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Fitting Community-Centered Population Health (CCPH) Into the Existing Health Care Delivery Patchwork

The Politics of CCPH

Goldfield, Norbert MD

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Journal of Ambulatory Care Management: July/September 2020 - Volume 43 - Issue 3 - p 191-198
doi: 10.1097/JAC.0000000000000339
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Abstract

THE COVID-19 crisis has nakedly exposed the problems and huge holes in the health care system of the United States. Some European medical systems offer a contrast to the US system. Part of the reason that the United Kingdom has come together as a country is the population's faith and trust in its National Health Service (Wiseman, 2020). Yet, the United Kingdom has pursued an inconsistent response to the COVID-19 epidemic, resulting in many deaths. In contrast to the United Kingdom, Germany has a very popular universal health insurance system, together with an excellent public health infrastructure. These 2 features encouraged the forceful political leadership response that has resulted in massive testing and, thus far, many fewer deaths in Germany (Tharoor, 2020).

The immediate challenge the United States faces in this and future pandemics is clear.

In order to save lives, reduce COVID-19's burden on our healthcare system, ease strict social distancing measures, and confidently make progress toward returning to work and school, the United States must implement a robust and comprehensive system to identify all COVID-19 cases and trace all close contacts of each identified case. It is estimated that each infected person can, on average, infect 2 to 3 others. This means that if 1 person spreads the virus to 3 others, that first positive case can turn into more than 59,000 cases in 10 rounds of infections. (Watson et al., 2020)

While projections on deaths are inherently conjectural, scientists have factually determined that COVID-19 is highly transmissible. To address this hurdle, a recent report specifies:

In order to trace all contacts, safely isolate the sick, and quarantine those exposed, we estimate that our public health workforce needs to add approximately 100,000 (paid or volunteer) contact tracers to assist with this large-scale effort. This workforce could be strategically deployed to areas of greatest need and managed through state and local public health agencies that are on the front lines of COVID-19 response. To do this, we also estimate that Congress will need to appropriate approximately $3.6 billion in emergency funding to state and territorial health departments. (Watson et al., 2020)

It is unclear whether the federal executive branch will sign on to fund even 10 000 contact tracers (CTCs), let alone the needed 100 000. At the same time, as of this writing, it is clear that a states-led effort with support from foundations and universities is emerging (Sun et al., 2020). One could easily imagine a consortium that, for example, involves Northeastern states (Craig & Dennis, 2020). The critical question is whether a bipartisan group of states will work together. This will be especially important if, as seems likely, the federal executive branch remains on the sidelines. Yet, given the political polarization currently straining the country (Aytac et al., 2018; Gadarian et al., 2020), it is hard to imagine cooperation between states such as Florida and New York.

For today, we need to address the current pandemic from the point of view of both control and suppression. But such efforts could also provide insights into a post-pandemic restructuring of health care in this country. Take Massachusetts, which was the first state to pass legislation that eventually became the Affordable Care Act (Massachusetts Legislature, 2006). What happens to the hundreds of CTCs that Massachusetts is hiring to address this pandemic? This article posits that community-centered population health (CCPH), as described in the companion paper (Goldfield et al., 2020), could represent the next step in the evolution of our health system. Massachusetts (among other states) could become a laboratory of a different order, demonstrating both the challenges and opportunities that emerge from the work that is being implemented to fight this pandemic. If CCPH is to become a reality and not just another aspirational document, political considerations must be addressed and interest groups become involved. However, while interest groups will ultimately determine the fate of CCPH, the key element in the theory of change is trust in government (Fukuyama, 2020). If one or several states succeed in addressing the COVID pandemic together with an associated, at least modest, economic resurgence, the population in those states could develop the trust in state leadership necessary to finally make fundamental changes in our health care system. Such change may be a once in a lifetime or once in a century opportunity. It is certain that the numbers of uninsured will skyrocket under the double pressures of illness and unemployment and not just among the poor and young. The key question is whether this increase will lead to pent-up demand for significant change in our health system. This article argues yes if there is sufficient trust in state leaders together with mobilization of interest groups discussed in the following paragraph.

INTEREST GROUPS THAT WILL BE ENGAGED IN ANY IMPLEMENTATION OF CCPH

Major political actors will determine whether or not this country can finally evolve toward a system that truly focuses on the CCPH. They include, in alphabetical order, with questions and/or brief comments appended.

Community health centers

Federally qualified health centers and others, many of them owned by hospitals, could play an important supportive role in shaping CCPH details.

Consumer groups

Consumers Union, Families USA, and Community Catalyst, among other consumer groups, could play the critical role in implementation of initiatives such as the one that Massachusetts, Washington, and other states are currently carrying out (https://www.communitycatalyst.org). Groups in Massachusetts will likely find that if they are able to work with the CTCs, such organizations—for example, Health Care for All (HCFA)—could be pivotal in implementing CCPH (https://www.hcfama.org).

Employers

While initially employers might be opposed to CCPH, their engagement will be critical to any statewide CCPH implementation. This support is more likely to emerge if CCPH results in more productive/satisfied employees and, over time, lower health care costs. Will employers now realize that a CCPH approach offers a better outcome than the current patchwork? It is clear that employers, who largely see health insurance as a benefit requiring cost control, have been historically uninterested in the details of health system change. Might this pandemic open employers to considering alternatives, such as CCPH? Even if employers might become supportive, other interest groups in this list with a greater stake in the detailed functioning of our health care system will have to make the compelling argument.

Federal government, executive branch

This sector of the government, in this administration, will have to be dragged kicking and screaming into constructive action. The executive branch will have to be forced by Congress, if it is politically strong enough, into covering the millions of newly uninsured (Cancryn et al., 2020). So far, the executive branch has not and most likely will not exert leadership on issues such as a national shelter-in-place directive (Mahdani et al., 2020). Its post-pandemic planning will be erratic with significant implementation challenges (Sun et al., 2020). In completely missing virtually every opportunity to address the pandemic until it was too late, the executive branch has substituted not only primarily personal but also ideological grievances in its incompetent efforts to mount an effective national response (Abualeb et al., 2020; Lipton et al., 2020).

Federal government, Congress

Together with state governments, this branch of government will be key to establishing CCPH. At this time, the House of Representatives is the only body that will be willing to consider legislation that could implement CCPH in a statewide demonstration-like initiative.

Federal government, judiciary

Although it will not come up until 2021, it is key that the Supreme Court not rule against the constitutionality of the Affordable Care Act to ensure as many people as possible have access to insurance and needed health services.

Health insurers

The trade association America's Health Insurance Plans (AHIP) represents a formidable opponent and will have to be engaged, as it was for the passage of the Affordable Care Act (McDonough, 2011) and for the defeat of the Clinton health reform effort (Duncan, 1994). As proposed later, the only possibility to avoid all-out opposition is to start small, in one or a handful of states. The ideal situation is a state with one dominant private insurer, in addition, to the important typical domination of Medicaid.

AHIP also includes many managed care organizations (MCOs), both for-profit (eg, United Health Care) and nonprofit (eg, Kaiser). Logically, it is the MCOs that should be coordinating with and linking up with state departments of public health for CCPH. Although making it happen presents formidable organizational challenges, community health workers (CHWs), as discussed in the previous article in this series, should act as the glue and form the center of CCPH. In such a system, they would be the link between MCOs and departments of public health. This organizational arrangement could encourage support from both MCOs and departments of public health. The challenge again will be payment. A regulatory approach similar to what is utilized in Germany and discussed in the article by Paul Ginsburg in this issue could represent a framework for resolving the payment conundrum.

Health professionals

Physicians, nurses, and all individual practitioners have their own professional associations that constitute important and powerful interest groups. These groups could be supportive of and will want to shape the contours of CCPH, provided that payment to these professionals continues and that the implementation of CCPH does not lead to another bureaucracy. Overall payment to some categories of health professionals represents an unknown in the long term, as it is likely that the COVID-19 pandemic will lead to changes in health professional practice patterns in ways that we cannot foresee. That said, health professional associations might support CHW-centered CCPH as long as they could shape the details.

Hospital associations

Will this pandemic force a political reckoning on the part of hospital executives that hospitals are not the appropriate center for population health care? Will this pandemic encourage the hospital industry to realize that it should focus on its core business, acute hospital care? Such an approach would constitute an off-loading of the pressure on hospitals for community outreach. This would, in turn, lead to the appropriate demise of accountable care organizations (ACOs), as hospitals will not be at the center of this CCPH system. At present, our American reality is that hospitals will still want to control the flow of money (via ACOs) or be guaranteed sufficient cash flow (as teaching hospitals). If we move to CCPH, hospitals will want to control these funds that will have to flow into these community entities. Despite this historical behavior, it is possible that hospitals could be induced to support CCPH that they do not control. Payment (as discussed in the article by Paul Ginsburg in this issue) is key to hospital support.

Labor unions

CCPH represents an important organizing opportunity—for the Service Employees International Union (SEIU), among others—for the hundreds of thousands of recently unemployed individuals. Labor unions could be critical to ensuring that these critical CTCs or CHWs obtain dignified payment and benefits. Unions such as SEIU have been at the forefront of efforts to promote CHWs, with hoped-for subsequent new union members to increase their ranks. In addition, labor unions such as the National Education Association, the United Auto Workers, and the Teamsters will see CCPH as a way to maintain employment for their own members.

Mayors and/or local public health departments, together with community activists

The approach of empowering communities to build the health and social service ecosystem their residents actually need starts with elevating the voices and power of local government and community groups in a federalism of meaning, as opposed to federal and state rules rolling downhill. Local public health departments have to be far better funded and empowered. The coronavirus crisis has raised awareness of just how essential it is that local health departments cooperate with the local health care delivery and surveillance systems. While not at all certain that recognition and appropriate funding of public health will come to pass, now is the time to refund those functions, as well as others that can improve population health.

Pharmaceutical companies and device manufacturers

The politics for these interest groups, especially pharma, will be tricky, considering that Americans are looking to “Big Pharma” for COVID-19 cures. New treatments and vaccines are all good for pharmaceutical and device manufacturers. However, their primary interest is to secure maximum prices for their products. Community health, which does not further this interest, would not be of concern to them. They are likely to be formidable opponents of any serious attempt to implement CCPH, and they are very well funded.

State government

Together with Congress, this branch of government will be the key to any implementation of CCPH, at least under this federal administration. Similar to what happened in the New Deal, one could easily imagine a different relationship between the “feds” and states. But for now, states such as California, Massachusetts, New York, and Washington will likely lead the way. Before now, states have been at the forefront of many initiatives that have led to national implementation. If CCPH is to be put into effect, it will happen at a state level first, especially under this federal administration, provided that its citizens have confidence and trust, as discussed later, in how the leadership has dealt with the COVID-19 pandemic.

THE IMPORTANCE OF TRUST

While Francis Fukuyama's book predicting the future success of liberal democracy (Fukuyama, 1992) is arguably problematic at best, his book, titled Trust: The Social Virtues and the Creation of Prosperity, has had longer staying power (Fukuyama, 1995). Most recently, Fukuyama highlighted 2 countries, South Korea and Germany, where there appears to be a high level of trust in government. What does trust mean? How does it relate to CCPH?

In his book, which weaves together trust and economic theory, Fukuyama emphasizes that standard economic theory does not apply to all human behavior. According to Fukuyama:

The power of neoclassical (economic theory) rests on the fact that its model of humanity is accurate a good deal of the time: people can indeed be relied on to pursue their own selfish interests more often than they pursue some kind of common good. ...the neoclassical premise is subject to significant qualification. ...there are numerous occasions when people pursue goals other than utility. (Fukuama, 1995)

Fukuyama's conception of trust, adapted from others, “is the expectation that arises within a community of regular, honest, and cooperative behavior, based on commonly shared norms, on the part of other members of that community” (Fukuyama, 1995).

Trust is built on two foundations. First, citizens must believe that their government has the expertise, technical knowledge, capacity, and impartiality to make the best available judgments.... The second foundation is trust in the top end of the political hierarchy. (Fukuyama, 1995)

A THEORY OF CHANGE

A public health crisis is unfolding, and the richest country in the world is struggling to effectively respond. Equipment, testing, and protective clothing are all in short supply. Most tragically, urgent messages about the importance of social distancing and the need for temporary shutdowns have been muddied by politics and poor leadership (Interlandi, 2020). Could a strong public health system have averted this problem? Alas, in the United States, no such system exists.

In 2019, a consortium of public health organizations lobbied the federal government for $1 billion to help the nation's public health system modernize its data infrastructure. They were granted $50 million. In the wake of COVID-19, that sum has been increased to $500 million. (Interlandi, 2020)

Could this increase in funding be a sign that “the times they are a-changing'”? What would it take to not only rebuild our public health infrastructure but also imagine a CCPH system? State- or region-wide demonstrations, with stakeholders supported at first by foundations and over time by governmental programs, can mitigate the strength of the political forces that interest groups will inevitably marshal against such a major endeavor. The current Massachusetts effort could evolve into a statewide CCPH. Importantly, the Commonwealth Health Insurance Connector Authority (CCA), one of the 4 key organizations participating in the Massachusetts effort, could end up as a link between the structure administering the current Massachusetts system and a future CCPH. The CCA eventually developed into the health insurance exchanges that are such a critical part of the Affordable Care Act.

Politics will determine whether payment for the CCPH will consist of grafting a public health component on top of our traditional patient care system or whether a single CCPH financial and administrative entity emerges—a form of a single-payer system. The latter may possibly make its debut as a response to this pandemic. In this issue of the journal, Paul Ginsburg details the challenges confronting consideration of single payer in the United States. It is even possible that support for single payer will become so strong in the coming months that, in the words of one writer, “If You Can't Support Medicare for All by Now, Become a Republican (Nolan, 2020).” But to be successful, single payer will need to evolve and, likely, not just in name. For example, the current Massachusetts governor, who has led the development of this potentially important public health effort described in the previous article, will not support anything called single payer. Perhaps, he and other politicians would support a CCPH dominated by the state, a system that would make room for health insurers, including MCOs, under very strict rules and would have an explicit mission of improving the health of the population. Such a homegrown CCPH could bring together elements of the German health system (which allows for tightly regulated private insurers; Busse et al., 2017) and the history of public health accomplishments of, among others, Partners in Health (https://www.pih.org/). If the Massachusetts effort is successful, it is more likely that major employers in the Massachusetts-based high-tech industry and the dominant health insurer, Blue Cross Blue Shield, will be convinced to be supportive of CCPH.

The wealthy are particularly successful in blocking changes they do not like. The political scientists Martin Gilens of the University of California, Los Angeles, and Benjamin Page of Northwestern University have calculated that between 1981 and 2002, policies supported by at least 80% of affluent voters passed into law about 45% of the time while policies opposed by at least 80% of those voters passed into law just 18% of the time. Importantly, the views of poor and middle-class voters had little influence (The Editorial Board, 2020a,2020b). Despite the fact that the poor are suffering disproportionately in the COVID-19 epidemic, many in the middle class are not just suffering economically but, more to the point, also losing their health insurance. Both the middle class and the poor will have to be a key political force in any push toward CCPH. This could happen particularly if millions of newly uninsured emerge.

Above all, for CCPH legislation to pass, citizens will need to trust that governmental leadership—both public and private, but led by public leaders—has the expertise to successfully implement CCPH. As a significant majority of American citizens will never exhibit this level of trust in the Trump administration (Boot, 2020; Interlandi, 2020), for now, only the states will be able to implement CCPH. Before state leadership can win the trust of its citizens to make this happen, it must demonstrate its ability to control and suppress the pandemic and then begin at least a modest economic resurgence. With the support of senior public leadership, at least several of the interest groups described earlier should pose the question: What are states such as Massachusetts or Washington going to do with all the CTCs that they have hired and used so effectively to control and suppress this pandemic? How will we call on them with sufficient lead time before the next pandemic? In particular, citizen groups and unions will have to “connect the dots” and link CTCs not just with an essential part of a strengthened public health system but one that could evolve into CCPH as defined in the previous article as well.

CONCLUDING COMMENTS

The journalist and activist Masha Gessen wrote recently in The New Yorker that “in the Midst of the Coronavirus Crisis We Must Start Envisioning the Future Now (Gessen, 2020).” She points to the impacts of this pandemic on our entire society: on us as human beings (for those of us who survive), our economic livelihoods, and our social fabric. These in turn will affect our political system.

To quote Gessen

Our political system, frayed as it was, is under extraordinary stress. The Supreme Court has delayed cases. The Justice Department is seeking extreme powers. The Trump Administration is using the crisis as an opportunity to push through a more extreme version of its agenda. The President now lies to the nation daily not only on Twitter but also on live television, during briefings that he has turned into versions of his rallies. The election campaign is in a state of suspended animation. The borders are effectively closed. At the federal level, there is a real possibility that the coronavirus will paralyze the work of Congress, leaving the White House without check. At the local level, quarantine measures either have stopped or will stop all town councils, school boards, and community meetings. Local news media, an endangered species before the crisis, may have been dealt a final, fatal blow by the coronavirus. (Gessen, 2020)

Yes, it is true that we are polarized as a country even around the COVID-19 pandemic (Gadarian et al., 2020). While many other countries are similarly polarized, Trump and his followers have singularly exacerbated polarization. Although it is unlikely that we, as Americans, can break through the societal logjam that Trump and his immediate circle have significantly increased (at least not until the November election), the COVID-19 pandemic provides us with a unique, once in a century crisis and opportunity. Starting local, at the state level, is the American way. Trust and confidence, as described in this article, in implementation of the control and suppression of COVID-19 together with an at least modest economic resurgence could translate into support for local and/or statewide political leaders. These leaders could, in turn, work with interest groups to carry out major change in our health care system.

Politics will ultimately determine how our current patient-centered acute care–focused health care system will change. The wealthy undoubtedly will continue to have an outsize influence on any legislation promoting CCPH. Despite this fact, we will at least think about becoming better in improving our response before the next pandemic hits. The question is whether the ongoing impact of this pandemic on our economic and social fabric will force states and Congress (the executive branch will continue to be MIA or, in fact, be actively hostile) to flesh out different approaches to our next health care system. I and others have described one of these options as CCPH. This article highlights the political challenges and opportunities to this option that builds on the CTCs needed to control and suppress the COVID-19 pandemic. Will we, similar to what occurred in the aftermath of the great Depression, be able to take this unique once in a century opportunity to address the gross inequities in our health system? It is incumbent on all of us (policy makers, interest groups, and individuals) to contribute to this conversation and then act—now.

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    Keywords:

    community-centered population health; interest groups; politics; state government; trust

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