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The COVID19 War and the New Urgency for Reform

· The U.S. needs a new approach to health reform. Our COVID19 failure proves it. ·

America's Upside Down Approach to Healthcare. Source: Adobe Stock

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.

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.

COVID19 Is a Three-Alarm Fire About America’s Health

Source: Adobe Stock

“WE HAVE MET THE ENEMY AND HE IS US”

This quote from the 1970 Walt Kelly cartoon, Pogo, celebrating the first annual observance of Earth Day, couldn’t be more fitting for describing America’s response to COVID19. Pogo’s friend Porkypine was complaining about the difficulty of walking over trash and filth left behind in the Forest Primeval.

COVID19 was an act of nature, and no individual is responsible for it. But, its effects, including the number of lives it has claimed in the U.S., were not a given.

The testing, contact tracing, and isolation that are currently the primary focus of discussion right now is essential and is critical for attacking the epidemic itself. However, in the end, we will still be at higher risk because of differences in the health of our population, access to care, and the structure of our healthcare system.

America’s Outsized Failure

The U.S. is 4.25% of the world’s population, while, as of the date of this post, we account for almost 27% of confirmed pandemic deaths globally.

No doubt results for the U.S. are skewed by the slowness of our response, the dismantling of crucial surveillance and monitoring programs, and failed actions in many areas. We will debate those issues for years to come and they must be addressed.

I know many of us may want to point our finger at Trump and his administration, charging them, and them alone, with the mind-boggling tragedy unfolding around us. But, as loathsome as some behavior might have been to many people, we are collectively responsible for what has occurred.

And, focusing only on politics or mismanagement of the response creates the risk that we overlook some more significant issues. It also risks that we miss more valuable lessons about the overall state of American health, and our healthcare system that are essential factors influencing the size and scope of the tragedy we’ve experienced.

Why are U.S. COVID19 deaths almost 500% greater than our share of the population in the world?

Beyond bureaucratic and political bungling, the bigger reality is that multiple factors have contributed to America serving as extraordinarily fertile ground to be the global epicenter for COVID19 mortality.

The Reality of Life for America’s Working Class and Poor

As with Hurricane Katrina, policymakers failed to appreciate the reality of life for many of those who make up the working class and poor in our country. These are people who couldn’t stay home. Low wage and hourly workers are more likely to be among the more than 30% of U.S. workers don’t have paid sick leave, forcing them to go to work even if they may be ill.

And for those who were fortunate enough not to have to go to work, telling them to shelter in place made them easy targets for infection. Limited resources and crowded living conditions experienced by many of these individuals allowed the disease to spread like wildfire. These facts are no mystery for those of us who work with safety net programs. But, it is still shocking that so few decision-makers seem to understand what life is like for many Americans, and it speaks to the growing disparities in our society.

And, whether you think this is a problem for you or not, the reality is that the sheer numbers of people falling into this category magnify the risk for all Americans. They are more likely to be essential workers, food processing, and nursing home employees. And, their numbers are large. After a sharp decline in poverty rates in the U.S. with the start of Johnson’s War on Poverty, numbers have stubbornly stabilized at a level of 11% to 15% of Americans. At any point in time, there are roughly another 5% of the population living near poverty.

In New York City, the center of the COVID19 epidemic, poverty rates are even higher, at an average of 19%, and with some areas experiencing rates of more than 30%. 43.1% of New Yorkers live near poverty. Think of that, in a city of 8.4 million people, approximately 3.6 million may very well not be in a position to follow social distancing and similar guidelines. It’s too early in this pandemic to have solid information on the income distribution of those infected and dying from COVID19. Still, an early investigation by the New York Times uncovered a clear pattern that shows the poorer boroughs of the city are suffering much higher rates of disease and death.

Many of those southern states now opening up their economies have similarly high poverty rates.

Being Elderly and Alone

Surprisingly, many also ignored the fact that one in three American’s experience chronic loneliness and social isolation, and that 28% of the elderly – a population highly vulnerable to COVID19 – lives alone. These numbers are even higher in urban settings. This isolation means telling them to stay home, to take care of themselves until they were too sick to do so, was equivalent to issuing a death sentence. It ignored the reality that for many people, there is no one to check in on them or to bring them food or medicine while they struggle with their illness. The result, record numbers of people dying at home.

The elderly and frail living in nursing homes are even more exposed – in part because workers in many of these facilities are exactly the near-poor talked about above. According to the Paraprofessional Healthcare Institute, the median pay in the industry is only $19,000 annually. And, the CDC’s analysis of the high rates of COVID19 nursing home deaths, identified the fact that most staff work in multiple facilities for the rapid spread of the disease. This pattern of multiple jobs is a common practice precisely because they cannot come close to making a living by only working at just one job.

Hubris About the American Healthcare System

American hubris and the belief that we were somehow protected from the virus by our “superior” medical technology allowed us to be oblivious to the underlying population-wide risks we faced. And the systematic and long-term dismantling of our public health infrastructure in pursuit of those “superior” technological solutions, left us flying blind without the tools needed for early detection and rapid intervention even where we could have done so. Thankfully, that superior technology probably saved some individuals who might have died elsewhere. But, at what cost to millions of others?

Healthcare Affordability

We’ve also ignored the fact that for many Americans, accessing the healthcare system is a dicey gamble, with fees they can’t afford to pay. Though the rate of uninsured is lower than it was before the ACA, according to the Kaiser Family Foundation, one-third of Americans find it very difficult to afford the deductibles for the insurance they have.

So, not surprisingly, many Americans avoid using the health system for fear of expenses they won’t be able to absorb. This reluctance to access care shows up in our health outcomes. The U.S. has the 7^th highest rate of deaths from preventable causes, and 11^th highest rate of deaths from treatable causes, among OECD (Organization for Economic Cooperation and Development) nations, falling behind countries like Columbia, Chile, and Slovenia.

Those data are typically indicators of a lack of timely access to care. So, showing total ignorance of that reality, many Americans have been told to stay home until their COVID19 symptoms were severe. This suggestion increases the likelihood their illness would become acute, that they had an undiagnosed or untreated underlying condition that would increase their risks, or that they would simply die without ever receiving care.

Those Who Do Not Understand History are Doomed to Repeat It

And, as usual, we have failed to pay any heed to our history. American cities, and New York in particular, with its unique character as a gateway to our country, has been the site of epidemics for centuries. This has included smallpox, typhus, typhoid, yellow fever, tuberculosis, and AIDS. As Laurie Garrett points out in her wonderful book, Betrayal of Trust: The Collapse of Global Public Health, “the 1743 yellow fever epidemic…claimed an estimated 5% of New York City’s population” At that time, the city also experienced extraordinarily high rates of smallpox, typhus, and typhoid. Though it’s been a while, epidemics in the region are not new.

And, predictably NYC, and other urban areas, have served as THE hotspots for COVID19. U.S. cases are heavily concentrated in a select number of more densely populated, diverse urban communities, with 24% of all U.S. deaths just in New York City, and an additional 6% clustered in Detroit, Chicago, and Los Angeles. If you add in smaller cities, you start getting very close to 40% of all deaths nationwide that have occurred in urban areas. To some extent, this is predictable, regardless of underlying demographics. The challenges of controlling such an easily transmitted disease are much greater due to sheer population density. Commuting and travel patterns increase infection risk, and that’s what the data show. The New York, New Jersey, and Connecticut corridor accounts for almost 50% of all deaths in the nation.

But, there is an even more significant underlying factor here than the tactical errors discussed above. A great big elephant is sitting in the middle of our living rooms.

America is An Unhealthy Country

Let’s be bluntly honest. Americans are profoundly unhealthy, particularly when compared to other wealthy nations. And this unhealthy state has had tragic, and undesired consequences for the American people, particularly when it comes to the COVID19 pandemic.

Three months into this outbreak, we still don’t have comprehensive data about who is most at risk of death from SARS-CoV-2. It is inexplicably killing some young people and individuals without diagnosed underlying conditions, with many dying from blood clots, strokes, and heart attacks. However, we do know the elderly are more at risk (75% of hospitalized are over 50). And, we have enough data from the U.S. and other countries to know that it is more likely to kill individuals with certain underlying conditions. Initial data from the CDC (Centers for Disease Control and Prevention) showed that 89% had one or more chronic diseases. And, the most common chronic diseases were hypertension/high blood pressure (49.7%), obesity (48.3%), chronic lung disease (34.6%), diabetes (28.3%), cardiovascular disease (27.8%). Data from New York state, several other hot spots, and other countries follow this pattern.

Why Does This Matter?

It is the higher risk associated with these underlying conditions that put Americans at greater risk, because of our overall higher burden of these and other chronic health conditions. Americans don’t consistently have the highest rates in the world for each of these chronic conditions. But, we consistently rank in the top three for ALL of these conditions, when compared to other developed countries.

Approximately 45% of Americans are living with at least one chronic disease, with that rate of illness being roughly double that of the OECD average.

And, almost across the board, Americans have extraordinarily high rates of the chronic “lifestyle” illnesses posing the most significant risks with COVID19. As an example, America is the most obese developed country in the world, with 42.4% of American adults who are obese, and a whopping 9.2% designated as seriously obese.

The U.S. has the third-highest age-adjusted rate of diabetes for adults among the OECD nations, at 10.8%, placing us just ahead of Mexico and Turkey.

And, hidden in the U.S. National Center for Health Statistics Health E-Stats, January 2020 summary of Changes in Life Expectancy at Birth, 2010 – 2018, was this nugget. One of the significant negative factors affecting life expectancy for women between 2017 and 2018 was nutritional deficiencies. Let that sink in. This deficiency is an outcome that is almost unheard of in a developed country.

Many would like to attribute these results to our ethnic diversity. And, indeed, we have some genuine issues with health disparities that do contribute to these poor outcomes. But, when you look behind the data, we find that regardless of ethnicity or economic status, Americans still live more years being unhealthy, and they die at a younger age.

As pointed out in “U.S. Health in International Perspective: Shorter Lives, Poorer Health,” written by The National Academies of Science, Engineering and Medicine, the gap between U.S. life expectancy and the world’s wealthy developed countries continues to grow. The startling outcomes contributing to these results when compared against this group include:

Highest infant mortality rates

Highest rates of injury and homicide

Highest rates of teen pregnancy and sexually transmitted disease

Second highest rates of HIV and AIDS

Highest rates of drug-related deaths

Second highest rates of ischemic heart disease

These results also apply to mental health. Suicide rates in the U.S., even before the pandemic, were already 14/100,000 overall and a whopping 22.4/100,000 for men. This rate was a 31% increase just between 2001 and 2017. By comparison, the highest rate seen in the Great Depression was 17.4/100,000, which up until that time, were the highest numbers ever recorded.

When combined with our tragically fumbled COVID19 response, this disturbing picture of American health has rendered the U.S. particularly vulnerable to the ravages of any disease, but especially this illness.

People of Color Are Even More Unhealthy and More at Risk

Data from both the CDC (Centers for Disease Control and Prevention) and the New York State Department of Health (NYDoH) have already revealed a striking pattern of disparities by race and by gender when it comes to COVID19. Men and individuals who are black or Hispanic are over-represented among non-elderly hospitalizations and fatalities.

That’s where the overall burden of disease that is evident across all U.S. populations places minority populations at even higher risk. 28.5% of individuals in OECD countries suffer from hypertension versus 29% overall in the U.S. That rate jumps to a whopping 39.9% among American black women and 40.6% among black men. We see similar results for obesity, with both blacks and Hispanics having higher obesity rates at 49.6% and 44.8%, respectively. Rates are even higher for women in both groups. And, blacks have substantially higher asthma rates, at 10.6% versus 7.6% for white Americans and 6.4% for Hispanics. Black men also have the highest smoking rates at 20.9%. Each of these put Americans of color at much higher risk if infected by COVID19.

When you consider that Americans of color also have uninsured rates at multiples of that of white Americans, it is not surprising that these populations are bearing disproportionate costs due to this tragedy.

The COVID19 epidemic has laid bare the reality of the issues we face when it comes to the health of Americans, with the poor, people of color, and the elderly bearing a disproportionate cost for our failures.

These Issues Point to the Lack of Clear Priorities Focused on Health

We must ask ourselves what this says about the health of Americans, our healthcare system, and the inequities experienced by so many.

Remember, these failures are despite the massive investments in healthcare that we make as a society. We spend more per capita on healthcare than any other country at approximately twice the average paid by other OECD countries.

And, health programs for poor and vulnerable populations are so significant that they threaten to bankrupt states, with Medicaid expenditures averaging 28.7% of state spending from all sources for the 2016 state fiscal year. These expenditures don’t count an equivalent amount paid by the federal government. And remember, this was before the mass unemployment caused by the COVID19 pandemic.

Remember the adage: “the definition of insanity is doing the same thing over and over and expecting a different outcome.”

These Outcomes Should Cause Us to Rethink Our Health Strategies, Policies and Priorities

The results of the COVID19 pandemic should be a clarion call. We’ve continued to throw more and more money at the healthcare industry, all while watching America’s performance on almost all measures of health outcomes fall further and further behind that of other countries. Simultaneously, Americans on both the right and left, and many in the healthcare industry itself, have looked the other way. In some instances, we’ve cheered on massive investments in new insurance programs, bigger and more stately hospitals, and health systems, and more expensive and sophisticated medical and information technology. Much of that investment has just added to the costs of care.

During this same period, there has been the systematic destruction of our public health programs and public health safety net starting as early as the Nixon administration. Those efforts gained full speed at the beginning of the Reagan administration. And in short order, the effects became clear as progress toward improved health, including American life expectancy, had stalled out.

Very quickly, after taking office, Reagan eliminated or implemented massive budget reductions for public health programs. These changes included shutting down the Public Health Services Hospitals and the Public Health Services Corps (which incidentally policy leaders are now clamoring to recreate). Massive cuts occurred in the Indian Health Service (another demographic group severely affected by COVID19), the Office of Refugee Health, and federally subsidized care for civilian seamen. Many public health programs that had previously been led by the federal government transferred to the states through block grants. This transfer ignored the fact that many of those states were ill-equipped to support those activities. Many lacked any capabilities at all. This pattern continued under the first Bush administration.

Still, as Laurie Garrett demonstrates in her book, Betrayal of Trust, (iBook page 548), she points out that neither political party is exempt from this peril. When discussing the reforms proposed as part of the Clinton healthcare reform program, several leaders in public health asked, “ ‘Why has the debate about health care reform neglected public health?’, asked public health leaders Phyllis Freeman and Anthony Robbins. ‘Health insurance is a necessity for every American. It buys medical services and avoids personal financial disaster. The ultimate purpose of health care reform, as currently debated in the United States, is to pay for insurance against the costs of illness. This narrow focus on sickness insurance misses opportunities to improve health, yet it is perfectly tuned to the concern of the public.’ ”

And sadly, more recent reform efforts, including the ACA, have just contributed to this phenomenon. (More about this later in several future posts.)

We’ve consistently failed to focus on building a balanced, comprehensive and well-designed system for safeguarding the health of Americans. Instead, we have focused almost exclusively on expansion of our system for financing treatment of American sickness. This approach has largely ignored the other elements required to keep a society healthy and improve that health over time. Sadly, our abysmal performance with COVID19 was the inevitable result.

In my next posts, I’ll explore the weaknesses of the strategies we’ve pursued. I’ll discuss why health insurers and healthcare systems, although essential, are ill-suited for the responsibility of managing the health of Americans. And, I will talk about what is missing in our overall approach.

Was This Epic COVID19 Disaster Absolutely Predictable?

Source: Adobe Stock

COVID19 will likely rear its horrible head again next year if it follows the pattern of previous pandemics as many experts believe. So, once we’re past our panicked response to the height of this year’s epidemic, we need to honestly and quickly address what we did wrong to make sure we respond more effectively in the next round. But, do we even have the infrastructure or governance tools to mount a more effective response the next time?

What Went Wrong?

Despite decades of warnings about the risks of cross-species epidemics, we mounted only half-hearted efforts to plan for the worst-case outcomes one could cause.

First and foremost, we, as a society, lacked the imagination to believe something like this could occur. Or, perhaps, this was just plain hubris. Of course, this couldn’t happen to us. The U.S. is home to some of the most highly regarded healthcare providers in the world, and we’re a leader in new health technologies.

Beyond that, we have consistently ignored the increasing number of our very real failures to respond to other health crises we have faced as a nation. The very immediate and painful failures in response to the COVID19 pandemic are not outsized, nor are they unusual. Although somewhat different, the last several years have seen similar failures of epidemic response to opioid abuse, obesity, suicide, and gun violence. And, we have also failed with each. But why?

Everyone’s in Charge and No One’s In Charge

Unlike issues in our broader healthcare system, we don’t lack planning or strategies for anticipating and responding to epidemics. It’s just that most aren’t worth the paper they’re written on and need to be scrapped and entirely re-worked.

Federal, state, local agencies, and providers have been planning, gaming, assessing preparedness, and practicing pandemic and other emergency responses at least since 9/11, SARS, swine flu (H1N1), and scares about bird flu (H1N1). The federal government created the Strategic National Stockpile in 2003 precisely in response to these concerns. We’ve had global pandemic surveillance programs in place in both the CDC (Centers for Disease Control) and (until recently) in USAID (U.S. Agency for International Development) for more than a decade.

At the federal level, we also have strategies and plans throughout federal agencies, raising the specter that, as with so much of the U.S. healthcare system, everyone is in charge, but no one is in charge. As stated with Dr. Suess-like clarity in the 2019-2022 National Health Security Strategy put out by the HHS Assistant Secretary for Preparedness and Response (ASPR):

“Ensuring a health-secure nation is a collective responsibility among federal, state, local, tribal, and territorial (SLTT) governments and public and private partners, non-governmental organizations, academic, professional associations, communities, volunteers, families, and individuals.”

All that is missing from that statement is the family dog. At a minimum, the U.S. Health and Human Services Agencies, Homeland Security Agencies, Defense Department, Veterans Administration, Agriculture Department (USDA), Department of Education, Environmental Protection Agency, State Department, and Occupational Safety and Health Administration (OSHA) all have plans. Just at the federal level, these include (at a minimum): Department of Health and Human Services Pandemic (Influenza) Plan; National Health Security Strategy; National Biodefense Strategy; U.S. Health Security National Action Plan; and, Global Health Security Agenda.

These federal plans are in addition to state, local, and hospital system pandemic preparedness plans. We’ve also had an ongoing assessment of each state’s ability to respond in this kind of crisis with measuring and reporting through the National Health Security Preparedness Index, which has been published annually for the last five years.

There has been near-continuous monitoring of U.S. and global threats and warnings from numerous experts that a deadly pandemic could emerge at any time. Before the Trump administration discontinued funding for the program, the USAID PREDICT program worked across the globe to identify and monitor zoonotic illnesses that had the potential to jump species and fuel a human epidemic. The program identified at least 1,000+ diseases. This effort was in addition to ongoing monitoring by the CDC in the U.S. and internationally. Just within the CDC monitoring includes the Laboratory Response Network (LRN) of 130 certified laboratories and reporting by local public health departments primarily focused on flu surveillance.

Our approach fails to consider and plan for the loose, private structure of the healthcare industry in this county.

But, this disjointed, multi-agency approach fails in one important way. Any response to an emergency like an infectious disease outbreak demands rapid action and military precision in coordination. We are a country with varied, broadly dispersed, and fragmented healthcare resources and decision making. If plans don’t include explicit mechanisms to corral key actors in advance, we lose critical time for our response. And, federal plans, and even to a large degree, state plans, lack those decisive mechanisms and decision making authority.

This is why the administration’s restructuring of the NSC office for global pandemics was potentially so disastrous. And, the administration’s government-wide efforts to “streamline” and restructure agencies involved in this kind of response, their minimizing of the role of the federal government in providing coordination and direction, and their drive to privatize solutions have magnified existing weaknesses. This includes shifting the National Stockpile between multiple agencies, which only added to the confusion and lack of preparation. The net result is that not unlike what we confronted with the 9/11 attacks, this disjointed approach increased risks that we would miss emerging threats or fail to mount a timely and adequate response.

If we don’t change our approach to these issues, this will not be the last time we face this kind of crisis.

Who Really Has Authority?

Though the public may clamor for the federal government to step in and exercise persuasive authority in a crisis like the COVID19 pandemic, national emergency response law and regulation generally does not grant that level of authority. Instead, those laws, our system of governance, and our healthcare system mostly delegate responsibility for an emergency response to our governors, local health authorities, and healthcare providers.

Existing law and health emergency response plans and strategies assume that the federal government performs a coordinating role, facilitating and providing technical support and some minimal funding for states and local governments. It does not direct.

The failed nationwide Medicaid expansion mandate reminded us that the states are not required to even participate in many federal programs. That includes pandemic planning. Each may also have its unique way of approaching the issue as is evidenced by the lack of a consistent approach to stay-at-home orders. A review of the most recent National Health Security Preparedness Index 2019 Summary of Key Findings shows this kind of wide variability in the state by state capabilities and readiness to respond to the kind of crisis we currently face.

The federal government’s ability to respond early and aggressively to an epidemic is limited mainly to ongoing, standardized health monitoring (testing and reporting through established, certified labs and local health departments) overseen by or certified by the CDC, risk monitoring, facilitating federal-state-local collaboration and development of planning frameworks and standards, maintenance of the strategic stockpile for emergency response, and shared funding and Hospital Preparedness Grants for specific activities. This limited capability leaves the federal government mostly dependent on states and local governments to carry out many of the actions necessary to respond to the urgent circumstances we are currently experiencing.

Even within the best run organization, these competing responsibilities, unclear lines of authority, and voluntary participation would be a recipe for mixed results. In the case of a country of 50 States, the District, and 16 territories, it is an invitation to disaster.

Plans Don’t Reflect the Real World of American Healthcare

Most plans that are in place also assume the American healthcare system has capabilities it does not have and can respond in ways for which it is ill-equipped. The issues we’re seeing in creating surge capacity and exponential increases in demand for supplies and equipment are Exhibit-A.

IP capacity has been significantly reduced and restructured over the last 30-40 years as more and more care has moved to outpatient settings, physician offices, and homes. Additionally, within hospital systems, capacity has been rationalized across facilities to limit the need to invest in high cost, specialized services in every facility. Although many hospitals retain unstaffed capacity, many newer facilities do not. And, even those that do have closed wings or other unused beds can’t always quickly shift that capacity for other uses, particularly if it requires the physical isolation of patients.

Though many plans anticipate the need for IP surge capacity, mechanisms to quickly and easily create it are weak at best, as the experience in New York is demonstrating. The plans that are in place also rely heavily on individual hospitals and states to quickly build and staff new capacity when needed. This is even more unrealistic since, as we are seeing now, many hospital systems simultaneously experience cash flow issues because of the need to limit elective procedures during an epidemic. Expecting individual hospitals or hospital systems to respond quickly to create new capacity in these circumstances fails to recognize the constraints under which many providers operate.

Most provider organizations operate under lean staffing models, making it challenging to support physical surge capacity even if brought online quickly. Additionally, it is a regular and ongoing challenge to recruit enough staff (particularly nurses) to fill open positions that exist even under normal operations. Few emergency response plans anticipate and include mechanisms to deliver additional staff to support surge capacity.

Most hospital systems utilize just-in-time inventory management systems. They don’t hold excessive levels of equipment and supplies, making it difficult to respond quickly to significant, rapid increases in needs. Additionally, most systems either use distributors/intermediaries or maintain shared services organizations that are responsible for sourcing and delivering those supplies. And, just like the hospitals they serve, most of those companies employ just-in-time inventory systems as well as having dispersed supply chains based on strategic sourcing principles to help reduce costs and drive asset efficiency. Anticipating that hospitals and health systems can respond to rapid, dramatic changes in demand for essential equipment and supplies is simply not realistic.

Reference labs and related services are used throughout the healthcare system to increase efficiency and rationalize capacity. This approach is, even more, the case for small rural and suburban providers. Many of the pandemic response plans assume the ability to identify and test for risks in the broader population quickly. But, as the COVID19 testing disaster has shown, they fail to address where and how that capacity will become available other than through the paltry 130 existing CDC-certified testing facilities that cover a population of almost 350 million. The CDC touts the fact that it tested more than 67,000 Zika virus specimens, a number far fewer than the millions needed to respond in an actual epidemic.

The financial state of rural and safety-net hospitals is precarious at best. At the same time, many of the pandemic and health emergency response plans assume these hospitals are the first line of defense. Without additional supports and emergency funding, many may not have the financial ability to respond to a significant, but temporary, increase in demand. Again, except as anticipated in state-level emergency planning, federal plans are mostly silent on the issue of how these facilities will have the resources to respond in this kind of crisis.

Hospitals and health systems are primarily independent businesses. Except for the 20% that are publicly owned and operated, we have limited ability to mandate their participation in any planned response. As noted previously, the largely voluntary nature of most plan elements magnifies the problem.

Private sector partners can’t pivot on a dime to shift manufacturing, retool machinery, or source products from closer in locations. As is the case with other parts of the healthcare value chain, most manufacturers have moved to just-in-time inventory and production practices. They have also rationalized capacity across a global supply chain, which may provide some flexibility in sourcing products, but becomes a challenge when borders are closed during an epidemic.

Making Sure People Can Get the Care They Need

But, even where authority is clear and realistic about how the industry works, existing plans fail to recognize problems with access to and financing of care. Our high uninsured rates, insurance that relies on employment, and high out-of-pocket costs make people reluctant to seek care even when they have coverage. When combined with the lack of paid sick leave for many individuals, we risk that people spread disease by continuing to work when sick or waiting to seek care until their illness is acute. The lack of clear sources of funding for the care needed during an epidemic also puts additional strains on the healthcare system just at the time when their resources are severely strained by increased demand.

The existing tools to address this issue are only half helpful. The federal government does have the authority to ease access to coverage by waiving some Medicaid and Medicare requirements during a declared national emergency. But, there is no automatic funding mechanism to support those changes, and final decision-making authority still rests with the states. This approach leaves a patchwork of coverage and no precise mechanism to ensure states can support these added costs and that providers, who are already stretched thin, will be paid.

Americans Are Not Healthy

Finally, let’s be really clear. Americans are unhealthy relative to other developed countries, and that increases clinical risks and the acuity of illness. Planning should, but doesn’t reflect that. As we’ve seen in this response, modeling is often based on the experience of other countries. Because of that it seriously underestimates the potential acuity of those infected, their need for care, and the demand that places on caregivers and system capacity.

What Do We Need to Do?

So, what are we supposed to do about all this?

First, we need to get realistic about the risks we face from a reoccurrence of COVID19 and, god forbid, the emergence of a new disease. If you think the COVID19 pandemic is like a 500-year flood that’s unlikely to occur again anytime soon, think again. Take a look at the graphic below from the World Health Organization Global Pandemic Monitoring Board. This chart is just a high-level cataloging of infectious diseases that the organization is currently monitoring.

Global Examples of Emerging and Re-Emerging Infectious Disease

So, assuming that this is not the last time we will deal with SARS-CoV-2, or the next pandemic threat, what are some of the things we can do, short of some sort of unlikely radical restructuring of our entire democracy and healthcare system?

1. Streamline responsibility at the federal level. We don’t need more plans. We need clear accountability and less confusion.

2. Engage the healthcare and manufacturing industry in crafting new plans that realistically reflect their capabilities and needs.

3. States should consider designing and adopting a common “Model Pandemic Response Law” (similar to what they do in the insurance industry) that standardizes state-level activities, including mutual aid, information sharing, region-wide planning, and implementation. States should assume they will be the first line of defense and must work collaboratively to meet their needs.

4. Standardize planning and response to implement surge capacity both nationally and at a state and local level. It should be clear who is responsible for identifying a need, maintaining capabilities to respond, and implementing that response. Planning should recognize that most states will not have the capacity to meet these needs without federal assistance.

5. Strengthen state and local surveillance, with consistent, standardized methods of collection, monitoring, and reporting. Programs should include a massive expansion of lab certification for testing and tracking, including engagement and certification of expanded private sector participants.

6. Consider “Pandemic Response Certification” for provider organizations, which would be responsible for rapid response and coordination in a community or region. Certification should be similar to what we do for trauma certification, requiring that designated facilities meet specific criteria, maintain ready capacity, and act in a coordinating role.

7. Require that all hospitals and health systems include planning and investment in pandemic response capabilities as part of their Community Benefit Plans.

8. Establish a real and functioning federal-level ready reserve corps of health professionals as was approved in 2010, and as envisioned by Senate Bill 2629 – the United States Public Health Modernization Act.

9. Pre-certify private sector partners, including manufacturers, as essential for pandemic and public health emergency response, allowing for rapid implementation of purchasing and procurement of needed resources.

10. Replenish the national stockpile and establish a transparent, multi-state framework and decision-making process for deploying resources in a national emergency.

11. Modify the Social Security Act to include an automatic funding mechanism for payments through Medicaid and Medicare for epidemic-related health care costs. Changes should also allow for direct payment (similar to disproportionate share – DSH) for hard-hit providers on the front-lines of any response.

Finally, as I’ve pointed out in earlier posts, we must address the severe misalignment of our health policy and resources. This current crisis should be a wake-up call that we need to start thinking about a lot more than just covering the uninsured. We need to re-think our approach to how we deliver health in America.

America’s Health System Unwinds

Source: Adobe Stock

This is Not My Beautiful Healthcare – Part 2

America has no national health strategy. And, the crisis we see in the U.S. healthcare system around COVID-19, as well as our out-of-control costs, reflect that lack of focus and a half-century-long lack of planning and misallocation of resources in our healthcare system.

During those 50 years, we’ve spent trillions building Christmas trees of fragmented and disjointed federal and state insurance programs in our pursuit of universal coverage. The result is a balkanized system with so many different programs and offerings that no one is in charge. This incremental insurance expansion has added complexity and inefficiency, resulting in much higher administrative costs – with 8% of spending in the U.S. going to administrative expense versus 3% spent in other developed countries.

For example, during the 1970s, rather than create a single program for disabled individuals, both the Medicaid and Medicare programs were expanded to cover disabled individuals, with slightly different criteria applied to each. Medicare expanded coverage to those qualifying for Social Security Disability Insurance (SSDI), while Medicaid covered those receiving the newly created Supplemental Security Income (SSI) program and some low-income disabled. This change was, of course, in addition to the Alcohol, Drug Abuse, and Mental Health Administration (now the Substance Abuse and Mental Health Services Administration, or SAMHSA), which had primary responsibility for behavioral health treatment and the organization and funding of those services across the country.

And, that wasn’t the end of Medicaid’s selective and disjointed expansion. What followed was the addition of Early and Periodic Screening, Diagnostics, and Treatment (EPSDT) for some low-income children and youth and intermediate care for developmentally disabled. Coverage was expanded for low-income pregnant women and children not receiving public assistance. Then we added Disproportionate Share (DSH) funding for hospitals serving large numbers of low-income individuals, and home and community-based services (HCBS). And, after yet another failed attempt to enact universal coverage during the Clinton administration, we adopted the State Children’s Health Insurance (S-CHIP) covering some low-income children who don’t qualify for Medicaid.

How did the promising reforms we enacted in the 1960’s fail to yield the improvements many had expected?

During this same period, we undermined and dismantled policies to control healthcare costs and address how and where care is delivered. These changes included eliminating or undermining Certificate of Need (CON), community rating, non-profit community benefit requirements, and antitrust limitations on market concentration. And many of the “improvements” that implemented, such as the creation of integrated systems (IDN’s, IHN’s or CHN’s) or value-based-purchasing (VBP), have fueled an ever-growing healthcare industry of mega health insurers and delivery systems.

The result is healthcare that is even more unaffordable, and therefore more inaccessible, for large numbers of Americans. Since the passage of Medicare and Medicaid, inflation-adjusted per capita healthcare costs have increased by 500%. And, during the heyday of mega health system creation and national health plan consolidation between 2000 and 2018, total healthcare spending MORE THAN DOUBLED to $3.6 trillion. And, we still had nearly 9% of Americans without insurance coverage for the full year in 2018 with growing numbers having insurance they can’t afford to use.

Newly implemented programs may have done little to improve access and outcomes. Instead, as multiple studies have shown, the primary driver of higher healthcare costs in the U.S. is the price we pay for our services. These ARE NOT the prices charged by insurance companies. These are the prices charged by those who deliver our care.

As Modern Healthcare pointed out in a 2018 article profiling a comprehensive study sponsored by JAMA (Journal of the American Medical Association), we pay more for everything. We have higher physician, nurse, and administrator salaries. As an example, they cite coronary artery bypass graft (CABG), which averages $78 thousand in the U.S. versus $34 thousand in Switzerland and $14 thousand in Spain. An abdominal C.T. scan averages $844 in the U.S. versus $483 in New Zealand and $85 in Spain.

The same study also points out that providers and executives are paid much more, with average U.S. specialist physicians making $316 thousand versus an average of $182 thousand. Primary care docs earn $218 thousand in the U.S. versus $133 thousand elsewhere. Even nurses earn $74 thousand versus $51 thousand in other countries. We also get much less for our money, with critical measures like life expectancy, infant mortality, and disease-free years at the end of life continuing to fall behind our developed peers.

Universal insurance coverage by itself will do little to address this issue unless it includes specific actions to limit the costs of care by thinking differently about how we support a healthy America.

Upside-Down Public Policy Focused on Sick Care

We’ve built an upside-down system in which solutions are focused on providing insurance and treatment for those who are already sick or at an age when health problems are more acute. At the same time, we’ve starved public health, prevention and primary care programs that would keep Americans from getting sick in the first place.

As a result of the formation of these massive programs heavily focused on sick Americans, Medicare (and to a much lesser degree, Medicaid) emerged as a primary driver of health policy and growth of the healthcare market through its dominance over health spending. As Rosemary A. Stevens, Ph.D. stated in a 1996 Healthcare Financing Review article: “[the] aggressive style of American medicine – science-based, disease-focused, technological, and interventionist – might be justified as a primary basis for national health policy in the future….invest in biomedical research and ensure population access to hospital and specialist care, rather than worry about primary care, long-term services, and comprehensive national health insurance. In essence, this is what Medicare was to do.”

The results of this backward approach to coverage, in which we won’t cover you when you’re well, but will when you finally get sick, were utterly predictable. Almost simultaneously, the system began to unravel as expenditures predictably followed the areas of most significant opportunity in the market, the rapidly growing elderly population (increasing from 10% of the population in 1970 and 16.9% in 2020) and disabled, who offered sure sources of financing through cost-based reimbursement.

This continued focus on a medical/technological model of health means that we have ignored many of the low-cost, public health solutions to improve the health of communities, reduce costs, and to be prepared for the kind of pandemic we are experiencing now. As total health expenditures have continued to grow, public health expenditures have declined by nearly 20% since 2000 alone. Additionally, 80-90% of public health expenditures are at the state and local level, with Federal contributions primarily targeted at emergency preparedness (ironic, given the current challenges we’re facing). By contrast, spending on public health programs in OECD countries averages 10%.

These reductions in funding occurred despite clear evidence of the benefits of these programs. According to the United Health Foundation America’s Health Rankings, “An investment of $10 per person per year in evidence-based programs in local communities that are proven to increase physical activity, improve nutrition, and prevent smoking or other tobacco use could save the country more than $16 billion annually within five years. This is a potential savings of $5.60 for every $1 invested.”

Loosening Regulatory Controls

This upside-down approach has accompanied continued loosening of regulatory controls and undermining of key protective features that had required industry participants such as not-for-profits to focus more heavily on population-wide benefits.

These changes occurred even though non-profits make up nearly 60% of providers, with an additional 20%+ being controlled by state and local governments. An even higher percentage of health plans are non-profits (63% of those with 100,000+ members), and even a higher number of smaller health plans fall into that category. This unraveling has included changes in the following areas:

Community Rating: Blue Shield plans were initially organized as insurers of last resort. However, during the 1950s, they had already begun moving away from community-rating as the commercial insurance industry, which was using experience rating, grew. By the 1960s most had abandoned community rating, with the result being increasing access and affordability problems for those in the individual insurance market with underlying health issues. Age-banded community rating was put in place with the passage of the ACA. During the intervening period, this change alone added significantly to higher uninsured rates and higher costs.

Certificate of Need (CON): On the provider side, CON programs, which regulated the building of health facilities and purchase of expensive equipment, were being abandoned at the federal level and loosened or eliminated at the state level. By 1987 the federal government repealed the CON mandate, and throughout the 1980s, states began retiring their CON programs. Within the next three years, twelve states had repealed their CON programs. And, although more than 30 states still have some form of CON program, most are limited with a more substantial focus on outpatient and other free-standing facilities and less attention directed to inpatient facilities, which are the most expensive part of the system.

Non-Profit Enforcement: Across the industry, the IRS failed to enforce requirements associated with the maintenance of non-profit status by healthcare organizations. Except for the Blue plans, which saw increased enforcement and some loss of tax-free status, there was little enforcement of the same requirements in other parts of the industry. The result has been massive increases in executive compensation, the building of enormous war chests and excessive levels of risk-based-capital (RBC), and lack of seriousness in meeting requirements to deliver community benefit, all of which have added to rapid cost increases.

Anti-Trust Enforcement: The loosening of antitrust controls across the industry has equaled the lack of attention given to the enforcement of non-profit status. Many mergers and acquisitions have simply flown under the radar as health systems have pursued smaller transactions that fail to trigger an antitrust review. And, the effects on the delivery of care, access to services, affordability, and community benefit are substantial. As Claire E. O’Hanlon a researcher on healthcare consolidation points out in a recent article in Health Affairs: “evidence suggests that non-profit hospitals are no more likely than for-profit hospitals to increase the charity care they provide as their market power increases.”

HMO’s Fuel For-Profit Insurer Growth and Integrated Delivery Systems

The emergence of HMO’s may have been the most critical market trend that has driven change and increasing costs across the system. It fueled the creation of some of the largest for-profit insurers. It also encouraged the creation of integrated delivery systems (most of which are not-for-profits), considerable investments in information technology, rapid industry consolidation and growth of mega-health systems, and massive increases in administrative costs.

Yet again the growth of HMOs and the for-profit insurance industry was primarily driven by the federal government as part of an effort to address calls for national insurance and rapidly rising costs. Health maintenance organizations (HMOs), which had emerged primarily in the west, were seen as an important innovation and solution to encourage a focus on health. The response was the passage of the HMO Act of 1973, which provided financing and incentives for their creation. Overnight, the industry exploded to 90 million members by 1999 and led to the formation of new, industry giants like United Healthcare.

Though some research suggests that HMOs have reduced the rate of healthcare cost increases, they have not lowered costs overall. Additionally, by their very nature, HMO’s require scale for efficient delivery of care and delivery management functions. In spite of mixed cost and outcomes results, the government has continued to promote them as a solution, liberalizing and then encouraging their use in Medicaid and then in Medicare with the creation of Medicare Advantage (M.A.) products. Those changes opened up the financially attractive and growing senior trade and the massive state healthcare markets to both for-profit and not-for-profit investors.

In response to the focus on HMO’s and a growing belief that vertically and horizontally integrated delivery systems could deliver better outcomes, the industry directed massive attention to the creation of ever bigger systems. Again, the government has helped fuel this growth by incentivizing the creation of Accountable Care Organizations (ACO’s) to compete for Medicare and Medicaid business. Many of these hospital systems have also pursued this growth in the belief that their formation is an appropriate defensive reaction to the growth of large insurers, requiring that providers become equally large and achieve significant or dominant market shares to secure profitable contracts.

The net result has been massive industry consolidation and the growth of mega provider organizations, most of which are not-for-profits, wielding extraordinary market power. The top non-profit provider organizations in the country have continued to see rapid increases in their net assets far above that of for-profits, as well as growing net income. Senior executives in these organizations are also richly compensated. The highest-paid executives make many multiples of the pay of their for-profit counterparts.

Again, much of the growth of these mega-systems and consolidation of market share has taken place in the face of only limited enforcement of federal tax regulations. Much of the concentration of this part of the industry has also taken place under the radar of antitrust enforcement, primarily through continuous smaller acquisitions that do not trigger reviews.

The benefits of this trend are far from proven. Though some studies have shown a correlation between improved quality and integrated care, few suggest integrated systems actually reduce costs. And, some question whether they even deliver on the first promise. As leading industry researcher Austin Frakt pointed out in a 2019 New York Times article, “studies show that rates of mortality and major health setbacks grow when competition falls. And there is also strong evidence that consolidation has contributed to increasing costs.”

As stated in the Urban Institute’s comprehensive January 2020 study on this issue: “Over 90 percent of hospital markets have become highly concentrated. In the meantime, hospital acquisition of physician practices, or “vertical mergers,” and development of multihospital health care systems crossing many local health care markets, or “cross-market mergers,” proceed unchallenged, despite evidence that both are associated with substantial price increases, without evidence of quality improvement or greater efficiency.”

The Emergence of For-Profit Healthcare

Finally, no evaluation of the current state of American healthcare can be complete without a discussion of the impact of the growth of for-profit entities in the industry, with particularly profound effects on specific sectors.

It’s tempting to place blame for higher costs on profit-making by health insurers. And, certainly, there are effects that may be unfavorable – as well as favorable. But, the overall contribution of this single factor is unclear. While the participation of these companies means some spending on profit, the average net profit for health insurers in 2018 totaled only 3.3% of the health insurance portion of expenditures. Nothing to sneeze at, but not the riches many believe.

However, that does not mean that healthcare is an unattractive sector for predatory investing and financial speculation, especially in many of the more ancillary services areas. Many of the most egregious examples of this have been in pharmaceuticals for which pricing is mostly unregulated. Fragmented purchasing across multiple organizations and government entities have encouraged financial arbitrage. Investors search for medications or whole classes of essential medicines where the market can quickly be secured, and prices can be raised to astronomical levels. Then they can extract massive profits before consumer backlash forces a course correction. “Pharma bro” Martin Shkreli is the poster child of this strategy but is by no means alone in pursuing these efforts, as is evidenced by extraordinary increases in essential medicines like insulin and Epi-pen prices that dominated headlines.

But, pharmaceuticals are by no means the only market segment targeted as an attractive sector for speculation and financial engineering. Many speculative investors, such as private equity and hedge funds shy away from larger health care sectors such as health plans and hospitals, which are low margin and subject to frequent regulatory intervention. But many target specific segments where they can exploit industry fragmentation.

Other industry features that have been exploited by investors include Stark laws that limit physician investment in businesses to which they refer; and, elimination of “corporate practice of medicine” laws that prohibited investment in physician practices. Both have led to substantial investment in physician practices and free-standing ambulatory services such as dialysis. The effects on those specific services can be significant with many experiencing rapid price increases and predatory billing practices such as those that have been widely reported in emergency medicine.

So, Where Does This Leave Us?

What each of these issues points to is an obvious conclusion that real healthcare reform is much more complicated than just providing universal insurance coverage, which is of limited value if care is unaffordable.

Meaningful solutions must address the many trends that have driven out-of-control cost increases and poorer clinical outcomes. And, in many instances, answers may be as simple as enforcing laws and regulations that are already on the books. Solutions MUST also be a data-informed analysis of the real drivers of improvement.

In future posts, I will dive deep into many of the topics included in this post. I’ll also discuss the real impact of many of the popular “solutions”, such as value-based purchasing (VBP), consumer-directed-health-plans (CDHP’s), and health technology promoted as promising solutions. I’ll offer other prescriptions for how we can begin to turn the corner on cost and start making healthcare more affordable.

This Is Not My Beautiful Healthcare

· How Did We Get Here? – Part 1 ·

Source: Adobe Stock

There are no quick fixes for what ails our healthcare system – in spite of what many policymakers and the media would like to have us think. Medicare-for-all or the public option would definitely provide insurance coverage for the millions of Americans who are still without. And, they might have marginal effects on the cost of care by reducing bad debt and increasing the use of preventive services to keep people from becoming so sick that their costs of care are excessive.

But, the U.S. healthcare system is governed by a complicated, convoluted set of programs, regulations, and competing interests that result in massive administrative complexity and costs in ALL parts of the system. To avoid the balloon effect of pushing on one place only to have another problem develop elsewhere, the solutions must address how the system is structured as well as how it is financed through insurance coverage.

Even protections we once had in place to limit profiteering are pretty much gone – chipped away by decades of legal and regulatory change at the federal, state and local levels. And, the system has become so fragmented through the enactment of one new, limited program after another, that it lacks any resemblance to efficient design, offering scant opportunity to gain scale economies. Even health insurers with nationwide reach are often organized at a local level, to accommodate differences in state regulatory requirements and the constitutional prohibition on federal regulation of commerce that crosses state lines.

The result is one of the largest and most highly fragmented economic segments in the world. It’s sheer size and design makes it ripe for speculation and financial engineering, which is why we’ve seen absurd and inexplicable increases in pharmaceutical and medical device costs as private equity has trolled the industry for opportunities to extract monopoly pricing power. Fixing this mess will mean unwinding a tangle of programs across the industry and, in some instances, instituting some of the types of mechanisms that used to be in place, and which are still used elsewhere to control the costs of care.

So, what are some of the features of the U.S. healthcare system that have gotten us to where we are?

The Scientific Model of Care and Its Impact on Costs

The formation of the American Medical Association (AMA) which was incorporated in 1897 (formed in the 1840s) and the American Hospital Association (AHA) founded in 1898 led to the establishment of standards for medical education, licensing, delivery of care, and health facility management and quality. They ushered in a new scientific model of medical care that changed how and where care was delivered, and what it cost. Care, that had largely been delivered in the home and may or may not has been overseen by a physician trained along scientific standards, moved into hospitals. A new, higher cost, an interventional model of health was born and control over licensing and regulation was largely ceded to the industry. (We’ll discuss this in greater detail in Part 2 of this article.)

The effects of these changes continue to reverberate through the healthcare system in the U.S. and many other western countries, reducing competition and slowing innovation through licensing and regulatory schemes that act as barriers to entry – limiting who can practice medicine, and how.

Both of these organizations’ professionalized American healthcare, became a model for programs across the globe and still have a profound effect on how our system is structured. However, it wasn’t long before these changes, along with changing health technology led to significant increases in the costs of healthcare as those stricter standards led to decreased physician supply and greater pricing power for both physicians and hospitals.

As the effects of these changes took hold and care that had previously been delivered in the home began moving into the hospital setting, hospital costs grew from approximately 14% in 1929 to 40% of medical bills by 1934. The age of big, institutional medicine had arrived. And, consumers were already pushing back with increasing calls for reform and the creation of national health insurance plans similar to those already created in some western nations.

America’s Belief in Volunteerism and Decentralized Power

While those calls for reform threatened to undermine the power of these new organizations, they also conflicted with America’s belief in personal responsibility and the value of work. And, this combination of forces led to dramatic differences in how healthcare was delivered and financed in the U.S., who would pay for it, and who had access. The result was an American healthcare system that is seriously fragmented and has been different from other countries pretty much from the beginning. And those differences profoundly impact the solutions we are willing to consider.

The dominance of these industry organizations, along with American beliefs in self-initiative, personal responsibility and volunteerism meant the emergence of community and religious-affiliated hospitals and mutual insurance companies to a degree not seen in other countries. When combined with our federal structure and constitutional prohibitions on federal regulation of NON-interstate commerce this contributed to a fragmented system with much of policy and decision making at the state and local level and virtually no national health planning.

The rural healthcare crisis in much of the U.S. and our slow uptake of solutions like telemedicine and the use of non-MD practitioners and para-professionals to deliver care are all largely a direct result of these differences.

Those institutions, including the Blue Cross and Blue Shield plans which grew out of them, were the original backbone of the system. And, through their association with those organizations, they were able to extract special legal and regulatory treatment that allowed them to limit competition and gain monopoly pricing power that still affects the structure and costs of healthcare in America.

The Emergence of Private Health Insurance

To address the growing problem of affordability and the lack of government solutions, employee organizations began entering into prepaid health services agreements with individual hospitals to provide care to their members. The first of these was the Dallas teacher’s contract with Baylor University. The original Blue plans arose in this environment as the American Hospital Association formed the not-for-profit Blue Cross insurance plans as an alternative to the prepaid agreements. It still covered the hospital services they were already delivering, but it also controlled the types of agreements that could be made.

Contract provisions included hospital participation requirements prohibiting the selling of single-hospital plans that might be able to offer reduced pricing of their services and limited competition between hospitals. The association also limited the number of plans that could operate in any market – to ONE – prohibiting the plans from competing with one another and limiting options for consumers.

From the beginning, these plans, which were not-for-profits, benefitted from regulatory protections that reduced competition, including exemption from taxes and insurance surplus requirements. In exchange, the plans were typically required to act as the “insurer of last resort” and only use community-rating (more about that later) for their products.

Because the Blue plans were voluntary associations and tax-exempt social-welfare plans, with the special regulatory status they also largely escaped any of the anti-trust oversight they would have otherwise had. Without those limits those anti-competitive features went largely unchecked for decades, allowing most to establish dominant market shares that persist to this day.

Within the decade, the Blue Cross plans were followed by the creation of Blue Shield plans by the doctors of the American Medical Association. Formed in the late 1930s, they were intended as an alternative to growing calls for compulsory health insurance, and to fill the gap in coverage from the hospital-focused Blue Cross plans. From the beginning though, they also included many of the same competition-limiting features and special regulatory exemptions.

Employer-Sponsored Coverage as a Safe Business Opportunity

For-profit insurers originally resisted the offering of health insurance because of the risks of “moral hazard” (the fear that only sick people would buy it) and perceived difficulties of actuarially sound underwriting of the product. (How could they price a product if they didn’t know whether people were sick or healthy?!). Besides, many of these companies already had lucrative businesses selling burial insurance (more of a sure bet) and laws in many states prohibited the selling of both health insurance and burial insurance – an obvious conflict.

However, as the success of the Blues became more apparent and the health insurance market grew, these for-profit insurers sought out new ways to participate – profitably. And, while they didn’t enjoy the regulatory protections of the Blues or their competitive benefits of close affiliation with hospitals and doctors, they also didn’t have the constraint of being the “insurer of last resort”.

So, they began looking for opportunities to participate while limiting their risks. The answer was to focus on a slice of the market which they believed was inherently healthier – those who were employed. Since these plans were for-profit and not tax-exempt they also were not subject to the same restrictions as the Blues. This means they could medically underwrite, further limiting their risks. And with that, the group health insurance market, with coverage linked to employers, was born.

It incidentally played right into America’s obsession with personal responsibility and the value of work, while adding to the fragmentation of coverage and incremental solutions targeting limited groups of citizens with different programs.

So, while other developed countries were implementing national health insurance programs that covered ALL populations and supported system-wide planning of resources, discussion of social safety net programs in the U.S., even during the Great Depression already emphasized program design linked to employment.

The result was a whole series of solutions to fill gaps in coverage rather than establishing comprehensive coverage for all citizens. And, the narrow interests that had designed each of these different coverage options – hospitals, physicians, and commercial insurers — found common cause to limit government intervention to protect their slice of the market.

Employer-Provided Coverage Becomes the Law of the Land

The challenges of supporting the industry with a workforce drained by the demands of the draft during World War II added to the attractiveness of employer-sponsored coverage. Employers, who were limited in their ability to offer pay increases due to price controls during the war, saw pre-paid health programs as an important tool to keep their workforces healthy and recruit employees since the offering of benefit plans was exempted from these prohibitions. This shift to employer-driven coverage was cemented by changes in the Internal Revenue Code during the 1950s, which exempted employer health contributions from taxation.

By the early 1960s, the health insurance industry had already exploded, with 70% of the population having some form of HOSPITAL insurance, but the major medical insurance industry was only beginning to emerge. The idea of insurance for primary care and non-hospital care had not yet taken hold, though there were some exceptions. Veterans had access to the Veterans Administration system which had been established after the Civil War, and federal employees had access to more comprehensive coverage.

This was before the creation of Medicare and since they were likely not employed, fewer than one-half of elderly Americans had any insurance at all. Although some did qualify as “medically indigent” and could receive state-delivered services under the Kerr-Mills Act. Because coverage was so closely tied to employment, the same conditions applied to the unemployed and those receiving welfare benefits.

Creation of the Original Medicare and Medicaid Programs

Some of these remaining gaps in coverage began to be addressed with the passage of the Medicare program in 1965. The program, which was an outgrowth of a conference on aging held by the Eisenhower administration, initially covered primarily the elderly and included Part A hospital and skilled nursing services (with restrictions) and Part B for non-hospital services provided by physicians and others.

In keeping with the fragmented, incremental approach to coverage, even the funding mechanisms for the two programs were separate, with Part A being funded through the Social Security payroll tax, and Part B funded by premiums paid by Medicare beneficiaries, with supplementation from federal general funds. And, once again, primary coverage (Part A) was linked to employment, so that individuals who had not paid into Social Security (or who had a spouse who did) were generally excluded from coverage under the original program design.

Interestingly, the close linkage to both hospitals and doctors, and to the Blue plans also continued with the formation of the program. Under Medicare, it is physicians associated with the AMA who advise the government on prices for Medicare services, with a similar process for hospitals that submit cost reports that become the foundation for reimbursement calculations. Much of the administration of the program was also outsourced to the Blue plans, who took on responsibility for claims processing and related activities as MAC contractors.

Following the same approach to coverage expansion, the separate Medicaid program was created at roughly the same time and followed a similar pattern of fragmented and incremental design – but to an even greater degree. First, what many people don’t understand is that Medicaid is largely a voluntary program for the states. They don’t have to participate. Remember the first assault on the ACA when the Supreme Court ruled that the states couldn’t be forced to expand Medicaid? That’s what we’re talking about. States need to opt into the program and must fund a share of the program at what is approximately 50% of the cost.

The original Medicaid program was also a skinny, skinny program that provided coverage for only a limited number of individuals and for limited services. It covered people getting cash assistance, low-income children deprived of parental support, their caretaker relatives, low-income elderly, the blind, and individuals with disabilities. This excluded most able-bodied adults – the assumption being they could work and get their coverage that way.

Original Medicaid benefits were also limited and varied between the states. States had minimum coverage they had to provide in order to receive Federal matching funds but had some limited ability to provide additional coverages. Some states did add benefits, although most offered the minimum (and some states still do). The program also covered little in the way of preventive care and mental health services — following the model of the early private insurers. Yet again, we had implemented a program that practically ensured massive variability.

So, by the late 1960’s we’d made some significant leaps forward, with more and more Americans having coverage. But, that coverage came from a patchwork quilt of programs and products that still left a large number of Americans uninsured. By 1968 roughly 81% of Americans had some form of hospital or surgical insurance. What that left was almost 20% of Americans with no coverage and an even larger number without coverage for basic preventive and primary care.

Probably, more importantly, we were also left with a seriously fragmented system. And, it was hooked on a model of incremental expansion that only contributed to that fragmentation. It was also a system that was largely directed and regulated by the very interests that stood to benefit financially from the decisions being made – and who were legally protected from the kind of competition that might have fostered innovation while being insulated from many anti-trust limitations.

As we entered the 1970’s, these same factors continued to play out. But, a whole series of new actors, new programs and new regulatory models started to gain traction. The result was a hodgepodge of federal and state programs (that persist to this day) and the dismantling of the few industry limitations and consumer protections that had been in place. By the end of the decade, healthcare was already becoming big business and healthcare costs were on the march again.

At the beginning of 1970 U.S. healthcare spending totaled $74.6 billion and was 6.9% of GDP. By 2018, spending would equal 17.7% of GDP and a whopping $3.6 TRILLION.

In part 2 of this article, I tackle the question of those changes that were made, and that brought us to our current state – a healthcare industry that is nearly 20% of our economy, and which is failing to deliver the kinds of outcomes citizens of other developed countries expect.

This is Not My Beautiful Healthcare. How Did We Get Here?

America’s Healthcare System is Failing Us

· And What Are We Going to Do About It? ·

Source: Adobe Stock

The American healthcare system is the industrial equivalent of “The Blob that ate…” pretty much anything in its path. It keeps growing from 6.9% of GDP in 1970 to 17.9% of GDP in 2019 – an approximate 160% increase. During that same period, real household incomes went up by a little less than 50%, largely driven by increased participation of women in the workforce. That means everyone in the family working, just to keep from falling even further behind.

So, yes, you guessed it. More and more of Americans’ paychecks went to this amoeba-like creature that seems to be consuming everything, leaving less behind to buy shoes for the kids, put food on the table, buy gas for the car, or — god forbid — put money toward retirement. Meanwhile, there is more than ample evidence that the system just isn’t working for a lot of people. And, little of what is being done today to “transform” the system will lead to the kind of fundamental change needed to really make a difference in the lives of healthcare consumers.

It’s time to come clean about what has really happened to the American healthcare system over the last 50 years; how the system actually works; the changes that are being proposed or are already in the works; the effects those changes really have; and, how things can be done differently — how they are being done differently – elsewhere and with better results.

This column is about that. Because, after decades of advising the industry I’ve become more convinced than ever that much of what the healthcare industry does is more about growing bigger and bigger, not shrinking it to a size that Americans can afford, with the results they deserve. And, I’m more convinced than ever that nothing short of a radical re-thinking of how we approach healthcare will be needed to turn things around.

So, sit down and buckle up and let’s BREAK SOME HEALTHCARE. A warning for the faint-of-heart: I’m notoriously blunt, and direct — which means I call it as I see it. So, prepare for burst bubbles and skewered sacred cows (but, I promise no cows were actually hurt in the writing of this blog). No prisoners will be taken. I only ask that you be equally direct in any responses and share the questions you have. The stakes for the American consumer are just too great to do otherwise.

Your Healthcare Beliefs May be Wrong

· Everything You Don't Know About the System Could Hurt You ·

Source: Adobe Stock

Americans can be pretty misinformed about how the U.S. healthcare system works. So, first things first. Let’s cut through the BS and popular beliefs about how things operate to get to the basics about who’s calling the shots and why we’re in this mess. Let’s do some myth-busting.

MYTH 1

The problem with the American healthcare system is greedy for-profit insurers who are making money “hand-over-fist”. We just need to get rid of insurance companies, take the profit out of the equation and that will solve the problem.

FACT: No doubt about it. There are some for-profit insurance companies out there. And some are better than others. And their shareholders do want to make as much money as possible from what they’ve invested. But, did you know most health insurers in the U. S. are actually NOT-FOR-PROFIT companies? In fact, the dominant insurer in most states is a Blue Cross-Blue Shield company, most of which are NOT-FOR-PROFITS. And, they typically controlling 50% or more of the insurance market in any given state. And guess what, those not-for-profit insurance companies are more than likely purchasing your care from a NOT-FOR-PROFIT hospital system. And that hospital system probably controls 30-50% of your local market. It may also be the largest employer in your community, giving it a lot of clout with policymakers. More about all these “not-for-profits” in a later column. By the way, most of these guys also don’t pay taxes like you.

MYTH 2

Most Americans get their health insurance from their employers. And they don’t want to give up their freedom of choice to participate in some “socialist” government-run healthcare system as they have in other countries.

FACT: Slightly more than 50% of Americans do get their insurance through their employer. However, nearly as many Americans already get their healthcare through a hodgepodge of government-run programs in the U.S. And, newsflash: All of those programs have their separate administration adding to the inefficiency of the system – rather than just having one single system to cover everyone. These existing programs include:

Medicare provides care for the elderly and the long-term disabled;

Medicaid provides care primarily for low-income children, low-income pregnant women, some families, certain disabled individuals, low-income seniors without Medicare, and some adults depending on the state. Medicaid also provides long-term care for low-income elderly and Medicare subsidies for low-income elderly;

State Children’s Health Insurance Program (S-CHIP) provides health insurance for low-income children without other coverage;

Veterans Administration (VA) provides care for qualifying veterans with service-related illness or injury and/or who may qualify because they are low-income;

Tricare insurance and military healthcare for active-duty military, retirees and their dependents;

Indian Health Service (IHS) provides care to qualified Native Americans based on U.S. treaty obligations and federal law;

Obamacare subsidies to purchase health insurance on public health exchanges established under the Affordable Care Act (ACA);

Federally-Qualified Health Center (FQHCs) and Rural Health Centers (RHCs) that receive reimbursement through the Medicaid program;

Community Mental Health Centers (CMHCs) funded through the Substance Abuse and Mental Health Services Administration (SAMHSA);

Disproportionate Share (DSH) funding for hospitals that provide services to communities that serve a “disproportionate” number of poor people; and

Graduate Medical Education (GME) funding distributed through the Medicare program and used to train doctors and provide care, primarily in hospitals.

I could go on and on, but I’m sure you get the picture. We have a lot of taxpayer-funded programs out there, and they’re already covering a lot of people. In fact, nearly 50% of Americans are covered by some form of public insurance, receive subsidies to purchase insurance, or receive care from taxpayer-funded providers. And, this doesn’t even include all the programs and services funded by states (Medicaid is jointly funded by states and the federal government, but largely state-run) and local governments. So, sorry to break it to you, but the U.S. isn’t some bastion of private, for-profit healthcare. It just isn’t.

FACT: Most developed countries (as well as some developing countries) that have national healthcare systems have mixed public and private healthcare systems (JUST LIKE WE HAVE CURRENTLY FOR MANY AMERICANS). Across the OECD nations, approximately 25% of healthcare spending is private. Even in the grand-daddy of national healthcare programs, the British National Health Services (NHS) people can get care through private programs. The difference is that everyone has access to some kind of care through the NHS if they need it. Additionally, much like America’s Medicare program and our employer-provided health care, British citizens pay for their healthcare through monthly contributions.

Finally, I hate to burst everyone’s bubbles, but the idea of a national healthcare system was first put forward by the conservative German Chancellor Otto von Bismarck, the architect of the modern German state — not exactly a socialist. And, his rationale for the program was to drive economic growth for the newly formed nation, with a healthy German population. (Don’t worry, we’ll profile many different systems in later columns. We’ll also profile the history of U.S. national health insurance proposals which were originally proposed by the Republicans.)

MYTH 3

Obamacare (Affordable Care Act) was a failure because it was poorly-designed, and Americans don’t want people telling them they have to buy insurance. It can’t be fixed, so we should just chuck it, and start over.

FACT: I’m sad to say that I was an on-the-ground observer of the “failure” of Obamacare through my work in Washington, DC. And, I hate to break it to all those haters out there, but it hasn’t been a failure. The uninsured rate before the passage of the law was a whopping 46.5 million (17.8%) Americans, with many people going without insurance because they simply couldn’t buy it. No one would sell them health insurance, at any price. And, not necessarily because they were sick. You could be denied for something as simple as having taken anti-depressants during a challenging period in your life –or maybe just because you were over the age of 40. Obamacare got rid of one the more inhumane features of American healthcare – medical underwriting for individual insurance purchasers — which allowed companies to deny you insurance altogether, or to make it so prohibitively expensive that you couldn’t afford it.

After the passage of Obamacare, the uninsured rate dropped to a low of 26.7 million (10%) in 2016, immediately before the end of President Obama’s second term. This is all while BOTH political parties, aided by the healthcare industry, did their level best to kill it off – which is why health insurance premiums have continued to rise.

The reality though, is that lots of people played a huge role in crippling the ACA. The Republicans largely didn’t want the law at all and didn’t want a law that they didn’t help craft. But, a whole lot of Democrats didn’t want the law either, because it didn’t include the public option. And once the battle lines were drawn, the law, which was known to be flawed at its passage, was doomed to not have any of those problems fixed because neither side could budge. The balance of forces that had allowed its passage was too fragile to touch.

But, neither party could leave well enough alone. First, the Democrats botched the roll-out of the law. Then the Republicans attacked Medicaid expansion in the courts and yanked the funding for crucial parts. Then the Democrats refused to make regulatory changes to address the yanked funding and blow to Medicaid. Then industry forces started asking for special dispensation for the parts of the law that had been disabled……then on and on and on…..The result – a massive taxpayer-subsidized transfer of wealth to all the Blue Cross-Blue Shield Plans that were already the dominant players in the market. And Boom! All those plans now had massive pricing power and up went insurance rates. The good news – all those problems can easily be addressed to fix the law and continue driving down uninsured rates. More about that and what happened to the law in a later article.

MYTH 4

America has the best healthcare you can buy, as long as you can afford it.

FACT: Definitely, we have a problem with the affordability of healthcare – even if you have insurance. According to a 2019 study by the Consumer Bankruptcy Project more than half a million Americans file for bankruptcy annually because of debt they piled up due to illness. Americans are also borrowing like crazy to pay medical bills, with the New York Times citing a recent study by Gallup and West Health that we borrowed a whopping $88 billion to pay for medical bills last year. And that doesn’t include the people who just plain go without care – even when they have insurance – because they just can’t afford it. According to a June 2019 Henry J. Kaiser Foundation Issue Brief, “at least one-fourth of insured (emphasis added) adults [report] it is difficult to afford to pay their deductible (34%), the cost of health insurance each month (28%), or their co-pays for doctor visits and prescription drugs (24%).” HOUSTON, WE HAVE A PROBLEM. Not only is the healthcare system eating up our economy, but I pretty much guarantee you that there isn’t much of anything being done in the industry to make it more affordable. The American Hospital Association is suing the Trump administration to block it from implementing very modest proposals to even make it possible for consumers to know the price of their care. Astounding.

FACT: Sorry America, but we don’t. The U.S., which had healthcare outcomes that were similar to many other developed countries in the 1970s has been in a downward spiral ever since. During the same period, we’ve poured more and more money into the system. Again, in 2019 we saw American life expectancy decreased for the third year in a row. And, although we continue to make improvements in many areas, Americans are sicker, experience more medical errors, get sick and die from treatable causes, and have higher rates of infant mortality and pregnancy complications than people in other developed countries. This is not because we aren’t spending enough on healthcare but is the result of a whole series of differences in how we approach health in America. We’ll talk a lot more about this in some later articles.

MYTH 5

American healthcare costs are so high because people abuse the system, use too much care, and use the wrong kind of care – like going to the emergency room when they don’t need to.

FACT: Americans do use the emergency room more often than people in other developed countries (except Canada). Care in that setting is not cheap. And, we do tend to use more expensive tests and expensive drugs, than people in other countries. This is partly because we have a lot more specialists and fewer primary care doctors. We also have higher rates of chronic disease. But, the biggest problem is the actual cost of the services we use. The price you pay is more, and we pay more to the people who deliver those services. A recent study by Harvard concluded that “the main drivers of higher health care spending in the U.S. are generally high prices – for salaries of physicians and nurses, pharmaceuticals, medical devices, and administration.” As you can see, there are a lot of misconceptions about our system. Tackling those myths is key to understanding what we’re dealing with, and what we can do better. Please share your comments and questions. And let’s figure out how we can do better by the American consumer.

Talk to you next week.

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· The U.S. needs a new approach to health reform. Our COVID19 failure proves it. ·

Insurance Is Not the Solution to Our Problems

We Must Reform the Delivery of Care

COVID19 Is An Important Learning Experience

Essential Lessons From How Countries Have Tackled COVID19

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

What Can We Learn From How Countries Have Performed?

Lesson Number One: Disease Surveillance Systems Are Outdated

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

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

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

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

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.

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

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

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.

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

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.

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

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.

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

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.

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.

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

A Guiding Principle for Reform

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

Modernize Our Approach to Disease Surveillance

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.

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.

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

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

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

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

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

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

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.

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

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

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

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

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

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

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

Consider Streamlining and Rationalizing Existing Public Insurance Programs

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

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

Shift Incentives to Engage Industry Stakeholders in Change

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.

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

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“WE HAVE MET THE ENEMY AND HE IS US”

America’s Outsized Failure

The U.S. is 4.25% of the world’s population, while, as of the date of this post, we account for almost 27% of confirmed pandemic deaths globally.

Why are U.S. COVID19 deaths almost 500% greater than our share of the population in the world?

The Reality of Life for America’s Working Class and Poor

Being Elderly and Alone

Hubris About the American Healthcare System

Healthcare Affordability

Those Who Do Not Understand History are Doomed to Repeat It

But, there is an even more significant underlying factor here than the tactical errors discussed above. A great big elephant is sitting in the middle of our living rooms.

America is An Unhealthy Country

Why Does This Matter?

When combined with our tragically fumbled COVID19 response, this disturbing picture of American health has rendered the U.S. particularly vulnerable to the ravages of any disease, but especially this illness.

People of Color Are Even More Unhealthy and More at Risk

The COVID19 epidemic has laid bare the reality of the issues we face when it comes to the health of Americans, with the poor, people of color, and the elderly bearing a disproportionate cost for our failures.

These Issues Point to the Lack of Clear Priorities Focused on Health

Remember the adage: “the definition of insanity is doing the same thing over and over and expecting a different outcome.”

These Outcomes Should Cause Us to Rethink Our Health Strategies, Policies and Priorities

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What Went Wrong?

Despite decades of warnings about the risks of cross-species epidemics, we mounted only half-hearted efforts to plan for the worst-case outcomes one could cause.

Everyone’s in Charge and No One’s In Charge

Our approach fails to consider and plan for the loose, private structure of the healthcare industry in this county.