Even this late in its course, no one can accurately predict the trajectory of COVID-19. Will the spread of the virus go from bad to worse? Or, will it show a dramatic decline in case numbers, hospitalizations, and deaths? Four experts from the Commonwealth Fund describe three possible scenarios in a timely article published in the Harvard Business Review.

The three scenarios include a dream case, a catastrophic case, and a “patchwork” middle case. How it all plays out will largely be determined by the availability of a safe, effective vaccine—one that’s widely accepted by a majority of the population. Another determining factor is the widespread use of effective anti-viral therapies to control the pandemic while we wait for a vaccine. A third determinant is the extent to which mask-wearing and social distancing are practiced.

In addition to these three factors, the authors make one additional assumption:“The linchpin for a return to the health care system’s pre-pandemic ‘normal’ state lies within the nation’s ability to assure the safety of segments of the population that are most vulnerable to the pandemic, especially the elderly and the chronically ill. These groups comprise the 5% of the population that consumes 50% of health care resources. Only when they feel safe to venture out will health care institutions experience a vigorous recovery in demand for their services. While telehealth can partially compensate for the falloff in the use of services, it will go only so
far.”

Under the dream case scenario, “everything goes as well as could reasonably be expected.” A safe, effective vaccine would be available by January 1, and more than half of the American public would be immunized by July 1. The pandemic in the United States would be officially declared over on December 1, 2021.

Under the most catastrophic scenario, the pandemic rages on in current hotspots and reemerges in others. A frustrated, anxious, and depressed general public gives up on masks and social distancing. An effective vaccine and new therapeutics prove to be of little to no value.

Under the “patchwork middle” scenario, a safe vaccine finally becomes available, but not until July 1, 2021. “Because of its low efficacy and known side effects or a lack of trust in the vaccine,only about 50% of Americans choose to get vaccinated over the following six months.” Although therapeutics and non-pharmacologic measures continue to lower the mortality rate among the elderly and those with underlying conditions, localized outbreaks remain an ongoing threat.

Regardless of which scenario plays out, the U.S. health care system will never be the same as it was before the pandemic. Medicine, as it was practiced a few months ago, will have changed forever.