🫘Intro to Public Policy Unit 6 – Healthcare Policy: Access, Quality, and Cost

Key Concepts in Healthcare Policy

• Healthcare policy encompasses the decisions, plans, and actions undertaken to achieve specific healthcare goals within a society
• Access to healthcare services is a critical component of healthcare policy and involves ensuring that individuals have the means and opportunity to obtain needed medical care
• Healthcare quality refers to the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
• Cost containment is a major focus of healthcare policy as rising healthcare expenditures strain budgets and affect affordability for individuals and society as a whole
• Health equity is an important consideration in healthcare policy, as disparities in access, quality, and outcomes exist across different populations (racial/ethnic minorities, low-income individuals)
• Social determinants of health, such as income, education, and living conditions, play a significant role in shaping health outcomes and are increasingly recognized in healthcare policy discussions
• Value-based care is a healthcare delivery model that seeks to align payment with the quality and efficiency of care provided, rather than the volume of services delivered

Historical Context of Healthcare in the US

• In the early 20th century, healthcare was primarily a private matter, with individuals paying out-of-pocket for services and limited government involvement
• The Social Security Act of 1935 laid the groundwork for federal involvement in healthcare by establishing programs like unemployment insurance and Aid to Dependent Children
• During World War II, employer-sponsored health insurance emerged as a way for companies to attract workers in a tight labor market, as wage controls prevented them from offering higher salaries
  • This trend continued in the post-war period, with employer-sponsored insurance becoming a key feature of the US healthcare system
• In 1965, Medicare and Medicaid were established as part of President Lyndon B. Johnson's Great Society programs
  • Medicare provides health insurance for individuals aged 65 and older, as well as some people with disabilities
  • Medicaid is a joint federal-state program that provides health coverage for low-income individuals and families
• The Patient Protection and Affordable Care Act (ACA) of 2010, also known as "Obamacare," represented a significant reform of the US healthcare system
  • Key provisions included the individual mandate, requiring most individuals to have health insurance or pay a penalty
  • The ACA also expanded Medicaid eligibility, established health insurance marketplaces, and introduced regulations on insurance companies (guaranteed issue, community rating)

Factors Affecting Healthcare Access

• Health insurance coverage is a major determinant of healthcare access, as individuals without insurance are more likely to delay or forgo needed care due to cost concerns
• Out-of-pocket costs, such as deductibles, copayments, and coinsurance, can create financial barriers to accessing care, even for those with insurance coverage
• Geographic location can impact access to healthcare services, with rural and underserved areas often facing shortages of healthcare providers and facilities
• Transportation challenges, such as lack of reliable public transit or long distances to healthcare facilities, can hinder access to care, particularly for low-income and elderly populations
• Language and cultural barriers can affect access to care for individuals with limited English proficiency or those from diverse cultural backgrounds
• Provider availability and acceptance of insurance can influence access, as some providers may not accept certain insurance plans or may have limited capacity to accept new patients
• Stigma and discrimination can deter individuals from seeking care, particularly for mental health or substance abuse issues

Measuring and Improving Healthcare Quality

• Structure, process, and outcome measures are used to assess healthcare quality
  • Structure measures evaluate the settings in which care is delivered (facilities, equipment, staff qualifications)
  • Process measures assess whether evidence-based practices are being followed in the delivery of care
  • Outcome measures examine the effects of care on patients' health status and well-being
• Quality improvement initiatives aim to systematically enhance the delivery of care and patient outcomes
  • Examples include the use of clinical practice guidelines, care coordination, and patient engagement strategies
• Patient safety is a critical component of healthcare quality and involves preventing errors, adverse events, and harm to patients in the course of care delivery
• Patient-centered care emphasizes the importance of considering patients' preferences, needs, and values in the delivery of care and involving patients in decision-making processes
• Health information technology, such as electronic health records (EHRs) and clinical decision support systems, can support quality improvement efforts by facilitating data collection, analysis, and communication among healthcare providers
• Public reporting of quality measures and pay-for-performance programs aim to incentivize providers to improve the quality of care they deliver

Cost Drivers in Healthcare

• Advances in medical technology and prescription drugs have contributed to rising healthcare costs, as new treatments and therapies are often more expensive than existing options
• An aging population and the increasing prevalence of chronic diseases have put upward pressure on healthcare spending, as older individuals and those with chronic conditions tend to require more healthcare services
• Provider payment models, such as fee-for-service, can incentivize the overuse of services and procedures, leading to higher costs
• Administrative costs, including billing and insurance-related activities, account for a significant portion of healthcare spending in the US compared to other developed countries
• Defensive medicine, or the practice of ordering tests and procedures primarily to avoid malpractice liability, can drive up healthcare costs
• Price variation across different healthcare providers and geographic regions contributes to cost growth, as there is often a lack of transparency and standardization in pricing
• Lifestyle factors, such as obesity, smoking, and lack of physical activity, can lead to the development of chronic diseases and increased healthcare utilization and costs

Current Healthcare Policy Landscape

• The Affordable Care Act (ACA) remains a central feature of the US healthcare policy landscape, despite ongoing debate and legal challenges
  • Efforts to repeal and replace the ACA have been unsuccessful, but some provisions have been modified or eliminated through executive actions and legislative changes
• Medicaid expansion under the ACA has extended coverage to millions of low-income individuals, but some states have chosen not to participate in the expansion
• The opioid epidemic has prompted policy responses at the federal and state levels, including increased funding for addiction treatment, prescription drug monitoring programs, and guidelines for opioid prescribing
• Surprise medical billing, which occurs when patients receive unexpected bills from out-of-network providers, has garnered attention from policymakers, with some states enacting laws to protect consumers
• Prescription drug pricing has been a focus of policy debates, with proposals to allow Medicare to negotiate drug prices, import drugs from other countries, and increase transparency in the pharmaceutical supply chain
• Telemedicine and remote care have gained prominence in the wake of the COVID-19 pandemic, with policymakers working to ensure access to and reimbursement for these services
• Efforts to address health disparities and promote health equity have included initiatives to improve data collection, increase diversity in the healthcare workforce, and target resources to underserved communities

Policy Tools and Interventions

• Regulation is a key policy tool in healthcare, with governments setting standards for the quality, safety, and accessibility of healthcare services
  • Examples include licensing requirements for healthcare providers, safety standards for medical devices, and non-discrimination rules for insurance coverage
• Financing mechanisms, such as government programs (Medicare, Medicaid), employer-sponsored insurance, and individual market plans, are used to fund healthcare services and distribute costs
• Payment reform initiatives aim to shift provider incentives away from volume-based care and toward value-based care
  • Examples include bundled payments, accountable care organizations (ACOs), and capitation models
• Public health interventions, such as vaccination programs, disease surveillance, and health education campaigns, focus on preventing disease and promoting population health
• Workforce development programs seek to address shortages and maldistribution of healthcare professionals, particularly in primary care and underserved areas
• Health information technology initiatives aim to promote the adoption and meaningful use of EHRs, health information exchange, and other digital tools to improve care coordination and decision-making
• Research and innovation policies support the development of new medical treatments, technologies, and care delivery models through funding, tax incentives, and regulatory pathways (FDA approval process)

Challenges and Future Directions

• Rising healthcare costs continue to strain budgets for governments, businesses, and individuals, necessitating ongoing efforts to control spending and improve efficiency
• Ensuring access to affordable, high-quality healthcare for all individuals remains a challenge, particularly for vulnerable populations and those living in underserved areas
• Addressing health disparities and the social determinants of health will require collaboration across sectors and sustained investment in public health and community-based interventions
• The growing burden of chronic diseases, such as diabetes, heart disease, and mental health conditions, will necessitate a shift toward prevention, early intervention, and care coordination
• Preparing for and responding to public health emergencies, such as pandemics and natural disasters, will require robust surveillance systems, stockpiles of medical supplies, and coordinated response plans
• Balancing the benefits and risks of new medical technologies and treatments, such as precision medicine and gene therapies, will be an ongoing challenge for policymakers and regulators
• Adapting to an aging population and the associated healthcare needs will require innovations in care delivery, such as home-based care and telemedicine, as well as policies to support family caregivers
• Addressing workforce shortages and ensuring an adequate supply of healthcare professionals will be critical to meeting future healthcare demands, particularly in primary care and behavioral health