The current wave of wildfires in California, Washington and Oregon reminds me of a quote I recently heard, “It’s not the match; it’s where it lands.”
With the COVID-19 pandemic, in which the combination of a deadly virus spreading rapidly between people is coupled with health care inequality and a relatively unhealthy population, the “match” has created a roaring conflagration of morbidity and mortality, worse in vulnerable communities.
In 2016, prior to COVID-19, 27 million Americans were uninsured. Since then, the number of uninsured Americans has increased by over half a million. Even among those insured, deductible payments for which the patient is responsible have steadily increased over the same time period.
The COVID-19 epidemic has made things worse. Because health insurance is provided by employers, the loss of jobs created by the pandemic has resulted in nearly 40 million new claims for unemployment. Loss of jobs results in loss of insurance unless the person facing unemployment can afford their own insurance policies, which typically are very expensive.
Although the CARES Act provided some economic relief, it did not include subsidies for health insurance. As a result, access to care has become even more limited during the pandemic, virtually ensuring that patients are sicker with the virus when they finally do seek treatment.
To further complicate our problem with underinsured citizens, lack of insurance and access to care is not evenly distributed across our population. Disparities with respect to ethnicity, education, location and family income are commonplace.
In 2018, Hispanics were two and a half times more likely to be uninsured than whites, and people living in poverty were four times as likely to be uninsured as average income households. In addition to financial issues, the social determinants of health in poorer neighborhoods lead to problems with access to a doctor, access to healthy foods and access to safe places to exercise. Health in such communities is further handicapped by discrimination, and the stress associated with being poor. Finally, with the current pandemic, many poorer Americans have jobs deemed essential, requiring them to report to work and exposing them to more people — increasing their likelihood of contracting the virus.
But poor health is not just a problem with vulnerable communities. The health of America as a whole is worse than other developed nations.
The World Health Organization ranks the U.S. health care system 37th in the world behind countries such as Oman, Cyprus and Dominica. Our infant mortality rate is 34th in the world, and the Commonwealth Fund ranks our quality of care last among developed nations. The only place that the U.S. is ranked first is in cost, with expenditures 25% higher than our closest competitor.
COVID-19 has caused over 200,000 U.S. deaths. Our death rate is higher than many countries in the world, including Iraq, Turkey, India and Ukraine.
What can be done? We need to develop a health care system that decouples health insurance from employment, income or underlying health status, and we need to make this readily available to all Americans.
We need to address disparities in health care and need to work to improve health in all communities — the better your health when you contract the virus, the better your chances of fighting it off.
Perhaps we should start by bringing health care to patients rather than bringing patients to health care. Once we get over social distancing policies imposed by the pandemic, we could begin by working within neighborhood schools and using the buildings during off hours as “neighborhood clinics” to provide services such as preventive care, mental and physical health services, nutrition counseling, smoking cessation classes and legal services.
Linking improvements in both education and health will have added benefits for future generations. This potential solution could be implemented quickly, as the bricks and mortar are already in place and most schools have the technology and internet bandwidth to provide telehealth services for more complicated medical conditions.
In addition to this local solution, we also need to set up systems that overcome barriers to care for vulnerable populations and to make sure no one is discriminated against based on ethnicity, gender or age.
Fundamentally, it is up to us as a society to plan for inevitable future pandemics so they land in healthier communities with safer, softer and less flammable landing spots.
Marc Kahn is dean of the UNLV School of Medicine, where he also is a professor.