As the Affordable Care Act unfolds, newscasters report statistics about the numbers of “newly insured.”
Is the figure 6 million or 7 million? How many of them had insurance previously? How many of those who attempted to sign up for insurance have paid their premiums and achieved coverage?
Conflating health care access with having insurance coverage is a bit simplistic, however. For example, years ago I learned that Zimbabwe offers universal health care to its citizens. The infrastructure, I was told, was at times lacking, but the entitlement remained a source of national pride.
Some of my colleagues who lived in the Warsaw Pact countries before the fall of communism described a similar scenario. Citizens were guaranteed health care, although access required the use of considerable ingenuity. At times, bribes may have occurred. In other words, carrying around an insurance card was not enough. Sick people also need access to primary care, specialized care, medications and treatment modalities.
One may also have access to care without an explicit health care insurance contract. For example, when I worked for a local county hospital system, I treated many patients who had “fallen between the cracks” in a formal sense. To the best of my knowledge, most of them received health care treatment, with or without insurance. I recall sending quite a few patients to the social workers who would attempt to sign them up for Medicaid.
When I worked in correctional and mental health settings in our state, health care was also routinely provided.
By contrast, I hear stories all day from working patients with health insurance who have difficulty accessing health care. In order to see a specialist, for example, it may be necessary to be referred through a primary care clinic. Getting in to see a primary care doctor may take a while. And the primary care doctor may not refer the patient to the specialist. For example, I recently examined a gentleman whose cancer diagnosis was delayed as he sought referral to a specialist. Delay of care, in some cases, may prove catastrophic.
If you are fortunate enough to score a prompt appointment, your primary care “provider” may not even be a doctor. In order to improve time management and efficiency, many physicians rely heavily on nurse practitioners or physician’s assistants. Many are quite capable, but they are not licensed doctors.
Patients with industrial injuries are often referred for industrial medical treatments, only to learn that many specialists will not accept workers’ compensation cases. The physicians are generally just fed up with the associated paperwork, hassles and poor reimbursement. Indeed, I have read that apart from workers’ compensation cases, some community physicians are limiting their participation in Medicare and Medicaid programs, as well.
Trying to telephone a physician is an exercise in frustration. For example, telephoning the Department of Veterans Affairs, which is relatively efficient, requires one to negotiate a lengthy telephone menu, typically resulting in a conversation with a clinic scheduler.
In the community, nearly every medical office routes telephone calls to a recorder, admonishing us to call 911 if we have an emergency. The traditional doctor-patient relationship, it seems, is fraying under the influence of managed care. Doctors are increasingly working as salaried employees, with little incentive to increase their patient-care workloads. Those clinging to private practice models depend on government agencies, insurance companies and third-party payers.
In this brave new world, we will have plenty of time to admire our new insurance cards, as we wait in line to see our health care “providers.”
Scott T. Anderson, M.D. (email [email protected]), is clinical professor at UC Davis Medical School. This column is informational, and does not constitute medical advice.