COVID ripped the sutures out from the inequitable US health care system

Listen Up! An urgent message from Dr. Atul Gawande:

Echo opinion STAT!  Atul Gawande is a surgeon, a public-health researcher, and the chairman of the health-care venture Haven. His four books include “Being Mortal” and “The Checklist Manifesto.”

The top priority for the next US President is clear: control the pandemic.

This isn’t just a matter of containing an ongoing threat. It’s also a crucial step toward addressing the larger failures of the nation’s health-care system.

Since January 20th, when the first covid-19 case was identified in the United States, Donald Trump has squandered every opportunity to fight the coronavirus. This country’s public-health expertise is unparalleled, and one would have expected it to have helped lead the global response, as it did with Ebola. 

Instead, Donald Trump has promoted quack cures, mocked mask-wearing, committed to withdrawing from the World Health Organization (WHO), and demanded that the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) show fealty to him rather than to science! 

Between Memorial Day and Labor Day, the number of confirmed cases in the U.S. quadrupled, from one and a half million to more than six million. In parts of the country, infections continue to spread unabated. By Inauguration Day, our one-year coronavirus anniversary, the death toll will likely exceed three hundred thousand.




We know what measures are needed to combat the virus: a national mask mandate (we should get mask-wearing, which remains lax in many states, above eighty per cent); investment in making testing free, timely, and widely available; and the mobilization of public-health teams to trace, test, and isolate contacts of positive cases. (Reopening bars and other high-risk settings must be the last step, not the first, where infection rates are high.) Once clinical trials establish that a vaccine is safe and effective, the President must be trusted to distribute it on the basis of need, not political caprice. And, critically, we need to assemble a modern public-health infrastructure that can support testing, treatments, and supplies not only for this pandemic but for the next one. Joe Biden has committed to doing exactly this. To reëstablish pandemic management as a national function instead of one carried out disjointedly among the states, he would launch a Pandemic Testing Board and a P.P.E.-production program to insure plentiful supplies; adhere to transparent criteria for vaccine approval and distribution; and expand the C.D.C.’s scientific team that tracks outbreaks around the world, including in China.

The deeper dysfunctions of our health-care system would have an equally urgent claim to the attentions of a Biden Administration. 

Tragically, the pandemic has clearly shown that the entire country is weakened when large segments of the population lack adequate medical coverage. This country cannot continue to tolerate the severe disparities we have—based on neighborhood, education, or skin color—in life expectancy, medical debt, access to mental-health or dental care, the ability to fill prescriptions, having a regular doctor, or simply having enough to eat. The Affordable Care Act reduced the number of uninsured by forty per cent, but twelve states, including Texas and Florida, still refuse the Medicaid funding that the bill provided to cover uninsured residents living in poverty. Even before the pandemic, forty-five per cent of working-age Americans either had no insurance or had insurance that carried deductibles and copays so high that they couldn’t afford medical care anyway.

The central error of our system has been attaching our health care to where we work. A company-sponsored insurance plan for a family adds an average of fifteen thousand dollars to the annual cost of employing a worker—effectively levying a fifty-per-cent tax on a fifteen-dollar-an-hour position. We’re all but paying employers to outsource or automate people’s jobs. The result is to make both work and health care less secure and more fragmented—and to deepen our inequalities.

That’s visible in the tragic increase, during the past few decades, in so-called deaths of despair—from suicide, opioids, and alcohol-related disease—which have produced an unprecedented decline in life expectancy for non-college-educated whites. Trump vowed to address opioid deaths, but fatal overdoses hit a record high last year, and have continued to climb since the onset of the covid-19 pandemic. This trend appears to reflect a generational loss of stable work and earnings for people without a four-year degree—a situation that our broken health system has gravely exacerbated. 

Fixing economic and racial inequality isn’t possible without fixing health care.

Our major health-policy issues will not all be solved in the next four years. A fractious Democratic Party has temporarily united in an effort to defeat Trump, but it remains divided on health care. Many Democrats would jettison Obamacare in favor of Medicare for All; Biden’s plan would build on Obamacare by lowering the Medicare eligibility age to sixty, and providing a public option enabling people to obtain coverage from a government plan. The Republican Party has developed no health-care strategy except to attack any solution that would deliver on the guiding tenet of medicine, not to mention of the Constitution: that all lives have equal worth.

Yet progress must be made. During the pandemic, we have seen a frightening willingness to regard some people as expendable, including the elderly and many essential workers, who are disproportionately Black, Latino, and low-income. The Obama Presidency launched with the swelling hope of a country finally unified in the belief that we are all created equal; a Biden Presidency would begin with a more sober sense of the opposition that meaningful reform must overcome. But this realism may yet provide the basis for lasting advancement. Repairing our systems of medical care and public health isn’t an elective procedure. The afflictions of our body politic threaten the well-being of us all. ♦

Echo opinion published in the print edition of the October 5, 2020, issue of The New Yorker, with the headline “Rescuing the System.”