Many Americans take for granted that we can get health care when we need it. Access and coverage are real concerns for some, yet even the most vulnerable among us know that if they are severely ill, there will be an emergency room and a hospital bed ready for them. But now the coronavirus pandemic is distorting our system in ways that are affecting everyone’s ability to get hospital care.
The virus is beginning to overrun our health-care defenses. We saw something similar during the first surge, in April, when New York and other cities around the United States resorted to field hospitals and mobile morgues. But this time, it is happening in large parts of the country. And counterintuitively, the reason we know covid-19 is overwhelming the system is because of what might look like a good sign at first glance: The hospitalization rate for patients with the virus is dropping quickly.
This development is a surprise. We know so much more about covid-19 than we did back in April – about how to prevent its spread and how best to treat it. But as the virus spread during much of September and October, policymakers were silent and did nothing. By November, we started seeing real strains on our system. Now, in December, some Americans who need hospital care – for covid-19 and other serious ailments – are having a hard time getting it.
And things are likely to get worse.
How do we know that there is a problem with hospitals? We can look at the covid-19 data itself. Every day, states report on how many new hospitalizations they had for covid patients. During September and October, as cases were rising, we could reliably predict how many people would be hospitalized based on the number of new diagnoses. Clinically, we know that after someone is diagnosed, it usually takes a few days before they get sick enough to be hospitalized.
So during most of the fall, we could look at any single day’s covid cases and predict that about a week later, a certain proportion of them – about 3.5% – would result in hospitalizations. The rate, in fact, was remarkably consistent. On Oct. 15, we had 53,000 new cases. On Oct. 22, you would expect 1,844 hospitalizations. What was it actually? 1,855.
But as we entered November, something began to change. For instance, on Nov. 1, the Covid Tracking Project’s seven-day average showed about 80,000 new cases – which we would predict should lead to about 2,800 new hospitalizations a week later, by Nov. 8. Instead, there were 2,600, a little fewer than expected. On Nov. 15, we had 146,000 new cases, which should have resulted in about 5,100 new hospitalizations by Nov. 22. However, there were fewer than 3,700. This pattern of declining rates of hospitalization continued through the end of November.
What is happening is pretty simple: As hospitals fill up, they are admitting fewer and fewer people. As any doctor or nurse will tell you, as the demand for beds soars, the threshold for admission rises with it.
The decision whether to admit a patient depends on two things: clinical judgment and bed availability. Critically ill patients will always be admitted. But as hospitals start to fill up, less sick patients – younger covid patients, or those whose oxygen levels haven’t yet sunk critically low – get sent home. These patients would be safer in a hospital bed, but there isn’t one available for them anymore. And this doesn’t just happen to covid patients. People who show up at the hospital with heart failure, wound infections and other ailments will be asked to manage their conditions at home, as doctors keep the remaining beds only for the very sickest patients. One patient with a brain abscess recently waited a day in a rural hospital in Missouri before being dispatched to a larger facility hundreds of miles away, in another state.
In effect, covid is leading to a rationing of care. Field hospitals – tents in parks and parking lots – can help to scale up capacity, but even with extra beds, there are still hard limits, especially around staffing. In previous waves of infection, it was possible to transfer patients to less overwhelmed hospitals, and health-care workers in areas with lower covid rates traveled to hot spots to help manage the surge of patients. Now, with the entire country seeing outbreaks, there is simply nowhere for hospitals to turn to send patients or recruit staff.
One theory that some have advanced is that better treatment is leading to fewer hospitalizations or that more testing is identifying milder cases, and that’s why hospitalization rates are dropping. But outpatient treatment of covid has not changed meaningfully in the past month. The most promising potential outpatient treatment, monoclonal antibodies, has yet to see wide usage. Testing has increased, with more than 2 million tests conducted on some recent days, but case numbers and test positive rates have been rising even more steeply, indicating that we are still missing many more cases – especially mild and asymptomatic cases – so there is no evidence that more testing explains the change in rates of hospitalization.
What is happening is that patients who would have been admitted to hospitals earlier in the year are not being admitted now. Indeed, by my best calculation, between a third and half of covid patients who would have been admitted in the beginning of October are now being sent home instead. This is really bad for patients. Some will get much sicker at home. Some may die there.
There is another cost to raising the threshold for admissions, too: Hospitals are running out of beds, and at the same time the United States is burning through its health-care workforce. Doctors and nurses are, in effect, being forced to choose which sick patients will receive care and which will not. The mental and emotional toll is immense. There is evidence of a growing number of suicides among nurses overwhelmed by caring for covid patients.
Some health-care workers are retiring or switching professions. Others are sharing tearful videos on social media, agonized by patients who refuse to believe in the disease that is killing them. In Wisconsin, hospital workers took out a two-page ad in the Wisconsin State Journal, asking residents to help prevent infections. All of them are frustrated by the failure to take more effective action against the virus.
We can do better, both for ourselves and for the health-care workers who care for us. None of us wants to be turned away at the hospital. But that is exactly what is starting to happen for both covid and non-covid patients as the health-care system gets crushed under a pandemic burden that just keeps growing and growing. We can mitigate the worst of it with basic public health measures such as social distancing and wearing masks – and demanding better public policies that limit indoor gatherings.
If we don’t, hospitals across America really will become incapable of caring for any but the sickest of us, causing so much unnecessary suffering and death. And with the pandemic’s end now in sight, that outcome would be particularly tragic.
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Jha is a physician, health policy researcher and the dean of the Brown University School of Public Health.