OMAHA — Freddie Warner Jr. couldn’t take it anymore.
His hip hurt, which caused him to put more pressure on his knee. That made his back hurt. He couldn’t sit or stand for long periods. The 51-year-old Omaha man gave up his job in lawn care, his occupation since high school.
Freddie Warner Jr.
On Dec. 1, Warner underwent surgery to replace his left hip. On Feb. 7, he had surgery on his right knee.
While hundreds of joint replacement surgeries are performed every day across the country, Warner’s operations came during a surge in COVID-19. At the time, staffed hospital beds were in short supply, and many elective surgeries like Warner’s had been postponed or canceled.
Instead of keeping Warner at least one night in the hospital after his surgeries, which had been the more common practice, his surgeon sent him home the same day.
After some physical therapy and exercises at home, Warner was able to start a new lawn-care job at the end of March.
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While a shift to more outpatient or same-day surgeries had been underway for some time, health system leaders say the pandemic accelerated it. It similarly sped the expansion of telehealth, which gave people access to clinicians when clinics were closed and many patients were leery of in-person encounters. It also provided remote support to staff at smaller hospitals, allowing them to keep more patients closer to their homes.
The pandemic also exposed the challenges facing the health care workforce and the gaps between the demand for such workers and educational programs’ ability to produce them. And just as worker shortages have helped drive wage increases in industries from transportation to food service, health systems also are seeing increased labor costs.
Cory Shaw
“It’s about making sure we’re competitively paying people for the work they’re doing,” said Cory Shaw, chief operating officer for Nebraska Medicine. ” … We have to make sure we pay competitively for the difficult jobs they’ve got.”
Steve Goeser, president and CEO of Methodist Health System, said some health care workers have retired or left the profession as a result of the pandemic. Others have moved to less stressful jobs. Some have left for more lucrative traveling medical jobs.
“So, yes, it’s really accelerated salaries,” Goeser said. “It’s put a real strain on finances. I think we’re fortunate in the staffing that we have and the people that stayed with us.”
Shaw said Nebraska Medicine already has begun alerting insurers to its increased costs. Reimbursements from Medicare and Medicaid, which make up 60%-70% of a typical hospital’s business, fall well short of cost increases in a normal year and will lag even more as health systems seek to cover increased costs.
“It’s going to force us to revisit with our health insurance partners and employers what they’re paying for health care,” Shaw said. That likely will eventually translate to higher premiums and out-of-pocket expenses.
Cary Ward
Dr. Cary Ward, chief medical officer with CHI Health, said the cost of health care has gone up dramatically and will stay that way for some time. CHI Health spent $8.7 million on traveling nurses in February alone. Pre-COVID, that tab was about $1.8 million a month.
At the same time, the recent decline in the number of COVID patients, while good news, has meant a reduction in reimbursements for their care. And the cost of supplies and pharmaceuticals also has gone up.
“It’s a very expensive time in health care,” Ward said.
For many consumers, health care already was costly. Premiums for employer-sponsored family health coverages rose 4% in 2021, according to the Kaiser Family Foundation’s annual survey, with workers on average contributing $5,969 toward the cost of family coverage. Since 2011, average family premiums have increased 47%, more than average wages — at 31% — or inflation — at 19%.
The federal government has taken steps during the pandemic to ease the financial impacts of the pandemic on Americans:
* Federal funding has covered out-of-pocket costs of COVID testing, vaccines and treatments.
* The public health emergency kept tens of thousands of people enrolled in Medicaid regardless of changes in their eligibility.
* The American Rescue Plan Act increased premium tax credits available through HealthCare.gov, the federal insurance marketplace. The number of Nebraskans enrolled in the marketplace increased by 12% to roughly 99,000, according to CMS.
What happens next, however, is up in the air. Federal funding for testing, vaccines and treatments for the uninsured is running out. An effort to provide an additional $10 billion in COVID assistance remains in flux. A Senate measure would allow the Biden administration to purchase more vaccines and therapeutics but would not replenish the program that pays for testing, treating and vaccinating the uninsured.
Meanwhile, the Biden administration has extended the public health emergency until mid-July. An earlier end could have caused thousands of Nebraskans who remained on Medicaid during the pandemic to lose that coverage, Nebraska Appleseed says. The expanded tax credits are scheduled to expire at the end of the year, although efforts are underway to include them in future legislation.
Health system leaders say the pandemic drove greater collaboration within and among the state’s health systems. Smaller hospitals, they say, managed patients with more serious conditions than they had before.
“Big or small, you still have to have those partnerships,” said Kelly Driscoll, president and CEO of Faith Regional Health Services in Norfolk. “Those are key roles to provide the health care that we all want to provide.”
The pandemic also required health systems to adapt quickly.
Allen Gaspers, a technician with Control Services, consults with Kenny Walters, Methodist Health System’s facilities director, and Morgan Hankins, Methodist construction project manager, during the installation of additional negative airflow systems at Methodist Women’s Hospital in April 2020. Hospitals quickly converted entire floors to negative air pressure during the pandemic to house infected patients.
Goeser said Methodist staff knew the value of negative airflow rooms in preventing the spread of pathogens but never fathomed they would create whole floors with negative airflow for treating patients with COVID. Doing so meant nurses and other caregivers could gown up once for a shift rather than changing between each room.
Like other health systems, Methodist quickly expanded its intensive care unit to other areas and used pre- and post-operative areas for overflow. The health system set up a call center over a weekend to triage patients and send them to a designated COVID clinic to avoid overburdening its emergency rooms.
Ward said the acceleration of outpatient and same-day surgeries was a positive development that came out of the pandemic. When done with the right patient who has adequate support at home, it’s better for patients and lowers the cost of care.
“It’s great,” Ward said, “and we hope that will be a trend that will continue.”
Dr. Clayton Thor, an orthopedic surgeon with CHI Health, Dr. Clayton Thor, an orthopedic surgeon with CHI Health, said most of his hip and knee replacement patients before the pandemic spent at least one night in the hospital. Now, roughly 80% to 85% go home the same day.
Dr. Clayton Thor, an orthopedic surgeon with CHI Health, said most of his hip and knee replacement patients before the pandemic spent at least one night in the hospital. Now, roughly 80% to 85% go home the same day, as Warner did.
“COVID did the shift for me,” Thor said. “We had to cancel inpatient surgeries for such a long period of time, and multiple periods of time … to where patients were hurting bad enough, the only option was to do it that way.”
Thor said he started shifting to same-day dismissals with younger, healthier, more active patients and gradually expanded his list. Patients with other significant health issues, such as cardiac histories or oxygen use, still are kept overnight.
Freddie Warner Jr. tidies up a neighborhood while working for a landscaping company in Omaha earlier this month. Warner had his left hip replaced in December and his right knee replaced in February. He was released from the hospital on the same day after both surgeries. The practice became more common during the pandemic.
Warner said he was happy to skip a night in the hospital. He had set a goal of getting back to work by May, which he beat by about a month. “I didn’t think it would be this early,” he said. “I feel brand new, like I have a lot of energy to go out and do things.”
Shaw said Nebraska Medicine performed 24,000 surgeries five years ago, 10,000 of them inpatient procedures and 14,000 outpatient ones. For the fiscal year that ended June 30, the numbers stayed about the same but shifted to 15,000 outpatient surgeries and 9,000 inpatient ones. He expects the shift to continue during the current fiscal year.
One reason for the shift, which Shaw said was highlighted during the pandemic, was to make sure hospital beds were available for those who really need them.
And just as schools and businesses flipped to remote sessions on Zoom, health systems and clinics quickly expanded their telemedicine offerings to provide clinical and behavioral health visits and offer online consultations with other, smaller hospitals.
Faith Regional’s respiratory therapists, for instance, trained staff at smaller hospitals to use BiPAP machines, Driscoll said. A noninvasive form of ventilation, BiPAP became an important treatment for COVID patients.
Shaw said telehealth made up a sliver of Nebraska Medicine’s clinical activity before the pandemic. At the peak, it comprised 80% to 90%. Now it’s back to 15% to 20%. Health systems with a greater share of primary care may be higher, he said.
Methodist peaked at about 250 virtual visits a week when some clinics were closed and now has dropped under 100, Goeser said. But the health system maintains robust virtual outreach to other hospitals and in behavioral health.
Ward said 32% of CHI Health’s visits during the peak of the pandemic were virtual. That has since declined as patients have returned to more in-person visits. But Ward said virtual care still offers an alternative for many, such as those who don’t feel well enough to come in and patients who live far from clinics.
“I think telehealth will play an increasingly important role in the future of health care,” he said.
Drive-up care also caught on during the pandemic, Ward said. Three new CHI Health family health centers, one near CHI Immanuel in Omaha, one in Elkhorn and another in Lincoln, will have heated drive-thru bays that patients can access.
Dr. Michael Romano, chief medical officer for the Nebraska Health Network, said the shift toward more virtual care and outpatient procedures generally is a good thing because both are done in lower-cost settings. The cost pressures in health care, he said, will create incentives for providers to look at how they can do things differently.
“I don’t necessarily look at the cost pressures as being a bad thing,” Romano said. “I think we ultimately end up doing things better because the cost pressures have forced us to do things better.”
The data on outcomes from virtual care, however, still is a few years away. “My gut feel is there are lots of situations where it’s very effective, some others not so much,” he said. “We need to be a little selective in how we use it.”
Lee Handke, the network’s CEO, said patient satisfaction with telehealth is high, which will make it difficult to reverse course. The health network, which formed in 2010, includes physicians in Nebraska Medicine, Methodist Health System and Fremont Health.
Eventually, Handke said, health plans will begin to steer members to providers and facilities with lower costs. What’s still missing from that equation, however, are easy-to-use tools to help customers compare and shop. Recent federal pricing transparency rules require health systems to post pricing information. That raw data will become easier to use once software developers create new tools tapping the information.
Romano added that employees still will need some incentive, such as being able to share in the savings on out-of-pocket costs, to shop around.
Meanwhile, health system leaders say they’re working to increase efficiencies.
Methodist, for instance, began using artificial intelligence to automate billing and claims in 2019 and since has increased the use of the technology. Jeff Francis, vice president of finance, said the automation saves about 1,400 hours of work a month that once was done by staff in claims alone.
Nebraska Medicine and the University of Nebraska Medical Center are developing an 18- to 25-bed inpatient unit on their campus as a futuristic setting where they can test different care team models and technologies. The goal is to have patients in the unit beginning in 2024.
Ward said CHI Health has looked at several different models of care intended to increase cost effectiveness and adjust to staff shortages.
One model, called iCARE, or Interprofessional Collaborative Alignment Resulting in Exceptional Patient Care Teams, involves bringing pharmacists onto floors to help nurses administer some medications, such as complex antibiotic infusions, and having occupational therapists assist nurses with tasks such as walking patients and strength training.
Shaw said the delaying of care during the pandemic is likely to have long-lasting effects. If patients avoided or didn’t have access to cancer screenings, they later might be diagnosed with a more advanced disease that will cost more to treat than if it had been detected earlier.
Because of such concerns, health systems have been encouraging people to get in for screenings and other preventative care.
Handke said the health network worked with providers during the pandemic to focus on the most vulnerable patients during the pandemic. As an accountable care organization, the network’s goal is to take good care of Medicare patients in order to improve their health and lower costs. Wellness visits for those patients during 2021 remained high.
Romano said some national data indicates that more strokes and heart attacks have occurred since the pandemic began. Cancer screenings and new diagnoses of cancer have fallen off, although it may take a few years before that impact is clear. “I don’t think we know how that’s going to hit,” he said.
A brief look at American health care’s long, complicated history
A brief look at American health care’s long, complicated history
America’s health care system has existed, in one form or another, since the time when the country’s founding fathers were still fighting for their freedom from Great Britain. Over the intervening 200-plus years, medical care in the U.S. has had a long history of ups and downs, from the difficulty of addressing racism toward the formerly enslaved to the historic enactment of the Affordable Care Act.
Health care in the U.S. may be best described as a hodgepodge of systems. From a global perspective, there are four main models of health care, each of which takes a different approach both legislatively and in practical terms of how it affects a populace’s ability to obtain health care coverage and services. The U.S. model is unique among nations in that it incorporates aspects of each of the four health care models into its own. Most Americans receive coverage under what is known as the Bismarck model, which is to say they are covered through their employer. But the U.S. Veterans Health Administration more closely resembles the Beveridge model, as it leans toward a more socialized coverage system. And then there is Medicare, whereby the U.S. government acts as a single-payer service for older Americans. This is in stark contrast to our neighbor to the north—Canada offers a national health insurance model, where the government essentially runs health care on behalf of its citizenry. In China, an out-of-pocket model is in place, meaning people are on the hook to pay their medical expenses as needed, while in Europe, various countries offer more socialized renditions of the Beveridge and Bismarck models.
The 2020 U.S. Census indicated that as many as 8.6% of Americans do not have health insurance. Universal health care has proven to be an especially tricky topic for Americans to navigate, as lobbyists and politicians alike have waged ferocious campaigns to try bringing it to life—or burying it from ever being signed into law. To this day, the Affordable Care Act, which in recent years brought the country closer to the universal health care model, remains under scrutiny.
With political battles over the health care system ongoing—the most recent controversies centering on health care for transgender youth and the COVID-19 vaccine—Sidecar Health identified 10 major milestones in U.S. health care policy from the colonial era to recent history, charting our nation’s fraught relationship with how it cares for its citizens.
1781: First medical society established
The Massachusetts Medical Society is the oldest medical society in the U.S. that is still in operation. It was incorporated in 1781 to “promote medical and surgical knowledge, inquiries into the animal economy & the promotion & effects of medicine.” Several of the nation’s founding fathers, including revolutionary leaders Samuel Adams and John Hancock, were among the Society’s 31 founding members. “It was born in troublous times; and its founders were still engaged more or less actively in a political struggle which even today, by reflex action, is exerting a powerful influence on the events of the world,” Samuel Abbott Green, a physician and historian, said in a speech in 1881. The “political struggle” Green referred to was the Revolutionary War and, in fact, the society was established just days after the Battle of Yorktown. A medical society had been previously established in 1735 in Boston, but it was short-lived and its records were lost. Since it was established, the Massachusetts Medical Society has grown from its original number of 70 members to its current roster of 23,000 members.
1865: Medical division of Freedmen’s Bureau is established
The medical division of the Freedmen’s Bureau was an institution dedicated to serving the formerly enslaved, or freedmen, in the South after the Civil War. The Freedmen’s Bureau was established on March 3, 1865, by Congress and played a vital role during the Reconstruction era as a means to “direct such issues of provisions, clothing, and fuel.” The organization, which was run by the U.S. War Department and General Oliver O. Howard, was meant to help bring unity in the South between Black and white Americans. The medical division addressed the health needs of the formerly enslaved, and despite poor conditions, it was often the only access to medical care many freedmen had. Demand for medical attention became so overwhelming, it was difficult for these hospitals to keep up and provide resources. The Freedmen’s Bureau came to an end in 1872 due to an overall lack of support in Congress.
1929: First employer-sponsored health care plan in the US is made available to teachers
In 1929, Blue Cross Blue Shield established the first employer-sponsored health coverage in Dallas as a partnership between the Baylor University hospital and its patients. The patients, many of whom were school teachers, were struggling to cover their medical bills. To counteract this, Justin Ford Kimball, an administrator at the university, offered a plan in which teachers were provided 21 days of hospital care for just $6 annually. Many employees began to sign up for the plan, and it didn’t take long for this plan to gain popularity across the U.S. Today, BCBS serves more than 106 million members across the U.S.
1943: IRS makes employer-sponsored health insurance tax-free
President Franklin D. Roosevelt’s Executive Order 9250 established the Office of Economic Stabilization, one of the direct effects thereof was a nationwide wage freeze. The executive order, issued in 1942, was in response to the labor shortage the country was facing due to its participation in World War II. As a result, businesses began to use employer-sponsored health care benefits as a way to attract employees. A year later, the Internal Revenue Service made health insurance provided by employers tax-free. As a result, this made it far cheaper for Americans to get health insurance through an employer than other providers. As the economy improved after World War II, employer-sponsored health insurance became even more popular among businesses.
[Pictured: Mrs. Franklin D. Roosevelt stands with Dr. Claude Munger, president of the American Hospital Association, during her visit to the American Hospital Association Convention.]
1945: Harry Truman’s proposal for a national health insurance fails
Despite it being a failed attempt, President Harry Truman’s proposal in 1954 for national health care was still a crucial moment in American history. After pointing out that millions of Americans were without health care, President Truman told Congress, “The time has arrived for action to help them attain that opportunity and that protection.” Truman wanted to introduce universal health insurance to address the shortage of health care available to workers in rural areas, improve the quality of hospitals, and slow rising health care costs. His bill, however, didn’t gain enough support. But it was a significant ask during a time when the country was mired in the early decades of the Cold War and any governmental system perceived to be “socialist” in nature was construed as anti-American.
1950-1960s: American Medical Association lobbies against single-payer systems
The American Medical Association has long been in opposition to single-payer systems, stretching as far back as the 1950s. During that time period, the AMA lobbied harshly against socialized health care, supporting employer-sponsored health care plans instead. Later, in the 1960s, the organization created Operation Coffee Cup in retaliation against President John F. Kennedy’s proposal to introduce federally supported health care for the elderly. The plan called for the Woman’s Auxiliary, which had partnered with the AMA, to rally support through morning coffee meetings. The campaign even featured a speech by Ronald Reagan who stated, “One of the traditional ways of imposing statism or socialism on a people has been by way of medicine.”
[Pictured: President Kennedy speaks at Madison Square Garden in New York to a crowd of 17,000 people, many of them elderly. In his address, Kennedy urged the nation’s doctors to get the facts on his proposed legislation to offer medical care for seniors.]
1965: Medicare and Medicaid programs established
One of the largest health care acts in American history, commonly referred to as the Medicare and Medicaid Act, was approved by President Lyndon B. Johnson in July 1965. Both Medicare and Medicaid are actually subtitles to the overall Social Security Amendments of 1965. In addition to providing health insurance to the elderly and to those with low incomes, they also established programs for retirement, disability benefits, and survivors’ benefits. During the first six months of its enactment, Medicare covered the health care of more than 2.5 million Americans. When the bill was first passed, it allowed users over age 65 to pay a monthly fee of just $3 for health insurance, which covered 80% of their health care services. Early forms of the Medicare and Medicaid Act also required that users promise that they were not members of the Communist Party. Former President Harry Truman, who originally proposed the legislation almost two decades before, and his wife, Bess, were the first people to register for Medicare at the act’s signing ceremony.
[Pictured: President Lyndon Johnson flips through the pages of the Medicare bill while former President Harry Truman holds the pens that Johnson used to sign the bill. Behind Johnson and Truman are Mrs. Johnson (L), Mrs. Truman, and Vice President Hubert Humphrey.]
1970s: First bills for single-payer system are proposed in Congress
In 1971, Senator Ted Kennedy introduced the Health Security Act, which called for health care coverage for all U.S. citizens and documented permanent residents. It competed with a similar bill, the National Health Insurance and Health Services Improvement Act, backed by Senator Jacob Javits. The legislation was offered up as a solution to skyrocketing inflation that was impacting the health care system. Eventually, in 1974, Kennedy presented a compromise, though it not only lost approval from unions, but also was dropped entirely due to President Nixon’s Watergate scandal and subsequent resignation from office. After Gerald Ford became president, Representative Grey Mills attempted to reintroduce the bill, but it lost traction after it received lukewarm support from both political parties.
[Pictured: Senator Edward Kennedy lectures in front of a chart on health care spending in June 1971.]
1996: Health Insurance Portability and Accountability Act passes
To protect the privacy of medical patients, in 1996 the Health Insurance Portability and Accountability Act was signed into federal law by President Bill Clinton. HIPAA prohibits the sharing of private medical information without a patient’s consent. This law can even extend to sharing medical information with an individual’s relatives, which has led to issues in some missing persons cases, such as in the case of the 2013 Asiana Airlines crash. According to the Centers for Disease Control and Prevention, “A major goal of the Privacy Rule is to ensure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high-quality health care and to protect the public’s health and well-being.” If a health care provider breaks HIPAA laws, they may face criminal charges as well as the loss of their medical license.
2010: Affordable Care Act passes
The Affordable Care Act, popularized in the media as “Obamacare,” was a sweeping health care reform law that expanded health care coverage for Americans and was the most dramatic overhaul of the U.S. health care system since the ratification of the Medicare and Medicaid Act in 1960s. The ACA expanded health care services and required that all American legal residents obtain and hold health insurance. The act also created a health insurance marketplace where people could search, compare, and sign up for health care plans. Of the reform legislation, President Barack Obama said, “In the wealthiest nation on Earth, no one should go broke just because they get sick.”
While the act remains in place and certain evidence shows that it has reduced health care disparity for minorities, there has been no shortage of challenges to its retention. On April 5, 2022, President Joe Biden signed an executive order directing federal agencies to expand quality, affordable health care coverage. The Biden Administration has also proposed eliminating “family glitch,” which is when employer-sponsored health care insurance is affordable only for the employee. Purchasing family coverage is often costly, so the proposal would give an employee’s family members premium tax credits to purchase more affordable insurance in the marketplace.
This story originally appeared on Sidecar Health and was produced and distributed in partnership with Stacker Studio.
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