Careers in Public Health Newsletter

Careers in Public Health is designed to answer your public health career questions.

The health care system and public health

Careers in Public Health has received many questions about the health care system in the United States. The authors of "The Health Care Handbook," Elisabeth Askin, Nathan Moore and Vikram Shankar, give us some insight.

Q: What's your prediction of future health care reform directions?

Elisabeth: People will like having easier access to insurance and care, so that will stay, politically. Big changes will have to be made in terms of cost. The professions will largely self-regulate in terms of quality.

Nathan: Paying for health outcomes rather than for services delivered – this is already happening in Massachusetts.

Vikram: In the long term, progressive expansion of public health insurance to rein in costs.

Q: For someone with very little background in the subject, how would you explain health insurance/economics and the U.S. health care system?

Vikram: A third party - the health insurance plan - makes payments on behalf of the patient for most health care services. To make things more complicated, physicians and hospitals charge different amounts for the same service depending on the insurance plan.

Elisabeth: Health care is rarely equivalent to the other goods and services to which it gets compared. For instance, the idea of insurance is borne out of an uncertainty about the timing and size of one’s need for resources. However, with health insurance: (1) many health costs are expected yet still covered by insurance, and (2) people don't choose their health status, the way they might choose to buy a house in a flood plain, (3) costs are rarely known until after the fact.

Nathan: Imagine visiting a car mechanic after your Check Engine light comes on. The mechanic determines that your alternator is not working and installs a new one after several hours of work. You leave with a newly functional car. However, neither you nor the mechanic knows the cost of the parts, or the total price for the repair. Sounds crazy, but that's how health care works.

Q: If you are going to categorize health care users, which categories would you use?

Nathan: By insurance status. The type of insurance someone has (i.e., private insurance, Medicare, Medicaid, no insurance, etc.) plays a role in determining where and how they get care–as well as how good that care is.

Elisabeth: By health status. In the U.S., the sickest 5 percent of the population accounts for half of total health care spending, while the healthiest 50 percent of the population only accounts for 3 percent of health care spending.

Q: What do you think is an effective way to tackle the primary care shortage problem?

Elisabeth: There are many efforts which are likely to have at least some success. One thing we can't forget is that just paying people more isn't enough – we ignore the "hassle factor" of primary care at our peril.

Vikram: Changing scope of practice laws so that nurse practitioners and physician assistants can take on more primary care responsibilities.

Nathan: Promoting the primary care medical home so that primary care physicians are truly in charge of their patients' care.