Teeter: Five steps for state health policy in a post-COVID world


COVID-19 has exposed the significant (and already known) flaws in our health care and public health systems; most likely thousands of people have died because of these flaws.  The acute anxiety and sorrow being experienced by US residents and our health care givers amplifies the imperative that we address and repair these flaws.

Our aspirations for healthier communities and responsive health systems must align with changed structures and processes that we know will do a better job of producing our desired outcomes. Leadership will be needed from the state level to build the platform for next level change; lives literally depend on bold and committed leadership throughout the health care and public health systems to achieve what is possible with the resources, expertise and technology that we have at our fingertips.

In the most recent State of Reform COVID-19 health policy series titled “The Special Session,” DJ Wilson laid out a construct for the future of state level health policy that supports a health system’s ability to effectively respond to community health needs, and concurrently ensures financial viability of health care systems.



Using relevant examples of state level health reform from Maryland, Hawaii and Oregon, he illustrates some of the ways in which states have been successful in wrestling with managing cost trends, improving population health, and supporting high quality health care delivery.  The familiar and relevant solution sets of rate setting and payment reform, primary care investment and community based planning and delivery is all discussed in his piece titled “The Special Session: Re-imagining hospital and community health funding.”

And yet, no one state has put it all together. 

Funding streams and outcomes for health care and public health remain separate from each other, obstructing the capabilities of both systems to work together synergistically to achieve improved health outcomes, lower cost trends, and evidence based, high quality health care services.



It is time to go further and faster in reforming state health policy frameworks and investments.

We cannot say that we need more detailed diagnoses of what is “wrong” with the numerous ways states and other payers are managing billions of dollars in health funding. Several states are taking the lead in addressing some of these flaws.  However, it is time to envision and activate a new framework for envisioning, funding and then delivering top-level performance from our health care and public health systems.

The new policy framework must be population based; health care funding and payment, health care delivery methods, health improvement methods and public health infrastructure must all be anchored in shared outcomes for the shared population the health systems serve.

For health care systems, this implies going beyond rate setting strategy to a total cost of care approach for funding and reimbursement; for public health, this implies a robust per capita funding mechanism that allows for a public infrastructure that can reliably protect and improve the health of the population.


The first step in this policy shift requires state leadership in both the executive and legislative branches to reach agreement that health care delivery services and organization, health care funding and payment policy, AND public health services and infrastructure should be designed and funded in an integrated and holistic fashion, based on the health needs of a state’s population.


Of course, this is a difficult shift to operationalize, but without it, siloed and uneven funding streams will continue to support programs and services that are naturally structured to suboptimize results for the population being served. It is impossible to address health inequities without the full engagement of the health care and public health systems owning the problems and the solutions together.

So what are some next steps a committed state leadership team can take to shift to a population based framework that supports health?


First, design and implement a total cost of care model of payment that includes all payers.  The state of Maryland is moving from a multipayer rate setting method for hospitals to a multipayer total cost of care approach for the full continuum of care, including long term care.  There is an opportunity to learn from Maryland, and to leapfrog the multiyear process of rate setting first, and move immediately to a TCOC model. There may be a chorus delineating the familiar (and often beloved) barriers of achieving this goal; taking a year or even two to agree on how this would work in any given state would still save time, money and lives over the longer term.

Think about it: If this mode of payment had been in place everywhere during the COVID response, health systems would not have experienced the sudden drop in FFS revenue that it did.  They would have had reliable population based payments that could be efficiently enhanced for surge care, and they would not have been forced to the revenue cliffs that DJ Wilson so aptly describes.



Second, fund public health on a robust per capita basis so that the necessary surveillance systems, emergency response infrastructure and stockpiles, prevention services, disease control mechanisms and staff, health improvement strategies and collaboration with the health care system are reliably funded, and can attract the talent that is needed to lead public health at the state and local levels.  Without an effective and responsive public health system that can actively collaborate, the health care system is at great risk of being unprepared as well.


Third, design and invest in an interoperable information technology infrastructure for data and predictive population based analytics that is shared and used routinely by policy makers, payers, public health, health care systems and social services organizations.  Relevant data from electronic health records must be efficiently and routinely shared with public health; public health must routinely share their surveillance data with health systems.

Regular population level health reports should be shared across the state with state policy leaders, health care systems, local health jurisdictions and community based organizations.  To do anything less than this robust level of information system investment encourages siloed and often discordant expenditures and systems which in turn produce continued wasteful cost growth, deepening health disparities and a public health and health care system caught off guard and unprepared for health emergencies.


Fourth, fund care and service coordination between clinical care (primary care), social health and public health services.  Imagine a post COVID world where trained care managers and data stewards, using interoperable data systems, can assist public health with contact tracing during an outbreak, support chronic disease management for a health system using the advice and expertise of both clinicians and epidemiologists, provide supportive housing services, or focus on community linkages to close the gaps in health equity.

In Washington State, the Accountable Communities of Health (ACHs) play a key role in linking services across clinical and community settings, and use whatever data they can obtain from public health and health care systems and health plans to assist them. Oregon has built CCOs to carry this linkage a step further into community level governance over health dollars.


Fifth, fund the obvious workforce gaps that COVID 19 has exposed.  Home health service providers, public health planning and response staff, telehealth providers (especially for behavioral health), infection control consultants for long term care, and population health data and analytics experts are all in undersupply.  For the most part, adequate salary and more robust budgets for these workforce categories are the first step in filling these gaps.   Ensuring at the state level that these workers can be included in the TCOC of care modeling will be vital.



Different states have different challenges, but all have the levers at their fingertips to make these significant shifts in framework, payment and investment strategy.  Until funding for health care and public health is calculated using a population based methodology and funders demand excellence in population based outcomes, the US will continue to lag behind other countries who have fewer resources but more impressive cost and health outcomes.

There has not been a time in many decades where the problems with the current health care and public health system in the US have been so clear and inescapable.

Each state has a brilliant opportunity in this moment to lead, by focusing on protecting and improving the health of those for whom it is responsible, using the collective leadership, collaborative spirit, resources, intelligence and willingness of health and public policy sectors to work together to build a new health platform for the future.



Dorothy Teeter led Washington State’s health care transformation project as the Director of the Health Care Authority. Previously, she served in the Obama administration in the Center for Medicare and Medicaid Innovation. State of Reform invited her to build upon the financing framework outlined in “The Special Session: Re-imagining hospital and community health funding” to both critique and continue the discussion of health policy in a post-COVID world.