Health Services Adm question

Essentials_of_the_U._S._Health_Care_System_----_Chapter_14_The_Future_of_Health_Services_Delivery.pdf

Home >Applied Sciences homework help >Health Services Adm question

Shi, L., & Singh, D. A. (2018). Essentials of the u. s. health care system. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from lehman-ebooks on 2020-12-07 17:15:49.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

CHAPTER 14 The Future of Health Services Delivery

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

F Introduction

undamental features of U.S. health care delivery, such as the largely private infrastructure and traditional American values,

have, in the past, resisted any proposals for a sweeping transformation of health care. How certain forces of change play out in the future will be particularly significant. The main forces affecting the U.S. health care system include social, demographic, and cultural trends; economic conditions; political will and legal rulings; technological innovation; global health issues; and ecological events, such as the emergence of new diseases and catastrophic occurrences. Some of these forces, such as demographic trends, will follow a foreseeable course, based on which some predictions can be made. For other factors, making even short-term predictions is difficult. For instance, it is impossible to predict the future course of the U.S. economy, employment, and family incomes, all of which will affect what individual Americans and the nation may or may not be able to afford in the wake of rising health care costs. It is clear, however, that U.S. health care stands at a tipping point—a convergence of a growing, graying, and highly consumptive population with increasingly limited financial and human capital resources (Frist, 2014).

Despite the intents and promises of the Affordable Care Act (ACA), serious issues remain to be resolved in the areas of coverage, cost, access, and affordability. As of spring 2018, the U.S. Congress had failed to pass a comprehensive reform bill. However, the ACA’s individual mandate—which had required all Americans to either have health insurance or pay a tax penalty—was effectively repealed by the Tax Cuts and Jobs Act of 2017. Going forward, it is unclear whether or how the lingering issues of health insurance associated with the ACA—such as the employer mandate, health

1Shi, L., & Singh, D. A. (2018). Essentials of the u. s. health care system. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from lehman-ebooks on 2020-12-07 17:15:49.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

insurance exchanges, federal subsidies for low-income people to

buy health insurance, and Medicaid expansion in the more than 30 states that implemented it—will be addressed. Moreover, a significant number of Americans continue to lack health insurance— an estimated 27 million people in 2016 (Congressional Budget Office [CBO], 2016).

This chapter puts the future of American health care in the larger national and global context. Likely future courses of health care reform, models of care delivery, and clinical technology are discussed.

1 Under the ACA, some states, and the federal government in states that opted not to do so, established online marketplaces where people could shop for an approved health

insurance plan.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Forces of Future Change

The framework presented here views health care delivery and policy from a macro perspective. Keen observers of these forces can create opportunities for change. These forces also ensure that the U.S. health care system will continue to evolve.

Social, Demographic, and Cultural Trends It is no secret that the rising tide of the elderly in America, concomitant with dropping birth rates, will put serious strains on Medicare and Social Security—the government-run medical and retirement programs, respectively, which are funded through workers’ payroll taxes. For example, according to recent Medicare trustees reports, this program faces a substantial financial shortfall with looming negative consequences for beneficiaries, providers, and taxpayers, despite the 165-some provisions contained in the ACA to reduce Medicare costs, increase revenues, and combat program fraud and abuse (Centers for Medicare and Medicaid Services [CMS], 2012).

Aging of the population will also affect the supply of and demand for health care workers. The demand for health care services, and hence for health care workers, will increase as the population becomes older because the elderly consume a disproportionately large share of health care services. Yet, the supply of health care workers may decrease as those workers become older themselves and large numbers retire or reduce their working hours. An aging population will also affect the nature of the skills and services the health care workforce must be equipped to provide (Willis Towers Watson, 2016). Rational policies on future immigration may be one factor that affects the supply of health care professionals.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

The U.S. society’s cultural mix, which also reflects the rate and nature of immigration, will continue to slowly transform health care delivery in the United States. Social and cultural factors affect exposure and vulnerability to disease, risk-taking behaviors, health promotion and disease prevention, and health care–seeking behaviors. For example, rates of health risk behaviors among students in grades 9–12 are generally higher among blacks and Hispanics compared to whites, and emergency department use is disproportionately higher among blacks compared to whites (National Center for Health Statistics [NCHS], 2017). Even though illegal immigrants are technically uninsured, they do get health care through a variety of sources, including emergency rooms, community health centers, and charity from hospitals. Increasing dependency on government assistance and a haphazard immigration policy that does not promote cultural assimilation have the potential to alter the traditional American health care system in important ways in the future.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Economic Forces Currently, health care expenditures consume one-fifth of the U.S. economic production. Hence, the nation’s economic health, to a large extent, depends on the expenses incurred for the delivery of health care. Expenditures can rise as long as people can afford them; in turn, affordability of health care at both individual and national levels is critical. Household income in relation to economic inflation is a fundamental determinant of affordability, and both employment and personal income depend on the nation’s economic health and quality of employment. In the past few years, President Donald Trump’s economic agenda, relief from some burdensome regulations, and tax cuts have inspired some early signs of a stronger economy and employment growth compared to previous years, but this trend needs to be maintained over the longer term. Following are some of the key elements of Trump’s economic agenda:

A manufacturing recovery within the United States would add to both household incomes and tax revenues. Energy self-sufficiency would provide a tremendous boost to the U.S. economy.

Repeal and replacement of the remaining portions of the ACA that deal with health insurance might help convert many part- time jobs into full-time positions, thereby boosting household incomes. Any new legislation must include policies that make health insurance more affordable. Increased spending on national defense and the country’s infrastructure could improve employment. Despite positive signs in the nation’s economy and personal incomes, many unknowns remain. For example, protracted military involvement overseas or even trade wars could produce negative results.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Political Will, Ideologies, and Legal Rulings The ACA is a textbook case that illustrates the role of political will on the part of the president and his political party in passing and rolling out a substantial piece of legislation. While it has improved health care access across the country to some extent, this legislation has also resulted in rising health insurance premiums for many Americans while still leaving a large number of people uninsured.

The ACA was overwhelmingly supported by Democrats, who held the majority in both houses of Congress in 2010. The political landscape was reversed in 2016, when Republicans captured the majority in Congress. Even so, the American Health Care Act of 2017, which was designed to partially repeal and replace the ACA, failed to pass. Hence, the future direction of health care reform remains unclear.

Nevertheless, based on Republicans’ campaign promises, health care reform is not likely to remain a dead issue. In the short term, much will depend on whether the Republican Party gains or loses congressional seats (and its majorities in the House of Representatives and Senate) in the November 2018 elections. As was the case with the ACA, the courts are also likely to play a pivotal role in deciding future challenges to any major reform efforts in the future.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Technological Innovation The adoption of new medical technology almost invariably increases health care costs. Yet, Americans strongly favor ongoing innovation, availability, and use of new technology. One recent example of this preference is the 21st Century Cures Act of 2016, which is aimed at advancing medical innovation and providing quick access to new treatments. The high cost of research and development and the subsequent costs associated with the use of technology, however, do call into question the unrestrained innovation and use of medical technology. In the future, the health care system is likely to focus on those technologies that promote a greater degree of self-reliance and self-care for patients, with remote monitoring to ensure effectiveness and safety.

Global Health Issues In many respects, the world has become progressively interconnected and interdependent through greater ease of trade and travel. Globalization presents both opportunities and challenges. For example, manufacture of generic and other drugs by Asian countries for export to Europe, Canada, and the United States helps the economies of both the manufacturing and importing countries. From the developed world’s perspective, however, safety can become an issue with remote manufacturing. The Food and Drug Administration (FDA) has warned that consumers may be buying potentially risky drugs over the Internet with no guarantee of their effectiveness or safety. From the developing world’s perspective, immigration of trained professionals, such as physicians, nurses, and therapists, results in “brain drains” that leave shortages of skilled health care workers in developing countries while relieving shortages in developed nations. This flow may go in the other direction when it comes to patients: The World Health Organization has estimated that over a 10-year period from 2007 to 2017, the number of Americans traveling

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

abroad to receive cosmetic as well as medical treatments (referred to as medical tourism) increased from 750,000 to 16 million (Saltsman & Lett, 2017).

On other fronts, the prevention and control of infectious diseases globally will continue to pose major challenges. In this young 21st century alone, increased cross-border travel has resulted in the spread to the United States of previously unknown communicable diseases such as severe acute respiratory syndrome (SARS), as well as deadly infections such as the Ebola virus and the Middle East respiratory syndrome (MERS) virus. Current efforts to strengthen global health security include disease surveillance for outbreaks of international importance and urgency, exchange of technical information on new pathogens, and early warning and control of serious animal disease outbreaks. In a rapidly changing world, renewed efforts and cooperation among nations will become necessary. The worldwide shortage of trained health care workers is another area of alarming concern, as lack of treatment and isolation capabilities often result in deadly pandemics, affecting large segments of a population.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Ecological Events New diseases, natural disasters, and bioterrorism have major implications for public health. Diseases that are communicable— such as new strains of influenza—and those related to environmental agents—such as vector-borne diseases (for example, West Nile virus and Chikungunya virus)—can bring about mass hysteria particularly in large population centers, especially when some diseases remain mysterious and treatments are not readily available, as was the case with Ebola-related illnesses in 2014. Growth of populations and expansion of the human footprint around the globe will intensify interactions at the human–animal– ecosystem interface, raising the probability that new diseases will emerge in the future. Whenever a significant number of people are affected or threatened by disease, research and technological innovation go into high gear. Technologies such as remote biosensing and geographic information systems, therefore, will find ongoing applications in public health and safety.

Natural disasters not only disrupt people’s daily lives, but also create conditions that pose serious health risks through contamination of food and water. Health problems and psychological distress often follow in their wake. Initiatives such as biosurveillance and infrastructure upgrades will be constantly needed to cope with the consequences of both natural and human- made disasters. The roles of the Centers for Disease Control and Prevention (CDC) and other partnering agencies will continue to evolve as new challenges emerge. On the downside, the need to combat new ecological threats will divert resources from the quest to provide routine health care to the patients in most need of those services, especially those in developing countries.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Coverage, Cost, and Access Dilemmas

The number of Americans who gained health insurance under the various provisions of the ACA has been estimated at approximately 20 million (Jost & Pollack, 2016), or an estimated 7.3% of the nonelderly U.S. population. Of these, almost 44% were enrolled in Medicaid, 23% in exchange-based plans (with premium subsidies), and 8.8% in other privately purchased health plans (without premium subsidies). Approximately 27 million people remain uninsured (CBO, 2016). It is estimated that the repeal of the ACA’s individual mandate will increase the number of uninsured by 13 million in 2027 (CBO, 2017). The rationale for this projection is that healthier people will be less likely to obtain insurance and, especially in the nongroup market, the resulting increases in premiums will cause more people to not purchase insurance. Hence, achieving universal coverage in the United States will remain a challenge well into the future.

One important test of a robust health care system is whether the insured get timely access to health care services. Health insurance facilitates access, but it does not guarantee it. Alcalá and colleagues (2018) concluded that despite ACA-related gains in insurance coverage, those persons who purchased insurance through government-established exchanges or in the individual health insurance market and those individuals covered by Medicaid encountered more barriers to care than those with employer-based insurance. Hence, costly and inefficient use of hospital emergency departments has persisted among many individuals with health insurance coverage because they cannot find a doctor to serve their medical needs. Finding a primary care physician appears to be the biggest hurdle; finding a specialist or a dentist has been even tougher (Millman, 2014).

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

For many years, the success of health policy has been measured by the number of insured versus uninsured, under the erroneous assumption that once insured, everyone will somehow be able to get appropriate health care services when needed. Thus, little has been done to address the shortage of health care practitioners. The capacity of the health care system to meet the demand for services is now recognized as a major issue that threatens future access to health care for most Americans. Hospital executives, for example, believe that across the nation there are shortages of physicians, nurses, and advanced practitioners (“Hospital Executives,” 2014). Economists estimate that one-third of the current physician workforce and at least half of the nurse workforce could retire by 2021. It is also projected that the United States will require 10 to 12 million new and replacement direct care workers—medical assistants, nursing aides, home health aides, and so on—to meet patients’ demands for various types of health care services (Okrent, 2011).

The cost of health care is another critical variable that affects both coverage and access. Under the ACA, the average health insurance premiums in the individual health insurance market were estimated to increase by 25% in 2017 (Herron, 2016) and by 37% in 2018 (Luhby, 2017). By comparison, in the employer-based health insurance market, premiums rose by less than 4% in 2017 (Claxton et al., 2017). Clearly, because of its many regulatory mandates, the ACA failed to control runaway health insurance premiums for those forced to purchase insurance in the government-established exchanges, but who did not benefit from taxpayer-supported federal subsidies.

Unaffordable premiums affect people’s ability to obtain coverage, but a second layer of costs—in the form of deductibles—influences their ability to obtain services despite having insurance. For 2018, the annual maximum deductible under the ACA was $14,700 for a

2Shi, L., & Singh, D. A. (2018). Essentials of the u. s. health care system. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from lehman-ebooks on 2020-12-07 17:15:49.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

family plan. By comparison, in employer-sponsored plans, the average annual deductible varied between $2,503 and $4,527 per family; this included high-deductible health plans (Claxton et al., 2017). According to one report, the “sticker shock” comes not on the front end when purchasing a plan, but on the back end when health care is needed; “sky-high deductibles . . . are leaving some newly insured feeling as vulnerable as they were before they had coverage” (Pear, 2015).

2 In two years, the deductible increased by more than 11%, from $13,200 in 2015 (Herman, 2015).

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

The Future of Health Care Reform

Health care reform in the United States is currently at a crossroads, with an unclear future. It does not appear that any major policy initiatives will emerge until after the November 2018 congressional elections. The Republicans in power have lacked the fortitude to come up with a solution to the problems and issues described in the previous sections. Their Democratic counterparts have opted for the status quo, perhaps hoping that given the opportunity in future they may be able to evolve the ACA into a single-payer system, a national health care program in which the financing and insurance functions are taken over by the federal government.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

The American Health Care Act The American Health Care Act (AHCA) of 2017 was crafted by the Republicans in the House of Representatives, but was not supported by all Republicans. It barely squeaked through the House with a 217–213 vote. For the conservatives who wanted to repeal the ACA fully, the AHCA did not go far enough; for moderates, its effects on lower- and middle-income Americans were too harsh. Even President Trump remarked that the proposed legislation did not adequately protect individuals who would buy health insurance through the exchanges (Davis, 2017). Republicans in the Senate then drafted their own version of a health care reform proposal, which failed to pass. As mentioned previously, the individual mandate was later repealed under the Tax Cuts and Jobs Act of 2017, leaving the rest of the ACA mainly intact.

It is noteworthy that public opinion about the AHCA was not positive, even though the ACA drew even more pessimistic ratings in public polls. A greater number of people said that, under the AHCA, costs would go up and quality of care would go down than those who had positive views about these two issues (Freeman, 2017).

Repeal of some of the ACA’s key insurance provisions under the AHCA would have increased the number of uninsured by as many as 24 million people by 2026. At the same time, the projected cost savings under the program would have reduced national budget deficits by $337 billion over the 2017–2026 period (Jost, 2017).

Will a Single-Payer System Emerge? In an interview, then Senator Harry Reid (Democrat–Nevada), one of the chief architects of the ACA, confessed that a number of Democrat lawmakers were ready to support a single-payer system (McHugh, 2013). Hence, a necessary (though not necessarily sufficient) precondition for development of a single-payer system in

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

the United States in the future would be control of Congress and the White House by the Democratic Party.

In a recent national survey by the Pew Research Foundation, a majority of Americans (60%) said that it was the federal government’s responsibility to make sure all Americans have health care coverage—the highest percentage favoring a role for the U.S. government in ensuring health insurance for all in nearly a decade. Overall, one-third of the public supported a single-payer approach run by the government, rather than delivered through a mix of private companies and government programs. Perhaps not surprisingly, support for such a system is highest among liberal Democrats (64%) (Kiley, 2017). Interestingly, such a scenario has occurred in American politics in the past: In 1993, President Bill Clinton’s Health Security Act failed to gain traction after the public became disenchanted with the prospects of paying higher taxes to fund a single-payer plan. Earlier polls had shown that the public would be in favor of a national health insurance program run by the government.

A single-payer system in the United States would be fairly similar to today’s Medicaid program, in which the beneficiaries get tax- financed health care, but with more controls over how that health care is delivered. Alternatively, a single-payer system might resemble today’s Medicare program, in which the beneficiaries get subsidized health care. Over time, however, such a program would likely start leaning toward the Medicaid model, with some out-of- pocket cost sharing still in place.

Unlike Medicaid and Medicare, however, a single-payer system would not have eligibility criteria. Instead, such a scheme aims to provide universal coverage—that is, all legal residents get health insurance—and some form of universal access—that is, all the insured get some degree of access to health care services. As

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

discussed previously, it remains unknown how a given degree of access would be assured for all.

Throughout the history of health care reform, political forces have taken center stage in the debates. Indeed, for largely political reasons, the central features of the ACA were not scheduled to be implemented until 2014, after Obama’s second-term election in 2012. The outcome of the 2014 congressional elections, in which Democrats ceded both houses of Congress to Republican control, may well have hinged on the widespread disenchantment with the promises of the ACA and the experiences of those who lost the coverage they had liked. Following the 2014 elections, Senator Chuck Schumer, an influential Democrat from New York, said that whatever the merits or demerits of health reform, it was “bad politics” (Goodman, 2014). In future, politicians will have to assess the political cost they would personally incur for taking a position in favor of a single-payer system, if it comes to that.

Transitioning the ACA into a single-payer system will also depend on social and economic factors. For example, if health insurance premium costs and out-of-pocket costs rise beyond what most people consider to be affordable, there could be a push for a single-payer system. Conversely, mass dissatisfaction with the ACA might kill the prospects of a single-payer system, unless crafty politicians could put the blame on corporate America and if Americans buy into that spin. Corporations could be accused of being insensitive to the rising cost of health insurance, and insurance companies could be labeled as profit mongers.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

The Cost-Control Imperative The ACA’s coverage expansion in 2014 spurred a spike in health care spending, as would be expected. The law enabled millions of people to get subsidized health insurance through the exchanges and “free” coverage through Medicaid expansion. Health care costs increased by 5.3% in 2014, up from a low of 2.9% in 2013. The Office of the CMS Actuary estimated that increased use of health care services accounted for nearly 40% of the increase in per capita health spending. Health costs grew by 5.8% in 2015 (Weiner et al., 2017).

For a system to remain solvent, any expansion of coverage must be accompanied by cost-control measures. To control costs materially, it is necessary to manage utilization, limit reimbursement to providers, and employ some sort of rationing for the supply of health care services. Only the government is in a position to wage war against costs on all three fronts at the same time, particularly in a single-payer national health care system. However, heavy- handed government controls would be strongly opposed by most Americans. Hence, this approach is not seen as a practical alternative for future reforms.

Other factors, such as benefit design and technology innovation, could have some impact on rising health care expenditures, which consumed almost 18% of the United States’ total economic production in 2015 (NCHS, 2017). In high-deductible health plans, for example, the insured monitor their own benefit design by seeking value in their health care consumption behavior. Slower adoption of expensive new medical technology and fewer new blockbuster drugs may also be important factors contributing to cost control (Weiner et al., 2017). Going forward, however, there are no easy answers to the health care cost dilemma.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

National Debt Any meaningful health care reform cannot be undertaken in isolation from broader economic realities. U.S. budget deficits (overspending) and the rising national debt (borrowing money to pay for the overspending) will affect all aspects of the economy, including health care. According to the U.S. Department of the Treasury (2018), the country’s total outstanding public debt was $20.5 trillion in January 2018. Since the previous edition of this text was prepared, the United States has racked up an additional $2.5 trillion in debt. If at some point in the future (no one knows when, and it may not happen for a few years to come), the United States defaults on its obligation to repay the debt, there would be unimaginable consequences that will reverberate throughout the world’s economies. The national debt has consequences for the world’s economies and the standard of living that Americans have been taking for granted.

This is what the CBO (2015) has said about the mounting debt:

The rising debt could not be sustained indefinitely; the government’s creditors would eventually begin to doubt its ability to cut spending or raise revenues by enough to pay its debt obligations, forcing the government to pay much higher interest rates to borrow money.

Higher interest rates will only exacerbate the problem because they will increase the cost of borrowing.

Medicare’s Generational Impact The financing of Medicare is essentially a generational transfer system in which current taxpayers pay for the benefits provided to current beneficiaries. Shortfalls in such a financing system must be paid by future generations. Data from the three most recent

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

reports (2014–2016) of the boards of trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds (trustees’ report) on annual Medicare deficits are presented in TABLE 14.1. The short-term trend is in a favorable direction, going from a deficit of $14.1 billion in 2014 to a surplus of $31.5 billion in 2016. Various provisions of the ACA seem to have made an impact on what had been out-of-control Medicare spending. More recently, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 seems to have made a difference in cost savings through its payment reform initiatives. Notably, the rate of growth of Medicare expenditures has slowed to 4.8% (Table 14.1), although it remains above the rate of growth of total health care expenditures between 2015 and 2016 (4.3%) (Office of Actuary, 2018).

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

TABLE 14.1 Deficits and Surpluses in Medicare Funding: 2014– 2016

Even though the estimated date for Medicare’s bankruptcy fluctuates from year to year, there is no denial that within the next 10 to 15 years the system will be insolvent, mainly because of the rapid rise in the number of beneficiaries. No meaningful health care reform can ignore the serious steps needed to address this impending disaster that will otherwise affect the lives of not only millions of senior citizens but also all working Americans. Going forward, the solvency of Medicare will depend on the size of the workforce and the level of workers’ earnings. Numerous economic and demographic factors will come into play, as well as more efficient methods of care delivery, productivity improvements in the

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

delivery of health care, and elimination of fraud and abuse in the program.

3 This idea was proposed in 2016 by Trump’s opponent, Hillary Clinton, during the presidential race.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Future Models of Care Delivery

Accountable care organizations and medical homes—discussed in other chapters of this text—have received much attention since the passage of the ACA. These care delivery models are still in their infancy and, as time progresses, new models of health care delivery will undoubtedly emerge. Indeed, there will be both successes and failures along the way. Yet, certain guiding principles will remain in place to inform the development of new approaches that achieve better health at reduced costs. To serve a variety of needs, several different models of care will find a footing in the U.S. health care delivery system. Even so, having different models of care by no means suggests a dismantling of the traditional infrastructure consisting of hospitals of different types, small and large clinics, and other existing settings of care. Innovative payment systems that reward providers for achieving the desired goals of quality and cost will incentivize newer approaches to care delivery.

Value-Based Shared Savings Payments Providers respond to incentives built into reimbursement methods— and they will have to be nimble to be able to respond to changes in those reimbursement schemes. To sustain their businesses, they will have to improve their productivity by “doing more with less” while still achieving their desired profit margins. Future payment methods may be based on achievement of health-related goals, management of chronic conditions and prevention of complications, preventing hospitalizations, and reaching population health targets. A payer–provider partnership that will share cost savings will enhance value in the delivery of health care.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Population Health In the health maintenance organization (HMO) model, the provider assumed the responsibility for meeting all the health care needs of a given population. During the managed care bashing of the 1990s, HMOs were given a bad name by doctors, enrollees, politicians, and the media. Subsequently, HMOs fell out of favor while preferred provider organizations (PPOs) gained popularity. Care delivery through PPOs, however, is fraught with inefficiencies because of the absence of gatekeeping and care coordination. In the future, provider-led organizations, such as ACOs and integrated delivery systems, will likely evolve into risk-bearing entities, somewhat like staff-model HMOs, at first through partnerships with health plans. Eventually, employers and payers such as Medicare and Medicaid are likely to enroll their insured populations into these organizations, which will provide insurance coverage and also manage the total health care needs of the covered populations for a negotiated fee per enrollee. A tighter consolidation within one organization—compared to what exists in today’s managed care organizations—of financing, insurance, delivery, and payment functions will achieve synergies and efficiencies that do not currently exist. The end result will be better health at a lower cost.

Community Outreach The type of organization just described will be in a position to engage in community health programs, such as prevention and/or management of diabetes, stroke, and cardiovascular issues. Health education through community outreach will improve health of the community on the one hand and bring goodwill to the organization on the other hand.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Virtual Care To some extent, the health care delivery system will evolve to replace periodic encounters between patients and providers with an ongoing relationship that includes remote monitoring and virtual consultations. Virtual video consultations are an effective way to provide timely medical interventions and promise to reduce or eliminate wait times for face-to-face encounters.

Technology-Driven Home Visits An increasing amount of care will be delivered where patients are, in their own homes. Home care will be used extensively to manage high-risk populations. Biosensors, early warning systems, and remote monitoring will enable the shift from frequent office visits to home care. A major objective of remote monitoring is to keep chronically ill patients connected to necessary clinical expertise in between office visits so as to avert medical crises that might otherwise land these patients in the emergency room (Moore, 2009). Further innovations in remote care may enable just-in-time provider interventions when needed (Kvedar et al., 2011).

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Future Workforce Challenges

An adequate and well-trained workforce is a critical component of the health care delivery infrastructure. The impending shortage of health care professionals has been pointed out previously. Hence, the most productive use of existing resources must be emphasized.

According to the recommendations included in a report produced by the National Academy of Sciences (2010), nurses should practice to the full extent of their education and training. Licensing requirements and rules governing the scope of practice across states need to be unified for advanced-practice nurses who have master’s or doctoral degrees. Residency programs for nurses need to incorporate training in community health, public health, and geriatrics.

Primary care physicians need training so they can adequately function as “comprehensivists” to address the needs of a growing number of people with complex chronic conditions. They must be prepared to manage complex pharmacology, understand end-of-life issues and medical ethics, and lead health care teams.

A shortage of health care professionals trained in geriatrics is a critical challenge with serious implications, given the anticipated growth in the U.S. elderly population. This problem is compounded by the shortage of faculty in colleges and universities who are trained in geriatrics. The elderly use the majority of home health care services and nursing home care, account for roughly half of all hospital inpatient days, and represent approximately one-fourth of all ambulatory care visits. Many elderly patients suffer from chronic conditions, and their care is often complicated by the presence of comorbidities, the use of multiple prescription drugs, and an increased prevalence of mental conditions and dementia. Evidence shows that care of older adults by health care professionals

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

specifically prepared in geriatrics yields better physical and mental outcomes without increasing costs (H. J. Cohen et al., 2002). The most effective strategies to incentivize future workers to train for geriatric care remain uncertain, however. Under alternative demographic scenarios, an additional 2.5 to 3 million professionals in various occupations (e.g., nurses, assistants, social workers) will be needed to meet the United States’ demand for long-term care services by 2030 (Spetz et al., 2015).

Integration of a racially and culturally diverse workforce is also a growing necessity. It is estimated that somewhere near the middle of the 21st century, more than half of all U.S. citizens will be nonwhite (U.S. Census Bureau, 2001). Developing skills in cultural competence will divert some resources from health care. The term cultural competence refers to knowledge, skills, attitudes, and behavior required of a practitioner to provide optimal health care services to persons from a wide range of cultural and ethnic backgrounds. To demonstrate cultural competence, health care providers need to understand how and why different belief systems, cultural biases, ethnic origins, family structures, and many other culture-based factors influence the manner in which people experiencing illness comply with medical advice and respond to treatment. Such variations have implications for outcomes of care (J. J. Cohen et al., 2002).

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Global Challenges

As pointed out previously, global issues can affect health care at the country level. Each year, more than 350 million foreign travelers arrive in the United States. To safeguard the public’s health, the CDC operates quarantine stations at several major entry points. In addition, American businesses have spread worldwide, so the CDC has become actively involved in global surveillance and early detection of health threats and works closely with U.S. embassies overseas. The CDC operates more than 60 Global Disease Detection Centers and other offices worldwide.

Even though international cooperation is absolutely critical for combating health threats, achieving this lofty goal has proved to be an ongoing challenge. Since 2007, International Health Regulations (IHRs) have been binding on 196 countries under the aegis of the World Health Organization (WHO). The IHRs require countries to report certain disease outbreaks and other public health events to WHO (WHO, 2015). However, 80% of the countries have failed to meet the requirements of the IHRs, according to the Office of Global Affairs of the U.S. Department of Health and Human Services (DHHS). Neither the United States nor the United Nations has the authority to enforce compliance—yet, when threats to public health arise anywhere in the world, the affected nations look to the United States and other developed countries to come to their aid.

U.S. government agencies lend their assistance primarily through critically needed scientific knowledge and technical expertise to address a wide range of health issues. Many U.S.-based private philanthropic organizations send supplies and aid workers to affected areas. The irony is that when major disturbances occur,

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

the affected areas are not safe either for the locals or for foreign aid workers.

Ongoing armed conflicts, in places such as the Middle East, affect medical care and public health services. In war zones, diseases such as diarrheal episodes and acute respiratory infections can spread rapidly. In this kind of scenario, the health care infrastructure may sustain damage; health workers may be injured, killed, or evacuated; supplies dwindle; and refugees often migrate in large numbers, putting a strain on food and water supplies and sanitation. Hence, both morbidity and mortality increase. Large- scale bioterrorism has not yet occurred, but global unrest amid the rise of extremism makes it a real possibility in the future. Conflicts occurring in other parts of the globe can be “exported” to countries such as the United States.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

New Frontiers in Clinical Technology

Despite its role in cost escalation, technological progress will most assuredly continue, albeit accompanied by increased efforts directed toward technology assessment. At some point, assessment and use of technology based on cost-effectiveness is likely to influence health policy.

Today, technology affects many aspects of medical practice, to the point that it currently drives much of the growth in the health services industry. Several areas of technological advance are especially noteworthy.

Genetic mapping is the first step in isolating a gene. The ability to collect and interpret human genetic information has opened the way for the field of molecular medicine, the branch of medicine that focuses on understanding the role that genes play in disease processes and treatment of diseases through gene therapy. In gene therapy, a functioning gene is inserted into targeted cells to correct an inborn defect or provide the cell with a new function. This technique is expected to replace treatment with medications or surgery in some areas. Cancer treatment is receiving much attention as a prime candidate for gene therapy because current treatment techniques (surgery, radiation, and chemotherapy) are effective in only half of all cases and can greatly reduce a patient’s quality of life.

Personalized medicine and pharmacogenomics are relatively new fields. Pharmacogenomics is the study of how genes affect a person’s response to drugs. Personal characteristics of individual patients can vary so much that not all medications work for everyone. In personalized medicine, specific gene variations among patients are matched with responses to particular medications to increase effectiveness and reduce unwanted side effects.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Rational drug design is expected to shorten the drug discovery process. The chief candidates for development through this process are drugs to treat neurologic and mental disorders and antiretroviral therapies for HIV/AIDS, encephalitis, measles, and influenza. New drug delivery systems will be used to target specific cells. For example, cancer tumors may be treated without incurring damage to healthy tissues through the use of nanoparticles as drug delivery vehicles.

Imaging technologies have undergone some of the most dramatic advances in health care. For example, focused energy beams can now avoid damage to adjacent tissue, 3-D technology can allow faster and more accurate analysis of images, and neuroimaging can help in early detection of strokes and Alzheimer’s disease.

Minimally invasive surgery is undergoing advances that include image-guided brain surgery, minimal-access cardiac procedures, and endovascular placement of grafts for abdominal aneurysms. The use of robotic surgery is in its early stages.

Vaccines have traditionally been used prophylactically to prevent specific infectious diseases. More recently, the therapeutic use of vaccines in the treatment of noninfectious diseases, such as cancer, has opened new frontiers in medicine. At the same time, development of new vaccines for emerging infectious diseases remains a key item on the research agenda.

Blood substitutes would likely be available one day for large-scale use. Substitutes for real blood are necessary when supplies fall short, particularly in war and in natural disasters.

Xenotransplantation, in which animal tissues are used for transplants in humans, is a growing research area. It presents the promise of overcoming the critical shortages of available donor organs. Organs from genetically engineered animals may one day be available for transplantation (Schneider & Seebach, 2013).

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Regenerative medicine holds the promise of regenerating damaged tissues and organs in vivo (in the living body) through reparative techniques that stimulate previously irreparable organs into healing themselves. Regenerative medicine also enables scientists to grow tissues and organs in vitro (in the laboratory) and safely implant them when the body cannot be prompted into healing itself.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Conclusion

Some features of U.S. health care delivery have remained stable in recent years, but the future will be determined by how certain forces of change interact. The ACA was passed in late 2010, but has not solved all problems related to health care insurance: Serious issues remain in the areas of coverage, cost, access, and affordability. Hence, a new wave of health care reform has just begun. Serious challenges lie ahead unless the United States can control its rising consumption of health care resources, the costs associated with that use, and put the economy on a growth trajectory. Eventually, the nation will have to come to grips with what it can reasonably afford in terms of health care.

The existing model of health care delivery is also likely to undergo major changes in the future. New models of care delivery are being investigated that focus on value-based shared savings, population health, community outreach, virtual consultations, and technology- driven home care.

Another critical area that must be addressed is the shortage of health care professionals. While the U.S. population is rapidly aging, little has been done to address the need for geriatric care. Addressing workforce diversity and training are other looming challenges that could threaten the adequacy of the health care workforce in a changing demographic landscape.

To combat global health threats, international readiness to respond quickly to those challenges must be maintained. Armed conflicts in unstable areas of the world not only create new health crises, but also siphon off limited resources. Catastrophic consequences could follow if global health threats are not identified and managed in a timely fashion.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

Technological innovations in the areas of advanced imaging, minimally invasive surgery, genetic mapping, and regenerative medicine, among others, will help shape the delivery of medical care in ways never before imagined. Many of these developments will likely shift the focus of medicine from the acute phase of illness to prevention and aftercare.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

References 1. Alcalá HE, et al. 2018. Insurance type and access to

health care providers and appointments under the Affordable Care Act. Med Care. 56(2):186–192.

2. Centers for Medicare and Medicaid Services (CMS). 2012. The Affordable Care Act: Lowering Medicare costs by improving care. http://www.cms.gov/apps/files/aca-savings- report-2012.pdf. Accessed June 2015.

3. Centers for Medicare and Medicaid Services (CMS). 2015, July 22. The 2015 annual report of the boards of trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance trust funds. https://www.cms.gov/Research-Statistics-Data- and-Systems/Statistics-Trends-and- Reports/ReportsTrustFunds/Downloads/TR2015.pdf. Accessed February 19, 2018.

4. Centers for Medicare and Medicaid Services (CMS). 2016, June 22. The 2016 annual report of the boards of trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance trust funds. https://www.cms.gov/Research-Statistics-Data- and-Systems/Statistics-Trends-and- Reports/ReportsTrustFunds/Downloads/TR2016.pdf. Accessed February 19, 2018.

5. Centers for Medicare and Medicaid Services (CMS). 2017, July 13. The 2016 annual report of the boards of trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance trust funds. https://www.cms.gov/Research-Statistics-Data- and-Systems/Statistics-Trends-and-

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

http://www.cms.gov/apps/files/aca-savings-report-2012.pdf

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2015.pdf

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2016.pdf

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2017.pdf

Reports/ReportsTrustFunds/Downloads/TR2017.pdf. Accessed February 19, 2018.

6. Claxton G, et al. 2017. Employer health benefits: 2017 annual survey. Chicago, IL: Henry J. Kaiser Family Foundation.

7. Cohen HJ, et al. 2002. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med. 346(12):906–912.

8. Cohen JJ, et al. 2002. The case for diversity in the health care workforce. Health Aff. 21(5):90–102.

9. Congressional Budget Office (CBO). 2015, June 16. The 2015 long-term budget outlook. https://www.cbo.gov/publication/50250. Accessed June 2015.

10. Congressional Budget Office (CBO). 2016. Federal subsidies for health insurance coverage for people under age 65: 2016 to 2026. https://www.cbo.gov/sites/default/files/114th- congress-2015-2016/reports/51385- HealthInsuranceBaseline_OneCol.pdf. Accessed February 18, 2018.

11. Congressional Budget Office (CBO). 2017, November. Repealing the individual health insurance mandate: An updated estimate. https://www.cbo.gov/system/files/115th- congress-2017-2018/reports/53300- individualmandate.pdf. Accessed February 19, 2018.

12. Davis KL. 2017, March 20. Why the American Health Care Act fell short. https://www.forbes.com/sites/kennethdavis/2017/03/20/compassion- must-drive-health-care-policy/#2d218f4caf6e. Accessed February 19, 2018.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

https://www.cbo.gov/publication/50250

https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51385-HealthInsuranceBaseline_OneCol.pdf

https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53300-individualmandate.pdf

https://www.forbes.com/sites/kennethdavis/2017/03/20/compassion-must-drive-health-care-policy/#2d218f4caf6e

13. Freeman B. 2017, March 13. Rasmussen poll: Public doesn’t have confidence in AHCA. https://www.newsmax.com/Politics/Rasmussen- AHCA-Obamacae-repeal-and- replace/2017/03/13/id/778462/. Accessed February 19, 2018.

14. Frist WH. 2014. Connected health and the rise of the patient-consumer. Health Aff. 33(2):191–193.

15. Goodman JC. 2014, November 28. Why the Democrats lost the election: Obamacare. Forbes. http://www.forbes.com/sites/johngoodman/2014/11/28/why- the-democrats-lost-the-election-obamacare. Accessed June 2015.

16. Herman B. 2015. Deductible debate. Mod Healthc. 45(24):22–24.

17. Herron, J. 2016, November 1. Here’s how much Obamacare premiums are rising in all 50 states. The Fiscal Times. http://www.thefiscaltimes.com/2016/11/01/Here-s- How-Much-Obamacare-Premiums-Are-Rising- All-50-States. Accessed February 19, 2018.

18. Hospital executives: Continued shortage of nurses, advanced practitioners, physicians. 2014. Am Nurse. 46(1):10.

19. Jost T. 2017, March 14. CBO projects coverage losses, cost savings from AHCA; administration signals flexibility to governors on waivers. https://www.healthaffairs.org/do/10.1377/hblog20170314.059186/full/ Accessed February 19, 2018.

20. Jost TS, Pollack HA. 2016. Making health care truly affordable after health care reform. J Law Med Ethics. 44(4):546–554.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

https://www.newsmax.com/Politics/Rasmussen-AHCA-Obamacae-repeal-and-replace/2017/03/13/id/778462/

http://www.forbes.com/sites/johngoodman/2014/11/28/why-the-democrats-lost-the-election-obamacare

http://www.thefiscaltimes.com/2016/11/01/Here-s-How-Much-Obamacare-Premiums-Are-Rising-All-50-States

https://www.healthaffairs.org/do/10.1377/hblog20170314.059186/full/

21. Kiley J. 2017, June 23. Public support for “single payer” health coverage grows, driven by Democrats. http://www.pewresearch.org/fact- tank/2017/06/23/public-support-for-single-payer- health-coverage-grows-driven-by-democrats/. Accessed February 19, 2018.

22. Kvedar J, et al. 2011. E-patient connectivity and the near term future. J Gen Intern Med. 26:636–638.

23. Luhby T. 2017, October 30. Premiums for popular Obamacare plans soar 37% for 2018. http://money.cnn.com/2017/10/30/news/economy/obamacare- premiums/index.html. Accessed February 19, 2018.

24. McHugh K. 2013, August 10. Reid says Obamacare will lead to a single-payer healthcare system. The Daily Caller. http://dailycaller.com/2013/08/10/absolutely-yes- reid-says-obamacare-will-lead-to-a-single-payer- healthcare-system. Accessed June 2015.

25. Millman J. (2014, September 19). Millions have joined Medicaid under Obamacare. Here’s what they think of it. The Washington Post. http://www.washingtonpost.com/blogs/wonkblog/wp/2014/09/19/millions- have-joined-medicaid-under-obamacare-heres- what-they-think-of-it. Accessed June 2015.

26. Moore R. 2009. Telehealth connected care. Health Manage Technol. 30(3):39–40.

27. National Academy of Sciences. 2010. The future of nursing: Leading change, advancing health. Washington, DC: Institute of Medicine.

28. National Center for Health Statistics (NCHS). 2017. Health, United States, 2016. Hyattsville, MD: U.S. Department of Health and Human Services.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

http://www.pewresearch.org/fact-tank/2017/06/23/public-support-for-single-payer-health-coverage-grows-driven-by-democrats/

http://money.cnn.com/2017/10/30/news/economy/obamacare-premiums/index.html

http://dailycaller.com/2013/08/10/absolutely-yes-reid-says-obamacare-will-lead-to-a-single-payer-healthcare-system

http://www.washingtonpost.com/blogs/wonkblog/wp/2014/09/19/millions-have-joined-medicaid-under-obamacare-heres-what-they-think-of-it

29. Office of Actuary, Centers for Medicare and Medicaid Services. 2018, January 8. National health expenditures by type of service and source of funds, CY 1960–2016. https://www.cms.gov/Research- Statistics-Data-and-Systems/Statistics-Trends- and- Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html Accessed February 13, 2018

30. Okrent D. 2011. Health care workforce: Future supply vs. demand. Washington, DC: Alliance for Health Reform.

31. Pear R. 2015, November 15. Many say high deductibles make their health law insurance all but useless. The New York Times, p. 22.

32. Saltsman W, Lett J. 2017, April. You had it done where? The rise of medical tourism. http://www.caringfortheages.com/article/S1526- 4114(17)30093-8/fulltext. Accessed February 18, 2018.

33. Schneider MKJ, Seebach JD. 2013. Xenotransplantation literature update, July–August 2013. Xenotransplantation. 20(5): 308–310.

34. Spetz J, et al. 2015. Future demand for long-term care workers will be influenced by demographic and utilization changes. Health Aff. 34(6):936–945.

35. U.S. Census Bureau. 2001. Statistical abstract of the United States, 2001. Washington, DC: U.S. Census Bureau.

36. U.S. Department of the Treasury. 2018. Monthly statement of the public debt of the United States. https://www.treasurydirect.gov/govt/reports/pd/mspd/2018/opds012018.prn Accessed February 19, 2018.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html

http://www.caringfortheages.com/article/S1526-4114(17)30093-8/fulltext

https://www.treasurydirect.gov/govt/reports/pd/mspd/2018/opds012018.prn

37. Weiner J, et al. 2017, March 2. Effects of the ACA on health care cost containment. https://ldi.upenn.edu/brief/effects-aca-health- care-cost-containment. Accessed February 19, 2018.

38. Willis Towers Watson. 2016, August. How an aging workforce and population will impact health care in the U.S. https://www.willis.com/documents/services/Claim%20and%20Risk%20Control/15937%20THOUGHT%20LEADERSHIP_Aging%20Workforce%20and%20HealthCare.final.pdf Accessed February 18, 2018.

39. World Health Organization (WHO). 2015. International health regulations (IHR). http://www.who.int/topics/international_health_regulations/en Accessed June 2015.

C op

yr ig

ht ©

2 01

8. J

on es

& B

ar tle

tt Le

ar ni

ng , L

LC . A

ll rig

ht s

re se

rv ed

https://ldi.upenn.edu/brief/effects-aca-health-care-cost-containment

https://www.willis.com/documents/services/Claim%20and%20Risk%20Control/15937%20THOUGHT%20LEADERSHIP_Aging%20Workforce%20and%20HealthCare.final.pdf

http://www.who.int/topics/international_health_regulations/en