Access vs. Coverage

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 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.

Comments (14)

Trackback URL | Comments RSS Feed

  1. John,
    An excellent description of the emerging debate. Sadly, few people are concerned about access as the primary problems and even many of the traditional small government types have bought into “universal coverage” as the solution.

    The AMA, where I am rather active as a grassroots leader, has completely bought into the “coverage size” of this debate. They have launched a mutli-million dollar campaign spreading the inaccurat “fact” that 47 million Americans are uninsured. This despite Census data showing 9.7 million of them are non-citizens!

    You are correct: Insurance does not equal access! In Florida, where medicaid pays 56% of the already low Medicare rate, patients have a terrible problem finding doctors. It is no wonder that ER usage as a source of primary care is twice as prevelant among this population!

    Thanks for the great points you make.

    Changing this debate is going to take a large group effort and pooling of resources to launch a legitimate public eductaion campaign on real solutions.

    David McKalip
    Chair, FMA Council on Medical Economics
    FMA Board, AMA delegate

  2. Of course….. I’m getting hoarse making the argument that an insurance card is not about access (except to a long line in an emergency room). An insurance card is “protection” against financial disaster in the unlikely event of a medical “disaster”. Remember the days of the mafia when store owners would buy “insurance” and the mafia would protect them??? When the government pretends to offer protection thru their benefit plan, they are not being honest. There is nothing protective about it. More often, it is obstructive and expensive. Let’s not let the government or any legislator or elected official continue to get away with misusing verbiage. It is clearly dangerous. Look how far off the beaten track we have allowed the debate to go. More important, it really doesn’t show any respect for the patients who must use the card.

    But, I think we must take this argument further … and get outside of the wire all together. The AMA and physicians need to create a media storm about the right for patients to invest in their health in a transparent competitive market place. Moreover, we MUST continue to respect the written word and only use the words “accident and sickness insurance”. We should never use the words “H… insurance” … it doesn’t really exist.

    Mr. Goodman is so right…. but I would love for him to take the debate to the next level with us.

    PS: about the AMA’s decision to march on Washington …… Any chance we can get them to change their mind? Isn’t it time that doctors stop whining about money? That is what I’m hearing from everyone. I think that this “march” will only put us into a deeper hole. When was the last time our AMA did a media event about quality ? Their press coverage is always about money even when we debate the liability issue. Wouldn’t it be much better for the profession if we stepped out to talk about quality … about the patient’s right to invest in their health and our obligation to work for our patients? It is time to change the context of the debate and make it about how to deliver better care to our patients.


  3. Chris Ewin says:

    Well said…
    Their is a big difference b/n universal access and universal “health” care. I totally agree with Marcy on the more accurate terminology…”accident and health insurance.”
    We need more quality driven models, not volume driven models…Chris
    M…you’re staying up too late..

  4. Nick E says:

    Excellent as usual, Dr. Goodman.

    The AMA as part of the solution to this? I know too many internists and family practitioners who’ve come to see it as the income-preservation PAC of specialists.

  5. Joel White says:

    I support access.

  6. Regina Herzlinger says:


  7. Ralph F. Weber says:


    It’s not about access or coverage; it’s about them regulating our health.

  8. Ralph F. Weber says:

    Signs like this are starting to pop up in Canadian emergency rooms:

    Canada ER Rates

  9. Bohn D. Allen, MD. says:

    Good show! I think the alert calls attention to what you and I were discussing the other night before the telecast. Coverage does not equate to access in a system that pays less than the cost to produce the service. I think there is some economic axiom that states that. In my case, it was my Dad when I left home. He told me, “Son if you sell your service or product for less than it cost you, you can’t make it up on volume.”

    Thanks for your continued insightful analysis of the health care landscape.

  10. John Graham says:

    [Response to Ralph F. Weber’s comment on March 5th, 2008 at 11:08 am]

    So, there is more price transparency in a Canadian hospital than a U.S. hospital! This is a good thing, because there is no such thing as DSH or similar payments in Canada, so the hospital has nowhere to go to get paid for the uncompensated care.

  11. Ralph F. Weber says:

    [Response to John Graham’s comment on March 7, 2008 at 10:47]

    Good point. Before Dr. Day was elected to the CMA, Canadian hospitals did not know how to bill at all.

  12. Kartik says:

    I think you hit the nail directly on the head Mr. Goodman!
    In Canada, we have universal coverage (but you have to buy additional coverage because the provinces refuse to cover 77% of drugs approved by Health Canada, including cancer drugs) but access is far from universal.
    This thing of the uninsured not receiving health care? Phooey… and profit is bad? In a competitive market, not AT ALL!!

  13. Diego says:

    I think they should wait until you have an accdneit that is your fault and then let you pay it off by the month. The good drivers lose money by buying auto insurance.You paid 900$ for liability insurance and that has turned out to be a bad decision. It is the same as if someone did 900$ damage to your car and you have no way to recover your losses. And you will probably be losing money year after year for the next 50 years. Why don’t they wait until you have an accdneit.??? I agree with you.

  14. Samantha says:

    I think its better for anyone to go for a full drug coverage plan rather then limited as now a days its Medicines which cost more then the service of the Doctors !