What is health care reform?

Organization and Function

The function of health care is to provide preventive diagnostic treatment and emergency care for the citizens of a country. The physical organization of the health care system in the United States consists of hospitals, outpatient clinics, pharmacies, home health care services, long-term care facilities, public health clinics, and other supportive services such as occupational therapy. There are many layers of staff including physicians, nurses, physician assistants, other medical support staff, office staff, and administrative staff. These organizations are regulated by state and federal agencies. Naturopathic, dental, optometric, and other services are sometimes excluded from health insurance or health care plans ,or these services sometimes offer separate insurance policies and programs.

Health Care in the United States

There are many misconceptions about the existing health care systems in North America and around the world. In the United States, access to healthcare services and direct cost to patients depend on an the patient's insurance plan or lack of insurance plan. The United States does not have universal health care, which covers every individual in a nation regardless of income level. Rather, many employers pay part or all of the health insurance costs for their employees. Working individuals whose employers do not pay health insurance costs buy insurance out-of-pocket. People who are unemployed or who cannot afford to purchase health insurance are sometimes eligible for free or low-cost insurance through various government programs such as Medicare and Medicaid.

Depending on the insurance plan offered, copayments may be due at the time of service, and certain services may not be offered or covered by the insurance. For the millions of people who have no insurance, the health care system is a purely fee-for-service system like that found in developing countries. Some are able to navigate and take advantage of a patchwork of government services such as state-run plans or county hospitals may pay for emergency care. The United States is one of the few developed countries without universal access to health care, and since access to health care is inextricably tied to access to affordable health insurance, many see the system as failing the American people. Historically there have been disparities in availability of health care for people from various income levels, and the care that is available is not of consistent quality. Immigrants, the poor, and the homeless seem to be most affected by inaccessibility to health care, and seniors and children are also vulnerable. Many feel that the United States has had one system for those who can afford health insurance, and thus quality health care, and another system, often of lesser quality, for those without insurance. The Affordable Care Act of 2010 was an attempt to make quality health care accessible to all US citizens.

The Affordable Care Act

The Patient Protection and Affordable Care Act (PPACA) of 2010—commonly called the Affordable Care Act (ACA) or Obamacare, after its major backer, US president Barack Obama—sought to reform a number of aspects of the US health insurance industry, as well as improve the access to and quality of health care services. Since the passage of the ACA, insurers have been required to cover preventive services without a deductible, copayment, or other out-of-pocket expense; extend coverage to children with existing medical conditions; cover young-adult children up to age twenty-six on their parents’ plans; spend most of their premiums on benefits to consumers rather than on administrative costs; and provide justification for rate increases. Starting in 2014, insurers were no longer allowed to set annual dollar limits on coverage, reject anyone based on preexisting medical conditions, discriminate against women, or restrict or deny coverage to those who participate in clinical trials. The ACA also expanded Medicare coverage and benefits through the state governments, and issues of substandard health care for children would be addressed by increasing Medicaid payment rates to health care providers to help ensure access to primary care providers for more low-income children. Children would also no longer be denied coverage for preexisting conditions and would no longer have annual or lifetime caps placed on their health insurance. For very poor or uninsured families, the ACA provided tax credits and vouchers to help with quality health insurance coverage.

At the time of its passage, the Affordable Care Act was the most substantial overhaul of the US healthcare system since the passage of the Medicare and Medicaid amendments during the Johnson administration in the mid-1960s. Despite facing intense opposition from the general public, medical professionals, and various public officials and numerous problems and glitches in its start-up, many still had hope that the ACA would dramatically improve the affordability of and access to health insurance and quality health care.

Services and Cost

There is a balance between the services provided by any system, the cost per service, and the reimbursement of the provider. The provision of health care varies from simple procedures such as suturing a wound to very complex care such as diagnosing a rare neurologic disorder. Cost will also increase with the time a provider spends with a patient. In systems that have a fixed cost per service, the provider will have a financial incentive to see as many patients as quickly as possible. Malpractice insurance costs and claims also may affect cost and services. In some cases, tests or treatments may be recommended in order to reduce chances of malpractice claims. Some providers will discontinue high-risk procedures because of malpractice insurance costs.

It is a complex equation to determine this balance of service to patients; cost to patients via insurance, taxes, or cash; and reimbursement to providers. Geography and ethnic diversity will also complicate the equation. In 2012, the population of the United States was more than 313 million, Canada was almost 35 million, and Sweden was about 9.5 million. The United States covers about 3.7 million square miles, Canada about 3.8 million square miles, and Sweden about 170,000 square miles. These factors will influence the feasibility of services in some cases. For example, in sparsely populated areas of any country, it is difficult to provide the same services that may be available in a more densely populated metropolitan areas or in major cities.

Cost is also influenced by insurance company profits, health care provider reimbursement, technology, and preventive care. Some health care systems attempt to limit overall costs by providing preventive education and care. Immunization programs are an example of preventive health care that can reduce illness and therefore reduce cost to the system. Other systems use government control such as rationing to control costs.

Rationing, or "prioritizing," health care invariably involves financial considerations, but it can also involve scheduling, medicinal, and technological factors. Countries that feature universal health care frequently ration technological resources and attempt to secure bargaining arrangements with drug suppliers in order to purchase bulk amounts at a lower rate. In the United States, medical resources are more commonly rationed through administrative managed care organizations such as HMOs (health maintenance organizations); this form is sometimes termed "explicit rationing." The general theory behind rationing is that reducing less-necessary treatment allows individuals suffering from more serious conditions to receive treatment. The "implicit rationing" practiced in Britain is less formally defined and is intended to balance cost and medical need. Rationing may also lead to long waiting lists for services. Insurance companies generally try not to ration resources but rather screen high-risk candidates for policies and impose high deductibles to discourage the use of policies for less-serious treatment

The balance between services and cost is at the core of any health care reform debate. This balance is influenced by decisions such as preventive care provisions, what is considered to be elective care versus necessary care, individual needs versus the needs of the population, long-term care provision, and a host of other factors.

Perspective and Prospects

People with steady employment with health care benefits will not necessarily perceive that there is any problem with the existing system. A portion of the millions of uninsured Americans may also not perceive a problem if they have not had a need to access services. However, those uninsured with serious health issues or those who become unemployed and lost their insurance may feel there is a need for reform.

In spite of leading in health care expenditure, the United States places low in many rankings of health indicators. Some use these statistics to point to the need for health care reform in the United States. According to the World Health Organization (WHO), average life expectancy at birth for Americans was 79 years in 2011; the country ranks below numerous industrialized nations, including Japan, France, and Israel. Life expectancy may be affected by other factors such as homicide, so some believe this is not a true indicator of the quality of health care. Other indicators are similarly complex.

Health care reform in the United States is a particularly difficult task due to the large population, the variety of health care delivery systems that exist, and the many diseases and other health concerns that must be treated.. Chronic diseases such as heart disease, mental illness, substance use disorder, asthma, and diabetes account for a large amount of spending. Some politicians and health care professionals believe that early intervention in these cases would ultimately save money. Reform that includes more access to care, preventive care, and early intervention for people with these chronic diseases may improve health quality while decreasing health costs.

There are several things to consider regarding health care reform in the United States. It comes down to the collective philosophy of the citizens, the financial assessment of the benefit of investing in care for the underserved populations, the cost to the citizens through taxation, the cost to citizens for poor health in a segment of the population, and the cost to businesses for employee insurance.

Points under debate include whether providing insurance and preventive care to the currently uninsured might save money, as such individuals might otherwise access costly emergency care when untreated preexisting conditions lead to more serious illness. Lack of affordable insurance may discourage people from becoming self-employed or may cause small businesses to hire only part-time employees to avoid having to pay for expensive employee insurance plans.

Philosophical issues abound as to whether health care is to be considered a fundamental right, and if so, what level of services should be considered and whether wealthier citizens be allowed to purchase faster and more extensive services. The question of whether citizens have a responsibility to have insurance and the role of low-cost insurance as a stimulus to small businesses and self-employed people are other factors to consider. Profit versus nonprofit provision of care, as well as reimbursement for providers, also affects the debate.

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