HARVARD MEDICAL SCHOOL PRIMARY CARE REVIEW

Exploring the Schism between Public Health and the Health Care System

December 28th, 2021

Patients tell me all the time that our health care infrastructure needs reformation. Many people, including myself, would agree with that statement, but reformed to what? As a Patient Access Specialist at Beaumont Health and public health student at Wayne State University, I have the opportunity of studying the United States (U.S.) health care system both in and out of the classroom. This piece will look at U.S. health care expenditures and access to care through a public health lens.

The Centers for Disease Control and Prevention (CDC) reported that within the last century, human life expectancy increased by 30 years, with twenty-five years attributed to public health prevention measures and five years attributed to medical advancements. Meanwhile, the U.S. allocated only 2.5% of the roughly 3.5 trillion spent on health care in 2017 to public health intervention and prevention programs. Looking at health care spending amongst the Organization for Economic Co-operation and Development (OECD) nations, the U.S. spent more than two times as much of its GDP on health care than the average OECD nation in 2018. Even though the U.S. spends the most on health care, we rank 28th in human life expectancy amongst the 37 OECD countries. A significant contributor to the low ranking in life expectancy is the structural inequality in the U.S. Such structural inequality is evident in recent reports from the World Bank which show that from 2000-2017 the U.S. ranked the highest in income inequality and the worst on health and social problems. This is a significant statistic, considering that social and economic factors comprise 40% of our health determination. It is worth investigating how the U.S. could better incorporate preventative health frameworks within health care. Based on my professional background in patient health care access and my academic involvement in public health, I propose the following recommendations to address community care management, wasted health care spending, and health inequity:

I. Use place-based public health and collaborative health networks to foster transdisciplinary health care delivery approaches.

Place-based public health is pivotal for introducing community-led efforts rooted in the needs and priorities of the people. One avenue for this approach is local pharmacies. Data from the CDC show that pharmacists see patients five to eight times more than primary care providers, and 90% of people live approximately five miles from a pharmacy. Pharmacies can serve as greater hubs for education on scientific research, clinical trial engagement, and digital accessibility of patient records. Using pharmacies as educational and awareness tools for patients can help prevent transactional care and promote robust partnerships among hospitals, health departments, and community organizations. Such partnerships are necessary to establish community trust, promote more efficient care, and provide patients with a network of health advocates and not only a provider. Ultimately, pharmacies can empower patients to have agency over their health through increased health literacy and improved patient-provider relationships.

II. Invest more in health care accountability and reallocate wasted funds. 

A study in the Journal of Patient Safety mentioned that between 210,000-400,000 patients each year who have hospital visits suffer some form of preventable harm that contributes to their death. That would make medical errors the third leading cause of death in America, at least $55 billion is wasted from missed prevention opportunities. Moreover, the Institute of Medicine (IOM) estimates that $210 billion is spent on unnecessary medicine. Such statistics should emphasize the importance of health care accountability and standardization of care through comparative effectiveness research. 

More importantly, an evaluation of health care consolidation on quality of care and its role in increasing prices for medical treatment can also address accountability. The U.S. does not have a fixed price system for drugs and services; instead, insurers negotiate with hospitals to get prices for their subscribers. Still, these private insurers do not have much bargaining power because individual insurance companies cover a small subset of the U.S. population. The bargaining capability decreases less with both hospital mergers and vertical acquisitions. The Kaiser Family Foundation mentioned that between 2010 and 2017, there were 778 hospital mergers. Over time, the number of independent hospitals has declined as a result of these mergers, while the number of hospitals that are part of larger health systems has risen. By 2017, 66% of all hospitals were part of a larger system, as compared to 53% in 2005” (Kaiser Family Foundation, 2020). For these reasons, the U.S. spends billions of dollars more on health care services and prescription drugs than other OECD countries. Essentially, we are paying higher prices to subsidize drugs and services for the rest of the world. This same price manipulation can be attributed to the growing monopsony of private insurance companies, leading to one payor. Due to exceedingly high costs, two-thirds of bankruptcy filings in the U.S. cite medical bills as a critical factor to their financial collapse. To avoid this, 22% of Americans say they have steered clear of medical care because of the expenses.

The reports on U.S. spending and the persistent increase of medical treatment costs show the cyclical nature of poor health outcomes perpetuated by the U.S health care system. Although consolidation may increase operational efficiency and profits, there has been no clear evidence to show its benefit on quality of care. By instituting price limits on health care buyers and sellers, we could save billions and not financially penalize Americans for having poor health outcomes. Intentionally reallocating wasted funds can also provide better support for social workers, hospital diversity and inclusion training, and the expansion of hospital environmental sustainability initiatives.  

Beyond data: collective action for future development

Looking ahead, we need to consider three critical questions: (1) What are the economic trade-offs for sustainable equity-centered solutions within the health care system? (2) How much are policymakers willing to invest and advocate for these changes toward preventive health? (3) Is there an ethical imperative for providing access to affordable health care? Such questions require long-term efforts, public health funding, and infrastructural change.

The transient mindsets of governments at the federal, state, and local levels allowed us to fall short in deciding public health priority, particularly in marginalized communities. We need to pivot focus to marginalized populations. In that case, we could potentially create better health outcomes for vulnerable populations while reducing costs. The money saved from cost-saving measures can be used for public health interventions to eliminate health inequities. At the crux, health care would not be so costly in the absence of social and health disparities. For this reason, investing in public goods that are non-rival and non-excludable can be a start toward systemic change and eventually minimize unnecessary expenditures. With collective action, comparative effectiveness research, public goods, government buy-in, an equitable health care system is achievable and will lead us towards dismantling the schism between public health and health care. 

**Feature photo by cottonbro from Pexels 

 

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Kamali Clora is a senior public health student at Wayne State University and an aspiring health administrator. Prior to his work at Beaumont Health, he served as a Certified Pharmacy Technician at CVS Pharmacy where he helped administer COVID-19 vaccinations. Kamali’s passions include alleviating health inequities, social justice, and legal epidemiology.

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