Yes We Can Reform Healthcare

This Sunday the US Congress passed a groundbreaking health reform bill. The reform bill seeks to extend health insurance coverage and control medical costs. Firstly, the bill includes an expansion of Medicaid and SCHIP. This means that more severly impoverished families will receive goverment health insurance. The bill also hopes to improve options for people looking to purchase health insurance individually. The bill established a cooperative where consumers can go to purchase health insurance. This is especially important for people that are unemployed, self-employed or do not work full-time. Also, health insurance companies will no longer be able to deny anyone insurance because of a pre-existing condition or high-risk situation. In order to create an insurance group that reflects the population (both high and low risk), the bill also requires that everyone purchase insurance. Those who choose not to follow this mandate will pay extra taxes. In order to help people afford insurance plans the government plans to subsidize insurance payments for low-income families and individuals. There will also be employer "pay or play" provisions which means that an insurer will either have to provide insurance for its employees or pay into a government pool. In addition, there will be tax increases for high income (above $250,000 per year) individuals.

The bill was passed with no republican support. The republican party takes issue with this reform both because it generally opposes big government and because opposition is a good way to undermine President Obama's efforts as a reformer. Although some democrats felt that this bill was not radical enough, most supported the effort to reduce the number of uninsured people and the efficacy of our health care system. Although many insurance companies do not like the government interfering in their business and not allowing them to refuse consumers with pre-exisiting conditions, the mandate to buy health insurance does greatly increase their consumer population. Health care providers are an important stakeholder group that has a somewhat complex view of this bill. On one hand, expanding insurance coverage helps doctors be able to provide quality care. However, there is some discomfort with government setting limits on how they care for their patients (i.e. prescriptions, expensive diagnostic tests). The US population can be broken down into many small interest groups. However, generally uninsured people should welcome a solution to their problem. Most Americans should recognize the overall good this will bring the country. Also, there will be some opposition from people who are already well-insured and those in high-income groups.

Overall, I think this is a very important bill. The healthcare system in this country has been struggling and changes were definitely necessary. This reform may help to lower the huge number of uninsured people in this country and to increase the quality of health outcomes for every dollar spent. Personally, I would have liked to see some more radical reforms (i.e. the inclusion of a public option or a larger emphasis on reducing administrative costs). However, I recognize that these would have been politically unpallatable and therefore were not an option this time. I think that this bill is definitely a step in the right direction. Hopefully the bill will lead to health improvements and the public will form a more positive opinion of government involvement in healthcare. The provision in this bill that allows children to stay on their parents insurance until 26 will most likely effect me. Also, the fines for those who choose not to buy insurance would definitely persuade me to stay insured through my 20s.

Dollars and Sense: The US Healthcare Debate

Okay, it's time for another blog. This week, we read an article outlining the impact of the recession on health economics. As we've learned in the course, health spending in the US makes up an enormous percentage of GDP. According to this article, that number will only continue to increase. An interesting point made in the article was that although overall spending may be decreasing, health care spending most likely will slow, but not decrease. Health care spending is usually effected by recessions over the long term (i.e. people will save less and thus spend less on health care in the next few years). Another interesting point is that as a result of the recession, more people are shifting from out-of-pocket payment plans to Medicaid. The government needs to plan to accomodate this extra cost.

This increase in health spending in the public sector has serious consequences. If health care spending continues to occupy more and more of the GDP, the nation is in essence spending all of its money on a service good, something that is not exportable or particularly profitable. And, as the proportion of the health spending that is done by the public sector increases, the US government (already in serious debt) continues to spend more and more money it does not have on an inefficient system. If the government is going to spend so much on health care, it makes sense to shift to a single payer system. At least that would eliminate the enormous administrative costs associated with the current system. As the government continues to shoulder more of the cost burden of the health care system, it seems they should be given the opportunity to have some administrative power in a system that is costing them so much.

Within the health care debate, there are many key issues. In many ways, the debate is rooted in the US value system. Our society values instant gratification and people feel they deserve immediate access to the best and newest technologies. The decision to shift to a government-run system would require an ideological shift. Another key issue is centered around reimbursement rates for physicians. In this country many medical students incur large debts to obtain a degree. It is important that these professionals are compensated appropriately for their efforts and advanced knowledge.

Although there are many more issues involved in the health care debate, if I had the ability to change one thing, it would be eliminating the uninsured portion of the American population. Sixteen percent of Americans are uninsured (more than 46 million people). This is not only a social injustice (in my opinion health care should be a human right) but it also has serious economic consequences. These people are highly unlikely to access primary care and thus receive little preventative care. Therefore, when they become ill, it is usually fairly serious, and many times could have been completely avoided. Then, when they finally seek help, it is usually in an emergency room. Visits to the emergency room cost the system many times more than visits to general practitioners. Finally, since these people often cannot pay the costs incurred during their visit, these costs are shifted to insured patients. It is through this system that the health care system accrues enormous extra costs.

That's all for this week. I will be back with more intro to public health blogs after Spring Break.

Global Health: The Challenges of Fund Allocation

Hi and welcome back to my Intro to Public Health blog. This week, we were asked to read an article about global health and development by Laurie Garret, an expert on Global Public Health who works for the Council on Foreign Relations. The article addresses the fact that in recent years health aid money to developing countries has increased tremendously. However, Garret expresses the concern that this money may not be improving health as well as it could be. The paper outlines some reasons for this, and explains how some organizations may actually be detrimental to local health. The author talks about the fact that donor money is often "stovepiped" to one very specific goal. For this reason, aid is given without building the infrastructure necessary to sustain a high-functioning health system. Also, developed countries tend to draw health care workers from the developing world. This "brain drain" is a major cause of poor health because nations are being stripped of their health work force. Another issue is that when all resources focus on one issue others are sure to cause problems. For example, the attention given to the HIV/AIDS pandemic has taken attention away from the severity of the emergence of multidrug resistant tuberculosis.

When considering the reasons for continued worsening health in the developing world, it seems that the most important is the failure to focus on infrastructure building. Although it is noble and important to focus on individual goals, it is impossible to promote health without a strong health care delivery system. The author cited an example of a country that was given vaccines, and yet could not vaccinate children due to a lack of facilities and workers. Also, it has been proven that education is one of the most effective ways to improve health in a nation. This is especially important in eliminating the tremendous gender inequities in health status.

Another significant problem is the issue of the "brain drain." In order for developing countries to support themselves, it is crucial that they have sufficient professionals. However, the numbers of physicians who train in developing nations and then emigrate is staggering. In order to promote improved health outcomes, aid organizations must both dedicate resources to creating incentives for doctors to stay in their home countries and regulate the methods which developed countries can use to draw talent away from the developing world.

The author states that there are two markers that should be considered when evaluating health: maternal survival and life expectancy. Although it is impressive to reduce AIDS transmission or increase polio vaccine coverage, if life expectancy is not increasing than health is not actually improving. Maternal mortality is a good health indicator because maternal mortality has been found to be directly correlated with the stability and quality of the health system (i.e. good hospitals, sufficient doctors, clean operating rooms). Similarly, life expectancy is crucial because it is sensitive to the rates of children (especially those under 5) who die. In countries with strong infrastructures (clean water, sanitation, proper food supply, health care access), life expectancies improve. In countries that lack these things, they flounder.

The author gave some examples of times when aid has actually damaged health. In one case, a strain of multidrug resistant tuberculosis caused devastation in a South African community. This virus emerges as a result of people not completing the antibiotic treatment regimen for TB. Since the country lacks the resources to ensure that the patient takes all doses, the distribution of antibiotics was actually detrimental. Another example occurred in Haiti. There, aid organizations funded a successful campaign to improve Haitian access to ARVs and to decrease prevalence. Although these goals were realized, Haitian health markers decreased in every other category. By creating a successful separate system of care, aid workers drew talent and resources away from the established health system and indirectly caused the country's overall health status to worsen.

That's all for this week, Bye!