Health Policy

Nancy Nielsen, MD ’76, PhD, senior associate dean for health policy and clinical professor of medicine in the Jacobs School of Medicine and Biomedical Sciences. She is a former president of the American Medical Association.

By Nancy Nielsen, MD ’76, PhD

Health policy decisions underpin the structure and function of any health care system. They determine how and where care is delivered, what is encouraged or discouraged, how care is paid for, and who benefits in the high-tech, innovative and entrepreneurial environment that makes up our current health care enterprise.

For more than a decade, health policy has taken center stage in the national debate, beginning with enactment of the Affordable Care Act (ACA) in 2010. At that time, nearly 20 percent of Americans had no health insurance and medical costs were the number one cause of personal bankruptcy. The number of uninsured has since been cut in half. Quality has improved somewhat, but medical care in the U.S. costs more, by far, than anywhere in the world. Tremendous medical advances are available, but equitable treatment for all has been elusive—we can’t decide if health care is a right or a privilege. This is not a new problem; policy-makers have grappled with it dating back to the time of Theodore Roosevelt.

Twenty-five years from now, any number of issues will require health-policy decisions to maximize benefit and reduce negative consequences. For example, artificial intelligence holds great promise for predictive modeling, risk assessment, improving diagnoses and therapeutic approaches. It can be used for remote monitoring and to facilitate communication between patients and clinicians. But the promise of these tools demands a careful analysis of ethical, legal, privacy, and equity-related issues.

Privacy concerns will loom large in 2046, when monitoring of big data is routine. Legal matters ranging from confidentiality to intellectual property rights will require attention, as will data security and the proper balance between commercialization and government investment in research.

American angst surrounding whether health care is a right or a privilege will remain, with movement toward “a right,” but vigorous partisan debates about financing will continue. Employer-based health insurance will remain, but will decline in prominence, giving way to a new public option for those who don’t have insurance through work and don’t qualify for Medicaid or Medicare. Medicare for All will not be enacted. The administration of government plans will be increasingly outsourced to commercial insurers, with growth in Medicare Advantage and privatization of Medicaid.

Physicians will derive much of their income from “pay for value” or “population-based pay”; fee for service payments will decline dramatically. More physicians will seek employment arrangements, rather than enter private practice. Consolidation of medical groups will accelerate, and more will align with, but not be employed by, hospital systems or insurers. Telemedicine will be routine, involving all specialties; it will cross state lines and will be paid on par with face-to-face encounters. With technology, in-person encounters will be fewer but more meaningful.

Chronic illnesses will be managed with wearable devices and remote monitoring tools. Some conditions that now call for hospitalization will be managed at home using advanced technology, real-time feedback and precise, individualized therapeutics.

New categories of health care workers will emerge, including monitoring technicians, population health specialists and sophisticated data analysts who can translate artificial intelligence into actionable items. Biomedical engineers will be integral to research and clinical care.

There will be increasing emphasis on understanding and influencing human behavior, so patients can live healthier lives, better understand their chronic conditions and take effective action. Motivational interviewing will become an integral tool for physicians in all specialties. Behavioral health will ascend in prominence in medical schools and residency programs.

For them to be prepared to shape future health policy, our medical students should be exposed to leadership training, and become well-versed in team science and data analysis. If we are to make health care equitable, there will need to be diverse voices in the ranks and in leadership, and tough conversations at the policy table.

There will always be tension between what may be ideal and what is doable. The powerful voices of physicians can influence decision-makers to craft benevolent, effective policies that will improve the health of all of us. That’s health policy in action.