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August 3, 2020

Reforming Health Care Reform

Author Affiliations
  • 1Duke-Margolis Center for Health Policy, Durham, North Carolina
  • 2Department of Population Health Science, Duke University School of Medicine, Durham, North Carolina
  • 3NoviSci, Inc, Durham, North Carolina
JAMA Health Forum. 2020;1(8):e200928. doi:10.1001/jamahealthforum.2020.0928

This campaign season, candidates for Congress and the White House will offer a range of proposals to reform the US health care system.

Some will argue for positioning Medicare as a central vehicle for insurance coverage, severing the linkage between employment and insurance. Others will argue for building incrementally on the Affordable Care Act, including the creation of a public option to compete with other insurance offerings. A final group of candidates will propose deregulating insurance requirements and transferring funding and discretion to states, such as through Medicaid block grants.

However divergent these approaches may be, this narrow framing of health care reform risks inadequately addressing key drivers of health and financial sustainability. This year, we need a more robust conversation about reform. In addition to addressing important, known problems within health care itself, a larger scope of reform should offer a more strategic framework for addressing the health of communities as well as the individuals who live in them.

Problems With Framing Health Care Reform Too Narrowly

Much of US health care spending is related to the expensive neglect of public health, primary care, and behavioral health, particularly among marginalized populations with complex needs. We need new proposals and models to address these defects, especially given the enormous strains these components of the health care system face amid the COVID-19 pandemic.

However, the usual technocratic tools of health policy (eg, eligibility criteria, benefit design, payment policy) can only accommodate narrow theories of change. Reforms in such areas, however important, cannot address why people earn insufficient wages and thus why assistance from safety-net programs like Medicaid is needed. They cannot address why some people become addicted to opioids or otherwise become vulnerable to “deaths of despair.” They cannot fully address why Black women experience worse pregnancy outcomes than White women, why some patients do not exercise or take their medications as directed, and why so many older adults live their last years in loneliness.

The leading health care reform approaches also tend to assume that the individual is the dispositive unit of analysis. But a person who lives in a community with rampant drug use and crime, limited job prospects, unsafe schools, and a declining tax base cannot be viewed as healthy even if she receives appropriate preventive screenings and manages to avoid emergency department visits. A person cannot be counted as healthy if the community in which she lives is not healthy.

Our definition of health—ie, the object of health care reform—should incorporate the health of local communities as well as that of their members. Kentucky farmer and writer Wendell Berry takes it even further: “I believe that the community—in the fullest sense a place and all its creatures—is the smallest unit of health and that to speak of the health of an isolated individual is a contradiction in terms.” Unfortunately, many of our communities are quite unhealthy.

What Might a Broader Framing of Reform Look Like?

First, within the health care industry, we need feasible ways to emphasize priorities such as public health, primary care, and behavioral health. This might include directly increasing funding or promoting organizational models that have this effect. But the larger challenge is finding practical ways to shift money away from expensive hospitals and specialty care even while respecting the important contributions they make and the challenges they face during the current pandemic. As Berwick recently noted, this shift will not be politically easy even if it’s clear that money is available within the system. Do candidates’ proposals for health care reform have the creativity and will to repurpose America’s existing health care spending?

Second, the scope of health care reform should expand beyond health services and even beyond traditional public health to incorporate other domains that characterize the health of a community. An expansive view of reform should give more strategic attention to domains such as education and learning, economic vitality, social trust, personal safety, family dynamics, and transportation networks. Health reformers should ask how our communities are faring along these dimensions, and why. Then they should offer concrete strategies to improve the potential for communities to flourish.

Although programs and pilots to address social determinants can be helpful, they are often implemented in an ad hoc and time-limited manner by health plan or health system executives. Health reformers should explore how to integrate such programs into a more strategic community framework.

Finally, improving the health of individuals and communities requires cultivating and activating leadership and systems of accountable governance at a community level. Health policy cannot be waged exclusively in state capitals or Washington, DC. We need fresh ideas and imagination combining the scale of policy and resources at the national level with the more active engagement and accountability of local leaders, including—and perhaps especially—those outside the traditional health care system.

Could the experience of health conversion foundations—formed when a nonprofit hospital, health care system, or health plan is acquired by a for-profit company—inform one approach for governing local resources for community health? These foundations won’t always be successful, but assuming significant resources, defined catchment areas, indefinite time horizons, and strong governance motivated around a specific mission, they can place big bets and measure results.

Why must such structures arise in some communities only as an arbitrary consequence of corporate mergers and acquisitions? Alongside large-scale national reform efforts, what would it take to ensure that more communities have well-resourced, well-governed, community-driven efforts to oversee long-term investments in health?

This campaign season, we need thoughtful action and meaningful change to improve and sustain the health of communities and the people who live in them. Many reforms are needed within the health care system itself. To have the biggest possible effect, though, voters should insist that our leaders find new ways to join traditional health policy approaches at a national level with a new paradigm that is expansive in scope but local in focus, looking through a holistic lens at the health of communities as a whole.

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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: Aaron McKethan, PhD, 1038 Rhodes Gap Trail, Durham, NC 27705 (aaron.mckethan@duke.edu).

Conflict of Interest Disclosures: In addition to his roles at Duke University, Aaron McKethan is cofounder and CEO of a data sciences company, NoviSci, Inc.

Acknowledgments: The author wishes to acknowledge and thank Hilary Campbell, PharmD, JD, for her assistance with this manuscript.

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