More than 20 months have passed since our first COVID-19 case here in New York. During this time, almost all of us have had to take stock of our operations, apply lessons learned over the past year, and adapt—ranging from how hospitals think about supply chains and “just-in-time” inventory strategy to corporations and their remote work and work-life balance policies. Similarly, it may be the right time to reflect on the lessons learned for the broader health care ecosystem. What follows are six key observations from the pandemic.
1. The pandemic reaffirmed the primacy of the hospital in New York’s health care ecosystem. Despite pre-pandemic efforts to rebalance health care from the hospital to ambulatory settings, we immediately turned to the hospitals when faced with an acute crisis. We looked to them not only for taking care of the sickest patients—which of course only they could do—but also things that could have been and in fact are now primarily done in outpatient settings. Recall all the images of long lines at hospitals for testing and evaluation early in the pandemic.
The pandemic affirmed the centrality of hospitals in New York, which feeds a self-reinforcing cycle: Because hospitals were the strongest part of the health system pre-pandemic, we turned to them early in the crisis, which further strengthened their position, and so on. Their strength was contrasted against the relatively weak infrastructure outside of hospitals, including in primary care and importantly public health. This leads us to the second lesson.
2. The pandemic exposed the consequences of our long-term underfunding of public health infrastructure. A pandemic caused by a novel infectious agent is supposed to be where public health shines. But early in the COVID-19 pandemic, it became clear that public health departments across the United States could not adequately execute the core function of surveillance. The first few months saw a largely uncoordinated assessment strategy, as testing shortages and an inability to adequately trace contacts of infected individuals made it difficult to contain the spread of the virus. And once there was a better grasp of the scope and scale of the pandemic, public health was hampered by political forces in its ability to develop public policies for containment strategies as well as effectively communicate a consistent message around issues like distancing and masking. Twenty months into the pandemic, things appear to be somewhat better, with public health departments asserting a much greater role. But those early days still leave a lasting impression.
This is not only about the underfunding or underinvestment in public health. Just as importantly, it reflects the lack of prominence and influence of public health in the overall U.S. health system. Our health system focuses on treatment—the purview of the clinical delivery system—as opposed to prevention, which is the focus of public health. And it will likely get worse; the backlash against public health departments for mask and vaccine mandates across the country may have further weakened their status by driving out experienced leadership. This has implications not only for the next infectious disease pandemic, but also for the ongoing pandemics of chronic disease, substance use disorders, and other threats to our physical and mental health.
3. The pandemic demonstrated that health and health care disparities are deeply rooted. Wide disparities in health care and health outcomes by race existed before the pandemic across many conditions, so it was unfortunately no surprise that these same disparities appeared in COVID-19 outcomes. COVID-19 and the related economic fallout had a disproportionate impact on communities that are underserved and historically disadvantaged. And although the proximate causes may be related to factors such as poverty, housing instability, and food insecurity, there are deeper roots related to structural racism. These include disinvestment in many historically Black and Latinx communities. While focused efforts—like the current push for vaccine equity—are important, achieving true health equity means ensuring that everyone has the opportunity to be as healthy as possible. This will require a long-term commitment as well as a rethinking of all our systems, policies, and practices.
4. The pandemic highlighted the fragility of our health care financing and payment system. Last year, we experienced the implications of having an insurance system that relies on employer-sponsored health insurance when there is a shock to the system that results in high unemployment. In New York State, we’re lucky that we have a strong insurance safety net system in Medicaid and the Essential Plan, but there was still widespread disruption. And on health care payment, when health care providers rely on a predominantly fee-for-service payment system, it is a financial disaster when health care encounters drop precipitously as they did last year.
5. The pandemic showed that technology adoption can be quick, but it doesn’t mean that it will necessarily stay. After languishing for years, telehealth was quickly adopted by many parts of the health care system, spurred by necessity and the relaxation of regulations and changes in payment policy. But just because adoption was quick, it doesn’t necessarily mean it’s here to stay. This depends on its long-term value both to patients and providers. To date, it looks promising for cases like mental health, established patient visits, chronic care management, and hard-to-reach specialists. But it’s unclear whether there will be continued widespread use, and there are important concerns to address regarding telehealth’s impact on equity.
6. The pandemic reminded us of the importance of mental health for our overall well-being. We ignore mental health issues at our own peril. Pre-pandemic, mental illness was already a leading cause of premature death and disability. And then the mental health impact of COVID-19 left virtually no one untouched. At the extremes, we’ve seen the rise of illicit substance use, overdoses, and deaths. But beyond that, nearly everyone has been affected by grieving for loved ones; loneliness and social isolation; anxiety from economic insecurity; the toll of constant exposure to death and dying for our health care workers; persistent fear of contracting COVID; adjusting to in-person school or work—and the list goes on. The pandemic reminded us that while we may be physically okay, that doesn’t mean we’re actually “well.”
Although certainly not an exhaustive list, these lessons have implications for how we work toward an effective and equitable health system for all New Yorkers.