President-elect Joe Biden will inherit a healthcare system that seeks to cater to a population made sicker from both coronavirus and skipped care while trying to make up for the money lost in 2020.
But he will face another immediate challenge: hospitals that tend to care for the poor and vulnerable are under great financial pressure, while wealthier hospital systems expect them to be easily injured but not broken.
“All of this will increase inequality,” said Alan Morgan, president of the National Rural Health Association. “There’s no way around it.”
The policies that Mr Biden adopts in his early months as president – such as how to pay for telemedicine visits as the pandemic progresses, or whether to provide additional incentives for health care providers – will be critical to shaping the long-term future of the health system.
“Every crisis brings change, and it will clearly make big changes,” said David Cutler, a Harvard health economist who served as a health advisor in the Obama administration. “We don’t know yet whether it will be good or bad.”
American doctors and hospitals have been used to constant growth in spending for decades. But 2020 was on track to be the only year in this era that healthcare spending is falling. Even if the pandemic overwhelms the capacity of some providers, they appear to be losing money due to the numerous profitable election processes that were canceled this spring.
For Mr Biden, this likely means fights between hospitals, insurers and patient advocates who fear that the equality gains made by the Affordable Care Act have been undermined. Healthcare providers, who typically care for vulnerable populations, may face difficult decisions between closing down or selling to a larger competitor.
“The health system lost a lot of money when people didn’t show up in March and April,” Cutler said. “It is not clear whether the money will be returned. I assume that a wave of providers will go under, demanding higher prices and bailouts. “
Pick almost any metric and it will show the tremendous growth of the American healthcare system over the past few years. Total healthcare spending soared from $ 2.9 trillion in 2010 to $ 3.6 trillion this year, driven by medical prices that rose faster than inflation. Healthcare jobs grew at the same time, peaking at 16.5 million workers in February.
The number of policyholders increased significantly in the 2010s, largely due to the expansion of insurance coverage under the Affordable Care Act. Even with some setbacks under President Trump, the uninsured rate is still lower than it was at the beginning of the decade, about 9 percent last year, up from 16 percent in 2010.
The growth of the past decade has not only meant more money poured into hospitals and doctor’s offices. It also appears to have made access to health care and certain health outcomes more equitable.
For example, the expansion of coverage under the Health Act had an overwhelming impact on the insurance of Black Americans and Latinos and the reduction in the disparity in uninsured rates. In 2013, there was a 25.7 percentage point gap between the uninsured rates for Hispanic and White Americans. By 2018, that number had dropped to 16.3 percentage points, a study by the nonprofit Commonwealth Fund found.
Medicaid’s expansion into many states is credited with keeping rural hospitals operating. Some research has found that the expansion reduced unequal outcomes in areas such as maternal and child mortality.
Now experts see that these profits are diminishing. The change began under the Trump administration, which restricted the promotion of health law and allowed states to impose new restrictions on the registration of Medicaid. One million Americans lost coverage between 2017 and 2019. Experts were particularly alarmed by the decline in public coverage among children.
The trend accelerated with the pandemic and a sharp drop in medical revenues this spring. Hospitals across the country lost billions when patients canceled lucrative procedures like hip replacements and cataract surgeries. Family doctors struggled to stay open as check-up dates dropped. Federal aid compensated for some, but not all, of these losses. Experts working on the health system now believe that much of the care canceled this spring will not be postponed.
Updated
Apr. 18, 2020 at 2:27 am ET
Safety net health systems, which because of their mission or mandate to provide care regardless of people’s ability to pay, say they are already starting to push richer hospitals forward. Employment in the health sector is recovering: around two thirds of the 1.5 million jobs lost during the recession have returned. However, there is evidence that these profits are not evenly distributed.
Mr. Morgan of the Rural Health Association hears from members who say they are having trouble keeping nurses. Some workers are getting better-paid offers from wealthier health systems who need traveling nurses to help fight the pandemic.
“Two weeks ago I heard from a hospital director that he was losing his clinical staff because they could make more money elsewhere,” he said. “His clinical staff are going offline in the middle of a pandemic. It’s a workforce crisis. “
Margaret Mary Health System, who operates a 90-year-old nonprofit hospital in rural Indiana, predicts a 4 percent deficit this year, even after factoring in state aid payments. The hospital has treated hundreds of coronavirus patients who sometimes occupied 23 of the hospital’s 25 beds.
“It all makes it so difficult, how hard we’ve worked this year,” said Tim Putnam, the hospital’s general manager. “We have invested so much to serve our community and it is difficult to suffer a loss as a financial result.”
Before the pandemic, Margaret Mary’s executives felt they had solid financial foundations. The hospital received a boost from Indiana’s Medicaid expansion in 2015. It looked so good last year that it decided to purchase a new electronic health record system.
Margaret Mary is now preparing for even greater financial losses after Indiana announced on Thursday that it would again suspend elective health procedures.
“It’s hard to pinpoint where this ends until we figure out how the pandemic ends,” Putnam said. “To remain viable and continue to serve our community, we need to do better than breakeven and we need to find a way to do it in 2021.”
North Oaks Medical Center in Hammond, La., Is a public hospital serving mostly low-income patients. It was planning its “best fiscal year in the history of the hospital” before the pandemic broke out, said chairman Michele Sutton.
Instead, it took many workers off this spring to break even. North Oaks encountered issues that a hospital with more affluent patients would not face – such as the fact that many of its patients did not have reliable access to the Internet to support video doctor visits.
“Because our community is poor, we didn’t have much access to telemedicine,” said Ms. Sutton. “We didn’t have the fiber capacity.”
Her hospital had to do extra work to set up wards where doctors could video chat with their patients, something other healthcare systems didn’t have to wear. Now it is preparing for another difficult year of treating sick patients.
“We’re seeing an increase in suicide, a lot more strokes, a lot more heart attacks,” Ms. Sutton said, “and a decrease in routine maintenance for fear of getting Covid.”
Some of the early decisions the Biden team is facing are small, practical: Should Medicare continue to pay the high but temporary reimbursement rates it offered for telemedicine visits this year, a signal that would encourage private plans to to do the same?
“Imagine that I am a general practitioner, I am already having great financial success and trying to decide: am I making a large investment in telemedicine or not?” said Dr. Ateev Mehrotra, a Harvard health researcher. “It’s hard for a clinical practice not to know what you’ll get paid for in a week or two.”
Other decisions are more extensive, e.g. For example, whether additional incentives should be provided for healthcare providers and how they should be allocated.
Doctors know that patients have put off some treatments and are preparing for the consequences. Dr. Mehrotra and his colleagues released research this week that found fewer patients starting treatment for opioid addiction during the pandemic, as some providers feel uncomfortable about prescribing a new drug without a face-to-face meeting.
The Biden government’s guidelines will help determine how providers are caring for this sick population as health coverage decreases. To increase the number of signups, the administration could use waivers to expand Medicaid coverage or restore the Affordable Care Act advertising budget. Major expansions to coverage, such as a public option that would allow all Americans to sign up for Medicare, would require Congressional approval.
“There is a large population that worries me very much that they have diabetes, high blood pressure, and heart failure and that has postponed all that care,” said Dr. Mehrotra. “The accumulation of inadequate care creates complications. But at this point it is unclear what exactly these complications of the disease will look like. “
