A Healthcare System, If We Can Keep it

We are in strange days, and they are only going to get stranger as COVID-19 works its way further through our society.  It makes me think of Benjamin Franklin's response when asked what kind of nation the U.S. was going to be:  "A Republic, if you can keep it." 

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The versions of that response that COVID-19 have me wondering about are: "A federal system, if we can keep it," and, more specifically, "a healthcare system, if we can keep it."  I'll talk about each of those in the context of the pandemic.

In times of national emergencies -- think 9/11, think World Wars -- we usually look to the federal government to lead.  The COVID-19 pandemic has been declared a national emergency, but we're still looking for strong federal leadership.  We have the Centers for Disease Control, infectious disease experts like Dr. Anthony Fauci, and a White House coronavirus task force.  But real national leadership is lacking. 

Credit: Dayton Daily News/Marshall Gorby

States and cities are forming their own responses.  Schools are being closed.  Other types of businesses -- e.g., malls, movie theaters, gyms, casinos -- are being closed.  Bars and restaurants are only allowed to do carryout/delivery.   Curfews are being imposed.  Primaries are being delayed.  But none is being done on a national level, and, in many cases, not even on a state-wide basis. 

As Gerald Seib said in The Wall Street Journal:

Put differently, Americans have learned they can’t really count on Washington to deal with this crisis for them. Local leaders, businesses, churches, sports leagues—all have taken up the task, and done so more effectively than the political leadership in Washington.

The House passed an emergency coronavirus bill last week, and now the Senate is  coming up with its own ideas.  When Congress finally passes what bill remains to be seen, after how much further damage has been done to our health and our economy. 

Anne Applebaum minces no words in her article in The Atlantic:

The problem is that American bureaucracies, and the antiquated, hidebound, unloved federal government of which they are part, are no longer up to the job of coping with the kinds of challenges that face us in the 21st century.

"The United States," she says, "is about to be proved an unclothed emperor."  Derek Thompson, also writing in The Atlantic, is equally blunt: "...executive branch of government—drained of scientific expertise, starved of moral vision—has taken on the qualities of a failed state."  In New York Magazine, David Wallace-Wells says: "America is broken...This is not how a functioning society responds to a crisis." 

These are descriptions of the United States, and it's hard to argue with them.

Pandemics are, by definition, catastrophes.  They're going to cause damage.  The question is how societies prepare for them, and respond when they hit.  So far, the U.S. is failing on both counts.

In our federal system of government, we delegate many duties to the states, which delegate many to localities. Public health is one such duty.  Michele Barry, senior associate dean of global health at Stanford University, told The New York Times:

We have a completely decentralized public health system.  It is difficult to mobilize a large containment strategy. That’s what Singapore did, or what China did. We don’t even work from the states up. We work from the counties up."

Unfortunately, as The New York Times also reported: 

A widespread failure in the United States to invest in public health has left local and state health departments struggling to respond to the coronavirus outbreak and ill-prepared to face the swelling crisis ahead...Many health departments are suffering from budget and staffing cuts that date to the Great Recession and have never been fully restored.

Our failure to have testing done earlier, and then quickly made widely available, is a public health failure, and it means we are still in the dark about many key questions. 

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Now we're worried about COVID-19 patients overwhelming our entire healthcare system.  Elective surgeries are being postponed.  We may not have enough ICU beds.  There may be a shortage of ventilators for those ICU patients.  People are stealing personal protective equipment, posing additional risks to medical personnel. 

When COVID-19 hit Wuhan, China scrambled to build new hospitals in little over a week.  I don't have much faith in our ability to accomplish that (although there are calls for the Army Corps of Engineers to try). 

The pandemic didn't create the problems in our healthcare system.  The failure to prioritize public health is longstanding.  Worry about how people pay for testing is symptomatic of the problem people have paying for healthcare generally.  Our inability to determine how to prioritize where necessary supplies and equipment go reflect the fact that our healthcare system is, for better and for worse, a largely capitalistic system where money rules, not need.  We decry pharmaceutical company profits but look to them to quickly develop COVID-19 vaccines.

Charley Grant of The Wall Street Journal says: "The issues exposed by the crisis are likely to linger far beyond the worst of the outbreak."  He goes on to predict:

How effectively the U.S. can beat back the novel coronavirus, and what parts of the system shine or disappoint, may well determine whether the federal government expands its role in the system or reduces it.

I'd go further: how we get through this crisis may well determine what kind of healthcare system we want to have, and perhaps even how much power the federal government should have.  

We're going to spend a lot of money on the pandemic.  Not all of it will be spent as it perhaps should have been.  Many people will get infected and many of them will die.  Parts of the healthcare system will flounder; some will fail.  There will be heroes and probably a few villains.  These are all in the nature of pandemics.

The key questions with the current crisis are how quickly we can act, how effective that action will be, and, perhaps, most importantly, what lessons will we learn?  How much power should the federal government exercise in such crises, or over healthcare generally?  What problems with our healthcare system are unique to pandemics, and which need broader fixes?  How best to ensure public health on an ongoing basis? 

There are no easy answers.  The next few months are not going to be pretty.  We're going to make some decisions that, in retrospect, will seem like mistakes.  But we will get through this.

But, as economist Paul Romer once said: "a crisis is a terrible thing to waste."

Let's not waste this one.