Low angle shot of a group of doctors stacking hands in a hospital, photo by Hiraman/Getty Images

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(The RAND Blog)

Out of the Ashes: Forging the Post-Pandemic U.S. Health System

Photo by Hiraman/Getty Images

by Sydney Fouche, Kaitlyn Entel, Christopher Nelson, Chloe E. Bird, Mahshid Abir

July 31, 2020

Drawing from one of Albert Camus's seminal works, The Plague, and from America's response to the influenza pandemic of 1918, medical historian Howard Markel wrote in 1996 for the National Academy of Medicine (NAM) that the most vexing phase of an epidemic is the final act: the act of “subsidence and retrospection.” After the revelation that an outbreak is occurring, after the mitigation tactics and the negotiations of those tactics have come and gone, “Epidemics often end as ambiguously as they appear…once an epidemic peters out and susceptible individuals die, recuperate, or escape, life begins to return to its normal patterns, and healthy people begin to place the epidemic in the past.” Today, it is both difficult and valuable to begin to envision and work toward a post-pandemic normal—one in which we retain some positive changes in the U.S. health and public health system forced by the pandemic.

Based on the shifting insights, new problems, or exacerbations of old problems revealed by the pandemic, there are opportunities for innovative solutions that are being adopted where rapid change would normally have been rare. Consequently, we have an opportunity—and perhaps a responsibility—to assess how these changes are working and where they can improve health, reduce inequity, and save money, so that those that work can be retained. Without this effort and insight, we may make changes that are less beneficial and effective, and fail to retain or institutionalize those that are more beneficial and effective. The crisis could stimulate a renewed purpose to ensure our health system's ability to respond to future shocks—be they months away or further down the line, potentially due to the health effects of climate change, or other causes—in addition to increasing everyday health needs in a setting of an aging population.

Further, widely publicized COVID-19 policy decisions, stark racial disparities, and disparate views of the pandemic across demographic groups and states which have been differentially impacted all highlight the importance of analyses of the impact of these policies and of making more equitable funding decisions around care delivery in routine and catastrophic settings now and in the years to come. Health system leaders need new models for thinking and acting collectively to serve communities without leaving marginalized populations behind.

Health system leaders need new models for thinking and acting collectively to serve communities without leaving marginalized populations behind.

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Conservative estimates of the impact of the COVID-19 pandemic on the U.S. health system project $163.4 billion in direct cost. This does not include the financial and health burdens related to postponement of care and the dramatic changes to health care delivery that began in March and continue to evolve. Within health systems themselves, the impact is unmistakably disruptive with nearly 1 in 10 health care workers losing their jobs between February and April. As Americans grapple with this new reality, many people are reflecting on where health systems have functioned well and where we have been left vulnerable. For example, in outbreak epicenters, the pandemic's disruption has exposed significant resource and planning gaps (PDF) regarding a foreseeable shock, while also revealing resiliency and innovation. In the wake of COVID-19, health leaders, researchers and policymakers have unique opportunities to address enduring health care delivery challenges, build on successes, and leverage the opportunity of a nation working to define a more equitable and robust post-pandemic American health system. And numerous emerging transformations point to a considerably different post-pandemic health care landscape in America from the one Americans have come to know.

Even as we work to respond to the increasingly challenging situation at hand, researchers and decisionmakers have an opportunity to facilitate enduring health system transformation by assessing which innovations are most beneficial and how they can be sustained. As a starting point, we consider here three spheres of positive change which are emerging because of COVID-19—reinvigoration of public health, telehealth uptake, and multifaceted stakeholder engagement.

Reinvigoration of U.S. Public Health Interest and Infrastructure

In response to skyrocketing health care spending, enduring racial/ethnic and socioeconomic health disparities, and poor health outcomes, the 2010 Affordable Care Act (ACA) was implemented to shift the emphasis in care from treatment to prevention. The resulting increase and diversity of patients accessing care, along with the ACA's patient satisfaction-based reimbursement models, challenged health system stakeholders to examine the social, economic, and political contexts that surround providers as well as patients.

Despite progress over the last decade, the U.S. health system still shows persisting dysfunction, including exorbitant health care spending and premiums alongside pervasive and growing gaps in insurance coverage. The United States continues to rank poorly on a variety of health indicators among developed nations. The prevailing U.S. business model reveals many health systems operating at capacity even as local health departments lost 23% of their total workforce between 2008 and 2017.

The pandemic exacerbated many of these weaknesses, demonstrating risks of reliance on fee-for-service procedures for hospitals to balance the budgets, limited capacity in public health systems, and reliance on employment-based insurance for individuals and households, which may fail those who need it most. Arguably, the work of pandemic response and the work to address health needs, which existed prior to the pandemic and will continue after, is impossible without adequate attention to how funding (PDF) is allocated to meet the nation's public health needs (PDF).

COVID-19 is a reminder of the critical need for financial capital to achieve health goals.

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COVID-19 is a reminder of the critical need for financial capital to achieve health goals. The recent cash infusion into the Public Health and Social Services Emergency Fund represents a renewed investment in public health to address surge capacity and emergency preparedness: at least $1 billion through the Families First Coronavirus Response Act (FFCRA) will facilitate access to testing for the nation's growing uninsured population, while an additional $27 billion through the Coronavirus Aid, Relief, and Economic Security (CARES) Act will fund vaccines research and purchasing, diagnostics, and medical surge capacity over the next four years.

The CARES Act also grants $500 million specifically to help modernize the public health data infrastructure into a state-of-the-art, secure system. This investment comes as part of a multiorganization, multiyear campaign initiated prior to the current pandemic based on the acknowledgement that “systems currently in use by public health agencies at all levels of government rely on obsolete data collection methods, leading to delayed detection and response to public health threat.” Prior to the pandemic, the campaign sought double the funding the CARES Act ultimately granted, and this combined with other pre-pandemic congressional funding still puts them $200 million short of their original request.

Notably, none of this funding works to alleviate the gaps in coverage, nor the social and economic drivers behind poor health outcomes and health disparities. Consider, for example, the disproportionate impacts of COVID-19 by race; COVID-19-related mortality among Black Americans stands at 3.57 times the mortality among white Americans. To address these gaps, funding decisions, especially regarding public health crisis management, will require intentional investment into vulnerable communities and root-case problems. Many health systems already recognized the need for intentional funding around social determinants of health. Recent events can drive more attention and governmental support for coalitions doing this work.

Telehealth and Digital Culture

Telehealth during the COVID-19 pandemic has become an essential way that providers, patients, and their families communicate and get access to care. Prior to the pandemic, integration of digital technologies into health systems had often been touted as a powerful way to improve quality of and access to health care and information for Americans. Despite this enthusiasm, reimbursement structures and institutional culture have relegated telehealth to niche applications. Following the March 17 expansion of Medicare telehealth coverage, supported by the concomitant shift in health systems nationally, the uptake has been quick and welcomed. The Center for Medicare and Medicaid Services data reported in The Wall Street Journal shows weekly utilization in March skyrocketed to three times the baseline, while the Ascension health system spanning 20 states reported an incredible 2000% increase in online care visits.

Telehealth during the COVID-19 pandemic has become an essential way that providers, patients, and their families communicate and get access to care.

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Such a surge in telehealth use was previously unimaginable. In addition to providing reimbursement for at least 85 services not previously covered, the rapid expansion dictated that the teleservices be covered at the same rates as in-person care, creating a powerful financial incentive for health systems to adopt. Additionally, the American Medical Association released tools to assist with operationalization of telehealth services. While the federal guidelines are currently temporary and apply only to public payers, many private payers have risen to the occasion, expanding the reimbursement of these services for their beneficiaries.

Insurers, federal and state agencies, and professional medical organizations that continue to support these policies can help assure that such positive system changes are sustained after the pandemic. However to assure increased quality and access among disadvantaged groups, internet and technology access for those seeking care must become a top priority, for example by making digital access a safeguarded utility, like access to drinking water. Yet despite the increased need for internet access for health care and public health information, in 62 percent of counties, the majority of residents lack the minimum necessary download speed for broadband internet. Regulatory policies at various levels of government can facilitate digital access through ensuring network resilience and consumer affordability.

Social Cohesion and Engagement Across Stakeholders

Prior to COVID-19, health care leaders across the United States recognized that culture is the key to sustaining health system transformation. Disasters drive us to innovate, as we are seeing today. A 2019 paper examining transformation in the wake of environmental disasters highlights that the process of post-disaster transformation depends on both a cultural shift toward resiliency through increased community participation, awareness, and trust, as well as the development of novel organizational networks.

Although social change is inherently messy and complex, the many communities coming together to support each other and health care workers as well as unprecedented diversity in social justice protests reflect the degree of renewed social cohesion during COVID-19. Along with protests against public health policies and organized looting that capitalized on social justice protests, volunteerism and spontaneous acts of community altruism appear to be on the rise. For example, organizations have reported turnout by thousands of volunteers from all walks of life to assist during the pandemic. The shared experience of a crisis may be working to prime the development of shared values and interconnected behaviors. Health and equity are increasingly viewed by many as key components of the public good. Health and industry leaders, as well as policymakers and officials, have an opportunity to tap into this renewed attention to health as a shared commodity to highlight the nation's health goals and how the American health system can better serve communities.

The many communities coming together to support each other and health care workers as well as unprecedented diversity in social justice protests reflect the degree of renewed social cohesion during COVID-19.

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Health systems themselves are seeing their own versions of interconnectedness to meet shared goals as a result of COVID-19. As hospitals radically rearranged spaces and the make-up of clinical teams to prepare for COVID-19 related surges and concerns, traditional silos between departments and staff broke down. If health systems can continue to engage in open, flexible strategies that encourage collaboration across medical specialties, and with public health entities, they might be better positioned to more effectively address shared goals in a post-pandemic landscape.

On a larger scale, the pandemic is once again demonstrating the power of coordinated multisector engagement around health issues. Recent history demonstrates the value of multi-sector partnerships between health systems, public health organizations, payers, and others to meet complex health needs. Between 1988 and 2005 the number of countries worldwide with inadequate access to the polio vaccine dropped from 125 to only four, thanks to a partnership between Rotary International, the CDC, UNICEF, WHO, and a group of international financial partners. During the COVID-19 response, cross-sector partnerships have been built as medical companies collaborated with automakers to produce ventilators and personal protective equipment, demonstrating efforts unseen since World War II to work towards a common national health goal.

Others are teaming up to design programs to increase the capacity for surveillance and testing in epicenters like New York City. One example is the data-driven approach to tracing strains of the virus that will be funded by Bloomberg Philanthropies. The collaboration will involve program development and training for universities and public health nonprofits. Multisector engagement promotes a shared understanding of health care challenges by key players and allows for consensus-driven planning for collaborative action.

While the pandemic is reshaping how communities relate to health systems, and is pushing us to reconceptualize the role of government in public health, COVID-19 is also teaching leaders of industry and medicine that the health trajectory of the nation can be changed with boldness of purpose paired with a culture of goodwill and collaboration. It is perhaps no coincidence then that a marked shift in awareness and concern for racial justice is occurring alongside these shifts. Although in the near term it is likely that funding for public health will be strained as the country and health systems deal with the economic ramifications of COVID-19, we can begin rethinking health system and public health priorities now to meet the needs of diverse communities. Still, using the current disruptions for positive change will require considerable work to evaluate what has and has not worked, to address gaps created or exacerbated by innovative response, and to identify best practices for health care delivery and funding, especially for vulnerable communities. In effect, there is both an opportunity and a responsibility to shape a U.S. health system and public health reborn, or perhaps even forged, by the hand of crisis.


Sydney Fouche is a policy analyst at the Acute Care Research Unit at the University of Michigan. Kaitlyn Entel is a research associate in the Acute Care Research Unit at the University of Michigan. Christopher Nelson is a senior political scientist at the nonprofit, nonpartisan RAND Corporation and a professor of policy analysis at the Pardee RAND Graduate School. Chloe E. Bird is chair of the Diversity and Inclusion Forum and a senior sociologist at RAND. Mahshid Abir is a senior physician policy researcher at RAND and director of the Acute Care Research Unit at the University of Michigan.

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