What do we mean when we talk about “access”?

by The Incidental Economist on July 27, 2012 · 3 comments

I spend a lot of time talking about the health care system. When I do, I usually reference three aspects of it: cost, quality, and access. Cost is pretty easy to define. Quality, less so. Access is almost always defined as having health insurance. On this metric, the United States does pretty poorly:

This is a chart of all 31 OECD countries with respect to the percent of the population covered by health insurance. The United States is that thick red line. We outperform three countries: Turkey, Mexico, and Chile, although they’ve been showing improvement in the last few years, while we’ve been standing still.

The Affordable Care Act changes this. Regardless of what you think about the law’s ability to control costs, or the fact that it only touches on quality, it first and foremost improves coverage. More than 30 million new Americans will get insurance through the law, about half through the exchanges, and half through Medicaid. That is, if the Medicaid expansion goes ahead as planned.

But this is a limited view of access. Insurance is only one part of access. Some argue that insurance isn’t really needed, as you can always get care in an emergency room if you need it. But this is a very narrow view of access as well. Care in the emergency room isn’t free, and collecting on debts can bankrupt people with limited means. Moreover, the vast majority of health care isn’t available in an emergency room. It’s no substitute for comprehensive care.

Even insurance isn’t enough. Many have argued that the Medicaid expansion isn’t worth the money. Getting past the unsupported claims that Medicaid is worse than being uninsured, it does have some problems. The reimbursement rates for the program are low, so low that some doctors refuse to accept it. However, it’s somewhat misleading to stop there. After all, some types of doctors are much more likely to see a Medicaid patient than others. Most Medicaid beneficiaries are children or pregnant women. Therefore, it’s more important that pediatricians and obstetricians see Medicaid patients than other types of physicians. They do.

It’s also important not to focus just on Medicaid patients, but on other types of insurance as well. It turns out doctors have been declining to accept many forms of capitated private insurance as well, sometimes even more so than Medicaid. We hear the same complaints about Medicare, and many networked private plans, too.

That’s another important point. With Medicare (a “government” insurance) you can see almost any doctor you want at almost any facility in the country. But if you have private insurance, you are often limited by a network. You can only see the physicians approved by your plan. This can result in much less “access” than you thought.

But all of these constitute just the first step of real access. They are concerned with payment and the ability to have the potential of a visit. But there are many other factors that also contribute to a person’s ability to see the doctor. The first is how long it might take to get an appointment.

This is the dreaded “wait time” problem, and it has been used to demonize other countries’ health care systems. We live under the illusion that in the United States, we can easily get in to see a physician if we need to. It’s true that, when it comes to elective procedures, our wait time is less than most other countries. But it’s important to remember that “elective” is another word for “optional”, and that’s not necessarily where we’d want to place our focus. We’re also great about getting people into specialty care, but again – that’s not necessarily where our focus should be.

But on a much more common, and simpler metric, we fail. The United States has one of the highest percentages of sick people who have to wait six days or more to see a doctor. Yes, we beat Canada. That’s one of the reasons Canada is used so often in comparisons. But other countries, many with much more socialized financing and care, have far fewer people who can get in to see the doctor when they are sick.

This is partially because we have a doctor shortage in the US. We have far fewer physicians per population than other industrialized nations. This makes is harder to get a doctor. We also have fewer physicians who work on off hours. More people have difficulty seeing a doctor on nights, weekends, or holidays than any other wealthy nation. Weekday daytime hours constitute a small percentage of the week. Lots of people work then, and lots of life happens at other times.

All of these issues show that the US continues to have an access problem. They are all fixable. Unfortunately, almost all of those fixes cost money. We can raise the reimbursement rates. We can train more physicians. We can keep offices open on off-hours. But all of those are somewhat expensive to do.

The ACA, should it hold, begins to confront our problems with access in the health care system. But we still have a long way to go.

 

Dr. Aaron E. Carroll is an associate professor and vice chair of health policy and outcomes research in the department of pediatrics at the Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.

As part of our ongoing effort to raise awareness of health services research and increase its application in policy and practice, AcademyHealth has partnered with Austin Frakt, Ph.D., and Aaron Carroll, M.D., M.S., to contribute posts on the subjects of health care costs, delivery system transformation, and public and population health – areas AcademyHealth has identified as a priority in the current policy environment. As regular contributors, they’ll be discussing current events with an eye toward how new and existing research informs the issues.

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Steven E. Waldren July 28, 2012 at 12:54 pm

Nice article.

Health insurance coverage is a poor proxy for access. I would encourage people to look at the MACPAC (www.macpac.gov) access framework. It was in their first report to Congress page 126 [pdf page 142] ( http://docs.google.com/viewer?a=v&pid=sites&srcid=bWFjcGFjLmdvdnxtYWNwYWN8Z3g6NTZmYjU1ZDcwMTQzMDc0MA )

I believe we must include coverage, utilization, appropriateness, and outcomes to truly understand if one has “access.”

Best,
Steven
Disclaimer: I am involved in MACPAC

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