What are the main issues facing American healthcare in 2020?

As voters across the country tuned in to the presidential primary debates, it has become evident that like never before the United States is trying to answer important questions about the future of its healthcare system. Most often the debate centers around issues of coverage and cost. How do we make sure that we cover the highest possible number of individuals, and how do we make sure we are not overpaying for this coverage as a country? Every candidate’s health plan has nuances regarding the most effective way to do that. As we take part in this debate, it is important to remind ourselves that healthcare in the United States is an industry, and like every industry it is affected by a multitude of dynamic factors, from digital transformation to business strategy. To be a conscious voter, it is crucial to think about how healthcare is changing in this country and what the implications of that change are. I have listed here 5 issues that I think are important to consider as we move into a new decade.

Cost

The issue that gets the most attention is the rising cost of healthcare in America. According to the official estimates of the National Health Expenditure Accounts (NHEA), health care spending grew 3.9 percent in 2017, reaching $3.5 trillion or $10,739 per person. An article written last month in the New York Times shows that since 2009, increases in worker’s earnings have not been able to keep up with the increases in healthcare premiums and deductibles. Furthermore, businesses are struggling to provide good plans for their employees. The Affordable Care Act has brought about additional coverage for millions of low-income workers, but it has not fixed the issue of cost in this country.

Currently liberals are debating whether the way forward is to continue adding regulations that would result in increased coverage and decreased out-of-pocket costs, or whether to revolutionize the system completely by switching to “single-payer”. A single-payer system is one in which the government becomes the ultimate entity that picks up the tab. The money to fuel such an endeavor would come from increased taxation, which means that we would all be paying some amount to make sure we all get appropriate care.

The idea is that the amount you pay in taxes, as a percentage of your income, would be less than what you would pay in premiums and out-of-pocket costs. That is, unless you make a significant amount of money which could mean you pay more in order to make healthcare affordable for those who do not.

What counts as “significant” in terms of money and where in that threshold you would find yourself is something the government would have to figure out.

Although policy changes might shuffle a few things around in terms of who is paying what, the reality is that healthcare in America is just very expensive. As an American, you pay more than in any other country for the simple reason that prices for healthcare goods and services are higher here. One of the culprits is rising administrative costs, that being the time and resources dedicated to mundane tasks such as billing and reporting to insurance companies. Ultimately, unless we find a way to either make the market more competitive, or introduce regulations that specifically address prices in the industry, we will continue to pay good money for our precious health.

Quality

Healthcare quality is an issue that is overshadowed by that of cost and often tangled into other matters. The United States is quoted as an example amongst high-income countries, where healthcare costs are really high and health outcomes are really low in comparison. Ironically, the United States provides amazing quality healthcare, that is once you get really sick.

The problem lies in not having regular access to primary care that can help patients manage their conditions or prevent them altogether. This is especially important if you belong to certain socio-economic groups or if you live in certain areas (read: isolated, rural and poor). Worse health outcomes are also attributable to behaviors that go beyond those of simply seeking medical care, for example choices of nutrition and exercise. We need to answer the question of whether we should define healthcare as also investing more in education, home visits and programs providing exercise incentives and healthy food to people who live in isolated areas like food deserts.

Furthermore, your experience with the healthcare system might be of a different quality if you are a woman or a person of color. Women and POC’s complaints of pain are more likely to be disregarded by doctors and they are more likely to not be recommended for more tests or procedures to address such pain.

This type of bias takes its full and scariest form when looking at maternal mortality. Black women are three times more likely to die from causes related to pregnancy compared to white women, a disparity that exists even when you control for confounders like education and insurance coverage.

Beyond the issue of health disparity and whether patients are getting equitable care depending on their identity and status, the issue of quality might become particularly relevant if an expanding government plan starts competing with private insurance. This might create a divide where the chunk of the population under government insurance is not covered for certain doctors, hospitals or clinics which might be deemed as higher quality and accessible only through an expensive private insurance plan. Many people opposing a “Medicare For All” plan fear that it would create tiers of healthcare, thus not fixing the issue of health equity.

Supply

America, like much of the rest of the world, has a shortage of doctors problem. The Association of American Medical Colleges reported that the United States could see a shortage of up to about 122,000 physicians by the year 2032.

Increasing shortages are connected to an aging population requiring more medical services, a lot of physician time spent on administrative work and finally admission policies for medical school which limit the supply of doctors every year.

The shortage of physicians has a direct effect on how much it costs to see a doctor, the quality of care that patients receive and how quickly they can get it. Solutions to this problem involve increasing incentives for doctors to work in more shortage prone areas. It also demands for a system where clinicians that are not MDs, like nurse practitioners, are able to perform a higher number of services, especially in a primary care setting. Finally, there should be a discussion about increasing educational resources to sustain a larger medical student population and residency programs considering there is significant talent applying every year that we might be missing out on.

There is also a prominent argument that the US does not necessarily have a shortage problem but rather a distribution one. Policy makers need to answer questions such as “Are we specializing our doctors in a proportional way to patient needs?” and “Are we distributing our doctors in a proportional way to patient populations?”.

Consumers

Another important issue to consider is how healthcare consumption habits have changed while accommodating a new generation of patients. Millennials have grown up with a different set of expectations for service, specifically in terms of transparency, immediacy, and convenience.

These expectations are reflected in many behaviors of this generation. Millennials distrust the status quo. They find it frustrating that they are not able to easily look up prices for services and therefore prefer getting primary care at urgent care clinics which are more consumer-friendly.

Millenials are more likely than their predecessors to request prices up front and discuss costs with doctors and use cost as a decisive factor on whether or not to receive care. They detest the complexity of the insurance system and are therefore also more likely to be uninsured.

Furthermore, millennials rely heavily on what they read online. They will google everything from their symptoms and conditions to their medications and doctor reviews. They’re informed (although sometimes misinformed) patients and are more critical of doctors and more demanding of them.

Millennials also have a more holistic approach to health. They put a lot of emphasis on nutrition and exercise, a lot of which they consume online. They are more concerned with issues such as mental health and stress management. They are obsessed with skin care and alternatives to western medicine and drugs and seek for doctors who can engage with them in these topics.

Millennials are also not developing a personal relationship with their primary care physician like prior generations. This way of consuming healthcare is changing the dynamics between doctors and patients and it’s creating space for new ideas on healthcare delivery, as indicated by the rise in popularity of telemedicine. Millennials are treating healthcare like any other commodity which might lead to healthcare services starting to look a lot more like Uber and Amazon, bringing us to the last point.

Technology

Healthcare is an extremely profitable industry because having good health will forever be a human priority. It should come as no surprise that tech giants want part in it.

Last year, Amazon acquired an online pharmacy start-up called PillPack. The collaboration has the potential to revolutionize the way we order and deliver drugs. Apple has also been dabbling in healthcare with its Apple Watch electrocardiogram application which heralds a new era of wearable technology that could change how we decide to seek medical services. Even Google has been investing heavily in the field, especially through its Artificial Intelligence (AI) research. AI is currently regarded as having unlimited potential for application — from helping doctors make medical decisions through computer vision technology, to helping research scientists discover and make new drugs from deep learning algorithms.

Drug discovery is particularly benefiting from technological advances. Our current ability to collect, store and process incredible amounts of data has exponentially increased the importance of genetics in the field. We are now able to sequence human genomes for a fraction of the price and time, allowing personalized medicine to become a reality. Technologies such as CRISPR, PROTACs and CAR T-cells are examples of how we have become very good at editing and customizing our toolbox in order to find solutions for a targeted problem or disease.

Simultaneously, our advances in health data analytics come with the prescription of being able to accurately interpret and most importantly protect the data. Hackers have now the potential to steal very sensitive private information about our health, and in a more dystopian scenario, hack into medical devices installed in patients. Data has become an extremely valuable asset and as we become more and more dependent on technology, cyber attacks could become more and more lethal.

In conclusion, as the 2020 election looms around the corner, American voters should spend some time thinking about the changes that the country is going through in the healthcare industry. The roadmap I provided above is a simplified summary considering these issues are far more complicated and often intertwined with one another. I recommend paying close attention to this industry because we won’t stop talking about it any time soon.

Originally published at https://tedbebi.blogspot.com on October 17, 2019.