1 INTRODUCTION

Over 3,815,486 people have died worldwide because of COVID-19 corona virus. The estimated total cumulative financial costs of the pandemic are over $16 trillion. About $8.6 trillion is the amount for hospital care of patients, and the long-term health implications and costs for those who contracted the virus, as well as the statistical estimate for the loss of life. The price tag is $2.6 trillion from people who survived but have resulting long-term health damage or impairment. Other expenditures are related to lost income and output from the pandemic-induced recession, company closings, job loss due to prolonged hospitalizations, and the economic effects of shorter and less healthy life. This crisis remains primarily a public health emergency, and has created the worst economic crisis in decades, resulting in significant impact in output, spending, employment, overall economic growth, and an enormous strain the healthcare industry and beyond.

The corona virus COVID-19 pandemic is an unprecedented crisis affecting a multitude of 213 countries across continents globally. This catastrophe is far from over. Rather, it is spreading continuously even with vaccines available to combat the virus. The World Health Organization (WHO) in 2020 suggested that we are fighting a series of epidemics. This statement is still true now in the 11th month of 2021. As of the second week of November 2021, the Center for Disease Control (CDC)1 reports that there are 46,783,309 cases and 757,663 deaths across 50 states in the United States (US) related to the virus, with 79,388 new infections reported on average each day. Globally, there are 253,606,198 confirmed cases, including 5,108,094 deaths reported to WHO.2 Only 182.5 million (55%) people have been fully vaccinated among the over 329.5 million people in the United States.3 About 64.% or 212 million of adults in the United States had at least one dose of the vaccine.1 The Organization for Economic Cooperation and Development4 stated, “It has triggered the most severe economic recession in nearly a century and is causing enormous damage to people's health, jobs and well-being” (para. 1). There is also uncertainty and confusion with the government's responses to limit the pandemic's human and economic effects.

The purpose of this article is to describe and evaluate the economic impact of the COVID-19 pandemic to the health care system including the policy responses and recommendations that will help in the recovery process.

2 IMPACT OF COVID-19 ON THE HEALTH CARE SYSTEM

The outbreak of COVID-19 has caused an unprecedented health care crisis. Its impact is not something the health care system had prepared for. The pandemic affected many aspects including: inpatient (critical care) and outpatient services (testing), costs (operating and overhead), diagnostic testing (inpatient and outpatient), increase in the use of telemedicine and telehealth, payers issues (government and insurance), suspended or furloughed elective services, shortage of resources from beds to personal protective equipment (PPEs) and ventilators, creation of negative-pressure rooms, surge of health care workers demand (labor supply), as well as furloughs of nonessential workers (clinic clerks, ancillary workers), and transmission of the virus among frontline staff, to and from patients. The overall cumulative COVID-19 hospitalization rate in March of 2019 was 107.2 per 100,000, with the highest rates in people aged 65 years and older (316.9 per 100,000) and 50–64 years (161.7 per 100,000).1 The surge of patients created an enormous shock to the health care industry.

Hospitals who are on the forefront of this pandemic have a thin operating margin.5 Other health care organizations already operating at near capacity struggled to meet the need for equipment such as ventilators, PPEs, intensive care beds and labor supply. The outbreak requires that patients and staff are provided a better and safer working environment despite the government payers and insurance companies further cutting reimbursements. All these factors led to increased business overhead expenses, and it reduced profit margin even further.6 Thus, several hospitals reduced physician pay, and canceled bonus payments on work already completed.5, 6 Outpatient clinics and primary care practices are also greatly affected. There has been lost revenue from the cancellation of outpatient office visits, elective procedures, and elective surgeries.

Some outpatient medical offices are open but resorted to telehealth to reduce the risk of being a point of disease spread. Primary care practices had significant reductions of 70% decrease in use of health care services. This is because, with tight financial situation, people who are at risk and with medical conditions were asked to stay home and curtail outside activities.5 Telehealth has become an essential tool for providing care to patients. It is allowing physicians and nurse practitioners both of different specialties to connect with patients, not only in the hospital, but also in clinics and at home.6 The CDC has reported that telehealth has grown exponentially since the late 1990s and is predicted to be a $30 billion corner of the health care market in 2020. Elective procedures are also halted including all kinds of nonemergency care, from office visits to imaging procedures to filling prescriptions for medications.7 The moratorium on elective procedures jeopardizes the financial integrity of health care systems that are disproportionately reliant on elective procedures as a revenue source.5, 8 The Mayo Clinic for example announced a projected $900 million shortfall related to furloughs of elective surgical procedures. Thus, spending is reduced, and it came from worker pay cuts and furloughs for some hourly employees.5

In response, the US Congress passed the Coronavirus Aid, Relief, and Economic Security Act (CARES), a $2.2 trillion bill with $100 billion designated to hospitals and $350 billion designated to small businesses including private orthopedic practice.9 President Joe Biden also signed into law a sweeping $1.9 trillion coronavirus stimulus package to further aid the pandemic recovery effort. This provided $1400 checks for most Americans and directs billions of dollars to schools, state and local governments and businesses. The relief program alleviated some of the economic burden, but it did not resolve all the financial losses accrued by health care systems.

2.1 Allocation of resources dilemma in healthcare during the acute phase of the pandemic

The scarcity of medical resources during the acute and early phase of the COVID-19 pandemic was extensive. It created sustained demands on public health, health systems, and on providers of essential community services.10 These health needs go well beyond the capacity of US hospitals, from ICU beds to ventilators, PPEs, including the health care workforce or labor supply.10 The American Medical Association (2020)11 emphasized that professionals should protect the interests of their patients during this pandemic by treating people equally, promoting and rewarding instrumental value, and giving priority to the worst cases. They also have a responsibility to contribute their expertise to developing allocation policies that are fair and will safeguard the welfare of clients based on the Code of Medical Ethics. How can medical resources be allocated fairly during a COVID-19 pandemic? Although rationing is not unprecedented, never has the American public been faced with the prospect of having to ration medical goods and services on this scale.12

Rationing of scarce medical equipment and interventions has happened. For example, there was a significant shortage of high-filtration N-95 masks and face shields for health care workers, prompting contingency guidance on how to reuse masks,9 or manufacture mask that can be washed. Physicians and intensivists also had to make crucial decisions about which patients can benefit most from treatment, and the available resources such as intensive care beds, and ventilators. Severe cases in patients with poor prognosis for example did not have to be “intubated” and connected to mechanical ventilators. In May 2020, acute care hospitals in the United States had about 62,000 full-function ventilators, and about 98,000 basic ventilators, with an additional 8900 in the Office of the Assistant Secretary for Preparedness and Response Strategic National Stockpile.12 Consequently, there was a big debate about which state should get these ventilators. Stable patients were instructed to stay home, rather than be further exposed in a hospital setting, while some patients died at home awaiting admission. A call to manufacture new ventilators was made by the government and they also purchased some from other countries. Aside from scarcity of medical equipment and the issue with allocation, there was also a big difficulty maintaining adequate staffing (labor supply) specifically asymptomatic and trained critical care nurses and respiratory therapists.10

To remedy the issue of under-staffing, hospital administrators had to hire out-of-state registered nurses and offered them high salary. They also provided free meals and hotel accommodations for permanent staff to make it convenient for them not to travel home if they prefer to do so, and to ensure that they have ease in reporting to work. These strategies added financial burden to the already constrained hospital budget.

3 WHAT WE DID RIGHT

There are several interventions that are appropriately done and put in place during this pandemic. This includes the development of new vaccines, the heroic efforts of healthcare workers, the public doing its part, and combatting misinformation. Vaccine development is one of the biggest success stories of the pandemic.13 Two vaccines are created in less than a year (Pfizer and Moderna), and another two thereafter (Moderna, Astra Zeneca). The recent approval of vaccines for children between five and eleven years old is also a big milestone. These vaccines prevent severe disease, hospitalization, and further death. Healthcare workers continuously and tirelessly worked to care for COVID-19 patients not only in hospitals, but in nursing homes as well. These physicians, nurses, aides, paramedics, respiratory therapists, and other ancillary medical staff also comforted dying patients and interacted with family members when they said farewell to their loved ones over video calls even though they were confronted with terror, exhaustion, and despair themselves.13 Many Americans continuously adhere to public health guidance regarding mask wearing, social distancing and avoiding unnecessary risks. Although there are some disparities, there is continued willingness to protect themselves and their communities from the coronavirus infection. Science journalists confronted the informational chaos with clear, evidence-based reporting, and media outlets remain on guard as misinformation about the disease and the vaccines continue to circulate.13

4 WHERE DO WE GO FROM HERE?

Experts and epidemiologists assert that COVID-19 will not disappear. It is with us to stay until the vaccine is distributed and administered globally in an equitable manner, or until herd immunity is achieved. Some countries are in the “second wave,” while the “third wave” has hit the United States which was even worse than the first two. During the wintertime when the weather was colder, the virus has migrated from metropolitan regions to more rural settings. The resurgence of infection surpassed than that of the summer of 2020. From March 2021, the 4th wave of coronavirus infection began to mount across states and the new delta variant of the virus surged and is still spreading. Infectious diseases specialists are lately predicting that a fifth wave is maybe coming to hit the already drained population and healthcare system. The policy recommendations that will help in the recovery process are presented below.

4.1 Effective, rapid, responsive, transparent leadership, communication, and collaboration

The COVID-19 pandemic is a novel and complex crisis. Kerrissey and Edmonson14 and Nagesh and Chakraborty15 asserted that what is needed during a crisis is a leader who acts with urgency, communicate with transparency, takes responsibilities or accountability, and focuses on solving problems, and engages in constant updating. Taking responsibility also means that leaders exhibit constancy and resilience. Kerrissey and Edmonson14 further emphasized that problems will arise regardless of how well a leader act during a “large system failure” as what happened in this pandemic. Communication proves to be an invaluable aspect of exemplar leadership.16 Collaboration is also important through engagement with the community local groups, across public and health sectors and nongovernmental organizations to ensure that there is local ownership or accountability, and that interventions are appropriate and acceptable. Forming a crucial network of relationships, alliances and horizontal coordination mechanisms are needed.17 Ahern and Loh17 stated, “The greater the communication and coordination, the more resilient the system is in the face of adversity” (p. 2).

4.2 Clarity of pandemic guidelines based on evidence and science

During a crisis, leaders should constantly seek relevant and timely information and data regarding the crisis's course and impact from reliable sources in accordance with credible expertise and advice based on evidence. This includes data from health professionals, researchers, international colleagues, networks and collaborative partners, surveillance systems, clinical data collection within the health system, aggregated case reports from international patient registries, and through research institutes such as John Hopkins University who provides globally transparent, aggregated, and real-time incidence and outcome data.14, 17

4.3 Need for adequate pandemic planning and preparedness within the community, health and social care sector

It is a fact that when COVID-19 hit, health and social care organizations are not adequately equipped to deal with the extreme situation owing to nonexistence of pandemic control and management policy and protocols. This caused panic, fear, and feeling of uncertainty among them leading to low morale and coordination in the workplace.18 Preparedness, a coordinated approach between government and health and social care organizations to manage and contain such pandemics, planning, and viable management policies are needed.17, 18

4.4 Vaccine equity and legislative mandate clarity

The US government needs better vaccine distribution and administration strategies that will be facilitated by continuous robust political action and support from the federal level. Until then, conventional measures will continue such as quarantine for those with acute infection, limited social contact, and masking for those who did not have the vaccine yet. The resilience of pandemic-exhausted individuals, families, neighborhoods, communities, and nations will still be tested severely these coming years. There is also an ongoing confusion and chaos whether the vaccine should be mandatory for all or not related to those individuals who refuse to be inoculated. This became an ongoing ethical-moral debate. Achieving high vaccination rates across individuals and communities is key to having broad protection mitigating the disproportionate impacts of the virus for people of color and preventing widening racial health disparities going forward. Vaccine equity is an important goal.19

4.5 Investing in the healthcare workforce

The recent talks circle around the “revolution in worker expectations” as the lasting effect of the pandemic which is labeled as the “Great Resignation.”20 Hospitals have been having noticeable number of nurses leaving their jobs and moving to something different. Employee retention is more and more an issue. Job-openings are sky-high with many positions going unfilled for months, and labor supply chains are breaking down. Hospitals are forced to offer bonuses and incentives to cover “holes” in staffing. Investing in the health workforce is recommended as a key intervention during economic crises due to the impact of the health workforce on the population's health and well-being, economic growth, and development of a region.21 Recommendations to transform the health workforce to meet the sustainable developmental goals relate to better and equitable pay, schedule flexibility, better perks, and benefits for employee self-care, supporting nurses' psychological and mental health and well-being, and peer and team support.22, 23

4.6 Investing in social safety net programs for youth and young adults

COVID-19 has significant impact on youth and young adults between 16 and 24 years old who are not in employment, education, or training. Governments must invest in social safety net programs that focus on supporting this group such as job creation, education and training, paid work experience, investments in early childhood care and education, housing, health, and mental health care. This will help offset the impact of the pandemic and help support thriving in the future for youth and young adults.24

5 CONCLUSION

The COVID-19 pandemic is a global catastrophe causing multiple impact to the healthcare system that consequently severed the entire economy of the country. The outbreak is far from over. Rather, it is still affecting countries globally. Worldwide efforts must be continued. Recommendations that will help him lead the country to economic and healthcare system recovery are presented. This includes effective, rapid, responsive and transparent leadership, communication and collaboration; clear pandemic guidelines based on evidence and science; the need for adequate pandemic preparedness and planning within the community, health, and social care sector; vaccine equity and legislative mandate clarity; an equitable, continuous, structured, well-planned distribution and administration of available vaccines to combat the virus, and tracking of new variants; investing in the healthcare workforce; and investing in social safety net programs for youth and young adults. Lastly, more research is needed about the long-term impact of the pandemic and vaccines including longitudinal mental health studies among children, youth, older adults, and frontline health and social care workers.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.