The United States healthcare system is a uniquely complex system made of both private and public sectors. From an international perspective, The United States spends more than any other country on healthcare though we do not necessarily have the best healthcare delivery system. The Department for Professional Employees (DPE) 2016 Fact Sheet shows though the US has the best doctors in the world, but that the treatment in the U.S. is inequitable, overspecialized, and neglects primary and preventative care (DPE, 2016). The result is that American’s health care is poor in comparison to other advanced industrialized nations.
There is much division in the United States over the Affordable Care Act and lawmakers are consistently trying to implement policies and reforms that will make our healthcare system better. American citizens want quality healthcare at affordable prices but can’t seem to agree how that can best be achieved. Right now, there are executive orders on President Biden’s desk that some groups are pushing for him to sign. Most recently, in March 2021, the President signed the American Rescue Act of 2021 (H.R.1319 – 117th Congress, 2021-2022) that focuses on incrementally implementing changes to the United States healthcare system and supporting citizens in need because of the Covid pandemic. Changes that President Biden is implementing now are similar to previous healthcare reform efforts made during the Obama administration.
The Affordable Care Act (ACA) is the name for a comprehensive health care reform law and its amendments. The law was enacted in two parts: The Patient Protection and Affordable Care Act was signed into law on March 23, 2010, and was amended by the Health Care and Education Reconciliation Act on March 30, 2010. The law reduced the number of uninsured but failed to provide insurance for millions and was repealed under the Tax Cuts and Jobs Act of 2017 (HHS.gov, 2021).
Health insurance is high, and many Americans still do not have health insurance. Vulnerable populations such as the homeless and people suffering from severe psychological disorders may not have access to healthcare at all. The American Public Health Association’s website focuses on how important the ACA is in the move towards making healthcare coverage affordable and accessible. The goal is to increase the number of Americans with coverage by funding community-based public health and prevention programs, and by supporting research and tracking on key health measures (APHA, (2021). APHA focuses on showing five reasons why repealing the ACA hurts Americans; (1) “Millions still need insurance: Though the ACA has helped about 20 million get health insurance, about 29 million people still lack coverage, (2) Unsustainable spending: Health care spending represented 17.7% of our gross domestic product in 2019, (3) Lack of emphasis on prevention: Today, seven in 10 deaths in the U.S. are related to chronic diseases such as obesity, diabetes, high blood pressure, heart disease, and cancer, which are largely preventable. Additionally, 90% of our health care dollars are spent treating such diseases. However, only three cents of each health care dollar spent in the U.S. goes toward prevention, (4) Poor health outcomes: The U.S. spends far more on medical care than any other industrialized nation but ranks 28 among 36 OECD countries in terms of life expectancy, and (5) Health disparities: While inequities related to income and access to coverage exist across demographic lines, population-based disparities are impossible to deny.” (APHA, (2021).
Socioeconomic factors prevent many people from receiving both preventative and curative healthcare. Emergency rooms end up being overwhelmed with people seeking emergency help that could have been prevented or treated in doctor’s offices. Poorer, less educated populations receive less care than educated, more financially stable Americans. Minority group membership is associated with lower overall health care access. Racial or ethnic minorities are less likely than their white counterparts to have a specific source of ongoing care (Shi & Singh, 2019). Blacks and Hispanics are more likely than Caucasians to visit hospitals for healthcare rather than doctor’s offices (36% versus 21%). Nonwhite beneficiaries of Medicare have fewer cancer screenings, fewer flu shots, less mental health care, and fewer ambulatory and physician visits than their white counterparts (Shi & Singh, 2019).
Geographic disparities also present barriers to access. It is believed that rural Americans have higher mortality and morbidity rates and shorter life expectancies because they have fewer doctors and because they have to travel to get medical and mental healthcare. Suicide rates in Wyoming are the highest in the U.S. while New Jersey has the lowest rates for suicide. Depression, unshakeable feelings of dread, despair, loneliness, and hopelessness seem to be leading signs and causes of suicide. The Pacific Northwest, and the Midwest seem to suffer more from mental illness than other regions.
Serious mental illness costs the United States an estimated $193.2 billion in lost earnings annually and only about 41% of persons with a mental disorder receive any treatment (Shi & Singh, 2019). Mentally ill patients are at higher risks of becoming homeless and homeless people do not have access to medical care and experience higher rates of adverse physical and mental health conditions, suicides, substance abuse, and respiratory diseases. SAMSHA’s national mental health statistics show that yearly, about 42.5 million (18.2%) American adults suffer from some mental illness (Health.am, 2021). Approximately 9.3 million adults (4%) experience severe mental illness that interferes with their daily lives. Nearly half (45%) of those with any mental disorder meet criteria for two or more disorders, with severity strongly related to comorbidity. Mood disorders affect about 20.9 million American adults (9.5%) with the median age being around 30 years old.
Racial profiling can traumatize people of color making their daily life experience different from Caucasians. Racial and ethnic minorities have less access to medical and mental health services and may not receive the same level of care. Statista shows that as of April 2021, around 25.5% of U.S. black, non-Hispanic public health workers reported having depression in the past 2 weeks, while 32.4% of white, non-Hispanic health workers reported the same. The numbers may not be accurate because other populations are not included in the study and because some people such as homeless people, do not have access to care. Stigmas surrounding mental health also prevent people from reporting mental health concerns.
Stakeholder Health is an organization on a mission to educate, examine, learn, and teach new ways to approach community health, especially to those with a vested interest in accountable care (Miller, & Peterson, 2021). Because many people may not have the ability to drive to doctor’s offices or have access to transportation that can get them to a doctor, community health centers are encouraged to team up with mobile teams to improve access to care. Mobile teams can greatly benefit low-income rural communities that cannot easily access medical care.
“About 3.6 million Americans miss or delay medical appointments every year because they lack a ride to the doctor”, writes Therese McMillan for the U.S. Department of Transportation (Miller, & Peterson, 2021).
Mental and physical health outcomes improve by closing the transportation gap. Other insightful approaches to making healthcare more accessible include “staffing retail outpatient health systems with nurse practitioners and physician assistants in places such as Target, Safeway and Kroger” (Miller, & Peterson, 2021). Expansion for such CHCs is provided for through the ACA (Shi, & Singh, 2019).
The Robert Wood Johnson Foundation is also closing the transportation gap and other barriers to healthcare to reduce economic, racial, and ethnic disparities, and to provide models for national quality health care reform in selected communities (AF4Q, 2021). There are 16 participating geographically, demographically, and economically diverse populations that the Robert Wood Johnson Foundation and Aligning Forces for Quality (AF4Q) cover and, together it covers 12.5% of the United States communities (AF4Q, 2021). The organization makes use of primary care practices and hospitals to improve healthcare. The organization’s products and resources provide lessons learned by regional alliances of providers, patients, and payers as they worked to transform their local health care and provide national models for reform.
Costs of healthcare is rising and there is a critical shortage of healthcare professionals that has to be addressed. Serious issues remain in the areas of coverage, quality, administrative costs, access, affordability, and training. One study shows that CNA supervisors were concerned that 16 clinical hours was insufficient to adequately prepare new CNAs for employment in long-term care facilities and that patients in long-term residential treatment do not feel they are getting the care they deserve (Trinkoff, et. al., 2017).
Intervention and the ability to challenge colleagues who are in authority when something does not seem right or is clearly wrong can save lives and create better outcomes. Identifying barriers between colleagues helps in the development of tools that can be implemented to create improved future outcomes. Because mistakes by medical professionals can be deadly and because challenging hierarchy in healthcare teams can be difficult if not impossible, the Royal College of Surgeons of Edinburgh runs popular regular non-technical skills courses for surgeons that teach how to ensure safety through good communication and teamwork (Green, et. al., 2017).
A physician workforce shortage was forecasted by a public database that was constructed to predict changing future healthcare needs (Zhang, et. al., 2020). As a result, “The Physician Shortage Reduction Act of 2017 (H. R. 2267) was introduced in Congress to increase by 3000 the annual number of residency slots from 2019 to 2023. States such as Arkansas, Kansas, Missouri, and Utah have also passed legislation to provide provisional licenses to some medical school graduates who have not been able to find residency spots. With these provisional licenses, they can practice primary care under the medical license of another physician, but only in medically underserved areas” (Zhang, et. al., 2020). The study also shows how doctors from other countries are filling the gaps in the United States healthcare system.
Understanding professional roles and being able to communicate with providers is important and trained multidisciplinary teams are showing improved trusts, teamwork, patient benefits, accessibility, convenience, treatment outcomes, patient satisfaction, waiting times, access to care, and that MDTs prevent and reduce complications. On the other hand, the review shows that poor interactions between healthcare professionals can hamper quality patient care (Tan, et. al., 2020).
The United States spends more than any other country on research and development (R&D) and advances in healthcare technology is changing the way that health care is delivered. Many believe that technology is a major cause of the rising costs of healthcare while others will argue that technology is making healthcare more affordable. Americans want the latest technology and although the initial costs of training and implementing new technology may raise the costs of healthcare, it is believed that technology will provide better outcomes and become cheaper over time.
Internet now enables patients and practitioners to access information and facilitates interaction between consumers and providers. The internet has added a convenience that is making virtual visits possible. Electronic health records (EHRs) have replaced the traditional paper medical records making it easier and faster for medical providers to share information about patients. Clinical applications support patient care delivery. Administrative information systems are designed to assist in carrying out financial and administrative support activities such as payroll, patient accounting, staff scheduling, materials management, budgeting and cost control, and office automation. Decision support systems forecast patient volume, project staffing requirements, evaluate financial performance, analyze utilization, conduct clinical research, and improve quality and productivity to provide information and analytical tools to support managerial decision making. Clinical decision support systems (CDSSs) are interactive software systems designed to help clinicians with decision-making tasks, such as determining a diagnosis or recommending a treatment for a patient. (Shi, & Singh, 2019)
Governments also use technology to improve healthcare delivery systems and to make healthcare more affordable. Lessons learned from providers, patients, and payers are transforming healthcare by identifying problems and inspiring national models for reform. MONAHRQ software is a digital software system that is used by state data organizations, chartered value exchanges, and hospital organizations to advance healthcare quality, safety, and effectiveness through the evidence collected from digital healthcare systems research (AHRQ, 2021). Risa Lavizzo-Mourey, MD, MBA, President and CEO of the Robert Wood Johnson Foundation says. “Aligning Forces for Quality has been a tremendous journey. Insights we’ve gained will shape our future work to build a national Culture of Health … one that will enable all Americans to live longer, healthier lives — now and for generations to come.” (AHRQ, 2021).
There are concerns about the use of technology in healthcare delivery. There are ethical and moral issues that have to be decided about the patient’s healthcare such as when a physician should use technology to save a life (Shi, & Singh, chapter 5, p140, 2019). Some Americans are concerned that too much data is being shared and that the internet is not secure enough to keep their personal data private.
The goal of healthcare reform is to lower the costs of healthcare and make it more affordable and accessible. The implementation of the Affordable Care Act (ACA) was intended to do that, but it failed to insure millions of Americans and was ultimately repealed in 2017. The United States healthcare system is complex and mostly misunderstood because it is financed by both by public funds and by private funds. Healthcare reform is still on the table, but there are many issues that have to be worked out. There are also disagreements among Americans about how healthcare reform should be accomplished. America is an independent nation. Many Americans do not trust the government to provide for them and believe that healthcare reform will limit the care that they can receive. Americans do not want to wait in line or wait for months to see a doctor. Americans also want to be able to choose their doctor and have a choice in treatment options.
One way the government measures the quality and outcomes of services provided to patients and accounting for the costs of resources used to produce them is MACRA. The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 is a health information system that established incentives for clinicians to produce better outcomes. It ended the Sustainable Growth Rate formula that for years resulted in congressional intervention to avoid reductions of payments to physicians. There is a concern though that Incident To Billing Coding can undermine the integrity of MACRA because with incident to billing, accurate measurement of both quality and costs are not possible. A solution may be for Medicare to adjust billing procedures so that payment identifies with the clinician that provides services (Buerhaus, et. al., 2018).
The financial status of a trust fund appropriately considers all sources of financing provided for that fund, including the availability of trust fund assets that Medicare or Social Security can use to meet program expenditures. From a budget perspective general fund transfers represent a draw on other Federal resources for which there is no source of revenue from the public. “The budget perspective does not reflect that publicly held debt and interest payments to the public are both lower because the trust funds hold some of the debt.” (Spitalnic, Paul, 2021). The financial status of the trust funds and financial operations of Medicare and Social Security in the context of the programs’ trust funds or in the context of the overall Federal budget are often misunderstood but are important when considering ways that we can reform healthcare to better meet the needs of populations (Spitalnic, Paul, 2021). The 2020 Annual Report Of The Boards Of Trustees Of The Federal Hospital Insurance And Federal Supplementary Medical Insurance Trust Funds, Associate, Society of Actuaries Member, American Academy of Actuaries, Chief Actuary, Centers for Medicare & Medicaid Services 2020 Federal Trustee Report states, “Medicare still faces a substantial financial shortfall that will need to be addressed with further legislation. Such legislation should be enacted sooner rather than later to minimize the impact on beneficiaries, providers, and taxpayers.” (Spitalnic, Paul, 2021).
Researchers wanted to know if lower Medicaid reimbursement rates would be associated with poor access to providers. The odds of being unable to access primary care providers, access specialty care providers and receive a needed doctor’s appointment in a timely manner were assessed and give insight into the effectiveness of the ACA (Relias Media, 2019). The study concluded that ACA insurance exchange offerings differed from other non-exchange insurance options in terms of access to healthcare. “The results show that poor access to primary care providers was seen among private coverage purchased via exchanges, relative to private coverage purchased on the individual market. Similar trends were seen with employer-based coverage that may not be attributable to reductions in Medicaid fees. If we are going to make improvements, we need to find ways to prevent barriers to care for those with on-exchange and off-exchange individual private insurance plans and Medicaid.” (Alcalá, et. al., 2018).
The ACA insured millions of previously uninsured people. However, barriers to quality healthcare persist for some populations (Relias Media, 2019). The study shows the ACA insurance exchange offerings differed poorly from other non-exchange insurance options in terms of access to healthcare (Alcalá, et. al., 2018). At the time that the reports of the study were published, Alcalá did not know how his team’s findings would affect hospitals. What he discovered later further suggested “Hospitals can offer financial counseling to help people understand what all this means. But if providers are unwilling to take patient’s health insurance coverage, this is unlikely to help those who are unable to pay for care out of pocket” (Relias Media, 2019).
Like most United States government policies that affect billions of people around the world, changes in our healthcare system will be slow. We are only in the beginning stages and experts have not figured out the answers although they do have promising visions of a better future for healthcare delivery systems. The goal will be to provide high-quality healthcare that is convenient and affordable. There are several bipartisan bills on the table as I am writing this paper and that gives me hope that we will find solutions to provide affordable quality healthcare to everyone. Surely the best doctors in the world with the help of interested organizations, stakeholders, and technology can find a way to provide equitable, affordable healthcare that does not leave anyone out or neglect primary and preventative care.
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