Remote Area Medical (RAM), a provider of pop-up medical clinics for underserved communities, was founded in 1985 to operate medical missions in the Amazon. Over the next 30 years, 90 percent of its operations shifted to the United States, where 740,000 people have lined up for its services—some driving hundreds of miles. In 2014, the group rented out the Javits Center in New York City to provide free care to the uninsured or anyone who needed care they couldn't otherwise afford. A few weeks before the event, the New York State Health Department blocked RAM from holding it, declaring that "no hospital can be operated without a valid operating certificate."
Six years later, amid a pandemic, there are makeshift tents in Central Park operated by medical missionaries, and the Javits Center has become a field hospital—valid operating certificate be damned. Although they have been heralded as bold acts of ingenuity, these stopgap solutions are better understood as emblems of a health care system that is uniquely vulnerable to failing the people who need it most.
The coronavirus pandemic has revealed that the US health care system is in bad shape; it is both overdeveloped and underdeveloped, creating a confusing pattern of excellence and profound failure.
Any pandemic can cause devastation, but Covid-19 has a higher mortality in people with diabetes, obesity, and heart disease and among older adults. Its secondary impacts on the economy also intensify the risk of deaths of despair (by suicide and addiction) or other causes. For most people, chronic conditions come in twos and threes. They take decades to set in and reverberate across generations. The prevalence of chronic conditions in the US population was already projected to grow substantially over the next decade, a burden disproportionately borne by the poor and working class, particularly devastating for people of color, and intensifying for all with age.
At first glance, the US health care system appears to just fail on the margins; however, Covid-19 illuminates that these failures are vast and growing. The current design of the health care system is failing Americans, and the $4 trillion per year question is why.
The US health care system has a basic repeating motif: regional hospitals at its center and satellite clinics in a starburst pattern around it. It is led by doctors and trailed by informal or underpaid caregivers. The basic idea is that when you're sick, you'll come to the clinic or hospital if your issue is serious enough. Then you're sent home to figure out the rest of your life. The system's job is to maintain sufficient flow and manage surges—like a power plant that delivers a regular output and protects itself from blackouts.
This power plant model of health care fails four types of people: (1) economically distressed people who can't afford to access it, (2) people in rural communities who live far from it, (3) people of color who have experienced institutional racism and do not trust it, and (4) people with disabilities, who are challenged at every turn if they seek to access it. Today, as US hospitals and clinics are struggling, calls for quick fixes grow louder. Instead of reflexively rescuing this distressed brick-and-mortar model, policymakers need to look beyond its walls.
There is an alternative: health care delivered at home and in communities, being pushed to people when they need it by local teams. The pattern is decentralized and powered by local talent, more akin to a microgrid than a power plant. Challenges that individuals and families face are identified and addressed in the context where they arise, unless they require higher levels of action.
A new generation of microgrid-style solutions has been slowly emerging across the United States: home-based primary care, hospital-level care at home, remote monitoring of chronic conditions at home, or telemedicine at home. However, most of these innovations have been designed through the lens of consumer convenience, which the nation's wealthy are best positioned to incorporate into their lives.
As isolated solutions, they lack the coherence, urgency, and vision to establish a microgrid form of delivering care that is cheaper, serves rural communities, is trusted by people of color, and is designed for people with disabilities. In the absence of a comprehensive effort to create a new locally oriented health care model, the forces that make these four groups vulnerable to Covid-19 are intensifying at breathtaking speed.
Today, US health care facilities are overwhelmed and seen as dangerous places to be, and Americans shuttered at home are looking for alternatives to waiting for their doctor in a waiting room. Some are simply avoiding health care altogether: Rough estimates project that Covid-19's secondary toll—deaths due to non-Covid-19 health issues (like heart disease) and socioeconomic conditions (such as mental health impacts)—may be in the same order of magnitude as the primary death toll from the disease.
In response, the federal government is deregulating the sector—by removing barriers to using telehealth, enabling some nurses and physician assistants to work without physician oversight, paying for some care at home at the same rate as in a clinic or hospital, and accelerating the use of remote care monitoring devices and self-testing kits.
Taken together, these regulatory changes could accelerate the shift to care at home that was already underway in small and scattered ways. This scatter threatens to spill into Americans' living spaces without a vision to guide it. That said, there is a visible and growing space where a missing half of the US health care system can emerge—one that is flexible and responsive in times of need. Americans will have arrived when the care they need moves through their homes and communities with ease, instead of standing aloof in the institutions outside of them.
For every technology-driven advance of the health care industry, such as the rapid growth of telehealth visits or the potential for remote monitoring of chronic conditions, there will be an academic cottage industry ready to measure how the same groups as before are left behind yet again. But critique without creation is a recipe for other people's misery.
One of the downsides of the futurism that will undoubtedly accompany the reimagining of every aspect of post-coronavirus life is that we all carry our old instincts with us into it. Anything that's left to theory is liable to snap back to habit—and in the case of America's $4 trillion health care industry, the gears of habit are well oiled.
It is therefore crucial to get a practical understanding of what a national-scale health care microgrid must accomplish in order to do what the United States' infrastructure-heavy and physician-led workforce cannot do alone. Fortunately, both wealthy and poor countries around the world have made significant strides toward developing health care microgrids. Americans don't need to imagine what it should look like on their own.
In 2006, a nurse in the Netherlands founded the home-care organization Buurtzorg (Dutch for "neighborhood care"). It comprises local, self-governing teams of nurses that provide home-based care for older adults and those with chronic health conditions. They work with people in their homes to help them develop independence but are also available around the clock and in communication with physicians. A small technology and administration team supports their operations and enables them to focus on solving the specific problems their clients face, including those beyond health care that inevitably impact their health.
The organization is financially independent and by 2018 had more than 10,000 nurses in 900 teams. More than half of all community-based nurses in the Netherlands work for the organization, and they see themselves as community builders. Dutch citizens seem to agree; instead of throttling their capability and independence, regulators have enabled professionals who care for people in their homes to lead.
In Rwanda, a country of 12 million people that is about the size of Vermont, a network of 50,000 health workers have been mobilized across its communities. This network was initially focused on identifying and supporting people with HIV/AIDS and tuberculosis, many of whom were at risk of these diseases because they were already economically marginalized.
This community-based network finds and logs new cases on mobile phones and provides home-based medication and support, which are critical for the management of both conditions. They are paid for performance, and they have delivered remarkable results: The network has better HIV/AIDS management statistics than most US states, and people who are supported by these teams have better mental health and access to benefits.
Rwanda has bolstered this microgrid network with aerial drones that carry labs and medicines and expanded its scope of work into areas like maternal care and child health. Although Rwanda still has work to do when it comes to properly paying and managing this workforce, necessity has forced these networks to evolve in sophisticated ways.
Like in Rwanda, a tuberculosis outbreak in Alaska pushed the state's tribal health authorities to search for an approach to health care that worked for the extremes of harsh weather and remote living. The state worked with the US federal government to develop a telehealth system on a mobile cart that could be accessed in outposts that are staffed by health assistants. Instead of sending in a costly emergency medical helicopter to transport someone for evaluation, patients could first be assessed near where they lived before further action was taken.
These carts have become more sophisticated over time and include a range of remote diagnostic equipment. The health assistants have also taken on more responsibility, riling those who see it as encroaching on their turf; in 2006, the American Dental Association and the Alaska Dental Society unsuccessfully sued Alaska's tribal health authorities because they trained health assistants to remove cavities in children who would have otherwise gone without care. After more than 100,000 visits, this creative mix of remote technology and local teams continues to significantly cut the cost of health care delivery in a difficult setting.
In each of these cases, physicians, hospitals, and clinics have an undisputedly important role. However, their presence is peripheral to the microgrid work done by other health care professionals, aided by remote technologies, and welcomed by patients and families in their homes and communities.
In these three cases, the pressure to develop microgrid strategies emerged from infectious diseases or rises in the costs of care for chronic conditions and older adults. For a highly infectious disease like Covid-19, it is an untenable national strategy to not care for migrants, the homeless, and undocumented or marginalized people. A country with a national pandemic strategy that leaves anyone out is a threat to itself and other countries beyond its borders.
Waiting until fewer people show up at hospitals is not a plan. Watching the costs of health care rise for people who do not overcome their circumstances is not a plan. Building a microgrid of localized health care is.
Taken together, the missing half of a full health care system—one that is home- and community-based first—is vital to America's Covid-19 response, as well as for reaching the groups where the lopsided US system fails.
Over the next months, and perhaps years, policymakers will be asking about a lot of missing systems. For example, the United States needs people who can identify people with Covid-19, trace whom they interacted with, and then find those contacts and test or isolate them. These contact tracing systems have been deployed in settings across the world with varying degrees of technological sophistication, from Iceland to Uganda. Some experts estimate that America will need 300,000 people to do this type of work.
Other systems—such as quickly responding to symptoms of Covid-19 in a community setting, such as for a cough or a fever, and administering a test—are also missing. These syndrome surveillance systems are already being proposed in Australia and deployed in China.
In the uniquely American setting, each of these systems requires community endorsement and engagement. People have to accept having these systems enter their lives and homes. Instead of building new fragmented and segmented systems, the United States should integrate them into microgrids of care, powered by local teams that are well paid, digitally equipped, and well organized. Doctors and hospitals need them, too.
Investing in Americans' health and in communities across the country will pay dividends beyond its immediate purpose, just as the Alaskan system was established to address tuberculosis and has since been repurposed to address a broad array of health challenges from dental care to common injuries.
An event like Covid-19 is larger than any one individual, and it illuminates both failed preexisting patterns of action and the new approaches that could be adopted. But it should also reveal that it is not good enough for the United States to simply get rid of Covid-19 and get back to where it was.
The US health care system must adapt and advance, and that means learning from what works—wherever it is from—and then making it better. Save the makeshift tents in Central Park and Javits Center makeovers for countries that lack the means, wisdom, or will to do better.
Prabhjot Singh is an associate professor of medicine, health system design, and global health at Mount Sinai's Icahn School of Medicine, as well as a special advisor for strategy and design at the Peterson Center on Healthcare. He is the author of Dying and Living in the Neighborhood: A Street-Level View of America's Healthcare Promise and the host of the podcast Should I Take Off My Shoes. Twitter: @prabhjotsinghNY
Disclaimer: This article first appeared on foreignpolicy.com, and is published by special syndication arrangement.