In the first decade of the 21st century, it is inconceivable that access to quality healthcare is unavailable to more than 42 million citizens of this nation. There are many complex reasons for this with no easy solutions. Access to healthcare in the United States is largely predicated on one’s employment status. If one is gainfully employed, it is likely that you have healthcare coverage.
If one is unemployed, or employed in one of the industries providing marginal employee benefits, it is likely that you do not have adequate healthcare coverage. This is not the case in much of the industrialized world. Some form of government sponsored healthcare coverage is the norm and all citizens have equal access to care. Unfortunately, we know from past experience that the political will to bring about the changes necessary to provide the best possible access to care for the greatest number of citizens is sadly lacking.
Lyndon Johnson’s Great Society programs, Medicare and Medicaid, offered the possibility of safety net protection for otherwise uninsured senior citizens and other segments of the population affected by poverty and disability. Unfortunately, despite the best of intentions, Medicare and Medicaid did not go far enough. Many of our most vulnerable citizens, children, remained ineligible for these programs and were still on the outside looking in.
The federal Child Health Plus program offered the promise of access to uninsured children who are ineligible for Medicaid or Medicare. Again, despite the best of intentions, Child Health Plus doesn’t go far enough because many of the parents of the children eligible for Child Health Plus are still uninsured. There is another program in New York State known as Family Health Plus, which intends to cover some, but not all of the adult population who are uninsured.
Managed care was envisioned as a panacea for the ills that plague the U.S. healthcare system. The vision of the pioneers of managed care was to contain or reduce the escalating costs of health care while enhancing health care access and quality. To do this, health maintenance organizations and other managed care organizations introduced new methods to the business of health care. Employers believed that managed care would deliver on its promise to reduce their costs while keeping their employees healthy.
In fact, managed care is one of the most important forces in changing the face of health care today. Healthcare as a business is a relatively new concept because for much of its history, healthcare institutions were operated as charities due to their origins in religious organizations. However conflicting forces are converging to force change in the way health care is provided in the United States. HMOs have achieved a critical mass in healthcare finance, largely displacing the old fee-for-service or indemnity model of health insurance. Hospitals and other healthcare providers have found HMOs to be difficult in crucial rate negotiations. They also now have enormous political clout.
Some will say that much of the promise of managed care has been largely expended. Cost savings have been squeezed out of the system so that employers and employees are now seeing their rates for coverage rising precipitously. There is also a tendency to demonize managed care and all that it represents to the American psyche for some justifiable reasons: access to necessary care denied; exorbitant executive compensation; doctors who feel that medical decisions are being supplanted by financial considerations; patients sent home from the hospital too soon.
The result has been a patchwork quilt of federal and state legislation limiting the scope of what managed care organizations can and can not do, and confusion for the general public as key issues have been distorted or sensationalized in the periodic media feeding frenzies which have occurred. Nevertheless, a positive outcome is that managed care organizations have been forced to be more accountable in terms of quality of care measures and outcomes available to the public.
We have a system in crisis and tough and reasonable solutions are needed. The world’s richest nation has a shameful record in providing adequate levels of healthcare access to all of its citizens. The solution to these ills may be deceptively simple, but political forces, which have prevented progress in health care reform at the beginning of the Clinton administration, need to be brought in line.
The government sponsored single-payer model, while not a panacea in some respects, offers the promise of reducing the administrative complexity inherent in multiple government programs while opening access to the entire population, without regard to age, income, employment or citizenship status. The beneficial aspects of managed care could be retained, particularly the emphasis on preventive care managed by a primary care physician with strong quality oversight. Let’s hope we don’t have to keep deliberating this issue into the 22nd century. The nation’s healthcare crisis requires the will to act; too much is at stake.