Blog II: Universal Health Coverage in the United States

By Martha Smee MPH (c) MMS (c) and Dr. Heather F. McClintock PhD MSPH MSW

The U.S. healthcare system is one of the biggest and most complicated healthcare systems in the world. Insurance and healthcare provision are provided through a mix of public and private, for-profit and nonprofit initiatives and organizations. Compared to other high-income countries, we spend the most amount of money on health care yet have the worst outcomes. At face value, that doesn’t add up. In a 2021 report, The Commonwealth Fund (CWF) took a closer look and found four factors that differentiate the U.S. health system from those of comparable countries. First, and perhaps most obviously, the U.S. lacks UHC. As a result, many Americans, most of which are low-income people of color, go uninsured. A host of poor outcomes are the result. Uninsured people are more likely to delay or go without care, be hospitalized for an avoidable reason, have higher rates of death when hospitalized, and financially suffer due to medical bills. Poor and marginalized individuals are more likely to suffer from chronic disease and less likely to be able to afford health insurance or treatment. Lack of UHC contributes to existing health disparities, and the cycle of poverty goes on. Second, CWF identified that the U.S. lags behind other industrialized nations in primary care. Although American primary care providers (PCP) are more likely to address social needs of patients, continuity of care is lacking. Americans are less likely to have a regular place to go for care or have a lasting relationship with a PCP. As a student [Martha Smee (MS)] entering the healthcare field as a future Physician Assistant, I see this deficiency in action, as many of my peers are more interested in entering specialties compared to primary care. Specialties are simply where the money is at. Third, the U.S. has a greater amount of administrative red tape compared to other countries. The American healthcare system is uniquely wasteful in terms of administrative expense, which mostly has to do with our free-market approach to healthcare and efforts to manage utilization (e.g., impeditive prior authorization). Fourth, the U.S. does not invest enough in social services. This is a problem, considering that social determinants of health, like housing, education, income, and insurance status, account for up to 40% of health outcomes. Even if not explicitly tied to health, social services play a role in disease prevention. For example, residents of states which had more supportive social policies (e.g., Medicaid, unemployment support, eviction moratoriums, etc.) had less adverse mental health outcomes during the COVID-19 pandemic. 

My [Martha Smee] interest in population social services led me to complete my MPH capstone research on the association between state Medicaid policies’ support of mental health and mental health outcomes. I conducted a policy analysis using Medicaid state plans and hospitalization rate data from the Healthcare Cost and Utilization Project. After combing through eight states’ Medicaid plans, I ranked them by their promotion of mental health services and evaluated them in relation to each state’s depression hospitalization rates. The main finding was that states with better mental health outcomes tended to have Medicaid policies that more strongly promoted accessibility of outpatient mental health services compared to states with worse mental health outcomes. Investment in social services increases the efficiency of our health system and the health of the American people. 

One simple sentence that I [Martha Smee] heard during my MPH studies has stuck with me since: “Health is not an individual decision.” If health were an individual decision, I would imagine most of us would be eating fresh fruits and vegetables every meal, getting enough exercise and sleep, and visiting a doctor regularly. In reality, health results from a collection of circumstances, some of which are within an individual’s control, but most of which are not. UHC has the potential to impact many of the underlying circumstances which contribute to individual and population health. UHC is the key to a more sustainable world which values health equity, and above all, human life.