Ngoc Uy Nguyen is a final-year PharmD candidate and Andrew S. Bzowyckyj, PharmD, BCPS, CDE, is an associate professor at the Pacific University School of Pharmacy.
The impact of the COVID–19 pandemic has illuminated the problems within the extremely fragile U.S. health care system. Even before the pandemic, steadily increasing medication costs, “surprise” medical bills, and unaffordable copays and deductibles were becoming increasingly commonplace. Something needs to change, and as some 2020 presidential candidates proposed, universal health care may be a potential solution moving forward.
As promising a solution as that sounds, such a complex problem requires a complex solution.
As aspiring health professionals, it is important for student pharmacists to remain informed about the nuance and complexity of the overall health care system from the perspectives of all stakeholders as we advocate for patients and the profession.
Workforce and financial perspectives
In 2018, America paid approximately $10,586 per person per year for health services.1 A large amount of this money is attributed to the convoluted process of care delivery, which results in high administrative costs that could be streamlined in a universal health care system. However, the same convoluted system provides over 18 million jobs, accounting for more than 11% of all jobs in the overall economy.2 This is a huge consideration when streamlining the overall health care reimbursement process: how to repurpose our existing health care workforce.
According to the U.S. Census Bureau, about 8.5% or 27.5 million Americans did not have insurance at one point in 2018.3 Uninsured individuals may have lower out-of-pocket costs due to the inability to afford medical services, but this often leads to higher overall health care expenditures in the future for more costly treatments. In 2016, health systems provided $38.3 billion in uncompensated care, and by some estimates, government funding offset only 65% of such costs.4 Presumably, much of this price tag likely went toward acute treatments of uncontrolled chronic conditions. Imagine how much further this money could go if it were invested in a stronger preventive care infrastructure.
Health care system perspective
In the current operating model, hospitals get more money for bringing people into the hospital, not keeping them out. As we look to move away from the current model, health systems are increasingly required to report metrics on patient outcomes and overall quality of care. Although data-driven decision making and transparency are certainly benefits, this shift may result in unintentional consequences, such as an incentive for health systems to exclude specific payers in “high-risk patient populations” (e.g., Medicaid patients) or find strategies to triage high-risk patients elsewhere to keep their quality measures intact.
Under universal health care, in which reimbursements are likely to be heavily regulated and somewhat standardized, health care systems can rely on a more consistent and predictable stream of reimbursement and thereby take on these higher risk patients. There should be no need to sacrifice quality patient care to justify the bottom line.
Patient perspectives
Chronic conditions cost the health care system up to 90% of the nation’s $3.5 trillion in annual health care expenditures.5 This high price tag is largely due to patients’ accessing care only when these conditions—which are best managed with routine scheduled follow-ups—flare up in an emergency. Because these conditions affect a large population, universal health care will likely prioritize services to treat them. However, there are rare conditions (often genetic) that do not affect a large population yet cost patients a significant amount of money for effective treatment. Under universal health care, in which everyone has the same predetermined services, how will these patients receive access to these life-saving medications?
American society encourages workplace stress and injury. The entertainment industry further promotes the use of prescription medications, alcohol, and sedentary lifestyles. These societal issues are frequently the reasons people get sick. Simply providing treatment for downstream problems without implementing any lifestyle changes targeting the root cause of the problem will not result in improved outcomes or financial savings.
It is worthwhile to note that “universal” means everyone contributes to everyone’s care equally. Currently, patients can choose their health coverage as tailored to their individual needs and financial ability. To what extent can the government dictate someone’s freedom of choice, at the price of societal health?
Educate yourself
This article considers some of the many valid perspectives from all stakeholders of this difficult yet necessary evolution of the U.S. health care system, including details and unintended consequences. There will never be a perfect solution—choosing one will result in some benefits and losses for everyone. Therefore, conversations that encourage compromise are critical.
Student pharmacists should lead the way in advocating for equitable and high-quality patient care. Specifically, it is important to get educated on the social and administrative aspects of pharmacy and not just focus on the clinical content of one’s own specialty. An issue can be fully comprehended only by identifying and understanding the root cause.
References
1. Organization for Economic Co-operation and Development (OECDS). Health expenditure and finance. https://stats.oecd.org/Index.aspx?DataSetCode=SHA. Accessed September 5, 2020.
2. HealthLeaders Media. Healthcare job growth outpaced nearly every other sector in 2018. www.healthleadersmedia.com/strategy/healthcare-job-growth-outpaced-nearly-every-other-sector-2018. Accessed September 5, 2020.
3. U.S. Census Bureau. Health insurance coverage in the United States: 2018 (November 2019). www.census.gov/library/publications/2019/demo/p60-267.html. Accessed September 5, 2020.
4. HealthAffairs. Safety-net health system at risk: Who bears the burden of uncompensated care? www.healthaffairs.org/do/10.1377/hblog20180503.138516/full/. Accessed September 5, 2020.
5. CDC. Health and economic costs of chronic diseases (September 2020). www.cdc.gov/chronicdisease/about/costs/index.htm. Accessed September 11, 2020.