Health_Affairs_Jan2015_300pPolicy change is hard. Just think about the 2010 Affordable Care Act, its tortuous path toward enactment, and the ongoing debates five years later that swirl around the law and its implementation.

There are many theories for how policy change happens, but one of my favorites is Kingdon’s policy streams model. To simplify a bit, it proposes that a window of opportunity opens when three separate streams come together: a problem gets defined and recognized as such, viable solutions are available, and there is political will to match them up.

Except for the political will part (thank you, partisan gridlock), at first glance this might seem easy. But think about how often your problem is not seen as a problem by others. For years, we faced this challenge when it came to making the case that older adults don’t get the care they should because they have special needs that require specialized, geriatrics-expert knowledge. Because of this challenge and the constantly shifting political landscape, it’s important to have policy solutions at the ready for the time when the problem and politics streams come together.

To more clearly and convincingly define the health care problems facing older adults and to help us identify solutions to those problems, we are supporting a special series in the nation’s leading health policy journal, Health Affairs. In the Aging & Health series launched with the January 2015 issue, we hope to bring to light both the problems and possible solutions that will help the biggest group of health care utilizers get the right care and the right health outcomes at the right cost to our system.

A rack of Health Affairs magazines in the office of Congresswoman Jan Schakowsky. A rack of Health Affairs magazines in the office of Congresswoman Jan Schakowsky.

We know that Health Affairs has an impact. It’s regularly cited in Congressional testimony and by the Supreme Court. When one of our staff recently visited a senior staffer of Congresswoman Jan Schakowsky, a shelf full of Health Affairs issues were on display.

In this inaugural set of Aging & Health stories, we learn about a range of topics related to the care of older adults. An Entry Point piece from journalist Susan Jaffe discusses the special problems facing older adults in rural areas. Jaffe talks to Casey Shillam, a Hartford Change AGEnt and one of our geriatric nursing scholars, who discusses how nurses can help be a solution to the issue of primary care provider shortages in these rural areas.

A research study from the Palo Alto Medical Foundation examined the impact of policy changes introduced by the Affordable Care Act that began covering preventive services for all Medicare beneficiaries through an Annual Wellness Visit. (See the results of the poll we conducted asking older adults about their experiences with Annual Wellness Visit.) Based on the ability to look at older adults with different kinds of health insurance within their system (Medicare fee-for-service, Medicare managed care, and private pay), they were able to analyze differences in uptake and could see increases in time-consuming activities such as advanced care planning as a result of the law. However, they note that rates of these important preventive services still remain much lower in the fee-for-service system than in managed care. More solutions are needed to bolster important practices that take substantial time.

Bruce Leff, MD Bruce Leff, MD

Helping policy makers see where the puck is moving to, so that we can skate there (thank you, Wayne Gretzky), Hartford grantees Bruce Leff, Charlotte Carlson, Debra Saliba, and Christine Ritchie also contributed a paper to the inaugural Health Affairs Aging & Health series on home-based primary and palliative care. They note that 4 million older adults are homebound due to frailty and functional limitations and are receiving care through house call programs. However, this kind of care and this very vulnerable population have been left out of most policy conversations related to quality and its measurement.

As the older adult population rapidly increases, especially the oldest old, this could become an even bigger policy problem. And I believe there will be continued movement toward home-based care as a patient-centered approach. Bruce Leff is one of the architects of the Hospital at Home model that is doing this for acute care. Through the development of a quality-of-care framework, quality measures, and a data registry that can be used for practice-based quality improvement and further research, the authors are also beginning to build out potential solutions that can help ensure home-based care meets the needs of patients.

We look forward to continuing to see articles over the next year in the Aging & Health series. And very importantly, we are looking for submissions. Please take a minute to check out the call for papers. In particular, Health Affairs is seeking articles that highlight new models of care and the management of chronic conditions among older adults, even if they are emerging and under the radar.

Help the country identify our health care policy problems and solutions for older adults. Then we can all get together and work on marshalling the political will to open the window for policy change.