Reforming public health, part 2: Four steps for a post-COVID public health system
In part one of this discussion, I outline a few key problem statements that must be addressed as we seek to bring public health into the post-COVID age. They include:
- This is about pandemics, not restaurants.
- Generally public health is led by local health officials at the county level. That isn’t good enough to fight pandemics.
- The system is deeply under-resourced.
- The needs of a modern pandemic response system require more scale, more creativity, and more political capital than our current public health system offers.
If the problems are as I lay out above, however, here is where I think the conversation on post-COVID reform of public health starts.
First, it’s time to centralize the operational responsibility and authority for pandemic response at the state-level.
Some of this has started as a result of this pandemic. Joint operations and command centers have opened in multiple states to coordinate state-level response across a range of state and local agencies. That has helped make a marked difference in state-level response efforts.
When this pandemic is gone, however, those joint command centers will stand down, as they should. However, the coordination that took place there should remain. In fact, it should be developed and scaled with intention.
This will mean a new centralized authority to lead the effort. It might be housed best in the existing state public health agencies, particularly when those agency leaders are cabinet level officials reporting directly to the governor.
But this would need to be a new entity within those DoH shops. They would need stand-alone cultures focused on research, technology and surveillance rather than process.
Budget would need to come from new monies to be sure. But, the funds allocated to part-time epidemiologists at the county level, as I discuss in part one of this series, those funds are probably not well spent in this decentralized manner. It makes sense to bring those dollars and those responsibilities to the state rather than counties.
Other key elements like water testing or restaurant and food safety would remain local elements. This isn’t a call to eviscerate all of local public health.
However, it is a call to make sure we’re clear that county-led public health is not able to meet the needs of tracking and mitigating a virus outbreak like this. We should task agencies that can do the job with the job.
Second, require Medicaid and public employee purchasing to play a role in pandemic surveillance and response.
Today, most states have mature, sophisticated purchasing models for managed care operations. States have largely moved into the space of purchaser for Medicaid benefits, a position that allows them to be directive to private contractors in ways that align with their state and community interests.
Moreover, MCOs in particular are often able to bring innovative private sector solutions to unique community challenges. This has been catalyzed by the 2010 adoption of the ACA, and ultimately the expansion of Medicaid in 2014 among 36 states. MCOs are thinking differently about community-level engagement and the data they need to support those operations.
Virus and pandemic preparation and response is a unique community challenge. States should start requiring their Medicaid contractors to support the solution.
That means states should consider the following:
- Integrate data from health plans, clinical data repositories, and public health surveillance tools into one data set and disease surveillance dashboard. This would mean requiring plans to have greater line of sight into clinical status of their members. It would mean requiring public health and MCOs to work together in ways they don’t currently. And, it would require process, technology and cultural integration across silos in a way that only the state could command.
- Request federal waivers to apply funds related to public health surveillance to the MCO’s medical cost ratio (MLR). These are dollars that have the end of health. While they may go to technology, process or infrastructure development, these are public health dollars. They should be counted as part of the MLR for accounting purposes.
- Align this integration strategy with the purchasing of public employee and school employee purchasing. These contracts should integrate with, support, and benefit from the public health integration strategy in Medicaid.
This strategy will allow the state, now the coordinating and centralized pandemic surveillance and response entity, to leverage state and federal dollars to integrate tools and infrastructure across existing health silos.
Since health plans serving the Medicaid and public employee communities are at financial risk when a disease strikes, they will have a profit motive, among a range of interests, to participate in this work. This is the private sector, at the direction of a state-led purchasing effort, at its best.
Third, use the tools of big data to support disease surveillance and modeling.
Tech companies have been providing de-identified data modeling for years now. From Google search term algorithms to Palantir’s predictive modeling, the state can employ the tools from big data to start to watch for signs of disease response in personal behavior.
For example, perhaps we might have known in late December or early January that individuals traveling to and from Wuhan were conducting online searches for respiratory ailments, and who were making purchases for thermometers from Amazon. If we could have known that through large data set management, it may have signals a disease spread much more quickly than our current system.
There is a “big brother” element there, of course. Many Americans will feel uncomfortable knowing the degree to which information about them is already employed in commerce in America today. I’m suggesting that data also be employed to help keep them healthy. So, opt-in measures, automatic permission sunsets, and other standard practices should apply to maintain privacy.
Fourth, it’s time we commit new dollars to public health.
Some of that will be required by building the infrastructure I mention above. Some will come through procurement, through state-federal Medicaid dollars, or from sweeping money from local agencies to better use at scale at the state level.
However, even with that, new state and local dollars will be required.
Public health has suffered from years of poor funding. It has created a challenge to resiliency, culture, and efficiency among public health leaders.
Public health professionals are doing the best with what they have. But their best could be significantly better with stable, predictable and increased resources.
Finally, it’s time to build a public education and engagement strategy.
States like California and Washington have taught their communities what they need to do to be ready for an earthquake.
Texas educates its citizens about tornadoes. Arizona teaches its residents how best to manage a heat wave. Sadly, every community is talking about active shooter drills.
We need to be thoughtful about how best to prepare our citizens for the next pandemic, too. It’s possible it will be significantly less than 100 years before we have our next pandemic. In fact, recall we had our last SARS outbreak in 2003 and our last flu outbreak in 2009-2010.
We’ll have another event like this sooner rather than later.
By then, we should develop thoughtful tools and responses that don’t require closing the economy and sending our community into recession.
There needs to be a better playbook of incremental steps, informed by data and science, that our states can take.
A public engagement effort can help elevate those strategies, making them better understood and accepted by the communities they are meant to serve.
Bottom line: These modernization steps are not out of our reach. They employ and re-organize the public and private sector tools already in place in our health system, and re-align them towards disease surveillance, preparedness and response.
They are policy tools legislatures might consider as they enter a post-COVID discussion of how best to modernize public health.