October 11, 2015

Disconnect Between Health Insurance And Health Reform Access

Many people have wondered why I, who have been passionate about universal access to health care, would have been, at best, lukewarm about both the recently enacted Patient Protection and Affordable Care Act (the name of the national health insurance reform legislation) and the earlier Massachusetts health insurance reform legislation.

Supporters of these pieces of legislation consider them a necessary first step toward longer-term health care system transformation. Many point to a September 2009 Harvard Medical School study which estimated that lack of health insurance cost 45,000 American lives each year. If this admittedly imperfect legislation saved those 45,000 lives, how could it be negative? Moreover, how could anyone who cares about human life not enthusiastically support this legislation?

The flaw in their thinking is that they assume that the legislation has no other consequences that might result in reduced health care access, and, therefore, a potentially greater loss of lives for other reasons.

People fail to seek out health care for many reasons, of which the fear of financial ruin is only one:

  • A significant reason for failing to get health care is lack of convenient access. Many low-income people who get health insurance through Medicaid or SCHIP (two federally-funded state-managed programs) or other state-funded programs for the poor and uninsured find that they cannot get access to physicians because those programs do not pay the physicians an amount that allows them to make a profit on those office visits, and many physicians refuse to accept Medicaid or even Medicare patients. In fact, based on the Massachusetts experience, the increased demand on scarce health care resources in Western Massachusetts and Cape Cod has actually reduced access to physicians for these populations.
  • Some people, including those with insurance, wait to get diagnosed for medical conditions or fail to adhere to drug treatment plans that would treat their conditions because they are afraid to confront the reality of their condition.
  • Some people do not know that they are at higher risk for a particular disease, and, therefore, do not get screenings that would detect that disease in time to get treated. One unintended consequence of regulations issued under the Genetic Information Non-Discrimination Act is that the process of gathering family history information outside the physician’s office is far more constrained, and, therefore, will happen less frequently. While everyone should get medical advice from his or her primary care physician, a significant part of the population does not have primary care physicians, and, therefore, will never get that advice. Since this legislation has made it harder to get appointments with physicians because it has increased demand, but not the supply of physicians, it has probably worsened this problem.

While supporters of these pieces of legislation can envision the improved access health insurance creates, they cannot easily comprehend the reduced access the greater demand-supply imbalance creates.

If 32 million Americans get added to the ranks of those seeking health care and we do not change the number of health care professionals, that means that physicians have to do one or more of five things to manage the increased workload, four of which definitely worsen the overall quality of system health care:

  • Lengthening their work days and weeks, which means that they are delivering more diagnoses and treatments while fatigued;
  • Spending less time with each patient, which means that they will gravitate toward quicker diagnoses and treatments, as opposed to a more holistic approach to the patient;
  • Delaying scheduling appointments for discretionary care, such as preventive screenings, in order to deal with acute care problems of their patients, especially the newly insured; or
  • Deciding to drop patients for whom they are paid the least or who are the most challenging (Medicaid and SCHIP patients).

The fifth tactic is to delegate more tasks to nurses and nurse-practitioners, which would not degrade care quality or access, but there is a shortage of these professionals as well, so it is not clear that this is a viable alternative for many physicians.

In Massachusetts, it appears that most physicians are either delaying non-emergency appointments or dropping Medicaid patients altogether. Why is this significant?

  • If, for example, I am not excited about getting an invasive screening like a colonoscopy, and I find that I have to wait six months, I might simply skip the procedure. We also have to ask whether delays in getting patients in for colonoscopies, mammograms or blood tests because of increased demand will cause individuals to reach stages of disease progression that they would not have reached if the physician’s office were less busy.
  • Under the best of circumstances, Medicaid patients fail to show up for appointments in private physician offices almost half the time. Both pieces of legislation create incentives for physicians to drop Medicaid and Medicare patients to absorb newly-insured patients coming from higher-paying insurance exchanges, especially since the Medicaid patients take the most time and have the most challenging medical problems. Putting low-income patients in a position in which they have to travel longer distances (especially if they do not own an automobile), seek out new physicians, wait longer for appointments, or wait within a doctor’s office longer even when they have an appointment makes it more likely that they will skip needed care.

We need an objective study by the Harvard Medical or a similarly reputable research organization that analyzes the behavioral responses of physicians and patients to an increased patient load, and that determines the health effects from those behavioral responses. Will patients who would have been saved through their current access to health care now see that access decline so much that they either delay or skip needed preventive screenings and end up dying because of that? I believe this is likely, but, obviously do not know whether it will end up being more or fewer than the arguable 45,000 lives that could be saved through giving people access to health insurance.

That is why I felt that the most compelling priority for lawmakers was to address the imbalances between health care demand and health care availability, not to do a massive health insurance expansion program and leave the health care availability problem largely untouched.

Many pieces of the federal legislation attempt to increase the supply of physicians and nurses, particularly in under-served areas. However, many major obstacles to health care capacity result from a variety of state and local laws, regulations, and practices that this legislation did not touch, such as Connecticut’s certificate of need process, which is often used as a weapon to protect small, local physician practices against perceived competition from small retail clinics.

I do not advocate centralizing the health care system, but the real obstacles to health care access, which is what matters more than health insurance access, relate to many policies and practices yet to be addressed.

It took much political will for the President and the Congress to enact this well-intentioned piece of legislation. I just wish they had staged the insurance expansion more in parallel with health care capacity expansion, rather than jumping out ahead with insurance and leaving the health care piece to be addressed more slowly.