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JAMA Forum
April 23, 2020

After COVID-19—Thinking Differently About Running the Health Care System

Author Affiliations
  • 1Brookings Institution, Washington, DC
JAMA Health Forum. 2020;1(4):e200478. doi:10.1001/jamahealthforum.2020.0478

Wars and other national crises force society to act differently for awhile. But in doing so, they highlight organizational actions and innovations that should not end with the crisis and should be allowed to play a greater role in the future. The coronavirus disease 2019 (COVID-19) pandemic has similar features, and it should spur policy makers who shape the US health care system, to—as Apple Computer cofounder Steve Jobs often urged—“think different.”

The US response to the COVID-19 pandemic highlights several strategies that should be emphasized more in the management of the health care system. These strategies include using waivers to boost federalism, reconsidering the role of hospitals and other institutions as hubs for care, expanding the use of telehealth, and bringing together funds from multiple programs to improve the delivery of health care and health-related services.

Using Waivers to Boost Federalism

Although frustrations about the failure of federal leadership often get highlighted, the real story is that states have been the key drivers of action and adaptation. The federal government has tools to help the states. For example, federal waivers are a particularly helpful policy that gives states partial exemptions from federal rules.

Section 1135 waivers, which are available whenever the president declares a national disaster or emergency, together with new state Medicaid options under the recently enacted Families First Coronavirus Response Act and existing Section 1115 Medicaid waivers, are helping states to move forward quickly on a number of fronts, such as opening new care access points, expanding eligibility rules for care, and waiving cost sharing for certain populations. The Trump administration has been acting swiftly on these waiver requests.

The section 1115 Medicaid waivers, together with the section 1332 waivers enacted under the Affordable Care Act, allow states to continuously adapt the health care system and experiment with new approaches for improving health, such as coordinating medical care with specialized social services. State-led experimentation can also be an antidote to polarization by resolving policy disputes with testing. After the COVID-19 pandemic, greater use of the existing waiver process should occur, and Congress should explore more opportunities to provide the statutory authority for program waivers.

Rethinking the Role of Hospitals and Other Institutions as Hubs

The enormous pressure on hospitals because of the COVID-19 pandemic should bring about a reexamination as to whether these institutions should be the first resort when people are sick. Urban Institute scholar Howard Gleckman points out that reconsidering the best settings for different patients could mean that with appropriate infection control practices, thousands of skilled nursing homes and inpatient rehabilitation facilities could be available for patients with COVID-19 and for other patients currently being sent to hospitals.

This observation raises the broader issue of where people in the US should get their care, as well as the future role of hospitals as hubs for care. Urgent care centers and walk-in clinics at pharmacy chains, and even Costco, are certainly changing patterns of care. But when considering integrating clinical care with social services, housing, and other nonclinical services—addressing so-called social determinants of health—there is a need to recognize that a variety of institutions may sometimes be better locations for care. Schools and public housing are particularly good examples. It is also time to consider some hospitals as possible hubs for a wider range of services related to wellness, rather than providing only clinical services. Many managed care organizations and community clinic systems are already diversifying in this way, with some even providing education and employment training through partnerships.

Expanding Telehealth

It is no surprise that telehealth has been surging during the last few weeks, and many health plans are incorporating it in a variety of ways. Some systems, such as Kaiser Permanente, have been using telehealth routinely for years, and employers—especially larger employers—have been adding it to coverage at a rapid clip, using it to increase worker convenience and to cut costs. Telehealth has also in recent years gradually come into use in obstetrics care, typically in rural areas but also in some urban areas where some pregnant women, such as certain immigrants, may be less inclined or able to visit medical facilities.

The response to the COVID-19 pandemic seems likely to trigger a sustained demand for telehealth. It has been on the brink of much greater use and acceptance for some time, but broader use of telehealth has been held back by payment systems and regulations that were designed for an era when telemedicine was seen mainly as just a second-best alternative in rural areas. Medicare took an important step this March to reduce the payment obstacle by covering telehealth in many more settings, at least temporarily. But such steps need to be made permanent; public and private insurers need to make sure this important medical tool can flourish after the pandemic is over.

Braiding and Blending of Public Funds

Public sector budgets at all levels of government are siloed. Programs and departments have their own rules and procedures; data systems are often incompatible in frustrating ways, making cooperation difficult; and cross-department planning is rare. The intensity of the COVID-19 pandemic, however, is forcing jurisdictions all across the country to find ways to be nimble so that multiple agencies can work together. Governors, county executives, and mayors are removing bureaucratic barriers and making sure funds are transferred and coordinated. The federal government has been helping with guidance on how to use federal programs like Medicaid more flexibly.

The government should not go back to bureaucratic normal after the COVID-19 pandemic is over. Dealing with the nation’s health-related problems, from the opioid crisis to homelessness to the challenges of aging, require budgeting to be flexible and agencies to collaborate. Governments at all levels need to learn from the COVID-19 pandemic that a critical key to effectiveness is to introduce steps to permit more “braiding and blending” of public funds. Braiding means bringing together funds from multiple programs, with funds from each program tracked by that program’s manager. Blending, which is much less common, means mixing funds from multiple programs and managing those resources as one pot of money.

The Brookings Institution has just published a guide on existing approaches the government can use to expand budget flexibility in this way and on the need to expand these approaches in the future. Many of the examples and steps described would improve the delivery of health care and health-related services. Governments at all levels, for instance, can create special intermediary bodies to cut through red tape and foster joint planning. Children’s Cabinets at the state level are a very successful example, as are Maryland’s county-level local management boards. Uncertainty is often an obstacle, with states and localities unsure of the legality of intermingling federal funds. The federal government can address that problem by issuing prominent guidance. Payment systems for Medicare, Medicaid, and other programs need to allow greater leeway for funding the social determinants of health. And as Congress considers additional fiscal relief for states, through Medicaid and other programs, it can encourage more braiding and blending of public funds.

The urgent steps that have been taken to make the health care system more flexible and innovative during the COVID-19 pandemic should not be forgotten once the crisis is over. Many of these steps need to be become central features of the health care system.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Stuart M. Butler, PhD, Brookings Institution, 1775 Massachusetts Ave NW, Washington, DC 20036 (smbutler@brookings.edu).

Conflict of Interest Disclosures: None reported.

5 Comments for this article
Paradigm Paralysis
Paul Nelson, M.S., M.D. | Family Health Care, P.C. ,Retired
Any strategy to achieve a paradigm shift for our nation's population health and its healthcare will likely encounter deeply entrenched traditions which will require as yet undiscovered levels of knowledge, resources, and human dignity to change (the ACA 2010 attempt to improve financial accessibility to healthcare for all citizens, eg). And yet, healthcare continues to be the number one cause of individual bankruptcy.

Our nation's total annual health spending has continued to increase faster than economic growth. The portion of our nation's GDP devoted to health spending was 5.0% in 1960. For 2019, it
was 18.0%. The current strategy to "fine-tune" our nation's healthcare reimbursement systems demonstrates absolutely no progress for persistently reducing its annual increase. Remember that the other OECD nations devote less than 13.0% of their economies to health spending. The difference between 18% and 13% of our GDP in 2019 was $1.008 trillion. This excess would represent the cost of fighting 10 Afghanistan/Iraqi wars simultaneously in 2005. In sum, we really have no reliably understandable plan to solve our nation's excess health spending other than coercive, autocratic, and centralized rationing. (Altarum 2020)

As for population health, we have no carefully conceived and broadly supported understanding for the annual worsening of the following list of health problems: maternal mortality, childhood maltreatment, childhood obesity, adolescent homicide/suicide, substance abuse/suicide, homelessness, mass shootings, mid-life depression/disability, and senile dementia. Since it affects 50% of our nation's citizens, everyone should understand that maternal mortality has worsened annually for 50 years. As compared to the other OECD nation's with the lowest maternal mortality incidence, we would need to reduce ours by 70% to rank among the 10 OECD nations with the lowest maternal mortality. Using birth rates of 4 million live-births annually, this means that nearly 700 women die in the United States annually with a pregnancy solely because they lived in the wrong nation at the time of conception.

The social adversities that linger unattended in most communities have evolved over many years. There is no current strategy to systematically invigorate the levels of social capital and social cohesion within every community, state by state as the best strategies for their prevention. And there is no associated process to identify and foster the local search for the collaborative mobilization of local assets to prevent, mitigate, and ameliorate the current deficiencies in the local safety net to improve the social mobility disparities and reduce social isolation. This local mobilization should be responsible for assuring that primary healthcare is equitably available to each resident person, a community Master Disaster Mitigation Plan is annually upgraded, and discontinuities within safety net resources are recognized and a collaborative-solution process organized.

Altarum Center For Value In Health Care. 2020. HEALTH SECTOR ECONOMIC INDICATORS-March 13,2020 Health Spending https://altarum.org/sites/default/files/uploaded-publication-files/SHSS-Spending-Brief_March_2020.pdf
Healthcare Insurers are Missing in Action During Covid
Michael Young |
What would we have done about Covid if the federal and state governments didn’t lead? It would have been a total disaster. Instead we are now thinking how to fix things. What about the role of the insurers? Most are hiding out hoping their lack of participation isn’t noticed. Can anyone tell me why profits in providing healthcare insurance are justified? What is the role of insurers - enforcing PAs, denying coverage- what about PPE provisions focus instead of insurers creating more coding?

My goodness isn’t it obvious they there is no role for private insurers in medicine? If
not now when will we fix this?
Thinking Differently Need Not Be Complicated
George Bohmfalk, MD, DABNS | Health Care Justice North Carolina, the Charlotte NC chapter of PNHP
Why braid and blend? Why create special intermediary bodies to cut through red tape and foster joint planning? One giant step to Medicare for All would get us there. Hospitals would immediately reduce their expenses by around 25% by eliminating their leviathan billing and insurance departments. Assured of regular payments through global budgeting, they would not fear the bankruptcy and closure that threaten so many in the pandemic. We would not be scrambling around to determine who might pay for what. Monetary and equipment resources could be efficiently redistributed where needed most during challenges like this. We would begin to address health social inequities. We would finally control healthcare costs. Very simply, the Health Care System after Covid-19 should be run as an expanded and improved Medicare, for all.
MCRA Smoother and More Effective than Medicare For All
John R. Dykers, Jr., MD | Chatham Hospital, Siler City,NC, USA
The Medical Care Restoration Act (MCRA) is both voluntary and universal, returns the non-monetary rewards to the practice of medicine and surgery and largely eliminates defensive medicine, thus lowering costs. It focuses the economic power on the doctor-patient relationship and uses government to prevent fraud and exploitation of taxpayers. Patient care and learning are improved. Bureaucratic cost and inflexibility are minimized. The 3 legged stool of Medical Staff, Hospital Board, and Administrator are put back into balance. It is time to stop bleeding patients. We physician will have to earn our keep but we can regain our honor, professionalism, and affection of those we care for.
It's Time for Meaningful Healthcare Reform
Lawrence Danto, MD |
The crisis of World War II brought government-sponsored systems of national health care to Europe and the Far East but left the United States, not under direct attack, with an overly expensive, inefficient, private, employment-based health system. Sadly now we are under direct attack; but hopefully this terrible pandemic leaves us with the will for much needed healthcare reform focused on essential patient care.