Repairing America’s Healthcare System: Overcoming the Impediments that Deny Americans the Right to Healthcare

By Keara Field, Gianna Grasso, Avantika Malla, Vaanya Salwan, Kimia Shahriyar, Leyla Tiryaki

Teen Think Tank Project | Change Agent Academy |Winter Session | Access to Healthcare Research Cohort | Apri 13, 2022

Introduction

The American Healthcare system, comprised of hospitals, ambulatory care centers, private practices, and homes, has slowly become polluted with a series of social, economic, and legal impediments that have prevented significant reform in our attempts to achieve health equity and guarantee access to care for all American citizens. Life with bias, lacking economic transparency, and possessing problematic legal and regulatory oversight, American healthcare has transitioned from a system centered on patient care to a system primarily concerned with profits. Unfortunately, this transition to “big business” has led to immense injustices, especially for those less fortunate, both socially and economically.

This framework will examine and discuss the various impediments preventing America from achieving a patient-first system of care that focuses on access and equity. First, we will observe multiple social constructs about race and immigration status that create barriers to health equity. Next, we will investigate the economic impediments to surprise healthcare costs and the bad debts that arise for patients. Then, we will examine the legal systems that allow the impediments above to perpetuate. By exploring these impediments, we hope to display the lack of transparency in the healthcare system and develop workable solutions that attempt to put patients before profits.

Social Impediment

The existence of socially-embedded stereotypes regarding race negatively influences people’s behavior toward each other. As early as childhood, people begin to form opinions about other demographics or ethnic groups based on societal influences. Developmental researchers have identified that rudimentary stereotypes develop by about two years (Kuhn et al., 1978), and many children develop basic stereotypes by age three (Signorella et al., 1993). This development of preconceived notions and associations eventually turns into bias, which leads to unfair treatment of individuals. This bias is found in all parts of our society, including the healthcare industry, and its effects are profound.

The Implicit Association Test and Implicit Bias

The Implicit Association Test (IAT) was created in 1998. The test calculates how quickly people associate terms with each other and works to determine unconscious race biases. The test takers associate pictures of black and white people with words like “good’ or “bad.” It has been taken over 4 million times between 2002 and 2017, and about 75% of people have been shown to possess an automatic white preference, showing that a racial bias is not only present but rampant in society. (Banaji, 2016). Whether or not this type of bias was taught through explicit indoctrination of racism or was a product of cues that are implicitly communicated through a racist system is irrelevant. There is a prevailing bias in our society.

The fact that an underlying prejudice exists in our society is troubling on a philosophical level, but the realization that it exists on a practical level is even more disturbing. Moreover, the thought that this bias would exist in healthcare is unthinkable; sadly, it is the truth. Since implicit biases develop early in life and are reinforced throughout a person’s lifetime, it stands to reason that healthcare industry members are not immune to such indoctrination. After all, before they achieve status in their chosen profession, members of the medical community are reared in the same biased systems that everyone else is brought up in.

The introduction of implicit bias in a physician’s training starts before they even crack open a medical textbook. Medical school admissions committees inadvertently perpetuate the ideas of implicit bias by allowing admission to white students at a greater rate than equally qualified black applicants (Diversity in Medicine: Facts and Figures 2019).

Medical school admission committees are meant to address and, to an extent, correct the significant disparity between racial and ethnic minorities in healthcare; however, they seem to be doing the opposite. In a study by Jasmine R. Marcelin and several editors, medical school admissions committee members displayed a significant, unconscious bias towards white students, leading to more medical doctors in the medical field, thus continuing the cycle (Marcelin et al., 2019). The new white doctors only increase the lack of diversity and further perpetuate the system.

Finding the Solution

Identifying the bias is not an issue, as it is evident to patients, especially those of color. Instead, the issue is finding ways to mitigate these racial biases successfully. One method to address the prevalence of racial bias in the medical profession is to increase diversity in medical schools nationwide. As mentioned, medical school admissions committees display an unconscious bias toward white students that impedes diversity. By creating a more diverse population in the medical community, we can confront the stereotypes and prejudices in medical training. — To help create a more diverse student population, medical schools, colleges, and residency programs should have a more diverse admissions board. By including equal representation for individuals of different ethnic backgrounds and genders, the healthcare industry can begin to foster a more diverse pool of healthcare professionals, thus addressing the implicit bias in medical training head-on. This issue will not repair itself overnight, but doing these things is certainly a start.

Economic Impediments

When discussing the impediments preventing meaningful healthcare reform, we must discuss funding and its role in the quality of care and the outcomes of treatments. Healthcare is one of the largest industries in America. In 2019, America spent $322 billion on healthcare. (Urban.com citation needed). That equates to nearly 17% of its gross domestic product and hospitals by local and state governments, slightly higher than what was spent on higher education. However, 65% of that amount goes to hospital services, and it is also vital to note that in that 65%, none includes money from Medicare and Medicaid, which is found under the public welfare section. Most of this funding comes from the state and local governments, and only a small portion is from the federal government.

These statistics show that healthcare in the U.S. has more than enough funding. So why is it so inefficient, expensive, and inaccessible?

Looking at the Statistics

Scorpion.co’s 2018 Hospital Patient survey showed that out of 1000 healthcare patients, the majority preferred to be aware of what insurances were accepted before the meeting, value education and training, have compassionate care, and have strong communication skills with doctors. They also preferred better service quality, shorter waiting times at the facility, and a reasonable distance from home and cleanliness. Many people who cannot afford to look at all these factors list it as affordability and a decent and sufficient quality of care. Healthcare is something that can be a matter of life and death, so there is a lot that should be put into the decisions made. Patients should not put up with poor care that yields terrible results simply because that is all they can afford and access. Our healthcare system is set up so that treatment outcomes are already decided just by walking in. Going back to what we discussed previously about for-profit healthcare facilities having worse treatment outcomes based on statistics, for-profit facilities are mainly set up in disadvantaged communities. At the same time, nonprofits (which are supposed to be making charitable contributions in exchange for their tax-exempt status) can be found in wealthy areas. That being said, people in these disadvantaged communities have no choice but to go to for-profit facilities that are known statistically for having a worse quality of care than nonprofit facilities. So people from low-income backgrounds and areas are already signed onto a poor quality of care just because of the funding of healthcare facilities accessible to them. Moreover, the only way to escape this is to break their banks and go to a nonprofit healthcare facility or a facility in more affluent areas or hope for upward economic mobility.

The unethical practices in the healthcare system are evident within the insurance sector, placing tremendous downward pressure on individuals and families. As a result, economics affects Americans’ utilization of health services more than proper care for well-being. “The economics of our health care system is horrifying,” according to Sara Collins, Ph.D., Vice President for Health Care Coverage and Access at The Commonwealth Fund. “We are seeing a perfect storm of negative economic trends threatening working families in the United States. While gas and food prices are increasing and home values are declining, the rise in health care costs surpasses income growth, and fewer people have adequate insurance. As a result, working people are struggling to pay their bills and acquiring medical debt’” (The Economics of Our Health Care System Are Horrifying 6). The Acts and Divisions that regulate state insurers cannot provide considerable assistance to high medical expenses. However, increasing healthcare coverage regulation would benefit individuals and economic providers.

Insurance

Insurance is a financial vehicle that helps spread risk from a single individual to keep their financial stability from crumbling in the case of an unforeseen event or experience. The states regulate health service insurance plans, meaning regulatory practices vary from state to state. Health insurance is a type of insurance that covers medical expenses that arise due to a health-related emergency. Medicare is regulated at the federal level, while Medicaid is regulated at both the federal and state levels. Rising costs could be due to hospitalization, medicine, or doctor consultation fees. According to the Center for Medicare and Medicaid Services, “U.S. health care spending grew 9.7 percent in 2020, reaching $4.1 trillion or $12,530 per person. As a share of the nation’s Gross Domestic Product, health spending accounted for 19.7 percent” (CMS Historical 2).

On the state level, New Jersey insurers are regulated by the State of New Jersey Department of Banking and Insurance under the National Association of Insurance Commissioners organization. The Division of Insurance issues licenses to insurance companies, reviews insurance products and rates, and monitors licenses to ensure the necessary availability and compliance with regulations. The Division also responds to consumer concerns and inquiries and endeavors to educate consumers regarding insurance products and issues. While government-regulated organizations serve citizens once they are in a health accident, what about transparency in healthcare coverage before incidents?

Transparency

While government-regulated organizations serve citizens once they are in a health accident, what about transparency in healthcare coverage before incidents?

The Public Health Service Act, a United States federal law enacted in 1944, addresses within Section 2715A “transparency in health coverage and imposes certain reporting and disclosure requirements for health plans seeking certification as qualified health plans” (Federal Register, 2020). The “transparency in coverage” defined in that section requires health plans and insurers to disclose financial and economic information to participants, beneficiaries, and enrollees. While revealing the necessary information, many U.S. citizens face surprise billing associated with high healthcare costs. In a well-functioning system, consumers should be able to observe price and quality differences when choosing their healthcare services. “​​In December 2020, Congress passed the “No Surprises Act,” which prohibits most surprise out-of-network billing for plan years beginning in 2022. Surprise bills occur when a patient receives care from an out-of-network provider or facility during an emergency visit or while receiving non-emergency care at an in-network hospital or facility. The law’s protections, however, do not apply to bills for ground ambulances, which Congress put off pending further study” (Peterson KFF Health System Tracker 4). When insured patients are informed that their provider has charged more than the patient expects, a downfall occurs in the family’s economic stability. Surprise billing is widespread in ambulance services and emergency department visits, furthering the insurance companies’ regulation since patients cannot choose the quality of their care even if they know the costs.

According to the Obama Administration’s release “The Economic Case for Health Care Reform,” a few critical impacts of expanding health care coverage exist. “Increased insurance coverage and improved health care are likely to increase labor supply by reducing disability and absenteeism in the workplace. This increase in labor supply would increase GDP and reduce the budget deficit” (Obama Administration 9). Increasing the labor supply would also improve the functioning of the labor market. The U.S. Centers for Medicare & Medicaid Services outlines the Patient Protection and Affordable Care Act for the labor side as it pertains to employees and employers on a federal level. The Affordable Care Act requires everyone to have health insurance or pay the penalty, especially businesses with 50 or more full-time workers, which are generally required to provide coverage.

Legal Impediments

The American Healthcare system is guided by the American Government and is mandated by its laws and activities. The healthcare system is extensive in itself, and therefore, there is a multitude of legal practices that regulate it. We will focus on two significant issues: pharmaceuticals and Medicare/Medicaid. Other major laws and regulations regarding the healthcare system must also be understood; however, these issues remain the largest.

Pharmaceutical Industry

Drug prices are inflated through corrupt patent regulation. The Hatch-Waxman Act was designed to be a comprehensive legal framework against these practices enacted by Congress in 1984. Its purpose was to lower the price of prescription drugs by allowing generic drug companies to create said generic forms of brand-name drugs. The act did this by incentivizing generic drug companies to challenge patents owned by pharmaceutical companies by allowing them to manufacture generic versions. In contrast, brand-name patents are still alive. The Hatch-Waxman Act expedited the process for generic drug-making companies to obtain FDA approval. This increased the accessibility of life-saving treatment and medications. Now, 90% of prescriptions in the United States are filled with generics instead of a mere 19% before the act. However, it does not directly combat pharmaceutical lobbying and competition as intended.

One case stands out as a glaring showcase of the impact of pharmaceutical lobbying. The Prescription Drug Affordability Act of 2015 was introduced by Senator Bernie Sanders (I-VT) and Representative Elijah Cummings (D-MD). It would have made life for pharmaceutical companies adamant since it would have forced them to submit reports on spending for research and prevent them from restricting other companies from producing generic drugs.

All in all, it would have been monumental and bettered the lives of many. However, the power of pharmaceutical companies reared its ugly head. According to CREW, “at least 14 corporations, trade organizations, and nonprofit groups lobbied on the PDAA” (CREW). The bill was never passed, and a similar one has never been introduced. These companies currently have the American population in a chokehold. They only think about their profits and use various techniques to get out of regulations. Big Pharma shamelessly runs advertisements to spook people into paying for unnecessary medicine. As human beings, it is our right to have affordable healthcare, and Americans must stand up for themselves in this fight against pharmaceutical companies.

Medication Marketing

Nearly one hundred thirty-one million people in the United States currently use prescription drugs. Those who take drugs are in the older demographic and tend to have illnesses requiring consistent medication. In exchange for treatment, people have to shackle themselves to a never-ending cycle of paying more and more for inflating drug prices. While the ordinary person struggles to make ends meet, pharmaceutical companies reap the benefits of this horrible charade.

American pharma is known to advertise medication, something that is uncommon globally. Americans are constantly shown commercials for newly discovered drugs and medicines. This pharmaceutical advertising allows patients to form a false reality and believe that medication will magically change their lives. As stated by Auburn EDU, “DTC advertising is leading to higher costs for medications– The ads can influence consumers to ask for drugs they cannot afford even though lower priced alternatives may be available.” Advertising prompts patients to pay more for medication than the cheaper option.

Furthermore, starting a drug plan can result in a lifetime of treatment. According to Elizabeth Rosenthal in her book, An American Sickness, the second rule of the dysfunctional medical market is that “A lifetime of treatment is preferable to a cure” (Rosenthal, 2017, p. 8). In addition, pharmaceutical companies spent 5.2 billion dollars on annual advertising in 2016 (Picchi). In the same year, there was an “average of 80 drug ads every hour of every day on American television” (Spiegel).

In 2016, Senator Al Franken introduced the Protecting Americans from Drug Marketing Act to combat this unfortunate phenomenon. The bill stated, “No deduction shall be allowed under this chapter for expenses relating to direct-to-consumer advertising of prescription drugs for any taxable year.” The bill would restrict companies in their advertising and marketing costs tax-deductible. Unfortunately, Congress never passed the bill. Influential lobby groups fought against legislation like Senator Franken’s bill with ferocity.

In addition to lobbying, government administrations such as the Federal Drug Administration or FDA are also to blame. The FDA protects the public by regulating drug-making and keeping pharmaceutical companies in check. In short, their purpose is to prevent companies from gaining immense power over the American people. Unfortunately, shrewd pharma companies impair this ability by corrupting funding and other strategies. Pharma companies have contributed 7.67 billion dollars to the FDA, and the FDA has practically become dependent on pharma companies. To conclude, the only way to combat pharma companies is through legal means, but government regulation has apparent flaws.

The Implementation of Medicaid in the United States

The United States Medicaid program, established in 1965, aims to provide medical insurance to low-income populations. It is one of America’s most extensive entitlement programs. However, despite its mission (to provide comprehensive health coverage to low-income people) and scope (acute-care treatment and long-term care services), we continue to see an increase in the number of non-elderly people without health insurance. If this is the case, it is reasonable to ask whether or not Medicaid successfully fulfills its intended goals.

Medicaid/Medicare A, B, C, D

Before deciphering whether or not Medicaid is or is not failing to service our non-elderly populations, we need to understand what Medicaid is. According to the DHHS, Medicaid is a government program administered at both the federal and state levels, which intends to help lessen the burden on low-income individuals in America needing access to the healthcare industry. Medicaid is split into four parts: A, B, C, and D. Part A covers inpatient/hospital coverage and skilled nursing visits. Under part A, patients may pay a monthly premium and a recurring coinsurance, an amount paid by a patient promptly and formally determined by the receiving party. Medicaid Part B covers outpatient/medical coverage. Under part B, patients must pay a monthly premium to receive the benefits of annual healthcare checkups. Regular visits to family physicians and some specialty offices are covered under part B. Medicaid Part C is a dual program that includes parts A and B. Private companies offer it and are, therefore, more selective. Medicaid Part D provides coverage for prescription drug costs through private plans. Beneficiaries who qualify for Medicaid or an MSP in a state automatically qualify for Extra Help (also known as the Low-Income Subsidy program) to help pay for monthly premiums, annual deductibles, and prescription co-payments related to Medicaid Part D.

Title XIX

Title XIX of the Social Security Act Amendments, signed by Lyndon B Johnson in 1965, initiated the Medicaid and Medicare programs and listed the guidelines for both. Medicaid continues the tradition of past welfare programs in that much of its implementation is solely based on state requirements. Under Public Law 89–97, each state’s governor determines an agency in charge of forming a sound structural plan for administering Medicaid. This plan is binding and determines the groups of individuals to be covered, health care services to be provided, payment methods, provider qualifications, and the administrative activities necessary to fruition (BIOMA 3). The plans developed by the states are referred to as SPAs (State Plan Amendments) and are sent to the CMS (Centers for Medicare and Medicaid Services) to be reviewed and further edited. Once complete, further editing must be done through a lengthy back-and-forth contact between the state agency and the CMS.

Statutory Eligibility

Under Medicaid, children, the blind, those physically disabled, specific mentally disabled patients, and others receive automatic coverage, regardless of the SPA administrative guidelines. Aside from the automatically qualifying populations mentioned above, most enrolled under Medicaid lack an alternate form of health care insurance and must apply for Medicaid. To be eligible, persons must earn an amount under the state poverty lines (stated in the SPA) or a specific rate that can vary based on family size, occupation, past medical history, and more.

The graph below displays the fiscal revenue per year for those under the poverty line. Individuals earning this amount are most likely to receive Medicaid; others may have to pay more significant portions out of pocket.

In perspective, a singular individual’s annual groceries cost roughly $2,641, and annual living expenses are roughly $38,266 per year (Statista 4). As displayed, those above the poverty line do not make enough money to live mediocre lives.

Residential Eligibility

In regards to legal restrictions, only those who are U.S. citizens or qualified aliens are eligible for Medicaid (NJDHS 2). Considering that nearly 38% of America’s population comprises immigrants on either visas or green cards, it is apparent that Medicaid does not reach the entire population (NIO). Those who have not lived in America for some time or are in the lengthy process of receiving American citizenship can not receive the benefits of Medicaid. This is concerning because American immigrants are the largest population in need of healthcare (Statistica 8). Immigrants working in physically or mentally exhausting conditions have no option but to acquire hefty debts from healthcare. These immigrants fit most of the requirements for receiving Medicaid, and most pay their fair share in taxes. A study conducted by American Voices discovered that “between 50 percent and 75 percent of unauthorized immigrants pay federal, state, and local taxes.” Those who follow tax guidelines on the meager salary should receive the proper benefits they deserve.

Federal Government Expense

Medicaid/ expenses have been steadily increasing since the two program’s inception. Medicaid’s growth rate has trampled that of the American GDP and shows an apparent increase in the rate of uninsured individuals. Since 1980, Medicaid has increased from 2.8% of the government’s expenses to greater than 10% in 2014. At this exponential rate, Medicaid will be over 20% of the federal government’s expenditure by 2050. The government spends nearly 650 billion dollars on Medicaid (and Medicare). Immense expenses such as these will only force the presidential administration to undergo cuts in other government areas.

The Coverage Gap

Despite the growing expenses associated with the administration of state-run healthcare, gaps in Medicaid/Medicare eligibility have caused impoverished, uninsured adults to amount to massive healthcare debts. In recent months, millions have gained health insurance coverage through Medicaid due to the economic effects of the pandemic, as well as the maintenance of eligibility and continuous coverage requirements tied to accessing the benefits of Medicaid. The increasing amount of adults eligible for Medicaid insurance has caused the poverty line to decrease. Simply put, the higher demand for Medicaid has caused it to become steeper and more challenging to receive. When many lose income and health coverage during a crisis, these eligibility gaps leave many without an affordable coverage option. They only contribute to growth in the uninsured rate. Unfortunately, there is no surefire way to decrease the rise in uninsured individuals. Experts hope that with the decline of the pandemic, individuals who lost jobs may rejoin the occupational field and regain their privatized insurance provider. This leaves out the large American population that was left with sequel disabilities due to COVID-19 (KFF).

**ACA is the Affordable Care Act — The ACA aims to extend health insurance coverage to about 32 million uninsured Americans by expanding private and public insurance.

Conclusion

In conclusion, the American healthcare system is entrenched in a complex web of social, economic, and legal impediments that hinder progress toward achieving health equity and universal access to care. From pervasive racial biases ingrained in medical training and practice to economic barriers leading to exorbitant healthcare costs and insurmountable medical debts, and from opaque insurance practices to legal frameworks that fail to regulate pharmaceutical pricing and Medicaid eligibility adequately, the system is rife with challenges. The prevalence of implicit bias among healthcare professionals underscores the urgent need for diversity initiatives in medical education and training to challenge stereotypes and foster a more inclusive healthcare workforce.

Implicit biases and prejudices in the healthcare system contribute to differences in treatment outcomes and access to care, which disproportionately impact underprivileged communities. The profit-driven nature of the healthcare industry often prioritizes financial gain over patient well-being, leaving many Americans struggling to afford essential medical services. To address these systemic problems, efforts to diversify the medical workforce and raise consciousness of unconscious bias are crucial. Increasing equity and affordability in healthcare requires regulatory changes to stop surprise billing and lessen the power of pharmaceutical lobbying, as well as openness in healthcare coverage and cost.

Furthermore, legal complexities within the healthcare system, such as pharmaceutical lobbying and Medicaid eligibility gaps, pose significant challenges to achieving comprehensive reform. Pharmaceutical companies’ influence on drug pricing and marketing strategies highlights the need for stricter regulations to ensure the affordability and accessibility of medications. Additionally, the evolving landscape of Medicaid underscores the importance of addressing eligibility disparities to prevent vulnerable populations from falling through the coverage gap.

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