After a blistering 2020, Americans are wondering what the new year will bring—especially as a new more contagious strain of COVID-19 takes hold. For at least the first half of the year, experts say, it will be more of the same. Because vaccines may take a while to roll out to the general public, mask wearing and social distancing must continue. But in the way only a crisis can, the pandemic has also opened up a chance for systemic change in a broken healthcare system—the beginnings of which we might start to see in 2021.
Whether or not we seize that opportunity depends largely on Congress. The introduction of a new presidential administration could bring much-needed changes to the healthcare system, including how we pay for it and how we access it. But progress on that front will hinge on which party wins the remaining Senate seats in Georgia’s January run-offs.
The promise of vaccines
Vaccines from Moderna and Pfizer are already being injected into arms around the country. However, those vaccines are likely to face barriers to delivery as they make their way around the country. Such delays are already taking place. That means that it will take a while for everyone to get vaccinated, which is of particular concern as a new strain of COVID-19 starts to make its way through the country. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, says it does not seem the new strain is resistant to the vaccines currently being used.
Operation Warp Speed aimed to administer 20 million vaccine doses by year end, but only was able to get out just over 3 million.
“There has to be more effort in the sense of resources for the locals, namely the states, the cities, the counties, the places where the vaccines are going into the arms of indiviudals,” Dr. Fauci said on the Today Show. “We have to help them to get this task done.”
As the vaccine roll out continues, the first half of 2021 may feel very similar to 2020.
The vaccine from Pfizer needs to be kept at intensely cold temperatures: 94 degrees below zero. The company has figured out a way to transport the vaccines in temperature-controlled coolers, but even this distribution plan has potential pitfalls. The smallest quantity of vaccines that Pfizer is shipping is a tray of 975 doses. For small hospitals in rural areas, that may be too many for their small staff of healthcare workers, as was the case for a hospital in Arkansas. Furthermore, some hospitals may not have the refrigeration capabilities to store them. Once the vaccines are taken out of cold storage, they must be used within five days.
“I foresee a lot of barriers to getting this out in a fast and equitable way,” says Ishani Ganguli, assistant professor at Harvard Medical School and a primary physician at Brigham and Women’s Hospital.
I foresee a lot of barriers to getting this out in a fast and equitable way.”
She says that in addition to the initial problems hospitals may be encountering now as they get vaccines to healthcare workers, there will no doubt be issues that come up as vaccines are rolled out more broadly. She sees vaccine hesitancy, which has seen an uptick thanks to viral social media campaigns, slowing down mass adoption despite evidence the Moderna and Pfizer vaccines are safe. But there are also more practical issues that may stop people from accessing a vaccine—such as how close they live to a hospital and whether they have access to transportation.
There is also necessary bureaucratic red tape that may gum up the process. Some 14 states have already experienced delays in receiving vaccines because of a miscommunication that resulted in smaller initial shipments.
The slower the process of vaccination, the longer that Americans will have to continue social distancing, wearing masks, and hand washing—measures that citizens have not embraced as well as we could have.
“We have this amazing feat of science with the vaccines yet we’re failing at some of the basic steps that individuals could be taking and simple policies that could make a much bigger difference,” says Ganguli.
Dr. Megan Ranney, an emergency room doctor at Rhode Island Hospital and director of the Brown Lifespan Center for Digital Health, says masks must stay on until at least 80% of the population is inoculated. Delays, even small ones, in getting the vaccine out mean that masks will be with us for a while longer.
“Until we reach that 80%, community spread will still happen,” says Ranney. “Realistically for most of us, it will be late spring or summer before many people in the United States have the option of getting vaccinated—that’s if all goes well.”
There are also still questions about what exactly these vaccines protect against. Initial studies show that both vaccines protect against symptomatic COVID-19 infection, but it’s still not totally clear how well they ward off asymptomatic infection. Until research proves that vaccine recipients aren’t capable of transmitting COVID-19, people should continue to wear masks.
I need something to look forward to.”
That said, Ranney expects that in post-vaccine America we will at least be able to get on a plane again without too much concern. She says she has a trip planned for this August. “I need something to look forward to,” she says.
Even in the best-case scenario, in which the COVID-19 vaccines truly block infection and transmission, masks could still be useful. Researchers say that mask wearing can bring down the number of annual flu cases (notably, there have been fewer flu cases this year). After the SARS and MERS outbreaks, mask wearing became more commonplace in countries such as Taiwan, South Korea, and China. Americans could adopt similar habits, such as wearing a mask when they feel sick.
A change in how we pay for healthcare
The pandemic has also exposed the elements of the healthcare system that aren’t working. One big problem continues to be paying for medical care. While there are several measures in place to protect Americans from receiving astronomical medical bills related to COVID-19, some people have wound up shouldering these costs.
The core of the problem is that the way we pay for healthcare in the U.S. is not conducive to providing comprehensive care. Healthcare systems are forever battling with insurers over whether or not individual procedures are necessary and should be covered under insurance.
But COVID-19 has put immense pressure on this system, known as fee-for-service (where doctors are paid a fee for rendering a single service). Hospitals were spending more on COVID-19 care than they could be reimbursed for through insurance. Hospitals have had to pay for an unprecedented amount of protective gear for healthcare workers and additional facilities, such as tents, in order to make room for the incredible number of patients seeking care. They are doing less specialty care that pays the bills at hospitals, such as surgery. Even though Congress has stepped in by providing some $175 billion in funds to healthcare providers, these problems have sent even well-funded hospitals into financial distress.
Ganguli says that during the pandemic, it was often hard to bill for the services she was providing to COVID-19 patients. As a primary care doctor, she spent a lot of time on the phone, checking up on patients at home who were sick with COVID-19. Phone calls are not typically reimbursable, though during the pandemic the Centers for Medicare & Medicaid Services (CMS) expanded coverage to include some phone calls with doctors.
“Sometimes we were told to bill for those [calls] and sometimes that felt weird,” she says, though she also recognizes that hospital administration needs to balance the budget at the end of the day. She says that doctors in her practice will always deliver the care that their patients need, regardless of the pay system. But it would be better to have a pay system that actually supports the way she works. “A model where you have a certain amount of cash to use or spend per patient where you can be flexible with how you spend that money is attractive,” says Ganguli.
A better system would do as Ganguli suggests—pay a doctor to do what’s in a patient’s best interest. President Biden is likely to champion such a system, known as value-based care, when he comes into office. Patients could start to see the benefits over the next 5 to 10 years.
Keith Figlioli, a partner at venture capital firm LRV Health, says experiences such as Ganguli’s and the financial hardship hospitals are experiencing is why Congress will likely consider more value-based care legislation in 2021. “I think COVID is showing everybody how disjointed fee-for-service is,” he says.
Figlioli notes that CMS is already working with its providers to develop more value-based care arrangements or contracts that pay providers based on quality of care and health outcomes. He thinks that with Joe Biden as president, value-based care will get a bigger push. The Obama administration, in which Biden served as vice president, was instrumental in creating and investing in this kind of care system for Medicare patients.
Figlioli thinks that whether or not Congress approves new healthcare initiatives such as these in 2021 will depend on which party wins in Georgia’s run-off elections.
The rise of digital health
COVID-19 has also introduced Americans to a whole new way of getting care: at home. Expanded insurance coverage for doctors’ visits conducted online, over video, and on the phone has created a more open dialogue between doctors and patients. If you haven’t already seen a doctor online, 2021 may be the year you finally have a virtual visit. However, whether this method really becomes part of the norm will depend on Congress.
Doctors are excited for a world where they can have more communication with patients in a wider variety of ways, whether that’s through real-time video or phone calls, or through emails and texts where physicians can be in regular contact with a patient over time. “There’s way too much emphasis on real-time communication between doctor and patient,” says Bon Ku, an emergency room physician, assistant dean of the Health & Design program at Thomas Jefferson University, and director of its Health Design Lab.
“Is it really a relationship if you meet with them for 30 minutes once a year? I don’t think so,” he says, referring to the traditional model of primary care where a patient comes in once a year for annual exams and then on an as-needed basis when problems pop up. Ku thinks that checking in with the doctor outside their office may create a more consistent relationship between doctor and patient, especially when the concerns are less serious. A substantive body of research shows that a strong continuous relationship with a single primary care doctor over time leads to better health outcomes for patients.
“With virtual platforms and asynchronous messaging once a month or—when you have an acute illness—multiple times in snippets, I think that would improve that relationship,” says Ku.
Whether or not this type of care sticks around will depend on two main issues. Ordinarily, doctors have to be certified in each state where they practice. But during the pandemic, doctors have been able to practice across state lines. This regulatory decision has increased access to medical care for Americans everywhere, including in the more remote areas with little access to a hospital. However, Congress now needs to determine whether the restrictions that were lifted under COVID-19 will remain.
Second, insurers, including Medicare, will also have to decide how they will cover telehealth services. Right now, they are being treated the same as an in-office doctor’s visit.
Both issues will likely come before Congress in 2021. Republican representative Ann Wagner of Missouri has already floated a bill that would reduce many of the previous telehealth restrictions and continue Medicare’s coverage of these services.
In total, all these experts agree that in 2021, there is potential to not only return to normal, but perhaps to a world that is slightly better than normal. It will be hard to see that opportunity in early 2021, but Americans may catch a glimpse of it in the latter half of the year. Of course, these possibilities could be squandered or lost in the trenches of bureaucracy. Still, our collective ability to lessen or mitigate 2020’s horrors in this new year will depend as much on the decisions that individuals make—to wear a mask, to socially distance, and to get vaccinated—as it will on Congress.