Web Roundups

Web Roundup: Access is the Problem

With the roll out of the Affordable Care Act and the persistent discussion/debate surrounding cost, access, and quality of care, it seems only natural to focus this Web Roundup around the topic of healthcare. In particular, I want to briefly discuss three ways that increasing access to medical care has been discussed in the news this month.

While the number varies from year to year, roughly 15% of the population or 46 million people live without insurance. If that number is not bad enough, many Americans with health insurance have to pay high deductibles and co-pays if, and that is a big if, the insurance provider covers the procedure. This problem is particularly visible in Jessica Silver-Greenberg’s recent article in the New York Times. The story that she tells is a familiar one, but with a new twist. It begins with Ms. Gannon, a 78-year-old woman living on a fixed income. While visiting the dentist, she was told that she needed a partial denture that would cost about $5,700. The dentist offered her a line of credit to pay for the procedure because her insurance would only cover a small portion of it and therefore she could afford the procedure. The interest rate was steep though, with a 23% APR and a 33% missed payment fee. To cover the remaining costs, the dentist also suggested a medical credit card. According to the article, offering patients a line of credit to encourage their use of medical services is a growing phenomenon. Marketed as altruistic way for patients to afford care, it can be anything but.  These financing plans do not lower the cost of care, they just alter the repayment plan and increase the overall cost of health care for the individual, which in the case of Ms. Gannon now exceeds 1/3 of her Social Security check. Moreover, many of the companies that offer these plans have pending lawsuits against them because of high-pressure sale tactics, over charging, and billing for unauthorized work.

So what are people to do?  We all need medical care and few people argue the point that it is too expensive for the average person to afford. This problem makes me think of an older article written by Milstein and Smith (2006), “America’s new refugees–seeking affordable surgery offshore.” In the article, the authors identify a large segment of the population who cannot afford care in the US and, thus look abroad for medical care. In the media, these people are commonly called medical tourists, a term that suggests frivolous medical care coupled with a vacation. However, the authors insightfully point out that limited access, not the lure of a vacation, influences people look for medical care outside the US. Traveling abroad for access to cheaper medical care in nothing new and just recently CBS News ran a story titled, “Medical tourism: What’s the risk of traveling for care?” The story itself is very cliché, providing testimonials of middle class Americans who price shopped for medical care until they found a foreign doctor who would provide the care they wanted at the price they could afford. The article then went on to discuss how patients have to weigh the lower costs of foreign medical care with the potential for danger when traveling abroad. In short, it suggests that if patients are savvy consumers then they can use and rely on the free market to access the care they need.

While increasing access to credit and providing low cost medical alternatives abroad do potentially increase access, they are not long-term solutions. They also do not address the fundamental issue of access and equity of care, which Atul Gawande has on numerous occasions referred to as a moral imperative for our society. This brings us to the most resent attempt to provide access to affordable care, and arguably the most comprehensive and just attempt in some time. This month health care exchanges opened up all over the country as a result of the Affordable Care Act. The exchanges are the product of the Act’s attempt to expand health insurance coverage and reduce overall costs. According to Larry Levitt of the Kaiser Family Foundation, the technical glitches that have been highlighted in news this past week will not deter people or derail the program because through the exchanges people will have at least two insurance choices, be able to compare them, and those choices are going to cost less than expected. Moreover, when all the glitches (Medicare Part D also had similar problems in 2005) are worked out of the system, enrollment will be easier than it is now, and hopefully more people will be able to get medical care without traveling abroad or taking out a loan.

As we know, the attempt to reform our medical system is not without detractors, as Atul Gawande wrote in his article, “States of Health.” According to Gawande, the Affordable Care Act is part of a long national discussion as to “whether we as a society have a duty to protect people” by providing them with access to affordable care. The Act however, has faced stiff resistance from twenty-five states who turned down financial assistance to expand Medicaid, denying affordable care to millions of Americans. Other states are refusing to operate their own health care exchanges, forcing the federal government to do so. In a few states such as Florida and Tennessee the state legislatures are making it difficult for people to enroll in these exchanges by placing strict regulations on “navigators”, who assist individuals in enrolling. Florida is even going as far as attempting to ban them from local health departments.

Regardless of what you believe about the Affordable Care Act, it is the most comprehensive solution to increasing access to an expensive health care market that limits usage for millions of Americans. It is also a more feasible and ethical solution than offering patients high interest credit, or expecting people to have the financial resources to travel abroad for care.