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Access Woes Intensify Cost Dilemma



June 27th, 2008

For the second time in as many weeks, a respected research organization has reported sharp increases in reported difficulties with access to care for insured as well as uninsured patients. Earlier this month, in a study on underinsurance widely reported by national media, Cathy Schoen and colleagues at the Commonwealth Fund found that the share of insured people with annual out-of-pocket health spending exceeding 10 percent of family income (5 percent for those below 200 percent of the federal poverty level) had risen from 9 percent in 2003 to 14 percent in 2007.

In a similar set of results released this week, Peter Cunningham and Laurie Felland of the Center for Studying Health System Change (HSC) found that 17.3 percent of insured respondents to an HSC survey said they had experienced access problems in 2007, up from 11.1 percent in 2003. A much larger proportion of uninsured people reported problems in both years, but the rate of growth in access problems from 2003 to 2007 was greater for the insured than for the uninsured in the HSC report, and the overall growth in access problems for insured and uninsured alike was “by far the biggest change we’ve seen” in the ten years HSC has been tracking these data, Cunningham said at a June 26 National Press Club briefing.

Both studies cite the trend toward increased cost sharing in insurance benefit design — copays, coinsurance, and deductibles — as a major factor in these access effects, although neither fully accounts for any offsetting mitigation of premium levels that might accompany the increased cost sharing. (The Commonwealth study takes a shot at this question but does not appear to capture the scope of forgone wages in employer premium contributions.)

The Cunningham-Felland study usefully adds to our understanding of the recent spike in access difficulties by exploring “health system-related” factors as well as costs and plan-related barriers that may be driving the trend. Thus, the respondent share reporting that providers would not accept their insurance grew from 11.9 percent in 2003 to 16.4 percent in 2007, and those reporting that their plan would not pay for treatment jumped from 18.9 percent to 28.1 percent.

Many others, though, said they delayed or went without care because they had too wait too long for an appointment (34.6 percent in 2007), couldn’t get to a visit during office hours (increasing from 18.4 percent to 28.6 percent in the study interval), couldn’t get through on the phone, or couldn’t handle travel distances (16 percent and 17.8 percent, respectively, in 2007). Participants in a panel discussion of the findings agreed that the study represents mounting evidence that the erosion of the nation’s primary care capacity (also cited in the June Report to the Congress of the Medicare Payment Advisory Commission) is beginning to creep into the lives of the middle class and the well-insured. Panelist Rick Kellerman of the American Academy of Family Physicians also referenced further discussion of primary care issues in the professional literature.

In the early 1990s, the champions of universal coverage tried to marshal broad-based support for the Clinton Health Security Act by highlighting worries among the middle class that they might easily lose their coverage with a loss or change of jobs. Since then, coverage and access have eroded to the point where such problems are less speculative and more immediate. The Commonwealth and HSC studies suggest that middle-class support for reform should be easier to muster than it was fifteen years ago.

At the same time, though, Cunningham and Felland inject a more problematic note in their discussion: “An alternative interpretation of these results is that as individuals are exposed to more of the costs of care, they are becoming more efficient users by delaying or forgoing care that may be of low marginal value, which is the key rationale for consumer-directed health care,” they write.

Love it or loathe it, “consumer-directed” care and coverage are aimed at the problem of overutilization that research on regional variations has embedded firmly in the consciousness of the public as well as the policy community. In the inevitable election-year conversation about system reform, “You can’t talk just about access any more,” said panelist Carmella Bocchino of America’s Health Insurance Plans — an observation other discussants seemed to acquiesce in.

More research on comparative effectiveness will help doctors and patients make better choices, the panel agreed. But effectiveness research, information technology, and building up primary care capacity are not quick fixes. In the meantime, reform advocates will need considerable finesse and ingenuity to forestall a polarization of the electorate over the competing priorities of access and cost control. For this reporter, a good first step toward building popular support for greater spending discipline would be requiring that all employee premium costs be reported on pay stubs — as they were in the early days of workplace coverage. But the guardians of the status quo will have their wedge issues handed to them on a silver platter. The question is, What has the other side got up its sleeve?

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