Deirdre Farrell, Zohal Ghiaszada, Erin Greco, Shevaun Harris, and Nina Hicks

Quinnipiac University HM 600

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Illustrates the growing issue facing the U.S. in terms of inadequate access to quality affordable health care for the uninsured and underinsured

Highlights the impact on the overall health care delivery system

Identifies potential health care models of success

Reviews solutions offered through the Patient Protection and Affordable Care Act

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49.9 million Americans lacked health insurance

Approximately 25 million individuals between the ages of 19 – 64 are underinsured

There is a strong correlation between access to health insurance coverage and better health outcomes

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Inadequate health care coverage disproportionately affects minorities:

20.8% of Among African Americans

30.7% of Hispanics

11.7% of Caucasians 9.8% of children Individuals with lower incomes are at a higher risk

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Erosion of Private Health Coverage

Intermittent Gaps in Coverage

Lack of Affordability of Health Insurance

Other Barriers◦ Lack of knowledge

about other available resources

◦ Inability to pay out◦ of-pocket expenses◦ Childcare◦ Difficulty taking time

off from work◦ Transportation◦ Past Experiences

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Lack of preventative health care

Delayed follow-up treatment

Increased risk for hospitalization

Higher levels of ER usage

Higher rates of medical morbidity

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Medicaid is an entitlement program for the poor and disabled◦ Categorical eligibility requirements◦ Income eligibility requirements◦ Residency requirements◦ Citizenship status requirements

State Children’s Health Insurance Program (SCHIP)◦ Covers children who are ineligible for Medicaid

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48.6 million individuals are covered by Medicaid

Over $300 billion spent on the Medicaid program

Limited coverage for non-disabled adults under the age of 65 without dependent children

States can impose more restrictive eligibility requirements and benefit coverage

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Increase in national health expenditures◦$2.5 trillion spent in 2009 (4% increase)

The uninsured pay $30 billion in out of pocket expenses

$56 billion in uncompensated care $122 billion more needed to cover

uninsured

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Solutions and Challenges

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“It is vital that health reform reduces costs to make health care affordable; protects a patient's choice of doctors, hospitals,

and insurance plans; invests in prevention and wellness; and assures quality, affordable health care for all Americans.”

(Halle, Lewis, & Seshamani, 2009)

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Managing the high prevalence of chronic diseases

Improving access to care

Preventing the lack of routine care

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STRENGTHS CHALLENGES

Decrease health care costs

Develop an advisory group

Funding for chronic disease prevention and management

Incentives for Medicaid enrollees

Prevent denial because of pre-existing conditions

Need individual incentives for people to lose weight

Need to pay doctors and hospitals differently to compensate for time and effort on prevention

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STRENGTHS CHALLENGES

Provides affordable options for purchasing health coverage

Extends dependent health insurance coverage until the age of 26

Expands Medicaid eligibility requirements

Increase funding to train more doctors

Increase access to quality care

Shortage of primary care physicians ◦ Project shortage of 63,000

doctors in 2015

◦ Need at least 15% more medical students than projected 7,000 from the increased funding

Longer wait times to see doctor

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STRENGTHS CHALLENGES

Creation of the Prevention and Public Health Fund

Investment in tobacco cessation programs

Increase funding for prevention and screening programs

Eliminates co-payments, co-insurance, or deductibles for preventative services

Longer wait times to get an appointment

Physician shortages Increase usage of the

emergency room Increase in preventable

deaths as a result of reduced physician access

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Veterans Health Administration

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Model for low-cost and high-quality healthcare since the mid-1990s

Nation’s largest integrated health care system

1,400 sites 152 medical

centers

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Provides a full array of preventative services

53,000 independent licensed health care practitioners

83 million veterans served each year Priority group enrollment Co-payment exemptions

◦ Purple Heart Recipient◦ Prisoner of War◦ Service-Connect Injury

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Dr. Kenneth Kizer, former undersecretary of the Veterans Administration (VA)

Transformed the VA health system under his leadership in the mid-1990s◦ Outpatient focused care◦ Decentralization◦ System-wide computer network ◦ Patient centered approach

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As a government entity, the VHA cannot be sued for malpractice

Focus on preventative medicine Electronic records system Lower overhead and administrative costs

Higher customer satisfaction index than private institutions

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France and Italy

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First major study of the world’s healthcare systems in 2000

Evaluated on 5 criteria:◦ Overall level of the population’s health ◦ Health inequalities within the population ◦ Overall level of the health system’s

responsiveness ◦ Distribution of responsiveness within the

population ◦ Distribution of financing the systems between

economic classes in each population

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1st Place – France

2nd Place – Italy

37th Place – United States

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Hybrid of socialized and competitive systems Universal coverage– no uninsured The sicker you are, the less you pay

◦ Full reimbursement for treatment, drugs, surgeries, and procedures for chronic illnesses.

10-11% of Gross Domestic Product 21% of income is paid to the national healthcare

system◦ Employers pay between 11-13%

Supplemental coverage

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Highest satisfaction levels in Europe Average Life expectancy – 80.5 years

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“There are no uninsured in France. That's completely unheard of. There is no case of

anybody going broke over their health costs. In fact, the system is so designed that for the 3 or 4

or 5 percent of the patients who are the very sickest, those patients are exempt from their co-

payments to begin with. There are no deductibles.”

-- Victor Rodwin

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Servizio Sanitario Nazionale (SSN) Mandatory universal healthcare coverage

◦ No uninsured◦ All essential healthcare services

Autonomous regions Low satisfaction rate

◦ Quality issues◦ Waiting lists

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Can potentially decrease quality Competition between public and private

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eReferral and eConsult

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Demand >> Supply

Onerous and unreliable referral system

Lack of equitable triage

Poor communication between specialists and primary care providers (PCP)

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Patients Experiencing Problems Obtaining Specialty Care:

◦ Uninsured – 80% - 90%◦ Medicaid and Medicare- 40% - 50%◦ Private Insurances – 5 – 10%

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Handwrite/fax the referral form Loss of referral documentations No centralized method to track

the referrals Reason for consultation (include

pertinent history, physical laboratory findings, medications)

Proven model in safety-net facilities serving the uninsured

Enhance efficiency and improve communication between specialists and PCPs

Improve triage of referrals Goals

◦ Reduce demand◦ Increase efficiency◦ Improve quality◦ Enhance timely access

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BENEFITS NEXT STEPS

Health◦ Reduces mortality and

morbidity

Economical◦ Cuts down healthcare

expenses

Social◦ Reduced inequities and

disparities

Spread to other departments◦ Radiology (MRI, CT,

U/S) Build relationship

and trust◦ Other specialists

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National healthcare reform is already showing some success with the uninsured and underinsured

Successful Models for Addressing the Issue:◦ Veterans Healthcare Administration

Key Elements in Any Approach◦ Must focus on quality◦ Patient centered◦ Builds upon partnerships

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