If you tried to design a weapon customized to exploit every weakness in the U.S. health care system, you might have come up with SARS-CoV-2: the novel coronavirus.
The pandemic caused by that spiky virus, now in its second year, has rampaged across the country in part because our disease defense system — the critical but neglected discipline known as “public health” — has been so starved of resources for so long that it had been effectively dismantled before the coronavirus arrived. Without robust disease surveillance, stockpiles of emergency equipment and a skilled public health work force, we were all but defenseless.
As a result, for the past year, Americans have watched as their vaunted health care system, with its massive hospitals, top-flight surgeons and expensive technology, struggled against an enemy best fought with low-tech measures like wearing face masks and staying home.
We knew our health care system had deep flaws: Too little emphasis on prevention and primary care. Clunky data systems. A porous mental health system. Deep health disparities, arising from poverty, racism and decades of neglect. High costs. Uneven quality. And despite the gains of Obamacare, a lot of people who still can’t get affordable care at all.
And under it all, there was a deep, dangerous erosion in the social foundation of public health: trust. Trust in science, in medicine, in expertise, in government and in one another. Our national lack of trust will make recovery and rebuilding from Covid-19 that much harder.
“This pandemic has really exposed the failures of our health care system,” said Rep. Raul Ruiz (D-Calif.), a physician who represents a heavily Latino district in southeastern California and who leads the Congressional Hispanic Caucus. “Our health care system is geared to take care of really sick people with really, really good and expensive technology,” he added. “What we are not good at is old-fashioned community health. Public health.”
Pandemic as opportunity
The good news is that health officials and policy experts know a lot about how to fix America’s health system. A cottage industry of consultants, advisers and advocates for a health care reboot has churned out volumes upon volumes of white papers, reports and conference proceedings for years. There’s even a fair amount of consensus on the big picture, if not the nitty-gritty. But change is hard, and for every would-be change promoter, there is a change resister, often benefiting from an army of lobbyists or inertia bestowed by the status quo.
So despite the devastation caused by Covid-19, despite the nearly half-million lives lost and the economic and social costs, the pandemic is also an opportunity. The work needed to contain and recover from the coronavirus might — just might — create momentum to fix things before the next catastrophe, which will inevitably come in one form or another, perhaps before we’ve healed from this one.
Any such opening may be fleeting. Americans have short attention spans, so policy makers need to act fast. Governors face many competing demands on their state budgets, some of which were hammered more than others by the pandemic economy. Fixing health is hard — and highly politicized. Some changes can be swift; others will take money and time. But there may not be a better moment to get started.
President Joe Biden has already made his health and pandemic priorities clear in the stimulus bill he submitted to Congress. He plans to shore up the Affordable Care Act and move ahead on sustainable public health, including creating a dedicated public health job corps. But with Washington polarized and often slow to act, states have an opportunity to lead and go big. Recovery doesn’t mean just getting back to where we were before the coronavirus. Recovery means finally fixing a lot of those things that everyone knew needed to be done, but never got done. It means using today’s crisis to prepare for tomorrow’s.
Traditionally, “public health” focused on the community — emergencies arising from events like floods or wildfires, contagious infections like tuberculosis, and programs like childhood vaccinations, maternal mortality and substance abuse. “Health care” was about patients and doctors and hospitals — really, about sickness more than wellness.
Now there’s a chance for states to better integrate the two, to make both communities and individuals healthier. And to finally make progress against racial and ethnic disparities — not as an add-on, or a box to check, but across the board. If a global contagion teaches anything, it’s that my ability to stay healthy depends on my neighbors not getting sick, either.
“Public health needs to be a strategy,” said Trish Riley, executive director of the National Academy for State Health Policy, “not a department.”
Prevention and containment
The essential concept driving public health is that the health begins in the community — on diseases being prevented when possible, and identified and contained when they do appear.
So when public health works and bad things don’t happen, you can’t see it. If you can’t see it, you think you don’t need it. And if you don’t need it, lawmakers ask, why pay for it?
Nothing could be more wrong. Yet that misconception has bedeviled public health for years. After the Sept. 11 terror and the anthrax attacks, Congress and states invested in bioterror defense and built up state and local public health capacity. Then complacency set in, and the 2008 economic crash wrecked state budgets. Public health was starved again — of staff, of data, of lab and surveillance capacity, of basic equipment — whether it was facing disasters like fires or floods, a surging opioid crisis, or a strange new disease like Zika. When the coronavirus pandemic hit, some public health departments were trying to trace its spread with faxes and pencils.
“Looking back at some of our public health plans — they were from post-9/11. They were outdated,” said West Virginia Public Health Officer Ayne Amjad, one of many state and local officials who found themselves doing combat with a pandemic with a depleted and obsolete arsenal.
In the early weeks of the pandemic, local health officials didn’t fully appreciate that an invisible invader was at their door — a situation that was aggravated by the Trump administration’s and the Centers for Disease Control and Prevention’s bad calls about testing and surveillance. From then on, the virus would always be two steps ahead of them — and as the vaccination missteps and emergence of alarming new virus variants illustrates, it still is.
“One of the things this pandemic makes clear is the perils of underinvesting in public health,” said Richard Besser, a former acting director of the CDC who now leads the Robert Wood Johnson Foundation. “This is what happens when you lose public health professionals, when you don’t invest in data systems, when you can’t respond quickly to new public health crises that arrive.”
The goal isn’t just acquiring data. It’s using it strategically, including to home in on inequity and discrimination which have been so pronounced in the pandemic, added Julie Morita, a former Chicago health commissioner who advised the Biden transition team and is executive vice president at the foundation.
Fixing public health also means repairing the CDC, the federal government’s lead public health agency, which does its own science and research and which also gives states grants and guidance on challenges ranging from teen vaping to reopening schools. Biden-appointed CDC director Rochelle Walensky has vowed to rebuild public confidence, after some agency policies were undermined or politicized by the Trump White House.
But it’s at the state level where public health war plans become boots on the ground. States don’t need to wait for Washington or the CDC to tell them what to do. Though they do need Congress to invest in public health and set a consistent national framework to fight the pandemic, many key-decision-makers are in the states; whether and how they seize the moment will determine not just whether their residents recover from Covid, but also if America will emerge from the pandemic with its public health restored.
Here are five key ways that states can combat Covid and prepare for the next threat at the same time.
Rehire public health workers and rebuild resources.
Perhaps counterintuitively, the Covid-19 pandemic has actually depleted the ranks of public health workers. The politicization of the pandemic meant some were fired, and others quit amid threats and harassment from people angry over business closures. Given that public health schools have been a popular destination the last decade or so, there’s a big — and increasingly racially and ethnically diverse — workforce to pull new public health professionals from. But states will need to make sure salaries are adequate to draw good people into the public sector.
Figuring out how to build up a steady workforce — instead of hiring a crush of new people in a crisis followed by a hollowing out — is essential, said Karen DeSalvo, Google’s chief health officer who was health commissioner in New Orleans as it recovered from Hurricane Katrina. “With public health, when [the crisis] is over, all the people who had come in to help you … everyone goes back to their corners. And the next crisis comes and you stand it all up again. I’d try to smooth that curve,” she said.
Of course, this all requires spending money. It’s been shown over and over again that investing in public health actually doesn’t cost that much compared to other government programs — and it pays off in lower costs for other public services. Total health spending in the U.S. is nearing $4 trillion a year; the CDC budget (before emergency pandemic infusions) generally ran under $10 billion in recent years — the equivalent of pennies on the dollar.
Get data and labs out of their silos.
Public health preparedness doesn’t just mean filling warehouses full of stuff. Increasingly, it’s having 21st century data collection, and sophisticated laboratories that not only respond to a crisis, but help detect the next one before it’s too late.
“It’s more than just, ‘Stockpile gloves and masks and we’ll be fine,’” said Josh Sharfstein, who has worked in health at the federal, state and local levels and is now a vice dean at the Johns Hopkins Bloomberg School of Public Health.
States need to invest in things like connecting their own public health labs to other parts of the health system. They need to be able to detect emerging threats, not just chase them in the full-blown crisis. State labs on their own can’t be expected to handle something like doing all the genomic sequencing needed to track emerging variants of the coronavirus; the CDC, private labs and academic institutions play a big role. But upgraded and linked labs could contribute more.
And time and again, the pandemic has shown that states’ antiquated data systems aren’t up to the job. They aren’t interconnected, they’ve been full of gaps (as are the CDC’s), and they don’t detect “the signal” from “the noise.” And public health data is siloed from other health care data.
“We’ve got to erase that separation,” said Alice Chen, the chief medical officer of Covered California, the state’s online Obamacare market. “That’s the biggest opportunity and I think that’s the least addressed.”
Put primary care back at the center of health care.
Integrating public health with the rest of the health care system doesn’t just pick up faster on crises; it could help shift the whole system more toward primary care and prevention. A primary care focus would be a change from medicine today, which is centered on specialists, subspecialists and expensive procedures — not all of which are necessary. It would put needed emphasis, too, on managing the chronic diseases that are the biggest burden on the health system, and on patients and families. The lingering effects of Covid-19 in some patients, so-called “long Covid,” though not yet well understood, may soon be our newest chronic disease challenge.
Rep. Ruiz, who volunteers in a street clinic when he’s back in his district, said the pandemic is a reminder that our system needs to provide more home- and community-based care, which can live at that intersection of public health and health care. Focusing on mental health, diabetes, nutrition, smoking cessation, maternal mortality — or even better, preventing them — can keep people out of the emergency rooms and hospitals, saving money and improving health.
A handful of states, among them Massachusetts and Maryland, are engaged in cost-containment efforts that can also nudge systems toward a more “value-based” health system that elevates primary care and prevention. The federal government, which has a lot of opportunity to experiment on a larger stage with pilot programs and waivers in Medicare and Medicaid, can do the same.
Even if Washington is slow to act, states have several other big levers to pull — chiefly, their purchasing power as an employer and Medicaid, the federal-state program that now covers about 75 million low-income Americans. The biggest employer in most states is the state itself, but few use their public sector worker and teacher health plans to drive change.
States that run their own Obamacare exchanges can use their influence in similar ways to boost primary care and prevention, although the relatively small size of these markets limits their ripple effect. The California exchange is one that’s making the effort.
“If you are a marketplace, to my mind, one of your obligations is not to only give people an insurance card, but to make sure they are getting the care they need and are being kept healthier,” Covered California Executive Director Peter Lee said. The whole idea is to keep people from getting sick when possible — and when people do inevitably fall ill, to keep them as well as possible for as long as possible.
More states now use managed care in Medicaid, and while there are good plans and not-so-good plans, they can give states flexibility on how to spend health care dollars, whether it be telemedicine or addressing social conditions that lead to poor health. And states can hold these plans accountable.
“If you believe that primary care is the most important single intervention to correct health care differentials — race, ethnicity, income — you need to ask, what can Medicaid do?” said David Blumenthal, the president of the Commonwealth Fund, who was the top health technology official early in the Obama administration.
Tackle the racial and social disparities that threaten the health of all communities.
Before the pandemic, health policy experts and government officials had begun to focus more on “social determinants of health,” a clumsy phrase for a simple concept: that people’s opportunities and environments, including racism, affect their health. Housing. Transportation. Education. Access to healthy food. Poverty. And more.
These circumstances are big reasons why poor and minority communities are so vulnerable to the coronavirus, and why so many of the pandemic hotspots are in disadvantaged parts of our cities and states. Nobody is advocating for the health care system to try on its own to fix all of the fallout of poverty and discrimination. But it has a role, often, again, through Medicaid health plans. Medicaid can partner creatively with other social service agencies or use its own dollars on needs that aren’t traditionally thought of as health care, but will improve health outcomes and health equity. For instance, Medicaid could team up with housing agencies, business groups, even a hospital system to get high-risk patients experiencing homelessness into homes.
Business and health groups can find ways to constructively interact. Former Surgeon General Jerome Adams tells a story about talking to some mayors who wanted to build sidewalks in their communities. His first thought was wow, they wanted to encourage walking to fight diabetes. Then he learned that they were actually trying to boost property values, and get more potential customers strolling into stores. And then he realized that it didn’t matter, the sidewalks would still fight diabetes — and create a way for business and health groups to join forces. Different goals. Shared gains.
“It’s not just a health care conversation. It’s an economic conversation, and health care is part of that conversation,” said Pennsylvania Insurance Commissioner Jessica Altman. “What part of this is the health care system’s responsibility to solve, and which is all of government’s responsibility?”
The pandemic, with its stark racial, ethnic and economic disparities, brought all that home. It turned social determinants from a talking point to an agenda item, entwined with, though not identical to, the national reckoning over race.
Every sector of society and the economy has been hit by the pandemic — and every one can be rebuilt with health and equity in mind. “We don’t just go back to where we were, because we weren’t in a great place,” said Cara James, who ran the Office on Minority Health at the Centers for Medicare and Medicaid Services during both the Obama and Trump administrations and now leads the Grantmakers in Health nonprofit. Equity has to be built in, she said. Not a P.S., but an “S.O.P.” — standard operating procedure.
Prepare now for a coming mental health tsunami.
Mental and behavioral health were daunting challenges well before the coronavirus plunged us into a year and counting of isolation, anxiety, economic hardship, disrupted relationships and grief. As we emerge, mental health will become an outright emergency; anxiety and depression are already elevated, and research has found that suicides often surge in the wake of disasters.
States should stand up hotlines and emergency services, as they work to expand mental health capacity longer term, including mental health community clinics, and a more robust behavioral health work force, including peer support and community mental health workers when appropriate.
“During the pandemic, everyone is triaging. Coming out of this, dealing with mental health will rise to near the top,” said Elinore McCance-Katz, who ran the Department of Health and Human Services’ mental health agency in the Trump administration, noting that not everyone will bounce back when the pandemic eases. “We can’t presume that when someone says, ‘It’s over,’ that everyone gets better.”
The federal government and the states should also expect to confront a rebounding opioid crisis, despite some hard-won pre-pandemic gains. “That is going to be a real driver of mortality — that and all the other deaths of despair,” said DeSalvo.
Still, the larger problem is that even before the pandemic, our health care system didn’t have adequate capacity. There aren’t enough mental health care providers, particularly in underserved areas, and many don’t accept the relatively low fees offered by insurers. Any “build it and they will come” state approach to growing the workforce will take time, so it should begin ASAP. States can also make sure their public employee health plans offer adequate psychiatric and counseling options, and create incentives like student loan forgiveness to encourage mental health professionals to go into underserved communities.
Christina Mullins, who runs West Virginia’s behavioral health, suggests that states need to improve their crisis services, including mobile units that can connect people to ongoing care. Congress can help by making permanent the emergency authorization allowing providers to be reimbursed for telemedicine — including covering telephone counseling and consults, not just audiovisual ones, for people who don’t have computers or who live in rural areas without broadband.
One of the biggest salves for mental health is to open schools as soon as safely possible for a whole long list of reasons, including that basic need of just letting kids have what they call “IRL” — for “in real life” — friendships and in-person contact with watchful adults who aren’t their parents (although the Biden administration may find that it’s easier said than done). McKance-Katz also wants mental health and behavioral clinics opened for in-person care — safely, with masks, distancing and fewer people gathering at any one time.
The bottom line is that it’s really hard for people to recover their mental health when they are facing all sorts of other real-life stresses. Recent data from the CDC upholds that assessment — and it’s worse for minorities. People with severe mental illnesses or who are in crisis need to be connected with social services, to get help with child care, housing and jobs.
None of those changes are easy, and all of them require money, focus and persistence from state officials and federal partners. But people working on improving public health have come to appreciate a central challenge that affects all of them: Trust in public health agencies and expertise has been damaged to the point that it is causing real harm.
Rebuilding trust is a theme new CDC director Walensky has emphasized in just about every public utterance since her appointment. She has pledged to lead with “facts, science and integrity,” even when the news is more bleak than what people or politicians want to hear.
Yet the erosion of trust predates Covid-19 and Donald Trump, although the former president’s assaults on science and depiction of public health as the enemy of economic recovery deepened it. Right now, the lack of confidence in vaccines — the only way out of the pandemic — is where addressing the corrosion is most urgent.
But vaccination may also be a second chance. If states and their federal partners use vaccination to show how governments really can keep people healthy, it could lay the foundation for rebuilding the national public health system we need to keep Americans healthier long-term.
“These are trust-building opportunities, and they should not end when the vaccination level is high enough,” said James, the former CMS minority health director. “There is work to be done. … Address this crisis to tackle other issues.”
Of course, it’s not only health care that has been stained by mistrust, she noted — it’s basically every sector of civil society. But conquering Covid, rebuilding public health, fairly and equitably, is a good way to start.