Today I'm going to let you in on a nasty little secret about health reform. Pay attention. This could be shocking.
Question: How many politicians, think tanks, business coalitions, etc., do you know who seriously advocate universal access to health care?
Answer: None, actually. Unless you count the National Center for Policy Analysis and a few academics scattered here and there who are mainly connected to us.
Question: How many support universal health insurance coverage?
Answer: A whole slew of them. On the Democratic side, almost everyone who ran for president. Even Obama on some days. Among Republicans, there is Romney and Schwarzenegger. Then there is the health insurance industry, the drug companies, the hospitals, the American Medical Association, the U.S. Chamber of Commerce and the NFIB..to say nothing of all their friends.
Question: What's the difference between universal access and universal coverage?
Answer: I thought you'd never ask. "Access" is about health care. "Coverage" is about money. Typical coverage questions are: Who pays whom? For what? and How much?
Question: Are you implying that special interests are using health reform as an opportunity to feather their own nests?
Answer: Good catch. But, try a kinder, gentler way of putting it. Virtually every universal coverage plan you've ever heard about was put together by people who spend money, or by people who receive the money, or by think tank and foundation folks who have spent too much time talking to payers and payees, or by some combination of the above. There are no universal coverage plans constructed by garden-variety patients.
[You can test out this assertion, by the way. Do a random survey of ordinary folks and ask them to list the 10 most important problems they have with the health care system. Then go to the Clinton, Obama, Romney and Schwarzenegger Web sites and see how many of the 10 are addressed in any serious way. Or you can take my word for it that "portability" is the biggest issue in all the polls. See if you can find that seriously addressed anywhere.]
Question: But isn't insurance coverage supposed to create access to care?
Answer: Good question. And without any prompt. The reason you probably think that is because there are dozens of studies that claim to find that result. However, these studies are poorly designed, and they never ask the right question anyway.
Question: What is the right question?
Answer: Right on cue. Since virtually all universal coverage plans envision enrolling a lot more people in Medicaid and/or enrolling them in S-CHIP plans that pay Medicaid rates and/or enrolling them in private plans that pay Medicaid rates, the right question is: Does the expansion of plans that pay Medicaid rates improve access to care?
Question: And the answer to that question is?
Answer: Not obvious. In a previous Alert, we reported on a very high crowd-out rate – as eligibility expands people drop their private insurance coverage to enroll in "free" government insurance programs. Surely access to care must decrease as a result of this substitution. We also reported on a RAND finding that once people access the system (see a doctor), the type of insurance or lack of it has no effect on the care they receive. But might people who lack insurance delay seeing a doctor when they need one? Could rationing by waiting and other obstacles delay access to care under Medicaid? A study (previously reported here and unfortunately gated) sponsored by the American Cancer Society sheds light on those questions:
- Among patients whose cancer was diagnosed in Stage I (early detection) vs. Stage II, there was no difference between those with private insurance and those who lacked it for breast and bladder cancer.
- Among the four cancer types for which lack of private insurance means delayed diagnoses, the uninsured were diagnosed earlier than Medicaid patients for two of them (melanoma and uterine cancer) and later than Medicaid patients for the other two (colorectal and non-Hodgkin's lymphoma).
- Comparing Stage I with Stages III and IV (very late detection), lack of private health insurance made no difference for three cancer types.
- Among the seven cancer types where lack of private insurance meant later detection, the uninsured fared better than Medicaid patients for two of them and fared worse for five of them.
[The American Cancer Society, by the way, has been spending millions of dollars promoting "universal coverage" through television ads. Clearly, their money is better spent on research.]
Here's the Bottom Line: First, expansion of programs that pay Medicaid rates does not necessarily expand access to care; in fact it may reduce access to care. Second, enrollment in Medicaid is only marginally better than being uninsured, a finding that is consistent with the observation that more than 10 million eligibles don't even bother to enroll. Third, real access to care means being able to pay more for care than what Medicaid pays.