Can We Attain Universal Health Care Coverage In The US Without Breaking The Bank: Access?

In earlier entries I discussed various aspects of the US health care mess, starting with an overview of the problems (poor access and high costs) and ending with a bit of a detour to discuss rationing health care as a means of controlling costs.  Now it’s time to take a step-by-step approach to solving the problems, starting with access.

What are the reasons for poor access to health care in the US and what is the magnitude of the problem?

First, the problem with access is HUGE; at least 40-50 million people in the US have no health care coverage (by “coverage” I mean health insurance, Medicaid, Medicare, VA Health Care, etc.).  In addition, many millions more (some experts estimate another 40-50 million people) have inadequate coverage.

Access vs. real access

So, part of the problem is that many people do not have adequate access to health care because they do not have health care coverage.  Theoretically, these people can obtain access to health care simply by paying for it “out of pocket.”   In practice, many health care providers will not see people needing health care unless they have some form of insurance (within the medical community, so-called “self-pay patients” are considered synonymous with “no-pay patients”).  If self-pay patients are “lucky enough” to obtain health care services, they are typically charged more (sometimes as much as 2-3 times as much) for the same services than an insured patient; most insurance plans have contracts with health care providers that allow for deep discounts for services.

Even having some form of health care coverage may not guarantee access to care.  Many physicians do not see patients with Medicaid, and a worrisome trend is that a growing number of physicians will not see Medicare patients .  At this point, I do not want to get into all the reasons for these access problems except to say that many physicians find the paperwork load for dealing with Medicaid and Medicare patients is not worth the bother given how low the reimbursement rates are for most services.  So, access doesn’t always mean real access.

Geographic barriers

Another problem with access is a geographic; patients who live in rural areas may be many miles from the closest health care facility and much further from specialty care.  Given the shortcomings of the US transportation system, most people who live far from health care facilities are completely dependent on the automobile to get health care.  What about an elderly person who lives in a rural setting and does not drive a motor vehicle?  That person might have the best health insurance possible but it doesn’t do them much good if they can’t get to the health care facility.

Manpower barriers

Last, but not least, a major problem with access is the shortage of health care professionals, particularly in primary care.  How can physicians afford not to see Medicaid and Medicare patients?  It’s easy.  They are very busy already with customers who pay well.  We need more primary care physicians (family medicine, internal medicine, and pediatrics) and nurse practitioners that specialize in primary care.

Part of the manpower problem is one of geographic  distribution; physicians, nurses, and other health professionals generally want to live near the bright city lights not in rural areas.  In many ways that is good since many more people live in the cities than in the small towns.  But even in large population areas, it’s much easier to get a timely appointment with a cardiologist or a dermatologist than with a primary care doctor.

Access vs. high quality access

Finally, there is a difference between access and high quality access.  Unfortunately, the quality of health care varies greatly in the US.  Some people are lucky enough to have high quality health care plans and easy access to high quality health care providers.  For example wouldn’t you rather see a health care provider who focuses on preventive care and who has access to highly skilled chronic disease management teams (e.g., for patients with diabetes, heart disease, and cancer)?  Some people are not so lucky.  Most reputable health care plans in the US now do include such services (for a good example of what I consider an excellent health care plan, take a look at one of the Kaiser-Permanente HMO plans).

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