*200 Words
*APA Formatting
*Resources Attached
By William H. Shrank, Nancy-Ann DeParle, Scott Gottlieb, Sachin H. Jain, Peter Orszag, Brian W. Powers,
and Gail R. Wilensky
Commentary
Health Costs And Financing:
Challenges And Strategies For A
New Administration
ABSTRACT It is likely that 2021 will be a dynamic year for US health care
policy. There is pressing need and opportunity for health reform that
helps achieve better access, affordability, and equity. In this commentary,
which is part of the National Academy of Medicines Vital Directions for
Health and Health Care: Priorities for 2021 initiative, we draw on our
collective backgrounds in health financing, delivery, and innovation to
offer consensus-based policy recommendations focused on health costs
and financing. We organize our recommendations around five 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.
Within each priority we provide recommendations for key elected
officials and political appointees that could be used as starting points for
evidence-based policy making that supports a more effective, efficient,
and equitable health system in the US.
I
t is likely that 2021will be adynamic year
for US health care policy. More than a
decade after the Affordable Care Act
(ACA) was passed, health reform re-
mains a top concern for the American
public.1 The number of uninsured Americans is
rising. Affordabilityat both the system and in-
dividual levelsis eroding. And the numerous
ways in which racism and prejudice drive unac-
ceptable disparities in health and well-being
are increasingly evident. The coronavirus dis-
ease 2019 (COVID-19) pandemic, which placed
historic stress on an already strained system, has
only exacerbated many of these shortcomings.
Against this backdrop, the National Academy
of Medicine convened the Vital Directions for
Health and Health Care: Priorities for 2021 ini-
tiative, which, following a 2016 initiative of the
same name,2 aims to provide expert guidance on
several focus areas for US health policy. In this
article we draw on our collective backgrounds in
health financing,delivery, and innovationtooffer
a setof consensus-basedpolicy recommendations
focused on health care costs and financing.
System Goals
Our recommendations are grounded in three
overarching goals for the US health system: ac-
cess, affordability, and equity.
Access Every American should have access to
health care. However, the US has a large and
growing uninsured population. After reaching
a nadir of 28.7 million (8.9 percent of the popu-
lation) in 2016, the number of uninsured people
is expected to rise to 37.2million (10.6 percent of
the population) by 2028.3 This comes at a time
when a growing body of research links insurance
coverage to improvements in financial security,
health, and longevity.46
Affordability Every American should have
access to affordable health care.However, health
doi: 10.1377/hlthaff.2020.01560
HEALTH AFFAIRS 40,
NO. 2 (2021): 235242
This open access article is
distributed in accordance with the
terms of the Creative Commons
Attribution (CC BY-NC-ND 4.0)
license.
William H. Shrank
([emailprotected]) is
chief medical and corporate
affairs officer of Humana in
Louisville, Kentucky.
Nancy-Ann DeParle is a
managing partner and
cofounder of Consonance
Capital Partners, in New York,
New York.
Scott Gottlieb is a resident
fellow at the American
Enterprise Institute, in
Washington, D.C.
Sachin H. Jain is president
and CEO of the SCAN Group
and Health Plan and an
adjunct professor of medicine,
Stanford University School of
Medicine, in Stanford,
California.
Peter Orszag is the CEO of
Financial Advisory at Lazard
Freres and Co., LLC, in New
York, New York.
Brian W. Powers is deputy
chief medical officer at
Humana in Boston,
Massachusetts.
Gail R. Wilensky is a senior
fellow at Project HOPE, in
Bethesda, Maryland.
February 2021 40:2 Health Affairs 235
Health Care Finance
care spending continues to growat anunsustain-
able rate. Whereas spending growth initially
slowed after implementation of the ACA, it has
accelerated once again.3,7 The consequences of
this acceleration arewell established and include
a growing national debt; strained federal, state,
and local budgets; stagnant wages; and in-
creased financial insecurity for Americans.2,8,9
Even for those with insurance coverage, health
care is increasinglyunaffordable:Roughlyhalf of
US adults have delayed or avoided care because
of cost.10
Equity Every American should have equal ac-
cess to affordable health care. However, there
remain unacceptable inequities in health care
access andoutcomes by race, ethnicity, socioeco-
nomic status, and other dimensions.11,12 This has
been made painfully obvious during the COVID-
19 pandemic, which has taken an unacceptably
high and disparate toll on underserved commu-
nities and people of color.1315
Interrelated Goals These three goals of ac-
cess, affordability, and equity are deeply interre-
lated. In some cases, improvements are comple-
mentary. Increased access can improve equity.16
In others, conflicts arise. Expanding access pre-
sents a substantial affordability challenge at the
system level. Although difficult trade-offs are in-
evitable, we believe there are opportunities to
simultaneously improve access, affordability,
and equity.When identifying policy recommen-
dations, we aimed to identify those most likely
to yield balanced improvements across all three
areas.
Policy Priorities
Wepropose fivepolicypriorities to advance these
system goals: expand insurance coverage, accel-
erate the transition to value-based care, advance
home-based care, improve the affordability of
drugs and other therapeutics, and develop a
high-value workforce.Within the broad domain
of health costs and financing, there surely are
many other policy priorities worth considering.
These five represent our view of the most prom-
ising near-term opportunities to leverage health
care financing and payment to improve access,
affordability, and equity.
Expand Insurance Coverage From 2010 to
2016, policies in the ACA led to a steady decline
in the number of uninsured Americans.17 These
coverage gains have led to improved health, eq-
uity, and financialwell-being.46,16When theorig-
inal Vital Directions initiative was convened in
2016,2 the uninsurance rate was at an all-time
low. Since then, the number of uninsured Amer-
icans has risen steadily.3,17 The COVID-19 pan-
demic will only accelerate this trend and has
highlighted the limitations of employer-spon-
sored insurance. During the height of the pan-
demic, millions of Americans lost their jobs and
their access to employer-based insurance cover-
age over the span of several months.18,19
Multifaceted and fiscally prudent approaches
to closing the growing coverage gap are neces-
sary but face significant barriers. There remains
political resistance to expanding coverage
through mechanisms set forth in the ACA.
Twelve states have not expanded Medicaid, sev-
eral coverage-related provisions in the ACA
have been repealed, and support of the Market-
places for individual coverage has been uneven.
Bipartisan approaches and public-private part-
nerships are needed.
Sustainable financing presents another chal-
lenge. Mechanisms for publicly financing cover-
age expansionthrough deficit spending, new
revenue sources, or revenue transferscome
with inherent trade-offs and will require biparti-
san compromise.We believe that reallocating the
substantial resources spent on care that does not
improve health20 represents an opportunity to
expand coverage without sacrificing affordabili-
ty or quality, but the impact of associated reve-
nue reductions on providers needs to be closely
considered.
Accelerate Transition To Value-Based
Care A central action priority identified in the
original Vital Directions initiativewas to pay for
valuespecifically, to drive health care pay-
ment innovation providing incentives for out-
comes and value.2 Since that time, value-based
payment has grown notably. According to the
Health Care Payment Learning and Action Net-
work, the share of health care payments admin-
istered via alternative paymentmodels increased
from23percent in2015 to36percent in2018.21,22
Although selectedmodels have generated signif-
icant savings,2325 the overall impact of new
payment models on cost and quality has been
mixed.2628
We believe that significant potential remains
for payment models to accelerate value-based
care delivery, but several barriers must be ad-
dressed. First, most alternative payment models
remain anchored in a fee-for-service architec-
ture. Only 5 percent of health care payments
in 2018 were population based (for example,
global budgets).22 Broader adoption of advanced
population-based payment is needed. Second,
the penetration of value-based payment lags
among commercial and Medicaid payers. In
2018, 40.9 percent of payments in traditional
Medicare and 53.6 percent of payments inMedi-
care Advantage occurred through advanced
value-basedmodels, comparedwith 23.3 percent
inMedicaid and 30.1 percent among commercial
Health Care Finance
236 Health Affairs February 2021 40:2
payers.22 Medicare can serve as a catalyst for
payment reform, but fundamental changes in
the delivery system will not occur without multi-
payer alignment. Finally, there are growing con-
cerns that certain value-based payment models
may exacerbate inequities or penalize organiza-
tions that care for vulnerable populations.29 It is
essential that value-based payment help amelio-
rate, not exacerbate, disparities.
Accelerating the transition to value-based care
necessitates more than new payment models.
Redesigning care delivery to provide more value
to patients requires new tools, competencies,
and infrastructure.2,30 To that end, it is necessary
that payment models be accompanied by techni-
cal assistance and infrastructure support. This
will be especially important to encourage partic-
ipation and ensure success for independent pro-
viders, who appear to be most successful when
engaging in value-based models.24
Infrastructure improvements at the system
level are also needed. Robust, interoperable data
exchange is a prerequisite for value-based care.31
There has been important progress on interop-
erability since the original Vital Directions ini-
tiative.2 In early 2020 the Department of Health
and Human Services (HHS) issued a final rule
implementing interoperability and the patient
access provisions of the 21st Century Cures Act
of 2016, although enforcement has been delayed
because of the COVID-19 pandemic.
Advance Home-Based Care Improvements in
internet, video, and remote monitoring capabil-
ities increasingly allow for the delivery of health
care services in more cost-effective, patient-
centered settings. Patients now can receive
home-based acute care,32 primary care,33 and be-
havioral health services34 of equal or better qual-
ity compared with facility-based delivery, and at
a lower cost. Despite promising evidence, few
programs have reached meaningful scale. In
2018 only 2 percent of commercially insured
peoplehad a telehealth visitwith aprovider,with
rates even lower in Medicare and Medicaid.35
Home-based acute, postacute, and long-term
care occur at even lower rates.
As the logistics and infrastructure to support
home-based care mature, reimbursement and
financing models present a substantial barrier
towidespreadadoption.Although telehealth ser-
vices were reimbursed by many payers before
2020, payment rates did not support the process
and workflow changes needed for adoption at
scale. For other home-based services such as
acute, postacute, and long-term care, there are
scant reimbursement models outside of small
pilots. The COVID-19 pandemic has made clear
the drastic impact that reimbursement policy
can have on the adoption of telehealth and
home-based care. Facilitated by the introduction
of reimbursement parity, there has been a rapid
transition to virtual visits in the ambulatory set-
ting during the pandemic.36 Shifting care to the
most appropriate and cost-effective settings will
require permanent reimbursement changes for
telehealth and tailored financing models for
home-based care across the continuum of dis-
ease severity.
Improve The Affordability Of Drugs And
Other Therapeutics Access to novel therapeu-
tics is a distinguishing feature of the US health
system, but also a key driver of high spending.3739
The crisis of affordability for drugs and other
therapeutics has only intensified since the origi-
nal Vital Directions initiative was convened in
2016.2,37 Highly effective therapeutics may lower
aggregate spending by reducing the need for
costly interventions or hospitalizations, but
many of these novel medicines command high
prices.40 More challenging is the fact that high
prices are not always aligned with value. Prices
on existing, branded drugs have increased sub-
stantially during thepast decade, limitingafford-
ability and access.37,41,42 And even in circumstanc-
es where the benefits are unclear or modest,
many new therapeutics are still reimbursed at
high rates.37,43
With continued innovation on the horizon
including gene therapythese challenges will
become more acute. Broadening the pool of
Americans who can obtain and afford high-value
therapeutics will require reimbursement struc-
tures that align payment with value and balance
affordability with the continued need for inno-
vation. Such efforts face a number of challenges:
regulatory barriers that limit generic and bio-
similar development; a lack of robust informa-
Although difficult
trade-offs are
inevitable, we believe
there are
opportunities to
simultaneously
improve access,
affordability, and
equity.
February 2021 40:2 Health Affairs 237
tion from which to base comparative effective-
ness, coverage, and reimbursement decisions;
and societal discomfort around limiting access
to any therapies, including those that are of
low value.
Develop A High-Value Workforce The US
benefits from a highly skilled health care work-
force and is home to premier training institu-
tions. But there are significant and growing
workforce shortages in the areas of primary care,
behavioral health, anddental care.44 A coordinat-
ed strategy to train, deploy, andsupport adiverse
health care workforce is an essential enabler of
access, quality, and value, particularly in under-
resourced communities.
Regulatory restrictions remain a key barrier
to progress. Current licensure and credentialing
requirements and state-by-state variation in
scope-of-practice laws limit the opportunity to
leverage technology and advanced practice pro-
viders to address workforce shortages, improve
access, and provide the most cost-effective
care.45,46 The response to COVID-19 has shown
the benefit of relaxing such structures. During
the pandemic, regulatory bodies and payers
moved quickly to augment in-person workforce
capacity in regions experiencing surges in
COVID-19 cases and to allow for telehealth to
serve as a substitute for in-person care. Many
state medical boards waived licensing require-
ments for telehealth and provided expedited,
temporary licenses for out-of-state providers.47
Formalizing these changes outside of the pan-
demic will be important.
Alongside reducing regulatory barriers, devel-
oping a high-value workforce will also require a
better use of community members and less spe-
cialized individuals (for example, community
health workers and navigators) to support care
delivery in uniquely effective, efficient, and cul-
turally appropriate ways.48
Recommendations For Key Elected
Officials And Political Appointees
The priorities we have outlined represent near-
term opportunities to improve access, afford-
ability, and equity. To help catalyze action along
these dimensions, we developed a short list of
recommendations for key stakeholders.We focus
on three key federal leadersthe secretary of
HHS, the administrator of the Centers for Medi-
care andMedicaid Services (CMS), and the com-
missioner of the Food and Drug Administration
(FDA)and state governors, because of their
ability to quickly and effectively affect change.
Comprehensive reform will require close collab-
oration with other elected officials and political
appointees and commensurate attention, activi-
ty, and innovation from the private sector.
Expand Insurance Coverage The HHS sec-
retary should develop alternative pathways to
insurance coverage, including strengthening
and better supporting the individual insurance
Marketplaces and working with Congress to de-
crease the age ofMedicare eligibility to fifty-five.
Doing so will help ensure coverage, improve
affordability, and offer greater choice for older
Americans unable to obtain employer-based
coverage.
Governors should also create opportunities
for expanded coverage in their states. Optimal
use of the Medicaid program offers the greatest
opportunity to expand coverage and promote
health equity. Governors in states that have
not yet expanded Medicaid should work closely
with their legislative bodies to do so. Outside of
Medicaid expansion, governorsworking with
their insurance commissionersshould support
the individual Marketplace by offering risk-
management mechanisms to private payers
providing individual coverage via state-based
exchanges and by extending open enrollment
periods.
Accelerate Transition To Value-Based
Care The CMS administrator should increase
the adoption of advanced value-based payment
models. Value-based payment in Medicare has
grown, but most value-based payments remain
anchored in a fee-for-service architecture. Popu-
lation-based payment has the greatest potential
to improve outcomes and lower costs. The CMS
administrator should set a goal of having 25 per-
cent of Medicare payments administered via
population-based payments by 2025.
The CMS administrator also must align pay-
ment models with equity. Value-based payment
has the potential to advance health equity but
may inadvertently exacerbate health disparities.
The administrator should conduct a thorough
review of existing payment models to evaluate
their impact on equity while developing new
payment models that create financing flexibility
to address structural racism and social determi-
nants of health and explicitly reward reductions
in health disparities.
It will also be important for CMS to help stabi-
lize independent primary care providers.
COVID-19 has placed significant financial strain
on independent primary care providers. This is
especially troubling, as these clinicians provide
critical access to health care for much of the US
population and have been uniquely successful at
delivering value-based care.24 The administrator
should take action to stabilize finances for inde-
pendent primary care providers by providing
prepayment to offset lost fee-for-service revenue
as a path to population-based payment.
Health Care Finance
238 Health Affairs February 2021 40:2
The CMS administrator can also play an im-
portant role in broadening value-based insur-
ance design. Expanding on existing pilot
programs in Medicare Advantage, the adminis-
trator should use the authority of the Center for
Medicare and Medicaid Innovation (CMMI) to
reduce cost sharing for cost-effective, high-value
services in traditional Medicare and Medicare
Advantage.
In addition, Medicare Advantage should be
strengthened. More than a third of Medicare
beneficiaries are now enrolled in Medicare Ad-
vantage plans.49 The program benefits from
strong bipartisan support50 and has catalyzed
the adoption of advanced value-based payment
models.21 Strengthening the program could po-
sition it to serve as a chassis for coverage expan-
sion. To achieve this goal, the administrator
should continue to increase flexibility for Medi-
careAdvantageplans to designnewbenefit pack-
ages, incentivize healthy choices, and redistrib-
ute funding to reduce disparities and improve
equity. As voluntary enrollment inMedicare Ad-
vantage begins to outpace that in traditional
Medicare in some regions, the administratorwill
need to reconsider financial models that deter-
mine benchmark payments as well. Finally, the
administrator should continue to explore new
approaches to sustainable risk adjustment for
Medicare Advantage plans.
TheCMSadministrator canhelp accelerate the
transition to value-based care by enforcing reg-
ulations that promote interoperability. Interop-
erable data exchange supports care coordination
and the delivery of high-quality, cost-effective
care.30 Although it was appropriate to delay en-
forcement of key interoperability provisions of
the 21st Century Cures Act in the context of the
COVID-19 pandemic, the administrator should
avoid any further delays.
State governors can also play an important
role in accelerating the transition to value-based
caremodels by expanding their use inMedicaid.
The penetration of value-based care in Medicaid
lags behind Medicare and commercial markets,
limiting the ability to achieve cost-effective,
high-quality care for vulnerable populations.
Governors, working with their Medicaid direc-
tors, should expand the use of value-based pay-
ment through Medicaid managed care contract-
ing and Section 1115 waivers. Governors should
aim to achieve the goal set by the Health Care
Payment Learning andActionNetwork of having
50 percent of Medicaid payments in advanced
value-based payment models with downside risk
by 2025.51
Advance Home-Based Care Toadvancehome-
based care, the CMS administrator should for-
malize changes to telehealth reimbursement.
Working with Congress where needed, the ad-
ministrator shouldmake permanent some of the
changes to telehealth reimbursement that were
instituted under the COVID-19 public health
emergency.Approaches could include continued
reimbursement at parity for audiovisual tele-
health visits, with more modest payments for
telephonic and asynchronous interactions. It
will be important to ensure that reimbursement
policies position telehealth as a substitute for
more expensive and less accessible sites of care
and do not induce unnecessary spending and
utilization.
The CMS administrator should also develop
reimbursement models for home-based care.
Under the authority of CMMI, the administrator
should create and test new payment models for
home-based acute, postacute, and long-term
care.
Improve Affordability Of Drugs And Oth-
er Therapeutics The FDA commissioner
should expand on recent efforts to reduce bar-
riers to generic and biosimilar development and
market entry with the goal of increasing compe-
tition, improving access, and reducing prices.
Potential strategies include enabling more effi-
cient pathways for the approval of safe and effec-
tive generic and biosimilar versions of complex
drugs that often face no or limited competition,
even after patents and exclusivities have lapsed;
closing regulatory loopholes that can be ex-
ploited to maintain a monopoly through the
granting of patents and other exclusivities; har-
monizing regulatory filing requirements for ge-
neric medicines with other global regulators;
and fostering the development of advanced
manufacturing platforms that lower costs and
improve quality and reliability. This is especially
important for biologics, for which manufactur-
ing challenges are a barrier to the entry of bio-
similars.
The FDA commissioner also should accelerate
efforts to build a robust real-world evidence pro-
gram and develop rigorous, science-based crite-
ria for how real-world evidence can be used to
inform decisions about the safety and effective-
ness of new therapeutics. Such a framework not
Any effort at reform
will occur in the
shadow of the COVID-
19 pandemic.
February 2021 40:2 Health Affairs 239
only would expand opportunities for pre- and
postmarket evidence on safety and efficacy but
also would be available to payers and other enti-
ties to support comparative effectiveness and
cost-effectiveness analyses. This infrastructure
is a prerequisite for any effort at value-based
pricing for therapeutics.
The CMSadministrator can also play a key role
in improving the affordability of drugs by devel-
oping value-based reimbursement models for
high-value therapeutics. Under the authority of
CMMI, the administrator should expand on re-
cent efforts to create and test new paymentmod-
els for prescription drugs,52 including reference
pricing, outcomes-basedpayment, andMedicare
Part B payment reform. As multiple models of
reimbursement are tested, it will be important to
both guard against and monitor for efforts at
gaming different pricing models.
Develop A High-Value Workforce Through
a partnership with state governments and pri-
vate payers, the HHS secretary should facilitate
the development and deployment of a national
workforce of community health workers. Evi-
dence suggests that such a programcould reduce
disparities, improve health outcomes, and lower
health care spending.5355 This workforce could
also aid in pandemic response (for example, con-
tact tracing) and support insurance education
and enrollment. Outside of the benefit to pa-
tients, it would provide valuable economic op-
portunity for the workers themselves, who
should be recruited from the historically disad-
vantaged communities they serve.
Governors could promote the development of
a high-value health care workforce by removing
barriers to affordable telehealth access. They
should, in collaborationwith state licensingbod-
ies, formalize changes to state licensure laws
made during the COVID-19 pandemic that re-
duce or eliminate the barriers facing out-of-state
providers who wish to provide telehealth ser-
vices and coordinate care across state lines.
Conclusion
As 2021 begins, there is pressing need and op-
portunity to reform health care financing to bet-
ter support access, affordability, and equity. Any
effort at reform will occur amidst the COVID-19
pandemic, which has placed unprecedented
strain on policy makers and public institutions.
There will simply not be the same capacity or
appetite for sweeping regulatory changes that
would have been present in other circumstances.
Limited attention and resources will require dis-
ciplined prioritization and a willingness to ac-
cept incremental progress and small wins. Fur-
thermore, reforms will need to occur under
increasingly strained federal and state budgets.
Achieving meaningful change in this environ-
ment will require significant resolve from policy
makers and public support for difficult decisions
(forexample, less coverage for low-value services
and technologies). We hope that the policy pri-
orities 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 US.
William Shrank reports equity holdings
in Humana and serving as a director at
GetWellNetwork. Nancy-Ann DeParle
(administrator of the Health Care
Financing Administration [HCFA], now
the Centers for Medicare and Medicaid
Services [CMS], from November 1997 to
September 2000) reports being a
director of CVS Health, HCA Healthcare,
Psychiatric Medical Care, and Sellers
Dorsey. Scott Gottlieb (commissioner of
the Food and Drug Administration from
2017 until April 2019) is affiliated with
New Enterprise Associates and CVS
Health and sits on the boards of Pfizer,
Illumina, Tempus, and Aetion. Sachin Jain
reports equity holdings in Anthem,
Merck, Blink Health, DataVant, Thrive,
Curisium, Valera, Firefly, and Vital and
serving as a director at Abode Hospice.
Peter Orszag (head of the Office of
Management and Budget from 2008
until July 2010) reports employment by
Bloomberg. Brian Powers reports
employment by Mass General Brigham,
prior employment by Anthem and
Fidelity Investments, and equity
holdings in Humana. He is the editor of
Healthcare: The Journal of Delivery
Science and Innovation (Elsevier). Gail
Wilensky (administrator of HCFA [now
CMS] from 1990 until 1992) is a
director for Quest Diagnostics Inc. and
UnitedHealth Group and a trustee for
the United Mineworkers of America
Combined Benefits Fund. The views
expressed in this article are those of
the authors and do not necessarily
reflect the position or policy of their
employers. 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.]
Health Care Finance
240 Health Affairs February 2021 40:2
NOTES
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