These are uncertain times for the future of health in the U.S. The context continues to shift with amendments to the original failed American Health Care Act (AHCA) bill under constant discussion, and swirling speculation about a vote on a new bill this week before Congress goes on recess.
It is nearly impossible to keep up with the pace of these developments and the overwhelming onslaught of articles discussing potential scenarios. For foundations focused on U.S. health, there is the additional concern of how this affects their current and future work. A number of foundations are considering changing their goals and strategies given the political climate, and many are interested in bringing a systems change approach to their work. Our FSG colleagues have also been considering what this means for foundations working on U.S. Health.
Like many observers, we are deeply concerned about what the Trump administration and Congress’s proposed changes to the Affordable Care Act (ACA) will mean for access to health care, and the quality and breadth services offered, both for individuals and at the population level. Based on what we know so far, the current administration’s eagerness to repeal key elements of the ACA means that there are several likely areas of policy change.
The first is reducing the scope of “Essential Health Benefits” that must be included in policies, resulting in fewer health care services covered than currently required by the ACA. Even though the majority of health insurance costs stem from benefits like hospitalization, physician services, and pharmaceuticals, services that were less commonly covered before the ACA, such as mental health, substance abuse, and maternity care could be under threat.
The second area of potential change involves charging higher premiums for “riskier” populations typically those who are older or have pre-existing conditions. Allowing insurers to consider health status as a factor in setting rates could mean that those rates would become so high as to effectively price these individuals out of the market, without taking the politically unpopular step of explicitly excluding them. Repealing the individual mandate of the ACA could lead to a negative spiral: resulting from rapid increases in premiums by insurers as healthy individuals drop coverage, increasing health care coverage costs for those sicker people who remain in the insured pool.
Third, policy aiming to change how the federal government finances health care at the state level is also a possibility. Shifting Medicaid funding to federal block grants to the states would result in more state control over eligibility requirements and covered services. Depending on how state governments choose to act, this flexibility could benefit population health or put it at additional risk. For example, states could choose to maintain or expand coverage of substance use disorder and mental health conditions, or they could choose to reduce or eliminate recently expanded coverage for certain income levels or types of services. One piece of good news is the growing sense that the move towards value-based payment and population health management initiated under the Affordable Care Act has enough momentum to continue, even if it’s unclear how it will be done, and to what extent it will be mandatory.
One major concern is the likelihood that the adverse effect of the changes in health care coverage being currently proposed would be concentrated among those who already suffer a disproportionate burden of poor health. The predictable result of this would be to exacerbate existing health disparities. Changes similar to those proposed under AHCA would disproportionately affect low-income communities and people of color who already face well-documented significant geographic, financial, linguistic, and other barriers to health care.
Perhaps most ominous for the health of the nation is that these changes to health care would likely be occurring along with other policy changes undermining the social determinants of health—such as housing, nutrition, and economic stability—that would substantially compound the challenges faced by at-risk communities. The cumulative risk of simultaneously diminishing health care access while also decreasing support for services that protect health—such as public and affordable housing, homelessness prevention, WIC, and school meal and other nutrition programs— sets up a perfect storm that will have predictable and devastating effects at both the individual and population level.
What could all of this mean for the work of foundations focused on health?
- Increased need for basic health care services, such as preventive care, depending on the number of people who lose coverage.
- Increased need for support for health conditions that would no longer be covered, such as chronic illnesses, reproductive health/maternity care, mental health, and substance use disorders.
- Growing importance around paying attention to health disparities and strategies targeting the needs of underserved groups.
- Increased need for taking on systems strengthening efforts, as the capacity and willingness of hospitals to focus on community health through their community benefits programs could decrease if they have to shift to cover care for uninsured individuals and face fewer incentives to work beyond their walls.
- Bolstered support of locally targeted strategies, as state-level variation in the health care landscape increases—requiring a shift in approach for national foundations, and an opportunity for local and regional foundations to highlight local needs and approaches.
Yet, there is plenty that foundations can do to avoid paralysis and continue to have deep impact in this ever-changing context:
- Accept the uncertainty and identify adaptable strategies: By building in processes that allow for quick learning, re-evaluation, and response to different scenarios and changes, foundations can increase their ability to focus their efforts where they are most needed and most effective. Staying true to big goals, but allowing strategies and activities to vary will be very important for responding to the most pressing needs.
- Maintain or increase the focus on health equity and the social determinants of health: By targeting investments and activities on the areas of highest need, and by focusing on addressing some of the underlying barriers to good health, foundations will achieve a greater return on investment and greater social impact.
- Embrace the complexity and deepen the focus on systems change: By focusing on the strength of the system surrounding a specific issue, foundations can build resilience and create lasting change. This involves looking beyond specific programs and activities and thinking about the relationships between different actors, and how they can work better together to make progress on challenges.
- Bring different actors together and build deep relationships with new actors: By building both deeper 1:1 relationships with new stakeholders (e.g., state agencies, community groups, and companies), convening different actors, and deepening community engagement, foundations can help bring about new insights on how different players can most effectively spur action and provide a counter balance to the forces promoting anxiety and apprehension in communities.
- Be willing to shape the public dialogue and ask tough questions: By shining a spotlight on specific national or local issues and asking tough questions, foundations can encourage the sharing of important information and perspectives, creating a deeper public dialogue.
Given the dizzying uncertainty surrounding health care and the social services that promote health, those of us focused on the health of our communities have much we can do. Moving forward as a community and maintaining a systems approach will be critical to our success in protecting and promoting the public’s health.