Insights into the future of COVID-19 care

DAVID SMITH, MD, MAS
Professor of Medicine
University of California, San Diego
San Diego, California

MHE: How does COVID-19 impact the healthcare system in 2025?

Smith: COVID-19 continues to impact the healthcare system today, though differently than at the pandemic’s peak. In 2020 and 2021, healthcare systems faced overwhelming challenges including widespread staff shortages due to illness and large influxes of patients. Public health measures including lockdowns strained both healthcare and economic systems, and delaying elective and non-urgent procedures led to significant backlogs.

Today, while there are still COVID-19 surges, the healthcare system is better equipped to handle these waves. Nevertheless, illness can still cause staffing shortages, and surges of multiple respiratory illnesses—such as COVID-19, RSV and influenza—can overwhelm hospitals. When surges coincide, elective procedures may again be delayed, again creating backlogs. These surges are a key factor for decision-makers to manage.

MHE: What defines severe COVID-19, and which populations are most at risk?

Smith: Severe COVID-19 is defined by negative outcomes including hospitalization and death. Patients exposed to the virus can develop pneumonia or pneumonia-like symptoms, which can progress to acute respiratory distress syndrome (ARDS)–a severe, inflammatory condition that impairs lung function. In extreme cases, patients may require a ventilator or even heart-lung bypass to support their breathing. This can strain both the patient and the health care system, as these interventions can be prolonged.

The populations most at risk for severe COVID-19 include the elderly, particularly those in their late 70s and older, and individuals with compromised immune systems, such as those undergoing chemotherapy (e.g., rituximab for lymphoma). These patients are more vulnerable to severe outcomes, and, once infected, their condition can rapidly deteriorate. While severe cases tend to be more common in these groups, younger, seemingly healthy individuals can also experience unpredictable and severe illness.

Managing risk involves not only minimizing exposure to COVID-19 but also using antiviral medications for high-risk individuals–those with conditions like diabetes, obesity or hypertension. It’s crucial for clinicians to remain vigilant, as the severity of COVID-19 can still be unpredictable, even among those who have previously recovered without complications.

MHE: How does severe COVID-19 affect patients and healthcare systems?

Smith: Severe COVID-19 has substantial impacts. For patients, it often results in high mortality, particularly if they don’t receive timely hospital care. During the 2020-2021 Delta wave, disparities in access to critical resources like ventilators highlighted the uneven capacity of healthcare systems across the country.

For those who survive severe COVID-19, recovery can be lengthy and challenging. Patients who require extended ventilation may experience muscle weakness and a prolonged healing process. Many take years to regain a sense of normalcy in their quality of life.

For healthcare systems, the biggest challenge is the unpredictability of COVID-19 surges. While a steady, manageable level of COVID-19 could be integrated into routine care, the waves create unpredictable spikes in demand. During surges, healthcare systems must balance COVID-19 care with ongoing needs such as elective procedures. This can lead to difficult decisions such as postponing surgeries like knee replacements. These surges strain resources and disrupt operational efficiency, often impacting healthcare systems’ financial stability due to already thin margins.

MHE: How safe and effective are current COVID-19 vaccines?

Smith: These vaccines are a major medical achievement, developed rapidly in response to an unprecedented global pandemic. The introduction of mRNA (messenger RNA) technology, which powers most of the current vaccines, has proven highly effective in preventing severe illness, hospitalization and death from COVID-19. While the vaccines may not fully prevent infection, they significantly reduce the risk of severe outcomes including pneumonia and respiratory failure.

In terms of safety, the vaccines underwent rigorous testing with comprehensive safety protocols in place. Overall, they are considered very safe. Some individuals may experience temporary side effects such as fever, aches and fatigue, which typically resolve within a day.

For most people, COVID-19 vaccines are both safe and highly effective at preventing severe disease, making them a critical tool in managing the ongoing pandemic.

MHE: How effective are COVID-19 treatments?

Smith: COVID-19 treatments evolved rapidly following the identification of the virus, with early efforts focusing on monoclonal antibodies. These antibody infusions were effective in preventing severe disease and saving lives, but their efficacy diminished as the virus mutated. When the Omicron variant emerged, many monoclonal antibodies no longer worked, presenting a challenge for clinicians.

During this period, oral antivirals such as Paxlovid (nirmatrelvir-ritonavir) and Lagevrio (molnupiravir) and the infusion-based Veklury (remdesivir) were developed; they showed effectiveness in reducing the viral load and preventing hospitalizations and death. Clinical trials demonstrated their antiviral properties, effectively lowering viral levels in patients. As the virus has become less deadly, focus has shifted toward managing milder cases with existing therapies.

MHE: How do social determinants of health like income, race, and coverage policies affect access to COVID-19 vaccines and treatments?

Smith: Infectious diseases disproportionately affect those with limited access to healthcare, and COVID-19 was no exception. Communities with limited access to quality healthcare–such as those living in poverty, members of racial minority groups or essential workers–were disproportionately affected. These groups often face barriers to essential resources like vaccines, treatments, sanitation and public health infrastructure.

During the pandemic, this disparity became particularly evident. Vulnerable individuals including those in nursing homes or those who could not afford to stay home due to financial constraints had limited access to vaccines and healthcare services. Moreover, these groups often had higher rates of underlying health conditions, which further increased their risk of severe COVID-19 outcomes including complications and death. For individuals with better access to healthcare, these comorbidities were often better managed, leading to better outcomes when they contracted COVID-19. The gap in healthcare access continues to impact vaccine uptake, treatment availability and mortality rates.

Addressing these inequities is crucial for improving health outcomes during future pandemics. Current disparities highlight the need for a more equitable distribution of resources and care.

MHE: What strategies can healthcare systems use to reduce barriers and ensure equitable access to COVID-19 care?

Smith: Healthcare systems must address underlying health disparities, particularly among historically marginalized communities. This requires proactive outreach and trust-building, recognizing that these populations often mistrust healthcare systems due to past negative experiences.

The strategy should be twofold: First, engage in consistent outreach to build relationships with these communities. Second, focus on overall health improvement, addressing key risk factors like diabetes and hypertension. When healthcare systems prioritize comprehensive care–not just COVID-19 care–they can help build long-term trust. If communities feel they are only being addressed in response to a crisis like COVID-19, they may continue to perceive a sense of neglect for their broader health needs. By fostering trust and addressing broader health concerns, healthcare systems can improve both COVID-19 outcomes and overall community health.

The societal benefits of COVID-19 prevention and treatment efforts can be seen in reduced transmission, increased use of telehealth, better access to medications and vaccines and a more informed public. These changes are helping to improve overall public health and are likely to continue influencing behaviors and healthcare practices in the future.

MHE: What is the economic value of COVID-19 prevention and treatment for healthcare systems?

Smith: COVID-19 prevention and treatment can reduce costly hospitalizations and mitigate disruptions to healthcare services. While vaccines and treatments like Paxlovid and Lagevrio are not inexpensive, they offer significant savings by preventing severe cases that require expensive hospital stays, including ventilator use.

Healthcare systems can save money by effectively managing surges. For example, during a surge, virtual clinics can assess and treat patients remotely, preventing hospital admissions and reducing strain on resources. For high-risk groups such as cancer patients, treatments like Veklury can be administered to prevent hospitalization. Preventing just one hospitalization per 100 patients treated can result in substantial cost savings.

On the prevention side, COVID-19 vaccine distribution, particularly boosters, also offers economic benefits. Organizing large-scale vaccination efforts, like holding vaccine clinics at community locations or in specialized clinics for immunocompromised populations, can increase vaccine uptake and reduce future hospitalization costs. Though booster uptake is low, targeted outreach in high-risk groups–such as through rheumatology and cancer centers–has proven effective in preventing costly hospitalizations.

Vaccination and treatment can mitigate surges, associated clinic closures, subsequent backlogs and worsened patient conditions. Thereby, they can defray higher hospital admissions and costs for conditions unrelated to COVID-19.

Ultimately, efficient prevention and treatment strategies can reduce both direct healthcare costs and the downstream effects of service disruptions, benefiting the healthcare system’s bottom line.

MHE: What essential insights should healthcare decision-makers understand about COVID-19 vaccination and treatment in 2025?

Smith: In 2025, COVID-19 vaccination and treatment remain critical components of public health. Vaccines continue to be essential for preventing severe illness, especially among vulnerable populations. Healthcare decision-makers should prioritize these groups to maximize the impact of limited resources, benefiting both healthcare systems and society at large.

Prevention is key, and it can take many forms including vaccination, widespread testing, health literacy campaigns and general health education. Early treatment is also an effective preventive measure, as it can prevent severe cases that drain hospital resources. Treatments like Paxlovid, Lagevrio and Veklury are proven to reduce hospitalizations, but they require proactive distribution and patient engagement.

One or two avoided severe COVID-19 cases during a surge can significantly impact a healthcare system’s capacity. The focus may have shifted away from these treatments, but their continued use is essential for keeping patients out of the hospital and alleviating pressure on critical care resources.

In summary, COVID-19 vaccines, treatments and prevention strategies remain indispensable in 2025. Targeted interventions for high-risk populations and early treatments can reduce hospital strain and improve outcomes, making them vital for both health systems and public health.