Health Care: Overview
Health Care: Overview
- Colleen GalambosColleen GalambosProfessor, School of Social Work and Sinclair School of Nursing, University of Missouri, and Director of the Graduate Certificate in Gerontological Social Work
This entry provides an overview of the state of health care in the United States. Service delivery problems such as access and affordability issues are examined, and health care disparities and the populations affected are identified. A discussion of two primary government-sponsored health care programs—Title XVIII (Medicare) and Title XIX (Medicaid), and the Patient Protection and Affordable Health Care Act—are reviewed along with various health care programs and major existing service delivery systems. Ethical conflicts in providing health care, and new directions and challenges are discussed, along with future roles for social workers.
- Addictions and Substance Use
- Clinical and Direct Practice
- Health Care and Illness
- Mental and Behavioral Health
Updated in this version
Section on “Patient Protection and Affordable Care Act” added.
Health care in the United States is in the forefront of national debates that highlight the problems and the costs of providing even the most basic of services equitably across all populations of people. The United States spends a larger share of its gross domestic product (GDP) on health care than any other major industrialized country. Approximately 17.6% of the nation’s GDP was spent on health care in 2009 and health spending in the U.S. averaged $8,086 per person in 2009. (Kaiser Family Foundation, 2011). The high expenditures do not guarantee equal access to health care; in fact, significant disparities by race, gender, and income levels exist in terms of health care quality and access (Agency for Healthcare Research and Quality [AHRQ], 2006). A survey conducted by the Commonwealth Fund Commission on a High Performance Health System reported that 48% of adults in middle-income families had serious problems paying for health care and health insurance. Even households with incomes of $50,000 or higher reported serious problems with paying their medical bills (Roszak, 2006). Over the years, national attention has centered on strategies and policy proposals that focus on how to improve access and affordability of health care in this country.
Health Care Affordability
Health care affordability is both a societal (macro level) issue affecting government and systems and a personal (micro level) issue that affects individuals and families (Chernew, Hirth, & Cutler, 2003). From a macro perspective, recent health care spending has risen at a rate that exceeds other economic sectors. There has been a national focus to contain health care costs with a vision on how to allocate scarce resources and still meet the most critical health care needs (AHRQ, 2006).
Others contend that the issue is less about affordability and more about how society values health care and whether we are willing to spend more on it. Chernew et al. (2003) observed that, in the past, overall income growth was substantial enough to allow growth in non–heath care spending by the public and private sectors even with the growing share of GDP spent on health care. Their economic model suggests that real health care spending increases one or two percentage points faster than real GDP and is predicted to be affordable for most citizens through 2039 and beyond. The authors are quick to point out, however, that what is affordable on the average may not be affordable to all segments of society. Increases in health care costs will affect health insurance coverage and contribute to problems in accessing care.
In 2004, per capita health care costs were estimated to be about $6,300 (Centers for Medicare and Medicaid Services, 2006a), with projections that this cost will increase to about $12,300 per capita in 2015 (Citizen’s Health Care Working Group, 2006). As health costs rise, the number of uninsured individuals continues to grow. It is estimated that over 49.1 million people in the United States had no health insurance in 2009 (Holahan & Garrett, 2010), and 29 million have been uninsured for more than a year (Cohen & Martinez, 2005).
Many reasons can be cited for the increases in uninsured Americans. For nonelderly individuals and families, health insurance coverage is obtained primarily through employers. The decline in economic conditions resulted in more individuals being unemployed or underemployed. Each employment change has the potential to affect health insurance benefits. Even in times of employment, individuals may find that health care benefits are beyond their economic reach. In challenging economic times, employers drop health insurance coverage as a benefit or shift costs to their employees. Only two-thirds of American workers are offered health insurance by their employers (National Center for Health Statistics, 2004), and, when offered, it is often cost prohibitive to purchase. It is estimated that 20% of employed workers cannot afford the health insurance offered by their employers. An average annual premium costs $9,068 for family coverage and 27% of this cost is passed on to the employee (Mitka, 2004).
While the offering of health benefits has remained fairly constant in large firms of 200 or more employees, firms with less than 200 workers are less likely to offer health insurance. Since 2000, the number of small firms that offer health benefits has dropped 9% (Kaiser Family Foundation, 2006). People are at risk for becoming uninsured during life transitions. Circumstances such as no longer being considered a dependent on a parent’s policy after age 25, 2 transitioning from student to employee, retiring before age 65, or losing a spouse through divorce or death place people at risk for losing their health insurance. For individuals dependent on government-sponsored health insurance, budget deficits at the federal, state, and local levels result in reductions in coverage affecting families in or near poverty. In the past, figures indicate that 10.5 million persons who were at or below the poverty level were not eligible for government-sponsored insurance (Robert Wood Johnson Foundation, 2004).
Affordability of prescription drugs is another health care problem facing Americans. Prescription drug costs have risen rapidly in the last decade since the mid-1990s. A growing population of people (estimated at 16.6 million in 2004) was unable to afford their prescribed medication, which leads to prescription noncompliance or the inability to take medication as directed by their physician (Kennedy, Coyne, & Sclar, 2004). Persons in poor health and the uninsured are at particular risk for prescription noncompliance. Prescription noncompliance due to cost occurs more frequently for women, working age adults, racial and ethnic minorities, Medicaid and Medicare beneficiaries, and heavier medical care users.
Accessibility of Health Care
The U.S. Institute of Medicine (IOM) defines access as “the timely use of personal health services to achieve the best possible outcome” (Millman, 1993). It requires an adequate supply of health services to cover basic needs. Indicators of accessibility often include such factors as the number of doctors, hospital beds per capita, and costs to the individual. However, another wide range of factors includes geography and environment, social and cultural influences, financial and insurance barriers, organizational and systemic barriers, efficiency and effectiveness, and inequity in service availability (Gulliford et al., 2002). Access to even basic health care services in this country is uneven.
Access is also uneven in rural areas because hospitals, clinics, and public health facilities are in short supply (Berkowitz, 2004). Where health care facilities exist, the availability of physicians, nurses, social workers, and other medical personnel to staff the facilities is problematic. Transportation and access problems exist for both patients and staff. Funding is scarce and access to grant funding is often limited.
Unequal access to health care affects women, particularly those who earn less, lack health insurance, and have limited employment opportunities (Anderson & Keegan, 2004). Uninsured women often delay or forgo health care, which can lead to more serious health concerns. Mann, Hudman, Salganicoff, and Folsom (2002) reported that low-income, uninsured women are 2.5 times more likely to report a delay in attending to their health care needs than low-income women having government-sponsored or private health insurance.
The lack of health insurance affects other populations as well. About 80% of the uninsured were in working families. Of this employed group, 20 million persons who were uninsured had full-time jobs, and 6 million had part-time jobs (U.S. Census Bureau, 2002). In relation to race, 52% of the uninsured were non-Hispanic whites; however, Hispanics and African Americans were more likely to be uninsured than non-Hispanic whites. The nonelderly age group is the most likely to experience being uninsured with 49.6% of 18–24 year olds falling in this category and 32.7% of 25–44 year olds having no insurance. More than 3 million adults in the 55–64 age range lacked health insurance. The youngest population is also vulnerable, with 8.5 million children under age 18 uninsured (McLellan, 2003).
The uninsured lack a consistent source of medical care and rely on emergency services for treatment. The uninsured are four times more likely to use emergency care than are insured individuals (Tunzi, 2004), but they receive fewer diagnostics and treatment services and less follow-up care. In 2009, uncompensated health care amounted to $62.1 billions (Holahan & Garrett, 2010).
The Institute of Medicine (IOM) (2002) reported that the uninsured have worse clinical outcomes for health and lack access to preventative services and screenings. The lack of health insurance results in higher rates of morbidity and mortality. Consequences of receiving inadequate care include fewer diagnostic and treatment services and a lack of access to medications and follow-up medical appointments. The IOM recommends the integration of primary care and public health as a means to improve the health and well-being of all people and as a means to reach more people with a broad array of services (Institute of Medicine, 2012).
Health Care Disparities
Disparities in health care exist in the United States and are often framed through two different perspectives. One perspective is the disease focus, which measures disparities in terms of disease prevalence and morbidity factors. The second perspective is the population health perspective, which uses an ecological model and incorporates all circumstances that influence health, emphasizing the interacting factors that exist at both individual and community levels (Kumanyika & Morssink, 2006). There are several definitions of health disparities as well. The IOM defines a disparity as a difference in treatment provided to members of different racial or ethnic groups that is not justified by the underlying health condition or treatment preferences of the patient (IOM, 2002). While this definition provides a starting point to recognize and address disparities, differences in treatment have also been documented to occur based on gender, socioeconomic, geographical, and other factors. A broader definition of health disparities incorporates differences based on these factors. Healthy People 2010 developed such a definition—differences in disease prevalence or treatment by sex, race, or ethnicity, educational attainment, income, sexual orientation, or geographical location (U.S. Department of Health and Human Services, 2000).
Federal recognition of health disparities occurred as early as 1979 when the Surgeon General’s report on health promotion and disease prevention included health priorities. This report led the U.S. Department of Health and Human Services to publish federal guidelines in the spring of 1980. Fifteen strategic areas and targets for intervention were identified (U. S. Department of Health and Human Services, 2000). This initiative became the model for the Healthy People 2000 campaign that identified the reduction of health disparities as a main objective. Despite a focus on reducing health disparities, by the end of the 1990s, the data showed that while disparities had been reduced, significant gaps in health care remained. These data provided the impetus for the next initiative, and in January 2000, Healthy People 2010 was launched; eliminating health disparities was one of its two major goals. Healthy People 2020 was implemented with four overarching goals. These goals focus on the achievement of health equity, the elimination of disparities, the attainment of high-quality, longer lives, the promotion of quality of life, and the creation of environments that promote good health (U.S. Department of Health and Human Services, 2013).
Despite federal efforts, disparities continue to exist. The largest disparities in quality care and access occurred among low-income people regardless of race and gender. A 2002 Institute of Medicine (IOM, 2002) report also indicated that significant disparities remained for lower income populations in relation to access and use of health care services (Swift, 2002) and a 2003 IOM report identified that disparities in health outcomes exist among minorities (Smedley, Stith, & Nelson, 2003). The 2005 National Healthcare Disparities Report revealed that while racial disparities in quality of care and access to care were narrowing, these disparities still exist, particularly for Hispanic populations (Hand, Chesley, Ho, & Clancy, 2006). To reduce remaining disparities, the IOM calls for the development and dissemination of evidence-based clinical practice guidelines, which encourage consistent, quality health care, and a move toward preventative care provided by multidisciplinary teams. An increase in the number of minority health professionals to more closely compare with the changing demographic characteristics of the U.S. population is also recommended (Sullivan Commission, 2007).
Three Major Policies
Three main acts that provide government sponsored support for health care are Title XVIII and Title XIX of the Social Security Act, originally administered by the Department of Health, Education, and Welfare, now called the Department of Health and Human Services, and the Patient Protection and Affordable Care Act, administered by the Department of Health and Human Services.
Title XVIII of the Social Security Act was enacted in 1965 to specifically address the medical care needs of the elderly and disabled. Referred to as Health Insurance for the Aged and Disabled, or Medicare, this program establishes health insurance for aged persons over the age of 65 and eligible disabled individuals. It is an offshoot of a group of social insurance programs legislated by the Social Security Act called Old Age, Survivors, Disability and Health Insurance (OASDHI, with the HI standing for Medicare). While the original Social Security Act was enacted in 1935, the Health Insurance component was the last to be added. In 1973, eligibility was extended to persons entitled to Social Security or Railroad Retirement disability cash benefits for 24 months, persons with end-stage renal disease, and other non-covered aged persons who elect to pay a premium for Medicare coverage. The program currently covers 95% of the aged population and also persons who receive Social Security Disability benefits (Hoffman, Klees, & Curtis, 2000).
Medicare includes several components. Employees and employers must pay into Part A or Hospital Insurance through a payroll tax. Medicare A provides coverage for the first 60 days of hospital stays, 20 days of skilled nursing care, skilled home health care services, and hospice care. Some services require a co-insurance payment. Workers having retired at age 65 and having accrued 40 quarters of employment and their spouses are eligible for Medicare after they sign up for the program. Retired workers with less quarters accrued can receive Medicare for a fee (Gorin & Moniz, 2003).
Medicare Part B is voluntary and beneficiaries contribute by paying a monthly premium. It provides coverage for medical services, diagnostic testing, outpatient medical, hospital rehabilitation and mental health care services, ambulatory surgery, some home health care not covered under Medicare A and durable medical equipment. In 2005, about 95% of the nation’s older population and the chronically disabled were covered by Medicare. Part A covered 42 million enrollees and Part B covered 40 million enrollees (Centers for Medicare and Medicaid Services, 2006).
Medicare C is the Medicare + Choice program, established by Public Law 105-33 in 1997. This program is provided through the private sector and has a variety of plan options. These plans may include coordinated care plans, including health maintenance organizations (HMOs), provider-sponsored organizations (PSOs), preferred provider organizations (PPOs), and other certified, coordinated private health care plans. Certain fee for service (FFS) plans that allow beneficiaries to select certain private providers are also available under Medicare Part C. Another option under Medicare C are medical savings account (MSA) plans after a deductible is met. Medicare deposits money into an account on an annual basis, and the beneficiary uses the money in the account to pay for medical expenses (Hoffman, Klees, & Curtis, 2000). All Medicare + Choice plans must provide the basic Medicare benefit package excluding hospice care. Plans may offer additional services.
Medicare Part D is the voluntary prescription drug plan that went into effect January 1, 2006, as authorized by the Medicare Modernization Act. The plan entitles enrollees to lower-cost prescription drugs. Medicare recipients who did not enroll in the program by May 15 may face penalties (i.e., higher premiums). Recipients generally choose from between 20 and 60 plans approved by individual states and offered by private providers. Each plan has a different formulary, monthly premium, and deductibles. Persons who are receiving drug coverage through other private insurance such as an employer’s retirement benefit can opt out of the plan. Even with Part D coverage, gaps still exist. The plan pays up to $2,250 annually. Recipients pay for costs exceeding that cap until the costs reach $3,600 (some higher premium plans do provide coverage for the gap). At $3,600 catastrophic coverage kicks in, and Medicare will pay for 95% of remaining costs. Despite the drug coverage offered, problems are found with the Part D enrollment process. Enrollment information is difficult to find, particularly for individuals who have limited access to website information. In addition, confusion abounds in the sheer number of available choices, and formularies may change, leaving enrollees paying higher costs than they expected.
Title XIX of the Social Security Act established a program of health assistance for the poor, which is commonly referred to as Medicaid. Prior to its enactment in 1965, health care services for the poor were provided piecemeal through an arrangement of services offered by state and local programs, charities, and hospitals (Provost & Hughes, 2000). Modeled on the 1960 Kerr-Mills Act, Medical Assistance for the Aged, and the Social Security Amendments of 1950, it was designed as a cooperative program funded jointly by the federal and state governments, including the District of Columbia and the U.S. Territories (Provost & Hughes, 2000). It is an entitlement program that pays for medical care for certain individuals and families who have low income and limited resources (Hoffman, Klees, & Curtis, 2000; Rowland and Garfield, 2000). Its particular emphasis is on dependent children and their mothers, pregnant women, the disabled, and older persons. Using broad federally established regulations, each state shapes and administers its own Medicaid program and develops its own standards. These standards include eligibility requirements (resource and assets tests), type, amount, duration, and scope of services, and rate of payment for services, which creates variability in Medicaid policies throughout the country. However, states are required to provide medical coverage for particular individuals who receive federally assisted income maintenance payments and for related groups who are not receiving cash payments.
Medicaid was never designed to provide medical assistance to all poor persons. States must cover certain categories of people but have discretion in whether to cover other groups. States may also develop state-only programs that provide medical assistance for designated poor persons who do not qualify for Medicaid. Great variability exists across the country in these optional programs (Hoffman, Klees, & Curtis, 2000). A “medically needy” option allows states to cover persons to qualify for medical assistance through a “spend down” process in which medical expenditures must exceed assets owned by the individual.
The Personal Responsibility and Work Opportunity Act of 1996 (Public Law 104-193) introduced restrictive changes to eligibility standards for Supplemental Security Income (SSI) coverage. SSI is a federal welfare program for persons with chronic health and mental health conditions and for the disabled. The law imposed restrictions on SSI eligibility among legal resident aliens and other qualified aliens who entered the United States on or after August 22, 1996. The law required a five-year waiting period before these individuals are eligible for SSI unless states opt to provide Medicaid coverage for them or they are covered under expanded Medicaid coverage . Emergency services continue to be mandatory for these groups
To address the lack of health insurance for uninsured children, the Balanced Budget Act of 1997 authorized Title XXI of the Social Security Act. Title XXI, known as the State Children’s Health Insurance Program (SCHIP), expanded Medicaid eligibility to include low-income children whose family’s income exceeds Medicaid eligibility requirements. In 2008, SCHIP was reauthorized and expanded by $32.8 billion to include approximately 4 million more children, including legal immigrants (News Medical, 2013).
Patient Protection and Affordable Care Act
Commonly referred to as the Affordable Care Act or Obamacare, the Patient Protection and Affordable Care Act (Public Law 111-148) was enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Not since the passage of Titles XVIII and XIX has there been a major regulatory change of this capacity. The primary aims of the Patient Protection and Affordable Care Act (PPACA) are to decrease the number of people who are uninsured and to reduce health care costs and to improve quality of health care (HealthCare.gov, 2012a). Most of the comprehensive reforms roll out over four years, which began in 2010 with a set of consumer protections against insurance industry abuses, including the denial of coverage for preexisting conditions, prohibiting insurance companies from rescinding coverage, and eliminating lifetime insurance limits (HealthCare.gov, 2012a). Other selected key features that started in 2010 include the provision of free preventative care, extended coverage for young adults, and expanded coverage for retirees (HealthCare.gov, 2012b). Selected 2011 reforms included an emphasis on improving health care quality and efficiency, improving transitional care for seniors, particularly around hospitalizations, increasing access to home- and community-based services, and providing free preventive care to seniors (HealthCare.gov, 2012b). The reforms occurring in 2012 continued to emphasize initiatives that improved quality and lowered costs, such as providing financial incentives to hospitals to improve care quality and giving incentives to physicians to develop accountable care organizations. Future initiatives include the expansion of consumer protections, cost reductions in health care, and more quality improvement measures (HealthCare.gov, 2012b). By 2014, provisions to increase access to Medicaid will include expanding Medicaid eligibility to include people who earn less than 133% of the poverty level. As a result of the PPACA, changes to Medicare include free annual wellness visits, some preventive services, reductions in out-of-pocket costs for brand-name drugs, and preserving the patient’s right to physician selection. The development of accountable care organizations, or a group of providers willing to work together to manage and coordinate the care of Medicare fee-for-service beneficiaries, is another development of the PPACA. It is also predicted that through cost savings incurred by the PPACA, it will be possible to preserve Medicare through 2029 (Medicare.gov, 2012). Projections also indicate that the cost of uncompensated care will decline over the next several years (Holahan & Garrett, 2010).
Other Health Care Programs
While Medicare and Medicaid are two of the largest government-sponsored programs, other significant programs also provide health care in America. Five such programs are Veteran’s Health Care, Indian Health Services, correctional facilities health care, public health, and long-term care.
Veteran’s Health Care
Health care for veterans is provided by the Veteran’s Health Administration under the Department of Veteran’s Affairs. Services are provided primarily to veterans with service connected disabilities and who are poor. Care is also available for progressive conditions that stem from a service disability. Eligibility does vary from site to site (Corder, 1998; U.S. Department of Veterans Affairs, 2007).
The Veteran’s Health Administration is an integrated health care system composed of hospitals, nursing homes, ambulatory care clinics, domiciliaries, readjustment counseling centers, and expanded mental health services. Services are structured through the use of Veterans Integrated Service Networks. The size of these networks are variable, including the type and range of medical facilities. The networks also contract with the private sector for some services.
The challenges inherent within the Veteran’s Health Administration is that the focus of care tends to be long term oriented without an orientation to preventive care. This orientation often clashes with the overall preventive managed care focus within the rest of society. Services provided under this structure are costly and inpatient care facilities have low occupancy rates and higher than average length of stays, which add to the expense of service delivery. There are close links with university medical schools, which provide high caliber faculty and residents to care for the veterans, but these arrangements are costly.
Case management is a model that has been integrated into veteran’s health care as well as the use of ambulatory surgery centers to shift the provision of care away from hospitals. Patients are followed by primary care providers and these providers interact with dieticians, social workers, pharmacists, psychologists, psychiatrists, and other health care disciplines to provide comprehensive care. While these types of services emphasize more of a community model of care, veterans report that coordination of care and communication could be improved (Parchman, Hitchcock Noel, & Lee, 2005). Future trends will be directed at providing quality care to our veterans using less expensive models of care. In particular, a shift to ambulatory and community-oriented care has taken place with an emphasis on ongoing monitoring to evaluate the health of veterans with a goal of improving their quality of life (Kazis et al., 2004).
Indian Health Services
Health services for American Indians and Alaskan Natives has been a federal responsibility since the early 19th century through treaties formed between the federal government and various tribes. The Department of the Interior was responsible for providing these services until 1955 when the responsibility was transferred to the Department of Health, Education, and Welfare as the Division of Indian Health. It has since been renamed the Indian Health Service, and it is a national program for federally recognized Indian tribes (Brenneman, Rhoades, Everett, & Chilton, 2006).
Indian Health Services (HIS) is composed of a comprehensive network of 33 hospitals, 54 health centers, 38 health stations, and 34 urban Indian health projects located in 35 states and provides care for 1.9 million Indians from 561 federally recognized tribes. With a budget of $3.1 billion, services include dentistry, nutrition, community health, sanitation, injury prevention, and institutional environmental services. More than 55% of Native Americans rely on IHS for their health care needs (Indian Health Services, 2007a; Indian Health Services 2007b). Only 28% have private health insurance (Roberts, 2000).
IHS is divided into two components. One component is direct care. This care is provided at an IHS facility. These facilities are located on reservations and include pharmacological, dental, mental health, and vision care in addition to medical services. Another component is contracted health services that are provided by a non-IHS facility or provider. Native Americans require a referral to be able to receive services by a non-IHS facility or provider.
A series of legislative mandates have attempted to improve health services for Indians. The Synder Act of 1921 established the first federal authorized expenditures for health care services for members of federally recognized tribes. In 1975, the Indian Self-Determination and Education Assistance Act was enacted, which provided tribes the option of managing their own health care services and programs. In 1976, the Indian Health Care Improvement Act was approved, which mandated that the federal government grant more resources to the Indian Health Services to enable the program to provide adequate health care (Guiden & Johnson, 2000; Roberts, 2003).
Despite these mandates, health care among Indian tribes remains inadequate. The congressional appropriations that fund Indian Health Services have not kept pace with the needs of the Native American population. There is a lack of coordination between IHS and non-IHS providers, often resulting in poor care. Also, insufficient funding results in the rationing of health care services for Native Americans and Alaskan Natives (Roberts, 2000).
Health Care in Correctional Facilities
In the landmark case of Estelle v. Gamble (429 US97 ), the United States Supreme Court ruled that indifference to the health care needs of inmates was a violation of the Eighth Amendment of the Constitution. This ruling established health care as a constitutional right of correctional facility inmates. At the time that the courts made this ruling, organized medicine became involved in correctional health care. The American Medical Association conducted a survey of health services in jails throughout the country and found substandard care abounded in correctional facilities. Through a grant received from the Law Enforcement Assistance Administration, correctional health services standards were developed and a pilot project began to accredit health programs through state medical associations. Eventually the National Commission on Correctional Health Care was developed and this group continues to update standards for health services in jails, prisons, and juvenile facilities (Thorburn, 1995).
While the 1970s can be viewed as a time period in which health services improved in correctional facilities, national public policy decisions in the 1980s created setbacks in this area. As crime became a national focus, more reliance was placed on incarceration as the primary sanction for the conviction of criminal offenses. At the same time, the National Drug Control Strategy mandated lengthy prison sentences for drug convictions. These factors created a swelling of the prison population. As the prison population rose in numbers, health care facilities were inadequate to take care of the increased demands. The population in correctional facilities changed with the addition of a growing number of drug offenders, incarcerated females, and a correctional population that is aging in place. These changes drastically affected the health care needs of correctional facilities.
Specifically, the prevalence of HIV infection among state prison inmates has increased, and the median incidence of AIDS among the prison population is 10 times higher than among the general population. To address this increase, there is a need for HIV prevention efforts including efforts to prevent disease transmission. Measures to prevent the spread of the disease include condom distribution, mandatory testing, and voluntary testing, and these measures are viewed as controversial (National Commission on Correctional Health Care, 2007).
Also, with the increase of an aging population, the incidence of chronic illnesses has risen along with more susceptibility to infectious diseases. As this aging prison population continues to become frailer, different health programs are needed to respond to these health concerns (National Commission on Correctional Health Care, 2007).
The increase in the female prison population mandates that different health services be offered to this population. Special health care services such as regular gynecologic and prenatal care are required to meet the medical needs of women. In addition, the monitoring of high-risk pregnancies is on the rise due to such factors as drug use by the mothers in the early stages of pregnancy.
Challenges in the future for correctional facilities center on providing services for a population of inmates susceptible to infectious diseases, working with increased numbers of female inmates, and responding to an aging population. A responseto the rising cost of health care in correctional facilities while mandating strong public health practices is a necessity both from a humane perspective and for the protection of the larger community (National Commission on Correctional Health Care, 2007).
The aim of public health is to protect and improve community health through education, healthy lifestyle advocacy, and promotion of research on disease and injury prevention. The focus is on the health protection of entire populations located in neighborhoods, communities, states, and countries through the prevention of health problems from happening or reoccurring. The Centers for Disease Control and Prevention (2007) identify the 10 essential public health services as:
Monitor health status to identify community health problems
Diagnose and investigate health problems and health hazards in the community
Inform, educate, and empower people about health issues
Mobilize community partnerships to identify and solve health problems
Develop policies and plans that support individual and community health efforts
Enforce laws and regulations that protect health and insure safety
Link people to needed personal health services and assure the provision of health care when otherwise unavailable
Assure a competent public health and personal health care workforce
Evaluate effectiveness, accessibility, and quality of personal and population-based health services
Research for new insights and innovative solutions to health problems (p. 1)
The frontline of public health services are state and local health departments that implement programs to mitigate problems and promote prevention programs at the community level. At the federal level, the U.S. Public Health Service, administered by the Surgeon General, the U.S. Department of Health and Human Services, and the Centers for Disease Control and Prevention lead the country on public health initiatives nationally and internationally.
One such initiative is Healthy People 2010, which is a set of national goals developed by the U.S. Department of Health and Human Services. The goals are directed to improve the health of the country by reducing health threats that could be prevented. Local, state, and national public health officials work to meet and exceed these goals through health interventions and policy development. The Healthy People 2010 initiative is based on 10 leading health indicators that were selected because they have the potential to motivate action, have available data to measure progress, and because they are deemed important as public health issues. The 10 leading health indicators are: physical activity, overweight and obesity, tobacco use, substance abuse, responsible sexual behavior, mental health, injury and violence, environmental quality, immunization, and access to health care (U.S. Department of Health and Human Services, 2007a).
In addition to the Healthy People 2010 initiatives, the Office of the Surgeon General has named five public health priorities: disease prevention, eliminating health disparities, public health preparedness, improving health literacy, and organ donation (U.S. Department of Health and Human Services, 2007b). Special attention is being given to preparedness activities in response to a national pandemic and preparedness in response to terrorist attacks.
Long-term care covers an array of services provided over a period of time to individuals of any age with chronic conditions and functional limitations. Services provided range from minimal personal assistance with activities to total care. Many settings are used to provide long-term care, such as nursing homes, clinics, community-based services, assisted living centers, residential care facilities, group homes, and personal homes.
In 2006, approximately 9 million people over the age of 65 needed long-term care. By 2020, as the aging population increases, 12 million older adults will need long-term care (U.S. Department of Health and Human Services, 2007c). It is estimated that 70% of the elderly are cared for at home by family and friends as informal caregivers. Of those elders entering the nursing home, about 10% will remain in nursing homes for five years or more (U.S. Department of Health and Human Services, 2007c). Long-term care is not just for older adults. About 40% of people receiving long-term care are adults between the ages of 18 and 64 (Federal Long Term Care Insurance Program, 2007).
Long-term care is paid for in a variety of ways. Medicare pays for long-term care only if there is a skilled need and only for short periods of time. Care must be provided in a skilled nursing facility or through home health care if the individual is home bound. Some Medicare Advantage Plans will pay for limited skilled nursing facility and home care if the care is medically necessary. Medicaid pays for some long-term care services at home and in the community and Institutional Medicaid will pay for custodial care or non-skilled care such as assistance with bathing, dressing, and meals within nursing home facilities. Coverage varies from state to state and eligibility is based on income and personal resources. Individuals may also pay privately for long-term care services and long-term care insurance policies are available that will provide coverage for care, although terms vary with each insurance plan.
The national focus on long-term care centers on both quality of care and affordability of services. In 1997, the federal government passed regulations on nursing home reform that were intended to enhance quality of life for residents. While some improvements were made with these regulations, more work is needed to improve care in nursing home settings. Nursing home care is expensive, averaging about $4,000 for a one-month stay in a facility. Increased access to home- and community-based services and an emphasis on keeping people in the community longer would reduce the expense of long-term care and enhance quality of life for individuals (Institute of Medicine, 2007).
Models of Health Care Service Delivery
The emphasis on service delivery in the United States has historically been individualistic with a fee-for-service structure (Gorin & Moniz, 2003). Physicians see patients in private offices and bill the patient for services rendered. Hospital care is arranged by the physician; however, hospitals operate independently from the physician. Private insurers offer coverage through an indemnity model, where the insured pays a premium to health insurance companies and are reimbursed for the cost of services. These types of plans can be expensive and are believed by some to promote inefficiency since physicians and consumers have little incentive to control health care use and costs (Starr, 1982). To control health care services use and costs, insurers have increased co-pay and deductible requirements, which the insured must pay out-of-pocket.
Health Maintenance Organizations
In an attempt to contain rising health care costs, the Nixon administration encouraged development of health maintenance organizations (HMOs) as an alternative to traditional fee-for-service plans. Under the HMO structure, prepaid group practices provide participants (members) comprehensive health care coverage and prevention services for an annual fee. In earlier models, physicians worked exclusively for the HMO. The HMO Act of 1973 further promoted the development of HMOs by overturning state laws that restricted prepaid group practices or practices in which the cost of care is paid for in advance of service delivery. The act also subsidized HMO start ups and required employers with 25 or more workers to offer an HMO option of health insurance (Gorin & Moniz, 2003).
In response to the success of the HMO model in lowering costs for the individual consumer and in providing less-expensive health care options for businesses and organizations (Luft, 1978), the 1980s saw the introduction of more managed care arrangements. Managed care plans (including HMOs) attempt to control costs through the development of prearranged agreements with physicians, medical services, and hospitals that form a network of providers which are used to receive medical care. Employers pay managed care companies a fixed amount for the contract or prearranged agreement. Employees buy into the plan at costs typically lower than fee-for-service plans. Consumers who use physicians and services outside of the plan pay more for these services. Managed care options are available for Medicare and Medicaid recipients as well.
Service Delivery Options
Another service delivery model that emerged in the 1980s was the preferred provider organization (PPO). The PPO is a combination of a fee-for-service plan and an HMO plan. The consumer may receive health care from a network of providers for a small fee in addition to premiums paid for by the consumer. If health care is received from a non-network provider, the charge for services is higher. Most PPOs require the consumer to choose a primary health care provider who oversees services.
Another model is the Point of Service (POS) Plan, where the consumer has a primary care doctor who refers to other members in the POS for additional services needed by the consumer. Providers outside the POS can be used if the physician makes a referral to these specialists; however, the consumer may have to pay an additional fee for the use of non-network providers.
Recently, Health Savings Accounts (HSAs) have emerged as what some believe to be a lower cost alternative to other health care arrangements. Pre-tax dollars are placed into an account to be used for medical expenses. The consumer chooses the provider and expenses are paid through this tax-free HSA account. Contributions remain in the tax deferred account and can be used to pay for future expenses. Money left in the account can be used for retirement expenses after age 65, much like a tax-free retirement savings account. These types of consumer-directed health plans are designed to enable consumers to manage their health care, support informed choice between the consumer and the provider, and provide financial incentives to the consumer to control expenses (Rosenthal, Hsuan, & Milstein, 2005). As the United States struggles with the rising cost of health care, the trend since the 1980s has been to develop service delivery systems that are less costly for the consumer, government payers, and employers. While the majority of these managed care arrangements are viewed as more efficient, criticism has emerged related to the loss of quality and effectiveness in health care services provided through these arrangements (Scandlen, 2001).
Rationing health care is at the forefront of public discussions, and some contend that health care rationing already exists (Sabin, 2000). Three primary factors contribute to this discourse. First, as the cost of health care rises and resources diminish, the average consumer finds it difficult to pay for basic care. Providers are forced to subsidize the cost of care, which can be financially prohibitive. Second, technological advances have led to an increase in the ability to treat life-threatening illnesses and accidents that were previously impossible to survive. The third is an increased life span. Discussions are emerging about how to limit health care interventions. Some propose the development of priorities that can be used as guidelines to limit care and medical interventions (O’Donnel, Smyth, & Frampton, 2005). Others suggest honoring advance directives and respecting people’s wishes in terminal conditions (Galambos, 1998). It is also suggested that by limiting the amount of health care available to individuals, rationing will occur and, in some cases, must occur to control health care costs (Aaron, 2005). Still others advocate that health care is a basic right and a minimum level of health care should be available for all individuals (Galambos, 2006; Institute of Medicine, 2004). Americans will need to determine whether each citizen is entitled to some access to health care and what, if any, limits will be placed on services.
In addition to rationing, ethical concerns have emerged related to equity in access to health care and outcomes related to that care. Equal access and equal outcomes are discussed in terms of horizontal and vertical equity (Rice & Smith, 2001). Horizontal equity pertains to equal treatment of equals and what factors society will use to define who and what is equal. Vertical equity refers to equal health outcomes. As Healthy People 2010 continues to define ideal health outcomes for this country, the issue of how to treat unequal factors and how to distribute resources in a just and fair way will continue to appear in the national debate.
Future Directions and Trends
National recognition is increasing that this country’s medical system is fragmented, overburdened, and underfunded. Emergency rooms are increasingly being used as the primary source of health care for the uninsured, and hospitals are overwhelmed from the demands of providing care to an increasingly aging population (Perry, 2006). There is a lack of available beds for hospital admissions in certain areas, and in other areas, the emphasis on cost containment has left many beds empty in health care facilities. There is a movement to discharge patients quicker and sicker in response to the Diagnostic Related Group’s (DRG’s) legislation, passed during the Reagan administration, which standardizes the amount of time individuals should stay in hospitals according to specific diagnoses. The DRG has contributed to a shift in care being assumed by long-term care facilities and home health care agencies (U.S. Congress, Office of Technology Assessment, 2013). Future directions in health care primarily focus on controlling health care expenditures, reducing health disparities, and increasing access to health care. Also, in response to the PPACA, health care systems are responding by altering care delivery models with an emphasis on smoother transitions between health facilities, increased collaboration among facilities and health care professionals, and more efficient care coordination (American Hospital Association, 2010). These new approaches, such as the integrated health model, emphasize the provision of interdisciplinary care through interdisciplinary professionals working together to provide care in a comprehensive manner (American Hospital Association, 2012).
Institute of Medicine Recommendations
To address the growing problems in America’s health care delivery system, the Institute of Medicine (2001) advocates reinventing the system from one that is devoted to the treatment of acute episodic care needs to one capable of handling chronic health conditions and promoting wellness. Six areas targeted for improvement include patient safety, service effectiveness, patient-centered care, timely treatment, efficiency of operations, and equitable care for all populations of people regardless of personal characteristics.
The IOM also identified several factors that must exist in the reinvented system: (a) evidence-based care; (b) effective and efficient use of information technology; (c) an emphasis on quality improvement through the alignment of payment policies with quality care; (d) workforce preparation including an emphasis on interdisciplinary care that utilizes an evidence-based approach.
Responding to the devastation that a lack of health insurance places on the system and individuals, the Institute of Medicine (2004) called for all U.S. citizens to have some form of health insurance by 2010, including universal, continuous coverage that is affordable and sustainable. Rather than recommending one specific plan, various approaches were recommended to achieve these recommendations. The PPACA and its provisions for health insurance coverage and expanded Medicaid is also likely to have an impact on this issue.
Lower Cost Options
Communities are developing strategies to provide health care resources for the growing uninsured in this country. One such approach is to use current safety net systems in place for the uninsured, such as inpatient and emergency department services, to enroll them in these services that will provide a basic minimum level of care, while emphasizing preventative and primary care. Another approach is to organize donated care initiatives in the community in which health care providers see patients on a pro bono basis. A third approach is providing discounted care to the uninsured. Participating safety net and private providers supply health care services at discounted rates, an approach that has attracted the working uninsured (Taylor, Cunningham, & McKenzie, 2006). A final approach is the development of limited benefit programs in which employers offer small group limited benefit products through local insurers that are in compliance with state laws (Taylor et al., 2006). In rural communities, telemedicine can be used to address accessibility issues and to deliver needed care while reducing expenditures in providing that care (Demiris, Parker Oliver, & Courtney, 2006).
Coordinated Model of Care
To address the fragmentation of health care service delivery, recommendations on how to improve care focus on the development of a better coordinated model of care. One proposed approach is to develop a case management system that focuses on a joint approach to service delivery between health and social services, and employs a stronger bio-psycho-social paradigm to health care. Case finding is a part of this model to identify consumers at risk. Once consumers are identified, intensive care coordination is offered, including a patient-centered assessment, emphasis on proactive, preventative care and self management, coordination of the treatment of chronic health conditions, and the provision of ongoing support and advocacy (Adams, 2006). Another approach is reorganizing the delivery system to expand multispecialty group practices (Crosson, 2005). This movement is aimed at improving the coordination of care, disseminating knowledge and skills to support outcome measurement and evidence-based medicine, and making effective use of technology. It is believed that this type of model leads to better outcomes and will increase both the efficiency and the effectiveness of health care services (Crosson, 2005).
A third approach focuses on the improvement of transitional care. Transitional care is the coordination and continuity of health care across different care locations and between various levels of care (Jacobs, 2007). Transitional care includes both sending the patient to a different location and admitting or receiving the patient into another setting. These various locations may consist of hospitals, subacute and post-acute nursing facilities, homes, physician’s offices, and long-term care facilities (Coleman, 2003). Successful transitional care models include strong communication and coordination components among health care practitioners, comprehensive care planning that incorporates patient goals, care preferences, and health care status, patient and family education, and a health care team trained in the complexities of acute and chronic illnesses (Jacobs, 2007; Coleman, 2003). The PPACA emphasizes increased efficiencies in transitional care and health care systems are responding to this federal mandate (HealthCare.gov, 2012).
A trend in providing health care services in rural areas is the use of a collaboration model of care, interdisciplinary and interorganizational in nature. This model emphasizes the enhancement of communication and the development of partnerships and communication between community-based agencies and the health care service delivery system, such as a partnership with senior services and public health. These models may be organized differently and run the gamut of formal partnerships to participation in community coalitions to the development of regional relationships with local health departments (Berkowitz, 2004).
There are also movements to modernize long term care services that emphasize partnerships among consumers, health care providers, and payers. An expansion of community based services that promote wellness, enhance individual autonomy, and incorporate a bio-psycho-social-cultural model of care will move long-term care into the 21st century (Institute of Medicine, 2007).
Roles for Social Workers
The IOM recommendations and movement toward a model that emphasizes the coordination of health and social services provide the impetus for social workers to become more involved in evolving health care structures beyond the traditional settings. Social work roles may include planning new service structures, advocating for fair and equitable health care policies, and conducting research to identify the best models of care. Social workers will need to be versed in evidence-based practice and culturally competent care and position themselves to be leaders and active participants in health care administration and on interdisciplinary health care teams. The discipline of social work has much to offer the team in its movement toward providing a patient-centered, community-involved approach to health care.
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