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Policy Action Plan: Access to Healthcare

There are many reasons why an individual might not have access to healthcare but, one

main reason is lack of insurance. There are many uninsured people in the United States despite

the Affordable Care Act (ACA) and healthcare policies such and Medicaid being put in place

(Tolbert et al, 2023). In 2022, 25.6 million nonelderly individuals were uninsured which were

mostly low-income families that included African American and Hispanic because they claimed

the cost of coverage was too high (Tolbert et al, 2023). Even with having at least one person

working in the family the cost was still too high for most. Even when an employer offers health

care as a benefit, some individuals would rather have the money to pay for other expenses

(Tolbert et al, 2013). This can cause issues because most of the uninsured population are less

likely to receive preventive care for major health conditions or chronic illnesses (Tolbert et al,

2023). Most people have access to Medicaid or Medicare but, there are still stipulations to these.

Medicaid is limited in states that have not expanded which is only 39 in 2022 (Tolbert et al,

2023). Medicaid is also only eligible to lawful immigrants after they have waited five years or an

exception has been made for children or pregnant individuals (Tolbert et al, 2023). This causes

them to be hospitalized for things that could have been prevented if they had seen a regular

physician.

Lack of Access Leads to Overcrowding

According to the Bayhealth Community Health Needs Assessment of 2022,

approximately 151 million people visit the emergency department annually and of those, 27

percent could have been managed with a PCP. Of the 151 million people, 25 percent were

uninsured while another 35 percent were living below the poverty level. Delaware ranks 17th in

the list of highest rate of emergency room visits and 37th of preventable hospitalizations
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(Bayhealth CHNA, 2022). Most people will choose to go to an emergency department or urgent

care rather than a doctor’s office because of lack of health insurance or low income.

In 1986, Congress passed the Emergency Medicine Treatment and Active Labor Act

(EMTALA) which was originally an attempt to prevent what is known as “patient dumping”

(Warby et al, 2023). Patient dumping became a problem because hospitals would look to see if a

patient was uninsured and then transport them to another facility without considering the

patient’s medical stability or condition strictly for financial reasons (Warby et al, 2023).

EMTALA requires any hospital with an emergency department to provide an examination and

stabilize the condition of a patient regardless if they have insurance or not (Warby et al, 2023).

This creates and influx of patients to seek medical care at an Emergency Department which in

turn creates overcrowding, a 33 percent increase in wait times and tripled the number of

individuals leaving the Emergency Department before being seen, according to the AMA Journal

of Ethics.

Resources for Coverage

One reason there could be so many uninsured individuals is because they lack the

knowledge of no-or-low-cost coverage options (CMS, 2022). Nurses should be aware of the

different resources they can provide for their uninsured patients and educate the patient on those

options. One of these options include insurance Marketplaces which were created by the ACA.

The Marketplaces is where individuals can apply for and enroll in health insurance plans that are

affordable to them (CMS, 2022). American Indians and Alaskan Natives who are members of a

Federally Recognized Tribe can have zero cost-sharing plans or limited cost-sharing plans

available to them if they meet certain criteria (CMS, 2022).

Medicare and Medicaid are two other coverage options however, they both come with

limitations. Medicare is health insurance that usually only covers individuals 65 or older

however, certain people with disabilities under the age of 65 and individuals with end stage renal

disease may qualify as well (Medicare, 2023). There are four parts to Medicare that cover

different things but, note that Medicare does not cover all expenses so there are things that need

to be paid out of pocket or with supplemental insurance (Medicare, 2023). Medicaid is a program

that is both federal and state that will help pay medical costs for individuals with limited income

or resources (Medicare, 2023). Each states has their own requirements for who qualifies for

Medicaid however, individuals must be a resident of that state and a U.S. citizen (Medicare,

2023). Individuals who may qualify are people older than 65, younger than 19, pregnant, have a

disability, or and adult without any dependents (Medicare, 2023).

Ideas to Improve Access and Overcrowding

One way to improve access to healthcare is with the American Rescue Plan which is a

federal expansion of the ACA that extends assistance to individuals whose income may be over

the original ACA eligibility limits (Calsyn, 2022). It was estimated that with this change, 1.7

million more individuals would enroll in the marketplaces in 2022 (Calsyn, 2022). A way to

reduce premiums is with state reinsurance programs. There are currently 14 states that have

reinsurance programs that allow the insurers to be reimbursed for high-cost enrollees (Calsyn,

2022). Some states have lowered their premiums by 40 percent since the implementation and in

others it has been lowered by 10 percent (Calsyn, 2022).

Initiating Plan of Action

If I had time to have a face to face with individuals who can make change in policy, I

would talk to them about these programs. I would address the issue at hand and how it affects
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medical facilities such as emergency departments. Each state has their own affordability and

coverage challenges, and its representatives need to understand the barriers to health care

coverage in order to make change (Calsyn, 2022). Policymakers need to know the individuals not

just on who is uninsured but why. They need to get to know the residents of their state by

breaking them down in groups of income, immigration status, age, and location. With the

information above, policymakers can tailor a reform that would address specific challenges for

the individuals in their state (Calsyn, 2022). There should also be more coverage on the different

resources available to individuals such as the marketplace. Because I am the one initiating the

plan, I would volunteer to create a study to break down the uninsured individuals of the state into

the different categories. I would then reach out to the state representatives to see if creating a

reform would be beneficial. I would also create a survey to see how many individuals are aware

of the different coverage options and how to access them.

Resources

Access to Primary Care. Access to Primary Care - Healthy People 2030. (2022).

https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-

summaries/access-primary-care#:~:text=Primary%20care%20is%20critical%20for

%20improving%20population%20health%20and%20reducing%20health

%20disparities.&text=Therefore%2C%20addressing%20barriers%20to%20accessing,risk

%20of%20poor%20health%20outcomes.

Bayhealth. (2022). (rep.). 2022 Bayhealth KENT County CHNA (pp. 51–52). Dover, DE.

Calsyn, M. (2022, April 11). How states can build on the ACA to improve affordability and

lower health care costs. Center for American Progress.

https://www.americanprogress.org/article/states-can-build-aca-improve-affordability-

lower-health-care-costs/

Medicare and Medicaid. Medicare.gov. (2023, May).

https://www.medicare.gov/Pubs/pdf/11306-Medicare-Medicaid.pdf

Resources for the uninsured. Centers for Medicare and Medicaid Services. (2022, November).

https://www.cms.gov/marketplace/technical-assistance-resources/connecting-uninsured-to-

health-care-resources.pdf

Tolbert, J., Drake, P., & Damico, A. (2023, December 18). Key facts about the uninsured

population. KFF. https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-

population/
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Warby, R., Leslie, S., & Borger, J. (2023, November 22). Home - books - NCBI. National Center

for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books