The ACP Advocate Blog

by Bob Doherty

Tuesday, August 7, 2012

Does health insurance ensure access?

A staple of conservative critiques of universal coverage is that having health insurance doesn’t equal access. The corollary is that the uninsured already have access to care—from doctors and hospitals willing to take care of them on a charitable basis and from "safety-net" institutions.

This argument isn’t new, having been made years before the Affordable Care Act became law. In 2007, the Council for Affordable Health Insurance opined that "Universal Coverage Doesn’t Mean Timely Access":

"One of the false assumptions behind the push for universal coverage is that everyone will have access to care. While that may occur initially, within a short period of time the waiting lines begin to grow and access and quality begin to decline as the government limits funding for health care. Moreover, the uninsured do have access to care. . . some of it provided free or at discounted rates in public clinics. Having insurance coverage would be better, but the uninsured can and do get care."

Writing for the libertarian Cato Institute, Michael Tanner similarly argues that "health insurance does not mean universal access to health care. In practice, many countries promise universal coverage but ration care or have long waiting lists for treatment."

Dr. Marc Siegel, a physician, takes the argument even further, blogging in the National Review that he objects not only to the government mandating health insurance for all, but to the very idea of health insurance:

"The individual mandate may be the glue that holds Obamacare together by shoehorning in young healthy people who don’t need health insurance to pay for the sick and elderly who do, but an even greater problem than the mandate lies in the unwieldy insurance itself... Obamacare will make things much worse by increasing the number of people who are insured, expanding the procedures and other items (e.g. contraception) that are covered, and enlarging the government’s involvement in running it all."

(I find it ironic that many conservatives who object to ObamaCare because it will result in more people getting health insurance also advocate for converting Medicare to a defined contribution program where the government will give you—you guessed it—a voucher to buy private health insurance!)

But let’s get back to the main argument: that the health insurance doesn’t equal access to care, and that the uninsured can get care anyway.

It is true that health insurance by itself doesn’t ensure access—you need enough doctors to take care of patients, for one thing—but the evidence also is clear that being without health insurance consistently is associated with poorer access and poorer outcomes.

Here is what the Institute of Medicine found in its groundbreaking 2009 report, "America’s Uninsured Crisis: Consequences for Health and Health Care":

"A robust body of well-designed, high-quality research provides compelling findings about the harms of being uninsured and the benefits of gaining health insurance for both children and adults. Despite the availability of some safety net services, there is a chasm between the health care needs of people without health insurance and access to effective health care services. This gap results in needless illness, suffering, and even death."

What about those long waits for care in countries that have universal coverage? Well, yes, there are longer waits for elective procedures in some of them, but the United States doesn’t compare very favorably itself when measured on elements like access to primary care physicians and forgoing care because of cost.

In 2011, the Commonwealth Fund published a report and chart pack comparing U.S. health care to eight other countries (all of which have some form of universal coverage), and found that the U.S. was second worst in waiting time to get an appointment when sick, third to last in getting care after hours without going to an emergency room, and had the highest percentage of people who reported that because of cost, they did not get medical care, did not fill a prescription, or skipped medical test, treatment, or follow-up.

In 2008, I co-wrote an ACP position paper with my colleague Jack Ginsburg that compared U.S. health care to other countries’ and drew lessons from them.

We found that countries that ensure coverage through single payer systems may be "more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access." But we also found that they "may result in shortages of services and delays in obtaining elective procedures and limit individuals' freedom to make their own health care choices." Canada and Great Britain are examples of single payer systems.

We also found that "pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs." The French, Swiss and German systems are examples of pluralistic models that still manage to ensure universal coverage. (The United States, of course, is a pluralistic system that does not assure universal coverage, although the ACA is trying to get us closer.)

Finally, we concluded that "health care in the United States has many positive features and in many respects is superb compared with health care anywhere else in the world. Those with adequate health insurance coverage or sufficient financial means have access to the latest technology and the best care. However . . . the U.S. health care system is inefficient and inconsistent: health care quality and access vary widely both geographically among populations, some services are overutilized, and costs are far in excess of those in other countries. Moreover, the United States ranks lower than other industrialized countries on many of the most important measures of health."

In other words, an evidence-based assessment of universal coverage and the importance of health insurance coverage would find that:
-- Having coverage doesn’t by itself ensure access, but lack of health insurance by itself is assuredly associated with poorer outcomes and even more deaths;
-- Relying on a charity and safety-net providers is not enough to ensure access and quality in the absence of good health insurance; and
-- Because there are not unlimited resources, people sometimes will sometimes have to wait for care, and that this is true in every country. (In the U.S., longer waits for appointments, and delayed and forgone care, are mainly because of cost barriers associated with not having health insurance and not having enough primary care doctors; in other countries, longer waits for some elective procedures are mainly because of limits on capacity, global budgets and price controls.)

Clearly, people will continue to disagree on whether the ACA goes about the problem of getting people covered the right way, but conservatives should rethink their insistence that health coverage doesn’t really matter that much when it comes to ensuring access and quality (the evidence says it does).

But liberals should also keep in mind that giving everyone access to health insurance by itself also doesn’t guarantee access—we also need to address problems like the growing shortage of physicians, and acknowledge that administrative hassles imposed by insurance companies and government alike may be one of the factors that are keeping doctors away.

Today’s question: Do you think having health insurance coverage is needed to ensure access?

7 Comments :

Blogger Jay Larson MD said...

It depends on what part of the U.S. health care system a patient needs access. Most people can afford to pay for primary care office appointments and simple lab tests. Access to primary care will mostly be determined by work force deficiency rather than a patient having insurance coverage. Access to other parts of the health care system, which are much more expensive, insurance coverage will be needed. Having a $2000 colonoscopy covered by insurance is much less painful then shelling out the money from personal funds.

August 7, 2012 at 2:16 PM  
Blogger ryanjo said...

People can see me in the office for what it costs to take the family to a restaurant. Most of the drugs I prescribe can be bought for $4 or less a month. But you know what, patients won't spend the money. They'll drive 20 miles to the pharmacy that gives them a $10 gift cards. They'll refuse a med unless we have samples. Americans want the best healthcare that other people's money can buy. This is the real America, where half the citizens don't pay taxes. Put that into your Institute of Medicine report. Obamacare just creates the next stage of dependency. FAIL.

And if you ask me to fill out reams of paper and wait 10 minutes on the phone to approve your diabetic test strips because of government mandates, I won't be able to see more patients, either for cash or Obama-bucks. So insurance or not, access is the key. Early indications are that ACA will do nothing for access, not for a decade. FAIL.

Statistics are wonderful at stating the obvious, and then drawing the wrong conclusions. Agreed, sick people without insurance don't do well. That couldn't be because they also don't have adequate food, shelter, transportation, education or health literacy. None of which is addressed by ACA. Again, FAIL.

Okay, we're ready for the next straw-man argument.

August 7, 2012 at 6:10 PM  
Blogger Arvind said...

Bob, you have once again put words in the mouth of conservatives. They have never said that insurance does not matter. What they have said is that insurance is necessary in its correct form, i.e. insurance to cover catastrophic and large expenses. What the ACA prescribes as "insurance" is first dollar pre-paid plans which are clearly not necessary, especially for the healthy folks who work hard to live healthy lifestyles. So a high-deductible insurance with an HSA (with equal tax treatment from the IRS) will go much further in ensuring access to care in a timely manner than what the ACA prescribes.

Besides, a vast majority of the 30 million newly covered folks are likely to be on Medicaid, which as we all know has worse access to care than the uninsured.

So far one of the few statements from you that speak the absolute truth is "limit individuals' freedom to make their own health care choices". Do I need to add anything to this? Does this single finding not make you cringe, Bob? Do you really want Sovietization of the USA?

And, BTW, patients usually don't care about paying cash for office-based services if they find value in doing so. I have seen this over and over again in my own practice over the past 3-4 years. Every time I opt out of an insurance plan, and I offer my discounted office visit rate, at least 1/3 of the patients simply say yes, because they know they cannot get the quality of care we provide at any other area practice. Unfortunately, only my Medicare patients do not even have an option to consider that because the Federal government criminalizes charity. Do you know any other regime around the world that punishes a physician for showing empathy and providing care at a discounted price to his/her patients?

August 7, 2012 at 7:53 PM  
Blogger Steve Lucas said...

I have a slightly different perspective, I know, here he goes again.

We are trying to use insurance as a means to guarantee access. What we need is to change the way we “do” medicine.

When you pay for widgets you get widgets, and insurance and the way we practice medicine in the US today is a widget based process. Numbers count, outcomes are only important in the paper keeping process. Maximizing insurance is the stated purpose of many medical practices.

The doctors have made the point that once you remove insurance from the most basic medical services process, cost go down. There is also the recognition that once you start moving up the ladder of medical complexity with testing, chronic illness, and accidents cost will quickly exceed an average person’s ability to pay. There is a need for insurance.

Decades of experience in other areas has also proven to me that many low income individuals expect zero first dollar expenses for their care, and for other expenses. Today we are seeing a class war being fermented for political gain that is only exasperating the situation.

I am most familiar with France, but understand that in Europe you can get an appointment with a doctor the same day or the next day with no problems. Seeing a specialist is a long term issue and unless you are in an accident, a CT scan just to be sure, is out of the question. People also only go to the doctor when they are sick, no 90 day visits unless necessary.

The doctors are frustrated because they see a lower cost way to provide better service to their patients. The government is looking for this one size fits all solution of insurance for all. Insurance companies now want to shift patient risk to doctors. People like me want to go to the doctor and discuss my problem, not be sold a series of test or procedures that have profit objectives for the doctor or practice owner. (Think HCA)

There is no magic bullet. We will need to change the tax laws to allow for medical payment deductions. We will need to change Medicare to allow doctors to charge cash, but remain a Medicare provider. We will need to change the way we practice medicine with fewer test and specialist. (Liability has been used as an excuse for much too long.)

People need to understand medicine is a profession and a resource and it is not to be wasted.

Sadly, the doctors here need to understand that they are a minority. When I speak with doctors about blogs or national practice issues I get a blank stare, or worse am told they do not have time because they are on call or some other poor excuse. They are only interested in their practice and how to make more money.

It was once said that with a long enough lever and a place to stand a person could move the earth. I fear it will take a very long lever to move those in medicine.

Steve Lucas

August 8, 2012 at 10:28 AM  
Blogger FFSMD said...

Bob,
Based on the same people making 90%of the comments,I am skeptical about this comment being published. This blog looks like a closed shop. I will sumbit it anyway, maybe I will be surprised.

The answer is health insurance will ensure access to Internists if the Internists
1.) are reimbursed properly ( see explanation below)
2.) the insurance does not require excessive administrative work,
3.) not interfere excessively with the medical decision making of licensed , skilled physicians following a combination of EBM and judgement
4.) not threaten legal and financial penalties after the service was provided in good faith
5.) Private contracts between doctor and patient are permitted which will of course include the option of balanced billing. Patient is allowed to use insurance and supplement payment by contract with doctor.
6.) Significant tort reform allows Internists to do what they were trained to do , that is take care of patients without the need for excessive referrals which today are significantly defensive .

Proper reimbursement will be determined will depend on the location of practice and practice overhead including all expenses associated with being in practice. Local physician peer groups will be allowed to suggest fees for office visits , home visits , telephone calls etc.

In the case of Internists such changes would dramatically change the number of medical students going into primary care. The expected physician shortages would be less than expected , as physicians now would have incentive to work hard The best and the brightest would now return to Internal medicine.


On the other hand Insurance will not ensure access to Internists if it provides :
1.) inadequate reimbursement
2.) increasing and excessive administrative work,
3.) interfere excessively with the medical decision making of licensed , skilled physicians
4.)constant threat of legal and financial penalties after the service was provided in good faith
5.) prohibits private contracts
6 .no tort reform associate with insurance restrictions making liability even more likely.

Plane and simple there must be willing , happy providers to ensure access .

August 12, 2012 at 4:16 AM  
Blogger FFSMD said...

Bob,
Based on the same people making 90%of the comments,I am skeptical about this comment being published. This blog looks like a closed shop. I will sumbit it anyway, maybe I will be surprised.

The answer is health insurance will ensure access to Internists if the Internists
1.) are reimbursed properly ( see explanation below)
2.) the insurance does not require excessive administrative work,
3.) not interfere excessively with the medical decision making of licensed , skilled physicians following a combination of EBM and judgement
4.) not threaten legal and financial penalties after the service was provided in good faith
5.) Private contracts between doctor and patient are permitted which will of course include the option of balanced billing. Patient is allowed to use insurance and supplement payment by contract with doctor.
6.) Significant tort reform allows Internists to do what they were trained to do , that is take care of patients without the need for excessive referrals which today are significantly defensive .

Proper reimbursement will be determined will depend on the location of practice and practice overhead including all expenses associated with being in practice. Local physician peer groups will be allowed to suggest fees for office visits , home visits , telephone calls etc.

In the case of Internists such changes would dramatically change the number of medical students going into primary care. The expected physician shortages would be less than expected , as physicians now would have incentive to work hard The best and the brightest would now return to Internal medicine.


On the other hand Insurance will not ensure access to Internists if it provides :
1.) inadequate reimbursement
2.) increasing and excessive administrative work,
3.) interfere excessively with the medical decision making of licensed , skilled physicians
4.)constant threat of legal and financial penalties after the service was provided in good faith
5.) prohibits private contracts
6 .no tort reform associate with insurance restrictions making liability even more likely.

Plane and simple there must be willing , happy providers to ensure access .

August 12, 2012 at 4:18 AM  
Blogger Linda Ray said...

Agree with FFSMD. That is well though out and frankly a consensus opinion in hospital, offices , chatting at meeting. These colleagues , btw are the real doctors seeing patients. Increasingly we are 2 camps, the physician doing the work and the ones who talk about it. And we do it for very little , and very high risk and the real criticism is not from our patient who for the most part appreciate me, .... the criticism and name calling comes from our own brothers and sisters in academics or government positions. And you are correct only rarely does any dissenting opinion get through here. Out here btw the system looks broken too , and we see the horror on no access.

August 18, 2012 at 3:26 PM  

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About the Author

Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog

Email Bob Doherty: TheACPAdvocateblog@acponline.org.

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