A Prescription for The US Healthcare System: Exploring Policy Interventions Designed to Assist Medically Underserved Areas (MUAs) and Populations
Wasan Rafat
Introduction
The United States, despite its position as the largest economy in the world, is also home to severe and systemic income inequality. In recent decades, average household income has increased across socioeconomic levels, yet the majority of this growth has remained concentrated among the wealthiest.1 Such economic disparities pervade the daily lives of the most vulnerable, limiting their access to resources such as healthcare and education. In doing so, economic inequality becomes entrenched and cyclical, deteriorating the quality of life for generations. We see the lasting effects of income and resource inequality today, with the prevalence and persistence of medically underserved areas (MUAs) and populations. MUAs are places that lack access to medical care due to a host of factors, including socioeconomic barriers and geographic limitations. MUAs are typically those without nearby healthcare infrastructure; for instance, rural areas have had their hospitals gutted due to lack of funding, forcing them to withdraw certain services or close entirely.2
Similarly, medically underserved populations are groups of people — both within and outside of MUAs — that cannot obtain safe and affordable healthcare services. Among these populations are the elderly, those living in rural areas, and those either near or below the federal poverty line. The federal and state governments as well as local communities must take measures to remedy the harsh reality that many of their constituents are deprived of access to necessary healthcare. In particular, healthcare access must be promoted by expanding welfare programs, addressing the hospital and physician shortage, and embracing new forms of healthcare that promise broader availability and affordability.
What Does Sufficient Access Look Like?
To explore potential solutions, the current status of the healthcare system must be contrasted with its idealized counterpart — an accessible system wherein each individual receives sufficient care. According to Georgetown University's Center on Health Insurance Reforms, healthcare access can be broken down into five components: availability, accessibility, accommodation, affordability, and acceptability (originally devised in 1981 by Roy Penchansky and J. William Thomas).3 An ideal healthcare system will ensure that all of these standards of care are met and, if possible, exceeded. This entails having healthcare providers available to see patients and ensuring that patients feel safe and comfortable with the doctors accessible to them.
Beyond the patient-provider relationship, an effective healthcare system is one where patients are situated geographically close to available health infrastructure, such as hospitals, to seek care when needed. On the provider side, healthcare networks must also have the time and capacity to treat everyone seeking care, as well as facilitate scheduling appointments for patients. Finally, an ideal healthcare system will never turn an individual away from necessary care due to a lack of funds; patients should be able to access care regardless of their financial standing, whether that involves out-of-pocket costs, welfare coverage, employee-based insurance, or another method entirely. Historically, the United States government has implemented policy interventions designed to assist medically underserved areas and populations, such as the social service programs Medicaid and Medicare and legislation encouraging growth of telehealth to circumvent existing barriers to access.4
Medicaid and Medicare were first introduced in 1965 under President Lyndon B. Johnson, and have since grown to provide insurance for over a hundred million Americans.5 The federal government also implemented the Children’s Health Insurance Program (CHIP) in 1997 to ensure that children still received healthcare coverage, even if their families did not qualify for Medicaid. 95% of children with Medicare or CHIP have regular access to healthcare insurance, which is comparable to the 97% of children with private insurance and a significant increase relative to the 69% of children without insurance.5,6 In terms of accessibility and contentment, those under Medicaid rank similarly to those with private insurance, though the uninsured are considerably worse off. Access to government-funded health insurance has tangible benefits for accessible and affordable care. Thus, to address growing income inequality and its lasting effects on healthcare access, the government must expand existing services so that fewer individuals fall under the uninsured category. Doing so would prove a massive step in the right direction, reducing the number of individuals medically underserved due to the cost of healthcare.
Healthcare Reimagined
An exploration of the current state of healthcare is incomplete without examining the rise of medical technologies that have redefined its landscape. Telehealth – the use of technology to provide healthcare services from a distance – has existed in various forms since the early 1900s, yet rapidly increased in popularity throughout and following the COVID-19 pandemic.7,8 As schools and workplaces transitioned to online communication in an attempt to avoid exposure to the virus, so too did doctor’s appointments. Now, doctors can offer consultations, perform examinations, and decide treatment plans remotely. This option proves especially useful in rural areas, where distance to the nearest healthcare provider is one of the largest barriers to seeking and receiving quality care. For the average rural resident, the nearest hospital is 10.5 miles away, compared with 4.4 miles for those in urban settings.9 Moreover, thirty percent of those in rural areas lack access to any public transportation options.10 Thus, the reality is that many in rural areas forgo care due to their geographic limitations. Expanding telehealth services to medically underserved rural communities could allow those who would otherwise go without healthcare services to access them relatively easily.
The accessibility of telemedicine services themselves, however, remains an issue. In rural areas, only two-thirds of households have broadband internet access, which is far lower than the 98% of households in urban areas which have broadband access.11 Thus, telehealth, although an effective substitute for in-person services that may be difficult to reach, remains inaccessible for many rural residents. Local governments should provide the tools for patients to access healthcare services online, such as iPad and computer loaners. Also, there must be a stride at the state and federal level to ensure that rural residents have fast access to a hospital or clinic, both for emergencies and so that patients do not have to rely on online services if they would prefer to see their healthcare provider in person.
The Importance of Addressing Disparities & How to Start
The issues outlined in this paper are and should be considered a matter of great legislative concern, on both the state and federal levels. Response measures must be comprehensive, well-designed, swift, and context-specific. Each medically underserved area and population must be assisted in a nuanced manner, befitting their specific needs and circumstances. Policymakers must first start by increasing funding to social insurance programs such as Medicaid, CHIP, and Medicare, so as to expand the number of beneficiaries they can serve. It is empirically evident that beneficiaries of government-sponsored healthcare have similar access to care as those under private insurance, and significantly outpace the uninsured. Simultaneously, governments should support telehealth services by ensuring sufficient technology and internet access for those living in MUAs. Telehealth can help bridge the accessibility gap, particularly for populations whose lack of access is a result of geographical barriers, such as in many rural areas. Already, the tangible benefits of both government-sponsored healthcare and telehealth services can be seen. Thus, the onus falls on local, state, and federal governments to build a future where every individual, regardless of location or socioeconomic status, can access quality healthcare.
About the Author
Wasan Rafat is an undergraduate student at Harvard University planning to concentrate in Human Developmental and Regenerative Biology. Specifically, she is interested in exploring stem cell biotechnology and advocating for equitable health policies.
References
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In 2023, the number of undocumented immigrants, or UIs, crossing the U.S.-Mexico border was at an all-time high, with 250,000 border crossings in December alone. Upon arriving in the United States, however, many migrants are met with a harsh reality: they have little to no access to medical care.