7.1 Factors Affecting Public Health Policy

Access, Cost, and Quality

In the United States, access to health care factors into many public policy discussions and decisions. Most Americans access their health care through an employer’s health insurance plan. In fact, employer-sponsored insurance in the United States covers 70 percent of workers, 36 percent of children, and 53 percent of nonworking adults (Commonwealth Fund, 2023). Although the country does not have a publicly funded universal health care system—a system that provides all people access to the full range of quality health services they need, when and where they need them, without financial hardship—the passage of the Patient Protection and Affordable Care Act (ACA) in 2010 led to millions of previously uninsured Americans receiving health care coverage (Congressional Budget Office, 2016). In addition, access to health insurance may be provided through Medicare—a government health insurance program established in 1965 that covers millions of Americans aged 65 and older and some others with disabilities, end-stage renal disease, and amyotrophic lateral sclerosis (ALS) (Medicare.gov, n.d.). Another health care access vehicle for some Americans is Medicaid, a national health insurance plan that covers some low-income families and children and individuals with disabilities. Established in 1965, Medicaid was expanded with the passage of the ACA, but because it is state-managed, its eligibility requirements and benefits differ from state to state (Centers for Medicare and Medicaid Services [CMS], 2023).

Access to health care is also impacted by technology. During the COVID-19 pandemic, telehealth, or telemedicine—delivering health care services through technology—increased dramatically (Figure 7.2). Although the use of technology to provide health care services was an essential step in providing health care at the time, its continued use poses questions about its quality and whether telehealth appointments are accessible to everyone (U.S. Government Accountability Office, 2022).

Health care cost is another factor that plays a role in public health policy discussions and decisions. The United States has one of the world’s highest costs of health care. In fact, in 2021, U.S. health care spending totaled $4.3 trillion (roughly equivalent to $12,914 per person) (CMS, 2022). This is about twice as much as the average cost of health care per person in other developed countries.

Figure 7.2 A nurse specialist with the Naval Medical Center San Diego’s Joint Tele-Critical Care Network provides support to a remote intensive care unit via teleconference. (credit: Luke Cunningham/U.S. Navy/Flickr, Public Domain)

The high spending rate per person has not led to higher health care quality in the United States. A 2021 Commonwealth Fund report ranked the United States last among 11 high-income countries on:

• access to care, with the United States ranking last on factors such health care affordability and timeliness
• health care efficiency, with the United States trailing other countries in terms of simplifying insurance, billing, and payment
• equity, with the United States ranking lowest in terms of disparities in health care experiences between lower- and higher-income groups
• health care outcomes, with the United States performing worst on outcomes such as infant mortality rate and life expectancy

How can the United States lower its health care expenditures while also increasing access to health care, health care efficiency, and equity? Policy changes are one way the United States can effect more positive outcomes. This section discusses some factors that affect health care policy, including containing costs through evolving payment models, improving client care using various client care models, and avoiding barriers to health care such as those found in health care deserts.

Payment Models

The quality of health care provided to clients in the United States depends in part on how health care professionals are allowed to administer and bill for their services. As noted earlier, despite having the highest per capita expenditure on health care across high-income countries, the United States has no universal health care system and a low quality of care. Public health policies that relate to payment models—the mechanisms by which health care services are established and paid for—may help to address this issue.

Currently, the health care system is transitioning from the traditional fee-for-service model—providers and organizations are reimbursed based upon the volume of services they provide—to payment based upon the value of those services, which includes value-based care and alternative payment models (American Hospital Association, 2023). The American Medical Association (2022) describes the most common payment models for physicians. It divides them into three categories: core payment models, supplementary payment models, and organizational models. Table 7.1 summarizes each type.

Like physicians, health care organizations are reimbursed in different ways, including prospective payment systems, bundled payments, and Accountable Care Organizations (American Hospital Association [AHA], 2023). Recently, value-based purchasing programs have significantly changed hospitals’ approach to providing care. For example, the Hospital Value-Based Purchasing Program bases Medicare payments on the quality of care rather than the services performed. Hospitals with higher rates of post-operative infections, ventilator-associated pneumonia, and other negative outcomes associated with hospital care receive decreased reimbursement. Accordingly, hospitals are incentivized to focus on health care quality. Another example of a reimbursement structure designed to increase the providers’ quality of care is the Hospital Readmissions Reduction Program. This program, administered through the CMS, penalizes hospitals with higher-than-expected levels of readmissions.

This complex framework of health care reimbursement influences how and where care is provided to clients and by whom (National Academies of Sciences, Engineering, and Medicine [NASEM] et al., 2021a). Accordingly, payment systems can affect nurses’ ability to address a community’s health needs. For example, the traditional fee-for-service payment system that focuses on physician reimbursement does not recognize the value of care provided by other health care team members, including nurses (NASEM et al., 2021a). This limits the ability of the health care system to address the social determinants of health (SDOH). It is currently unclear which newer payment model(s) will prevail and become dominant. However, nurses have the opportunity to make a more measurable impact in the newer reimbursement models. For example, nurses working as case managers and care coordinators can help manage a population’s health and reduce costs associated with chronic illness (NASEM et al., 2021a). Overall, community nurses will be better able to promote continuity of care between the health systems and clients at home.

Care Delivery Models

The payment models previously described are the foundation for delivering care. Care delivery models refer to how health care providers work together to provide health care to clients. One example of a care delivery model is the collaborative care model, which “seeks to impact the clinical outcomes of patients who present with depression in primary care” (Collaborative Family Healthcare Association, 2023). Through this model, a psychiatrist and care manager are members of an interdisciplinary care team that manages a group of clients who have been screened for depression and need a higher level of intervention to achieve positive health outcomes. In addition to addressing the clients’ behavioral and psychological needs, the team addresses physical needs, such as the maintenance of chronic diseases (e.g., diabetes, hypertension, cancer, and heart disease). Through this model, health care team members collaborate to achieve the common goal of ensuring the best possible health outcomes for clients.

According to the AHA (2019a), to achieve better outcomes for clients, hospitals and health systems across the United States have had to redesign how they provide client care. The AHA identifies four care models as the most common in the United States: accountable care organizations and medical homes, previously defined in Table 7.2, integrated service lines, and provider-sponsored health plans.

With integrated service lines, hospitals and health care systems organize around specific disease states such as cancer, heart disease, and diabetes throughout the continuum of client care. This model contrasts the traditional care provision, where service lines based on disease state are siloed. In provider-sponsored health plans, plans are either sponsored or acquired by hospitals, physician groups, or health systems, which take over responsibility for the total cost of care for the clients enrolled in the health plan. These organizations may often take on financial risks of providing care for the clients enrolled in the health plan.

Table 7.2 provides examples of these four care delivery models. The type of care model health care professionals choose to provide care is in part determined by health care policy and, in part, determines health care policies based on the revenues and outcomes it achieves.

Care Deserts

Care deserts (or medical deserts) are areas where individuals have limited access to health care services such as hospitals or health clinics (Nguyen & Kim, 2021). Care deserts are most often found in rural areas and in tribal communities and can take many forms, including limited to no access to maternal health services—maternal care deserts—or limited to no access to pharmacy services—pharmacy deserts. More than 80 percent of counties in the United States lack proper access to needed medical services (Nguyen & Kim, 2021). Almost 50 million Americans are more than 60 minutes from a level I and II trauma center (Soto et al., 2018). It is estimated that over one-third of the U.S. population lives in counties that lack sufficient health care infrastructure to ensure good health outcomes. This may include a lack of access to services, medications, primary care providers, hospitals, and community health centers (Nguyen & Kim, 2021). For example, 136 rural hospitals closed between 2010 and 2021; 19 went out of business in 2020, the highest number since 2005 (AHA, 2022). Although this number dropped dramatically in 2021—when only two rural hospitals closed—the improvement may be attributed to federal relief funds associated with the COVID-19 pandemic that have now ended (Levinson et al., 2023). While fewer urban hospitals have closed over the past decade, those that do close tend to be in lower-income communities and treat clients who are uninsured or covered by Medicaid (KFF, 2020b). Closures of hospitals have compound effects because they are sometimes the only form of care to which local residents have access (Figure 7.3) (AHA, 2019b).

Figure 7.3 U.S. Department of Agriculture (USDA) Deputy Secretary Jewel Bronaugh speaks during the groundbreaking for the construction of a new rural hospital funded through the USDA. (credit: Lance Cheung/USDA/Flickr, Public Domain)

A care desert may be created for various reasons. One contributing factor is demographic shifts. Over the past decades, many rural areas in the United States have experienced a sharp decrease in their overall population. Such shifts lead to declines in revenue for health care providers like hospitals and health clinics. Because of this, organizations may choose to leave less populated areas for more populated ones. Health care providers also have little motivation to offer care in neighborhoods where many people are uninsured or underinsured or covered through Medicare and Medicaid. Medicaid reimburses health care providers at a lower rate than private insurance companies such as Blue Cross Blue Shield (KFF, 2020a). As such, there is often a hesitancy to offer care in areas with a high rate of Medicaid-eligible individuals.

Communities that lack high-quality schools or work opportunities for spouses of medical professionals may find it difficult to recruit health care providers such as primary care and specialty care providers (Association of American Medical Colleges, 2023; Health Resources and Services Administration [HRSA], 2023). Research shows that although 20 percent of the U.S. population lives in rural areas, fewer than 10 percent of U.S. doctors practice in rural communities (Joynt et al., 2016). This exacerbates care deserts.

Lack of access to health care in such care deserts leads to many negative health outcomes, including untreated health problems and chronic diseases such as diabetes and hypertension. Communities with less access to primary care struggle with disease diagnosis and prevention, client education, and treating acute and chronic illnesses. Lack of health care access especially affects communities of color (Alfred, 2022).

Finally, clients who must travel long distances to secure care lose valuable work time and incur costs related to travel. In contrast to urban areas, rural regions frequently lack public transportation services. Older adult clients often have chronic conditions, the management of which may necessitate frequent medical appointments (Rural Health Information Hub [RHIhub], 2022). When rural hospitals close, employment opportunities in the community decrease, as the hospital may be one of the main employers in that community, and local economies suffer through revenue loss and tax base loss (AHA, 2019b; Harsha, 2022).

As discussed in Demographic Trends and Societal Changes, care deserts are often addressed using technology such as telemedicine. Because the health care provider (e.g., physician, nurse practitioner, or other specialist) can provide care to individuals remotely, clients in care deserts can receive routine health care (RHIhub, 2021). However, in many areas, clients are still left without access to emergency, inpatient, and surgical care. Many also lack access to simple urgent care for conditions like acute pharyngitis because group A Streptococcus (group A strep) tests must currently be done in person, not via telehealth. Finally, in-person primary care visits for screenings like skin cancer are still preferred to telehealth until the technology improves.

The government offers some care options to those living in care deserts through Federally Qualified Health Centers (FQHCs). These federally funded nonprofit health centers or clinics serve “medically underserved” areas and populations throughout the United States. FQHCs provide primary care services to all individuals, even those not able to pay, on a sliding scale basis (HealthCare.gov, n.d.).

One organization seeking to address physician shortages in health care deserts is the National Health Services Corps, which is operated by the Health Resources and Services Administration (HRSA) arm of the U.S. Department of Health and Human Services (HHS). This organization connects underserved rural, urban, and tribal communities with health care providers. The organization’s 20,000 members currently provide care to over 21 million people in the United States in over 9,000 community health care sites (HRSA, 2023). The organization offers loan repayment and scholarships to its member health care practitioners, making practicing in underserved areas more appealing.

In its report Nowhere to Go: Maternity Care Deserts Across the U.S. 2022 Report, the March of Dimes recommends several policy solutions to federal and state governments to reduce maternity care deserts (March of Dimes, 2022). Recommended solutions include passing a Medicaid postpartum extension from 60 days to 12 months, expanding telehealth services to bridge gaps in health care, and strengthening network requirements for health care plans made available through the ACA (March of Dimes, 2022).

According to the National Academies of Sciences, Engineering, and Medicine (NASEM, 2021b), nurses play a significant role in addressing health inequities such as the lack of qualified health care professionals and the lack of access to health services available to populations. The NASEM (2021b) points to the profession’s deep roots in community health advocacy and social justice, which refers to seeking to ensure equal access to health care services for everyone within a society. The NASEM identifies five key roles to improve health equity for populations: awareness, adjustment, assistance, alignment, and advocacy (NASEM, 2021b). Let’s briefly discuss each.

• With awareness, the nurse seeks to identify and understand social risks and opportunities for a select population. For example, the nurse would inquire about the availability of quality housing and health care services for the population.
• Adjustment has to do with incorporating activities that seek to accommodate populations to address identified barriers, such as providing care through telehealth for individuals lacking adequate transportation.
• Assistance refers to actions the nurse takes to connect populations with various resources such as providing transportation vouchers to ensure individuals have a means by which to get to and from appointments.
• Alignment refers to the actions of the nurse or a health care system to understand the needs of a community or population and implement mechanisms to address health inequities such as investing in ridesharing or time-bank programs, which are geared at increasing access to health care services.
• Advocacy has to do with partnerships between organizations to promote policies that create and deploy programming to address health inequities within communities, such as improving infrastructure that improves transportation for individuals with limited transportation to and from health care services.

Since its inception, the nursing profession has been heavily involved in ensuring everyone has equal access to resources. As such, the community health nurse and the advanced practice nurse are key partners in minimizing health inequities within communities (NASEM, 2021b).