By Adam Gaffney, M.D., M.P.H.
Dissent, Summer 2020
When the COVID-19 pandemic hit, my life as a critical care physician in a Boston-area hospital changed quickly. Massachusetts weathered the third biggest outbreak, in total cases, in the nation. Patients who had contracted the novel coronavirus filled our intensive care units. Their lungs failed; our days started early and ran late. To expand capacity, we acquired more ventilators and brought in new staff. Our surgical recovery room was converted into an open-ward ICU exclusively for critically ill COVID-19 patients.
Another change: we began to cooperate with other hospitals in a novel way.
The ICU capacity at our region’s mid-sized hospitals could evaporate overnight with a surge of admissions of patients in respiratory failure. Much larger institutions nearby had more space and some specialized technologies, like extracorporeal membrane oxygenation (ECMO)—a sort of external artificial lung that pushes oxygen into the bloodstream and sucks out the carbon dioxide, which can help some of those with refractory lung failure. When I wasn’t treating patients, I joined daily phone meetings with physicians working throughout the greater Boston area. We shared data and learned where we could send critically ill patients when we ran out of beds. Something similar played out in New York, where the crisis, by necessity, spurred unprecedented cooperation among the state’s hospitals.
Pandemics lay bare the need for cooperation in health services. But cooperation, and planning, will be equally important after the pandemic is over, and must go well beyond meetings. We need to envision a health system where the distribution of infrastructure and resources is not left to the dictates of the market, but rationally planned according to the needs of communities—and the certainty of future disasters.
Planning has been a dirty word in healthcare for decades. Competition is today’s idol. But it was not always so: in the postwar era, though the United States failed to achieve European-style reform, a “health planning” movement emerged. The Hill−Burton Act of 1946 provided billions of federal dollars to expand existing hospitals and build new ones, particularly in underserved regions. In the 1960s and 1970s, state and later federal legislation—culminating in the 1974 National Health Planning and Resources Development Act—created planning bodies tasked with assessing local community health needs, approving new capital projects, and ensuring an adequate distribution of health infrastructure. But in the absence of universal healthcare financing for patients, à la Medicare for All, the movement was only marginally effective—and the rise of a new capitalist healthcare paradigm in the Reagan era easily brushed it aside.
The consequence has been simultaneous excess and deficit in health infrastructure. Today, market forces dictate the life and death of American hospitals. The epidemic of rural hospital closures, for instance, is not the consequence of a lack of rural health needs, but of the cold reality that serving those needs is unprofitable. A large academic hospital closed in Philadelphia last year not because its disproportionately low-income and minority patients no longer needed its services, but because those patients did not generate sufficient revenue. One Journal of the American Medical Association study found that, per capita, Manhattan has the most hospital beds among the five boroughs but had the fewest COVID-19 hospitalizations. Little wonder, then, that the virus battered outer boroughs’ hospitals with such ferocity.
The lack of planning is evident not only in the mismatch of hospitals and patients but in the distribution of basic supplies. “California’s Coronavirus Testing Still A Frustrating Patchwork Of Haves And Have-Nots” ran the headline of an NPR story that described glaring geographic disparities in access to testing months into the pandemic. The logic of competition that informs our national approach to healthcare has also meant chaotic and wasteful bidding wars for testing supplies and personal protective equipment (PPE) among hospitals and state and local governments.
The Medicare for All bills in Congress, if enacted, would do much to advance planning: they mandate dedicated funding streams for healthcare capital expenditures. Adequate investment in stockpiles of PPE and other equipment—and the capacity to rapidly distribute it—could also be undertaken by such a system. But we need to think of other ways that planning could prepare us for the pandemics of the future.
Maintaining a large, unused, yet readily deployable ICU “surge capacity,” for instance, is illogical in market terms: it costs money but delivers no revenue outside of plague years. But that unused reserve capacity benefits society. We need to rethink hospital design, with areas that can be used in times of emergencies but otherwise be idled. Israel’s Ramban Health Care Campus—which has a large underground parking garage that can be converted into a 2,000-bed hospital within hours—offers one example. Similar innovations could be envisioned for the inevitable calamities of our future—and be made available to everyone on a truly equal basis.
That necessitates, of course, abandoning the market ethos that currently drives the expansion and contraction of healthcare infrastructure. It requires discarding the false promise of anarchical medical competition as the salve of our healthcare cost crisis. It does not mean returning to the last era of health planning, but instead reinventing planning for the post-COVID age.
Dr. Adam Gaffney is a pulmonary and critical care physician, a public health researcher, and an Instructor in Medicine at Harvard Medical School. He serves as president of Physicians for a National Health Program and is the author of “To Heal Humankind: The Right to Health in History.”