Experts Issue Recommendations for Improving Health Care, Costs in 2021

With the ongoing coronavirus disease 2019 pandemic, a rising number of uninsured Americans, and a new Democratic president and Senate majority, 2021 is shaping up to be a dynamic year for health care policy.

With the ongoing coronavirus disease 2019 (COVID-19) pandemic, a rising number of uninsured Americans, and a new Democratic president and Senate majority, 2021 is shaping up to be a dynamic year for health care policy, according to the authors of a recent Health Affairs commentary.

As part of the National Academy of Medicine’s Vital Directions for Health and Health Care: Priorities for 2021 initiative, industry experts, including William H. Shrank, MD, chief medical and corporate affairs officer at Humana, and Nancy-Ann DeParle, JD, a managing partner and cofounder of Consonance Capital Partners, outlined health reforms that can lead to improved health care access, affordability, and equity in the United States.

Drawing on their collective backgrounds in health financing, delivery, and innovation, the authors focused on 5 policy priorities: expanding insurance coverage, accelerating the transition to value-based care, advancing home-based care, improving the affordability of drugs and other therapeutics, and developing a high-value workforce.

“After reaching a nadir of 28.7 million (8.9% of the population) in 2016, the number of uninsured people is expected to rise to 37.2 million (10.6% of the population) by 2028. This comes at a time when a growing body of research links insurance coverage to improvements in financial security, health, and longevity,” they wrote.

Concurrent accelerating rates of health care spending will result in a growing national debt and increased financial insecurity among Americans, while inequities in health care access have led to dire ramifications on underserved communities throughout the country.

When it comes to improving these barriers, the authors noted difficult trade-offs are inevitable, but “we believe there are opportunities to simultaneously improve access, affordability, and equity.”

Since the Affordable Care Act (ACA) was implemented in 2010, rates of uninsured Americans have steadily declined, and coverage gains have led to improved health, equity, and financial well-being. In 2019 alone, 11.4 million individuals enrolled in coverage through state and federal marketplaces, while between 2013 and 2019, enrollment in Medicaid expansion states increased by 13.1 million.

But since 2016, the uninsurance rate has also increased and been exacerbated by the COVID-19 pandemic. “During the height of the pandemic, millions of Americans lost their jobs and their access to employer-based insurance coverage over the span of several months,” underscoring the limitations of employer-sponsored insurance, the authors noted.

As political resistance to expanding insurance access under certain ACA provisions persists, the authors call for bipartisan approaches and public-private partnerships. In particular, experts propose reallocating the considerable resources spent on care that does not improve health to sustainably finance coverage expansion. Although this method will not sacrifice affordability or quality, “the impact of associated revenue reductions on providers needs to be closely considered,” the authors cautioned.

However, on January 28, President Biden took steps to increase coverage by reopening the health exchanges created by the ACA and directing his administration to reexamine Medicaid work requirements.

Potential also exists for payment models to accelerate value-based care delivery. But as most alternative payment models are anchored in a fee-for-services architecture, “broader adoption of advanced population-based payment is needed.” In addition, fundamental changes in the delivery system via multipayer alignment are needed to implement value-based payment among commercial and Medicaid payers. Value-based payments must also help to reduce disparities in care as opposed to exacerbating inequities.

“Redesigning care delivery to provide more value to patients requires new tools, competencies, and infrastructure,” authors wrote. “To that end, it is necessary that payment models be accompanied by technical assistance and infrastructure support,” both at the independent provider and system levels.

Improvements in internet, video, and remote monitoring capabilities will also be vital to improving the delivery of health care services in patient-centered, cost-effective settings. Despite the large uptick in telehealth adoption during the COVID-19 pandemic, reimbursement and financing models pose significant barriers to widespread, long-term adoption. “Permanent reimbursement changes for telehealth and tailored financing models for home-based care across the continuum of disease severity” are thus warranted.

To drive down prices of novel medications and therapeutics and of existing branded drugs, creating reimbursement structures that align payment with value and balancing affordability with the need for innovation also pose major challenges. Regulatory barriers, a lack of robust data on which to base coverage and reimbursement decisions, and societal discomfort around limiting access to therapies are all hurdles that must be overcome in order to reduce drug prices.

However, even if numerous improvements are made in these areas, workforce shortages in primary care, behavioral health, and dental care may render these innovations mute. “A coordinated strategy to train, deploy, and support a diverse health care workforce is an essential enabler of access, quality, and value, particularly in under-resourced communities,” the experts noted.

Licensure and credentialing requirements, in addition to state-by-state variation in scope-of-practice laws, all limit the opportunity to leverage innovations to provide the most cost-effective care.

Throughout the pandemic, greater flexibility in this area has led to augmentation of in-person workforces in regions that experienced surges of COVID-19 cases. “Many state medical boards waived licensing requirements for telehealth and provided expedited, temporary licenses for out-of-state providers. Formalizing these changes outside of the pandemic will be important,” the authors said. Increased use of community health workers and navigators, as opposed to specialized individuals, will also be essential to bolster care delivery in culturally appropriate ways.

To take advantage of these near-term opportunities, the authors called on the HHS secretary, the CMS administrator, the FDA commissioner, and state governors to implement recommendations aimed at improving access, affordability, and equity, as these individuals have a unique ability to quickly and effectively bring about change.

Despite time, funding, and resource constraints due to the COVID-19 pandemic, the authors push for disciplined prioritization and a willingness to accept incremental progress and small wins in the effort to implement these proposals.

“Achieving meaningful change in this environment will require significant resolve from policy makers and public support for difficult decisions (for example, less coverage for low-value services and technologies),” they wrote.

“We hope that the policy priorities and recommendations articulated in this commentary provide a focused starting point for evidence-based policy making that supports a more effective, efficient, and equitable health system in the United States.”


Shrank WH, DeParle N, Gottlieb S, et al. Health costs and financing: challenges and strategies for a new administration. Health Aff (Millwood). 2021;40(2):235-242. doi:10.1377/hlthaff.2020.01560

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