While never far from the headlines for the last six years, health policy is now squarely center stage as the process to repeal and replace the Affordable Care Act (ACA) begins. At the same time, there is no shortage of other health policy issues confounding the nation, from the continued struggle to improve patient safety, to persistent and pervasive health disparities and now rising mortality rates, to drug prices and the opioid epidemic. Thus, as we move into the uncertainty that comes with every new administration and Congress, a key question is whether, and if so, how, evidence from research will inform this new era of health policy debates.
Leading health care decision-makers and policy experts will convene at the AcademyHealth National Health Policy Conference next week to discuss many of these health policy topics and the latest evidence informing them. Reflecting on the volume and variety of issues under discussion, there are at least four main areas where evidence is shaping the conversation and where evidence is needed to answer the questions policymakers are confronting. Among these are insurance coverage, the push for value, health equity, and the trends in data, innovation and consumerism.
Coverage: Will the audience for evidence change?
The January 2017 issue of Health Affairs containing more evidence of the impact of the ACA could not be more timely. As editor-in-chief Alan Weil notes, “It is more important than ever to have a solid base of evidence regarding the law’s accomplishments and shortcomings.” The articles in the issue build on prior work, including a systematic review that concluded the ACA has substantially decreased the number of uninsured individuals while pointing to persisting disparities by geography, race/ethnicity, and income. For the last three years, late breaking abstracts at the AcademyHealth Annual Research Meeting have also brought to light the latest marketplace and Medicaid enrollment data.
While answering the big “did it work?” question is important, it is not enough to inform the debate going forward. We also need evidence on the many details of coverage dynamics in order to inform the choices ahead. What have we learned about consumer behavior in purchasing coverage? How will coverage for children be affected? How much subsidy is needed to ensure coverage and access to appropriate services?
States are important laboratories for many of these questions. Under the ACA, the evidence to date shows that states that expanded Medicaid coverage reduced their uninsured rate by half overall as well as early findings that expansion led to improved access to care, self-reported health, and even a drop in mortality. Perhaps more importantly across states employing a variety of expansion approaches, findings on affordability, consumer experience, and preliminary impacts on cost, quality, and access are helping state policymakers weigh different options as they consider the particular needs of their populations and the most effective and efficient ways to address them.
Whatever the eventual shape and outcome of congressional and presidential actions on the ACA, the role of states remains important. This will become even more urgent if additional waivers are granted and Medicaid becomes a block grant as some close to the Trump administration are signaling. Various commentators point out that shifting the decisions to the states could be more easily achieved (e.g. expanding Section 1332 waivers) than certain legislative changes to the ACA and could preclude a protracted legislative debate.
While many researchers bemoan the challenges of translating research into state policy, the reality is that many states do rely heavily on evidence and analyses as well as their peers’ experiences. As one example, 22 states have established partnerships with their state university partners to support the production of evidence to inform policy. Building on such capacity, and extending it to remaining states would ensure that evidence be not only developed, but also made available in a timely way to inform state decisions.
Volume to Value: Full speed ahead!
While uncertainty abounds when contemplating coverage, the move from “volume to value” is a safer bet, as payment reform efforts continue to be a priority for accelerating health system transformation. That is not to say that this transformation is easy or the evidence clear. In fact, the sheer volume and variety of payment reform tactics and goals in any one market could be called chaotic. This complexity requires that researchers step up their evaluation approaches to ensure the most rigorous and appropriate designs to support attribution and generalizability, and do so in a timely enough manner.
Adding to this complexity, the Medicare And CHIP Reauthorization Act (MACRA), the result of bipartisan support, ushered in a new era of Medicare physician payment policy that will have ripple effects on Medicaid, the State Children’s Health Insurance Program (SCHIP), and the private sector. This is potential manna from heaven for researchers who now have the opportunity to design studies to answer key questions about the success of alternative payment models (APMs) in achieving the goals of higher quality and better outcomes, as well as shedding light on factors and choices instrumental to their implementation. The latter will help us understand not just “did MACRA work?” but more importantly, what type of APM worked, under what conditions, for which types of providers and different population sub-groups. These and other insights will be needed by those on the front lines as the law is implemented — especially in the context of a new administration, current market pressures, and provider concerns.
The value mantra extends well beyond payment models to include expanding efforts to tackle low-value care and the high prices of biopharmaceuticals. There is also a growing recognition of the potential of payment reform to support population health. Right now, most of these value-based payment models focus on clinical services and specifically on the needs and outcomes of a particular health care provider’s patients, a health plan’s enrollees, or the purchaser’s employee subscribers. However, a number of efforts are examining how financing sources can pay for population health-based services focused on the social determinants of health and the barriers to realizing lasting, meaningful change.
Health Equity: Broadening the conversation
Given the pervasive and persistent disparities in health outcomes by income and race/ethnicity, the policy conversation on health equity has appropriately focused heavily on impoverished and disinvested communities and communities of color. However, if the 2016 election showed nothing else, it revealed a strong desire for change in Washington on the part of a large number of voters. Could this desire for change be fueled—at least in part—by the very real trends in declining health status and futures of many in this country?
From the opioid crisis to gun violence, persistent health disparities or the broader findings of increases in the “diseases of despair,” it is clear that achieving equity in health will require us to address a very broad swath of needs. We must consider rural as well as urban poverty, lack of opportunity and upward social mobility, poverty for white as well as African American and Hispanic communities, and the institutional racism and systemic bias that exists within so many organizations, including health care organizations.
The evidence on disparities has grown substantially since the 2002 Institute of Medicine report, Unequal Treatment. However, a majority of this research has been on identifying and understanding disparities and far less on developing and testing policy or system interventions to overcome them. In addition, too many of the interventions that have been shown to be effective have simply not been implemented. Whether it is case studies on evidence-based policies to address public health crises such as the opioid epidemic, or detailed geographic data on Medicare disparities, or effective intervention for specific disparities, decision makers need this evidence to effectively overcome them.
Data, Innovation, and Consumerism: How fast can innovation and new opportunities from data truly transform health care?
The last several years have seen an explosion of investments in health care innovation, especially the digital health sector, to develop new and disruptive approaches to financing, organizing, and delivering care, particularly those that are consumer facing. Many of these rely on the opportunities created by the growing volume, variety, and liquidity of health-related data five years after the passage of the HITECH Act and concerted efforts in the public sector to make public data available, as well as the explosion of data analytics and data science as the new currency in health care. These data trends are redefining traditional relationships in the health care marketplace.
As we move into a time of uncertainty for markets and key stakeholders in health care, will these investments continue? Some point to the new administration and Congress together with some evidence of slower adoption by consumers and providers as factors that will have many waiting in 2017 to see just what directions health policy will take. At the same time, understanding which of the innovations will truly improve care and reduce costs and for whom is only beginning to be addressed in research studies. To answer these questions, we need to promote a more transparent data ecosystem and connect innovators and entrepreneurs to health system leaders and policymakers.
Finally, as researchers, we really are still in the infancy of a new way of thinking about and using massive streams of new information to inform our work, and there remains a need for new methods and collaborations to extract actionable insights from new and newly available data sources.
So, will evidence matter in 2017? If we want to truly transform health and health care in this country, it must. As an optimist, I believe it will. Great evidence can serve as an anchor in uncertain times and should be the North Star for policymakers charged with designing a health system that can achieve better care, smarter spending, and healthier people. However, great evidence—and the data needed to create it—take investment and are a fundamental public good, as are other types of science on the health research continuum. These must be supported by sustained and reliable funding, particularly at times of such great uncertainty.