Hopes, Worries for US Health Care in Wake of COVID-19: A Q&A With Donald M. Berwick, MD, MPP

Am J Manag Care. 2020;26(6):238-239. https://doi.org/10.37765/ajmc.2020.43485

AJMC^®:

It’s our 25th anniversary, and we had originally planned to talk about the Affordable Care Act and other related topics, then the pandemic happened. I noticed that you’ve been out front the past few months talking about the gaps and inequities that coronavirus disease 2019 (COVID-19) has exposed, and so I’m wondering about your hopes and fears for health care access and affordability in the wake of this crisis.

Don Berwick:

What COVID-19 has revealed, as you said, about the lack of secure health care insurance coverage in this country, and the enormous burden of disparities, especially racial and socioeconomic disparities, is no surprise. It’s just a very vivid reminder of what we’ve been living with for far too long. My hope is that we would finally confront this and work hard to end these disparities. That involves really investing in the well-being of people, of disadvantaged people, people [of color], people in poverty, people in marginalized communities. They get hit hard, and only when we commit to compassionate and effective social policies will we end this embarrassment. It’s a tragic continuing problem in America, and it isn’t just health care. We’re talking here about disparities in education and housing and food security. And this is going to take a really strong social policy to redress. It’s also going to take redistribution of public policies in which we ask the wealthy to contribute a greater share of their wealth to redressing these problems of poverty and inequity. The other piece of this that affects everybody, not just the poor, is insecurity in health insurance coverage. We have people who are losing their jobs, scrambling to find a way to get health insurance coverage, and many are failing. The rates of uninsurance are rising. And even [some] people who have insurance are finding out that their insurance policies are ineffective, that they’re junk policies. And we need, again, public policy that addresses my own view, which is that health care is a human right. Coverage should be universal. The best way to do that is with public coverage, national health insurance of some form, but at a minimum, we need to make, one way or another, a guarantee to every American that they can have health insurance that they can afford and that will cover them when they need it. My hope is that we wake up to these issues, [but] I just don’t know if we will. My fear is that we won’t [and that the situation] will regress back into the inequity and greed and sense of division that has afflicted this country for decades now.

AJMC^®:

I was reading the column you wrote that was published in JAMA [“To Isaiah”],¹ and I think maybe what you’re saying is that it’s not enough to get payers to invest in social determinants of health, for example; it really has to go beyond what payers can do.

Berwick:

Yes—it’s 2 parts. One is that we need everyone to be able to get health care when they need it, and we don’t do that now. We have a very fragile and incomplete health care insurance system that leaves people out. And that’s sad. When people get sick, they ought to be able to get care. And they ought to be able to get the preventive care that they need to keep from getting sick. But the bigger picture that you’re referring to in that essay is that we have to look at why we get ill. What kills us in America? It isn’t health care. Health care is a repair shop. The actual causes lie in conditions in communities and society—the foods we eat, our patterns of exercise, and structural racism and violence and housing shortages and homelessness and the kind of unfairness in a society in which the disparities in wealth are phenomenally large, and the rich get richer. That disparity, that unfairness, that inequity, is a deep cause of illness. So, if we want to be a healthy America, we have to invest in these social determinants, in reversing the things that actually make us sick and improving the things that keep us healthy. It can’t just be done within the health care system or within the health care insurance system; this has to do with social and economic policies.

We need public policy that ends homelessness, that ends hunger, that ends the insecurities people feel in their lives. And we have to work on very special populations who are particularly vulnerable: incarcerated people, Alaska Natives and American Indians, people in isolated communities, rural communities, which need a lot of robust support. So the problems we have need to be addressed through health care, but they can’t be solved only through health care, and that’s what you read about in that piece.

AJMC^®:

Something you haven’t mentioned yet is waste: You’re one of the leading researchers and scholars on waste in the health care system.² Do you think that if we move to a universal system, or to Medicare for All, that would help eliminate the massive waste problem that you’ve documented?

Berwick:

Yes, the [problems] overlap. I mean, the frequent claim that we can’t afford health insurance for everyone is pure nonsense. We’re spending nearly twice as much as the next most expensive country. We have well-documented evidence of waste in our system, administrative hassles that just pour money down the drain, pricing nonsense where pharma companies or drug or device manufacturers or even hospitals raise prices to levels that cannot be justified. We have problems with fraud that need to be dealt with through strict enforcement; we have problems of inappropriate care, ineffective care that can’t help people and just keeps the machines going and the tests going, [which happens] because we have a payment system that pays for that. And the idea that we can’t afford to give every American all the care they want and need is simply incorrect. It’s not based in the evidence. So we do need a national agenda to make health care far more efficient on behalf of patients. And remember, a lot of health care costs today are paid out of pocket, in co-payments and deductibles and by uninsured people, uninsured processes. So, you know, saving money by reducing waste helps individuals directly as well as helping governments and businesses. One thing we need to strictly avoid is any thought of rationing care, withholding care: We don’t need to do that. We can give all the care people want and need if we really attend to waste as our target.

AJMC^®:

We’ve seen plans in the past couple of months to attack the virus with the involvement of private contracts and private business relationships to help speed things along. Are you concerned that in the effort to move things faster, and in maybe lowering the regulation bar, that a new source of waste might develop?

Berwick:

Well, your question has 2 or 3 points. The first is that in terms of public health and health care, we need public-private partnerships and there can be good ones. We need sound partnering between the public sector and the private sector, with diligence. That [kind of partnering is] good, but it also opens the door to abuse that we cannot allow. Profiteering and greed in the private sector hurt everyone, and they are widespread. I am in favor of controls, including, if necessary, price controls, that keep greed out of the picture. With respect to pace, COVID-19 is so serious that we’ve increased the tempo of innovation in the public and private sectors, exploring all sorts of new drugs and new therapies, new vaccines. I am glad that we’re going fast on it, but we cannot lose the discipline of science. We have to make sure that proper evaluation and scientific scrutiny are applied to everything that we subject patients to. If we go over that line, if we allow myth and salesmanship and profiteering to control what happens, patients will pay a very high price, both in their health and in money. So we have to pair the activation of the private health part of the health system with strict adherence to science. That’s crucial.

AJMC^®:

Are you hopeful that some of the innovations that have occurred, whether it’s a faster possible timeline to a vaccine or treatment, or even something like telehealth, can be applied to other diseases or other populations?

Berwick:

Yes, COVID-19 is rapidly bringing us some very good innovations, and one of them is telehealth. Again, we have to make sure that telehealth is scrutinized, that we understand what it looks like when it’s done responsibly, and that we know how to maintain quality. But much of the progress we’re making in telehealth, very fast, is good for patients, good for families, good for the economy. I also think that we will be seeing faster progress, I hope, toward vaccines and antiviral treatments. Again, these have to be subjected to science, but we’re seeing a kind of energy that is exciting and almost unprecedented. This is also happening at the clinical level; the amount of information that’s speeding around in our clinical journals and our scientific community, between scientists and clinicians, is rising very quickly. I serve on the Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats, convened by the National Academies of Sciences, Engineering, and Medicine. And it’s stunning how quickly that very disciplined process in the National Academies has moved ahead and offered badly needed guidance to the country. That’s an example of pace and tempo that I think is good to learn and to keep as long as we keep science in the foreground.

AJMC^®:

You’re a pediatrician, and, talking about science and mistrust again, you know well that there’s an element of people who are not in favor of vaccinations. With so many kids home right now, and not seeing their doctors, what are your concerns about them in regard to public health?

Berwick:

The antivaccine movement is motivated by fear—it’s nurtured by demagogues, and it’s unscientific. Vaccines have brought us levels of security and health for children and adults that prior generations did not have. So it’s a concern to see people—without scientific backing—backing away from vaccines. I think, though, that the lack of access right now to usual care because of fear of exposure, which is totally understandable, is something we’re going to have to repair pretty quickly when the COVID-19 epidemic is over. We can’t leave children without the well-child care and vaccines they need; we can’t leave adults without access to diagnostic and therapeutic procedures for symptoms that they have. We don’t know exactly what’s happening right now. For example, Kaiser Permanente recently reported a big decline in hospital admissions for heart attacks. We don’t know what that means: Are people having heart attacks and staying home and maybe even dying from them, or are they getting better? We don’t know. And so research will be done in the next year or two that will help us understand the effects of these patterns. But I do worry that people are forgoing needed and important care now, and I hope we get back on track soon.

AJMC^®:

I was thinking of that in terms of the storm that hit Puerto Rico a few years ago. Death estimates were revised months later to reflect that there were people who were not directly killed in the storm, but died from not getting care for their chronic illnesses.³ I’m imagining the same thing could possibly happen here.

Berwick:

Yes, epidemiologists are already working hard on that question trying to track down what’s happening in community-level death rates and disease rates. Not everybody who has COVID-19 is coming to the hospital, not everybody who dies of COVID-19 [dies in] the hospital, and not everybody who is sick from or dying from other conditions is showing up. So there’ll be good research on this within the months or years ahead, and we’ll know a lot more about those patterns. Most of the scientists I speak with believe that the current estimates of the COVID-19 burden are probably low because we’re missing cases that never show up in the health care system.

AJMC^®:

Do you think that will enhance the efforts to create value-based care? For instance, say someone goes a year or two without getting treatment for chronic illness and then all of a sudden, they come back to the health care system with uncontrolled disease. Do you think that could create a new set of changes?

Berwick:

I don’t know. I think it’s 2 separate questions.…Value-based care means paying for results, paying for outcomes of care instead of for just volume. And that’s the journey we should be on in this country, no matter what—COVID-19 or no COVID-19. We are [creating] high cost and low quality by having a payment system that encourages doing more and more things, whether they help or not, and that discourages investments in some of those upstream causes that we talked about earlier….There are some technical problems with it right now because many of the value-based payment models put health care systems at risk financially. They have a certain amount of money that they overspend, which is to their disadvantage. And here comes COVID-19, which is causing massive shocks to the system and forcing hospitals and clinics to spend a lot more that they never thought they would. But that’s all repairable, that can be taken into account. But in the longer run, you know, I think universal health insurance, coverage of everybody, and then payment in ways other than fee-for-service is the way to go. It will help us adapt to the consequences of COVID-19 and prepare us better for future threats.

AJMC^®:

I don’t really want to think about future threats right now, but I know exactly what you mean.

Berwick:

There’s a whole list of 21st century threats that we’re going to have to understand are present—other diseases, bioterrorism, cyberattacks on the electric grid, massive trauma. These are all possible. They’re hopefully unlikely and we need to do everything we can to prevent them. But we also have to be ready for them because the world has hazards in it and we have to be ready for those hazards. We were caught on our heels with COVID-19 despite many, many reports that warned that we were not ready—and indeed we were not.

AJMC^®:

In thinking about those future threats, what can we do to strengthen the health care workforce right now, which is obviously burnt out, exhausted, in some areas unemployed? Some Asian American doctors are even being hit with racist attacks by their own patients. What do we do to boost the workforce right now?

Berwick:

Well, we have 2 phases: recovery, then readiness. Right now the workforce is taking a serious battering, physically and emotionally, because they have to work so hard under such difficult circumstances against a disease that’s severe. And they need mental health support, encouragement, obviously fair pay, and thanks. And they need protection. We fell way, way behind on personal protective equipment. We have not recovered there yet. And we need to promise this workforce that [ such a shortfall] not going to happen again. We should be using national stockpiles and a national plan to get supports out there. It stuns me that we still do not have from this White House a national plan for sustaining the workforce and ending this pandemic, and there’s no plan that I can see. It’s all happening at the levels of states and localities and in the private sector, in a rather good-hearted but very heterogeneous way. In the longer run, I may think this is a reminder that you can’t have good health care, great health care, without a supported and robust workforce. They need protection. And we understand now more than ever before that the health care workforce is far more than physicians and nurses who are right on the front line. There are technicians, there are assistants, and there are the people who keep our hospitals running—in the cafeterias and the cleaning services, in the supply chain—and all of them are health care workers and we need to understand the conditions they work under to make them continually better. We also have community-based work that’s crucial: public health, home health care, community-based health care delivery that is essential in this crisis. And we need more respect for, and more involvement in, the mental health workforce. Behavioral health is crucial. And by the way, it’s going to be more crucial. The aftereffects of COVID-19 in terms of posttraumatic effects and depression in economic recovery are going to be massive. And we need a strong mental health and behavioral health workforce, just in the same way that we need a strong workforce in our intensive care units. So we’ve got a ways to go. What I hope for is that we can recognize it and have a workforce policy that makes sense. Do you know that this country is headed for a shortage of nurses in the next few years that will amount to a million fewer nurses than we need? We need to deal with that in public policy terms and make supports to nursing and the nursing profession much better.

AJMC^®:

The other thing that’s alarming is the shortage of health care aides who work in institutions or at home, the private home health aides who make very little money and have very few benefits. They are caring for this vulnerable population. But I think sometimes maybe they’re not thought of in the same light as other health care workers, even though they’re sometimes doing the most hands-on, direct care.

Berwick:

We may not notice how essential they are until they’re not there. And by the way, how about health insurance for those people? That’s where health care as a human right makes even more difference. And this of course also includes the really big issue of long-term care. In my state, I think half of the deaths from COVID-19 are occurring in in facilities and residences where elders live. And we don’t yet have a long-term care policy in this country that has anything like the traction it needs to deal with an aging society. We need to make health care age-friendly. I think we need a massive national project on envisioning and then implementing the long-term care system that we would like in this country. Right now, it is not a sector that’s been well addressed at all, and we’re seeing it reeling under the COVID-19 stress.

AJMC^®:

Some of the problems you mentioned are most acutely felt in rural areas, so whether it’s long-term care or care for the elderly, what do we do about rural areas where the disparities are even greater?

Berwick:

Those areas need special attention. The rules need to be different for rural areas and for concentrated urban areas, in special needs and special opportunities. My own vision, which I probably should work out a little more thoroughly, is that we need to convert our rural areas from having rural hospitals, which are important, to rural health systems. We might want to consider some programs of population-based funding for rural health care as a system in which a small hospital appears as a component, but the actual thinking is about the population in a rural area. That’s a much better, much stronger way to think of things and harnessing all of the resources that rural areas do have, but you can’t treat every type of area of this country the same way, and rural areas have, as I said, special needs.REFERENCES

1. Berwick D. To Isaiah. JAMA. 2020;323(17):1663-1665. doi:10.1001/jama.2020.2754

2. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-1516. doi:10.1001/jama.2012.362

3. Kishore N, Marqués D, Mahmud A, et al. Mortality in Puerto Rico after Hurricane Maria. N Engl J Med. 2018;379(2):162-170. doi:10.1056/NEJMsa1803972

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