Tuesday, June 9, 2009

Access to Health Care

In the United States, the stated goal of health care reform debate has been to provide universal access to high quality health care at a reasonable cost. However, most of the rhetoric has focused myopically of universal access. Unfortunately, in the real world proponents of universal access must also take into account the quality and cost of that health care. After all, no one aspires to provide universal access to low quality health care or universal access to high quality health care that no one can afford. Unfortunately, any reasonable account of access, quality, and cost of health care generates mind-boggling complexity. Let’s start with access.

Today, about 55% of all Americans gain access to health care via private health insurance purchased through their employers, while 45% gain access to public insurance via Medicaid, Medicare, Veterans Medicine, and SCHIP. (poor, elderly, veterans, and children). In 2005, the Census Bureau reported that at least 44.8 million Americans were without either private or public health insurance coverage. By 2006, that number rose to 47 million: a 15% increase. Since, 2000 the number of uninsured Americans has grown by 8.6 million: an increase of about 22 percent. The largest segments of uninsured are employed young adults 19-29 and older adults 45-64. The uninsured rate among young adults, signals a corresponding rise in the number of uninsured young children; which has led to the recent reauthorization of SCHIP. Due to the ongoing economic recession the number of privately-insured Americans has decreased and the number of publically insured has increased. Although the public policy goal has been to increase the ranks of the insured, what is the precise relationship between “access to health insurance” and “access to health care? That answer is hardly straightforward.

When reformers call for universal access to health insurance, presumably they mean “good health insurance.” In an ideal world, “good insurance” is “comprehensive insurance” that covers every possible health care need (or want). Conversely, “bad insurance” covers nothing. So in the real world, the mere fact that you have health insurance does not necessarily guarantee that you have access to the health care products and services that you may need or want. Therefore, what most of us really want is universal access to comprehensive health insurance. But in the context of health care what does “comprehensive” mean? Does it include “all health care” or just “basic health care?”

Well, what precisely is this alleged distinction between “comprehensive” and “basic” health care and who decides? Does “basic” include access to all known preventive care, including: annual physicals, vitamins, and all known tests, imaging technologies (eye exams, hearing exams, MRIs, mammograms etc.), and vaccines? Does it include access to all known treatments, including: laser surgery, stem cell therapy, and genetic therapy? How about doctor’s office visits for minor illnesses such as colds and flu? Should everyone have equal access to: state-of-the-art trauma centers, organ transplants, hip replacement surgery, physical therapy, fertility treatment, psychiatric treatment, eye glasses, vision correction surgery and cosmetic surgery? Should all Americans have access to both new and old drugs, including: AIDS drugs, and diabetic drugs? How about access to weight loss therapy (including surgery), smoking cessation programs, and mental health treatment? Does basic insurance cover Tommy John’s surgery for 53 year old beer-league baseball pitchers, motorized scooters for the morbidly obese, or psychiatric drugs for children diagnosed with Attention Deficit Disorder or depression, erectile dysfunction drugs for old men, or chemo and radiation therapy for all cancer patients (including for ninety year-olds)? In Vitro Fertilization, abortions, or birth control pills for the poor? Does basic health insurance include unimpeded access to experimental, futile, and/or low-quality treatments (that are less-than safe, or less-than effective)?

Therefore, it seems obvious that the distinction between “basic” and “comprehensive” insurance is far from clear. Even if you are a member of congress that has the most comprehensive health insurance coverage in the world, there is still wide variability in access to specialists and state-of-the-art technology. That’s because access to health care products and services depends largely upon where you live. Our current health care system has evolved to serve major urban populations. Therefore, even insured congressmen from rural districts may not have access to the health care they need or want. Other rural patients have “access” to specialists and state-of-the-art technology, but only to the extent that they are willing (and/or able) to wait for an appointment and/or travel to a distant urban area. And, of course, rural patients that are uninsured (or under-insured) have access to health care to the extent that they are willing or able to pay for both the trip and the treatment. So one might argue that rural patients in the United States have “access” to a vast market of health care products and services, but only to the extent that they are willing (and/or able) to overcome geographical and financial barriers. Now is that really “universal access to health care?” If not, how would congress go about addressing this alleged injustice?

Although most patients with health insurance believe that they have access to health care, most policies cover much less than they think. That’s because, “good insurance,” which is comprehensive is very expensive and difficult to sell employers, especially to small businesses. Therefore insurance companies adapted by devising innovative marketing strategies that help them sell that “bad health insurance.” Their solution: disguise the quality of their insurance policies behind a veil of complex, obscure jargon that only insurance adjusters can decipher. Systemic obscurantism has no doubt contributed to the growing number of uninsured and under-insured patients. Why buy expensive health insurance, if you don’t know what it will cover? Therefore, one area more than ripe for reform is the restoration of transparency in health insurance.

In conclusion the single-minded pursuit of universal access to health insurance is really an overly-simplistic basis for health care reform. We must also take into account quality and cost of that insurance and the actual health care covered by those policies.

1 comment:

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