argument essay on national healthcare

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Pro Universal health care would improve individual and national health outcomes. Since 2020, the COVID-19 pandemic has underscored the public health, economic and moral repercussions of widespread dependence on employer-sponsored insurance, the most common source of coverage for working-age Americans…. Business closures and restrictions led to unemployment for more than 9 million individuals following the emergence of COVID-19. Consequently, many Americans lost their healthcare precisely at a time when COVID-19 sharply heightened the need for medical services,” argue researchers from the Yale School of Public Health and colleagues. The researchers estimated more than 131,000 COVID-19 (coronavirus) deaths and almost 78,000 non-COVID-19 deaths could have been prevented with universal health care in 2020 alone. [ 198 ] Another study finds a change to “single-payer health care would… save more than 68,000 lives and 1.73 million life-years every year compared with the status quo.” [ 201 ] Meanwhile, more people would be able to access much-needed health care. A Jan. 2021 study concludes that universal health care would increase outpatient visits by 7% to 10% and hospital visits by 0% to 3%, which are modest increases when compared to saved and lengthened lives. [ 202 ] Other studies find that universal health coverage is linked to longer life expectancy, lower child mortality rates, higher smoking cessation rates, lower depression rates, and a higher general sense of well-being, with more people reporting being in “excellent health.” Further, universal health care leads to appropriate use of health care facilities, including lower rates of emergency room visits for non-emergencies and a higher use of preventative doctors’ visits to manage chronic conditions. [ 203 ] [ 204 ] [ 205 ] An American Hospital Association report argues, the “high rate of uninsured [patients] puts stress on the broader health care system. People without insurance put off needed care and rely more heavily on hospital emergency departments, resulting in scarce resources being directed to treat conditions that often could have been prevented or managed in a lower-cost setting. Being uninsured also has serious financial implications for individuals, communities and the health care system.” [ 205 ] Read More

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Exploring what works, what doesn’t, and why.

Healthcare is a human right – but not in the United States

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The Supreme Court’s ruling on Dobbs v. Jackson in June is just the latest blow to health rights in the United States. National medical associations in the U.S. agree that abortion is essential to reproductive healthcare. So why would abortion not be protected as such? Because the U.S. does not, and never has, protected a right to health.  

Good health is the foundation of a person’s life and liberty. Injury and disease are always disruptive, and sometimes crippling. We might have to stop working, cancel plans, quarantine, hire help, and in cases of long-term disability, build whole new support systems to accommodate a new normal.

The U.S. remains the only high-income nation in the world without universal access to healthcare. However, the U.S. has signed and ratified one of the most widely adopted international treaties that includes the duty to protect the right to life. Under international law, the right to life simply means that humans have a right to live, and that nobody can try to kill another. Healthcare, the United Nations says, is an essential part of that duty. In 2018, the U.N. Committee on Civil and Political Rights said the right to life cannot exist without equal access to affordable healthcare services (including in prisons), mental health services, and notably, access to abortion. The U.N. committee mentioned health more than a dozen times in its statement on the right to life.

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The bottom line is: the U.S. can’t claim to protect life if it fails to protect health. And it has consistently failed on all three of the U.N.’s measures— the latest being access to abortion.

In the U.S., our debates around healthcare, and especially abortion, are hampered by a lack of right to health. Instead, the Supreme Court in 1973 protected access to abortion through the rights to privacy and due process, not health. Privacy is mentioned only twice by the U.N. committee commentary on the right to life.

Since Dobbs, several state legislatures have declared it fair game to criminalize abortion procedures even in cases where pregnancy threatens maternal health or life. Despite ample evidence that restrictive abortion laws lead to spikes in maternal mortality and morbidity—core public health indicators—the Court prior to the Dobb’s decision has defended abortion as merely a matter of privacy, not health or life. We know this is a myth. Abortion is deeply tied to the ability to stay healthy and in some cases, alive.

Regardless, our political parties remain deeply polarized on access to healthcare, including abortion. But lawmakers should know there is historical backing in the U.S. for elevating a right to health. None other than U.S. president Franklin D. Roosevelt, first proposed healthcare as a human right in his State of the Union address in 1944, as part of his ‘Second Bill of Rights.’ His list featured aspirational economic and social guarantees to the American people, like the right to a decent home and, of course, the right to adequate medical care.

Eleanor Roosevelt later took the Second Bill of Rights to the U.N., where it contributed to the right to health being included in the Universal Declaration of Human Rights in 1948. The right to health is now accepted international law, and is part of numerous treaties, none of which the U.S. Senate has seen fit to ratify. The U.S. conservative movement has historically declared itself averse to adopting rights that might expand government function and responsibility. In contrast, state legislatures in red states are keen to expand government responsibility when it comes to abortion. The conservative movement condemns government interference in the delivery of healthcare—except when it comes to reproductive health. The American Medical Association has called abortion bans a “direct attack” on medicine, and a “brazen violation of patients’ rights to evidence-based reproductive health services.”

Excepting access to abortion, U.S. lawmakers have largely left healthcare to the markets, rather than government. True, the government funds programs like Medicaid and Medicare but these programs vary significantly in quality and access by state, falling far short of providing fair, equitable, universal access to good healthcare.

The only two places where the U.S. government accepts some responsibility for the provision of healthcare are 1) in prisons and mental health facilities; and 2) in the military. While healthcare services in the U.S. prison system are notoriously deficient, they nevertheless exist and are recognized as an entitlement, underpinning the right to life. As an example, in 2005 a federal court seized control of the failing healthcare system in California’s Department of Corrections citing preventable deaths. In the military, free healthcare is an entitlement, and the quality of that care is deemed good enough even for the U.S. president.

So why doesn’t everyone in the U.S. have the same rights?

It is an uphill battle in a country that sees health and healthcare as a private matter for markets and individuals to navigate. But if we want to improve public health in the U.S. we need to start legislating healthcare as a right—and recognize that achieving the highest possible standards of public health is a legitimate government function.

photo: Tony Gutierrez / AP Photo

More in Equity

We can’t fix health disparities we don’t see

Good health care is rooted in evidence. So is DEI.

Daniel Dawes on why Meharry is adding a school of global health

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• Universal Health Care

The Importance of Universal Health Care in Improving Our Nation’s Response to Pandemics and Health Disparities

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• Date: Oct 24 2020
• Policy Number: LB20-06

Key Words: Health Insurance, Health Care, Health Equity

Abstract The COVID pandemic adds a new sense of urgency to establish a universal health care system in the United States. Our current system is inequitable, does not adequately cover vulnerable groups, is cost prohibitive, and lacks the flexibility to respond to periods of economic and health downturns. During economic declines, our employer-supported insurance system results in millions of Americans losing access to care. While the Affordable Care Act significantly increased Americans’ coverage, it remains expensive and is under constant legal threat, making it an unreliable conduit of care. Relying on Medicaid as a safety net is untenable because, although enrollment has increased, states are making significant Medicaid cuts to balance budgets. During the COVID-19 pandemic, countries with universal health care leveraged their systems to mobilize resources and ensure testing and care for their residents. In addition, research shows that expanding health coverage decreases health disparities and supports vulnerable populations’ access to care. This policy statement advocates for universal health care as adopted by the United Nations General Assembly in October 2019. The statement promotes the overall goal of achieving a system that cares for everyone. It refrains from supporting one particular system, as the substantial topic of payment models deserves singular attention and is beyond the present scope.

Relationship to Existing APHA Policy Statements We propose that this statement replace APHA Policy Statement 20007 (Support for a New Campaign for Universal Health Care), which is set to be archived in 2020. The following policy statements support the purpose of this statement by advocating for health reform:

• APHA Policy Statement Statement 200911: Public Health’s Critical Role in Health Reform in the United States
• APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health

In addition, this statement is consistent with the following APHA policies that reference public health’s role in disaster response:

• APHA Policy Statement 20198: Public Health Support for Long-Term Responses in High-Impact, Postdisaster Settings
• APHA Policy Statement 6211(PP): The Role of State and Local Health Departments in Planning for Community Health Emergencies
• APHA Policy Statement 9116: Health Professionals and Disaster Preparedness
• APHA Policy Statement 20069: Response to Disasters: Protection of Rescue and Recovery Workers, Volunteers, and Residents Responding to Disasters

Problem Statement Discussions around universal health care in the United States started in the 1910s and have resurfaced periodically.[1] President Franklin D. Roosevelt attempted twice in the 1940s to establish universal health care and failed both times.[1] Eventually, the U.S. Congress passed Medicare and Medicaid in the 1960s. Universal health care more recently gained attention during debates on and eventual passage of the Affordable Care Act (ACA).[2]

To date, the U.S. government remains the largest payer of health care in the United States, covering nearly 90 million Americans through Medicare, Medicaid, TRICARE, and the Children’s Health Insurance Program (CHIP).[3] However, this coverage is not universal, and many Americans were uninsured[4] or underinsured[5] before the COVID-19 pandemic.

The COVID-19 pandemic has exacerbated underlying issues in our current health care system and highlighted the urgent need for universal health care for all Americans.

Health care is inaccessible for many individuals in the United States: For many Americans, accessing health care is cost prohibitive.[6] Coverage under employer-based insurance is vulnerable to fluctuations in the economy. Due to the COVID-19 pandemic, an estimated 10 million Americans may lose their employer-sponsored health insurance by December 2020 as a result of job loss.[7] When uninsured or underinsured people refrain from seeking care secondary to cost issues, this leads to delayed diagnosis and treatment, promotes the spread of COVID-19, and may increase overall health care system costs.

The ACA reformed health care by, for instance, eliminating exclusions for preexisting conditions, requiring coverage of 10 standardized essential health care services, capping out-of-pocket expenses, and significantly increasing the number of insured Americans. However, many benefits remain uncovered, and out-of-pocket costs can vary considerably. For example, an ACA average deductible ($3,064) is twice the rate of a private health plan ($1,478).[4] Those living with a disability or chronic illness are likely to use more health services and pay more. A recent survey conducted during the COVID-19 pandemic revealed that 38.2% of working adults and 59.6% of adults receiving unemployment benefits from the Coronavirus Aid, Relief, and Economic Security (CARES) Act could not afford a $400 expense, highlighting that the COVID-19 pandemic has exacerbated lack of access to health care because of high out-of-pocket expenses.[8] In addition, the ACA did not cover optometry or dental services for adults, thereby inhibiting access to care even among the insured population.[9]

Our current health care system cannot adequately respond to the pandemic and supply the care it demands: As in other economic downturns wherein people lost their employer-based insurance, more people enrolled in Medicaid during the pandemic. States’ efforts to cover their population, such as expanding eligibility, allowing self-attestation of eligibility criteria, and simplifying the application process, also increased Medicaid enrollment numbers.[10] The federal “maintenance of eligibility” requirements further increased the number of people on Medicaid by postponing eligibility redeterminations. While resuming eligibility redeterminations will cause some to lose coverage, many will remain eligible because their incomes continue to fall below Medicaid income thresholds.[10]

An urgent need for coverage during the pandemic exists. Virginia’s enrollment has increased by 20% since March 2020. In Arizona, 78,000 people enrolled in Medicaid and CHIP in 2 months.[11] In New Mexico, where 42% of the population was already enrolled in Medicaid, 10,000 more people signed up in the first 2 weeks of April than expected before the pandemic.[11] Nearly 17 million people who lost their jobs during the pandemic could be eligible for Medicaid by January 2021.[12]

While increasing Medicaid enrollment can cover individuals who otherwise cannot afford care, it further strains state budgets.[11] Medicaid spending represents a significant portion of states’ budgets, making it a prime target for cuts. Ohio announced $210 million in cuts to Medicaid, a significant part of Colorado’s $229 million in spending cuts came from Medicaid, Alaska cut $31 million in Medicaid, and Georgia anticipates 14% reductions overall.[11]

While Congress has authorized a 6.2% increase in federal Medicaid matching, this increase is set to expire at the end of the public health emergency declaration (currently set for October 23, 2020)[13] and is unlikely to sufficiently make up the gap caused by increased spending and decreased revenue.[14] Given the severity and projected longevity of the pandemic’s economic consequences, many people will remain enrolled in Medicaid throughout state and federal funding cuts. This piecemeal funding strategy is unsustainable and will strain Medicaid, making accessibility even more difficult for patients.

Our health care system is inequitable: Racial disparities are embedded in our health care system and lead to worse COVID-19 health outcomes in minority groups. The first federal health care program, the medical division of the Freedmen’s Bureau, was established arguably out of Congress’s desire for newly emancipated slaves to return to working plantations in the midst of a smallpox outbreak in their community rather than out of concern for their well-being.[15] An effort in 1945 to expand the nation’s health care system actually reinforced segregation of hospitals.[15] Moreover, similar to today, health insurance was employer based, making it difficult for Black Americans to obtain.

Although the 1964 Civil Rights Act outlawed segregation of health care facilities receiving federal funding and the 2010 ACA significantly benefited people of color, racial and sexual minority disparities persist today in our health care system. For example, under a distribution formula set by the U.S. Department of Health and Human Services (DHHS), hospitals reimbursed mostly by Medicaid and Medicare received far less federal funding from the March 2020 CARES Act and the Paycheck Protection Program and Health Care Enhancement Act than hospitals mostly reimbursed by private insurance.[16] Hospitals in the bottom 10% based on private insurance revenue received less than half of what hospitals in the top 10% received. Medicare reimburses hospitals, on average, at half the rate of private insurers. Therefore, hospitals that primarily serve low-income patients received a disproportionately smaller share of total federal funding.[16]

Additional barriers for these communities include fewer and more distant testing sites, longer wait times,[17] prohibitive costs, and lack of a usual source of care.[18] Black Americans diagnosed with COVID-19 are more likely than their White counterparts to live in lower-income zip codes, to receive tests in the emergency department or as inpatients, and to be hospitalized and require care in an intensive care unit.[19] Nationally, only 20% of U.S. counties are disproportionately Black, but these counties account for 52% of COVID-19 diagnoses and 58% of deaths.[20] The pre-pandemic racial gaps in health care catalyzed pandemic disparities and will continue to widen them in the future.

Our health care system insufficiently covers vulnerable groups: About 14 million U.S. adults needed long-term care in 2018.[21] Medicare, employer-based insurance, and the ACA do not cover home- and community-based long-term care. Only private long-term care insurance and patchwork systems for Medicaid-eligible recipients cover such assistance. For those paying out of pocket, estimated home care services average $51,480 to $52,624 per year, with adult day services at more than $19,500 per year.[22]

Our current health care system also inadequately supports individuals with mental illness. APHA officially recognized this issue in 2014, stating that we have “lacked an adequate and consistent public health response [to behavioral health disorders] for several reasons” and that the “treatment of mental health and substance use disorders in the United States has been provided in segregated, fragmented, and underfunded care settings.”[23]

The COVID-19 pandemic has brought urgency to the universal health care discussion in the United States. This is an unprecedented time, and the pandemic has exacerbated many of the existing problems in our current patchwork health care system. The COVID-19 pandemic is a watershed moment where we can reconstruct a fractured health insurance system into a system of universal health care.

Evidence-Based Strategies to Address the Problem We advocate for the definition of universal health care outlined in the 2019 resolution adopted by the United Nations General Assembly, which member nations signed on to, including the United States. According to this resolution, “universal health coverage implies that all people have access, without discrimination, to nationally determined sets of the needed promotive, preventive, curative, rehabilitative and palliative essential health services, and essential, safe, affordable, effective and quality medicines and vaccines, while ensuring that the use of these services does not expose the users to financial hardship, with a special emphasis on the poor, vulnerable and marginalized segments of the population.”[24]

Our current system is inaccessible, inflexible, and inequitable, and it insufficiently covers vulnerable populations. Here we present supporting evidence that universal health care can help address these issues.

Universal health care can increase accessibility to care: Evidence supporting universal health care is mostly limited to natural experiments and examples from other countries. Although countries with universal health care systems also struggle in containing the COVID-19 pandemic, their response and mortality outcomes are better owing to their robust universal systems.[25]

While individuals in the United States lost health care coverage during the pandemic, individuals in countries with universal health care were able to maintain access to care.[26–28] Some European and East Asian countries continue to offer comprehensive, continuous care to their citizens during the pandemic.

Taiwan’s single-payer national health insurance covers more than 99% of the country’s population, allowing easy access to care with copayments of $14 for physician visits and $7 for prescriptions. On average, people in Taiwan see their physician 15 times per year.[27] Also, coronavirus tests are provided free of charge, and there are sufficient hospital isolation rooms for confirmed and suspected cases of COVID-19.[28]

Thai epidemiologists credit their universal health care system with controlling the COVID-19 pandemic.[29] They have described how their first patient, a taxi driver, sought medical attention unencumbered by doubts about paying for his care. They benefit from one of the lowest caseloads in the world.[29]

Universal health care is a more cohesive system that can better respond to health care demands during the pandemic and in future routine care: Leveraging its universal health care system, Norway began aggressively tracking and testing known contacts of individuals infected with COVID-19 as early as February 2020. Public health officials identified community spread and quickly shut down areas of contagion. By April 30, Norway had administered 172,586 tests and recorded 7,667 positive cases of COVID-19. Experts attribute Norway’s success, in part, to its universal health care system.[26] Norway’s early comprehensive response and relentless testing and tracing benefited the country’s case counts and mortality outcomes.

Once China released the genetic sequence of COVID-19, Taiwan’s Centers for Disease Control laboratory rapidly developed a test kit and expanded capacity via the national laboratory diagnostic network, engaging 37 laboratories that can perform 3,900 tests per day.[28] Taiwan quickly mobilized approaches for case identification, distribution of face masks, containment, and resource allocation by leveraging its national health insurance database and integrating it with the country’s customs and immigration database daily.[28] Taiwan’s system proved to be flexible in meeting disaster response needs.

Although these countries’ success in containing COVID-19 varied, their universal health care systems allowed comprehensive responses.

Universal health care can help decrease disparities and inequities in health: Several factors point to decreased racial and ethnic disparities under a universal health care model. CHIP’s creation in 1997 covered children in low-income families who did not qualify for Medicaid; this coverage is associated with increased access to care and reduced racial disparities.[30] Similarly, differences in diabetes and cardiovascular disease outcomes by race, ethnicity, and socioeconomic status decline among previously uninsured adults once they become eligible for Medicare coverage.[31] While universal access to medical care can reduce health disparities, it does not eliminate them; health inequity is a much larger systemic issue that society needs to address.

Universal health care better supports the needs of vulnerable groups: The United States can adopt strategies from existing models in other countries with long-term care policies already in place. For example, Germany offers mandatory long-term disability and illness coverage as part of its national social insurance system, operated since 2014 by 131 nonprofit sickness funds. German citizens can receive an array of subsidized long-term care services without age restrictions.[32] In France, citizens 60 years and older receive long-term care support through an income-adjusted universal program.[33]

Universal health care can also decrease health disparities among individuals with mental illness. For instance, the ACA Medicaid expansion helped individuals with mental health concerns by improving access to care and effective mental health treatment.[34]

Opposing Arguments/Evidence Universal health care is more expensive: Government spending on Medicare, Medicaid, and CHIP has been increasing and is projected to grow 6.3% on average annually between 2018 and 2028.[35] In 1968, spending on major health care programs represented 0.7% of the gross domestic product (GDP); in 2018 it represented 5.2% of the GDP, and it is projected to represent 6.8% in 2028.[35] These estimates do not account for universal health care, which, by some estimates, may add $32.6 trillion to the federal budget during the first 10 years and equal 10% of the GDP in 2022.[36]

Counterpoint: Some models of single-payer universal health care systems estimate savings of $450 billion annually.[37] Others estimate $1.8 trillion in savings over a 10-year period.[38] In 2019, 17% of the U.S. GDP was spent on health care; comparable countries with universal health care spent, on average, only 8.8%.[39]

Counterpoint: Health care services in the United States are more expensive than in other economically comparable countries. For example, per capita spending on inpatient and outpatient care (the biggest driver of health care costs in the United States) is more than two times greater even with shorter hospital stays and fewer physician visits.[40] Overall, the United States spends over $5,000 more per person in health costs than countries of similar size and wealth.[40]

Counterpoint: Administrative costs are lower in countries with universal health care. The United States spends four times more per capita on administrative costs than similar countries with universal health care.[41] Nine percent of U.S. health care spending goes toward administrative costs, while other countries average only 3.6%. In addition, the United States has the highest growth rate in administrative costs (5.4%), a rate that is currently double that of other countries.[41]

Universal health care will lead to rationing of medical services, increase wait times, and result in care that is inferior to that currently offered by the U.S. health care system. Opponents of universal health care point to the longer wait times of Medicaid beneficiaries and other countries as a sign of worse care. It has been shown that 9.4% of Medicaid beneficiaries have trouble accessing care due to long wait times, as compared with 4.2% of privately insured patients.[42] Patients in some countries with universal health care, such as Canada and the United Kingdom, experience longer wait times to see their physicians than patients in the United States.[43] In addition, some point to lower cancer death rates in the United States than in countries with universal health care as a sign of a superior system.[44]

Another concern is rationing of medical services due to increased demands from newly insured individuals. Countries with universal health care use methods such as price setting, service restriction, controlled distribution, budgeting, and cost-benefit analysis to ration services.[45]

Counterpoint: The Unites States already rations health care services by excluding patients who are unable to pay for care. This entrenched rationing leads to widening health disparities. It also increases the prevalence of chronic conditions in low-income and minority groups and, in turn, predisposes these groups to disproportionately worse outcomes during the pandemic. Allocation of resources should not be determined by what patients can and cannot afford. This policy statement calls for high-value, evidence-based health care, which will reduce waste and decrease rationing.

Counterpoint: Opponents of universal health care note that Medicaid patients endure longer wait times to obtain care than privately insured patients[42] and that countries with universal health care have longer wait times than the United States.[43] Although the United States enjoys shorter wait times, this does not translate into better health outcomes. For instance, the United States has higher respiratory disease, maternal mortality, and premature death rates and carries a higher disease burden than comparable wealthy countries.[46]

Counterpoint: A review of more than 100 countries’ health care systems suggests that broader coverage increases access to care and improves population health.

Counterpoint: While it is reasonable to assume that eliminating financial barriers to care will lead to a rise in health care utilization because use will increase in groups that previously could not afford care, a review of the implementation of universal health care in 13 capitalist countries revealed no or only small (less than 10%) post-implementation increases in overall health care use.[47] This finding was likely related to some diseases being treated earlier, when less intense utilization was required, as well as a shift in use of care from the wealthy to the poorest.[47]

Alternative Strategies States and the federal government can implement several alternative strategies to increase access to health care. However, these strategies are piecemeal responses, face legal challenges, and offer unreliable assurance for coverage. Importantly, these alternative strategies also do not necessarily or explicitly acknowledge health as a right.

State strategies: The remaining 14 states can adopt the Medicaid expansions in the ACA, and states that previously expanded can open new enrollment periods for their ACA marketplaces to encourage enrollment.[48] While this is a strategy to extend coverage to many of those left behind, frequent legal challenges to the ACA and Medicaid cuts make it an unreliable source of coverage in the future. In addition, although many people gained insurance, access to care remained challenging due to prohibitively priced premiums and direct costs.

Before the pandemic, the New York state legislature began exploring universal single-payer coverage, and the New Mexico legislature started considering a Medicaid buy-in option.[49] These systems would cover only residents of a particular state, and they remain susceptible to fluctuations in Medicaid cuts, state revenues, and business decisions of private contractors in the marketplace.

Federal government strategies: Congress can continue to pass legislation in the vein of the Families First Coronavirus Response Act and the CARES Act. These acts required all private insurers, Medicare, and Medicaid to cover COVID-19 testing, eliminate cost sharing, and set funds to cover testing for uninsured individuals. They fell short in requiring assistance with COVID-19 treatment. A strategy of incremental legislation to address the pandemic is highly susceptible to the political climate, is unreliable, and does not address non-COVID-19 health outcomes. Most importantly, this system perpetuates a fragmented response to the COVID-19 pandemic.

An additional option for the federal government is to cover the full costs of Medicaid expansion in the 14 states yet to expand coverage. If states increased expansion and enforced existing ACA regulations, nearly all Americans could gain health insurance.[50] This alternative is risky, however, due to frequent legal challenges to the ACA. Furthermore, high costs to access care would continue to exist.

Action Steps This statement reaffirms APHA’s support of the right to health through universal health care. Therefore, APHA:

• Urges Congress and the president to recognize universal health care as a right.
• Urges Congress to fund and design and the president to enact and implement a comprehensive universal health care system that is accessible and affordable for all residents; that ensures access to rural populations, people experiencing homelessness, sexual minority groups, those with disabilities, and marginalized populations; that is not dependent on employment, medical or mental health status, immigration status, or income; that emphasizes high-value, evidence-based care; that includes automatic and mandatory enrollment; and that minimizes administrative burden.
• Urges Congress and states to use the COVID-19 pandemic as a catalyst to develop an inclusive and comprehensive health care system that is resilient, equitable, and accessible.
• Urges the DHHS, the Agency for Healthcare Research and Quality, the Institute of Medicine, the National Institutes of Health, academic institutions, researchers, and think tanks to examine equitable access to health care, including provision of mental health care, long-term care, dental care, and vision care.
• Urges Congress, national health care leaders, academic institutions, hospitals, and each person living in the United States to recognize the harms caused by institutionalized racism in our health care system and collaborate to build a system that is equitable and just.
• Urges Congress to mandate the Federal Register Standards for Accessible Medical Diagnostic Equipment to meet the everyday health care physical access challenges of children and adults with disabilities.
• Urges national health care leaders to design a transition and implementation strategy that communicates the impact of a proposed universal health care system on individuals, hospitals, health care companies, health care workers, and communities.
• Urges Congress, the Centers for Disease Control and Prevention, the DHHS, and other public health partners, in light of the COVID-19 pandemic, to recognize the need for and supply adequate funding for a robust public health system. This public health system will prepare for, prevent, and respond to both imminent and long-term threats to public health, as previously supported in APHA Policy Statement 200911.

References 1. Palmer K. A brief history: universal health care efforts in the US. Available at: https://pnhp.org/a-brief-history-universal-health-care-efforts-in-the-us/. Accessed September 30, 2020. 2. Serakos M, Wolfe B. The ACA: impacts on health, access, and employment. Forum Health Econ Policy. 2016;19(2):201–259. 3. Centers for Medicare and Medicaid Services. CMS roadmaps for the traditional fee-for-service program: overview. Available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualityinitiativesgeninfo/downloads/roadmapoverview_oea_1-16.pdf. Accessed September 30, 2020. 4. Goldman AL, McCormick D, Haas JS, Sommers BD. Effects of the ACA’s health insurance marketplaces on the previously uninsured: a quasi-experimental analysis. Health Aff (Millwood). 2018;37(4):591–599. 5. Collins SR, Gunja MZ, Doty MM, Bhupal HK. Americans’ views on health insurance at the end of a turbulent year. Available at: https://www.commonwealthfund.org/publications/issue-briefs/2018/mar/americans-views-health-insurance-end-turbulent-year. Accessed August 28, 2020. 6. Tolbert J, Orgera K, Singer N, Damico A. Key facts about the uninsured population. Available at: https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/. Accessed September 12, 2020. 7. Banthin J, Simpson M, Buettgens M, Blumberg LJ, Wang R. Changes in health insurance coverage due to the COVID-19 recession. Available at: https://www.urban.org/research/publication/changes-health-insurance-coverage-due-covid-19-recession. Accessed September 30, 2020. 8. Gaffney AW, Himmelstein DU, McCormick D, Woolhandler S. Health and social precarity among Americans receiving unemployment benefits during the COVID-19 outbreak. J Gen Intern Med. 2020;35(11):3416–3419. 9. Lutfiyya MN, Gross AJ, Soffe B, Lipsky MS. Dental care utilization: examining the associations between health services deficits and not having a dental visit in the past 12 months. BMC Public Health. 2019;19(1):265. 10. Rudowitz R, Hinton, E. Early look at Medicaid spending and enrollment trends amid COVID-19. Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/early-look-at-medicaid-spending-and-enrollment-trends-amid-covid-19/. Accessed August 14, 2020. 11. Roubein R, Goldberg D. States cut Medicaid as millions of jobless workers look to safety net. Available at: https://www.politico.com/news/2020/05/05/states-cut-medicaid-programs-239208. Accessed August 14, 2020. 12. Garfield R, Claxton G, Damico A, Levitt L. Eligibility for ACA health coverage following job loss. Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/eligibility-for-aca-health-coverage-following-job-loss/. Accessed August 14, 2020. 13. U.S. Department of Health and Human Services. Renewal of determination that a public health emergency exists. Available at: https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-2Oct2020.aspx. Accessed September 30, 2020. 14. Rudowitz RC, Garfield R. How much fiscal relief can states expect from the temporary increase in the Medicaid FMAP? Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/how-much-fiscal-relief-can-states-expect-from-the-temporary-increase-in-the-medicaid-fmap/. Accessed August 14, 2020. 15. Downs J. Sick from Freedom: African-American Illness and Suffering during the Civil War and Reconstruction. New York, NY: Oxford University Press; 2015. 16. Schwartz K, Damico A. Distribution of CARES Act funding among hospitals. 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Health Aff (Millwood). 2020;39(7):1253–1262. 20. Millett GA, Jones AT, Benkeser D, et al. Assessing differential impacts of COVID-19 on black communities. Ann Epidemiol. 2020;47:37–44. 21. Hado E, Komisar H. Long-term services and supports. Available at: https://www.aarp.org/ppi/info-2017/long-term-services-and-supports.html. Accessed September 1, 2020. 22. GenWorth Financial. Cost of care survey. Available at: https://www.genworth.com/aging-and-you/finances/cost-of-care.html. Accessed September 1, 2020. 23. American Public Health Association. Policy statement 201415: support for social determinants of behavioral health and pathways for integrated and better public health. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/01/28/14/58/support-for-social-determinants-of-behavioral-health. Accessed September 1, 2020. 24. UN General Assembly. Resolution adopted by the General Assembly on 10 October 2019—political declaration of the high-level meeting on universal health coverage. Available at: https://www.un.org/pga/73/wp-content/uploads/sites/53/2019/07/FINAL-draft-UHC-Political-Declaration.pdf. Accessed September 30, 2020. 25. Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions. N Engl J Med. 2012;367(11):1025–1034. 26. Jones A. I left Norway’s lockdown for the US: the difference is shocking. Available at: https://www.thenation.com/article/world/coronavirus-norway-lockdown/. Accessed September 1, 2020. 27. Maizland L. Comparing six health-care systems in a pandemic. Available at: https://www.cfr.org/backgrounder/comparing-six-health-care-systems-pandemicX. Accessed August 20, 2020. 28. Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing. JAMA. 2020;323(14):1341–1342. 29. Gharib M. Universal health care supports Thailand’s coronavirus strategy. Available at: https://www.npr.org/2020/06/28/884458999/universal-health-care-supports-thailands-coronavirus-strategy. Accessed August 30, 2020. 30. Shone LP, Dick AW, Klein JD, Zwanziger J, Szilagyi PG. Reduction in racial and ethnic disparities after enrollment in the State Children’s Health Insurance Program. Pediatrics. 2005;115(6):e697–e705. 31. McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of previously uninsured adults after acquiring Medicare coverage. JAMA. 2007;298(24):2886–2894. 32. Rhee JC, Done N, Anderson GF. Considering long-term care insurance for middle-income countries: comparing South Korea with Japan and Germany. Health Policy. 2015;119(10):1319–1329. 33. Doty P, Nadash P, Racco N. Long-term care financing: lessons from France. Milbank Q. 2015;93(2):359–391. 34. Wen H, Druss BG, Cummings JR. Effect of Medicaid expansions on health insurance coverage and access to care among low-income adults with behavioral health conditions. Health Serv Res. 2015;50(6):1787–1809. 35. Congressional Budget Office. Projections of federal spending on major health care programs. Available at: https://www.cbo.gov/system/files/115th-congress-2017-2018/presentation/53887-presentation.pdf. Accessed October 12, 2020. 36. Blahous C. The costs of a national single-payer healthcare system. Available at: https://www.mercatus.org/publications/government-spending/costs-national-single-payer-healthcare-system. Accessed October 10, 2020. 37. Galvani AP, Parpia AS, Foster EM, Singer BH, Fitzpatrick MC. Improving the prognosis of health care in the USA. Lancet. 2020;395(10223):524–533. 38. Friedman G. Funding HR 676: the Expanded and Improved Medicare for All Act. How we can afford a national single-payer health plan. Available at: https://www.pnhp.org/sites/default/files/Funding%20HR%20676_Friedman_7.31.13_proofed.pdf. Accessed September 15, 2020. 39. Organisation for Economic Co-operation and Development. Health expenditure and financing. Available at: https://stats.oecd.org/Index.aspx?ThemeTreeId=9. Accessed September 27, 2020. 40. Kurani N, Cox C. What drives health spending in the U.S. compared to other countries? Available at: https://www.healthsystemtracker.org/brief/what-drives-health-spending-in-the-u-s-compared-to-other-countries/. Accessed September 30, 2020. 41. Tollen L, Keating E, Weil A. How administrative spending contributes to excess US health spending. Available at: https://www.healthaffairs.org/do/10.1377/hblog20200218.375060/abs/. Accessed August 30, 2020. 42. U.S. Government Accountability Office. Medicaid: states made multiple program changes, and beneficiaries generally reported access comparable to private insurance. Available at: https://www.gao.gov/assets/650/649788.pdf. Accessed August 30, 2020. 43. How Canada Compares: Results from the Commonwealth Fund’s 2016 International Health Policy Survey of Adults in 11 Countries. Ottawa, Ontario, Canada: Canadian Institute for Health Information; 2017. 44. Organisation for Economic Co-operation and Development. Deaths from cancer: total, per 100,000 persons, 2018 or latest available. Available at: https://data.oecd.org/healthstat/deaths-from-cancer.htm. Accessed October 12, 2020. 45. Hoffman B. Health Care for Some: Rights and Rationing in the United States since 1930. Chicago, IL: University of Chicago Press; 2012. 46. Kurani N, McDermott D, Shanosky N. How does the quality of the U.S. healthcare system compare to other countries? Available at: https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/#item-start. Accessed September 20, 2020. 47. Gaffney A, Woolhandler S, Himmelstein D. The effect of large-scale health coverage expansions in wealthy nations on society-wide healthcare utilization. J Gen Intern Med. 2020;35(8):2406–2417. 48. King JS. COVID-19 and the need for health care reform. N Engl J Med. 2020;382(26):e104. 49. Hughes M. COVID-19 proves that we need universal health care. States are exploring their options. Available at: https://rooseveltinstitute.org/2020/06/25/covid-19-proves-that-we-need-universal-health-care-states-are-exploring-their-options/. Accessed September 1, 2020. 50. Blumenthal D, Fowler EJ, Abrams M, Collins SR. COVID-19—implications for the health care system. N Engl J Med. 2020;383(15):1483–1488.

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7 Strong Arguments For Why America Should Have Universal Healthcare

With COVID-19 still running its course and no end in sight, the integrity of American healthcare has never been more important. Is the current system truly the best the United States can do for its citizens? Or is socialized medicine a better alternative? Here are seven strong arguments for universal healthcare in America.

1. Lower Overall Costs

The costs of universal healthcare are far lower in other Western countries than private coverage in the United States. For example, administrative expenses alone make up 8% of the nation’s total healthcare costs . On the other hand, other developed countries with universal care don’t reach any higher than 3%.

What’s more, many Americans don’t seek the care they need because the cost of one visit can bankrupt them. Compared to other countries, prices for vital medicine, such as insulin, are sky-high in the United States. Universal healthcare guarantees service to everyone, no matter their financial status. When medical care isn’t such a financial strain, citizens can prioritize their health and seek the treatment they need.

2. Greater Hospital-Patient Trust

One disturbing reason American healthcare is so expensive is the trend of surprise billing. A routine surgery or treatment can cost thousands of dollars more than expected due to additional vague charges. You can even face a hefty fee just for sitting in a waiting room. The U.S. government has made some efforts to fix this problem , but private medical facilities have managed to find loopholes in the legislation.

Universal healthcare takes the billing power away from these facilities, creating more trust between hospital and patient: Payment comes in the form of taxes. While nobody likes to pay more taxes, it’s fairer to pay a fixed amount every year than receive a debilitating hospital bill after one visit.

3. Better Quality Care

The quality of treatment under socialized medicine seems to work better for its citizens than America’s privatized system. Infant mortality rates are lower, average life expectancy is higher and fewer people die from medical malpractice, which happens to be the third-leading cause of death in the United States. 

America also has obesity and cardiovascular disease epidemic, which fills up hospitals and leads to many preventable deaths. Comparable countries with universal healthcare have much lower mortality rates. This is because these nations promote more healthy lifestyles , easing the workload on hospitals and opening up space for people who need urgent care. 

4. More Coverage

Americans rely on their insurance companies to pay for their medical bills, but insurance doesn’t cover every injury or sickness. As you might expect, many citizens go bankrupt from hospital expenses. In contrast, universal healthcare covers any medical issue that might happen to a citizen. So patients don’t need to worry about any loopholes or caveats in their insurance coverage.

5. Shorter Wait Times

Perhaps the biggest criticism of universal healthcare is the extended wait times, but Americans already have long waits. COVID-19 patients are filling up waiting rooms and hospital beds. Because of that, many doctors have begun to hold virtual appointments for patients who can’t see them in person. Still, this solution has only put a dent in the problem. 

Patients under a universal system don’t have to wait for their insurance’s approval before seeking the care they need.

6. Greater Mobility

Since Americans often have to pay their own medical bills, they might feel pressured to keep unfulfilling jobs just for the insurance coverage. So in an ironic twist, they’re forced to put work over their health and well-being just so they can afford healthcare.

Universal healthcare allows you to change jobs without losing coverage. The current privatized system doesn’t embody American values of freedom and liberty. Rather, it restricts their life choices and access to care.

7. Coverage for the Uninsured

Insured citizens at least have access to some healthcare coverage, but the uninsured are entirely on their own. A large percentage of the uninsured have little to no disposable income, and they can’t afford the coverage they need.

Some evidence also suggests that uninsured patients wait longer and receive poorer care than more financially stable patients. As a result, the uninsured have an excess mortality rate of 25% , according to the Institute of Medicine. This negligence is unacceptable and largely avoidable. A universal healthcare system provides its people with care regardless of their insurance status.

America needs universal healthcare. The United States’ private healthcare system has too many glaring flaws to justify its existence. Adopting a universal plan would grant more cost-effective coverage to everyone, including the millions of people who currently can’t afford treatment. A more efficient and trustworthy system would help Americans exercise their fundamental rights to life, liberty, and the pursuit of happiness.

Featured image via CDC on Unsplash

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Should Healthcare be Free for Everyone Essay

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Health protection is one of the basic human rights because everyone wants to be healthy. At the same time, assistance in ensuring this health should come from the state as a guarantor of the protection of the person. The right to health is a fundamental aspect of any society; without a health system, this right cannot be fulfilled. Many aspects of similar institutions worldwide are paid, which hinders access to medicine for some people. In this way, a free healthcare system could lead to equality.

First, health care refers to absolute human rights that any state cannot alienate. Thus, by depriving a person of this right, the state violates ethical standards and can significantly harm the health of people who cannot afford paid medicine. A free healthcare system could provide everyone access to basic health services such as prevention, treatment of illness and injury, and access to medicines. Free medical care would help to establish full equality among all groups of the population, thus eliminating many of the divisions that currently exist in society. In this way, people could become much healthier and happier because many health problems would be solved.

The second argument favoring a free healthcare system is the economic factor. This is because healthy citizens can contribute more to the country’s economy. Citizens who are properly healed will be able to feel better, and investigators will be able to work more productively, ultimately leading to increased economic growth. In addition, a free health care system can significantly affect private businesses since companies do not have to invest in payments to constantly provide insurance for citizens. It was possible to include part of this amount instead as a separate tax, and thus both the state and firms could earn more money. Thus, companies will be able to redirect the financial resources of their organizations to the development of their kind of activity. This would increase competition in all sectors of the economy and thus improve the quality of business. Increasing the turnover and revenue of companies can then lead to the payment of large taxes and an improvement in the position of the national economy.

As a counterargument, it can be said that transferring the entire healthcare system to a free regime would create many difficulties both at the transition stage and in the future. Indeed, to fully make medicine accessible, it will be necessary to carry out many reforms that can significantly burden the economy. In addition, many private clinics will also have to be dealt with and either leaves the possibility of such services or transfer them to state dates. Financing all medical institutions from the country’s budget can be complicated and costly. In this regard, it would be necessary to look for additional sources of income to support the economy. However, moving to a free system can result in greater cost savings, as in Canada or the UK.

In conclusion, we can say that the health care system should be accessible and free for all citizens who need help, as this is one of the most important human rights that cannot be neglected. In addition, establishing such state care can help stimulate economic growth since most people who are now in poor health will be able to work. This will help companies develop more intensively and not spend money on paying insurance for employees. There are some downsides to moving to a public system, such as high initial process costs. However, in the future, this can be fully compensated. Based on all the factors considered, it can be concluded that a free healthcare system should be implemented.

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Argumentative Essay On Universal Healthcare

Info: 2468 words (10 pages) Nursing Essay Published: 12th Apr 2021

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Universal Healthcare in the United States

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Works Cited

• Cecere, David. “The Harvard Gazette.” 17 September 2009. Harvard News. 11 December 2018. .
• Edwards, Sweetland Haley. “The Health Care Voters.” TIME 12 November 2018: 41.
• “Formosa.” 17 March 2018. Formosa Post. 12 November 2018. .
• Gawande, Atul. “The United States Can Achieve Universal Health Care Without Dismantling the Existing Health Care System.” Universal Health Care . Detroit: Greenhaven Press, 2010. 190.
• Jackson Jr., Jesse L. “The United States Should Guarantee the Right to Health Care Through a Constitutional Amendment.” Grover, Jan. Healthcare . Detroit: Greenhaven Press, 2007. 28.
• “NIMH.” November 2017. National Institute of Mental Health. 12 December 2018. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml
• Salyer, Kirsten. “TIME.” 1 July 2016. TIME Web Site. 5 November 2018.
• Tanner, Michael D. “CATO.” 23 February 2009. CATO Institute. 12 November 2018. .
• Wilper, Andrew P., et al. “U.S. National Library of Medicine.” December 2009. U.S. National Library of Medicine. 11 December 2018.

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Current debates in health care policy: A brief overview

Subscribe to the economic studies bulletin, matthew fiedler and matthew fiedler joseph a. pechman senior fellow - economic studies , center on health policy christen linke young christen linke young deputy assistant to the president for health and veterans affairs - domestic policy council for health and veterans, former fellow - usc-brookings schaeffer initiative for health policy.

October 15, 2019

Issues in health care policy fall in two broad categories: those related to health care coverage and those related to the underlying cost of health care. Coverage policy addresses where Americans get health insurance, how it is paid for, and what it covers, while policies related to underlying costs seek to reduce overall health care spending by lowering either the price or utilization of health care.

A Closer Look

Health care is a major issue in American politics, with important debates related to health care coverage and the underlying cost of health care. The role of health care coverage is to insulate people from high health care spending burdens and facilitate access to health care. Policies related to coverage include those affecting how Americans get health insurance, how that insurance is paid for, and what insurance does and does not cover. Debates about how to reduce the number of people without health insurance, whether Americans should continue to get coverage through their jobs, if health insurance deductibles are too high, or how to change the premiums required under federal coverage programs all fall into this category.

Many coverage policies change how much families have to pay for health care, generally by changing what government programs pay on their behalf or by changing how health care spending burdens are shared between people with larger and smaller health care needs. But other proposals aim to reduce the underlying cost of health care, either by reducing how many health care services patients receive or by reducing the prices paid for those services. Policies like these have the potential to reduce overall health care spending throughout the system, but this is often easier said than done.

Policies related to health care coverage

More than 90% of Americans have health insurance. About half get coverage from an employer, and a third get coverage from a government program like Medicare or Medicaid. Another 5% buy coverage on the individual market, while 9% are uninsured. Different policymakers see different problems with the way people get coverage today and, correspondingly, propose different solutions.

Some policymakers believe that current federal programs that provide health care coverage are too generous and inappropriately burden taxpayers. These policymakers often support proposals that would narrow eligibility for or reduce the generosity of those programs, particularly Medicaid and programs that subsidize individual market coverage, even though fewer people would have coverage and some people’s coverage would become less generous. President Trump has supported proposals like these .

Other policymakers are primarily concerned with reducing the number of uninsured or reducing the burdens people face from premiums and cost-sharing. These policymakers often support proposals that would broaden eligibility for existing coverage programs or make those programs more generous, even though it would require additional federal spending. Many Democratic presidential candidates have supported approaches like these . Some proposals focus primarily on people who are currently uninsured or face particularly high health care spending burdens, while others support a program like Medicare for All that would commit a great deal more federal funds and insure all Americans through a single federal program.

Learn more about broad proposals related to health care coverage here . In addition to these broad proposals, some policymakers also support proposals that target specific problems with our existing health insurance system. One example is the fact that people with insurance can sometimes receive large “surprise” bills for health care services, discussed more here .  

Policies related to underlying health care costs

Health care spending is determined by two factors: how many health care services patients receive and the prices paid for each service. While there is broad agreement that some health care services are unnecessary and that the prices of some services are excessive, there is much less agreement about how to address these excesses.

Starting with the volume of services patients receive, the main challenge policymakers face is discouraging delivery of services that provide little health benefit without discouraging delivery of valuable services. One approach is to give health care providers financial incentives to eliminate unnecessary services by paying them based on the overall costs their patients incur rather than the number of services they personally deliver. Reforms like these can reduce utilization, seemingly without harming patients’ health, although total savings have been relatively modest so far.

Another approach is to require consumers to bear more of the cost of care themselves by increasing cost-sharing in hopes that they will become more cost-conscious and forgo low-value services. Research finds that this approach can also reduce service volume, but consumers often cut back on both high-value and low-value services rather than just low-value services. Increasing cost-sharing also reduces the effectiveness of health insurance in protecting against the costs of illness.

Policymakers may also be interested in lowering health care prices. A major cause of excessive prices is that health care provider markets—particularly hospital markets—are concentrated , with relatively few competitors in many parts of the country. In addition, many patients value a broad choice of providers. These and other features of health care markets allow many providers to demand prices from private insurers that substantially exceed providers’ costs of delivering health care services.

Policymakers have some options for addressing high prices. One is to make health care markets more competitive . This may include encouraging new entrants, blocking mergers, and aggressively policing anti-competitive behavior. Another approach is to take advantage of the fact that public insurance programs generally pay much lower prices than private insurers by introducing a “public option” or transitioning to a single payer system. Alternatively, policymakers could lower prices by regulating them directly. No matter how policymakers aim to reduce prices, they will need to balance the savings from lower prices against the risk of driving prices too low and jeopardizing access to or quality of care. Prescription drug prices raise somewhat different issues. In most cases, the main reason drugs are expensive is because the government grants a time-limited monopoly to inventors of new drugs via patents and related policies. That monopoly allows manufacturers to set high prices, with the goal of encouraging development of new drugs. Correspondingly, most approaches to lowering prices boil down to reducing the scope or duration of manufacturers’ monopoly or limiting the prices manufacturers can charge while the monopoly lasts. But, here too, there are tradeoffs: the benefits of lower prices on existing drugs must be weighed against the reduction in incentives to develop new drugs.

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2021 National Healthcare Quality and Disparities Report [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2021 Dec.

2021 National Healthcare Quality and Disparities Report [Internet].

Overview of u.s. healthcare system landscape.

The National Academy of Medicine defines healthcare quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Many factors contribute to the quality of care in the United States, including access to timely care, affordability of care, and use of evidence-based guidelines to drive treatment.

This section of the report highlights utilization of healthcare services, healthcare workforce statistics, healthcare expenditures, and major contributors to morbidity and mortality. These factors help paint an overall picture of the U.S. healthcare system, particularly areas that need improvement. Quality measures show whether the healthcare system is adequately addressing risk factors, diseases, and conditions that place the greatest burden on the healthcare system and if change has occurred over time.

• Overview of the U.S. Healthcare System Infrastructure

The NHQDR tracks care delivered by providers in many types of healthcare settings. The goal is to provide high-quality healthcare that is culturally and linguistically sensitive, patient centered, timely, affordable, well coordinated, and safe. The receipt of appropriate high-quality services and counseling about healthy lifestyles can facilitate the maintenance of well-being and functioning. In addition, social determinants of health, such as education, income, and residence location can affect access to care and quality of care.

Improving care requires facility administrators and providers to work together to expand access, enhance quality, and reduce disparities. It also requires coordination between the healthcare sector and other sectors for social welfare, education, and economic development. For example, Healthy People 2030 includes 5 domains (shown in the diagram below) and 78 social determinants of health objectives for federal programs and interventions.

Healthy People 2030 social determinants of health domains.

The numbers of health service encounters and people working in health occupations illustrate the large scale and inherent complexity of the U.S. healthcare system. The tracking of healthcare quality measures in this report iii attempts to quantify progress made in improving quality and reducing disparities in the delivery of healthcare to the American people.

Number of healthcare service encounters, United States, 2018 and 2019.

• In 2018, there were 860 million physician office visits ( Figure 1 ).
• In 2019, patients spent 149 million days in hospice.
• In 2019, there were 100 million home health visits.
• Overview of Disease Burden in the United States

The National Institutes of Health defines disease burden as the impact of a health problem, as measured by prevalence, incidence, mortality, morbidity, extent of disability, financial cost, or other indicators.

This section of the report highlights two areas of disease burden that have major impact on the health system of the United States: years of potential life lost and leading causes of death. The NHQDR tracks measures of quality for most of these conditions. Variation in access to care and care delivery across communities contributes to disparities related to race, ethnicity, sex, and socioeconomic status.

The concept of years of potential life lost (YPLL) involves estimating the average time a person would have lived had he or she not died prematurely. This measure is used to help quantify social and economic loss from premature death, and it has been promoted to emphasize specific causes of death affecting younger age groups. YPLL inherently incorporates age at death, and its calculation mathematically weights the total deaths by applying values to death at each age. 1

According to the Centers for Disease Control and Prevention (CDC), unintentional injuries include opioid overdoses (unintentional poisoning), motor vehicle crashes, suffocation, drowning, falls, fire/burns, and sports and recreational injuries. Overdose deaths involving opioids, including prescription opioids , heroin , and synthetic opioids (e.g., fentanyl ), have been a major contributor to the increase in unintentional injuries. Opioid overdose has increased to more than six times its 1999 rate. 2

Age-adjusted years of potential life lost before age 65, by cause of death, 2010–2019. Key: YPLL = years of potential life lost. Note: The perinatal period occurs from 22 completed weeks (154 days) of gestation and ends 7 completed days after (more...)

• From 2010 to 2019, there were no changes in the ranking of the top 10 leading diseases and injuries contributing to YPLL. The top 5 were unintentional injury, cancer, heart disease, suicide, and complications during the perinatal period ( Figure 2 ). The remaining 5 were homicide, congenital anomalies, liver disease, diabetes, and cerebrovascular disease.
• Unintentional injury increased from 791.8 per 100,000 population in 2010 to 1,024.3 per 100,000 population in 2019.
• Cancer decreased from 635.2 per 100,000 population in 2010 to 533.3 per 100,000 population in 2019.
• Heart disease decreased from 474.3 per 100,000 population in 2010 to 453.2 per 100,000 population in 2019.

Age-adjusted years of potential life lost before age 65, by cause of death and race, 2019. Key: AI/AN = American Indian or Alaska Native; PI = Pacific Islander.

• In 2019, among American Indian and Alaska Native (AI/AN) people, the top five contributing factors for YPLL were unintentional injuries (1,284.6 per 100,000 population), suicide (457.7 per 100,000 population), liver disease (451.6 per 100,000 population), heart disease (399.8 per 100,000 population), and cancer (339.6 per 100,000 population) ( Figure 3 ).
• In 2019, among Asian and Pacific Islander people, the top five contributing factors for YPLL were cancer (375.7 per 100,000 population), unintentional injuries (299.4 per 100,000 population), complications in the perinatal period (203.4 per 100,000 population), suicide (198.5 per 100,000), and heart disease (197.7 per 100,000 population).
• In 2019 among Black people, the top five contributing factors for YPLL were unintentional injuries (1,085.8 per 100,000 population), heart disease (843.5 per 100,000 population), homicide (801.7 per 100,000 population), cancer (652.7 per 100,000 population), and complications in the perinatal period (560.4 per 100,000 population).
• In 2019, among White people, the top five contributing factors for YPLL were unintentional injuries (1,080.0 per 100,000 population), cancer (530.1 per 100,000 population), heart disease (406.6 per 100,000 population), suicide (387.6 per 100,000 population), and complications in the perinatal period (215.7 per 100,000 population).

Leading causes of death for the total population, United States, 2018 and 2019.

• In 2019, heart disease, cancer, unintentional injuries, chronic lower respiratory diseases, stroke, Alzheimer’s disease, and diabetes were among the leading causes of death for the overall U.S. population ( Figure 4 ).
• Overall, kidney disease moved from the 9 th leading cause of death in 2018 to the 8 th leading cause of death in 2019.
• Suicide remained the 10 th leading cause of death in 2018 and 2019.

The years of potential life lost, years with disability, and leading causes of death represent some aspects of the burden of disease experienced by the American people. Findings highlighted in this report attempt to quantify progress made in improving quality of care, reducing disparities in healthcare, and ultimately reducing disease burden.

• Overview of U.S. Community Hospital Intensive Care Beds

The United States has almost 1 million staffed hospital beds; nearly 800,000 are community hospital beds and 107,000 are intensive care beds. Figure 5 shows the numbers of different types of staffed intensive care hospital beds.

Medical-surgical intensive care provides patient care of a more intensive nature than the usual medical and surgical care delivered in hospitals, on the basis of physicians’ orders and approved nursing care plans. These units are staffed with specially trained nursing personnel and contain specialized equipment for monitoring and supporting patients who, because of shock, trauma, or other life-threatening conditions, require intensified comprehensive observation and care. These units include mixed intensive care units.

Pediatric intensive care provides care to pediatric patients that is more intensive in nature than that usually provided to pediatric patients. The unit is staffed with specially trained personnel and contains monitoring and specialized support equipment for treating pediatric patients who, because of shock, trauma, or other life-threatening conditions, require intensified, comprehensive observation and care.

Cardiac intensive care provides patient care of a more specialized nature than the usual medical and surgical care, on the basis of physicians’ orders and approved nursing care plans. The unit is staffed with specially trained nursing personnel and contains specialized equipment for monitoring, support, or treatment for patients who, because of severe cardiac disease such as myocardial infarction, open-heart surgery, or other life-threatening conditions, require intensified, comprehensive observation and care.

Neonatal intensive care units (NICUs) are distinct from the newborn nursery and provide intensive care to sick infants, including those with the very lowest birth weights (less than 1,500 grams). NICUs may provide mechanical ventilation, care before or after neonatal surgery, and special care for the sickest infants born in the hospital or transferred from another institution. Neonatologists typically serve as directors of NICUs.

Burn care provides care to severely burned patients. Severely burned patients are those with the following: (1) second-degree burns of more than 25% total body surface area for adults or 20% total body surface area for children; (2) third-degree burns of more than 10% total body surface area; (3) any severe burns of the hands, face, eyes, ears, or feet; or (4) all inhalation injuries, electrical burns, complicated burn injuries involving fractures and other major traumas, and all other poor risk factors.

Other intensive care unit beds are in specially staffed, specialty-equipped, separate sections of a hospital dedicated to the observation, care, and treatment of patients with life-threatening illnesses, injuries, or complications from which recovery is possible. This type of care includes special expertise and facilities for the support of vital functions and uses the skill of medical, nursing, and other staff experienced in the management of conditions that require this higher level of care.

U.S. community hospital intensive care staffed beds, by type of intensive care, 2019. Note: Community hospitals are defined as all nonfederal, short-term general, and other special hospitals. Other special hospitals include obstetrics and gynecology; (more...)

• In 2019, of the more than 900,000 staffed hospital beds in the United States, 86% were in community hospitals (data not shown).
• Most of the more than 107,000 intensive care beds in community hospitals were medical-surgical intensive care (51.9%) and neonatal intensive care beds (21.1%) ( Figure 5 ).

Critical access hospital (CAH) is a designation given to eligible rural hospitals by the Centers for Medicare & Medicaid Services (CMS). The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. To accomplish this goal, CAHs receive certain benefits, such as cost-based reimbursement for Medicare services. As of July 16, 2021, 1,353 CAHs were located throughout the United States. 3 , iv

Distribution of critical access hospitals in the United States, 2021.

• According to CMS, CAHs must be located in a rural area or an area that is treated as rural, v so the number of CAHs varies by state ( Figure 6 ).
• In 2019, California had a population of 39.5 million and 36 CAHs compared with Iowa, which had a population of only 3.2 million but 82 CAHs.
• U.S. Healthcare Workforce

Healthcare access and quality can be affected by workforce shortages, particularly in rural areas. In addition, lack of racial, ethnic, and gender concordance between providers and patients can lead to miscommunication, stereotyping, and stigma, and, ultimately, suboptimal healthcare.

Healthcare Workforce Availability

Improving quality of care, increasing access to care, and controlling healthcare costs depend on the adequate availability of healthcare providers. 4 Physician shortages currently exist in many states across the nation, with relatively fewer primary care and specialty physicians available in nonmetropolitan counties compared with metropolitan counties. 5

The Health Resources and Services Administration (HRSA) further projects that the supply of key professions, including primary care providers, general dentists, adult psychiatrists, and addiction counselors, will fall short of demand by 2030. 6 These concerns have the potential to influence the delivery of healthcare and negatively affect patient outcomes.

Number of people working in health occupations, United States, 2019. Key: EMT = emergency medical technician. Note: Doctors of medicine also include doctors of osteopathic medicine. Active physicians include those working in direct patient care, administration, (more...)

• In 2019, there were 3.7 million registered nurses ( Figure 7 ).
• In 2019, there were 2.4 million healthcare aides, which includes nursing, psychiatric, home health, and occupational therapy aides and physical therapy assistants and aides.
• In 2019, there were 2.1 million health technologists.
• In 2019, 2.0 million other health practitioners provided care, including more than 145,000 physician assistants (PAs).
• In 2019, there were 972,000 active medical doctors in the United States, which include doctors of medicine and doctors of osteopathy.
• In 2019, there were 183,000 dentists.

In recent decades, promising approaches that address the supply-demand imbalance have emerged as alternatives to simply increasing the number of physicians. One strategy relies on telehealth technologies to improve physicians’ efficiency or to increase access to their services. For example, Project ECHO is a telehealth model in which specialists remotely support multiple rural primary care providers so that they can treat patients for conditions that might otherwise require traveling to distant specialty centers. 7

Another strategy relies on peer-led models, in which community-based laypeople receive the training and support needed to deliver care for a (typically) narrow range of conditions. Successful examples of this approach exist, including the deployment of community health workers to manage chronic diseases, 8 promotoras to provide maternal health services, 9 peer counselors for mental health and substance use disorders, 10 and dental health aides to deliver oral health services in remote locations. 11

The National Institutes of Health, HRSA, and the Agency for Healthcare Research and Quality (AHRQ) have sponsored formative research to examine key issues that must be addressed to further develop these models, but all show promise for expanding access to care and increasing overall diversity within the healthcare workforce.

Workforce Diversity

The number of full-time, year-round workers in healthcare occupations has almost doubled since 2000, increasing from 5 million to 9 million workers, according to the U.S. Census Bureau’s American Community Survey .

A racially and ethnically diverse health workforce has been shown to promote better access and healthcare for underserved populations and to better meet the health needs of an increasingly diverse population. People of color, however, remain underrepresented in several health professions, despite longstanding efforts to increase the diversity of the healthcare field. 12

Additional research has found that physicians from groups underrepresented in the health professions are more likely to serve minority and economically disadvantaged patients. It has also been found that Black and Hispanic physicians practice in areas with larger Black and Hispanic populations than other physicians do. 13

Gender diversity is also important. Women currently account for three-quarters of full-time, year-round healthcare workers. Although the number of men who are dentists or veterinarians has decreased over the past two decades, men still make up more than half of dentists, optometrists, and emergency medical technicians/paramedics, as well as physicians and surgeons earning over $100,000. 14

Women working as registered nurses, the most common healthcare occupation, earn on average $66,000. Women working as nursing, psychiatric, and home health aides, the second most common healthcare occupation, earn only $27,000. 14

The impact of unequal gender distribution in the healthcare workforce is observed in the persistence of gender inequality in heart attack mortality. Most physicians are male, and some may not recognize differences in symptoms in female patients. The fact that gender concordance correlates with whether a patient survives a heart attack has implications for theory and practice. Medical practitioners should be aware of the possible challenges male providers face when treating female heart attack patients. 15

Research has shown that some mental health workforce groups, such as psychiatrists, are more diverse than many other medical specialties, and this diversity has improved over time. However, this diversity has not translated as well to academic faculty or leadership positions for underrepresented minorities. It was found that there was more minority representation among psychiatry residents (16.2%) compared with faculty (8.7%) and practicing physicians (10.4%). This difference results in minority students and trainees having fewer minority mentors to guide them in the profession.

Racial and Ethnic Diversity Among Physicians

Diversification of the physician workforce has been a goal for several years and could improve access to primary care for underserved populations and address health disparities. Family physicians’ race/ethnicity has become more diverse over time but still does not reflect the national racial and ethnic composition. 16 , vi

Racial and ethnic distribution of all active physicians (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due (more...)

• In 2019, White people were 60% of the U.S. population and approximately 64% of physicians ( Figure 8 ).
• Asian people were about 6% of the U.S. population and approximately 22% of physicians.
• Black people were 12% of the U.S. population but only 5% of physicians.
• Hispanic people were 18% of the U.S. population but only 7% of physicians.
• People of more than race made up about 3% of the U.S. population but less than 2% of physicians.
• AI/AN people and Native Hawaiian/Pacific Islander (NHPI) people accounted for 1% or less of the U.S. population and 1% or less of physicians (data not shown).

Preventive care, including screenings, is key to reducing death and disability and improving health. Evidence has shown that patients with providers of the same gender have higher rates of breast, cervical, and colorectal cancer screenings. 17

Physicians by race/ethnicity and sex, 2018. Key: AI/AN = American Indian or Alaska Native; NHPI = Native Hawaiian/Pacific Islander. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working (more...)

• In 2018, among Black physicians, females (53.0%) constituted a larger percentage than males (47.0%) ( Figure 9 ).
• Among White physicians, 65.5% were male.
• Among Asian physicians, 55.7% were male.
• Among AI/AN physicians, 60.1% were male.
• Among Hispanic physicians, 59.5% were male.

White physicians by age and sex, 2018. Note : Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more...)

• In 2018, among White physicians, males were the vast majority of those age 65 years and over (79.3%) and of those ages 55–64 years (71.5%) ( Figure 10 ).
• A little more than half of White physicians age 34 and younger were females (50.6%).
• Among White physicians age 35 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.

Black physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more...)

• In 2018, among Black physicians under age 55, females made up a larger percentage of the workforce than males. This percentage decreased with increasing age ( Figure 11 ).
• Females were 44.2% of Black physicians ages 55–64 and 34.9% of Black physicians age 65 and over.

Asian physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more...)

• In 2018, among Asian physicians, males were the vast majority of those age 65 years and over (72.7%) and of those ages 55–64 years (66.3%) ( Figure 12 ).
• Among Asian physicians age 34 and younger, there were more females (52.0%) than males (48.0%).
• Among Asian physicians age 35 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.

American Indian or Alaska Native physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, (more...)

• In 2018, among AI/AN physicians, males were the vast majority of those age 65 years and over (73.2%) and of those ages 55–64 years (62.6%) ( Figure 13 ).
• Among AI/AN physicians age 34 and younger, there were more females (57.9%) than males (42.1%).
• Among AI/AN physicians age 45 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.

Hispanic physicians by age and sex, 2018. Note: Physicians (federal and nonfederal) who are licensed by a state are considered active, provided they are working at least 20 hours per week. Physicians who are retired, semiretired, temporarily not in practice, (more...)

• In 2018, most Hispanic physicians age 65 years and over (77.5%) and ages 55–64 years (67.5%) were males ( Figure 14 ).
• Among Hispanic physicians age 34 and younger, there were more females (55.3%) compared with males (44.7%).
• Among Hispanic physicians age 35 and over, males made up a larger percentage of the workforce than females. This percentage increased with age.

Racial and Ethnic Diversity Among Dentists

The racial and ethnic diversity of the oral healthcare workforce is insufficient to meet the needs of a diverse population and to address persistent health disparities. 18 However, among first-time, first-year enrollees in dental school, improved diversity has been observed. The number of African American enrollees nearly doubled and the number of Hispanic enrollees has increased threefold between 2000 and 2020. 19 Increased diversity among dentists may improve access and quality of care, particularly in the area of culturally and linguistically sensitive care.

Dentists by race (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and Other are non-Hispanic. If estimates for certain racial and ethnic groups meet data suppression criteria, they are recategorized into (more...)

• In 2019, the vast majority of dentists (70%) were non-Hispanic White ( Figure 15 ).
• Asian people, 18%,
• Hispanic people, 6%
• Black people, 5%, and
• Other (multiracial and AI/AN people), 1.0%.

Racial and Ethnic Diversity Among Registered Nurses

Ensuring workforce diversity and leadership development opportunities for racial and ethnic minority nurses must remain a high priority in order to eliminate health disparities and, ultimately, achieve health equity. 20

Registered nurses by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and (more...)

• In 2019, the vast majority of RNs (69%) were non-Hispanic White ( Figure 16 ).
• Black people, 11%,
• Asian people, 9%,
• Hispanic people, 8%,
• Multiracial people, 2%, and
• Other (AI/AN and NHPI people), 1%.

Racial and Ethnic Diversity Among Pharmacists

Most healthcare diagnostic and treating occupations such as pharmacists, physicians, nurses, and dentists are primarily White while healthcare support roles such as dental assistants, medical assistants, and personal care aides are more diverse. To decrease disparities and enhance patient care, racial and ethnic diversity must be improved on all levels of the healthcare workforce, not just in support roles. 21

Progress has been made toward increased racial and ethnic diversity, but more work is needed. As Bush notes in an article on underrepresented minorities in pharmacy school, “If we are determined to reduce existing healthcare disparities among racial, ethnic, and socioeconomic groups, then we must be determined to diversify the healthcare workforce.” 22

Pharmacists by race (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and the exclusion of groups (more...)

• In 2019, the vast majority of pharmacists (65%) were non-Hispanic White ( Figure 17 ).
• Asian people, 20%,
• Black people, 7%,
• Hispanic people, 5%, and
• Multiracial people, 2%.

Racial and Ethnic Diversity Among Therapists

Occupational therapists, physical therapists, radiation therapists, recreational therapists, and respiratory therapists are classified as health diagnosing and treating practitioners. Hispanic people are significantly underrepresented in all of the occupations in the category of Health Diagnosing and Treating Practitioners. Among non-Hispanic people, Black people are underrepresented in most of these occupations.

Asian people are underrepresented among speech-language pathologists, and AI/AN people are underrepresented in nearly all occupations. To the extent they can be reliably reported, data also show that NHPI people are underrepresented in all occupations in the Health Diagnosing and Treating Practitioners group. 21

Therapists include occupational therapists, physical therapists, radiation therapists, recreational therapists, respiratory therapists, speech-language pathologists, exercise physiologists, and other therapists.

Therapists by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and the exclusion (more...)

• In 2019, the vast majority of therapists (74%) were non-Hispanic White ( Figure 18 ).
• Black people, 8%,
• Asian people, 8%,
• Hispanic people, 8%, and

Racial and Ethnic Diversity Among Advanced Practice Registered Nurses

The adequacy and distribution of the primary care workforce to meet the current and future needs of Americans continue to be cause for concern. Advanced practice registered nurses are increasingly being used to fill this gap but may include clinicians in areas beyond primary care, such as clinical nurse specialists, nurse-midwives, and nurse anesthetists.

Advanced practice registered nurses are registered nurses educated at the master’s or post-master’s level who serve in a specific role with a specific patient population. They include certified nurse practitioners, clinical nurse specialists, certified nurse anesthetists, and certified nurse-midwives.

While physicians continue to account for most of the primary care workforce (74%) in the United States, nurse practitioners represent nearly one-fifth (19%) of the primary care workforce, followed by physician assistants, accounting for 7%. 23

Nurse practitioners provide an extensive range of services that includes taking health histories and providing complete physical exams. They diagnose and treat acute and chronic illnesses, provide immunizations, prescribe and manage medications and other therapies, order and interpret lab tests and x rays, and provide health education and supportive counseling.

Nurse practitioners deliver primary care in practices of various sizes, types (e.g., private, public), and settings, such as clinics, schools, and workplaces. Nurse practitioners work independently and collaboratively. They often take the lead in providing care in innovative primary care arrangements, such as retail clinics. 24

Advanced practice registered nurses by race (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding (more...)

• In 2019, the vast majority of advanced practice registered nurses (78 %) were non-Hispanic White ( Figure 19 ).
• Asian people, 6%,
• Hispanic people, 6%, and

Racial and Ethnic Diversity Among Emergency Professionals

Workforce diversity can reduce communication barriers and inequalities in healthcare delivery, especially in settings such as emergency departments, where time pressure and incomplete information may worsen the effects of implicit biases. The racial and ethnic makeup of the paramedic and emergency medical technician workforce indicates that concerted efforts are needed to encourage students of diverse backgrounds to pursue emergency service careers. 25

Emergency medical technicians and paramedics by race (left), and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages do not add to 100 due to rounding. In addition, (more...)

• In 2019, the vast majority of emergency medical technicians (EMTs) and paramedics (72%) were non-Hispanic White ( Figure 20 ).
• Hispanic people, 13%
• Asian people, 3%,

Racial and Ethnic Diversity Among Other Health Practitioners

Other health practitioners include physician assistants, medical assistants, dental assistants, chiropractors, dietitians and nutritionists, optometrists, podiatrists, and audiologists, as well as massage therapists, medical equipment preparers, medical transcriptionists, pharmacy aides, veterinary assistants and laboratory animal caretakers, phlebotomists, and healthcare support workers.

Other health practitioners by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding (more...)

• In 2019, the distribution of other health practitioners closely aligned with the racial and ethnic distribution of the U.S. population ( Figure 21 ).
• In 2019, 58% of other health practitioners were non-Hispanic White.
• In 2019, Hispanic people accounted for 20% of other health practitioners.
• Black people, 12%,
• Asian people, 7%,

Racial and Ethnic Diversity Among Physician Assistants

Physician assistants (PAs) are included in the Other Health Practitioners workforce group but are highlighted because they play a critical role in frontline primary care services in many settings, especially medically underserved and rural areas. With the demand for primary care services projected to grow and PAs’ roles in direct care, understanding this occupation’s racial and ethnic diversity is important.

Studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, and patient and staff satisfaction. These providers can also enhance the educational experience of residents and fellows. 26 However, a lack of workforce diversity has detrimental effects on patient outcomes, access to care, and patient trust, as well as on workplace experiences and employee retention. 27

Physician assistants by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding (more...)

• In 2019, the vast majority of physician assistants (73%) were non-Hispanic White ( Figure 22 ).
• Black people, 6%,
• Multiracial people, 3%, and

Racial and Ethnic Diversity Among Other Health Occupations

Other health occupations include veterinarians, acupuncturists, all other healthcare diagnosing or treating practitioners, dental hygienists, and licensed practical and licensed vocational nurses.

Other health occupations by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding (more...)

• In 2019, the vast majority of staff in other health occupations (61%) were non-Hispanic White ( Figure 23 ).
• Black people, 19%,
• Hispanic people, 11%
• Asian people, 6 %,

Racial and Ethnic Diversity Among Health Technologists

Health technologists include clinical laboratory technologists and technicians, cardiovascular technologists and technicians, diagnostic medical sonographers, radiologic technologists and technicians, magnetic resonance imaging technologists, nuclear medicine technologists and medical dosimetrists, pharmacy technicians, surgical technologists, veterinary technologists and technicians, dietetic technicians and ophthalmic medical technicians, medical records specialists, and opticians (dispensing), miscellaneous health technologists and technicians, and technical occupations.

Health technologists by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and the (more...)

• In 2019, the vast majority of health technologists (63%) were non-Hispanic White ( Figure 24 ).
• Black people, 14%,
• Hispanic people, 13%,
• Asian people, 8%, and

Racial and Ethnic Diversity Among Healthcare Aides

Healthcare aides include nursing, psychiatric, home health, occupational therapy, and physical therapy assistants and aides.

Healthcare aides by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, >1 Race, and Other are non-Hispanic. Percentages of the U.S. population do not add to 100 due to rounding and (more...)

• In 2019, 41% of healthcare aides were non-Hispanic White ( Figure 25 ).
• Black people, 32%,
• Hispanic people, 18%,

Racial and Ethnic Diversity Among Psychologists

The United States has an inadequate workforce to meet the mental health needs of the population, 28 , 29 , 30 and it is estimated that in 2020, nearly 54% of the U.S. population age 18 and over with any mental illness did not receive needed treatment. 31 This unmet need is even greater for racial and ethnic minority populations. Nearly 80% of Asian and Pacific Islander people, vii 63% of African Americans, and 65% of Hispanic people with a mental illness do not receive mental health treatment. 29 , 32 , 33 , 34

These gaps in mental health care may be attributed to a number of reasons, including stigma, cultural attitudes and beliefs, lack of insurance, or lack of familiarity with the mental health system. 35 , 36 , 37 However, a significant contributor to this treatment gap is the composition of the workforce.

The current mental health workforce lacks racial and ethnic diversity. 34 , 38 Research has shown that racial and ethnic patient-provider concordance is correlated with patient engagement and retention in mental health treatment. 39 In addition, racial and ethnic minority providers are more likely to serve patients of color than White providers. 34 , 36

Among psychologists, a key practitioner group in the mental health workforce, 37 , 40 minorities are significantly underrepresented. Psychologists in the United States are predominantly non-Hispanic White, while all racial and ethnic minorities represented only about one-sixth of all psychologists from 2011 to 2015.

Reducing the serious gaps in mental health care for racial and ethnic minority populations will require a significant shift in the workforce. Workforce recruitment, training, and education of more racially, ethnically, and culturally diverse practitioners will be essential to reduce these disparities.

Psychologists by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Note: White, Black, Asian, and >1 Race are non-Hispanic. Psychologists include practitioners of general psychology, developmental and child (more...)

• In 2019, the vast majority of psychologists (79%) were non-Hispanic White ( Figure 26 ).
• Hispanic people,10%,
• Asian people, 4%, and
• Multiracial people, 2.0%.

Although the outpatient substance use treatment field has seen an increase in referrals of Black and Hispanic clients, there have been limited changes in the diversity of the workforce. This discordance may exacerbate treatment disparities experienced by these clients. 41

Substance abuse and behavioral disorder counselors by race/ethnicity (left) and U.S. population racial and ethnic distribution (right), 2019. Key: AI/AN = American Indian/Alaska Native. Note: White, Black, Asian, AI/AN, and >1 Race are non-Hispanic. (more...)

• In 2019, the majority of substance abuse and behavioral disorder counselors (58%) were non-Hispanic White ( Figure 27 ).
• Black people, 18%,
• Hispanic people, 16 %,
• Asian people, 4%,
• AI/AN people, 1%.
• Overview of Healthcare Expenditures in the United States
• Hospital care expenditures grew by 6.2% to $1.2 trillion in 2019, faster than the 4.2% growth in 2018.
• Physician and clinical services expenditures grew 4.6% to $772.1 billion in 2019, a faster growth than the 4.0% in 2018.
• Prescription drug spending increased by 5.7% to $369.7 billion in 2019, faster than the 3.8% growth in 2018.
• In 2019, the federal government (29%) and households (28%) each accounted for the largest shares of healthcare spending, followed by private businesses (19%), state and local governments (16%), and other private revenues (7%). Federal government spending on health accelerated in 2019, increasing 5.8% after 5.4% growth in 2018.

Personal Healthcare Expenditures

“Personal healthcare expenditures” measures the total amount spent to treat individuals with specific medical conditions. It comprises all of the medical goods and services used to treat or prevent a specific disease or condition in a specific person. These include hospital care; professional services; other health, residential, and personal care; home health care; nursing care facilities and continuing care retirement communities; and retail outlet sales of medical products. 43

Distribution of personal healthcare expenditures by type of expenditure, 2019. Key: CCRCs = continuing care retirement communities. Note: Percentages do not add to 100 due to rounding. Personal healthcare expenditures are outlays for goods and services (more...)

• In 2019, hospital care expenditures were $1.192 trillion, nearly 40% of personal healthcare expenditures ( Figure 28 ).
• Expenditures for physician and clinical services were $772.1 billion, almost one-fourth of personal healthcare expenditures.
• Prescription drug expenditures were $369.7 billion, 10% of personal healthcare expenditures.
• Expenditures for dental services were $143.2 billion, 5% of personal healthcare expenditures.
• Nursing care facility expenditures were $172.7 billion and home health care expenditures were $113.5 billion, 5% and 4% of personal healthcare expenditures, respectively.

Personal healthcare expenditures, by source of funds, 2019. Note: Data are available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Personal healthcare (more...)

• In 2019, private insurance accounted for 33% of personal healthcare expenditures, followed by Medicare (23%), Medicaid (17%), and out of pocket (13%) ( Figure 29 ).
• Private insurance accounted for 37% of hospital, 40% of physician, 15% of home health, 10% of nursing home, 43% of dental, and 45% of prescription drug expenditures.
• Medicare accounted for 27% of hospital, 25% of physician, 39% of home health, 22% of nursing home, 1.0% of dental, and 28% of prescription drug expenditures.
• Medicaid accounted for 17% of hospital, 11% of physician, 32% of home health, 29% of nursing home, 10% of dental, and 9% of prescription drug expenditures.
• Out-of-pocket payments accounted for 3% of hospital, 8% of physician, 11% of home health, 26% of nursing home, 42% of dental, and 15% of prescription drug expenditures.

Prescription drug expenditures, by source of funds, 2019. Note: Data are available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. Percentages do (more...)

• Private health insurance companies accounted for 44.5% of retail drug expenses ($164.6 billion in 2019).
• Medicare accounted for 28.3% of retail drug expenses ($104.6 billion).
• Medicaid accounted for 8.5% of retail drug expenses ($31.4 billion).
• Other health insurance programs accounted for 3.0% of retail drug expenses ($11.0 billion).

Other third-party payers had the smallest percentage of costs (1.2%), which represented $4.3 billion in retail drug costs.

• Variation in Healthcare Quality

State-level analysis included 182 measures for which state data were available. Of these measures, 140 are core measures and 42 are supplemental measures from the National CAHPS Benchmarking Database (NCBD), which provides state data for core measures with MEPS national data only.

The state healthcare quality analysis included all 182 measures, and the state disparities analysis included 108 measures for which state-by-race or state-by-ethnicity data were available. State-level data are also available for 136 supplemental measures. These data are available from the Data Query tool on the NHQDR website but are not included in data analysis.

State-level data show that healthcare quality and disparities vary widely depending on state and region. Although a state may perform well in overall quality, the same state may face significant disparities in healthcare access or disparities within specific areas of quality.

Overall quality of care, by state, 2015–2020. Note: All state-level measures with data were used to compute an overall quality score for each state based on the number of quality measures above, at, or below the average across all states. States (more...)

• Some states in the Northeast (Maine, Massachusetts, New Hampshire, and Rhode Island), some in the Midwest (Iowa, Minnesota, North Dakota, and Wisconsin), two states in the West (Colorado and Utah), and North Carolina and Kentucky had the highest overall quality scores.
• Some Southern and Southwestern states (District of Columbia, viii Florida, Georgia, New Mexico, and Texas), two Western states (California and Nevada), some Northwestern states (Montana, Oregon, Washington, and Wyoming), and New York and Alaska had the lowest overall quality scores.
• More information about the measures and data sources included in the creation of this map can be found in Appendix C .
• More information about healthcare quality in each state can be found on the NHQDR website, https://datatools ​.ahrq.gov/nhqdr .
• Variation in Disparities in Healthcare

The disparities map ( Figure 32 ) shows average differences in quality of care for Black, Hispanic, Asian, NHPI, AI/AN, and multiracial people compared with the reference group, non-Hispanic White or White people. States with fewer than 50 data points are excluded.

Average differences in quality of care for Black, Hispanic, Asian, Native Hawaiian/Pacific Islander, American Indian or Alaska Native, and multiracial people compared with White people, by state, 2018–2019. Note: All measures in this report that (more...)

• Some Western and Midwestern states (Idaho, Iowa, Kansas, Montana, Nevada, New Mexico, Oregon, Utah, and Washington), several Southern states (Kentucky, Mississippi, Virginia, and West Virginia), and Maine had the fewest racial and ethnic disparities overall.
• Several Northeastern states (Massachusetts, New York, and Pennsylvania), two Midwestern states (Illinois and Ohio), two Southern States (Louisiana and Tennessee), and Texas had the most racial and ethnic disparities overall.

Major updates made to three data sources since 2018, specifically the Medical Expenditure Panel Survey, Healthcare Cost and Utilization Project, and National Health Interview Survey, have had an outsized impact on what the 2021 NHQDR can include. Trend data were provided in prior versions of the NHQDR but were not directly comparable for almost half of the core measures at the time this report was developed. Therefore, the 2021 NHQDR does not include a summary figure showing all trend measures or all changes in disparities. The report includes summary figures for trends and change in disparities for some populations and the results for individual measures.

More information on providers that may be eligible to become CAHs and the criteria a Medicare-participating hospital must meet to be designated by CMS as a CAH can be found at https://www ​.cms.gov/Medicare ​/Provider-Enrollment-and-Certification ​/CertificationandComplianc/CAHs .

All the criteria for a Medicare-participating hospital to be designated by CMS as a CAH can be found at https://www ​.cms.gov/Medicare ​/Provider-Enrollment-and-Certification ​/CertificationandComplianc/CAHs .

The most recent data year available is 2018 from the Association of American Medical Colleges, the current source for workforce data broken down by both race/ethnicity and sex.

The National Survey on Drug Use and Health at the Substance Abuse and Mental Health Services Administration combines data for Asian and Pacific Islander populations, which include Native Hawaiian populations.

For purposes of this report, the District of Columbia is treated as a state.

This document is in the public domain and may be used and reprinted without permission. Citation of the source is appreciated.

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Does Income Affect Health? Evidence from a Randomized Controlled Trial of a Guaranteed Income

This paper provides new evidence on the causal relationship between income and health by studying a randomized experiment in which 1,000 low-income adults in the United States received $1,000 per month for three years, with 2,000 control participants receiving $50 over that same period. The cash transfer resulted in large but short-lived improvements in stress and food security, greater use of hospital and emergency department care, and increased medical spending of about $20 per month in the treatment relative to the control group. Our results also suggest that the use of other office-based care—particularly dental care—may have increased as a result of the transfer. However, we find no effect of the transfer across several measures of physical health as captured by multiple well-validated survey measures and biomarkers derived from blood draws. We can rule out even very small improvements in physical health and the effect that would be implied by the cross-sectional correlation between income and health lies well outside our confidence intervals. We also find that the transfer did not improve mental health after the first year and by year 2 we can again reject very small improvements. We also find precise null effects on self-reported access to health care, physical activity, sleep, and several other measures related to preventive care and health behaviors. Our results imply that more targeted interventions may be more effective at reducing health inequality between high- and low-income individuals, at least for the population and time frame that we study.

Many people were instrumental in the success of this project. The program we study and the associated research were supported by generous private funding sources, and we thank the non-profit organizations that implemented the program. We are grateful to Jake Cosgrove, Leo Dai, Joshua Lin, Anthony McCanny, Ethan Sansom, Kevin Didi, Sophia Scaglioni, Oliver Scott Pankratz, Angela Wang-Lin, Jill Adona, Oscar Alonso, Rashad Dixon, Marc-Andrea Fiorina, Ricardo Robles, Jack Bunge, Isaac Ahuvia, and Francisco Brady, all of whom provided excellent research assistance. Alex Nawar, Sam Manning, Elizabeth Proehl, Tess Cotter, Karina Dotson, and Aristia Kinis were invaluable contributors through their work at OpenResearch. Carmelo Barbaro, Janelle Blackwood, Katie Buitrago, Melinda Croes, Crystal Godina, Kelly Hallberg, Kirsten Jacobson, Timi Koyejo, Misuzu Schexnider, and the staff of the Inclusive Economy Lab at the University of Chicago more broadly have provided key support throughout all stages of the project. Kirsten Herrick provided help with the nutrition diary data collection effort of this project. We are grateful for the feedback we received throughout the project from numerous researchers and from our advisory board, as well as useful feedback from seminar and conference participants. This study was approved by Advarra Institutional Review Board (IRB).We received funding for this paper from NIH grant 1R01HD108716-01A1. Any views expressed are those of the authors and not those of the U.S. Census Bureau. The Census Bureau has reviewed this data product to ensure appropriate access, use, and disclosure avoidance protection of the confidential source data used to produce this product. This research was performed at a Federal Statistical Research Data Center under FSRDC Project Number 3011. (CBDRB-FY24-P3011-R11537). The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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A Searing Reminder That Trump Is Unwell

His bizarre diatribe at the RNC shows why the pro-democracy coalition is so worried about beating him.

This is an edition of The Atlantic Daily, a newsletter that guides you through the biggest stories of the day, helps you discover new ideas, and recommends the best in culture. Sign up for it here.

Donald Trump’s bizarre diatribe at the Republican National Convention shows why the prodemocracy coalition is so worried about beating the GOP nominee—even if it means that Joe Biden must step down.

But first, here are three new stories from The Atlantic .

• It’s official: The Supreme Court ignores its own precedent.
• What the Microsoft outage reveals
• “Hillbilly” women will get no help from J. D. Vance.

Not Comparable

It’s been quite a year in politics, what with President Biden facing calls to drop out of the race and Trump having a meltdown in public after an assassination attempt and …

I’m sorry, did I say a year ? I meant a week .

So much has happened, and political events have become so freakish, that we can all be forgiven for losing our bearings a bit. For the past few days, I’ve felt like Homer Simpson after he accidentally turned a toaster into a time machine and came back to find that Ned Flanders was the unchallenged dictator of the world.

But in the midst of all this, two things remain clear:

• Joe Biden is showing significant signs of frailty and faces real opposition within his party to continuing his campaign.
• Donald Trump is emotionally unwell.

These are not comparable problems.

Nor did Biden and Trump have equally bad weeks. Biden is facing a revolt in his own party and is now recovering from COVID. Trump was nearly killed by a young loner .

Biden claims to still be in the race, an answer many elected Democrats have refused to accept. My colleague Russell Berman wrote yesterday afternoon that Senator Peter Welch of Vermont believes that the Biden campaign may be at an end; more telling is that Russell described Welch as the only member of the upper chamber making that argument, but from the time that Russell wrote that article to this afternoon, three more sitting Democratic U.S. senators— Sherrod Brown of Ohio, Jon Tester of Montana, and Martin Heinrich of New Mexico—called for Biden to step down.

The case for Biden leaving the race is evident to anyone who’s watched him over the past month. He seems to be no better in his public outings than he was during the debate, and has sometimes seemed worse. As I’ve said here , I don’t think that means he can’t run the country for the remainder of his term, but Trump is going to be fired up and on the road, and I doubt that Biden can match that level of engagement, which could be decisive in a race that will be won on slim margins in a handful of states. I suspect that the people voting to save democracy would vote for Biden if he were governing from a cryostatic tube, but the Democrats calling on him to wrap it up have perfectly valid fears that he could lose and take the down-ballot races with him.

Meanwhile, the Republican National Convention was a searing reminder that Trump is a vengeful autocrat with obvious mental deficits who has surrounded himself with a crew of vicious goons.

I approached Trump’s speech with genuine curiosity. I was for most of my life a working political scientist, and I have written speeches for politicians; I think I know a good one when I see one. So I watched last night to see if Trump, tamed by a brush with death, would strike a new tone or, at the very least, try to make peace with one of his most hated enemies: the teleprompter.

No chance. To be fair, some people who watched the speech thought that the first 10 minutes or so, in which Trump recounted being injured, were good, even thoughtful. I thought they were terrible; although Trump and his people have emphasized Trump’s defiance in the moment after he was hurt, his blow-by-blow account of the incident came across to me as creepy and solipsistic rather than brave.

Contrast that with Ronald Reagan, the previous president injured in an attempt on his life. Karen Tumulty of The Washington Post reminded us today that Reagan appeared before Congress a month after he was nearly killed. (His injuries were severe and life-threatening.) Reagan was on the Hill to talk about the economy, but he started by thanking the country for its prayers and good wishes, noting a cute letter he got from a child while he was in the hospital, and paying tribute to the people injured alongside him. This digression took all of four paragraphs, a matter of a few minutes. “Now, let’s talk about getting spending and inflation under control and cutting your tax rates,” he then said. Trump, however, droned on about how much the human ear can bleed, while the screens behind him showed huge pictures of blood on his face. He then went over to the equipment owned by Corey Comperatore, the volunteer firefighter killed in the attack, and kissed the helmet. Some in the crowd may have loved it, but I prefer a bit more stoicism in national leaders; I’ve always thought that Trump’s penchant for hugging and kissing flags was weird, and planting a kiss on the headgear of a dead man was even weirder.

And then things really went off the rails. If you didn’t sit through it, I can’t blame you; it was the longest presidential-nomination-acceptance speech on record. Basking in the friendliest audience he will ever find on this planet, Trump couldn’t help himself. He was supposed to be like a band at a concert doing a tight set, playing some favorites for the loyal fans, introducing a little new material, and gaining a wider audience. Instead, he blew the chance and ran overtime as he noodled, improvised, and even mangled some of his classics.

The speech wasn’t written that way, of course, but Trump can’t stick to a script. You can always tell when Trump is trying to read the teleprompter: His shoulders tense up, he cocks his head and squints, and he rushes through words he has clearly never seen before. It doesn’t help that Trump’s writers stuff his speeches with baroque constructions that are supposed to be soaring and majestic but that always end up sounding more like dollar-store Churchill imitations. Trump struggles with these complex sentences, and then he abandons them—and that is when the real Trump comes out, in all his whiny and aggrieved glory.

I do not have the space (or the endurance) to relive those moments with you, but they were the ramblings of a man who has serious psychological problems . All of it was on display last night: rage, paranoia, pettiness, desolating selfishness.

I’m always sorry to leave readers with these sorts of observations just before a weekend, but much of the media response to Biden’s troubles and Trump’s madness has been mired in equivalences that obscure what’s happening to both men, and what’s at stake for the nation. (As I was writing this, for example, a Washington Post newsletter arrived in my inbox and told me that the GOP had just wrapped up “an energized, focused convention.” That’s an interesting description of a Republican gathering that featured a sex worker, Hulk Hogan, and a spaced-out Trump.)

Yes, Biden is old, and he’s having trouble communicating. The people expressing serious concerns about him have good reason to worry about both his health and his ability to defeat Trump. He might be out of the race by next week. But Trump is mentally and emotionally unwell. He and his valet, J. D. Vance, are not going anywhere. The real tragedy is that, in a serious country, Biden might step down without incident, and a normal race would continue, because decent people would have banished Trump from the public square long ago.

• David Frum: This crew is totally beatable.
• The new Trump is always the old Trump.

Today’s News

• A software update from the cybersecurity company CrowdStrike caused a digital outage that disrupted airlines, health care, shipping, and many other services on Friday.
• A federal appeals court temporarily blocked a Biden-administration student-loan-repayment plan, leading the Department of Education to pause payments for 8 million borrowers.
• Depending on his recovery from COVID-19, Biden expects to meet Israeli Prime Minister Benjamin Netanyahu when the latter is in Washington next week to address a joint session of Congress.
• The Books Briefing : Emma Sarappo explores the books that keep readers awake at night .
• Atlantic Intelligence : Damon Beres asks: What happens when a bot gets too good at its job ?

Explore all of our newsletters here.

Evening Read

How I Faked My Way to Rock Stardom

By J. R. Patterson

Before John Fogerty’s life became mine, there was cold. In November 2012, I was 22 and had left the family farm in Manitoba to find work in the oil fields of Alberta. I arrived during a bust and, because work was not immediate, spent the days driving my Ford F-150 around the country surrounding Calgary, listening to AM radio and my small collection of CDs—a few Rolling Stones albums, some outlaw-country records, and the complete discography of Creedence Clearwater Revival. The Ford was what they call a SuperCab, with a rear backward-opening half door and a narrow bench for a back seat. At night, lacking the money for a hotel, I would find a quiet place to park, crawl into the back seat, and stretch out on the bench, my clothes wrapped around my boots for a pillow. I kept my guitars—an acoustic Martin and an electric Epiphone Les Paul—beside me to warm them, lest they crack in the cold. The nights weren’t kind to me either, and I often woke up shivering, the world outside covered with frost or snow. To allay myself, I’d run the engine for a while and put on Creedence.

Read the full article.

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• Whoops! The internet broke.

Culture Break

Watch. Twisters , in theaters, squeezes a lot of juice out of the weather-driven disaster flick.

Read. In Yasmin Zaher’s debut novel, The Coin , the promise of exclusivity is a facade .

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Some of you may have noticed that I don’t particularly admire Trump’s running mate, Senator J. D. Vance of Ohio. (Vance has noticed it too.) I wrote about his RNC speech here . I remain appalled at Vance’s casual betrayal of the people he claims to care about, the poor and working-class whites he grew up with in Ohio.

Perhaps I feel this more keenly because I grew up in a working-class town in Massachusetts, and I think working people deserve a better spokesperson than an opportunistic plutocrat like Vance. You may find it striking to think of New England as a depressed area; people who are not from the region probably think of it as a lovely expanse of college greens and church steeples and foliage. And it is—but much of New England was once home to mills and factories that produced shoes, textiles, and even military swords. (The bronze doors of the U.S. Capitol’s House wing were cast in 1903 in my hometown of Chicopee.) By the late 1970s, many of those workplaces, abandoned as industries moved out of the Northeast and sometimes out of the United States, were rotting hulks.

If you’d like to read a memoir that shows what it was like to grow up in Massachusetts in those days, I’d suggest Townie: A Memoir , by Andre Dubus III, who is near my age and grew up in a mill town much like mine. It’s not a pretty read, but it is evocative—so much so that some passages made me wince. I can affirm that it captures the reality of growing up in a part of America, far from Vance’s hometown, that was also plagued by dysfunction and decline.

When you buy a book using a link in this newsletter, we receive a commission. Thank you for supporting The Atlantic .

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USC researchers recognized with manuscript awards in two athletic training journals

July 22, 2024  | Erin Bluvas,  [email protected]

Papers published by researchers in the Department of Exercise Science have been selected as the nationwide winners of outstanding manuscript awards from two major athletic training journals. They were recognized at the National Athletic Trainers’ Association’s Annual Convention last month.

Understanding how mental health, specifically suicidal ideation, may be impacted by concussions, as well as how we can explore constructs of patient-centered care, such as the social determinants of health, is critical to the ever-changing landscape of sports medicine.

Alumni Kaitlynn Moll (M.S. in Advanced Athletic Training ’23) and Nancy Uriegas (Ph.D. in Exercise Science, ’24) and clinical assistant professor Zachary Winkelmann won the Athletic Training Education Journal Award for the Outstanding Manuscript for their paper on the use of a social determinants of health history focused script to facilitate patient conversations . Ph.D. in Exercise Science alumni Jacob Kay (’20) and Adam Harrison (’22 and currently a postdoctoral fellow) and exercise science associate professors Toni Torres-McGehee and Davis Moore won the Journal of Athletic Training Kenneth L. Knight Award for the Outstanding Research Manuscript for their paper on the connection between concussions and suicide , which was featured in a special edition of the journal.

“The JAT and ATEJ are the flagship journals for athletic training clinical practice and education,” Winkelmann says. “These awards highlight the contributions of research to ultimately improve patient care.”

Prior research has demonstrated the importance of identifying social determinants of health to overcome barriers to positive health outcomes and address access limitations to resources that facilitate patient-centered care. Yet, screening for these factors is not always a part of standard care – particularly due to the absence of an effective tool to navigate this process.

In their exploration of using a focused history script as an aid to collecting information about social determinants of health, the authors for the winning paper in the Athletic Training Education Journal found that using this type of screening tool helped facilitate conversations between athletic training students and patients. Further, most health care students that were not required to use the script as a screening tool failed to elicit information about social determinants of health from their patients.

In response to growing interest in the relationship between multiple concussions and mental health, the authors of the Journal of Athletic Training award-winning paper investigated the association between concussion frequency and adverse mental health outcomes among male and female youth.

The researchers found that high school students who reported concussion/s were more likely to experience poor mental health and suicidal behaviors. Further, the more concussions experienced by these adolescents, the greater the odds of reporting suicidal attempts (particularly among males). These results suggest a need for careful monitoring by health care professionals of youth who experience repeated concussions, especially those in the close proximity to one another.

“The intersection of these topics with clinical outcomes has been pivotal,” Winkelmann says. “Understanding how mental health, specifically suicidal ideation, may be impacted by concussions, as well as how we can explore constructs of patient-centered care, such as the social determinants of health, is critical to the ever-changing landscape of sports medicine.”

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Our federal government exists on fake money, borrowed time.

“Freedom is always just one generation away from extinction.” — Ronald Reagan (1911-2004)

In December 1776, just six months after the Declaration of Independence had been signed and a year and a half into the Revolutionary War, Thomas Paine sensed desperation throughout the Colonies. This prompted him to write a candid and now iconic essay entitled “The American,” which began with the famous line “These are the times that try men’s souls.” He made an argument similar to one that presidential candidate Ronald Reagan would 204 years later.

The essence of that argument is that our personal liberty is fragile. Since government is essentially the negation of liberty, government is liberty’s greatest threat. So we must exercise our freedoms with prudence and courage. We must also be skeptical of what the government says and does.

Paine and Reagan, and those who risked all to sign the declaration and fight England, recognized that our freedoms are natural to us.

Freedom is the right to make personal choices — about religion, speech, association, self-defense, travel, privacy, money and property — without a government permission slip or anyone’s approval. A right is an indefeasible claim against the whole world that all humans possess. Our rights can be extinguished or denied only when we have been convicted by a jury of violating someone else’s rights.

That is, at least, the theory of the declaration, the theory upon which the Colonies seceded from England and the theory upon which the states created the American republic.

Today, our rights can be extinguished or denied, and our liberty and property can be taken by politicians and bureaucrats without a jury trial.

These are the times that try our souls because, at home, we have a government that spends $1.7 trillion a year more than it takes in, while abroad, it taunts Russian dictator Vladimir Putin by paying for a war in Ukraine that the Ukrainians cannot win.

At home, both political parties in Congress have spent $35 trillion more than the feds have collected in the past 100 years, written any law, regulated any behavior, taxed any event, spent any sum, killed any foe — real or imagined — and intruded upon any property or process that they believed would advance themselves politically.

Last month, U.S. private industry added 206,000 new jobs to its payrolls, decreasing the unemployment rate. When the traders who moved the equity markets learned this, the markets went down.

Down? That’s because the traders fear that their masters at the Federal Reserve will continue to respond to good economic news by maintaining artificially high interest rates. Why? Because the Fed has flooded the market with fake money — more dollars chasing the same amount of goods and services — inflation is rampant.

So, to correct its mistakes, the Fed is making it more expensive to borrow money by raising its base interest rate, thus inducing the large banks that depend on it for artificial cash to raise their interest rates. Higher interest rates will induce less or deferred borrowing and thus — this modern monetary theory goes — a reduction in economic activity and a lessening of inflation.

But interest on borrowing is the rent we pay to use other people’s money. Why should government planners regulate that rent? It shouldn’t. It should only be regulated as all rents are (except real estate in New York City, where World War II-era rent controls still abide and continue to produce housing shortages) by the law of supply and demand. Is it constitutional for the Fed to regulate interest rates? The Supreme Court, in 100 years of fake money, has never ruled on this.

But the federal government is one of limited powers, all of which are derived exclusively from the Constitution — and there is no grant or even hint of a grant in the Constitution of power to the feds or their offspring to regulate interest rates.

The Constitution expressly prohibits the government from taking property without just compensation. When the government spends more than it collects in revenue, it borrows — often Fed-created money — to pay its bills. This causes more inflation and pushes the obligation to repay the borrowing with interest on to generations of Americans yet unborn.

Stated differently, the government takes your money without raising taxes.

So, today, we have a federal government existing on fake money and borrowed time.

What is the goal of spending $175 billion in Ukraine? Is it the expulsion of Russian troops and citizens from Crimea and eastern Ukraine, or is it the expulsion of Mr. Putin from office? Does either circumstance remotely affect or threaten American national security? No.

Has Mr. Putin threatened the United States? No. The United States has threatened him. Just ask Sen. Lindsey Graham, South Carolina Republican, who publicly asked the president to assassinate Mr. Putin. We have arms at the Russian border. The Russians have none at ours.

Do we know who in Ukraine received American military equipment and cash? No. Has Congress declared war on Russia? No. Can Congress fund a war without declaring it? No, but Congress does what it thinks is politically popular, the Constitution be damned.

Then why are we funding a war against Russia? We are doing so because the government here is out of control and the president is unpopular, and when that happens, the government chooses war. Presidents kill because they can.

So, our property is being devalued at home by a political system that is incapable of living within its means and abiding the Constitution, and by saber rattling abroad in the face of a country that poses no threat to America.

Freedom is one generation, maybe one nightmare event, from extinction because the people in whose hands we have reposed the Constitution for safekeeping hate it. And in the process, these constitutionally unfaithful stewards have given away our property and taken our liberty.

• To learn more about Judge Andrew Napolitano, visit https://JudgeNap.com.

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What is Project 2025?

It’s a blueprint for what a second Trump administration could look like, dreamed up by his allies and former aides.

If Donald Trump struggled somewhat in his first administration to move the country dramatically to the right, he’ll be ready to go in a second term.

That’s the aim behind Project 2025, a comprehensive plan by former and likely future leaders of a Trump administration to remake America in a conservative mold while dramatically expanding presidential power and allowing Trump to use it to go after his critics.

The plan is gaining attention just as Trump is trying to moderate his stated positions to win the election, so he’s criticized some of what’s in it as “absolutely ridiculous and abysmal” and insisted that neither he nor his campaign had anything to do with Project 2025.

Still, what’s in this document is a pretty good indicator of what a second Trump presidency could look like. Here’s what Project 2025 is and how it could reshape America.

It’s a blueprint for a second Trump administration

The centerpiece is a 900-page plan that calls for extreme policies on nearly every aspect of Americans’ lives, from mass deportations, to politicizing the federal government in a way that would give Trump control over the Justice Department, to cutting entire federal agencies, to infusing Christian nationalism into every facet of government policy by calling for a ban on pornography and promoting policies that encourage “marriage, work, motherhood, fatherhood, and nuclear families.”

This isn’t coming directly from the Trump campaign. But it should be taken seriously because of the people who wrote it, analysts say. The main organization behind the plan, the Heritage Foundation, is a revolving door for Trump officials (and Heritage is a sponsor of the Republican National Convention, which will hand him the nomination next week).

“This is meant as an organized statement of the Trumpist, conservative movement, both on policy and personnel, and politics,” said William Galston, head of governance studies at the Brookings Institution.

2024 presidential election

Project 2025 calls for abortion limits, slashing climate change and LGBTQ health care funding, and much more

A few of the highlights:

Remake the federal workforce to be political : Instead of nonpartisan civil servants implementing policies on everything from health to education and climate, the executive branch would be filled with Trump loyalists. “It is necessary to ensure that departments and agencies have robust cadres of political staff,” the plan says. That means nearly every decision federal agencies make could advance a political agenda — as in whether to spend money on constituencies that lean Democratic. The project calls for cutting LGBTQ health programs, for example.

Cut the Education Department: Project 2025 would make extensive changes to public schooling, cutting longtime low-income and early education federal programs like Head Start, for example, and even the entire Education Department. “Federal education policy should be limited and, ultimately, the federal Department of Education should be eliminated,” the plan reads.

Give Trump power to investigate his opponents : Project 2025 would move the Justice Department, and all of its law enforcement arms like the FBI, directly under presidential control. It calls for a “top-to-bottom overhaul” of the FBI and for the administration to go over its investigations with a fine-toothed comb to nix any the president doesn’t like. This would dramatically weaken the independence of federal law enforcement agencies. “There’s going to be an all-out assault on the Department of Justice and the FBI,” said Galston, of Brookings. “It will mean tight White House control of the DOJ and FBI.”

Make reproductive care, particularly abortion pills, harder to get : It doesn’t specifically call for a national abortion ban, but abortion is one of the most-discussed topics in the plan, with proposals throughout encouraging the next president “to lead the nation in restoring a culture of life in America again.” It would do this by prosecuting anyone mailing abortion pills (“Abortion pills pose the single greatest threat to unborn children in a post-Roe world,” the plan says). It would raise the threat of criminalizing those who provide abortion care by using the government to track miscarriage, stillbirths and abortions, and make it harder to get emergency contraceptive care covered by insurance. It would also end federal government protections for members of the military and their families to get abortion care.

Crack down on even legal immigration : It would create a new “border patrol and immigration agency” to resurrect Trump’s border wall, build camps to detain children and families at the border, and send out the military to deport millions of people who are already in the country illegally ( including dreamers ) — a deportation effort so big that it could put a major dent in the U.S. economy. “Illegal immigration should be ended, not mitigated; the border sealed, not reprioritized,” the plan says.

Slash climate change protections : Project 2025 calls for getting rid of the National Oceanic and Atmospheric Administration, which forecasts weather and tracks climate change, describing it as “one of the main drivers of the climate change alarm industry.” It would increase Arctic drilling and shutter the Environmental Protection Agency’s climate change departments, all while making it easier to up fossil fuel production.

Ban transgender people from the military and consider reinstating the draft : “Gender dysphoria is incompatible with the demands of military service,” it reads. The author of this part of the plan led the Defense Department at the end of Trump’s presidency, and he told The Washington Post that the government should seriously consider mandatory military service.

How all of this would be implemented

A huge part of this project is to recruit and train people on how to pull the levers of government or read the law in novel ways to carry out these dramatic changes to federal policy. There’s even a place on the plan’s website where you can submit your résumé.

But there are some major hurdles to getting the big stuff done, even if Trump and Republicans win control of Washington next year. For one, Trump doesn’t appear to agree with everything in it. His campaign platform barely mentions abortion, while Project 2025 zeroes in on it repeatedly.

Also, some of these ideas are impractical or possibly illegal. Analysts are divided about whether Trump can politicize the civil workforce to fire them at will, for example. And the plan calls for using the military to carry out mass deportations on a historic scale , which could be constitutionally iffy.

Ominously, one of the project’s leaders opened the door to political violence to will all of this into being: “We are in the process of the second American revolution,” Heritage Foundation President Kevin Roberts warned recently, “which will remain bloodless, if the left allows it to be.”

Why Project 2025 is getting so much attention right now

It’s not unusual for wannabe administration officials to plan for how they’d govern once they get back in power. But what is unusual is how dramatic and unapologetically extreme many of these proposals are.

And the Biden campaign — which is obviously struggling right now with existential questions about its nominee — sees this as an easy target to campaign on.

Democrats are circulating a survey from a liberal organization that suggests talking about Project 2025 as a “takeover” of American government by Trumpists resonates with voters.

“It’s like reading a horror novel,” said Democratic strategist Jesse Ferguson. “Each page makes you want to read the next one, but when you finish reading it, you’re scared and disgusted.”

That’s much to the frustration of the Trump campaign, which doesn’t want such specific (and politically unpopular) ideas out there pegged to his campaign, as he’s trying to moderate some of his positions to win the election.

“It makes no sense to put all the crazy things you’ll be attacked for down on paper while you’re running,” a Trump adviser told The Washington Post recently .

But it’s fair to think of Project 2025 as a pretty good indicator of what a second Trump presidency would look like, analysts say.

“It’s not like Trump is going to hand out this booklet to his Cabinet on Day One and say, ‘Here you go,’” said Michael Strain, the director of economic policy studies at the conservative-leaning American Enterprise Institute. “But it reflects real goals of important people in Trump’s community.”

A previous version of this article misspelled the name of the American Enterprise Institute's Michael Strain as Michel. The article has been corrected.

Election 2024

Follow live updates on the 2024 election from our reporters on the campaign trail and in Washington.

Kamala Harris: A majority of Democratic delegates have pledged to support Harris , signaling she is likely to secure the presidential nomination next month. We broke down seven options for her vice-presidential pick .

Biden drops out: President Biden addressed the nation , seeking to define his legacy and explain his decision to exit the presidential race. Here’s what happened in the hours before Biden posted a letter announcing his decision to end his campaign .

Trump VP pick: Donald Trump has chosen Sen. J.D. Vance (Ohio) as his running mate , selecting a rising star in the Republican Party and a previously outspoken Trump critic who in recent years has closely aligned himself with the former president.

Presidential election polls: Here’s what voters think about Harris replacing Biden and how Harris performs against Trump in recent polls .

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Amid the Mayhem, Trump Pumped His Fist and Revealed His Instincts

A bloodied Donald J. Trump made Secret Service agents wait while he expressed his defiance. The moment epitomized his visceral connection with his supporters, and his mastery of the modern media age.

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By Shawn McCreesh

• July 13, 2024

Donald J. Trump was back on his feet. He had just been shot at, his white shirt was undone and his red hat was no longer on his head. Blood streaked across his face as riflemen patrolled the perimeter of the stage. A pack of Secret Service agents pressed their bodies against his. “We’ve got to move, we’ve got to move,” one pleaded.

“Wait, wait, wait, wait,” the former president instructed, his voice a harried — but startlingly clear — command. Reluctantly, they halted. He peered out into the crowd.

And then his arm reached toward the sky, and he began punching the air.

The crowd started to chant — “ U-S-A! U-S-A! ” — as the agents inched Mr. Trump toward the stairs. When they reached the top step, they paused once more, so Mr. Trump could lift his arm a little higher, and pump his fist a little faster. The crowd roared a little louder.

It’s difficult to imagine a moment that more fully epitomizes Mr. Trump’s visceral connection with his supporters, and his mastery of the modern media age.

Mr. Trump would not leave the stage without signaling to his fans that he was OK — even as some were still wailing in fear. And he did not just wave or nod, he raised his fist in defiance above his bloodied face — making an image history will not forget.

He has always been highly conscious of how he looks in big moments, practicing his Clint Eastwood squint and preparing for his mean mug-shot grimace. But there was no time to prepare for this.

This was instinct.

As the agents coaxed him onto his feet, he stammered, “Let me get my shoes on, let me get my shoes on.”

“I got you, sir, I got you, sir,” an agent replied. Mr. Trump rose, his voice uneven at first, still repeating himself: “Let me get my shoes on.”

“Hold that on your head,” an agent told him, “it’s bloody.”

“Sir, we’ve got to move to the cars,” another said.

“Let me get my shoes on,” Mr. Trump said again.

Fierce one moment, he looked drained and stricken the next.

After the agents managed to hustle him off the stage, they led him toward an idling Chevrolet Suburban. He began to clamber inside, but before the door could close, he turned back toward the crowd again. His head appeared more blood-soaked than before. He raised his fist one more time.