During the current delta-driven Covid-19 wave, Americans are being transported hundreds of kilometers from their homes because there is no nearby hospital. Some of them even died waiting for medical attention.
In other words, US hospitals are being forced to ration health care for their patients in the midst of a public health emergency.
Rationing has long been a dirty word in US health policy, used as an attack on any socialized health program that more centrally determines what medical services are covered for whom. The US healthcare system has always rationed care through cost: it is de facto rationing when a patient does not get the medical care they need because they cannot pay for their own costs or because they live in a rural community with no facilities near.
"We're so used to rationing by solvency in this country that classic capacity rationing feels a bit strange," said Hannah Neprash, a health economist at the University of Minnesota, in an email.
A funeral home covered the body of a 54-year-old woman who died at home of Covid-19 in Houston on September 13th.
John Moore / Getty Images
The Delta variant, more contagious and virulent than its predecessors, and America's lagging vaccination rates are fueling the current crisis.
The states with the worst outbreaks of confirmed cases per capita right now – Tennessee, Kentucky, Alaska, Wyoming, and West Virginia, according to the New York Times Tracker – have either set new hospital admission records in the past few weeks or are near their previous highs from the winter wave. All of them have vaccination rates below the national average. Hospitals across the south are reporting having more patients in need of intensive care than there are ICU beds available, the Times reported Tuesday.
America, the richest country in the world, shouldn't be a place where patients have to die. But that's exactly what is happening now – 18 months after the pandemic began.
The American healthcare system was not built to withstand a pandemic
Many parts of the American healthcare system are grappling with the pandemic. The current hospitalization crisis is just the latest iteration of an institutional failure.
There are still many unvaccinated people in the United States who are completely susceptible to the delta variant of the novel coronavirus, which appears to be causing a more contagious disease. One in four people over the age of 18 has still not received a dose of a Covid-19 vaccine, and younger age groups have lower vaccination rates than their older ones. As a result, the number of hospital admissions has changed: people over 65 accounted for more than half of hospital admissions in December and January; now it's about a third. Children under the age of 12 are still not eligible for the vaccines, and children's hospitals see the highest number of Covid-19 patients ever.
But while the demographics of people being hospitalized may have shifted, the number of people who become seriously ill with Covid-19 and end up in the hospital is almost higher than ever.
Texas, to take an example, has almost hit its winter high with more than 14,200 people currently hospitalized with Covid-19. According to the Covid Act Now, more than 90 percent of the state's intensive care beds are occupied. In Idaho, where around 88 percent of ICU beds are occupied, hospitals have had to activate so-called "crisis" care standards. This gives them more discretion to prioritize the most likely patients for ICU beds and other treatments.
In Bellville, Texas, 46-year-old military veteran Daniel Wilkinson was admitted to the emergency room. He was diagnosed with gallstone pancreatitis, which is treatable but for which his local hospital was not equipped, according to the KPRC. The doctor called across the region – including hospitals in Texas, Oklahoma, and Arkansas – but couldn't find a hospital that would accept him. These states currently have some of the highest Covid-19 hospitalization rates in the country.
An intensive care bed was eventually found in a Houston Veterans Administration hospital, more than an hour from Bellville. But Wilkinson's organs failed on the helicopter flight there and he died. It had been more than seven hours since his mother first took him to the local emergency room.
Rescue workers prepare to transport a Covid-positive woman to a hospital in Houston, Texas on August 25.
John Moore / Getty Images
There are more stories like Wilkinson's in the United States. On Monday, the Washington Post reported that a 73-year-old Alabama man died of a heart attack after being turned away from more than 40 hospitals. The nearest hospital that would take him was 200 miles away in Mississippi. Alabama is currently experiencing the second highest number of Covid-19 hospital admissions per capita in the country.
Hospitals are trying to balance handling a new Covid-19 surge with medical care for all other patients in need of their attention. But that has forced her to make some tough decisions.
Karen Joynt Maddox, a practicing physician and health policy researcher at Washington University in St. Louis, said her local hospital had been instructed not to take patients from small rural facilities unless there was absolute medical necessity during the pandemic which sometimes meant rejection of referral requests by family members.
The US does not have many hospital beds compared to many other affluent countries; according to the Peterson-Kaiser Health System Tracker, about 2.9 per 1,000 population compared to the average of 4.6.
There are good reasons for this: Over the decades, more and more medical services have been shifted from inpatient to outpatient areas in order to save costs. But that still resulted in the number of hospital beds available in a one-time emergency still shrinking.
We wouldn't necessarily want the US healthcare system to be always cluttered with excess hospital capacity, some experts claim. It would cost considerable resources to maintain. But even in normal times, urban hospitals will operate at almost 100 percent capacity, while rural hospitals will sit with beds half open.
"We have beds, just not in the right places," said Joynt Maddox, "and with no system to try to use the available beds as rationally as possible."
An Oregon nurse awaits her next Covid-19 case shortly after a patient died on Jan.
Nathan Howard / Getty Images
The current crisis has shown how disorganized the US healthcare system really is. American hospitals do not have a reliable source of income, as hospitals do in countries with budgets that pay providers a predictable amount of money each year.
And there is no single agency to help manage patient stress when US hospitals are overburdened; Daniel Wilkinson's doctor made these calls alone. Local hospital managers across the country have been abandoned to make desperate appeals to other facilities hundreds of miles away, NPR reported.
Other wealthy nations were better equipped to handle their Covid-19 surges
This disorganization sets the US apart from other wealthy countries with different health systems – and arguably contributed to some of these terrible results.
America is not alone when it is tested for the coronavirus. Other wealthy nations saw their hospitals under pressure from the pandemic, especially at the beginning when countries like Italy suffered some of the worst initial coronavirus outbreaks.
But a year and a half after the pandemic, these other countries seem better equipped to handle the stress, aided by both higher vaccination rates and more coherent health systems.
The US is mediocre in terms of hospital capacity, but not at the low end of its economic competitors. Both Canada and the UK, with government health programs for every citizen, actually have slightly fewer hospital beds per capita.
And they reached their limits in the worst waves of the pandemic. The UK's National Health Service was forced to move ICU patients to less congested areas during the autumn and winter waves. In Ontario, more than 2,500 patients have been transferred to other cities for life-saving treatment. Even in France, which has significantly more hospital beds per capita than the USA, more than 100 Covid-19 patients had to be evacuated as beds in Paris hospitals became scarce.
Hospital beds are being removed during the shutdown of a makeshift NHS hospital in Glasgow on April 8th.
Jane Barlow / PA Images via Getty Images
These aren't quite the same horror stories as they are in the US, however, as there has been more coordination between hospitals. In all of these international cases, either the national or local government managed patient transportation.
There is no such system in the USA; it is largely informal. I spoke to a California hospital director last summer who himself had to call a nearby hospital to look for a ventilator when his facility ran out of life-saving equipment.
Other countries seem to have avoided unnecessary deaths because they have a real system of coordinating care. In the UK, hospitals are currently able to handle more emergency care than the pre-pandemic average, according to recent research by the Nuffield Trust, although elective surgeries are still sometimes canceled.
"Hospitals were incredibly busy, but they could always provide emergency and emergency care," said Nick Scriven, a British doctor and past president of the Society of Acute Medicine. "People weren't turned away when they needed a hospital bed."
The pandemic has shown how disastrous the US healthcare system is. But that has always been the case. It usually just shows up in more subtle ways.
An overwhelmed emergency room in an urban downtown setting can cause some patients to go unnoticed. Low staffing at certain times – US hospitals stand out from their international counterparts because they have more administrative staff and fewer medical staff – seems to lead to worse results. And then you have the higher out-of-pocket expenses that Americans have to bear, which has been shown to cause people to skip or postpone necessary medical care.
As Ezra Klein wrote for Vox last year, every health system rationing in its coverage of the UK's National Health Service. There are no unlimited resources. But while in the US this rationing is done in a subtle and arbitrary way, other countries have tried to build a more rational system for managing their medical capacities.
This put them in a better position to deal with the surge in sick patients during the pandemic. America pays the price for not doing the same.
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