Pearls and Irritations

In the United States there are serious problems with the adequacy and appropriateness of the health measures to control coronavirus and its impact.

Many Americans don’t have health insurance, don’t get paid sick leave or care leave, and don’t have the ability to work remotely. This will make the coronavirus harder to contain and unequal access to precautionary measures will exacerbate the inequalities already found in the US.

The world is obsessed with issues around the growing spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), nowhere more so than in the United States. The situation has been complicated and hindered by President Trump who has put ideology, myths and personal beliefs above objective and scientific facts, and who has been quicker to respond to economic disruptions than to protect public health. These deficits have compounded to mean a lack of trust in pronouncements from Trump and the White House which has served to muddle advice from the experts.

The issues are not just around how to contain the spread of this disease and the adequacy and appropriateness of the current measures put in place by President Trump and the White House Coronavirus Task Force, but about how the recognised advice gets implemented in a country where so many people do not have affordable access to health care and other social services.

“Stay home from work if you get sick. See a doctor. Use a separate bathroom from the people you live with. Prepare for schools to close, and to work from home.” These are measures the Centers for Disease Control and Prevention (CDC) has recommended to slow the outbreak in the United States.

But many Americans don’t have health insurance, don’t get paid sick leave or care leave, and don’t have the ability to work remotely. This will likely make the coronavirus harder to contain in the US than in other developed countries that have universal benefits like health care and family leave. Research highlights that pandemic outcomes vary with income and socioeconomic status and unequal access to precautionary measures will exacerbate the inequalities based on income, education and race already found in the US.

A key issue is who pays the health care and quarantine costs for coronavirus, specifically in cases where quarantine has been mandated and especially for uninsured and under-insured Americans? This story about two people who were held in mandatory hospital isolation for suspected infection with coronavirus and now find themselves with thousands of dollars in outstanding medical bills highlights the problems. There are fears that many people will not stay home and not access care in a timely fashion because of cost. This will risk undermining the recommended public health response.

In fact, there are legal mechanisms in place to address this situation – if only the Trump Administration will choose to use them. Under such circumstances the Department of Health and Human Services (HHS), via the CDC, is the “payer of final resort”; the Director of the CDC can authorise payment for quarantine, care and treatment, although this is secondary to any state, local or private insurance obligations.

Of course, this assumes funds are available. The Trump Administration has consistently sought to cut CDC funding, although this has been resisted in the budgets passed by the Congress and then signed into law by the president.

Last week the Congress, in a very unusual bipartisan mood, acted quickly to pass a $8.3 billion emergency spending package (much more than the $2.5 billion Trump requested) which the President signed on 6 March. Unlike the president’s funding request, this did not repurpose other health funds and the legislation includes a provision that will ensure funds cannot be raided by the Trump Administration for purposes other than addressing the coronavirus epidemic. Now every effort must be made to get these funds out to the communities and health care facilities where they are desperately needed.

Despite a push from the health care lobby (hospitals and insurers) to add in funds to cover the costs of housing, care and monitoring of patients who don’t require hospitalisation but need to be isolated, this was not included in the emergency package.

The ability to test everyone who presents with coronavirus symptoms is an ongoing constraint on appropriate public health controls. There are several factors at play here. The CDC chose to develop its own test for the virus and then, when this was found to be flawed, insisted on taking time to revamp the test rather than adopting the WHO test or allowing other US-based labs to develop their own testing procedures. Currently only several thousand people have been tested (the CDC doesn’t know or won’t tell the number). Only now is this starting to ramp up, but it is nowhere near meeting the need. The whole situation has been described as “botched”.

Alongside this is the cost to individuals of the testing and then the care that might be needed in a nation where millions of people are without insurance or are under-insured or have substantial annual deductibles that have not yet been met. Some states have taken action to address this. In New York state, the Democrat Governor Andrew Cuomo has issued a directive requiring New York health insurers to waive cost sharing associated with testing for novel coronavirus including emergency room, urgent care and office visits. The Governor also announced New Yorkers receiving Medicaid coverage will not be expected to make a co-payment for any testing related to COVID-19. Sadly, these are not initiatives we are likely to see in Republican-controlled states.

Even if every state used their available authorities to issue blanket orders requiring that all public and privately insured people were covered for coronavirus testing and treatment at zero costs, there would still be some 130 million people (one third of the population) left out. These are people who are uninsured (29 million), or whose plans are not covered by Obamacare.

A 2018 poll found that more Americans were afraid of paying for health care if they became seriously ill (40 percent) than were afraid of getting seriously ill (33 percent). This situation is aggravated if hourly wage earners now have their work hours limited.

Trump has stymied by the coronavirus which is immune to his usual modus operandi – it can’t be warded off by nasty tweets or rally chants, spin and denial will not make the illness and deaths it causes disappear, and it is unaffected by wishful thinking that all the right things have been done and this was something unforeseen.

“Who would have thought?” mused Trump during his recent CDC visit, blind to the fact that he not only ignored advice from the global health security unit of the National Security Council (“The threat of a pandemic flu is the number 1 health security concern” it stated in 2017) but then abolished the unit.

On February 25 Trump tweeted “ The coronavirus is very much under control … Stock market is starting to look very good to me”. Since then, he continues to insist that everything is “perfect”.

All of that makes the coronavirus, and the potential for greater illness and the economic damage it could bring, a singular threat to Trump’s legacy and his re-election.

Dr Lesley Russell is an Adjunct Associate Professor at the Menzies Centre for Health Policy at the University of Sydney.

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