Voices of the Virus

Our Health Care Is ‘Market Chaos’

Harvard pulmonary care specialist Adam Gaffney explains how COVID makes the case for radical health-care changes.

By Adam Gaffney

Tagged COVID-19Health Care

The United States’s poor response to the COVID-19 pandemic has included comparatively high infection rates, shortages of essential medical goods, and a slew of news stories about patients receiving absurd bills after being treated for the virus. Meanwhile, millions of Americans have found themselves without either a job or insurance, galvanizing more interest than ever in the idea of Medicare for All. Meanwhile, our health-care practitioners are being celebrated like never before. Yet, historically, many doctors have opposed a single-payer system.

This is not the case for Adam Gaffney, who is both a pulmonary specialist at Cambridge Health Alliance, as well as president of Physicians for a National Health Program. He spoke to associate editor Sophia Crabbe-Field on June 24 about the fight for Medicare for All as a physician in the time of COVID, the need to bring more medical professionals into the fight, as well as their duty to speak out against other public health threats like police violence.

Sophia Crabbe-Field: My first question to you is: How much do you think the pandemic will have lasting effects on the movement for Medicare for All? I know a lot of people are talking about it more now.

Adam Gaffney: There’s no question that the epidemic intensified the debate about health-care reform in this country. It clearly laid bare many of the dysfunctions and the injustices of the U.S. way of paying for health care. Obviously it made clear the absurdity in having 30 million people uninsured. It made clear that cost barriers to care don’t really make sense in a pandemic. And I think that may broaden thought about whether they make sense outside of a pandemic as well. The pandemic also demonstrated how completely unplanned our health system is, the utter lack of coordination. Finally, it made evident the fact that we need an enormous investment in public health infrastructure in this country. So I think for all of those reasons, COVID-19 will, in retrospect, be seen as a moment that was a turning point in the health-care discussion in the United States.

SC-F: So how do you think that we can keep people interested in public health when people don’t usually see it play out on an individual basis?

AG: I think that the cliché is: When public health is working well, you don’t really see it working at all. A lot of it is behind the scenes. What our federal agencies are doing—the CDC, what our state and local public health agencies are doing to keep us safe in terms of disease surveillance, contact tracing, and so forth—we don’t experience it the same way we do medical care. So you’re absolutely right that there is a danger of it being neglected, which is precisely what’s happened in the age of austerity. There’s been an underinvestment and an underfunding of our public health infrastructure. And we are paying for that now—from the disastrous rollout of testing to the inadequate responses on the local level to the lack of resources in doing things like contact tracing that other countries have used to suppress this. How do we keep that discussion going? I think that this will not be so easily forgotten. And I think that those of us in the Medicare for All movement need to couple the demand for Medicare for All with an increase in expenditures in public health. Don’t forget that public health currently only accounts for about 2.5 percent of total health-care spending. At Physicians for a National Health Program, we think that proportion should be doubled.

SC-F: What kind of responses have you seen in other countries that we might’ve been able to emulate or implement in the United States if we had that kind of public health infrastructure?

AG: Certainly our testing rollout was a disaster. That story has not been fully told yet. It’s hard for me to imagine that the neglect of and underinvestment in public health didn’t play some role. I think that the fact that many localities had to not test people unless they had significant symptoms because of a lack of resources, even though we know that widespread testing allows for surveillance and quarantine—even if it’s not needed for treatment because someone has mild symptoms—I think that reflects the complete underinvestment. We know that places like China, South Korea, for instance, used extensive contact tracing. That’s when you follow up on the contacts of the person who is known to have the coronavirus. They use those traditional shoe leather epidemiological tools to good effect.

We don’t have that infrastructure, and states are now trying to hire those individuals. So we’re totally behind on that. I know that Taiwan was able to leverage its national health insurance and electronic database in order to find cases. So there are examples of ways in which other countries’ health-care systems allowed them to be more adept, nimble, and efficacious, in control. Let’s not forget also that there’s the debate going on right now about who’s going to pay for COVID testing that’s done for surveillance and not for clinical treatment. The insurers were saying that they’re not going to pay for it. So there you have an absurd example of how a privatized, fragmented health-care financing system is an utter disaster in the face of a pandemic.

SC-F: You wrote recently about the fact that 18.2 million individuals are at risk of severe COVID illness and are underinsured or uninsured. Have you seen this play out directly in your role as a physician?

AG: Yes. We did a study using data from before the pandemic to look at how many people who are high risk of severe COVID, because of either comorbidities or age, are either uninsured or underinsured. And it was 18 million who are at high risk of severe COVID who lack adequate insurance. There’s certainly people who have been out of care, uninsured, or underinsured, for a long time and then got sick, and who knows what difference primary care might have made in fortifying them prior to this pandemic. I work at a safety-net institution. We take care of everyone. But if you go to the news media, you certainly can find cases of people getting stuck with big bills, people getting long hospital bills delineating all of the costs that went into their care.

There have been certain steps taken at the federal level to provide some protection for patients with coronavirus. So the CARES Act provided funds for hospitals that could be used for the care of patients who are uninsured with the coronavirus. But first of all, those provisions are inadequate and there are gaps and holes, and there’s still going to be some people who are not fully covered. Second of all, the reality is that 14 percent of Americans, according to a Gallup poll, said they would not obtain care even if they develop coronavirus symptoms because of fear of costs. And third of all, the reality is that people need to be cared for for all of their illnesses. We have historic increases in unemployment, tens of millions of people losing their jobs. By one estimate, seven million people could be uninsured as a result of the COVID recession. So this is about coronavirus, but it’s also about everyone with heart disease and lung disease and diabetes and asthma and pancreatic cancer. They all need full coverage as well.

SC-F: Have you seen other problems specific to this system being highlighted by the pandemic as well as a lack of insurance?

AG: Yeah. So uninsured and underinsured certainly were highlighted, but there are other ways in which this pandemic has laid bare the dysfunctional structure of our health-care financing system. Just to give an example, coordination among providers and organizations: What do we see? We saw lots of hospitals, states, and the federal government in bidding wars with each other to acquire equipment and PPE and ventilators, driving up prices on the one hand and on the other hand a complete and utter lack of knowledge of whether we had the right equipment in the right place. Presumably, some places had more than enough. Other places did not have enough. When you run a health-care system like a market commodity, you get surpluses and gluts and deficiencies. You get distribution not according to need, but according to means.

So the fact that all these different levels of government and hospitals were fighting each other and bidding against each other to purchase goods is another reflection of how our system failed. It was more market chaos than it was a well oiled, functioning system. Now we did see that efforts were made at cooperation by hospitals in a novel way. Certainly, in Boston we’re getting on the phone frequently with other hospitals and are having regular conferences to talk about who has beds, where ICU beds are available, where patients can be sent. In New York, for a time, there was an effort to coordinate all of New York hospitals sort of as one system. These were temporary measures taken at a moment of need, which makes sense because pandemics lay bare the need for cooperation, not competition, in health services. But we need to go beyond that and look into the future and start thinking once again about the idea of “health planning,” which is now a sort of a dirty word, but it wasn’t always.

SC-F: What do you mean exactly by “health planning”? Do you mean what steps we need to take to prepare for a future pandemic?

AG: Back in the 1970s, there was a whole movement referred to as “health planning.” The idea was that there should be a public accountability for where we have health-care facilities, where we have hospitals, where we have hospital beds, to make sure we don’t have excesses in certain areas, deficiencies in others. That movement, in the absence of a single-payer system, didn’t accomplish very much. And in any event it was brushed easily aside by the pro-market policies of the Reagan era and is now mostly nonexistent. But when this pandemic started, people started looking at our health-care resources and there were articles saying: Why is it that we have so fewer hospital beds per capita than the vast majority of other nations, a fraction of Japan’s, half as much as some countries?

Well, it turns out that the number of hospital beds has been declining over time because of the market-based system that we have. It wasn’t a rational decision that was made because people didn’t need hospital care. It was just the dictates of the market. Obviously we have rural hospitals that are closing all the time. The Hahnemann Hospital in Philadelphia closed last year because it couldn’t turn a profit because it took care of poor people. We have hospitals closing in areas of need. You have other places where hospitals are expanding constantly and building giant beautiful new atriums. So what is this about? This is about when we finance health-care infrastructure by market mechanisms the invariable result is inequities in supply. So that’s what I mean by health planning—ensuring that we have the care where we need it, not merely where the profits are generated. And that’s important for everyday health care, but it’s especially important when thinking about planning for a future pandemic.

I do think we should think about novel ways to ensure that we have an adequate supply of unused but readily deployable spare capacity. And there’s different ways you can think about that architecturally, but we don’t need more ICU beds than we have in this country. We have more than many other countries, but we do need ways to suddenly make new ICU capacity available when a climate disaster strikes or an earthquake or a respiratory virus. So those are some of the things that go under the rubric of “health planning.”

SC-F: Do you think some of these are possible to achieve within a market-based health-care system?

AG: I think that there are some things you can do. But I think for the most part what history has showed us is that you need public financing of health care itself to be able to achieve a just and rational allocation of health-care infrastructure. It goes back to what a famous primary care doctor in Britain, named Julian Tudor Hart, once said. He wrote in the 1970s, in the medical journal Lancet, about something called the “inverse care law.” He said the inverse care law basically means that the places that need care the most have had the least of it. He said that that law was most in operation in countries with more market-driven health-care systems. It exists to some extent even in countries with public health-care systems, but those countries have the tools to actually rectify those imbalances. Whereas here it’s the invisible hand.

SC-F: So what do you think is the best argument to be made against those who say that countries with single payer or universal health-care programs, like the UK, have also had a very bad time dealing with COVID?

AG: This came up in the last primary debate between Sanders and Biden, where [Biden] kind of referenced that—well it really is getting clobbered, so what does that say about single payer? There are things that a single-payer system can do. There are things that it can’t do. It doesn’t keep a respiratory virus from getting into the country. It doesn’t prevent it from disseminating. What it does, however, is, first of all, it ensures that everyone can get care and will not go bankrupt because of it. That is often not the case in the United States. Countries with universal health-care systems also had AIDS crises. But at the very least people could get the drugs and care they needed whether they were rich, poor, Black, or white. And that was not true in the United States, even though steps were taken to expand access to those individuals. The reality is that single-payer systems do not prevent public health disasters, but they protect the populace from the financial ramifications of the crisis. By providing that protection, they ensure that no one is afraid to seek care or testing because of financial barriers. And they provide tools for planning in the future and for cooperation in the present.

SC-F: So for those people who might be interested now in getting involved in the movement for single-payer health care, but are worried about doing so in the COVID era, what would your suggestions be?

AG: I think that there are a lot of organizations in this country that are focusing on this fight, either as a primary goal or as one of many goals. I would urge people to find out if there is an organization that fits their interests. I’m currently president of Physicians for a National Health Program. We focus on organizing predominantly physicians, although our membership is broader, but there are other organizations. There’s National Nurses United, which is the largest nursing union in the country, which has made single payer a priority. There’s Health Care Now. There’s Democratic Socialists of America. Many of these organizations have made this a priority. So I think the first step is joining an organization. And then I think what each of us does as part of this often relates to what it is that brought us to the fight and where we can make the most difference. At PNHP, we’ve long felt that it’s not only important to have the medical profession behind Medicare for All, it’s necessary. I spend a lot of my time and energy focusing on the education of the medical profession, but that’s obviously not going to be for everyone.

SC-F: To what extent do you feel that, through your work, you’ve been able to get physicians more interested in Medicare for All?

AG: I think that the sum effects of this crisis are probably going to be to increase support even within the medical profession. Why do I say that? For one, it’s the things I’ve already said—laying bare the ways in which the current system fails patients. But you have to realize, too, that this is a tremendous shock to the health-care delivery sector. Hospitals are often dependent on lucrative elective procedures. That’s just how the system functions in order to make up their operating budget. And those got canceled and hospital budgets have totally sunk. And there are mass furloughs and layoffs of health-care workers. Private practices are also suffering tremendously.

It’s my opinion that this is going to exacerbate the already existing trend toward greater consolidation and corporatization of the health-care delivery system. The little fish are going to get eaten by the big fish. There was just a long article in Bloomberg about Walmart becoming a big health-care provider and having a more diverse portfolio of care services delivered in its stores. What a time it would be for a corporation to enter the health-care space, as doctors’ offices are laying off workers and are on the verge, in some cases, of going out of business. I think that this is going to, again, push us further down that road toward a corporatized, consolidated health-care space. And I don’t think that health-care providers, meaning nurses and doctors and respiratory therapists and social workers, are going to like that very much. In fact, I know they don’t like it, and I don’t think the patients are going to like it either. So I think you might actually see a further galvanizing of support for Medicare for All as we march further down that dark road.

SC-F: So as a practicing physician, do you feel, on a daily basis, the impact of the existing health-care system in your relationships with your patients?

AG: When COVID hit, it did not hit every group equally. Black people, Latinos, working-class people, lower-income people have been disproportionately hit. And we saw that in our ICUs in the people coming in, we saw that in Massachusetts in the tremendous disparity of cases between upper-class white neighborhoods and working-class, Latinx, immigrant communities. So you see these social determinants of health, which are broader than the medical system, playing out in the way COVID struck. But that’s one side. In terms of the medical side, certainly I’ve seen patients in the intensive care unit, sadly, with life-threatening complications of common chronic illnesses, things like hypertension, diabetes, who had gone years without getting any health care because they couldn’t afford it, because they were uninsured. And you see those complications, and it really drives home the absurdity of a market-based way of financing health care.

SC-F: So just shifting a little bit, I saw that you recently wrote in The Lancet about the potential public health threats from police tactics used during the Black Lives Matter protests. Could you briefly speak to that and to whether you’ve seen evidence of these mass arrests leading to increased cases of COVID?

AG: As medical professionals, I believe we have a duty to speak out about human rights abuses and public health threats. And one of those I think was the outrageous and disproportional response by many law enforcement agencies to Black Lives Matter protests that emerged in the wake of the murder of George Floyd. First, you saw indiscriminate, widespread use of tear gas. Tear gas is not a benign substance, as people know. And certainly for people with lung disease, which is the kind of patients that I see, it’s a severe threat. My medical society, the American Thoracic Society, actually called for a moratorium on tear gas by law enforcement, and [PNHP] joined that call. Even more concerning has been the widespread use so-called “rubber bullets.” This includes things that go by a lot of names. There was some instances where law enforcement said, “We don’t use rubber bullets,” but it turns out that they use something called “bean bag rounds,” which are basically fired out of a 12-gauge shotgun and pack a tremendous punch. And we compiled from news media, in the last few days of May alone, 12 grievous injuries by these projectiles, eyes being lost. So we try to draw some light on that and cite some of the literature on the fact that these are projectiles that maim and kill. Finally, the mass arrest question. It’s a little early to talk about the public health impact of the protests so far.

But what we do know is that jails serve as major sites of coronavirus incubation, not merely threatening the health of people in the jail and of the workers, but also the community at large. A study in Health Affairs found that people cycling in and out of Cook County Jail may have accounted for as much as 15 percent of coronavirus infections in the state of Illinois, which is really astounding. I don’t have data about what’s happened yet in these mass arrests, but that is certainly enough data to be very concerned. Finally, I would say that when protestors are not harassed, when they’re not tear gassed, they don’t have to take off their masks, and they’re not coughing and sneezing, being arrested or kettled, it’s not clear that those protests are necessarily leading to increased infections. It’s certainly a risk, but recent data from Boston suggested that widespread testing of people who participated in protests found a COVID positivity rate that was similar to that of the general population, which is reassuring that a combination of outdoor air and masks might provide the needed protection for protests to happen without undue risk. We need more time and more data to be able to clarify that.

SC-F: Do you think that this movement has highlighted a bit more broadly, as well, the impacts of the criminal justice system on public health?

AG: Absolutely. I think the COVID pandemic, the disproportionate impact it has had on Black communities and other disadvantaged groups, police violence against Black people disproportionately, as well as American Indians, and the law enforcement’s response, and the fact that jails and prisons are serving as major sites of coronavirus, all of these strands really interconnect and weave with each other. I think there’s no question that the sum total of these health-related injustices is driving home the interconnection between structural racism in multiple parts of our society: in the health-care system, in the criminal justice system. These are not separate or medically sealed compartments. These are interconnected problems.

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Adam Gaffney is president of Physicians for a National Health Program and a pulmonary specialist at Cambridge Health Alliance/Harvard Medical School.

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