This debacle pushed Michigan’s legislature to revise its Lead and Copper Rule to 1) require water utilities to conduct inventory of existing water service lines in the next two years and 2) replace all the identified lead-containing lines by 2041. Michigan is the first state to require this proactive replacement and will be using funding from the Bipartisan Infrastructure Law of 2021 to complete the replacements.

There is no safe level of lead exposure, especially for young children. Lead exposure is known to impact neurodevelopment, translating to negative health impacts like mental illness and increased mortality down the line. Water through lead service lines is the primary source of exposure for children; it follows that replacing old lead service lines would be an effective preventative measure. But to what degree exactly? Let’s take a look.

The Breakdown

Dr. Hanna-Attisha and colleagues recently co-authored a cost-benefit analysis in Health Affairs, attempting to nail down the quantitative benefits of replacing lead service lines according to the revised Michigan Lead and Copper Rule. 

The analysis estimates 423,479 lead service lines in Michigan that should be replaced. Over a forty-year period (2020-2060), predicted benefits based on 5% per year replacement rate over the next twenty years are:

• A reduction in lead exposure for 420,800 newborns
  • 86% of which live in a household 250% below FPL 
  • 36% of which are non-white
• A net societal program benefit of $1.91 billion
  • $130 million in health cost benefits
  • $43 million in education cost benefits
  • $602.9 million in total benefits to Black households, which have been historically been disproportionately exposed to lead
• A societal return on investment of $2.44 per dollar invested

The estimated break-even year when societal benefits first exceed cost is 2038, meaning the break-even year would come 2 years before the project was even completed.

The authors note several limitations with their cost-benefit analysis. Lead exposure has numerous impacts on human health, such as its impact on aggression and violence, and this article was unable to capture the full scope of those health effects. This resulted in a conservative estimate of the total societal benefits of lead service line replacement, as not all the potential improvements could be captured in statistically significant ways. 

The state has four potential plans it could take to replace the lines on both a 10- and 20-year timeline. This analysis found that the expedited replacement timeline has the potential to benefit an additional 68,700 children and increase the estimated total net societal program benefits to $2.48 billion, up from $1.91 billion. 

Implications of these findings

Preventative care is often overlooked and devalued as not profitable, but this cost-benefit analysis calls that assumption into question. 

This data suggests that an effective way to follow through would be to invest in widespread, community-based preventative care. Rather than treating individual patients after lead exposure damage is done, it would be far more efficient and cost-effective to simply remove that exposure in the first place. 

Hospitals often include health equity as one of their core missions. Factors like income and insurance status are closely linked with health and can be difficult for hospitals to address. These findings suggest hospitals could make a significant positive societal impact by applying their community investment funds to public health interventions like de-leading water lines.

“By taking on a life in medicine, we have places ourselves on the front lines of some of the most important battlegrounds of society…sometimes that means being on guard for a city that’s being poisoned.”

-Dr. Mona Hanna-Attisha receiving the 2022 Bernard Lown Award for Social Responsibility

While this study only looked at Michigan, other states should take note. The country as a whole has a $14.2 billion “Fair Share” deficit, meaning most nonprofit hospitals spent less on charity care and community investment than the value of their tax breaks. What if we applied even a portion of those funds toward tangible, effective public health interventions? 

The research is certainly promising. A 1987 EPA cost-benefit analysis estimated the benefits to outweigh the costs by about 4 to 1. The Environmental Defense Fund estimates that lead service line replacement could prevent up to 6,150 deaths from cardiovascular disease alone and deliver societal benefits of up to $51 billion across the country. 

To be a strong, productive nation, we need to be healthy. Perhaps our best return on investment would be prioritizing preventative care, rather than attempting to whack-a-mole problems as they come up.

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Black Americans face a disproportionate amount of gun violence

According to Everytown, a nonprofit advocating for gun control, Black Americans are disproportionately subjected to gun violence. The statistics are astounding: with ten times the gun homicides as compared to white Americans, eighteen times the gun injuries, and three times the fatal police shootings, Black Americans face a horrific threat of gun violence. 

Apart from the obvious trauma inflicted by guns, firearm violence deteriorates the wellbeing of entire communities. The constant threat compounds an individual’s cumulative stress load, leading to chronic health conditions even if one isn’t directly victimized by gun violence. The problem intensifies in historically underfunded cities, correlating with deep inequities in resources, support, and economic instability. 

It gets even trickier when considering mental health – over half of suicides in the United States involved a gun, and the vast majority who attempt suicide with a gun are successful in their attempt. Suicide rates, specifically amongst young Black men, are on the rise, leading some experts to posit that higher rates of gun ownership are connected to higher rates of self-inflicted gun violence.

Hospital staff get traumatized too

It can feel like we are in a never-ending cycle of firearm trauma. From Tyre Nichols to the six mass shootings in California just last month, it can feel endless. The damage ranges from mass shootings to domestic violence to self-harm to police brutality, and it doesn’t just impact victims and their families. Hospital staff are subjected to devastating cases time and time again, especially staff who work in emergency departments in metro areas. 

Seeing so many cases of needless gun violence takes a toll. Depression, PTSD, and anxiety can all emerge from repeatedly treating victims and having hard conversations with their families. Quickly moving on to the next patient feels empty of empathy yet is expected. Hospital staff are struggling more than ever and repeated instances of gun violence can be triggering – especially for Black staff who feel the extra burden of racialized gun and police violence.  Black hospital workers may feel the impacts even deeper when working with Black victims. It’s traumatizing to try and save a gun or police violence victim with the knowledge that you personally belong to the group being targeted.

Just ask our Board member Dr. Selwyn O. Rogers, Jr., M.D., M.P.H., a surgeon, public health expert, and founding director of  the University of Chicago Trauma Center. In an article published in NEJM last month, Dr. Rogers describes the trauma he carries from treating victims of gun violence day after day.

“In reality, I harbor and carry the burden of suffering within me. The piercing screams, the severed limbs, the brain matter exuding from the temporal lobes haunt me. Many evenings on the drive home, I know that my inner battery is spent, that I have no more strength to shoulder the hurt. I have nothing left to give. Sometimes when I get home, I cry like a baby on my wife’s shoulder. My wife, my three sons, my friends, and my faith — a belief in things not seen — recharge me.”

From Grief to Hope

While the nation continues to cycle through gun violence-related grief, healthcare workers are still standing up for their patients and communities. People in healthcare can leverage their unique knowledge and experience to advocate for gun control and police reform as they continue to heal victims. In recent years, clinicians have been stepping up and speaking out about firearm violence, declaring “This is our lane.” Collective power, especially from a highly trained and vital workforce like that of healthcare, is the way forward. 

Just as recovery after violence provides hope in the ER, recovery from our social conditions is possible and can provide hope for a better future. As Dr. Rogers wrote in his NEJM piece, “Despite the uncountable victims, the howls of pain, the repeated sadness, such moments give me hope — hope that if such a patient can recover and find joy and communion, perhaps someday our society can too.”

Do you know a clinician leading the way in preventing firearm violence? Nominate them for a BLASR!

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What is community power, and why is it important for health? Community power is when people facing similar circumstances organize together, increasing their ability to set policy agendas and influence government decisions. By organizing, communities can use policy to change socioeconomic conditions such as the environment, income, working conditions, etc. that have been shown to impact long-term health. 

Community Power + Policy = Progress

Why is community power needed? Currently, many of the strategies that aim to improve health focus on individual change–what Iton et al. call “technocratic” strategies. These can only go so far, because — our behavior is constrained by what is available and accessible.  For example, it’s not easy to go for a daily walk if there are no sidewalks or parks. Being told to “eat healthier” is a challenge if you live in a food desert and have no time to cook. Who has time to meditate when they’re working two jobs just to make ends meet? 

Clearly, it’s not enough to try and change individuals’ health behaviors without addressing the underlying socioeconomic factors that impact these behaviors. With that in mind, researchers have started to focus on policy changes, what the authors refer to as “democratic” strategies. The idea here is not to impact behaviors on an individual level but to change the conditions in communities to make it easier for people to live healthier lives. However, often these policy changes are undertaken without substantive input from the people in the community who are most impacted. Iton et al stress that community advocacy is the missing piece to make health policy most effective.

Community power has the unique ability to influence well-being on both the structural and personal levels. Take the example used by the authors: parks in Fresno, California. Residents were asked, “If you had all the money in the world, what would you change about your neighborhood?” A significant amount of residents identified parks and open spaces. Residents and city leaders then engaged in a campaign and alliance called Parks4All, which was successful in its goals to have the city create more parks and ultimately secured $2 billion in funding over the next thirty years in order to maintain the new spaces.

Policy without community power is just another prescriptive measure.

Leveraging the community’s local politics allowed for the development of green park space in an area previously deprived of nature. This improvement was simultaneously a step towards mitigating the impacts of income and racial bias while also serving as a new space to exercise, play, and spend time with other community members, further strengthening the bonds between the community.

By allowing the community to drive changes based on its own identified needs, triaging problems and solutions becomes significantly easier. From building more parks to replacing school officers with restorative justice practices to raising the minimum wage, the opportunities for community-led policy progress are countless. Those impacted by changes know best, as they are the ones living day in and day out with the good or bad consequences. Policy without community power is just another prescriptive measure. In 2023, may our communities lead the way.

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The COVID pandemic threw these long-standing disparities into overdrive. The average American life expectancy fell by nearly two years from 2019 to 2020 while similarly wealthy countries experienced only a 0.58 year drop. 

If the US had mortality rates similar to other wealthy countries, more than one million Americans would not have died in 2021.

How many people are impacted by America’s lower life expectancy? In a preprint analysis of excess death rates, members of the Lancet Commission on public policy and health in the Trump era answer the question: How many deaths could have been avoided if the US had mortality rates similar to other wealthy countries? Jacob Bor, assistant professor of global health at Boston University, and colleagues used data from the Human Mortality Database to compare mortality rates across 18 wealthy countries and identify rates of excess mortality in the US by age group. Data from the Centers for Disease Control and Prevention was used to compare age-stratified mortality in the US by racial/ethnic groups.

To find out how many deaths could have been avoided if the US had mortality rates similar to its peers — what the authors refer to as “missing Americans,” they applied the average age-stratified mortality rates of other wealthy countries to the US population and subtracted this from the actual number of deaths in the US.

The authors found that even before Covid-19, higher excess mortality rates in the US led to hundreds of thousands of missing Americans each year. Starting in the 1970s, excess mortality in the US began to veer away from other wealthy countries, excess mortality increasing for younger Americans in particular after 2000. In 2018, there were about 461,000 excess deaths — more than the number of deaths caused by Covid-19 in 2020 and 2021. In 2019 there were about 626,000 missing Americans. That means our country’s substandard mortality rates resulted in the same number of deaths as Covid-19 before the pandemic even hit.

The pandemic led excess deaths to increase dramatically, especially for young people. From 2019-2021, the mortality rate for people under age 65 increased ten times more in the US than in other wealthy countries. In 2020 there were more than 990,000 missing Americans, and there were more than one million missing Americans in 2021. Nearly half of the 1,092,293 excess deaths in 2021 were people under age 65. While the majority of excess deaths in the US were among white Americans, the proportion of excess deaths among Black Americans and Native Americans were greater than expected.

Responding to the crisis

This report shows that are sacrificing hundreds of thousands of lives each year by not acting to ensure our country’s health and wellbeing. What are other wealthy countries doing that we are not, and how can we better follow their example? There are dozens of differences, but research points to a few broad categories worth exploring.

We can’t ignore the differences in preventable deaths from lack of access to healthcare. According to a recent report from the Commonwealth Fund, rates of “avoidable mortality” in America are far higher than other wealthy countries. Avoidable mortality refers to deaths from preventable or treatable conditions, such as diabetes, certain infections, breast and colon cancer, appendicitis, and renal failure.

The average rate of avoidable death pre-Covid was 272 per 100,000 people in the US, worse than 30 other OECD countries. Even the US states with the lowest rates of avoiding death lag behind 25 other OECD countries. The states with the highest rates (Mississippi and West Virginia, with avoidable mortality rates of more than 400 per 100,000 people) are worse than all other OECD countries.

In other wealthy nations, healthcare coverage is universal and cost-sharing is minimal. In the US, however, our fragmented and unaffordable healthcare system makes it more difficult for people to access the same primary care and preventive services. Filling the gaps in healthcare coverage; offering more assistance for premiums, deductibles, and co-pays; providing more community-based primary care services; and training more primary care clinicians are needed to make healthcare more accessible.

Another challenge to accessing preventive care in the US: primary care providers are paid less in the fee-for-service system, leading to a “conveyer belt” style of care that doesn’t allow for real relationship-building. We need to better improve primary care in underserved communities by providing incentives — both financial incentives and the reduction of administrative burden– and by expanding our investment in training primary care clinicians.

At the same time, healthcare access is only a small part of what makes us healthy. Social factors like food security, educational access, economic equality, and a clean and safe environment determine our health much more than medical care — and the US underperforms on these factors as well. Ironically, the amount the US spends on medical care may be crowding out investments that federal and state governments could be making to social drivers of health. Rebalancing government spending towards essential social services is crucial for our nation’s health. Given that Black and Native Americans are over-represented among the missing Americans, these communities should be prioritized for investments in both social services and preventive healthcare.

The avoidable loss of more than one million Americans in a year is incredibly sobering. Each of these deaths is the result of policy choices that set us apart from our peers (and not in a good way). This report should be a call to action for policymakers to rebuild the health and social safety nets, which are currently letting too many Americans fall through the cracks.

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Given the outsized impact of social factors on health, doctors and health systems are addressing the problem by going upstream. A recent article in the Boston Globe profiles doctors who are “prescribing” social supports like financial assistance to improve health. A concept that was controversial a few years ago (“Giving patients money? That’s unprofessional!”) is now seen as an important element of addressing overall health.

“We have clinical tools we use on the front lines for a host of other health issues. So I thought, let’s do the same for poverty.”

Dr. Gary Bloch, St. Michael’s Hospital and Inner City Health Associates, Toronto

For example, what started out as a small movement in Canada to screen and treat poverty has become commonplace; most Canadian doctors now prescribe some sort of social support. But while some US hospitals are screening for social needs, it’s still underutilized. Fewer than a quarter of US hospitals currently screen for social risks, according to a 2019 study.

Why aren’t more hospitals implementing social supports for patients? Part of the problem is that there aren’t always social supports available to refer patients. In 2020, a promising program to address social needs for the sickest patients in Camden, NJ did not reduce hospitalizations compared to a similar patient group. One reason why the program failed was a lack of resources in the community to help patients who received the referrals in the hospital.

“The bottom line is, we built a brilliant intervention to navigate people to nowhere.”

Dr. Jeffrey Brenner, founder of the Camden Coalition, in Kaiser Health News

Another issue is that the way hospitals are funded provides little incentive for hospitals to that address the upstream determinants of health. With the exception of Maryland hospitals and integrated systems like Kaiser and Geisinger, most hospitals are paid for volume rather than value. High-tech elective procedures give hospitals the greatest payout while preventive care like addiction services and mental health are poorly reimbursed.

However, that doesn’t mean that hospitals are powerless. Nonprofit hospitals are granted significant tax benefits worth billions, but few pay this back in full to their communities. And programs to address social determinants of health are the lowest funded category of spending for hospitals, despite being arguably the most important. On average, hospitals spend less than 1% of their total expenses on these programs, while the value of their tax exemption is estimated at 5.9% of their expenses. We should hold hospitals accountable for spending their fair share on programs that do the most for community health.

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In 2018, a group of physicians and public health researchers took Dr. Lown’s words to heart, and waded into the political conversation to call attention to impact of the Trump administration’s policies on public health. They formed a Lancet Commission to “catalyse research on the health impacts of Trump-era public policy… and analyse current policies and alternatives.”

The Commission members had no idea the impact of Trump’s policies would have two years later, as a pandemic (and misinformation) spread across the world. Their timely final report, released in February 2021, pulls no punches. The Commission, co-chaired by Harvard Medical School professors Dr. Steffie Woolhandler and Dr. David Himmelstein, calls out the negative health impacts of Trump’s virulent racism, abuse of immigrant detainees, evisceration of environmental protections, repudiation of science, and more.

Of course, the structural problems in our health and social systems did not start with Trump. The Commission report describes how decades of neoliberal policies have contributed to lowered life expectancy, income inequality, and racial health disparities (which themselves are a result of 400 years of oppression starting in 1619). The Commission sets out an ambitious and needed policy agenda for health, which includes bolstering social programs and education, reinstating environmental protections, and creating an all-payer universal system of health coverage.

“Many of those who call the US their home know little of its history. This needs to change, and the report contributes importantly to historical truth-telling.”

Dr. Mary Bassett, member of the Lancet Commission

Importantly, the Commission’s recommendations emphasize policies to narrow the racial health and wealth gaps, such as reparations for Native Americans, Native Hawaiians, Puerto Ricans and African Americans for the wealth denied and taken from those groups in the past; enforcement of civil rights laws, voting rights, and fair-housing laws; and closing for-profit prisons and immigration detention facilities; just to name a few.

Our country’s long-standing racial disparities were manifested in disproportionate rates of infection, death, and economic consequences during Covid-19. “In 2020, 65 year old women white women were dying of Covid at the same rate as 53-year old Latinas, 52-year old Black women, and 48 year old Indigenous women,” said Dr. Mary Bassett, Lancet Commission member and Lown Institute Board Member, at the launch event of the Lancet Commission’s report. Yet our vaccine priorities do not reflect these disparities.

“The most important conclusion of this report is that we not sit on the sidelines.”

Dr. Mary Bassett

Knowing our history is essential for moving forward, said Bassett. “Many of those who call the US their home know little of its history. This needs to change, and the report contributes importantly to historical truth-telling,” she said. Bringing public health funding up to adequate levels is also essential if we want to avoid the next pandemic. “The whole public health infrastructure is too rickety, and it’s too rickety bc we don’t have enough funding,” said Bassett.

“The most important conclusion of this report is that we not sit on the sidelines. Bad policies have cost many thousands of lives and those of us committed to people’s health cannot accept this. Let’s join with others to change what we cannot accept,” said Bassett.

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Community conditions are essential for health

Lack of access to a steady income, education, good food and clean water, stable housing, a safe family environment, and community ties have a significant impact on health. For example, studies find that lower educational attainment is associated with lower life expectancy, worse reported health, and higher rates of infant mortality.

But there may be less to spend on these vital community conditions because of rising health care costs. In a report last year, we found that the share of California’s spending on medical care rose from 16% of general fund expenditures to 26% from 2007-2018. This is not just a California problem either; a 2018 report from the Government Accountability Office (GAO) predicted that over the next several decades, state spending in all other sectors will significantly decline to make up for increases in health spending.

Covid-19 is hurting state budgets

The coronavirus pandemic has further exacerbated the state budget crisis. With unemployment rates climbing to Great Depression-era levels, tens of millions of Americans have applied for assistance from their state. And because health coverage is often tied to employment, the loss of jobs also means loss of insurance. An estimated 27 million people became newly uninsured due to job loss as of May 2nd due to Covid-19. Enrollment in Medicaid increased by 2.8% just from February to April of this year.

With state tax revenues down, many states are facing a budget crisis, and the federal government has not offered enough assistance to mitigate the problem, according to state governors. This has already led to cuts in state public health budgets at a time when we need this funding more than ever.

Potential solutions

In response to the budget crisis, Ezekiel J Emanuel, health policy researcher and vice provost of global initiatives at the University of Pennsylvania, and Rahm Emanuel, former chief of staff to President Barack Obama and mayor of Chicago, proposed a solution in a New York Times op-ed. They suggest unburdening states with funding for Medicaid, instead having the federal government take on the full cost of expanded Medicaid. They also believe that the federal government should assume responsibility for unemployment insurance, which has put a huge burden on states during Covid-19.

“Nothing would give greater assistance to state and local budgets than to be relieved of their share of funding for Medicaid and unemployment insurance,” the authors write. However, in return states “should be required to use that savings to boost their investment in infrastructure and education,” the authors suggest. This would not only improve states’ fiscal situations, but also improve health of communities in the long run.

Shifting the responsibility of health care spending to the federal government would relieve states of this responsibility and allow them to focus on investing in the community conditions that determine health. But the cost of health care is still something we need to tackle, regardless of how is paying for it. That means taking larger steps to reduce drug prices and inflated fees for hospital services, moving toward reimbursements based on value rather than volume, and exploring more initiatives to reduce low-value care.

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Despite this confident declaration, it is becoming increasingly clear that America is ill-equipped to handle this pandemic–not just because of a lack of preventive action taken at the start of the virus, but because our health care system is fundamentally flawed. If we want to be ready for the next epidemic (and there will be a next epidemic) we should be making the following radical changes to our health care system now.

America is ill-equipped to handle this pandemic because our health care priorities as a country are fundamentally flawed.

Build our infrastructure to fight communicable diseases

It seems obvious that in order to fight viruses and other diseases, we need more research, funding, and manpower dedicated to this topic. However, even in the midst of the current pandemic, Russ Vought, acting director of the White House Office of Management and Budget, requested a 15 percent cut of $1.2 billion to the Centers for Disease Control and Prevention (CDC). The message is clear: The government will do everything to help the financial sector, but public health agencies will have to scrape for every dollar they get.

Our health care system also provides few incentives for private companies to develop vaccines and other treatments for communicable diseases. While orphan drugs and gene therapies are being sold at exorbitant prices, and drug companies abuse patent laws to maintain their profits, scientists trying to develop new vaccines struggle for funding.

Gayle Esposito, a patient advocate whose late husband Joe worked as a virologist at the CDC, told me in an email exchange: “I see my husband’s friends and former colleagues in the news commenting on this contagion and think how gutted public health has been as drug companies concentrate on their ‘profitable’ drugs. Many times Joe would tell me that vaccines and antibiotics are not profitable for drug companies so the infrastructure for communicable diseases is always difficult to maintain. I know he would be saying that about this recent pandemic.”

“Public health has been gutted as drug companies concentrate on their ‘profitable’ drugs.”

Gayle Esposito, patient advocate, Mothers Against Medical Error

Give everyone access to affordable care

Health care experts have noted that the lack of universal health care along with high health care costs could pose a dangerous barrier to access for low-income people who become infected with coronavirus. For example, a father and daughter who were put under mandated quarantine later received bills for nearly $4,000 from the hospital. If people are afraid they will be charged surprise bills for coronavirus care, will they seek this care?

Further, government officials have not committed to making a coronavirus vaccine or other treatment affordable for all, which compromises not only the health of low-income individuals, but the health of the entire country. In a meeting in late February, Health and Human Services secretary Alex Azar said, regarding a hypothetical coronavirus vaccine, “We would want to ensure that we work to make it affordable, but we can’t control that price because we need the private sector to invest.” Trusting the market to decide who gets lifesaving medications is the problem with drug prices in America in a nutshell. Our inability to do anything to control drug prices has already killed many people with type 1 diabetes who depend on insulin to survive; now it may result in needless deaths from coronavirus.

There are countless actions the government could take to increase access and reduce the cost of care: Expanding Medicaid in all states, making health coverage universal, regulating drug prices, switching to an “all-payer” plan for hospitals, reforming drug patent laws, and much more. Without available care, more people will avoid seeing a doctor when they have coronavirus, putting them and their communities at increased risk of harm.

Focus on the right kind of prevention

“Prevention” is a buzzword in health care. Theoretically, preventing health problems early can reduce the harm and cost of health problems later. However, not all prevention is equally helpful. As Silicon Valley invests millions in high-tech testing and screening to “disrupt” primary care, states and communities in the US are struggling to fund social services that greatly impact health.

As with public health infrastructure, the lack of funding for “social infrastructure” is coming to a head in this coronavirus crisis. While workers in some European countries can count on keeping their salary when they stay home, not all Americans share that security. About one-quarter of US workers do not have paid sick leave, which means that millions of people have to choose between staying home when sick or making enough money to support their families. Similarly, declining funding for SNAP (food assistance) and other social services has reduced Americans’ trust in the social safety net as a whole. If people do stay home, there is no indication that they will receive help later receive help later to supplement the income they lost.

Improving our social infrastructure, starting with paid sick leave, and expanding income, housing, and food support will be necessary to contain diseases like coronavirus in the future.

Pay attention to value

Lastly, value is an important but overlooked issue in the coronavirus pandemic: Which health care services do we invest in, and how are these allocated? Our health care system is generally a fee-for-service model, which means that health care providers are paid for each service they deliver, rather than a set amount per patient or pay-for-performance model. Fee-for-service gives clinicians the incentive to do more tests and procedures, whether or not they are necessary or beneficial. Hospitals and other health care institutions may make decisions about which health care services to offer based on the potential profitability, rather than patient need.

Intensive Care Unit (ICU) beds are a perfect example of this phenomenon. When hospitals build or expand their ICU, they then have to justify this expansion by filling the beds, even if patients do not need intensive care. A 2017 study found that in one hospital, “over 50% of patients admitted to the ICU had priority ranks suggesting that they were potentially either too well or too sick to benefit from ICU care, or could have received equivalent care in non-ICU settings.”

What does this have to do with coronavirus? When ICU beds are filled with people who do not benefit, it is not only a waste of money, but it leaves less room for incoming coronavirus patients. In a recent Twitter thread, health policy researcher Dr. Aaron Carroll asked hospital workers how many of them had empty ICUs in preparation for coronavirus. Most people responded that their ICUs were not empty, waiting for an influx of new patients; on the contrary, they were as full as ever.

One doctor said, “Our unit hasn’t been even close to remotely empty for two years. We’ve been running average of 66% capacity for at least a year and a half, and haven’t had the staffing for even that. Last month we’ve been close to 80%, and that’s without any Covid patients.” Another responder hit the nail on the head: “The business model of ICUs keeps them full. An empty ICU bed is a huge earning opportunity lost. That’s a big part of our impending problem. No extra bandwidth.”

Similarly, clinicians are working at capacity themselves; a significant portion are burned out on a regular basis. What will happen when clinicians who are already weighed down by exhaustion and moral injury face this crisis?

There is a serious need to lessen the pressure on health care institutions and clinicians to keep doing more, regardless of the need. We need to allocate funding based on value, not volume, and increase our bandwidth to respond to crises that require more of our resources.

***

Coronavirus is creating a perfect storm of harm because of systemic flaws in our health care system and social safety net. If we want to reduce this harm, now and in the future, we need to get our health care priorities straight: improving health care access, investing in public health, transitioning to value-based care, and building up our frayed social safety net.

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