Health Care in the United States: Not up to Par

Katie Meyer

Biology Senior Seminar

November 6, 2006

Thesis: The health care system in the United States is inadequate because it promotes the health of wealthier people, the quality of the health care is not always maintained, and it is not easily accessible to some. There are several ways the system could be improved, including a two-tiered system and a public health care system.

Outline

I. Introduction

A. Stories: those who cannot get adequate health care

B. History—How did this system of health care develop?

II. Problems with the current system

A. Promotion of health of the wealthy over that of the lower classes

1. Insurance costs

2. Why are they so high?

B. Lack of quality maintenance

C. Lack of accessibility for some

1. Those in poverty

2. Those in rural areas

D. Diminished choices

1. Patients’ choice of physician, hospital

2. Physician’s choice of treatment options

E. Counter-argument: current system is adequate, has best technology possible

1. Poor health is related to lifestyle choices

2. Response: lifestyle choices related to poverty/wealth, many don’t have extra money to spend on insurance, medicine.

III. Conclusion: suggested improvements

A. Two-tiered systems

B. Public Health Care systems/ National Health Program

1. Canadian example

2. Application to U.S. situation

a. positives

b. negatives

Introduction

Stories

Imagine a young parent, attempting to raise his family while working, and not making a lot of money. He budgets what income he does bring home, and is able to pay for basic necessities, like rent and groceries. He adds a little money to his savings account occasionally, but he does not have the extra money needed to pay for health insurance for himself or his family. He works full-time, but does not receive health insurance benefits from his job. What happens to this man and his family if one of the children becomes seriously or even moderately ill? Emergency room costs are extremely high, and even medicines prescribed by a family physician could be too much for the family’s small budget. While an emergency might warrant use of the money in the savings account, less serious medical problems, or chronic conditions, may be left untreated, possibly causing greater problems later in life.

Health care in the United States has been a hot topic in recent years. Some believe that the current system is working just fine: the United States has some of the most advanced medical knowledge, training, and technology in the world (Bar-Yam, 2006). However, the system tends to let a lot of people slip through the cracks. According to Balkin (2003), over 40 million Americans are uninsured, and therefore their access to health care is greatly diminished. In a recent report (released September, 2006) from the Commonwealth Fund, the United States ranked lowest among industrialized nations for life expectancy and infant mortality. The U.S. system also received low grades on “outcomes, quality of care, access to care, and efficiency” (Arnst, 2006, p. 1).

History

How did health care get to be this way? What is the history behind today’s $1.7 trillion-per-year health care? Years ago, in the late 1800s and early 1900s, most hospitals were run by religious or non-profit organizations, and were funded by charitable foundations. The main part of the history of national health care begins in the early 1900s, when some politicians and other reformers began advocating a national health insurance plan (McLaughlin, 2005). These reformers included Louis D. Brandeis (a Supreme Court justice), Teddy Roosevelt, and Harry Truman (Balkin, 2003). Great advances were being made in science and medicine, and continued to be made, especially during and after the first and second World Wars. In the mid twentieth century, the development of medicine really got going; antibiotics made many major infections into minor ailments, and vaccines were developed against many terrible diseases (Edge & Groves, 2006).

Some continued to fight for national health insurance, especially for the poor and elderly, and eventually, in 1965, legislation signed into law by the Johnson administration created Medicare and Medicaid (McLaughlin, 2005). These national programs were created to help the old and the poor (Edge & Groves, 2006). But the costs of all the new technology and advanced treatments began building up. From the mid-twentieth century onward, healthcare in the United States became more and more expensive. The costs were shared by taxpayers, insurance companies, hospitals, sometimes employers, and, after the Great Depression and the Medicare/Medicaid act, the government (Dombeck & Olsan, 2002).

In 1973, the HMO Act was passed. HMOs, or Health Maintenance Organizations, are one type of “managed care organization,” designed to help suppress the rising costs of healthcare by encouraging preventative measures. A general model involves employees paying premiums and employers paying some of the cost of treatments and procedures. Eventually (by the 1990s) many of these organizations became for-profit, realizing that money could be made if the organizations became investor-owned corporations (Dombeck & Olsan, 2002). This set the scene for a conflict of interests: providing care and making profits.

Currently, there are many types of managed care organizations, of which HMOs are just one. Others include Preferred Provider Organizations (PPOs), Exclusive Provider Organizations (EPOs), and Individual Physician Associations (IPAs) (Edge & Groves, 2006).

Problems with the current system

Promotion of the wealthy

One of the main problems with the current system is the way it promotes the health of those with money over that of the lower classes. Insurance costs are very high, too high for many families to afford. It is actually the lower middle class that is most affected by these high costs, because the government program Medicaid covers those in real poverty (Edge & Groves, 2006). However, even those with Medicare or Medicaid can have trouble getting reimbursement for certain procedures and treatments. Medicaid especially is recognized as a program with many problems (McLaughlin, 2005).

Certainly, there is some amazing medical technology in the United States, but who can pay for it? Most of those who are uninsured are part of working families. About a third of uninsured families come from below the poverty line, another third are from near poverty, and the rest are from families with up to twice the income of the poverty line-families (Balkin, 2003). Many middle-class people have trouble paying for even basic treatments and procedures; the Commonwealth Fund report indicated that one third of all U.S. adults have cannot pay their medical bills, or have medical debt (Arnst, 2006).

The way that health care is financed in the United States is mainly based on employer-provided benefits (through managed care organizations), meaning that people who are employed in jobs that give benefits are covered by insurance. According to J. Meyer, M.D. (2006), These tend to be younger than the general population and relatively healthy. Says Meyer, “Insurance companies love to ensure employee groups…they can pay premiums, but have a much lower chance of requiring benefit payouts. Very profitable.”

One of the problems is that, when dealing with healthcare, the timing and extent of needed treatment and medicines is uncertain, so some party must assume the financial risk. When the organizations that assume the risk are for-profit corporations, they must generate profit for their shareholders, as these investors share in the risk as well (Dombeck & Olsan, 2002). That risk is substantial, considering the United States spends the most per capita on health care of any nation in the world (Balkin, 2003). Providing healthcare for those who need it is only one of the corporations’ priorities. Generating profits is the other. In order to do both, insurance must be expensive, and insurance companies must target those who have money and are able to make more (Dombeck & Olsan, 2002).

Health care costs more than just insurance premiums and deductibles, too. There are also co-payments for medicines and co-insurance payments for the amounts the insurance does not cover. There is a ten percent surcharge on all insurance payments that helps compensate for care that is not paid for (generally emergency care for those who cannot pay), and, of course, there are taxes that help pay for Medicare, Medicaid, and other public programs that try to help those in need (White House, 1993).

Lack of Quality Maintenance

Despite all the money that is spent on health care in the United States, despite Medicare and Medicaid, the quality of care is not always maintained (Arnst, 2006). Although high-quality care is available to certain people with certain incomes in certain locations, these pockets of excellent care are tempered by pockets of very poor care (Live here, 2006). For example, less than half of all adults in the U.S. get all the preventative and screening procedures done for their age group and sex. In some states, preventable hospital admission rates for those with chronic conditions are very low, but in the nationwide average, the rates are nearly twice as high as in those states (Arnst, 2006). It ends up being the uninsured who have the poorest-quality care; they tend to live shorter, less healthy lives than those with insurance (Balkin, 2003). The difference in quality of care between insured and uninsured is great; according to Arnst (2006), the quality of care for the uninsured would have to improve by one-third to reach the standards of those with insurance.

According to Meyer (2006), patients without insurance will not seek medical care unless they have a “dire emergency.” Such patients often allow chronic problems such as hypertension, diabetes, and high cholesterol to go untreated, because they cannot pay for the medications or follow-up for these conditions. This is a serious problem; it not only diminishes the quality of life at present, but can cause severe conditions in the future, and lower life expectancy dramatically (Meyer, 2006).

Not only does this cause low quality of life for individuals and lower overall quality of U.S. healthcare, it also causes costs of health care to rise even higher. When the uninsured do have emergencies, when they must be attended to at a hospital or emergency room (often because they lacked preventative care), the cost of that treatment must be shifted onto others: taxpayers and those who pay insurance premiums (White House, 1993).

Not only must the uninsured delay or miss treatment of chronic and/or minor conditions until they become serious emergencies, but also much preventative medicine is unaffordable to them. For example, uninsured children often miss vision, hearing, and developmental screening that could be useful in preventing more serious conditions. Also missed are immunizations against infectious diseases and other conditions (Edge & Groves, 2006). According to Edge & Groves (2006, p.170), the uninsured “are twice as likely as insured patients to be at risk of dying before reaching the hospital.” Obviously, the quality of care is not maintained from one patient to the next.

Lack of Accessibility for Some

Lack of accessibility and poor quality of health care are often linked; lack of accessibility often leads to poor quality care. But the lack of accessibility should be examined by itself, as it could be an area for reform measures to focus (Edge & Groves, 2006).

While access to good health, and good healthcare, might seem like a basic right of all citizens, it is currently not so. Unfortunately, as we have seen, health care in the United States is treated as a commodity, something which must be purchased as a product (Dombeck & Olsan, 2002). One way, as previously mentioned, that poorer people are denied access to good health care is through lack of insurance. People who cannot pay for insurance are likely to be in worse health than those with insurance (Arnst, 2006).

There are other ways that those with little money are kept from having good quality healthcare. For example, hospitals are often built in more affluent neighborhoods or areas of a city, making it more difficult for urban poor to get to them for treatment. When there are hospitals in poorer areas, they are likely to have less advanced medical technology. These hospitals are also less likely to expand or develop special units, because they have the disadvantage of lack of capital (Economic disparities, 2006).

It is not necessarily just those without extra money who are affected by lack of access to healthcare. Another problem with access occurs in rural areas, where there are far fewer physicians per capita than in cities. People who live in the country, then, often have little choice in which doctor to see. When emergencies arise, those who live in rural areas are much less likely to get to a hospital in time than those who live in urban areas (Edge & Groves, 2006).

Also affecting the distribution of access is the fact that more doctors are specializing now than had in the past. Specialized physicians require more education, higher salaries, specialized equipment, and new types of equipment operators, causing more expense. In addition, it is more difficult for patients to find a general practitioner (Economic disparities, 2006).

Diminished choices

While some people may have limited options for their general practitioner because of location, others are limited by their insurance companies (Physicians, 2006). Often the insurance coverage offered by a person’s employer is only one health plan, and often the one health plan offered limits choice of doctors. Because of this, some people find themselves having to switch doctors when their insurance benefits change, or when they change jobs (White House, 1993).

In addition to patients’ reduced options, doctors also often find themselves limited by insurance companies. Certain treatments a doctor may have considered for a patient’s therapy may be foregone because they are not covered by the patient’s insurance plan (Orin, 2001).

Does the system work?

Some argue in favor of the keeping the current system. They say that we have the best system for treating people in the world. It is obvious that the United States has very advanced medical technology when foreign heads of state come to our nation to be treated for their serious health conditions. When confronted with the issue of people who cannot pay for insurance, those in favor of the system point to Medicare and Medicaid as programs that take care of such problems (Balkin, 2003). When those who do not qualify for such programs, but are still without insurance come up, some infer that they choose to spend their money on things other than healthcare (Meyer, 2006). However, according to Meyer (2006), “most of these people have no money left after they have purchased basic necessities.” It seems obvious that people who are struggling to make ends meet cannot afford health insurance.

Some point to lifestyle choices as the reason for lower health and quality of life, thus discounting lower income as the main cause (Balkin, 2006). There are some indicators that this may be at least partially true. A study on mortality in the United States (life expectancy is often correlated with overall health and quality of life) found that local variations such as diet and health care options affected lifespan more than income levels (Live here, 2006).

However, it is important to note that diet and other lifestyle choices themselves are often linked to income levels. Without education, many poor people are unaware of important lifestyle choices that could increase their overall health (Leichter, 2003). It is also recognized that healthier foods tend to be more expensive, and that is one reason that people with lower incomes tend to have less healthy diets than more affluent people. For example, one study found that “proportions of persons eating fruits and vegetables increase[s] with income” (Block & Patterson, 1988, p. 282). Perhaps with better education, lower-income families could make better lifestyle choices, but it may still be difficult for them to do so, especially in regard to food choices.

In addition, the local differences noted in the mortality study (Live here, 2006) may reflect differences in access to healthcare related to how rural or urban a place is. In that case, those with lower overall health may have reduced access to hospitals or doctors, another aspect of the system that needs change (Edge & Groves, 2006).

While the United States does have extremely advanced medical knowledge and technology, its system of making this available to its citizens is far from perfect. Many people do not have the money to pay for insurance and are subsequently kept from adequate heath care (Meyer, 2006). Some make poor lifestyle choices that may reflect lack of education or low income (Block & Patterson, 1988). Some may live in rural areas with diminished access to hospitals and doctors (Edge & Groves, 2006). Many U.S. citizens are worried about the future of health care; a healthy majority of Americans believe the system needs complete and fundamental rebuilding (Time for, 2006). It is apparent that the system requires change.

Conclusion: Suggested Improvements

Two-tiered/multiscale system

One suggestion for improving the health care system in the United States is a two-tiered or multiscale system. This type of system would divide the treatments given to patients into two categories. The first category includes routine procedures, screening tests, preventative shots, catastrophic health needs, and all other general health care; the second includes highly technical or expensive treatments for individual patients (Bar-Yam, 2006). Some suggest that in a two-tiered system, everyone should be guaranteed the basic treatments in the first tier. The idea is that everyone should have access to a decent minimum of health care, but those who wish for more can pay privately to have special treatments. This type of system could be useful in the United Sates, where many fear that the government will ration the health care that they can receive if it becomes too involved (Edge & Groves, 2006). Still, it seems such a system might continue to promote the health of the wealthy over that of the less affluent.

Public health care

Some believe that the United States needs a system of public health care, in which the government is more involved in distributing health care (Meyer, 2006). Physicians for a National Health Program (2006), an organization of doctors in favor of public health care, says that the reason U.S. health care is so expensive and yet so inadequate is because “we have a patchwork system of for-profit payers.” These doctors are in favor of single –payer national health insurance. In the single-payer program, a public organization would organize financing of health care, but the delivery of treatment itself would stay private (Physicians, 2006).

Often when the issue of public health care in the United States is discussed, Canada’s health care system is cited as an example. Canada has a national health care system that guarantees basic health care for all, much like many other industrialized nations. The system is paid for through taxation, coupled with a system of utilization authorization. This means that the most expensive treatments and procedures are regulated (Meyer, 2006).

What many U.S. citizens dislike about the Canadian system is that it involves this form of “rationing” what treatments may be used for which patients. Some believe that any form of rationing is unacceptable when it comes to health care. In other words, if there is a treatment for a condition, then every patient with that condition should have that treatment available to them (Balkin, 2003). However, this line of thought does not take into account all those who cannot even receive basic care because of the high costs (Meyer, 2006), nor the fact that rationing of some kind or other is happening all the time in health care. In the U.S., this means some people getting treatment and others not based on income, greater need, or even random chance, as in the case of first-come first-served hospital beds (Edge & Groves, 2006).

It may seem wrong to think that not every patient should have every treatment available to them. But sometimes the most expensive treatments are the most uncertain, and may end up having the least value. According to Meyer, “If access to expensive treatments…were not authorized unless there was significant benefit to the patient, a large amount of funding might be available to provide a basic level of care to all.” It is important that critical thought is put in to what U.S. citizens want out of their health care system. Public health care would require some sacrifice of expensive treatments, but it could provide all with basic care. What direction will the system grow in the future?

BIBLIOGRAHPY

Arnst, C. (2006). U.S. Health-Care System gets a “D.” Business Week Online, Sept. 21 1-1.

Balkin, K. (2003). Health Care: Opposing Viewpoints. Farmington Hills, MI: Greenhaven Press.

Bar-Yam, B. (2006). Improving the Effectiveness of Health Care and Public Health: A Multiscale Complex Systems Analysis. American Journal of Public Health 96(3), 459-466.

Block, G., and Patterson, B. H. (1988). Food choices and cancer guidelines. American Journal of Public Health 78(3), 282-286.

Dombeck, M.T., and Olsan, T.H. (2002). Ethics and managed care. Journal of Interprofessional Care 16(3), 221-233.

Economic Disparities, lack of insurance, and pricing practices continue to affect healthcare access. (2006). Healthcare Financial Management 60(1), 13-15.

Edge, R.S. and Groves, J.R. (2006). Ethics of Health Care: A Guide for Clinical Practice. (3^rd Edition). Clifton Park, NY: Thomson Delmar Learning.

Leichter, H.M. (2003). “Evil habits” and “personal choices:” assigning responsibility for health in the 20^th century. Milbank Quarterly 81(4), 603-626.

Live Here and Prosper. (2006). Time 168(13) 20-20.

Meyer, J., M.D. (2006). Email interview, November 2-3.

McLaughlin, N. (2005). Learning from history. Modern Healthcare 35(29), 20-20.

Orin, R.D. (2001). Making Them Pay: How to Get the Most from Health Insuranceand Managed Care. New York: St. Martin’s Griffin.

Physicians for a National Health Program (PNHP). (2006). Single-Payer National Health Insurance. Retrieved November 2, 2006, from http://www.pnhp.org

Time for a debate on health care in the USA. (2006). Lancet 368(9540) 963-963.

White House Domestic Policy Council. (1993). The President’s Health Security Plan. New York: Times Books/Random House.