Health Reform and Access to Care

March 8, 2010

Today we are releasing a survey of Michigan citizens’ views[CHRTS CM SURVEY 2010] on access to health care. The findings from this survey paint a picture that differs from some conventional wisdom and adds a different dimension to the debate on health reform in Washington. In particular, the survey makes it clear that having health insurance is important but no guarantee of access to health care or self-perceptions of health status. The survey tells us that those with Medicaid coverage are having difficulties finding providers who will care for them; that even those with health insurance delay needed care at times because of the cost of that care; and, that there is no difference in perceived health status based on insurance coverage. Instead, the survey points to the importance of socio-demographic factors in perceptions of health status and the ability to obtain needed health care: income, education, gender. An exception to that finding is that urban residents — though averaging the lowest income of the survey respondents — had an easier time getting access to health care than all but the highest income, suburban residents. That finding could be an indication that the safety net ‚ more evident in urban areas — is making a difference in providing access to health care.

The implications of the survey are important and relevant to current discussions on health care reform at the state and federal level. The focus of federal health reform today is largely on expanding insurance coverage. While there is some effort to deal more directly with access to health care (the President’s health reform proposal, for example does include $11 billion in additional funding for Federally Qualified Health Centers and the National Health Service Corps), the principal mechanism used to expand access for the poor is the provide Medicaid coverage to all citizens at or below 133 percent of poverty. As our survey shows, however, expanding Medicaid may be problematic at best. Indeed, though the President’s health reform proposal contemplates full federal funding of the Medicaid expansion, it does nothing to correct the underlying structural flaws in the Medicaid program.

Medicaid has historically been designed to pay less than the cost of delivering health care and those ratios have worsened over time, especially in Michigan where budget challenges have forced a choice between keeping coverage broad and avoiding further cuts in payments to providers. Michigan’s payments to physicians are particularly low [CHRT’S IB ON HEALTH CARE SPENDING BY COUNTRY, STATE, PAYER] relative to Medicare and to other states. So, while intending to improve access to care, as currently structured the health reform bills might actually worsen the situation for some. How could that happen? Isn’t some coverage better than none? Well, already today Medicaid covers approximately one out of every six Michigan citizens. If there is a significant increase in the numbers of Michigan citizens covered by Medicaid, more physicians may stop accepting Medicaid patients worsening the availability of providers to both those who currently have Medicaid coverage and those who might gain coverage under health reform. So, while some coverage might be better than none, providing coverage while doing nothing to make sure that coverage is meaningful certainly doesn’t solve the problem of making sure people can get the care they need when they need it.

While raising questions about the viability Medicaid (without changes to strengthen its financial model) as a vehicle to expand access to health care, the survey does help point policy makers to one possible solution: expansion of community health centers and other such direct care options. Thinking about access to health care in a different way — based on data like these — may lead to different types of solutions than those in the bills currently under consideration in Congress. It’s not that insurance reform isn’t important — it most certainly is — but it is simply not sufficient. Expanding direct service — to an even greater degree than now proposed or even contemplated — might be a fresh way to think about the problem of access to care, and may in fact have a bigger payoff in improvements to health of the population. Maybe it could even get bi-partisan support.

Wouldn’t that be something?