Literature Review Chapter: Healthcare Policy Reform

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Healthcare Reform

Review of Literature: Healthcare Reform Debate

Review of Literature; Health Care Reform Debate

The debate regarding the reformation of health care in the U.S. has been heated for decades, with real change plans being proposed by several sitting presidential administrations beginning near the close of WWII. All of these administrations' proposals were the source of near endless debate and ranged in nature from full universal state sponsored health coverage to massive overhauls of the current fee for service private pay option, usually including a sizable public funding option. (Helms, 2006, pp. 5-6) According to Helms and many other experts on the subject of health care reform this dichotomy is the basic outline of the debate regarding health care reform, as some believe that like most developed nations the U.S. should adopt some variation of universal health care while others believe that our health care system is the best because of its private competitive nature and wish to reform the current system to better meet the needs of the nation. (2006, pp. 5-14) Helms then goes on to discuss the manner in which the system has already been reformed, in the form of the Medicare Modernization Act, which established a prescription drug policy for Medicare beneficiaries, mostly seniors, and allowed health care savings plans that would in theory address catastrophic health care expenditures. (2006, p. 8) the nature of the healthcare reform debate, though put in rather simplistic terms by Helms is fundamentally focused on several hypothetic aspects, the politics of healthcare, the cost of health care, the quality of healthcare and finally the availability of healthcare, very much in that order. This work will serve as a review of the current literature on healthcare reform and will attempt to build a comprehensive view regarding what the literature and research is saying about health care in all the above aspects.

There is little question, by anyone that there is a universal need for availability and access to quality health care for every person living and that this need cannot be separated from the concept of innate human rights. (Epstein, 1999, p. 27) There is also an argument strongly planted in the need to continue to develop health care to its greatest possible state, as if it has done so in the past without peril, an issue often voiced by those who deserve such care and those who have foundational investments in bringing healthcare to the consumer. The conflict then arises when the development of healthcare, especially in its life saving allopathic rather than preventative form creates a cost conflict for consumers, or so the provider and the politician would have us believe.

For most of recorded history life was, as Hobbes famously said, "solitary, poor, nasty, brutish, and short." Modern medicine has changed some of that. Yet for many of us, while we live longer, our dying is accompanied by ever longer periods of deterioration and dependency. Having only recently gained the power to ward off premature death, doctors have been reluctant to relinquish it." (Saunders, 2003, p. 12)

The result according to Bix and others has been an extremely aggressive medical care system that has created a cost prohibitive demand for heroic measures, rather than a system that takes the whole of the community into account and allows the consumer preventative care and reasonable end of life care. (2004, p. 171)

Certainly not secondary to the fact that healthcare in the U.S. has been historically dominated by high cost and most claim high quality care, healthcare system in the U.S. is fundamentally girded by employer provided private insurance coverage. The public aspects of it are then designed to supplement for those who cannot access health coverage through employers and for the most part who cannot pay for it when it is available. (Rajan, 1998, pp. 101-102) Rajan also points out that uninsurance is a relatively common social phenomena in the U.S. that varies by state and region; "The rate of uninsurance varies greatly across states, from a low of 7.2% in Tennessee to a high of 25.7% in New Mexico." (1998, p. 101) Uninsured persons frequently avoid health care interventions, seeking care only when symptoms, usually intractable pain and/or discomfort, force their hand and require them to seek care in the most expensive manner possible, from an emergency room, and when the patient is in a state that requires costly intervention rather than preventative medical care.

Since the 1980s, the number of uninsured individuals in this country has continued to grow. It is estimated that over 43 million people in the United States do not have health insurance, or 15.2% of the total population (Mitka, 2004). Of those people without health insurance, about 53% of uninsured individuals were estimated to be uninsured for at least nine months (McLellan, 2003). (Galambos, 2005, p. 3)

Among the estimated 43 million uninsured persons in the U.S. health care crisis is one of the most substantial fears faced as they are aware through media and anecdotal information that health care catastrophes can and often do take from individuals everything they have worked for.

Going on to discuss the fact that uninsurance rates are to some degree dictated by the various states driven public options for those who cannot pay for health insurance and/or health care. It must also be pointed out here that these statistics are from 1995 and the situation with employee paid health insurance coverage has changed significantly over the last 15 years, and not in a positive way, as more and more employers are having to opt out of insurance provision or seriously curtail the level of coverage, based mostly on the cost prohibitive nature of many plans.

More than half of the decline in coverage rates experienced over the 1990s is attributable to the increase in health insurance premiums (2.0 percentage points of the 3.1 percentage point decline). Medicaid expansions led to a 1 percentage point increase in coverage. Changes in economic and demographic factors had little net effect. The number of people uninsured could increase by 1.9 -- 6.3 million in the decade ending 2010 if real, per capita medical costs increase at a rate of 1 -- 3 percentage points, holding all else constant. (Chernew, Cutler, & Seliger Keenan, 2005, p. 1021)

Though experts hardly agree, when it comes to either on how many people are problematically uninsured or how many will likely be uninsured soon. The current trend of employer sponsored health benefit decline as well as the rising cost of insurance premiums and health care costs in general are trends that will likely make things much worse before they get better. Another compounding factor is the overall economy, as Fisher, Berwick & Davis point out in their call to action article about how physicians can be a positive part of the change process. (2009, pp. 2495-2497 ) Fisher, Berwick & Davis then go on to explain that the first step in positive reform is consensus and integration.

The second step is for physicians to recognize that achieving savings sufficient to cover the cost of expanded coverage need not impose a hardship on patients or providers. A 1.5-percentage-point reduction would still allow spending & #8230; but because of the miracle of compounding, a "1-percent solution" that reduced the growth in annual spending from 6.7% to 5.2% could save the health care system $3.1 trillion of the $40 trillion we are currently projected to spend between 2010 and 2020… the federal government would harvest about $1.1 trillion in savings over the 11-year period -- enough, perhaps, to close the deal on affordable health insurance for all. (Fisher, Berwick, & Davis, 2009, p. 2497)

The writers then go on to claim that doing the same math and with the same percentage cost cap, employers would save $497 billion, state and local governments would save about $529 billion and most importantly households would save $671 billion.

One simple way for physicians to start contributing to this goal is by reassessing and scaling back, where appropriate, their use of clinical practices now listed as "overused" by the National Quality Forum's National Priorities Partnership.5 Ideally, providers would also agree to slow fee increases for private payers further, allowing Medicare to catch up. (Fisher, Berwick, & Davis, 2009, p. 2497)

As a hot button topic advocates of fee for service private payer plans for health delivery would have the consumer believe that if the prices for services do not meet the growing demand for highly skilled, specialized, highly technical health care delivery then the consumer will be making a sacrifice. The assumption being made by Menzel that in the event that he or she has a dire need for some highly technologically-based service, it will not be available to his or her, or anyone else for that matter. (1990, p. 3) Though the argument, against cost control in health care does not end there, economists and healthcare providers are also willing to say that in a universal health care system, where… [END OF PREVIEW]

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