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A bipartisan health care deal recently brokered by Sens. Lamar Alexander (R-Tenn.) and Patty Murray (D-Wash.) would give states greater power over health policy. But even if this nascent legislation falters, states will likely see their influence grow through actions of the Trump administration.

If state governors are going to be in the driver’s seat, they should understand something that Congress, with its narrow focus on insurance coverage, seems to have missed: the main problem with American health care is the care. Although it is important to have stable insurance markets, changes to coverage or benefit design will ultimately do little to reduce costs or make Americans healthier.

Our health care system is stuck in the 1950s, when the prevailing epidemics were polio and influenza. Today’s public health challenges are chronic diseases like diabetes, obesity, and opioid addiction. Half of all adults — 117 million Americans — have a chronic condition; the projected cost is $794 billion in lost productivity alone between 2016 and 2030.


For the most part, chronic diseases aren’t caused by microbes but by problems for which there are no pills or vaccines: deeply rooted personal, social, financial, and behavioral issues, messy, real-life problems like job layoffs, eviction notices, or loneliness. These issues have a profound effect on health, particularly in working-class communities where health care costs are high.

Our health care system hasn’t caught up with the evolving face of disease in America. It is still mostly a workforce of doctors and nurses who dutifully treat patients in hospitals with expensive drugs and high-tech medical devices. If we could reconfigure health care to detect and address the root causes of costly illness, health reform would be a true success.


Several initiatives have laid a path forward. This year, the Center for Medicare and Medicaid Innovation will begin Accountable Health Communities, a five-year grant that enables hospitals and doctor’s offices to check their patients for real-life issues that affect health. Once these have been identified, community health workers — trained laypeople from local communities — would help support patients and connect them to resources like housing or child care. This type of support can have a profound effect on health and lower costs.

In a recent study, my colleagues and I found that a community health worker program called IMPaCT lowered hospitalizations by 30 percent and reduced cigarette smoking, obesity, the severity of diabetes, and mental illness. This model yields a 2-to-1 return on investment, which has prompted large health systems and payers to invest millions in scaling it up.

The current debate around state waivers is focused on limiting health insurance coverage or scaling back essential benefits. Maine has joined Wisconsin, Kentucky, Arkansas, and Utah in submitting waiver applications that impose premiums for Medicaid beneficiaries and coverage lockouts that bar them from re-enrolling in health insurance coverage if they lose it because of unpaid premiums. Maine anticipates that its proposed waiver would lose its members a collective 55,000 months of coverage.

Instead of this approach, governors could apply for waivers to shift Medicaid funds into programs that screen for and address root causes of health through hospitals and doctor’s offices. These programs could yield significant cost savings while improving health, instead of cutting coverage.

Reshuffling insurance coverage schemes as a way to reduce costs is basically a shell game — a dangerous one — that does little to address the core ills of the system. It would be a wasted opportunity if health care reform did not also transform the way we deliver health care so Americans can have better health at lower cost.

Shreya Kangovi, M.D., is an assistant professor of medicine at the Perelman School of Medicine at the University of Pennsylvania and the founding executive director of the Penn Center for Community Health Workers, a national center of excellence focused on improving population health.

  • Certainly these ‘root causes’ are far afield from what doctors and nurses are trained to do. Yet we doctors regularly complain about patient compliance, so this broad expansion of what constitutes healthcare certainly sounds like a good idea.
    The link to the study goes to an abstract only. But even so the results really don’t support the author’s statements. The only outcome to achieve p<.051 was a quality of care metric measured by a “Consumer Assessment” tool, despite a selection criteria that include those most at risk.
    And ramping up pilot studies is frequently fraught with problems leading to poorer results. Then there’s the question of replication of individual studies.
    Sorry but the ideas presented here are not very efficient, if at all, where it comes to spending our healthcare dollars.
    The comparison to 1950’s medicine is facile. Physician practice has always been about individual patients. One might as easily say the author is stuck in the 1880’s, as the greatest health benefits of public health accrued during the late 19th and early 20th centuries with vast improvements in public sanitation.

    • I think the comments are very relevant & could be “efficient,” if seriously considered & funded. Our current system doesn’t take into account our total mental, physical & emotional health of the many problematic scenarios that result in so many of our lives. Also, it doesn’t address the exorbitant costs to improve our health & recover. I’m assuming you are a physician who helps people in the current system. However, thinking outside the box, recognizing the complexities & looking beyond the concerns that you have been trained would be valued & greatly appreciated.

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