vox--2020-03-16--How the US stacks up to other countries in confirmed coronavirus cases

America is testing people for coronavirus at a lower rate than other developed countries , and yet the data also shows the rate of people diagnosed with Covid-19 in the US is steadily rising , as quickly or more quickly than our peers abroad .
We don ’ t know the full extent of the outbreak , and America appears to have been less prepared for a pandemic than other countries in the first place .
“ Everyone working in this space would agree that no matter how you measure it , the US is far behind on this , @ @ @ @ @ @ @ health and HIV policy at the Kaiser Family Foundation , told Vox of the coronavirus response .
Here ’ s how the number of confirmed cases in the US compare to select other countries , based on days since each country reached 100 confirmed cases , according to data we analyzed from the Johns Hopkins University coronavirus dashboard .
( This is an adaptation of a widely shared chart made by the Financial Times ’ s John Burn-Murdoch . )
As of March 15 , the Johns Hopkins research data shows about 3,500 @ @ @ @ @ @ @ actual number of cases is likely much higher .
As you can see , the confirmed cases in the US are already more in line with Iran and Italy than with places like Hong Kong and Singapore , where the governments were able to mobilize more quickly .
Japan , like the US , has been criticized over not having enough tests to properly judge the true number of cases .
And the slow start of testing in the US is only going to exacerbate the situation .
Testing is important not only @ @ @ @ @ @ @ treatment if they do have an infection .
It also establishes how widespread a virus actually is .
Experts know the size of the problem , they know the rate at which people are being hospitalized or dying , and they can follow its movements .
That leads to a more informed response .
But the United States has faltered in rolling out coronavirus tests , putting us far behind our economic peers in tracing the outbreak .
A manufacturing problem with the test kits that were initially sent out in the field @ @ @ @ @ @ @ tests , set the nation back in stopping or slowing down Covid-19 .
As of March 12 , when the chart below was published , Americans had tested fewer than 10,000 people total when South Korea was testing that number of people in a day .
Even Italy , where the coronavirus ’ s spread has forced the country to shut down , was testing people at a much higher rate than the US .
For now , given the testing problems , one of the central problems facing America during this pandemic @ @ @ @ @ @ @ don ’ t know how big the problem is .
“ The testing failure is putting additional strain on our already challenged health system , ” Cynthia Cox , director of the Peterson-Kaiser Health System Tracker , said .
“ The combination of all of these factors will make the US worse off than similar countries .
”

The United States has the most confirmed Covid-19 cases in the world, with more than 15 times the number of cases reported in China and about six times as many cases as Italy and Spain, other epicenters of the global outbreak. Confirmed infections in the US make up around a third of the world’s coronavirus cases.
America started off testing people for the coronavirus at a slower rate than most other developed countries, but the number of people diagnosed with Covid-19 in the US has risen more quickly than the country’s peers abroad. We don’t yet know the full extent of the outbreak, but America remains a focal point of the coronavirus pandemic.
The US health system was less prepared for a pandemic than those of other wealthy nations. A high uninsured rate, high out-of-pocket health care costs, and low medical system capacity together make the country more vulnerable to a pathogen before the coronavirus ever came to our shores. America’s lax response in the early days of the outbreak only compounded those structural problems.
“Everyone working in this space would agree that no matter how you measure it, the US is far behind on this,” Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation, told Vox in mid-March of the initial coronavirus response.
Here’s how the number of confirmed cases in the US compares to select other countries, based on days since each country reached 100 confirmed cases, according to data we analyzed from the Johns Hopkins University coronavirus dashboard.
Note that the chart uses a log scale, meaning that the Y-axis goes up in equal distances between 100, 1,000, and 10,000 to mimic the exponential rate at which a contagion like the coronavirus spreads.
Here’s that same chart on a traditional linear scale.
As of May 11, the Johns Hopkins research data shows more than 4.1 million confirmed cases worldwide, about 1.3 million of which were in the US. The actual number of cases is likely much higher. About 280,000 people have died across the world from Covid-19, including nearly 80,000 in the United States. There are signs that social distancing measures in the US are making an impact, but the country surpassed Iran, Italy, and China to have the highest number of confirmed cases in the world.
As the Wall Street Journal has reported, Chinese health officials have acknowledged they did not include 1,500 asymptomatic cases in their previous national tallies, but said that such cases would be counted starting on April 1. Based on reporting by the South China Morning Post, China may be undercounting asymptomatic cases to an even greater degree. But remember, most countries’ numbers are probably low because people who have no or mild symptoms often don’t get tested.
Case numbers in the US have also far outpaced places like South Korea, Hong Kong, and Singapore, where the governments mobilized more quickly and certain cultural norms (like mask-wearing) may have helped slow the spread. (Early signs of a second wave of cases have appeared in Singapore, however; this was a fear among public health experts who worried societies would be too quick to reopen.)
Japan’s case numbers have started rising more quickly in recent weeks, and the government has been criticized over not having enough tests to properly judge the number of cases.
As America implements dramatic measures to control the spread of Covid-19, with schools and businesses closing and general social distancing underway, the country is still struggling to understand the full scope of the outbreak because of the slow start of testing. It has undeniably hindered the US response.
“The testing failure is putting additional strain on our already challenged health system,” Cynthia Cox, director of the Peterson-Kaiser Health System Tracker, said in March. “The combination of all of these factors will make the US worse off than similar countries.”
Testing is not only important because it gets people diagnosed and appropriate treatment if they have an infection, it also establishes how widespread a virus actually is. Experts know the size of the problem, they know the rate at which people are being hospitalized or dying, and they can follow its movements.
But the United States faltered in rolling out coronavirus tests, initially putting America behind its economic peers in tracing the outbreak. A manufacturing problem with the test kits that were initially sent out in the field, and a delay in approving commercial tests, set the nation back in stopping or slowing down Covid-19.
Even as testing capacity has ramped up in the US, as of May 4 America is still lagging behind other places in the world hit hardest by the virus in the share of its population being tested. The US has still tested fewer people per million residents than Italy, a focal point of Europe’s outbreak, and Germany, which is considered a model of rapid and widespread testing.
There have been about 9 million tests conducted in the US for its population of 329 million, but the number of tests per capita conducted varies greatly by state.
The US has finally started to catch up to the rest of the developed world in responding to Covid-19. But as case numbers and deaths continue to increase, we’re still learning the full scope of the crisis.


vox--2020-03-16--Why businesses can still get away with paying pennies to employees with disabilities

Share All sharing options for : Why businesses can still get away with paying pennies to employees with disabilities As we head into the endgame of the Democratic primary , it may not seem like the remaining candidates have very much in common .
Former Vice President Joe Biden has campaigned for a return to the comfort and normalcy of the Obama era , while Sen. Bernie Sanders is asking for a revolution and fundamental changes to how American government functions .
And yet there are a handful of issues upon which they agree , not only with each other @ @ @ @ @ @ @ not-at-all-moderate Republicans .
One of those shared issues : Ending below-minimum wage for people with disabilities .
Under a little-known regulation called 14 ( c ) of the Fair Labor Standards Act , businesses can apply for permits to pay disabled employees well below the federal minimum wage of $ 7.25 an hour .
That amount can dip down to mere pennies in some cases .
In one particularly galling story from a 2012 report from the National Council on Disability , an Ohio woman who had promised to take her family out @ @ @ @ @ @ @ sad and surprised to find out she had only earned 38 cents for the entire pay period .
Over the past decade , though , there has been a quiet battle raging to end the practice .
Both Sanders and Biden have pledged to do away with below-minimum wage for people with disabilities .
And even under the Trump administration and in some red states , the fight to end subminimum wage , as it ’ s called in policy terms , has not been deterred .
Last year , Texas banned state @ @ @ @ @ @ @ the federal minimum wage .
Meanwhile , one of the biggest advocates for ending subminimum wage is Rep. Cathy McMorris Rodgers , the highest-ranking Republican woman in the House .
McMorris Rodgers is also one of the most reliable votes for President Trump ’ s agenda .
She has supported Trump ’ s tax cuts , consistently gets an A rating from the NRA , and recently appeared on a podcast put out by the Heritage Foundation to promote a new restriction on abortion .
She is also a cosponsor , along with @ @ @ @ @ @ @ latest legislation to stop this exception to the minimum wage .
Part of how McMorris Rodgers and Ocasio-Cortez ended up on the same side of an issue : Disability is not constrained by concerns like class , race , religion , or any of the other demographic divisions that often form political opinion .
Anyone can become disabled .
Anyone can have a disabled child .
McMorris Rodgers ’ s son Cole has Down syndrome .
In 2017 , McMorris Rodgers told Roll Call , “ You want to do everything you can @ @ @ @ @ @ @ succeed.
” In 1937 , President Franklin Delano Roosevelt first called for the enactment of a federal minimum wage , resulting in the Fair Labor Standards Act of 1938 .
During the hearings for the legislation , Labor Secretary Frances Perkins asked for a subminimum wage for people she called “ substandard workers , ” who she defined as “ persons who by reason of illness or age or something else are not up to normal production.
” It soon became clear that “ substandard workers ” and “ or something else ” @ @ @ @ @ @ @ ways .
Some in Congress argued that people in the Southern United States should be paid less than minimum wage on account of being “ slower.
” Others argued that black workers were intrinsically “ substandard , ” according to a report from the Congressional Research Service .
Subminimum wage for disabled people , unlike these other recommendations , was uncontroversial .
Over the years , disabled people have remained one of the few groups to be given subminimum wage .
Subminimum wage for some specific categories of workers , like prisoners , @ @ @ @ @ @ @ designed with racial bias in mind .
Restaurants and rail operators embraced tipping because it allowed them to save money by not paying newly freed slaves .
However , these laws do not explicitly single out people of color as a class for subminimum wage .
Julie Christensen , the policy and advocacy director for the Association of People Supporting Employment First , said to this day , disabled people remain the only group of people who can be paid below minimum wage based on an indelible trait .
“ Disability is the @ @ @ @ @ @ @ , ” she told Vox .
Additionally , unlike subminimum wage for agricultural and tipped workers , there is no floor for how little a disabled person can be paid .
Instead , people are paid based on how productive they are , or rate per piece .
The rate is set as a percentage of a non-disabled person ’ s productivity .
So , if a non-disabled person makes 100 widgets an hour at $ 7.25 an hour and a disabled person makes 20 widgets an hour , that disabled person receives @ @ @ @ @ @ @ if productivity is down for reasons unrelated to a person ’ s disability , like poor management or short stock , the person still receives their wage based on rate per piece .
So their wage may be extremely low for arbitrary reasons beyond the person ’ s physical capacity or control .
( Meanwhile , non-disabled people are not always at peak productivity , and it is not legal or acceptable to pay them less when they have an off day . )
According to Christensen , subminimum wage for disabled people @ @ @ @ @ @ @ It was originally intended to serve as a transition for the large number of disabled soldiers returning from the world wars .
Eventually , people were supposed to be able to work themselves up to full productivity before graduating out of the sheltered workshop — a segregated , disabled-only workplace that is supposed to double as job training for disabled people However , instead of their original intended use , subminimum wage and sheltered workshops have become permanent for many disabled workers , especially those with intellectual disabilities .
Despite being classified as @ @ @ @ @ @ @ graduate to the mainstream working world .
According to a 2001 audit from the Government Accountability Office , only 5 percent of sheltered workshop employees ever transition to outside jobs with normal pay .
In addition to simple lack of opportunity , there are numerous financial incentives to keep people employed in subminimum wage for the rest of their working lives .
Ross Ryan , an Oregon man with an intellectual disability , stayed at a sheltered workshop for 22 years until a class action lawsuit shut it down .
“ I was @ @ @ @ @ @ @ this led to me feeling trapped in a sheltered workshop for most of my adult life.
” Social service providers for disabled people were , from the beginning , the largest industry represented in 14 ( c ) .
This meant that they had a dual role as people who were supposed to be providing some level of care and support to disabled people , as well as being the bosses of disabled people .
Due to disability , their workers were often extremely poor and were ignored by organized labor .
This @ @ @ @ @ @ @ to this day .
Large nonprofits like Goodwill can provide cheaper clothes in their thrift stores , and organizations like SourceAmerica are able to make a bigger profit margin and deliver goods and services through lucrative government contracts for a fraction of the cost , because they can legally pay their labor force pennies an hour .
The first challenge to subminimum wages came in the 1960s during an explosion of the expansion of civil rights for many marginalized groups in America .
The National Federation of the Blind led the charge .
@ @ @ @ @ @ @ Oregon , proposed bringing the “ moderately disabled ” up to full minimum wage during a three-year transition period and that wages for the “ severely disabled ” be at least half of the federal minimum wage .
Employers of disabled people being paid subminimum wage , like Goodwill , called it “ unrealistic ” and “ a drain on the economy ” during Senate hearings .
They also claimed that the change would deprive the “ severely disabled ” of the opportunity to work .
These are the same criticisms leveled by @ @ @ @ @ @ @ More challenges came soon after .
Since the 1970s , there have been several attempts to alter or end subminimum wage .
All of them have gone nowhere .
During one 1980 hearing before the House Subcommittee on Labor Standards , Jerry Daugherty of the National Industries for the Severely Handicapped claimed , “ more important than wages to the disabled , is the opportunity to work.
” He and others representing subminimum-wage nonprofits and businesses argued that disabled people did not need real payment because they were supported by Social Security and @ @ @ @ @ @ @ was apparently convincing , and subminimum wage continued more or less unchanged .
There have , however , been some advances .
In the late ’ 60s , the Self-Advocacy Movement — the first political rights organization by and for people with intellectual disabilities — formed , and by 1974 the movement had spread to the United States .
More and more people with intellectual disabilities were being moved out of large state institutions and into everyday society as deinstitutionalization ramped up .
Faced with freedom , some people seized the opportunity to @ @ @ @ @ @ @ people like them .
Then , in 1988 , the Association of People Supporting Employment First was formed using newly created federal grants from the US Department of Education .
Forty states received grants to help people find and maintain ordinary jobs in the community , rather than in traditional subminimum wage sheltered workshops .
But it wasn ’ t until 1990 that the crowning achievement of disability civil rights policy was passed .
The Americans with Disabilities Act included provisions intended to end discrimination against hiring disabled people and to legally require @ @ @ @ @ @ @ Unfortunately , it has had seemingly little impact in terms of improving the unemployment rate for disabled people .
However , what the ADA did do was cement disability rights as a bipartisan issue .
The ADA and ensuing amendments have been championed by Democrats and Republicans alike .
While some major aspects of disability policy , like Medicaid , have become extremely politically charged , much disability policy is still the purview of both parties .
In 2002 , Vermont became the first state to abolish subminimum wage .
In addition to @ @ @ @ @ @ @ one of the most successful .
Not only is there no longer subminimum wage , but they also have the highest rate of employment and the highest median annual income for people with intellectual and developmental disabilities in the country .
Ari Ne ’ eman , a former Obama appointee to the National Council on Disability , told Vox that Vermont is considered by many experts to be a model for disabled employment .
Ne ’ eman was especially struck by the shift in sentiment .
“ Years later , many of the @ @ @ @ @ @ @ had come to see it as a blessing and as the beginning of greater opportunities for their loved ones , ” he said .
The number of subminimum wage workers are dwindling .
But where are they going ?
The movement against subminimum wage has been picking up steam slowly but surely since Vermont made the first leap .
In the past five years alone , there ’ s been more than a 56 percent drop in the number of disabled people being paid less than minimum wage for their work .
Part @ @ @ @ @ @ @ of more and more states banning subminimum wage for disabled people , or at least significantly limiting the practice .
From Alaska to Texas , 21 states already have some limit on the books to subminimum wage for disabled people .
In the 2020 legislative session alone , nine more states are set to address the issue .
What is unclear , however , is where those workers are going instead .
The unemployment rate for disabled people has remained static since the Americans with Disabilities Act passed in 1990 .
Not everyone @ @ @ @ @ @ @ a mainstream job .
So how does 100,000 people leaving sheltered workshops not impact the unemployment rate ?
The answer is that the basic unemployment rate is not actually an estimate of the number of people who are or aren ’ t working .
That measure is the number of people who are actively looking for work and who have previously been employed for at least six months .
People in sheltered workshops being paid subminimum wage are counted as employed .
But people who have simply given up looking for work after @ @ @ @ @ @ @ never worked in the first place don ’ t exist in unemployment calculations .
They seemingly disappear .
Some research hints that more people are entering adult day care programs instead of sheltered workshops .
Whether that ’ s an improvement is disputed , even within the movement to end subminimum wage .
Julie Christensen feels strongly that it is not .
“ From APSE ’ s perspective , we don ’ t want people ending up in [ adult day care ] programs , ” she said .
It isn ’ t @ @ @ @ @ @ @ Real victory for the disability community will mean increasing the number of disabled people in the mainstream workforce .
“ Unemployment is going to fluctuate with the economy .
That ’ s just life , ” Christensen said .
“ We want to close the employment gap .
We want people with disabilities to be working at the same rate as people without disabilities.
” Importantly , the level of disability a person has is not necessarily related to whether that person can get and maintain a mainstream job .
Bill Stumpf ’ @ @ @ @ @ @ @ Down syndrome and does not speak , has been successfully employed at a Papa John ’ s in Dubuque , Iowa , for five years , after leaving a sheltered workshop .
Stumpf said that initially , like many parents , he had been afraid of what would happen to Kyle if the sheltered workshop closed .
“ Change is hard , ” he said .
But Stumpf said that Kyle loves his new job .
“ You can see it in his face , ” Stumpf said .
“ He basically runs @ @ @ @ @ @ @ time to go to work.
” For Shawn Fulton , who said he prefers not to be referred to by his disability — “ I ’ m just Shawn ” — the turning point was getting involved in the Self-Advocacy Movement .
He had previously been employed in a sheltered workshop for 25 years , where he was paid half a cent per piece to grind bits of metal .
He still doesn ’ t know what the bits of metal were used for .
“ I started learning about how I can @ @ @ @ @ @ @ said .
“ I owe it all to self-advocacy.
” He now works as an education and training coordinator at the Arc of Indiana , teaching other people with intellectual disabilities how to better advocate for what they want in life .
Shawn called working for the Arc of Indiana “ the greatest thing that ever happened to [ him ] .
” The fate of the subminimum wage lies with Congress There are currently two bills in Congress that address subminimum wage .
The first , the Raise the Wage Act , @ @ @ @ @ @ @ workers , including those with disabilities , to $ 15 an hour .
It passed the Democratic House , and senators including presidential candidate Bernie Sanders have cosponsored it , but the bill seems unlikely to move in the Senate .
Christensen praised the inclusion of disabled people in the bill , but “ most people don ’ t even realize [ ending the subminimum wage for people with disabilities ] is in there.
” She said it also does not build the capacity needed to get disabled people into the mainstream workforce @ @ @ @ @ @ @ the Transformation to Competitive Employment Act , which would provide for a phase-out period and build capacity to make sure disabled people currently working for subminimum wage don ’ t fall through the cracks .
“ How do we make such a significant shift and simultaneously do the least harm ?
There aren ’ t enough direct support professionals , there aren ’ t enough job coaches .
If we woke up tomorrow and everyone in a 14 ( c ) setting needed a job coach , that wouldn ’ t exist , @ @ @ @ @ @ @ Competitive Employment Act would address these problems .
With the House bill cosponsored by Reps. McMorris Rodgers and Ocasio-Cortez , it is considerably more likely to pass than the Raise the Wage Act , with broad , bipartisan support .
A fair wage for disabled people is “ much more than just a paycheck , ” McMorris Rodgers told Vox .
“ It ’ s a foundation for a better life.
” So far , however , the Senate version of the bill has not been cosponsored by any of the senators currently @ @ @ @ @ @ @ Sanders and Elizabeth Warren included — except Kamala Harris .
Biden , though , has endorsed the bill .
He also answered the American Association of People with Disabilities questionnaire in early March , which gives a small glimpse into what a Biden administration ’ s disability policy might look like , since he still hasn ’ t released a comprehensive disability plan .
( In contrast , Sanders and former presidential candidate Pete Buttigieg submitted theirs last year and both put out detailed disability plans . )
While most of Biden ’ @ @ @ @ @ @ @ policies , subminimum wage is one significant area where Biden is willing to take a step forward .
Meanwhile , Sanders ’ s campaign told Vox that in addition to supporting legislative solutions like the Raise the Wage Act , Sanders would be open to exploring the use of executive power to end subminimum wages .
He could , theoretically , tell the Department of Labor to stop issuing and renewing subminimum wage certificates .
This would force a phase-out period and end subminimum wages for disabled people .
The use of executive @ @ @ @ @ @ @ Vermont and Maine simply declined to renew certificates for subminimum wage as part of their strategies to abolish it .
While Biden and Sanders are in agreement about curbing subminimum wages , their wildly different approaches are an illuminating look into how each might choose to govern .
While Sanders is willing to explore radical and nontraditional avenues to get the job done , Biden is interested in consensus-driven bipartisan legislation — as rare as that is these days .
In the coming weeks , it will become clearer who will lead the @ @ @ @ @ @ @ one way or another , the subminimum wage will be on the agenda .
Sara Luterman is a Washington , DC-based freelance journalist and commentator .
She writes about disability politics , research , and culture .
Her work has appeared in the Washington Post , Slate , the New York Times , and Undark Magazine , among other outlets .
Follow her on Twitter .

Share All sharing options for: Why businesses can still get away with paying pennies to employees with disabilities
As we head into the endgame of the Democratic primary, it may not seem like the remaining candidates have very much in common. Former Vice President Joe Biden has campaigned for a return to the comfort and normalcy of the Obama era, while Sen. Bernie Sanders is asking for a revolution and fundamental changes to how American government functions. And yet there are a handful of issues upon which they agree, not only with each other, but with a surprising number of not-at-all-moderate Republicans. One of those shared issues: Ending below-minimum wage for people with disabilities.
Under a little-known regulation called 14(c) of the Fair Labor Standards Act, businesses can apply for permits to pay disabled employees well below the federal minimum wage of $7.25 an hour. That amount can dip down to mere pennies in some cases. In one particularly galling story from a 2012 report from the National Council on Disability, an Ohio woman who had promised to take her family out to dinner with her first paycheck was sad and surprised to find out she had only earned 38 cents for the entire pay period.
Over the past decade, though, there has been a quiet battle raging to end the practice. Both Sanders and Biden have pledged to do away with below-minimum wage for people with disabilities. And even under the Trump administration and in some red states, the fight to end subminimum wage, as it’s called in policy terms, has not been deterred.
Last year, Texas banned state contracts with organizations that pay less than the federal minimum wage. Meanwhile, one of the biggest advocates for ending subminimum wage is Rep. Cathy McMorris Rodgers, previously the highest-ranking Republican woman in the House. McMorris Rodgers is also one of the most reliable votes for President Trump’s agenda. She has supported Trump’s tax cuts, consistently gets an A rating from the NRA, and recently appeared on a podcast put out by the Heritage Foundation to promote a new restriction on abortion. She is also a cosponsor, along with Democratic Rep. Alexandria Ocasio-Cortez, on the latest legislation to stop this exception to the minimum wage.
Part of how McMorris Rodgers and Ocasio-Cortez ended up on the same side of an issue: Disability is not constrained by concerns like class, race, religion, or any of the other demographic divisions that often form political opinion. Anyone can become disabled. Anyone can have a disabled child. McMorris Rodgers’s son Cole has Down syndrome. In 2017, McMorris Rodgers told Roll Call, “You want to do everything you can so your child has every tool to succeed.”
The history of subminimum wages
In 1937, President Franklin Delano Roosevelt first called for the enactment of a federal minimum wage, resulting in the Fair Labor Standards Act of 1938. During the hearings for the legislation, Labor Secretary Frances Perkins asked for a subminimum wage for people she called “substandard workers,” who she defined as “persons who by reason of illness or age or something else are not up to normal production.” It soon became clear that “substandard workers” and “or something else” would be interpreted in the worst possible ways. Some in Congress argued that people in the Southern United States should be paid less than minimum wage on account of being “slower.” Others argued that black workers were intrinsically “substandard,” according to a report from the Congressional Research Service.
Subminimum wage for disabled people, unlike these other recommendations, was uncontroversial. Over the years, disabled people have remained one of the few groups to be given subminimum wage.
Subminimum wage for some specific categories of workers, like prisoners, agricultural, and tipped workers, was designed with racial bias in mind. Restaurants and rail operators embraced tipping because it allowed them to save money by not paying newly freed slaves.
However, these laws do not explicitly single out people of color as a class for subminimum wage. Julie Christensen, the policy and advocacy director for the Association of People Supporting Employment First, said to this day, disabled people remain the only group of people who can be paid below minimum wage based on an indelible trait. “Disability is the only exemption based on class of citizen,” she told Vox.
Additionally, unlike subminimum wage for agricultural and tipped workers, there is no floor for how little a disabled person can be paid. Instead, people are paid based on how productive they are, or rate per piece. The rate is set as a percentage of a non-disabled person’s productivity.
So, if a non-disabled person makes 100 widgets an hour at $7.25 an hour and a disabled person makes 20 widgets an hour, that disabled person receives $1.45 an hour. Additionally, if productivity is down for reasons unrelated to a person’s disability, like poor management or short stock, the person still receives their wage based on rate per piece. So their wage may be extremely low for arbitrary reasons beyond the person’s physical capacity or control. (Meanwhile, non-disabled people are not always at peak productivity, and it is not legal or acceptable to pay them less when they have an off day.)
According to Christensen, subminimum wage for disabled people wasn’t nefarious by design. It was originally intended to serve as a transition for the large number of disabled soldiers returning from the world wars. Eventually, people were supposed to be able to work themselves up to full productivity before graduating out of the sheltered workshop — a segregated, disabled-only workplace that is supposed to double as job training for disabled people
However, instead of their original intended use, subminimum wage and sheltered workshops have become permanent for many disabled workers, especially those with intellectual disabilities. Despite being classified as “vocational rehabilitation,” few ever graduate to the mainstream working world. According to a 2001 audit from the Government Accountability Office, only 5 percent of sheltered workshop employees ever transition to outside jobs with normal pay.
In addition to simple lack of opportunity, there are numerous financial incentives to keep people employed in subminimum wage for the rest of their working lives. Ross Ryan, an Oregon man with an intellectual disability, stayed at a sheltered workshop for 22 years until a class action lawsuit shut it down. “I was not given choices growing up, and this led to me feeling trapped in a sheltered workshop for most of my adult life.”
Social service providers for disabled people were, from the beginning, the largest industry represented in 14(c). This meant that they had a dual role as people who were supposed to be providing some level of care and support to disabled people, as well as being the bosses of disabled people.
Due to disability, their workers were often extremely poor and were ignored by organized labor. This created a conflict of interest that persists to this day. Large nonprofits like Goodwill can provide cheaper clothes in their thrift stores, and organizations like SourceAmerica are able to make a bigger profit margin and deliver goods and services through lucrative government contracts for a fraction of the cost, because they can legally pay their labor force pennies an hour.
The long fight against subminimum wages
The first challenge to subminimum wages came in the 1960s during an explosion of the expansion of civil rights for many marginalized groups in America. The National Federation of the Blind led the charge.
Sen. Wayne Morse, a Democrat from Oregon, proposed bringing the “moderately disabled” up to full minimum wage during a three-year transition period and that wages for the “severely disabled” be at least half of the federal minimum wage. Employers of disabled people being paid subminimum wage, like Goodwill, called it “unrealistic” and “a drain on the economy” during Senate hearings. They also claimed that the change would deprive the “severely disabled” of the opportunity to work. These are the same criticisms leveled by supporters of subminimum wage decades later.
More challenges came soon after. Since the 1970s, there have been several attempts to alter or end subminimum wage. All of them have gone nowhere.
During one 1980 hearing before the House Subcommittee on Labor Standards, Jerry Daugherty of the National Industries for the Severely Handicapped claimed, “more important than wages to the disabled, is the opportunity to work.”
He and others representing subminimum-wage nonprofits and businesses argued that disabled people did not need real payment because they were supported by Social Security and other government benefits instead. His argument was apparently convincing, and subminimum wage continued more or less unchanged.
There have, however, been some advances. In the late ’60s, the Self-Advocacy Movement — the first political rights organization by and for people with intellectual disabilities — formed, and by 1974 the movement had spread to the United States. More and more people with intellectual disabilities were being moved out of large state institutions and into everyday society as deinstitutionalization ramped up. Faced with freedom, some people seized the opportunity to advocate for themselves and the rights of people like them.
Then, in 1988, the Association of People Supporting Employment First was formed using newly created federal grants from the US Department of Education. Forty states received grants to help people find and maintain ordinary jobs in the community, rather than in traditional subminimum wage sheltered workshops.
But it wasn’t until 1990 that the crowning achievement of disability civil rights policy was passed. The Americans with Disabilities Act included provisions intended to end discrimination against hiring disabled people and to legally require accommodations like ramps and screen readers. Unfortunately, it has had seemingly little impact in terms of improving the unemployment rate for disabled people.
However, what the ADA did do was cement disability rights as a bipartisan issue. The ADA and ensuing amendments have been championed by Democrats and Republicans alike. While some major aspects of disability policy, like Medicaid, have become extremely politically charged, much disability policy is still the purview of both parties.
In 2002, Vermont became the first state to abolish subminimum wage. In addition to being first, they’ve been one of the most successful. Not only is there no longer subminimum wage, but they also have the highest rate of employment and the highest median annual income for people with intellectual and developmental disabilities in the country.
Ari Ne’eman, a former Obama appointee to the National Council on Disability, told Vox that Vermont is considered by many experts to be a model for disabled employment. Ne’eman was especially struck by the shift in sentiment. “Years later, many of the same people who had opposed workshop closure had come to see it as a blessing and as the beginning of greater opportunities for their loved ones,” he said.
The number of subminimum wage workers are dwindling. But where are they going?
The movement against subminimum wage has been picking up steam slowly but surely since Vermont made the first leap. In the past five years alone, there’s been more than a 56 percent drop in the number of disabled people being paid less than minimum wage for their work.
Part of the decrease is simply a result of more and more states banning subminimum wage for disabled people, or at least significantly limiting the practice. From Alaska to Texas, 21 states already have some limit on the books to subminimum wage for disabled people. In the 2020 legislative session alone, nine more states are set to address the issue.
What is unclear, however, is where those workers are going instead. The unemployment rate for disabled people has remained static since the Americans with Disabilities Act passed in 1990. Not everyone who leaves a sheltered workshop automatically gets a mainstream job. So how does 100,000 people leaving sheltered workshops not impact the unemployment rate?
The answer is that the basic unemployment rate is not actually an estimate of the number of people who are or aren’t working. That measure is the number of people who are actively looking for work and who have previously been employed for at least six months. People in sheltered workshops being paid subminimum wage are counted as employed. But people who have simply given up looking for work after leaving the sheltered workshop or who have never worked in the first place don’t exist in unemployment calculations. They seemingly disappear.
Some research hints that more people are entering adult day care programs instead of sheltered workshops. Whether that’s an improvement is disputed, even within the movement to end subminimum wage.
Julie Christensen feels strongly that it is not. “From APSE’s perspective, we don’t want people ending up in [adult day care] programs,” she said. It isn’t enough just to end subminimum wage. Real victory for the disability community will mean increasing the number of disabled people in the mainstream workforce.
“Unemployment is going to fluctuate with the economy. That’s just life,” Christensen said. “We want to close the employment gap. We want people with disabilities to be working at the same rate as people without disabilities.”
Importantly, the level of disability a person has is not necessarily related to whether that person can get and maintain a mainstream job. Bill Stumpf’s son, Kyle, who has Down syndrome and does not speak, has been successfully employed at a Papa John’s in Dubuque, Iowa, for five years, after leaving a sheltered workshop. Stumpf said that initially, like many parents, he had been afraid of what would happen to Kyle if the sheltered workshop closed. “Change is hard,” he said. But Stumpf said that Kyle loves his new job. “You can see it in his face,” Stumpf said. “He basically runs to the car when it’s time to go to work.”
For Shawn Fulton, who said he prefers not to be referred to by his disability — “I’m just Shawn” — the turning point was getting involved in the Self-Advocacy Movement. He had previously been employed in a sheltered workshop for 25 years, where he was paid half a cent per piece to grind bits of metal. He still doesn’t know what the bits of metal were used for.
“I started learning about how I can get out and work,” he said. “I owe it all to self-advocacy.” He now works as an education and training coordinator at the Arc of Indiana, teaching other people with intellectual disabilities how to better advocate for what they want in life. Shawn called working for the Arc of Indiana “the greatest thing that ever happened to [him].”
The fate of the subminimum wage lies with Congress
There are currently two bills in Congress that address subminimum wage. The first, the Raise the Wage Act, pledges to raise minimum wage for all workers, including those with disabilities, to $15 an hour. It passed the Democratic House, and senators including presidential candidate Bernie Sanders have cosponsored it, but the bill seems unlikely to move in the Senate. Christensen praised the inclusion of disabled people in the bill, but “most people don’t even realize [ending the subminimum wage for people with disabilities] is in there.” She said it also does not build the capacity needed to get disabled people into the mainstream workforce.
Instead, Christensen is enthusiastic about the Transformation to Competitive Employment Act, which would provide for a phase-out period and build capacity to make sure disabled people currently working for subminimum wage don’t fall through the cracks. “How do we make such a significant shift and simultaneously do the least harm? There aren’t enough direct support professionals, there aren’t enough job coaches. If we woke up tomorrow and everyone in a 14(c) setting needed a job coach, that wouldn’t exist,” she said.
The Transformation to Competitive Employment Act would address these problems. With the House bill cosponsored by Reps. McMorris Rodgers and Ocasio-Cortez, it is considerably more likely to pass than the Raise the Wage Act, with broad, bipartisan support.
A fair wage for disabled people is “much more than just a paycheck,” McMorris Rodgers told Vox. “It’s a foundation for a better life.”
So far, however, the Senate version of the bill has not been cosponsored by any of the senators currently or previously running for president — Bernie Sanders and Elizabeth Warren included — except Kamala Harris.
Biden, though, has endorsed the bill. He also answered the American Association of People with Disabilities questionnaire in early March, which gives a small glimpse into what a Biden administration’s disability policy might look like, since he still hasn’t released a comprehensive disability plan. (In contrast, Sanders and former presidential candidate Pete Buttigieg submitted theirs last year and both put out detailed disability plans.) While most of Biden’s answers seem focused on restoring Obama-era policies, subminimum wage is one significant area where Biden is willing to take a step forward.
Meanwhile, Sanders’s campaign told Vox that in addition to supporting legislative solutions like the Raise the Wage Act, Sanders would be open to exploring the use of executive power to end subminimum wages. He could, theoretically, tell the Department of Labor to stop issuing and renewing subminimum wage certificates. This would force a phase-out period and end subminimum wages for disabled people. The use of executive power isn’t totally unprecedented — Vermont and Maine simply declined to renew certificates for subminimum wage as part of their strategies to abolish it.
While Biden and Sanders are in agreement about curbing subminimum wages, their wildly different approaches are an illuminating look into how each might choose to govern. While Sanders is willing to explore radical and nontraditional avenues to get the job done, Biden is interested in consensus-driven bipartisan legislation — as rare as that is these days. In the coming weeks, it will become clearer who will lead the Democratic Party in the election, but one way or another, the subminimum wage will be on the agenda.
Sara Luterman is a Washington, DC-based freelance journalist and commentator. She writes about disability politics, research, and culture. Her work has appeared in the Washington Post, Slate, the New York Times, and Undark Magazine, among other outlets. Follow her on Twitter.


vox--2020-03-16--Coronavirus is exposing all of the weaknesses in the US health system

Coronavirus is exposing all of the weaknesses in the US health system Share All sharing options for : Coronavirus is exposing all of the weaknesses in the US health system The international response to the novel coronavirus has laid this bare : America was less prepared for a pandemic than countries with universal health systems .
There is a real concern that Americans , with a high uninsured rate and high out-of-pocket costs compared to the rest of the world , won ’ t seek care because of the costs .
Before the crisis even began , the United States @ @ @ @ @ @ @ per capita than most other developed countries .
The rollout of Covid-19 testing has been patchy , reliant on a mix of government and private labs to scale up the capacity to perform the tens of thousands of tests that will be necessary .
“ Everyone working in this space would agree that no matter how you measure it , the US is far behind on this , ” says Jen Kates , director of global health and HIV policy at the Kaiser Family Foundation .
People need to go to the doctor @ @ @ @ @ @ @ symptoms , yet Americans may avoid medical care , even for serious conditions , because of the costs .
Hospitals will need rooms for the people who require close monitoring in a clinical setting , and ICU beds and ventilators for patients who take a turn for the worse and require mechanical support to keep their bodies functioning .
But none of those units are sitting empty right now — they already have non-coronavirus patients who need them and will continue to need them through the crisis .
New York Gov .
Andrew @ @ @ @ @ @ @ of New York City ’ s intensive care units were already filled , even with the Covid-19 outbreak still expanding .
By any of these metrics on pandemic preparedness , America trails most of the rest of the developed world .
“ The U.S. performs worse than average among similarly large and wealthy countries across nearly all measures of preparedness for a pandemic , ” Cynthia Cox , director of the Peterson-Kaiser Health System Tracker , told me .
“ The coronavirus outbreak is already exposing inefficiencies and inequities in our health system @ @ @ @ @ @ @ much more strain on the system in the coming weeks.
” And the slow start to testing in the US is only going to exacerbate those problems .
Testing is important not only because it gets people diagnosed and on an appropriate treatment if they do have an infection .
It also establishes how widespread a virus actually is .
Experts know the size of the problem , they know the rate at which people are being hospitalized or dying , and they can follow its movements .
That leads to a more @ @ @ @ @ @ @ has faltered in rolling out coronavirus tests , putting us far behind our economic peers in tracing the outbreak .
A manufacturing problem with the test kits that were initially sent out in the field , and a delay in approving commercial tests , set the nation back in stopping or slowing down Covid-19 .
“ The testing failure is putting additional strain on our already challenged health system , ” Cox said .
“ The combination of all of these factors will make the U.S. worse off than similar countries.
” Universal @ @ @ @ @ @ @ for emergencies like this .
Italy has a universal health care system , a federalized national health insurance program similar to Canada ’ s , but an uncontained outbreak has still forced the country to lock itself down as cases and deaths continue to pile up .
Nevertheless , other countries are still generally better prepared for a pandemic than the US is , and we are seeing right now the consequences of that gap .
For the time being , US politicians are proposing to make American health care more like these @ @ @ @ @ @ @ cheap at the point of service , either by having the government cover more of the cost or by mandating private insurers cover services related to the outbreak .
They are , however , only a temporary patch on these structural problems .
Why America is less prepared for a pandemic than other countries On many measures , the United States has one of the worst health systems among developed economies .
A bigger share of the population lacks health insurance .
We carry more medical debt .
We die more often from @ @ @ @ @ @ @ system , which already puts the US behind its peers on many health outcomes , are exposed in an outbreak .
And the biggest single problem , the one most unique to the American system , is costs .
Americans face higher out-of-pocket costs for their medical care than citizens of almost any other country , and research shows people forgo care they need , including for serious conditions , because of the cost barriers .
Patients here are much more likely than those in most other countries to say they had a @ @ @ @ @ @ @ 33 percent in America vs. between 7 percent ( Germany ) and 22 percent ( Switzerland ) in other developed economies .
Americans are more likely to say they struggled to afford or couldn ’ t afford medical bills and that their insurance plan had refused to cover some of their medical claims .
We know Americans delay care as a result of these cost barriers : in 2019 , 33 percent of Americans said they put off treatment for a medical condition because of the cost ; 25 percent said they postponed @ @ @ @ @ @ @ 2018 study found that even women with breast cancer — a life-threatening diagnosis — would delay care because of the high deductibles on their insurance plan , even for basic services like imaging .
Those cost barriers hit patients at several points in a pandemic situation .
First , they might be wary about going to the doctor at all because they are afraid they can ’ t afford the check-up or any testing .
But then if they do get a Covid-19 diagnosis and require hospitalization , they have the bills from @ @ @ @ @ @ @ , and any treatment they receive to worry about .
In America , and only in America among developed countries , do patients risk thousands of dollars in medical bills by seeking help in a crisis .
Some Americans have already been billed nearly $ 4,000 over a government-imposed quarantine , as the New York Times reported .
Making matters worse is our system ’ s health care infrastructure , built on top of this fractured payer system .
There are capacity shortages that put us at further disadvantage in a time of @ @ @ @ @ @ @ .
Hospital beds , for example , will be necessary for Covid-19 patients with more serious symptoms .
America has fewer hospital beds per capita than most other countries in the developed world .
A potential shortage of hospital beds is compounded by the fact that the US has higher rates of hospitalizations for chronic conditions that , with proper management , shouldn ’ t require the patient to go to the hospital .
Those conditions include congestive heart failure , diabetes , and asthma .
Researchers think a lack of access to @ @ @ @ @ @ @ of seeking even this routine care compared to other countries , drive potentially preventable hospitalizations in the US .
That means our hospitals are already taking in patients they wouldn ’ t have to if the system functioned better , and now they will have to accommodate an influx of Covid-19 patients .
We have fewer doctors per capita too : 2.6 per 1,000 people , well below the comparable country average of 3.5 and lower than every country tracked by Peterson-Kaiser except for Japan .
Experts blame the high cost of a @ @ @ @ @ @ @ linked to America ’ s world-leading health care prices , for much of that shortfall .
And , likely as a result , Americans struggle more than people in most other places to get a same-day or next-day appointment with their doctor .
Take these structural problems together with America ’ s slow start to testing for coronavirus , and we are far behind where we should be .
“ A failure to widely test and slow the spread means that we could have large spikes in the number of people who need @ @ @ @ @ @ @ exceptional strain on our health system , ” Cox told me .
“ By not acting quickly enough to prevent spread , our health system will be under greater , more concentrated strain.
” Many countries with universal health care are doing better than the US , but some have problems too Countries with universal health care are testing more people and seem to be faring better with Covid-19 death rates than the United States .
More centralized planning is an asset in a crisis .
Taiwan has seen a remarkably low level @ @ @ @ @ @ @ the Chinese mainland .
As Vox ’ s Kelsey Piper reported : In Taiwan , with its single-payer health program , every citizen has their digital medical records loaded into the same system .
In the coronavirus outbreak , the country has added travel records to that online medical file , so every doctor can check whether their patients have visited an area affected by the outbreak .
And by getting jumpstarted on their response , those countries are able to lower the burden on their health systems .
The primary goal with @ @ @ @ @ @ @ to slow the spread so health care providers aren ’ t overrun : to flatten the curve in this chart so patient needs don ’ t exceed the system ’ s capacity .
So even though , as you may have noticed above , countries like Canada and United Kingdom have about the same number of hospital beds as the United States does , they should be better positioned to mitigate the outbreak .
They are already testing a lot more people .
More testing allows them to take smarter protective measures , @ @ @ @ @ @ @ the scope of the pandemic , which helps to reduce the burden on their health system during the worst peak of the outbreak .
But even universal health care can not fully prepare a country for the unpredictable movements of a pandemic virus .
Italy , with a national health service that provides care to each of its citizens , has seen its coronavirus situation spin quickly out of control .
On Monday , the country decided to close its borders in a desperate attempt to stem the crisis .
As Vox ’ @ @ @ @ @ @ @ competing theories for the problem .
Perhaps the aggressive testing had just made the scale of the problem clear earlier than in other places .
It ’ s hard to say for sure .
Or : And yet , Italy still has more hospital beds per capita and doctors per capita than the United States , according to OECD and World Bank estimates .
As experts worry whether Italy shows a glimpse of what ’ s to come in America , it ’ s worth remembering their health system still had a bigger @ @ @ @ @ @ @ than the US system currently does .
But the point is , pandemics are unpredictable .
Their spread and containment depends a lot on human factors that even the most well-designed health system , or pandemic response plan , can ’ t fully anticipate .
And if the pandemic does overcome a country ’ s best preparedness efforts , some other countries could conceivably be at a deeper disadvantage than the US .
Patients who develop pneumonia because of Covid-19 may require mechanical ventilators .
The Johns Hopkins Center for Health Security reported @ @ @ @ @ @ @ and New Zealand ( each with their own version of national health insurance ) had fewer ICU beds with mechanical ventilation capability per capita than America does , though we too are not equipped to handle a crisis on the scale of the Spanish flu .
Nevertheless , “ these numbers suggest that the capacity of other countries to provide ventilation therapy might be significantly lower than our own , ” the Johns Hopkins experts wrote .
For now , US officials want to temporarily make our health care more like other places @ @ @ @ @ @ @ made it more vulnerable to coronavirus .
And in response , members of Congress and state governors keep proposing to make our health care more like other countries ’ systems — at least during this emergency .
Some states are doing what they can to lower those burdens .
New York Gov .
Andrew Cuomo announced last week he would require insurers and Medicaid in New York to cover treatment and testing cost-free with an emergency declaration .
States have some discretion with what their Medicaid programs cover , and more states are @ @ @ @ @ @ @ .
Gavin Newsom issued a similar order in the last few days .
States are limited in what they can do , though ERISA , the federal law regulating the large employer health insurance plans that cover about 100 million Americans , is a barrier to state officials who want to do more .
Cuomo ’ s order , for example , noted it applied to private health plans regulated by the state — the plans available to small businesses or individuals — but not the self-funded employer plans covered by ERISA .
@ @ @ @ @ @ @ decentralized health system complicates the response to an outbreak .
Rep. Ruben Gallego ( D-AZ ) announced last week he would introduce a bill that would make Medicaid cover testing for and treatment of Covid-19 for every American , no matter how they get their insurance .
This would be an important change to US health care : The federal government would assume responsibility for medical care for every American under these particular circumstances .
And the Trump administration appears to see a need to do something drastic , too , even if @ @ @ @ @ @ @ their proposed actions will have a significant effect .
Vice President Mike Pence , for example , said Covid-19 testing and treatment would be treated as an “ essential health benefit ” ( a standard established by the Affordable Care Act ) to cover everyone ’ s care .
But that change would actually not apply to the self-funded plans , nor to Medicare , as Nicholas Bagley , a law professor at the University of Michigan , wrote for The Incidental Economist : Though that may be , Pence ’ s statement @ @ @ @ @ @ @ at least a temporary patch on our health system .
Everybody seems to agree on that .
But these problems don ’ t go away when the coronavirus disappears .
They are still there , if treated less urgently than in a crisis , affecting the lives of millions of Americans every day .

Share All sharing options for: Coronavirus is exposing all of the weaknesses in the US health system
The international response to the novel coronavirus has laid this bare: America was less prepared for a pandemic than countries with universal health systems.
There is a real concern that Americans, with a high uninsured rate and high out-of-pocket costs compared to the rest of the world, won’t seek care because of the costs. Before the crisis even began, the United States had fewer doctors and fewer hospital beds per capita than most other developed countries. The rollout of Covid-19 testing has been patchy, reliant on a mix of government and private labs to scale up the capacity to perform the tens of thousands of tests that will be necessary.
“Everyone working in this space would agree that no matter how you measure it, the US is far behind on this,” says Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation.
People need to go to the doctor and get checked if they have Covid-19 symptoms, yet Americans may avoid medical care, even for serious conditions, because of the costs. Hospitals will need rooms for the people who require close monitoring in a clinical setting, and ICU beds and ventilators for patients who take a turn for the worse and require mechanical support to keep their bodies functioning.
But none of those units are sitting empty right now — they already have non-coronavirus patients who need them and will continue to need them through the crisis. New York Gov. Andrew Cuomo said Sunday that nearly 80 percent of New York City’s intensive care units were already filled, even with the Covid-19 outbreak still expanding.
By any of these metrics on pandemic preparedness, America trails most of the rest of the developed world.
“The U.S. performs worse than average among similarly large and wealthy countries across nearly all measures of preparedness for a pandemic,” Cynthia Cox, director of the Peterson-Kaiser Health System Tracker, told me. “The coronavirus outbreak is already exposing inefficiencies and inequities in our health system, and it is likely to put much more strain on the system in the coming weeks.”
And the slow start to testing in the US is only going to exacerbate those problems.
Testing is important not only because it gets people diagnosed and on an appropriate treatment if they do have an infection. It also establishes how widespread a virus actually is. Experts know the size of the problem, they know the rate at which people are being hospitalized or dying, and they can follow its movements. That leads to a more informed response.
But the United States has faltered in rolling out coronavirus tests, putting us far behind our economic peers in tracing the outbreak. A manufacturing problem with the test kits that were initially sent out in the field, and a delay in approving commercial tests, set the nation back in stopping or slowing down Covid-19.
“The testing failure is putting additional strain on our already challenged health system,” Cox said. “The combination of all of these factors will make the U.S. worse off than similar countries.”
Universal health care is not a perfect treatment for emergencies like this. Italy has a universal health care system, a federalized national health insurance program similar to Canada’s, but an uncontained outbreak has still forced the country to lock itself down as cases and deaths continue to pile up.
Nevertheless, other countries are still generally better prepared for a pandemic than the US is, and we are seeing right now the consequences of that gap.
For the time being, US politicians are proposing to make American health care more like these other nations: making care free or cheap at the point of service, either by having the government cover more of the cost or by mandating private insurers cover services related to the outbreak.
They are, however, only a temporary patch on these structural problems.
Why America is less prepared for a pandemic than other countries
On many measures, the United States has one of the worst health systems among developed economies. A bigger share of the population lacks health insurance. We carry more medical debt. We die more often from preventable causes. The weaknesses in this system, which already puts the US behind its peers on many health outcomes, are exposed in an outbreak.
And the biggest single problem, the one most unique to the American system, is costs.
Americans face higher out-of-pocket costs for their medical care than citizens of almost any other country, and research shows people forgo care they need, including for serious conditions, because of the cost barriers. Patients here are much more likely than those in most other countries to say they had a cost-related barrier to getting medical care: 33 percent in America vs. between 7 percent (Germany) and 22 percent (Switzerland) in other developed economies. Americans are more likely to say they struggled to afford or couldn’t afford medical bills and that their insurance plan had refused to cover some of their medical claims.
We know Americans delay care as a result of these cost barriers: in 2019, 33 percent of Americans said they put off treatment for a medical condition because of the cost; 25 percent said they postponed care for a serious condition. A 2018 study found that even women with breast cancer — a life-threatening diagnosis — would delay care because of the high deductibles on their insurance plan, even for basic services like imaging.
Those cost barriers hit patients at several points in a pandemic situation. First, they might be wary about going to the doctor at all because they are afraid they can’t afford the check-up or any testing. But then if they do get a Covid-19 diagnosis and require hospitalization, they have the bills from the hospital, the doctors they see, and any treatment they receive to worry about.
In America, and only in America among developed countries, do patients risk thousands of dollars in medical bills by seeking help in a crisis. Some Americans have already been billed nearly $4,000 over a government-imposed quarantine, as the New York Times reported.
Making matters worse is our system’s health care infrastructure, built on top of this fractured payer system. There are capacity shortages that put us at further disadvantage in a time of pandemic, when they are most needed.
Hospital beds, for example, will be necessary for Covid-19 patients with more serious symptoms. America has fewer hospital beds per capita than most other countries in the developed world.
A potential shortage of hospital beds is compounded by the fact that the US has higher rates of hospitalizations for chronic conditions that, with proper management, shouldn’t require the patient to go to the hospital. Those conditions include congestive heart failure, diabetes, and asthma. Researchers think a lack of access to primary care, and the high costs of seeking even this routine care compared to other countries, drive potentially preventable hospitalizations in the US.
That means our hospitals are already taking in patients they wouldn’t have to if the system functioned better, and now they will have to accommodate an influx of Covid-19 patients.
We have fewer doctors per capita too: 2.6 per 1,000 people, well below the comparable country average of 3.5 and lower than every country tracked by Peterson-Kaiser except for Japan. Experts blame the high cost of a medical education in the US, inextricably linked to America’s world-leading health care prices, for much of that shortfall.
And, likely as a result, Americans struggle more than people in most other places to get a same-day or next-day appointment with their doctor.
Take these structural problems together with America’s slow start to testing for coronavirus, and we are far behind where we should be.
“A failure to widely test and slow the spread means that we could have large spikes in the number of people who need medical care all at once, putting exceptional strain on our health system,” Cox told me. “By not acting quickly enough to prevent spread, our health system will be under greater, more concentrated strain.”
Many countries with universal health care are doing better than the US, but some have problems too
Countries with universal health care are testing more people and seem to be faring better with Covid-19 death rates than the United States. More centralized planning is an asset in a crisis.
Taiwan has seen a remarkably low level of coronavirus cases despite high traffic with the Chinese mainland. As Vox’s Kelsey Piper reported:
As of March 10, Taiwan has just 45 coronavirus disease (Covid-19) cases, and only one death. Health experts do not expect that Taiwan is overlooking many cases, either. That’s many fewer than its neighbors like Japan and South Korea and one of the best containment track records in the world so far. The Netherlands, with a comparable population, has five times as many cases despite having much less frequent direct travel with China.
In Taiwan, with its single-payer health program, every citizen has their digital medical records loaded into the same system. In the coronavirus outbreak, the country has added travel records to that online medical file, so every doctor can check whether their patients have visited an area affected by the outbreak.
And by getting jumpstarted on their response, those countries are able to lower the burden on their health systems. The primary goal with the coronavirus outbreak at this point is to slow the spread so health care providers aren’t overrun: to flatten the curve in this chart so patient needs don’t exceed the system’s capacity.
So even though, as you may have noticed above, countries like Canada and United Kingdom have about the same number of hospital beds as the United States does, they should be better positioned to mitigate the outbreak. They are already testing a lot more people. More testing allows them to take smarter protective measures, because they have a better idea of the scope of the pandemic, which helps to reduce the burden on their health system during the worst peak of the outbreak.
But even universal health care cannot fully prepare a country for the unpredictable movements of a pandemic virus. Italy, with a national health service that provides care to each of its citizens, has seen its coronavirus situation spin quickly out of control. On Monday, the country decided to close its borders in a desperate attempt to stem the crisis.
As Vox’s Julia Belluz reported, there are competing theories for the problem. Perhaps the aggressive testing had just made the scale of the problem clear earlier than in other places. It’s hard to say for sure. Or:
Another is that intense spread of the virus in the hospital system, before doctors realized there was a problem, may have amplified the outbreak. Some 10 percent of medical workers in Lombardy have been infected, according to a March 3 Washington Post report, and health workers account for 5 percent of those infected in the country. (Bolstering this explanation: The WHO-ECDC joint mission report suggests Italy should work on its infection prevention and control measures in hospitals.) There’s also speculation about whether Italy’s burden is particularly severe because of the country’s aging population. Covid-19 is known to hit the elderly particularly hard. That, along with the fast rise in confirmed cases, has tested the limits of the health system.
And yet, Italy still has more hospital beds per capita and doctors per capita than the United States, according to OECD and World Bank estimates. As experts worry whether Italy shows a glimpse of what’s to come in America, it’s worth remembering their health system still had a bigger capacity to handle a surge in patients than the US system currently does.
But the point is, pandemics are unpredictable. Their spread and containment depends a lot on human factors that even the most well-designed health system, or pandemic response plan, can’t fully anticipate.
And if the pandemic does overcome a country’s best preparedness efforts, some other countries could conceivably be at a deeper disadvantage than the US.
Patients who develop pneumonia because of Covid-19 may require mechanical ventilators. The Johns Hopkins Center for Health Security reported in 2018 that Canada, Australia, and New Zealand (each with their own version of national health insurance) had fewer ICU beds with mechanical ventilation capability per capita than America does, though we too are not equipped to handle a crisis on the scale of the Spanish flu.
Nevertheless, “these numbers suggest that the capacity of other countries to provide ventilation therapy might be significantly lower than our own,” the Johns Hopkins experts wrote.
For now, US officials want to temporarily make our health care more like other places
America’s fractured health system has made it more vulnerable to coronavirus. And in response, members of Congress and state governors keep proposing to make our health care more like other countries’ systems — at least during this emergency.
Some states are doing what they can to lower those burdens. New York Gov. Andrew Cuomo announced last week he would require insurers and Medicaid in New York to cover treatment and testing cost-free with an emergency declaration. States have some discretion with what their Medicaid programs cover, and more states are taking their own actions: California Gov. Gavin Newsom issued a similar order in the last few days.
States are limited in what they can do, though ERISA, the federal law regulating the large employer health insurance plans that cover about 100 million Americans, is a barrier to state officials who want to do more. Cuomo’s order, for example, noted it applied to private health plans regulated by the state — the plans available to small businesses or individuals — but not the self-funded employer plans covered by ERISA. It’s another way a more decentralized health system complicates the response to an outbreak.
Rep. Ruben Gallego (D-AZ) announced last week he would introduce a bill that would make Medicaid cover testing for and treatment of Covid-19 for every American, no matter how they get their insurance. This would be an important change to US health care: The federal government would assume responsibility for medical care for every American under these particular circumstances.
And the Trump administration appears to see a need to do something drastic, too, even if experts don’t think some of their proposed actions will have a significant effect.
Vice President Mike Pence, for example, said Covid-19 testing and treatment would be treated as an “essential health benefit” (a standard established by the Affordable Care Act) to cover everyone’s care. But that change would actually not apply to the self-funded plans, nor to Medicare, as Nicholas Bagley, a law professor at the University of Michigan, wrote for The Incidental Economist:
Even if they did, insurers can (and do!) impose cost-sharing for EHBs, and could do so for a COVID-19 test. It’s a completely meaningless statement.
Though that may be, Pence’s statement still reflected a real need to put at least a temporary patch on our health system. Everybody seems to agree on that.
But these problems don’t go away when the coronavirus disappears. They are still there, if treated less urgently than in a crisis, affecting the lives of millions of Americans every day.