Main menu


Reopening the United States: Creating a more equitable healthcare system

Parts of the U.S. healthcare system have taken a heavy financial hit during the COVID-19 crisis, including hospitals that have had to cancel lucrative elective surgeries and cash-strapped clinics that have suspended employees as Routine visits that are compensated are exhausted while uncompensated care has increased. But healthcare is not the same as retail or the hotel industry. Total healthcare industry revenue this year is likely to rise at least modestly, accounting for significantly more than GDP. In terms of total income and employment, it should be relatively easy to get back to normal. In the current situation, the real challenge is to ensure that the health system does not return to normal.

COVID-19 has clearly shown that our healthcare system is riddled with literally inequality that kills people in recent months. It revealed the fact that chronic disease and poor health closely track race, zip code, low-wage service sector employment, poor housing conditions, and other social determinants of health. As we rebuild, we must focus on creating a new normal and building a more equitable public health.

Integrated services

Reforming all the factors that contribute to health inequality is a staggering and politically cumbersome task given the economic conditions and the projected budget. But the COVID-19 experience confirmed several ways in which we can begin to restore balance in the healthcare system. The core of the rebalancing strategy should be to improve the health of the most vulnerable families by integrating medical services with non-medical services, such as housing, social services, and long-term care support. Public policies should be designed to expand service delivery opportunities outside of health facilities, including schools and housing projects that serve as centers. The combination of these services is common in many developed countries. The United States will overtake OECD countries in spending more on health services than social services, and will have poor overall health outcomes.

California's Complete Personal Care Program (WPC) is an example of what should be viewed more broadly as part of rebalancing the healthcare system as the economy reopens. The WPC currently consists of 25 pilot programs that combine county medical and social needs for the most vulnerable Medicaid recipients, utilizing multidisciplinary staff, interagency partnerships, and improved data sharing. Hundreds of organizations across the country, known as the district agencies on aging, are taking a similar approach to older people.

Credible evaluation research to guide the National Strategy for Integrated Services is improving, but 23 remains insufficient. Therefore, including more and better assessments will be important as we are reshaping the health system of the post-COVID-19 economy.

Communications expansion

With the need to avoid risky medical confrontations, the COVID-19 pandemic is unleashing a storm of massive boom in the use of telehealth services. Recent changes to federal rules have made out-of-office consultation much easier. Among other things, patients and doctors can use more popular platforms, such as Skype and iMessage. In addition, the government issued a temporary exemption allowing the use of telehealth services across state lines if the state agrees, and Medicare adjusted its payment schedule to make telemedicine more attractive for doctors to use visits. virtual. Special plans follow suit.

These emergency changes should not be reversed when the crisis subsides. The expansion of telehealth services underscores the fact that many medical meetings can take place outside of expensive hospitals. This has been particularly important in improving the availability and quality of services for people and places that have long been chronically underserved. Hourly workers facing long trips to the doctor's office now have an alternative. Obstetricians and nurses can perform routine iPhone exams with women who can't stop working, and dermatologists can quickly identify skin conditions that require an in-person visit.

As doctors and patients become more familiar with procedures and technology improves, telehealth can become a powerful way to provide better health care, especially for the many people who today suffer from a systematic lack of services.

It is true that the expansion of telehealth services raises some concerns, such as the possibility of such fraud and the possibility of poor services. But as doctors and patients become more familiar with procedures and technology improves, telehealth can become a powerful way to provide better health care, especially for the many who today suffer from a systematic lack of services. The time has come to reform the organization and push telehealth to make this possible. Going back to the pre-crisis structure would be a big mistake.

Improve care for the elderly

Generally, a wide range of services are needed to maintain health and happiness as we age, including social services and the connections that come with a family community. Yet for many Americans, and not just those living in low-income households, the usual path leads to an unfamiliar Medicaid-funded nursing home or inadequate home care.

Successful aging requires flexibility in where and how services are delivered, and a greater focus on integrated and in-home services. There has been progress to build on. For example, rule changes for Medicare Advantage plans in 2018 allowed plans to pay for a wide range of non-clinical services, such as non-urgent transportation, home delivery, and sometimes air conditioning. Meanwhile, some states, like Vermont, have taken steps to coordinate health and social services to allow more seniors to age at home.

About 12 million Americans receive some level of home care, and nearly a million more live in nursing homes for long periods of time. COVID-19 has revealed the extent to which nursing homes and home care are linked to a vulnerable workforce. Professional home caregivers are especially the workforce under pressure. Many jobs work, more than 30 percent of immigrants and more than half of them have no formal education after high school, and their average hourly earnings in 2018 were less than $ 12. Almost half of them live in poverty or close to it and depend on health care, housing benefits and other supports. Many work as entrepreneurs in industries that are fragmented or present in the informal economy. Not surprisingly, the combination of coronavirus risks and immigration restrictions, including the 2019 General Officer rule, makes nursing homes and home care a riskier profession and exposes caregivers and home care agencies to financial risks.

Two steps are needed if we are to redesign this part of the healthcare system in a post-COVID-19 economy. The first is to increase Medicaid and Medicare payments to improve the level of wages and skills of direct care workers, and the second is to reform the training and regulation of these workers. There are several job classifications, each of which is structured to perform specific clinical and home care services. The workforce is regulated by the Federal Ministry of Labor and individual states, and training requirements vary by state. Meanwhile, direct care workers in many states are prohibited from providing essential drug-related services, such as administering medications. The restrictions mean that agencies or private payers often have to pay for more than one professional to care for a client.

COVID-19 has caused many states to stop amending or suspending professional licensing laws for medical workers to fill in loopholes during an emergency. Going forward, there must be comprehensive reform of professional licensing by states and training for both nurses and care workers to provide greater career opportunities for home care workers. But this must be combined with better wage levels, or more skilled workers will leave home care to the hospital system to secure better wages.

Provide greater flexibility in health spending

The COVID-19 crisis forced a rapid adjustment in the health system, and both states and the federal government had to use program funds more flexibly. States acted quickly to request exemptions from the rules governing spending for Medicaid and other programs, and the federal government acted quickly on most requests.

To build a health system that reflects a greater focus on public health, equity, and integrated services, governments at all levels will need to embrace the variety of existing tools and create agencies to "pool and mix money." More exemptions are an example. The Medicaid waivers granted to North Carolina in late 2018 are a good example to consider in other states, as they have allowed it to create pilot programs for high-cost, high-risk target groups, and provide better case management than integrates clinical services with housing, food, transportation, and other services.

One concern with federal exemptions is always that they reflect the administration's agenda at the time. For a stronger, more consistent, and lasting commitment to public health, Congress should consider an enhanced version of the concessions that my Brookings Institution colleague, Henry Aaron, and I proposed in 2004, in the context of expanding coverage. One of the characteristics of our proposal was to create a bipartisan concession body or commission, with members representing the states, as well as Congress and the administration. The committee will review state applications and propose, for urgent action in Congress, packages of state legislative changes to existing programs to allow states to pursue a national goal in a variety of ways. A relevant national goal today would certainly be an integrated service approach to improve public health and be more equitable in the United States.