An evidence based assessment of universal coverage

A staple of conservative critiques of universal coverage is that having health insurance doesn’t equal access. The corollary is that the uninsured already have access to care—from doctors and hospitals willing to take care of them on a charitable basis and from “safety-net” institutions.

This argument isn’t new, having been made years before the Affordable Care Act became law. In 2007, the Council for Affordable Health Insurance opined that universal coverage doesn’t mean timely access:

One of the false assumptions behind the push for universal coverage is that everyone will have access to care. While that may occur initially, within a short period of time the waiting lines begin to grow and access and quality begin to decline as the government limits funding for health care. Moreover, the uninsured do have access to care … some of it provided free or at discounted rates in public clinics. Having insurance coverage would be better, but the uninsured can and do get care.

Writing for the libertarian Cato Institute, Michael Tanner similarly argues that “health insurance does not mean universal access to health care. In practice, many countries promise universal coverage but ration care or have long waiting lists for treatment.”

Dr. Marc Siegel, a physician, takes the argument even further, blogging in the National Review that he objects not only to the government mandating health insurance for all, but to the very idea of health insurance:

The individual mandate may be the glue that holds Obamacare together by shoehorning in young healthy people who don’t need health insurance to pay for the sick and elderly who do, but an even greater problem than the mandate lies in the unwieldy insurance itself … Obamacare will make things much worse by increasing the number of people who are insured, expanding the procedures and other items (e.g. contraception) that are covered, and enlarging the government’s involvement in running it all.

But let’s get back to the main argument: that the health insurance doesn’t equal access to care, and that the uninsured can get care anyway.

It is true that health insurance by itself doesn’t ensure access—you need enough doctors to take care of patients, for one thing—but the evidence also is clear that being without health insurance consistently is associated with poorer access and poorer outcomes.

Here is what the Institute of Medicine found in its groundbreaking 2009 report, “America’s Uninsured Crisis: Consequences for Health and Health Care”:

A robust body of well-designed, high-quality research provides compelling findings about the harms of being uninsured and the benefits of gaining health insurance for both children and adults. Despite the availability of some safety net services, there is a chasm between the health care needs of people without health insurance and access to effective health care services. This gap results in needless illness, suffering, and even death.

What about those long waits for care in countries that have universal coverage? Well, yes, there are longer waits for elective procedures in some of them, but the United States doesn’t compare very favorably itself when measured on elements like access to primary care physicians and forgoing care because of cost.

In 2011, the Commonwealth Fund published a report and chart pack comparing U.S. health care to eight other countries (all of which have some form of universal coverage), and found that the U.S. was second worst in waiting time to get an appointment when sick, third to last in getting care after hours without going to an emergency room, and had the highest percentage of people who reported that because of cost, they did not get medical care, did not fill a prescription, or skipped medical test, treatment, or follow-up.

In 2008, I co-wrote an ACP position paper with my colleague Jack Ginsburg that compared U.S. health care to other countries’ and drew lessons from them.

We found that countries that ensure coverage through single payer systems may be “more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access.” But we also found that they “may result in shortages of services and delays in obtaining elective procedures and limit individuals’ freedom to make their own health care choices.” Canada and Great Britain are examples of single payer systems.

We also found that “pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs.” The French, Swiss and German systems are examples of pluralistic models that still manage to ensure universal coverage. (The United States, of course, is a pluralistic system that does not assure universal coverage, although the ACA is trying to get us closer.)

Finally, we concluded that “health care in the United States has many positive features and in many respects is superb compared with health care anywhere else in the world. Those with adequate health insurance coverage or sufficient financial means have access to the latest technology and the best care. However … the U.S. health care system is inefficient and inconsistent: health care quality and access vary widely both geographically among populations, some services are overutilized, and costs are far in excess of those in other countries. Moreover, the United States ranks lower than other industrialized countries on many of the most important measures of health.”

In other words, an evidence-based assessment of universal coverage and the importance of health insurance coverage would find that:

  • Having coverage doesn’t by itself ensure access, but lack of health insurance by itself is assuredly associated with poorer outcomes and even more deaths;
  • Relying on a charity and safety-net providers is not enough to ensure access and quality in the absence of good health insurance; and
  • Because there are not unlimited resources, people sometimes will sometimes have to wait for care, and that this is true in every country. (In the U.S., longer waits for appointments, and delayed and forgone care, are mainly because of cost barriers associated with not having health insurance and not having enough primary care doctors; in other countries, longer waits for some elective procedures are mainly because of limits on capacity, global budgets and price controls.)

Clearly, people will continue to disagree on whether the ACA goes about the problem of getting people covered the right way, but conservatives should rethink their insistence that health coverage doesn’t really matter that much when it comes to ensuring access and quality (the evidence says it does).

But liberals should also keep in mind that giving everyone access to health insurance by itself also doesn’t guarantee access—we also need to address problems like the growing shortage of physicians, and acknowledge that administrative hassles imposed by insurance companies and government alike may be one of the factors that are keeping doctors away.

Bob Doherty is Senior Vice President of Governmental Affairs and Public Policy, American College of Physicians and blogs at The ACP Advocate Blog.

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