Money Counts in Access to Health Care

Inadequate coverage, high deductibles mean even insured are going without, studies find

Written by Steven Reinberg

Updated on March 14, 2007

TUESDAY, March 13, 2007 (HealthDay News) -- Even when Americans are lucky enough to have some form of health insurance, too many find that the services they need are not covered by their plans, new research shows.

"It's not just about insurance," said Dr. Harlan Krumholz, the lead researcher of a study that found that poor coverage kept one in five heart attack patients from getting needed care.

"Two-thirds of the patients had insurance," noted Krumholz, a professor of medicine at Yale University School of Medicine.

His team's study is one of a series of reports on the issue of health coverage published in the March 14 edition of the Journal of the American Medical Association.

In the first study, which surveyed almost 2,500 heart attack patients, Krumholz's team found that 20 percent of them said money had been a roadblock to getting needed health care services after their attack. Generally, these patients ended up having a poorer quality of life and an increased rate of re-hospitalization, the study found.

"It's one thing to say we really want full insurance in this country, but as long as you've got people who are inadequately covered and feel they have barriers to access to health care, then we are going to have continuing problems," Krumholz said. "The debate needs to be about coverage and how to eliminate these barriers to needed care."

Another report found that among people who have a serious injury or develop a chronic condition, those who are uninsured find it much more difficult to get health care and are more likely to suffer poor short-term health.

"People who don't have health insurance run a serious risk of declining health should they have an accident or develop a chronic condition," said study author Jack Hadley, from the Urban Institute, a nonpartisan research group based in Washington, D.C. "There is a real difference between people with insurance and without insurance in terms of what happens to them when they get sick," he said.

Furthermore, Americans who do not have insurance and then get sick find it becomes much harder to get insured. He said insurance companies have screening and selection rules in place that limit who gets affordable insurance.

The result of not having health insurance has social consequences too, Hadley said. "Ultimately, it can be a spiral effect that leads to greater difficulty getting a job and winding up on some sort of public health insurance program," he said.

The results of a third study found that people with health insurance who switched to high-deductible health plans were less likely to go to the emergency room for minor medical problems and less likely to be hospitalized.

"Emergency room visits were cut by about 10 percent compared with patients in traditional plans," said lead author Dr. J. Frank Wharam, of the department of ambulatory care and prevention at Harvard Medical School. "This is because these patients stopped going to the emergency room for problems such as colds, headaches, nausea and back pain," he said.

When people are aware that they will have to pay high out-of-pocket fees, emergency department visits are reduced, Wharam said. "They also try to avoid additional costs by avoiding being hospitalized and they are also negotiating shorter lengths of stay in the hospital," he said.

Whether people are avoiding medically necessary care because of high out-of-pocket costs is unclear, Wharam said. "We did find evidence that people in low-income areas may be reducing visits for high severity conditions that would require emergency department visits," he said.

Wharam noted that his group didn't study health outcomes to see if care was being compromised. "We need more studies to see what conditions are being affected and what are the long-term outcomes," he said.

Another report in the same journal issue found that illegal immigrants are using the Emergency Medicaid system in record numbers.

According to the report, the majority of the Emergency Medicaid expenditures in North Carolina are for childbirth and complications of pregnancy by women who are undocumented immigrants. In addition, spending for undocumented elderly and disabled patients is increasing at a faster rate.

Finally, another study in the journal outlined a plan to revamp the U.S. health-care system by increasing the value of the care delivered to patients.

"Improving value for patients is clearly the only valid goal for ethical reasons. It is also the only goal that aligns the interests of patients, physicians, health insurance plans, employers and government," authors Michael E. Porter, of Harvard University and the Harvard Business School and Elizabeth Olmsted Teisberg, from the University of Virginia, wrote.

Integrating care around the patient's illness or illnesses -- instead of spreading costs across a variety of medical disciplines, as happens now -- could end up providing each patient with better care for the same amount of money, the experts wrote.

"If physicians improve value for patients, they will be able to credibly engage Medicare and health plans in new contracting and reimbursement practices that reward such value," they added.

One critic of the current health insurance system believes that people should be able to spend their own money on health care, using health savings accounts and tax incentives.

"Clearly, people without health insurance will get fewer services than people who are covered," said Greg Scandlen, founder of the Maryland-based Consumers for Health Care Choices, which receives funding from the health insurance industry. "The real injustice would be if the uninsured got the same level of care as people that are paying for insurance," he said.

Scandlen believes that people need to be responsible for their health-care costs. This includes cost sharing and health care savings accounts. And the best way to get people covered is to make it more affordable, he said.

"The problem is excessive reliance on third-party payment," Scandlen said. "We would rather put the money in the hands of the patients and let them make their health-care decisions," he said. "You will always need insurance for the big stuff. But for the ordinary kinds of expenses, any third-party payment system is wasteful, bureaucratic and inefficient."

Another expert offered up a different solution.

Jay Bhatt, the national president of the American Medical Students Association, believes the answer lies in a single-payer system, where the government provides universal health care. "What we need is a health plan that offers high quality basic health care to everyone in this country with an emphasis on preventive services," he said.

More information

For more information on access to care, visit the U.S. National Coalition on Health Care.

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