The COVID-19 pandemic has exacerbated long-standing health disparities and shined a light on the need for greater emphasis on health equity. The Biden administration is well-positioned to improve population health through ensuring executive branch collaboration, leveraging mandatory spending, and focusing on the leading causes of death. This blog provides a federal framework for population health improvement and outlines three overarching tactics to accelerate progress.
Optimal population health requires a focus on public health, prevention, and primary care. Federal population health improvements must also take into consideration the social drivers of health, the conditions in which we live, learn, pray, and play, and the health inequities which lead to health disparities in this country.
Public Health. COVID-19 has highlighted the gross underinvestment we have made in our nation’s public health system—in spite of public health efforts leading to the majority of gains in life expectancy during the previous century. While COVID-19 supplemental packages infused significant short-term funding into the system, long-term sustainable funding for the nation’s public health infrastructure remains lacking. Efforts to fill this gap are underway in Congress, and separately the Bipartisan Policy Center’s Future of Health Care Task Force recently issued recommendations to create a permanent mandatory account to address this shortfall.
Prevention (clinical and community). Pre COVID-19, there were suboptimal and disparate uptake rates of high-value clinical preventive services, and studies have shown that Americans fell further behind in obtaining routine clinical preventive services such as cancer screenings because of the pandemic. Health care practitioners will need to prioritize helping patients catch up with necessary services. Community preventive services, such as smoke-free policies, motor vehicle injury prevention, and school-based health programs, are recommended by the Task Force on Community Preventive Services but supported by the federal government only through limited discretionary grants and have not been fully implemented at the state and local levels.
Primary Care. As emphasized in a recent National Academy of Sciences, Engineering, and Medicine report, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, primary care is one of the few medical services for which a greater supply leads to better and more equitable health outcomes. However, the U.S. spends half as much on primary care compared to other industrialized countries. Recommendations from the report for primary care payment reform, universal access to primary care, greater support of workforce programs, and the establishment of a Secretary’s Council on Primary Care are steps in the right direction.
SDOH (Social Determinants of Health). The overarching drivers of health, such as food, education, economic stability, and the built environment, must be taken into account when formulating population health initiatives. This is emphasized as a key principle of Healthy People 2030 which correctly notes that “healthy physical, social and economic environments strengthen the potential to achieve health and well-being.”
Equity. Encompassing all population health efforts, a focus on equity is critical to ensure that all Americans have the opportunity for health improvement. Tackling structural inequities will help to reverse the long-standing health disparities that we see along racial, income, and geographic lines.
With this framework in mind, the administration can catalyze and accelerate population health improvements by ensuring executive branch collaboration, leveraging mandatory spending, and focusing on the leading causes of death.
Ensure Executive Branch Collaboration. As every sector of society impacts the nation’s health, so too do all federal departments and agencies. The Affordable Care Act created the National Prevention Council, composed of 17 heads of departments, agencies, and offices, to coordinate health promotion and disease prevention activities. The council, staffed by the CDC and chaired by the surgeon general, did not receive adequate attention from the highest levels of the administration. The White House Domestic Policy Council should convene federal departments to establish a Health and Equity in All Policies Council with a mission to advance population health improvement through policy, systems, and environmental changes. In addition, the White House Office of Management and Budget should look for ways to blend and braid funding streams to further promote coordination on health issues as well as require departments to integrate a health and equity in all policies approach in budgeting and strategic planning efforts.
In addition to White House leadership, inter-departmental initiatives can catalyze actions which address the drivers of health. This is especially true with respect to nutrition and housing, as food is medicine, and housing is health. The secretary of health and human services should launch joint initiatives with the secretaries of agriculture and housing and urban development, respectively, to further collaborations between the departments. Potential HHS-USDA collaborations could include increasing nutrition research (a recent GAO study found significant lack of coordination across the executive branch), aligning administration of Medicare and Medicaid with SNAP and WIC to improve nutrition and diet-related health outcomes, and disseminating the Dietary Guidelines for Americans to ensure adoption and support implementation. Potential HHS-HUD collaborations could address expanding home and community-based services to support long-term care needs, integrating housing and behavioral health resources to provide a better platform for treatment and long-term recovery, and creating more healthy homes to reduce lead poisoning and asthma triggers. Foundational to both initiatives include expanding efforts to collect, match, and share data across federal departments to best serve vulnerable Americans.
Leverage Mandatory Dollars. While increasing discretionary dollars would certainly bolster population health initiatives, these programs only make up 10% of HHS fiscal year 2022 $1.7 trillion budget outlays. Eighty percent of the budget is represented by Medicare and Medicaid. Leveraging these mandatory dollars to support population health efforts for the over 130 million beneficiaries in these programs presents a significant opportunity.
CMS should establish an office and position of chief public health officer to leverage CMS’ full suite of regulatory, coverage, and reimbursement authorities to tackle public health challenges, including diabetes, tobacco use, HIV, opioids, hepatitis, older adult falls, and many others. This office and official would partner with other HHS agencies to ensure that CMS’ authorities and resources are fully utilized in order to improve population health. As an example, BPC’s Future of Health Care Task Force recently released recommendations to leverage Medicaid to expand coverage of non-medical services that address social needs, clinical preventive services, and community-based interventions.
A second step that should be taken is to develop a public health orientation to the Centers for Medicare and Medicaid Innovation. While improvements in process and outcome measures of quality clinical care have been a focus of most CMMI models, broader public health outcomes such as the incidence of diseases (e.g., heart disease, stroke, cancer, COPD, diabetes, drug overdoses, suicide), the prevalence of their respective risk factors (e.g., tobacco use, obesity), and other population health metrics (e.g., infant mortality, maternal mortality) have not generally been tracked. In addition, the impact of models on specifically reducing health disparities or health inequities have not been measured. These metrics should be applied to all appropriate CMMI models at the level of beneficiaries accountable to participating provider organizations. In conjunction with the National Quality Forum and other partners, CMS should ensure that public health metrics are developed, tested, endorsed, and utilized for CMMI models. In addition, CMMI should launch a specific model to incentivize a consortium of partners including health care providers, public health departments, and community-based organizations to take accountability for health outcomes for the entire Medicare population in a defined geographic region. The model would seek to improve not only the clinical care of patients, but also their actual health status (metrics outlined above).
Focus on Leading Causes of Death. While the pandemic and its long-term effects will continue to be a top priority in the months ahead, as will other public health challenges such as climate change, maternal mortality, and firearm violence, the administration should not lose sight of preventing the leading causes of death—cardiovascular disease, cancer, unintentional injuries, chronic lower respiratory diseases, stroke, and diabetes. These conditions can largely be attributed to poor nutrition, lack of physical activity, obesity, tobacco use, and other substance abuse and addiction and are also connected to emotional well-being and mental health.
Tackling obesity requires supporting local programs, policies, systems, and environmental changes that increase access to nutritious food and physical activity and help make the healthy choice, the easy choice. Past examples of evidence-based CDC initiatives include Communities Putting Prevention to Work and Community Transformation Grants. Further scaling of the Diabetes Prevention Program, including increasing uptake of the current Medicare benefit and legislation that would allow non-physician health care professionals to provide intensive behavioral counseling for Medicare beneficiaries with obesity would also be impactful. With respect to nutrition, Congress should pass the Child Nutrition Reauthorization Act to provide nutritious food to children and families and prevent childhood obesity. FDA should also build on its recent short-term guidance and finalize long-term voluntary targets for reducing sodium in commercially processed and produced food.
Tackling all forms of addiction will require a myriad of tactics. FDA should follow through on its proposal to ban menthol cigarettes, consider limits on minimally addictive levels of nicotine, and work to eliminate youth access to e-cigarettes while continuing to help adult smokers quit. CDC’s National Tobacco Control Program funding should be significantly increased to support state smoking cessation and tobacco prevention activities, and Medicaid should provide incentives for states to offer comprehensive, barrier-free smoking cessation benefits.
Fentanyl and polysubstance use continue to drive the opioid epidemic and require not just greater, but smarter funding to ensure dollars support evidenced-based prevention, treatment, and recovery programs. Long-term sustainable and flexible funding to states and localities, along with Medicaid’s role as a payor for evidence-based treatment, will be critical to build the infrastructure to address addiction and its associated stigma. The Office of National Drug Control Policy should drive improved data collection, performance measurement, and accountability to ensure that the impact of federal efforts is maximized.
Finally, it’s imperative that prevention policy activities be continuously informed by biomedical, social, and behavioral science research. The envisioned Advanced Research Projects Agency for Health has great potential in addressing a range of conditions, including cancer, mental illness, and Alzheimer’s disease. However, it’s important that this effort support the full range of prevention research spanning biology, behavior change, and policy implementation. As an example, a number of Alzheimer’s groups recently recommended that HHS set a national prevention goal and strategy to combat Alzheimer’s disease and related dementia through research into reducing risk factors.
Implementing the recommendations above will require that the Biden administration and Congress prioritize public health, primary care, and prevention. The recommendations recognize the central role of the social determinants of health and should be targeted in each case so that vulnerable populations experiencing health disparities are reached. Life expectancy in the United States had already stagnated for a decade prior to COVID-19, and now COVID-19 has further pushed us backwards. While getting through the pandemic is the current priority, we will soon have to get back to the challenge of improving the overall long-term health of the American public. These recommendations are a start to get us there.
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