Ibrahim R, Ashraf S, Takruri Y. The United States healthcare system today: The COVID-19 era. Harvard Public Health Review. 2021; 29.
Although the COVID-19 pandemic was a surprise for many, this was anticipated by many public health officials. Organizations have long warned of the potential of a viral outbreak, however many of these organizations were eventually defunded, or ignored. As we know, COVID-19 is a highly transmissible virus with the potential for life-threatening outcomes, while also capable of dismantling economic and healthcare infrastructure. The first case of COVID-19 in the United States was confirmed on January 20, 2020, and now the US leads in the highest number of confirmed cases globally. On March 11, 2020, the World Health Organization (WHO) declared the coronavirus a pandemic (1). The initial response to COVID-19 was inefficient and consisted of strict testing requirements that severely underestimated the prevalence of the disease, setting the US back months from containing the spread. This pandemic has magnified the weakness of the current healthcare system in the US and has identified areas that are in need of improvement. In this article, we describe inefficiencies that have been brought to light by this global pandemic while comparing similar points seen in other countries outside of the United States. Greater efforts are warranted to improve the current healthcare system and to potentially prevent the spread of future outbreaks within the United States.
In October 2019, the Global Health Security (GHS) Index attempted to assess the readiness of countries of their ability to respond to viral outbreaks (2). This index contained 140 questions used as a benchmarking tool that measures the country’s ability and national capacity to mitigate the spread of an infectious disease. The index scoring system is stratified into 6 categories, as described in table 1. The scoring system is on a 0 to a 100-point scale, with 100 being the highest possible score one country can receive, and indicative of a stronger and more robust program to respond to biological threats. It can also identify gaps in pandemic preparedness. However, national experts do agree that this GHS index needs configuration to more accurately assess a nation’s capacity to respond to an outbreak. A more detailed analysis regarding a nation’s leadership and the confidence of the leadership by the people may provide additional, yet valuable, information.
The GHS Index found that no countries from a total of 195 countries were fully prepared for a major health emergency involving an infectious disease (2). However, the US was deemed better positioned to respond to global pandemics as indicated by the GHS Index in comparison to the other 194 countries. This is partly due to the high-quality laboratories and strongly-trained epidemiologists that are devoted to combating infectious diseases (3). Additionally, the US is the home to the US Center for Disease Control and Prevention (CDC) that includes a global initiative to combat infectious diseases. Unfortunately, this was not the case for the US. There are vulnerabilities and gaps within the US healthcare system and leadership at a federal and state level that have led to the worsening of the COVID-19 spread. The US makes up less than 5% of the world’s population, however, has greater than 25% of all the total COVID-19 cases globally. It also has one of the highest rate per capita case fatality rates in the world (4-5). These outcomes were not inevitable and could have been mitigated significantly.
Despite a top ranking by the GHS scoring system, there was a clear lack of public confidence in the government, which was unlike many other high-income countries. Another downfall observed by the GHS scaling system was the lack of access to healthcare for many individuals in the US. In 2014, the World Health Organization showed that the US healthcare system uses 17.1% of its annual GDP, estimating slightly over 9,000 per person, the highest of any nation worldwide while the Organization for Economic Co-operation and Development (OECD) statistics in 2018 showed the American healthcare as the most expensive worldwide, despite having approximately 27.5 million Americans with no health insurance (6). In fact, in the US, there is a lower life expectancy when compared to other developed countries such as Canada and Germany regardless of a higher cost per capita. For the average American, the fear of being responsible for high out-of-pocket costs despite being insured is likely to further exacerbate delays in seeking medical attention. On the GHS Index assessment, the US ranked 38th out of 60 high-income countries in respect to physicians per capita, and 40th for hospital beds per capita. In addition to this, the US ranked 175th from 195 countries on access to health care due to its absence of laws that mandate universal health insurance. Even though the US was well prepared to respond to a pandemic in accordance with the GHS Index, this failed to be the case. COVID-19 has clearly exposed many of the weaknesses in the US and the public health governance system.
The US national response to the COVID-19 pandemic has exercised their powers unevenly. The confusion fostered into the public by unproportioned strategies across the nation and undermining the seriousness of this pandemic has led to the non-compliance of many individuals. The lack of inter-jurisdictional coordination has cost the nation toppling control of the virus. Public health governance at the federal level is vastly responsible for the interstate and international spread of the disease while the governance from individual states and counties hold various other responsibilities including individualized state restrictions. From a federal standpoint, ambiguity within their statements regarding the threat of the virus and the pandemic is costly, causing a lack of trust in public health officials. From a state perspective, certain regions in the US had a greater implementation of halting business operations and restricting out-of-home activities during certain hours, however, this was not introduced uniformly across the nation. Additionally, mask mandates and regulations regarding gatherings varied from state to state. For example, one month after the beginning of the pandemic, around 20 states across the nation failed to issue stay-at-home orders, and many nonessential businesses failed to close (3). There was also a lack of enforcement mechanisms to permit compliance with these regulations. A unified response to control viral spread did not occur.
All things considered, the call made to restore supplies of crucial stockpiles consisting of medicine and personal protective equipment was not well responded to. Federal restrictions placed on laboratories across the US also hindered the process of developing timely assays to detect COVID-19. As a result, inadequate testing led to the further spread of an undetected virus across the nation. These restrictions were eventually lifted; however, time was of the essence.
Additional factors to consider include the fact that in 2018, the Presidential administration disbanded the White House’s National Security Council Directorate for Global Health Security and Biodefense. This global health unit was appointed to prevent and combat pandemics. This was not the only agency that could have helped predict and prepare the US for COVID-19. In October 2019, the US Agency for International Development’s Predict program, which helps track early-stage viruses and diseases globally, was also shut down. Similarly enough, these changes have been consistent with prior acts in the early 1990s. For example, the antibiotic-resistant tuberculosis outbreak in 1992 was strongly impacted by the discontinuation of funds into research programs that were dedicated to tuberculosis. Overall, comparing CDC budgets from 2018, there is a prominent decline in funding in almost all areas, most notably in “Emerging and Zoonotic Infectious Diseases” and “Public Health Preparedness and Response”.
The US has been, and still, at the forefront of providing foreign aid to countries for means of increasing their public health capacity, regardless of its own capacity. For example, the Global Health Security Agenda, founded during the Obama presidency, granted support to other countries to increase their public health capacity of responding to infectious diseases. Interestingly, when comparing the US to other countries in the OECD, we see higher expenditure compounded by the fact that the US has fewer hospital beds and physicians per capita than other developed nations (7). Data from the OECD in 2016, shows that the US has 2.8 hospital beds per 1000 inhabitants versus Italy having 3.2 beds per 1000 inhabitants.
A review of various countries and their responses to the COVID-19 pandemic is discussed here:
South Korea experienced a large outbreak of the Middle East respiratory syndrome in 2015, primarily due to slow detection of the virus. However, this experience led to the growth of surveillance programs and the strengthening of the health care infrastructure (8). As a result, South Korea has been undoubtedly more prepared for COVID-19, leading to the 9th overall highest score on the GHS index. South Korea had its first confirmed case on the same day the US did. They responded with drive-through testing centers and home visits that aggressively identified the infected individuals (9). South Korea was also testing those who were asymptomatic. Within a month, they were able to slow down the number of new cases from 900 a day in February to about 100 a day in mid-March. The rapid testing and identification of close contacts, combined with effective quarantining have helped South Korea contain the spread. As a result of testing 214,640 individuals, as of March 11, South Korea has 7,755 confirmed cases of COVID-19. South Korea was able to test about 12,000 people a day, unlike the US who had tested about 12,000 people in the first two weeks of March. South Korea also provided these services for free. This facilitated rapid testing and as screening, treatment, and hospitalization were covered, it seemed to encourage South Koreans to get tested without the threat of a bill.
Italy is another example of how early testing can impact the spread of disease. Within the first few weeks, Italy had tested around 73,000 people and identified more than 15,000 positive cases. Comparing Lombardy and Veneto, two regions in Italy, we see a drastic difference in initial response and number of cases. Veneto, like South Korea, employed testing to symptomatic and asymptomatic people, home care, and successful quarantines. Unlike Veneto, Lombardy did not use these strategies. When Veneto had about 7,000 cases, Lombardy had around 35,000 cases. While Lombardy and surrounding regions in Italy eventually started implementing the above-mentioned strategies, it took weeks to slow the spread of disease (10).
Another example in Italy comes from Vò, where they ran a small experiment and began testing all of their residents, regardless of symptoms. By early testing and effectively quarantining, they were able to eradicate the virus within two weeks. While the population is minute compared to the large cities affected today, the effect of early widespread testing and quarantining becomes obvious (10).
Taiwan is a mere 80 miles from China and the proximity allows Taiwanese citizens to travel frequently back and forth. During early March, Taiwan reported just over 100 cases of COVID-19. When the outbreak began in China, the Taiwan CDC joined forces with the National Health Command Center (NHCC). The NHCC, established in 2004 after the SARS outbreak, includes the Central Epidemic Command Center (CECC), and together they coordinated with various agencies including ministries of transportation, economics, labor, and education, to contain the potential spread of disease. A list of 124 action items including resource allocation, early testing, proper screening of recent travelers, and successful quarantine helped Taiwan keep its numbers low. Taiwan saw an emerging public health crisis and responded effectively using agencies that began preparing early (11).
Thailand, ranked number 6 out of 195 in the GHS Index, had an exceptional laboratory transport system, risk communication plan, and a surveillance system. It was also one of the only countries out of the 195 countries assessed by the GHS Index that gave priority access to care for health care workers who develop an illness while working in public health emergencies. These effective measures lead to fewer daily cases when compared to many other countries, even though Thailand was the first country to report a positive COVID-19 case outside of China. Interestingly enough, Thailand’s robust epidemiological capacity was primarily a result of support and funding from the US.
In the US, the COVID-19 pandemic has clearly tested the capacity of the nation to respond to a global viral outbreak. Governing authorities from the federal and state perspective need reform as strength and confidence in a nation’s leadership is crucial. Increased access to healthcare is also of utmost importance in times like these. The United States has relied on the private sector to deliver health care under the concept that competition allows for the rapid growth of research and innovation. The notion to rely on private sectors or to evolve into a fully publicized healthcare system is a subject of debate and a matter of controversy. However, it is clear that the inefficiencies are being brought to light and should warrant greater efforts to improve the current healthcare system. Until consequential changes are made, the current system in place for the nation’s healthcare infrastructure will continue to be adversely affected and will provide many barriers to its residents.
Ramzi Ibrahim is a first year Internal Medicine resident at the University of Arizona, with a passion for population health, medical education, and cardiology.
Sana Ashraf is one of the co-authors of “The United States Healthcare System Today: The COVID-19 Era.”
Yessar Takruri, MD is a Cardiology Fellow at St. Joseph Mercy Oakland, Pontiac, MI.