2018 and Beyond

For those of us working in health policy, 2017 was a remarkable year. Not since 2009-10 has the general public been so interested in debates on how to improve the performance of the U.S. health care system. For me, not a dinner party went by without somebody sincerely asking about the details of particular health care issues—from the Obamacare repeal-and-replace effort to more arcane topics like the executive order on association health plans or the details of CSR funding, to the almost inexplicable, like why Washington can't agree on a long-term funding plan for the popular Children's Health Insurance Program. And now, of course, there's the Tax Cuts and Jobs Act—bringing a double strike on our current health system, with its repeal of the penalty for ignoring Obamacare's individual mandate and its increase of the federal deficit, setting the stage for future cuts in Medicare and Medicaid. And that's just what's happening on the national scene.

At the state level, in addition to what's flowing down from Washington, we're experiencing ever-increasing cost pressures on our health care system, with our safety net particularly at risk. A pending state budget crisis, coupled with potential federal cuts to health programs, means we need to continue to do more with less. In response, well-intentioned efforts to transform our delivery system are not, and arguably cannot be, happening quickly enough.

Still, health care does continue to evolve at a rapid pace, with several major trends affecting health system performance. We need to not only be aware of these trends, but also account for and, when possible, take advantage of them. Along with the federal and state policy environment, here are five issues that especially merit our attention:

1. Changing demographics, particularly the aging of the population. This is a national trend, but locally there are already over one million people over age 65 in New York City, with those numbers growing by a projected 40 percent from 2010 to 2040. By 2030, the number of older adults will exceed the number of school children. This is largely a success story of modern medicine and public health, but both our health care and long-term care systems are unprepared for the impact of this explosive growth of older, likely sicker patients.

2. Accelerating advances in genomics, immunotherapy, and precision/personalized medicine. For many years there have been targeted cancer treatments for groups of patients with certain gene mutations, but the science is now progressing quickly toward truly individualized treatment. Last summer, for instance, the FDA approved the first adoptive cell transfer immunotherapy approach: chimeric antigen receptor T-cell treatment. CAR-T cell therapy, as it is known, engineers a patient's own T-cells to treat specific cancers. This is an enormous step forward, but it also poses challenges, not least economically. The pharmaceutical company initially set the cost for this treatment at $475,000—and that does not include related care such as hospitalization, which will easily push the total to over $1 million.

3. Continued progress in health information technology. On the provider side, the first wave of technology adoption happened over the past decade, with rapid and widespread take-up of electronic health records by hospitals and physicians. That only scratches the surface, though, in terms of reaping potential benefits. Although interoperability and user friendliness remain barriers, advances in patient management tools, telemedicine, use of big data, and artificial intelligence may have a profound impact on patient care—including where it is delivered (“care anywhere”). Simultaneous with the increasing technological sophistication within the health care system, there has been equally rapid growth in consumer-oriented health technologies, with thousands of health care apps and widespread use of wearable technologies like Fitbit®. In addition to helping consumers manage their own health care, wellness, and fitness, technology and data companies are providing information and resources in hopes of supporting the growing consumerism in health care.

4. Ongoing reorganization of health care markets. Consolidation of both health care providers and payers continues. In the New York City metropolitan area, this has been especially dramatic, with primarily five dominant systems—Montefiore, Mount Sinai, NewYork-Presbyterian, Northwell, and NYU Langone—remaining, along with the public system, NYC Health + Hospitals. On the payer side, one of the largest nonprofit health insurers in New York State, Fidelis, is in the process of being sold to a national managed care company, Centene. And new types of alliances are being formed that have the potential to disrupt the market, such as the proposed acquisition of Aetna by CVS Health, and the partnership between Walgreens and NewYork-Presbyterian.

5. Potential slowing of the march toward value-based payment. Although the cost pressures that have fueled this change in how we pay for care remain, the pace of change is slower than most people anticipated several years ago. Both providers and payers have taken longer than expected to prepare for it, and signals from the current administration have indicated less federal enthusiasm, or at least more caution, for bundled value-based payments. Yet despite the slowdown in adopting VBP, there appears to be continued interest in population health. Health systems, particularly those serving disadvantaged populations, are increasingly looking beyond the walls of the clinical care system for new approaches and partnerships to keep people healthy.

These five trends can potentially alleviate, or aggravate, the long-term challenges facing health care: a sizeable population still without insurance or underinsured; uneven access to care; high and rising costs; wide variations in quality; persistent disparities in health outcomes. Changing demographics and advances in medicine will likely put upward pressure on costs, while technology and reorganization may make the system more efficient—although one can imagine the opposite as well. The expansion of health information technology can increase disparities, if new tools are available only to the few, or decrease them, if those tools are used systematically to improve quality and deploy resources to underserved areas. And, of course, all of these trends will interact heavily with federal and state health policy changes, as well as changing patterns of disease burden, most notably the current opioid crisis. How we collectively respond to and manage these challenges will define how our health care system performs as a whole moving forward.

In the midst of this uncertainty and flux, it helps to be reminded of our ultimate aim: quality health care and better health for all New Yorkers. For UHF this means universal, affordable, comprehensive insurance coverage and access to services for all; a health care system that delivers consistently high-quality and efficient care, with particular attention paid to vulnerable populations and reducing disparities; and, in recognition that health is the product of much more than the health care system, effective partnerships between health care and the community and other sectors. These three goals are the cornerstones of UHF's program and policy activities. We look forward to working with all of you to achieve them, to build a more effective health care system for all New Yorkers.