Population health framework for setting national and state health goals

Population Health

To prepare: • Review article "A Population Health Framework Setting National State Health Goals," focusing population health determinants. • Review information blog post "What Is Population Health?" • With information mind, elect a population health issue interest.

Population health interest: Access to health care

The United States is one of the few major industrialized democracies that does not regard healthcare as a right. 55.3% of the U.S. population is covered by employer-provided insurance vs. The 14% covered by Medicare (the federal government-sponsored program for the elderly) and the 15.9% covered by Medicaid (the state government-sponsored program for the poor). Some individuals are covered by a combination of different types of insurances. "Among the non-elderly, 18.4% of individuals were uninsured in 2010" (Overview of the uninsured in the United States, 2011, ASPE). Because of the recently-passed Affordable Care Act, (ACA) "18- to 24-year-olds were the only age group to experience a significant increase in the percentage with health insurance…from 70.7% in 2009 to 72.8% in 2010," given that this group was now allowed to remain for longer on their parent's insurance as a result of the ACA (Overview of the uninsured in the United States, 2011, ASPE).

Access to healthcare is a critical component of good health outcomes. Individuals without health insurance have significantly poorer health than those who do. They are "less likely to receive medical care; more likely to die early" and when they must seek care at an emergency room, they are more likely to incur high medical bills (Access to health services, 2012, Healthy People 2020). Having a primary care provider makes it more likely that patients can access appropriate information pertinent to their health history and status. It better ensures that they will engage in preventative self-care and can have the support of healthcare institutions in the form of advice, counseling, and regular health screening.

The ADA "will expand health coverage to 30 million people starting in 2014" but it is not a panacea for healthcare access (Galewich 2012). One of the ways in which it expands care is through changing the restrictions upon Medicaid eligibility and enabling more of the working poor to obtain insurance. But physicians are often reluctant to take on Medicaid patients, because of lower government reimbursement rates. "While the law does increase payments temporarily to primary care doctors who see people covered by Medicaid, it will not force more doctors into the program, or require states to provide dental coverage to adults" (Galewich 2012). Medicaid patients struggle to find primary care physicians who will accept their insurance: "primary care doctors were 73% more likely to reject Medicaid patients relative to the privately insured (34% rejection rate)" (Trapp 2008). Doctors are actually more likely to accept patients without insurance than Medicaid insurance, provided the uninsured pay out-of-pocket. According to a recent survey, 26% of patients who obtained access to care through public programming "had an unmet medical need in 2010, up from 20% in 2000. About 19% experienced delays getting care due to non-cost factors in 2010, up from 14% in 2000. Nearly one in four people in public programs in 2010 had an unmet dental need, up from 15% in 2000" (Galewich 2012).

Access to physicians is declining, even for patients with health insurance in the U.S. "An increasing number of consumers are also facing delays finding a physician…To make more money, physicians prefer to fill their days with quick turnaround type patients, such as those with chronic illnesses that need regular monitoring" (Galewich 2012). Patients have to pay more and more healthcare-related expenses themselves, given increases in deductibles, lower spending limits, and greater vigilance over what types of care is covered. "There are no guarantees that the law [the ADA] may not alter the trend toward private insurance policies with larger deductibles and higher co-payments" (Galewich 2012).

Additionally, some problems regarding access to care are not solely related to those pertaining to cost and a lack of insurance. The lack of available doctors in a given area may also be an issue. "The Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed. And that number will more than double by 2025, as the expansion of insurance coverage and the aging of baby boomers drive up demand for care. Even without the health care law, the shortfall of doctors in 2025 would still exceed 100,000" (Lowrey & Pear 2912). It is recommended that an area have 60 to 80 primary care doctors per 100,000 residents, and 85 to 105 specialists while some areas have few as 40 primary care doctors and 70 specialists per 100,000 residents (Lowrey & Pear 2012). Rural areas, in particular, are underserved by physicians. These difficulties will worsen, as more persons have insurance and the influx of patients in the system grows. The aging of the population and the increase of patients with chronic lifestyle conditions like diabetes also will create barriers to access.

The shortage of primary care providers is a series subset of the issue of care access. Fewer and fewer physicians are willing to specialize in primary care. "Primary care doctors made about $200,000 a year. Specialists often made twice as much" (Lowrey & Pear 2012). Exorbitant medical school loans and a wide discrepancy in salaries have caused fewer and fewer doctors to select the field of primary care.

The ACA was an important step in encouraging more Americans to obtain health insurance, and ensuring that there are more venues through which citizens can obtain coverage, either through their parents in the case of young people or through Medicaid in the case of the working poor who may be working multiple part-time jobs and are not eligible for insurance. It also placed restrictions upon health insurance companies, prohibiting the wholesale discrimination against patients with preexisting conditions and laid the foundation for health insurance 'exchanges' for individuals to find affordable care. Beginning in 2014, these "exchanges are new organizations that will be set up to create a more organized and competitive market for buying health insurance. They will offer a choice of different health plans, certifying plans that participate and providing information to help consumers better understand their options" (What is a health insurance exchange, 2012, Kaiser Permanente).