Question: The Review Should Be At Least 3 Pages In Length And Provide Your Thoughts And Impressions Of The Issues In The Article I DO NOT Need You To Tell Me What The Article Is About, I Already Know That Place Of Information. As You Read The Article Think About Yourself As A Health Care Administrator/manager. Provide Me With Thoughts, Ideas, Opinions As To What …

The review should be at least 3 pages in length and provide your thoughts and impressions of the issues in the article I DO NOT need you to tell me what the article is about, I already know that place of information. As you read the article think about yourself as a health care administrator/manager. Provide me with thoughts, ideas, opinions as to what the issues are and how can the system be fixed and the delivery of health care made better for having addressed the issues. Remember we are discussing health care delivery so what can you tell me about health care delivery and the issues in the article. PLEASE DO NOT SIMPLY TELL ME WHAT THE ARTICLE IS ABOUT, THINK ABOUT WHAT THE ARTICLE IS DRIVING AT AND HOW HEALTH CARE DELIVERY IS AFFECTED Covid-19-Implications for the Health Care System David Blumenthal, M.D., M.P.P., Elizabeth). Fowler, Ph.D.J.D. Melinda Abrams, M.S., and Sara R. Collins, Ph.D. The novel coronavirus pandemic has spawned able for the purchase of individual insurance in four intertwined health care crises that reveal the ACA marketplaces, by expanding Medicaid and compound deep underlying problems in the eligibility, and by requiring that private insur- health care system of the United States. In so ance cover preexisting conditions and a basic doing, however, the pandemic points the way package of benefits. However, although states toward reforms that could improve our ability with their own marketplaces have alerted the not only to cope with likely future epidemics but recently unemployed to their potential eligibility also to serve the basic health care needs of for subsidized plans, the federal government has Americans. not engaged in a parallel effort. It has neither educated the newly unemployed about their im- THE CRISES AND THEIR ORIGINS mediate eligibility outside of open enrollment periods for subsidized insurance in the federally INSURANCE COVERAGE run ACA marketplaces nor opened special enroll- The pandemic has significantly undermined ment periods for those wishing to enroll even health insurance coverage in the United States. if they did not previously have coverage. Fur- A sudden surge in unemployment — exceeding thermore, 14 states have chosen not to expand 20 million workers’ – has caused many Ameri- Medicaid. cans to lose employer-sponsored insurance. A recent Commonwealth Fund survey showed that DEEP FINANCIAL LOSSES FOR PROVIDERS 40% of respondents or their spouse or partner for the first time since the Great Depression, who lost a job or were furloughed had insurance crippling financial losses threaten the viability through the job that was lost.? Although many of substantial numbers of hospitals and office will continue to get employer coverage or be practices, especially those that were already finan- come eligible for Medicaid or marketplace plans, cially vulnerable, including rural and safety-net a substantial number will probably become un- providers and primary care practices. The im- insured. Even workers who keep their jobs may mediate cause of this unprecedented financial find their coverage dropped or curtailed as fi- crisis is substantial, unexpected changes in de nancially strained employers cut costs. These mand for health services. On the one hand, a developments will add to the 31 million persons novel infectious illness has increased demand who were uninsured and the more than 40 mil- for specialized acute care that has overtaxed lion estimated to be underinsured before the some hospitals and imposed unexpected costs pandemic struck. on many more. On the other hand, precipitous This new crisis of coverage has at least two declines in demand for routine services have causes. The first is our continued reliance on reduced providers’ revenue. Office-based prac- employer-sponsored insurance to cover approxi- tices had reductions of 60% in visit volumes in mately half of Americans against the cost of the first months of the crisis, and, by their own illness. The second is failure to vigorously imple estimates, hospitals will lose an estimated $323.1 ment current law. By design, the Affordable Care billion in 2020.40 Employment in the health care Act (ACA) helps persons who lose employer system is down by more than 1 million jobs sponsored insurance by making subsidies avail through May. Providers vulnerability to these demand flue- Disparities in access and health outcomes are tuations raises a fundamental question about entrenched features of the U.S. health care sys- the way we currently pay for health care in the tem. They reflect a history of racism and dis- United States. Providers operate as businesses crimination that permeates society generally. that charge for services in a predominantly fee- for-service marketplace. When the market for A CRISIS IN PUBLIC HEALTH well-paid services collapses, so do health care The United States has 4% of the world’s popula- providers. tion but, as of July 16, approximately 26% of its This system has a number of adverse effects Covid-19 cases and 24% of its Covid-19 deaths. in normal times. It creates incentives to raise These startling figures reflect a deep crisis in prices and push up volumes, shortages of poorly our public health system. compensated services such as primary care and Pur simply that system failed to quickly iden- behavioral health, and an undersupply of sertify and control the spread of the novel corona- vices in less financially attractive poor and rural virus. The United States did not make testing communities. But in the extreme circumstances widely available early in the pandemic, was late of a pandemic, a new question arises is health to impose physical distancing guidelines, and has care an essential national resource that warrants still not implemented either as widely as needed. secure financing beyond what the current fee- National guidance on managing the pandemic for service system offers? has been inconsistent and delayed. Many states have now abandoned stringent physical-distanc- SUBSTANTIAL RACIAL AND ETHNIC DISPARITIES ing guidelines without careful attention to public IN THE HEALTH CARE SYSTEM health measures needed to prevent resurgence. Black persons constitute 13% of the U.S. popula- Although inadequate leadership and excessive tion but account for 20% of Covid-19 cases and partisanship have played a role in these short- more than 22% of Covid-19 deaths, as of July 22, comings, other factors are also in play. Public 2020. Hispanic persons, at 18% of the population, health is a quintessentially governmental func- account for almost 33% of new cases nation- tion, undertaken collectively for the public good wide. Nearly 20% of U.S. counties are dispropor at the national, state, and local levels. In part tionately Black, and these counties have account because of many Americans’ distrust of govern- ed for more than half of Covid-19 cases and ment, public health functions have historically almost 60% of Covid-19 deaths nationally been underresourced. The trained personnel These racial and ethnic disparities constitute who are needed for contact tracing-a tradi- a new crisis compounding the long-standing tional public health function long applied to such failure of our health system to care adequately age-old afflictions as tuberculosis and sexually for persons of color. The causes start with a transmitted disease – are now scarce. Tellingly, system that disproportionately fails to insure there is no national public health information persons of color for the cost of illness, a prob- system – clectronic or otherwise – that en- lem reduced but not eliminated by the ACA.” ables authorities to identify regional variation in Lack of coverage causes less access care, the demand for, and supply of, resources critical which results in a higher prevalence of and less to managing Covid-19. Without such information, well-controlled chronic illness among persons of authorities have no way to direct vital resources color. These illnesses leave them more vulnera- from areas of surplus to areas of undersupply. It ble to the ravages of Cavid-19. is no exaggeration to say that the United States Another cause is that persons of color are currently lacks a functioning national system for more affected by nonmedical threats to health, responding to pandemics. including food and housing insecurity. They also tend to have jobs that are riskier during pan. RESPONSES TO THE CRISES demics, such as providing care at home and long-term care facilities. Once ill, persons of OPPORTUNITIES FOR FEDERAL POLICY BEFORM color are more likely to get care in safety-net National trauma can change national psychology facilities overwhelmed by surges in demand for and create opportunities for major reform. Wheth- honored certain, but even if it does not, the pandemic has the considerable advantage of keeping the may open the way to meaningful incremental full costs of insuring Americans – a projected changes that are normally difficult for our $34 trillion over a period of 10 years – off the highly divided and partisan political institutions federal budget at a time of already sobering fed- to accomplish. Major reforms may prove most eral deficits. In this vein, building on and fully feasible in the area of public health, where re enforcing existing ACA authorities could ensure cent events have made deficiencies so obvious. virtually universal health coverage. A first step We focus here on policy solutions at the fede might be to have the federal government absorb eral level, both for reasons of space and because the full costs of expanding Medicaid, thus en the pandemic has ilustrated the critical role that couraging resistant states to take this step. An- federal leadership- and its absence-play in other reform might include extending and en- our health care system. The changes that are hancing subsidies for ACA marketplace coverage. envisioned will naturally require additional fed- Still another possibility is a public option avail- eral outlays. The amounts are difficult to predict able to people with employer plans. The achieve- because some, such as reforms envisioned in ment of universal coverage under this incremen- provider payment, may actually generate savings tal approach will also require a strong individual over the middle-to-long term by reducing the mandate or autoenrollment mechanism. costs of health care. Expenses might be defrayed by adopting other cost-reducing policies, such as SECURING THE FINANCES OF OUR HEALTH CARE modifications in how Medicare pays for phar. SYSTEM maceuticals. However, it is also possible that Just a few months ago, health care providers in paying for these reforms – and for the other the United States seemed, if anything, overcom- major federal programs adopted to combat pensated. Even now, many of the nation’s most pandemic-induced economic dislocations wealthy and prestigious health care institutions may require reversing some of the tax reductions and practices can probably absorb and survive enacted in 2017 the immediate losses inflicted by Covid-19.2 However, the pandemic also shows that some INSURANCE COVERAGE hospitals and health professionals are far too The United States has fiercely debated for nearly vulnerable under current financial arrangements, a century whether and how to protect Americans and the failure of these providers could leave against the cost of illness. That debate has major gaps in critical health care services. This generated steady incremental progress that most raises obvious questions about whether the United recently, through the ACA, reduced the numbers States needs a financing system that preserves of uninsured Americans to a historic low of 28.6 essential health services in the face of market million in 2015. Will a sudden increase in un- disruption insured Americans create the political will to Part of the solution might be to adopt pay expand coverage again? ment models that sever the link between com- If it does, proponents of expanded coverage pensation and the volume of services provided. have multiple policy options to choose from. The most promising as a way to assure more ranging from a government-financed single-payer secure funding for the health care industry is system such as Medicare for all to reforms that capitation, in which a provider organization re- build on current law. One of several arguments celves prospective, monthly payments for provid- for a single-payer system is that it would unlinking all necessary care to groups of patients. employment and health insurance. If recent Medicare Advantage plans already operate under events have soured Americans and their employ this system ers on employer-sponsored insurance, a transi There are many variations on this theme, in- tion to an increasingly public insurance system cluding capitation for selected services (e.g.. may become more politically appealing. primary or specialty care) or a combination of It seems equally or more likely, however, that capitation with fee for service for certain types our national preference for incrementalism would of care leg. preventive services that might other favor reforms that preserve employer-sponsored wise be undersupplied or are particularly valu- insurance while compensating for its flaws. This able. For hospitals, a capitation equivalent might be a prospective annual budget for providing all solve this problem by itself. Social determinants necessary hospital services to patients in particu- of health that partially explain the heightened lar geographic areas. vulnerability of persons of color to the novel There is no perfect approach to compensating coronavirus originate outside health care-in providers. One advantage of full or partial capi- differential access to education, employment, tation and prospective budgeting is that they housing, and justice, offer hospitals and health professionals a pre- Nevertheless, the pandemic refocuses atten dictable stream of revenue that is unlinked from tion on how the health care system can amelio- the volume of services provided. Capitation would rate health inequities, Universal coverage would have protected many providers against the sharp improve access to primary and preventive care short-tery losses they are sustaining as a result services, which in turn could reduce the preva- of Covic 19, reduced the need for immediate lence and severity of chronic illnesses that exac- federal subsidies (now totaling hundreds of bil erbate the health effects of disasters of all types. lions of dollars), and provided time to consider Although expanded health coverage under the their amount and distribution with more care. ACA reduced the uninsured rate across all groups, Upfront, global payments also offer providers the racial and ethnic minorities saw the biggest gains flexibility to innovate. For example, they could in coverage and access to care. substitute virtual care for in-person care without Greater support for safety-net facilities and worrying about how telemedicine is compensated small community providers, including inner-city under fee-for-service rules. and rural hospitals and community health cen- Payment models such as capitation would not ters, could also improve access to basic and ad- completely stabilize the financing of vital health vanced services for populations of color. These care services. If volumes and associated costs to providers also would need support to transition providers are consistently lower than expected, to value-based care. payers will insist on reduced capitation levels The education and licensing of health profes- when existing agreements end. However, provid- sionals could be required to include anti-bias ers will have more time to plan for and adapt to training. In addition, all health care organiza- such reductions than they have had in the early tions could be required to compare the quality months of the pandemic. If reduced prepay of care for patients of different races and ethnic ments nevertheless threaten the availability of groups and report these data to local and na- critical services, additional public policies may tional health authorities as a condition for eligi- be necessary to subsidize providers whose losses bility for Medicare and Medicaid funding. Re- might jeopardize the health of communities. All porting is the starting point for coming to terms capitated payment models should include mea with inequity in our health system, sures of quality and efficiency to ensure that health professionals and institutions do not un- A HONUST PUBLIC HEALTH CAPACITY dersupply services and that compensation is The novel coronavirus is unlikely to be the last proportional to the value provided. pandemic we face.” To control Covid-19 and Another part of the financing puzzle is guar prevent unnecessary suffering and economic anteeing that essential services that were under damage from future pandemics, the United supported in fee-for-service markets before the States will need to improve its capacity for col- pandemic are adequate in the future. This will lective action to protect the public’s health. mean public policies to shore up primary care This starts with building the ability of state services, behavioral health care, safety.net pro- and local public health authorities to implement viders, and rural health care services. The pan. basic disease control measures, such as testing, demic has shown the limitations of insuf- contact tracing, and isolation of affected persons ciently planned markets in caring for Americans, Because states often lack the means to create both in normal times and in emergencies. these capabilities, federal support and guidance would be required. And because microbes do not respect state boundaries, containing infection Clear inequities in the effect of the pandemic on depends on cross-state coordination. Only the communities of solar shine a light on systemie federal government can reliably lead such inter- RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE and antimicrobial authorities needed to play this role effectively. agents. Fifth, it would grant the federal govern- This leadership vacuum leaves the country un- ment emergency powers to require states to al prepared to mount an effective, unified response low licensed health professionals to participate to emerging infectious threats. Of all the prob- in cross-state telehealth. The use of some of these lems highlighted by Covid-19, creating federal authorities could be conditional on a presidential leadership capacity may be the most challeng- declaration of a public health emergency and could ing. Some Americans simply have an aversion to be time limited unless extended by Congress. centralized power of any kind. And an increase in the federal role would potentially shift the CONCLUSTONS balance of power between Washington and state governments. The Covid-19 pandemic recalls once more the Nevertheless, it is hard to imagine an effec old truism attributed to Winston Churchill: one tive approach to containing pandemics that should never let a crisis go to waste. We may doesn’t involve national direction. As long as now have the opportunity to reform a flawed one state or region continues to harbor infec health care system that made the novel corona- tion, the nation as a whole remains at risk. visus far more damaging in the United States New federal legislation is necessary to clarify than it had to be and bolster the ability of the federal government Disclosure forms provided by the authors are wailable with to intervene decisively and rapidly, and espe- the full text of this article at NEM.Org cially to require states and localities to imple. From the Commonwealth Fund, New York ment critical health measures that are currently This article was published on July 22, 2020, and updated on July the responsibility of states but are vital to the 23, 2020, at NEJM.org health and welfare of persons in other states. This legislation would have several aims. First, it ington, DC. Bureau of Labor Statistics, July 2, 2020 (httpwww 1. News release the employment situation-June 2020. Wasb- would enable the federal government to estab- blagovnews.release/pdfjempsit pdf). lish a national public health information system 2 Collins SR, Gunja Mz, Aboulafia GN, et al. An early look at that provides real-time data on disease preva- inanance coverage. New York Commonwealth Fund, June 23, the potential implications of the COVID-19 pandemic for health lence and incidence of illness as well as on the 2020 (http://www.commonwealthfund.org/publications in availability of critical resources to treat affected briefs/2030.jun implications-cowid-19 pandemic-health-insurance patients. This system should connect state and 1. Banthin ), Simpson M. Boettgens M, Blumberg . Wang R local health departments with one another and changes in health insurance coverage due to the COVID-19 te- with private health care providers and require cession. Washington, DC Urban Institute. July 2000 (http/ familienusa.org/resources/the-covid-19-pandemic and resulting the participation of private health care facilities, -economic crasb-have-caused-the-greatest-health-insurance-losses laboratories, and manufacturers to give a com- n-american history). plete picture of available resources. Second, it Dom S. The COVID-49 pandemie and resulting economie would allow the federal government to expend can have caused the greatest health insurance losses in Ameri can history. Washington, DC Families USA, July 2020 chup federal funds, without prior congressional ap- familiesus.org/resources the-covid-19-pandemic and rewalting proval, on emergency responses, including the economic crash barecared the greatest health insurance comes development and distribution of new diagnostic 5 Cohen RA, Terlini, Martine M, Cha Al Health inuar tests, new therapeutic approaches, and new vac ance coverage early release of estimates from the National cines and the hiring and training of personnel Health Interview Survey, Jonaty June 2013 Washington, DC needed to track and contain epidemics at the National Center for Health Statistics, May 2020 (http:www local level. Third, it would let the federal govern-Collins SR, Bhopal HK. Doty MM. Health insurance coverage ment require states to adopt measures needed to eight years after the CAfewer suninsured Americans and short contain the spread of infections. In particular, wealth Pud, February 7, 2019 Chappeliwww.commonwealthfund legislation could facilitate the use by the federal or publication e-brief 2019 febhealth Insurance coverage government of its constitutional powers to regu- tight yean-after) late interstate commerce by forcing states that Corlette S. Lucak Orarien M. Wature state officials dolne did not comply with critical infection-control ing the coronavire public health crisis? New York Common measures to cease participation in interstate wealth Fund, March 20, 2020 httpwww.commonwealthfund travel and commercial activities. Fourth, it would go what are state-oficial-doing male peinte health allow the federal government to regulate the 1. Barnett M1, Mehrotra , Landon M. Corid 19 and the up-