What Are the 10 Top Challenges for Health Policy?

A new journal is being launched, Health Affairs Scholar, described at the website as “a new fully open access, peer-reviewed journal dedicated to global health policy and emerging health services research.” I wish them success!

For non-researchers like me, one interesting part of the journal is the “Commentary” section. At the start of the first issue, the core members of the editorial group get the ball rolling with their essay, “Ten health policy challenges for the next 10 years,” by Kathryn A Phillips, Deborah A Marshall, Loren Adler, Jose Figueroa, Simon F Haeder, Rita Hamad, Inmaculada Hernandez, Corrina Moucheraud, and Sayeh Nikpay (July 2023) Like all such lists, this one is thought-provoking both for what it emphasizes, and for what it doesn’t. Let’s start with their list of 10 challenges: they have more to say about each challenge, with citations to the literature, in the essay.

Thinking beyond the insurance card: How do systemic barriers affect access to care and what we can do about it?

Despite reaching an all-time low uninsurance rate in 2022, a growing realization has started to set in across the United States that handing out insurance cards does not serve as the final step in the goal of increasing the health of all Americans. Indeed, enrolling individuals into health coverage is only meaningful if they can access the medical care they need, and if they can do so in a timely manner. …

New health care over-the-counter products: What will be required to meet consumer needs?

The market for over-the-counter (OTC) health products continues to expand dramatically. This increase is not only for products that have been on the market for decades, such as nutritional supplements, but also for new categories of products, such as online eye exams and prescription glasses, direct-to-consumer genetic and other types of screening tests such as those for COVID-19 infection, and online pharmacies. These trends are changing the relationship between consumers and health care in significant ways … A prime example of the advantages—and challenges—of the move to OTC health products is the recent US Food and Drug Administration (FDA) approval of the marketing of OTC hearing aids. There is a huge unmet need for affordable and accessible hearing device products as statistics show that the majority of individuals who would benefit from hearing aids do not use them …

Safety-net programs: Why do we make it so hard for families to receive social safety-net benefits?

It is increasingly recognized that social factors like poverty and housing are key determinants of health. Yet, the United States dedicates a smaller percentage of its Gross Domestic Product (GDP) to social spending on families than the average Organization for Economic Co-operation and Development (OECD) country (0.6% vs. 2.1% in 2019). … Another major understudied component of this problem is that it is challenging for economically disadvantaged families to access the benefits for which they are eligible….

Ensuring access to care for patients with limited ability to pay: What are the unintended impacts of poorly targeted support for the health care safety net?

All countries, regardless of their specific health payment approach, must consider how patients can equitably access care. Even countries with publicly funded systems have gaps in access. For example, although the United Kingdom has the world’s largest government-run and -funded health care system, a recent survey found that and one in eight adults paid for private insurance because waits were too long. These issues are particularly acute in the United States, with its complex mix of private and public insurance programs. …

Are structural inequities hampering hospitals’ ability to address social determinants of health?

Hospitals and health systems have the potential to play a significant role in addressing health inequities in the communities they serve. … Emerging evidence, however, raises substantial concern that structural inequities may hamper the ability of safety-net hospitals, which disproportionately serve low-income and racially/ethnically minoritized populations, to address their patients’ and communities’ social needs. These inequities are, in part, driven by structurally discriminant factors at the core of our current hospital financing system. Our current hospital reimbursement system effectively assigns a lower dollar amount for the care of low-income, Black, and Latino people, given their disproportionate enrollment in insurance plans like Medicaid, which reimburse hospitals less. …

With mergers of insurers and pharmacy chains and growth of online generic retailers, can community pharmacies survive?

Pharmacies play a crucial role in the provision of medications and patient-centered medication management services, as demonstrated in the COVID-19 pandemic. Pharmacy accessibility is indispensable for equity in health care access, as pharmacies can reach individuals who do not interact with other health care providers. Pharmacy access is jeopardized by the increasing trend in pharmacy closures observed in the past few years. …

The private equity “takeover” of health care: What does it mean?

Private equity investment into health care accelerated rapidly over the last decade and shows no signs of slowing down. Private equity firms now play a meaningful role across the health care industry, from hospitals and nursing homes to physician practices and dental clinics to biotechnology, medical devices, and information technology. This infusion of capital offers the potential for investments that may improve patient care and generate economies of scale, but private equity’s focus on short-term profits and efficiency also raises concerns about patient harms and higher costs. Numerous news stories have identified examples of fraudulent activity, overtreatment, aggressive billing practices, and widespread use of noncompete and nondisclosure agreements associated with private equity–owned facilities and medical groups. Also, recent empirical evidence suggests that private equity acquisitions of medical practices lead to higher prices and, perhaps more concerningly, that their acquisitions of nursing homes tend to increase mortality rates. …

The road ahead for health policies on genomic testing and precision medicine: Much accomplished but what remains to be addressed? …

[G]enomic testing and the general field of “precision medicine”—which uses information about a person’s genome and advanced computing tools for data aggregation to precisely target prevention, diagnosis, and treatment—have made great advances. Genomic testing is routinely used in a range of clinical scenarios, including cancer risk screening for BRCA1/2, noninvasive prenatal testing for fetal anomalies, and genomic sequencing of tumors to target effective treatments and to diagnose rare diseases in newborns. Yet, much more health policy research is needed, both on existing uses of genomics and those that are emerging.  …

“Nothing about us without us”: How can patient engagement contribute to meaningful health policy research?

Several global initiatives have emerged to recognize the value of patient-centered care. … Health care delivery and health policy change that does not actively engage patients is no longer acceptable. With the ongoing challenges facing health care systems, patient engagement in health policy research to inform health policy changes will become increasingly important to the delivery of effective and financially sustainable health care to an aging population with complex chronic care needs. …

Building a truly global perspective: How can researchers contribute?

Recent phenomena have made apparent the interconnectedness of our global community; what happens in one country touches us all, whether the spread of COVID-19 infection and of technologies to combat it, or crises from wars to climate change and their humanitarian consequences. … However, the public health and health policy literature has long been dominated by authors and perspectives from high-income countries: over 80% of the world’s population lives in low- and middle-income countries (LMICs), yet authors from LMICs are underrepresented in the scientific literature, particularly in meaningful authorship roles. …

I especially appreciate the concreteness of this list. It sometimes feels to me as if health policy disputes are phrased in terms of “spend more” or “spend less,” without consideration of specifics. For example, thinking about improving people’s practical and actual access to health care in ways that go beyond the starting point of health insurance coverage, like what people know about how to obtain information and care, or whether they can get to a pharmacy, seems important to me.  The issue of over-the-counter health care is in the news right now because of the FDA has for the first time approved an over-the-counter birth control pill. But there has been a dramatic rise in what’s available over-the-counter, and our aging society would benefit if hearing aids were more widely available and used.

A list like this is also an expression of encouragement to researchers. Thus, including items like genomic treatments, patient engagement, and health care provision in low- and middle-income countries are both important in themselves, and also a sign of topics that the journal presumably seeks to publish.

But with encouragement duly given, my own personal list of health policy challenges would include (at least) two items not listed here. One is the set of issues arising from online provision of health care, which exploded in size during the pandemic, now seems to be getting scaled back. Even more patients are probably getting their online health care advice from a Google search or ChatGPT or an advocacy website. The issues arising from dramatically expanded access to health care information of highly varying degrees of quality–and how players in the system from health care providers to for-profit companies to government interact with that information–are only growing in size.

The other set of issues is cost control. The list from the editors of the new journal is heavy on issues of access, systemic barriers, structural inequality, limited ability to pay, pharmacies closing down, Medicaid not paying enough, health care needs in other countries, and so on. But it’s just a fact that US health care spending is nearly one-fifth of the entire US economy. There have been studies for years suggesting that as much as 25% of US health care spending doesn’t provide any therapeutic benefit. The incentives to produce new health care technologies that cost a lot and will be covered by insurance are substantial; the incentives to develop new technologies and practices that reduce costs by a few percent each year, if you can get health care providers to adopt the, are minimal. Finding ways to hold down costs related to some of the biggest health care issues–like encouraging patients with chronic conditions to stick to their meds and diet, or addressing the opioid epidemic, or helping the elderly to age at home where possible–will require policies outside the conventional health care delivery system. If the US health care bill was a lot lower, then expanding access would be a lot easier. As it is, US health care spending is a main driver of the projections for federal budget deficits in the years ahead.

Where the list of 10 health care policy challenges mentions cost-cutting or efficiency– say, the role of private equity or health care mergers–it’s skeptical of their benefits. I’m skeptical, too. But finding some cost-cutting measures that could be broadly supported seems like a worthy policy challenge.