Regulating Health Insurance and Health Services-Nursing Paper Examples

Question 1 (Regulating Health Insurance-Nursing Paper Examples)

1. Discuss controversies surrounding the development of the government\’s role in providing, financing, and regulating health insurance and health services. Include in your discussion the economic reasons for government intervention in a market-based healthcare system. Please be sure to incorporate the reasons identified in your text as well as any additional reasons you wish to provide. Provide a critique of these reasons.

The government plays an instrumental role in health development by bolstering health systems and the generation of human, financial, and other resources. By so doing, the healthcare systems achieve their goals of improving health, and improving and maintaining health equity in financing and addressing population needs. Besides healthcare systems, the government should address social, economic, and environmental factors contributing to improved health outcomes (Regulating Health Insurance-Nursing Paper Examples).

The government collaborates with nongovernmental organizations, the private sector, and charitable organizations towards health development. The government plays a central role in shaping different healthcare aspects in the health sector. Strong leadership aided through setting clear directions to pursue common aims, consistent policies and practices across government programs and functions raise the quality of care for the different program’s beneficiaries (Regulating Health Insurance-Nursing Paper Examples).

As such, the government maximizes its unique position as a healthcare purchaser, regulator, healthcare provider, and sponsor of health services. The government also plays a vital role in healthcare financing. The government mobilizes various resources through the public budget and pools resources necessary for healthy development. For instance, the government levies taxes, benefits from natural resources, and promotes healthy development through education and socioeconomic development (Regulating Health Insurance-Nursing Paper Examples).

The government has healthcare programs that serve older people, Persons with Disability (PWDs), low-income mothers and children, active-duty military personnel and their dependents, veterans, and Native Americans. Older people, Persons with Disability (PWDs), low-income mothers, and children are covered. Their healthcare markets have historically failed due to the high demand for health services and low-income socioeconomic factors. In contrast, active-duty military personnel and their dependents, veterans, and Native Americans are covered by special relationships with the government (The Commonwealth Fund, 2023) (Regulating Health Insurance-Nursing Paper Examples).

In this case, Medicare covers older people, and Persons with Disability (PWDs), Medicaid covers low-income mothers and children, while the Children’s Health Insurance Program (CHIP) covers children. DOD TRICARE, VHA, and HIS cover active-duty military personnel and their dependents, veterans, and Native Americans. However, major controversies arise in healthcare coverage based on who and how it is paid for, what services are covered underlying costs relating to lowering the cost or utilization of healthcare services (Regulating Health Insurance-Nursing Paper Examples).

 The government ranks Healthcare as a major healthcare issue reflecting that it is a major expense for many individuals. The government has different proposals to change coverage through policies to expand its role in health coverage while reducing the number of uninsured people (Regulating Health Insurance-Nursing Paper Examples).

However, the government’s role in lowering the underlying care costs through reducing the prices and reducing utilization of services comes with trade-offs. The main role of healthcare coverage is to insulate people from healthcare cost burdens while facilitating access to quality care. Thus, the government formulates or passes policies that affect how people get health insurance, how the insurance is paid for, and what healthcare services are covered (Regulating Health Insurance-Nursing Paper Examples).

There are contentious debates on how the government can reduce the number of uninsured individuals. The government decides whether the people continue to obtain coverage through their employees, whether the health insurance deductions are too high and expensive, or how to modify or change premiums required under the provided coverage programs. Most governmental health coverage policies change how people and families pay for healthcare services (Regulating Health Insurance-Nursing Paper Examples).

The policies generally change how the government-sponsored programs pay on the people’s behalf or change how healthcare burdens are shared between individuals between people with small and large healthcare needs. However, some government proposals change underlying healthcare costs by reducing the number of healthcare services received or the costs paid. Although the mentioned policies could potentially reduce healthcare spending in the entire health system, they are often easier said than done.

Globally, a free healthcare market is nonexistent. A free market does not work well as it does not guarantee that people can access and afford care. One of the economic reasons for government intervention in Healthcare is to prevent market failure. The intervention may be administered through subsidies, taxes, regulations, and direct services. The subsidies are mostly for older people, persons with disability, and children (Regulating Health Insurance-Nursing Paper Examples).

Another economic reason for government intervention in Healthcare is to create a value-based system. In a value-based healthcare system, consumers can judge the value of their health services (Moriates et al., 2019). On the contrary, a free market would result in substandard services and exorbitant prices. Through taxes and budget regulations, the government regulates and controls healthcare spending that can impact the nation’s GDP spent on Healthcare (Regulating Health Insurance-Nursing Paper Examples).

The government continues increasing the number of people with health insurance to achieve universal coverage. Over 90% of Americans have healthcare insurance (The World Health Organisation, 2023). Most people are covered by their employers; some obtain health coverage from government programs such as Medicare and Medicaid, while others buy their insurance from the individual markets. Different stakeholders, such as government, policymakers, private insurance companies, and consumers, see varying problems in how people obtain health insurance and correspond by proposing different solutions (Regulating Health Insurance-Nursing Paper Examples).

 First, some policymakers and health consumers perceive that the current government health coverage programs are inappropriate, burden the taxpayers, and are overly generous. Thus, the policymakers propose that the government narrow the eligibility or reduce the generosity of government programs such as Medicare and Medicaid and other programs subsidizing individual market coverage (Young & Fielder, 2019). Although fewer people will have health coverage, some insurance will become less generous, reducing healthcare spending (Regulating Health Insurance-Nursing Paper Examples).

Other proposals relate to reducing the number of uninsured people or minimizing the burden people experience from the premiums and cost-sharing. As such, different policymakers and consumers propose changes that will broaden the eligibility for the current coverage programs or make them more generous, although it will increase the government’s healthcare spending (Regulating Health Insurance-Nursing Paper Examples).

Subsequently, other proposals majorly focus on the people who do not have healthcare insurance or encounter healthcare cost burdens. Some stakeholders suggest the government should look for a single health insurance program. In this case, there are proposals for the government to increase the funding of a program like Medicare to insure all Americans (Regulating Health Insurance-Nursing Paper Examples).

 Subsequently, there are controversies on how the government should reduce the underlying health costs. The number of services patients receive and the costs incurred for services delivered primarily determine health spending. While there are agreements that some health services are unnecessary and that the costs of some services are unnecessarily high, there exists immense disagreement on the strategies on how to address the problem. The main challenge the government encounters in regulating the volume of services is discouraging the delivery of less valuable services without limiting the health service delivery (Regulating Health Insurance-Nursing Paper Examples).

First, the government can offer financial incentives for health providers directed towards eliminating unnecessary services by paying them through the cost incurred instead of the number of services delivered (Yabroff et al., 2019). Thus, the government will reduce the utilization of health services without harming patients’ health. Secondly, the government can require the consumers to bear most of their care costs through increasing cost sharing to become more cost-conscious and forego low-value healthcare costs.

 The government also contributes to the lowering of healthcare prices. The government’s strategy to address high prices is to make the healthcare markets more competitive. In this case, the government blocks mergers, encourages new entrants in the health industry, and policies anti-competitive behavior by healthcare providers. Transitioning into a single-payer system will allow the government full control over healthcare prices. Importantly, the government can also regulate health prices directly (Regulating Health Insurance-Nursing Paper Examples).

Conclusion

 The government plays an instrumental role in health development by bolstering health systems and generating human, financial, and other resources. The government also takes maximal advantage of its unique position as a healthcare purchaser, regulator, healthcare provider, and sponsor of health services to regulate the accessibility and affordability of Healthcare (Regulating Health Insurance-Nursing Paper Examples).

Through taxes and budget regulations, the government regulates and controls healthcare spending that can impact the nation’s GDP spent on Healthcare. The government addresses high health prices by making the healthcare market more competitive. Regardless of how the government targets reducing health pricing, it should balance saving and reducing the prices too low, thus affecting the quality of care and its accessibility (Regulating Health Insurance-Nursing Paper Examples).

References

Moriates, C., Valencia, V., Stamets, S., Joo, J., MacClements, J., Wilkerson, L., … & Cox, S. M. (2019). Using interactive learning modules to teach value-based health care to health professions trainees across the United States. Academic Medicine, 94(9), 1332. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6727932/

The Commonwealth Fund (2023). How does Universal Healthcare Work? https://www.commonwealthfund.org/international-health-policy-center/system-features/how-does-universal-health-coverage-work

The World Health Organisation (2023). Universal Health Coverage. https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(UHC)

Yabroff, K. R., Gansler, T., Wender, R. C., Cullen, K. J., & Brawley, O. W. (2019). Minimizing the burden of cancer in the United States: Goals for a high‐performing health care system. CA: a cancer journal for clinicians, 69(3), 166-183. https://acsjournals.onlinelibrary.wiley.com/doi/full/10.3322/caac.21556

Young & Fielder (2019). Current debates in health care policy: A brief overview. https://www.brookings.edu/policy2020/votervital/current-debates-in-health-care-policy-a-brief-overview/

Question 2

2. Discuss the structure, conduct, and performance of the pharmaceutical industry. How do its structure, conduct, and performance impact patients? Given the structure, conduct, and performance of the pharmaceutical industry, predict the responsiveness of the industry to a common disease as compared to a very rare disease. Assume both diseases have very similar impacts on patients.

The structure of the pharmaceutical industry is oligopolistic owing to its high-profit nature and immense price variation within the market. The industry is highly concentrated on heavy product differentiation leading to very high competition (Florio & Gamba, 2021). Critics claim that high and illogical pricing leads to unethical product marketing and sales marked by the rise of unsafe and ineffective medication in the market.

The pharmaceutical industry is structured in different operational wings. The industry has research, development, pricing, profit, and drug promotion wings. The industry also has a wing that interacts directly with consumers, the local pharmaceutical stores. The mentioned wings have different roles and functions within their jurisdiction to deliver quality and safe medications for the people. The government formulated regulations to govern these structured pharmaceutical wings.

The U.S. is one of the leading global pharmaceutical markets based on conduct and performance. However, the relationship between healthcare professionals and pharmaceutical businesses leads to a conflict of interest between both parties. However, the conduct of both parties should be governed by their respective ethical standards and guidelines (Borysowski & Górski, 2019).

One problem in the conduct of relevant stakeholders in the pharmaceutical industry is the rise in opioid use in different parts of the nation. The rise in medication prices, unethical competition leading to the rise of unsafe and ineffective medications, and corporate portray miscounts harm the pharmaceutical industry’s performance.

Subsequently, the pharmaceutical industry has become an absorber of consumers’ money instead of quality, effective, and affordable medication for the public. The industry’s problem can be realized during an outbreak of different diseases. For instance, during disease outbreaks, less severe conditions appear catastrophic for the consumers to spend much money while seeking Healthcare through purchasing medications.

Although rare diseases may have similar impacts on the patients, they are made to appear life-threatening even if they are not, so consumers can also spend more on drugs offered for the illness. The response to a rare disease will be slower than a common disease despite having a similar effect. Pharmaceutical companies will profit more from common illnesses than from rare ones. They will respond quickly to reap the profits while waiting for the government’s strategy during a rare disease.

References

Florio, M., & Gamba, S. (2021). Biomed Europa: after the coronavirus, a public infrastructure to overcome the pharmaceutical oligopoly. Annals of Public and Cooperative Economics, 92(3), 387-409. https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/apce.12341

Borysowski, J., & Górski, A. (2019). Compassionate use of unauthorized drugs: legal regulations and ethical challenges. European Journal of Internal Medicine, 65, 12-16. https://www.sciencedirect.com/science/article/abs/pii/S0953620519301141

Question 3

3. Some view the healthcare systems of other developed countries as reasonable models for the reform of the U.S. healthcare system. Choose one of the healthcare systems covered in chapter 14 of your text and describe it in some detail. Provide reasons why you consider it a workable or unworkable model for the United States.

Enacted in 2010, the Patient Protection and Affordable Care (ACA), also known as Obamacare, revolutionized the distribution of Healthcare in the United States. The act increases health insurance coverage for uninsured individuals and implements reforms in the health market. The law has three primary goals. First, the act makes affordable health insurance accessible to more people in the U.S.

The law provides health consumers with subsidies (premium tax credits) to reduce health costs for households with Federal Poverty Levels (FPL) income from 100% to 400%. Secondly, the law also expanded the Medicaid program to provide health insurance for people with income 138% below the FPL (Shupe, 2023). However, not all States have expanded the Medicaid program. Lastly, the reform supports innovative healthcare delivery methods to lower the overall cost of care.

The Affordable Care Act (ACA) is workable for the United States, making health insurance more accessible and affordable. By 2014, about 5 million people had benefited with about $4700 from cost deductions sharing and premium tax credits (U.S. Department of Health and Human Services, 2023). The number of people covered by ACA has continued to increase over the years and is expected to increase. For instance, the number of uninsured people approached an all-time low towards the end of 2012 owing to an increased number of people selecting the ACA.

President Biden’s administration announced a record-breaking of about 16.3 million people selecting Affordable Care Act market health plan during the nationwide 2023 Marketplace Enrolment Period (MEP) that took place between November 1, 2022-January 15, 2023, for the majority of marketplaces in the United States (U.S. Department of Health and Human Services, 2023). Therefore, the increased number of insured people implies that the ACA over the years implies the more Healthcare is made accessible and affordable, the more it continues to attract more people.

The United States government’s continued commitment to improving the Affordable Care Act will ensure coverage of as many people as possible. Through comprehensive ACA coverage, the government will make comprehensive health services accessible and equitable for all people promoting healthier communities.

References

Shupe, C. (2023). Public Health Insurance and Medical Spending: The Incidence of the ACA Medicaid Expansion. Journal of Policy Analysis and Management. DOI:10.1002/pam.22435

US Department of Health and Human Services (2023). New Reports Show Record 35 Million People Enrolled in Coverage Related to the Affordable Care Act, with Historic 21 Million People Enrolled in Medicaid Expansion Coverage. https://www.hhs.gov/about/news/2022/04/29/new-reports-show-record-35-million-people-enrolled-in-coverage-related-to-the-affordable-care-act.html