U.S. alone, Covid-19 has claimed nearly 100,000 lives and 30 million
jobs. Beyond grinding day-to-day life to a halt, the pandemic has prompted a
reckoning throughout the country’s health care infrastructure, shattering
decades-old assumptions about how Americans conceive of medicine, and the
doctors, hospitals, insurance companies, and pharmaceutical manufacturers they
pay to provide it.
Already,
the coronavirus has led to sweeping changes in who can receive care and how
they access it. Millions of Americans, newly out of work, are also newly
uninsured. Millions more who still have insurance have been forced to delay
necessary but noncritical treatments. At the same time, doctors across the
country have been granted broad flexibility to treat patients remotely, using
telemedicine, instantly reshaping services ranging from routine checkups
to addiction treatment.
STAT
surveyed a host of prominent health policy experts — top health advisers to
both Republican and Democratic presidents, lawmakers, executives, physicians,
and top lobbyists — who forecast a new status quo that they say will
upend what American health care looks like for decades.
Among
their predictions: The pandemic could help bring about an end to the American
tradition of tying health insurance to employment status. It could prompt a
reckoning about why Black people and other historically marginalized
populations have long suffered so disproportionately — not just from Covid-19,
but from nearly every common health condition. And it could represent the
beginning of the end for the very concept of nursing homes and assisted living
facilities.
Below,
STAT lays out nine ways in which the coronavirus pandemic is likely to forever
change health care, the policies that guide it.
The
comments below have been edited for length and clarity.
1. How Covid-19 has accelerated telemedicine ‘by
a decade’:
Health
care providers in the U.S. have been inching toward making more services
available via telehealth for years. But health care leaders across the
ideological spectrum agree: Covid-19 has pushed the inevitable telemedicine
revolution forward by a decade, if not more, according to health care leaders.
Chris
Jennings, policy consultant and former health care adviser to the Obama and
Clinton administrations: “There’s the assumption in
primary care that you always had to have in-person contact, and that telemedicine
would be unsatisfactory, or wouldn’t fill the void. That’s been exposed —
actually, it’s safer, it’s quicker, and it’s easier. If I just have a quick
question, I want to see someone and engage them and see their focus is on me.
But do I have to be in that office? And for a physician, can I get more things
done, be more efficient, and protect myself, as well as my patients? People are
now seeing this model, which we thought would take years and years to develop.
And it’s probably been accelerated by a decade.”
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While the
changes are most broadly relevant to primary care, other experts said the same
trend is increasingly applicable to specialists. From addiction doctors
prescribing drugs to treat opioid dependency after video chat visits to
podiatrists using cameras to treat patients with diabetes, thanks to Covid-19
physicians across the country are providing care that, until now, was thought
to only be feasible in person.
Karen
Ignagni, president of the nonprofit health plan EmblemHealth and former CEO of
the insurance lobbying group AHIP: “The convenience
factor of being able to talk to your clinician via video conference, or even
text, is something that we haven’t internalized as a country until recently. I
can speak from the perspective of the specialists in our medical group:
Podiatrists are learning, for routine maintenance of checking the feet of
diabetics, to ask our diabetic patients to put the camera near their feet, so
they can properly space their toes, so they can properly look at their feet.
One could suggest it’s not as great as being there in person. But in the past,
people would likely not have had that option at all.”
2. Another step away from traditional
employer-based health insurance
In a
floundering economy, employers will be under more pressure than ever to reduce
costs. Some conservative thinkers see it as a chance to bolster the prominence
of health reimbursement arrangements, or HRAs, in which employers reimburse employees
for medical expenses and in some cases, insurance premiums — in place of
providing insurance to employees as a company. Proponents say HRAs offer
employees more flexibility, but detractors caution that they often offer
employees less help with their medical costs than under traditional
employer-based insurance.
Brian Blase,
former Trump administration health care adviser and health policy consultant: “Employers
are going to look to HRAs as a potential way to get more certainty over their
costs, and basically say: All right, we can afford $4,000 per employee for
health insurance in a year, so we’re going to give employees $4,000 for health
insurance and let them go shop for coverage that works best for them. I see
HRAs as politically viable — it’s the only big thing I worked on when I was in
the administration that didn’t get sued by attorneys general or by liberal
groups, and there’s no love for traditional employer coverage.”
Many
progressives, of course, see things differently. But there’s agreement across
the ideological spectrum — 30 million newly unemployed Americans, and scores of
others who worry they’ll lose their job and their health care with it — have
made traditional models of employer-based health insurance less relevant than
ever.
Don
Berwick, former administrator Centers for Medicare and Medicaid Services during
the Obama administration: “You notice the number of band-aids that
Congress is having to apply to help people who have lost their jobs. It’s
interesting to me: Amid Covid-19, the only people in America who don’t have to
worry about their health insurance are people on Medicare, or people covered by
the Department of Veterans Affairs or the Military Health System. What we have
now is a whole series of band-aids and special measures. What if instead, we
just had universal health insurance?”
3. Out with nursing homes and assisted living
facilities — and in with home health aides
In most
states, deaths in nursing homes and other long-term care facilities have
accounted for over one-third of Covid-19 fatalities. It’s a disturbing
statistic that some experts say could finally flip modern-day thinking about
long-term care on its head. While assisted living or nursing facilities can
provide consolidated services and around-the-clock medical care, the idea that
society’s most vulnerable should be housed in such close quarters may have
forever lost its appeal.
Grace-Marie
Turner, president of the Galen Institute, a conservative health policy research
group: “I served on the Medicaid Commission 10 years ago. It was so
obvious that the last place that anybody wants to go is a nursing home — and
this was before the coronavirus. People want their own independent life. Now,
they don’t want to be in what’s basically a nursing-home prison, as some have
called it, because they’re locked up, they can’t leave, and nobody can come see
them — it might as well be a jail. There are going to be major changes,
particularly with an aging baby boom, with so many tens of millions of people
who are going to need longer-term care and do not want to go to a nursing home.
So how’s the private sector going to respond?”
Such a
shift, however, could lead to a staggering increase in demand for home health
aides, house calls, and in-person medical services delivered to elderly
Americans with significant needs but who, understandably, have little interest
in living in such close quarters with dozens or hundreds of others.
Billy
Tauzin, former Republican congressman from Louisiana and former president of
PhRMA: “I think there’s going to be a major shift in terms of support for
the nursing care industry in America, and toward home care. The notion that
seniors would prefer to be in their homes has always been around. We used to
raise our grandparents in our homes — I remember my grandparents used to live
right next to me, and we took care of them. We even had a buzzer system in our
home when our grandparents needed help.”
4. An inflection point on racial disparities
Black
people represent 6% of Wisconsin’s population — but account for nearly half of
the state’s coronavirus deaths. Black people, similarly, account for two-thirds
of Chicago’s deaths despite constituting only one-third of its population.
Across the country, the story is the same: Covid-19 is killing people of color,
particularly Black people, at staggeringly disproportionate rates.
To
longtime observers of the U.S.’s health care system, the numbers are hardly
surprising. But there’s hope among some experts that the tragedy could prompt a
long-overdue reckoning about health disparities and the social determinants of
health. The differences in coronavirus death rates between white and Black
people in the U.S., many argued, are too dramatic, and too immediate, to
ignore.
Risa
Lavizzo-Mourey, former president, Robert Wood Johnson Foundation and professor
of health policy at the University of Pennsylvania: “The
stark disparities in Covid-19 infection rates and outcomes among different
populations and different parts of the country has been hard to ignore. While
there’s a rich body of work that has demonstrated this in the past, it’s a
unique moment where it’s happening all at once, and you can see it in real
time. I think that the moment is one that hopefully will sort of force us to
address some of the potential policy solutions.”
Berwick: “Anyone
who’s been studying equity and justice in health care knows that the
vulnerabilities have been there — this has always been true. But Covid-19 has
kind of underlined it, made it more visible. My feeling is: For Pete’s sake,
can’t this country finally get serious about closing racial and socioeconomic
gaps in access to health care and health status and being able to lead a good
life?”
Georges
Benjamin, executive director for the American Public Health Association: “We have
to recognize that inequities still exist. Why do we think it’s going to be any
different when we get a vaccine or antiviral agent? We need a plan now to make
sure that those existing disparities are not exacerbated by inadequate access
to treatment or access to vaccines. We have to pay attention to that now, and
make sure we plan.”
5. Yet another reckoning on drug affordability,
with a chance for pharma to rehab its reputation
For
years, politicians ranging from Sen. Bernie Sanders (I-Vt.) to President Trump
have blasted major pharmaceutical companies as profiteers. But Covid-19 has
flipped the script: Never before has the public placed such pressure on drug
companies to develop, at a breakneck pace, treatments and vaccines to guard
against the novel coronavirus. Already, two major U.S. drug companies have made
strides toward approvals for a therapeutic and a vaccine: Gilead Sciences and Moderna, respectively. Some experts see the
pandemic as a chance for the pharmaceutical industry to rehab its reputation in
Washington, and for drug companies to showcase their vast research and
development capabilities.
In
addition to those questions about pharma’s reputation, experts said the
pandemic would also raise new questions about how the U.S. prices drugs. Some
Democratic lawmakers have advocated for NIH to reexamine its mandate to license
potential drug candidates to companies that will make them available on
“reasonable terms” — and to interpret “reasonableness” more narrowly. They say
the Covid-19 pandemic could provide unprecedented leverage for the government
to finally exercise negotiating power.
But NIH
and its director Francis Collins have long said the agency isn’t in a position
to enact drug pricing constraints.
Tauzin: “People
love [pharma] when they produce a product that takes care of their problem.
When we get a cure for hepatitis C, we love the idea that we can now cure — not
just treat, but cure — hepatitis C. We hate the idea that it costs so damn
much. That’s always going to be the equation.”
More
broadly, with millions of Americans newly out of work, high drug prices could
pose a bigger barrier to care than ever before — even if the public gives the
pharmaceutical industry some credit for scrambling to develop cures and
vaccines.
Sheila
Burke, former chief of staff to onetime Senate majority leader Bob Dole
(R-Kan.) and former executive dean of Harvard’s Kennedy School of Government: “It’s
been interesting to see issues at the top of the list six or eight months ago,
like drug pricing and surprise billing, disappear in the coronavirus
discussions. I think drug pricing will continue to be an issue even after the
pandemic subsides, particularly with people now under more economic strain and
essentially having to foot the bill. Will there be some forgiveness on prices because
of the moves to scale up production of a vaccine, or whatever it might be? Yes,
but there will still be growing sensitivity and concern, and real desire to
resolve this question of what should be the right structure of the pricing
mechanism.”
6. American drugs, made once again in American
factories
Janet
Woodcock, a top official at the Food and Drug Administration, has already
pointed to Covid-19’s potential to “revitalize drug manufacturing in the U.S.”
— a step Democrats and Republicans alike have called for amid concerns that, as
China entered a national lockdown in early 2020, its shuttered factories could
cause shortages for drugs and other critical medical supplies in North America.
Rep.
Donna Shalala, Democratic congresswoman from Florida and former Clinton
administration health secretary: “In the 1990s, I was so
worried about the possibility of a flu pandemic, and that we weren’t making the
flu shots, the vaccines, in the United States. I actually moved the vaccine
production to the U.S. and did a huge contract with a company in Pennsylvania.
… We have to look, fundamentally, at the supply chain. It doesn’t mean that we
don’t believe in a global market, but it does mean that we have to be able to
ramp up production here quickly, and do some of the manufacturing here so that
we can ramp up production.”
It’s a
school of thought that, since the start of the Covid-19 pandemic, has become
surprisingly bipartisan — Republicans and Democrats have historically differed
both on free-trade issues, and GOP figures have been far more aggressive in
blaming China for the initial coronavirus outbreak more broadly. Similarly,
many Republicans have used far harsher words than Shalala to characterize the
U.S. biomedical supply chain’s reliance on China. Sens. Marsha Blackburn
(R-Tenn.) and Bob Menendez (D-N.J.) introduced legislation advocating for the
U.S. to become less reliant on both China and India for pharmaceutical
manufacturing capacity.
Turner: “You’re
going to see that more companies will do what Pfizer already has done, and
that’s bring more of their manufacturing capability into the United States — or
at least diversify it away from China. That’s almost inevitable. I think people
should be looking at all those Harvard MBAs who, for the last 20 years, have
been saying, ‘Oh, move all your manufacturing to China, it’s a lot cheaper,’
and maybe had to rethink that.”
7. A new era of health care preparedness
Covid-19
has already prompted calls for a dramatic scaling up of the country’s disaster
readiness workforce. By consensus, America’s health care infrastructure wasn’t
ready for the pandemic — at first incapable of conducting testing and later
short on the workforce required to carry out the Herculean task of
contact-tracing tens of thousands of new Covid-19 cases per day.
There are
several proposals to increase the health care workforce in times of emergency.
A bill from House Democrats would fund a $75 billion contact-tracing workforce
through which hundreds of thousands of Americans use shoe-leather epidemiology
to track Covid-19’s spread. Other ideas have focused on creating networks of
retired doctors, once-trained practitioners who no longer work in medicine, and
even advanced medical students participate in the medical equivalent of a
National Guard.
Shalala: “The
federal government needs to have real plans for how they can find health
personnel to augment during an infectious disease disaster. And one way of
doing that is for the federal government to develop a reserve corps in every
part of the United States that’s ready and able to come back in emergencies.
They can be a wide variety of people, including the possibility of taking a
look at foreign medical graduates, and maybe upgrade their training so they
could be brought back under doctor’s supervision.”
Burke: “I
don’t think the U.S. Public Health Service Commissioned Corps, which is
spectacular, will ever be adequate. Contact tracing is a perfect example:
You’re going to have to scale up extraordinarily large numbers of people. And
these aren’t necessarily people who are MDs or nurse practitioners or
physicians’ assistants. They are classic public health workers who can do that
basic kind of work. Much like the last time we went through this extraordinary
economic disaster, we found things for people to do — instead of building
bridges, maybe they do contact tracing.”
8. Allowing nonphysicians, like nurses, nurse
practitioners, and physician assistants to play a bigger role in care
The
coronavirus pandemic has placed immense pressure on emergency rooms and
intensive care units, highlighting the immense role of nurses, nurse
practitioners, and physician assistants.
The
phenomenon is compounded by a reality that predates Covid-19 by decades: Rural
hospitals across America are struggling to stay afloat, and many practices
could provide care at lower cost to more patients by leaning more heavily on
the nondoctor medical practitioners already on their payrolls — if Congress,
state legislatures, and state medical boards, which have varying powers over
scope-of-practice rules, let them.
Shalala: “Frankly,
70% of primary care could be handled by advanced practice nurses.”
Tauzin: “You’re
going to see a shift toward more authority for skilled nurse training and
skilled nurse activities in health care, as family doctors become more scarce
and hospitals in parts of our country are shutting down. That’s going to be a
major shift to decentralize health care, and toward preventive care and home
care.”
9. Who makes money in health care — and how they
make it
While
there’s immense demand for coronavirus treatment, there’s almost no demand for
any other health service — meaning that many doctors’ and hospitals’ revenue
streams have taken a nosedive. Hospitals and physician practices across the
country have laid off support staff and cut wages or benefits for their staff
doctors.
That
dynamic could eventually upend the traditional American model of paying for
health care services in individual line items, known as fee-for-service
medicine, the experts said. Other payment structures — under which a hospital
might be paid a lump sum for caring for an entire group of patients, or
compensated for keeping a patient healthy and avoiding an unnecessary
readmission, for example — had previously been met with mixed interest, since
they forced providers to accept some responsibility for keeping costs down.
Jennings: “We’ve
seen physician offices that live off fee-for-service just get freakin’ killed,
because you can’t bill for services you’re not providing. What physicians are
also noticing is that for those few practices that had per capita contracts,
and had guaranteed payment structures, they’re surviving and thriving. They’re
learning that the risk factor they’re so worried about goes both ways. There
are benefits to that guaranteed, per capita contract, and that’s never been
really understood — but now it is. Now the question is whether enough practices
see it and digest it, and whether it will have applications.”
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