Download Week 2 Discussion Uninsured

The most obvious impact from health care reform to the U.S. uninsured population is giving them
insurance. ACA reforms will provide insurance to 32 million people who previously were not insured
(Alliance for Health Reform, 2011). This provides access to preventive care, primary care physicians to
help guide health care decisions and wellness, as well as coverage for urgent care needs so they can be
seen in a timely manner in the appropriate venue rather than waiting until the situation is dire and
much more expensive to treat.
Rising costs to businesses mandated to provide employee insurance drives up the cost of doing business
and impacts their economic viability. Some may choose to not offer insurance or to reduce workforce
and avoid penalties. With fewer employers offering insurance, people will have to rely on health
exchanges and state-run insurance programs. Currently, private pay insurance is expensive.
Public changes to health care models mean that as more individuals gain access to insurance coverage
for medical care, the base of private primary care providers shrinks. Current ACA reforms call for 32
million new people who previously did not have health care insurance to become insured (Alliance for
Health Reform, 2011). Conversely, economists say a third of physicians could retire in the next 10 years,
and fewer people are seeking to practice in primary care due to the pay not covering the costs of their
student loans (Alliance for Health Reform, 2011). Depending on the level at or how the government
funds care for these individuals, some private physicians may choose not to accept patients with
government payers, which also could limits access to care.
Another proposed change -- expand the scope of practice among nurses – can counteract the physician
shortage. Reforms propose to increase the scope of practice for advance nurse practitioners. Currently,
what they can do with and without physician supervision varies from state to state. The ACA creates a
$50 million grant program to support nurse-managed clinics (Alliance for Health Reform, 2011).
A number of quality improvements will directly impact the uninsured and have the potential of greatly
reducing health disparities. I will outline a few of the reforms that most piqued my interest:
a. Requiring insurers to cover (without cost sharing) women’s preventive health care
including screenings for cervical cancer, prenatal care and mammography throughout a
woman’s life (CMS.gov, 2010). More women can experience better health outcomes
through early detection and intervention.
b. Reducing payment to hospitals for preventable hospital readmissions for certain disease
states (CMS.gov, 2013). This measure forces hospitals to examine their plans of care to
find the best practices for delivering care, which benefits the uninsured as well as the
insured. The reduction in disparity comes in that the burden of bouncing in and out of a
hospital is likely much greater to uninsured individuals with unstable housing, limited
economic resources and small support systems.
c. Providing incentives for private health systems and physician groups to adopt the
Accountable Care Organization concept and implement the patient-centered medical
home (Report to Congress, p. 12). Through the ACOs, providers should be able to focus
more on providing higher-quality care to a patient population with coordination and
cost-effectiveness in mind. If this means physicians will focus on keeping patients
healthy for life rather than treating the symptoms to cure an illness today, I’m all for it.
If the uninsured who become newly insured receive care through an ACO, they will reap
these benefits.
If universal health insurance is offered to all citizens in exchange for payment, but those citizens are
given the choice of whether to enroll, some will opt out. Those who believe they are at low-risk for
illness and injury may not want to spend their money on a product they don’t think they’ll ever need
(Gruber, p. 6). Some people who have catastrophic illness will choose to not purchase insurance because
they know the hospitals where they seek care provide “uncompensated care.” Federal law requires
hospitals that participate in Medicare programs to treat any person that comes to the hospital in an
emergency (Gruber, p. 7).
I also believe restricting a segment of the population – illegal immigrants – means people still will live in
this country without access to insurance or care.
From purely a personal analysis, I would say the United States allows the uninsured to exist because we
created the country on certain “unalienable Rights, that among these are Life, Liberty and the pursuit of
Happiness (Declaration of Independence, 1776). In the freedom to use one’s best efforts to pursue
happiness, a lifestyle, a career and an economic situation of our choosing, people cling to the concept
that you work hard for what you get. If you don’t work, you don’t get. Some attitudes have changed
with social reforms and the introduction of Medicare, Medicaid and welfare programs. However, the
unwillingness to let go of those values has prevented the country from recognizing whole heartedly the
importance and benefits of making health care an unalienable right for all.
Resources
Alliance for Health Reform, (2011). Health care workforce: future supply vs. demand. Retrieved from
https://engage.cune.edu/learn/pluginfile.php/9207/mod_page/content/9/Health_Care_Workforce_104
.pdf
Centers for Medicare & Medicaid Services (2013). Readmissions reduction program. Retrieved from
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/ReadmissionsReduction-Program.html
Gruber, J. (2008). Covering the uninsured in the United States. Journal of Economic Literature Vol. XLVI
Retrieved from http://www.macalester.edu/~wests/econ431/sep08_Gruber.pdf
Gwinnett, B., et al, (1776) Declaration of independence, The Charters of Freedom: A New World is at
Hand. Retrieved from http://www.archives.gov/exhibits/charters/declaration_transcript.html
U.S. Department of Health and Human Services (2011). Report to Congress, National strategy for quality
improvement in health care. Retrieved from
U.S. Department of Health and Human Services (2010). Women’s preventive services guidelines.
Retrieved from http://www.hrsa.gov/womensguidelines/
http://www.law.harvard.edu/students/orgs/jlg/vol322/463-504.pdf
Squale Reply#1
Expanding insurance coverage to the previously uninsured is a step in the right direction toward
improving the U.S. health care system. As Leah noted, it will require an increased investment to pay
for more providers to meet that demand. Not only is the supply of physicians and nurses pressured
by increased numbers of newly insured, they face a large percent of their workforce nearing
retirement and the greying of America with 78 million baby boomers reaching 65 by 2030 (Alliance
for Health Reform, 2011). That pattern of increasing demand and diminishing supply seems
unsustainable.
One area worthy of more focus is in reducing the consumption of health care. That means lowering
the rates of preventable chronic diseases. About 600,000 people (one in four) die of heart disease
each year in the United States (CDC, 2013). In 2010, about 18.8 million people in the United States
had been diagnosed with diabetes (CDC, 2011). More than 795,000 people have a stroke every year
in the United States (CDC, 2013). Each of those conditions includes a number of cases that are due to
lifestyle choices. Each also contributes greatly to the total of U.S. expenditures on health care. The
United States spent $2.7 trillion on health care in 2011 (CMS, 2012).
Here are examples of what the country spends to treat these three chronic conditions:

$108.9 billion a year on coronary heart disease (including health care services, medications,
and lost productivity. Heart disease accounts for one in four deaths annually (CDC, 2013).

$174 billion in 2007 in direct and indirect costs for people with diabetes (CDC, 2011).

$38.6 billion annually to care for health services, medication and missed days of work due to
illness for people who suffer stroke (CDC, 2013).
In addition to addressing chronic disease, the United State must ask itself some very difficult
questions regarding end of life care. More studies promote the benefits of hospice and palliative
care and end-of-life planning in terms of quality of life for the patients and families as well as
reduced costs. However in 2011, 28 percent of Medicare expenses, or $170 billion, was spent on care
for patients in their last six months of life (Pasternak, 2013).
At the other end of the life cycle, I read parts of a 2008 paper from Harvard Law, “The Costs of
Multiple Gestation Pregnancies in Assisted Reproduction” that explained the financial impacts of
delivering multiples after fertility treatments (Velikonja, U., 2008). To be honest, I couldn’t read the
whole thing because the concept of restricting that reproductive freedom made me cringe. Still, the
author compared laws that address the practice in the United States and foreign countries and
weighed financial implications.
I do see that direction as way too controversial for any U.S. Congressman to explore, though.
Resources:
Alliance for Health Reform, (2011). Health care workforce: future supply vs. demand. Retrieved
from
https://engage.cune.edu/learn/pluginfile.php/9207/mod_page/content/9/Health_Care_Workforce
_104.pdf
Centers for Disease Control and Prevention (2013). Heart disease facts. Retrieved from
http://www.cdc.gov/heartdisease/facts.htm
Centers for Disease Control and Prevention (2011). 2011 National diabetes fact sheet. Retrieved from
http://www.cdc.gov/diabetes/pubs/estimates11.htm#11
Centers for Disease Control and Prevention (2013). Stroke facts. Retrieved from
http://www.cdc.gov/stroke/facts.htm
Centers for Medicare and Medicaid Services (2012) National Health Expenditures fact sheet.
Retrieved from http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/NationalHealthExpendData/NHE-Fact-Sheet.html
Pasternak, S., (2013) End-of-life care constitutes third rail of U.S. health care policy debate. Retrieved
from http://www.medicarenewsgroup.com/context/understanding-medicare-blog/understandingmedicare-blog/2013/06/03/end-of-life-care-constitutes-third-rail-of-u.s.-health-care-policy-debate
Velikonja, U. (2008) Harvard Law School, Retrieved from
http://www.law.harvard.edu/students/orgs/jlg/vol322/463-504.pdf
SQualeReply#2
Part of my job involves sharing positive stories of the delivery of care within our hospital system or
great patient success stories. Recently a nurse emailed me from one of the rural facilities to tell me
about caring for a high-risk obstetrics patient. The patient came to the hospital in her second
trimester and in labor. This critical-access facility and the obstetrician on call worked over two days
to stop the labor and stabilize the patient for transfer. The nurse was very proud of all the work that
team had done.
I said it sounded like a great patient story and asked if they could follow up with the patient’s doctor,
who might find out if she was doing well and would like to share her story. The doctor returned the
message to me directly.
He didn’t know. Once the patient arrived at the second hospital, she left. He hadn’t heard from her
since.
The acronym colleagues use to describe this situation is AMA or Against Medical Advice. My point in
is despite efforts of the health care system to inspire, educate, equip and remind patients of the best
course of action to improve or sustain health, human beings go Against Medical Advice. That might
mean leaving the Emergency Department without recommended stitches, skipping a refill of blood
pressure medication, or failing to get a colonoscopy when it’s a recommended procedure for
someone with a family history. In Colorado, the percentage of adults aged 50-75 who said they were
up to date with their recommended colorectal cancer screenings was between 63.6% to 68.9% (CDC,
2012). Based on the map displayed, screening rates are higher among residents on the East and West
coasts, the southern Rocky Mountain States and Minnesota, Wisconsin and Michigan. Much of the
center of the United States shows rates no higher than 63.5% compliance (CDC, 2012).
I enjoyed reading the explanation provided in a Boston Globe column written by physician Suzanne
Koven, “Why patients don’t always follow doctor’s orders,” (Koven, 2013). She explores the idea of
why patients don’t follow the advice of their physicians and ultimately determines that as with many
other issues in the United States, it’s about personal freedom. In this case, it’s the freedom to decide
for oneself when to follow doctor’s order. Whether that’s the smartest choice depends on the
individual.
Resources:
Centers for Disease Control and Preparedness (2012) Colorectal Cancer Screening Rates. Retrieved
from http://www.cdc.gov/cancer/colorectal/statistics/screening_rates.htm
Koven, S. (2013) Why patients don’t always follow doctor’s orders. The Boston Globe. Retrieved from
http://www.bostonglobe.com/lifestyle/health-wellness/2013/04/21/practice-why-patients-donalways-follow-orders/6HRxBeEuLf7jCk2pu7iIKP/story.html
Sara,
So far, my only care experience with a provider other than an MD or a D.O. has been with a
physician’s assistant in our local Emergency Department: Once for stitches to the head of my then
18-month-old, and once to track the whereabouts of a small pen battery that had been swallowed by
my then 5-year-old. The first visit was scary and he provided a calm I needed. The second time was
much more confusing and he provided the information and recommendations from evidence-based
research that helped us resolve the situation. He also provided the little hat and rubber gloves I
would need over the next seven days. At either time, I don’t think it occurred to me that he was a P.A.
as opposed to an MD or D.O.
I also work with a number of nurse practitioners who seem to take lead positions in outreach clinics –
breast health, heart failure, anticoagulation, outpatient oncology services. As physician extenders, the
nurse practitioners bring a talent to their roles of being able to coordinate the clinical aspects of care
as well as the social and psychological needs of the patient.
Most importantly, providers of any discipline must be held to a high-standard of excellence not only
in clinical knowledge, but also in ethics and commitment to putting the patient at the center of care.
I am grateful that I have the opportunity to meet and work with providers whom I trust and feel most
comfortable.