The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 91, Issue 2

The Orthopaedic Forum | February 01, 2009

The Need for Increased Access to the U.S. Health-Care System

Jesse E. Bible, BS¹; Richard S. Lee, MD¹; Gary E. Friedlaender, MD¹

¹ Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071. E-mail address for J.E. Bible: jesse.bible@yale.edu

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2009 Feb 01;91(2):476-484. doi: 10.2106/JBJS.H.00735

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Health-care costs in the United States are rising at an alarming rate. Despite increasing national spending, health-care access remains an important issue to many Americans and is a topic of intense political debate. Over the last forty years, the health-care system in the U.S. experienced a steady increase in both the absolute and relative amounts of spending. In 2005, the U.S. health-care budget increased 6.9%, a figure close to two times the rate of general inflation¹. Total expenditures amounted to $1.99 trillion or $6700 per capita and accounted for 16% of the gross domestic product (Fig. 1)^1,2. Health-care spending surpasses the national defense budget by more than threefold^1,2. While the U.S. spends more on health care than any other country, it remains the only industrialized country that does not offer all citizens guaranteed health-care coverage. For comparison with other nations, the U.S. represents only one-quarter of the population of the Organization for Economic Cooperation and Development (OECD, a group of thirty developed countries), yet accounts for more than half of the total health-care expenses of this multinational group³. In 2003, the OECD countries' combined average for health-care spending as a percentage of gross domestic product was 8.6% and the group's average health-care spending per capita was $2307³. That same year, the U.S. spent 15% of its gross domestic product and $5635 per capita on health care³. With so much money spent on health care, some have questioned why the U.S. life expectancy stands at 77.2 years and the infant mortality rate is seven deaths per 1000 live births while the OECD averages are 77.8 years and 6.1 deaths, respectively³. Others have questioned why so many Americans are living without health coverage or have limited access to quality health care and the effect this lack of coverage might have on heath-related statistics. Most importantly, what changes in the U.S. health-care system should be considered for moving forward?

Figures in this Article

Introduction

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Fig. 1: National health expenditures as a percent of gross domestic product (GDP) from 1970 to 2005. (Based on data from Catlin et al.¹.)

It is both beyond the scope of this discussion and presumptuous to propose specific answers to these critical questions. Our intent is to provide sufficient information and context to allow individuals to participate productively in the broader, ongoing dialogue concerning potential solutions to the shortcomings of the current U.S. health-care system.

Facts About the Uninsured

Along with rising health-care costs, insurance premiums have increased. As a result, more Americans have difficulty obtaining health insurance. When examining the group of uninsured Americans, almost 70% are from families with at least one full-time worker⁴. Among the uninsured individuals who are eighteen to sixty-four years old, 58.2% work full time but lack insurance from their employers⁵. Two-thirds of the families are low-income households earning less than twice the federal poverty level and therefore cannot afford the expensive cost of a health insurance plan⁴.

With some governmental assistance by way of the State Children's Health Insurance Program (SCHIP) and Medicare, children and adults who are more than sixty-four years old are less likely to be uninsured. However, children under eighteen years old still make up 18.4% of the uninsured, and the number of uninsured children has continued to rise each year from 8.0 million in 2005 to 8.7 million in 2006⁵. The majority of the uninsured fall between the ages of eighteen and sixty-four years, with young adults (from nineteen to twenty-nine years old) accounting for 30% of this group^5,6. On their nineteenth birthday or on graduation from high school or college, young adults often lose coverage under their parents' health insurance policies, Medicaid, or SCHIP⁶. Additionally, jobs available to young adults are usually low-wage or temporary positions and often do not provide health-care benefits⁶.

Overall, white Americans are less likely to be without insurance compared with minorities. The rate of uninsured individuals is 10.8% among non-Hispanic whites⁵, whereas it is 34.1% among Hispanics, 20.5% among blacks, and 15.5% among Asians⁵. Similar to young adults, Hispanics and blacks are more likely to have low incomes and to be employed in companies that do not provide health-care coverage, making it more difficult to obtain health insurance⁷. However, disparities in insurance rates between whites and minorities persist across income levels, particularly for Hispanics⁷. A common misconception is that the majority of the uninsured are noncitizens. While close to half of noncitizens are uninsured, 78.2% of the uninsured individuals in the U.S. are citizens⁵.

The Increasing Number of Uninsured Americans

The number of uninsured Americans continues to rise as 15.8% (forty-seven million) were without insurance in 2006 (Fig. 2)⁵. Many attribute this process to the attrition of employer-based insurance along with inadequate expansion of the governmental insurance system to cover these losses. From 2000 to 2005, the percentage of workers receiving health-care coverage fell from 69% to 60%⁸. This decline reflects a continuing trend in decreasing employer-sponsored coverage since the late 1970s, largely believed to be a result of skyrocketing premiums^9,10. Since 2000, employer health insurance premiums have increased by double-digit percentages every year. This rate is four times more than the increase in employee wages⁸.

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Fig. 2: The absolute number of uninsured individuals (in millions) and the uninsured rate (percentage) from 1987 to 2006. (Reprinted, with modification, from: DeNavas-Walt C, Proctor BD, Smith J. U.S. Census Bureau, Current Population Reports, P60-233, Income, Poverty, and Health Insurance Coverage in the United States: 2006. Washington, DC: U.S. Government Printing Office; 2007. p 26.)

To address corporate financial pressures, many employers have simply stopped offering health insurance coverage or have shifted a greater amount of the cost of insurance to their employees. From 2000 to 2004, the average amount that an employee contributed to employer-based insurance rose more than 143%¹¹. During this period, out-of-pocket costs, such as deductibles, copayments, and coinsurance for physician and hospital visits, also increased 115%¹¹. These escalating costs, along with increasing numbers of low-wage jobs that do not offer health insurance as a benefit, make health-care costs more burdensome to millions of employed Americans. Some studies have found that up to three-quarters of the increase in the number of uninsured Americans is attributable to increased premiums^12-14. Chernew et al. found that, for every 1% increase in premiums, there is a corresponding increase of 164,000 uninsured individuals¹².

Cost of Health Care

Increasing national medical expenditures have impacted numerous households across America. With health insurance premiums rising at an average of two to three times the rate of inflation, many families have felt the financial impact^1,15. The average total medical spending for a family of four increased by 8.4% from 2006 to 2007 to a total cost of $14,500¹⁶. While the majority of insured American families are covered by an employer-sponsored health insurance program, this benefit does not fully shelter family finances as there has been a shift in cost-sharing from employers to employees in recent years¹⁶. Combining payroll deductions and out-of-pocket cost-sharing payments, a family of four paid an average of $5591 in 2007 for medical expenses¹⁶.

As costs continue to rise quickly, it can be challenging to obtain health insurance. Many families are left without any coverage. The lack of health insurance exposes a family to potential price markups for any given type of medical care. When uninsured families pay out of pocket for health care, the price can be substantially higher than what an insurance company is able to negotiate with providers, institutions, and pharmaceutical companies. Hospitals have attempted to justify this practice in several ways, stating that (1) it is the patient's responsibility to negotiate a discount from the hospital in advance, (2) many uninsured patients do not actually pay their bills, (3) higher charges are a good negotiating strategy with managed care plans, and (4) other hospitals in the same geographic area are charging similar rates¹⁷. Similarly, many hospitals justify "cost shifting" because they are being squeezed by Medicare, Medicaid, managed care plans, and other insurers to negotiate prices below their actual costs¹⁷. Possible solutions that have been proposed to help to alleviate these unfair practices include having everyone pay a single rate, having government set the rates, setting maximum rates for all payers, and providing price transparency¹⁷. Each of these would involve a voluntary effort by hospitals and legislation.

Barriers to Health-Care Access

Health-care access is often equated with having health insurance. However, health-care access is truly the ability to obtain preventive, routine, and acute health care in a timely fashion. The increasing cost of services has become the largest barrier to obtaining proper access by individuals and families. This financial barrier creates population-based differences in health-care access (by sex, race and ethnicity, education, and geography) that are observed across the nation.

Although the 1990s were considered a decade of economic prosperity, the number of uninsured Americans grew over 16% from 1990 to 1998⁵. In 2006, approximately one in six Americans (15.8%) was without insurance (Fig. 2)⁵. This percentage was even larger for individuals younger than sixty-five years as one in five Americans in this age category had no health insurance⁵. Forty-seven million Americans were uninsured in 2006; millions more were underinsured, i.e., they had insurance yet lacked adequate access to health care⁵. These Americans generally have some form of governmental or health maintenance organization insurance that may limit and/or hinder their access to certain forms of health care.

Several studies have illustrated the limitations in accessing orthopaedic care for children with Medicaid^18-20. A small study in California found that only one in fifty community-based offices surveyed by the authors offered an appointment to a child with Medicaid¹⁹. A larger, blinded telephone survey conducted nationwide in 2003 involved 150 orthopaedic offices. The investigators requested an appointment for a fictitious child with an arm fracture. In that study, 55% offered an appointment to the child with Medicaid compared with 100% who offered an appointment when the child had private insurance¹⁸. A more recent study has found similar numbers, with 38.5% of offices limiting or not offering appointments to children with Medicaid²⁰. These studies also found that Medicaid physician reimbursement was highly correlated with patient access to medical care, and the authors argued that the current disparity in access has reached its present magnitude because state governments rely on the willingness of physicians to see patients at a net financial loss²⁰.

Even when a child is able to obtain an appointment, the child might not always receive the local standard of care in a timely fashion. A recent study looked at the delays that children with government insurance face in obtaining orthotic treatment²¹. The study found that the children with insurance from a preferred provider organization received authorization faster for both an ankle-foot orthosis and a thoracolumbosacral orthosis than did those with government insurance²¹. Furthermore, the lag-time between authorization and procurement of a thoracolumbosacral orthosis was thirty-six days for children with insurance from a preferred provider organization compared with 123 days for those with government insurance²¹. However, the authors of that study acknowledged that they had more frequent difficulties reaching families with government insurance on the telephone and that families who did not invest their own money in a brace (i.e., they had government insurance) did not seem as eager to pick the device up²¹. Additionally, other factors, such as transportation issues, language barriers, time off from work, and overall medical compliance, may have contributed to this disparity, suggesting that children with government insurance may benefit from a streamlining of the process to facilitate patient and family compliance²¹.

Other Nonfinancial Barriers

While we have focused largely on the increasing cost of medical care as the primary obstacle preventing individuals from obtaining adequate health-care access, it would be remiss to neglect mentioning the demographic differences in access to health care. Often created as an indirect consequence of financial pressures, barriers to health-care access exist for particular groups, including women, individuals of a particular race and ethnicity, Americans with a low level of education, and residents in rural areas.

Sex

Overall, women are more likely to have difficulty accessing health care than are men. One potential explanation is the fact that one in four women depends on someone else's (typically a spouse's) employer-based insurance²². Women are also more likely to work in a part-time job, thereby decreasing the chances that an employer will provide health insurance benefits for them.

Race and Ethnicity

The value of medical care and the attitudes toward seeking treatment vary among cultures and may play a role in creating a barrier to health-care access. Likewise, language barriers can hinder one's ability to receive proper care. Racial and ethnic minorities are more likely to report poor communication with their physicians and problems with some aspect of the patient-provider relationship²³. Other possible barriers to receiving more health-care services include religious beliefs, a lack of trust in Western medicine, and cultural factors. For example, the cultural attitude that tends to discourage black women from seeking care early for breast problems has been found to be an important reason for the higher mortality seen in this group of women²⁴.

The importance of various cultural factors that cause some Americans to avoid seeking care has started to be recognized by professional societies, such as the American Academy of Orthopaedic Surgeons (AAOS). The AAOS recently established a Diversity Advisory Board and a Culturally Competent Care program to provide clinicians with some tools to meet the demands of today's changing population²⁵. Additionally, some states have set standards requiring that the state's medical schools must provide instruction in cultural competency to their students prior to receiving a degree, as well as requiring cultural training as part of every continuing medical education course²⁶.

Although these training programs offer educational tools to enhance one's ability to communicate effectively with and to treat a diverse population of patients, this is merely a start in the process of cultural competency. Cultural competency is not just being aware of the patients' beliefs, customs, or behavior patterns, but is furthermore characterized by a genuine understanding and appreciation for the individual and the culture he or she exists within. By understanding, valuing, and incorporating cultural differences in addition to examining one's own health-care values and beliefs, clinicians can deliver more effective and cost-efficient care. Similarly, as clinicians demonstrate sensitivity, access barriers to health care are lowered. Patients and their families may no longer see health care as a source of stress and frustration in which they are at the mercy of values and beliefs that are not consistent with their own, and therefore they will continue to seek services in our health-care system.

The chairman of New Mexico's Cultural Competence Task Force stated that "the critical thing here is developing sensitivity and the understanding that not every culture responds to medical providers in the same way, sees medicine in the same way."²⁶ For example, Navajo patients view Western health care as foreign and will not question a physician even if they do not understand his or her recommendation²⁶. Similarly, not looking an Asian patient in the eye might be seen as a sign of respect, while making eye contact is recommended with black patients^25,26. It is clear that knowing everything about every culture is impossible; however, having an awareness and sensitivity to the fact that different cultures have different rules of behavior, beliefs, or values will help to prevent patients from feeling alienated from the American health-care system.

Along with possible cultural barriers, insurance status has emerged in several studies as a key predictor of the quality of care received, yet when controlled for insurance status, race and ethnicity remain important predictors of the quality of care. This disparity has been illustrated in studies of care among Medicare patients, which have found lower rates of use of effective, more technologically advanced diagnostic and therapeutic procedures among minorities and higher rates of less desirable procedures, such as amputation and bilateral orchiectomy^27,28. A partial explanation for this difference is that minorities tend to receive more patient care at nonteaching hospitals, public hospitals, and clinics than at teaching hospitals or in private settings²⁹. In addition, minorities are more likely to access care in the emergency department and less likely to benefit from the continuity of care intrinsic to using a regular source of care³⁰. Similarly, minorities tend to have less access to specialty care compared with whites and are less likely to be treated in settings that offer higher-technology procedures²⁹. Overall, white patients receive more renal transplants, cardiac surgical procedures, and total joint replacements^31-37. Escalante et al. found that Hispanic patients with Medicare receive total hip replacements at lower rates than do non-Hispanic persons with Medicare, independent of their level of income³³. Given that Medicare covers a majority of total hip replacement costs, this suggests that such a difference is not solely due to the lack of health insurance or income status and that other possible factors, such as language barriers or ethnic variation in the preferences regarding medical procedures, again need to be considered.

Education

According to the national survey by the Centers for Disease Control and Prevention in 2003, Americans with the least education were three times more likely not to receive needed medical care, due in part to cost, compared with those with the most education³⁸. Although other socioeconomic factors (such as income status, job, and health-care coverage) also likely contributed to less care, those with lower levels of education were also nearly twice as likely to delay care because of cost³⁸. A recent study investigating the time of follow-up after total hip replacement found that patients with no college education were less likely to have radiographic follow-up than were those with more education³⁹.

Geography

Several factors may lead to a variation in geographic availability and utilization of health-care providers and facilities. Rural Americans visit their health-care provider less often and are less likely to receive the recommended preventive services^40,41. One explanation for this disparity is that residents from rural areas have longer travel times to reach health-care services, leading to less timely access compared with those in urban areas^42,43. A larger proportion of individuals fall under the federal poverty index in rural areas compared with those in urban areas, such that a financial barrier disproportionately affects the rural population^42,43. Lastly, many rural Americans receive suboptimal care as rural physicians more commonly provide care outside their specialty than do physicians at urban centers⁴². A recent study has found that both poor and nonurban patients were more likely to use low-volume hospitals for total knee replacements⁴⁴. This suggests the possibility of worse outcomes after surgery for this group, as a higher volume of total knee replacements performed by the hospital and surgeon is associated with less perioperative mortality and complications along with better postoperative functional status^45-48.

Current State of Health

For many of the uninsured Americans, financial barriers again are not the predominant barrier to their ability to obtain health-care coverage, as their family and/or they can easily be denied coverage for being "high risk." In many states, the individual health insurance market is "medically underwritten," which means that applicants can be denied coverage, their premiums can be surcharged, or their covered benefits can be limited⁴⁹. One insurance survey found that close to 25% of the applicants for medically underwritten individual coverage are turned down, charged more than other applicants, or offered policies with riders that limit coverage⁵⁰.

Thirty states have established high-risk pools intended to offer coverage to persons who are denied coverage in the individual health insurance market⁵¹. In practice, however, high-risk pools have typically mirrored this market's problems of access, affordability, and benefit adequacy, and they offer more costly and less complete coverage than many policy makers anticipated⁵¹. All states set high-risk-pool premiums at above-market rates, usually 125% to 200% of prevailing individual market premiums⁴⁹. Twenty-seven of the thirty states temporarily exclude coverage of preexisting conditions for at least some enrollees⁴⁹. In addition, many impose high-cost sharing for covered services, with annual deductibles of greater than $1000⁴⁹. A study of patients with diabetes who required individual coverage and lived in high-risk-pool states found that only seven of 344 patients had successfully enrolled in high-risk pools⁵². High premiums and preexisting condition exclusions were the leading factors discouraging the remaining patients from obtaining coverage⁵².

Problems with Inadequate Health-Care Access

The problem with inadequate health-care access reaches far beyond the health needs of the individual. The effects of poor health-care access reach across entire communities, states, and the country.

A discussion regarding this domino effect begins with some statistics relating to uninsured individuals. When questioned for a survey, one in five uninsured Americans reported fair or poor health, compared with one in nine individuals with insurance^53,54. The uninsured individuals are more likely to die when hospitalized⁵⁵. Even after accounting for social, demographic, and health status factors and behaviors, uninsured individuals are at a 25% greater risk of premature death^56,57. In 2002, the Institute of Medicine attributed 18,314 premature deaths in the U.S. among individuals in the age range from twenty-five to sixty-four years to poor health-care access⁵⁸.

Numerous theories have been proposed to explain the relative poor health of uninsured Americans. The reasons include difficulty in having prescriptions filled, difficulty in accessing health-care services, lack of a regular primary medical doctor, poor preventive health care, and inadequate treatment for chronic diseases. Over one-third of uninsured individuals (compared with 13% of insured individuals) are unable to have a prescription filled because of the cost. When uninsured Americans are able to have a prescription filled, on the average, they pay up to 88% of the full price⁵⁹. In 2003, 41.3% of uninsured adults were unable to see a doctor for a needed visit because of the cost, compared with 8.6% of insured individuals^53,54. Overall, Americans without any health-care coverage are three to four times more likely to report difficulty acquiring needed care⁶⁰. Thirty-five percent of those without coverage failed to receive a recommended diagnostic test or treatment for an illness⁶⁰. Fifty-six percent of the uninsured lack a primary care provider, while only 16% of insured individuals are without a regular primary care physician^53,54.

Lack of continuity with a regular provider plays a role in the poor preventive health screening and control of chronic diseases seen in individuals living without adequate insurance coverage. This deficiency also creates a lack of knowledge about disease prevention for many patients, indirectly creating additional barriers to preventive health care⁶¹. Several studies have found a much lower probability of uninsured individuals receiving routine health screening tests, such as measurement of blood pressure and cholesterol level, Pap smear, mammogram, sigmoidoscopy, and prostate examination^62-64. As a result, uninsured adults are more likely than insured adults to have a late-stage diagnosis of cancer, with a 1.7 times greater likelihood of having a late-stage diagnosis of colorectal cancer; a 2.6 times greater likelihood, of melanoma; a 1.4 times greater likelihood, of breast cancer; and a 1.5 times greater likelihood, of prostate cancer⁶⁵. In terms of chronic disease management, patients with diabetes without insurance have an increased risk for hospitalization and disability because of less frequent glucose monitoring and fewer foot and eye examinations^66,67. Uninsured adults with cardiovascular disease receive blood pressure monitoring less frequently and are less likely to receive recommended antihypertensive medications compared with those with insurance^68,69. Uninsured adults are less likely to receive recommended treatment from mental health services⁷⁰.

Without access to a regular primary doctor, 20% of uninsured individuals consider the hospital emergency department their usual source of care⁶⁰. Aside from poor continuity of care, the overutilization of the emergency department for nonurgent care leads to increased medical costs for the health-care system. The charges for visits to the emergency department are, on the average, two to three times more than the charges for the same medical visit in a primary care setting⁷⁰. The importance of this misuse remains somewhat unclear, as studies have found that "misusers" represent only a small portion of the emergency department caseload⁷¹. Nevertheless, the marginal cost of each nontrauma emergency department visit is estimated to be $295^72,73.

The consequences of inadequate health-care access for the individual can affect entire communities. As individual hospital departments treat more uninsured patients, hospitals will eliminate certain services because of cost control measures. Additionally, as individual providers care for increasing numbers of indigent patients in a given area, the practitioner may experience financial pressures to relocate to an area with a better payer mix⁷⁴. The net effect is an overall decreased capacity for health-care delivery for a given community. Furthermore, medical spending for the uninsured individuals competes for public health funds. These funds pay for public health programs, community disease surveillance, communicable disease control, and immunizations⁷⁴.

Strategies to Increase Health-Care Access

In a survey by USA Today and ABC News in 2006, 80% of Americans reported dissatisfaction with the high cost of U.S. health care⁷⁵. Similarly, 43% of surveyed Americans felt that high cost was one of the top two priorities for health-care reform⁷⁶. Although a large majority of Americans think that increasing health-care access is a top national priority, public opinion is divided with regard to the most appropriate solution. A survey conducted by the Kaiser Family Foundation found that Americans could not agree on which single strategy (discussed below) would be best to improve health-care coverage and access⁷⁷.

When attempting to resolve the deficiencies of our health-care system, several issues should be addressed. Reducing the high cost of health-care delivery is paramount. Increasing coverage to more Americans is another top priority. Any proposal must be acceptable to public opinion as well as politically feasible. When considering all of the aforementioned concerns, it is unlikely that a quick and simple plan could solve all of the issues. Numerous strategies have been proposed. The strategies summarized in the present report are not exhaustive, and they represent only several of the more frequently discussed proposals. Similarly, the advantages and disadvantages summarized in each scenario are not comprehensive but, rather, illustrative.

A Single-Payer System (National Health Plan)

The single-payer system, usually assumed to be the federal government, has been widely discussed, debated, proposed (state of Oregon), and implemented in neighboring Canada. Other than achieving universal coverage, arguments favoring such a system include the theoretical decrease in administrative costs of private insurance (estimated at $200 to $300 billion a year), possible elimination of the for-profit model of health insurance, and decreasing health-care costs by providing the government with strong bargaining power against pharmaceutical companies and health-care facilities⁷⁸. The regulation of drug prices by the Canadian government remains an excellent example. Such a system would be fundamentally accountable to the public in that decisions about the allocation of health-care resources would remain in the public sector instead of with private companies⁷⁹. Physicians might have more autonomy, and patients may have a broader choice of providers with a national health plan⁷⁹.

Changing to this system would require a major overhaul of the current system and is likely to encounter resistance from many interest groups, including private insurance groups, the pharmaceutical industry, and device manufacturers. A single-payer system would be very susceptible to political consideration and budgetary control. Eliminating many financial barriers to health care, which many Americans want, may allow wider access to health care but can potentially lead to overconsumption of resources or limitations on their availability. Studies have found that 24% of Canadians waited four hours or more in the emergency department compared with 12% of Americans, and 57% of Canadians waited four weeks or more to see a specialist compared with 23% of Americans⁸⁰. In the province of Saskatchewan, a twenty-two-month waiting time has been reported, with close to 4500 people waiting to have a magnetic resonance imaging scan⁸¹.

Federal-State Expansion

The idea behind a federalist approach is that the federal government would provide funding for state-run universal health care. There would be federally defined criteria, with each state formulating individual plans to suit the needs of the state. This would achieve universal coverage while concomitantly addressing each state's specific health-care deficiencies. Political support would be easier to obtain across all states. Finally, fifty different solutions could be simultaneously tested with more flexibility to make adjustments.

This approach does not in itself offer a solution to the fundamental problems currently plaguing our health-care system. Rather, it will shift the responsibility of finding a solution from the national to the state level. Such a system would undoubtedly set up inequalities between states. As certain states might provide more favorable coverage than others, Americans may be encouraged to move to another state, thus adding more strain to an individual state's health resource capacity⁷⁹. Likewise, differences in plans between states may force some people to stay in a particular state.

Population-Based Expansion

This plan incrementally increases coverage for specific groups by expanding existing governmental programs, such as SCHIP, to cover all children, Medicaid to cover more low-income adults, and Medicare to include a lower age limit. A few issues favor this strategy. Restructuring of the current health-care system is not required, and thus this strategy could be implemented quickly. Public and political support is more likely to be achievable compared with other proposals that require more complicated changes to the current system.

Although this strategy provides health coverage for more Americans, it would not provide universal coverage in a short time frame. As the amount of public coverage expanded, employer-based coverage would likely decrease as companies would assume that a particular individual would be covered by another plan. History has already demonstrated a failure to achieve universal coverage through population-based expansion, as this strategy has been employed through the introduction of our current government-based coverage plans (SCHIP, Medicare, and Medicaid). Perhaps most importantly, expanding the current system does little to address cost control.

Tax Credits

This strategy involves offering various tax credits with the intention of helping individuals to afford health insurance⁸². Theoretically, this system would be easy to implement as it would not require a major change in the current health-care infrastructure. It would likely be accepted by the general public as few people will argue against a tax break. Consumers will have more purchasing power and choices in a free-market environment that encourages competition among the insurance companies.

However, solely providing tax credits does not address several of the key issues mentioned above. It neither guarantees coverage for everyone nor directly attempts to control costs. This approach can be expensive when considering the costs involved with the administration of the tax credits along with the fact that individual health insurance is 30% more expensive than employer-purchased group plans⁸². As mentioned with other strategic options, this plan also provides employers with a reason to decrease health-care benefits.

Employer Mandate

This approach requires an employer to provide health insurance to its employees or be subjected to extra business taxes intended to support a public health system (a so-called play-or-pay system)⁸³. This concept has been implemented as part of recent health-care reform in Massachusetts, as businesses with more than a certain number of employees are required to pay a fee per employee per year if they do not provide insurance for their workers. Such an approach is simple in concept and does not require any major overhauls to the current health-care system. Some argue that the burden created for businesses could potentially slow the economy. Again, this system does little to address the current inherent deficiencies of the health-care system.

Individual Mandate

For individuals without employer-based or public insurance, this system requires the self-purchase of health insurance much like the requirement for liability automobile insurance. It does have positive aspects similar to the employer mandate by not requiring major changes in the current health-care system. This plan theoretically achieves universal coverage. A disadvantage with this proposal includes the disproportionate financial burden on lower income groups. This plan may be costly as individual insurance is more expensive than group plans. This kind of strategy cannot be implemented without a mechanism of enforcement, and thus the monitoring and penalizing of offenders will generate a new set of expenses⁸². Some form of subsidized health care will be required to cover those without sufficient income, similar to our current sponsored programs like Medicaid or the current Massachusetts health-care "voucher."

The aforementioned strategies to increase health-care access summarize several of the plans currently considered by policy makers. The scope of this paper does not permit discussion of all proposals, and the intention is to merely highlight key aspects of certain strategies and encourage more dialogue.

Overview

The U.S. health-care system is very expensive, and costs continue to increase much faster than the rate of inflation. Approximately one in six Americans is currently without health insurance. Limited access to health care resulting from increased costs, as well as from other nonfinancial barriers, affects every American, irrespective of insurance status. Poor health-care access not only affects the well-being of the individuals involved but also negatively impacts entire communities and impairs the economy at local and national levels. Presently, there is strong public support to address our health-care system's shortcomings. Various strategies have been proposed to address the key issues of broader coverage and the cost of health-care delivery. The most appropriate strategies remain to be determined, but it will be important for individuals with differing perspectives, knowledge, and understanding to participate in the dialogue and the actions that shape solutions.

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Jesse E. Bible, BS

Posted on March 09, 2009

Mr. Bible and Dr. Friedlaender respond to Dr. Novack

Yale University School of Medicine

We thank Dr. Novack for his interest in our review article on access to health-care in the United States, as well as his thoughtful comments. It was not our purpose to â€œpropose and critique specific solutionsâ€ to several of the health-care problems highlighted in the article, but rather â€œto merely highlight key aspects of certain strategies and encourage more dialogueâ€ (p.482). Such discussions are vital to improving orthopaedic care at the local and national level.

One of the issues raised by Dr. Novack involved the 6.5 of the 9 million uninsured children who are eligible for public health-care coverage, but not currently enrolled. The remaining 2.5 million children are not eligible, primarily because their family incomes exceed program eligibility levels. Several possible explanations have been raised to explain the discrepancy between eligibility and enrollment. First, premiums and cost sharing required for Medicaid/SCHIP participation in many states can cause coverage to become less affordable for low-income families and, thereby, reduce participation in public services. Second, is a lack of awareness in how to apply for Medicaid/SCHIP programs. States have recently developed strategies to simplify the enrollment and renewal process to obtain coverage, as well as reduced verification requirements. A deviation from this process of streamlining enrollment was the Deficit Reduction Act of 2005, which requires individuals to provide proof of U.S. citizenship for applying or renewing Medicaid coverage. However, even with this act, an overall increase in enrollment was seen as states invested more money into community-based outreach activities. Such outreach programs will need to have additional funding in order to further increase enrollment, and such resources are unlikely with the current economic crisis.

Another issue mentioned by Dr. Novack is that, â€œmany adults who are currently healthyâ€¦choose to forgo paying health insurance premiums when very affordable individual polices existâ€. We would agree that many healthy Americans opt out of health insurance thinking or hoping that sickness or injury will not come their way. However, we would disagree with the position that very affordable policies exist for all. National surveys have continuously found the high cost of health insurance coverage as the primary reason people are uninsured. According to a 2008 survey, premiums for employer-sponsored health insurance have been rising four times faster on average than workersâ€™ earnings since 1999 (1). Indeed, the annual premiums for individual family coverage significantly eclipsed the gross earnings for a full-time, minimum-wage worker (1).

Thirdly, Dr. Novack correctly stated that â€œillegal immigrants account for many more of the uninsuredâ€. It is likely that the current U.S. Census Bureau reports underestimate the number of noncitizens; however, as mentioned in our article, according to the 2006 Census Report 78.2% of the uninsured individuals in the U.S. are citizens (2). While U.S. citizens encompass more of the uninsured population, noncitizens have a much higher uninsured rate at 45.0% (2).

Lastly, like Dr. Novack, we feel issues of health-care â€œmust be part of the AAOS agendaâ€, and we find abundant evidence of this commitment. We hope that comments from individual orthopaedic surgeons, such as Novack and ourselves, will serve to strengthen our collective message and resolve these issues on behalf of our patients.

References

1. The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2008 Annual Survey. September 2008.

2. DeNavas-Walt C, Proctor BD, Smith J; US Census Bureau. Income, poverty, and health insurance coverage in the United States: 2006. Current Population Reports, P60-233. Washington, DC: U.S. Government Printing Office; 2007.

Eric N. Novack

Posted on February 15, 2009

We Need AAOS Leadership

NULL

To the Editor:

I read the article by Bible et al. (1) with the anticipation that perhaps the AAOS and its leadership would finally be taking a stand on the goals of health care and health care reform, but I write to express my disappointment in the tenor of this article. In it,the authors lay out the talking points and proposals with one apparent goal in mind: to keep the AAOS and its leadership 'at the table' regardless of the costs.

Never mind the abundant data showing that the vast majority of uninsured children are ALREADY eligible for health care coverage under existing government programs. Never mind that many adults who are currently healthy choose to forgo paying health insurance premiums when very affordable individual policies exist. Never mind that illegal immigrants account for many more of the uninsured. Those data were omitted from the article.

The most galling sentence to me, however, is on page 476, "It is...presumptuous to propose specific answers to these critical questions". Is not the purpose of such an article to do exactly that-- present, propose and critique specific solutions to enormously important problems facing orthopedists and their patients?

I believe we must stand for principles that put patients first and protect orthopedists' freedom to innovate that has resulted in so many life-saving and function improving advances. These principles must be part of the AAOS agenda. They include:

1. Patients have the right to be in control of their own health and health care.

2. The right of patients to keep their medical history private.

3. The right of the fellows of the AAOS to seek to improve their knowledge and their profession, thus providing the best patient care for a mutually agreed upon fee.

4. The right of patients to spend their own money for their health and health care.

5. The right of doctors and patients to choose to NOT participate in a government-mandated, bureaucrat-controlled health care system.

These simple principles, or those like it, used to be the foundation of our profession. But it seems that to our modern leadership they do not have the salving effect as seeking 'universal health care' and 'reducing health care disparities'. I fear that the Academy may become only a fabulous source of CME, rather than the deserved leader of the country's orthopedic community.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. The author, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Smith and Nephew). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

Reference

1. Jesse E. Bible, Richard S. Lee, and Gary E. Friedlaender. The Need for Increased Access to the U.S. Health-Care System J Bone Joint Surg Am 2009;91:476-484.

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Jesse E. Bible, Richard S. Lee, Gary E. Friedlaender; The Need for Increased Access to the U.S. Health-Care System. The Journal of Bone & Joint Surgery. 2009 Feb;91(2):476-484.

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