U.S. Health Care Expenditures: Costs, Lessons, and Opportunities: Proceedings of a Workshop (2023)

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Anna Nicholson and Tamara Haag, Rapporteurs Roundtable on Population Health Improvement Board on Population Health and Public Health Practice Health and Medicine Division 

THE NATIONAL ACADEMIES PRESS   500 Fifth Street, NW   Washington, DC 20001 This activity was supported by contracts between the National Academy of Sci- ences and Aetna Foundation, Kresge Foundation, New York Health Foundation, Robert Wood Johnson Foundation, and additional support from the Association from American Medical Colleges, Blue Cross Blue Shield of North Carolina, F ­ annie ­Rippel Foundation, Nemours, Samueli Foundation, and Wake Forest Baptist Health. Any opinions, findings, conclusions, or recommendations expressed in this publica- tion do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-27515-6 International Standard Book Number-10: 0-309-27515-6 Digital Object Identifier: https://doi.org/10.17226/26425 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2023 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2023. U.S. health care expenditures: Costs, lessons, and opportunities: Proceed- ings of a workshop. Washington, DC: The National Academies Press. https://doi. org/10.17226/26425. 

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PLANNING COMMITTEE ON U.S. HEALTH CARE EXPENDITURES: COSTS, LESSONS, AND OPPORTUNITIES1 SANNE MAGNAN (Chair), Senior Fellow, HealthPartners Institute, Emerald Isle, NC RACHEL BLOCK, Program Officer, Milbank Memorial Fund, New York, NY ADAM BRESS, Associate Professor of Population Health Sciences, Division of Health System Innovation and Research, University of Utah School of Medicine, Salt Lake City DORA HUGHES, Associate Research Professor, The George Washington University, Washington, DC MARC GOUREVITCH, Chair and Muriel G. and George W. Singer Professor of Population Health, Department of Population Health; Professor, Department of Medicine; Professor, Department of Psychiatry, NYU Grossman School of Medicine and NYU Langone Health, New York, NY MEG GUERIN-CALVERT, Senior Managing Director and President, Center for Healthcare Economics and Policy; Economic Consultant, FTI Consulting, Washington, DC ERIC SCHNEIDER, Senior Vice President for Policy and Research, The Commonwealth Fund, New York, NY KOSALI SIMON, O’Neill School of Public and Environmental Affairs, Class of 1948 Herman Wells Professor, Associate Vice Provost for Health Sciences, Indiana University, Bloomington LAUREN TAYLOR, Postdoctoral Fellow, Department of Population Health, NYU Grossman School of Medicine, New York, NY 1  The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speak- ers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteur and the institution. v 

ROUNDTABLE ON POPULATION HEALTH IMPROVEMENT1 RAYMOND BAXTER (Co-chair), Trustee, Blue Shield of California Foundation, San Francisco, CA KIRSTEN BIBBINS-DOMINGO (Co-chair), Professor and Chair of the Department of Epidemiology and Biostatistics; Lee Goldman, M.D., Endowed Professor of Medicine; Vice Dean for Population Health and Health Equity, University of California, San Francisco, School of Medicine PHILIP M. ALBERTI, Senior Director, Health Equity Research and Policy, Association of American Medical Colleges, Washington, DC DAWN ALLEY, Chief Strategy Officer, Center for Medicare & Medicaid Innovation, Washington, DC JOHN AUERBACH, Executive Director, Trust for America’s Health, Washington, DC CATHY BAASE, Chair, Board of Directors, Michigan Health Improvement Alliance; Consultant for Health Strategy, Dow Chemical Company, Saginaw, MI DEBBIE I. CHANG, President and Chief Executive Officer, Blue Shield of California Foundation, San Francisco, CA ALLISON GERTEL-ROSENBERG, Operational Vice President, National Policy and Practice, Nemours, Washington, DC MARC N. GOUREVITCH, Professor and Chair, Department of Population Health, NYU Grossman School of Medicine and NYU Langone Health, New York, NY GARTH GRAHAM, President, Aetna Foundation, Hartford, CT MEG GUERIN-CALVERT, Senior Managing Director and President, Center for Healthcare, Economics and Policy, FTI Consulting, Washington, DC GARY R. GUNDERSON, Vice President, Faith Health, School of Divinity, Wake Forest University, Winston-Salem, NC DORA HUGHES, Associate Research Professor of Health Policy and Management, Milken Institute School of Public Health, The George Washington University, Washington, DC SHERI JOHNSON, Director, Population Health Institute; Associate Professor, Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin–Madison 1  The National Academies of Sciences, Engineering, and Medicines planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rap- porteurs and the institution. vii 

WAYNE JONAS, Executive Director, Integrative Health Programs, H & S Ventures, Samueli Foundation, Alexandria, VA ROBERT M. KAPLAN, Professor, Center for Advanced Study in the Behavioral Sciences, Stanford University, Stanford, CA MICHELLE LARKIN, Associate Vice President, Associate Chief of Staff, Robert Wood Johnson Foundation, Princeton, NJ MILTON LITTLE, President, United Way of Greater Atlanta, Atlanta, GA PHYLLIS D. MEADOWS, Senior Fellow, Health Program, Kresge Foundation, Troy, MI BOBBY MILSTEIN, Director, ReThink Health, Morristown, NJ JOSÉ T. MONTERO, Director, Center for State, Tribal, Local and Territorial Support; Deputy Director, Centers for Disease Control and Prevention, Atlanta, GA VON NGUYEN, Senior Vice President and Chief Medical Officer, Blue Cross Blue Shield of North Carolina, Durham, NC WILLIE OGLESBY, Interim Dean, College of Population Health, Jefferson University, Philadelphia, PA JASON PURNELL, Vice President, Community Health Improvement, BJC HealthCare; Associate Professor, Brown School, Washington University in St. Louis, St. Louis, MO LOURDES J. RODRÍGUEZ, Senior Program Officer, St. David’s Foundation, Austin, TX PAMELA RUSSO, Senior Program Officer, Robert Wood Johnson Foundation, Princeton, NJ KOSALI SIMON, Herman B. Wells Endowed Professor, Associate Vice Provost for Health Sciences, Paul H. O’Neill School of Public and Environmental Affairs, Indiana University, Bloomington HANH CAO YU, Chief Learning Officer, The California Endowment, Oakland, CA Health and Medicine Division Staff CARLA ALVARADO, Program Officer (through January 2021) MAGGIE ANDERSON, Research Assistant (beginning September 2021) ALINA BACIU, Roundtable Director AYSHIA COLETRANE, Senior Program Assistant HARIKA DYER, Research Assistant (through July 2021) ROSE M. MARTINEZ, Senior Board Director viii 

Reviewers This Proceedings of a Workshop was reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical com- ments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evi- dence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: SHIRLEY GIROUARD, SUNY Downstate Health Sciences University JOANN YÁNEZ, Association of Accredited Naturopathic Medical Colleges Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by MARTIN J. SEPULVEDA, Claraluz LLC. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully consid- ered. Responsibility for the final content rests entirely with the rapporteur and the National Academies. We also thank staff member Constance F. Citro for reading and provid- ing helpful comments on this manuscript. ix 

Contents ACRONYMS AND ABBREVIATIONS xiii 1 INTRODUCTION 1 Workshop Overview, 3 Organization of the Proceedings, 5 2 ECONOMIC PERSPECTIVES FRAMING HEALTH CARE EXPENDITURES 7 A Health Dividend for America: U.S. Health Care Expenditures and Opportunity Costs, 8 Expanding Health Access While Decreasing Wasteful Health Spending, 13 Health Equity Initiatives, 14 Discussion, 17 3 INNOVATION TO BEND THE SPENDING CURVE 21 A State Roadmap to Developing Health Care Cost Growth Benchmarks, 22 Case Example: Delaware’s Journey Toward Health and Quality Benchmarks, 24 Collaborative Approach to Public Goods Investment, 25 A Federal-Level Perspective, 28 Discussion, 30 xi 

xii CONTENTS 4 FRAMING AND SHIFTING THE HEALTH NARRATIVE IN THE UNITED STATES 37 Perspectives on Health Care Challenges, 38 Shifting an Individualistic Mindset, 41 The Potential Impact of COVID-19 and the Racial Equity Movement on Health Policy, 42 Role of Community-Level Efforts in Policy Change, 45 Perspectives of Medicare Recipients, 46 Techniques Used in Framing Health Spending Reform, 47 Final Thoughts, 50 5 RESEARCH PRIORITIES 51 Areas of Current Research, 52 Discussion, 58 Closing Remarks and Reflections, 63 APPENDIXES A References 67 B Biographical Sketches 73 C Workshop Agenda 89 D Readings and Resources 93 

Acronyms and Abbreviations ACA Affordable Care Act ACO accountable care organization AHC accountable health communities ARP American Rescue Plan CAPGI Collaborative Approach to Public Goods Investment CDC Centers for Disease Control and Prevention CBO Congressional Budget Office CHART Community Health Access and Rural Transformation CMMI Center for Medicare & Medicaid Innovation CMS Centers for Medicare & Medicaid Services COVID-19 coronavirus disease 2019 DHSS Department of Health and Social Services ED emergency department Geo Geographic Direct Contracting GDP gross domestic product HUD U.S. Department of Housing and Urban Development HCE health care expenditure HIPAA Health Insurance Portability and Accountability Act IOM Institute of Medicine xiii 

xiv ACRONYMS AND ABBREVIATIONS Mass DPH Massachusetts Department of Public Health MassUP Moving Massachusetts Upstream MMF Milbank Memorial Fund MRI magnetic resonance imaging OECD Organisation for Economic Co-operation and Development ROI return on investment SNAP Supplemental Nutrition Assistance Program TCF The Commonwealth Fund USofCare United States of Care UWGC United Way of Greater Cleveland 

In Memoriam David K. Jones 1981–2021 xv