Here in the U.S., we slip and slide around the reality of rationing. We like to believe we can have it all, do it all, that there are no bounds. And if you have money in the U.S., that is more or less true. Until now.
Personal protective equipment and test kits for COVID-19 are in short supply. I won’t explore the myriad of reasons of why we are here now, but we are. And it forces us to grapple with some challenging realities that we in the U.S. like to ignore. 1) We cannot continue to spend infinite resources on health care without making some tough decisions. 2) We can’t continue to pretend that we aren’t making choices about who gets what. But first, an international perspective.
In many countries where I have worked, the sheet on the exam table is not changed after every patient. In some countries, gloves are washed and reused. Often less examining of the patient occurs, so less handwashing may be needed. I am not advocating for these practices, but when I have practiced in Central America, Cambodia, the Former Soviet Union, and most recently Palestine, I am reminded of the luxury of fresh gloves, a pair or more, for every patient and ripping away the old paper sheet every time. In fact, when I return from international work, it takes me a few weeks to adjust to the dramatic difference. I realize what I, and other U.S. health professionals, take for granted. We practice like there is an endless supply.
Now hand washing is another issue. One of the physicians I worked within Palestine was campaigning to remind physicians to wash their hands. Thanks to the coronavirus, compliance has gone up 3,000 percent. Some good things may come from this. Soap and water is old fashion and cheap. Hand sanitizer is convenient, and now some liquor distilleries are making it.
So as uncomfortable, anxiety-provoking, and tragic as this disruptive change is to experience and watch, there are opportunities. Now to my initial points.
1. In the U.S., we must wrestle with the finiteness of our resources for health care. Our lack of priority for funding basic public health has left us ill-prepared for this pandemic. Our love affair with technology, preserving youth, and profit is bankrupting resources for other basic necessities: education, transportation infrastructure, and clean air and water.
2. We are rationing although we don’t like to admit it. If you are well-to-do or a celebrity, you go to the top of the list. If you are poor and/or old enough to qualify for the government insurance (Medicaid and Medicare), you get adequate coverage. But if you make enough so that you don’t qualify for Medicaid, forced to work part-time so your employer doesn’t have to provide insurance, live in a state that didn’t expand Medicaid under the ACA (Obamacare), are undocumented and qualify for some health care services only, then you are experiencing rationing. It’s not the fair way to do it. It’s not equitable. And we don’t like to talk about it. But in the U.S., there are the haves and the have-nots.
In the early 1990s, the state of Oregon set priorities to start a public conversation about what benefits were covered and which ones were not for patients on the state health plan for the poor–Medicaid. This occurred after a seven-year-old boy on Medicaid could not have a bone marrow transplant. More patients could be enrolled in Medicaid if bone marrow transplants were not part of the benefits package. While tragic for the boy, it acknowledged the finiteness of resources and the need for an up-front conversation. To date, Oregon is the only state to have a public conversation about setting priorities with health care resources.
In this coronavirus world, health care providers are making tough decisions. Which patient gets the ventilator? Which patients get the COVID-19 test? How do we reuse personal protective equipment? Which health care providers can we put at risk?
My hope and prayers during this time are that we have leaders that use this opportunity to grapple with some of the big questions. That health care may become a universal right in the U.S. and that we define what are essential priorities for coverage. We need to begin the difficult conversation about what is and is not realistic. As one of my patients said to me, we all have expiration dates. While these are tough conversations to have publicly, they need to occur.
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