Coronavirus Will Have Long-Lasting Impacts on the U.S. Health Care System—And the Poorest Will Suffer Most

When Dr. Mark Lewis has to tell a cancer patient they’re dying, he tries to do so as compassionately as possible, usually offering a hug or a hand to hold. The thought of doing so by phone, he says, once felt heartbreakingly impersonal. But in the face of the current COVID-19 pandemic, the Salt Lake City-based gastrointestinal oncologist has had to do many things that make his “conscience weigh heavy.” He’s delivered bad news virtually, to limit the possibility of spreading the virus. He’s delayed chemotherapy for patients who—he hopes—can wait, knowing the treatment would wipe out their immune systems at a high-risk time. He’s made the opposite choice for patients with cancer spreading faster than coronavirus. Each time, all he can do is hope he’s gambled well. Welcome to medicine in the age of COVID-19.

The worsening coronavirus epidemic in the U.S. has upended the country’s medical system. It has led to system-wide disruptions that physicians say are necessary for combatting the immediate, un-ignorable threat of COVID-19—but that may, by default, force patients who do not have coronavirus to shoulder a heavy burden. Those with chronic conditions will have to fight harder to get the care they need, not only now but also after the outbreak ends, when hospitals are left to deal with backlogs from appointments canceled en masse. Anyone with the misfortune to get into a car accident or have a heart attack during the outbreak will be at the mercy of a strained system. And in this environment, the gulf between people who can and cannot afford to spend the time and money to seek out good care will become ever-more apparent.

As of publication, U.S. hospitals are still operating smoothly for the most part, but obstacles are mounting. Protective gear and supplies are running short. In a health care system in which routine supply and demand leaves only about a third of hospital beds available on a normal day, medical centers are creeping dangerously close to capacity, particularly in hard-hit areas like New York City and King County, Washington. As fears mount and supplies dwindle, “morale is low,” says Dr. Chethan Sathya, an assistant professor of surgery and pediatrics at New York’s Cohen Children’s Hospital. Each day in the hospital, Sathya says, raises the chances of doctors getting sick, and passing the virus on to their families. Ready though they are to serve, that thought is never far from their minds.

Surgeons like Sathya have been directed by the Centers for Medicare and Medicaid Services to postpone elective procedures to keep hospital beds and supplies available, prioritizing conditions that require “emergent or urgent attention to save a life, preserve organ function, and avoid further harms from underlying condition or disease.” Deciding who fits that case description, however, often falls to individual doctors and hospitals, and it’s not always easy—a patient on dialysis can wait a few more weeks for a kidney transplant, but should they? For patients who are admitted, facilities have placed often-heartbreaking limits on bedside visitors—including, in the NewYork-Presbyterian and Mount Sinai hospital systems, on partners of women in labor—to reduce the risk of viral transmission. Job descriptions are blurring, with doctors of all specialities and career stages joining the pandemic response—whether by pausing their day jobs to provide more-urgent critical care, or by pitching in to provide childcare and other support for physicians on the front lines.

“I’ve been brushing up on how to manage a ventilator, because I haven’t had to do that in almost a decade,” Lewis says. “In a week, two weeks, I might have to shift from the long-term care of cancer patients to acute critical care.”

Lewis and other doctors have little choice, but these decisions aren’t without consequence. Dr. Anupam Jena, an associate professor of health care policy at Harvard Medical School, says patients with urgent medical conditions, such as strokes and heart attacks, might fare worse than normal, either because they voluntarily delay going to the hospital or because at-capacity emergency departments can’t see them as quickly as usual. Some people who follow directions and cancel routine screenings may also go longer without knowing they have cancer, diabetes or heart disease, potentially hurting their long-term prognoses, he says.

The outbreak has also thrown the relationship between wealth and health into sharper relief than ever. Research has shown that the richest 1% of Americans can expect to live more than a decade longer than the poorest 1%—and that’s without a pandemic in the mix. COVID-19 has drawn a clear line between people with white-collar jobs that allow them to follow public-health advice and work from home, and those in service-focused jobs who must be physically present—thereby risking infection—to collect a paycheck. The country’s most vulnerable populations, such as those who are homeless or living below the poverty line, are the least able to stock up on groceries, prescription medication and other supplies and hunker down inside; they’re also less likely to own a car, or otherwise have the means to safely travel to a doctor’s office if needed.

The class-based health care gap is likely only to widen, Sathya says. “As the unemployment rate rises because of this, people are going to have less and less access to health insurance,” he says. If health care is in high demand and short supply, wealth, and access to pricey private doctors, will play an increasingly ugly role in who gets it.

If there’s any bright spot, it’s that COVID-19 has pushed one fairly egalitarian solution into the primetime: telemedicine. Virtual doctor appointments, usually done via video chat, have long been pitched as a way to expand access to care, but adoption has historically been sluggish. That’s changing: Telemedicine provider Amwell, which works with more than 55 health plans and 2,000 U.S. hospitals, has seen its usage grow 257% nationwide during the COVID-19 pandemic, and by around 700% in Washington State, a company representative tells TIME.

Telemedicine isn’t a cure-all. Some ailments can’t be treated this way, and some patients don’t have access to the technology. But the pandemic has prompted the U.S. government to temporarily ease long-standing restrictions, allowing Medicare to cover more telehealth services, and health systems are using it more enthusiastically than ever before. Doctors hope those changes—and a growing awareness of the disparities that prompted them—will stick around even after life returns to normal.

“Out of every catastrophe,” Lewis says, “we try to see the silver lining.”