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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
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How the “Deep State” Is Ready to Improve Medicare and Medicaid

Twenty years ago, any path to improving health care in the United States began and ended with Congress. In today’s world, that no longer suffices. Thankfully, it doesn’t have to.

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Congress has stepped up to many challenges over the years. When the AIDS epidemic was its peak in 1990, Congress passed the Ryan White Comprehensive AIDS Resources Emergency Act, and US HIV deaths today are down 75%, even as the virus has continued to affect more people. Congress cut the uninsured rate among US children in the late 1990s by passing the Children’s Health Insurance Program (CHIP). In 2003, most US seniors did not have reliable access to prescription drugs and Congress remedied that with Medicare Part D.

And if we want major change to provide coverage to all, which many in the United States desperately need, Congress is still the only game in town.

But improving the US health care system requires reacting to twists and relying on Congressional action makes progress too infrequent and often too late. Back in the days of Congressional earmarks and deficit spending, it was easier for Congress to be responsive. But gridlock and partisanship mean it often takes a crisis growing big enough to affect the public’s consciousness, often after many lives are lost, for Congress to act. And in situations in which underrepresented minorities are affected, there’s often not going to be the political will. Can we expect Congress to act boldly or quickly enough to the maternal mortality crisis among African American women? 

Thankfully, for the Medicare and Medicaid programs, the paradigm has begun to change and for many improvements, the country no longer needs to wait on Congress to act. Three tools put into practice over the last several years allow clinicians, patients, states, and private-sector innovators to move quickly in collaboration with Centers for Medicare & Medicaid (CMS), which is the largest payer, customer, and regulator.

Three Tools to Accelerate Change

These 3 tools—Medicare Advantage, the Centers for Medicare and Medicaid Innovation (CMMI), and the Medicaid Waiver program—each serve to move responsively to real-time developments to build a better health care system. There are steps we can take to make these programs more permanent, more effective, and more accountable, as well as extend the thinking further to account for a new set of scientific breakthroughs that will affect our care.

Medicare Advantage is most often thought of as the private Medicare option, but it has become more than that. With 22 million beneficiaries, it offers primary care physicians and those who help seniors manage chronic conditions the opportunity to have more autonomy for a patient’s health needs and to enter value-based population health payment arrangements. Although the program has flaws, including its expense, the opportunities to manage change and innovation are powerful and often have resulted in deeper primary care relationships, as well as better outcomes and lower inpatient stays.

CMMI was created in 2009 with a perpetual $10 billion allocation for developing and funding new payment models for Medicare and Medicaid to improve patient outcomes more efficiently. Forty new approaches to patients care have already been released and the pace of the releases, including new generations of initial models, is increasing. CMMI’s role in creating payment models should be seen in the context of a broad mission to offer clinicians tools to align more closely with the medical care they believe achieves better patient outcomes.  CMMI has already begun in primary care, orthopedics, oncology, and more recently, nephrology, pushing models that promote teamwork and prevention. With the Medicare Access and CHIP Reauthorization Act legislation that passed in 2015 and 18 million Medicare beneficiaries now participating in some type of CMMI model, the country should look forward to more models and model improvements.

Like Medicare, Medicaid is seeing a renaissance of new models of care. Currently, 43 states have delivery system reform waivers that are designed to be budget neutral while improving payments to clinicians and health care delivery systems who deliver lower costs and better health outcomes. Maternal health, substance abuse and recovery, spending on programs addressing social determinants of health, and programs such as Programs of All-Inclusive Care for the Elderly (PACE) that effect people eligible for both Medicare and Medicaid are all areas for which states are innovating. North Carolina’s recent waiver that allows for coordination of clinical and nonclinical services to improve health outcomes is a great example.

To be clear, new payment models in Medicare and Medicaid won’t deliver instant results and will need patience and a lot of input to improve. But Medicare and Medicaid are best positioned to drive change across communities more rapidly by including commercially insured patients as they introduce new programs. CMMI’s primary care medical home model (CPC+) did this and, as a result, doesn’t force physicians to look differently at different patients in their practice.

Improving What We Started

Congress does have an essential role to play in providing good oversight, and the General Accountability Office should be given more formal responsibilities to enforce the guardrails of these models and prevent the current and future administrations from actions could undermine care for beneficiaries. Such actions are already occurring with Medicaid work requirements and block grant proposals. Similarly, President Trump’s recent executive order proposes changes that could potentially leave some Medicare beneficiaries with surprise medical bills from balance billing. To maintain this authority, administrations should pledge to consult actively with both parties, including in public hearings, and treat red and blue states fairly and equally when it comes to approving waivers—or see their power restricted.

Multiple parties need to be involved to turn any changes into lasting improvements. Policy changes that emerge from the use of these 3 tools should be open to more public review and require patient and clinician input. Too often, only the lobbyists get an outsized say in new Medicare rule changes or CMMI models. The best policy thinkers, innovators, and advocates should be enlisted to measure effects of these programs and make sure implications are accessible to the public. And innovators should develop better technology and data to make new models more user-friendly to implement.

Finally, these 3 tools should be extended to include a fourth. The development of scientific innovation should now be seen as a new normal and Congress should establish a new entity, the Center for New Therapy Implementation, with the authority and funding to rapidly evaluate, analyze, approve, and reimburse for innovative gene-based therapies, diagnostics, and other scientific advances. Modeled after CMMI, this entity, with resources from the National Institutes of Health, the US Food and Drug Administration, and CMS, would be tasked with bringing together the scientific, safety and efficacy, and payment expertise in one place to rapidly approve value-based payment for a new era of diagnostics, therapies, and cures.

At a time when US life expectancy is declining and health outcomes fall short of those of many other nations at too high a cost, the US health system needs the ability to adapt rapidly. Such rapid adaptability is needed to prevent the next epidemic, to respond when costs rise without benefit, to implement better evidence on approaches to care, and to address seemingly intractable public health issues—including deep inequities—while shaping a system that incorporates tomorrow’s needs.

About the author: Andy Slavitt, MBA, Founder and Board Chair of United States of Care, served as the Acting Administrator for the Centers for Medicare & Medicaid Services under President Obama from 2015 to 2017, where he focused on advances in health care coverage and accelerating health care delivery system transformation. He has 2 decades of private–sector health care leadership, both as a senior executive at Optum, a health services and innovation company, and as an entrepreneur. He tweets at @ASlavitt. (Image: US Department of Health and Human Services)
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