Vital Directions For Health And Health Care: Priorities For 2021
With its congressional charter as advisor to the nation and in anticipation of the 2016 US presidential election and forthcoming new administration, in 2016 the National Academy of Medicine launched a strategic initiative to marshal expert insights on health and health care priorities. Published as Vital Directions for Health and Health Care, the products of the initiative provided trusted, nonpartisan, evidence-based analysis of critical issues in health, health care, and biomedical science.
In its initial series, the project engaged more than 150 experts, who undertook analysis of compelling policy opportunities across nineteen key areas important to progress in three domains: better health and well-being, high-value health care, and strong science and technology.1 The resulting framework from this initiative is organized into eight crosscutting policy directions for all levels of leadership, including four action priorities (pay for value, empower people, activate communities, and connect care) and four essential infrastructure needs (measure what matters most, modernize skills, accelerate real-world evidence, and advance science). Together, these policy directions serve as a foundation for the US to achieve its vision for a health system that performs optimally in improving the health of the population; promoting, protecting, and restoring the health of individuals; and helping each person reach their full potential for health and well-being.2
Since the 2016 publication of Vital Directions, much has happened in health and health care, underscoring concerns about the nation’s persistent challenges related to maternal mortality, child health and development, behavioral health, the opioid crisis, and pervasive health inequities, among others. These developments, coupled with the emergence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and the coronavirus disease 2019 (COVID-19) pandemic, in the context of another US presidential election, prompt the need for renewed assessment of health care priorities and guidance. In addressing these challenges, the next administration must combat the health disparities that have negatively affected Black people, Indigenous people, and other people of color for decades and prioritize the pursuit of health equity for all Americans.3 The COVID-19 pandemic has further exacerbated racial health inequities across public health and health care systems in the US.
This collection of articles published in Health Affairs builds on the initial Vital Directions series by selecting a set of issues with a particularly compelling need for leadership and decision making at multiple levels. Accordingly, the articles highlight five topical areas: health costs and financing, early childhood and maternal health, mental health and addiction, better health and health care for older adults, and infectious disease threats. All of these articles highlight the crosscutting theme of the disproportionate negative impact of health inequities on vulnerable and underserved populations and the importance of giving the highest priority to eliminating these inequities. The articles also reflect the current experience with the COVID-19 pandemic at the time of writing and the implications for action going forward.
An Unprecedented Juncture
During the past four years the US health system has confronted unprecedented challenges and uncertainties. The period began with heated debate about the repeal of the Affordable Care Act of 2010, and the law’s implementation and revision remain active topics of discussion and debate. Then 2019–20 saw the emergence of COVID-19 and the dramatic escalation of public attention to long-standing racial and ethnic disparities in society as a whole, with health care being an arena where those disparities are particularly pronounced.
A persistent and serious challenge has been health care expenditures,4 with US health expenditures as a proportion of gross domestic product continuing to far outstrip comparable expenditures in other Organization for Economic Cooperation and Development countries. To compound the problem, Americans continue to have worse health outcomes even in the face of such high expenditures, including lower life expectancy, higher suicide rates, and a higher chronic disease burden, with people of color suffering disproportionately.5 Partly as a result of high costs, access to care is often limited and unequal. Of the estimated 20.3 million Americans with substance use disorder, 89.8 percent did not receive treatment in 2018.6 Disparities between racial groups in maternal mortality persist, with mortality rates for non-Hispanic Black women remaining more than double those of their non-Hispanic White counterparts.7
The tragedy of these disproportionate burdens has been underscored in the experience of the COVID-19 pandemic. As of January 5, 2021, the Centers for Disease Control and Prevention (CDC) reported 20,732,404 cumulative COVID-19 cases and 352,464 total deaths due to SARS-CoV-2 in the US.8 In addition to pandemic-related morbidity and mortality, US unemployment rates reached a peak of 14.7 percent in April 2020 and continued to persist at a higher-than-average rate of 6.7 percent as of November 2020.9 Furthermore, the associated school closures have disrupted the education of millions of American children.10 COVID-19 also has exacerbated health disparities in the US. Black, Indigenous, Pacific Islander, and Latino Americans are proportionately more likely than White Americans to die from COVID-19,11 accentuating the urgency of the need for action to address health inequities. An effective approach will require multisector collaboration that considers the social determinants of health, confronts economic inequities, and rejects policies that perpetuate structural racism.
High-Priority Challenges
Each of the five topical articles published in Vital Directions: Priorities for 2021 reviews the status and trends for the problem, the priorities involved, an analysis of approaches, and reflections on strategies to address the problem. Of particular importance, as reflected throughout all of the articles, is the clear and urgent obligation for the US to turn its full attention to the growing problem of health inequities and to the structural racism that perpetuates such disparities.
Health Costs And Financing: Challenges And Strategies
Despite high health care expenditures,12 Americans generally experience poorer health outcomes compared with their counterparts in other high-income countries.5 Not surprisingly, many Americans are concerned about US health care costs, making health reform one of the most prominent current political issues.13 The COVID-19 pandemic has highlighted the weaknesses of the US health system and exacerbated already prevalent health disparities across the nation.14,15 Rising numbers of uninsured people16 that have worsened during the pandemic,17 high costs of novel therapeutics,12 and access barriers underscore the need for health reform. The article “Health Costs and Financing: Challenges and Strategies for a New Administration,” by William Shrank and colleagues, takes a deeper look into these issues and provides recommendations to improve the efficacy and efficiency of the US health care system in the context of the COVID-19 pandemic and beyond, with explicit consideration of how to address disparities in outcomes to improve equity in doing so.18
There is an urgent need to provide more equitable access to affordable health care in the interest of national public health.
Given the high costs and substandard health outcomes of the US health system, ensuring effective and high-value health care for all Americans must be a top priority for the next administration. There is an urgent need to provide more equitable access to affordable health care in the interest of national public health. To achieve these goals, the US will need to develop innovative ways of improving access to coverage, address health provider workforce shortages in areas such as primary care,17 and reform health care payment methods. Recent shifts to value-based payment have sometimes resulted in significant savings, especially models that move farther away from fee-for-service payment.19 A continued shift to alternative payment methods, including population-based payment with an emphasis on accountability for addressing health disparities, may decrease future costs while improving care.20
As part of these reforms, there are clear opportunities for telehealth services, therapeutic innovations, and health care data sharing. Although telehealth visits have significantly increased since the beginning of the COVID-19 pandemic21 and multiple payers have expanded reimbursement for these services,22 future telehealth regulations and reimbursement remain uncertain. The federal government will also need to reexamine the regulatory and reimbursement frameworks for medical therapeutics and health care data with a focus on supporting value and encouraging innovative models of care. The cost of therapeutics is not always aligned with the benefits they provide, and high prices limit access to pharmaceuticals for many Americans.23 Patients also experience difficultly in gaining access to their own health information because of a lack of robust data systems accessible to both public and private providers.24 To address these challenges, Shrank and colleagues present near-term opportunities to improve access, affordability, and equity, as well a list of recommendations for key elected officials and political appointees.
Optimizing Health And Well-Being For Women And Children
Women and children continue to experience high rates of morbidity and mortality in the US, which are further intensified by racial inequities.25 More than 700 women die each year in the US during pregnancy and childbirth, and non-Hispanic Black women are more than twice as likely to die during pregnancy and childbirth as White women.26 The US also has high rates of prematurity—at a rate of one in ten newborns—which is a leading cause of infant mortality and lifelong morbidity. Compared with their peers in other countries, US children experience higher rates of poor health outcomes, such as developmental problems, mental health conditions, and severe asthma, coupled with and worsened by social and environmental stressors such as poverty and hunger. Notably, the prevalence of adverse childhood outcomes is higher for Black, Hispanic, and low-income children regardless of race or ethnicity.27
To address these issues, the article by Elena Fuentes-Afflick and colleagues, titled “Optimizing Health and Well-Being for Women and Children,” adopts a life-course perspective to assess both causes for and solutions to issues in child and maternal health.28 This framework underscores the impacts of both positive and negative cumulative health outcomes through multiple phases of life from preconception to adulthood and highlights the interrelatedness of each developmental phase. As the authors of this article express, “Maternal health and well-being . . . may determine the health of the next generation and, ultimately, the health of the nation.” The cumulative impacts of poor health outcomes in early childhood reverberate throughout the life course.
The authors note that prevention is key to improving maternity care and health outcomes for childbearing women. Several state-level and national strategies, such as the California Maternal Quality Care Collaborative and the Maternal and Child Health Bureau’s Alliance for Innovation in Maternal Health, use a quality improvement approach to improve health outcomes. Addressing coverage gaps in health care can also reduce maternal mortality; in 2018 there were 10.8 million uninsured adult women, and more than one million women in poverty fell into the ACA’s “coverage gap” between Medicaid and subsidized Marketplace eligibility.29 The authors note that the US should set the world’s standard for promoting the health and well-being of women and children, and they provide recommendations for a health system that leads to successful outcomes by focusing on targeted and moonshot recommendations. The targeted recommendations focus on existing policies or programs that are eminently achievable, which include the following elements: data, safety, and research. The moonshot recommendations, which are transformative and require endorsement, support, and resources from multiple sectors, include the following elements: ensuring access, transforming health care delivery and financing, and addressing social and environmental factors.
Transforming Mental Health And Addiction Services
Behavioral health, mental health, and addiction significantly affect society in the US and around the world. As of 2018, 20.3 million Americans (ages twelve and older) had a substance use disorder, and 47.6 million American adults suffered from at least one mental illness.6 Although the US has made some strides in improving access to treatment for behavioral health conditions, significant gaps in care remain. Barriers to quality care are particularly high for people of color and people with socioeconomic disadvantage, emphasizing the need for special consideration of vulnerable populations in policies relevant to behavioral health.30 Improving mental health and addiction treatment for all Americans requires combating stigma and promoting evidence-based, comprehensive care. In their article, “Transforming Mental Health and Addiction Services,” Margarita Alegría and colleagues discuss the most pressing needs in behavioral health care and offer policy solutions that call for a reconceptualization of the behavioral health care system to prioritize the social needs of patients and to foster greater support of the behavioral health workforce.31
Current behavioral health interventions often focus on volume of services and symptom reduction as a benchmark for success. However, given scientific advancements and improvements in patient-centered care, people with mental illness are increasingly in recovery and able to live full lives despite their symptoms. Thus, it is possible to move beyond symptom reduction and to emphasize everyday functioning and societal involvement in behavioral health care.32 A shift toward prioritizing social context and addressing the social needs of patients with behavioral health conditions will be a vital part of behavioral health care going forward. Further, improving functional outcomes requires transforming the behavioral health system to meet patients “where they are” in terms of physical location and their current acceptance of their illness. Promotion of community-based organization outreach,33 telehealth services,34 and home visiting programs35 to augment behavioral health care presents an opportunity to expand patient enrollment in care and diagnose disease sooner.
Another pressing need in the advancement of mental health and addiction care is decriminalization of people who have behavioral health conditions, based on the recognition that addiction is a brain disease.36 Such change is urgently needed both to improve health outcomes and because people of color are disproportionately negatively affected by the criminal justice system.37 Efforts to improve behavioral health outcomes should include a reconfiguration of the crisis response system with a workforce trained in deescalation tactics instead of criminalization.38
Actualizing Better Health And Health Care For Older Adults
By 2040, people ages sixty-five and older are predicted to account for 21.6 percent of the US population, and resources will need to be appropriately allocated to ensure that they receive person-centered, high-quality care.39 The COVID-19 pandemic has further exposed the consequences of fragmented and unequal care for older adults, as well as the enduring impacts of structural racism. To address systemic inequities and to address many of the challenges facing older adults, it is imperative to take a population health approach. By actualizing this vision of population health for older adults, the nation can address many of the outstanding challenges and issues faced by older Americans.
In their article, “Actualizing Better Health and Health Care for Older Adults,” Terry Fulmer and colleagues address core challenges facing health and health care for older adults, ranging from recruitment in the geriatrics workforce and digital health barriers to the importance of age-friendly public health systems and addressing social isolation.40 As the population of older adults continues to rise during the next decade, it will be important that the geriatrics workforce—ranging from specialists to caregivers—expands to meet the increase in demand for care. As of 2018 the older adult population in the US was 49.2 million; however, there were only 3,590 full-time practicing geriatricians.41 Equally important are the issues faced by the geriatrics workforce—especially issues worsened or brought on by the COVID-19 pandemic, which range from burnout42 to specific hardships faced by nursing home staff and paid caregivers. A disproportionate number of all deaths from COVID-19 in the US are tied to nursing facilities, and working in these facilities increases the risk for transmission to exposure among patients and staff.
Telehealth is an important innovation, especially within the context of the pandemic, to increase access to care. However, barriers remain for engagement via virtual platforms, including limited digital health literacy, unequal access to technology, design barriers, and integration of telehealth with other services needed for effective care. An additional concern for care delivery for older adults is that public health funding is often disease or condition specific rather than population focused, yet the development of age-friendly health systems is integral to promoting healthy aging. Redesigning long-term services and supports is also a critical challenge that must be addressed, especially given that twelve million adults are living with serious illness. Innovative long-term care should provide more support for older adults remaining at home and aging in place. The disproportionate mortality rates resulting from COVID-19, particularly in nursing homes, also highlight the importance of improving care quality in long-term care facilities and other community living arrangements.
To address these challenges, the authors identify six vital directions to improve the care and quality of life for older Americans: create an adequately prepared workforce for the health care of older people; strengthen the role of public health; promote equity and address the social determinants of health; develop, evaluate, and implement new approaches to the delivery of health care for older adults that incorporate evidence-based telehealth and technology; allocate resources to support person-centered care including palliative and end-of-life care; and redesign the structure and financing of long-term services and supports, including nursing home and community care.
Infectious Disease Threats: A Rebound To Resilience
During the past five years there have been increasingly serious infectious disease threats in the US and globally, ranging from new foodborne and drug-resistant pathogens to antimicrobial resistance and vectorborne diseases such as Zika. However, COVID-19 in particular has tested the US response and resilience to global threats, revealing the importance of national and international coordinated responses to pandemics. The economic, political, and social impacts of COVID-19 will continue to demand ongoing attention in 2021, remaining significant challenges. Further responses should aim to improve resilience against future infectious disease threats.
In “Infectious Disease Threats: A Rebound to Resilience,” Peter Daszak and colleagues outline key lessons learned from more than a century of pandemics and those yet to be learned from the COVID-19 experience.43 Infectious disease epidemics and pandemics result in dire health, social, and economic consequences, with significant impacts on underserved and disenfranchised communities. In particular, the COVID-19 pandemic has disproportionally affected hospitalization and mortality rates for communities of color, people with disabilities, people in detention, and elderly populations.
Daszak and colleagues propose six critical steps to build resilience to address the current pandemic and also to prepare for future infectious disease threats. These recommendations call for launching an expert Pandemic Preparedness and Response Commission, reinforcing a science-based approach to public health policy, and increasing federal funding to agencies involved in pandemic preparedness and control. Across all of these recommendations, and especially for an effective response to COVID-19, structural changes to the US public health system and infrastructure are essential to addressing infectious disease threats, as is collaboration among federal agencies and state governments. The authors maintain that evidence-based national leadership, in coordination with public health guidance, is critical to preventing and containing pandemics. The role of the US as global leader in pandemic response and recovery not only protects Americans in the short and long term but also promotes global health security in the face of potential future threats.
Health Equity: The Most Vital Direction For 2021
US leaders must address the preventable health disparities that negatively affect millions of Americans.
The unacceptable health inequities that persist in the US today, compounded by the enormous and uneven impact of the COVID-19 pandemic, emphasize the need and the opportunity for the next administration to address the fundamental challenges that the nation faces in health and health care. US leaders must address the preventable health disparities that negatively affect millions of Americans and regain the public’s trust in health science. Across the articles contained in the 2021 Vital Directions series is the clear message to the nation—and those stewarding health policy—that the most fundamental obligation is to view health system reform through a health equity lens. It is incumbent on all involved to advance an evidence-based and population-engaged assessment of the equity implications of every policy, program, and activity in the health sector, including those related to payment reform; reach and operation of the digital health infrastructure; links among health care, public health, and social services; the adequacy and nature of the workforce; and the focus and conduct of health and biomedical research. With myriad interacting public and private players and policies shaping health and health outcomes, the health sector cannot in isolation correct health, social, and racial inequities. But those of us in the health field—clinicians, patients, health organizations, public health and social service agencies, payers, manufacturers, and policy makers—constitute a powerful force for leadership. Testament to the importance of that leadership is the core message of Vital Directions 2021, and it is a message that will be prominent as the National Academy of Medicine works with partners throughout the nation to ensure that every American reaches their full potential for health and well-being.
ACKNOWLEDGMENTS
The views presented in this publication are those of individual contributors and do not represent formal consensus positions of the authors’ organizations; the National Academy of Medicine (NAM); or the National Academies of Sciences, Engineering, and Medicine. The NAM thanks the sponsors of Vital Directions 2021, whose support made this work possible. This collection of articles is funded in part by the Robert Wood Johnson Foundation, The John A. Hartford Foundation, and the Gordon and Betty Moore Foundation. Additional information on this and other NAM activities may be found at NAM.edu. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) license, which permits others to distribute this work provided the original work is properly cited, not altered, and not used for commercial purposes. See https://creativecommons.org/licenses/by-nc-nd/4.0/. [Published online January 21, 2021.]
NOTES
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