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The Bipartisan Infrastructure Deal Is Now Law, But Here’s What It Forgets

Op-Med is a collection of original articles contributed by Doximity members.

In June 2021, the Biden administration announced bipartisan support for federal legislation to rebuild our nation’s crumbling infrastructure. The Infrastructure Investment and Jobs Act seeks to revive highway, transit, rail, and public work systems, as well as improve broadband internet access, mitigate the supply chain crisis, and combat climate change. Like most Americans, I am grateful that we are finally addressing our deficits in infrastructure. Nevertheless, this recently signed law forgets one blatantly obvious thing: our deficits in health care infrastructure, as demonstrated vividly by the COVID-19 pandemic.

The past two years of COVID-19 halted our economy and our daily lives, and, more importantly, resulted in over 5.4 million deaths. Emergency legislation such as the CARES Act and HEROES Act supported already thinly-stretched hospitals, but only covered a fraction of lost revenue. Despite the best intentions, these band-aid solutions resulted in minimal improvement of health care capacity to meet the new demands of the COVID-19 pandemic. Many hospitals faced bankruptcy and were shut down, particularly in rural areas where access to care and materials were already limited. Others had to make tough decisions regarding how they would allocate ventilators, space, staff, and other scarce resources.  

Over the past several years, the number of natural and human-made disasters in the U.S. has increased, from shootings to contagious infectious diseases. Even climate change has taken a toll on the health of our population; Hurricanes Sandy, Harvey, and Katrina disabled the operating capacity of entire hospitals and resulted in death both inside and outside of hospitals. In addition, Hurricane Maria’s impact in Puerto Rico resulted in critical shortages of saline across the U.S. These disasters have severely impacted population health in this country, with hospital and public health systems often lacking the infrastructure, supplies, staff, and space to respond effectively. And yet, health care and government leadership have not yet conducted the post-mortem analysis to understand fundamentally how and why this breakdown has occurred.

As a practicing physician who has witnessed hospital ceilings collapse and flooding occur during routine thunderstorms, I see how our health care infrastructure is crumbling every day. High-consequence events demonstrate one truth that biosecurity and emergency management experts have been screaming for decades, that unless we seriously invest in public health and health care delivery, we will be unable to meet the demands of emerging disasters, which will in turn result in profound economic and societal loss. 

Although the Infrastructure Investment and Jobs Act adopts a broad definition of infrastructure, cognizant that the physical plants, spaces, and policies we create in service of the public ultimately impact the well-being of a nation and its people, it still lacks explicit funding for health system preparedness and infrastructure. This is disheartening, but unsurprising: Investing in our health care delivery and public health systems has historically been deficient — likely because disaster preparedness and health care resilience are not revenue-generating in the short-term. The last large-scale investment in health care infrastructure was accomplished in 1946 via the Hill-Burton Act, which attempted to construct and repair hospitals across the U.S. Though the Act resulted in inequitable, segregated allocation of funding, it proved that infrastructure investment could launch an era of health care transformation. Despite this, no such government funding for already-outdated hospital systems has occurred in the past 75 years. This is alarming.

As politics continue to be divisive, perhaps the lessons we have yet to learn from this pandemic could be common ground. Recognizing public health as an essential element of U.S. national security would make public health an attractive business value proposition. The health of our nation and our national security are intertwined, and our health care financing should reflect this. Currently, the Infrastructure Investment and Jobs Act includes noble efforts to address the detrimental impacts of climate change, and to replace lead pipes in our water systems which have notable societal consequences and implications for improving population health. If these efforts were broadened, infrastructure development could support and sustain a range of physical plant, supply chain, and other improvements in public health and health care systems. Such development would create large numbers of well-paying health sector jobs, improve health care access and equity, and lead to sustainable economic growth. 

Upstream interventions have been desperately needed for some time. We should be repairing and replacing our bridges, tunnels, internet, power grid, and the entire U.S. infrastructure — and these efforts will certainly improve population health. However, these interventions represent only an infinitesimal portion of what is required to repair many years of neglect. The COVID-19 pandemic taught us what happens in times of disaster, and it makes sense to start with rebuilding our society and economy. But now, two years into a global pandemic with an embarrassingly uncoordinated, underwhelming response, we urgently need to start with health care. Our safety net in this country has been, and will continue to be, our health systems. Health care infrastructure demands our immediate attention, not just another emergency act of Congress the next time we are in trouble. With the emergence of ever-new COVID-19 variants, our future depends on reviving and transforming health care. In 2022, health care delivery and public health should be our highest priority, greatest return on investment, and most pressing infrastructure allocation. Thoughtful investment in health care delivery with an eye toward disaster preparedness and health equity would improve population health for generations to come.

What kind of health care infrastructure initiatives would you like to see? Share your suggestions in the comments below.

Charles Sanky, MD MPH is an emergency medicine physician at the Mount Sinai Health System in New York and former public health policy analyst who has seen the impacts of the COVID-19 pandemic on our patients and national health care systems first-hand.

Illustration by April Brust

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