US, the useless superpower

The US health system has not defended public health. On the contrary, Covid-19 pandemic has showed the blatant healthcare inequalities between Counties and neighbourhoods and, therefore, the census disparities

In September 2019, the President Trump’s Council of Economic Advisers issued a report which showed the potential magnitude of the health and economic effects of a hypothetical pandemic in the US. The Council warned that the private market’s incentives were insufficient for the developing of new vaccines within the time that would have been required.

This, however, was just one among the many warnings issued by several agencies and experts to the Trump administration, before and during the pandemic. Therefore, one of the main causes that led to the disastrous American response to the pandemic was surely represented by President Trump’s refusal to listen a whole series of alarms or even to have shut down them. During his three years of administration, the President tried many times to cut the Center for Disease Control’s funds – an agency whose task is precisely to monitor the spread of infective diseases in the US and the world – and he was stopped only by the Democrats’ opposition. The Center was nevertheless severely depowered over the years. For example, bringing back home a scientist who was working at the Chinese corresponding agency – who could have been a useful lookout at the end of 2019.

Furthermore, the disbandment of the National Security Council’s global health unit has to be taken into account. Months before, the National Security Advisor John Bolton had already knocked out Tom Bossert, the White House’s Homeland Security Advisor, who was pushing for a well defined strategy against pandemics and biological attacks. According to Anthony Fauci’s – director of the National Institute of Allergy and Infectious Diseases – hearing to the US Congress: “We worked very well with that office. It would be useful if it was still there”. So, US were perfectly aware that a pandemic would have occurred, and all the system disbanded by Trump was built up precisely to respond in an adequate way.

A pandemic such as the one occurring is a pure stress test for any health system, such as the monitoring one – undermined by Trump’s administration choices –, the one responsible to provide rapid pharmacological responses and, finally, the one that has to provide healthcare to all the patients in need. The inadequacies and the inequalities inherent to the US healthcare system led to an unequal and inefficient response. Something that, after all, we experienced also in Italy (as shown by the Lombard and Venetian examples, administrated by the same political majority), with a fragmented system with different decision-making places which make very difficult to provide an immediate and homogeneous response.

If then the central government, instead of coordinating, supporting and imposing rules, focus its efforts on the electoral consensus while the contagion is spreading, the outcome may not be than negative. The only luck of the US, at least at this very moment, is the lack of urbanization of a vast part of the country and the population’s dispersion, that limited the contagion’s spread only to certain areas. Areas that, however, are crucial from an economic perspective.

What made so inadequate the US response to the Coronavirus? If we make a list of elements, we can cite: the differences between the States’ healthcare systems, the missed federal coordination, the health coverage’s inequalities and the subsequent missing therapies, general bad health conditions of the population, a private health sector too focused on profit and not keen on patients and health personnel.

Finally, there is also been a disastrous central policy that initially denied the existence of the pandemic – and then put the blame on the governors while accusing China of the whole situation –, delayed the shut down of economic activities, lockdown and social distancing, did everything to reopen the States’ borders and, finally, promoted the foolish use of untested medicines. The list of the various mistakes and faults of the Trump administration in this circumstance could be also longer but let us stop here. A final element, shown by a New York Times’ investigative report on the experts’ warnings issued in this pandemic, is the Trump’s lack of will to cooperate with China while the trade dealings were ongoing – a crucial aspect for his re-election. He finally talked about China only when it became necessary to find an external scapegoat to justify his disastrous response to the emergency and new topics were to be find for his electoral campaign.

The most well know aspect of the whole question, however, remain the fact that the United States are the only developed country with no universal healthcare. Almost 28 million Americans, the 10.4% of the non-aged population (covered by Medicare), had no health insurance in 2018 (Census Bureau data). Nevertheless, a step ahead of the situation before the Affordable Care Act approval in 2010. In that year, the uninsured were 46.5 million. Since 2016, however, the percentage of uninsured people started to rise again.

During the contagion’s spreading weeks, each State, health company and health insurance company adopted their own policies – as the governors, who maintained open different activities or closed the schools in different periods. All this was made worst also by structural disparities. A Washington Post analysis on the amount of hospitals’ beds and adequate structures to respond to Covid-19 has pointed out that 70 million of Americans live in Counties where the scarce availability of beds would lead the local health system into chaos if hit by the pandemic in way similar to certain metropolitan areas. 125 million Americans live in areas where there are simply not enough ventilators.

Let us analyse the case of Texas, the top State for number of uninsured people (5 million). During the Obama administration, the Republican governor rejected the offer of federal funds to increase the covering of public insurances for the poor (Medicaid). In this State, the hospitals closed in rural areas are 26. This is due to the fact that, in a mainly private health system, hospitals have to male profit and, therefore, the ones stationed in scarcely inhabited areas just fail – in Italy occurred almost the same phenomenon, because of rationalization and saving-money policies. In 33 Counties out of 254 there are no medical offices. The Trump’s administration proposed a 11 billion cut to Medicaid federal budget, which could accelerate this phenomenon. Furthermore, the President refused to reopen the chance to apply to the Obamacare during the crisis – the program includes the possibility for uninsured people to find a health insurance in a protected market during a certain period of the year. This would have consented to million of people who were losing their jobs – and their health insurance – to not spend money for healthcare, which represents a severe expenditure.

According to the Kaiser Family Foundation (KFF), an influential foundation focusing on health policies, has reported the case of a young patient who decided to take the test to be sure to not transmit the virus. The first test was negative, but after few days the patient was still ill (with flu symptoms) and his doctor recommended him to take a second test. The result? 2,000 dollars of receipt. There is another trick called deductible, that is the amount of money that an individual has to pay before the insurance intervention. So, if you have to pay 2,000 and your deductible amounts to 1,000, the other 1,000 are at your expense. Another KFF’s study points out that the 45% of the insured population has an average deductible of 2,000 dollars.

Now ask yourselves, if you were unemployed and/or uninsured and with no symptoms, would you take the test? If all this was not enough, consider that in some companies’ owned emergency rooms, doctors of other companies work. So, if you are insured and covered in a hospital, you could be visited by a “non-resident” doctor and to pay him. The same happens if a medical sample is sent to laboratories which are outside your insurance network. It is a system made with the main aim to increase private expenditures. A NPR’s program, called Bill Of The Month, that tell incredible non-sense stories related to health related expenditures.

Another report, by Covered California, the State’s fund for insurances instituted by Obama, affirms that: “Private insurance companies are fixing their tariffs for 2021. If they want to recover the 2020 costs, and assure their solvency, 2021 premiums for single individuals and employers could rise from the 4% up to the 40%”.

Covid-19 has also showed the blatant healthcare inequalities between Counties and neighbourhoods and, therefore, the census disparities. It is widely well-known that the black population was the most affected by the pandemic – for reasons related to this population jobs, that make them unable to work at home, and to their major use of public transportation. The related data are frightening: the 80% of the ill population in Georgia and the 70% of the deceased in Chicago are blacks. The higher level of mortality can be reconducted to 4 main elements: the fact that the black population generally waits to go to hospital as long as possible, fearing the costs; the insufficient hospital capacities in poor areas; the bad health conditions of aged black population (diabetes, obesity, heart and respiratory diseases); the doctors’ tendency to not send black people in hospitals (related to their supposed spending power).

Altogether, an inequality within an inequality. Nevertheless, the white-majority rural areas are not in better conditions. Now the difference is constituted just by the fact that the pandemic hit harder the cities, and that the poor urban neighbourhoods have a black majority population (for example in New York, Detroit, Chicago, Atlanta and New Orleans).

A remarkable example of the risk present in rural areas, the private company Alecto acquired, between Ohio and West Virginia, three hospitals just in order to close them, leaving the County with no medical centre to face the pandemic. In Scranton, Pennsylvania (Joe Biden hometown), a hospital allowed the health personnel to pass among different departments, included the ones where Covid-19 patients were present, with no protection at all. This hospital is owned by the Community Health Systems (CHS), which manage 102 hospitals in 18 States, and a Washington Post report revealed that the same practice occurred also in several other health structures managed by this company. SEIU, the healthcare labour union, reported the fact that those who protested were threaten of dismissal (the CHS is listed on the stock-exchange and cannot afford bad press).

The final issue that has to be analysed is the scarcity of ventilators, protective material for the health personnel and of testing kits. All material that has to be added to the usual equipment, since a pandemic constitutes an exceptional event. That’s the reason why CDC and federal instruments related to public health exist, despite the fragmentation and the privatization of the health system. Trump’s administration, however, managed the issue forcing governors to compete among them for this equipment. The New York governor Cuomo asserted, in relation to the necessity to offer more to the medical supplier with respect with other governors: “it looks like to be on eBay”. According to a report of the Department of Health and Human Services’ general inspector, who investigated on 300 hospitals, there are contradicting indications on how to use the instruments of personal protection from federal, statal and local authorities. It cites a “sense of confusion, fear and mistrust against the personnel responsible of the hospitals’ security procedures”. It happened that, when the hospitals and the governors obtained the equipment required, they found out this to consist of non-working machines, expired face masks and so on.

Let us close with a significative episode described by Andrew W. Artenstein, doctor in Springfield, Massachusetts, on the New England Journal of Medicine. Desperately searching for the needed medical equipment, the hospital’s administration manages to find ventilators and face masks by a quite obscure supplier with a price 5 times higher than usual. They organize a meeting at an airport, inspect the equipment and manage the transportation of it with two food-transport trucks – in order to not be stopped and having the equipment confiscated.

Two FBI’s officers arrive on place and, after a long reassurance that the material is not to be destined to the black market, allow them to go. When they arrive at the hospital, they find out that the Homeland Security Department could have had been able to send the material elsewhere. Only a local Representative intervention impeded this. It looks like a TV series episode, but instead is the disastrous result of a system whose aim is not to defend public health and managed in an absurd way by Trump and his entourage.

This article is also published in the June/July issue of eastwest.

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