Pandemic to endemic: Where do US public-health systems go from here?

As COVID-19 moves from a pandemic to an endemic disease in the United States, the country could take the opportunity to create stronger, more equitable public-health systems.

All pandemics eventually run their course. The United States has reached a point where it is starting to shift from a COVID-19 crisis footing to an endemic one. Although new variants of SARS-CoV-2 (novel coronavirus), the virus that causes COVID-19, could upend this trajectory, the country may be well positioned now to reimagine its public-health systems.

Over the past two years, as new variants of the novel coronavirus have emerged, US public-health priorities have focused on the critical missions of getting people tested, vaccinated, and boosted while maintaining access to healthcare. Inequalities that predated the pandemic were also laid bare as historically marginalized communities bore the brunt of the pandemic’s ill effects. 1

Many public-health-system authorities are now redressing vulnerabilities and planning a stronger path forward. To help guide them on this journey, McKinsey previously set forth four imperatives authorities can consider when framing a strategy for living with COVID-19 as the transition from pandemic to endemic gets under way: defining the next normal, tracking progress, limiting illness and death, and slowing transmission.

US state and local governments have a unique role to play in stewarding this evolution by defining and supporting how residents will live in a world with endemic COVID-19 and other health concerns. The ground on which this next normal settles may determine whether the lessons of the pandemic are heeded and could create fertile soil for public-health systems to emerge more resilient, equitable, and responsive to whatever challenges lie ahead.

Defining the next normal

In the thick of the COVID-19 pandemic, much of the public discourse focused on disease-specific metrics to understand the spread of the novel coronavirus. As endemic COVID-19 beckons, a broader set of criteria will likely become increasingly relevant.

McKinsey previously suggested that societies may need to define goals that recognize and balance differing public-health needs. 2 That means focusing concurrently on reducing hospitalizations and death while also minimizing the impacts of economic and social disruptions stemming from pandemic-related policies, such as missed school days and workdays. The secondary impacts of COVID-19 on other public-health priorities, such as behavioral health and delays in seeking care, are also considerations. Moreover, some have suggested viewing the burden of COVID-19 in relation to other relevant diseases, by shifting from a focused lens to one encompassing the impact of all respiratory diseases collectively. 3

As the US federal, state, and local governments consider public health over the next five years, they will be determining what markers are important for a holistic, balanced view of US society’s next normal. Four actions could help:

  • Developing a set of vital signs to track the health of society. As the pandemic becomes endemic, evaluating the public-health system could extend beyond the current key COVID-19-related measures, which include the excess mortality, hospitalization, case fatality, and transmission rates for the specific disease. The pandemic has focused the public’s attention on a narrow set of health measures, and now may be the time to broaden this attention to a set of measures that encompasses broader societal healthcare outcomes (such as maternal and infant health, behavioral health, communicable disease, chronic disease, and environmental health). Factors that affect health (such as childhood lead exposure) could be part of the set, as could socioeconomic indicators (such as schooldays and workdays lost because of health issues, changes in employment rate, and demographic differences across various metrics).
  • Engaging a diverse range of stakeholders to create the vital signs. Including stakeholders across different demographic and socioeconomic groups can provide varying viewpoints that are key to society’s functioning and illuminate priorities for the public-health system.
  • Maintaining an evidence-based approach. An evidence-based approach to public health could provide a better understanding of how vital signs can interact with one another and affect daily life. For instance, as rising COVID-19-immunity levels lower the risk of severe COVID-19 illness, the emphasis may begin to shift away from case rates and toward the number of hospitalizations, deaths, and acute-care access, in addition to tracking variants.
  • Communicating the reasoning with clarity and empathy. Clear, considerate communications may help residents understand what goals are driving policy decisions and why they are important. As situations evolve, pandemic-related policies will likely change, but they could still consistently move society toward these objectives. Throughout the process, leaders can acknowledge empathetically the difficulties faced when adapting to changing policies and could consider reemphasizing the shared goals of the next normal.

Tracking progress

Once public-health goals are defined, it will be important to track progress toward them and communicate it to the US public. Two principles could guide how federal, state, and local governments may best achieve that:

  • Communicating vital signs simply. Communicating data in simple ways could help governments reach a comprehensive set of constituents. Many US states have made investments to improve the quality of data and data visualization tools to democratize public-health information, enabling their constituents to understand what is happening in their own communities. Continuing to advance these solutions could enable governments to align the goals that define the next normal to a system of alerts akin to air quality level and forest fire risk level, for example. That may enable policy decisions to be adapted transparently based on public-health conditions. Separately, providing individuals with access to data on the public-health condition of their communities could allow them to determine their own risk appetites.
  • Reinforcing health data infrastructure and public-health surveillance systems. Public-health surveillance, with tracking and early intervention of any new variants, will likely prove critical in the next normal. Governments could play a pivotal role in deepening public-health infrastructure and investing in surveillance capabilities to ensure that any changes in population health can be detected early and monitored thoroughly to minimize the severity of outbreaks. Establishing robust integrated data sets from across healthcare stakeholders, public sources, and private sources—as well as the means to determine insights quickly and efficiently—will further strengthen the ability to understand or anticipate risks. Next-generation surveillance may require the use of a broader set of bioinformatics tools (such as genomic sequencing to detect variant mutations and wastewater-monitoring systems to detect community transmission).

Limiting illness and death

Limiting illness and death may pivot on a combination of initiatives spanning vaccines, treatments, investment in robust healthcare delivery systems, resources for the highest risk populations, and health equity.

Vaccines

Vaccines have proven essential for curbing the spread of COVID-19, limiting COVID-19-related hospitalization and death, and alleviating pressure on hospital systems. As the novel coronavirus evolves, so too does the vaccination effort. US state and local governments could play a vital role in expanding access and uptake of COVID-19 vaccines by incentivizing hesitant adults, immunizing younger people, and providing boosters for the general population as required. This could be achieved through the following initiatives:

  • Integrating COVID-19 boosters into annual vaccination campaigns. While vaccines bolster immune defense against COVID-19, recent evidence shows that this immunity wanes over time. 4 Accordingly, the US Centers for Disease Control and Prevention (CDC) has recommended booster vaccinations for the general population. 5 As variants continue to evolve and arise, periodic booster shots may provide an effective public-health tool to anticipate and control future outbreaks. In the short term, US state health departments and local health departments (LHDs) could combine campaigns related to annual vaccinations to simplify communications. Ensuring access to both COVID-19 and flu vaccines at dispensing locations could further simplify the journey. Longer-term, combination vaccines across multiple respiratory illnesses are in development and could simplify vaccination regimens and logistics. These measures to minimize friction could have meaningful impact on the pace and scale of booster uptake—more than half of respondents recently surveyed by McKinsey who have been vaccinated with primary series COVID-19 shots but not booster shots said they plan to get the boosters.
  • Requiring evidence of receiving COVID-19 vaccines or recent negative test results when important to protect the public. Vaccine requirements have been shown to rapidly increase immunization and could be applied to a narrower group engaged in high-risk settings or to a broader population when appropriate for public-health reasons. For instance, New York City previously instituted a COVID-19 vaccine requirement for its 160,000 municipal workers and 150,000 staff in public schools. Vaccination numbers increased significantly among these populations. The vaccination rate (of at least one dose) among healthcare workers and full-time New York City school staff increased to 92 percent and more than 95 percent, respectively. 6

Treatments

The past two years of the COVID-19 pandemic have led to key breakthroughs beyond vaccines, including new antiviral medications and other COVID-19 treatments. As the situation in the United States shifts from pandemic to endemic, it may be essential for those who become infected with the novel coronavirus to have adequate access to such therapies.

A strategy to consider is building capacity for end-to-end testing to treatment. In March 2022, President Biden announced a COVID-19 preparedness plan with a Test to Treat initiative, where the federal government offers free antiviral medications, such as PAXLOVID (nirmatrelvir and ritonavir) and LAGEVRIO (molnupiravir), for those who test positive for COVID-19. 7 US state and local governments could play a vital role in the supply chain to enable access to those medications, including by ensuring adequate resource allocation, reinforcing distribution channels with local pharmacies, and communicating treatment availability to the public.

Health system robustness

Immunity remains the most powerful tool in curbing the progression of COVID-19. But vaccination will likely need to be complemented by a robust healthcare delivery system to treat those with more serious infection or higher baseline risk while managing the availability of general acute-care capacity. Significant funding from the US government has been made available to state and local governments for purposes such as building workforce and foundational capabilities. As such, they could consider the following actions:

  • Rebuilding the healthcare and public-health system workforces now. Both within the public-health system and within the healthcare delivery system, COVID-19 has exacted a high toll on the workforce, with nearly half of healthcare workers reporting some form of burnout (exhibit). 8 Across the United States, healthcare workers have opted out of the workforce and continue to state that they will keep doing so at alarming numbers. This suggests that now could be an ideal time for states to reassess holistically the current talent pool, projected needs, and estimated pipeline of healthcare workers capable of treating patients for all diseases, of which COVID-19 is one acute stressor. The public-sector workforce may face a similar challenge. By some estimates, US state and local governmental departments will need to grow their workforces by nearly 80 percent to provide a minimum set of healthcare services to Americans. 9 This challenge is particularly amplified in foundational and cross-cutting capabilities in public health, such as communications and emergency preparedness, given that much of the funding for the public-health system has been program or disease area specific. Rebuilding the US healthcare and public-health-system workforces quickly through investments in training, clinical-process redesign, workforce allocation, and automation could be a critical priority for every state to ensure a robust workforce for decades to come.
Over 40 percent of surveyed physicians reported experiencing burnout to  some extent.
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  • Ensuring appropriate access to care for populations. There is no question that the COVID-19 pandemic changed patient behavior. As a case in point, there has been an increase in the proportion of patients seeking virtual healthcare. There is also no question that the pandemic has caused some people to delay seeking care, resulting in a healthcare backlog. Some of these changes could inform governments on how to increase equitable access to care across populations. US states could use this moment in time to consider where and how to support or incentivize the healthcare delivery system to improve access for patients (such as through flexibility in telemedicine and licensing regulations and assessment of the overall mix of outpatient versus acute-care assets).
  • Codifying the playbook for future surges. If US state and local governments haven’t already done so, they could codify a “surge playbook” so that it can be quickly dusted off if and when needed. The playbook could include a host of measures, including the following:
    • modeling potential supply and demand of beds to identify areas at greatest risk
    • establishing longer-term contracts with temporary staffing agencies to channel additional staff to targeted areas of need
    • exploring potential policy or regulatory levers to enable flexibility in staffing levels, increase top-of-license practice, or upskill workers to meet needed roles
    • building supply chain robustness to enable rapid procurement of pandemic resources, including personal protective equipment and testing capacity
    • activating strategic healthcare capacity (for example, in partnership with the National Guard) as needed
    • providing access to mental-health and wellness resources for workers to support retention and well-being

High-risk populations

As vaccines provide robust COVID-19 protection for most of the US population, jurisdictions may wish to focus resources on high-risk groups. As has been the case throughout the pandemic, this would include the elderly (people aged 65 and older), the immunocompromised, those who suffer from behavioral-health conditions, and those who have other high-risk underlying conditions. The risk factors for COVID-19 have been shown to be even greater for individuals who live in congregate settings. In that regard, placing special emphasis on locations such as long-term-care facilities, homeless shelters, group homes, and correctional facilities through all interventions (vaccination, testing, and treatment) could further curb severe illness and death.

Health equity

The pandemic has undoubtedly had a disproportionate impact on marginalized communities in the United States, where Black people are nearly 2.5 times more likely than their White counterparts to be hospitalized for COVID-19 and 1.7 times more likely to die from the disease, according to the CDC. 10 The COVID-19 hospitalization rate is 2.2 times greater for Latinos than their White counterparts, and the death rate is 1.8 times greater.

With healthcare workers opting out of the workforce at alarming numbers, now could be an ideal time for states to reassess holistically the current talent pool, projected needs, and estimated pipeline of healthcare workers capable of treating patients for all diseases.

While the pandemic has shone a long overdue spotlight on racial health inequities in the United States, one prepandemic analysis estimated that deaths stemming from persistent health disparities have resulted in a loss of 3.5 million life years, heaped $93 billion in excess healthcare costs on the economy, and cost $42 billion in untapped productivity. 11 Health departments could play a pivotal role in ensuring that funding and resources are appropriately focused on interventions that close these health equity gaps. To advance health equity, US state and local governments may need to tailor their capabilities to serve marginalized communities.

First, they could use analytic methods and tools to collect and report data on tests, hospitalization, and vaccination rates in various demographics. Having such information can help identify inequities in healthcare outcomes. According to the CDC, more than 25 percent of COVID-19 vaccinations are missing race or ethnicity data. 12 Gaps in such knowledge can have an adverse impact on the ability to target interventions that can help address health equity challenges.

Second, governments could engage in community-centered, multilingual messaging campaigns to support historically marginalized populations. Given that vulnerable populations often foundationally face lower health literacy, tailored approaches may prove crucial. As an example, North Carolina has created a program to “enhance messaging to the public and specific groups to promote vaccination and prevention efforts,” including a focus on reaching “American Indian, disability, and Spanish-speaking communities.” 13 New York City, with its diverse population, provides priority information in 14 different languages. Such tools of cultural competency and congruency could help bridge gaps of mistrust and overcome hesitancy toward disease treatment and prevention.

Finally, governments could develop initiatives dedicated to increasing healthcare access for those who need it most. For many marginalized communities, access—not hesitancy—limits equitable healthcare delivery. Using insights from equitable data analyses and community engagement, state health departments and LHDs could strategically deploy resources to such populations. For instance, a US county is developing a series of initiatives targeted at reducing healthcare inequities in underserved communities. The programs include developing the healthcare workforce, promoting healthy behaviors in younger populations, and engaging with community healthcare workers. The effort could potentially reduce the likelihood of emergency department admissions by an estimated 50 to 75 percent for underserved individuals, reducing healthcare costs by $75 million to $200 million (primarily through Medicaid savings), in its first two decades. Facilitating partnerships across healthcare providers, community organizations, retail sites, and philanthropists could also provide more routine and reliable healthcare access, improve overall healthcare outcomes, and create a network to utilize when health crisis situations arise.

Slowing transmission

To slow disease transmission and endemic disease, US state and local governments could be guided by three fundamental principles for enabling a robust public life: maximize ability to detect disease outbreaks, minimize the time needed to coordinate and mobilize resources to address them, and promote nonpharmaceutical interventions as needed. Investing in the following could help:

  • Always-on public-health surveillance that uses a broad range of data sources. Health departments may want to ensure that public-health surveillance systems are designed to be always on by continuously monitoring for outbreaks through a broad set of tools (such as wastewater surveillance and sampled testing). Investments could prioritize more passive surveillance approaches that minimize impacts on individuals. Spikes in disease incidence could then trigger rapid responses.
  • Agile rapid-response teams. Always-on public-health surveillance systems could be coupled with rapid-response teams that could be quickly scaled up to perform essential outbreak control operations. Such operations could include testing, therapeutic interventions, securing hospital resources (for example, by pooling staffing resources during surges), and developing safe interaction policies. Governments could work with community stakeholders (such as schools, employers, and faith-based organizations) to develop scenario playbooks that would cater to different outbreak severities and local situational factors.
  • Coordination among state health departments and LHDs. In steady state and especially in preparation for emergencies, seamless coordination and a clear definition of roles and responsibilities among centralized US state actors and LHDs could prove crucial for mounting an effective outbreak response. State governments could begin by gathering information from LHDs through focus groups or listening tours. They could then form coordination teams that liaise operationally among state agencies and LHDs under a shared understanding of goals and each stakeholder’s role in achieving them. For instance, the California Department of Public Health has set up a local coordination team that consolidates a menu of resources, including technical assistance, information, translation services, and vendor contracts, available to LHDs. The coordination teams could also facilitate local-to-local or cross-jurisdictional resource sharing to minimize siloing of LHDs.
  • Promoting nonpharmaceutical interventions that reduce local transmission. As more data about COVID-19 transmission and epidemiology emerge, governments could enable communities to have a vibrant public life while offering protection through nonpharmaceutical interventions that reduce disease spread. That could include maintaining policies that allow safe social interaction when case rates increase or new variants emerge (for example, through outdoor dining, physical distancing, and mask use in crowded areas). Investing in infrastructure that reduces disease transmission (such as air quality infrastructure in schools and workplaces) is another consideration.

We may not know what exactly the transition to endemic COVID-19 in the United States will look like, but society will eventually reach the next normal, and state and local governments will play essential roles in determining its shape and contours. The design, prioritization, and sequencing of how each health department shapes its future could be very different, depending on its operating model, governance structures, community needs, and other strategic considerations. Planning now for this future state could ensure that the United States moves toward it intentionally—and could help create a society that’s safer, healthier, and reunited with confidence.

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