Systemic Failure of American Healthcare: Part I

Our healthcare gap is widening. It’s been under construction for nearly a century. So why is it so much worse? I am a mental health care provider, and here’s my experience.

What makes up the medical and behavioral health system?

There are several factors that compromise healthcare as a whole. It includes hospitals, medical and behavioral health providers and facilities, or any entity that provides services to the general public for their mental and physical wellness. I refer to the healthcare system as a whole, including interworking parts from financial flow to provider practices. Its makeup includes payment sources, government tax or private insurance disbursement, and healthcare providers. Public funding and private insurance combine to drive this web of service for our physical and behavioral needs.

In short, it is driven by money. Money comes from the government, privately funded plans, and payments. IPSO reports the primary source of this funding comes from out-of-pocket payments and market provision of coverage. Most of us use insurance.

Money drives the economy. Medical workers have to make a living at what they do.

This is not bad. It’s simply a part.

This chart broadly explains the setup:

According to the International Society for Pharmacoeconomics and Outcomes (ISPO) (2023), “The United States (US) has a population of over 330 million people and is supported by one of the most complex healthcare systems in the world, formed by intertwining relationships between providers, payers, and patients receiving care. The US healthcare system is in a constant state of evolution.”

I interpret this as unstable.

Source: Reinhardt UE. The Money Flow From Household to Health Care Providers (2011)⁴

What’s wrong with insurance?

It’s not just insurance. The policies and practices get in the way.

This current healthcare system is akin to a wrecking yard.

The United States keeps piling rules onto an already broken system. Parts may work. You can go in, pull out, and reuse some components, but the whole itself is broken. But at the end of the day, you’re left with a big pile of garbage with few salvageable bits.

The newest changes come from the Affordable Healthcare Act (ACA), passed in 2010. This revolutionized our system, for better and for worse. More people can get better coverage because of these changes. You have access to preventative care without high copays, and there is no “maximum” coverage on procedures (Khawar, 2022).

While in college 20 years ago, the disaster plans that covered major occurrences were the only affordable options. Should I have to have brain surgery, they would cover all but $50,000 of the procedure, not much else- all for $500/month. This was not a great plan for someone making $25,000/year and spending $20,000 per year on college.

I didn’t have the option to stay on my parents’ insurance. Emancipated at 16 years old, I took what I could get from the insurance the restaurants I worked for offered if offered at all. There were no independent plans with long-term health coverage unless the company I worked for offered it. I paid cash or used non-profit facilities.

Insurances now have more controlled practices and accept a broader array of people. They cannot refuse someone for preexisting conditions. I was denied coverage having “depression.” That was severely misdiagnosed. PTSD and autism share similar behaviors with many other diagnoses, and the treatment regimens are incredibly different. No one asked questions, only prescribed for symptoms. A 10-minute conversation could have changed my life then.

We wonder why there is a mental health crisis today. Long-term stigmatization and avoidance of addressing our issues are actively exhibited daily through crises, like active shootings, drug overdoses, and other tragedies.

The fastest way to kill people is to ignore their addiction, and mental health conditions, and shame them for struggling. They will build hate and distrust for everyone, with no motivation to change.

I’ve seen it occur in real time, with people close to me.

Look at how effective that tactic has been so far. 160 mass shootings occurred in 2023 alone.

Note: this is not a plug for or against gun control. I will not debate that. That dismisses the big picture as the mental illness that drives a person to murder others would get expressed with or without firearms as evidenced by multiple similar tragedies in countries where firearms are not readily available.

Time cites several problems in their 2023 piece. “The Coming Collapse of the U.S. Healthcare System.” Many of the issues are rooted in the current business models used in hospitals and outpatient clinics. Those that worked overtime and dedicated themselves to helping the public during COVID were later granted layoffs due to lack of business. From the standpoint of individual healthcare workers, their appreciation came in the form of losing their jobs. From the standpoint of the hospitals and clinics that employed them, it was an effort to stay afloat financially and continue to stay open to provide medical care. Unfortunately, this discourages any loyalty to any position. Time also mentions the effects of burnout and how it affected the current staff crisis. As an issue prior to COVID, it caught fire during the crisis. Healthcare workers now choose to retire and work other positions rather than return to clinics. This wasn’t addressed until it became a primary reason for staff shortage, leading to a major shutdown for hospitals and other medical services. For the insurance companies, lost profits sounded the alarm.

Mental health in America sucks. We put it off and shamed it into silence until it festered into an undeniable problem. 21% of adults have at least one mental illness (Darice Warren, 2023). 55% of adults with mental illness have not received any treatment. Difficulties in accessing care block the majority from receiving the help they need. Lack of affordability, time to engage in the treatment, or awareness makeup this obstacle.

Money over Humanity

Slow to change, America’s healthcare system continues forward in the doldrums to prize money over human lives.

Business is an essential component of healthcare.

The question becomes where to draw the fine line between patient care and profit.

Dean T. Jamison writes in Disease Control Priorities in Developing Countries that improved health outcomes reduce economic spending. They quote, “These returns go far beyond the contribution better health makes to per capita income, which itself appears substantial.”

If we invested in people’s physical and mental health earlier, we would spend less long-term.

Jamison continues to dissect how improved health improves community and economic spending by assessing the areas of work productivity, economic welfare, and whether income or healthcare policies have an effect on lifespan. He quotes, “The magnitude across countries suggests important effects of a country’s health-related policies (Fuchs 1980; Oeppen 1999). This point bears reiterating in a slightly different way: income growth is neither necessary nor sufficient for sustained improvements in health. Today’s tools for improving health are so powerful and inexpensive that health conditions can be reasonably good even in countries with low incomes.”

You don’t have to pump money into the system to improve lives. Small tweaks, and you can create healthier populations sans additional financial factors that burden the system.

But, that’s not profitable.

Hospitals and clinics, whether for-profit or not, have narrow profit margins. So where does the money go?

9% of the population remains uninsured, despite how “affordable” this is (IPSO, 2023). The ACA aimed to relieve the strain of millions of Americans otherwise cut off from medical treatment for political and business-related reasons. Despite this, the mortality rate in the United States has increased. The average American’s lifespan has decreased from a high from 2012 to 2019 of 78.5-78.8 years to 76.5 years in 2023 matching levels from the year 2000 (CDC, 2023). This is of course multifactorial with COVID, but it does demonstrate that despite huge financial expenditures, the health of our population is not improving.

IPSO explains, “Hospitals are typically paid through a diagnostic-related group (DRG), which assigns a set payment amount for a particular condition or treatment sequence. Inpatient DRGs are widely used by the Centers for Medicare & Medicaid Services (CMS) and by many private payers as a payment scheme for hospitals. Rather than paying the hospital for a line-item list of procedures and medications, Medicare pays the hospital a fixed amount based on the DRG, regardless of the actual cost of treatment. The DRG-based payments cover accommodation costs in a hospital (ie, room and board, facility costs, etc), procedure costs, support staff (nurses, technicians, etc), and drug/medical device costs; however, this system does not include physician fees.”

Hospitals and doctors are reimbursed for the codes of the conditions they diagnose, not a flat fee.

There are many pieces to the puzzle. I own one, as a mental health provider.

There are several problems here.

To be continued in Systemic Failure of American Healthcare Part II: A System Not Set Up for Mental Health

References:

1. International Society for Pharmacoeconomics and Outcomes. “US Healthcare System Overview-Background.” (2023). Retrieved from: ispor.org/heor-resources/more-heor-resources/us-healthcare-system-overview/us-healthcare-system-overview-background-page-1
2. Khawar, Ali. Reflecting on how the Affordable Care Act Changed Health Coverage; 2022. Accessed from: https://blog.dol.gov/2022/03/23/reflecting-on-how-the-affordable-care-act-changed-health-coverage
3. Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006. Chapter 1. Available from: https://www.ncbi.nlm.nih.gov/books/NBK11754/ Co-published by Oxford University Press, New York.
4. https://www.dataversity.net/diagnosis-fraud-how-data-science-can-diagnose-healthcare-fraud-and-identify-dirty-doctors/
5. Hoffman, K. Addiction and Autism. March 23, 2023; https://www.addictionhelp.com/addiction/autism/
6. Szalavitz, M. March 2, 2017. The Hidden Link Between Autism and Addiction. Accessed from: https://www.theatlantic.com/health/archive/2017/03/autism-and-addiction/518289/
7. Gaurav, D. and Blaschka, T. “Diagnosis Fraud: How Data Science Can Diagnose Healthcare Fraud and Identify Dirty Doctors.” December 16, 2019. Accessed from: https://www.dataversity.net/diagnosis-fraud-how-data-science-can-diagnose-healthcare-fraud-and-identify-dirty-doctors/
8. Washington Post. “Declining life expectancy in the U.S.” 2023. Accessed from: https://www.washingtonpost.com/podcasts/post-live/declining-life-expectancy-in-the-us/
9. https://news.harvard.edu/gazette/story/2022/01/study-explores-autism-link-in-teens-treated-for-addiction/
10. Abelson, R and Sanger-Katz, M. “The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions.” October 8, 2022. Retrieved from: https://www.nytimes.com/2022/10/08/upshot/medicare-advantage-fraud-allegations.html
11. Kilbourne AM, Beck K, Spaeth-Rublee B, Ramanuj P, O’Brien RW, Tomoyasu N, Pincus HA. Measuring and improving the quality of mental health care: a global perspective. World Psychiatry. 2018 Feb;17(1):30-38. doi: 10.1002/wps.20482. PMID: 29352529; PMCID: PMC5775149.
12. BBC. How many US mass shootings have there been in 2023? April 17, 2023. Accessed from: https://www.bbc.com/news/world-us-canada-41488081
13. Warren, D. “The State of Mental Health in America 2023: Adult Prevalence and Access to Care.” Next Step Solutions. Accessed from: https://www.nssbehavioralhealth.com/nss-blog-the-state-of-mental-health-in-america-2023-adult-prevalence-and-access-to-care/#:~:text=Key%20Takeaways%20from%20the%202023,adults%20experience%20severe%20mental%20illness.