U.S. & World
Stories that affect your life across the U.S. and around the world.
I’m healthy now, but what if I get sick? Will I have a choice of doctors and treatment plans? Will I be able to afford care?
What about my parents, who are retired? They have Medicare, but they have a tough time paying for prescription drugs. What happens if one of them gets really sick and needs to go into a nursing home?
How can I be sure about the quality of care in my local hospital?
I have a strong family history of breast cancer, and my doctor says I should consider a genetic test. But who has access to my test results, and, if I test positive, who gets to see my results? Will that affect my health insurance?
These questions, and others like them, are asked by millions of Americans who have watched the changing health care scene over the last decade. The answers influence the lives and well being of health care consumers and patients. We are all affected by critical health care decisions, policies, and plans that are made by the government, by employers, by health care professionals, and by private health care businesses. As a consumer, you too have an important role in determining health policy.
Health policy refers to decisions, plans, and actions that are undertaken to achieve specific health care goals within a society. The three major aspects of health care policy involve: services provided, organization and delivery of those services, and the financing of services. In other words, what services do I get, how and where do I get them, and who is going to pay for them?
Health policy decisions affect the big picture of medical health care — they result in regulations that affect the quality of services provided by hospitals, the training of health professionals, the safety and effectiveness of pharmaceutical medications, and the coverage for medical care for the elderly, disabled, and needy. They also affect many aspects of personal medical care, including access to doctors, insurance coverage of particular medical services and procedures, the confidentiality of medical records, and the ability of consumers to plan for health care after retirement.
Setting the Stage: The United States' Health Care System
The United States offers the most advanced, and the most expensive, health care in the world. For several decades, health care costs have risen astronomically due to the continual emergence of sophisticated and expensive medical technologies, the increasing costs of administering health care, and, more recently, the rising cost of prescription drugs. These soaring costs have driven major changes in the health care system and have created today’s foremost health policy concern — how to assure fair access to quality medical care at affordable prices.
One major effect of rising costs has been the movement away from traditional fee-for-service medicine and towards managed care. In fee-for-service, doctors decide appropriate medical tests and treatments for their patients, and insurance companies pay, no questions asked. This system places no limits on available services or choice of doctors, but it also results in excessive use of expensive services. In the long run, excessive use of tests and procedures drives up the cost of medical insurance premiums. Managed care arose as an alternative that could control costs by reducing excess and streamlining delivery of care. In doing so, however, it may restrict access to specialty care doctors and to certain types of tests and procedures. It also may limit the time that patients get to spend with their doctors.
Paying for Health Care: Insurance
Another consequence of the spiraling costs of medical care and health insurance premiums is an increase in the number of uninsured and underinsured Americans. The United States, unlike other industrialized nations, does not have universal health care coverage. Health care is a tangled mix of private and public service providers and payers. It is also a mostly voluntary system. For the elderly, poor or disabled, government programs provide medical coverage. For most Americans, however, medical care insurance is purely voluntary; it is not freely provided, and no one is required to purchase it.
Most, but not all, working Americans and their families receive health insurance coverage from their employers. Some people who do not receive health insurance from their employers buy it on their own, often at higher prices. Others, a growing number, are daunted by costs and remain uninsured. Even for those who have health insurance, however, there is a growing concern about gaps in coverage and an increasing share of out-of-pocket expenses.
Health Care Policy: Who Makes it, Who is Affected
The main players in the organization, delivery, and payment of health care services include:
- The federal government, whose agencies sponsor programs such as Medicare, which helps pay for medical care of the elderly. Federal agencies oversee pharmaceutical safety and funding for medical research. Congress, too, plays a role by passing laws to promote safe medical care for patients, by regulating the content of private health plans, and by assuring access to group health insurance. For example, a 1996 federal law called HIPPA (Health Insurance Portability and Accountability Act) mandates that if you lose your job and the health insurance that goes with it, you will be able to purchase insurance at the same, lower group rate, even if you have predisposing conditions.
- State governments, which work with the federal government to carry out programs such as Medicaid, the safety net program for poor women and children. States regulate the quality of medical care by establishing and enforcing rules to assure safe hospitals and testing laboratories and by licensing health care professionals. State laws deal with a growing number of other health care issues, too. In 1999, health care policy accounted for more bills in state legislatures than any other issue.
- Private employers, who are the largest payers for health care. Employers determine the type of health care services available to their employees. They determine whether employees have a choice in health care plans and what their share of out-of-pocket expenses will be.
- Health care providers, including doctors, nurses, and other allied health professionals, and professional medical associations, such as the American Medical Association.
- Hospitals and clinics, which may be not-for-profit, for-profit, or run by the government.
- Managed care companies and underwriters for health insurance and long-term care insurance.
- Pharmaceutical companies and companies that make medical equipment and supplies.
- Consumers, who are the recipients of health care services and who are assuming a growing percentage of costs for health insurance coverage through employee contributions, co-pays, and deductibles.
- Consumer advocacy groups, which play a growing role in policy decisions, including decisions about the funding of disease research and the passing of laws to require insurance coverage of particular services.
- Health policy professors, special advisory panels, and think tanks, which study policy issues and make recommendations to decision makers.
The Policy Process: How Are Health Policy Decisions Made?
To make a policy, the key players first define the problem, decide on a goal, and then look at alternative options to meet that goal. They consider the impact on patients, providers of health care services, and those paying for them. They need to consider the potential ramifications of any choice on all parties, to balance anticipated risks and benefits, and to choose the best option. They also need to consider the best way to assure that goal. In some cases, it may call on professional associations to establish guidelines of standard clinical practice; in others, it may call for establishing laws or regulations.
Health policy discussions also occur within a political framework, subject to the voices of consumers and lobbyists, to distortions of the media, and to political infighting. Policy makers also need to work with existing laws and programs, rather than starting from scratch. They can choose policies that are incremental and which may build on a program or a law that already exists, for example, expanding or reducing the number of people who are eligible for Medicaid or Medicare. Alternately, they can try to effect more fundamental changes, a process that may be more difficult. Sometimes, they can look at model programs already set up by other countries or states and decide which model best fits their needs.
Health Policy in Action: Banning “Drive-Through Deliveries”
A major health care policy issue today is what some refer to as the managed care backlash, which has prompted consumers to petition state and federal governments to mandate coverage of particular health care services. For example, in 1995 and 1996, about half the states passed laws that require health plans to cover a minimum length of hospital stay for women giving birth. These laws resulted from a backlash to managed care plans that limited such stays, so called “drive-through deliveries”.
The issue was defined by medical consumers like you, concerned about mandated shorter hospital stays and about who got to make the decisions — health plans instead of mothers and their doctors. The media embraced the issue. Physician experts and medical specialty societies weighed in, defining “early discharge” following an uncomplicated birth as a stay of less than 48 hours. In this case, the solution was a practically and politically easy one, in most cases mandating coverage for an extra day or so of inpatient care. In 1996, Congress also took on the “drive-through delivery” issue, resulting in the Newborns and Mothers Protection Act, which requires that health plans cover a specified minimum hospital stay.
Health Policy Issues Today and How They Affect You
In the 1990's, movements to require coverage for other medical services (e.g., mammography screening) and access to providers (e.g., chiropractors) resulted in over 1,000 mandates. This movement is still active and has culminated in a call by some for a more broad-based Patients’ Bill of Rights. These and other important health policy concerns are being discussed today. These issues include:
- Ensuring that your local hospitals, nursing homes, and doctors provide safe and effective care.
- Decreasing the numbers of Americans who are uninsured or underinsured.
- Providing avenues of recourse to patients who are improperly denied particular medical services, including the right to sue your HMO by patient protection laws.
- Ensuring confidentiality of your medical records: who gets to see the information shared between you and your doctors, and how it can affect you.
- Providing you, as a consumer, with affordable options for purchasing long-term care insurance that will help you pay for nursing home care without forcing you and your family members to spend your lifetime savings.
- Addressing the lack of coverage for prescription drugs for Medicare recipients, a rising share of their medical costs.
These issues and others affect your relationship with your doctor and the quality of medical services available to you and your family. Your voice in the policy process, as an informed medical consumer, is an important one.
