As I sit in my doctor’s office for what is going on the third hour, I think back to just a few years ago when I could expect to be in and out of my doctor’s office in under an hour. Not anymore. It is January 15, 2015 and thanks to President Obama’s success in expanding healthcare coverage to an additional 23 million people, I have become accustomed to long waiting times, reduced choices, and less face-to-face time with my doctor. If only we had learned from England’s National Health Service, where patients wait for up to 18 weeks to see a doctor[1]. Ironically, in an effort to increase access to health insurance, President Obama decreased access to the healthcare system. While many problems lie ahead of the Obama administration in its final term, two of the biggest health policy issues facing the nation are increasing access to the health system and improving quality of care.

The first and most urgent issue is to increase access. Due to the massive increase in the volume of care being demanded, hospitals and primary care facilities across the nation have been unable to meet the needs of a majority of patients—resulting in excessively long waiting times and a shortage of key medical resources. One of the least favorable, yet nearly inevitable, solutions to this problem is rationing care. While hospitals cannot turn people away due to regulations such as EMTALA[2], healthcare organizations will ration care by allocating the most scarce and highly demanded resources only to those who are most in need.

While rationing care is one way to address increased volume by forcibly decreasing demand, other less controversial methods can be used to increase supply. With more people accessing the healthcare system, there are not enough doctors, nurses, or medical resources to go around. As such, policy makers must work to recruit more doctors, nurses, and clinical staff, especially in primary care. In addition to recruiting medical professionals, healthcare organizations will begin substituting between key medical staff, such as substituting nurse practitioners and physician assistants for doctors, whenever possible. More medical schools will be established throughout the country and existing medical and nursing schools will begin to lower their acceptance criteria to increase the amount of trained medical professionals. While increasing the number of medical professionals is one aspect of increasing accessibility to the health system, increasing the number of medical institutions is another.

The second component of increasing supply is to increase the number of institutions where patients can be seen. First and foremost, more primary care facilities must be built. Also, to alleviate the burden on emergency rooms, there must be an increased reliance on urgent care centers, wound care centers, outpatient clinics, and the like. Policy makers must develop innovative solutions and consider new models of healthcare delivery such as the patient-centered medical home (PCMH). The PCMH model is a healthcare setting that aims to deliver comprehensive and high quality care by facilitating personal relationships between patients and physicians, coordinating care through the use of health information technology (HIT) and relying on evidence-based practice (EBP) to provide safe and effective care to all patients. Progressive models such as the PCMH seek to address not only the problem of access, but also issues such as quality.

If the first health policy priority is to increase access, the second is to improve quality. While there are many ways to address quality improvement, three viable solutions include utilizing HIT, increasing the role of EBP, and mandating the implementation of patient safety initiatives. In regard to HIT, policy makers must render a decision as to which system of electronic medical records (EMR) will be used and require all healthcare organizations to demonstrate meaningful use of the selected system. Widespread use of uniform EMRs will greatly increase coordination of care and eliminate inefficiencies currently present in our healthcare system. In addition, other advances in HIT, such as electronic prescribing and picture archiving and communication systems (PACS), should be required in hospital settings to reduce the incidence of preventable medical errors and reduce waste and inefficiencies in the system. PACS enable the electronic transfer of images, such as X-rays and CAT scans, between medical professionals—reducing the need for duplicate tests and the physical transfer of films. Used in conjunction with other initiatives, HIT can greatly improve quality of care.

Another aspect of improving quality of care is to increase the reliance on EBP to develop standards of care. EBP allows doctors to rely on the best available scientific evidence when making decisions regarding an individual patient’s care. By relying on clear-cut evidence, EBP can improve patient outcomes by decreasing variation among providers and discouraging unsystematic and opinionated clinical observations. Finally, policy makers must urge healthcare organizations to implement patient safety standards. Preventable medical errors are the eighth leading cause of death in the US, killing more people than breast cancer, automobile accidents, or AIDS[3]. As such, it is crucial that patient safety be addressed and that initiatives such as checklists, HIT, and human factors engineering be mandated in all healthcare organizations. Human factors engineering is an applied science of systems design that seeks to ensure that working environments are designed in such a way to reduce the likelihood of human error and optimize patient safety. In addition, healthcare organizations should implement processes that would enable employees to anonymously report medical errors. In so doing, employees are more likely to report errors, allowing administrators to identify problem areas to be addressed.

Anyone who has picked up a newspaper lately knows that there are many problems in our current healthcare system and even more opinions as to which are the most urgent. In my opinion, the top two priorities for health policy experts to address are to increase access and improve quality. By making tough decisions such as rationing care and developing innovative solutions to healthcare delivery, policy makers can lead Americans on a revolutionary journey to the future of American healthcare