© 2015 Gina Crosley-Corcoran, MPH, CD(DONA)
Across the world, the United States is still the only developed nation without universal access to healthcare (Fisher, 2012). The introduction of the Patient Protection and Affordable Care Act has been an attempt to expand healthcare coverage to every American. However, major gaps in coverage still persist that may never be filled under the current structure. The Healthy People 2020 objectives call for an increase in the proportion of persons with health insurance coverage from the baseline rate of 83.2% coverage in 2008 to 100% coverage in the year 2020 (United States Department of Health and Human Services, 2015a). Yet the same objectives call only for a 10% increase in the proportion of persons with a primary care provider, from 76.3% to 83.9% (United States Department of Health and Human Services, 2015c). Some say the fundamental flaw with the ACA is the lack of available primary health care providers or health centers to care for the newly insured (Ollove, 2014). What role can public health play in continuing to improve population health despite a lack in universal healthcare?
Health Policy & Law
Contrary to traditional thoughts about the delivery of healthcare, “Health is made outside the health care sector” (De Leeuw & Clavier, 2011) Public health leaders have the potential to influence health policy and law that can increase access to care for millions more Americans, particularly those that are underserved. For example, one-fifth of Americans live in an area where there are two few primary healthcare providers to meet demand (Ollove, 2014). But health policies, not just healthcare providers, can help to play a role in improving population health. Healthy public health policy can influence laws and statutes that improve environmental health, workplace health, and the planning of public spaces, all which could improve quality of life and thus healthcare.
The Health Impact Pyramid
The Health Impact Pyramid illustrates the ways in which public health policy and actions can improve population health (Frieden, 2010). From socioeconomic factors, environmental and cultural norms, clinical interventions, and individual education, these determinants can be impacted by public health programs and policies rather than clinicians alone. These programs may help individuals maintain health or gain access to treatment and care when they may otherwise not have access.
Coverage Doesn’t Cut It
With a shortage of care providers, public health leaders may need to be more creative in expanding and improving access to direct care services. For example, improving electronic medical records systems may streamline and expedite care, allowing providers to see more patients and provide a higher quality of care in shorter visits. Additionally, other licensed “mid-level” providers such as nurses can provide treatment and care to expand access (Block et al., 2014).
The ACA’s Progress
While the ACA appears to have increased access to millions of Americans, it may have inadvertently created more disparities in across states that have chosen not to expand Medicaid access (Blumenthal & Collins, 2014). In these states, public health programs may be even more necessary to provide access to those who have fallen through the cracks. According to Blumenthal, et. al., 2014, “innovative approaches to health care delivery” will be “next great challenge” that public health leaders must address in order to keep healthcare costs low and quality high.
While cultural competency in healthcare has helped to enable care providers to communicate with patients, understanding structural barriers to healthcare compliance may be even more important (Metzl & Hansen, 2014). As clinicians advise more exercise, some people remain sedentary due to lack of access to outdoor spaces. As medical doctors prescribe medications that must be taken with food, the same individuals may experience food shortages. These are areas in which public health program planning may be able to increase health and wellness outside of the medical model of healthcare delivery. Fundamental structural changes must be made in order to promote health-seeking behaviors for marginalized peoples.
While the ACA may have expanded insurance coverage to millions of Americans, it did not necessarily decrease the need for public health policies and programs. In fact, it may have only increased the need for more creative public health planning in order to address the persistent gaps in the system. Critics of the ACA assert that it cannot increase access, improve quality, and decrease costs all at the same time (Penson, 2015). In its current form, that may be true. However, creative strategies to deliver healthcare, remove structural barriers to health, and improve social determinants of health may improve population health in the United States.
- Block, L., Cook, B. G., Hanyok, L. A., de la Torre, D., Rogers, M. M., Noronha, G., & Sylvia, M. (2014). Coverage isn’t enough: building primary care capacity in the setting of health reform. J Health Care Poor Underserved, 25(1), 25-28. doi: 10.1353/hpu.2014.0046
- Blumenthal, D., & Collins, S. R. (2014). Health care coverage under the Affordable Care Act–a progress report. N Engl J Med, 371(3), 275-281. doi: 10.1056/NEJMhpr1405667
- De Leeuw, E., & Clavier, C. (2011). Healthy public in all policies. Health promotion international, 26(suppl 2), ii237-ii244.
- Fisher, M. (2012). Here’s a Map of the Countries That Provide Universal Health Care (America’s Still Not on It). The Atlantic. Retrieved May 3, 2015, from http://www.theatlantic.com/international/archive/2012/06/heres-a-map-of-the-countries-that-provide-universal-health-care-americas-still-not-on-it/259153/
- Frieden, T. R. (2010). A framework for public health action: the health impact pyramid. Am J Public Health, 100(4), 590-595. doi: 10.2105/ajph.2009.185652
- Metzl, J. M., & Hansen, H. (2014). Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med, 103, 126-133. doi: 10.1016/j.socscimed.2013.06.032
- Ollove, M. (2014). Are There Enough Doctors For The Newly Insured? Kaiser Health News. Retrieved May 3, 2015, from http://kaiserhealthnews.org/news/doctor-shortage-primary-care-specialist/
- Penson, D. F. (2015). Re: Health care coverage under the Affordable Care Act–a progress report. J Urol, 193(3), 952. doi: 10.1016/j.juro.2014.11.052
- United States Department of Health and Human Services. (2015a). Increase the proportion of persons with health insurance. Healthy People 2020. Retrieved May 3, 2015, from http://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services/objectives#3966
- United States Department of Health and Human Services. (2015c). Increase the proportions of persons with a usual primary care provider. Healthy People 2020. Retrieved May 3, 2015, from http://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services/objectives#3966