Why COVID-19 is unstoppable in USA despite it being ranked at the top of GHS Index?

Several worst-hit countries such as Italy, France, Spain, the UK, Canada, and Russia have peaked COVID-19 cases in April. Almost all of them have gradually flattened the curve. However, the USA is setting new daily records of infections that no country will ever aspire to break. The failures of the USA in preventing COVID-19 indicate deep structural and operational loopholes to combat the pandemic.

The United States of America (USA) is often hailed as the superpower and global leader but the COVID-19 seems to have dismantled this image at least in the public healthcare system. In the last couple of decades, the country has created corporate style hospital groups wherein medical professionals are appointed as chief executive officers (CEOs) on fat salaries. However, according to reports, the entire public healthcare system in the USA is crumbling down in front of the pandemic. The hospitals are unable to pay their employees, healthcare professionals are not getting masks and personal protective equipment (PPE) kits while hospitals are forced to shut down due to lack of operational funds.

This is despite the USA expends 16.9% of its GDP on healthcare which is the highest in the world and far away from Switzerland’s 12.2%, the second-highest. In absolute terms, the USA expends about $3.6 trillion on healthcare. The country has fast increased expenditure on healthcare from 8% of its GDP in 1980, equal to France in those days, to 16.9% in 2018. In the Global Health Security (GHS) Index, the USA was ranked on the top among 195 countries in pandemic preparedness and response.  

Though the healthcare system of several developed countries collapsed in front of the COVID-19 pandemic, they improved gradually and are now out of ‘daily thousand cases club’. This could be better understood with the following comparative analysis of the data available on COVID-19 situation board of WHO: 

1. France entered the ‘daily thousands cases club’ on March 13 with 1,359 cases which peaked with 7,500 cases on April 1. Thereafter, from May 8 to July 4, it crossed 1,000 cases per day only on three days.
2. Canada registered 1,816 cases on March 26, peaked with 3,793 on May 4, and is continuously below 1,000 cases per day from May 27.
3. Italy reported 1,247 cases on March 7, peaked at 6,557 on March 21, and is below 1,000 cases per day since May 14.
4. The UK registered 1,035 cases on March 22, a maximum of 8,719 on April 12, and is below 1,000 since June 28.
5. The USA entered in the ‘daily thousand cases club’ with 1,822 cases on March 17 and has been above 20,000 cases per day for most of the days since then. The maximum 54,271 cases were reported on July 3 which is an all-time world record.

The analysis indicates that the public healthcare system in the USA is not showing any sign of bouncing back to combat the pandemic. Furthermore, the US could not make it in the ‘safe travel list’ of the European Union which includes 14 countries. How a system which was graded as ‘the best prepared’ is performing so badly in front of a pandemic? Besides raising a question on the grading system of the GHS Index, the failure of the USA in combating the COVID-19 pandemic also highlights deep-rooted flaws in its public healthcare system. As the 'Country Cooperation Strategy' (CCS) of the USA is not available on the WHO website, we are more dependent on secondary information. Here we take up the issues plaguing the USA’s public healthcare system which warrants an urgent reform.

Weak Healthcare Information System

As the COVID-19 virus is highly contagious and has a long life on objects outside the host body, a real-time based integrated healthcare information system becomes imminent to track the movement of infected persons and trace their contacts for possible infections.

However, due to the topmost priority on the ‘right to privacy’, there is a lack of legal backing to collect the real-time geospatial data at the national level. Besides, there is hardly any discourse on this issue as the responsibility of ‘tracking and tracing’ for testing of COVID-19 infection has been left on state/ local governments. These governments have their own guidelines for preventive healthcare, testing, social distancing, and lockdowns which are sometimes contradictory, competitive, and confusing. Though several countries have developed mobile apps, tracking, and publishing real-time mobility data, the US has not announced any smartphone app.

US’s Centre for Disease Control and Prevention (CDC) is projected as the federal agency of the country on public healthcare but even it lacks an integrated health information system. The National Notifiable Disease Surveillance System (NNDSS) of CDC is responsible for data collection but its approach is outdated in terms of challenges posed by the COVID-19 as NNDSS simply coordinates with the states, hospitals, and local governments. CDC gathers health data voluntarily reported by 50 states, four affiliated islands, and the District of Columbia. In this system, there seems a remote possibility of getting real-time geospatial location-based data required for effective pandemic response.

In comparison to South Korea, the healthcare information system of the US is very week and outdated. However, CDC has announced a plan to  Public Health Data Modernization Initiative but this system coming to rescue Americans from COVID-19 seems a remote possibility. As the COVID-19 struck in the USA, CDC rushed to appoint first-ever Chief Data Officer. This is another indication of the agency’s lackadaisical approach towards developing an effective and pandemic resilient healthcare information system.

Through two schemes - Medicare for seniors and Medicaid for the poor- the US government finances one of the largest healthcare insurance schemes in the world. However, unlike South Korea, these insurance schemes are not used for data collection and surveillance but primarily for reimbursement of the bills of private hospitals as the government does not run its own hospital system. The corporate style hospitals in the US have their own excellent form of healthcare information systems but are like data islands which is a major hurdle in collective response against the pandemic.

This lack of integrated healthcare information system has also hit the supply chains hard as frontline healthcare workers -  doctors and nurses – were reportedly deprived of essential supplies such as masks, PPE kits, and other consumables. The management of ‘One Brooklyn’, one of the best-funded hospital groups in the US, reportedly had to use 23 jumpsuits used for nuclear reactors which were provided by a donor. Nevertheless, about 500 employees of the hospital were infected with COVID-19. Time magazine reported that the young nurses in the US and the UK had to use trash bags as masks to protect themselves from infection.

The number of infected healthcare workers is also very high in the US but this data is also not updated on the CDC website after April 9. As per CDC data, between the period from February 12 to April 9 at least 49,370 (16%) health care workers were infected out of which 9,282 were identified as health care personnel (HCPs). Among HCPs females were 73% which places it the group of countries where female health workers constitute a very high percentage of COVID-19 cases.

The American Hospital Association (AHA) which provides the most comprehensive information about the healthcare system in the US including the number of various kinds of hospitals, hospital beds including ICUs, bed occupancy is dependent on annual surveys. The most recent data of AHA was collected in 2018 and published in 2020.  

Fragmented and Profit Oriented Healthcare System

Hospitals in the USA are hailed as global leaders in healthcare innovations and attract elites from throughout the world. However, this is the half-truth of the public healthcare system of the US which is plagued with deep-rooted fragmentation and disparities.   

The hospitals in the US are primarily owned and operated by the private sector and almost entire spending of the government goes in the form of reimbursement of medical bills through insurance policies. As per data of AHA, the total number of hospitals in the US stands at 6,146 out of which 58% are non-profit community hospitals, 21% are for-profit hospitals, and 21% hospitals are owned by state and local governments but none by the federal government. Besides the public-funded insurance schemes, there exists a parallel system of commercial health insurance as well which offers hundreds of health insurance schemes. Even then about 27.5 million Americans are not covered under any insurance scheme in 2018.

As private hospitals need to achieve a certain amount of financial backing from commercial insurance system to get qualified for public insurance schemes, the entire system is profit-oriented and dependent on costly surgeries. In this environment, the focus of the hospitals is to showcase and compete in the latest healthcare technologies, hospitality, healthcare information system, and poplar medical professionals particularly surgeons to attract the clients or customers. These hospitals are so profit-oriented that they promote ‘birth tourism’ wherein foreigner couples are offered facilitation for US citizenship to their newborn babies in lieu of availing their maternity facilities. 

As per the report of the Organization for Economic Cooperation and Development in 2019,  healthcare costs per capita in the U.S. were about $10,000 in 2019, more than double of neighboring Canada. This is primarily due to the high cost of medical professionals, healthcare workers, and hospital management in the US.

Import Dependent Supply Chains

This is another problem arising out of the fragmented healthcare system in the US. In their search for cheap healthcare supplies, the hospitals in the US are heavily dependent on imports from China. Surprisingly, the US government agencies do not have credible data of healthcare imports which gives enough scope for estimates to the market research agencies/ experts. According to different estimates, Chinese pharmaceutical companies supplied more than 90 percent of U.S. antibiotics, vitamin C, ibuprofen, and hydrocortisone, as well as 70 percent of acetaminophen and 40 to 45 percent of heparin in recent years.  Besides the country is also heavily dependent on imports for face masks, ventilators, and other medical products from China and other foreign countries. As China banned exports of healthcare items to combat COVID-19, the supplies in the US and other dependent countries of Europe dried up.

While South Korea maintains a real-time national level record of pharmaceuticals and other consumables in the hospitals, the US has no such data at the country level due to the autonomy of private hospitals.

Lack of Centralized Decision Making System

A system for centralized decision making is a prerequisite to the national level unified response against a pandemic but the typical federal structure of the US makes it difficult for the national government to prepare and implement a uniform policy. This might have been achieved through a consensus among the state governments and the Federal Government but there seems no such effort from any side.

Immediate Reasons for the US’ failure against COVID-19

COVID-19 outbreak and subsequent lockdowns have collapsed the healthcare system of several countries but the inability of the US to bounce back seems the most appalling. Despite being continuously on the top both in the total number of COVID-19 patients and casualties for weeks, the US is setting daily new records of infections and deaths. Followings are the key reasons, people in the US are suffering due to COVID-19 outbreak:

Superiority Complex: The entire system of the US particularly President Donald Trump and his team, were so overconfident into the healthcare and pandemic response system of the US that in the initial days of warnings of WHO they used to mock the COVID-19 outbreak in China. Trump himself reportedly twitted about three dozen fake news on COVID-19 only in March. While people were falling ill, Trump used the maps of the GHS Index to derive the point that the US healthcare system was resilient to the pandemic. Several such statements by Trump and his colleagues made a majority of the US citizens believe that they are beyond the reach of the outbreak.

Sociopolitical Issues: While people throughout the world have deferred protests and mass gatherings and on the request of the UN Secretary-General Antonio Gutters, the UN Security Council adopted a resolution for a ceasefire in all the conflict zones but the US is witnessing the largest ever public protests in its history. Though the culprits of George Floyd have been arrested, the protests against racial discrimination have reportedly become highly politicized due to upcoming presidential elections. These huge public gatherings have also allegedly contributed to the spread of the virus.  Nevertheless, the reports of higher death rates among African and Latin Americans due to COVID-19 infection provided a racial dimension to the health crisis in the US which is already facing the largest ever protests against racial discrimination.

Political interference into the healthcare issues has also been a major problem in the US as the White House is blamed for pressurizing CDC to change its COVID-19 guidelines on places of worship as churches protested the ban on prayers. In another classic case of political interference in healthcare, the Trump administration approached the Supreme Court to get the Affordable Care Act or Obamacare scrapped which was constituted by the democrat dominated Congress. Trump reportedly rejected the advice of scientists and ordered the procurement of HCQ which has now been rejected by the WHO as a possible treatment for COVID-19.

Flawed Bailout Package: Several countries provided/ are providing direct financial benefits such as paid leave to employees or cash transfers equal to their daily wages to privately employed/ unorganized sector employees to promote them for testing. However, the US has not launched any such scheme but announced a US$175 billion bailout package for the hospitals which was to be disbursed through healthcare insurance as per their previous year’s requirements. Trump administration has promised a special package for the hospitals in the COVID-19 hotspot zones but it is yet to be released. Meanwhile, the COVID-19 has forced the hospitals to stop or defer ‘profit-making surgeries’ leading to their shutdowns particularly in rural areas.

Conclusion and Agenda for Discussion

The COVID-19 health crisis in the US is sufficient to conclude that the best healthcare professionals, hospitals, and policymakers are no guarantee for a pandemic resilient healthcare system. In the absence of an integrated, holistic, and robust healthcare management information system (HMIS), even a well-acclaimed healthcare system like that of the US will not be able to save lives during a pandemic.

“These data are compiled from a number of sources. Not all tests are reported to CDC,” reads a disclaimer on CDC’s newly launched page on ‘Coronavirus Disease 2019’. This is another indication that the healthcare system in the US is yet to launch a collective effort against the pandemic. The US authorities need to understand that pandemics don’t differentiate among humans and also for such a highly contagious pandemic like COVID-19, the safety of everyone is important to develop resilience. Besides, US citizens should also learn to sacrifice a little bit of their ‘right to privacy’ for a pandemic resilient healthcare system. There is a great need to develop a transparent system to enable real-time data collection for an integrated and holistic HMIS to save lives from the pandemic. This will also be helpful for unforeseen pandemics and disasters in the future.

VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.