Wednesday, October 18, 2017

Three reasons for optimism in health policy

For clinicians like me who worry about how health policy changes may harm our patients, there have been plenty of reasons for pessimism this fall. Congressional re-authorization of the highly effective, popular, bipartisan Children's Health Insurance Program (CHIP), whose funding expired on September 30, was derailed by yet another "repeal Obamacare" attempt that failed to muster 50 of 52 Republican votes (or any Democratic votes) in the Senate. Dr. Tom Price, the now-former Secretary of Health and Human Services, was dismissed after billing taxpayers nearly $1 million for travel on private and military jets between obscure destinations with few commercial options such as ... Washington, DC to Philadelphia. (I was happy to see him go.) And building on his Administration's record of partisan actions on science policy, President Trump has confused just about everybody on whether he will ultimately support a bipartisan agreement to pass legislation stabilizing the Affordable Care Act's health insurance marketplaces in exchange for making it easier for states to obtain waivers to develop their own programs.

So why am I feeling optimistic, instead? Two weeks ago, I attended the 25th anniversary celebration of the Alliance for Health Policy, "a nonpartisan forum for learning and dialogue among policymakers and other leaders working to address the country’s most pressing health and health care issues." (Thanks to my friends at Health Is Primary for the invite.) This is one of the few health-related groups in Washington that could bestow honors on prominent conservative (Gail Wilensky) and liberal (Uwe Reinhardt) health care economists, as well as longtime Republican and Democratic congressional staffers, on the same night. And it was reassuring to see that family medicine had not one but many seats at the table, with the American Academy of Family Physicians' CEO, immediate past President, President, and President-Elect all in attendance.

Another nonpartisan health policy group that I've been following for the past few years is the Milbank Memorial Fund, which focuses on developing evidence to support state-level population health strategies, including but not limited to insurance reforms. In three recent reports, the Fund examined how some states achieved "significant, sustained improvements ... in one or more key population health outcome measures" and what lessons could be generalized from those experiences. For example, Georgia and Florida both made significant strides in reducing infant mortality relative to the rest of the nation between 2004 and 2014. In Georgia, a campaign led by then-public health commissioner Dr. Brenda Fitzgerald (now director of the Centers for Disease Control and Prevention), the Fund concluded that stakeholder engagement, champions, strategic use of data, and partnerships focused on postnatal care were crucial elements.

My third reason for optimism is my students. It strikes me as ironic that the medical school course that I co-direct at Georgetown was not even part of the curriculum of my own alma mater (NYU) or any other school of medicine in the 1990s. This year, for the first time, the course is concentrated into two intensive one-week blocks - one last week on Health Disparities and Health Equity, and another next spring on Health Policy and Advocacy - rather than being parceled out through five months of the academic year in direct competition with basic science courses. The result has been the most engaged, enthusiastic group of first-year medical students whom I've had the pleasure to teach. These students not only understand social determinants of health, they are ready to take action to address the root causes of health disparities where people live, work and play. They are prepared to advocate for patients in their neighborhoods and communities, far outside the walls of the hospital and clinic. They are motivated to change the culture of medical education to provide more than lip service to the social mission of caring for historically disadvantaged populations. They are part of the future of medicine and population health in this country, and they give me reason to believe that the future is bright.

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