Thomas R. Frieden is president and CEO of Resolve to Save Lives, an initiative of Vital Strategies, New York, NY. Rahul Rajkumar is COO of Care Solutions, Optum, Washington, DC. Farzad Mostashari is a visiting fellow at Duke-Margolis Center for Health Policy, Washington, DC, and CEO at Aledade, Inc., Bethesda, MD.
Corresponding author.Correspondence should be sent to Thomas R. Frieden, MD, MPH, President and CEO, Resolve to Save Lives, 100 Broadway, 4th Floor, New York, NY 10005 (e-mail: gro.lstr@nedeirft). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.
CONTRIBUTORSThe authors contributed equally to this editorial.
Accepted December 13, 2020. Copyright © American Public Health Association 2021 See "Health Equity and the Allocation of COVID-19 Provider Relief Funds" in volume 111 on page 628. See "Politics, Pandemic, and Racial Justice Through the Lens of Medicaid" in volume 111 on page 643. See the referenced article with doi: 10.2105/xxxx.Despite a history of public health progress and the most expensive health care system in the world, the United States failed in its initial response to COVID-19. Much of this failure resulted from a presidential administration that sidelined, undermined, and maligned public health. But the roots of failure are deeper. Recovering from the pandemic and building health and public health back better will require recognizing the roots of failure and working persistently to achieve the progress that the country needs—especially among the most underserved communities. This must begin with recognizing the shortcomings in the US health system response to the pandemic, but the multiple overlapping failures laid bare by this crisis demonstrate the need for a systemic, multifaceted, sustained approach to reform that goes beyond pandemic preparedness.
Over the past 40 years, the United States has gone from having a life expectancy near the average for upper-income countries and average per capita health care costs to being a negative outlier (Figures A and B [available as a supplement to the online version of this article at http://www.ajph.org]). This does not have to be. The current moment affords us the opportunity to examine and address the fundamental structural defects that underly these failures. We can improve both healthy life expectancy and the efficiency of our health system if we (1) strengthen our public health systems, (2) reorient health care delivery to reward providers for preventing illness and managing the overall health of populations efficiently (a reversal of current incentives), and (3) empower individuals to make healthier decisions by addressing the preventable root causes of poor health.
The first responsibility of public health is to protect people from outbreaks and other health risks. Yet the COVID-19 pandemic showed how fragmented, insufficient, and marginalized public health departments have become. At the national, state, and local levels, we need a public health renaissance. From the trauma and failure of the response to COVID-19, we must build a resilient, effectively interconnected system that addresses the full range of health threats facing communities throughout the country. A reinvigorated federalist approach must create a common framework, leaving room for local innovation and action. For this, we need better information, better funding, and better action.
To improve information, the US public health informatics infrastructure must be dramatically improved to make real-time, accurate, consistently presented information available from national, state, and local public health departments, with inputs from laboratories and health care providers. Lack of accurate, real-time information was one of the greatest failures of the US response to the COVID-19 pandemic. As a result of investments sparked by the 2009 stimulus spending (with funding as part of the American Recovery and Reinvestment Act [Pub L. No. 111-5]), health care interactions are now supported by electronic information systems, but public health informatics has not kept pace.
The elements are in place for a transformational, nationwide approach to public health informatics with data from all providers and reporting and public dissemination at local, state, and national levels. 1 This will require full protection of privacy within the broad authorities granted to public health. To achieve this goal, it will be necessary to attract data-driven and tech savvy public health workers.
This investment—unlike past efforts—must be implemented with modern, agile informatics approaches. Federal funding for state and local public health should be predictable and sustained and should offer local and state health departments the flexibility to strengthen the information infrastructure for evidence-based policy adoption, in addition to categorical and disease-based funding streams. 2 Practically, this means both increasing funding and exercising existing authority to fund public health informatics in addition to disease-specific surveillance systems, and ensuring a coordinated approach to mandating that providers and laboratories report to this system in an efficient, complete, and timely way and supporting them as they do so.
For better action, we must address the chasms between federal and state and, in most states, between state and local public health agencies. A greatly expanded Centers for Disease Control and Prevention program to embed thousands of epidemiologists and public health implementation specialists in state, city, and local public health departments, with regular rotation of staff back to the Atlanta, Georgia, headquarters after two to five years, would help build a common culture and forge a way forward to take practical action to confront the full range of health threats facing the country. These embedded specialists and experts should focus on reducing preventable illness, injury, and death, especially in underserved and Black, Latinx, and Native American/American Indian communities.
The United States has a health care industry that costs far more money but allows higher rates of preventable hospitalizations and avoidable deaths than most other countries of the Organisation for Economic Co-operation and Development. 3 Too many people do not have access to affordable, high-quality health care, and too many people get sick and die early from preventable disease. We must reorient our health care financing and delivery systems to reward providers for prevention, improve efficiency, and further reduce barriers patients face to receiving care and preventing illness.
The COVID-19 pandemic created a financial crisis for primary care providers (PCPs) that laid bare the irrationality of the dominant fee-for-service payment model for health care. Primary care practices are laying off staff, reducing hours, and preparing to close their doors in the midst of an emergency that demands more frontline diagnosis, testing, treatment, and vaccination. 4 But this crisis has also generated a new openness in providers to better ways of financing health care. We must not lose this moment.
In the short term, we must save family doctors and local health centers by reorienting compensation to prevent illness. This can be done by launching a program under existing Centers for Medicare and Medicaid Services (CMS) Innovation Center authority to protect primary care practices and ensure that they remain open while creating a pathway to a more financially secure future for PCPs. Under Innovation Center authority, CMS can test at national scale—and scientifically evaluate—payment models that aim to improve health care quality and reduce total cost of care. There is already evidence suggesting that participants in the CMS Accountable Care Organization programs, as a whole, have lower total cost of care and significant gains in health care quality. We propose to test a model that combines the best elements of these programs with capitated payments for primary care for patients in fee-for-service Medicare. This model would be national in scope but voluntary for providers.
In the long term, we need to make primary care the center of our health care system. We can do this through a compensation model that offers primary care practices substantial financial incentives to improve disease prevention and reduce the total cost of health care. A risk-adjusted capitated payment system for primary care, in which doctors and medical practices are paid per patient, not per visit or procedure, coupled with entry into an Accountable Care Organization model, with payment substantially dependent on improved health outcomes, will provide practices more income stability—especially in a public health crisis such as a pandemic—while reducing insurance-related administrative burdens.
This compensation model would incentivize primary care practices to employ multidisciplinary teams and provide care in person, virtually, by phone, by e-mail, and even by text message. More nonphysician health workers could provide care appropriate to their skills and training, leaving physicians to use their skills where needed most. Mental health treatment, pain and addiction management services, and programs to better address noncommunicable disease could also be more fully incorporated into routine care.
This compensation approach must also reform the current quality measurement paradigm that has failed to focus on a handful of measures that matter. To the greatest extent possible, quality measurement should be aligned across all payers, and quality measurement should be both simple and focused on critical national priorities. Blood pressure control is a good place to start. Improved treatment of hypertension can save more lives and achieve larger reductions in health inequalities than any other clinical intervention, and it should be the initial guiding indicator to track the improvement in value we get for our health dollar. 5,6
This approach would transform primary care and improve the health of Medicare beneficiaries with a two-part process; these are fundamental reforms, quite distinct from what has been tried in pilot programs so far, and would change the crucial component of how physicians and other providers are paid. First, provide all fee-for-service Medicare beneficiaries with a primary care clinician while preserving the right of all beneficiaries to see any provider who accepts Medicare. The foundation of good health care is a one-to-one, long-term relationship between a beneficiary and a PCP. Understanding which patients a provider is responsible for is the basis for the accountability needed to change the way we pay for health care. Within this national test, the innovation center could evaluate the impact of additional benefits for Medicare beneficiaries with a selected accountable PCP, possibly including the following: (1) no copayments when using their PCP; (2) no copayments when using preferred specialists upon referral from their PCP; (3) no copayments for core, designated preventive medications prescribed by their PCP; and (4) a Part B (outpatient medical coverage) premium discount.
Second, provide these PCPs with payment and regulatory flexibility and accountability to provide high-quality, person-centered health care. PCPs would receive a risk-adjusted monthly payment per patient to cover all costs associated with primary care visits for the beneficiaries who select them. PCPs would not have to submit claims for services. Medicare would provide claims information to these practices so they would see all Medicare-reimbursed services received by their patients from all providers. Hospitals would be required to provide these practices with timely event notifications (admissions, emergency visits) for their patients.
In exchange for flexibilities, and to guard against stinting on care, CMS would evaluate practices on, initially, the three highest-impact indicators: risk-adjusted total cost of care, survey-based patient satisfaction, and blood pressure control. CMS would tie PCP capitation rate increases to performance on these measures, with practice income ranging, for example, from −10% to +25%, based on performance. Consistently poor performers would not be able to enroll new patients, and their patients would be informed of the performance problem and invited and supported to change PCPs.
Primary care practices receiving capitated payments would enter a CMS Accountable Care Organization program—a network of primary care practices that join to increase quality and reduce cost of care. Practices would be able to choose a program appropriate to their size and risk tolerance. Practices willing to accept greater risk sharing could receive higher rewards. A similar approach must be promoted for all payers, including Medicaid, commercial insurance, and public health care services such as the Federal Employees Health Benefits Program, Tricare, the Veterans’ Administration, and the Indian Health Service.
The COVID-19 pandemic has highlighted the pivotal role of individual behavior in affecting population outcomes, but also the structural and environmental drivers of this behavior. We must support individuals in making healthier decisions every day and address the preventable root causes of ill health by structuring the environment and health care systems to support healthy behavior so the healthiest choice is the easiest, default option. This will not only reduce avoidable illness, injury, disability, and death and counter continuing unacceptable health disparities but also increase resilience to reduce risk and harm of health emergencies. When it comes to the environment within which people make decisions—and with a particular focus on children, disadvantaged populations, and other vulnerable populations—we must take the following actions, which can also prevent up to half of all cancers—a major priority for the current presidential administration.
End the tobacco epidemic by taxing, increasing tax enforcement with a track and trace approach, fully funding comprehensive tobacco control, and regulating the nicotine content in combustible tobacco down to nonaddictive levels and allowing use of controlled-dose noncombustible nicotine as this is done. 7 Banning menthol and other flavored cigarettes, which the Food and Drug Administration has the authority to do, would greatly reduce smoking among African Americans in the United States.
Reduce the heavy burden of harmful alcohol use by following evidence-based recommendations, 8 particularly taxation, limitations on time and place of sale, and server liability laws for drunk driving. The concentration of alcohol sales in poor and minority neighborhoods can be addressed through zoning and other initiatives.
Protect Americans from unhealthy food and promote wholesome, sustainable, farmer-supportive food production and distribution policies, particularly in underserved areas. Correcting food deserts; implementing a two-cent per ounce tax on sugar-sweetened beverages or a tax on the amount of sugar 9 ; changing supplemental nutrition and school food policies so unhealthy food cannot be purchased with these supports; restricting the marketing, promotion, and sponsorship of unhealthy food; and implementing front-of-pack warnings on food that exceeds healthy levels, as Chile 10 and other countries have done, would protect all children, especially those in underserved communities. Long-delayed action to establish mandatory limits on sodium in food should be implemented and include mandatory upper limits, with the first level coming into force within 18 months and the second, lower level within two years after that.
Promote healthy physical activity, including by redesigning communities to promote walking and cycling to reduce infectious disease risk and air pollution and to increase personal and community resilience. Safer communities with ample opportunities for physical activity will reduce health disparities and contribute to community renewal.
Reduce air pollution, with a focus on communities subject to disproportionate risk, regulating particulate matter, increasing fuel efficiency standards, and reducing dependence on polluting fuels to reduce the risk of heart attacks, lung disease, and cancer. Addressing environmental racism be reducing air, water, and surface pollution is particularly important.
Protect our children from addiction to tobacco, alcohol, and drugs and from predatory marketing by junk food companies, with the vision that every child will reach adulthood free of addiction, at a healthy weight, and with no health or mental health impediment to achieving their full potential.
When it comes to empowering individuals through health care, we must remove all barriers to primary care and prevention. Building on the successful waiver of patient costs for preventive services under the Affordable Care Act, beneficiaries who opt in to a family clinician should have zero copayments for diagnosis, treatment, and core medications for common causes of death and disability, including at least hypertension, diabetes, high cholesterol, depression, and nicotine addiction. Through legislative action, if necessary, we must fix the anomaly in patient copayments for cancer screening and prevention so that there is no copayment for breast biopsy, as was recently done for removal of colonic polyps discovered during covered colonoscopy procedures; reverse the opiate epidemic with far-reaching policies to improve management of pain and addiction; and empower women, including through full access to reproductive health and family-planning services with no out-of-pocket cost.
We must reconfigure public health and health care through action at federal, state, and local levels. Adopting a unified approach with the overarching goal of saving as many lives as possible will provide the direction and focus that is all too often lacking. Healthier people means healthier communities and a healthier economy better able to weather the inevitable next health emergency. The United States also needs to lead global initiatives to make the world safer from pandemics. The world cannot afford another multitrillion-dollar pandemic that kills millions of people around the world—but we can afford to invest in health security to prevent it.
President Biden will have the unprecedented opportunity to be the public health president. In addition to controlling COVID-19, he can reverse the long-standing relative decline in the performance of the US health system. Instead of a laggard, the United States can be a leader, becoming the first country in the world to regulate nicotine out of combustible tobacco; to implement best-practice policies on alcohol, nutrition, physical activity, and environmental health; and to greatly increase the health value we receive for our health care dollars.
Given the likelihood of continued sharp divisions in Congress and the courts, the new presidential administration will need to work quickly and strategically to implement programs, issue regulations, and perform enforcement as legally allowed, particularly through the Food and Drug Administration and CMS. Quick wins will be essential to establish the foundation for long-term, sustained progress. In addition to these health-specific measures, broader societal action is needed to address discrimination and improve access to stable and well-paying employment, financial resources, educational opportunities, and more. Sustainable societal changes can improve health, increase life expectancy, eliminate health disparities, reduce health care costs, and strengthen resilience against pandemics and other threats to health. A public health renaissance and a primary care reorientation will take years; we must start now as we confront the COVID-19 pandemic.
The authors thank Drew Blakeman for assistance with editorial preparation.
T. R. Frieden has nothing to disclose. R. Rajkumar is COO of Care Solutions, Optum and is an advisor to Google Ventures and holds shares in Advantia Health, PicassoMD, and OM1. F. Mostashari is CEO of Aledade, a company that supports physician-led accountable care organizations.
See also Erwin et al., p. 540, and the Fixing US Health Policy section, pp. 620–657.
1. Hagan CN, Holubowich EJ, Criss T. Driving public health in the fast lane: the urgent need for a 21st century data superhighway. 2019. Available at: https://cdn.ymaws.com/www.cste.org/resource/resmgr/pdfs/pdfs2/Driving_PH_Print.pdf. Accessed December 15, 2020.
2. Vital Strategies; Resolve to Save Lives. Health defense operations funding: ensuring we are able to prevent, detect and respond to health threats. 2020. Available at: https://preventepidemics.org/wp-content/uploads/2020/05/HDO-1-pager.pdf. Accessed December 15, 2020.
3. Tikkanen R, Abrams MK. US health care from a global perspective. 2019. higher spending, worse outcomes? 2020. Available at: https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019. Accessed December 15, 2020.
4. Basu S, Phillips RS, Phillips R, Peterson LE, Landon BE. Primary care practice finances in the United States amid the COVID-19 pandemic. Health Aff (Millwood) 2020; 39 (9):1605–1614. doi: 10.1377/hlthaff.2020.00794. [PubMed] [CrossRef] [Google Scholar]
5. Farley TA, Dalal MA, Mostashari F, Frieden TR. Deaths preventable in the US by improvements in use of clinical preventive services. Am J Prev Med. 2010; 38 (6):600–609. doi: 10.1016/j.amepre.2010.02.016. [PubMed] [CrossRef] [Google Scholar]
6. Muntner P, Hardy ST, Fine LJ et al. Trends in blood pressure control among US adults with hypertension, 1999–2000 to 2017–2018. JAMA. 2020; 324 (12):1190–1200. doi: 10.1001/jama.2020.14545. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
7. Benowitz NL. Comprehensive nicotine regulation to end the combustible tobacco epidemic. Ann Intern Med. 2017; 167 (10):736–737. doi: 10.7326/M17-2071. [PubMed] [CrossRef] [Google Scholar]
8. Community Guide. CPSTF findings for excessive alcohol consumption. 2019. Available at: https://www.thecommunityguide.org/content/task-force-findings-excessive-alcohol-consumption. Accessed December 15, 2020.
9. Brownell KD, Frieden TR. Ounces of prevention—the public policy case for taxes on sugared beverages. N Engl J Med. 2009; 360 (18):1805–1808. https://doi.org/0.1056/NEJMp0902392. [PubMed] [Google Scholar]
10. Smith Taillie L, Reyes M, Arantxa Colchero M, Popkin B, Corvalán C. An evaluation of Chile’s law of food labeling and advertising on sugar-sweetened beverage purchases from 2015 to 2017: a before-and-after study. PLoS Med. 2020; 17 (2):e1003015. doi: 10.1371/journal.pmed.1003015. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
Articles from American Journal of Public Health are provided here courtesy of American Public Health Association