Learning from History: It’s Time to Invest in Public Health

This month marks the grim two-year anniversary of the COVID-19 pandemic changing life as we knew it. New York emerged as the original epicenter of the pandemic in the U.S.

To date, New York State has had nearly 5 million confirmed COVID cases and more than 67,000 deaths. Those numbers are chilling and behind them are real New Yorkers: family members, friends, coworkers, neighbors.

Certain images and memories from the early days of the pandemic are indelible. Here in New York City, the normal intense energy and hustle-bustle turned into an eerie ghost town. Zoom calls were punctuated by ambulance sirens wailing in the background. A field hospital was set up in the middle of Central Park. A front-page photo revealed health care workers wearing plastic garbage bags as gowns. A Navy hospital ship docked on the western piers of Manhattan, though it went almost entirely unused.

As painful as those memories are, we can’t forget them. Spanish philosopher George Santayana is credited with the aphorism, “Those who cannot remember the past are condemned to repeat it,” which he wrote in 1905. In a 1948 speech to the House of Commons, Winston Churchill paraphrased, “those who fail to learn from history are condemned to repeat it.” She’s not a famous statesman, but a friend of mine said recently, “At a minimum, can we at least make new mistakes instead of the same old ones?”

Santayana, Churchill, and my friend all had it right. We need to learn our lessons from past mistakes.

The main lesson: our public health infrastructure was woefully unprepared. For decades, we as a nation and as a State had disinvested in public health. In 2018, only 2.9% of total U.S. health spending went toward public health and preventive services. When COVID hit, we paid a terrible price for that neglect. We lacked adequate epidemiological surveillance. We lacked testing capacity. We lacked contact tracing. We lacked adequate supplies of personal protective equipment like masks and gowns. We lacked clear and coordinated public messaging. These are all elements of public health 101 — bread and butter functions that are essential to any outbreak of infectious disease. But we weren’t ready.

Despite the obvious and unnecessary devastation from that lack of preparedness, we keep repeating the same mistakes. When the Omicron variant first raced through the U.S. in December 2021, it was nearly impossible to find tests or high-quality masks. Just last week, Congress failed to approve additional pandemic funding that would have given the federal government the resources to invest in more testing, vaccines, and therapeutics. Nearly 1 million Americans are dead from COVID; have we learned nothing?

With COVID cases and deaths again trending upward in Asia and Europe, it’s clear that the pandemic is not over. We are all tired of it, but COVID isn’t done with us. We need adequate tools and resources to fight the ongoing pandemic. And we must prepare for the next inevitable public health emergency.

Here at home, we are making a bit of progress. A new report by Trust for America’s Health examines states’ performance on emergency preparedness. New York State’s overall performance improved between 2020 and 2021; we’re now in the middle of the pack of states and have moved up from the lowest tier.

We still have a long way to go. According to the New York State Association of County Health Officials (NYSACHO), budget cuts across all of New York State’s 58 local health departments over the past decade add up to more than $150 million. As a result, public health departments were stretched thin even before the pandemic. Between 2015 and 2020, local health department staff decreased by 7% while New York State’s population grew by 3%. Even more alarming, nearly 25% of local health department leaders have retired or left their jobs since February 2020. According to NYSACHO, 90% of local health departments in New York State don’t have enough staff to address basic community health needs. More than 1,000 additional full-time staff are needed across New York to provide adequate services.

I’m encouraged that New York may rise to the challenge. Recent budget proposals by the Governor and legislature all include additional funding for public health. That boost in funding could support increases in State aid for local health departments’ core work; health care worker retention bonuses and nurse loan repayment programs that could shore up the public health workforce; and additional resources for prenatal and postpartum care, mental health supports, and substance use treatment.

When it’s functioning well, public health can be almost invisible. Too often in the U.S., we take for granted that we have safe drinking water, that our kids are protected from lead poisoning, that disease outbreaks can be monitored and contained. But protecting public health requires careful planning and preparation, it requires money, and it requires a robust and skilled workforce.

On this anniversary of the pandemic, one way to honor those who’ve died from COVID is to learn from history. Stop repeating the same mistakes over and over. Don’t neglect public health — because we will surely regret it. Instead, let’s invest in public health and be better prepared the next time. We’ve learned things the hard way and we can do better.

By David Sandman, President and CEO, New York Health Foundation
Published in Medium on March 17, 2022

Photo: The U.S. Navy hospital ship USNS Comfort sails into New York Harbor as part of COVID-19 pandemic relief efforts in New York City in March 2020. Photo credit: nycshooter

The Super Bowl of Health Care Prices

When the Super Bowl rolls around each year, some people care more about the mega-expensive ads than the game itself.

While the LA Rams came out on top, the consensus winners of the advertising competition seem to be Uber Eats, Flamin’ Hot Doritos, and Google Pixel 6. It’s the one time of year that viewers look forward to commercials instead of hitting fast-forward. And the prices reflect that; a 30-second spot cost a record-breaking $6.5 million.

A lot less expensive, but perhaps more important, were ads flying above Los Angeles as part of the Power to the Patients campaign leading up to the big game. Featuring artwork by Shepard Fairey (who did the famous Obama Hope poster), they promoted price transparency in health care. One version of the ad says, “Prices are now a patient’s right. Demand them!” Another version uses the tagline “Demand Hospital Prices.”

Behind the bold graphics was a public policy reality: hospitals are now required to disclose their prices, thanks to a federal rule that took effect in January 2021. The rule requires hospitals to publish online the standard charges for their services, providing the information in two ways: (1) machine-readable files for all hospital services and (2) consumer-friendly displays of 300 common “shoppable” services. The rule is imperfect, but it’s a start on lifting the veil of secrecy that has long shadowed health care pricing and left consumers in the dark.

Yet, multiple analyses have found that compliance is low and that true transparency remains elusive. A new report found that only 14.3% of hospitals nationwide were complying with transparency requirements. And compliance was only 0.5% among hospitals that are part of the nation’s three largest hospital systems.

To be fair, the rule took effect at an especially trying time for hospitals. Given the enormous strain of the COVID-19 pandemic, it’s not surprising that implementing price transparency measures hasn’t been many hospitals’ top priority. And the penalties for noncompliance have been quite weak. As of December 2021, the Centers for Medicare & Medicaid Services had issued only 335 warning notices to hospitals that hadn’t adequately implemented the rule. Those warnings outlined specific issues for hospitals to address, but none included a financial penalty. (The rule allowed for penalties of up to $300 per day in 2021 for noncompliance — a relatively tiny amount, particularly for larger hospitals — although that daily maximum increased to $5,500 this year for hospitals with more than 30 beds.)

No rule is going to work without adequate enforcement. But levying fines will also only get us so far. Using a different lens that focused on whether hospitals were embracing the spirit if not the letter of the transparency rule, Manatt Health (with support from the New York Health Foundation) recently examined New York hospitals’ compliance and concluded that most had made incremental progress. That analysis found that 69% of New York’s hospitals had only partially implemented the requirements for machine-readable information, while 69% had implemented the shoppable services requirement.

The Manatt report also highlights examples of effective approaches to price transparency that can serve as models for hospitals that may be further behind in implementation. The most effective examples of machine-readable files were those that made it easy for a broad range of audiences (including researchers, data aggregators, app developers, and other hospitals, as well as consumers) to find pricing information that is comprehensive, accurate, and comparable across the industry. For example, many hospitals provide a single Excel file with a single Excel sheet inclusive of the required information, separated by columns; this approach makes it easy for the information to be used, sorted, shared, and compared. In the case of shoppable services, the most effective implementation included a consumer-friendly online price estimator tool to help individual consumers shop for services based on price. These are easy to find on a hospital’s website; ask the user simple, plain-language questions to guide them in their search; and provide clear estimates of a consumer’s expected out-of-pocket costs for the specified service.

Beyond the technicalities, what matters is hospitals’ desire to embrace the spirit of the law and not simply the letter of the law. Providers should want their patients to have meaningful information so they can make smart choices that provide value for money. And it’s possible. I’ve written before that “Where There’s a Will There’s a Way.” Even before the new rule took effect, pioneering hospitals were sharing price information in meaningful ways and meeting many of the requirements. Early adopters recognize that the most frequent “pain points” for patients at hospitals involve their financial experiences, and they believe that patients who know the price ahead of time are more likely to pay.

I’ve also said this before: health care transparency alone isn’t going to bring down health care costs or fix a broken system. It isn’t a magic bullet and there are serious limitations: a lot of care isn’t shoppable, the ways that prices are presented to consumers aren’t comprehensible, high prices might be used by some as an inaccurate proxy for quality, information has to be paired with financial incentives, and some people are in insurance arrangements that make them immune to the need for price information.

But information is power, and we should continue to demand more and better transparency in health care. Secrecy has been monetized — to the detriment of the consumer. A reckoning in health care is coming — perhaps its own kind of Super Bowl, where providers who deliver high-quality care at fair and transparent prices will come out on top.

By David Sandman, President and CEO, New York Health Foundation
Published in Medium on February 17, 2022

A Wish List for 2022

This year began with great optimism, as COVID-19 vaccines became available and an end to the pandemic seemed within reach.

And with vaccines, treatments, and continued behaviors like masking, hand-washing, and social-distancing, we’ve made strides in putting the worst of the pandemic behind us. But the rise of new viral variants, vaccine hesitancy, misinformation, and the politicization of public health have resulted in swings of the pendulum and continuing uncertainty. For better and for worse, we’ve all learned to live with new realities in the COVID era.

It has become an annual tradition for me to share a wish list for the coming year. Wishes can come true, if you make them so. In 2021, an item that had been on the list for years came to pass: New York State enacted universal access to Veterans Treatment Courts for every veteran who needs one. Veterans dealing with mental health and/or substance use issues will receive treatment and an opportunity to get their lives back on track, instead of being trapped in the revolving door of a justice system that is not equipped to meet their needs. I’m optimistic that more wishes can come true.

Here are my wishes for 2022:

1. An end to COVID and the building of a more equitable health system. I don’t know if we’ll ever be able to fully end COVID, but I’m hopeful we can at least get it under control. And as we emerge from the pandemic, we must address the structural challenges and failures it glaringly revealed. The pandemic is just the most recent example of racial health inequities, with death rates and hospitalization rates roughly twice as high for Black residents as for their white counterparts. Black and Hispanic New Yorkers are also less likely to have health insurance and adequate access to care and more likely to experience food insecurity, complications with childbirth, chronic health conditions like diabetes and asthma, and premature death. These disparities have long existed, but the pandemic and our national reckoning on racial equity have laid them bare and made them impossible to ignore. As we rebuild our health care and public health systems, we need to do so in a way that prioritizes and ensures equity.

2. A rebalanced health system built on primary care. We also need to build a system that emphasizes and invests adequately in primary care. A slew of research (which I outlined in a blog post earlier this year) supports the benefits of primary care: more access to preventive services and screenings; fewer hospital visits; fewer emergency department visits; and fewer surgeries, to name just a few. And yet we chronically underinvest in primary care even as we extol its virtues. New York can strengthen and invest more in primary care without increasing the total cost of health care. Proposals are circulating in Albany to define and measure our baseline spending on primary care, set targets for enhanced investments in primary care, and test out pilot programs to identify the most promising models. There’s no reason to wait; this work needs to happen now so we can start putting our money where our mouth is.

3. Healthy food for all, aided by collective purchasing power. Healthy food is a necessity, but too many New Yorkers lack stable access to affordable nutritious food. Through its agencies and public institutions, New York State purchases and serves hundreds of millions of meals annually in venues like schools, hospitals, correctional and long-term care facilities, homeless shelters, and senior and childcare centers. Before the COVID-19 pandemic, the State spent more than $957 million a year on food to feed 6.6 million people; New York City alone spends more than $500 million a year. Given their massive scale, public institutions can harness their purchasing power to buy foods of higher nutritional value, lower costs, and transform the State’s food systems. We’re seeing progress at the local level — including in New York City and Buffalo — through a model called the Good Food Purchasing Program. Implemented well, this approach will allow municipalities to provide healthier meals to millions of New Yorkers.

By David Sandman, President and CEO, New York Health Foundation
Published in Medium on December 15, 2021

An Affordable Feast for All

As many of us look forward to celebrating Thanksgiving with family and friends next week, we’re also bracing for the added hit to our wallets.

A recent piece in The New York Times put it bluntly: “Thanksgiving 2021 could be the most expensive meal in the history of the holiday.” Almost all ingredients — from turkey to sweet potatoes to coffee — are expected to cost more. A range of factors — from supply chain issues to labor shortages to inflation to extreme weather — contribute to the rising cost.

Higher prices affect everyone, but especially so for those who are barely making ends meet. More than 2 million New Yorkers — including more than 625,000 children — are facing hunger, according to Feeding America. Especially in high-cost states like New York, food-insecure families have to make agonizing choices: Buy food or pay rent? Buy food or cover the electric bill? Buy food or get medicine? Put food on the table or send children to bed hungry?

Fortunately, some help is on the way. Earlier this year, the Biden Administration announced the largest permanent increase in Supplemental Nutrition Assistance Program (SNAP, also known as food stamps) benefits since the program’s inception. Average monthly benefits have now increased more than 25% over pre-pandemic levels, to about $157 per month. For the 2.7 million New Yorkers — and roughly 42 million people nationwide — who depend on SNAP, that additional assistance could make the difference between going hungry and having a healthy Thanksgiving meal.

Prior to this increase in benefits, a national survey found that nearly 90% of SNAP recipients reported facing some type of barrier to achieving a healthy diet. Not surprisingly, the most common barrier was the affordability of healthy food. When budgets are tight, sometimes cheap, calorie-dense foods like pasta and fast food are the only viable option. The enhanced SNAP benefit will put more nutritious, delicious, and culturally appropriate food in reach of more New Yorkers.

A boost to SNAP benefits also means a boost to local retailers, particularly when the economy is weaker. Increased SNAP spending could help jumpstart local economies as we emerge from the COVID-19 pandemic.

Of course, there is always more work to be done. Besides spending more money on benefits, we have to make programs work better. Enrollment processes should be improved and simplified. Congress recently introduced a bill that would require student financial aid forms to inform college students about their eligibility for SNAP benefits. Hunger is a problem on college campuses, but SNAP enrollment rates among college students tend to be low, largely because those who qualify often don’t know they’re eligible.

Here in New York, Governor Hochul recently signed legislation that, pending USDA approval, will allow homeless, disabled, and elderly New Yorkers to use SNAP benefits to purchase reduced-price meals from participating grocery stores, delis, and restaurants. SNAP benefits cannot normally be used to buy prepared meals. New York has also implemented numerous nutrition incentive programs like Double Up Food Bucks, which help families stretch their SNAP dollars even further at farmers markets and some retail establishments to encourage healthy food purchases. (The New York Health Foundation prepared an overview of the range of nutrition incentive programs, which are funded and administered by different entities and vary in how they operate, including eligibility requirements, geographic availability, distribution method, and incentive amount.)

Hunger Solutions New York has laid out a number of ideas for further improvements. For example, the State could do more to identify Medicaid recipients who are not enrolled in SNAP to allow for more targeted outreach. Similarly, we should identify opportunities to enroll seniors, community college students, and people newly reentering their communities after incarceration. Nutrition incentive providers should work with retailers to increase the types of food purchases eligible under nutrition incentive programs to include canned and frozen produce. Doing so would help families stretch their budgets further and encourage healthier eating.

Thanksgiving is my favorite holiday. In my family, as in so many others, food equals love. Food also equals medicine, and tradition, and culture, and dignity, and inclusion, and health. I wish a happy holiday to you and your families, and I hope that all New Yorkers will enjoy a bountiful and healthy meal on Thanksgiving and every day.

By David Sandman, President and CEO, New York Health Foundation
Published in Medium on November 18, 2021

Simpler and Easier: What Patients Want and Need

The seasons are changing and the weather is getting cooler. That transition means some nice things: the brilliant colors of fall foliage, hot apple cider, and maybe a snowy winter. It could also bring some not-so-nice things like the onset of flu season.

The 2019–20 seasonal flu infected more New Yorkers—almost 160,000—than ever previously recorded by the State. By comparison, last year’s flu season was mercifully mild; New York had 97% fewer cases compared with the prior year. Flu activity was also unusually low nationally and globally. COVID-19 mitigation measures like mask-wearing, hand-washing, and social distancing likely helped keep flu rates low, but flu vaccination was also at a record high during the 2020–21 season; Particularly with COVID-19 raging, it was vital to ramp up flu shot rates to limit preventable deaths and avoid further straining a health care system that had been pushed to the breaking point.

As we continue to navigate the COVID-19 pandemic, controlling this year’s flu season will be just as important. Public service advertisements are running widely urging all New Yorkers—especially children under age 5, adults over age 50, and people who are pregnant or may be pregnant—to get their flu shots. Getting a flu shot is one of the most basic public health measures you can take to protect yourself and others from illness. It should be easy, simple, and free.

In my case, it wasn’t. Across the street from my apartment building is huge chain drugstore (they seem like they’re on every block in NYC). I’ve been spontaneously walking in there for years now and getting my annual flu shot; no fuss, no muss. I strolled in ready to roll up my sleeve, but this time they refused to give me a vaccine without an appointment. There was literally no one else there, which I pointed out. They said it didn’t matter, maybe people were coming who had an appointment. I said I was happy to wait, wasn’t trying to cut a line, and that I was there and ready to go. But they were adamant: no appointment, no shot. They seemed a lot more interested in following rules than providing health care.

Frustrated, I walked half a block away to the nearest urgent care center. They said sure I could walk in, and it would cost me $25. Why the charge? Thanks to Obamacare, health plans cover a set of preventive services—including flu shots—at no cost to the patient. This $25 “fee” was just outright profiteering, and a barrier to the promotion of a core public health measure. No thanks. It would’ve been free at the drugstore had they been willing to give me my shot.

Now beyond frustrated, I went back to my apartment to make an online appointment at the drugstore across the street. One of the scheduling options was “I’m here now and ready.” (I couldn’t make this up if I tried.) I clicked it, completed the registration, and was granted an appointment for 5 minutes later. I ran back downstairs, got my shot, and walked out.

In some ways, this story is nothing but one of those minor irritations of daily life. I don’t want to sound whiny; I know I have a host of privileges that made this a lot easier for me than it would’ve been for others. I have health insurance. I had the time to weave through this stupid obstacle course to a flu shot. I could’ve afforded the $25, but I also know enough about health policy to know when health care should be free. And I live in a city saturated with pharmacies and other convenient locations for flu shots; it wouldn’t have been so easy for me if I lived in a rural area, where I might have had to drive 30 minutes or more to the nearest drug store, only to be turned away.

The issue is that the story illustrates all too common patterns that characterize a health care system that is not patient-friendly or consumer-centric. We talk all the time about meeting patients where they are, making health care easy and convenient, eliminating barriers, and so on. But I faced a set of wholly unnecessary and arbitrary barriers that made it hard to get health care for myself. And it’s not just about me—flu shots are public health guidance for the good of the population.

As we continue to battle COVID, these reminders about eliminating or at least lowering barriers in health care are especially relevant. To boost vaccination rates, people have gotten creative. Mobile vans are roaming the streets to deliver on-the-spot vaccines, no appointment needed and free of charge. New York City residents can get $100, free tickets, free transit passes, memberships, or gifts for getting vaccinated against COVID-19. Vaccinated people can enjoy giveaways from Krispy Kreme, Shake Shack, and Crunch Gym (at least one of those options is healthy). There are headline-grabbing approaches like million-dollar lotteries, and “shots for shots” events at local bars. Combined with traditional approaches like patient education, all these efforts are designed to make getting vaccinated easy, simple, and rewarding.

One day, the COVID pandemic will be over. But the need to make health care simpler won’t cease. The futurist Ian Morrison offers 4 principles of reducing complexity in health care:

  • Simplicity requires hard work. Just because the patient experience is clear, that does not mean complex structures aren’t operating behind the scenes.
  • Simplicity benefits both providers and patients. Such a business model is easy for consumers to understand, and makes financial sense for providers.
  • Simplicity requires technology. Expect the future to become increasingly digital.
  • Simplicity will put patients at the center of care.  Always consider the patient’s perspective first to develop simple solutions and processes.

I got my flu shot. It wasn’t simple or easy, but I got it which is good for me and for the health of the public. For health care as basic and important as that, there should be no obstacles to maneuver or hoops to jump through. I encourage you to get your shot too, and let’s put those principles into practice as we rebuild systems that empower consumers and promote health.

By David Sandman, President and CEO, New York Health Foundation
Published in Medium on October 12, 2021

It’s Still the Prices, Stupid

The late, great economist Uwe Reinhardt and colleagues published a seminal 2003 paper titled, “It’s the Prices, Stupid,” to explain why U.S. health care spending was so different from that of other industrialized nations.

The answer: higher prices, not higher utilization of services. The authors found that the U.S. spends more on health care than any other country and “the difference in spending is caused mostly by higher prices for health care goods and services in the United States.”

If prices are the main driver of high health care spending, it’s even more astonishing that prices have long been shrouded in secrecy. Historically, it’s been almost impossible to know ahead of time what you can expect to pay for a health care procedure or service. This remains true even as consumers are increasingly on the hook for larger shares of the bill. I hope you have a lot of time and patience if you decide to take a trip through the twilight zone of health care costs.

About two years ago, I wrote about a baby step toward greater price transparency. Back then, a then-new federal rule took effect requiring that all hospitals post online the prices of surgery, procedures, and medications. It was better than nothing, but it was seriously deficient. Hospitals were then required to post their so-called “chargemasters.” The numbers included in chargemasters often bear no relation to what patients can expect to pay, so the information is not especially useful or actionable. Still, it sent a strong signal about the growing expectation for transparency in health care and it opened the door to progress. And others agreed; colleagues at the Commonwealth Fund wrote that “there’s no question that the tectonic plates of public policy are shifting on the issue of price transparency.”

Fast forward to now, and that shift is obvious. In January of this year, another federal rule took effect on price transparency that goes beyond the fantasyland of chargemasters. Hospitals must now disclose the real, negotiated prices with insurers on an easily accessible public website. Plus, there must be a consumer-friendly display of at least 300 shoppable services that consumers can schedule in advance.

It’s progress for sure, but we are far from the end game. Compliance with the rule has been uneven. And even when there is technical compliance with the rule, very few have embraced the spirit of the rule. That’s not surprising; the American Hospital Association and others unsuccessfully sued to try to block the rule from ever taking effect. An analysis by The Wall Street Journal earlier this year found that many hospitals had used special coding to block their price information from web searches. And a recent New York Times article, called “How to Look Up Prices at Your Hospital, if They Exist,” shows just how difficult it remains to find pricing information easily.

Why so much secrecy? Because the rule is further revealing just how irrational health care prices can be. Last month, The New York Times published some of the findings from an analysis in partnership with researchers at the University of Maryland-Baltimore County. They examined prices at 60 major hospitals; the findings range from head-scratching to jaw-dropping to blood-boiling. Consider these examples:

  • At one hospital in Philadelphia, they found that a pregnancy test may cost $10 (without health insurance), $18 (for Blue Cross patients who live in Pennsylvania), $58 (for Blue Cross HMO patients who cross the bridge from New Jersey), or $93 (for Blue Cross PPO patients from New Jersey). Same test, same facility—and a ninefold difference in the price, depending on where you live and what insurance you have.
  • At a Florida hospital, the cost of an MRI ranged from $262 with a Medicare plan to nearly 10 times as much—$2,455—with a Blue Cross plan.
  • And at a Milwaukee facility, the price for an MRI is $1,093 with a United HMO plan, compared with $4,029 for patients in a United PPO plan.

The examples are endless, but you get the point: prices are all over the place, they’re arbitrary, and it’s no wonder so many places don’t want us to see what they are. And by the way, these dynamics occur in every part of the health care system. Prescription drug prices may be even less transparent and make even less sense. Weird but true: it’s sometimes cheaper to pay cash and not use your insurance for medications. And until very recently, pharmacists were bound by “gag clauses” that prevented them from telling you that.

I’ve said it before and I’m sure I’ll say it again: health care transparency alone isn’t going to bring down health care costs or fix a broken system. It isn’t a magic bullet and there are serious limitations: a lot of care isn’t shoppable, the ways that prices are presented to consumers aren’t comprehensible, high prices might be used by some as an inaccurate proxy for quality, information has to be paired with financial incentives, and some people are in insurance arrangements that make them immune to the need for price information.

But information is power, and we should continue to demand more and better transparency in health care. Secrecy has been monetized—to the detriment of the consumer. Dr. Reinhardt’s words still hold true today: focusing on prices is key to controlling spending and maximizing value from our health care dollars.

By David Sandman, President and CEO, New York Health Foundation
Published in Medium on September 21, 2021