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WASHINGTON, DC -- HEALTHCARE UPDATE NEWS SERVICE™ -- JUNE 18, 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."
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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