A divided Congress, the loss of health care champions on both sides of the political aisle, the upcoming presidential election in 2024, and a general sense that the health care system is irretrievably broken could stymie any major health policy reforms in the next 18 months.
But that doesn’t mean that some incremental change isn’t possible. That was the overarching theme of a discussion at Learn Serve Lead 2023: The AAMC Annual Meeting spearheaded by the AAMC Research and Action Institute and its executive director Atul Grover, MD, PhD.
Titled “We’re on a Highway to Health With a Broken GPS,” which Grover kicked off by playing the opening minute from AC/DC’s 1979 hit, “Highway to Hell,” – “who says academic medicine is stuffy,” Grover said to laughter from the audience – the session captured both the complexity of the problems facing academic medicine and the challenges inherent in solving any of those problems through bipartisan public policy interventions.
“Congress is so dysfunctional,” Lanhee Chen, JD, PhD, the David and Diane Steffy Fellow in American Public Policy Studies at Stanford University, told the audience. “Some of the connective tissue that used to exist, let's say 15 or 20 years ago, between members of Congress or staffs of different political orientations, doesn't exist anymore. So even if you want to get together with a colleague on the other side and try and move something forward, it's actually remarkably difficult to do it because they don't know each other.”
A lack of trust between Democrats and Republicans also makes it difficult to get much done, said Sarah Dash, MPH, president and CEO of the Alliance for Health Policy in Washington, D.C. “I think the biggest deficit we have in health care right now is a deficit of trust,” Dash said, “a deficit of trust between the parties and a deficit of trust between the different stakeholders.”
That said, there seem to be a few issues, including workforce shortages, the need to curtail the proliferation of pharmacy benefit managers, and a recognition of the need for more mental health care, that have bipartisan support, the panelists agreed.
“Mental health in particular is one of the areas where I do think federal and state governments are likely to invest,” Chen said. However, a dearth of mental health providers is likely to be a barrier to improving access to care. “It's a fundamental problem that a lot of state Medicaid programs are having now. You've got a bunch of people who are on Medicaid. They can't see the people they need to see. So what good is Medicaid [if you don’t have providers]. It's a similar concept with mental health care, which is you can give people access, but if the providers aren't there to see them, it's not going to matter very much.”
Dash noted that her organization this year hosted a series of focus groups on mental health care during which they convened numerous invested parties in envisioning what a patient-first health system might look like. “I think what's remarkable is when you get the pharma and the payer and the provider and the patient all in the same focus group, they're all like, Yeah, we all want more seamless, easy to navigate care. We want care that's affordable … there's a lot of convergence there.” Exactly what that care might look like is still up for interpretation, but convening the parties to discuss the issue holistically is a place to start, she noted.
Efforts to mitigate health care workforce shortages also have bipartisan support, but there is disagreement on whether urban or rural areas are in greater need, the panelists said. Grover mentioned that the Research and Action Institute had recently published an issue brief on rural health care, including data showing that rural residents utilized primary care services at about the same rate as urban residents.
“So what is the problem we are trying to solve? Are we trying to figure out why rural residents die earlier, smoke more, and have greater rates of obesity, or are we trying to deal with access to primary care when they have more trouble with pre-hospital services and specialty care?” Grover asked.
Both Chen and Dash agreed that access to specialty care – and in particular, maternal and fetal care – is what most troubles policymakers, as is the closure of so many rural hospitals.
“The issue is primarily this issue of access to certain specialists, distance to travel to see the specialist and many facility closures, large tertiary care facility closures -- those are the concerns that I hear most often,” said Chen, who served as a senior appointee at the U.S. Department of Health and Human Services during the George W. Bush Administration and has advised numerous other presidential, gubernatorial, and congressional campaigns.
He noted that his father was a small-town physician who came to the United States because of an immigration program that supported a path to citizenship for foreign-trained doctors.
“I've actually talked to a number of members of Congress about this very issue and they say it sounds like a great idea. We just can never talk about immigration right now. And I'm like, I'm not talking about anything that's remotely controversial. We agree that we have a workforce shortage, and there are people who want to help fill that. … My point is this is not an unsolvable problem, which is the frustrating part for me.”
Acknowledging the frustration of seeing the need for all of these health policy changes while working within the health care system, Dash encouraged the audience to speak up and tell their stories. “I guess the one thing I would just say is tell your story. … As hard as it is, I do think there are people who are trying to spark better kinds of conversations and dialogue and I think that's a choice. We can all be a part of that.”
