Healthcare’s Bridge Fire
We had a bridge fire here in Cincinnati last week. Two semis collided in the overnight hours. The collision ignited a blaze that burned at up to 1500 degrees Fahrenheit and took hours to quell. Fortunately, no one was killed or injured, but the bridge remains closed while investigators determine how much damage was done. It is expected to remain closed for at least another month.
Unfortunately, the bridge in question is the Brent Spence Bridge, which is the focal point for I-71 and I-75 between Ohio and Kentucky. It normally carries over 160,000 vehicles daily, and is one of the busiest trucking routes in the U.S. Over $1 billion of freight crosses each day. There are other bridges nearby, but each requires significant detouring, and none were designed for that traffic load.
What makes this all so galling is that it has been recognized for over 25 years that the bridge has been, to quote the Federal Highway Administration, “functionally obsolete” — yet no action was taken to replace it. This most recent disaster was a disaster hiding in plain sight.
Just like, as the coronavirus pandemic has illustrated, we have in health care.
The Brent Spence Bridge was opened in 1963, intended to carry a maximum of 80,000 vehicles daily. That had been surpassed by the 1990’s, causing calls to replace it with a newer, bigger bridge. At one time, Rep. John Boehner, from the Cincinnati area, was Speaker of the House and Kentucky’s Mitch McConnell was Senate Majority leader, yet were not able to obtain funding for the replacement, despite strong support from then President Obama and, in turn, President Trump.
Money is the problem, of course. The federal gasoline tax, intended to fund interstate highways and bridges hasn’t been raised since 1993. There was talk about funding a new bridge via tolls, but neither Kentucky nor Ohio politicians were keen to impose them; in 2016, the Kentucky legislature prohibited using tolls for such a replacement. This short-sighted parsimony isn’t limited to the Brent Spence Bridge, of course; the American Society of Civil Engineers gives America’s infrastructure a D+.
We know there is a problem, but we choose to ignore it, letting future generations deal with it, and we certainly don’t opt to fund addressing it. Just like we are doing with climate change — and just like we have done with our healthcare system.
Epidemiologists had long warned of a global pandemic. The Obama Administration prepared a detailed “playbook” for such a pandemic, but, nonetheless, the Trump Administration was caught flat-footed when COVID-19 hit. It’s easy to blame it for our lack of timely and comprehensive response, but not many state or local governments have covered themselves in glory for their responses either, not after years of public health cuts.
Our global, just-in-time systems for supplies was found severely wanting in the case of an exponentially spreading global pandemic, leaving healthcare workers short of essential protective gear and equipment like ventilators.
Similarly, our testing efforts were botched from the beginning. Even today accurate, rapid tests remain a pipe dream, making it hard to determine when someone has COVID-19, where they were infected, or who they might have given it to.
As we’ve learned, COVID-19 hits people with comorbidities hardest; as we’ve long known, the U.S. leads in world in people with chronic conditions. It has also disproportionately impacted people of color — reflected, in part, their increased likelihood of being essential workers who cannot work from home, and underlying health disparities.
Just within the past week, we’ve received promising news on vaccines from Pfizer and Moderna. Unfortunately, vaccine development has become politicized. Only half of Americans say they are willing to get a COVID-19 vaccine, a figure that dropped twenty percentage points from May to September. We should not be surprised; American’s trust in vaccines generally had been dropping even before COVID-19, as evidenced by the anti-vax movement.
We’ve thrown trillions of dollars at COVID-19 relief, including large amounts to the healthcare system, yet hospitals claim they are losing hundreds of billions of dollars, and our already weakened system of primary care is on the verge of collapse. Burnout among healthcare workers was already a problem, but the pandemic has caused it to reach new levels, especially when many people shun basic precautionary measures like masks or social distancing.
It’s embarrassing that in the richest country in the world, 11% of the non-elderly lack health coverage. It is disturbing that 25% of Americans report that they or a family member have put off treatment for a serious medical condition in the past year due to cost — and that was before the pandemic. It is tragic that our morbidity and mortality rates are, at best, middle-of-the-pack despite our extravagant health care spending. And it is shameful that, for measures like maternal health or infant mortality, our results are third-world, especially for persons of color.
All of which is to say, the pandemic is a bridge fire, all right, but it is taking place on a healthcare bridge that we’ve long known is “functionally obsolete.”
We can’t entirely avoid bridge fires, but we can design the bridges to minimize their likelihood and can ensure they are structurally sound enough to withstand them. Similarly, we can’t preclude the possibility of a pandemic, but we can have the public heath infrastructure in place for one, and a healthcare system that is robust enough to cope with one.
What we can’t do — or, rather, what we shouldn’t do — is to wait for disasters to happen and only then try to figure out what to do.
In the case of a bridge fire, that might mean millions of hours of traffic delays and probably higher prices for many goods. In the case of a pandemic, though, that means hundreds of thousands of “excess deaths” and crippling economic impacts. It’s no way to run a highway system and it’s most certainly no way to run a healthcare system.
The pandemic may be healthcare’s bridge fire, but it didn’t cause our healthcare system’s shortcomings; it only helped expose them. The question is, will it spur us to do something about them?
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