Crittenden: Politics will stand in the way of meaningful reform


DJ Wilson’s proposal, which he lays out in “The Special Session: Re-imagining hospital and community health funding,” is both interesting and good place to begin our discussion about the future of health care among the states.  Given the COVID-19 experience we are in, the future health care system will change – but how much and in what ways?

Rural hospitals have been on the brink of disaster for years and are more so now. Our hospitals are only providing care for very sick people, primarily people with COVID-19.

Meanwhile, they are losing their most profitable business – elective surgeries. Primary care clinics and specialist offices are empty with physicians doing more tele-health than ever – but fewer visits than before. All are hurting and will come to the state and federal government asking for fiscal relief.

Public Health – the chronically financially starved segment of health care – has risen to the occasion and provided real leadership during this crisis.

They have done a remarkable job – developing a BMW response on a duct taped tricycle infrastructure.

We could change our hospital financing system to look more like Maryland, but that alone would not be sufficient.  Maryland has changed incentives and has decreased re-admissions, unneeded emergency room use and increased a focus by hospitals on chronic illnesses. These are the people who cost us all a lot of money.

But this system has not saved money overall and has allowed the costs to move to other cost centers, like freestanding surgicenters and increasing drug costs. Focusing on hospitals is not enough.



Maryland’s financing system for hospitals parallels the systems in France, Switzerland, Japan and Germany.  But those countries have inclusive systems that also include universal coverage, pharmaceutical negotiation, support for care by doctors both specialties and primary care in ways that improve care and are not overpriced.

They have systems that address the social determinants like vaccines, public health, housing, behavioral health and food access. Other countries have decision mechanisms to rationalize and balance funding between hospitals, doctors, pharmaceuticals and social needs.

The US does not have those mechanisms and does not allocate money in a way that focuses on improving health. And, it turns out that health care has a much smaller impact on our health than having a home, a job, sufficient healthy food, a place to exercise and a supportive community.

We absolutely need health care, but DJ is right: we do not allocate the huge amount we now invest in health care in a way that improves our health. We were the healthiest country in the world, yet we are in last place behind all developed countries and many underdeveloped countries.



The COVID crisis is an opportunity for us to re-examine our approach and hopefully make improvements. But, our political system is slow moving and requires broad support for large changes.  Most of the groups now negatively impacted by the COVID crisis are not asking to change what they are doing, but would like to be bailed out so they can go back to normal operations.

If these groups are asking for more funding from tax payers, there is a need to pay for improvements and not a continuation of a system that supports us being the least healthy people in the developed world.

Hospitals should have an incentive structure to keep people healthy and not prioritizing high cost services. Health providers do need budgeting that supports essential services like rural hospitals and systems that focus on improving community health. They need to provide specialty care and pharmaceuticals that are affordably priced.

We need primary care that can provide the team based care like behavioral health, connection with community services and patient education that can make us healthier. And, we all need community health support so barriers are removed and all of the people in our community can be healthy.

But, to change health care financing and systems substantially will raise the hackles of a system that is (at least was) doing very well.

Urban hospitals, surgicenters, many physicians, pharmaceutical companies and the huge cadre of for-profit suppliers for health services will resist change.

At the national and state level, these stakeholders do not want the comprehensive changes that DJ has outlined.  They do not want financial limits on hospitals, doctors and drugs. The adoption of the ACA was only possible by neutralizing some of the groups that could stop the bill.

Making a change as large as that outlined by DJ will activate and align the health industry and progress would be stopped.

So, without an aligned vision by the public and provider, insurers and payers all asking for a change, we will be stuck with a fragmented, inefficient, poor functioning and expensive health care system that leaves poor and brown people with worse health outcomes.

We have a few choices. We could go back to the bad old days of unaffordable and insecure health care for 80% of the people in our communities.

We could make incremental and very small improvements like changes in primary care or hospital cost control like in Maryland.

Or we could use this crisis as an opportunity to act and make a real difference for the health of our communities as DJ has outlined – like changes that have been made in a few states.

I support the latter, but am fearful we will get the former.

The future is up to you.



Bob Crittenden, MD is a board member of Families USA, servied two governors as a senior health policy advisory, and is a retired practicing physician and executive. State of Reform invited him to both critique and continue discussion of the financing framework outlined in “The Special Session: Re-imagining hospital and community health funding” as part of re-imagining health policy in a post-COVID world.