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A group of authors, including experts with lead roles in the passage of the Affordable Care Act, offer advice on the next wave of reform.
Should the next HHS Secretary, Xavier Becerra, create a national corps of community healthcare workers, who would do everything from contract tracing to helping patients with multiple chronic conditions navigate the health system?
A well-known group of healthcare experts—many of whom helped launch of the 2010 Affordable Care Act—called for developing just such a workforce in a recent paper published in Health Affairs just as President Joe Biden was sworn in.
Their commentary, “Health Costs And Financing: Challenges And Strategies For A New Administration,” calls for halting the slide in the uninsured rate that began 2017, when polices of the Trump administration sought to reverse parts of President Barack Obama’s signature law. But the authors also highlight areas where the ACA met resistance or had unintended consequences.
Authors of the commentary are Dr. William Shrank, chief medical officer, Humana; Nancy-Ann DeParle, managing partner and cofounder of Consonance Capital Partners and Obama’s deputy chief of staff for Policy during passage of the ACA; Dr. Scott Gottlieb, Trump’s first FDA Commissioner and a resident fellow at the American Enterprise Institute; Dr. Sachin H. Jain, president and CEO of the SCAN Group and Health Plan; Peter Orszag, CEO of Financial Advisory at Lazard Freres and the Obama’s first director of the Office of Management and Budget; Dr. Brian W. Powers, deputy chief medical officer, Humana; and Gail R. Wilensky, senior fellow, Project HOPE.
DeParle and Wilensky each led the Health Care Financing Administration (now CMS), and Gottlieb served as a senior advisor at CMS between stints at FDA. Shrank and Jain were among the early leaders at the Center for Medicare and Medicaid Innovation.
The ACA succeeded in getting more people health coverage: the authors note that by 2016, only 8.9% of the U.S. population lacked insurance. But the rate has climbed since then and is on track to reach 10.6%, or 37.2 million people, by 2028.
Getting people health coverage is important, the authors argue, not for its own sake but because the evidence shows that having insurance leads to financial security, better health, and longevity. Three pillars—access, affordability, and equity—can be addressed in the years ahead if public officials work toward five goals: expand health coverage, accelerate the shift to value-based care, promote home-based care, make drugs affordable, and develop a high-value workforce.
The pandemic has cost thousands of Americans their employer-sponsored coverage and strained the government’s ability to come up with new financing solutions, the authors write. Twelve states stubbornly refuse to expand Medicaid. But that does not make coverage expansion impossible, if policy leaders can stop funding care that does not improve health, the authors say.
A Community Health Workforce
Each of these concepts has been discussed previously but the idea of expanding a workforce of community health workers would perhaps represent the biggest departure in who delivers care.
“Evidence suggests that such a program could reduce disparities, improve health outcomes, and lower health care spending,” the authors write. A key element is that the workers would be drawn from the disadvantaged communities they would serve, and would help the health system build trust among hard-to-serve populations while overcoming the known barriers to telehealth access.
For example, a 2018 study by researchers from Penn Medicine, published in JAMA Internal Medicine, found that community health workers can reduce hospital stays by 65% and double the rate of patient satisfaction.
In an interview, Jain elaborated on the role these workers would play within the health system.
“Community health workers have long been recognized as a potential foundational piece of the healthcare system of the future,” he said. The concept is not new—in fact, “community health workers have existed for as long as we've had communities.”
In the United States, however, “We've made healthcare exclusively the domain of doctors and nurses, when in fact, a lot of the work that needs to be done to better serve communities, is to engage people where they live.”
People spent very little actual time in healthcare settings, Jain said, but spend most of their time—and make most of their healthcare decisions—in the community, where lay people could offer support in managing chronic diseases. “There’s a growing evidence of body that when trained appropriately, they work. But we haven't, I think, had an opportunity and an obligation to start to scale some of these ideas.”
Pride in Small Wins
Political and budgetary limits likely put another big package like the ACA out of reach. But with discipline, the authors say, much can be done with “a willingness to accept incremental progress and small wins.”
The Biden administration offers policy makers the chance to fine-tune some areas of the ACA, such as payment models that may have inadvertently punished those health systems that took on the most high-risk populations. Such areas should be addressed, the commentary states. Jain offered an example of the Medicare Advantage Star rating system, which has many pluses—and appropriately offers rewards for preventive care—but could do more in the area of risk adjustment. “Some populations are harder to serve than others,” he said.
Although the authors stop short of saying so, their advice to find opportunities for meaningful, incremental change may be well-suited for Biden, who spent 36 years doing that in the US Senate. The coronavirus disease 2019 pandemic demands a “go big” response, and Biden’s $1.9 trillion package in moving through Congress to address it, but other steps to undo Trump’s changes at Medicaid or move the ACA forward may be less dramatic.
“Reforms will need to occur under increasingly strained federal and state budgets. Achieving meaningful change in this environment will require significant resolve from policy makers and public support for difficult decisions,” they write.