Written by A. J. Kay
On March 15th, Janet Mills of Maine became the first US Governor to recommend statewide cancellation of all elective medical procedures. Governor Mills proclaimed that such action would, “relieve the strain on the healthcare system as Maine prioritizes COVID-19-related cases.”
That same day, the American Hospital Association (AHA), in cooperation with three other healthcare advocacy organizations, published an open letter to the Surgeon General rejecting the idea that the COVID response necessitated such sweeping measures. They stated declaratively,
“Our ability to respond to patients must not be prevented by arbitrary directives.”
In the following weeks, a cascade of 35 states included similar restrictions on elective procedures in their stay-at-home and shelter-in-place (commonly known as “lockdown”) orders. These directives ranged from instruction on the prioritization of “grey area” elective surgeries to compulsory cancellation and postponement of all non-emergent procedures. Orders in seven of those states outlined explicit civil and criminal penalties (some including imprisonment) for doctors who failed to comply.
In the weeks since the unprecedented multi-state lockdowns, the US Healthcare system has been left with an opaque patchwork of the very same ‘arbitrary directives’ against which the AHA cautioned. The lockdown orders and elective procedure bans were instituted with the intent to save lives. However, our failure to safely and quickly resume elective surgeries when lockdowns helped blunt the impending crisis has financially crippled our hospitals and private practices, led to mass furloughs, and denied healthcare to those who need it most.
The classification of a procedure as “elective” is not as intuitive as one might imagine.
There are only two types of procedures: emergent and elective. Emergent procedures must be performed without delay, typically to save the life of the patient. Conversely, any procedure that can be scheduled in advance (regardless of how far in advance) is deemed elective.
It’s important not to conflate ‘elective’ with ‘optional’. Optional procedures are done for reasons other than the patient’s health (i.e. cosmetic surgery) and while all optional procedures are elective, not all elective procedures are optional.
Examples of elective procedures include: coronary artery bypasses, pacemaker insertions, spinal fusions, cancer resections, tumor biopsies, organ donations, gallbladder and kidney stone removals, orthopedic repairs, joint replacements, blood work, diagnostic imaging, ECGs & EKGs, cardiac catheterizations, nerve-block injections, colonoscopies, mammograms, and bone marrow transplants.
Delay of these elective procedures is no small matter, either for the patients who need them, nor for the healthcare facilities who provide them.
The AHA’s letter to the Surgeon General cautioned against “arbitrary directives” for good reasons:
“…many patients, such as those with cancer or a need for cardiac surgery, will not be able to postpone medical interventions.
“…“elective” surgeries could include replacement of a faulty heart valve, removal of a serious cancerous tumor, or a pediatric hernia repair. Often, if these types of procedures are delayed or canceled, the person’s condition gets rapidly worse and can even be life threatening. This is particularly true with children who are all in an active phase of their life growth and development. The resulting decline in their health could make them more vulnerable to COVID-19.
“A blanket directive to cancel elective and non-urgent procedures usurps the proper role of the physicians caring for patients and their families, collaborating closely with the hospital, to determine what is in the patient’s best interests.
“Hospitals are here to protect and promote the health of all Americans.”
And yet states proceeded with the bans, rendering the AHA’s words darkly prophetic.
As COVID patients were hospitalized in widely varying numbers in different locations, the cost of the one-size-fits-all lockdowns, in terms of human lives, is becoming more clear.
People are unable to access much needed treatment and their conditions are deteriorating. Cancers are progressing from treatable to incurable. People on dialysis, awaiting transplants will die praying for the bans to lift. And many will suffer and die due to a massive appointment backlog once the bans do lift.
Most tragically, in all of these categories, there are children.
The difficulty in quantifying the potential number affected can’t be overstated.
One way to attempt an estimate is to conceptualize how many Americans need regularly scheduled healthcare. Roughly 157 million Americans are currently diagnosed with a chronic disease. That’s approximately 40% of the population.
Chronic diseases are defined as medical conditions that last more than three months and include, but aren’t limited to, heart disease, diabetes, kidney disease, cancer, and mental illness. Typically, keeping these conditions under control requires monitoring and regular communication with healthcare providers. Take cancer for example:
According to the World Health Organization,
“The consequences of delayed or inaccessible cancer care are lower likelihood of survival, greater morbidity of treatment and higher costs of care, resulting in avoidable deaths and disability from cancer.”
That quote doesn’t state that the consequences “might be…” It says they ‘“are.”
If 1 out of 100 of those 157 million chronically ill patients die due to lack of access to healthcare, that’s an additional 1,570,000 preventable deaths we can expect, not as a result of COVID, but from the response. Even if it’s only 1 in 1000, that’s still a loss of 157,000 American lives–far more than the current anticipated death toll of COVID.
And there are additional downstream adverse outcomes that cannot be quantified.
For example, patients in need of orthopedic or spinal surgeries to reduce chronic pain are being prescribed opiates via telemedicine, unnecessarily risking dependency and addiction.
Additionally, a study by Cambridge University found that risk of death by suicide is, at a minimum, doubled in chronic pain patients. Factors that increase suicidal ideation even further were ‘helplessness and hopelessness’ about the pain, ‘the desire for escape from pain’, and ‘duration of the pain’, all of which are likely to be exacerbated by delays in elective, pain-relieving surgery.
And those are just for pain patients. Cancer patients, diabetics, patients with neurological conditions–they all have respective, complicating risks that extend far beyond just a reduced rate of survival.
And what about the kids? Children at a far higher risk from delayed or deferred care than they are from COVID, which poses almost no statistical risk to children. Still, pediatric procedures performed at Children’s Hospitals are included in the elective ban, as well. Minor procedures like hernia repairs, ear tubes, and tonsillectomies have been cancelled, in addition to more life-saving surgeries, including kidney transplants. A 7-year-old boy in Washington suffering kidney failure has been put on dialysis indefinitely since his transplant was cancelled in March. And he’s not alone. Another 16-year old boy is making the same mandated sacrifice. And these are just two cases unearthed by the media.
There are 120,000 elective pediatric surgical admissions per year. Every month the lockdown is extended, roughly 10,000 children in the United States, who are, again, at negligible risk for COVID, will have their surgeries indefinitely delayed or cancelled.
The volume of neglected patients is substantial and includes patients now waiting to have brain tumors removed, transplants rescheduled, cancer excised, and pain eliminated.
Hospitals and providers are suffering as well.
At last count on April 7th, Beckett’s Hospital Review reported 140 hospitals across the country furloughing workers, citing suspension of elective procedures and the subsequent income drop as the causal mechanism. High-margin elective procedures can account for up to 80% of a hospital’s revenue and instituting the ban was akin to a financial knee-capping.
In addition, The US already suffers a dearth of healthcare providers in underserved areas. Many of these rural areas have very few COVID cases and are still unable to meet the needs of their community due to the arbitrary restrictions. Two rural hospitals have already closed since March 17th, as a result of lost revenue from elective procedures, and two more have announced plans to shutter by the end of the month.
And there is no shortage of stories regarding their plight. You can read about a few here:
According to Fox News,
“Rural hospitals like the one in Blaine County have limited resources and are “being strained to the breaking point,” the National Rural Health Association wrote in a letter to congressional leaders earlier this month. Hundreds of other rural providers “are bleeding cash and on the verge of closure as they wait for the pandemic to surge in their communities,” the NRHA said.”
According to Dallas News,
“Faith Community Health System in Jack County has had to furlough, reduce hours or reassign roughly 75% of staff as revenue from elective procedures has dried up, said CEO Frank Beaman. Meanwhile he said a surge of coronavirus patients has yet to materialize in the county — northwest of Fort Worth — where 3 people have tested positive for COVID-19 to date.”
According to CNBC,
“In California, one of the states hit hardest by COVID-19, some physician practices have already closed, and widespread closures nationwide may be less than six weeks away, Shawn Martin, senior vice president of the American Academy of Family Physicians, told the Los Angeles Times.”
On April 20th, The New York Times suggested an alternative scenario to explain the lack of access to healthcare. They cast deaths from untreated non-COVID illnesses as unavoidable casualties of an overwhelmed healthcare system. While care may be halted due COVID overruns in a few areas, the majority of delays in treatment are a result of the elective procedure bans alone. To be more blunt, deaths from untreated non-COVID illnesses are primarily a result of our ham-fisted response. The reality is that the vast majority of hospitals are not overwhelmed with COVID and are, in fact, operating far below capacity.
This a map of current domestic COVID hotspots:
As you can see, most areas in the US have only minimal total cases. And since it’s important to note that known cases increase as testing capacity increases, let’s further characterize the situation in terms of total number of deaths for each state. This will give us an idea of how over (or under) whelmed hospitals actually are.
Total Number of Deaths per State
There’s no shortage of regions like Arizona, which has a population of 7.3 million and a total of only 150 COVID deaths. Per the widely-referenced IHME model, Arizona’s medical resource demand peaked 15 days ago and, yet, they have not lifted their ban on elective procedures.
In Minnesota, where they have explicit threats of imprisonment written into their lockdown orders for providers who do not comply with the elective surgery ban, only two days have passed since peak resource demand. To date, they have suffered 87 deaths from COVID among their population of 5.6 million.
And in Texas, which has not only threatened providers with imprisonment for performing elective surgeries, but mandated that other healthcare providers report their non-compliant colleagues to the state, is one day past peak resource use. The state has suffered a total of 414 COVID deaths among their population of 29 million. They also operate within their borders 299 rural health clinics which, as previously mentioned, serve some of the country’s most vulnerable populations.
When you consider both the demand for elective procedures from non-COVID patients, and the concentrated distribution of COVID deaths in New York (and relatively few deaths everywhere else), it is easy to conceptualize how the elective healthcare crisis death toll will rapidly dwarf the total death counts attributed to COVID-19.
Our singular focus on COVID as the only urgent healthcare need will cost us gravely. Every day we extend the lockdown and, ergo, the ban on elective procedures, we decrease the likelihood that Americans will win the fight against their diseases, COVID and non-COVID alike.
And the real tragedy is that there are plenty of available providers and hospitals with the ability to treat patients and, yet, we will not allow it.
Financially crippling hospitals to the point of furloughing providers impacts all patients. The result is reduced capacity to care for current and future COVID patients and treatment backlogs for all others. Delays in diagnosis and treatment, even after the bans are lifted, will likely linger for years.
Right now, in various cities and towns across the country, Americans are waiting for their leaders to act.
John has a stent in his heart. He has been stable for the last year, but he has now missed his six-month follow-up scan and wonders if the pain in his arm is worrisome. Jessica had an abnormal mammogram in February and has a family history of breast cancer. Her biopsy previously scheduled for March is now indefinitely delayed. Amy has an inoperable liver tumor and is experiencing persistent gastrointestinal symptoms. She knows that something is wrong but her doctor is unable to order a colonoscopy or an MRI to rule out metastasis.
We are reserving space in the healthcare system for COVID patients who may never come. And at what cost? Will Amy’s young children feel that it was a justifiable sacrifice to lose their only parent when, at the time she needed life-saving imaging, there were only 100 COVID patients hospitalized in her entire state? Will John’s wife find shortening his life by 3-4 years an acceptable price to pay when their community of 10,000 has a final COVID death toll of three? Will Jessica’s grief about her mastectomy be blunted knowing her diagnosis was delayed in service of a crisis that never materialized?
If we are going to double-down on lockdown measures we must be willing to sit down a year from now with Amy’s orphaned children or John’s widowed wife and look them in the eye and tell them that there was no other way to manage this public health crisis than to confine them to their homes and deny their mom and their husband care.
And we can’t do that, because it’s not true.
Americans value life, yet we must accept that people die every day. We die from cancer. We die from heart disease. We die from car accidents and random acts of violence. We die from COVID-19. We die from suicide. But never in our collective history have Americans died, en masse, from treatable illnesses because we actively prevented them seeing their doctors. We will not accept that.
Extending lockdowns will come with deadly consequences. We can protect the vulnerable from both the immediate risk of COVID infection AND the massive holistic risks that accompany stay-at-home mandates.
The all-or-nothing proposition of full-scale lockdowns & elective procedure bans are a false dichotomy. We do not have to prioritize one group of American’s needs over another.
We must find a way to care for both.