$44,000 for an Ambulance, Hour-long drives to an ER photo by in The Impossible Cost of Healthcare in Appalachia. The US has a low density of hospitals and fewer physicians per capita compared to other wealthier countries.
The road less travelled
Redefining "public" health in the United States
toward universal coverage
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Winter came to the time-worn Appalachian spine. The lone nurse got off her mule and walked across a rickety wooden bridge far back in the "hollers." She reached a small home of grayed wood and a tar-papered roof. There were three rooms, two adults, and four children. The family told the nurse that the grandmother had"pneumonia fever." Every one in the hollers gets pneumonia fever because pneuomy fever was being sick.
The nurse worked for the Frontier Nursing Services. She did not speak the language of disease to the family. She listened to generations and did what she could.
Most coal bearing counties have one doctor. There was no physician her county. Another nurse working in a clinic said, "I collect life histories. When a doctor comes I try to communicate that. They don't understand. "
One doctor had been a primary care doctor for over 40 years. He was the only doctor for over 100 miles. He shook his head as he related that many changes were changing his practice in unexpected ways - drugs, depression, etc. He needed new medical knowledge and a network but he said he was a primary care provider and so not in the loop like the specialists in Lexington and beyond.
In a small living room a man lay on a bed and coughed. He was yet another coal miner with black lung disease. He worked for the company. They had no help for him. Rather, there were mandates to keep injured miners working—and from claiming disability insurance by prescribing drugs for pain.
What is public health
As a public we assign and pay for rights and responsibilities to big government which does things individuals cannot do. Public health is perhaps our biggest need.
In the most basic definition of health care public health, primary care, secondary care, and tertiary care are viewed as parts of an overall health care system.
Public health deals with the spread of disease.
In terms of daily life, it provides for healthier living. through prevention and health education. It potentially links scientific research, clinical practice, population research, and environmental health, including climate change effects. It generates policies.
Public health organizes the delivery of health care allocations (and potentially social care) based on populations in a given geography with common needs (such as asthma, end of life, urgent care, nutrition and clean water sources). This includes people currently being treated, and those that are not being treated but should be (i.e.. where there is health inequity).
Within in its scope public health addresses the increasing movement of people, a changing environment, and causes of disease spreads.
Generally, public health relates to hospitals, primary care, and community care.
There are institutional meanings of public health however here "public" health meanings are viewed in terms of more universal and equitable health care delivery.
the parts do not add up to a whole.
Health care and public health are too frequently seen as mutually exclusive when in fact they are interdependent in that a strong public health system means less need for health care and lower costs.
A denial of this interdependence has led to widely imbalanced funding that under-funds public health and primary care.
Without a coherent health care system that recognizes prevention as important to medicine, individuals are largely treated within the confines of clinical practice and they experience high drug costs.
An expanded meaning of public health is limited by the highly politicized subject of universal health care in the US as in circular references to "medicare for all." It is further limited by the varying attitudes and practices which contributes to fragmentation across US states.
The pandemic and relatedly the threat of climate changes have heightened awareness of gaps in the US health care delivery system. This is an opportunistic time for a new dialogue toward a rubric to co-join institutional public health meanings and health care toward a more equitable universal health care system as a human right.
The United States is a market-driven system. It does not recognize public health care as a human right nor does it participate in a human rights treaty that specifies a right to health.
Human rights to health care are implied indirectly in the US constitution's Tenth Amendment which gives states all powers not specifically given to the federal government including the power to make laws relating to the public health. The Fourteenth Amendment places a limit on that power to protect people's civil liberties. e.g.. the equal protection clause. However, since the human right to health care is not codified rights are open to political interpretations in an adverse political climate.
The two parties in the US are polarized over these amendments as to the responsibility of the US government to ensure everyone has health coverage. Proponents determined to protect the US market-driven health care system are likely to reference universal health care as the threat of big government supporting a welfare state versus American values, erg. the work ethic.
The patchwork of state-level orders versus coordinated federal actions creates an even more fragmented health care system.
The US has greater expenditures overall than other countries. However, it is only when private spending is added with too few governmental controls that United States spending exceeds other nations.
In FY 2021, private insurance in the US accounted for more than one third of all health expenditures while public health insurance only covered 34 percent of the population; which is much less than the universal coverage in countries such as Canada and the United Kingdom as examples, at higher costs.
There are gaps between investments in public health, primary care, and health care expenditures. In 2017 US health care spending increased 3.9% to $3.6 trillion. The largest expenditures by far were hospital care, physician and clinical services and prescription drugs which experienced high rates of growth. On average, the United States spends an average range of 5%-7% on primary care across states as a percentage of total health care spending.
Medicare funding, primarily for prescription drugs, hospital care and physician services, accounted for 20 percent of total national health spending and 15 percent of the total US budget. In 2019 per-person health care expenditures was $11,582 in the US. European OCED countries ranged from $1,337 dollars to $7732. US federal government spending for health care increased 36.0% in 2020, partially due to the pandemic, compared to a 5.9% growth in 2019. Health care spending was $12, 530 in 2020 per person in the US compared to $3,538.79 in France.
By 2028 it is expected that U.S. healthcare spending will reach $6.2 trillion and account for almost 20% of the gross national product GDP. Although the US spends more money on healthcare per head than other countries, compared to other high-income countries US life expectancy is lower and mortality is higher.
The lack of investment in public health in terms of prevention and detection is one reason why. Public health spending as a proportion of total health spending has been decreasing since 2000 and falling in inflation-adjusted terms since the Great Recession. The fact that public health department budgets are historically underfunded means unstable programs or no funds to enact meaningful programs.
If there is no significant change to what is currently a siloed and fragmented health care system, U.S. healthcare costs will continue to grow with less positive outcomes.
Authors of a December 2020 European Observatory report observed that while it is difficult to determine the extent to which deficiencies in the US health care system are health-system related, there is little doubt that some of the problems with the US performance with respect to health outcomes are a result of poor access to care and high costs to consumers. This includes out-of-pocket payments per capita, namely direct payment by consumers for health services, surprise billings, as well as the financial burdens of coinsurance, co-payments, and deductible amounts, which have increased substantially in real terms in recent years.
Hospitals and their mergers are too often run as profit centers with no set prices and arbirtrary charges.
In terms of drug costs Americans pay almost four times as much for pharmaceutical drugs as citizens of other countries.
Practices are commonly defined by defensive medicine, which is medicine practiced in such a way so as to reduce the risk of malpractice litigation. There is frequently excessive diagnostic testing.
Billing fraud has increased (reaching $360 billion in 2021 just in the healthcare industry).
US administration costs for delivering health care represent one third of all health care spending.
Costs to the consumer can also be associated with the US political divide and the power of lobbyists in an overpriced, perpetual market-driven health care system.
Without a common oversight for health care and public health the cumulation of health care costs, including health issues that were preventable with increased funding to public health, results in inequities, poorer health, as well as bankruptcies for many people.
The COVID 19 experience revealed some of the costs of poorly funded or non-existent programs and institutions in a siloed health care system that weights clinical care over prevention, including those that were greatly needed during the pandemic.
For example, the Hospital Preparedness Program, which falls under the US Department of Health and Human Services, helps regional healthcare systems prepare for emergencies. The program's FY 2019 and FY 2020 Funding for emergency preparedness was halved over a decade. The program's budget was $515 million in FY 2004 compared to $275 million in FY 2020.
During the pandemic the Centers for Disease Control, (CDC) has been accused, somewhat unfairly, for its perceived rushed science, its uneven and confusing responses as far as guidelines, and what appears to be increasing politicization.
In its defense, CDC's funding history reveals a persisting gap between actual need and funding levels. A Trust for America's health report for the fiscal year 2020 showed that the US Centers for Disease Control and Prevention's (CDC) budget stayed just about its level in FY 2008 when adjusting for inflation.
Hospital closures have increased. Over 138 hospitals have closed nationwide since 2010, primarily in rural areas. According to Sisk (2021) smaller hospitals operate on tight margins and money isn't there to keep them open. Not only are there maintenance costs and outdated equipment, the demand for more modernized health care and the transition to electronic records create additional costs. COVID 19 contributed to a further drop in revenues.
Rural hospitals face some special challenges because of a high population of older people with co-morbid conditions. The practitioners themselves tend to older and aging out. Many seniors are low income and are part of a higher percentage of people who are under or uninsured.
Many rural hospital still in existence struggle to survive with the same challenges.
The pandemic focus in general has meant further neglect of serious problems and inequities, including needed end of life care, chronic diseases, and surgeries.
Some populations fare worse than others.
Care facilities are significantly under-served in the health care system. They accounted for 30%-50% of the total COVID-19 deaths in geographical areas, including high rates among staff members who make a large difference to residents' quality of life.
The increased experience of aging residents in these facilities, with a greater loss of contact because of COVID restrictions, is isolation, loneliness, and fear.
Medicare beneficiaries are commonly trapped in a spend-down, fee for service, coporatized world. Over 40% of elderly beneficiaries are under corporate plans. Home care is expensive though it is preferred by many beneficiaries. As a number of other countries have realized, home care or other alternatives to nursing homes can be a cheaper and more humane option.
There is a significant gender gap in the current health care system that also affects generations. For instance, maternal mortality at the beginning of life in the US is higher than most nations. The CDC has identified 21 indicators (16 diagnoses and five procedures) drawn from hospital records at the time of childbirth, that make up the most widely used measure of severe maternal morbidity. Approximately 140 of 10,000 women (1.4%) giving birth in 2016–17 had at least one of those conditions or procedures. If that rate were applied to the 3.6 million U.S. births in 2020, the result would be approximately 50,500 women experiencing severe maternal morbidity every year.
The measure of US public health is found with its failure to adequately deal with rates of obesity as a preventable public health problem. While the average bmi is 19.81 in most countries the US bmi is around 26.6 %. Obesity is life threatening and a factor in a number of diseases. However, while obesity is a large health issue in the US, and an increasing problem globally, funding for prevention in the US is minimal.
Finally, there are those deep political issues that distract from and stall any effort to build a more equitable health care system, particularly those related to reproductive health such as current threat to Roe v Wade.
Does public health play a role in the abortion issues before the US Supreme Court. The Turnaway Study was a longitudinal study and the largest of its kind examining the effects of unwanted pregnancy on women’s lives. The main finding of The Turnaway Study is that receiving an abortion does not harm the health and wellbeing of women, but in fact, being denied an abortion results in worse financial, health and family outcomes.
Finally, medicare, and to an extent medicaid as social insurance systems, is the single US foothold on universal coverage. Medicare coverage is provided through the federal government, while Medicaid is given state-by-state and has different eligibility standards throughout the country. Public insurance programs Medicare and Medicaid accounted for 22 and 16 percent, respectively, of health expenditures.
As usual Medicare is under debate. Proponents want to see Medicare for all expanded. Opponents, however, have fears of big government, including states rights.
Proponents see that Medicare negotiations following global drug prices is critical to lowering health care costs. Surveys indicate that the general public tends to agree that drug costs need to be negotiated. However, Big Pharm is a powerful lobbying force with too few controls.
Medicare pricing overall is costly, confusing, and unfair enough to the extent that many seniors in particular avoid receiving treatment and do not go to physicians.
Fee-for-service schedules are too confusing and unpredictable. There is also significant variance among localities and states. Furthermore, it is argued that fee-for-service creates a "perverse incentive" to provide yet more procedures, when less procedures are needed.
The fee-for-service practice brings up the question of a serious imbalance in the health care system when it is coupled with the fact that the U.S. also spends less than other countries on social support systems and long-term care.
Is there any chance that the legislative process will lead to lower drug prices and more broadly a move toward universal health care through equitable funding as a moral and economic commitment - whether is called medicare for all or by some other name? It is hard to say. Hopefully, the idea of a more equitable funding and co-joining of public health, primary care and a health care system driven by the market will happen. Too many lives are at stake.
Part two will look at global movements and governmental and non governmental actions abroad and in the US toward better health care delivery.
It will survey what other countries are doing to enact a more universal health.
Each country has had to struggle with the effects of COVID-19 as well as disasters attributed to climate change, along with disruptions such as wars and political leadership.
No system is perfect and some countries have egregious human rights violations. Yet no nation, including the US, is an island.
A review of the literature reveals a heartbeat shared by many countries as they commit to processes that codify a human right to health care; as they struggle toward an end goal - universal health care.
There are significant challenges facing humanity including the effects of climate change. Finding and holding on to that heartbeat is critical .
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