Understanding Stability, Agility, and Distribution of Our Healthcare

When we talk about healthcare in the United States we tend to focus on insurance status and the cost of services. These are natural focal points in a country with such high rates of uninsurance (or underinsurance) and where the cost of care seems to just keep increasing. But these are also only a small part of the total picture of our healthcare infrastructure. 

Another important component of our national conversation is the stability, agility, and distribution of our healthcare infrastructure. This includes our health care facilities, workforce, and how we utilize (or inhibit) technology and innovation to supplement gaps in the foregoing. As a result (in part) of the COVID-19 pandemic, a growing Rural Health Crisis, and growing political debate, there is renewed popular, political focus on the healthcare infrastructure in the United States. For example:

• Congress is grappling with the continuation of tele-based care following the end of the COVID-19 Public Health Emergency. (In our opinion, the COVID-19 pandemic provided abundant evidence of the effectiveness and accessibility afforded by telehealth services, so I am not sure why there is a “grapple” or grumble to have at all.)
• The Supreme Court is slated to revisit the constitutionality of state-imposed restrictions on the availability of abortions. Reversal of Roe v. Wade protections would effectively eliminate access to abortions for women within those states.
• The Centers for Medicare & Medicaid Services is facing calls to both end and continue its Direct Contracting Model in a continued dialogue on how to best pay for the quality of healthcare that we, as a country, want.
• All eyes are on North Carolina as it pilots use of its Medicaid funds to help address non-medical drivers of health in an attempt to more effectively bridge the gap between clinical and non-clinical needs of patients.

These are all necessary and important discussions for the United States to be engaging in. The purpose of this series is not so much to advocate for any one of these, or other positions as it relates to our healthcare system, but instead to facilitate the conversation. While the past few years (and many more before that) have given us cause to question the transparency and integrity of our political process, at the end of the day, we are (for now at least) a representative democracy. We do still have systems in place that can allow for the checks and balances we learned existed during third grade Social Studies. Not every country has a system in place whose operations allow challenges to the status quo, or have even contemplated that its own citizens may want to stand up and ask, “Why?” 

It may not seem like much in this moment, but it is an important starting point.
That is why, in this continuing series, I want to examine perceptions (and realities) of stability and fragility within our healthcare system, and by extension within our political system. Debates in recent times have focused on the overreach of governments in mitigating the spread of COVID-19; these are, in fact, arguments that the government is doing too much. However, if you have worked in healthcare for any period of time, you know that we have historically and systematically underserved wide swaths of those living within the United States; there is a compelling evidence that the government is doing too little. Take, as one example, the growing Rural Health Crisis and the widening disparity in access and quality of care between rural and more urban counterparts. The maldistribution of healthcare resources is a product of the state’s failure to act (in a direct, targeted and timely manner) as opposed to any one government action. The same holds true when you look at comparative inaction by the Federal Trade Commission as it relates to health system (and health insurer) consolidation, and its impact on the affordability, accessibility, and competitiveness of health services. When you start adding in non-medical factors of health (e.g., housing, food access, the environment, etc.), the list of government action (or inaction) grows exponentially. That is a central understanding we all should come to: it is not solely the action or inaction of government, but the felt and/or perceived ineffectiveness of it, that can bring about instability. To quote President Ronald Reagan’s political strategist, Lee Atwater, “perception is reality.”

The countries discussed in the course were those who had experienced a conflict or disaster which resulted in the destabilizing of their governmental infrastructure: Afghanistan, Mozambique, and Haiti, to name a few. As students, we learned about what had occurred in each country, and then spent time discussing how each country’s government had, had not, and could have used the provision of health services to help provide stability to its citizens. My takeaway: a government’s legitimacy is predicated on its ability to provide security to its citizens that is not restricted to physical security, but also, in the words of President Franklin Roosevelt, to provide an avenue for freedom from want. And that includes health security for its citizens.

The United States is, to the best of my knowledge, not in the middle of nor recovering from a domestic armed conflict or natural disaster. But, then again, aren’t we? Thirteen months ago, armed American citizens stormed the Capitol in an attempt to disrupt the peaceful transition of power. In October 2020, we learned about a plot by, you got it, armed American citizens to kidnap the sitting elected Governor of Michigan. On the natural disaster front, we are seeing an increase in the number and severity of wildfires. The American West is in a worsening decades-long drought.

Today there is an unremitting series of emergencies that both individually and collectively are proving to take a toll on our systems. The fact that we are deeply divided among party lines is of no support, as each dominant policy party has a fundamentally different view on how to best address (or not) the challenges (real or perceived) facing our country. Our federalist system of government, which is, by design, heavily weighted against legislative action is ill-equipped, in a period of high partisanship, to navigate this challenge.

HEALTH AS ONE OF THE SOLUTIONS

These are all big problems. Big problems require collaboration, cross-sector partnerships, and a willingness to admit error and start again. But big problems also require us to understand our role in them. We cannot go about asking for help if we do not yet have a foundational grasp on what is at play, and how we impact them.

So that is where I’d like to go with you this year: How does health play into these big problems, and what can we do about them?

Do I think health solves all of the problems? No. But I do think health has a role. The plot to kidnap Governor Whitmer was born, at least partially, out of a frustration with COVID-19 mitigation efforts Michigan put in place to reduce the spread of a highly infectious virus, and to preserve health services for those in dire need of them. The impacts of climate change, be it smoky air or less access to fresh water, will have drastic impacts on how we can provide care for our patients.

If the last few years has asked anything of us, it has asked us all to look at our roles in the bigger picture. This includes questioning how well the structure and systems we have put in place are serving us, as citizens. Are we quietly complacent because the event does not directly impact us individually? How are we holding ourselves, and our elected official accountable? For those of us in healthcare, I think it is sometimes hard to consider how what we do plays into these big problems. But I think it is imperative that we begin to grasp that understanding.

WHAT’S TO COME

This article includes some potentially worrisome words: illegitimacy, fragility, unstable. While use of these words are intended to pique your interest, and perhaps speak to the part of you that doomscrolls current events every so often, it is not intended to ring every alarm (at least not yet).

According to the Fund For Peace, the United States is considered a Stable state. (And has been since at least 2006.) So we should take this opportunity to really consider the factors that promote or move us away from our current state of stability. One thing that I hope you take from this is that stability is not something that we can just take for granted. Our current ability to weather challenges is in part reliant upon the institutions we have built over generations, and the trust that remains in them and in ourselves as a collective community. We have all, to varying degrees, experienced an erosion of trust in recent years. It is long and hard work to build that back. This is the next stop along our journey together: Looking at those factors we in healthcare have some authority over, and how can we understand them not just for our patients, providers, and communities, but also for how we function as a government overall. (Hint: If you want to read ahead, start with the FFP’s Public Services webpage.)