At AIR, Yael Harris leads research projects to advance access, quality, payment reform, and other policies to transform health care delivery. She is involved in a wide range of health-related projects, including Understanding Omissions of Care in Nursing Homes, the Comprehensive Primary Care pilot, and Technical Assistance to States Participating in the Medicaid Electronic Health Record (EHR) Incentive Program. Prior to joining AIR, she worked at Mathematica Policy Research; she also served as the director of the Office of Health Care Quality under the HHS Assistant Secretary for Health.

POSITION: Vice President, Research and Evaluation

AREAS OF EXPERTISE: Health disparities, long-term and primary care, health information technology/telehealth, quality measurement and improvement

YEARS OF EXPERIENCE: 22

Q: How did you become interested in public health?

Yael: Originally, I wanted to be a physician or a psychologist, working with children who are in palliative care. Those programs require research experience, so after earning my bachelor’s degree, I found a job at Georgetown University’s Center for Health Policy. I had the opportunity there to work for one of the Deputy Assistant Secretaries for Health under President Clinton, and after two years, I realized my true passion is public health. I’m still very passionate about children, but I was excited by the chance to have an impact on an even larger scale, through policy.

Q: What big changes have you observed in the field since you began this work?

Yael: The biggest transformation in health care in my lifetime—until the COVID-19 pandemic—was the Affordable Care Act. I remember where I was sitting when it was signed into law. It’s hard to overstate its effect on health care, and health care access.

Another big one is the changing emphasis from acute disease to recognizing the importance of disease prevention and the management of chronic conditions. When I first started in this work, health insurance and health services research primarily focused on events that resulted in hospitalizations. They rarely considered addressing the factors that lead to and could prevent hospitalizations. The importance of preventive care and effective management of chronic conditions like diabetes and heart disease is now universally recognized.  It gives me hope that people are thinking ahead of the curve, as opposed to waiting for patients to get sick.

Lastly, the de-stigmatization of mental illness has also been transformative. My dissertation, which was published in 2000, focused on whether depression in older adults increased the risk of being admitted to a nursing home. Two out of the five members of my panel were convinced that it didn’t. Now, 20 years later, no one would even bother to ask that question—everyone knows that it does.

Q: You’ve done a lot of work in health care quality. What are the most important measures to determine whether patients are receiving quality care?

Yael: That’s a great question, because there is no perfect measure. There are a lot of factors that need to be balanced with one another. Clinical quality is important, but it fails to consider patient preferences and care experience, patient engagement with the clinician in selecting the best treatment path, and long-term outcomes and care coordination. That’s why AIR’s Patient-Centered Measurement Pilot Projects are so exciting—because patients help us understand what measurements of quality really matter to them. Quality health care is like a diamond with many facets. We’re only able to measure some of those facets right now, but all of them are important.

Q: Can you define social determinants of health? Why is it a useful framework?

Yael: It’s actually very hard to define, because it’s so all-encompassing. I like the National Academy of Sciences’ definition: “The conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”

Social determinants of health requires us to recognize that health care, as we typically think of it, is just a small factor in an individual’s overall health and well-being. Our current conception of “health” ignores the multiple components of an individual’s life that contribute to well-being—factors such as environment, education, financial resources, housing, lifestyle, attitudes, and preferences.

Q: How does AIR approach social determinants of health?

Yael: Social determinants of health connect many of AIR’s different areas of work. If we think of our projects as overlapping factors that affect someone’s overall health, we can leverage our expertise and make an even greater impact.

We recently convened 31 experts from across AIR, which isn’t comprehensive of the whole organization, but was small enough to facilitate real dialogue. In addition to highlighting cross-cutting projects, we talked about how to influence well-being at the community level—be it through transportation, or schools, or access to food and housing. All these factors, and many more, affect health outcomes and require community-level initiatives.

Q: What factors will affect equity in health outcomes over the next five to 10 years?

Yael: One major factor is politics—which is not a domain in which AIR operates, but nevertheless plays a big role in how many resources are made available, and how they’re deployed. There are a lot of public health issues that will also have an outsized impact, including gun violence and school safety; health insurance and how it is—or isn’t—tied to employment; and issues like access to services, including remote education classes and telehealth. We’re seeing that right now during this COVID-19 crisis—people are turning to technology to fill in resource gaps, and, for better and worse, they may continue to rely on them post-pandemic. 

Q: What do you think will most affect the U.S. health system in the next decade?

Yael: Demographics are going to change everything. People talk about the “silver tsunami,” of the baby-boom generation, which has implications across the board: on the cost of health care, on the needs and demands of the health care system, and even on the need to reconsider how the health insurance system is structured in the United States. Because of demographics, there are fewer people paying premiums into the Medicare Trust Fund to cover the growing number of individuals eligible for Medicare.

Also, we’re living longer lives than when Medicare was established, but as a result, we have more expensive and long term chronic health conditions that need to be covered.

Finally, when Medicare was designed, it was designed primarily as a program to cover hospitalization costs. While it has been modernized to cover prescription drugs and vision, the benefits for other primary health care needs like behavioral health, oral health, and long-term care are still insufficient.