The United States of America has always been weary of a federal and unified healthcare system. With this country’s history, it is not unreasonable to suggest that we may face a backwards turn if another political party enters office to reverse the direction we have taken so far. The basis of all questions about affordable care extend to our government and address its control of the public by issuing mandated penalties and fines for non-compliance to entitle everyone to our healthcare system. If a Republican were to enter office, these penalties would be retracted and Americans would be left in the same position as before.

There has been a long and difficult history regarding the introduction of healthcare in the United States. What can be viewed as a ‘socialist’ reform, Congress usually vetoes or modifies acts that can directly benefit citizens from all economic backgrounds. This election is proving to be the most contentious one for the issue, as Presidential nominees from both parties have shared their views on other social issues, such as race relations and same-sex marriage. In the event that a Republican inherits the Oval Office, it is clear that federal healthcare will be retracted and returned as a states’ issue.

Despite healthcare remaining a right and not a privilege, it is not as affordable or beneficial as implied by liberal media outlets. Due to the higher cost of small businesses that provide healthcare for all its employers, universal healthcare is hardly free. Its costs hit both employees and customers hard, and reports suggest a decrease in employees’ hours, an increased risk in going out of business, and costs being passed on to consumers.  A Republican president would oversee the reversal of these problems that small companies face when trying to manage the added responsibilities for its employees.

Healthcare has always remained a contentious issue among citizens in the United States. Branded ‘home of the brave’, there is a seemingly apparent divide among Americans as to how to approach the concept of federal healthcare available for the public – regardless of financial status or severity of diagnosis.

An opinion that healthcare is a basic human right means that a sustainable system must be put in place to ensure some extent of equity of care. However, despite the Affordable Care Act making it illegal to deny service to anyone due to economic status, the current mindset of Americans towards the system is proving difficult to combat. It begs these kinds of questions. What kind of impact does that have on our health care system when providing emergency care without any sort of insurance coverage? With immigrants who have come in under the radar not paying taxes, what kind of effect does this have on our economy as a whole?”

The 2016 presidential election will be a major factor in the discussion towards future healthcare reforms. Democratic underdog Bernie Saunders has been a pioneer in leading the debate about introducing a fully-fledged federal system to provide unlimited healthcare services to citizens in all 50 states. However, there has been a backlash among more right wing politicians who negatively describe Saunders as a ‘socialist’.

There are several controversies regarding the possibility to federalize healthcare, which may jeopardize certain aspects such as the cost, quality, and access for individuals. It simply means that the government would have more regulation over medical and hospital care, resulting in more overall service due to raised taxation from citizens. This socialization is not seen as desirable to many Americans, who usually favor the political ideology of capitalism and an overall reduction of the powers given to large governments.

In ancient Greece, there existed a business practice that was still alive in America as late as the 19th century. A master artisan, whether his trade be medicine, animal husbandry, or cabinet making, would take on one or more apprentices. These young men would serve the role that employees do in today’s business world.

The cost of maintaining an apprentice or running a business was perceived to be complex according to the Washington State Department of Labor and Industries. While being trained to take on a practice of his own in the future, the apprentice also served the role of employee, and to a certain degree, that of a family member. A business owner risked his family’s security, his business’ reputation and quality of his product, and the good terms of his connections in the community by taking on an apprentice. On the other hand adding another mouth to feed wasn’t quite as difficult as paying a living wage capable of situating the apprentice in his own home or apartment as is the practice in today’s United States.

Now enter the 21st century, the cost of running a business is significantly more complex integrating workers’ compensation programs that benefit insurance and medical providers more than the intended recipient: the employee.  Health, labor, liability, and property laws also are designed for entities other than the target audience.

In short, the cost of doing business in today’s business climate colors the question: Could a return to the 19th century model somehow make sense in today’s business world?

Days ago, the Department of Health and Human Services released a report that “Nearly 10.8 Million Additional Individuals Enrolled in Medicaid as of December 2014.” While HHS touts these numbers as a great achievement of the Affordable Care Act, it is worth examining the full implications of these numbers.

HHS boasts that their statistics “affirm the fact that the Affordable Care Act is working and is truly an important part of the everyday lives of millions of Americans. Individuals finally have the financial and health security that comes with affordable health coverage.” While it may be true that more Americans have coverage, which is a great achievement in taking care of our own, what are the other implications of the Affordable Care Act, and what does it mean on a macro level?

One question is the financial impact of the Affordable Care Act on small business, the drivers of the U.S. economy. According to the Small Business Administration, small businesses account for “64 percent of net new private-sector jobs” and “49.2 percent of private-sector employment”. While you may not consider a 50-plus-employee business, or a 400-employee for that matter, a “small business,” the fact is that these businesses under 500 employees provide jobs to millions around the country.

Referencing group health insurance Forbes contributor Holly Magister writes about employers with less than 50 workers and how they were affected, using data from ObamacareFacts.com: “If I do the math, that’s nearly 5.6 million small business owners in the United States who are experiencing an increase in costs. That certainly feels like a penalty to me.” In regards to penalties levied on larger small businesses, Investors.com asserts that “Universal health care is hardly “free,” and its costs hit both employees and customers hard,”reporting decreases in employees’ hours, an increased risk in going out of business, and costs being passed on to consumers.

With the increasing costs of providing meaningful jobs, let alone benefits the question is: Are the lower and middle classes really better off than before Obamacare?

https://www.sba.gov/sites/default/files/FAQ_Sept_2012.pdf

http://www.forbes.com/sites/hollymagister/2014/04/30/5-6m-small-businesses-blindsided-by-obamacare/

http://news.investors.com/ibd-editorials-obama-care/122914-732483-obamacare-rings-in-new-year-with-gloom-for-small-business.htm

“Doctors and hospitals will have to be paid differently. Not simply for procedures—the more they do the more they make—but for outcomes,” – Dr. Tim Johnson explained on ABC News.

Outcome-based, performance-based, results based, value based – these different terms have slightly different implications but all convey a similar message: that providers will receive payment based upon the outcome of care. At issue here is whether or not incentive-based initiatives improve the quality and overall quality of our health care.

Health reform legislation has offered the promise of dramatically altering the way providers are paid, changing from paying for volume to paying for value. But, in doing so, are we sacrificing the quality of care?

Performance-based regulations rely on quality measures that may fall in four general categories. Process measures, outcome measures, patient experience measures, and technology.The effects of all four categories influences pay for performance programs. Of the four, the most subjective measurement will be patient experience. It simply relies on the perception of the quality of care received and the patient’s satisfaction with the care. While it is difficult to argue against process or outcome measures of care, it can present an environment amongst healthcare providers to promote an assembly-line effect in an effort to generate revenues.

The amount of red tape and government regulations could compromise the doctor-patient relationship. While pay for performance encourages the identification of proven practices using evidence-based medicine, it begs the question: Will these policies increase pressures on an already high-pressured profession?

Sources:
http://www.heritage.org/research/reports/2013/08/obamacares-impact-on-doctors-an-update

http://www.thedoctors.com/ecm/groups/public/@tdc/@web/documents/web_content/con_id_004676.pdf

“In no instance can it be justified to spend $100,000 in public resources to increase an individual’s expected survival by three months when hundreds of thousands of Oregonians are without any form of health insurance,” the Oregon Health Evidence Review Commission was quoted as saying in an opinion article by Hope Landsem featured in The Wall Street Journal.

According to a scholarly article by Jonathan Oberlander, Theodore Marmor, and Lawrence Jacobs in the Canadian Medical Association Journal, “The core idea behind the Oregon reforms was that the legislature would decide each session how much money to allocate for the OHP, and a line would literally be drawn on the list according to how many services that allocation covered. All the services above the line would be covered by the state; however, the OHP would not pay for any of the services below the line.”

While a line obviously needs to be drawn somewhere, and there needs to be some sort of accountability in order to sustain care for our citizens who need it the most, drawing that line becomes a tricky procedure. While the legislature in Oregon theoretically debates conditions and diagnoses, the bottom line is we’re dealing with people. When an inherently impersonal government makes health care decisions for those who need access to care, with what do we result? If we decide to just let someone die in Oregon for the sake of the impersonal “greater good,” as the intent of the Oregon Health Plan is, what is our measuring stick?

While, as Landsem states, “the Affordable Care Act… says coverage decisions cannot discriminate against people because of their diagnoses and life expectancies,” where will the federal government draw the line? How can such a large, impersonal, and cumbersome organization expect to deal access to care ethically as well as equitably? If one state has resorted to a system of rationing, what will keep a larger entity from doing the same?

http://online.wsj.com/news/articles/SB10001424127887324522504579000560184822956

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC81116/

One of the touchiest subjects we face apart from health care in our society today is that of immigration. But perhaps, it’s not really an issue “apart from health care,” but rather it plays an important role in the sustainability – or unsustainability – of our government-led health care system. We need to address the issue of immigration as it pertains to health care from a couple of lenses: ethics and finances.

A couple of weeks ago, we debated whether or not access to health care is a right or a privilege. I believe it’s a right for all, not a privilege reserved for some, but should that apply to people who are in the country illegally? Societies throughout history have valued taking care of immigrants, and certainly, we wouldn’t turn away a human being who needs emergency care. Where, though, should the line be drawn?

The Immigration Policy Center, for one, claims that “Unauthorized immigrants do not game the system and receive health care for which they are not eligible” and asserts, citing Kaiser Commission numbers, that only 13% of noncitizen adults, as opposed to 20% of citizen adults, used emergency room care in 2006. The IPC also believes that eligibility verification systems would be costly and inaccurate.

On the other hand, we must consider what it means that, as of 2007, immigrants – both those here legally and illegally – “account for 31.9 percent of the entire uninsured population,” as the Center for Immigration Studies asserts, adding that “Immigrants and their children are 16.8 percent of the nation’s total population.” What kind of impact does that have on our health care system when providing emergency care without any sort of insurance coverage? With immigrants who have come in under the radar not paying taxes, what kind of effect does this have on our economy as a whole?

It’s not my intent to get into an immigration debate. At this point, both sides recognize that our current system is not ideal. However, the decisions we make in immigration policy weigh heavily on virtually every other sector of society, including health care. What we as health care professionals can do now is to care for the vulnerable, such as immigrants, and to ensure that our system can sustain caring for the vulnerable ones in our midst over the long term.

http://www.immigrationpolicy.org/issues/health

http://cis.org/HealthCare-Immigration

In the country with the world’s highest per-capita health care spending, it may seem a bit odd to present the question of whether or not doctors are well-paid. Doctors are known for being one of the highest paid professions in our society – so what are we asking?

The problem with high cost and unsustainability that our health care system in the United States faces is one of percentages. Compared to administrative costs of running health care facilities and practices, our medical practitioners do not get paid a high enough percentage of our health care dollars, and too much goes to activities that do not directly contribute to caring for the sick.

According to an article by Drs. Woolhandler, Campbell, and Himmelstein published in 2003 in The New England Journal of Medicine, “After exclusions, administration accounted for 31.0 percent of health care expenditures in the United States and 16.7 percent of health care expenditures in Canada.” The top three administrative costs per capita, in order, are the administrative costs of practitioners, hospital administration, and insurance overhead, all of which are over three times the corresponding cost amounts in Canada, according to a table in the article.

In a more recent article, published 2012 in The New England Journal of Medicine, Dr. David Cutler, Elizabeth Wikler, and Peter Basch claim that “According to the Institute of Medicine (IOM), the United States spends $361 billion annually on health care administration – more than twice our total spending on heart disease and three times our spending on cancer.”

The authors of the latter article argue that “Standardization is a central factor in reducing administrative costs.” Indeed, our health care system is far too complicated, especially in regards to juggling numerous billing systems. Simplification of our system, not increased complication, is what’s needed to create a more sustainable health care system that can effectively serve the needs of the poor and the sick.

http://www.nejm.org/doi/full/10.1056/NEJMsa022033

http://www.nejm.org/doi/full/10.1056/NEJMp1209711

The fundamental belief underlying the implementation of Affordable Care Act, commonly referred to as Obamacare is that everyone is entitled to quality health care.

The implementation of this program begs the age old questions of whether access to care is a basic human right or a privilege reserved for some or most. The basis of all questions about affordable care extend to our government and address its control of the general public by issuing mandated penalties and fines for non-compliance so as to entitle everyone to our healthcare system.

It would be difficult as health care professionals to say from an ethics perspective that the sick and dying should be denied care because of their socioeconomic status. While I support the Emergency Medical Treatment and Active Labor Act (EMTALA) part of the COBRA legislation of 1986, presented to prevent the discriminatory practice of some hospitals transferring, discharging, or refusing to treat indigent patients coming to the emergency department, the issues here are to what extent health care is a basic human right and to what extent access to care should be restricted.

An opinion that health care is a basic human right means that a sustainable system must be put in place to ensure some extent of equity of care, but the word “sustainable” here is key. When individual plan premiums for those without employer or government health insurance programs have gone up by an average 49% (Forbes), among other increases, it’s important to question how well our new system provides access to those who need it, and with our exploding national debt, we need to question how long our government can sustain such a program.

Armstrong Williams’ sentiments are that “we should reserve our right to purchase healthcare on the free market, allowing opportunities for those to purchase at affordable rates, not by allowing healthcare controlled by bureaucrats.” Others, such as Congressman John Dingell from Michigan, support health care for all Americans and assert it is an issue of both humanitarian and economic importance. But as Thomas J. Papdimos points out in Philosophy, Ethics, and Humanities in Medicine, “Once healthcare access is a right difficulties will invariably ensue… There are no clear answers.”

http://www.forbes.com/special-report/2013/what-will-obamacare-cost-you-map.html
http://thehill.com/blogs/pundits-blog/healthcare/268403-is-healthcare-a-right-a-privilege-or-neither
http://circ.ahajournals.org/content/109/12/1460.full http://www.peh-med.com/content/2/1/2

One of the biggest considerations in our nation’s health and in the viability of our health care system is the epidemic of obesity, one that is largely dependent on lifestyle. In every state, at least one-fifth of the population is obese, with percentages ranging from 20.5% in Colorado to 34.7% in Louisiana, according to 2012 number from the CDC, with a national prevalence of over one-third of the population.

In contrast, the European Union recorded an obesity rate of 16.6% among adults 18 and older, with Hungary, the country with the highest percentage (28.5%), ranking significantly below the United States, though it is on the rise, according to Deutsche Welle.

The National Heart, Lung, and Blood Institute lists among the risks of overweight and obesity coronary heart disease, high blood pressure, stroke, and cancer – some major morbidities burdening our system. “The estimated annual health care costs of obesity-related illness are a staggering $190.2 billion or nearly 21% of annual medical spending in the United States,” asserts the National League of Cities’ Institute for Youth, Education and Families.

With over a third of our population struggling with obesity, over a fifth of our health care dollars go to treating its effects. With that kind of toll on our nation’s pocketbooks, what kind of effect is it having on effectiveness of care? The good thing is obesity is preventable and with the right education, it shouldn’t be such a burden on our health care system.

http://www.cdc.gov/obesity/data/adult.html
http://www.dw.de/rising-eu-obesity-rings-alarm-bells-in-brussels/a-16821112
http://www.nhlbi.nih.gov/health/health-topics/topics/obe/risks.html

Economic Costs of Obesity