America’s Health Care Crisis

by Michael_Koger

In the United States and across the globe, there are crises with the delivery of healthcare.

In America especially, there has been much debate over its future in light of a new administration in Washington. Despite claims from the previous administration that the Affordable Care Act has improved health disparities in the United States, some suggest that a new plan is necessary. Hence, much controversy exists today over whether repeal of this statute will make matters better or worse.

This analysis explores those issues and other factors which can influence the outcome.

Abstract

This study is a qualitative research which entails a review of scholarly articles about the Affordable Care Act (ACA).  Research questions include whether 2017 is a reasonable time to repeal the ACA and what is the future of America’s health care system.  The methodology for data collection is perusal of medical literature which addresses health care in the United States from a clinical and economic approach.

Two important issues that have a role in this complex topic include identity politics and systemic racism.

Systemic racism has to do with inequities in income, employment availability, government surveillance, immigration arrests, infant mortality, and other issues which adversely affect minorities in the United States (The Center for Racial Justice, 2017).

Concepts include assessment of inclusiveness for ACA as well as any changes to the current health insurance plans.  In other words, will a 2017 repeal lead to a disruptive situation that may leave poor people, elderly persons, and others such as racial/ethnic minorities at a disadvantage for medical care?

The analysis demonstrates the controversial nature of these questions as political issues exert a strong influence on these interactions.  Despite the complexity of all this, there are conclusions which appear to have a sound basis.  In general, there may be serious risk in an immediate or near repeal of the ACA because of the network of government offices and legal barriers which will inevitably affect the process.

     Keywords:    health care, preventive care, preexisting conditions, medical costs, Medicaid expansion, federal poverty level                                

 

Introduction

     In the United States and across the globe, there are crises with the delivery of healthcare.  In America especially, there has been much debate over its future in light of a new administration in Washington.

     The concept of mandatory health insurance is not new.  In 1790, President George Washington required medical insurance for seamen.  Also, in the United States today, Medicare automatically enrolls all senior citizens as soon as they attain the age of 65 (Herzlinger et al, 2017).

     The Obama administration spent six years with the assembly of the ACA.  When the federal government shut down during those years, Republicans demanded that the President dismiss the entire new health care plan before they would end this shutdown.  The President, however, remained firm and denied the request to discard the ACA (Silverleib, 2013).

     The matter of the ACA went before the U.S. Supreme Court twice during the Obama administration.  In what may have been President Obama’s best week in office, the High Court upheld the constitutionality of the ACA for the second time.  This was also around the time of the High Court’s reassessment of marriage equality in which the Court ruled that same-sex marriage would be legal in every state of the country.

     Several questions arise, therefore, in terms of the direction of America’s health care.  Specifically, is it prudent to make a dramatic turn with repeal of the ACA this year, or is a gradual approach better?  What can the new administration in Washington learn from the medical literature about various strategies on this matter?

     Identity politics has to do with activities or movements which focus on racial/ethnic groups, religion, culture, social groups, or other demographic variables.  In other words, the matter of health insurance will largely affect people from disadvantaged backgrounds.  Opposition to universal health coverage may lead to a discriminatory or unbalanced approach to dealing with health disparities, health inequities, and minority health (Stanford Encyclopedia of Philosophy, 2016).

Review of Literature

     Systemic racism has to do with inequities in income, employment availability, government surveillance, immigration arrests, infant mortality, and other issues which adversely affect minorities in the United States (The Center for Racial Justice, 2017).

     The research question is as follows:  Will a 2017 repeal of the ACA lead to a disruptive situation that may leave poor people, elderly persons, and others such as racial/ethnic minorities at a disadvantage for medical care?

     With the turn of the New Year of 2017 only three months ago, there is concern about the status of health care insurance coverage in the United States.  Specifically, there have been efforts to repeal the ACA and replace it with something else.  Though Republicans have said for eight years that this is their intent, the proposal has essentially vanished because of an insufficient number of Republican votes to move it forward (Eltorai, A. and Eltorai, M., 2017).  These striking events took place despite Mr. Trump’s campaign promise that he would repeal the ACA (Jost, T. and Lazarus, S., 2017).                                                                                                

     The President of the United States cannot repeal the ACA via executive order because it is a statute which Congress enacted.  Hence, Congress has to be the entity which executes the repeal.  Moreover, there must be mutual cooperation between federal and state agencies in order to bring about such a dramatic change (Jost, T. and Lazarus, S., 2017).  The Administrative Procedure Act enabled the Obama administration to create the ACA.  If one were to override the ACA, there will need to be an alteration of rulemaking (Jost, T. and Lazarus, S., 2017).

     Congress has already indicated that it wants to “provide affordable health care for all Americans” via the ACA (Jost, T. and Lazarus, S., 2017, page 1201).  However, the Trump administration has suggested an approach which will “provide greater flexibility to States” and “encourage…a free and open market in…health care services and health insurance” (Jost, T. and Lazarus, S., 2017, page 1201).  A concern of researchers is that the President’s strategy will weaken the administration’s legal defense of some initiatives for the ACA (Jost, T. and Lazarus, S., 2017).  Researchers contend that dramatic changes in the ACA will disrupt insurance markets as well as lead to political consequences (Eltorai, A. and Eltorai, M., 2017; Obama, B., 2017; Clinton, H., 2016)

     This opposition to repeal of the ACA, of course, somewhat stems from the Congressional Budget Office report, which suggests that the new plan will lead to a rise in health insurance premiums.  This increase in cost for patients may result from the discontinuation of health insurance in young healthy individuals.  In other words, as more healthy people leave the ACA, insurance companies will raise premiums in order to maintain adequate cash flow for themselves (Jost, T. and Lazarus, S, 2017; Eltorai, A. and Eltorai, M., 2017; Obama, B., 2017; Clinton, H., 2016).

     In 1974, the United States spent $14.8 billion on major health care programs.  Now that country spends $3.2 trillion yearly on health care, and these expenditures are the highest on the globe.  Nearly a third of that has to do with excessive prices, inefficiencies, and waste.  In the meantime, health disparities continue to be a serious problem there (Dzau et al, 2017).

     In 2013, 44 million nonelderly individuals in the United States did not have health insurance.  This situation left many poor people who were not able to pay for health care (Eltorai, A. and Eltorai, M., 2017).  In 2014, the ACA became available.  This enabled the establishment of marketplaces and Medicaid expansion.  It offered coverage for those who had preexisting medical conditions.  Additionally, patients whose incomes were less than 400 percent of the federal poverty level received subsidies (Eltorai, A. and Eltorai, M., 2017; Obama, B., 2017).

     During 2014 and 2015, 31 states expanded Medicaid under the ACA.  This led to $79 billion of federal funds for them.  The outcome was increases in employment, hospital and physician revenues, and savings in state-funded programs such as prisons and mental health facilities.  Additionally, the occurrence of uncompensated medical care declined (Eltorai, A. and Eltorai, M., 2017).

     By 2015, there were still 28.5 million individuals without health insurance even though the ACA was already in place.  Of those without coverage, more than four-fifths were from low to moderate income households (Eltorai, A. and Eltorai, M., 2017).  Moreover, by 2016, the number of uninsured had declined to 17 million, and this too was obviously a result of the ACA.  Nevertheless, 19 states chose not to expand Medicaid during that same year, and this left three

million Americans without health insurance (Eltorai, A. and Eltorai, M., 2017; Clinton, H., 2016).

     The ACA also provides benefits for 150 million Americans who have coverage through their employer.  It also furnishes a young adult option up to the age of 26 via their parents’ health insurance (Clinton, H., 2016).  Through the Children’s Health Insurance Program, the ACA has enabled 8 million children to benefit from coverage.  Furthermore, by 2016, 3 million African-Americans and 4 million Hispanic Americans were able to have health insurance through the ACA (Clinton, H., 2016).

     Secretary Clinton observed in 2016 that less than a 10th of Americans were without health insurance, and this has not previously occurred in United States history (Clinton, H., 2016).  She also advocates access to reproductive health care for all American women and that they have an input into decision-making on these issues along with physician and family.  Women must also be free to consider their own religious belief with regard to these matters (Clinton, H., 2016).

     It may be that by 2018, millions of other Americans will be without health insurance as a result (Jost, T. and Lazarus, S., 2017).  Moreover, the Joint Committee on Taxation has a concern about removal of Medicaid expansion and an increase of premiums twofold by the year 2026 (Eltorai, A. and Eltorai, M., 2017).

     Under the new American Health Care Act approach, coverage may not be very good for clients who have preexisting conditions, and protection will not be comprehensive (Eltorai, A. and Eltorai, M., 2017; Obama, B., 2017; Clinton, H., 2016).

     The long-term consequences of inadequate or no insurance are evident.  First, the patient may not receive preventive health care such as vaccinations and cancer screening, as they have under the ACA, in which the clinician can detect disease in its early stages.  This also leads to chronic disease which perhaps will not receive proper medical attention.  Subsequently, the individual may become seriously ill and require admission to a hospital (Eltorai, A. and Eltorai, M., 2017; Obama, B., 2017; Clinton, H., 2016).  An important item to remember is that undocumented immigrants are not eligible for ACA coverage or Medicaid (Eltorai, A. and Eltorai, M., 2017).

     The result of all this is a revolving door which worsens rather than improves the medical condition of the person.  In essence, it is a vicious cycle which makes it even more of a challenge for the patient and the health care team.  These clients are at greater risk of mortality than those who have money and insurance coverage (Eltorai, A. and Eltorai, M., 2017; Obama, B., 2017; Clinton, H., 2016).

     In addition, this situation may lead to action from debt collectors, and the individual suffers from emotional stress.  The financial crisis finds its way to consumer credit bureaus, and some of these patients face bankruptcy (Eltorai, A. and Eltorai, M., 2017).

     The ACA, of course, removed preexisting medical conditions from the insurance application.  This meant that illnesses such as heart disease, epilepsy, cancer, and diabetes mellitus were no longer reasons to deny health insurance to Americans.  The same was true for pregnancy which is not, in many instances, a disease (Eltorai, A. and Eltorai, M., 2017; Obama, B., 2017).

     Currently in the United States, there are 52 million adults who have not yet attained the age of 65 and who have preexisting conditions (Eltorai, A. and Eltorai, M., 2017).  In fact, there are 133 million Americans overall with preexisting conditions (Obama, B., 2017; Clinton, H., 2016).

     Medical literature suggests that there is a need for modernization of skills, advancement in science, and measurements of what is most important.  The health care system has several problems such as structural inefficiencies, fragments in care delivery, cost, administrative matters, and hardship with payments (Dzau et al, 2017; Clinton, H., 2016).  These issues present difficulties for clinicians, communities, employers, and others (Dzau et al, 2017).

     Among those who suffer the most are poor clients who tend to have short life expectancies.  Also, they may not have adequate social services or medical care in general.  Very sick patients are obviously at a disadvantage as well (Dzau et al, 2017).  Inadequate medical care on the part of the physician aggravates the situation too.  This includes improper patient diagnosis and evaluation as well as other medical errors (Dzau et al, 2017).

     In the 21st century, the changing scenario of public health leaves many issues which further complicate health care management.  Some of these are disability, whether mental or physicial, advanced age, new infectious diseases, and overweight and obesity (Dzau et al, 2017; Clinton, H., 2016).

     Though these complex issues pose concern everywhere across the globe, it is reasonable to say that some countries handle them better than others.  In fact, Germany, Singapore, and Switzerland have been successful with mandatory health insurance and universal coverage while at the same time the ability to manage their health care budgets (Herzlinger et al, 2017).  The three countries have various approaches.  For example, the government will automatically enroll citizens of Switzerland into health coverage in the event they fail to do so voluntarily.  Singapore requires employers to contribute to a medical savings account, and this provides coverage for all workers.  Furthermore, impoverished individuals will benefit from government subsidies to cover insurance premiums (Herzlinger et al, 2017).  Germany also requires contributions for health insurance as well (Herzlinger et al, 2017).

     Some contend that although the United States has similarities to these other countries with the ACA, the differences leave the health care budget with an imbalance.  This may stem from America’s use of only a few insurers whereas the other three countries have as many as several dozen.  Moreover, the use of penalties in the United States may be too lenient to handle the high costs for very sick clients who have a lot of medical problems (Herzlinger et al, 2017).

     It is obvious that high medical costs will occur with older patients, and the view of Germany, Singapore, and Switzerland is that a pooling of risk may alleviate the situation.  In other words, those who have preexisting conditions perhaps will not create much of an imbalance in health costs when managers create risk pools (Herzlinger et al, 2017).

     The use of pools in the United States may lead to more financial risk in the long run especially when Medicare recipients are of interest.  If one were to direct a pool of patients who may have large medical bills, the federal government will have to inherit those expenses (Herzlinger et al, 2017).  As do other countries, the United States utilizes private sector insurance.  However, the use of a governmental single-payer model as a method to achieve universal coverage is not politically feasible in America (Herzlinger et al, 2017).

     Some have suggested that the United States can lower insurance premiums for individuals whose health care will not yield high costs.  Nevertheless, this avenue requires disbursement of large amounts of funds (Herzlinger et al, 2017).

Methodology

     The assessment of this situation was entirely via the literature, and it considers the real situations that occur in several countries such as the United States and others.  There is concern everywhere about health costs and how to manage it.  Nevertheless, there is, to a certain degree considerable success with health care not only because of modernization and scientific research, but also efforts to contain costs and still render good medical care.

Results

     There is much concern among politicians, the general public, and the medical community about how the transition to a new administration will progress.  Politician votes are necessary to repeal the ACA, but it is also true that experts in health care management will insist that numerous other concerns must receive attention in order to effect a smooth transition to a new health care structure should that be necessary.

Discussion

     With America’s financial complexities, health care has always been a challenge.  This is in addition to systemic racism and the issue of identity politics which leave minorities in a precarious situation with regard to health care, housing, employment, and other ways.  Since 2017 and the new administration began, the research question has been:  Will an aggressive repeal of the ACA alleviate some of these inequities and disparities, or will it worsen health care?

     The complex nature of the situation will entail further research--very likely over a period of one to two years.  The present health care structure is secure though there are concerns that it needs revisions.  In the meantime, millions of Americans continue to benefit from the ACA without serious disruption of health benefits.  The type of consultants who assume positions in the White House cabinet will naturally have a great deal of influence.

Conclusion

     The situation of health care in the United States is undergoing a review because of a new administration in Washington.  At the same time, it needs assessment because the immediate past President knew that adjustments were necessary near the end of his second term, but there was insufficient time for the lame duck politician to address that.

     The right method for the system will, of course, be a controversial matter.  Regardless of how America assesses the present arrangement for health care insurance, it is clear that the ACA has a firm establishment as the new administration makes decisions for its future.  One must keep in mind that the United States Supreme Court reviewed the ACA twice during the Obama administration and upheld its constitutionality both times.

     The success of health care management in some regions of the world deserves the attention of countries everywhere.  However, there are political issues and government structural differences which may not make it easy for the United States or other regions of the world to accept the methods of certain other localities.

References

  1. Eltorai, A. and Eltorai, M.  (2017).  The risk of expanding the uninsured population by repealing the Affordable Care Act.  Journal of the American Medical Association,  Editorial online, E1-E2.
  2. Jost, T. and Lazarus, S.  (2017).  Trump’s executive order on health care—Can it undermine the ACA if Congress fails to act?  New England Journal of Medicine, 376, 1201-1203.
  3. Obama, B.  (2017).  Repealing the ACA without a replacement—The risks to American health care.  New England Journal of Medicine, 376, 297-299.
  4. Dzau, V., McClellan, M., McGinnis, J. et al.  (2017).  Vital directions for health and health care priorities from a National Academy of Medicine Initiative.  Journal of the American Medical Association, Editorial online, E1-E10.
  5. Clinton, H. (2016).  Health care policy and the presidential campaign.  New England Journal of Medicine, 375, e36(1)-e36(3).
  6. Herzlinger, R., Richman, B., and Boxer, R.  (2017).  Achieving universal coverage without turning to a single payer.  Journal of the American Medical Association, 317, 14, 1409-1410.
  7. The Center for Racial Justice.  Race forward.  (2017).  What is systemic racism?
  8. Stanford Encyclopedia of Philosophy. (2016).  Identity politics.
  9. Silverleib, A.  (2013).  Cable Network News.  House GOP:  defund Obamacare or shut government down.
  10. The photo shows a library at the U.S. Centers for Disease Control and Prevention and is reprinted with permission from that organization.
  11. Copyright Michael Koger, Sr., 2017.  All Rights Reserved.
Updated: 05/26/2017, Michael_Koger
 
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