Do No Harm

While channel surfing Tuesday night, I came upon the above documentary film, Do No Harm: Exposing the Hippocratic Myth, when I saw a scene of medical students graduating from Des Moines University. I wondered if this was the same school that my younger brother, who is a D.O. graduated from. It was, so I continued watching it to the end.

According to the documentary, physicians have the highest rate of suicide among the professions. And the toll on their friends and families is one of shock and despair that they never received any help for their depression and thoughts of suicide. The feeling of isolation overwhelms many of our young doctors, and the only way out is to commit suicide by whatever means is available.

At one point in the film when the producer interviewed him, the President/CEO of the Accreditation Council of Graduate Medical Education (ACGME), said they agreed with recommendations made to deal with this crisis, and then in the next sequence, the film states that hours were increased from 18 to 28 hours. However, in 2003 the ACGME set new rules limiting residents’ hours to 80 hours a week and to 16 hour shifts, so something is wrong here.

69 percent of doctors report having abused drugs. Medical errors are the third highest cause of death in the United States after Heart Disease and Cancer, with 251,000 deaths a year. Depressed residents cause 6.2 times more errors than their peers, and 1 out of 20 admit making an error that leads to the death of a patient.

The reason for this problem stems from the fact that residents are a cheap source of labor for hospitals. Residents are paid on average $40,000 a year, while Medicare pays the hospitals an average of $112,000 per resident. Hospital CEO’s annual salary range from $600,000 to $1 million, and with bonuses and incentives, it can go as high as $12 million or more.

Physician burnout among physicians, as the chart below shows, is highest among Emergency Medicine, followed by Ob/GYN, Family Medicine (as I can attest to with regard to my brother, who began his practice as one of six doctors, and is now the lone doctor in two offices. Needless to say, it has caused him some personal distress, but thankfully for my family, he is not a statistic).

Sixty percent of Emergency Medicine physicians experience burnout, OB/GYN physicians exhibit more than fifty percent burnout, and Family Medicine physicians exhibit roughly fifty-five percent burnout.

Until the medical profession comes clean and realizes that working physicians to death is not healthy for the body of American medicine, this abuse will continue. At one point, Pamela Wible says that this system is a violation of human rights according to the United Nations.

Please watch this very informative and eye-opening documentary, and if you have any power to end this crisis, please do.

COVID and American Exceptionalism

American Exceptionalism

American exceptionalism has been historically referred to as the belief that the United States differs qualitatively from other developed nations because of its national credo, historical evolution, or distinctive political and religious institutions. The difference is often expressed in American circles as some categorical superiority, to which is usually attached some alleged proof, rationalization or explanation that may vary greatly depending on the historical period and the political context. However, the term can also be used in a negative sense by critics of American policies to refer to a willful nationalistic ignorance of faults committed by the American government.

New World Encyclopedia

In the nearly nine years writing this blog, I have mentioned the idea of American Exceptionalism fifteen times, but at no time since the arrival of the COVID-19 virus, have I mentioned it in relation to the pandemic.

Thanks to Elizabeth Ziemba, Founder and President of Medical Tourism Training Inc., the following article is re-posted with her kind permission.

She correctly states that the pandemic has exposed the American health care system as unable to deal effectively with COVID, and while she has not offered any alternative to our current system, it is apparent to me that the only alternative left, especially after the Supreme Court of the United States overturns the ACA, once Trump’s nominee to fill Ruth Bader Ginsburg’s seat, Amy Coney (Island) Barrett is confirmed, is Single Payer/Medicare for All.

Here is Liz’s article in full:

COVID-19 has ended the age of American exceptionalism in healthcare

Published on September 28, 2020

 

 

How difficult will it be to rebuild its damaged brand?

By Elizabeth Ziemba, JD, MPH, President of Medical Tourism Training and Regional Office Director for Temos International Healthcare Accreditation

“From Myanmar to Canada, people are asking: How did a superpower allow itself to be felled by a virus? And why won’t the president commit to a peaceful transition of power?” From the NY Times article, “I feel sorry for Americans” [iv]

A global pandemic has finally ripped the bandages off the US healthcare system that has been struggling and failing its citizens for years, revealing its weaknesses for all the world to see. With more than 200,000 COVID-related deaths and counting, it is a system that is going off the rails with no one at the wheel. What happens next will impact the health of Americans for years to come.

Some of the world’s best healthcare institutions are in the United States. Stars like Cleveland Clinic and Mayo Clinic shine so brightly that they blind many to the truth that they represent the exceptions rather than the norm. The devastation of COVID-19 is so profound that it is casting black clouds over the few examples of international excellence and shining rays of light on the abundant weaknesses of the country’s healthcare system.

The US has long spent more on healthcare per person than any other country in the world but produces outcomes that do not justify the investment. Global healthcare rankings of countries place the US as 30th[i] or 37th[ii]. Access to healthcare services is a major factor in determining “best in class”. The US consistently scores low with millions of people with inadequate insurance or no insurance at all. At the end of June 2020, 42 US hospitals have closed or declared bankruptcy[iii], mostly in rural areas where they were the primary services for their communities. People will have to travel farther for care or forego services altogether. Rural and minority areas are particularly hard hit, further increasing inequities of access.

The country’s response to COVID-19 has been mishandled at every step of the way. Public health experts have been sidelined in favor of political gain. Lessons that could have been learned from other countries what were hit hard before the US represent missed opportunities, supplanted by “we know what is best”. This attitude of exceptionalism – the United States is different, better than everyone else – may have worked in the past, creating a “Can Do” attitude that fosters innovation in medical technology and highly sophisticated treatment but that fails during a pandemic.

The national pandemic response should have been immediate, uniform, and standardized according to international best clinical practices. These three pillars of public health are what has enabled governments around the world to respond with the best results. Instead the 50 states were left to fend for themselves, combatting shortages, inconsistent and confusing messages on the national level, and political nonsense. What a recipe for disaster resulting in a mounting death toll and economic devastation for millions of Americans – all for lack of national leadership and the political will to behave like the United States of America.

The damage done to the country’s international reputation will further hamper the rebuilding of the healthcare system that is needed not only to serve the country but to resuscitate its international brand. The best and the brightest healthcare professionals including scientists and public health experts will retire or take their skills to countries and organizations where their knowledge will be respected and utilized. International patients and the money that they bring to the US when seeking highly specialized and expensive care will go elsewhere. These patients are abandoning the US for destinations with better healthcare.

Exceptionalism during this pandemic leaves Americans with fewer choices for accessing care. Lack of access to healthcare services typically results in people foregoing treatment and presenting sicker with fewer treatment options. The cost of healthcare rises to account for this trend. People’s health, the most precious of all commodities, will suffer. It is time to acknowledge that exceptionalism is dead, and our healthcare system must get back to the business of getting and keeping people healthy.

This virus and the other pandemics that will come in the future require engagement with the international community. Diseases do not observe the niceties of national boundaries. The US government must fully support the efforts of the World Health Organization to create the best possible solutions to pandemics. Engagement by our scientific and pharmaceutical experts in COVAX represents the fast and sensible way forward for the United States to assert global leadership, now and in the future.

By persisting on the course of exceptionalism, the country will struggle to rebuild its healthcare system for the people of the United States and its reputation for the world.

#COVID-19 #clevelandclinic #mayoclinic #publichealth #exceptionalism #WHO #COVAX #reputationdamage #brandreputation #brand #healthcare #hospitals #clinics #access


[i] https://www.numbeo.com/health-care/rankings_by_country.jsp

[ii] https://www.who.int/whr/2000/media_centre/press_release/en/

[iii] https://www.beckershospitalreview.com/finance/42-hospitals-closed-filed-for-bankruptcy-this-year.html?_ga=2.253900616.1111462226.1600093493-1451317812.1600093493

[iv] https://www.nytimes.com/2020/09/25/world/asia/trump-united-states.html?action=click&module=Top%20Stories&pgtype=Homepage

Carlos Arceo

This morning, I learned of the passing on Saturday of Carlos Arceo, the President of the Global Medical Tourism Congress and the President and CEO of the 11th Mexico Medical Tourism Congress, to be held next May in Chihuahua, Mexico.

This was confirmed for me by two individuals I met in November 2014 when Carlos invited me to speak at the 5th Medical Tourism and Wellness Business Summit in Reynosa, Mexico.

Carlos died from renal failure, a condition I am acutely aware of since I am a home dialysis patient.

I know I speak for the rest of the medical travel community when I offer his family and friends my sincere condolences on his passing. He will be missed by the entire medical travel community.

He invited me to attend the 6th Medical Tourism and Wellness Business Summit, but due to personal issues, I was unable to attend.

MfA Endorsed by Internal Medicine Physician Society

Past President of PNHP, Don McCanne posted the following on their website. Slowly, but surely, physicians are recognizing that the current health care system in the US is failing and must be changed for the better.

I can hear the criticisms from the medical business community, but ask yourselves this one question: if our system is better than MfA or Single Payer, then why is it that no other Western, Capitalist country does not have the system we have?

Because it doesn’t work for all their citizens and they want all of their citizens to have health care, not as a commodity or privilege, but as a right — A HUMAN RIGHT. PEOPLE BEFORE PROFITS.

Here is the link to the PNHP website article: https://pnhp.org/news/another-physicians-group-endorses-medicare-for-all/

A Few Comments About Yesterday’s Post

After putting yesterday’s post to bed, I realized that there were some more things I wanted to say about COVID and the end of neoliberalism.

Recall that John McDonough had mentioned that the Orangutan’s war on trade and other economic policies, signaled the aging of the Neoliberal era. Well, over night, the baboon struck again when he asked the Supreme Court to overturn the ACA (Obamacare), which if it happens, will mean 20 million Americans will lose their health care during a global pandemic.

Their rationale — because it is unlawful. Really? From the most corrupt and unlawful Administration in US history. Could you try any harder to kill more Americans when the number of deaths has already passed 120,000?

In an Opinion piece in Wednesday’s New York Times, Charles Blow asked, “Can We Call Trump a Killer?” According to Blow, things are so bad, that the European Union is considering banning US citizens, and it is abysmal had Trump not intentionally neglected to protect American citizens.

In fact, several times since the pandemic began, he was quoted as saying the following about Corona, “Looks like by April, you know, in theory, when it gets a little warmer, it miraculously goes away.”

Early on in the crisis, some have suggested that perhaps it is time to consider single payer health care. In fact, some have argued that single payer systems have coped with Corona better than for-profit systems.

Shortages of Personal Protection Equipment (PPE), ventilators, and the lack of enough ICU beds is proof that for-profit health systems cannot effectively handle a global pandemic. “Having a healthcare system that’s a public strategic asset rather than a business run for profit allows for a degree of coordination and optimal use of resources,” according to David Fisman, epidemiologist at the University of Toronto.

One country that has been able to deal effectively with Corona has been South Korea, and despite recent setbacks, the following data and chart from a tweet by @hancocktom, highlights what Korea did right.

South Korea has done more than just “flatten the curve” of new Covid-19 infections. It bought the curve down through: – Aggressive testing (20,000 tests daily, “drive through” testing)/isolation – School holiday extended – Government advice to stay inside – large events cancelled

Image

“Unhampered government intervention into the healthcare sector is an advantage when the virus is spreading fast across the country,” said Choi Jae-wook, professor of preventive medicine at Korea University in Seoul.

Denmark also has a single payer system, and like South Korea, offered drive-thru testing. Jorgen Kurtzhals, the head of the University of Copenhagen medical school, told the Washington Post that the strength of Denmark’s single-payer system is that it has “a lot of really highly educated and well-trained staff, and given some quite un-detailed instructions, they can actually develop plans for an extremely rapid response.”

“We don’t have to worry too much about whether this response or that response demands specific payments here and there,” said Kurtzhals… “We are aware that there will be huge expenditure within the system. But we’re not too concerned about it because we have a direct line of communication from the national government to the regional government to the hospital directors.”

One nation that has a single payer system and has had a bad experience with COVID is Italy. Presumptive Democratic nominee, Joe Biden, in a primary debate with Sen. Bernie Sanders in March, said that, “With all due respect for Medicare for All, you have a single-payer system in Italy,” said Biden. “It doesn’t work there.”

HuffPost healthcare reporter Jonathan Cohn said in a tweet, “[Single-payer] isn’t the reason Italy is having problems,”…”Italy’s problem is health system capacity. Independent of health system design.”

Another critic said the following:

This is the dumbest point. No, single payer does not solve the problem of pandemics. But it definitely solves the problem of thousands and thousands of people going bankrupt because there’s a pandemic. It solves the problem of people not seeking out care for fear of bankruptcy. 

— Jill Filipovic (@JillFilipovic) March 16, 2020

There is no panacea for dealing with such a deadly and fast moving virus. Within a few short months it spread from China to Western Europe, the US (first cases found in a Washington State nursing home), and then globally.

Instead of going piecemeal to find a solution, all nations should have pooled their resources and worked to find a vaccine as soon as possible. Estimate recently said the world will hit 2,000,000 cases in the near future.

Single payer won’t cure it, but will make it easier to manage so that all infected will have the use of ventilators and ICU beds if needed, and medical personnel won’t have to reuse PPE that should have been discarded after treating one patient.

COVID-19 and the End of the Neoliberal Era in Health Care

The subject of neoliberalism has been discussed in this blog five times between 2018 and 2019, and is the focus of an article in The Milbank Quarterly, by John E. McDonough, professor of public health practice at Harvard’s TH Chan School of Public Health.

In the article, Professor McDonough points to a Commonwealth Fund chart (see below) that shows the growth in gross domestic product (GDP) for health care, comparing the US to 10 other high income nations. The chart shows that from 1980 to 2018, spending by the US was among the highest 40 years ago, but that in the early 1980s, US spending leapt above the others. and growing wider over four decades.

 

He then asks, “what happened to US health care in the early 1980s-and since then?”

McDonough responds by pointing to two New York Times columns by Austin Frakt, Medical Mystery: Something Happened to U.S. Health Care Spending After 1980 and Reagan, Deregulation and America’s Exceptional Rise In Health Care Costs.

McDonough suggested that a big part of the answer involves the broad economic and political trade winds of the late 1970s and 1980s, often called “Reaganomics” or “supply-side economics”, because Reagan ushered in a new era in the US. Some, like George H. W. Bush, running for President in 1980 for the Republican nomination, called it “voodoo economics.” However. as McDonough states, and as my previous posts on the subject calls it, it is “neoliberalism.”

This term evokes Adam Smith, but the 20th century version owes itself more to the works of Friedrich Hayek and Milton Friedman, among others. According to McDonough, the neoliberal agenda consists of cutting taxes, repealing regulations, shrinking or privatizing government (remember Grover Norquist’s desire to shrink government to fit in his bathtub and strangle it), suppressing labor, encouraging free-market trade, accepting inequality as price for economic freedom (something that has come under fire this year and since the 2016 election, making people receiving services and benefits pay as much as possible, and reorienting corporate thinking and behavior to promote return on equity as their only goal.

The New Deal era that was replaced by neoliberalism, McDonough states, lasted 48 years, from 1933 to Reagan’s inauguration in 1981. The neoliberal era, he points out, is 40 years old and showing signs of rust, cracks, and failing systems. Signs of this are Trump’s war on trade, deficit-exploding tax cuts for the wealthy and corporations,, anger over “deaths of despair” from opioid and other addictions and economic distress, awareness and revulsion about rising levels of inequality across society, and spreading rejection of absolutist “shareholder capitalism.”

In addition, recent protests over the deaths of African-American males at the hands of police, coupled with the Corona virus pandemic, are all signs that something is terribly wrong.

But what about health care, McDonough asks again?

Reiterating what he said above, US health care between 1980 and 2020 saw spending rise far above US economic growth, while growth in insurance premiums and cost-sharing increased well beyond advances in household incomes. On key indicators, he reports, the US performs worse than most nations on life expectancy, infant and maternal mortality, chronic disease mortality, levels of overweight and obesity, suicides, and gun violence, as well as glaring systemic health inequalities, as has been discussed during the BLM protests as one factor in people taking to the streets.

Despite the advances in technology and high spending, Americans give their system the lowest satisfaction ratings.

Yet, between 1965 and the 1980s, major infusions of investor capital has gone to all corners of our health care system, courtesy of shareholder-owned for-profit companies who often cut long-lasting ties with local communities, according to McDonough. It did not help that in 1986, the Institutes of Medicine, instead of convicting for-profits of “killing” health care, released a 600 page report on “For-Profit Enterprises in Health Care, that identified pluses and minuses that called for greater monitoring.

Finally, McDonough concludes that the US need to look outward, not inward, as is usually the case to solve big problems with health care. One such study, in 2018 from the William and Flora Hewlett Foundation, Beyond Neoliberalism, is a clarion call for a new policy sphere forming in think tanks, academia, advocacy and activist groups, and the legal community, as well as some Republican/conservative quarters as Marco Rubio, who rejects shareholder primacy. He says the search is on for a new paradigm, and hopes the election in November will bring it forth.

He doesn’t have to look far. Bernie Sanders, Elizabeth Warren, the PHNP, and others have the paradigm. It is Medicare for All/Single Payer. But first we have to rid ourselves of the baboon in the Oval Office and his economic minions, Mnuchin the Mieskeit, and Kudlow the Meshuggeneh.

Stay safe everyone.

Public Health Emergencies and Health Care

In light of recent protests and violence, especially the state-sponsored violence that was unleashed by a fascist would-be dictator last night in the nation’s capital for a political photo-op that cleared peaceful protesters with tear gas and flash bombs, we must stop defending an economic system that believes that human rights such as health care are a priviledge of one’s pocketbook, and not their humanity. This attitude is not limited to health care, but in the midst of a pandemic, it is imcumbent on us to begin somewhere.

The statement below from Dr. Adam Gaffney, President of the Physicians for a National Health Program (PNHP) rightly states that police violence and racism are public health emergencies, must be understood from an historical perspective as well.

In my post, Why The US Doesn’t Have Universal Health Care – It Is Not What You Think, the reluctance of the US to implement universal health care is tied to Southern White racism.

So, those whose career or jobs depend on the status quo, and you know who you are, are  standing in the way of change or defend the status quo, are the ones who can bring change, or else change will be made without you.

Here is the statement:

June 2, 2020

Statement from Physicians for a National Health Program:

The horrific murder of George Floyd at the hands of Minneapolis police has sparked protests nationwide. Physicians for a National Health Program (PNHP), an organization of more than 23,000 doctors who support Medicare for All, denounces police brutality and racism in all forms; demands immediate steps to ensure racial justice at all levels of government; and calls for racism and racial health inequity to be treated as public health emergencies.

“The murder of Floyd,” said Dr. Adam Gaffney, president of PNHP, “is yet the latest example of the pervasive racism that sickens our nation. It is emblematic of the deeply entrenched system of institutionalized racism that afflicts both our criminal justice and health care systems.”

Police violence is a public health emergency.

Police violence is a leading cause of death for young men of color. Black men in particular face a 1 in 1,000 chance of being killed by police, and are 2.5 times more likely to be killed by police than are white men. Over-policing in communities of color and sentencing disparities mean that in the U.S. — which has the highest rate of incineration in the world — Black Americans are incarcerated at a rate that is 5.1 times that of whites.

Mass incarceration imposes a particular threat to health during the COVID-19 pandemic given crowding and poor access to health care in these facilities. PNHP has previously joined other groups in calling for immediate actions to safeguard the health of prisoners during the COVID-19 pandemic, including early release.

Racism is a public health emergency.

The current COVID-19 pandemic has laid bare the deep inequalities in our health system, as Black Americans are more than twice as likely (and in some states seven times as likely) to die from the virus than whites.

“Racial inequities have, for too long, been tolerated and accepted as normal in this country,” stated Dr. Susan Rogers, president-elect of PNHP. “The overt brutality displayed by police makes this clear, but these inequities extend to health care, housing, and education.”

Compared to whites, people of color are more likely to be uninsured, face barriers to care, and suffer and die from preventable health conditions like diabetes, heart disease, and cancer. Black families are also three times more likely to live in poverty compared to white families, and twice as likely to be food insecure, factors known to contribute to poor health.

PNHP is committed to fighting all forms of racial inequity, including the structural racism that puts Black people at substantially higher risk of police violence and incarceration, and a broken health care system that denies patients of color the right to health and health care.

Now more than ever we must speak out against all acts of racial injustice. Here are a few ideas for what you can do today:

  • Support racial justice organizations in your community with your time or financial resources.
  • Educate yourself about racial disparities in health care by exploring PNHP’s TOOLKIT on racial health inequities, which includes materials for hosting webinars, a guide for writing letters and op-eds, talking points, and materials to share on social media.
  • Commit to educating your colleagues on racial justice with this slide show and with tools for a Grand Rounds presentation.

Please join me in demanding an end the scourge of police violence, as well as racism and discrimination in all its forms.

Sincerely,

Adam Gaffney, M.D., M.P.H.
President

Eligibility Waivers to Leave Many With Costs From COVID-19

One more reason, now that COVID is causing so much unemployment, that we desparately need Medicare for All, with no qualifications other than US citizenship. We can give corporations and wealthy people billions in tax breaks, but not one red cent for people’s health care in a nationwide, single payer system that would have responded rationally and logistically to a pandemic, instead of as a “chaotic disaster.”

Health Affairs Blog

May 8, 2020

Medicaid Retroactive Eligibility Waivers Will Leave Thousands Responsible For Coronavirus Treatment Costs

By Paul Shafer  Nicole Huberfeld  Ezra Golberstein

The coronavirus pandemic has led to record numbers of American workers being laid off or seeing their hours and paychecks dwindle. The economy is on the brink of a deep recession, and waves of coronavirus infections may continue for the foreseeable future. Medicaid will be a crucial piece of the puzzle that helps to ensure access to health care while protecting people from further financial ruin. Yet, one of Medicaid’s key provisions has been weakened by recently approved section 1115 “demonstration projects”, commonly referred to as waivers, that eliminate or reduce retroactive coverage. These waivers will diminish coverage for thousands of people seeking testing and treatment for COVID-19 and other medical care.

Retroactive eligibility is a long-standing feature of Medicaid that covers health care expenses for three months prior to the application date, provided that the beneficiary would have been eligible during that period. Before the Affordable Care Act (ACA), a handful of states imposed narrow restrictions on retroactive eligibility, but these limitations were paired with expansions of eligibility and had exemptions for vulnerable groups. Recently, however, many states—including Arizona, Arkansas, Florida, Indiana, Iowa, Kentucky, and New Hampshire—have gained Department of Health and Human Services (HHS) approval for 1115 waivers that drastically limit or completely eliminate retroactive eligibility, though four have been stayed by courts or halted by states as part of litigation challenging the legality of those waivers that include work requirements (Arkansas, Kentucky, Indiana, and New Hampshire).

A core purpose of Medicaid is supporting people when they need help, which is why Medicaid has continual open enrollment and retroactive eligibility to cover the cost of care when those who are eligible aren’t already enrolled before a crisis. States should restore full retroactive eligibility immediately to protect thousands of newly-unemployed workers from even greater health and economic suffering.

https://www.healthaffairs.org/do/10.1377/hblog20200506.111318/full/

The Sad Downside to Globalization: Economics Over Public Health In The Age of Covid-19

Tom Lynch of Workers’ Comp Insider posted the following yesterday about where most of the masks and other protective equipment worn by health care workers comes from, and in particular, one CEO’s experience with the beginning of a global pandemic.

Here is the article.

If you are wondering why there have been mass protests (mostly supported by, and instigated by, conservative groups and wealthy, libertarian right-wing families such as the DeVos, Dorr, and other families, and commentators such as Alex Jones and Fox News), it is because many of these people have been outsourced from jobs that were sent to China and elsewhere.

Some are just members of militia groups flexing their muscles, but thankfully, polls show more Americans support restrictions, rather than opening up the economy. Apparently, it is the economy of these families that are most affected by the shutdowns, and thus they are only interested in their economic interests, not public health.

Witness the statements of some GOP elected officials who stated that the economy was more important than living (Texas’ Attorney General, for one).

So, while Trump makes a clusterf**k of the response, let’s remember that we did not understand that there were consequences for shipping our manufacturing jobs to China, and COVID-19 is the result.

Richard’s note: The masks I use for my dialysis treatment come from China.

Mass Unemployment and COVID-19: What It Means for Health Insurance

Steffie Woolhandler, M.D. and David Himmelstein, M.D. wrote yesterday in the Annals of Internal Medicine that many of those who lose, or already lost their jobs due to the coronavirus pandemic have a lack of health insurance. Many did not have insurance before the outbreak, and now that they are unemployed, their employer-based insurance will end as well.

Here is the article in full:

Annals of Internal Medicine

April 7, 2020

Intersecting U.S. Epidemics: COVID-19 and Lack of Health Insurance

By Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD

During the final week of March 2020, the U.S. Department of Labor reported that a record number of workers—6.648 million—filed new claims for unemployment benefits. That beat the previous record of 3.307 million filings, which was set the week before, bringing the 2-week total to 9.955 million. This is just the beginning of the surge in joblessness due to the coronavirus disease 2019 (COVID-19) pandemic. A Federal Reserve Bank economist estimated that the ranks of unemployed persons will swell by 47.05 million by the end of June.

For many, job loss will carry the added sting of losing health insurance. Congress has moved to cover severe acute respiratory syndrome coronavirus 2 testing for uninsured persons, but did not include provisions to cover treatment of COVID-19 (or other illnesses). The recent $2 trillion bailout bill offered no new health insurance subsidies or coverage.

Estimating Coverage Losses

We estimated the likely effects of current job losses on the number of uninsured persons by using data from the U.S. Census Bureau’s March 2019 Current Population Survey on health insurance coverage rates among persons who lost or left a job. The uninsurance rate among unemployed persons who had lost or left a job was 26.3% versus 10.7% among those with jobs. Applying the 15.6–percentage point difference to the 9.955 million who filed new unemployment claims last week, we estimate that 1.553 million newly unemployed persons will lose health coverage. This figure excludes family members who will become uninsured because a breadwinner lost coverage and self-employed persons who may lose coverage because their businesses were shuttered, but are ineligible for unemployment benefits. If, as the Federal Reserve economist projects, an additional 47.05 million people become unemployed, 7.3 million workers (along with several million family members) are likely to join the ranks of the U.S. uninsured population.

Coverage losses are likely to be steepest in states that have turned down the Patient Protection and Affordable Care Act’s Medicaid expansion. In expansion states, the share of persons who have lost or left a job who lacked coverage was 22.1% versus 8.3% for employed persons—a difference of 13.8 percentage points. In nonexpansion states, the uninsurance rate among such unemployed persons was 38.4% versus 15.8% for employed persons—a difference of 22.6 percentage points. In other words, nearly 1 in 4 newly unemployed workers in nonexpansion states are likely to lose coverage, bringing their overall uninsurance rate to nearly 40%.

Our projections are based on differences in coverage rates for employed and unemployed persons in 2019, but there is little reason to believe that the predicament of unemployed workers has improved since then. Although many who lose their jobs are likely to be eligible for Medicaid or subsidized Affordable Care Act coverage, and some will purchase continuing coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act), the same was true in 2019. Indeed, the situation may be worse today because some laid-off workers probably gained coverage through an employed spouse in 2019, an option less likely to be available in the face of the impending massive layoffs.

Urgent Policy Needs and Longer-Term Solutions

With jobs and health insurance coverage disappearing as the COVID-19 pandemic rages, states that have declined to expand Medicaid should urgently reconsider. Yet, the high uninsurance rate among unemployed persons in Medicaid expansion states underlines the need for action in Washington. Tax revenues are plunging, and all states except Vermont are required to balance their budgets annually. Hence, only the federal government has the wherewithal to address the impending crisis.

Thus far, neither Congress nor the administration has offered plans to expand coverage. Some have suggested that the federal government cover COVID-19–related care for uninsured persons through Medicaid, but some states would probably decline such a Medicaid expansion, leaving many newly jobless persons—and the 28 million who were uninsured before the pandemic—without coverage. Instead, we advocate for passage of an emergency measure authorizing Medicare coverage for all persons eligible for unemployment benefits.

Although the COVID-19 crisis demands urgent action, it also exposes the imprudence of tying health insurance to employment, and the need for more thoroughgoing reform. A trickle of families facing the dual disaster of job loss and health insurance loss can remain under Washington’s radar. However, the current tsunami of job and coverage losses along with a heightened risk for severe illness demands action. A decade ago, Victor Fuchs forecasted that “National health insurance will probably come to the United States after a major change in the political climate—the kind of change that often accompanies a war, a depression, or large-scale civil unrest.” Such a major change may be upon us.

https://annals.org/aim/fullarticle/2764415/intersecting-u-s-epidemics-covid-19-lack-health-insurance