The Principles of Good Health Care in the U.S. in the 2020s

Andrew Targowski

Professor Emeritus, International Society for the Comparative Study of Civilizations President (2007-2013), Western Michigan University, Kalamazoo, MI 4908, USA; E-mail: Andrew.targowski@wmich.edu

INTRODUCTION

The policy for improving American health care can be analyzed from the legal and moral point of views. From the former view three comprehensive national plans have been implemented in the United States so far:

• The Medicaid (begun in 1965) is a health care program that assists low-income families or individuals in paying for doctor visits, hospital stays, long-term medical, custodial care costs and more. It is a joint program, funded primarily by the federal government and run at the state level, where coverage may vary.It provides free health insurance to 74 million low-income and disabled people (23% of Americans) as of 2017.¹
• The Medicare (begun in 1966) is a national health insurance program in the United States, under the Social Security Administration for people who are 65 or older. Certain younger people with disabilities. People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD). About 59 million people applied for this program in 2017.²
• The Affordable Care Act (ACA) (“Obamacare” 2009)-requires that all Americans have health insurance that meets minimum essential coverage standards, such as through an employer, veteran’s benefits, or another source.

The first two plans serve to about 133 million people (40% of the population) and provide good health insurance, comparable with the famous Scandinavian plans. However, what about the remaining 60% of the population? Those lucky who work may have plans co-paid by the employers. Unfortunately, not all employers finance such plans. What about part-time workers, who in the majority cases do not have any health care plans, since are too young for the Medicare or not so poor yet to get the Medicaid plan? What about those who are homeless or cannot afford any health care insurance plan? They in the case of weakness go to the emergency rooms of hospitals and get a limited help, causing the massive rise of the hospitalization cost for those who are insured.

The response for those people with limited abilities to have the right health care–President Barack Obama implemented the ACA plan in 2009. After almost ten years of applying this plan, many weak points of this plan have been recognized, like the following³ :

1. It is difficult to understand how much Obamacare taxes your pay if you do not buy insurance. In 2016, it increased to 2.5 percent of adjusted gross income.
2. Experts disagree on whether the ACA reduced the deficit. The original projection was $143 billion in savings. Others forecast it would add $1.76 trillion to the debt. That would be bad because Congress passed the ACA to reduce the cost of Medicare and Medicaid. Federal payments for these benefits eat up the entire budget. That leaves less for programs in the discretionary budget. It is difficult to understand the true cost of Obamacare to the nation when even the experts disagree so much.
3. President Obama promised that, if you like your plan, you can keep it. However, health insurance companies canceled plans for 1 million people. That is because they did not comply with the ACA’s 10 essential health benefits. That was their decision, not Obama’s. However, many people lost insurance as a result.
4. The ACA changes how Medicare reimburses hospitals. It is switching from a fee-for-service to value-based payment. It will stop paying for every test, exam, and procedure. Instead, it will base payments on how well the patient does. It should cut costs in the long run. However, it creates a painful transition for hospital systems in the short term.
5. It requires doctors’ offices to computerize all medical records. The government first introduced this mandate in 2009 as part of the Economic Stimulus Act. It is making life miserable for doctors’ offices. As of October 1, 2013, doctors must choose from 140,000 codes when entering data about a diagnosis. It is up from 18,000 codes. Hospital records need to comply with the new Medicare value-based payment system.
6. It made health care available to millions more—however, that increased health care costs over the short term. Many people received preventive care for the first time in decades. Tests and treatments for cancer, cholesterol, and diabetes raised costs for insurance companies.
7. Families lost some tax deductions for uninsured medical costs. The ACA raised the deductible level from 7.5 percent of adjusted gross income to 10 percent. Trump’s tax plan restored the deductible level for 2017 and 2018.
8. Higher income families paid additional Medicare taxes. It affected 1 million individuals and 4 million couples who made more than $200,000 and $250,000 respectively. It affected both income taxes and capital gains taxes.
9. Between 3 million and 5 million people lost their company sponsored health care plans. Many businesses found it was more cost-effective to pay the penalty than provide health insurance benefits. Many small businesses found out their workers could get a better plan through the exchanges.
10. Health care providers and health insurance companies paid additional taxes to help fund Obamacare’s benefits. They may pass these costs on to consumers as higher premiums. Indoor tanning services were assessed a 10 percent excise tax. Drug companies will pay an extra $84.8 billion in fees over the next 10 years. That will pay for closing the “doughnut hole” in Medicare Part D. Medical device manufacturers and importers were assessed a 2.3 percent excise tax in 2013. Congress suspended the medical device tax for 2016-2018. Insurance companies will pay a 40 percent excise tax on “Cadillac” health plans in 2022. These plans are for people in high-risk pools, such as older workers or those with dangerous jobs.
11. Buying health insurance is still complicated. For example, the exchanges offer four types of insurance policy levels: Bronze, Silver, Gold, and Platinum. So now you’ve got to figure out which level you want. You must also compare the copays, deductibles, and co-insurance levels between the different providers. On the other hand, the exchanges gave consumers more control over the shopping process. Before the ACA, one had to rely on a broker and hope for the best.

These weak points of Obama care triggereda roasting criticism by President Donald Trump, who wants to have a less costly plan, based on the competition of insurance companies. Also, according to the President, such a plan should provide minimal coverage of desires and situations, like should not pay for pre-existing diseases. The latter requirement caused the lost election to the House of Congress in 2018. Since the promised “best” plan was not yet implemented even not elaborated beyond the general PR-oriented slogans.

Jost TS⁴ argues that even though many Americans lack access to health care, we spent over $1.9 trillion on health care in 2004-more (this cost was $3.5 trillion in 2017, or $10,739 per person, and accounted for 17.9% of gross domestic product (GDP)5 than we spent on food, housing, transportation, or anything else-and the amount that we spend on health care is increasing every year at rates far in excess of inflation generally.

Wolman D, et al⁶ stated that the uninsured get less health care than the insured, and they get it later when it is often less effective or too late.

Anderson G⁷just openly states that perhaps the most important factor explaining higher costs in the United States is that we just pay higher prices for health care than other countries do.

Pauly MV, et al⁸ argues that consumer-driven health care attempts to direct competition to the point at which health care goods and services are purchased. It is firmly rooted in a belief that too good insurance drives health care cost. Another word, is good health too costly for the Americans?

It seems that the weakness of a new “affordable” health insurance plan is in the fact that before defining such plan one must agree on the moral principles of the health care in the most powerful country in the world. Otherwise, one can argue that “The only good American is a sick American?” It is a paraphrasing of the ill-famed saying in the 19^th century.

TOWARD THE PRINCIPLES OF THE HEALTH CARE IN THE UNITED STATES IN THE 21ST CENTURY

In order to pursue the universal reform of health care in the U.S. one must define the principles and aims of this reform. The principles of 2020s Reform of Health Care in the U.S. (known so far as The Patient Protection and Affordable Care Act, often shortened to the Affordable Care Act or nicknamed Obamacare) should include the following:

1. The fundamental laws of the U.S. should be the foundation for the concept of health care.
2. The Declaration of Independence of the U.S. (1776) states, that “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of happiness.
3. The United States Constitution (1787) is also the base for the concept of health care. In the Constitution’s preamble is stated: “We the People of the United States, in order to form a more perfect union, establish justice, insure domestic tranquility, provide for the common defense, promote the general welfare, and secure the blessings of liberty to ourselves and our posterity, do ordain and establish this Constitution for the United States of America.”
4. The concept of “Happiness” and “Welfare” in the 18th century was slightly different than today. We can assume that both terms currently mean “Well-Being of Americans”. This value is the constitutional opportunity of an American. Well-being is a very time and process-oriented value that cannot be guaranteed forever. Once accomplished, it can be lost to many internal and external factors. On the other hand, the American constitution supports this value by providing tools that help in pursuing this opportunity.
5. Good health of Americans is a constituent of their wellbeing. In other words, good well-being is usually a determinant of good health. Without good well-being, Americans may not have good health.
6. Good health care is the constitutional opportunity of Americans. Today health care is costly. If it is free, it certainly will not satisfy the high expectations of Americans. Do they often perceive death as an option? The choice is between the right and the privilege of having health care. It depends on the state’s economic situation and societal and political support. In this respect today, Americans are divided almost equally between the right and privilege. Due to the following:

a. Almost 16.3% percent of the population not having health insurance (49.9 million) in 2012⁹ and high inequality (for 2010, 40.8 % are below perfect distribution, according to the GINI index, comparable to Morocco’s and in contrast to Norway’s 25.8% in 2000.¹⁰
b. It took place in times when 10 percent is unemployed, and another 5 percent is out of statistics.
c. To have a privilege of health care, it may lead to the lack of social tranquility which is expected by the U.S. Constitution. Therefore, basichealth care should be perceived as the controlled right. It means that basic medical help is secured but its use will be controlled. If it is abused by unwise lifestyles, it can be suspended.

7. The intense effort to improve the American Health System is the number 1 in the political agenda of President Barak Obama’s administration (2009-16) and president Donald Trump’s administration (2017-2020). The fund of $30 billion supported the provision of the Health Information Technology for Economic and Clinical Health (HITECH) Act under the American Recovery and Reinvestment Act of 2009 (signed in February 2009) and of the Patient Protection and ACA. It led to significant changes in the adoption of electronic health records by eligible providers (EP) and eligible hospitals (EH). However, the digital national registration system was malfunctioning for several months, due to poor design and lack of testing before going to the public.
8. When President Trump was elected (2017-2020), he promised to repeal the Affordable Care Act on his first day in White House; he issued an executive order envisioned to turn back ACA execution. He has kept a constant tide of declarations criticizing the law, often saying that it has already been smashed or limited. ACA supporters proclaim that the president’s activities reflect his words; that he is intentionally “harming” enforcement of the ACA. Truly, a first-of-its-kind lawsuit was recently filed claiming that President Trump is violating his constitutional duty to “take care that the laws be faithfully executed.”
9. However, its first year of complete Act implementation, which began on October 1, 2009, led to the profound political crisis, resulted in shutting down the federal government due to the budget dispute at the Congress. This crisis is mostly caused by the lack of agreed principles of the American Health Care System and limited to the insurance issues.
10. Some positive changes have been implemented in 2009- 2016 as the result of the mentioned Acts in p. 4, namely in quality reporting, population health monitoring, electronic health record (EHR) certification for meaningful use and adoption and the start of significant healthcare practice and payment reforms.^11,12 The Obama Care Act triggered many positive changes in the improvements of the American Health Care System; among such improvements, one can notice;

a. Vendor investment in the healthcare sector has grown significantly since 2009-2010.
b. The Federal Advisory Committees (FACA) for HIT Policy and HIT Standards has been created inguiding the development of standards and working to improve interoperability and reduce cost, improve quality reporting and increase transparency.
c. However, many individual physicians implementing EMR reduced their productivity and lowered health quality by limiting good bedside manners (looking in patients’ eyes) by replacing them with a look at the screen of a computer.

The principles of the American Health Care System should also include the following:

1. The well-being of Americans means equal access to sustainable economic vitality with minimized inequality, based upon a sustainable environment, which delivers healthy food, fresh water and air, and culture-oriented activities.
2. The well-being of Americans is achievable through human and societal wisdom, meaning prudent choices made in economic, cultural, and technology-oriented processes at all levels of American society.

a. In particular, political wisdom is essential, since it leads the whole regions and nation.
b. Human and societal wisdom requires mentally healthy people.
c. Human and societal wisdom requires well-educated citizens.

3. Good health is possible if the Americans’ lifestyles are wise and good. It means that the citizens have the responsibility to conduct a healthy lifestyle.
4. The United States as a verywell developed nation and world superpower should secure health care for the poor citizens, who according to the headline were 39.7 million in 2017. It works out to 12.3 percent of the population or 1 in 8 Americans. Why are so many poor people in a country that are so rich?¹³
5. How does one justify our distribution of 90% for treatment to other nations who appropriate 90% for prevention? The major socioeconomic determinant for health or well-being in the USA is poverty.¹⁴

THE STATE AND AIMS OF THE HEALTH CARE REFORM IN 2020

The U.S. State in 2018:

• The state of the Americans is below its peak in 1960 (socalled fabulous years). In the 20^th century, America towered over its rivals. At the end of the Second World War, America’s dreams were collectively ambitious but individually modest. Nowadays, the collective ambitions of America have shrunk but the individual aspirations of its citizens–their dreams of prosperity, freedom, and happiness¹⁵ are undiminished.¹⁶ The question for the future is whether the relative decline of America (due to unregulated globalization) means that the dreams of individual Americans will need to be downsized as well.

• The state of the well-being of the Americans

is low. The service economy is too weak to support the American Way as used to be. The offshore out sourcing of manufacturing is the permanent cause of high unemployment. The Americans borrow too much money and capital and soon may be internationally bankrupt. The 2008-2013 financial crises indicate that the Managerial Revolution (executives intercept dividends under a form of huge bonuses) is at the peak. Wall Street turned the American financial system into a casino. Bad economy limits taxes at all levels, and as a result, schools are closing (ex. 44 in Detroit in 2009) and colleges are in financial crises. The national IQ of 98 is far behind too many countries. Regarding social-civilizational wisdom, the U.S. is not the first, as its level of Academia could indicate. Mass culture lowered academic standards of social taste and behavior, which is reflected in this statement: “no logic, be nice and have fun”.

• The state of health care of the Americans

is in a state, which is not appropriate for the richest and powerful, and influential country in the world. The quality of health care is at the level of 54 percent.¹⁷The cost of health care per capita is twice bigger than in some developed countries. While, life expectancy is lower than Japan and Sweden, in countries which are less affluent than the U.S.? Even in the U.S., the same difference is among northern (New England) and southern states (Louisiana and Texas) as between the U.S. and leading countries.¹⁸

• The vision of American Society Americans achieved the highest standard of living among large nations in the second part of the 20^th century and should strive to maintain it throughout the 21^st century. It can be achieved if:

o Manufacturing will return to the U.S and business will secure jobs for the Americans as its best well-being customers.
o Schools and colleges should shift from education based on the knowledge to wisdom inquiry and rise national IQ from 98 to 105. It will lead to the shift from the fun to a wise, good, and healthy society.
o Mental health should be meaningfully improved. Such society should practice wise lifestyles and pursue happiness as it is aimed in the Declaration of Independence, 237-years-ago.
o The Americans will keep playingthe roleas a stabilizing force in the world affairs, as it was provided in the last almost 100 years (since 1914). Because in the 21^st century, there is no other state in the world which could play this role instead of the U.S. The Americans are perhaps the only nation which is interested in almost all countries’ state of affairs which means that Americans’ well-being in general defines wellbeing of other countries.

Creed: Wise Americans are healthy.

Goals:

Goals are defined in the scope of Well-Being (Table 1), Health Care (Table 2) and Information Infrastructure (Table 3). These goals are defined first at the big picture of the national level, and when it is necessary they are also defined at the small-picture of levels below the national one.

Strategies:

1. The implementation of 10 well-being-oriented goals of Americans for the next 20 years requires top-down leadership at the federal, state and local governments’ levels and bottomup engagement at the level of schools, colleges, civic organizations, and citizens. Special coordination offices should be created and supported by updated well-being indexes and information systems for reporting and analysis.
2. The implementation of 10 healthcare-oriented goals of Americans for the next 20 years requires top-down leadership at the federal, state and local governments’ levels and bottomup engagement at the level of local health care providers. Special coordination offices should be created and supported by updated health care indexes and information systems for reporting and analysis. The critical issue of improving the quality of health care can be solved in the following approaches (by each one or their combination):

a. Comprehensive public reporting on quality (using The Quality Assessment and Analysis Systems) and pay for quality-driven performance.
b. Secured market-oriented competition among providers should be guaranteed. The Quality Assessment and Analysis Systems at local, regional, and national levels should be available for the public and serve in supporting their judgment and choices of the most suited providers.
c. The number of physicians from 2.3 (2000) to 4.0 per 1,000 people should be implemented. d. Physicians should be reimbursed by pay rate per day.

3. The implementation of four information infrastructure-oriented goals of Americans for the next 20 years requires topdown leadership at the federal, state and local governments levels and bottom-up engagement at the level of local health care providers. Special coordination offices office of national coordinator (ONC) for Health IT, office of legal counsel
(OLC), and other office of should be created and supported by updated indexes and information systems for reporting and analysis.

a. The critical issue of the successful Health Information Infrastructure is in implementing EMR at the physicians’ level. The significant improvements in the health care delivery can not occur without physicians making the transition from paper medical records to EMR.¹⁹ b. The most significant barriers that prevent most American physicians from adopting EMRs are in their cost ($15,000 to 50,000 per physician) and their probable loss in productivity (due to slower data entry in comparison to quick notes on paper). According to a critical doctors’ opinion, this system raises costs, without increasing revenues. On the other hand, those physicians who implemented EMRs never gone back to paper charts.¹⁹

i. Part of the federal economic stimulus package that passed in February 2009 included a provision for physicians who accepted Medicare patients to earn $44,000 over five years if they prove they are “meaningful users” of a certified EMR system. The rule also includes a 1 percent penalty on Medicare reimbursements for physicians who do not adopt records by 2015.
ii. Being electronic and connected to the Internet allows physicians to access records on an iPhone or Blackberry. The mobile system does not contain all functions available in the office, but physicians can view patient summary information in real time for active problems, allergies, current medications and immunizations, social history, and values from the most recent lab tests.

c. Perhaps the user-unfriendliness of some EMR software packages is the reason that physicians do not want to use this solution. It is a room for nation-wide standardization and acceptance rules for EMR software. Then the best solutions (certified) would be more successfully applied.

CONCLUSION

The implementation of this comprehensive concept of goals and strategies leading to better well-being and healthy Americans requires:

1. The integration of well-being, health care, and information infrastructure-oriented components into one comprehensive solution should be implemented. If each one of these elements is treated in isolation, the improvements will not be lasting and positive (Figure 1).

Figure 1. The Relationships Among Americans’ Good Lives

2. Political will and leadership at all levels of the nation.
3. Professional leadership at all significant professional associations (ex. AMA).
4. Academic leadership at selected schools and colleges, at the preparatory phase of the program.
5. Business leadership of this program-oriented health care providers.
6. Media’s support in developing and implementing this program.
7. Other necessary initiatives.

At the time of publishing this paper (2019), the author is rather pessimistic about the possibility of successful implementation of this program. The American national political and societal climate is negative for large-scale and innovative initiatives. The status quo is the most popular policy among established political and professional leaders. It is because the 19^th century attitude was supposedly very successful in developing of Americanism (an efficient way to wealth and “happiness”). Unfortunately, after the passing of almost two centuries, today we enter a new epoch of new societal issues and required solutions, which require bold conceptualization and tough choices, through the 21^st century.

Perhaps, the American Medical Association (AMA) and medical schools should take the lead in promoting professional and political ways of wise and good health care in the U.S.

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