SOTU and health - not much new

There are several issues that ought to be on Biden's agenda, though. Here's what I'm hoping to hear.

Health care will have its moments in the sun during President Biden’s state-of-the-union address tonight. But don’t expect any bold initiatives.

The administration’s backgrounder for the press on his SOTU address offered little that was new. The president plans to tout the health care provisions in the Inflation Reduction Act, which caps on out-of-pocket spending in Medicare drug plans; sets a maximum $35 price for insulin in Medicare (he’ll call for extending that to the privately insured); and allows the government to negotiate prices for a handful of pricey drugs.

On the insurance front, he’ll celebrate the latest gains on the Obamacare exchanges (lower premiums and a record-low uninsured rate); and highlight the three Republican-run states that expanded Medicaid. He will call for legislation that would force the remaining 11 state holdouts to expand their own programs. Alas, that’s going nowhere in the House.

Bipartisanship will get a nod when the president celebrates the end of surprise billing (although it still faces significant challenges in the courts). He’ll also tout a new FDA rule that can save seniors as much as $3,000 for hearing aids, which can now be sold over-the-counter.

While it wasn’t in his backgrounder, I would be very surprised if Biden didn’t also give a shout out to his cancer moonshot program and the creation last March of the Advanced Research Project Agency-Health. There is always broad bipartisan support for pouring more money into research.

It is a decidedly small-bore agenda. What’s missing? There was nothing in the backgrounder about the sorry state of the nation’s public health infrastructure; the deteriorating morale of the nation’s health care workforce; and the festering sore of the nation’s broken system for providing long-term care for the aged, infirm, and intellectually and physically impaired.

Let’s take those issues one at a time and suggest what initiatives the president could include in his proposed budget, which is set for release on March 9^th. (Yes, I know the budget is going nowhere given the looming debt ceiling fight. But the annual production of an administration budget plan does allow the White House to signal its priorities and lay out an agenda for future legislative initiatives.)

Public Health

President Biden will likely laud the official end of the COVID-19 public health emergency on May 11. What will be left in its wake is a battered public health system that proved completely inadequate during the pandemic and now is even less prepared for the next one.

State and local agencies, who have primary responsibility for carrying out pandemic preparedness, need a major infusion of federal funding to rebuild their staffs, which were reduced by 20% or about 50,000 staffers in the decade leading up to the pandemic. States need more epidemiologists, statisticians, surveillance personnel and community health workers. Instead, the agencies are going through another round of layoffs because the COVID-related grants are expiring.

Moreover, the leadership at many of these local bodies is in disarray. Scores of top officials left their posts after being publicly attacked for promoting vaccines, masking and other preventive measures. The Prevention and Public Health Fund, approved at a $2 billion annual level in the 2010 Affordable Care Act, was never fully funded, which is making their tasks all that much harder.

Biden’s health advisers would be wise to come up with a plan for reinvigorating public health in the name of preventing future pandemics. Such a program could, in non-pandemic times, devote itself to a broad public attack on the festering problems of obesity, opioid addiction, substance abuse, smoking, deteriorating mental health (especially among the young) and the glaring inequities in health outcomes for the poor and minorities.

Long-term care

Last October, the Biden administration released its blue print for improving the quality of care in the nation’s nursing homes, where an estimated 20% of all deaths during the pandemic took place. It promised to step up enforcement against the industry’s bad actors with repeat safety violations; increase staffing by requiring minimum staff-patient ratios (a new rule to that effect is expected soon); and create “good-paying union jobs” in the industry.

But where will the money come from to achieve these goals? Yes, some private nursing home operators are siphoning off cash by paying exorbitant rents to their private equity investors and real estate investment trusts (often owned by the same corporation or individuals as the operating company); and cutting deals with closely held staffing and ancillary service firms.

But the industry’s core problem is the low rates paid by Medicaid, which accounts for 65% of all patient days in the nation’s 15,000-plus nursing homes but only half its revenue. Medicaid pays on average $266 a day – less than a decent hotel room in most large cities. Medicare, which only covers short stays after hospitalization, pays on average $587 a day.

Meanwhile, millions of American families go without long-term care insurance or any benefits to cover the huge expenses that hit when a loved one requires 24-hour care in a skilled nursing facility, which in many cases (dementia, severe chronic illness, permanent intellectual and physical disabilities) can last for years. Isn’t it time an American president bite the bullet and suggest a practical program for providing Americans with a long-term care benefit – one generous enough to give nursing home operators enough revenue to raise the wages and improve the working conditions of their impoverished workforce?

Workforce morale

COVID took its toll on the nation’s health care workers. But sagging morale, frustrating work rules and paperwork, and burnout long predated the pandemic. Important professions like primary care specialists, community health workers and social work are cruelly underfunded, while specialists and many hospitals feast on a payment system that is overly generous to sick care and gives short shrift to prevention, outreach to vulnerable people and addressing the inequities in access to care.

Today, the Wall Street Journal reported that CVS plans to pay over $10 billion to acquire Oak Street Health, a start-up primary care practice that focuses on providing coordinated care and social support to keep people with chronic diseases out of hospitals. Wall Street (and ambitious new entrants in the provider space like CVS) clearly sees the value in what health care wonks call value-based care. When will the government double-down on its most successful experiments at the Center for Medicare and Medicaid Innovation and make them mandatory for all providers taking money from government programs?

As I’ve written elsewhere (see here and here), providers that are put on budgets rather fee-for-service medicine have the flexibility to channel their resources into the services that can promote the best health outcomes for the most people, especially when it comes to those with multiple chronic conditions. Not only would such a system go a long way toward improving morale among providers, it would begin the journey of turning what now is a sick care system that mostly rewards providers, drug companies and insurers into one that promotes both personal health and the general health outcomes of the entire population.

What could be more satisfying to a workforce that went into health care to help people? Wouldn’t it be appropriate for the nation’s oldest president to lead the charge by articulating such a vision for the general public?