health care

Yesterday, I wrote about four challenges which demand immediate attention so that we may begin to repair our fractured and failed health system: health inequities, workforce needs, lack of investment in public health infrastructure, and health data ecosystem disappointments. These challenges are the direct result of a lack of federal leadership leading to a complex interplay of state and local policies and have resulted in wide variation in the degree of disruption, disproportionate impact, and decision-making capacity across states and localities.

Disruption in health care is happening at different times and in different ways depending on both market and populations characteristics and where on the pandemic trajectory a given community finds itself. The impact on primary care, the backbone of care delivery in communities has been devastating: recent estimates predict the loss of 60,000 primary care practice physicians and nearly 800,000 jobs. Others estimate the national costs of neutralizing the revenue losses caused by COVID-19 among primary care practices to be $15.1 billion.  Pediatrics (my background) is among the specialties particularly hit during the pandemic as so few patients are Medicare beneficiaries, thus excluding pediatricians from the financial relief policies issued by HHS which are limited to Medicare. However, hospitals are not immune: recent studies have confirmed reports of significant declines in admissions for acute conditions normally cared for in hospital settings and others have documented the declines in hospital revenues and profitability.

The disproportionate impact of the pandemic on certain populations (low wage workers, people of color) and certain settings (e.g. long term care) means state Medicaid policy has a critical role to play.  Yet, Medicaid agencies are still seen too often as “insurance agencies” and not key components in a state’s strategy to improve health. They also have a highly variable track record of effective collaboration with state health departments. Today, we have the opportunity to break down these silos and codify policies and processes, launched in response to the pandemic, to sustain Medicaid and state health departments collaborations to more effectively meet the needs of their populations.

 However, for states to effectively respond to the disruption in their health care systems and disproportionate impact on populations at risk, they desperately need access to evidence and data to support informed decision-making. Like so many other aspects of state policy, this varies greatly and supportive networks are key to building that capacity.  In addition to supporting real time decision-making, states need to learn as they act. While peer networks help them share experiences, this is no substitute for robust – and yes, timely – assessments of the impacts of their policy choices in the face of COVID. The reality is that despite many public agencies and foundations making pandemic related funding available quickly, no major national effort has been mounted to assess the impact – both general and distributional – of state actions on health and healthcare.

So in the face of these and other challenges accentuating our fractured and failed health system, what can be done?  I am working very hard these days to stay optimistic, so to rebuild this fractured health system for health equity I want to propose three strategies:

First, we must go beyond applying an “equity lens” to policy and system actions, we must support designing for equity up front. This will not be easy as we all clamor for a ‘return to normal.’ In fact, I’d argue a return to normal should not be our goal. We need to move toward a better baseline, one that goes beyond simply asking how to target interventions for those most at risk for poor outcomes to designing systems that will prevent the disparities in the first place. Tackling structural and systemic racism in all forms will be daunting and disruptive, but we need to commit ourselves to this goal. We must also learn from our actions and generate evidence so that we may continually refine our strategies for designing healthy systems,  communities, and organizations.  Moving forward means we need to spur and reward innovation at a scale we have not seen before. How can this be accomplished? Our nation has declared “moonshots” in the past – this must garner the same attention and investment from both the public and private sectors. Now is the time to think boldly. It can be done. One of the few bright points of the pandemic response has been the example of health systems making a pivot to telehealth in a matter of weeks as states loosened their regulatory constraints and federal policy shifted course. Transitions of this speed were inconceivable pre-pandemic. What else is possible that was previously impossible?

Health services research comprises examples of rapid evidence generation and use – from the growth of data-driven learning health systems and rapid cycle designs to the innovations in implementation science that help bridge the gap from research to intervention. How might we build on these skills and tools? We must create, support and reward a much more diverse workforce in health care and public health. Diversity is a much maligned and misrepresented notion, so let me write it plainly. We need to recruit, retain and celebrate more black and brown people in the fields health services research and health policy. We need to create environments where underrepresented scholars feel welcome and valued regardless of race, ethnicity, sexual orientation, gender identity or ability. And, we need to co-create our research questions and areas of inquiry with the communities and patients whose lives we hope to improve through better health and health care.   

Second, we must dismantle the incentives that have brought us to this breaking point. The first system that comes to mind is usually our payment system, and that is certainly still true. While we must accelerate our move to value and its focus on population and community health, we must also create guardrails to prevent this move from worsening inequities. The first 10 years of federal payment demonstrations has shown that poorly designed payment models that do not attend to equity up front will penalize those serving the neediest. But less discussed and still unaddressed are the power incentives – those who have power are not prone to part with it. Academic systems, training, promotion and tenure, funding systems, awards and recognition – all were developed and are centered in norms and expectations that tend to advantage white scholars. And this is where we need to systematically examine ourselves, our systems, and our policies and identify and eliminate those that contribute to structural racism. A final – and too often forgotten - aspect of incentives is the impact of federal policy and its inherent incentives on state action. This is particularly the case with Medicaid policy driving state action, including what services or investments can be matched and at what level (50% or 75%). Could one imagine a set of Medicaid federal policies that would reward states to achieve equitable health systems? Now that would be powerful!

Finally, we can no longer starve public health. Today, we are reaping what we have sown over decades, if not centuries, of disinvestments. While one can sometimes find solace in dark humor that more Americans now know the word epidemiology than ever before, the stark reality is that to turn our country around, to move toward equity, will require an unprecedented investments of taxpayer funds at the federal and state levels. We have neglected public health for far too long. On the eve of an election, with current federal funding held in stasis by a “continuing resolution” and while the Congress and the Administration debate the future of another COVID relief package, we must continue to advocate for increased, stable and appropriate funding for public health, evaluation, and health services research. We must invest in our nation’s research infrastructure.

These are trying times to be an optimist. Our country faces significant health and health care challenges that stem from policy and system choices that date back over decades. But optimism must be grounded in reality – a key lesson known as the Stockdale paradox. We can acknowledge what is happening and what is to come, while holding confident in our ability to rise to the challenge. I believe in our field and its contributions. Health services research, with its applied, multi-disciplinary, evidence-centered approach to problem solving is, and must be, a critical tool in shaping our response.

My email signature, a quote attributed to Hillel the Elder sums it up, “if not us, who? If not now, when?”

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