The Certainty of Uncertainty

In the wake of the presidential and congressional elections, a host of questions about the short- and medium-term future have inevitably arisen, but some things remain relatively certain.

For New York, health policy will be governed by a set of at least four givens: the diversity of our population and the extensive needs that must be met, regardless of potential shifts in federal policies; a significant commitment to the Medicaid program, the anchor of care for people in need, including those who would otherwise be uninsured; an equal commitment to coordinating services for greater efficiency and effectiveness, in pursuit of payments based on value, not volume; and the intention to maintain the leadership role New York has played over the decades, in administrations of both political parties.


Simultaneously, tremendous uncertainty exists, notably on the federal relationship with the states as manifested in Medicaid budget policies—including whether current waiver arrangements will continue, and whether Congress ultimately restructures Medicaid to include a capped allocation in the form of a block grant. In both cases, the degree to which New York can continue to depend on substantial reimbursement for its comprehensive Medicaid program is by no means sure.

Medicare—critical to the financing of care for more than three million New Yorkers—is a topic of uncertainty as well. Previous discussions in Washington have offered the notion of a substantial restructuring of the program, effective perhaps five to seven years in the future, so that Medicare beneficiaries would be provided access to financial support to purchase a health plan or maintain traditional Medicare benefits but with a fixed subsidy payment. This approach, known as premium support, has been a mainstay of efforts in the House of Representatives to craft an alternative Medicare policy to reduce long-term cost growth in the program.

The Affordable Care Act will, of course, continue to come under attack. Senate rules requiring a supermajority for legislative action may be able to avert outright repeal, but there will doubtless be proposals for diminution of subsidies under the law. New York has taken extensive advantage of the ACA through its New York State of Health insurance exchange. The challenge for the State will be maintaining expanded insurance coverage should federal payments be dramatically curtailed.


In the face of these potentially significant changes, United Hospital Fund's focus on the key policy areas of health insurance and Medicaid remains steady. We may have to take several steps back—concentrating, as in decades past, on efforts to maintain expanded coverage—but both of these areas are central to our mission of building a better health care system for all New Yorkers. Work on coverage will be more critical than ever. Helping guide and support New York's efforts at value-based payment, in part through coordination of services and improvements in primary care, is also an essential element of our work.

Equally important, for both patient outcomes and health care financing, is attention to the quality dimension of care. The three pillars on which we based our recently launched Quality Institute—improving the effectiveness and efficiency of measures of quality, boosting the capacity of health care providers to promote quality improvement, and increasing patient and family engagement in and understanding of health care quality—remain legitimate, and urgent, targets for us. So too does our newest program area, attention to the health care system's role in children's long-term emotional, cognitive, and social development, through early interventions for children and families alike. Similarly, we look to continuing the gains we have made on family caregiving and on the linkages between health care and community organizations that support healthier aging.

With an enormous injection of uncertainty into the health care landscape, the election clearly poses a challenge to the current relationship between Washington and the states. But while the political winds of change will present significant budget challenges, in this new climate of leadership issuing from state governments, New York will remain very much at the center of the continuing challenge to deliver comprehensive services to all of our very diverse population.