Background Information: The following essay was originally written in 2017. At the time I was in graduate school for social work. This essay was a response to an assignment to identify a policy problem and determine possible solutions to the problem. All figures were accurate as of 2017.
Access to Adequate Health Insurance Coverage
The problem of access to adequate health insurance coverage will be the focus of analysis in this essay. I will briefly describe why lack of access to adequate health insurance coverage is a problem. I will use the Gilbert and Terrell Implementation Model to review policy provisions that are currently in place to address the identified problem. I will then analyze these policies collectively to determine their strengths and weaknesses as they relate to adequacy, equality and equity. I will conclude with three policy recommendations which would strengthen current policies related to health insurance coverage and ultimately provide Americans with more adequate, equal and equitable access to good healthcare.
Defining the problem
In 1945, the United Nations issued a decree that stated access to healthcare is a universal right for all persons (OHCHR, 2008). According to recent estimates, 400 million people are currently without access to regular and routine healthcare (WHO, 2015). In the United States, a country where health insurance coverage is mandated by law, it is estimated approximately 28.2 million people under the age of 65 are still without adequate health insurance coverage (CDC, 2016). The purpose of health insurance is to protect the individual from having to pay for the full costs of medical emergencies and routine medical care, both of which often can easily cost thousands of dollars (Smith and Medalia, 2014). If a person does not have health insurance coverage, they are then fully responsible for their medical costs. Not surprisingly, due to this cost, people without health insurance coverage seek medical care much less often than people with health insurance coverage (CDC, 2017).
Not seeking medical care leads to preventable negative health outcomes. Examples of these outcomes include later than necessary detection of serious disease and limited prenatal care (Weissman and Epstein, 1993). These preventable negative health outcomes also lead to further health complications which are often more debilitating and thus more expensive to treat (Weissman and Epstein, 1993). This then creates a cycle of expensive specialized care, the costs of which are unable to be paid by those who are uninsured.
To cover these costs, medical practitioners are then forced to charge more to those who can afford to pay which means insurers raise health insurance rates across the board which causes many to not be able to afford health insurance coverage meaning they go without and start the cycle all over again until only the wealthiest households are able to afford health insurance coverage.
Current Policy Provisions
In the United States, there are several policies in place that attempt to solve the problem of so many Americans not having access to quality and affordable health care insurance coverage. Common options for health insurance coverage include: private health insurance through an employer, the Health Insurance Marketplace, Medicare and Medicaid. Collectively, these options for health insurance coverage are regulated through provisions set forth in the ACA and in the Social Security Act (Barusch, 2017).
Employee-based private health insurance plans cover more Americans than any other form of health insurance coverage. Approximately 70% of American adults and over half of American children are covered by private employer-based health insurance plans (CDC, 2017). Health benefits vary depending on the plan chosen but at minimum they must adhere to federal guidelines set forth in the ACA. Private health insurance is funded by employers and employees. The employee’s contribution is generally taken directly out of their paycheck. The cost to the employee varies greatly from workplace to workplace (Villegas, 2009).
Individuals and families who do not receive employee based insurance and due to income levels or age do not qualify for government programs such as Medicare or Medicaid may receive health insurance through the Health Insurance Marketplace. Persons who fall in this category may be those who work for businesses with less than 50 employees as these employers are not required to provide their employees with health insurance benefits. Self-employed persons and their families also often use the Health Insurance Marketplace to find health insurance coverage (Healthcare.gov, 2017). The health insurance plans offered on the Health Insurance Marketplace are like the group plans mentioned above in that they are administered through private health insurance companies and all must meet a minimum level of coverage as outlined in the ACA. Health Insurance Marketplace plans are paid for by the plan receipt through monthly payments called premiums. Premiums are often costly, but the high cost is sometimes mitigated if the recipient qualifies for income-based government tax credits (Fitzgerald, Bias, and Gurley-Calvez, 2015).
Medicaid is a health insurance coverage option for low-income households. Medicaid also covers children in the foster care system. Medicaid pays 100% of qualifying medical costs for eligible recipients (HHS, 2014). Eligibility is determined on an annual basis. Medicaid was established by the Social Security Act and is funded through a combination of federal and state taxes (Medicaid.gov, 2017). The ACA expanded Medicaid eligibility. Currently, there are approximately 55 million Americans who receive Medicaid benefits (CDC, 2017).
Like Medicaid, Medicare is a government run health insurance program. Also like Medicaid, it was established through the Social Security Act (Barusch, 2017). Eligibility for Medicare is open to all Americans over the age of 65. Medicare consists of four parts covering emergency care, regular care, long-term care, private insurers and insurers (HHS, 2014). Medicaid is funded by working individuals and their employers through federal payroll taxes mandated from the Federal Insurance Contributions Act or FICA (Barusch, 2017).
The ACA and Social Security Act in and of themselves does not provide health insurance coverage. The purpose of these Acts are to regulate health insurance coverage and ensure more people have access to affordable coverage (Barusch, 2017). The benefits of the ACA and the Social Security Act are available to all Americans but the degree to which the ACA and Social Security Act are helpful varies depending on an individual’s income level, age, etc.
Strengths and Weaknesses of Health Insurance Coverage Policies
Collectively, the four health insurance coverage options and the two legislative acts mentioned above provide a comprehensive but patchwork attempt at ensuring most Americans have access to quality health care. There are strengths to this patchwork approach including that it is strong in equality. But, there are also many weaknesses and gaps to this approach that have led to a system that is generally lacking in adequacy and equity.
A strength of the American approach to health insurance coverage is that it does, in theory, allow equal access for all to health insurance coverage. Provisions in the ACA forbid insurers from rejecting applicants for pre-existing conditions and ensures a minimum level of coverage is met for health insurance plans (Fitzgerald, Bias, and Gurley-Calvez, 2015). The ACA also provides a means by which middle-class families can receive tax credits to help offset monthly premium costs (Fitzgerald, Bias, and Gurley-Calvez, 2015). Medicaid is an opportunity for the poorest Americans to have access to medical care they normally would be unable to afford while Medicare is available for all Americans over the age of 65. Taken together, there is a health insurance system in place in the United States that attempts to provide access to all regardless of status. Though, the statistic mentioned above regarding the number of Americans still without health insurance coverage would suggest there is still significant work to be done to create a system with truly equal access.
One of the most glaring weaknesses of the American approach to health insurance coverage is that it does not promote adequate or equitable medical care. That is, the American approach fails to provide good quality medical care to all and it often unfairly punishes the most vulnerable populations due to high costs of even routine medical care. There is a significant gap in the quality of medical care a person can receive depending on the health insurance coverage they have. This gap generally follows socioeconomic divisions. In other words, wealthier Americans can pay for better care than poorer Americans as the ACA only mandates minimum health insurance standards rather than best practice standards (Fitzgerald, Bias, and Gurley-Calvez, 2015). Wealthier Americans are also better able to recover from medical emergencies. The ACA and the Social Security Act were attempts to provide better adequacy and equity in all Americans having access to good health insurance coverage but, similar to the attempt to bring equal access to all, there is still much work to be done.
Policy Recommendations
Policy recommendation one. Better regulate fees for medical care and prescriptions. A few years ago, some friends and I started a free health clinic. We were awarded Federally Qualified Health Center status which allowed us to bill for services regardless of the insurance status of our clients. When we submitted our proposed fee schedule, we were given feedback that we essentially were not charging Medicaid patients enough. That is, if we charged these specific clients more, we could get a larger reimbursement from Medicaid. It seemed odd to charge the most to those who had the least but when considering these clients were not paying out of pocket, rather that the federal government was paying the bill, it made sense to adjust our fee schedule not based on client’s ability to pay but based on client insurance’s ability to reimburse for services.
This is an oversimplification of the process, but the point remains that there was no real standard cost for medical care. In a sense, the costs are arbitrary. This creates a highly inconsistent system in which health insurers estimate higher than needed costs for medical procedures followed by medical practitioners raising the cost of medical care procedures to match what the health insurers are willing to pay them. Low and middle-class households are quickly priced out of the ability to pay for adequate medical care.
In implementing and enforcing a universal standardized fee schedule, there will be more stability in the health insurance market as insurers will not need to overestimate benefit costs and instead can focus on providing cost-effective plans which offer more adequate coverage for policy holders. Further, equality would be increased. If all medical practitioners were charging the same amount, then in theory, even the poorest clients would have opportunity to see the best doctors.
Policy recommendation two. Regulate health care coverage as a public utility. If all medical costs were the same, there would be risk of collusion between insurers and medical practitioners in which they could agree to raise costs beyond what is reasonable in order to make bigger profits. A public utility commission regulating health insurance and medical costs would be independent and thus less susceptible to corrupt business practices that emphasize profit over care for all. Insurers and practitioners would retain their autonomy in that these businesses and organizations would remain privately owned. A regulatory commission would increase equity by ensuring the system is fair to insurers, practitioners and patients of all income levels (Aaron, 1995).
Policy recommendation three. Establish a faith-based initiative to explore the notion that health insurance coverage (and subsequently access to adequate health care) is a privilege rather than a basic human right. I purposely have not included a single payer recommendation. Due to the current sharply partisan views of the two major parties towards health care, I do not foresee this option becoming viable for at least another decade. Policy recommendation three is an attempt at circumventing the divisiveness of our current national politics and work towards framing universal health care as a non-partisan issue.
I currently live in a very conservative area of the country. Many in my community loathe the thought of universal health care coverage. It is seen as a form of socialism that is at odds with American individualism and capitalism. Most, if not all, of these same people claim adherence to the Christian faith. There are several strong arguments to be made using Christian theology that universal health care is very much in line with a faithful interpretation of Christian teachings. If they were to come to believe these arguments, then the question of universal health care would not be a question so much of if it should be done but more a question of how best to fund it. This policy initiative, if successful in bringing about universal health care, would greatly improve the adequacy, equality and equity of America’s current patchwork of health insurance coverage policies and options.
References
Aaron, H. (1996). Newest public utility? Health care. Washington, DC: Brookings Institution.
Barusch, A. (2017). Brooks/Cole Empowerment Series: Foundations of Social Policy: Social Justice in Human Perspective, 6th edition. Boston, MA: Cengage Learning.
Centers for Disease Control and Prevention. (2016). Health insurance coverage. Retrieved from www.cdc.gov/nchs/fastats/health-insurance.htm
Centers for Disease Control and Prevention. (2017). NCHS health insurance data. Retrieved from www.cdc.gov/nchs/data/factsheets/factsheet_health_insurance.htm
Fitzgerald, M. P., Bias, T. K., & Gurley‐Calvez, T. (2017). The Affordable Care Act and consumer well‐being: Knowns and unknowns. Journal of Consumer Affairs, 51(1), 27-53.
HealthCare.gov. (2017). Health coverage if you’re self-employed. https://www.healthcare.gov/self-employed/coverage/
HHS. (2014). Category: Medicare and Medicaid. Retrieved from: https://www.hhs.gov/answers/medicare-and-medicaid
Medicaid.gov. (2017). Financing & reimbursement. Retrieved from: https://www.medicaid.gov/medicaid/financing-and-reimbursement/
Office of the High Commissioner for Human Rights. (2008). Factsheet 31. Geneva: United Nations.
Smith, J. and Medalia, C. (2014). Health insurance coverage in the United States. Washington, D.C.: U.S. Government Printing Office.
Villegas, Andrew. (2009). Employer-based insurance explained. Retrieved from https://khn.org/news/npr-employer-explainer/
Weissman, J. S., & Epstein, A. M. (1993). The insurance gap: does it make a difference? Annual review of public health, 14(1), 243-270.
World Health Organization. (2015). Tracking universal health coverage – First global monitoring report. Geneva: United Nations.
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