Should all Americans be guaranteed access to basic health and medical care?
Is healthcare a right, like police protection, fire protection, education or even libraries? Or is healthcare a responsibility or obligation, meaning an individual must purchase it for herself and her family like we do for food or shelter?
Should the child of an unskilled hourly worker have access to the same care options as the CEO of a large corporation, or a U.S. Congress member or a retired union member? Should the child of a corporate CEO have access to better quality care than the child of a laborer?
Should there be differences in the care available from state to state?
Should health insurers be allowed to deny care or reimbursement to some individuals?
Should patients be told which doctors they may, or may not, see for their care?
What about prevention? Should patients be allowed to seek assistance for problems like quitting smoking or losing weight? Should a healthcare payer be expected to pay for those services?
These are some of the questions being asked as Americans consider the ways they believe healthcare should be reformed.
According to the Institute of Medicine, one of the National Academies Sciences of the United States government, the United States is the only wealthy, industrialized nation that does not ensure all citizens access to healthcare as part of a universal healthcare system. It is estimated that 47 million Americans do not have health insurance, meaning, they cannot access medical care without having to pay for it out of their pockets.
The majority of healthcare in the United States is paid for through an employer-based system. This means that most Americans have healthcare coverage tied to their jobs. One issue in this coverage reform discussion relates to portability; that is, healthcare coverage becomes a part of any decision about changing jobs, or moving from one location to another, whether or not that move is tied to employment.
There are a number of reasons people don't have health payment coverage, all related to the cost of that coverage. Among those reasons:
- Not all employers offer health insurance as a benefit. Therefore, even among those who work and should have access, not everyone does.
- Some people have worked for an employer that offered health insurance coverage but lost their jobs through layoffs. That makes them eligible for COBRA (a program that allows them to keep their insurance) but they are then required to pay the full amount of the premiums, which are no longer subsidized by their employer. That addition to their premiums, plus the fact that they no longer receive a paycheck, may make insurance too expensive.
- Not all employers offer health insurance as a benefit. When that is the case, an individual must purchase health insurance for himself and his family on his own. Individual health insurance is very expensive and unaffordable for many families.
- There is no requirement, law or regulation that forces a health insurance company to sell a policy to anyone. That means that an individual who wants to purchase a health insurance policy may be denied that coverage due to a pre-existing condition, a health problem she already has, for which a health insurance company doesn't want to be responsible for payment.
- Health payers deny care for some tests and treatments. Denial of coverage is a form of rationing, and and takes place when the insurer thinks the test or treatment will not provide enough of a benefit for the cost.
- Some people can afford insurance, but don't think they need it. This is an attitude most prevalent among younger workers who are too old to be included on a parent's health insurance policy, and are healthy enough that they don't consider health insurance to be a priority. Ironically, if these younger, healthier individuals would participate in health insurance, it would reduce the cost for others.
- Not all types of healthcare are covered by insurance or government programs. Mental health needs often lack coverage. Dental insurance, vision coverage and other necessary types of healthcare are often excluded from coverage.
Not all coverage and access is inhibited by money or payment directly. In some cases, coverage and ability to see the doctor one needs to see for care is related to a shortage of some kinds of doctors, or their location. The cost is still part of the conversation, however. Shortages of primary care providers are problematic across the country because fewer and fewer medical students are choosing to go into primary care. They don't choose primary care because once they are in practice, they are not reimbursed by payers at the same higher rates as other specialists are. Further, finding good medical providers in rural areas is becoming more difficult.
The results of a study undertaken by the journal Health Affairs in late 2007, demonstrated that this lack of payment coverage also affects mortality. It was estimated that as many as 101,000 people die each year because they did not have insurance.
Decisions about who, or who should not, have access to healthcare in America is only one healthcare reform issue. It is directly affected by the other issues, particularly payment systems and rationing.
