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A New Look at Healthcare Access

August 22, 2011
12:31 am

When we talk about people who don’t have access to healthcare, there’s a natural assumption that it’s because they can’t afford it.  A new study shows that’s not necessarily the case.

According to the study published in the journal Health Services Research, 21 percent of American adults said they had delayed care for non-financial reasons compared to 19 percent that cited cost as the primary reason for not seeking healthcare.

Those non-financial reasons included not being able to get to a doctor’s office during working hours, long commutes to the medical office, or not being able to get an appointment soon enough.  As the study’s lead author said, “In reality, there are all kinds of reasons why people can’t get the care they need when they need it.”

There are at least a couple of important points to take from this report.  One is that healthcare providers have to continue exploring creative ways, from telemedicine to non-traditional office hours, to meet the needs of today’s patient population.

More importantly, though, as we’ve said often over the past several months, coverage and access are not synonymous with each other.  The Affordable Care Act makes health coverage available to all Americans, but that doesn’t mean that all of these newly-insured patients will have easy access to quality care.  If some patients today, as the study indicates, have difficulty getting an immediate appointment with a physician, that problem may only worsen when an influx of new patients, the aging of the baby boom generation and a future shortage of healthcare professionals converge.


In a post in this column last week, we mentioned that Texas Governor Rick Perry’s candidacy for the presidency may help ignite a national debate over medical liability reform, since Texas has adopted one of the most effective tort reform measures in the country.

It didn’t take long for those battle lines to be drawn.  Politico is reporting today that the nation’s trial attorneys are ready to dig deeply into their pockets to make sure Perry is defeated.

Taking On Texas

August 19, 2011
8:05 am

The Healthcare Leadership Council has never endorsed candidates for public office and we’re not going to start doing that now.  I have to say, though, that there is a tangible benefit to Texas Governor Rick Perry (R) announcing his candidacy for President.  It presents an opportunity to have a real debate about the merits of medical liability reform.

In his campaign, Perry will undoubtedly talk about the gains Texas has realized since its state legislature passed a measure capping non-economic damages in medical liability suits.  Conversely, pundits and bloggers have already started taking shots at Lone Star-style tort reform ever since Perry announced his run for the White House.

A good example was found this week in The Incidental Economist blog.  Relying heavily on the work of the interest group Public Citizen, a virulently anti-tort reform organization, the blog makes the case that Texas liability reform has not succeeded in reducing healthcare costs or the number of uninsured citizens. 

Those opposed to tort reform tend to make these apples-and-oranges arguments.  It’s akin to saying, if reforms make my car insurance premiums go down, shouldn’t I also have safer roads and better gas mileage.  The fact is that malpractice insurance premiums and the costs associated with defensive medicine are just two components in the overall healthcare cost equation. (A logical question would be, what would healthcare costs be in Texas had tort reform not been enacted.)

And, as for the uninsured population, Sarah Kliff, formerly of Politico and now with the Washington Post, does a nice analysis here regarding the reasons Texas has a relatively high number of uninsured citizens.

Another piece worth reading is an op-ed in the New York Post this week, written by a Texas tort reform advocate, about the number of New York doctors heading south because of New York’s high malpractice premiums.  The op-ed tells the story of an obstetrician whose medical liability premiums were heading toward $200,000 per year, making it impossible to continue to do business. 

Now, Texas patients benefit from the services of that doctor and over 1,200 other physicians that have made the New York-to-Texas exodus since the latter state passed liability reform.

With the study released this week in the New England Journal of Medicine showing that three-fourths of the nation’s physicians will likely be sued at some point in their career – with a 99 percent probability in the high-risk specialties – let’s hope that Governor Perry’s candidacy does indeed ignite a national debate over the need for medical liability reform.

Change to: The Debate We Need

August 12, 2011
10:49 am

AFP-Getty_120874037The Republican presidential candidates who participated in last night’s Iowa debate put on quite an interesting, as well as entertaining, show.  With political analysts pointing out that this weekend’s Ames straw poll could winnow the field, the gloves came off as the eight candidates fought to maintain a critical mass of voter support.

Anyone who turned on the debate, though, to learn the candidates’ visions for healthcare in the United States would have come away disappointed.

We learned, to no one’s surprise, that the GOP presidential contenders have a steadfast dislike for the Affordable Care Act that President Obama signed into law last year.  Most of the candidates also believe that the individual health insurance mandate contained in the ACA is unconstitutional. 

It was also clear that, as long as former Massachusetts Governor Mitt Romney is the frontrunner, he will be criticized for what rival Tim Pawlenty calls “Obamneycare.”

But future GOP debates need to do more than reaffirm what the White House aspirants are against.  There are indeed widespread concerns about the current health reform law, including questions over affordability, healthcare quality and whether an unprecedented expansion of Medicaid is the best approach for reducing the uninsured population.  Those who would take Mr. Obama’s place need to spell out for us how they would do things differently.  The questions they need to answer include:

•     Do you support eliminating pre-existing conditions as a barrier to health coverage?  And, if so, how do you achieve that without an individual mandate to ensure that consumers don’t wait until they’re sick or injured to purchase health insurance?

•     How do you slow down the growth in healthcare costs without undermine healthcare quality, access or innovation?

•     How do you address the question of Medicare sustainability? 

•     What are your answers to the projected workforce shortages in healthcare?  How do we ensure enough medical professionals to treat a growing patient population?

•     With the CDC calling for a huge escalation in the number of Americans with diabetes, how do you propose to address the rise in chronic disease cases that are driving healthcare costs?

With these questions and many others, there’s an important health policy debate to be had among the Republican presidential contenders.  It just hasn’t happened yet.

The Efficiency Fallacy

August 09, 2011
8:33 pm

Members of Congress say it.  Administration officials say it.  People regarded as healthcare and economic experts say it.  Repeatedly.

Medicare is significantly more efficient in its operations than private health insurance.  It’s said with such frequency that it absolutely has to be true, right?


This is an argument used on a host of issues, from health plan regulation to Medicare prescription drug coverage to whether Medicare’s future should include some element of private plan competition.  People who should, and likely do, know better continue to make the point that Medicare can do its job with far less administrative costs than private plans do.

On today’s Health Affairs blog, there’s a post by John Goodman and Thomas Saving that dismantles this argument.  It’s well worth reading and keeping handy the next time a politician or television talking head makes this apples-to-oranges argument about Medicare and private insurance.

Here are some of their key points:

•     Private plans incur the costs not only of marketing and selling insurance, but also of collecting premiums.  The Centers for Medicare and Medicaid Services (CMS) doesn’t collect taxes.  That falls under the IRS’s administrative expenses.

•     Many of Medicare’s administrative burdens are shifted to the healthcare providers who treat Medicare patients.

•     In raw numbers, studies have shown that Medicare’s administrative expenses per enrollee are actually higher than private insurance.  As a percentage of total budget, though, Medicare administrative costs look smaller because seniors utilize more healthcare services than younger citizens.

•     What some call efficiency is actually Medicare’s price controls on provider costs.  Medicare’s future costs are projected to grow more slowly than private healthcare because of the expected suppression of provider reimbursements.  This is the kind of “efficiency” that results in reduced healthcare access for seniors.

There’s considerably more substance in the Goodman-Saving post than I’ve written here and I urge you to check it out.  As we consider Medicare’s future, it’s critical that we honestly debate the program’s merits and its shortcomings and not perpetuate misconceptions to advance political goals.

The Deal That Would “Only Affect Providers”

August 01, 2011
4:06 pm

I wonder how long it will take before people who should know better stop implying, or even saying outright, that payment cuts to Medicare providers don’t affect beneficiaries.

This weekend, I was among those following the cable news shows to see if Congress would finally reach agreement on a debt ceiling package.  It appears now that, even though it may be a “sugar-coated Satan sandwich” to some, a legislative approach has been crafted that will raise the debt ceiling and establish a process for achieving approximately $2.5 trillion in budget cuts over 10 years. 

In this process, a congressional super-committee will be charged with identifying $1.5 trillion in deficit reductions by Thanksgiving.  If they fail to do so, automatic cuts will occur and fall most heavily on the defense budget and Medicare.

As I was watching the news analysis, though, I saw a continued misunderstanding of what it means to cut Medicare provider payments.  One commentator praised the deal for protecting the most vulnerable in society, pointing out that Social Security and Medicaid were exempt from cuts, and Medicare cuts “would only affect providers.’  We’ve seen the same type of analysis several times today in print reports.

This kind of verbage creates the impression that an acceptable way to reduce Medicare spending, in a way that doesn’t do harm to patients, is to ratchet down payments for physicians, hospitals, medical devices, pharmaceuticals and medical supplies.

What is seldom acknowledged is that, for every percentage point shaved off of Medicare provider payments, seniors lose a little more access to quality healthcare.  We’ve already learned, thanks to a survey by the American Medical Association, that approximately one in every three primary care physicians is limiting the number of Medicare patients in their practice.  That’s the consequence of payment levels that are significantly below private insurance levels.  Given the rising number of baby boomers entering the Medicare program, the last policy change we need is one that will reduce the number of physicians available for this population.

That’s the consequence, though, of budget reductions that “only affect providers.”