While all nations have struggled to combat the spread of COVID-19, those with universal healthcare systems held an advantage over the United States. Universal systems allow data to be standardized, centralized, and complete for every patient, which improves care and can better inform public health strategies.
Universal healthcare has been a continual source of division and debate in the United States despite the fact that, as of 2020, at least 63% of residents believe that the federal government should at least be partially responsible for citizens’ healthcare coverage.1 Among those polled, 36% favored a single national program, such as the proposed “Medicare for All” system.2 U.S. healthcare expenditures are also excessive and unjustifiable. As we discussed last week with Dr. Scott Zeger, the United States spends over $2 billion more per capita than the next developed nation yet still ranks between 20th and 30th in most major negative health outcomes. Our system is inefficient and costly. People living in the richest country in the history of the human race should have access to quality care without fearing for their financial security. Additionally, this fractured and private system makes it impossible to accumulate and access complete data on any patient to inform their personal healthcare and the public health responses to crises.
Universal healthcare systems better support public health and healthcare officials in the decision-making process because all patients have unified, complete medical records accessible outside of the single institute where they received treatment. This uniformity allows for standardization in definition, accountability, and cost. In terms of health data, we are lagging significantly behind our European peers, specifically in Scandinavia, as explained by Dr. Michael Darden. We must often rely on studies performed in other countries with better data even though we have the funds, capacity, and talent necessary to do the same here.
While change can be concerning to many people, we already have experience with a unified health system in the United States through the Department of Veterans Affairs (VA). The VA is currently undergoing electronic health record (EHR) modernization scheduled to be completed in 2028. This will mean that any healthcare professional at any VA location can access a patient’s full VA medical history even if they have been seen at different locations, across state lines, at various times. This is valuable information for any healthcare provider, enabling them to provide tailored, appropriate care to their patients. It has even been shown that patients are more likely to have better outcomes by staying at their usual hospital as opposed to seeking a specialist in a different hospital. This is primarily due to your the fact that your usual hospital has access to your complete EHR, demonstrating the power of a complete EHR to improve patient care.3 A system of unified healthcare data like the VA could enable each new healthcare professional a patient sees to have that same, powerful data available, improving each patient’s care.
Apart from directly benefiting patients, unified health data brought about through universal healthcare is also an incredible boon to public health officials in the midst of crises like the COVID-19 pandemic, as shown by the United Kingdom’s National Health Service (NHS). Briefly, the NHS (composed of four components representing England, Northern Ireland, Scotland, and Wales) was founded in the wake of World War II to provide free, comprehensive healthcare to everyone, paid for through general taxation. There are still major critics of the NHS even within the United Kingdom,4 but the results are clear: the system is more effective, less costly, and more equitable than our private healthcare system in the United States.5
Since the beginning of the COVID-19 pandemic, the Transformative Directorate at the NHS (previously NHSX) has been working to best utilize the unified patient data available. One of their first efforts was the establishment of the NHS COVID-19 Data Store, which centralized patient COVID-19 data (including tests, cases, hospitalizations, and deaths) to feed three dashboards: one for the public, one for high-level policymakers, and one for NHS officials. Each dashboard provides different types and quantities of data depending on the users. There was no need to create a centralized dashboard, like the Coronavirus Resource Center, that provided real-time data sourced from every region since all U.K. data was already in the NHS-unified EHR. This allowed complete, updated datasets to be available almost instantly to decision-makers on every level, removing much of the lag that has plagued U.S. COVID-19 data reporting.
The NHS established another platform for COVID-19 research called OpenSAFELY, which is similar to the Observational Health Data Sciences and Informatics initiative (OHDSI) and the common data model, OMOP, that we covered in our interview with Dr. Paul Nagy. With OpenSAFELY, Researchers can design models and analytical studies based on the universal NHS EHR and then apply their code to the NHS COVID-19 patient datasets that remain fully protected and private behind NHS firewalls. The model runs on the protected data and then releases results in aggregate. The researchers do not access any protected patient data, but receive all the benefits of access to the full data set. While we are making strides at U.S. healthcare institutions through the implementation of the OMOP common data model, data available to the NHS is much more comprehensive and complete.
Since a single system provides all health services, the NHS has complete data on every patient, the data is real-time, and the data can be protected and shared sparingly. U.S. COVID-19 research would have gotten an incredible boost from a unified data system like the NHS. Researchers would not have been restricted to studying patients at just their home institution, collaborator institutions, or those part of the OHDSI initiative. The impacts of new medicines and treatments on patients would have been clear much earlier, possibly stemming the spread of misinformation. Patients could have also been guaranteed that their healthcare providers knew every possible detail of their health history to aid in their treatment for COVID-19. It is discouraging to realize that simply the design of our healthcare system incredibly hindered the national response to COVID-19.
It is important to recognize and contemplate the concept of better data for both personal and community health as a key component of our healthcare system. The federal government will continue to debate how healthcare should be administered in the United States, and it is almost certain that one day we will change the system yet again. The 2010 Affordable Care Act was a much-needed improvement, but it’s not a permanent fix. The accessibility, privacy, and utility of health data will need to be a major part of these debates as we start to design the next iteration of healthcare in the United States to prepare for future pandemics and ensure every person's right to life and the pursuit of happiness.
1. B. Jones, Increasing share of Americans favor a single government program to provide health care coverage, 29 September 2020. https://www.pewresearch.org/fact-tank/2020/09/29/increasing-share-of-americans-favor-a-single-government-program-to-provide-health-care-coverage/. (Accessed 25 April 2022).
2. Z.B. Wolf, T. Luhby, C. Merrill, Here’s what Bernie Sanders’ ‘Medicare for All’ proposal actually says, 2 March 2020. https://edition.cnn.com/interactive/2020/03/politics/medicare-for-all-annotated/. (Accessed 25 April 2022).
3. S. Turbow, N. Sudharsanan, K.J. Rask, M.K. Ali, Association between interhospital care fragmentation, readmission diagnosis, and outcomes, Am J Manag Care 27(5) (2021) e164-e170.
4. F. Harvey, Tories accused of corruption and NHS privatisation by former chief scientist, 13 April 2021. https://www.theguardian.com/politics/2021/apr/13/tories-accused-of-corruption-and-nhs-privatisation-by-former-chief-scientist. (Accessed 26 April 2022).
5. H.T.O. Davies, M.N. Marshall, UK and US health-care systems: divided by more than a common language, The Lancet 355(9201) (2000) 336.
Title image courtesy of The Blue Diamond Gallery via Creative Commons License CC BY-SA 3.0