Reflecting on my thirty-two years of life, I have no hesitation when I
say I have lived a very privileged life and have been blessed with
many things. One of these blessings has always been having had
health insurance. I was one of the fortunate ones positively affected
by the Affordable Care Act and was able to stay on my parent’s
health insurance until I turned 26. By that time, I had what I always
referred to as my “big girl job” and was fully settled in my
organization and luckily, transitioning from my parent’s health
insurance plan to my own was an easy task. This week, as we have
learned more about health insurance coverage and the laws
surrounding health care, I cannot help but feel for those that have or
are currently struggling with this challenge. As a nurse it’s
heartbreaking, and more specifically as a triage nurse, I hear the
struggle people are going through daily. Whether it is the cost of
their medications or their hesitancy in coming in for an appointment
or going to the emergency room due to financial strain, there are
many Americans, both insured and uninsured, affected by our health
care system.
Tang et al. (2004) reports access to quality health care for all
Americans cannot be provided by the market alone and as a result
the government needs to assist. For this to be a success and to help
ensure all Americans have access to health insurance, there must be
collaborations between federal, state, and local governments as well
as the private sector. The government created programs for the
public, such as Medicare and Medicaid, and influences private
insurers with policy regulations. To ensure affordable healthcare, the
federal government has policies in place, such as tax subsidies and
regulations. On a state level, there are different functions including
official insurance companies and agents and while it is each State’s
responsibility to regulate insurance, the federal government looks to
come to a resolution on medical insurance selected problems.
Straube (2013) mentions having the governments involvement in
healthcare has pushed the use of healthcare organizations putting
emphasis on preventative medicine to promote quality healthcare for
all.
In 2010, the Affordable Care Act was adopted with the hopes all
Americans would have the ability to be insured and receive quality
healthcare. Bowling et al. (2018) mentions Medicare developed a
shared cost-saving incentive to reward providers through their use of
preventative care and patient outcomes with the hopes of increasing
quality care and the movement toward value-based reimbursement.
The Office of the National Coordinator for Health Information
Technology (2020) reported from 2015 to 2018, the value-based
pay-for-performance model went up 23 percent. From this increase
and my experience as an ambulatory nurse, I have gathered
providers, while looking to help people, are also motivated by money.
If the provider feels they are likely to get something out of the care
they are providing, such as reimbursement, they are more likely to
provide quality health care. But what does this mean for those that
are uninsured? The Patient Advocate Foundation (2019) finds the
uninsured population are at risk for poorer health outcomes because
of putting off or declining preventive and routine healthcare. The
Office of the National Coordinator for Health Information
Technology (2020) found individuals will avoid receiving healthcare if
they are uninsured and if they do receive healthcare, they are more
likely to suffer financially as a result than their insured counterparts.
However, for individuals with health insurance, receiving proper care
continues to be a challenge due to affordability through the costs of
deductibles and co-payments. Providers treating the uninsured and
those who are insured but are unable to make their payment, forces
the providers to go uncompensated. With this, access to healthcare
is further limited by placing specific healthcare providers within the
insurer’s network. I have a hard time trusting that insurers having “in-
network providers,” is in the best interest of the patient. Having had
my primary care physician retire after being my provider for 28 years,
I felt lost trying to find a new provider. As a nurse and a patient, I
understand the bond patients form with their providers. Patients
need to feel comfortable with their provider and a level of trust
needs to be established. Removing patients from their entrusted
provider may deter the patient from receiving the care they need
including preventative medicine.
Knowing all of this leads to the million-dollar question, how can we
reduce the number of uninsured people while maximizing quality and
access and minimizing costs? When addressing this issue special
attention should be paid to the underserved or disadvantaged
communities and populations, such as those patients in rural areas,
health professional shortage areas, or communities with a high
prevalence of negative health outcomes associated with social
detriments of health. Also, in America we deal with the immigration
issue as well the returning veteran issue. These are all key
stakeholders in the area of under insurability.
Short of green lighting Universal Healthcare for all creating an
innovative all-payer model using rate setting is a viable option to
consider. Crowley et al. (2020) reports prospective hospital rate
setting was once a popular policy option, with as many as 30 states
implementing programs by 1980. However, deregulation—
attributable to the rise of managed care and political, economic, or
institutional factors—reduced the number of states participating in
these types of programs to two by 1997. However, policymakers are
again considering whether all-payer models and global budgets can
limit unsustainable spending growth. I want to put my point of
emphasis here as political. Profits didn’t come fast enough, and the
patient’s affordability never mattered and neither did their care.
Corporate greed won the day.
The all-encompassing answer to maximizing quality health care while
minimizing overall costs can only be found if we truly are looking for
an answer. Example, in the 1990s the National Transportation
Safety Board put the greatest aviators together to stop planes from
crashing. We have also seen the greatest medical minds get together
and stop medical fatalities in hospitals with improvements in medical
patient recordation. This needs to happen NOW with health care as
we know it and how we are about to experience it. We will never get
a grip around this behemoth until a) our politicians want an answer
and b) we get the right people chasing the answer. Until then, our
world will be full of the haves and the have nots of the medical
menagerie.
References
Bowling, B., Newman, D., White, C., Wood, A., Coustasse, A. (2018).
Provider reimbursement following the affordable care act. The
Health Care Manager, 37(2), 129-135.
https://doi.org/10.1097/HCM.0000000000000205
Crowley, R., Daniel, H, Cooney, T.G., Engel, L.S. (2020). Envisioning a
better u.s. health care system for all: coverage and cost of
care. Annals of Internal Medicine, 172(2), 7-
32. https://doi.org/10.7326/M19-2415
Patient Advocate Foundation. (2019). Finding care when
uninsured. https://www.patientadvocate.org/explore-our-
resources/getting-care-while-uninsured/finding-care-when-
uninsured/
Straube, B. M. (2013). A role for government. American Journal of
Preventive Medicine, 44(1), 39-42.
https://doi.org/10.1016/j.amepre.2012.09.009
Tang, N., Eisenberg, J.M., & Meyer, G.S. (2004). The roles of
government in improving health care quality and safety. The Joint
Commission Journal on Quality and Safety, 30(1), 47-
55. https://doi.org/10.1016/S1549-3741(04)30006-7
The Office of the National Coordinator for Health Information
Technology. (2020). 2020-2025 federal health it strategic plan.
https://www.healthit.gov/sites/default/files/page/2020-10/Federal
%20Health%20IT%20Strategic%20Plan_2020_2025.pdf#:~:text=The
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