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Douglas Noble: US healthcare and the Harkness fellowship

4 Dec, 12 | by BMJ

Having decided to write a blog during this academic year living in the US, I hadn’t anticipated my tardiness would be because moving the family overseas was vastly more effort than I anticipated. A stroke in a family member at home came suddenly and unexpectedly, and a hurricane hit the city I’m currently calling home. The after effect of Sandy still continues to disrupt normal life for many. These events, combined with an unpredictable, and at times ugly, presidential election has made the start of the Harkness fellowship rather fascinating, if at times nerve wracking.

My interest in the Harkness fellowship in healthcare policy and practice originated some years ago whilst I was working at the Department of Health, and taking part in discussions comparing UK and US healthcare. I’ve now found, though, that actually being here, immersed in the system, has given me a fresh understanding of just how complex healthcare is across the Atlantic, something that was harder to appreciate from within the Ivory Towers. For all the learning to be had from best practice, like integrated care arrangements, there are many other warnings of paths better not trod.

Most notable is the lack of healthcare insurance affecting large sections of the American population. Current estimates suggest 48.6 million uninsured people. This is despite excessive rises in overall healthcare costs: between 1960 and 2010 the proportion of gross domestic product spent on healthcare rose from 5.1 to 17.6% (by contrast, the UK rise was from 3.9 to 9.4%).

Major US healthcare reforms to help address these problems thankfully now have the potential to take shape with, first, the Supreme Court ruling in favour of the Affordable Care Act on 28 June this year, and second, on 6 November 2012, the re-election of President Obama for a further four years in the White House. The latter in the end looked like it was never in question, but the final results don’t portray the extreme nervousness there was in the medical community that I have been interacting with. One doctor with whom I share an office was already looking at flight options out of the country on 7 November had the electorate decided to put Romney in the White House. However, with Obama remaining in charge, and the Supreme Court ruling in favour of the Affordable Care Act, we’re now going to see what changes can actually be achieved.

The current direction of the health reforms is not surprising. It’s mainly geared to ensure more coverage for those sections of the population with no, or inadequate, health insurance. The mechanisms of how this will be achieved are complex. They include (amongst many other things): mandatory affordable and less discriminatory health insurance plans (under threat of financial penalties for people who choose no insurance), state level health insurance exchanges to improve choice and access to affordable plans, expansion of the Medicaid program to cover a larger share of the low income population, and the construction of Accountable Care Organizations to coordinate care by bringing organizations into closer working relationships with financial rewards.

These reforms, along with other major changes included in the Affordable Care Act, present the opportunity for increased access to healthcare, but also possible improvements in quality of care, cost savings, and a rise in the standard of overall population health. Importantly these widespread changes are spurning an impressive growth in innovation across the healthcare sector. At a recent conference in Los Angeles, I certainly got the impression that the sector was booming with ideas and excitement, even before the election.

There is also nerdy public health stuff to discover as well. In the US, multiple payers (federal, employer, and private health insurance and plans), and multiple providers (public and private) make up the basic building blocks of the healthcare system. The denominators for many of the health statistics are derived from patients attending the multiple providers, and are quite often based on health insurance claims. This model of healthcare delivery, which has little in the way of fixed geographical or area based limits, is in contrast to the (almost) single payer single provider system in the UK. Traditionally, the UK health system has been constrained by geographical boundaries and delivered in specified areas. The denominators for health statistics are often the residents of a district, consistent with the area based healthcare provision. The risks of the US style model, which by definition excludes certain residents in any one local area, include: unequal distribution of services according to ability to pay rather than health needs; development of high risk communities with little or no access to healthcare in their local area; and a difficult task to collect area based health statistics. Invariably these problems affect deprived and vulnerable sections of the population most.

The Affordable Care Act with its raft of interventions to improve access could start to rectify parts of these problems. The individual mandate to purchase health insurance could offer the potential for a modest shift towards a more area based approach, with areas having the possibility of higher levels of insurance coverage. Certain commentators have also started to discuss the new legislation within the context of improving overall health in any given community. For example, Accountable Care Organizations, which in the Affordable Care Act describe improved arrangements for Medicare beneficiaries (the federal health plan for the elderly and disabled people), are being used as a platform to discuss new ways of working across entire geographical areas for all residents. One suggestion is the development of Accountable Health Communities to tackle the underlying wider determinants of health for whole populations by working across public health and healthcare sectors.

It’s an exciting time for American healthcare, although admittedly it may not transpire to be as rosy as some are predicting. However, there is certainly great potential!

Douglas Noble is a public health doctor from the UK, currently a Harkness fellow in healthcare policy and practice in New York City, USA. You can follow him on twitter @DouglasNobleMD

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