The COVID-19 pandemic has forced our medical community to critically examine our care delivery systems. But this is not the first instance of a pandemic forcing such a reckoning. Nearly four decades ago, our country faced another infectious disease that threatened public health: HIV/AIDS. Looking back, the HIV/AIDS crisis offers lessons in how we might identify flaws and reform our contemporary healthcare system in the wake of COVID-19.
At the outset of the HIV/AIDS epidemic, the U.S. healthcare system was marked by overspecialization, fragmentation of services, service gaps, and poor coordination — leaving it ill-equipped to supply and finance long-term care, particularly as AIDS transformed from a universally fatal disease to a chronic condition. Recognition of these shortcomings helped drive much-needed change.
First, the HIV/AIDS epidemic pushed the United States to move closer to a more equitably accessible healthcare system — something that ought to be replicated in our present pandemic. In 1990, the Ryan White program was enacted to provide comprehensive primary medical care, support services, and medications for low-income, uninsured individuals living with HIV. This program has enabled high rates of viral suppression in patients — in 2017, 85.9% of Ryan White HIV/AIDS Program clients were virally suppressed, exceeding the national average of 59.8%. A focus on health equity is just as important with the present pandemic. In the context of COVID-19, facing record-high unemployment rates, many more Americans are now likely to become uninsured, demonstrating the limits of employment-based health insurance models. Without a health system that ensures equitable access to healthcare and applies community-based care models, regardless of insurance status, for testing, education, and resources, reducing the spread of infectious diseases like COVID-19 will be hindered.
Second, we must quickly increase the breadth of value-based models to pay for healthcare. Much of American healthcare operates under a fee-for-service system, in which physicians are paid for the services they perform on patients. In normal times, this is a recipe for overutilization, as physicians are incentivized to perform as many services as possible. During the pandemic, this model has been a catalyst for physician bankruptcy, as patients avoid physicals and other care they deem unnecessary. Value-based models offer a better way forward. In these models, physicians are generally paid a risk-adjusted, fixed amount per patient, with bonuses for quality metric performance. Physicians are not incentivized to maximize the volume of patient visits, but to concentrate their efforts on patients who need it the most. This notion, in part, helped inform HIV treatment modalities, which employed capitated payment systems and utilized team-based models of care. Widespread adoption of such a payment system would help to shore up the finances of struggling physician groups around the country, in addition to incentivizing quality care at a lower cost.
Third, to prevent future limitations of resources, there must be a nationally coordinated consolidation of healthcare equipment and supplies. The Strategic National Stockpile (SNS) is responsible for supplementing state and local supplies of medical products. By early April, the U.S. national stockpile of protective gear was nearly depleted. With states relegated to procuring their own supplies, the nation was consumed by an avoidable bidding war, costing precious time and many lives. Experts such as Julie Gerberding, MD, MPH, the former CDC director, have called for a restructuring of the SNS system and reevaluation of its role in coordinating resource allocation.
The HIV/AIDS epidemic heightened awareness around legislation — such as the Ryan White Comprehensive AIDS Resources Emergency Act and the Food and Drug Administration Modernization Act — that created avenues for concerted, institutionalized federal responses to healthcare equipment shortages. In today’s fight against COVID-19, we must have a robust national stockpile of healthcare equipment and an efficient method to mobilize such resources in times of need.
COVID-19 has exposed vulnerabilities in American healthcare access, healthcare financing, and medical equipment supply. Just as our healthcare system was forced to address its shortcomings and improve through the HIV/AIDS epidemic, so too must we grow stronger through the ongoing crisis.
Prateek Sharma and John Connolly are second-year medical students in the Perelman School of Medicine at the University of Pennsylvania.
Last Updated January 15, 2021