Designing Resilient Health Systems Under Policy Volatility: An Integrated Care and Financing Framework for Gender-Affirming Care, Substance Use Harm Reduction, and Affirming Mental Health

The qualitative conditions of policy instability that influence the practices of health systems are becoming more and more demanding concerning their provision of gender-affirming care, substance use harm reduction services, and affirming mental health interventions. Although operational and financial risk are present where the provision of care is disjointed, variability in regulatory interpretation, payer policy, and service availability creates operational and financial risk. The impact of this volatility is especially felt by lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority communities not due to the fact that such populations are niche clinical populations, but rather because they are structurally positioned to experience the impact of health system stressors with the first and most obvious effects. This paper offers a resilience-based health system design, which incorporates gender-affirming continuity of care, harm reduction of substance use, and affirming mental health services into one accountable operating platform. With a healthcare management and finance prism, we propose the Resilient Minority-Integrated Medical Framework, a model of delivery and financing with a specific design to operate in the conditions of policy uncertainty. Using clear assumptions of utilization and cost modeling and contracting, we show how integrated design can decrease unnecessary high-acuity utilization, stabilize access to care, and provide a financially viable channel of payers and providers. The framework is pegged as a practical solution to volatility and integrating and financially disciplined, as opposed to political affiliation.