What is the government's role in healthcare? d How does the government impact healthcare
organizations?
There are several roles for the government in healthcare. d 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. d 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). d 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. d 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. d 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). d 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. d 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. d 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). d 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. d 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. d 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. d 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. d 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). d d 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. d 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. d d 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. d 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. d A few cases here and there are absorbable by healthcare systems, but becomes increasingly
less sustainable the more this experience happens. d 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. d 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. d 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. d 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). d
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.
