In medicine, finding the right prescription starts with making an accurate diagnosis. Have we made the right diagnosis when it comes to the devastating effects of the coronavirus? We are growing worried that the understanding of COVID-19’s impact has not focused enough on the pandemic’s reverberating effects — particularly from delayed and foregone care for non-COVID-19 conditions.
One of our patients was diagnosed with colon cancer just before the pandemic hit the United States. He had been scheduled for surgery, but it was delayed since operating rooms were refitted as part of surge preparations. He was started on chemotherapy instead, even though it was not the recommended first-line treatment. The patient’s roommate, who had been helping as a caregiver, then contracted COVID-19. This resulted in a further interruption in care as our patient moved to live with relatives in a different part of the state.
The dangers of lacking health care
Delayed and foregone care, as in this patient’s case, contribute to suffering beyond the direct effects of COVID-19. Screening for cervical, colon and breast cancer were down between 86% and 94% in May, compared to the prior three years. Beyond cancer, immunizations for children have dropped precipitously, raising the specter of outbreaks of measles and other vaccine-preventable diseases. Kaiser Permanente reported a decline of almost half of patients with heart attacks who would have been expected to present to their hospitals during springtime.
Why is this happening? Certainly, some patients are fearful of the risk of COVID-19 associated with visiting hospitals and clinics. But COVID-19 has also unmasked pre-existing barriers in accessing care. The 28 million Americans who were uninsured before the pandemic often face a wrenching choice between paying for care or paying for other basic needs, like food or rent. Another 25 million people have lost their employer-sponsored health insurance due to the economic recession, according to the Urban Institute. As the economy reopens, patients like ours will feel pressure to go back to work just to maintain their health coverage — even, and perhaps especially, if they are ill.
The number of COVID-19 deaths recently surpassed the 116,516 Americans who died during World War I. Evidence published yesterday in JAMA suggests that 1 in 3 “excess deaths” — number of deaths above expected baseline levels — nationally could not be attributed to COVID-19. We know from other crises that deferred care compounds suffering. For example, after Hurricane Maria hit Puerto Rico, the leading cause of death was interrupted access to care.
Steps to improving health care in this moment
Given this diagnosis, the right prescription begins with calm and steady leadership. In moments of fear and uncertainty, people look to their leaders for honesty, hope and a clear path forward. We suggest four actions.
First, we must ensure health care settings are safe and communicate this effectively to the public. Health systems should tout their enhanced cleaning procedures, implement universal masking and symptom screening and designate hours for preventive care, including well-child visits, vaccinations and cancer screenings. Credible voices in health care and government should launch a public messaging campaign to ensure that patients who need care, seek care. Local and state leaders will need to feature prominently in this effort, especially given how ongoing missteps in the federal COVID-19 response have damaged trust.
Second, our nation must finally get the job done when it comes to expanding health coverage. The Trump administration has relentlessly attacked the Affordable Care Act (ACA), including protections for pre-existing conditions. Our patient’s roommate, who recovered from the coronavirus, would encounter challenges if the law were repealed, since COVID-19 would be a pre-existing condition, making someone “uninsurable” were it not for the ACA. Now is the time to move forward, not backward, by giving every American access to affordable health insurance. The 14 states that have not yet expanded their Medicaid programs can save lives — and infuse federal dollars into their economies — by choosing expansion.
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Third, we must stabilize the finances of medical practices and support investment in community-based care. Practices are struggling with insolvency; many will require emergency financing to survive. Medicare should extend its Advance Payment Program, with a particular focus on shoring up primary care offices, mental health and substance use disorder clinics, safety-net systems and critical rural hospitals. COVID-19 has also shown the importance of extending care to where people live, using telemedicine and mobile outreach. Such care can enable clinicians to manage both acute and chronic conditions in the safest location for the patient: their own home. We challenge technology entrepreneurs, health leaders and policymakers to deliver on the vision of moving services closer to people’s neighborhoods and homes.
Fourth, we need to identify and target populations disproportionately at risk for health complications — including racial and ethnic minorities, low-income and veteran patients — with dedicated support for non-COVID-19 conditions. This is particularly true for mental illness and substance use disorders, which have soared since the pandemic began. For instance, before the pandemic, 44% of veterans reported being lonely, exacerbating their risk of anxiety, depression and suicide during this particularly isolating time. Residents of rural areas are particularly affected but have less access to both in-person and virtual care. Virtual services should be targeted and tailored for such groups at higher risk.
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As some hospitals reopen to non-COVID-19 care, we will try to make up for lost time with patients like our gentleman with colon cancer. The country as a whole is reckoning with its own delayed care, certainly for COVID-19, but also more broadly. These four steps are a prescription that can help save lives and rebuild trust in our health system.
Dave A. Chokshi is a physician at Bellevue Hospital, clinical associate professor at the NYU School of Medicine and the Gould Visiting Scholar at the United Hospital Fund. Vivek H. Murthy served as surgeon general of the United States and is the author of New York Times bestseller “Together: The Healing Power of Human Connection in a Sometimes Lonely World.”