Yogi Berra famously said, “The future ain’t what it used to be,” but sometimes it is, especially in Washington.
Vinyl records may be back, but the health policy needle that skips and repeats the problems of access, cost, and quality endlessly has never left. None of these health policy problems have ever been solved to the satisfaction of policymakers (or patients).
Take the problem of access.
Despite our best efforts for well over a century, the United States (and other countries) has found it impossible to permanently locate physicians everywhere people need access to health care. It may be time to shift the traditional focus from geographic location as the route for access to care to perhaps more equitable routes. Now, by employing new technology and by empowering all members of the health care team, we have the opportunity to make progress on the problem of ensuring access to care for all Americans. The question is, Can every person get the right care — even virtually — at the right time from the right provider or team?
These are far from new ideas. In 1976, my late father published a book with Carl E. Taylor, MD, DrPH, and other Johns Hopkins colleagues titled Doctors for the Villages, in which they wrote, “It is increasingly apparent that relationships among all members of the health care team require major changes.”
Those changes almost certainly will require physicians to drop the need to always be the only solution to greater access and, instead, to consider how members of a health care team can function most effectively.
At the AAMC Research and Action Institute, we’ve been working with our fellow in residence, Gaetano Forte, assistant director of the Center for Health Workforce Studies, School of Public Health, University at Albany, SUNY, for several months to update and look more closely at the assumptions and data that go into health care workforce projections and why they’ve been right, wrong, or ignored in the past. Later this year, with AAMC colleagues and the RAND Corporation, we hope to release some preliminary findings from our work on workforce projection models. The answer to the question, What does it take to meet the health care needs of our communities today and in the future? may not be, We need a doctor in every neighborhood.
Even if we create better models to improve how and where we deliver care, some services are perpetually in short supply or mismatched with needs. The Research and Action Institute recently published an issue brief about the persistent and worsening challenges in caring for people with mental health needs. Again, not a new issue. We’ve long suffered from an overburdened mental health care system, but we repeat the same cycles of large-scale policies rather than testing new targeted, team-based approaches.
Deinstitutionalization of patients with psychiatric illness began in earnest in the 1960s, with roughly 90% of patients being discharged to care in the community — care that has yet to materialize for them or for most other people with mental illness ever since. Sixty years later, several cities, most prominently New York City, have considered or are already implementing a re-institutionalization policy — this time, focused on unhoused people — that doesn’t appear to incorporate what has and hasn’t worked for people with mental illness over the past six decades.
Cost concerns have also been handled with blunt instruments. For example, policymakers have increasingly relied on reducing reimbursement for clinical care rather than investing in social policies that lead to improved health. Policymakers may seek to restrain spending on federal health programs because dealing with the underlying problems in communities seems too difficult, indirect, or expensive. It’s important to keep in mind that the value of care depends not just on how much we spend but on what we spend it on and what we define as desirable outcomes.
There is no shortage of issues I expect we’ll be discussing in the months ahead, but I remain optimistic that incremental, problem-focused policy solutions can be found — and sometimes even implemented.
To quote another incidental philosopher, Bob Marley, “In this bright future, you can't forget your past.”
I look forward to exploring ideas — old and new — together with our outstanding external advisory committee and, I hope, with input from many of you gracious enough to read this message.
Wishing you a very happy new year.
