Posts About Cost & Quality

As we attempt to stave off the on-again, off-again House Republican repeal efforts, the Trump administration is also taking a quieter “wait for failure” approach that sets the stage for administrative and regulatory actions that could weaken the foundation of the law. One of these foundational provisions is the assurance that marketplace consumers have sufficient access to providers and care – or network adequacy. Therefore, it is more important than ever for states to step up to the plate to protect coverage and access to care for the millions of consumers who rely on marketplace plans.

Network Adequacy Advocacy Matters More than Ever in the Trump Era

Over the past few years, insurers have trended towards narrow network plans – especially those in the marketplace – in order to reduce premium costs for consumers. Although narrow networks are not inherently bad, consumers have little information on the tradeoff between lower premiums and network size, and are put at greater risk for surprise balance billing. Evidence has shown profound impacts of narrow networks on consumers, including inadequate coverage for some chronic health conditions, disruption in care and confusion over provider directories that can result in burdensome balance billing from out-of-network providers.

To a certain extent, consumers on the marketplace are protected by the ACA’s minimum network adequacy standards. However, in its first health care regulatory action, the Trump administration proposes to take a hands-off approach to enforcing network adequacy matters, punting responsibility to the states.

State Activity Around Network Adequacy Is Alive and Well

Fortunately, state activity around network adequacy is still active. During the current legislative session, initiatives to address surprise billing sprang up in several states – including Georgia, New Jersey, Texas, Oregon and Washington. Massachusetts is also working on improving provider directories. Success stories from the last couple years can guide continued advocacy efforts to strengthen state network adequacy protections where federal regulation and enforcement fall short. For instance, advocates played a pivotal role in helping pass laws in Georgia and Maryland that ensure updated and accurate provider directories, and helped put an end to surprise medical billing in California, Florida and New York.

We developed a case study highlighting how leadership from consumer advocacy groups like Georgians for a Healthy Future lead to a legislative win for one of the strongest provider directory laws in the country. One of the key advocacy strategies advocates in Georgia employed was strong engagement with state officials, policymakers and industry stakeholders. This strategy and more can be found in the case study as well as the strategic campaign template we developed specifically for network adequacy advocacy.

As the future of the ACA remains uncertain, insurers are likely to push for more narrow networks in order to deliver competitive low premiums for consumers. Moving forward, it is important that consumer health advocates work closely with policymakers and government officials in their states to shape policies that protect access to affordable and comprehensive coverage.

Movie sequels often fail to live up to the original, and Republicans' effort to repeal the ACA falls into this familiar pattern. As bad as the original was (and it was really bad), the sequel was even worse. Not content with taking health insurance away from 24 million people, increasing premiums and out-of-pocket costs for millions more, fundamentally undermining the Medicaid program, and shifting new costs onto states and providers, last week the Trump administration and House leaders continued to try to undermine health care coverage.

Fortunately, the revised proposal was quickly rejected and "pulled from the theatre." Republican lawmakers left town with nothing more to show for their flurry of activity than what appears to be a face-saving effort to get themselves out of the corner they painted themselves into when they attacked the idea of reinsurance as an "insurance industry bailout" by renaming it an "invisible high risk pool".

As much as this was a short-lived effort to bring the bill back to the floor, it contains two critical lessons:

First, if this was not already clear enough, President Trump's commitments on health care are meaningless. The huge gulf between his words and actions has been laid bare for everyone who doesn't have blinders on to see. Despite promising otherwise during the campaign, the original ACHA, which the Trump administration enthusiastically embraced, included a massive cut to Medicaid and even a cut to Medicare. It also undermined the insurance market reforms Trump promised to preserve by allowing states to waive Essential Health Benefits.

The EHB changes already in the AHCA would have undercut the ban on pre-existing condition exclusions by allowing the sale of insurance that excludes coverage for specific benefits or diseases while also exposing people to uncapped out-of-pocket charges. The proposed change in the rating rules would compound this by allowing insurers to charge people more based on their health status. These are devious proposals: while a guaranteed right to purchase would nominally remain, it would be virtually useless since insurers could charge sicker people such high premiums that coverage is priced out of reach.

Fortunately, the new deal collapsed for the same reason as the old one -- it was caught in a squeeze between the demands of the Freedom Caucus, which seeks an even more drastic rollback, and the outrage of an activated populace determined not to allow their health care to be stripped away.

Second, as in the typical horror flick, the monster can return from the dead multiple times. Despite the first failure, the House made a second effort, driven by the Trump administration, which again demanded they put a bill on the floor before April recess.

In a strange way, this abortive effort did us a favor. If anyone was feeling complacent after the collapse of the AHCA, the revived effort should have put people on notice. While the public outcry and GOP infighting have dealt ACA and Medicaid entitlement repeal a setback, the effort is far from dead. We should expect an effort to bring a bill back to the House floor in May, following the debate on spending for the remainder of 2017, which will occur in late April, and prepare accordingly. 

More Dragons on the Road Ahead

The AHCA, in whatever metastasized form, is not the only threat. Even if Republicans in Congress abandon a straight repeal effort, there are several other critical danger points. If, and when, Congress turns its attention to taxes, they are likely to need spending offsets to pay for (wait for it…) tax cuts for the rich. That could lead lawmakers back to looking at Medicaid (or the ACA) as a pay-for. Similarly, an effort to increase military spending might also create a hunt for spending offsets and put Medicaid and/or the ACA back on the chopping block. CHIP refinancing presents another "opportunity" for lawmakers predisposed to undermining the Medicaid financing structure.

Perhaps even more dangerous than these various legislative threats is the damage Congress and the Trump administration could inflict upon the ACA through both harmful actions and "malign neglect.” By creating a climate of uncertainty about the "rules of the road," including whether they will finance cost-sharing reductions and enforce the individual mandate, we can expect more insurance carriers to drop out of the Marketplace. This could leave more counties with only one option - and others with none at all (at least temporarily). Coupled with this uncertainty, and in the absence of action to improve the risk pool or a commitment to a robust enrollment push, we expect many insurers that stay in the Marketplace could seek another year of large rate increases. This could reverse the surge in popular support for the ACA and fuel the "ACA is broken" narrative.

To be very clear, ACA defenders are in a much stronger position after the defeat of the AHCA in the House, and there are plenty of things Congress or the states could do to lower premiums and cost-sharing and expand coverage, if they are so inclined. However, the bottom line is attacks on our health security are not going to subside any time soon. If people want to keep their health care, they are going to have to keep fighting to defend it. In other words, the only way to make sure this zombie stays in the ground is to keep shoveling dirt on the grave.

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.

Even with health care coverage, Medicaid beneficiaries still find themselves facing numerous barriers to accessing the care they need and achieving better health outcomes. One barrier that continues to cause serious access problems is transportation. There are an estimated 3.6 million people in the United States who miss or delay medical care because they don’t have access to transportation.

NEMT 3 Million PeopleIn early August, the Center for Consumer Engagement in Health Innovation (the Center) submitted a comment letter to the Centers for Medicare and Medicaid Services (CMS) regarding Iowa’s request to extend its waiver of Non-Emergency Medical Transportation (NEMT) benefits from its state Medicaid demonstrations (Iowa Wellness Plan and Marketplace Choice Plan). The waiver excludes coverage for NEMT services, a benefit that is standard in non-waiver Medicaid programs.

NEMT provides access to and from medical appointments for consumers who do not have other means of transportation. Reimbursed services can include shared van programs, taxis or public transit. Many in need of NEMT are lower-income beneficiaries, often older adults or people with disabilities. A high proportion of these individuals live with multiple chronic conditions such as end-stage renal disease, cancer or chronic obstructive pulmonary disease. Monitoring and treatment for these conditions require frequent medical appointments and limited transportation options may prevent access to timely, life-sustaining care.

Transportation barriers can have a “domino effect” on health outcomes and cost of care. Missed or delayed appointments can worsen health conditions and end up necessitating expensive ambulance services and costly emergency department visits. This is why NEMT has proven to be highly cost-effective.

For individuals in need of behavioral health services, NEMT is particularly critical. One study found that the largest proportion of adult beneficiaries who use NEMT do so to access mental and behavioral health services. More than 40 percent of NEMT trips in New Jersey and 30 percent of trips in Nevada were used to access mental health or substance use treatment appointments.  

The Center is concerned that several states have sought to exclude NEMT for some of their Medicaid beneficiaries. These actions reveal the need for consumer advocates to ensure that other states do not follow suit. 

This is why the Center submitted comments on Iowa’s waiver request and why we plan to also submit comments opposing Indiana’s similar proposal. We encourage others to do the same. The comment period for Indiana’s NEMT waiver request is open from August 12 - September 11, 2016. 

Submitted by Andrew Jopson, Summer Intern. Andrew is a graduate student at the University of Washington, Seattle.

After six-plus years of rhetoric and sixty-some repeal votes, the House Republican caucus finally produced a document they refer to as a plan to replace the Affordable Care Act. (To call the plan disappointing would be an understatement. Despite my low expectations, the document the Republican working group produced was even worse than I thought it would be.)

It is a paltry effort. Six of the document's 37 pages are essentially devoid of content. Much of the remainder is taken up with political bombast full of misleading and flat out untrue statements. The actual policy proposals it does contain, when it pauses for breath from excoriating the ACA, are a warmed over rehash of the same harmful, unworkable ideas various Republican lawmakers have been pushing for years with nearly all of the critical details missing. Although the lack of detail makes any precise comparison to the ACA impossible, it is safe to say that if adopted, the proposals released this week would cause millions of people to lose their health insurance, and increase health care costs for millions more.

It's not worth the time to read, let alone to write a correction of every misstatement and deconstruction of every bad idea, but here are some of the "highlights."

Undermines critical insurance reforms while shifting costs to lower-income people and benefits to the affluent

A few of the ACA insurance reforms would remain, such as allowing young adults to stay on their parents' plan and no lifetime benefit cap. However, most reforms would likely be swept away, such as access to preventive services with no cost sharing. There would be no guaranteed minimum benefit package, and tax credits would not adjust with income, so lower-income people would be less able to afford coverage. Many would drop out of the insurance pool since the individual mandate would also be repealed. Credits would not adjust to keep pace with the rising cost of insurance, so every year fewer and fewer people would be able to afford coverage.

The Republican "plan" would also make shopping for coverage much more difficult. There would be no plan standardization. Competing "private exchanges" would be allowed, each of which might have a different set of insurers and benefit designs. Making "apples – to - apples" comparisons would become almost impossible.

At the same time tax credits for low-income people are wiped out, Republican lawmakers would double down on high deductible health plans and Health Savings Accounts (HSAs) by increasing the amounts that could be contributed to HSAs. This change primarily benefits those in higher tax brackets who also have the spare cash to put into their accounts.

Would cause millions to lose Medicaid coverage and increase financial barriers for those that remain. Children, in particular, could lose vital protections.

Apparently, the drafters couldn't decide between a Medicaid block grant and a Medicaid per capita cap, so they included both ideas and would let states decide. Either way, beneficiaries would lose. Federal contributions would not keep up with health care costs, and states could for the first time create enrollment caps or waiting lists to exclude otherwise eligible beneficiaries from coverage. Financial protections would be scaled back allowing states to impose higher premiums on beneficiaries that would force many to drop coverage. Those who remain could also get fewer services and pay more in cost sharing. If states chose a block grant instead of a per capita cap, beneficiaries would fare even worse, especially children, who would lose nearly all of the current legal protections that ensure low-income children have a comprehensive benefit package with no cost sharing.

With more and more costs shifted onto states, and with states having more freedom to shift costs onto beneficiaries or exclude currently eligible people altogether, there is little doubt that millions would be harmed.

Erodes benefits and increases costs for Medicare beneficiaries

Repeal of the ACA would immediately increase prescription drug costs for Medicare beneficiaries by eliminating the expansion of the Medicare drug benefit. Most beneficiaries (those who didn't go to the hospital in a given year) would also see higher out-of-pocket costs through a new deductible structure that would increase the amount they would have to pay for most services before Medicare kicked in. The Republican work group also proposes increasing the Medicare eligibility age, an idea that CBO has determined does not save much money for the federal government but does increase costs for employers and individuals.

But wait, there's more. Starting in 2024 Medicare beneficiaries would lose guaranteed access to a defined benefit package. Instead, they would be given a set amount of money they could put toward a plan. While the details are lacking, one thing that is clear from the document is the size of this payment would shrink over time relative to the cost of health care, leaving seniors and people with disabilities with ever skimpier coverage.

And now for the good news (sort of)

The ideas contained in this grab bag of horribles are wildly unpopular, and an attempt to enact them would provoke a huge backlash. Even in the event of a Trump election this doesn't represent where actual health policy would go, since under any conceivable scenario Republicans would not have enough votes to pass a bill like this. Moreover, not all of these changes could be made via budget reconciliation. That said, and despite all the missing detail, this compendium of "greatest hits" creates a chilling picture of where health care could be heading depending on what happens this November.

(Last year, the Robert Wood Johnson Foundation launched a joint initiative with Community Catalyst called the Value Advocacy Project (VAP). The project is supporting consumer health advocacy organizations in six states in their non-lobbying advocacy efforts to pursue local and state policy and health system changes that increase the value of health care by improving health outcomes and lowering health care costs, especially for populations that have disproportionately poor outcomes. Building on the Center for Consumer Engagement in Health Innovation’s recently released Consumer Policy Platform for Health System Transformation, we will be highlighting our state partners working on issues outlined in the policy platform and encouraging them to share how their work can translate to advocates across the country.)

Ohio is one of the nation’s unhealthiest states, ranking 40th in overall population health, yet we spend more per person than all but 15 states. Additionally, the state ranks last in racial disparities of infant mortality, speaking to the need for a more robust approach to health equity.

In 2009, Governor John Kasich created the Office of Health Transformation to change the way we pay for and deliver health care, to move from volume to value. Leveraging the influence of large self-insured employers, the administration brought together the four largest insurers, public payers and providers to develop a payment/delivery reform plan (described below), leading to the award of a federal State Innovation Model (SIM) Implementation Grant.

But what about the role of consumers? That’s where we come in.

In the next five years, Ohio plans to move 80 percent of Ohioans into two new payment models: Patient-Centered Medical Homes (PCMH) and episode-based payments. Episode-based payments refer to paying providers for treating a whole “episode of care,” such as joint replacement, rather than the individual services. This incentivizes providers to get the care right (they get paid the same even if the patient gets a bad infection requiring multiple hospitalizations), creates more price transparency and narrows the wide variation in charges among providers for the same treatment.

The SIM application talks about patient engagement, but we need to identify the strategies for building in robust and meaningful patient engagement. Furthermore, strategies for addressing population health also need to be identified. Thus our coalition, Ohio Consumers for Health Coverage, is focusing its Value Advocacy Project campaign on shaping the PCMH model of care as an instrument to improve population health driven by a robust, institutionalized consumer voice at all levels of Ohio’s health transformation efforts.

Regional PCMH collaboratives in Ohio demonstrate both the potential and challenges of relying on primary care transformation to make strides in population health. On the one hand, we’ve seen PCMH practices virtually eliminate racial disparities in delivery of diabetes care in Cleveland (check out Better Health Partnership). On the other hand, The Southwest Ohio Comprehensive Primary Care Initiative (which is one of seven sites in the federal CPCI initiative), has Medicaid covering only 5 percent of patients, due to federal restrictions. And CPCI’s patient population does not reflect the racial and ethnic diversity of Ohio. Yet, the Kasich administration is calling it the model for Ohio’s PCMH model.

On the plus side, a handful of PCMH practices in the southwest Ohio demonstration are using Patient-Family Advisory Councils (PFACs) to involve their patients in improving care quality – a best practice for patient engagement that we plan to promote as a state benchmark.

Where do we begin?

We’re working in three areas:

  1. Advocating that the Ohio PCMH model include standards and metrics to measure and improve consumers’ experience – including their participation in their care – and promote population health by connecting consumers to resources like patient self-management programs, housing and food assistance that improve their health and overcome non-health barriers;
  2. Building the voice of consumers at several levels: at the individual level by promoting expanded use of PFACs in PCMHs and recruiting consumers for them, at the systems level by getting consumers and advocates more vocal, at the regional collaborative levels in our three largest metropolitan areas and the policy level where we recently won four seats on the PCMH model design workgroup; and
  3. Ensuring that Ohio’s PCMH initiative promotes health equity, including institutionalizing effective use of community health workers to reduce health disparities and engaging the Ohio Statewide Health Disparities Collaborative in developing a health equity action agenda for this initiative.

Perhaps our greatest challenge is figuring out how to energize consumers in the three biggest metropolitan regions (and beyond) to get involved as advocates for better primary care that supports efforts to lead healthier lives. We hope to draw in people newly enrolled by community-based assisters, especially ones we trained and placed primarily in communities of color, as part of our enrollment follow-up activities to promote better health literacy and patient engagement. And we’ll turn to our activated enrollees in our integrated care (“dual eligibles”) demonstration, some of whom we are training for managed care plan consumer advisory committees.

Most of all, we plan to borrow promising practices from consumer advocates in other states who have been infinitely creative in causing a stir. Ohio needs a lot of creativity!

Author: Cathy Levine, Former Executive Director, UHCAN Ohio

(Last year, the Robert Wood Johnson Foundation launched a joint initiative with Community Catalyst called the Value Advocacy Project (VAP). The project is supporting consumer health advocacy organizations in six states in their non-lobbying advocacy efforts to pursue local and state policy and health system changes that increase the value of health care by improving health outcomes and lowering health care costs, especially for populations that have disproportionately poor outcomes. Building on the Center for Consumer Engagement in Health Innovation’s recently released Consumer Policy Platform for Health System Transformation, we will be highlighting our state partners working on issues outlined in the policy platform and encouraging them to share how their work can translate to advocates across the country.)

In Washington state, newly-created Accountable Communities of Health (ACHs) are bringing together stakeholders from across the health care and social service systems (e.g., local governments, public health departments, insurance carriers, housing providers, hospitals, educators, health care providers and consumers) in a collective decision-making process to improve health care and health outcomes. These diverse cross-sectoral partnerships promise to increase collaboration across the health care system, better coordinate care, reduce costs, address social determinants of health (factors such as income, education and housing that are the primary contributors to health disparities within and between regions), and increase equity in health outcomes in nine regions across the state.

The projects are meant to address the unique needs and priorities of the regions from which their members are drawn and thus may differ greatly from one region to another. For example, one ACH has chosen to focus first on youth behavioral health, while another has devoted its initial substantive efforts to care coordination for individuals with multiple chronic conditions. The decisions that ACHs make have the potential to significantly improve health care for low-income people and people of color. Yet despite the fact that reducing health disparities while addressing quality and affordability is part of their mandate, success in these goals is not a given and implementation will require a strong consumer voice.

Too often, decisions by health care institutions are made to maximize efficiency, revenue and profit. That’s why Washington CAN! and Northwest Health Law Advocates (NoHLA) believe the ACHs must include substantial consumer representation, particularly from low-income people, people of color, non-English speakers and older adults, so populations who face the highest barriers to good health and health care will have a voice in the ACH process to ensure their needs and interests are met. 

Washington CAN!, NoHLA and our partners will ensure that strong community involvement is a cornerstone of the ACHs, beginning with crafting a best practices report for consumer engagement. An accompanying toolkit will summarize how an ACH can welcome meaningful participation from marginalized communities and make decisions within a racial equity framework.

This work will inform “Principles for Community Participation,” an organizational framework pushing new ACHs to adopt consistent policies and practices. We will increase community engagement with grassroots outreach, technical assistance, such as policy analysis and trainings, and organizing support to low-income consumers and allied organizations. Finally, we will end our work with an evaluative assessment of the ACHs (i.e. a report card). It is our goal that these tools will be useful to advocates in our state and around the nation as models for strong and diverse consumer engagement.

Washington state has been a policy leader and innovator in health care to date, and our state is committed to maintaining that leadership at all levels of the health care system, from state and local government, to insurance carriers and hospitals, to the consumer advocacy groups that have pushed Washington to deliver one of the fullest and most successful state implementations of the Affordable Care Act (ACA) in the country. We know the next steps in health care reform include focusing on improving how care is delivered and how we address social determinants of health. We also know that effective decision makers, strong advocates, and engaged consumers are what make health care advances possible. By elevating a consumer voice in our state’s ACHs, we will strengthen our network of health care activist leaders, improve our health care system and support consumer-driven innovation in this next level of ACA implementation.

Author: Gerald Hankerson, Main Street Alliance Director, Washington CAN!

Despite political opposition to the Affordable Care Act at the highest levels of state government, Florida led the nation as the state with the most people gaining new health insurance through the Affordable Care Act. However, for Floridians with coverage, being insured has not completely provided assurance against exorbitant and unfair surprise medical bills. Stories in Florida newspapers and national media have highlighted the problem of “balance billing” for out-of-network services to people who thought they were covered. Fixing this problem for consumers became a focus of both opponents and advocates of the Affordable Care Act, resulting in Florida’s enactment of one of the strongest consumer protections against unfair out-of-network balance bills in the nation. The law exempts consumers from being held responsible for out-of-network rates in emergency and non-emergency situations if they’re denied opportunities to receive treatment by in-network providers.

As a statewide consumer health advocacy organization, Florida CHAIN is advocating to improve health insurance through state regulation and oversight of carriers. CHAIN has a seat, appointed by the Insurance Commissioner, on the Florida Health Insurance Advisory Board (FHIAB). For the past two years the CHAIN representative has recommended to the Board that the Insurance Commissioner propose and support legislation that protects consumers from out-of-network balance billing.

Despite the optics, the political will in Florida this year was strong to address high-health care prices. The Florida House and Governor remain unyielding in opposition to expanding Medicaid in conflict with the Florida Senate, which seeks to cover the expansion population with a waiver approach. This intra-legislature disagreement led to myriad health care-related bills in 2016 designed by the House in a charade that lowering costs, mostly through deregulation, would fix the health care access problem for more than three million uninsured Floridians. The bills to prevent out-of-network balance billing were a part of the pretense.

We took advantage of the unique political climate that positioned consumer advocates alongside our anti-ACA ‘surprise bedfellows’ in support of protections from unfair surprise medical bills. Using our proposal to the FHIAB, the Insurance Commissioner recommended legislation that prohibited balance billing and helped increase our visibility with other state agencies. When the Florida Insurance Consumer Advocate (ICA) convened a Balance Billing Forum, she invited CHAIN to present the consumer perspective along with industry speakers.

As a consumer advocacy organization, we stood firm on our goal to hold consumers harmless when they have no opportunity to choose an in-network provider. Our one-page brief for stakeholder groups and legislators highlighted that the consumer should not be party to any dispute resolution process. Despite a wide chasm in the design and definitions of a payment resolution process between providers and payers with no middle ground in sight, we successfully advocated for a “clean bill” that only addressed the consumer protections.

Our allies at Consumers Union worked to mobilize a groundswell of email and phone action from Florida constituents urging their legislators to “pass a bill – clean.” State media reported on the bills and the advocacy by highlighting consumer stories we referred to them as the bills made their way to the finish line.

Advocating through our seat on the state advisory board, working with close allies and key stakeholders, and taking advantage of the media’s interest in the issue helped move this legislation from a bill into a law that will protect 11.5 million Floridians with private insurance from the financial distress of unfair surprise medical bills.

Laura Brennaman PhD RN, Policy and Research Director at Florida CHAIN

Efforts To Close The Coverage Gap Inch Forward With Brighter Days Likely Coming

Despite the health, economic and fiscal benefits of closing the coverage gap for people who fall between state Medicaid eligibility levels and eligibility for subsidized Exchange coverage, 2016 has been a tough year to get new states to take advantage of federal funding with efforts coming up short in Idaho, Nebraska and South Dakota (so far, though there is still hope for later in the year). But support for closing the gap remains strong with important votes taking place in New Hampshire and Arkansas to continue their expanded Medicaid programs and an important procedural milestone occurring in Louisiana, where the House has taken steps to approve the financing needed to make  the expansion recently approved by Governor Edwards successful.

The logic of refusing federal funds is purely political and the costs of refusal are becoming clearer all the time. Refusal to do the right thing is provoking anger among state residents as political leaders in Tennessee and Florida have discovered. With 2017 perhaps offering a more favorable political environment and continued strong support from key interest groups and the general public, look for renewed momentum in the months ahead.

Health Care Is Not Crowding Out The Other Stuff We Need

It seems like the recent news on the health care spending front is mostly good, with spending growth still running well below historic averages. But recent growth in health care employment has prompted the usual hand-wringing about crowd-out. Here are two reasons why that anxiety is misplaced. First, it ignores the universal tendency of richer countries to devote more of their total economy to health care – because they can. Think about it. Imagine you are an anthropologist and you visit some remote island where the entire economy is subsistence agriculture, with maybe one medicine woman doing a little part-time doctoring. Then, they get much more efficient at farming (perhaps because you violated the Prime Directive on your previous trip) that allows them to devote more effort to other things. When you come back you now find that 20 percent of the population is now engaged in providing medical care so you file an emergency report back home saying that the populace is in danger of starvation because health care is growing so fast it is crowding out agriculture...

Still not convinced? Then consider this: the U.S. is practically the lowest taxed country in the Organisation for Economic Co-operation and Development (OECD) with only Mexico and Chile and lower. Our struggle to finance human needs in this country is a result of political choices, not economic constraints. The "health care crowd out" argument is a political argument masquerading as an analytic one that is often unwittingly advanced by people who actually do not support the agenda of economic austerity. Don't fall for it. Not to say that we should waste money on inefficient or over-priced health care and speaking of which...

Another Week, Another Drug Pricing Outrage

Drug companies continue their price-gouging ways as yet another report shows that the industry routinely hikes the price of existing medications far faster and higher than any conceivable increase in production costs could justify. While a few outliers have drawn the most media attention, the problem is actually widespread and underscores the need for stronger action by government to keep medications available and affordable.

The ACA Has Done A Lot, But There Is A Lot More To Do

A new report from Gallup shows that, thanks to the ACA, the uninsurance rate in the U.S. has dropped to the lowest rate since they began tracking eight years ago. However, there is still a lot of room to make more coverage gains. A recent Robert Wood Johnson Foundation/Urban Institute report found that nearly half of the remaining uninsured are currently eligible for subsidized coverage in some form and an even greater number would be added if more states closed the coverage gap. But many people, especially in communities of color, are unaware that they or members of their family may be eligible for financial help. Fortunately, there is at least one easy way to spread the word. The IRS could notify families that qualify for the earned income tax credit and don't have employer sponsored coverage that they are likely eligible for financial assistance and direct them to enrollment assisters who could help them get coverage.


This post in our Health System Transformation series is an update of the Jan. 26, 2016 blog post titled, “How America’s Social Structures Affect Our Health.”  This updated post adds some key policy prescriptions that are central to the vision of Community Catalyst’s new Center for Consumer Engagement in Health Innovation.

In the initial blog post of this series, we mapped out Community Catalyst's policy agenda for Health System Transformation (HST). In order to achieve our goals of better value for our dollars and better health for all, we believe it is necessary to think beyond the delivery of medical services. Often the factors that have the greatest impact on health don’t involve the health care system at all. For example:

  • If you did not have a home or a refrigerator to store your insulin, how well would you be able to control your diabetes? Being provided with a safe place to store your medications would be the better solution, compared to waiting until you got so sick from high blood sugars that you needed to be hospitalized.

  • If your child’s asthma is made worse by air pollution in your neighborhood or the dust in your home, wouldn’t addressing the living conditions — by the provision of a home air filter or by public health measures to improve regional air quality — be more effective than increasing the number of your child’s medications and trips to the emergency room?

  • If a family doesn’t have enough to eat, wouldn’t food be the most important medicine?

Traditionally, the health care system has not taken on these and many other social and environmental factors that contribute to poor health, but we believe that must change. Social determinants of health — which encompass social, environmental and behavioral influences like access to healthy food and water, safe housing, employment/working conditions, gender and culture — play an important role in promoting health and potentially lowering health care costs, and must be addressed by health system transformation efforts.

The County Health Rankings Model included in our report, The Path to a People-Centered System: Next Generation Consumer Health Advocacy, and reproduced below, nicely illustrates the many factors that contribute to health. Furthermore, a substantial body of research, including data compiled in The American Healthcare Paradox and “Leveraging the Social Determinants of Health: What Works?,” demonstrates that higher ratios of social-to-health care spending are associated with better health outcomes.

The U.S. health care system is the most costly in the world, but our population’s health outcomes are worse than those of most other Organization for Economic Cooperation and Development (OECD) countries. A driver behind this gap could be the relative “underspending” on social services compared to medical care: in the U.S., for every dollar spent on health care, only about $0.91 is spent on social services. In comparison, for every dollar spent on health care, OECD countries spend $2 on social services. Increasing spending on social services could help improve health, while decreasing health care costs. Across the country, there have been many examples of forward-looking programs that are working to direct resources to address social determinants of health:

There are many more examples of initiatives that can improve the underlying health status of populations, but too often they lack adequate and stable funding. To address this problem, as health advocates, we need to broaden our partnerships to include organizations that work to secure affordable housing, promote access to healthy food, and address the other social and public health needs of a community.  We also need to advance policies that can build support for addressing these issues right into the health care system, such as by:

  • Ensuring that hospital community benefits programs (a requirement of non-profit hospitals in order to earn their tax-exempt status) help address the identified needs of their communities, including social supports and housing.

  • Structuring new models of integrated health care delivery to include community-based organizations, who can then share in cost savings generated by achieving better health, as New Jersey has done with its Medicaid Accountable Care Organization model.

  • Investing in organizations that assess patients’ needs and connect them to social support services in the community. One excellent example is Health Leads, which allows health care providers to prescribe basic resources like food and heat just as they do medications, then refers patients to advocates who help fill the prescriptions, working side-by-side with patients to connect them to the additional prescribed resources.

  • Encouraging adequate payments for the housing, transportation, and social support services that people need to improve their health and ultimately reduce costs.

  • Ensuring that payment models encourage prevention. One way to do this is to make sure that organizations delivering care are evaluated based on how well they are improving the health of the communities they serve, through the use of quality measures that assess community/population health. This can also be done by designing payment models like the all-payer model in Maryland that gives a fixed budget to hospitals, so that hospitals benefit if they keep people healthy.

  • Directly supporting prevention and wellness activities. Massachusetts, as part of its 2012 comprehensive health care cost containment law, levied assessments on plans and providers to create a Prevention and Wellness Trust Fund to support population health interventions.

We have the most costly health care system in the world, but we don't get results commensurate with our level of spending. At the same time, relative to other countries we spend much less on addressing the social and environmental conditions that can lead to poor health. Addressing this imbalance must figure prominently in our Health System Transformation agenda if we are to be successful at improving the value we get for our health care dollars.

Note: Lauren Banks, was a contributing author to the earlier version of this blog post

This guest blog by Marcus Escobedo, Senior Program Officer at The John A. Hartford Foundation, was originally published February 18 in the foundation’s Health AGEnda blog.

To fulfill our mission of improving the care of older adults, it is critical to know what is working—and what is not—when it comes to health care for the nation’s growing number of older people. That is why The John A. Hartford Foundation supported a new report from the Dartmouth Atlas Project titled Our Parents, Ourselves: Health Care for an Aging Population.

“This report is really about success,” says Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation. “Life expectancy has almost doubled since the 1900s, from 40 years to 80 years today. The number of adults over age 65 also is projected to almost double in the coming decades, from 43.1 million in 2012 to 83.7 million by 2050. This is truly remarkable and something to celebrate. However, we now need to achieve the same level of success in meeting the care needs of this growing aging population.”

The Dartmouth Atlas report should help. In fact it should be required reading for health system leaders, advocates, and policymakers. It can help them understand the composition of Medicare beneficiaries in their communities, those beneficiaries’ experience of care, and whether they are receiving evidence-based health care along a number of dimensions directly meaningful to older adults and their families. For example, the report looks at the number of unique clinicians that patients see on average, as well as end-of-life treatments, such as late hospice referral and the number of days spent in intensive care.

Based on 2012 Medicare data, this report card is helpful because it breaks down by geographic region where the United States is making progress in patient-centered care for older adults and where improvements are needed. It also breaks new ground, sharing data that has never been public before, including:

  • Older adults with two or more chronic conditions spent 33 days—or just over one month of the year—in contact with the health care system (in the hospital, at a doctor’s office, or at a lab visit).
  • The average Medicare beneficiary was in contact with the health care system on 17 days. Looking at the data by geographic region, the range spanned from 10.2 days in Lebanon, N.H., to 24.9 days in East Long Island, N.Y.
  • 18.4 percent of older adults filled at least one prescription for medication identified as high-risk by the National Committee for Quality Assurance. Again, the rates varied greatly depending on geographic region, from 9.8 percent in Rochester, Minn., to 29.1 percent in Monroe, La. Progress in this area is being made, as the percentage of Medicare beneficiaries who filled at least one high-risk medication prescription dropped 43 percent from 2006. But more work is needed to eliminate this dangerous practice.
  • Preventable hospital readmissions have declined 23 percent, from 5.5 percent of Medicare beneficiaries in 2003 to 4.2 percent in 2012. Again, since these are by definition “preventable” readmissions, we must keep working to lower the rate to as close to zero as possible.

The John A. Hartford Foundation is very proud to support the work of the Dartmouth Atlas Project, and our commitment to patient-centered and patient-directed care for all older adults is only strengthened after reading about the large variations in quality of care that currently exist depending on where people live. This report describes both the real and potential care needs that we must address. The discussion we need to have in light of this eye-opening report must center on the kind of care that older adults want, need, and how they want that care delivered.

The John A. Hartford Foundation was one of the earliest supporters of Dartmouth’s work looking at regional variation in the 1980s. The resulting Dartmouth Atlas Project underscores that big data can make a big difference in our ability to improve the care of older adults. The Atlas provides a huge service to everyone who does research, makes policy, or cares about the health of older people. It is a great tool that we know our grantees and the field will find helpful.

Download and share Our Parents, Ourselves: Health Care for an Aging Population so that it will be referenced and used by hospitals, community providers, and others in their field to make important and needed changes in the care we deliver to older people in this country.

For more information, including links to The John A. Hartford Foundation’s full press release and key data tables, visit the foundation’s Our Parents, Ourselves page.

Marcus Escobedo
Senior Program Officer, The John A. Hartford Foundation

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