When we—present company included—talk about health care reform, we tend to be talking about insurance: making it more affordable, expanding coverage to protect people with pre-existing conditions, extending plans for dependents to age 26 (as some insurance plans intend to do with or without the Affordable Care Act; see Karan’s post here), eliminating lifetime caps on reimbursements… all of that delightful stuff that’s up in the air until the Supreme Court passes their ruling on the ACA. We like to fantasize about achieving universal coverage, that mythic thing wherein all citizens have health insurance (mythic, you know, as in inexplicably out-of-reach even though every other developed nation has it—we’re still at 16% uninsured). Anyway, when we do this, we tend to use the word access—a lot. And that leads us to overlook a critical distinction: while insurance is a vital part of health care access, the two aren’t the same thing. And insurance isn’t a silver bullet or (mixing metal metaphors—metalphors?) a golden ticket out of our present situation.
Access issues in Massachusetts—a state that achieved ~98% coverage following 2006 state-level reforms—were highlighted earlier this week. A poll conducted in April and May found that 14% of Massachusetts adults could not get needed health care—and nearly three-quarters of them cited financial difficulty as the primary barrier. Out-of-pocket payments can still present a serious obstacle, especially with the rising popularity of high-deductible health plans. Dr. Paul Hattis, cochairman of the health policy task force for the consumer group Greater Boston Interfaith Organization, put it this way:
Even if you put an insurance card in everybody’s pocket,
don’t believe that that solved the access problem.
Cost issues aside, other problems plague access and quality of care in Massachusetts. Lower-income patients report complaints of bias/prejudice in the health care system. This takes the form of longer waits for service, rushed and/or rude physicians, and a lack of thoroughness in care. Insurance can reduce those disparities, but it cannot eliminate them completely. The takeaway lesson here is not that universal coverage is inefficient or inherently of poor quality; over half of sick adults surveyed in Massachusetts indicated that they were “very satisfied” with their care. The lesson is that universal coverage is the beginning, not the end, of expanding access.
Forgive me; I’m going to dip into my lecture notes for a second time. There’s a straightforward, fairly comprehensive way to break down components of health care access. It’s called “the five As:”
Affordability: This is the axis of access (go on, say that five times fast) that health insurance does address, on some level. As discussed above, the plan types, co-payments, and extent of coverage can greatly influence affordability, even among the insured.
Availability: The presence or absence of resources needed to provide care is another element of access. Importantly, this refers to having enough personnel and medical technologies to meet demand. Depending on who you ask, we either have a shortage or a maldistribution of physicians. Either way, the consequence is too few physicians for too many people, which can lead to longer waits for care and physicians having less time for each patient. It’s anticipated that this situation will be exacerbated if the ACA is upheld (and an additional 32 million people obtain health care coverage). This issue is a beast unto itself… and will probably merit its own post the future.
Accessibility: At the risk of sounding redundant, accessibility is key to access—geographic accessibility. How difficult is it for patients to physically get to the necessary providers? This is especially of concern in rural communities, where telemedicine is making advances.
Accommodation: This refers to how well providers meet the needs and preferences of their patients. “Regular” hours of operation (9-5) can make seeking care exceptionally difficult for working families without flexible schedules. A more modern development is the provider’s willingness to use email, texting and social media to engage with their clients.
Acceptability: The last facet of access reflects the subjective comfort levels between patient and provider on characteristics that include age, sex, social class, and ethnicity. Additionally, this encompasses whether the provider literally “accepts” a client’s coverage.
If it’s still standing at the end of this month, the Affordable Care Act has the potential to make important strides in the realm of (surprise, surprise) affordability, which is only the beginning of a long and arduous reform effort. “We must also remember that these five As of access form a chain that is no stronger than its weakest link.” Insurance isn’t a golden ticket to the world of health care bliss (but hey, dibs on the movie rights to that Willy Wonka reinterpretation). It’s more like an invitation to a party—one with plenty of details that still need to be sussed out.
photo credit: geek.com
Adrianna works in clinical research and will begin graduate studies at the University of Michigan this fall.
Follow her on Twitter @onceuponA.