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Strengthening Our Public Health Infrastructure: COVID-19 Lessons

Summary

Amid the continuing pandemic and calls for healthcare reform, the new administration seeks to confront the myriad public health issues facing our country today.

The importance of public health continues to be elevated among US policymakers, healthcare providers, and the general public, as evidenced by the renewal of the COVID-19 public health emergency last month. Rising costs of healthcare, increasing prevalence of conditions that are often preventable, declining life expectancy, and other related trends all point to a need to better promote and protect the public’s health. And yet, public health funding has decreased by almost 30%, and state and local health agencies have lost 13% of their workforce over the past decade, representing a significant loss of public health infrastructure and an impediment to improving health.

The new administration confronts many health crises facing our country, necessitating strategies to address public health as we continue to work toward meeting the Healthy People 2030 objectives to improve Americans’ health and well-being. These strategies include responding to the COVID-19 pandemic, which has increased rates of unemployment (and underemployment) and presented many other barriers to good health for Americans across the country. The following Insight, which serves as an update to our previous Insight about 2020 presidential candidates’ public health platforms, focuses on priorities for the Biden administration related to nutrition, opioids, mental/behavioral health, and health disparities. While this is not an exhaustive list of the current issues and opportunities, it includes those both aggravated and elevated in public importance over the past year.

Promoting Good Nutrition Is Critical for Preventing Chronic and Infectious Diseases

Amid the continued rise in obesity and diet-related diseases and the continued need to control rising healthcare costs, good nutrition is increasingly recognized as critical in preventing and managing disease. Further, the COVID-19 pandemic has highlighted important links between a nutritious diet and resilience against infectious disease. The release of the 2020–2025 Dietary Guidelines for Americans at the end of 2020 (which is the first iteration to address nutritional needs at different life stages across the lifespan), continued news about the public health problems associated with food production—such as antibiotic resistance and water pollution—as well as COVID-19 outbreaks in meat-processing facilities were all prominent news stories in 2020. These issues all brought increasing attention to food production and supply chains, the desire for greater transparency in the food supply, and fundamental change in our food and farming policies by the new administration. However, the appointment of USDA Secretary Vilsack, who previously served under the Obama administration, suggests similarity in approach for President Biden’s food and farming policies.

Adding to efforts from the Trump administration, the Biden administration has taken emergency action to address pressing needs during the pandemic. For example, an executive order signed on January 22 allowed states to expand Supplemental Nutrition Assistance Program (SNAP) and increase benefits to low-income children participating in the National School Lunch Program through the temporary Pandemic Electronic Benefit Transfer.

Though it preceded President Biden’s inauguration, the NIH’s release of its strategic plan to accelerate nutrition research last spring—with 3 of its 4 goals focused on the role of food in health promotion and intersecting with priorities such as health disparities and data science—indicates a greater focus on generating evidence related to nutrition to advance its role in “improving public health and reducing disease.” The Biden administration’s focus on nutrition throughout its campaign has been primarily on addressing the “hunger crisis”; this is anticipated to continue as goals of his administration include expanding access to SNAP, expanding access to free school lunch, providing grants to colleges to address student food insecurity, and more. It remains to be seen how the administration will address the continued patterns of poor diet and food behaviors among the general population.

Continued Rise in Mental and Behavioral Health Conditions Top of Mind for Stakeholders

The COVID-19 pandemic has limited access to in-person mental health counseling at the same time as the disruption of daily life caused an increase in the number of individuals seeking care. According to a study by the National Council on Behavioral Health, 52% of mental health provider organizations reported an increase in demand for mental health services, but 65% had to turn away, cancel, or reschedule patients due to COVID-19. To respond to the increase need, President Biden committed to expanding access to mental health care and behavioral health services. As part of this effort, Biden proposed better enforcement of mental health parity laws (which require equal coverage for mental health services as traditional medical services), establishing federal standards on mental and behavioral health coverage, and increasing the size of the mental health work force. Additionally, Biden’s previous proposals to strengthen the Affordable Care Act, expand Medicaid, and create a public insurance option could offer new pathways for individuals with mental or behavioral health conditions to obtain affordable and quality health insurance.

Telehealth is also an important means to expand access to behavioral health care. The pandemic has accelerated trends in telehealth utilization, as regulatory flexibilities have allowed individuals to use interactive apps with audio and video capabilities to meet with their clinicians and for clinicians to be reimbursed for a broader range of services. Following the public health emergency, the Biden administration will need to consider the benefits of telehealth counseling when deciding whether to rescind or revise these flexibilities to include behavioral healthcare, which may influence reimbursement for those who are commercially insured.

COVID-19 Has Both Exacerbated the Opioid Epidemic and Made It More Challenging to Address

Addressing the opioid epidemic could be particularly challenging given the impact of the COVID-19 pandemic on opioid/substance use disorders (OUD/SUD), as well as the potential disproportionate effect of COVID-19 infection on certain populations with SUD. While COVID-19 has increased stress and poor mental health that may lead to SUD, mitigation strategies (e.g., social distancing and business closures) have limited access to opioid abuse prevention and therapies. Likewise, pandemic-related unemployment, housing and food insecurity, isolation, and stress could trigger misuse of opioids and other substances. People with OUD are particularly vulnerable to discrimination and stigma, and are more likely to experience homelessness and enter correctional facilities, which report high rates of COVID-19; a recent study event suggests they are more likely to contract COVID-19 and suffer complications.

During his campaign, President Biden outlined a national plan to end the opioid crisis, which comes after the Trump administration’s 2017 5-Point Strategy to Combat Opioid Abuse, Misuse, and Overdose. Among other priorities, Biden’s plan aims to improve access to opioid prevention, treatment, and recovery services; reform the criminal justice system; and expand use of effective pain management. Developing a comprehensive plan to address the opioid epidemic will require implementation of evidence-based strategies and policies (e.g., expansion of comprehensive pain management) and public-private coordination at all levels of government. Given the impact of the COVID-19 pandemic on access to vaccines, various treatments, and other preventive care, the Biden administration may need to take a holistic approach—such as that outlined in a recent report by the National Academies of Sciences, Engineering, and Medicine—to address OUD, SUD, and associated infectious diseases. Such a strategy would present opportunities for testing alternative payment models that incentivize coordinated care as well as support for the development of non-pharmacologic, non-opioid pain therapeutics.

COVID-19 Has Further Exposed and Widened Preexisting Inequalities in the US Healthcare System

The disproportionately higher COVID-19 hospitalization rates and death rates among racial minority groups come as no surprise to public health experts, who for years have shown that social and economic factors affect healthcare access and outcomes. For example, early data reveal disparities in vaccination rates between different racial and ethnic groups. Further, recent data from the CDC showed that while overall US life expectancy fell by 1 year during the first half of 2020 (i.e., the first wave of COVID-19), it fell by nearly 3 years for Black Americans. Spurred by the COVID-19 crisis, the Biden administration has started to address health equity in a variety of ways. New CDC Director Rochelle Walensky has highlighted the need to address the US’ fragile public health infrastructure that widened health outcome disparities during the pandemic. The appointment of Dr. Marcella Nunez-Smith as head of HHS’ COVID-19 Health Equity Task Force represents the first time a presidential advisor has been specifically tasked with reducing racial disparities in healthcare. In addition to focusing on outreach and communication for underserved minority groups, the task force also aims to improve the collection and use of data and address shortfalls in the use of data representing underserved minority groups. Indeed, an executive order signed on January 21 signaled the need for enhanced public health data collection, analytics, and systems, which Nunez-Smith says are key for informing and driving policies.

Collection and analysis of data on social determinants of health (SDOH) are currently piecemeal and disjointed since claims data rarely capture this information. The level of data collected is also a concern. As Avalere has highlighted, analyzing data at a 9-digit zip code level can allow for more accurate predictions of both health behaviors and outcomes than with 5-digit zip codes. Opportunities to pinpoint and address health disparities range from implementing consistent SDOH information to collecting data at more granular levels.

Conclusion

With new leaders and programs in place, the administration is already taking actionable steps to find solutions to longstanding public health issues and narrow the gap of health disparities that are taking a toll on populations across the US. Important next steps include reinvesting in our nation’s public health system, enhancing our capacity for program evaluation and data collection (spanning from genomics of infectious agents all the way to epidemiologic trends), and reinforcing science-driven public health education and communication. These steps can help to improve our resilience, productivity, and quality of life in the aftermath of the COVID-19 pandemic and into the future.

Stakeholders throughout the healthcare industry can play an important role in creating these solutions. Healthcare providers and administrators can conduct and publish research on cross-sector interventions involving public-facing programs that seek to improve health measured even down to the individual patient level. Expanding use of Z-codes to document SDOH and other non-clinical factors influencing health status can also help to better track and address patients’ needs outside of clinical settings. Nonprofit hospitals can optimize strategies to address findings from community health needs assessments to target their community benefit dollars toward local initiatives that can best meet their communities’ needs.

Health plans should act proactively to develop and evaluate strategies to meet needs for public programs among their local populations, facilitating tighter links with appropriate programs and evaluating what could be most efficiently offered through their benefit packages. And by similarly developing strategies to better meet the non-medical needs of their end users—particularly those with complex conditions—life sciences companies can help patients to better comply with treatment plans, manage their diseases, and avoid unnecessary care. As the pandemic has limited patients’ access to care management and services, this is particularly important for being able to continue to provide holistic, patient-centered care. Together with the Robert Wood Johnson Foundation, Avalere released a research agenda for health equity for its Health Systems Transformation Research Coordinating Center in 2020. We look forward to continuing to work with such partners to address these issues and strengthen our nation’s public health system.

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