Health care costs in the U.S. is a particularly important health policy issue because it is increasingly becoming unaffordable for all stakeholders. While we have a growing affordability problem, it is a manifestation that the fundamentals of our system are broken. As a nation, we annually spend over five trillion dollars on health, and yet we have the highest preventable morbidity and mortality compared to other high-income nations and rank at the bottom for health system performance. These poor rankings have several root causes: the lack of universal health coverage for all, the administrative inefficiencies and complexity of our system for both payment and delivery, the underutilization of primary care compared to specialty care, our inadequately resourced public health system, and our underinvestment in social supports that impact health.
The lack of universal health insurance coverage causes numerous access issues for those that are uninsured, but it also is a factor in the underinsured which together  cause distortions in the marketplace that facilitate high administrative costs and cost shifting that drives up the cost of care for all. Recent regulatory program changes to the Affordable Care Act, legislative actions and funding cuts have begun to send us backward. This will result in delays in care and create health inequities that will increase preventable morbidity and mortality. The underutilization of primary care is a system design problem. While we articulate the value of primary care, we do not actively facilitate it as proactively as we could by addressing payment policy, primary care physician and other provider workforce shortages and administrative burden.
The complexity of our system drives costs, facilities overutilization, and underutilization which impacts quality and the predictability of outcomes in even the best health systems. You can’t fix the cost situation in our country until you stop the health leaks from the uninsured and underinsured. The amount of time spent on who pays the bill adds to the cost of being healthy.
One example of our system’s problem and complexity is the lack of an interoperable health information highway. While we have developed robust medical record technology that facilitates payment and local facility or system health information exchange, we don’t have the national capacity to reliably send health information to the right person at the right time at the point of service. The fact that we as a nation still have large areas of our country without interconnectivity is a failure for both health and national security. For example, we still use fax machines to send material. This is emblematic of this failure and system complexity. The world’s financial systems, product sellers, ride share, and food delivery services have mastered the interconnectivity paradox to support consumers. You can get food delivered across the street, but not an EKG. Patients nor their health care providers often don’t have the information in a timely way to make data-driven decisions.
We, as a nation, have not invested as much in the social determinants of health as other high-income nations. Lower social service investment in things like education, housing, food security coupled with higher income inequality and inadequate social supports like paid sick leave and universal childcare undermine our ability to be amongst the healthiest nations.
           From a leadership perspective, we need to ensure the enormous investment we have in health becomes a best buy. First, we need to have a system with everyone in and no one out. There are models from a single payer system, Medicare for All, to an enhanced Affordable Care Act. Optimal health means we need universal coverage and ensuring access to care, including emergency care. We need to effectively control costs to include both the out-of-pocket costs to the individual consumer as well as control the costs to public and private payers. It must be comprehensive and should consider national all payer systems as seen in the state of Maryland for hospital costs, national negotiation for prescription drugs and other such global cost control models. CMS is experimenting with several of these models already. We need to eliminate Wi-Fi deserts and build a national health technology information highway to ensure interoperability and access anywhere at any time. The national highway system built in 1956 is an example of what happens when we proactively design a national resource that works for everyone with the appropriate governance rules and financing mechanism in place. We can do the same thing with our health data systems. The COVID pandemic has demonstrated that this is needed as a national, economic, and health security priority.
Our worsening workforce shortage is creating a significant barrier to achieving access to care. We have both an overall shortage of health providers, certain provider types, and a worker maldistribution problem. This will continue to worsen as baby boomer health providers retire. There are solutions to address many of these issues, but we have not focused on a way to address them holistically. A combination of more financial incentives, scope of practice adjustments and incentives to move to workforce shortage areas would be helpful. In addition, better utilization of telemedicine tools can help mitigate, but not solve the problem.
The next generation public health system must address public health across the nation. Where prevention, wellness, and health promotion are a way of life. That would require our governmental public health system to be well-funded and structured, to address domestic and global threats. The ability to manage large and complex data systems is a centerpiece of a modernized public health system. Having a sound data system allows us to make more informed data-driven decisions, put on an individual basis and a population basis. Finally, there needs to be continued investment in research and innovation that leads to better health across the globe.
Building a health system that achieves optimal health for all is the leadership challenge of our day. We can either work through that challenge or keep falling short.