Health Care's Circular Journey

As I prepare to leave United Hospital Fund after 24 years, it's instructive to look back over the path that health care has taken in that time. While there have been some surprising turns, several clear trends emerged along the way.

The first of those was, of course, the expansion of health insurance coverage, marked by a number of notable initiatives—New York's creation of Child Health Plus, which I worked on with colleagues shortly before I left the Assembly, and which became the model for the national Children's Health Insurance Program that followed; Family Health Plus, Cover the Uninsured Week, Disaster Relief Medicaid, and a Blueprint for Universal Health Insurance Coverage in New York; and the State's aggressive implementation of the Affordable Care Act.

What became increasingly evident with each of those was that telling the story of who the uninsured are could build something approaching consensus on the need for covering all of us—a growing awareness and acceptance of coverage as a public good and public goal. 


That understanding informed New York's substantial commitment, as well, to its Medicaid program. Expanding to some 6 million beneficiaries today, Medicaid has become the work horse of health care, providing low-income people (including 40 percent of the state's children), the chronically ill and disabled, and those with multiple and complex conditions with the coverage they previously lacked—often because their health kept them out of the workforce. Medicaid is also the de facto payer for the bulk of nursing home residents, and its subsidies to safety-net hospitals have kept that critical provider sector afloat.

Medicaid has become an engine for reforming the way care is delivered, as well, with a host of innovative initiatives aimed at improving quality, controlling cost growth, and enhancing value. It has become, in essence, the glue that fits many of the system's moving parts together, both reflecting and advancing a number of other growing trends.

Fitting the parts together has become a major theme, as consolidation and integration reshape health care. The fragmentation marked by dozens of community hospitals—many of them in deep financial distress—has given way to a small number of major provider systems offering a continuum of primary, acute, and post-acute care. This is still very much a work in progress, but clearly a way toward financial sustainability.

Simultaneously, efforts to integrate payment mechanisms with these new coordinated systems, incentivize value and quality, and move away from traditional fee-for-service have shown New York to be a leader, willing to experiment and to deal with the challenges of how health services interact with society.

Finally, patients' functioning and their perceptions of their quality of life are increasingly being seen as critical to accurately assessing the outcomes of care. It's a relatively new focus, one in need of enhancement—in part through the kind of patient-centric work UHF is doing, like ensuring that quality measures reflect patients' priorities, supporting family caregivers with a wealth of information, and educating providers on how to better work with caregivers.


The burgeoning success of all these efforts may soon be mooted, however, for substantial numbers of Americans. Tied, as they are, to adequate health insurance coverage, these advances will become simply out of reach because of the current federal attack on the Affordable Care Act. The renewed health care debate is a fundamental rejection of the value that says everyone deserves access to ongoing care.

Coverage is not simply a humanitarian gesture, but rather the anchor for every change needed to make our health care system work optimally, because each of those elements is interconnected. That understanding is what has guided UHF's vision and decisions on strategically building program initiatives through the years. The current debate is not about the efficiency of the ACA, it's fundamentally a rejection of the value that says every New Yorker, every American, deserves coverage that guarantees real access to coordinated, ongoing care.

As a society we've come—we had come—a long way, although in fact we've done nothing more than join the rest of the industrialized world. That makes this current assault even more jarring.