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Resilient, Accessible, and Affordable Healthcare: Bouncing Forward From COVID-19

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Robert Johnson:
This is Public Health Review. I'm Robert Johnson.

On this episode: using policy tools, funding, flexibility, and common sense to eliminate barriers to healthcare now exposed by the COVID-19 pandemic.

Esther Muña:
People here access care only if they're in pain or they're injured. And that's the sad part about that is because when COVID came, it just adds more salt to that wound.

Lance Robertson:
There's a real growing popularity on how do we impact the social determinants of health, or the nonmedical things that people often need that are—honestly, Robert, they're low-cost, high-impact.

Johnson:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, the barriers to healthcare that helped give COVID-19 the advantage.

Sadly, the list is long: limited access to quality and affordable care; lack of health insurance; in rural and underserved areas, the inability to find a doctor; bad internet connections all but ruling out a telehealth visit; and, of course, hospital closures, small facilities decimated by the economic impact of the coronavirus.

Two guests consider these challenges and discuss the response.

Lance Robertson served almost four years as assistant secretary for aging at HHS. Today, he's a director at Guidehouse, a Virginia-based consulting firm with the Public Health Practice. He's along shortly to tell us how public health might move forward in this ongoing crisis.

But first, we talk with one ASTHO health official who's always a day ahead of the rest of us. She's Esther Muña, chief executive officer of the Commonwealth Healthcare Corporation, the health agency for the Northern Mariana Islands, a U.S. territory in the Philippine Sea.

Johnson:
When you first heard about this new coronavirus—this novel coronavirus—out there on those islands that are much closer to the Philippines and China than they are to the U.S., what was going through your mind? Were you worried?

Muña:
Absolutely. You know, we know that people here in the CNMI do not access care the way they should. We knew that because of the COVID. We are the single health system here, the single hospital here on the islands, and how will people come to access care if they are scared?

And that's what we saw. Appointments were getting canceled. We had to make sure that telehealth was readily available and ensuring that people can still pick up the phone and talk to the providers here. So, that's one of the things that we had to implement, but definitely it was fearful.

I mean, I was worried about that. I described this one time, I was asked this question, what do you look at healthcare after a disaster?

It's like driving through a rocky road, basically through a storm. The rain has stopped, but the rocky road is still there. And if you're not addressing the problem, the roads have gone deeper because of the fact that people are not accessing care, we needed to make sure that access was available.

We needed to make sure that we address the five dimensions of access: availability, affordability, approachability, acceptability. You are looking at all these things and saying, "How can we make sure that people can still come?" So, we needed to make sure of that, but you know, there's a lot of things going on at the time, but we were worried about that.

Johnson:
How have the people on the islands managed this last year or so? How are they doing health-wise?

Muña:
You know, we're seeing delayed care. So, we are in for—the first couple of months after maybe about June of 2020, we were seeing more hospitalizations. People could have avoided the hospitalizations, but because of the delayed care, that's what we were seeing.

We are back to some normalcy, we're seeing our numbers, you know, to an acceptable census amount. But in the beginning, right after COVID, we were really worried about that.

And so, you know, we addressed the affordability, worked with the governor to make sure that anyone can walk into the facility and be able to receive care without worry of that, of the affordability, so we got rid of the affordability issue.

So, we have presumptive eligibility for Medicaid here, so anyone that walks in was presumed eligible. And, so, there's no worry about that.

The availability of time—we knew that the census was increasing in the clinics. How do we address that? Well, we have more hours and added an additional day on a Saturday to address the access.

Again, our people here are—we're going back to the military times, the trustee times, that's how the health care system was. People here access care only if they're in pain or they're injured.

And that's the sad part about that is because when COVID came, it just adds more salt to that wound and it really prevents even more people to be accessing care.

So, we needed to try to find a way to put the messaging out there, you know, get people to come and making sure that it's available and accessible—more accessible than ever.

Johnson:
Those changes in eligibility that you made in order to get people to come in and get care during the early months of the pandemic—were those changes made possible by some action in Washington, D.C.?

Or were you able to make those changes on your own there in the Islands?

Muña:
It required the public health emergency by the HHS secretary, and it required for me, as a health official, to make the request to the governor to make that request and to ensure that that was available.

So, our census has increased in the clinics—from last year in this same month, 700 more visits. And to us, this is the sad part again about the Islands is that you don't know—these individuals have not accessed care, and now all of a sudden they're accessing care. And so, we need to reach to these individuals. And I'm so glad that they're in here.

What happens if the presumptive eligibility ends? For us, it's going to be a challenge, but it is worth it because we are seeing individuals that could have basically increased our census in the hospital.

You know, again, we are a health system. We run the hospital, the public health, mental health, behavioral health, that's all us. And so, by addressing the overall health of the individual, patient-centered, we are making that difference.

Johnson:
So those flexibilities then have really helped you address the access to care issues in the Islands and the numbers—even though they sound small to us here in the mainland, those are big numbers for you on the Islands.

Muña:
Absolutely. Imagine this: during the pandemic, we actually opened our first oncology center.

So, Saipan is the largest island in the Northern Mariana Islands. Right next to it—basically about, I can't say the miles, but about 20 minutes away by jet plane—is Guam. What was happening in Guam was different than what was happening on Saipan for COVID.

And our people did not want to leave the islands. If they are going to be referred, if we don't have the care here, prior to COVID we were referring individuals to Guam, and Hawaii, and, you know, other Asian facilities and healthcare system.

So, they were afraid to travel, and sometimes there's not availability of travel either, right? So that, again, that's the delayed care, the chronic illnesses that are just building in the CNMI and it's—you know, for us, when we reopened back in June, July, we made sure that we try as much as possible to make the services available here.

And that's the reason why the oncology center was going to open, whether with COVID or without COVID. We wanted to make sure that people can stay home.

And that's the thing too. I wanted to mention is that people want to be with their families. They don't want to leave the Islands, and sometimes here people don't access care because they know. They are worried about expecting to leave the island.

What we are seeing in the oncology center is that people don't necessarily want to know that they have cancer. And so, what they do is they don't see their provider because they probably suspect it, but they don't want to know because they know that they would have to take their families or they have to leave their families behind. And that's expensive, and that's just not culturally acceptable to have care without your family nearby.

So that's one of the things that we're also seeing here in the Islands.

Johnson:
It's getting safer by the day to fly but, for a long time, people were really concerned about that. It's not something that all people are ready to do just yet, if at all.

Muña:
Again, you know, the challenge here is that we only have an acute hospital. It does not have a lot of the specialty care of that you get from the mainland. And so, here in the Islands, you are either healthy and you try and live a healthy life here; or you, basically, if you're not healthy, what's going to happen to you is that you're likely going to travel off-island. And that is the scary part.

And it seems to be an acceptable part, but again, for me, and one of the things going back to the Medicaid eligibility. We have a problem here in the territories, they have a Medicaid disparity that's affecting the territories. There's a cap, there's the FMAP that's different.

And then, why I'm mentioning that is because if we can't invest in our health system to be strong as well so that when things like this happened, like when there's COVID, that people can just walk across the street and get health care, it's just doesn't happen so often here. And that's the challenge, again.

Johnson:
Is that a change you'd still like to see come out of this whole pandemic? Maybe addressing that issue here in Washington?

Muña:
Absolutely. Our people are Americans. You know, we feel that, I mean, I'm born and raised here and, you know, I lived through the trustee territory health system and you know, it just amazes me that we're still—it's almost just the same after all these years.

In order for us to make that change, we need to have more funding, not only to our hospital, but overall in public health and all of the health issues that the residents—the citizens—here are experiencing.

Johnson:
I had wanted to ask you about what other tools you could use in the territories—and maybe there are others, we could get to those in a minute—but you also talked about hospitals.

A lot of rural hospitals have closed or really suffered during the pandemic—revenue's down, they couldn't deal with all of the issues that came as a result of the flood of cases.

How many hospitals do you have in the Islands and how have they held up in the last year?

Muña:
I'm glad you asked that question because that's the other fear that I had when we, you know, of course with that COVID threat, is that we are a fragile health system.

We are only a 76-bed hospital. And I don't know if you've ever seen that chart where FEMA basically says that there's going to be this much of cases that you're going to be experiencing, how many hospitalizations you are going to be experiencing. That was a worry for us to the point that we needed to make sure that we protect this community as well.

So luckily for us, we are the integration of our public health, and our hospital is there, so that the hospital team, our doctors, our nurses, are right there in the forefront, not to respond to cases being hospitalized, but to prevent those cases from even being here.

And so, once we had a case, even initially, we didn't even have testing. Just to go back to January, we were actually working on trying to increase our testing capabilities. And when we had our first case in March 28, 2020, we were just like, "We need to figure this out."

Basically, use the medical team, the hospital team, to try to address. We had worked with the governor to make sure that we have an isolation site. So, we had two deaths here in the CNMI. Our cases are at 161 now.

What we had done was more on prevention. And honestly, I wish we could prevent chronic disease the way we prevent COVID here, because we were very successful. You know, that collaboration, I think, is very key to our team to make sure that the Islands are protected from COVID, and that's what we did. And I wish we could do the same for all of the chronic diseases, like I said.

Johnson:
It's been over a year since the pandemic started. What are some of the lessons you've learned in these last 14 or 15 months?

Muña:
I think the first lesson that I learned is that the collaboration that we have in our health system is, you know, if there is a mission to address things, we can make things happen. And I'm looking at that as an opportunity to continue to address other health issues, to make it even stronger. You know, building a more resilient community requires us to be also resilient, healthy, you know.

Our team needs to work together so that when someone comes into the clinic, they don't need to go to another room or another section of our building just to access public health services. When they walk into the clinic, when a patient comes in, they are the center of attention, and we need to make sure that those services are reachable to them without having to have so much barriers to get there.

So, one of the first things that I learned is that the collaboration that we have works, we need to make it work even more for other health issues here on the CNMI.

The second lesson that I have is that, you know, our people, our healthcare workers are our key to our success. I worry about some of the things that we don't do, but at the same time, I need to try to support them as much as possible.

So, those were one of the other lessons that I learned is that I need to be more understanding and more accepting of what they're experiencing as well. Because again, healthcare workers are keys to our success.

Johnson:
What's on your list of changes or reforms to make through the rest of this year?

You're still dealing with the pandemic, of course, but people are starting to think about post-pandemic actions. What's on your list, in that regard?

Muña:
There's a lot of the organization in our healthcare system—we have looked at, for example, the maternal-child health, putting the WIC program under one umbrella, making sure that they work together.

Again, you know, one of the challenges that we have is that when you come—when an individual, our patients, come and see us—you better take care of that patient because if they leave and walk out the door, you know, you're going to have a problem trying to get them back in.

And so, a lot of reorganizations have happened and will continue throughout the year. And these reorganizations are, in some ways, a result of COVID, but it's about, you know, again, integration, a lot of integration and collaboration has to happen.

What we've learned with COVID is that integration and collaboration works. Let's make it even better.

And so, we've done with the maternal-child health, with WIC working together, as well as the oncology center and the clinics working with public health is not just under one umbrella, but it's also about working together, not just, "Oh yeah, we're under, you know, CEO Muña, who is the lady in charge."

No, it's patient-centered. Think about that. Think about being patient-centered and that's what we're going to be doing along the way to address chronic health here in the CNMI.

Johnson:
We touched on things you'd like to see Washington do even now to help address pandemic response, post-pandemic planning and response.

Anything else on your list?

Muña:
Yes. The healthcare and the hospitals in the territories are treated differently. You know, we are required to comply to Medicare regulations—we have the same requirement as a hospital in rural America, even in urban America, we have the same requirement. The payment is not the same; and, so, that has affected our health system.

So, it's, you know, to me, for Washington to take a look at that, and, you know, when there are opportunities to improve hospitals in the U.S., think also about the territories, because that's the challenge.

You know, I explained earlier about 70% of our population are indigent, and yet we don't have 340B in our hospitals. We're not considered disproportionate share hospitals. Those are the things that exclude the territories.

So, what happened during COVID where there's lots of money that was going to the hospitals, we were getting money, but it wasn't as huge as if we were a state. And, you know, for us, that's one of the reasons why being the health official and the CEO for the hospital is that I needed to get back to business. You know, yes, I need to take care of my population, to protect them from the COVID, but I also need to make sure that there are hospitals so I can pay for my healthcare workers, so that they still have a job. And so, we did not let go of anyone, we did not cut hours, despite that.

And so, that's what I'm hoping for is that, you know, take a look at the territorial hospitals and have the benefits whatever benefit you offer to the 50 states, because think of the territories when you're talking about hospital benefits.

Johnson:
Lance Robertson began his career in higher education, working as an administrator at a university in his home state, Oklahoma. That's where he also served two governors before a federal assignment that just ended, advocating for America's seniors as a top official at the U.S. Department of Health and Human Services. Today, he's at Guidehouse, a global consultancy with a public health practice.

Johnson:
What do you think state and territorial health officials need to consider if they want to seize on the awareness and focus that has come from the events of the past year?

Robertson:
I think, no doubt, you know, the pandemic is something that can be leveraged. I mean, we all have to just appreciate that none of us had control over that. We were dealt something quite unexpectedly that I know our country has really done its best to try to address and resolve.

But I do think that, as we emerge out of the pandemic, it is an opportunity that state health officials and other state leaders need to really take advantage of in creating honest conversations.

So, you know, for me, it involves really—how do we make sure that we appreciate what the pandemic has taught us around, as one example, public health data modernization? How do we make sure that all the different records and all the different ways that we touch the patient can be connected in a way to create greater efficiency within the healthcare delivery system?

I also think it's a real opportunity to better collaborate, to be honest with you, Robert.

I think that a crisis creates a willingness to work together, and to compromise, and to come together. And I know that in the current state of play, particularly pre-pandemic, you know, so many states just worked in silos. And the health department probably didn't work a lot with the Medicaid agency and sometimes marginalized yet powerful organizations like your aging and disability networks are left out.

But thankfully, through the pandemic—if, again, we can appreciate that—there's just a lot more synergy and collaboration happening that needs to be carried forward post-pandemic.

And I think also we just need to get back to being better at the basics, Robert. So many people don't know where to turn when it comes to just standard health issues, much less a health crisis.

We got to be better at making sure that our information systems are out there, that we address health equity, and that we're doing all that we can to prevent people from being marginalized. And again, a lot of that just starts with basic information, knowing where to turn and knowing where the best information's at relative to their own health situation.

Johnson:
Washington has done a lot since March of last year to give leaders like Esther Muña flexibility in their response. In our conversation that we just heard, she talked about how they used presumptive eligibility for Medicaid to get people to come in for care.

It's a big issue out there, people don't like going to the doctor or into the hospital—sounds like me actually, but that's for another day—and it's one example.

Do you think that's a shining example of change that has come out of this crisis?

Robertson:
I do think that we are definitely at the highest watermark ever when it comes to federal government flexibility. And again, being part of the past administration, I know firsthand what those conversations were like.

Because, again, the pandemic forced us to really empower the states, which ultimately that's what federalism is about, making sure that states make the decisions about how money is spent and how services are delivered.

So, you know, I think that the presumptive eligibility conversation—which, that's something that I've been a part of for many years, even back in my state role—there's a value there. There is a risk proposition to that, but there's a value. And certainly I think that sort of flexibility and embracing more risk are sort of outcomes of dealing with a pandemic.

So, I know even our own world in human services, I bet a lot of the flexibilities that so many of our state partners have seen will likely stay. It forced all of us to have a much more basic conversation about what is absolutely the most important thing.

And we're talking about the federal government, Robert, you're talking about a regulatory body, a group that spends most of its energy making sure that money is spent in a way that can be, again, defensible, but we believe that that responsibility does rest at the state level.

So yeah, I'm excited about the flexibilities that we've seen that I think many of which will stay. The Medicaid space was overdue for some of those conversations. Even on the non-Medicaid side, so many flexibilities that I'm proud to say are probably going to stay. And that just further creates that flexibility that I know state and local officials are always craving.

Johnson:
Other than the changes having to do with Medicaid, anything else that you think is working well that has come out of those various pieces of legislation passed over the last year?

Robertson:
Yeah, yeah, I think so, Robert.

You know, having—again, the way the federal process works, we often as federal agencies would offer technical assistance to Congress as all of those bills were being drafted.

So, the good news is we sort of have a key insight on what the intent is of a lot of what you're seeing now and the laws, particularly in response to COVID, and Congress really wants that flexibility and they support it. So, I do think even on the non-Medicaid side, just many, many examples abound.

And I will tell you that in serving as, a key example, being the former assistant secretary for aging and serving older adults, our biggest program was about meals, making sure that folks had food, that they were not food insecure.

But honestly, Robert, a lot of that, both policy and program delivery, was just wrapped with requirements that we sort of have stripped back that I think maybe we'll just leave on the ground or on the cutting table because, at the end of the day, we want to make sure that we battle food insecurity and that we combat social isolation with that particular program.

So, a lot of what we've been able to do has now been reworked from that angle. And I think a lot of the flexibilities, whether it's the DRAs—which are the regulatory requirements around the type of food that's being given—or delivery, all of those different things now—packaging—have become so much more flexible.

Because we just want to make sure, as the federal partner, we're offering the support that we know is needed at the state and local level, and then giving that authority to those partners to make sure that things are done as efficiently and as effectively as possible.

Johnson:
Thinking of the response overall, is there anything now looking back that could be improved?

Robertson: I definitely think—again, this is as a former federal administrator—I definitely think that, very inadvertently, we had some populations that were initially marginalized.

A good example would be the disability community. I think for a lot of what we did in response, we could have done a better job of really embracing the unique needs of certain population cohorts, like people with disabilities.

And, you know, a good example, Robert, for so many of those individuals, if they were to get regular immunizations, they would do it at their workplace because so often they don't have the ability, you know, for free transportation like a lot of us do, so it's less convenient for them. And some of the traditional ways we set up initial immunization that we could have thought through and may be offered some other home-delivered sort of things that could have helped that population group.

And, you know, we can go on with other examples. Tribes, another good example, heavily impacted by the pandemic and health services I thought did a great job, but you know, so much of that, we just didn't have the fortune of having the foresight to put the most efficient remedies in place.

I think now, post-pandemic, a lot of that we've learned from, I suspect if America faces a crisis like this again, we'll be a bit more resilient and less reactive when it comes to how we can serve some of those marginalized populations.

Johnson:
So, is there anything Washington must consider if it wants to help states and territories continue to address a pandemic fallout and build a better public health system bouncing forward?

Robertson:
I think as one example to your question, Robert, one difficulty states have had, has been a really unique and massive infusion of money that they weren't really set up to distribute and make sure it was properly monitored and used.

So again, I hope that, at the highest level, folks are beginning to think through, you know, how do we properly create that money flow pipeline in a way that can really help states and local communities effectively use the dollars.

A good example, back to the Older Americans Act and serving senior meals. A lot of those programs, it wasn't a matter of, "Hey, did they need the money?" It was simply a matter of, "Did they have the capacity to deliver five times more meals than they had pre-pandemic?"

So, I think some of the bigger issues for me, Robert, are, again, more infrastructure-related, which are easily resolvable. We just have to have the time to think through what makes the most sense.

I think on the policy side, everything was done pretty well, I think admirably done, but I do think that on the infrastructure conversation, that was more of the tripping hazards that I think are just hard to work through when you don't have enough lead time to sort of effectively have those conversations. Coming out of the pandemic, I hope that we'll take the time to have those conversations now so that we can be even more resilient in responding to what may be ahead.

Johnson:
Is that your advice for state and territorial health officials when it comes to figuring out a way to deliver these programs long-term?

Robertson:
I do. And honestly, Robert, it's even—if I can just piggyback and just say, you know, at the state level, what I really hope officials will look at is how do you leverage the different sources? Because coming out of packages like the most recent ARPA package, there's a lot of different funding streams that can be leveraged.

And then, if you're at a state level, you know, it's easier then to turn $2 into $3 of federal support because you've leveraged one side of the funding pool against another. And again, not in a way that causes some sort of friction in how federal money can be used, but a way that again, can amplify impact.

So, take as a quick example, family caregivers, who are often left out of this equation, yet they provide most of the care in most homes and communities across America. An enormous, unprecedented amount of flexibility now in the Medicaid side to support caregivers.

So, you got to make sure across all state-level conversations that the caregiver becomes a focus of the conversation because you have money coming down specifically for the non-Medicaid Older Americans Act to support caregivers.

But how do you leverage that? Can you leverage that with some of the Medicaid money as well, to do some really creative piloting work, maybe build some caregiver support infrastructure programming in your state? So, a lot of good options there.

Johnson:
So, we've touched on a lot of different programs and flexibilities and changes that have all come about over the last 12, 15 months. How do you see all of that leading to a more resilient, accessible, and affordable healthcare system?

Robertson:
So, I think what our experience now with the pandemic has taught us is that we have other additional ways to help build a healthcare infrastructure system that works. So, if we simplify things a bit, there's a real growing popularity on how do we impact the social determinants of health or the non-medical things that people often need that are—honestly, Robert, they're low-cost, high-impact.

What the pandemic has taught us is, "Hey, you know, let's make sure that we can do our best to really support those, again, low-cost, high-impact sort of services."

A good example is falls prevention. That's every 11 seconds, a senior falls in this country, and the health impact is just phenomenal. So, how do we help prevent falls? I think that's a big thing.

I think there are other ways that, again, states can look at coming out of the pandemic, partnering, working better together. I think that's going to be a key.

If we talk about the healthcare structure of the future, it's not going to be as siloed as it's been pre-pandemic. We got to make sure all working together, we're communicating, state agencies are sharing data, we're leveraging that, we're using the federal resources most effectively.

And again, I think if I were a state health official, this has created an opportunity that really hasn't existed before. You're in the driver's seat as the state health official and making sure that there is a coordinated response across our state. Some of those elements don't even relate to the pandemic, but undeniably have an impact on how well a state can or cannot respond to a crisis.

Johnson:
Let's bounce forward big time, two years from now. Do you think we'll have better systems in place then?

Robertson:
I absolutely believe, and I can tell you that knowing that we work right now, Robert, in our firm with a number of states who are doing remarkable work, I think that the federal conversation has advanced and really, I think, is now in a position to support states in a very effective way.

So yeah, I do think that, fast-forward 24 months or so, not only will we have some emerging best practices that we can all embrace and hopefully replicate, but I think there's just an openness to the conversation that really hasn't quite been there before.

So again, talking about just modernizing data collection, talking about how you take public health data, leverage that with Medicaid spend, and all of the different things we can do to, again, be more efficient in how we ultimately serve a patient and, Robert, that's where it's all about. It's got to be person-centered care.

But our systems, even though we talk that talk, haven't always been set up to support that. Now, I think we're going on in the right direction.

Johnson:
Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues. And, if you have comments or questions, we'd like to hear from you. Email us pr@astho.org. That's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.


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