In the health policy world, the last two years were dominated by the battle over the Affordable Care Act (ACA). Otherwise known as “Obamacare,” the ACA was enacted in 2010 and, as of 2016, had successfully expanded health insurance coverage for an additional 20 million people. Despite the law’s success, the 2016 elections ushered in a new wave of attacks. Following the failure to repeal the ACA in 2017, there were multiple attempts to damage or otherwise dismantle the law—with some success. Not only was the individual mandate penalty eliminated as part of the Tax Cuts and Jobs Act of 2017, the administration also used executive actions to greatly curtail ACA outreach and education and eliminate cost-sharing reduction payments to insurers for low-income enrollees. The administration also promoted the expansion of association health plans and short-term, limited duration insurance plans, both of which have the potential to greatly destabilize the individual and small-group insurance markets. Notwithstanding a federal court judgment in Texas in late 2018 that invalidated the ACA (the ultimate outcome is still pending), the 2018 elections offered some reprieve.
With a now divided Congress, further legislative efforts to dismantle the law will likely fail. On the progressive front, the focus has changed from defending the ACA to once again expanding coverage. At the federal level, many, if not most, Democratic presidential candidates in 2020 will likely develop some version of “Medicare for All” (keep in mind that this term can mean many different things). In New York State, a single-payer bill that has passed the Assembly multiple times in recent years but stalled in the Senate now no longer faces a Republican-controlled Senate roadblock. And at the city level, the Mayor recently announced a plan to expand health care access (not necessarily insurance coverage) to all residents.
All this is to say that, over the next few years, the health policy discourse may be driven by a debate about single-payer and other means of extending coverage. Of course, at United Hospital Fund, we believe that access to essential health care services is a right, and we support universal, affordable health insurance coverage. And as we have in the past, we will continue to provide independent analysis and expertise that supports evidence-based decision-making on complex policy proposals to achieve these goals.
However, often lost in this blizzard of health news is a simple and critically important fact: insurance coverage and access are not ends in and of themselves. Ultimately, the goal of a health system should be to produce better health. And while health insurance coverage and access to care are vital to making this happen, they are not sufficient. So what more do we need to do?
It’s been almost 20 years since the 1999 Institute of Medicine report, To Err is Human, estimated that “at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented.” Yet, despite the rapid growth of quality and patient safety activities over the past two decades, wide variations in quality stubbornly persist. That’s why UHF continues our work to advance high-quality care for everyone, focusing recently on antibiotic stewardship, transitions in care, and supporting the next generation of quality leaders—among other critical issues. Of particular note over the past few years are our efforts to elevate the voices of patients and caregivers in the quality dialogue.
While quality improvement is clearly within the scope of a health care delivery system, “social determinants of health,” until recently, were not. But these social and environmental factors—employment, housing, education, food access—have an even greater influence on health than clinical care, especially among disadvantaged populations. What is the role of the health care delivery system in addressing social determinants of health? It’s a complicated question and a subject of active debate, but as we progress toward value-based payment, health systems must confront it directly. But how these systems interact with communities and community-based organizations to tackle social determinants is an extremely complex matter—in my opinion, doing so effectively is harder by several orders of magnitude than getting players within the health care system to collaborate on issues such as transitions between care settings. We are in the early days of this field, and UHF is at the forefront of generating and disseminating knowledge about clinical-community partnerships.
The federal and state health care debates over the next few years will certainly be exciting. Will we finally reach a tipping point for extending health insurance coverage and access to all? I hope so, but whether we do or not, let’s not lose sight of our ultimate goal: better health for all. Many thanks for your continued support and interest in the mission of UHF, and I look forward to working together to improve the health of all New Yorkers.
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