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The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
President’s Blog: The View from Here
Dec 17, 2015 | Christopher F. Koller, President
At the end of 2015, it is worth taking a look at some of the progress that has been made this year advancing population health in this country. A little bit of love is called for: advocacy to improve the health of large numbers of people can be a lonely trail. It is far easier to arouse public sympathies for health care—for named victims, heroic healers, and miracle therapies. Health improvement initiatives, on the other hand, can take a long time to grow roots. Costs avoided are rarely savings recognized. Prevention is nameless and faceless.
But the good news is—there is good news. We are making progress in improving our collective health. A subjective list of five big-impact items in 2015 follows. If we cannot put a face to a “population,” we can at least celebrate the accomplishments.
Teen Birth Rates
Want to help more people live longer, more fulfilling lives? Make sure they graduate from high school. Want to have more people graduate from high school? Make sure they are not teenage moms or children of teenage moms. There is clear evidence on this; so it is good news that teen birth rates continue to decline, as do racial and ethnic disparities in teen birth rates.
This trend has now persisted for 20 years, a remarkable feat. Moreover, Colorado’s experience shows that even greater decreases can be made with creative use of public funds, public education, and long-acting reversible contraceptives.
Reductions in Rates of Uninsured
We can argue about the details of implementation, but the evidence is clear that elimination of barriers to medical care—and reduction in the stresses caused by fear of medical bankruptcy—improves expected lifespan. Being uninsured increases the likelihood of death by 25% to 40%.
Thanks largely to decisions by states to expand Medicaid eligibility under the Affordable Care Act (ACA), uninsured rates in the US have dipped below 10% for the first time since they began to be measured.
And the march continues.
With Pennsylvania (1/1/2015), Indiana (2/1/2015), Alaska (9/1/2015), and Montana (1/1/2016) joining up, 31 states have now expanded Medicaid eligibility. More states are expected to come on board in 2016. Political controversies notwithstanding, reductions in uninsured rates are cause for celebration.
The connection between the former hedge fund manager turned Pharma CEO— whose only regret about raising the price of the drug his company had just acquired by 5500% was that he had not raised it higher—and population health may not be as tenuous as it first seems. Shkreli’s behavior is perfectly permissible under the policies we have in place, in which the assessment of drug effectiveness and safety is independent from an assessment of value. The current system encourages large, high-risk investments in blockbuster cures, sky-high “launch pricing,” and short-term profiteering. Shkreli is guilty only of brazenness and juvenile behavior.
With prescription drugs now driving health care inflation and polls showing them to be the major health care issue for Americans, perhaps Shkreli’s break from the gentleman’s agreement that governed the pharma pack will focus public attention on finding new ways to assess the value of prescription drugs. Then those new methods can be applied to the dizzying array of public and private pharmacy purchasing programs and can create financial incentives better aligned with evidence that demonstrates improvement in population health.
The Medicare Access and CHIP Reauthorization Act of 2015 was a twofer for population health advocates. First, in extending the CHIP program and eliminating the dreaded Sustainable Growth Rate, it showed that informed health policymaking and political compromise have not both been permanently exiled from Congress, as had been feared.
Second, it deepened the roots of payment reform in Medicare, especially for primary care. The legislative commitment to alternative payment model in MACRA builds on the pioneering multi-payer primary care transformation work of the Multi-Payer Advanced Primary Care Practice (MAPCP) project and Comprehensive Primary Care (CPC) Initiative. These programs are proving that transformed primary care is not only possible, but also the foundation of any high-performing delivery system. This commitment to building and rewarding high-performing primary care should be celebrated, nurtured, and accelerated.
Childhood Obesity Rates
Evidence continues to show that increasing obesity rates are not our destiny in the US and that change is possible. Childhood obesity rates have flattened and in some places are declining.
We should not be too self-congratulatory, however. Adult obesity rates continue to climb. The numbers vary by state, and rates are particularly high in non-white and uneducated populations. However, the progress with children—accruing from myriad locally driven policies—should result in habits that last a lifetime. It also shows that evidence-supported, collective, long-term efforts to build healthy environments and behaviors can be successful.
Most population health improvement efforts are precisely that—evidence-supported, long-term, and collective. The areas for improvement are many; they include widening inequities and a poor return in lifespan for the public and private dollars we spend. The successes noted here, however, give us hope for the work ahead.
The Milbank Memorial Fund is an endowed operating foundation that works to improve the health of populations by connecting leaders and decision makers with the best available evidence and experience.
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