What is the government's role in healthcare? c How does the government impact healthcare
organizations?
There are several roles for the government in healthcare. c As the largest insurer within the
American Healthcare system the government today is a significant payer within healthcare,
providing access to healthcare for those on the margins, especially the poor and the elderly through
Medicaid and Medicare respectively. c Since the establishment of these programs in the 1960s the
US government has continued to dramatically expand its role and accounts for 45.2% of healthcare
payments as of 2016 (Johnson & Waltson, 2021). c The government plays a role in healthcare as a
significant insurer within healthcare, helping to establish standards and regulations for care in order
to benefit patients and the communities served, and incentivizing health care systems to reduce
costs and adapt to new technologies and innovations.
As part of this system the government has a role in regulating and shaping how healthcare is
delivered and reported in hospitals that participate in government insurance reimbursement
programs. c Both these programs gave the government a significant opportunity through its role as a
financer of healthcare to demand greater transparency within healthcare and begin negotiating
costs within healthcare. c As part of this they began to limit reimbursement for particular procedures
and have increasingly passed regulation to improve the quality of care and ensure that fraud and
waste are minimized within healthcare (Oliver, 2014). c This movement toward quality has led the
government to incentivize organizations to embrace new technologies like electronic medical
record systems with the intention of increasing transparency within healthcare, promoting best
practices, and ensuring that providers are forthright and truthful about the care they do provide
(Bowie, 2014).
How does health insurance impact healthcare delivery?
Within the United States, healthcare has become an increasingly complex endeavor. c Over the years
the integration of technology and the professionalization of care practices have increased the cost
associated with healthcare and has necessitated the need of a complex payer system that is reliant
on health insurance for most individuals to meet most of the cost of expensive treatments and care.
While the government has increasingly broadened who meets the qualifications for Medicaid and
Medicare government health insurance plans, there is a wide arrangement of employer sponsored
healthcare plans that are managed by private businesses and agencies who view health insurance
as an additional benefit and incentive for their workforce (Johnson & Waltson, 2021). c Health
insurance agencies have necessitated the need for robust reporting and billing structures within
healthcare systems to help justify reimbursement for care and coverage provided. c This has
expanded the amount of administrative FTEs that are needed within healthcare in order to
developed report out this information (Bowie, 2014).
Due to the increasing costs associated with care, healthcare insurance agencies have begun working
with healthcare systems to explore new arrangements for payment models for care provided, in an
effort to increase the quality and reduce the of care. Traditional payment models have often
provided reimbursement for care based on a fee for service model, where the health systems were
reimbursed for the quantity of care provided. c Medicare and Medicaid has sought to reduce costs
and incentivize healthcare agencies to develop and adapt best practices that reduce length of stays
and possibly reward high performing systems with a bundled payment model. In this model
healthcare systems are reimbursed a set amount for a procedure (such as a knee replacement)
based on national averages (Johnson & Waltson, 2021). c The goal of this type of payment model is
to encourage health systems to reduce the amount of spend they need for procedures and
eliminate the incentive for unnecessary charges like additional testing, etc. c Health systems are also
incentivized to make sure the care provided meets the needs of the patient and does not lead to
readmissions as the whole bundled cost of care includes 30 days following the procedure. c c This is
one example of how health insurance companies are attempting to influence the delivery of care
and reduce costs associated with healthcare.
How can we reduce the number of uninsured people while maximizing quality and access and
minimizing costs?
Reducing the number of uninsured people is something that is important for the continued
functioning and sustainability of the American healthcare system. c When an uninsured individual
comes to our emergency rooms and hospitals the cost of that care, especially for emergent and
necessary procedures, will be absorbed by the hospital or healthcare entity with which the patient
goes. c A few cases here and there are absorbable by healthcare systems, but becomes increasingly
less sustainable the more this experience happens. c As an example, since the passing of EMTALA
within 1990 through 2016, hospitals have provided nearly $576 billion of uncompensated care that
they have been legally required to (Weismann & Jorge, 2019).
The goal of the Affordable Care Act was to attempt to reduce the number of uninsured folks by
creating a healthcare mandate, and attempting to provide greater government subsidies to make
insurance more affordable for folks or free for those on the margins. According to a study done by
Ferreira and Gomes in 2017, the best way to reduce the number of uninsured is through working to
continue to provide low cost or free health insurance to the uninsured. While a lot of efforts have
focused on reducing the cost of healthcare, the reality is that reducing the cost of healthcare has a
broad benefit for all across the board in terms of health coverage, but does not focus and utilize
funds to provide maximum coverage and support for those who are uninsured (Ferreira & Gomes,
2017).
Thus, it would appear that moving toward as a basic minimum some form of government insurance
for all folks is the most effective way for reducing the number of uninsured. c As we have seen
through the history of government involvement in healthcare, the greater their role as a financial
provider within healthcare, the greater the opportunity to influence and regulate quality and
increase access to those on the margins. c While at times this may appear to be inefficient, the cost
of the care for the uninsured are born by the communities and healthcare entities that serve the
uninsured and overtime have led to the closure and reduction of access to care for communities.
This type of proposal toward having at least a basic universal healthcare plan throughout the United
States is one that is divisive among the general population (Weismann & Jorge, 2019). c
References:
Bowie, M. J. (2018). Essentials of Health Information Management: Principles and Practices (4th
ed.). Cengage Learning
Ferreira, P. C., & Gomes, D. B. P. (2017). Health care reform or more affordable health care? Journal
of Economic Dynamics and Control, 79, 126–153. https://doi-
org.ezproxy.snhu.edu/10.1016/j.jedc.2017.03.011
Johnson, K. & Waltson, S. (2021). Healthcare in the United States: Clinical, Financial, and
Operational Dimensions. Health Administration Press.
Oliver, T. (2014). Guide to U.S. Health and Health Care Policy. CQ Press.
Weismann, M. F., & Jorge, I. (2019). The Regulatory Vision of Universal Healthcare in the United
States: Strategic, Economic, and Moral Decision-Making. University of Pennsylvania Journal of
Business Law, 21(3), 647–705.
