In All Health Care Is Local, Revisited, Sarah Klein, Martha Hostetter, and Douglas McCarthy explored how communities dealing with a less-than-stellar economy and a range of social ills manage to get their residents’ health back on track. In talking to leaders of public health departments, health plans, hospitals, and local organizations in four geographically diverse communities, the researchers found that the capacity to improve isn’t limited to regions with ample economic resources. For example:

• Stockton, the northern California city that filed for bankruptcy after the 2008 housing crash, has managed to reduce avoidable hospitalizations, emergency department visits, and readmissions
• Pueblo, a Colorado community where nearly half of the population lives below the poverty line, is promoting shared accountability for solving problems
• Paducah, in rural western Kentucky, is leveraging Medicaid expansion to meet the primary care needs of newly insured low-income residents
• Akron, Ohio, in the nation’s Rust Belt, is tackling obesity, infant mortality, and opioid addiction.

Across the four communities — among the nation’s most improved, according to the Commonwealth Fund’s most recent Scorecard on Local Health System Performance — local governments act as catalysts for change, the authors found. In Akron, the health department partnered with the city and county governments to identify opportunities for collective action. For instance, funds from the health, housing, transit, aging, and social service agencies were pooled to purchase baby cribs for low-income families, leading to drastic reduction in infant deaths from co-sleeping. In Stockton, the city council sought to curb child obesity by requiring restaurants serving children’s meals to make water or low-fat milk the default beverage; the public health department also began offering neighborhood stores financial incentives to sell produce from the San Joaquin Valley’s many farms. And in Pueblo, the fire department began partnering with health care providers to connect frequent users of the emergency response system with a regular source of care.

These are just a few illustrations of how leaders across sectors can work together to increase access to care, promote delivery system reforms, and address the nonmedical determinants of health.

Prescription drugs account for 17 percent of spending on health care in the United States — $457 billion in 2015. That share is expected to rise over the next decade as costs for drugs outpace those for all other health care services. Research shows that about one-third of the rise in prescription spending from 2010 to 2014 was the result of either price increases for drugs or a shift in prescribing toward higher-priced products.

Escalating drug prices have hit consumers especially hard: more than one in four Americans now report difficulties paying for the medications they need. That’s why the Commonwealth Fund launched a pharmaceutical spending initiative in 2017 to inform efforts to lower drug spending growth and to make drugs more affordable. To start, the Fund partnered with Memorial Sloan Kettering’s Drug Pricing Lab to produce a series of 12 drug pricing explainers in the journal Health Affairs, covering everything from orphan drugs and biosimilars to the ins-and-outs of health plan formularies. We also supported research by Aaron S. Kesselheim, M.D., a regulatory expert based at Harvard Medical School and Brigham and Women’s Hospital, into the strategies manufacturers of brand-name pharmaceuticals employ to delay generic competitors from entering the market, including restrictions on access to drug samples needed for bioequivalence testing. Kesselheim found that brand-name drugmakers typically enjoy a 12-to-16-year window during which they’re free of competition from lower-cost generics.

Another project, jointly funded with the Laura and John Arnold Foundation, investigated the root causes of high U.S. drug prices. In a Commonwealth Fund report, former congressman Henry Waxman and colleagues Bill Corr and Kristi Martin argue that prescription drug prices over the past decade reflect a distortion of the original balance Congress intended between pharmaceutical innovation and price competition. They call for rebalancing incentives for innovation and pathways for price competition, so that manufacturers and patients both benefit from pharmaceutical market laws and regulations; prioritizing patient access and affordability; and better utilizing the available information on clinical value, comparative effectiveness, and pricing.

The Commonwealth Fund will continue to provide policymakers with the unbiased information and analysis they need to develop feasible, effective policy solutions to the drug affordability crisis.

The important health and financial protections that Medicare provides have not kept pace with beneficiaries’ longer lifespans and higher rates of chronic illness. Medicare’s high cost-sharing, for example, can undercut beneficiaries’ access to needed care. A detailed look at health care costs for Medicare beneficiaries published by the Commonwealth Fund last May found more than one-fourth of beneficiaries — an estimated 15 million elderly and disabled people — spent 20 percent or more of their household income on out-of-pocket medical expenses and monthly premiums in 2016.

Beneficiaries with multiple chronic conditions, or physical or mental disabilities, are at the greatest risk of incurring high costs, reported authors Cathy Schoen, Karen Davis, and Amber Willink. Nearly one-third of those with three or more conditions spent 20 percent or more of their annual income on premiums and medical care.

Medicare doesn’t limit its enrollees’ annual out-of-pocket spending, and it has relatively high cost-sharing requirements. And, with nearly half of beneficiaries earning less than $24,000 a year, many cannot afford supplemental coverage.

“If Medicare reforms are discussed by the new Congress, we have to keep in mind the impact any changes would have on beneficiaries, especially those who are the sickest or have low incomes,” said Schoen, who’s currently based at the New York Academy of Medicine.

To maximize Medicare’s positive impact on health and financial security, the Commonwealth Fund supports efforts to align Medicare’s benefits with the needs of beneficiaries — including designing and evaluating promising policy options.