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Healthcare in the U.S. is comprised of multiple payers (private insurers and government programs, including the ACA), confusing coverage rules, myriad delivery systems of varying quality, and a huge number of different state and national regulations. It’s no wonder people are confused and often misinformed about who pays for what, when, and how.

This confusion is not helped by the fact that the Affordable Care Act (ACA) is persistently labeled “Obamacare” which often seems like a deliberate attempt to politicize healthcare funding at a time when it needs to be focused on the needs of patients. It also provides a convenient ruse for politicians who want to obfuscate their support of insurance, pharmaceutical, and medical equipment companies who lobby for their own interests at patients’ expense.

What can we do to encourage awareness of healthcare insurance policies and legislative issues at the local and the national level? How can healthcare reforms, such as the move toward more integrated care, help bridge gaps between paperwork, bureaucracy, legislation, insurance shortfalls, and the pressure to increase the value and quality of care for patients? Here are some observations about how we got into this mess and some suggestions about what we can do to make things better moving forward.


Public opinion regarding federal healthcare funding

While out-of-pocket costs continue to increase, single-payer healthcare bills and similar proposals will likely garner support from the public. According to the Pew Research Center, a majority of Americans believe

[I]t is the federal government’s responsibility to make sure all Americans have healthcare coverage.”

At odds with this finding is the staunch opposition to government funding that exists among certain Americans, even some who have been driven into debt by medical expenses.

As Atul Gawande’s New Yorker article, “Is Health Care a Right?” points out, it almost seems to be a matter of principal for some individuals to reject any assistance from the federal government with regards to healthcare despite the fact that it is deemed reasonable and expected in almost all of the other countries in the industrialized world. Upon having to file for bankruptcy due to medical bills, Gawande notes that some people feel shame rather than frustration or anger over a corrupt and unfair healthcare system that puts beneficiaries at such horrific financial risk. As he writes, “Here [Athens, Ohio], self-reliance is a totemic value.”


What does medical tourism say about our healthcare system?

Concerns about today’s healthcare market are not limited only to those without health insurance. The very existence of a robust medical tourism industry reflects the need for a more affordable healthcare system even for those who have health insurance. This is because needed services may not be covered or may have unacceptably high out-of-pocket expenses that render them unaffordable.

For example, AMR Air cites a New York Times story about a man whose insurance plan didn’t cover the cost of his needed hip replacement so he flew to Belgium to have the procedure done instead. The surgery, plus the price of airfare and travel accommodations combined, cost him ~$13,000, a fraction of the U.S. cost of ~$100,000 for the surgery alone.

Comedian David Sedaris’ New Yorker story provides another example of how medical tourism has become “a thing”. He describes visiting a small community doctor’s office for dental care in France. He made it sound relatively inexpensive and painless compared to what would have happened if he tried to get the same dental procedure in the U.S. which would have necessitated a separate, and undoubtedly expensive, orthodontist referral. Though France may not be every American’s first choice for dental care, dental tourism among U.S. citizens is, in fact, alive and well. The most popular destination for orthodontic surgery is Mexico, followed closely by countries like Hungary, Thailand, and India.


The need for integrated care

Another trend that is becoming the norm as we slowly move toward value-based care and perhaps even comprehensive healthcare reform is integrated care, particularly the integration of mental health with physical healthcare. According to Colleen Clemency Cordes, who earned a Ph.D in counseling psychology from Arizona State University, integrated care is critical to “treating the mental health aspect of chronic health conditions like depression and anxiety, diabetes and irritable bowel syndrome.”

As the number of people living with multiple comorbid physical and mental health conditions continues to rise, it is increasingly important to ensure patients and teams of doctors, surgeons, case managers, nurse coordinators, and mental health professionals are able to effectively communicate with each other as well as with their patients, families, and caregivers. Good communication, including the use of electronic health records and other digital communication tools, can help prevent inadvertent prescription drug interactions as well as treatment plans that might be contraindicated if previously undisclosed health issues are now revealed.

Because of the ongoing stigma concerning mental health—especially among older generations—doctors and nurses must work with psychologists to spot undiagnosed anxiety, depression, or substance abuse that could interfere with or significantly hinder a patient’s improvement and eventual recovery. Fully integrated healthcare teams can work to ensure patients’ needs are met in ways that are more beneficial than when providers work in unconnected silos.


ACA enrollment & current legislation

The window for signing up for ACA-funding healthcare was shortened this year only lasting through the middle of December (12/15/17), it will take a combined, concerted effort from local public health officials, healthcare administrators, and other community healthcare workers to clearly inform the public of their healthcare insurance options.

Depending on their state of residence, prices for ACA plans may have gone up or down—it all depends upon whether their state’s legislators opted into the ACA-funded Medicare expansion for their state in the first place. The voters in some states, such as Maine, have voted to expand Medicare despite their legislators’ previous votes against optional expansion. Considering the determination on the part of the current administration to confuse constituents, many may not even realize ACA-funded healthcare is still an option for them. But, ironically, as the New York Times reports,

Republican attacks on the Affordable Care Act appear to be fortifying support for the law.”


The need to stay informed

Because it is so bewildering to keep up with the various arguments for and against healthcare-related legislation—especially since public health issues in the U.S. are so often politicized—it can be helpful for both patients and healthcare administrators to seek out healthcare legislation and policy information from foundations and organizations like the Healthcare Leadership Council, the Henry J. Kaiser Family Foundation, and The Robert Wood Johnson Foundation—as well as information about open enrollment with the Health Insurance Marketplace from the federal government.

Part of moving forward with comprehensive healthcare for all will undoubtedly involve addressing some of the self-defeating attitudes and cultural stigmas involving government assistance. We can work together to bypass politicization and false dichotomies by educating individuals about the best professional treatment and insurance options available to them.


  1. Would love to hear your perspective on how we can change the paradigm so that people understand healthcare not as a freebie or a hand-out but a fundamental right that they’re entitled to

    Daniel G

    • Daniel, I don’t know how to change brainwashing. It’s a deeply held belief for many that we are not entitled to anything that is free of charge. However, I’m hoping that the next generation helps to influence future trends. There are plenty of countries where people can access affordable health care, and more people are becoming aware of this due to the existence of medical tourism–e.g. U.S. citizens going to Mexico or India for affordable dental care.


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