Why Health Care Coverage Does Not Equal Health Care Access

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 8th 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.