The most obvious impact from health care reform to the U.S. uninsured population is giving them insurance. ACA reforms will provide insurance to 32 million people who previously were not insured (Alliance for Health Reform, 2011). This provides access to preventive care, primary care physicians to help guide health care decisions and wellness, as well as coverage for urgent care needs so they can be seen in a timely manner in the appropriate venue rather than waiting until the situation is dire and much more expensive to treat.

Rising costs to businesses mandated to provide employee insurance drives up the cost of doing business and impacts their economic viability. Some may choose to not offer insurance or to reduce workforce and avoid penalties. With fewer employers offering insurance, people will have to rely on health exchanges and state-run insurance programs. Currently, private pay insurance is expensive.

Public changes to health care models mean that as more individuals gain access to insurance coverage for medical care, the base of private primary care providers shrinks. Current ACA reforms call for 32 million new people who previously did not have health care insurance to become insured (Alliance for Health Reform, 2011). Conversely, economists say a third of physicians could retire in the next 10 years, and fewer people are seeking to practice in primary care due to the pay not covering the costs of their student loans (Alliance for Health Reform, 2011). Depending on the level at or how the government funds care for these individuals, some private physicians may choose not to accept patients with government payers, which also could limits access to care.

Another proposed change -- expand the scope of practice among nurses – can counteract the physician shortage. Reforms propose to increase the scope of practice for advance nurse practitioners. Currently, what they can do with and without physician supervision varies from state to state. The ACA creates a $50 million grant program to support nurse-managed clinics (Alliance for Health Reform, 2011).

A number of quality improvements will directly impact the uninsured and have the potential of greatly reducinghealth disparities. I will outline a few of the reforms that most piqued my interest:

  1. Requiring insurers to cover (without cost sharing)women’s preventive health care including screenings for cervical cancer, prenatal care and mammography throughout a woman’s life (, 2010). More women can experience better health outcomes through early detection and intervention.
  2. Reducing payment to hospitals for preventable hospital readmissions for certain disease states (, 2013). This measure forces hospitals to examine their plans of care to find the best practices for delivering care, which benefits the uninsured as well as the insured.The reduction in disparity comes in that the burden of bouncing in and out of a hospital is likely much greater to uninsured individuals with unstable housing, limited economic resources and small support systems.
  3. Providing incentives for private health systems and physician groups to adopt the Accountable Care Organization concept and implement the patient-centered medical home (Report to Congress, p. 12). Through the ACOs, providers should be able to focus more on providing higher-quality care to a patient population with coordination and cost-effectiveness in mind. If this means physicians will focus on keeping patients healthy for life rather than treating the symptoms to cure an illness today, I’m all for it. If the uninsured who become newly insured receive care through an ACO, they will reap these benefits.

If universal health insurance is offered to all citizens in exchange for payment, but those citizens are given the choice of whether to enroll, some will opt out. Those who believe they are at low-risk for illness and injury may not want to spend their money on a product they don’t think they’ll ever need (Gruber, p. 6). Some people who have catastrophic illness will choose to not purchase insurance because they know the hospitals where they seek care provide “uncompensated care.” Federal law requires hospitals that participate in Medicare programs to treat any person that comes to the hospital in an emergency (Gruber, p. 7).

I also believe restricting a segment of the population – illegal immigrants – means people still will live in this country without access to insurance or care.

From purely a personal analysis, I would say the United States allows the uninsured to exist because we created the country on certain “unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness (Declaration of Independence, 1776). In the freedom to use one’s best efforts to pursue happiness, a lifestyle, a career and an economic situation of our choosing, people cling to the concept that you work hard for what you get. If you don’t work, you don’t get. Some attitudes have changed with social reforms and the introduction of Medicare, Medicaid and welfare programs. However, the unwillingness to let go of those values has prevented the country from recognizing whole heartedly the importance and benefits of making health care an unalienable right for all.


Alliance for Health Reform, (2011). Health care workforce: future supply vs. demand. Retrieved from

Centers for Medicare & Medicaid Services (2013). Readmissions reduction program. Retrieved from

Gruber, J. (2008). Covering the uninsured in the United States. Journal of Economic Literature Vol. XLVI Retrieved from

Gwinnett, B., et al, (1776) Declaration of independence, The Charters of Freedom: A New World is at Hand. Retrieved from

U.S. Department of Health and Human Services (2011). Report to Congress, National strategy for quality improvement in health care. Retrieved from

U.S. Department of Health and Human Services (2010). Women’s preventive services guidelines. Retrieved from

Squale Reply#1

Expanding insurance coverage to the previously uninsured is a step in the right direction toward improving the U.S. health care system. As Leah noted, it will require an increased investment to pay for more providers to meet that demand. Not only is the supply of physicians and nurses pressured by increased numbers of newly insured, they face a large percent of their workforce nearing retirement and the greying of America with 78 million baby boomers reaching 65 by 2030 (Alliance for Health Reform, 2011). That pattern of increasing demand and diminishing supply seems unsustainable.

One area worthy of more focus is in reducing the consumption of health care. That means lowering the rates of preventable chronic diseases. About 600,000 people (one in four) die of heart disease each year in the United States (CDC, 2013). In 2010, about 18.8 million people in the United States had been diagnosed with diabetes (CDC, 2011). More than 795,000 people have a stroke every year in the United States (CDC, 2013). Each of those conditions includes a number of cases that are due to lifestyle choices. Each also contributes greatly to the total of U.S. expenditures on health care. The United States spent $2.7 trillion on health care in 2011 (CMS, 2012).

Here are examples of what the country spends to treat these three chronic conditions:

  • $108.9 billion a year on coronary heart disease (including health care services, medications, and lost productivity. Heart disease accounts for one in four deaths annually (CDC, 2013).
  • $174 billion in 2007 in direct and indirect costs for people with diabetes (CDC, 2011).
  • $38.6 billion annually to care for health services, medication and missed days of work due to illness for people who suffer stroke (CDC, 2013).

In addition to addressing chronic disease, the United State must ask itself some very difficult questions regarding end of life care. More studies promote the benefits of hospice and palliative care and end-of-life planning in terms of quality of life for the patients and families as well as reduced costs. However in 2011, 28 percent of Medicare expenses, or $170 billion, was spent on care for patients in their last six months of life (Pasternak, 2013).

At the other end of the life cycle, I read parts of a 2008 paper from Harvard Law, “The Costs of Multiple Gestation Pregnancies in Assisted Reproduction” that explained the financial impacts of delivering multiples after fertility treatments (Velikonja, U., 2008). To be honest, I couldn’t read the whole thing because the concept of restricting that reproductive freedom made me cringe. Still, the author compared laws that address the practice in the United States and foreign countries and weighed financial implications.

I do see that direction as way too controversial for any U.S. Congressman to explore, though.


Alliance for Health Reform, (2011). Health care workforce: future supply vs. demand. Retrieved from

Centers for Disease Control and Prevention (2013). Heart disease facts. Retrieved from

Centers for Disease Control and Prevention (2011). 2011 National diabetes fact sheet. Retrieved from

Centers for Disease Control and Prevention (2013). Stroke facts. Retrieved from

Centers for Medicare and Medicaid Services (2012) National Health Expenditures fact sheet. Retrieved from

Pasternak, S., (2013) End-of-life care constitutes third rail of U.S. health care policy debate. Retrieved from

Velikonja, U. (2008) Harvard Law School, Retrieved from


Part of my job involves sharing positive stories of the delivery of care within our hospital system or great patient success stories. Recently a nurse emailed me from one of the rural facilities to tell me about caring for a high-risk obstetrics patient. The patient came to the hospital in her second trimester and in labor. This critical-access facility and the obstetrician on call worked over two days to stop the labor and stabilize the patient for transfer. The nurse was very proud of all the work that team had done.

I said it sounded like a great patient story and asked if they could follow up with the patient’s doctor, who might find out if she was doing well and would like to share her story. The doctor returned the message to me directly.

He didn’t know. Once the patient arrived at the second hospital, she left. He hadn’t heard from her since.

The acronym colleagues use to describe this situation is AMA or Against Medical Advice. My point in is despite efforts of the health care system to inspire, educate, equip and remind patients of the best course of action to improve or sustain health, human beings go Against Medical Advice. That might mean leaving the Emergency Department without recommended stitches, skipping a refill of blood pressure medication, or failing to get a colonoscopy when it’s a recommended procedure for someone with a family history.In Colorado, the percentage of adults aged 50-75 who said they were up to date with their recommended colorectal cancer screenings was between 63.6% to 68.9% (CDC, 2012). Based on the map displayed, screening rates are higher among residents on the East and West coasts, the southern Rocky Mountain States and Minnesota, Wisconsin and Michigan. Much of the center of the United States shows rates no higher than 63.5% compliance (CDC, 2012).

I enjoyed reading the explanation provided in a Boston Globe column written by physician Suzanne Koven, “Why patients don’t always follow doctor’s orders,” (Koven, 2013). She explores the idea of why patients don’t follow the advice of their physicians and ultimately determines that as with many other issues in the United States, it’s about personal freedom. In this case, it’s the freedom to decide for oneself when to follow doctor’s order. Whether that’s the smartest choice depends on the individual.


Centers for Disease Control and Preparedness (2012) Colorectal Cancer Screening Rates. Retrieved from

Koven, S. (2013) Why patients don’t always follow doctor’s orders. The Boston Globe. Retrieved from


So far, my only care experience with a provider other than an MD or a D.O. has beenwith a physician’s assistant in our local Emergency Department: Once for stitches to the head of my then 18-month-old, and once to track the whereabouts of a small pen battery that had been swallowed by my then 5-year-old. The first visit was scary and he provided a calm I needed. The second time was much more confusing and he provided the information and recommendations from evidence-based research that helped us resolve the situation. He also provided the little hat and rubber gloves I would need over the next seven days. At either time, I don’t think it occurred to me that he was a P.A. as opposed to an MD or D.O.

I also work with a number of nurse practitioners who seem to take lead positions in outreach clinics – breast health, heart failure, anticoagulation, outpatient oncology services. As physician extenders, the nurse practitioners bring a talent to their roles of being able to coordinate the clinical aspects of care as well as the social and psychological needs of the patient.

Most importantly, providers of any discipline must be held to a high-standard of excellence not only in clinical knowledge, but also in ethics and commitment to putting the patient at the center of care. I am grateful that I have the opportunity to meet and work with providers whom I trust and feel most comfortable.