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EClinicalMedicine 23 (2020) 100380

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EClinicalMedicine

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Commentary

The imperative for universal healthcare to curtail the COVID-19 outbreak in the USA

Alison P. Galvania,*, Alyssa S. Parpiaa, Abhishek Pandeya, Charlotte Zimmera, James G. Kahnb, Meagan C. Fitzpatricka,c

a Center for Infectious Disease Modeling and Analysis (CIDMA), Yale School of Public Health, New Haven, CT, United States b Department of Epidemiology and Biostatistics, School of Medicine, The University of California, San Francisco, United States c Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, United States

A R T I C L E I N F O

Article History: Received 28 April 2020 Revised 29 April 2020 Accepted 30 April 2020 Available online 17 May 2020

The COVID-19 outbreak in the United States is growing steeply and spreading widely. As of March 26, national incidence surpassed every other country, and as of April 28 has reported over a million cases. The COVID-19 crisis is exposing the systemic frailties in our healthcare system. More than 78 million people in America do not have access to adequate health insurance [1]. Given that health insur- ance in the US is typically provided by employers, millions more are at risk of losing their healthcare coverage as unemployment surges. Here we discuss how the pervasive healthcare insecurity in the US hampers control of COVID-19. Further, we argue that universal healthcare would alleviate the cost barriers that are impeding control of this pandemic.

Outbreak mitigation relies on prompt diagnosis and case-isolation, in which mild cases are quarantined at home and more severe cases are hospitalized. These measures must be implemented rapidly in order to be effective. However, for the millions of people who are either uninsured or underinsured, concern about the medical expenses that could be incurred delays diagnosis and treatment. While the Fam- ilies First Coronavirus Response Act recently approved by Congress stipulates that COVID-19 diagnostic testing is nominally free for every- one, treatment is not covered. Those who are hospitalized may face major medical expenses. For instance, the cost of 12 days in the ICU on ventilation would likely exceed US $80,000 [2,3], even without consid- ering the additional hospital care before and after ICU admission. In addition to the burden on the uninsured, the under-insured are obli- gated to pay substantial out-of-pocket sums, including thousands of dollars in deductibles and copays. Although the Coronavirus Aid, Relief, and Economic Security Act has invested $100 billion into the Public

* Corresponding author. E-mail address: alison.galvani@yale.edu (A.P. Galvani).

https://doi.org/10.1016/j.eclinm.2020.100380 2589-5370/© 2020 The Authors. Published by Elsevier Ltd. This is an open access article unde

Health and Social Service Emergency Fund for healthcare providers, less than one third of this sum can be used to fund the treatment of uninsured COVID-19 patients. Compounding the crisis, legal action being pursued by the current Administration is jeopardizing the Affordable Care Act, which would lead to the loss of health insurance for as many as 30 million people [4].

The COVID-19 pandemic also underscores the precariousness of a system in which insurance is linked to employment. Initial unem- ployment claims rose from 282,000 for the week ending March 14 to 6.6 million, 5.2 million and 4.4 million, for the weeks ending April 4, April 11, and April 18, respectively, compared with a previous record high of 695,000 from 1982 [5]. Many of these newly unemployed individuals will lose their health insurance. Although they are per- mitted to purchase insurance on the federal exchange, switching net- works disrupts continuity of care, which is particularly detrimental for those living with chronic health conditions. Furthermore, the majority of families are unable to afford health insurance upon becoming unemployed, given that more than half of American fami- lies live paycheck to paycheck [6].

Racial and economic disparities in the US healthcare system are being magnified by the pandemic. Rates of adequate health insurance coverage are much lower among people of color [7]. With less access to preventative healthcare, people of color are disproportionately affected by comorbidities, such as diabetes, obesity, asthma, and car- diovascular disease. These comorbidities exacerbate the severity of COVID-19 clinical outcomes, including death [8], as does delay in seeking care due to concerns about medical bills. COVID-19 is widen- ing socioeconomic fissures facing people of color as well. Since the start of the outbreak, Latino populations have reported much higher rates of job and wage loss than Americans at large [9].

The solution to these challenges is the provision of comprehensive healthcare as a human right. Further, universal healthcare will be most cost-effectively achieved by a single-payer system, such as that proposed in the Medicare for All Act [1]. Not only would Medicare- for-All save lives, it would resolve costly inefficiencies that currently make our healthcare system the most expensive in the world. Among the major sources of savings, a single-payer system would consoli- date administrative costs, reduce overhead, empower pharmaceuti- cal price negotiations, and truncate executive pay. A single-payer system is also incentivized to invest in cost-effective preventative

r the CC BY-NC-ND license. (http://creativecommons.org/licenses/by-nc-nd/4.0/)

2 A.P. Galvani et al. / EClinicalMedicine 23 (2020) 100380

services that can avert life-threatening clinical outcomes and expen- sive downstream treatment.

Another advantage of Medicare-for-All during this pandemic would be its implementation of a standard billing and payment system, which would accelerate COVID-19 case reporting. Billing procedures currently vary across dozens of insurers, and for private insurance is proprietary. Within a consolidated system, patterns in the billing data can signal out- break hotspots to public health surveillance officials. This consideration is not hypothetical � the single-payer system in Taiwan has facilitated exhaustive COVID-19 data collection and reporting [10].

Universal healthcare is fundamental to the continued prosperity of our country in the wake of this and future infectious disease threats. Obstacles to prompt diagnosis and case isolation not only impact the individual, but pose a broader societal risk. A pandemic illustrates an omnipresent truth: that we are each only as safe as the most vulnerable member of our society. We urge investment now in the common good of healthcare security, by extending comprehen- sive insurance to all who currently lack it. Then, we should move swiftly to create a single-payer system, such as Medicare for All, which is the more efficient way to provide universal coverage [1]. By eliminating financial obstacles to healthcare, we can pave the way for more efficient outbreak control, in both this pandemic and the next.

Declaration of Competing Interest

None.

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