A Question of “Access” Part 2: Coverage <> Access

As I mentioned in my last post, the healthcare reform bill has been touted as a way to increase “access” to healthcare for all Americans. I discussed the fact that the bill mainly serves to increase the coverage for healthcare expenditures through mandates. In today’s post, I will take a look at how ensuring coverage does not necessarily result in increasing access to the care itself. I will start by looking at the State of Massachusetts and the results of their efforts to increase access to healthcare.

In Massachusetts, one of the very first goals of their healthcare reform efforts was to ensure coverage for all citizens of the state through mandates. They have been very successful in their efforts. With over 97% of residents having some form of healthcare insurance, Massachusetts boasts one of the highest coverage rates in the entire country.

One of the first issues that Massachusetts began to see early in the process was that the supply of primary care physicians was not sufficient to meet the newly created demand for their services. Wait times to see primary care physicians increased, and many primary care physicians stopped taking on new patients.

This does not bode well for the newly insured who are seeking care in the primary care setting. In fact, there is recent evidence in Massachusetts to suggest that many have been driven to meet their care needs (including primary care) in the more costly, already crowded emergency room setting. While this does provide them with access to care, it is certainly not the most appropriate level of care for many of these cases, and it raises some major concerns about the cost of care to both the patients and the State of Massachusetts.

The shortages in Massachusetts are not limited to primary care either. Specialties such as neurosurgery and oncology are seeing shortages as well. Of particular interest is the fact that emergency medicine is one of the specialties identified as being in short supply in the state. At some point, you have to wonder whether even the combination of primary care providers and emergency care providers will be enough to meet the demand of the previously insured plus the 440,000 newly insured residents of the state.

There are certainly concerns about access on a national scale as well. Similar to the healthcare reform in Massachusetts, the national healthcare reform bill also attempts to address access via mandated coverage. This, of course, will be on a much larger scale as tens of millions of people gain coverage.

In a detailed analysis of the estimated impact of the healthcare reform bill, the chief actuary of the Centers for Medicare and Medicaid Services expressed much concern that the combination of supply issues and unfavorable reimbursement rates would likely result in both higher prices and decreased access to care for Medicare and Medicaid patients:

“In practice, supply constraints might interfere with providing the services desired by the additional 34 million insured persons. Price reactions – that is, providers successfully negotiating higher fees in response to the greater demand – could result in higher total expenditures or in some of this demand being unsatisfied. Alternatively, providers might tend to accept more patients who have private insurance (with relatively attractive payment rates) and fewer Medicaid patients, exacerbating existing problems for the latter group. Either outcome (or a combination of both) should be considered plausible”

“[P]roviders for whom Medicare constitutes a substantive portion of their business could find it difficult to remain profitable and might end their participation in the program (possibly jeopardizing access to care for beneficiaries).”

Since it takes many years to educate and train new physicians and to have physicians from other markets move and enter underserved markets to meet the demand, it is unlikely in the short run that the supply of physicians will catch up to the newly created demands for care. In the long run, we will need to consider the possibility that the supply may never catch up to demand. In fact, an AAMC study estimates that the US will be short by more than 150,000 physicians by the year 2025 given current patterns of declining first-year medical school enrollment.

While the health reform bill is very likely to increase the coverage of the uninsured, it fails to truly increase access to actual healthcare services. It is apparent from what we have already seen in Massachusetts that coverage and access are not synonymous. Increasing access to healthcare services will require other solutions that include a re-examination of government reimbursement and funding and the use of solutions that improve the operational efficiency and effectiveness of the healthcare providers themselves (topics for a future post) to increase the available supply of those services.