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The Health of a Nation

Physician and Harvard Health Policy Researcher, Ashish Jha, became concerned that his

heart was beating abnormally fast, which is often a sign of an impending heart attack. As a

doctor himself, he tried to stop his speeding heart rate through neck massages, ice, and pressure

to his eyes but unfortunately to no success. He was finally asked by his wife as to what he would

recommend to a patient in a similar situation. His response was that the patient should visit the

Emergency Department immediately. However, he did not go, as he was concerned about his

exorbitant out of pocket costs associated with going to an emergency room due to his high

deductible health care plan. Stories like Jhas are not unique and in fact according to Paul

Fronstin at the Employee Benefit Institute, over 46 million Americans face similar problems due

to their high deductible healthcare plans (Gorenstein). It is dumbfounding that in America, where

the defence budget is larger than the next ten countries of the world combined, there are still

Americans without access to adequate health care (Koba). As such, for millions of Americans,

health care costs make coverage a privilege, whereby individuals either do not have healthcare or

receive inadequate treatment. To remedy this issue, in 2010, the United States Congress passed

the Affordable Care Act (i.e. ACA), which was designed to increase access to healthcare and to

reduce the overall cost for coverage. The result of implementing the ACA is that over twenty

million people have gained access to health care coverage. Despite this landmark achievement,

the ACA has been controversial with certain flaws that include high deductible health plans (The

IRS defines a high deductible health plan as any plan with a deductible of at least $1,300 for an

individual or $2,600 for a family) (High Deductible Health). These types of plans meet the

individual requirement that all Americans obtain health care coverage, however they do not

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provide adequate coverage. The level of controversy surrounding the ACA can vary depending

on a persons political affiliation and geography. For instance, the topic of health care first came

to my attention after a visit to my grandparents farm in Oklahoma in 2015 for a family reunion.

My familys reunion consisted of individual characters of all types: proud Southerners,

blue blooded Yankees, successful chemists, unsuccessful chemists, etc. Of these characters was

my great Uncle Dan, an eighty-year-old man who was born in Oklahoma and has lived there his

entire life. During a health care conversation, he was pressed about the ACA, to which he

responded that it was un-American. Directly opposite of him was my Aunt Anita, who had

also lived in Oklahoma her entire life but was previously denied coverage due to a pre-existing

condition, before the ACA was implemented and thus was not amused by his remark. And then

there was of course myself and my father, who as an employee of Kaiser Permanente (Benefits

and Administration) was an enormous fan of the ACA. Unlike my aunt, he allowed the remark

to be left unchallenged. The whole situation struck me as not only humorous but also interesting

in the fact that the topic was so controversial. Two weeks later, the presidential primaries were

launched, where the topic of healthcare was repeatedly brought to the front stage and was

lambasted from various angles. The election caused me to look at how healthcare truly was

perceived by Americans and to ask myself: Do Americans view their health care system as a

right or privilege?

The doors to the Kaiser Permanente Hospital and Clinic in Walnut Creek open, revealing

a lounge. The lounge bears a resemblance to a motel with the ancient grey carpet and the aging

olive wallpaper. A second set of doors open to the scene of two women at a help desk, who

(when they are not too enamored with the day's gossip) attempt to greet passersby with

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discourteous advice. To the right, there is the pharmacy, a claustrophobic box with numerous

amounts of drugs and people. This is purgatory, for the motley crew inside who are treated to an

endless wait, full of the incessant chatter of gossip, coughing, and the ringing of cell phones. Exit

purgatory to find the impressive main hall towering above you; there are countless halls of

medical offices for the sick. Each hall is a clinic and as you walk forward you can the see the

dreaded Oncology Offices, often with very few people in line. To the right is the Orthopedist

Office where most people, including the elderly, can be found. The air is stale here, smelling of

anti-bacterial wash, as if fresh air hadnt entered since the clinic had been built. The admissions

counter is as busy as ever, with an ever-flowing line of people waiting to be cured. I am a regular

here, having visited what feels like once a month since the sixth grade to the point that the

clerical staff now recognize me well. The wait time to see a doctor is often long, allowing me the

opportunity to enjoy the complimentary internet and a televisione set, which often is set to the

Central News Network (CNN). The topic of healthcare appears often, which naturally illicites

passionate conversation and sometimes arguments from the talking heads on television as they

discuss coverage for the poor and elderly. In general, the television commentators represent the

views of the American people, who have diverse views about the implementation of health care.

Since the creation of Medicaid and Medicare Programs in 1965, they have been a

contested subject, as this is a government provided health care plan, only available to the elderly,

poor, and disabled. The programs, according to the official Social Security Website, are: ...a

joint federal and state program that helps with medical costs for some people with limited

income and resources (Medicaid). The reaction to Medicaid was mixed originally, with many

people believing that its inclusion was a step towards socialism, a concern for many Americans

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as it was introduced at the height of the Cold War. A prominent politician at the time and a

vehement critic of Medicaid was Ronald Reagan, who stated in his famous A Time for

Choosing Speech, that: It is socialized medicine, and it forces all citizens, regardless of need,

into a compulsory government program. From this program, its a short step to all the rest of

socialism (Leonhardt). This sentiment that governmental health care is an abuse of power that

restricts the rights of American Citizens is still found today. The Medicaid Expansion Act under

the Affordable Care Act (ACA) exacerbated the divide, as the bill helped to increase the

minimum wage required to apply for Medicaid, thus resulting in an increase of almost ten

million Americans on the program (Davidson, Baumeister, and Davidson 12). This resulted in a

sharp increase of insured people and consequently increased favorability of the ACA. A Kaiser

Family Foundation poll found that: More than six in ten (63 percent) say Medicaid is very

important [governmental program] (Brodie, et al). However, the increased amount of insured

raised the demand for service from providers but the supply of physicians did not increase, which

affected the quality of care received.

The increase of people on Medicaid has put stress on the system as doctors are

reimbursed less from the government for Medicaid patients than from other private insured

individuals. As such, some doctors have stopped accepting Medicaid. Thus, for many of the 70

million Americans currently on Medicaid, a major concern is the ability for the program to

provide adequate treatment. For example, the U.S. National Library of Medicine has found that

for surgeries: Unadjusted mortality for Medicare (4.4%; odds ratio [OR], 3.51), Medicaid

(3.7%; OR, 2.86), and Uninsured (3.2%; OR, 2.51) patient groups were higher compared to

Private Insurance groups (1.3%, P < 0.001) (Ailawadi, et al). Many of the Physicians that accept

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Medicaid, do so as a pseudo pro-bono effort or to help increase their number of patients. Both

scenarios demonstrate that the number of doctors that accept Medicaid has reduced because of

the ACA. For example, it was found that: The number of physicians willing to provide

obstetrician-gynecologist services, particularly to low-income, uninsured, or Medicaid-eligible

women and those residing in inner-city or rural areas became lower (Aday 183). As such, the

number of uninsured individuals remains high amongst the poorest people in the country. The

ACA has also caused concern due to its impact on American freedoms.

On both sides of the debate there is concern over the role of the government in health

care, including controls over physicians and private health care. In a 2006 Health Affairs survey,

it was found that: When asked whether or not they agreed with the statement that the current

system has lots of problems and needs to be improved, 80 percent of respondents agreed,

compared with only 20 percent who said that the employer-based system is working well (Berk,

Gaylin, and Schur). The implementation of the ACA has contributed to the positive shift in

public opinion. According to a Kaiser Family Foundation tracking poll held from the ACAs

passage onward, initial public perception was low. Original perception of the ACA at launch was

not positive, at 44% unfavorable and 41% favorable, however, as of February 2017, opinion has

increased to only 42% unfavorable and 48% favorable (Public View of ACA). Public opinion

has shifted due to a multitude of factors including increased coverage through Medicaid

expansion, health care providers can no longer turn down individuals with pre-existing

conditions, and government subsidies for certain health plans. Despite its currently high

favorability, the ACAs inclusion has led to the question of whether government involvement has

shackled a persons free choice to not have health coverage due to the individual mandate, which

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states everyone in the U.S. must either have health coverage or pay a tax. This concern is

presented by various politicians such as the Secretary of Housing and Urban Development,

Doctor Ben Carson, who stated that: "You know Obamacare [ACA] is really, I think the worst

thing that has happened in this nation since slavery"(Sullivan). While hyperbolic, many

Americans have similar views to Dr. Carsons, including the impact of restrictions over the

choices of doctors participating in the system. To better understand the issue Mr. Ty Lawson, an

energetic, cheery and knowledgeable man who is the Vice President of National Market

Solutions at Kaiser Permanente was interviewed at the Shadelands Kaiser Permanente Office.

When asked about which demographics in the United States favor or disfavor the current medical

care system, he stated: [Although the opinions are generally diverse even amongst

demographics] certain low income citizens view this very positively as it gives them the option

and funds to purchase health care, yet it is still unaffordable even after the subsidies or they view

the mandates to have healthcare as an infringement (All statements by Mr. Lawson are his and

do not necessarily reflect Kaiser Permanentes official position). However, Mr. Lawson has

found that, while the opinions about health care are diverse, they have created clear positive and

negatives across party lines about quality of care. Besides quality, the affordability and

accessibility of healthcare coverage has not been impacted for a large amount of people.

While this is not the case for most Americans who have a high level private healthcare

plan, individuals who have purchased health care plans through the public exchange find that:

Many of the people who buy health plans on the exchanges have fewer hospitals and doctors to

choose from than those with coverage through their employers (Barker and Denisco 685). Some

individuals income levels prevent them from qualifying for subsidies and there is limited

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participation of doctors, coverage areas, and health plans in the public exchanges. A

controversial option to address these limitations would be for the Federal Government to offer a

Single Payer healthcare system, which would allow all Americans to enroll in Medicare as an

option to private health coverage. This could potentially worsen the quality of care for currently

insured individuals as the current system works fine for them. Low income individuals and

families would benefit. For instance, with the passage of the ACA roughly 48 million Americans

could attain Health Insurance through what is known as the Public Market. Despite this, roughly

28.5 million Americans are still unable to attain coverage: In 2015, 46% of uninsured adults

said that they tried to get coverage but did not because it was too expensive (Uninsured

Population). For millions, health care coverage is simply too expensive to attain and for those

who can obtain health insurance, quality is not assured.

While health care coverage became more attainable, affordability and quality were not,

noted by Mr. Lawson, who stated that: The current legislation helped with one of the three

pillars - Access (opened this up), Quality (touched on this a little), and Affordability (did not

really get to it). Despite increased coverage, health care is still too expensive. A major concern

that has plagued the healthcare industry, is rising premiums (the amount paid annually every

month for health insurance). For example, in 2016, the average insurance premiums for a family

covered by job-based health plans rose just 3 percent (Mangan). The concern of funding for

programs such as Medicaid expansion and other increases.

In accordance with their political views many do not believe that they should have to pay

the health care costs for others, and that it adds more taxes for a very small result. However, this

is not a uniform opinion and that others in the upper class may support the ACA as it has made it

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easier to provide health care as noted by Mr. Lawson. Through the public exchange, there has

been the creation of various health care coverages that essentially bankrupts the insured such as

the high deductible plans including the one that plagued Ashish Jha. This has become a speaking

point for those who potentially seek to move towards a single payer health care system, noting

that the healthcare industry in America currently accounts for one-sixth of the gross domestic

product (Jones). As such, the economic impact of implementing a single payer system compared

to the potential loss of business is a notable concern, as it could lead to reduced competition

amongst different healthcare companies.

Under the American system and by extension privatized health care, the individual can

decide to afford the ability for improved coverage plans to allow for better treatment. Another

problem with a single payer system is long wait times to see a physician. Consider the U.S.

Department of Veterans Affairs, which provides governmental paid health care to American

Military Veterans. The program has been criticized by veterans, due to the poor coverage offered

and the long wait times to see a doctor. For example: At one facility in Phoenix, for example,

veterans waited an average of 115 days for an appointment (Whitney). This is despite a ten

billion dollar increase to the budget showing its negative effects. A noted area of business is the

pharmaceutical industry and its interaction with various health care plans. e relation is of the

currently high pharmaceuticals cost with recent large upticks in price of vital medications. Many

Americans would like to see the often touted Big Pharma be lessened and potentially put under

heavier governmental control to regulate business and pricing. While this could lower costs, as

currently the pharmaceutical industry marks up the prices of their products due to marketing

costs as noted by John Varellas, a pharmaceutical salesman and former researcher of the Centers

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for Medicare and Medicaid. Heavier regulation of the pharmaceutical industry could lead to

potentially better affordability. Many health care plans do not cover expensive medications,

costing the insured potentially large amount of money lost. For example, Mr. Varellas stated

that: One of the leading problems for those with cancer is the cost of medication, often the

health care companies wont cover the costs of medications, leaving the guy with cancer to

instead pay for it, bankrupting them. Despite this scenario health care providers in America

spend the most amount of money per member as compared to countries that offer socialized

medicine.

Currently, the United States spends more per capita than Canada, spending $1,059 per

capita compared to Canada's $307 per capita (Campbell, Himmelstein, and Woolhandler).

Although the United States may spend more on health care costs than Canada an advantage is

that generally American health facilities, machinations and coverage plans are well funded due to

the funding source not being taxpayers. The Canadian system relies on revenue from taxpayers

as found by Jasjeet Sekhon (Campbell, Himmelstein, and Woolhandler). This has allowed for

better or worse funding based on the number of patients at hospitals as they are able to afford

better or worse equipment based off the income of the users of the hospital. Another advantage

of the U.S system is the higher wage paid to doctors. In a private health care system physicians

can be paid at free market prices rather than their counterparts who instead work for the

government. A health affairs study found that: US primary care and orthopedic physicians also

earned higher incomes ($186,582 and $442,450, respectively) than their foreign counterparts

(Glied and Laugesen). The higher wages with privatized health care ultimately leads to more

specialists, but a decrease in people who are covered. There is also the concern of how the

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healthcare industry can influence the national economy, as: the nation's five largest for-profit

insurers closed 2009 with a combined profit of $12.2 billion (Walker). If these companies were

to be instead delegated to the government the resultant loss could prove catastrophic to the

economy. Showing that there is no perfect choice.

People in America have very diverse opinions of their health care. There is no definitive

answer to the question regarding healthcare as a right or privilege. There is no set belief or

opinion even amongst the different factions within the same political party lines. The clear

majority had believed that it was a simple topic that could be solved with a one or two-word

phrase. As Mr. Lawson said, Words like failure or success do nothing but create unproductive

energy. There are parts that work and parts that do not -- there is no perfect; otherwise it would

have been solved a long time ago. While the state of healthcare in this United States must

change as the current system in flawed, there is no clear answer as to how this should be solved.

When looking at the process involved in writing this paper I can truly empathize with

President Donald J. Trump when he said: Nobody knew health care could be so complicated.

As someone who closely followed the recent Presidential Election, the debate over health care

was held in the spotlight but was spoken about casually and made it seem like it was simple. I

went into this project confused about the health care industry and I am now even more confused.

Preparation for this paper involved copious amounts of research and I still cannot say whether

the health care coverage for all people should be a privilege or a right.

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