Author: Mat Reidhead, Vice President of Research and Analytics
Throughout the inaugural weekend, the Trump administration began
to demystify its plans for the future health care delivery system for socially
at-risk Americans. On Jan. 22, White House Counselor Kellyanne Conway suggested
President Trump’s repeal plan for the Affordable Care Act would convert the
Medicaid program to block
grants for states. It remains to be seen whether the move is designed to
ensure President Trump’s pledge of health coverage for all, or to curtail
national spending on health care by limiting safety-net funding for the poor. Conway
defended the strategy by saying it would afford states the flexibility to
ensure the program is administered by “those who are closest to the people in
need” — at least a socially benevolent signal.
Uncertainty clouds the future of the health care system in
our country. One thing is certain: New data from HIDI make very conjunctive the
fact that hospitals are among “those who are closest to the people in need” in
Missouri, and there is much opportunity to improve the delivery system under
which they receive health care.
submission in the New England Journal of Medicine
highlights many of the considerations for population health and
patient-centered care facing the new administration. The authors lay the claim
that “as a society we are spending our health care dollars in the wrong ways
for the wrong things — emphasizing treatment over prevention and medical care
over social services.” They call for more attention to the social causes of
downstream physical and emotional health outcomes.
Upstream interventions, such as those being carried out by
the Saint Louis Integrated Health Network, help build bridges between hospitals
and community health centers with the goal of connecting patients with
community-based resources across the clinical and social continuum of
While emerging models like the Community
Referral Coordinator Program at IHN solidify the place of upstreamism in
the future delivery of health care, several policy decisions have placed
Missouri’s collective health further downstream than other states.
Missouri has by far the lowest funding for
public health in the nation. At $5.86 per capita, Missouri is $21.63 per person
behind the national median, and $80 behind states in the top decile.
Missouri did not participate in expansion of
health care coverage for our working poor under the ACA. This decision could
place us at a permanent disadvantage in net tax outlays under a fixed block
grant model compared to expansion states.
Missouri is set to expand the Medicaid managed care
delivery model — a system that’s surprisingly woeful at living up to its name
according to evidence that we
and others have laid bare.
Emergency department visits for Medicaid managed care have
exploded in Missouri throughout the last 10 years, with a 54 percent increase
since 2006. This was compared to an 8 percent increase for traditional Medicaid
during the same period. And last year, for the first time, more managed care
patients visited an ED than fee-for-service in Missouri. In fairness, the data
also show high utilization for certain fee-for-service patients. The shocking
reveal from our latest analysis
this — virtually identical cost concentration curves for each Medicaid delivery
model in the state. The rub? Managed care patients are mostly children and
their parents. Conversely, fee-for-service covers virtually all clinically
complex and resource-intense aged, blind and disabled beneficiaries alongside
children and custodial parents outside of the existing managed care region.
Changes in the health care delivery system for our most
vulnerable populations cannot be driven solely by the allure of anticipated budget
predictability through block grants or managed care contracts. They must be
grounded in thoughtful, patient-centered upstream approaches to the
coordination of social and clinical care, aimed at improving health and
well-being. The return on investment is long, but the return on mission is