One of my biggest frustrations with the national health care debate is the casual and sloppy way those who discuss health care routinely confuse “insurance coverage” with “access.”  The implication is that if there is universal, affordable coverage, those with coverage will automatically have appropriate access to health care.

As Dr. Marc Siegel points out in the April 17 op-ed section of The Wall street Journal, entitled “When Doctors Opt out,” coverage does not equal access.  There are a number of reasons, some of which he points out in the article:

•       If coverage is delivered through a system that underpays doctors or delays payments to them, such as Medicaid or SCHIP, then doctors who lose money on every Medicaid and SCHIP patient will simply not accept those patients.
•       Many individuals live in communities that have a shortage of physicians of all kinds, such as the 8^th Ward of Washington, DC, which is within a mile of the Capitol Building.
•       In some communities, physicians simply have decided not to accept any more patients unless they can be assured of a long-term relationship.  As far back as 1991, when my wife and I moved our family from New York to Connecticut, we had trouble securing a pediatric practice that would accept our children, even though we had great insurance, because they could afford to be selective and wanted to insure that we were going to be in the area for a long time.

One of the risks of creating a system of universal, affordable coverage without addressing primary care supply shortages is that we end up with either of two bad outcomes:

•       Individuals with coverage that is the least profitable to physicians being dropped from access; or
•       Every physician increasing his or her patient load, with the likely decrease in quality of care.

That is why I strongly believe that we need to address the demand and physician quality and supply issues concurrently with, or preferably prior to, the time we create a system of universal, affordable insurance.

Unfortunately, the cases of people who are denied care or go bankrupt because they are uninsured grab more headlines than the people who cannot get care because of inadequate provider reimbursement or inadequate supplies of physicians.  Therefore, I am concerned that our elected officials will congratulate themselves for creating a system of universal coverage, which will diminish access and quality of care in the process.

We are reading more and more frequently about the desire of health care reformers to make sure that our health care system delivers only the highest quality.  I will not repeat the multiple authorities who point out that, although we spend over $2.3 trillion on health care, our outcomes in life expectancy, infant mortality, and general states of health are nowhere near the top.

It becomes easy to say that we need to monitor and pay for only high quality health care.  That is a laudable goal, but far more complex than it first appears.  A very insightful op-ed piece appeared in the April 8 Wall Street Journal, entitled “Why ‘Quality Care” is Dangerous” by Drs. Jerome Groopman and Pamela Hartzband.

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Given the recent attention to “millionaire’s tax” proposals, I have been asked about higher tax rates on high-income individuals.  Whether I support paying higher taxes depends on whether government is spending those tax revenues wisely.

We have many unmet societal needs for which increased government spending could be helpful.  In fact, we spend too little on public transportation, supportive housing for people ready to leave homeless shelters, but not ready to pay for market-rate housing, and cutting-edge medical diagnostic tests. 

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