Meet the Expert: Melissa Hafner
Melissa Hafner is a health policy researcher at AIR. Prior to joining IMPAQ, which recently became an affiliate of AIR, she conducted health research at Mathematica Policy Research and the Massachusetts Medical Society. She also served as a senior program analyst in the Office of the Inspector General at the U.S. Department of Health and Human Services, evaluating programs to identify waste, abuse, and areas for program improvement.
POSITION: Principal Research Associate, IMPAQ
AREAS OF EXPERTISE: Medicare, Medicaid, Value-Based Care
YEARS OF EXPERIENCE: 20
Q: What piqued your interest in a health policy research career?
Melissa: Health policy research is actually my second career. After college, I worked in publishing and communications for about eight years, and spent half of that at a health care nonprofit, managing their clinical journal and learning about health care as a system. During this time, a close family member went through a terrible health situation, including being denied care and having unreasonable limits placed on their care. This had long-lasting ramifications on their health and made me realize I wanted to do research—to better understand the health care system and help prompt changes. So I enrolled in graduate school for health care policy and gradually made the transition here.
Q: What are the biggest changes you’ve observed in the U.S. health system over the course of your career? What has remained constant?
Melissa: I’ve been fortunate to work in the field during times of big change. The passage of the Affordable Care Act (ACA) was a watershed moment; it put the problems of health care front and center in the national consciousness.
Another change is that the ACA triggered a lot of new types of payment models that focus on value more than volume. We’re still grappling with how to define value, but these models are a step in the right direction.
In addition, there is more attention on patients’ actual needs, including social needs that affect their health, and issues of equity like racial bias.
Unfortunately, the one constant is that health care remains really expensive. There are lots of reasons for that: there are many actors in the system who all need to earn a profit, and so on, so it’s not a simple problem to solve.
Q: What is the most common misconception around health care policy in this country?
Melissa: The biggest misconception among the general public is that the federal government can just fix health care. It’s true that the federal government is the biggest payer of health care services, but health policy is made at a lot of different levels—federal, state, insurance plans, health systems, and so on. There is a lack of coordination, there are competing interests, and different legal authorities among those levels, and that makes it impossible to just pass a law that covers everyone and makes health care affordable.
Q: You led a study on dually eligible individuals and their experiences accessing health care. Who are dually eligible individuals?
Melissa: Dually eligible individuals, often called “duals,” are people who receive both Medicare and Medicaid benefits. They must separately meet two sets of eligibility criteria—the low-income guidelines for Medicaid within their state, as well as the guidelines for Medicare, meaning they are either 65 and older, or they are under 65 and permanently disabled.
Dually eligible individuals are often medically complex. They may have multiple health care conditions and unmet social needs that go along with being low income—including unstable housing, limited access to transportation, and food insecurity.
Q: This study relied on the principles of Human-Centered Design. Why was Human-Centered Design a particularly helpful framework for this research question?
Melissa: The Human-Centered Design process puts the needs and motivations of people at the center, which seemed fitting for a population like duals. It captures a lot of things that can be missed in other approaches, like the nuances and pain points of their experiences.
We conducted empathy interviews, exploring the idea of care integration and how it should work. Care integration can mean different things to different people. We often think of it as care coordination, or in this study, blending two sets of benefits (Medicare and Medicaid). But to dually eligible individuals, care integration is more about tangible things, like how they’re going to get to and from the doctor’s office because they don’t have a car, or how they’re going to access a medication they need. We wanted to meet people where they were, unpack their stories, and connect—as opposed to traditional interviewing techniques, where the interviewer sets the agenda, comes in with a set of questions, and tries to extract specific information.
The conversations were an emotional rollercoaster—illuminating, humbling, inspiring, and sometimes even funny. We knew about some of these challenges, of course. But hearing the specific challenges of what people have to overcome really brought the issues into stark relief.
For example, we spoke to a woman who has narcolepsy and two young children. She struggles to get her medication, and she can’t function without it. What a terrifying experience—to fear that you might fall asleep and be unable to take care of your children, just because you can’t access your medicine. Another woman in our study has mobility issues. While she struggled to get to around her house, she couldn’t get a walker approved by insurance. Believe it or not, her family retrofitted an office chair to wheel her around in.
Q: What else did your research uncover about how dually eligible individuals experience health care?
Melissa: Ultimately, duals want the same health care experience that we all want: access to high quality providers, without having to jump through lots of administrative hoops. Some duals have positive experiences, though that generally means they love their doctor, without loving their insurance plan.
Duals also face numerous logistical hurdles to care. For example, when people can’t get to and from appointments in a timely way, they tend to delay or forego care. Many duals don’t own a car, or can’t drive because of their health conditions. Even daily needs, like shopping, cooking, and cleaning can be challenging for individuals who are really sick, and many patients rely on family for that kind of informal caregiving, but that isn’t always a sustainable option.
Another major challenge is understanding and navigating benefits. Half of our study participants are enrolled in integrated care plans, and yet their experience navigating benefits was as disjointed as those in other plans. In general, duals spent an inordinate amount of time trying to find providers who would take them, trying to find out what was covered, trying to get care approved—and not always getting answers. People with private insurance may be able to go out-of-network and pay the extra cost, which duals cannot afford to do. That’s why it’s especially important for duals to have integrated care that meets their needs and isn’t administratively cumbersome.
Q: Where can we find you on a typical Saturday?
Melissa: I’m a runner, so you’ll probably find me on a long run. Then I’m usually busy with “mom stuff”: taking my kids to their games, hanging out with friends and neighbors.
Q: What book would you suggest everyone read?
Melissa: Heather McGhee’s “The Sum of Us,” is about how racism in America has led to so many bad policies and limited our ability to grow together as a country and prosper. She discusses how race as a concept has been wielded—both explicitly and implicitly—to divide communities and preserve whites’ sense of dominance, but that dominance is an illusion. In reality, we’re all losing in the long run.