Pushing for Improvement One Step at a Time

Health care policy has dominated the headlines for yet another year, spurred by the upcoming presidential election as well as continued uncertainty about the fate of the Affordable Care Act. The robust national debate is partly about how health care should be paid for and financed, but at its core, it’s about even more fundamental questions: whether or not health care is a basic human right, and what roles government and private industry should play in the health care system. Regardless of where you stand on these issues, the likelihood that sweeping changes will occur in the U.S. health care system in the short term—either wholesale repeal or invalidation of the Affordable Care Act from the right, or a universal, government-financed system from the left—is unlikely. However, this certainly does not mean that we who work in health care and health policy can relax.

Improving the health care system is rarely about sweeping and dramatic changes. More often than not, progress is achieved through incremental steps. For instance, at the beginning of 2019, nine years after the passage of the Affordable Care Act, the rate of those without health insurance in New York State reached its lowest level ever, around 5%—down from 12% in 2010. This significant progress was the sum of modest gains made each year and was accomplished by systematically taking advantage of the tools made available by the ACA, as well as specific protections for New Yorkers. These protections shielded our state from harmful executive orders from the federal administration, including those related to short-term health plans and association health plans.

And new threats are still emerging, such as the recent “public charge” rule, which has had a chilling effect on health insurance coverage of immigrants who are legally eligible for Medicaid or financial assistance. At United Hospital Fund, we are committed to both protecting the coverage gains we’ve made and to continued progress. To do this, we must be vigilant on two fronts: keeping an eye on ambitious national health reform legislation, while also engaging in smaller-scale legislative and administrative issues often overlooked by the public.

Incremental improvement is also a hallmark of changes in the health care delivery system. Care for any given patient is based on countless variables from the patient, provider, and the environment that all interact with each other. In this uniquely complex system, wholesale change doesn’t happen overnight. For more than a decade now, we have been on the path toward value-based payment, which was supposed to make care better, more coordinated, and focused on patients’ overall health and well-being. Even with New York’s recent $8 billion Medicaid Delivery System Reform Incentive Payment (DSRIP) program, progress has been incremental versus transformative. The lesson is not that we should give up—rather, that we should commit to continuous improvement, one step at a time, as opposed to expecting one giant leap. In order to do this, we need to support a learning health system. At United Hospital Fund, this means leveraging our Clinical Quality Fellowship Program to continue expanding a health care workforce that understands the principles and practice of quality improvement. For UHF, it also means a commitment to identifying innovations that are worthy of replicating and an ongoing engagement in the creation of new knowledge and tools, especially in emerging areas. One of these areas is the collaboration between the health care delivery system and the community to address social needs and the social determinants of health. A good example of this is our Partnerships for Early Childhood Development program, which seeks to improve the long-term health and well-being of children by figuring out how to best identify psychosocial risks among pediatric patients and to work with community partners to address those risks.

Our groundbreaking work on the opioid crisis this year reminds me of another reality of working in health and health care: the effects of any single event can be long-lasting. Our Ripple Effect report, for the first time ever, estimated the number of children affected by the opioid epidemic as well as the cumulative, lifetime costs to our society. Even if the opioid epidemic magically disappeared right now, we would be dealing with the sequelae of harmed children for decades to come. This, of course, is not unique to opioids. Any problem happening right now—whether a medical error, a failure in disease prevention, or inadequate nutrition—may well lead to bigger and more complex problems that last a lifetime.

These two general characteristics—the slow-changing nature of our health care system and the lasting impact of health-related events—both speak to the urgency of UHF’s push for improvement. I’m proud that our team understands this and works tirelessly on behalf of all New Yorkers, especially the most vulnerable. Thank you for your continued support and interest in the mission of UHF.

This commentary is featured in United Hospital Fund's 2019 Annual Report, published on February 26, 2020.