The Hidden Costs of COVID-19

As we enter 2022, the COVID-19 pandemic is surging through the United States yet again, this time fueled by the highly transmissible Omicron variant. Although the symptoms of this variant appear to be more mild than previous variants, the increased transmissibility has sent case counts soaring and put pressure on hospitals for a second winter in a row.

News headlines about COVID-19 usually focus on the raw number of cases and the positive test percentage per state, but there are other costs that the virus has inflicted upon society that cannot be measured by those statistics alone. The hidden costs of COVID-19 are harder to discern than positive viral tests but may prove to be just as damaging to society’s long-term health and wellness.

1. Adolescent Mental Health

When schools closed as part of the nationwide precautions taken during the emergence of COVID-19 in March 2020, it marked the beginning of a tumultuous two years for school-aged children and young adults. The shift to remote learning and increased restrictions for in-person schooling have affected children’s ability to both attend school and enjoy its full benefits when present. Research suggests that remote learning has not provided an adequate substitute for in person schooling; NWEA’s Center for School and Student Progress reports that student achievement in both math and reading levels were down compared to previous years, which can be attributed to both shortcomings in the effectiveness of remote teaching and remote learning. This academic progress was most stunted for those in minority and lower income communities[1].

The pandemic has also led to worsening mental health in adolescents. In October, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry and Children’s Hospital Association declared a national emergency in child and adolescent mental health, stating the mental health crisis is “inextricably tied to the stress brought on by COVID-19 and the ongoing struggle for racial justice and represents an acceleration of trends observed prior to 2020”.

These trends include an increase in the rate of national youth suicide and mental health emergencies:

In 2018, suicide was the second leading cause of death for youth ages 10-24 and that rate only increased during the pandemic.
Among youths ages 12-17, the percentage of mental health–related emergency department visits in Summer 2020 increased by 22% from Summer 2019.
The rise was even more stark in girls between the ages of 12-17, whose rate of suicide increased drastically in two different time blocks (February 21-March 20 and July 26-August 22) from 2019 to 2020[2].

Children have suffered in other ways during the pandemic as well. Incidents of violence against children has risen as part of a nationwide crime increase. Many cities across the country saw an increase in the number of children murdered and school shootings have reached a record high of 42, which is up from 27 in 2019[3].

Policy Proposals

There are a few ways that policymakers can address the children’s mental health crisis. The resumption of in-person learning should be a main priority, supported by increased funding for schools. Additionally, a focus on behavioral health (BH) interventions and suicide prevention programs is needed to help reverse the increase in BH and suicide cases.

Increase testing capabilities and funding to keep schools open – The continuation of in-person schooling is one of the most crucial parts of supporting children and their mental health during the pandemic. The Biden administration has taken a firm stance on this, reiterating that schools should be kept open despite the Omicron variant surge. The administration should prioritize this goal by increasing school systems’ testing capabilities and putting additional funding towards keeping schools open. The American Rescue Plan allocated $130 billion toward reopening schools and $10 billion toward COVID-19 testing in schools. Supplementary funding should be given to account for the additional challenges that schools have faced since this legislation was passed last spring.

Earlier this month, steps were taken to that end when the Biden administration announced that insurance companies and group health plans would cover the cost of over-the-counter, at home COVID-19 tests starting on January 15^th. This will allow most consumers get tests for free or be reimbursed by their health plan and incentivizes insurers to cover the costs of the test, which will help rapid testing capabilities for school systems.

Integrate mental health resources into school settings – Many schools have used funding from the American Rescue Plan to hire and train more mental health workers[4]. Bringing these clinicians into a setting where they can directly interact with children is important in treating a population that may not necessarily seek help on their own. Additionally, schools are training teachers to address mental health issues and trauma, as well as incorporating mental health lessons into their curriculum.

Legislation to improve mental health care for adolescents – Although the American Rescue Plan laid the groundwork for keeping schools open, it was only passed as a short-term funding bill. Additional legislation is required for the changes made through the legislation to be sustainable. In the Build Back Better Act, $1 billion is pledged for procuring healthcare professionals specifically for schools. Another proposed bill that can address this issue is the Student Mental Health Helpline Act, which would create a grant to support existing and new statewide student mental health and safety helplines. Finally, the Mental Health Services for Students Act, awaiting passage in the Senate, would create partnerships between schools and community organizations to provide students with mental health resources.

2. Hospital Staff Burnout and Turnover

Another population that has acutely suffered from global pandemic is hospital staff. Doctors and nurses have been the celebrated heroes of COVID-19 prevention efforts, and as the third year of the pandemic approaches, most medical staff have reported feelings of exhaustion and burnout. This has created a cycle in which healthcare workers are driven from the industry, thus placing additional strains on their peers and creating further feelings of burnout, which lead to more turnover.

Before the pandemic, burnout was a major concern for healthcare workers, and this has only intensified since 2020. In 2020, 49% of healthcare workers reported feeling burnout and 60% to 75% of clinicians reported some symptoms of exhaustion, depression, sleep disorder and PTSD.
One Morning Consult poll found that since February 2020, 18% of healthcare workers surveyed had quit their job and another 12% had been laid off. Of those healthcare workers who were still employed, 31% of them had thought about quitting their jobs at one point, with 19% of those workers having thought about leaving the healthcare field entirely. The survey respondents attributed these feelings primarily to the pandemic, burnout, and insufficient pay[5].

In addition to exacerbating existing feelings of burnout, the recent influx of COVID-19 patients has placed a strain on other aspects of hospital care. There have been mass instances of delayed care occurring at locations across the country; one study determined that one in three Americans between the ages of 50 and 80 put off in-person medical care because of COVID-19 concerns. States have also recently begun mandating the cancellation or delay of elective surgeries in order to help hospitals cope with the growing number of COVID-19 patients. Although the procedures being delayed are less urgent than a COVID-19 patient in need of ICU care, they are leading to negative health outcomes in other areas. For example, preventative cancer screenings dropped by 94% in the first four months of 2020, and the National Cancer Institute anticipates 10,000 preventable deaths over the next decade because of delayed diagnoses attributable to the pandemic[6]. Another example is the number of preventative amputations being delayed: one study of 147 U.S. and Canadian sites showed that preventive procedures fell by 71% and hospital deaths increased by five times for patients with severe limb problems[7].

Finally, the failed promise of a return to normalcy with mass vaccination was not realized to the extent that was promised due to the transmissibility of the virus even among vaccinated people. All of this has contributed to a healthcare workforce that has diminished both by choice and by layoff, putting a physical and financial strain on hospitals. Hospitals have lost almost $24 billion during the pandemic, in addition to the thousands of people who have died in hospital care[8]. The financial, mental, and human cost of COVID-19 has strained the hospital system in ways that are not always apparent to the public.

Policy Proposals

Addressing burnout among healthcare workers requires interventions from hospital leadership that can be supplemented with additional government support. The American Rescue Plan has already begun to tackle the latter issue, designating $103 million for the Health Resources and Services administration to address the goals of strengthening resiliency and addressing burnout in the healthcare force. Department of Health and Human Services (HHS) Secretary Xavier Becerra highlighted the current administration’s attention to this issue in the press release in which this funding was announced, saying:

“The Biden-Harris Administration is committed to ensuring our frontline health care workers have access to the services they need to limit and prevent burnout, fatigue and stress during the COVID-19 pandemic and beyond. It is essential that we provide behavioral health resources for our health care providers – from paraprofessionals to public safety officers – so that they can continue to deliver quality care to our most vulnerable communities.”

Possible interventions that hospital leadership can implement include:

Peer-to-peer coaching sessions – The most important culture change that can be made is a change in the mentality of encouraging medical staff to never complain. An environment where healthcare workers can voice their concerns and anxieties and consult their peers for advice on handling burnout can be a useful platform if given the proper amount of consideration and respect.
Establishment of provider wellness committees – Provider wellness committees can take an active role in establishing a more supportive culture in hospitals, such as hosting wellness seminars, fostering support groups for clinicians, and implementing peer-to-peer coaching.
Hospital-level interventions – Although coaching and support sessions are important, hospitals should treat physician burnout and staff shortages as a safety issue. Recommendations from the Annals of Family Medicine journal provide an outline for how to address these issues at a hospital level. The study recommends hospitals to put funding towards additional staffing and solving deficiencies in work conditions and communications. The recommendations also advise hospitals to create indicators of healthcare worker burnout and the factors that lead to this burnout, and to give staff a leading role in decisions that could alleviate burnout.

3. Increased Incidence of Substance Use Disorder

The incidence of substance use disorders (SUD) is another trend that has been accelerated by the COVID-19 pandemic. In recent years, an increase in people have received treatment for SUDs and more overdoses have been reported.

In the 2017 National Survey on Drug Use and Health facilitated by the Substance Abuse and Mental Health Services Administration (SAMHSA), 1 in 12 American adults (18.7 million) had an SUD. Around this time, the amount of people receiving treatment for SUDs drastically increased, especially for heroin related opioid use disorders, where treatment jumped from 37.5% of people in 2016 to 54.9% in 2017.

Five years and one global pandemic later, these numbers have only gotten worse:

As of June 2020, there has been a 13% increase in Americans reporting substance use cases. Compared to a similar timeframe in 2019, there has been an 18% increase in overdoses as well.
More than 40 states have reported an increase in opioid related mortality incidents and maintain ongoing concerns over SUD cases with their residents[9].

No matter what study is analyzed, the data is consistent and clear – people have turned to substance use to cope with the stress of the pandemic.

The combination of isolation, confusion over the state of the world, and increased unemployment has engineered a rise in SUD cases across all populations. Remote interactions also make it harder for people to detect symptoms of SUDs in others. “You can’t smell someone’s breath [over Zoom]. You may get some visual signs [of substance use], but they aren’t as obvious as they are when you see someone in person,” said Michael Thompson, president and CEO of the National Alliance of Healthcare Purchaser Coalitions[10]. These detection challenges have made treating SUD cases more difficult in a time where they have become more prevalent than ever.

Policy Proposals

To address the increased prevalence of SUD cases during the pandemic, policymakers should combine support for providers and interventions with a loosening of care restrictions. The emergence of telemedicine has provided a method to deliver care remotely and continuing to utilize this care delivery method is a key component in treating SUD patients during the pandemic.

Increased use of telemedicine and general removal of restrictions or regulations surrounding care – Because of the limited options for in-person care during the pandemic, creativity must be adopted when treating SUD patients. States have removed restrictions related to accessing SUD treatment, such as allowing the initiation of buprenorphine without an in-person visit, eliminating prior authorization and additional barriers to treatment, and increasing telehealth availability as an alternative to in-person treatment[11].
Increased support of SUD providers to access federal funding – In order to treat their patients, SUD providers need to be supported with adequate funds from the federal government. The American Rescue Plan designated portions of funding to be used for SAMHSA block grants that would address SUD issues. Additionally, SAMHSA has awarded $123 million in grants for communities and healthcare providers to combat the country’s overdose epidemic. Continued funding for programs such as these will prove to be a valuable resource in addressing SUD during the COVID-19 pandemic.
Use of Value-Based Payment to reward providers – Value-Based Payment (VBP) has been a major tool in bringing healthcare costs down while maintaining a high level of positive health outcomes and many states have begun to incorporate it into their SUD treatment delivery. Implementing VBP arrangements will incentivize high quality of care using nationally certified innovations and treatments for SUD patients[12].

Conclusion

Although the COVID-19 case counts take up most of the headlines, there are many hidden costs of COVID-19 that are not as readily apparent to the public. Worsening behavioral health in adolescents, hospital staff burnout, and increased SUD cases are all negative health outcomes that have intensified over the last two years. It is incumbent upon policymakers and those in leadership positions to design interventions and legislation to alleviate these problems so that they will not continue to be exacerbated and further drive up the hidden costs of COVID-19.