Breaking Healthcare

America’s experience with COVID19 demands a different approach to health reform. Historically our health policy dialogue has focused almost exclusively on achieving universal health insurance. We’ve shown little interest in how we organize the delivery of care. That lack of attention has shown through in our poor performance in the COVID19 war.

Many Americans believe that resolving the debate over public vs. private insurance and expanding coverage will fix our healthcare system. Healthcare costs will miraculously fall and the health of American’s will improve to be on par with other countries.

Insurance Is Not the Solution to Our Problems

Though resolving this single issue should help access it may not yield any of those other benefits. And, by focusing so heavily on insurance coverage, we miss the other crucial features that drive superior results elsewhere.

COVID19 has shown us that failure to address our poor health outcomes, health disparities, and structural system weaknesses poses too great a risk.

We Must Reform the Delivery of Care

Whether we reform the Affordable Care Act (ACA) or implement a public option or Medicare-for-All, we must fix the basic underpinnings of how we deliver care. Otherwise, our system and how we organize and deliver healthcare will continue to drive costs higher.

Without reform we will not be able to mount a successful response when the next crisis hits.

COVID19 Is An Important Learning Experience

The events of this year have put healthcare at the forefront of debate once again. COVID19 is a proxy for understanding how governments protect the health of their citizens. Understanding what has and has not worked offers an unprecedented opportunity. And it can set the stage for more meaningful reform at a time when American’s may be more accepting of the change.

Essential Lessons From How Countries Have Tackled COVID19

First, let me be clear. I am by no stretch of the imagination, an apologist for America’s response to COVID19. It has been horrifyingly inadequate for the wealthiest country in the world.

But, we must be willing to look at the performance of the U.S. and other developed countries, in an honest, unbiased way to make necessary improvements to our healthcare system.

Sadly, the U.S. is in first place for the total number of confirmed COVID19 cases and deaths in the world. And infections continue growing mostly unchecked. Our poor performance is primarily the result of our inability or unwillingness to take aggressive steps to control infection rates.

In other areas, the U.S. is not a high performer. But, we’re also not the worst performer among our peers.

When adjusted for population, other measures place the U.S. pretty middle of the pack. Our case fatality rate of 3.1% for confirmed cases puts us ahead of more than 50 countries, including Germany, Denmark, and Switzerland. Shockingly, the United Kingdom (U.K.), with universal insurance coverage and access to care, has had a much higher case fatality rate of 12.7%. Italy, France, and Spain having similarly higher death rates.

The U.S. also is the tenth worst performing nation based on deaths per 100,000 population, performing ahead of Belgium, Spain, the United Kingdom, and Sweden. Even Germany and Denmark, which are generally standout countries based on their performance, have experienced case fatality rates higher than those of the U.S. at 4% and 3.7%, respectively.

What Can We Learn From How Countries Have Performed?

So, why haven’t the countries of the developed world, all with some form of universal insurance, performed better?

Where have each of these countries and the U.S. failed?  

What are some of the critical lessons we should learn for reforming our healthcare system to drive real improvement in health?

Lesson Number One: Disease Surveillance Systems Are Outdated

Across most countries, including China, the highest death rates occurred early in the outbreak. As an example, the case fatality rate was 17% in the early stages of the epidemic in China and dropped as low as .7% a month later. Italy, Spain, and the U.S. followed similar trends.

This trend of much higher early deaths makes robust surveillance programs one of the most effective tools for quickly identifying outbreaks and responding aggressively. Early outbreak detection supports rapid genetic and clinical analysis, development of treatments, and isolation of infection before the disease spreads broadly.

COVID19 was able to reach pandemic levels because countries throughout the world are using outmoded disease detection systems that depend heavily on testing, clinical monitoring, and disease registries for known illnesses. They lack population-wide symptom surveillance for early detection of new diseases, despite the availability of tools to do so.

We need robust, technology-driven global surveillance that will allow us to identify the NEXT disease BEFORE it can become an epidemic.

We already have exactly this type of technology in use by businesses, governments, and other organizations across the globe. Unfortunately, the U.S. government and other decision-makers aren’t using these tools. The result is that we failed to anticipate and respond to the outbreak before it exploded. 

Lesson Number Two: Inability to Control Rates of Infection Has Been Key

In spite of relatively lower case fatalities rates in the U.S., our massively higher infection rates have had tragic consequences. And, unfortunately, those higher infection rates have dwarfed any benefits from our advanced care systems.

Across all countries, a lack of organized, robust disease surveillance allowed the condition to enter populations without notice. But, once the disease had entered a population, the inability or unwillingness to control infection rates has been the most significant factor affecting death rates. This has been the case for the U.S. as well as Brazil, India, and Russia.

Lack of data-informed, aggressive action after detection allowed the explosion of illness – particularly in the U.S.

This inability to control rates of infection reflects weaknesses and failures in epidemiological response systems. But, it also has resulted from an inability to consistently deliver prevention services at a local level. This includes an unwillingness and inability to effectively intervene to affect human behavior, or limit activities that could cause the spread of disease.

Lesson Number Three: Access to Health Insurance Has Not Been a Driver of Outcomes

Even with universal insurance, countries like Britain delivered results on a per capita basis no better than that of the U.S. If we look at case fatality rates, results are similar in other countries like France, the Netherlands, Canada, and Finland. And, all those countries have universal coverage.

In fact, the likelihood of severe illness or death and the overall effectiveness of each country’s response to COVID19 has had little to do with their insurance markets.

To some degree, the nature of this particular event itself has driven this outcome. Given its urgency, even in the U.S., people have generally had broad access to needed services regardless of ability to pay. COVID19 has burned through our society not because people lack coverage, but because other factors affect their risks of becoming infected and developing severe illness.

Lesson Number Four: Elder and Disabled Care Has Been THE Weak Link in Most Countries

Across the developed countries of the world, the elderly and disabled have paid the highest price during the COVID19 epidemic. It’s easy to attribute this to overall worse health and weakened immune systems. But, the results are much more nuanced.

Where individuals live is more closely tied to whether they experience severe illness or death from COVID19. 

Across nearly all countries, risks of severe illness and death were most significant among those individuals with health risks and who were also living in some form of congregate housing such as skilled nursing facilities or retirement communities.

Death rates for individuals in long-term care (LTC), homeless shelters, refugee centers, and prisons/jails have been shockingly high at 80% in Canada, 66% for both France and Spain, 61% in Norway, 51% in Belgium, and 50% in Sweden and Britain. 

The mostly fragmented nature of care and housing for the elderly in most countries, where they are often dealt with through social welfare programs, has magnified COVID19 risks.

The exception has been Germany, which recently redesigned its systems for long-term care and supportive housing, creating tighter integration with other elements of its healthcare system. Those reforms led to much lower COVID19 death rates among these populations. They significantly limited infection rates in these populations even though their case fatality rates have been similar to other European countries. 

Only 19% of COVID19 cases in Germany have been in people over 70, while that rate has been 36% in Spain and 39% in Italy. (South Korea has fared even better at 11% of infections.) Long-term care and housing management were integrated with other parts of the healthcare system, allowing Germany to develop an effective containment strategy quickly.  

Britain, which lost a higher percentage of elderly and disabled than any European country except Spain, serves as a profound example of the challenges posed by an elder care system without adequate integration with the overall systems of care. As noted in The Atlantic,

“This tragedy is an example of Britain’s systemic failures of governance…an indictment of the country’s short-term, centralized government apparatus. Britain failed to foresee the dangers…because of years of underfunding and decades of missed opportunities to bridge the divide between the NHS and retirement homes, which other countries, such as Germany, had found the political will to do.”

The Atlantic, “How the Pandemic Revealed Britain’s National Illness”, Tom McTague, 8/12/2020

To some extent, the U.S. performed better, although still seeing more than 40% of deaths occurring in some form of LTC facility. Given the lessons we’ve seen from other countries, it is likely that the integration of LTC in both our Medicaid and Medicare programs may have resulted in fewer deaths since it allowed for localized, but integrated response within state and local systems of care.

Lesson Number Five: Understanding and Responding to Unique Community Needs is Critical

Across the globe, the most significant drivers of the risk of severe illness and death have been environmental and socioeconomic conditions and the effectiveness of health systems in responding to that uniqueness.

In the U.S., the disproportionate impact of COVID19 on persons of color and those at lower income levels are already well known. Other countries such as Germany and Italy have experienced similar results with large outbreaks in migrant facilities and food packing facilities.

Across the globe, COVID19 has driven home the need for health delivery and management to respond to underlying demographics and the conditions in which people live. 

Countries such as Germany and Denmark, which have been most effective in responding to COVID19, have health systems designed to manage and deliver health across all levels of government. They also have robust local systems of care that integrate public health with the delivery and management of other health services along the care continuum. In most instances, that integration is an essential feature of the design of their healthcare model, making for a seamless, rapid response to crises. 

Both Germany and Denmark have national insurance and national standard-setting to ensure consistency for all citizens. But, the administration of healthcare delivery is highly decentralized which has allowed the kind of rapid response to local needs that has been so critical with COVID19.

As an example, in Denmark, local regions and municipalities receive BLOCK GRANTS for the delivery of services, with amounts adjusted for demographic and social differences. The state does not have a direct role in the delivery of health care services. Instead, five regions governed by DEMOCRATICALLY ELECTED COUNCILS are responsible for the planning and delivery of specialized health care services and play a role in specialized social care and coordination. ORGANIZED PATIENT GROUPS engage in policymaking at the national, regional, and municipal levels. Danish Regions and Local Government Denmark negotiate economic agreements on behalf of regions and municipalities and participate in monitoring agreed-upon performance targets. They also play essential roles in collecting and sharing knowledge to facilitate development and implementation.

The German health care system follows a similar model. It is notable for the sharing of decision-making powers among the federal and state governments and self-regulated organizations of payers and providers. Within Germany’s legal framework, the federal government has wide-ranging regulatory authority over health care but is not directly involved in care delivery. Responsibility for public health lies primarily with intermediate and local public health authorities in 16 federal states and approximately 400 counties. This allows the system to be adaptive to local needs within a framework of national standards and guidelines.

By contrast, according to that same recent article in The Atlantic referenced above, Britain’s failure to mount a successful COVID19 response has been directly attributed to structural weaknesses in its management of health. Specifically, Britain’s over-centralized approach to health has limited its ability to adapt to local conditions quickly. This poor performance is in spite of the country having one of the most highly developed and comprehensive pandemic response plans in the world.

Lesson Number Six: The Underlying Health of a Population Matters and Must Drive Intervention

Across the globe, healthier populations have suffered less during the pandemic. Just in the U.S., we know that more than 76.4% of deaths have been individuals with at least one underlying condition. This is a deadly combination when so many Americans have those same chronic conditions that put them most at risk. 

The most common comorbidities have been cardiovascular disease (60.9%), diabetes (39.5%), chronic kidney disease (20.8%), and chronic lung disease (19.2%), all of which are prevalent among Americans. Additionally, we are increasingly finding genetic risk factors for severe illness and death, including sickle cell disease and sickle cell trait.

Despite this knowledge, governments (and the U.S. in particular) have done little to educate the public about their risks or provide special supports or care for individuals with these conditions. Instead, interventions have been broad-brush and applied to all populations.

This untargeted approach is in spite of well-developed care management models that demonstrate the effectiveness of a targeted intervention. This has spread resources thin and encouraged a lack of support from those individuals who rightly, or wrongly, believe they are at a reduced risk from COVID19.

Worse yet, as we do with so many other health issues in the U.S., we have left the responsibility for understanding and responding to health risks almost entirely up to the individual.

The consequences of this hands-off approach have been deadly, particularly for those many Americans without close primary care relationships and support in managing illness.

Lesson Number Seven: Human Behavior Can be the Enemy or the Savior of Improved Health

One of the most significant factors affecting our ability to manage COVID19 infection rates in the U.S., in particular, has been our inability to encourage behavior change.

We have failed to gain consistent public support for the widespread use of low-cost self-care solutions like masking and social distancing. And, this experience serves as an essential lesson for efforts to improve health in other areas.

Despite clear evidence of the benefits of masks for reducing infection rates, only 44% of Americans report consistent mask usage, although the CDC claims a 76.4% rate of occasional mask use outside the home. Social distancing is a more mixed issue given the wide variability in each individual’s ability to distance and state and local rules and guidelines on the subject. 

Although it is easy to blame this issue on the politicization of these recommendations, again, the reality is much more nuanced. As another recent article in The Atlantic found, there is indeed a political element to individual responses to mask-wearing. In an early survey, 38% of Democrats and 24% of Republicans said they wore masks at all times. But, by June of this year, the numbers had increased to 60% of Democrats who were wearing masks, but only 34% of Republicans with party affiliation being the single most significant indicator of the likelihood of wearing a mask. 

But the ‘mask wars’ are not just a political issue. They also reflect a failure by the health community to follow known, practical approaches from previous efforts to change health behavior.

In addition to some severe stumbles in providing consistent messaging about the importance of masks in particular, we have not followed known standards for injury prevention which include education, engineering, and enforcement. This messy approach has reduced acceptance and lengthened the time to achieve compliance. 

As Steven Taylor points out in his book, “The Psychology of Pandemics,” people often rebel against directives. They commonly underestimate threats, and the value of prevention is difficult to measure and prove. This makes consistent messaging and accurate information critically important.

A recent article in Forbes drives home this challenge of encouraging behavior change. It profiles a study that concluded that non-mask wearers typically misunderstand how COVID-19 spreads. Additionally, the crisis itself may magnify this issue because the trauma of the situation encourages denial, avoidance, and an unwillingness or inability to hear the facts.

As pointed out in that same recent Atlantic article,

“When the public-health community talks about harm reduction, we often talk of ‘meeting people where they are.’ A fundamental part of that is, well, literally meeting people where they are. Just like the buckets of free condoms stationed in gay bars, masks need to be dispensed where they’re needed most: at the front of every bus and the entrance to every airport, grocery store, and workplace. Masks should become ubiquitous, but distribution should begin in areas where the coronavirus has hit hardest, including black and Latino neighborhoods. (That black men who wear masks may be at heightened risk of violence is one more grim illustration of why combatting racism is inextricable from public health.) What matters most is that people choose to wear a mask when they are indoors or in close proximity to others—and that choice needs to be rendered as effortless as possible.” 

The Atlantic, “The Dudes Who Won’t Wear Masks”, by Julia Marcus, 6/23/2020

Sadly, the failures of the ‘mask war’ are not unlike our efforts to address issues such as obesity, drug, and alcohol use, gun violence, and chronic disease.

So, What Does This Suggest About Healthcare Reform in America?

Unfortunately, COVID19 will not be our last brush with an infectious disease epidemic. And, beyond that frightening reality, Americans are also increasingly sick, obese, and our population is rapidly aging.

So, there is a critical need to adapt our system to respond to these challenges and drive real improvement in America’s health. The high-level blueprint I provide below provides a start.

In succeeding posts, I’ll dive into each area in greater depth, with specific recommendations for change. 

A Guiding Principle for Reform 

An essential lesson of the ACA is that breaking what is already in place to implement new solutions leads to resistance. And, that makes real change difficult to achieve.

Building on top of existing system features and providing incentives for participation by stakeholders reduces pushback. And it allows for more rapid change and greater flexibility in steering the incredibly complex U.S. healthcare system in a different direction. 

So, here are some ideas for what we should do.

Modernize Our Approach to Disease Surveillance

In an age of changing climate conditions and increasing infectious disease, we should be using the best and most advanced tools to detect, understand, and respond to new illnesses as they arise.

We must reform and strengthen the CDC by refocusing the agency on infectious and contagious disease monitoring, research, and support for state and local surveillance and response.

While we’re at it, the CDC should be given greater authority for planning, policy, standard-setting, and financing of public health surveillance. And that authority should be linked to activities at the state and local level, where it can be most impactful.

Ideally, this increased CDC authority would include a significant increase in funding for public health programs on a model similar to Medicaid. The plan should consist of basic federal program design and requirements and federal-state matching. It should include funding for robust public-private partnerships to support rapid response using the significant private resources available to respond to a crisis. 

Other CMS chronic disease and population health programs should be moved elsewhere, becoming part of health planning and blueprint development.

As part of this refocusing of the CDC, we must significantly modernize our approach to disease surveillance with investment in new technology and analytical tools.

Even relatively unsophisticated tools like Google’s flu tracker could have provided crucial early warning. More sophisticated analytics using currently available data sources can be even more useful. As an example, a Harvard study published earlier this summer used satellite imaging and traffic data to suggest that COVID19 may have been present in the Chinese population nearly six months earlier than thought. This is before detection through conventional disease surveillance. How different might this outbreak look if we had used these kinds of tools to detect it earlier?

More sophisticated tools for predicting outbreaks are already in use elsewhere.

As detailed in a recent whitepaper by San Francisco-based technology company LeewayHertz, there is growing use and acceptance of monitoring using artificial intelligence, machine learning, and advanced computational science. These new models dynamically identify illness-related trends as they emerge.

The Global Public Health Intelligence Network (GPHIN) is an event-based system that actively scans data across multiple sources for early disease detection. Also in use is HealthMap, EpiSPIDER (Semantic Processing and Integration of Distributed Electronic Resources), and BioCaster.

Environmental remote sensing technologies are already in use in some countries. Two of the industry-leading companies, Metabiota and Bluedot, having powerful tools used for early detection. Canadian company Bluedot already uses these technologies to monitor and predict infectious disease outbreaks. They identified the COVID19 outbreak and a Zika outbreak in Florida before government agencies.

We typically think of our country as a leader in technology. We should be embracing these tools to drive improvement in this area.

Fix the ACA to Close Known Gaps, Minimize Conflict and Redirect Policy Focus

Implementation of the ACA was not without problems. But, it did reduce the number of uninsured Americans, limit out-of-pocket costs for many more, and provide much-needed security to the millions of Americans. We forget that many people could not buy insurance at any price because of preexisting conditions or their age.

We know where the problems are in the ACA and how to fix them.

Many of those problems were caused by political infighting. And we will need to address that problem.

But, the ACA still provides a solid framework to expand coverage. It can be much more effective with known, less-controversial, straight-forward fixes.

We know how to reduce premiums, increase competition, and expand product availability. 

To fix the ACA we must address the flawed implementation of the program’s risk adjustment model and Republican refusals to allow payments of the risk corridor and CSR (cost-sharing reduction). These two issues alone account for much of the rapid increase in insurance rates and reduced market competition.

Beyond that, the refusal to allow modifications to enable the COOP to health plans contributed to their failure. Whether you are a supporter of the COOPs or not, they led to the creation of some of the first new health plans in decades in many markets.

Increased competition by supporting new market entrants is critical for innovation and keeping prices in check.

We should allow states the flexibility to reinvigorate the COOP health plans that remain (many remain legal entities), create public health plans, or form true cooperative health plans (note the ACA COOPs were not actual coops) if desired. Some states, such as California, already have public health plans as part of their Medicaid programs. So, creating these health plans is not a huge leap, but could have big impacts on health insurance markets.

Making these easier changes to the ACA would allow more room in the political and policy dialogue for shifting focus away from health insurance, and toward solutions to drive society-wide health improvement. 

Develop Nationwide Blueprints for Health That Integrate Health Policy and Delivery Across All Jurisdictions and Industry Participants

In the U.S., we tend to conflate health insurance coverage with health reform – which it is not. By doing so, we miss many of the significant features of well-designed national health policy models.

This includes the organization of policy setting, delivery, and oversight. In fact, most other developed countries have national health programs that include an organized, structured approach to health strategy, governance, and oversight. 

By contrast, the U.S. has a mostly disjointed and balkanized model of multiple, separate agencies that are responsible for various elements of health policy.

At nearly every level of government health policy is largely advisory except in the case of public insurance programs like Medicare and Medicaid.

The U.S. lacks anything close to a national health strategy or a coordinated approach for addressing the health of Americans. And, agencies typically have little ability to drive change since they are largely divorced from decisions about the delivery of care.

Is it any surprise that we have had such a challenging time mounting an organized and systematic response to COVID19?

American health strategy is mostly laissez-faire and driven by a fragmented mix of private non-profit and for-profit, and public health plans, public health agencies, and health providers. This program blend includes an alphabet soup of:

• Underfunded public health agencies and clinics,
• Mostly private (non-profit, for-profit, and publicly owned) hospitals and hospital systems,
• An assortment of federally-qualified health centers (FQHCs), rural health centers (RHCs), community health centers,
• Community mental health centers,
• Private medical, behavioral health, and ancillary services providers, and
• Public veterans, and Indian Health systems.

We must develop a new, thoughtful approach to how we orchestrate the movement of these disparate elements.

We need comprehensive health planning and the development of clear priorities for our health goals and clear tactics to achieve them.

This approach doesn’t require top-down, prescriptive planning, and allocation of resources. That would be anathema to many Americans.

Following the successful models of Germany and Denmark, we can design these solutions to engage the disparate health industry participants with open dialogue, collaboration, and voluntary participation. This would include incentives tied to involvement in publicly-funded health insurance programs.

Plans would guide resource allocation to target drivers of health and premature death, shifting focus to achieving and maintaining population health. Priority-setting and planning can and should engage all levels of government and critical stakeholders.

There are already voluntary collaborative ventures that have come together to accomplish precisely these goals in several communities. They need resources and support.

We also already have starting points through the federal government’s Healthy People Goals. These provide a national health promotion and disease prevention framework. 

We also have some excellent, but limited examples in programs such as EPSDT (Early, Periodic Screening, Detection, and Treatment for children), WIC (Women, Infants, and Children) supplemental nutrition program, and Title X Family Planning programs.

Ideally, a comprehensive and holistic blueprint would incorporate these and other programs, as well as the variety of non-communicable disease surveillance systems and research programs that are already in place primarily within the CDC.

Focus at the national level would be on setting national health improvement goals, determining national level financing and investment needs, and supporting research and standard-setting.

This new model would combine activities that are currently in the CDC (Centers for Disease Control) and CMS (Center for Medicare and Medicaid Services) through its many additions to Medicare, Medicaid, and the ACA.

A more organized approach to managing America’s health would begin to address the failures we’ve seen with COVID19 as well as America’s epidemic of chronic disease.

Meet People Where They Are and Engage Communities to Drive Closer Connection to Policy

Population health is local – a point driven home by the challenges and failures of the responses of the U.S. and other developed countries to COVID19.

Effective engagement must reflect underlying health, social and environmental conditions to drive behavior change and health improvement.

State and local health planning and blueprint development should be combined with funding should support health goals. We have successful examples of this model. The DSRIP (Delivery System Reform Incentive Payment Program), which included community and stakeholder engagement, serves as an example of this approach. Unfortunately, it was tied primarily to the Medicaid program which limited its ability to drive broader change.

We also must strengthen community capabilities to monitor and deliver health improvement while creating tighter connections to community needs. The health priorities of Fargo are likely very different from those of Albuquerque or San Francisco. Health planning and policy setting should allow for those differences.

We need to create new mechanisms to replace the structural elements that we used to have – including community hospitals and robust Certificate of Need programs — that encouraged the development of local solutions reflective of local needs.

In earlier periods, community hospital boards might have served as a mechanism for engaging the local population in identifying health needs and setting health care priorities. But, that engagement has mostly been lost. In most instances, it has been replaced by large integrated systems focused on optimizing market share, and toothless Community Needs Assessments tied to ACA Community Benefit accounting. 

Regional and demographic differences demand localized approaches with common national standards to ensure equal treatment for all Americans.

Community engagement in the overall delivery of health is the concept behind successful health improvement models such as Recovery Oriented Systems of Care (ROSC) and community health worker (CHW) programs.

By engaging local communities in policy and planning, we can bring decisions about care closer to the point where people live and how they live. It will provide a closer connection between poor health, the effects of a misaligned system, the costs of interventions (and lack thereof), and health benefits.

Supercharge States as Laboratories of Innovation by Reforming State and Local Health Funding

I know many of my left-of-center friends are going to be shocked by what I am saying, but Medicaid should no longer be used as a backdoor solution to drive state-level health policy.

We should streamline Medicaid to focus only on low-income health insurance, stripping out all other non-insurance program funding. 

All other non-insurance funding sources should be combined (braided financing), and states should receive block grants tied to demonstrated improvement in health outcomes in support of the federal, state, and local Health Blueprints.

Ideally, these non-insurance, health block grants would include all health-related funding sources, including public health, occupational health, environmental health, behavioral health infrastructure, federally qualified health centers (FQHCs) and rural health centers (RHCs), critical access, and disproportionate share (DSH) hospital funding, food and nutrition, and health-related urban planning and policy.

Please note that I am not suggesting we replace the Medicaid insurance program with block grants.

I believe the current Medicaid insurance funding model that ties funding to state poverty levels is precisely the kind of useful model that is adaptive to state needs. 

Under the changes I propose, health block grant funding would be tied to clear metrics for outcomes. Each state government would set its own goals based on its unique conditions. The goal would be to embrace “health in all things” at the state and community level but to tie it to funding for all health-related sources.

States should be incentivized to engage local communities in planning and implementation and should share in the financial benefits of any improvements beyond targets.

The DSRIP (Delivery System Reform Incentive Payment Program), as well as the Medicaid 1115 Waiver Program both provide useful starting points for moving in this direction.

The goal of this approach would be to support innovation and experimentation consistent with some of the best examples we have seen in the Medicaid program.

The French economist Thomas Piketty makes a compelling case for this approach. He states that,

“evolving ideas are nothing unless they lead to institutional experiments and practical demonstrations…political actors caught up in fast-moving events often have no choice but to draw on a repertoire of political and economic ideologies elaborated in the past. At times they may be able to invent new tools on the spur of the moment, but to do so takes time and capacity for experimentation that are generally lacking.”

Thomas Piketty, Capital and Ideology, Page 113

The goal is to provide mechanisms to support and incentivize that experimentation.

Consider Streamlining and Rationalizing Existing Public Insurance Programs

I realize that even suggesting the following is inviting stakeholder warfare on a level that is hard to comprehend.

As I’ve detailed in previous posts, the U.S. operates an assortment of public insurance programs which increases inefficiency.

We must reduce administrative inefficiency and costs and provide a more focused program design for our public insurance programs.

The absolute ideal, of course, would be to eliminate the separate programs and consolidate them into one single national program. But, this is the U.S.  I recognize the political challenges that poses. But, any steps taken in this direction would provide real benefits, though.

At a minimum, I believe we should consider some streamlining of what is covered by each program.

As an example, in general, care for the elderly is more complex and demands a different programmatic focus and approaches to delivery and management. But, these requirements are not unique to the elderly. They are very similar to those for the aged, blind, and disabled (ABD) beneficiaries and long-term care beneficiaries in Medicaid.

The Medicare and Medicaid programs could be streamlined, with all long-term disabled and elderly populations moved into Medicare, since the needs of both populations are similar.

Similarly, despite the presence of a strong advocacy community, it makes no sense to maintain a separate Children’s Health Insurance Program (CHIP). We could serve children just as quickly through Medicaid and ACA Health Exchange plans. 

We should also reform CMS, which has become an unweildy behemoth. This would include shifting its focus exclusively to insurance program management.

Health policy and planning functions could then be moved to a new organization specifically focused on those areas discussed above. That would allow this new, more focused agency to provide greater support for state and local activities.

Shift Incentives to Engage Industry Stakeholders in Change

To fully engage private sector providers and payers, we must use both incentives and enforcement to drive participation.

As part of comprehensive reform, we need to shift incentives and create a market for provider and payer investment in planning, programs, and services directed at improving community health.

Creating new incentives and reimbursement would allow us to begin shifting focus and resource allocation from sickness to reducing the burden of disease.

The reality is that the historical foundations of much modern investment in healthcare through the creation of such mechanisms as “sickness funds” and prepaid hospital plans have placed most developed country health systems on a spiral of continually increasing costs.

The very appropriate desire of most societies to take care of the oldest, sickest, and most vulnerable in our community has led to an ‘upside-down’ system that increasingly intervenes with heroic efforts rather than preventing illness. We see solutions to escape this trend as robbing the sick and elderly of needed care by shifting resources to an earlier point in the management of human health.

In the U.S. this ‘upside-down’ approach comes at a high cost. Shifting attention to community health and prevention means asking healthcare payers and providers to redirect resources from the areas of the most significant opportunity and profitability.

Reform must recognize the challenges a shift to population health improvement poses, and provide financial and other incentives to encourage that change.

Providing some form of reimbursement for these programs would provide incentives for participation.

However, this is also an area where existing laws and programs could be significantly enhanced to put more force behind them. We need the forceful application of laws such as ACA Community Benefit planning. The same is also true for requirements for spending and community good tied to provider (and health plan) non-profit status.

Many policy experts have recommended reform of these areas. I recommend linking Community Benefit planning and non-status enforcement to state and local blueprint development. This would increase the incentives for providers and payers to act as important partners in these efforts.

We know how to reduce the burden of disease by preventing its occurrence through community interventions based on the concepts of social medicine.  But, we just don’t do it. Or, depending on the country, we under-invest in required interventions and tools.

It’s time to change this approach and begin creating a foundation for reducing the burden of disease so that we can not only bend the cost curve but also start reversing out of control health costs.