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Health Care as Essential Infrastructure


By Anne Montgomery

In the aftermath of Congress’ rejection of the “American Health Care Act” (H.R. 1628), it has become clear that the largest health care program in the country—Medicaid—is poorly understood and dramatically undervalued. The House of Representative’s budget-driven proposal to remove one out of every four dollars from this bedrock federal-state partnership program would only serve to crush invaluable health system infrastructure—detonating the ability of many hospitals, nursing facilities, home care agencies, physicians, and care workers in communities across the country to provide services to those who are already ill and disabled, and those who will someday become so. This is a primary reason that the American Medical Association stepped up to oppose the measure. Equally important, it explains why tens of thousands of people signed petitions, demanded and attended town hall meetings with their congressional representatives to express concerns, wrote letters, and more.

To slash and partially defund Medicaid at a time of rising need and in the teeth of the U.S. age wave is extremely dangerous. Removing close to $900 billion over 10 years from the program would yield widespread suffering and kill thousands of jobs in the health care sector—leaving governors, mayors, county executives and state legislators in a position of being the scapegoat. Defunding Medicaid would stall economic activity and commerce across the health care sector, causing serious harm and likely plunging some states into a recession. Defunding Medicaid would leave tens of millions of Americans without good-quality health insurance. Knowing this, state executives have raised objections and fielded alternative proposals.

In the post-AHCA period, the practicalities of health care are becoming clearer. Whether or not you believe that health care is an individual right, or an optional and highly variable product that anyone can choose to buy or not, the reality on the ground is that the health care delivery system is basic, shared infrastructure. And first-class publicly-financed infrastructure—whether highways, the military, Medicaid and Medicare, or other shared responsibilities—demands adequate, stable funding, clear accountability for spending taxpayer dollars efficiently, and incentives that maximize quality. In proposing to shatter a substantial part of the U.S. health care infrastructure, which has been built in communities across the country over many decades, H.R. 1628 represented the health care equivalent of taking out one-quarter of the interstate highway system. This is a road to nowhere: disconnected from research and evidence on how to improve the health care system, and unworkable in an increasingly long-lived society.

During the last century, the U.S. has steadily improved its medical care infrastructure, which is closely intertwined with key public health achievements, such as immunization and clean drinking water systems. The results are dramatic improvements in the health status of most citizens and an extension of average life spans by several decades. Now is the time to do good things for the economy by significantly slowing per-capita cost growth and shifting incentives to require highly coordinated services—including long-term care—for each patient living with complicated or serious illness and using multiple health care and supportive service providers. In the case of our fast-growing elderly population, this means scaling up evidence-informed protocols that are proven to bring more health care and cost-effective supportive services into the home. The U.S. faces a rapidly diminishing number of family caregivers who have historically coordinated and provided most of the needed support for elders who are living at home. A massive “care gap” will develop if we fail to provide much more meaningful support for working families, who are increasingly struggling to provide assistance for disabled and ill loved ones and for raising children, and if we decline to provide decent benefits, wages and career advancement opportunities that boost the fortunes of care workers.

Accordingly, we call on policymakers to embrace:

  • Greater flexibility in existing Medicare and Medicaid programs that enable them to support and encourage reliable, integrated delivery systems in communities across the country that can provide the sophisticated mix of medical services and long-term care that frail elders need;
  • Reinvestment of savings from Medicare and Medicaid, harvested from avoiding unnecessary high-cost care and used to bolster supportive community services that are vital to keeping frail elders out of hospitals and nursing homes
  • Reshaping of the delivery system to achieve population health goals, recognizing that this will require changes in how we organize care to incorporate elements of local control and monitoring of service quality and supply;
  • Implementation of comprehensive care plans that put patients first and connect their medical care providers, social services organizations, and family caregivers in virtual care teams – thereby going beyond the typical list of medications and diagnosed problems, and expanding to consider likely prognosis and quality-of-life goals;
  • Improved access to reliable, life-long home care and other supportive services for elders and their family caregivers; and
  • Excellent training and career advancement opportunities for care workers providing services in home settings, in assisted living facilities and in nursing homes.

The attention of the Center for Elder Care and Advanced Illness is focused on achieving these objectives, and a growing number of organizations are coalescing around similar goals. To be collectively successful, we need to present arguments and evidence about how to adapt Medicare and Medicaid on the basis of what actually works, and to translate what people say they want and need into a care system that focuses on longitudinal outcomes and individual goals. Now is the time to make continuity of services and person-centeredness our watchwords for elder care, and to move away from focusing on short-term outcomes from high-cost interventions. Should Congress and the Department of Health and Human Services turn away from these challenges and from generating evidence as to what works, the likely consequences are that the U.S. will not be able to adequately serve a fast-growing population of elders and individuals with disabilities, and the health care system overall will decline in effectiveness.

A mere 13 years from now, 20% of the population will be 65 years and older. The demographics of longevity are unstoppable, and our ingenuity and resourcefulness are being challenged on multiple fronts. We look forward to hearing your ideas and to sharing thoughts, and we urge you to contact all of your federal and state policymakers to let them know what is truly needed to meet the challenge of America’s age wave. Let’s hold them accountable!

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