Why improving access to affordable health insurance is key to increasing access to quality health care - a personal story

The first step in increasing access to quality health care is making sure that people have access to the system that provides that care. In the U.S., that means having affordable health insurance - something you can pay into and is there when you need it to cover large medical expenses. Now of course, anyone can access health care without health insurance, but no matter where you seek care - a providers office, "safety net" clinics that offer services on a "sliding fee scale" (based on your income), or through the emergency room - the result is usually same, you end up footing the bill.  I don't know about you, but I don't consider that quality care, especially since health care costs so much in this country. Further, I don't think most Americans have hundreds or thousands of dollars that they can suddenly part with. I think the most expensive place to seek care by far is the emergency room.

A personal story

I have a relative who was uninsured and experiencing one of those conditions that I like to call "50/50 symptoms/conditions"- one of those symptoms/conditions that you could be experiencing randomly or because you have an underlying life-threatening condition that needs to be checked out. After debating and being in pain for hours, the decision was made to go to the emergency room to get an expert opinion. In the end, all they got was a bill for close to $1,000, a few ibuprofen, and was sent on their way without even a diagnosis - except for the indication that it was not life-threatening. An urgent care would have probably been a cheaper alternative but there was no way of knowing that that would have been the better place to go upfront. I'm sure my relative is not alone and there are echos of this story across the U.S.

To be positive, there are hundreds and maybe even thousands of organizations across the country working right now to address this issue and prevent this from happening to others. So what is actually being done to help improve access to quality care by increasing access to health insurance? Check back often as I'll be highlighting some of these organizations and the great work they are doing. 

Barriers to accessing quality health care: finding a good doctor

So you have health insurance. Great! You've overcome what I would define as the first major barrier to receiving access to quality health care (having access to a health system). Now you have to find a doctor. Piece of cake right? Not really. In my experience, finding a doctor can be an extremely frustrating process that comes with its own set of obstacles. These obstacles vary from person-to- person depending on your situation - health issues, where you live, the type of insurance you have, etc. but no doubt propose challenges to anyone who wants to receive care.

I recently had to find a doctor for a loved one and it was no easy feat. If you're like me, you equate trusting a doctor with your (or your loved one's) health, as trusting them with your life and the fate of your finances. So, just any doctor will not do. You want to find a good (scratch that) great doctor, because you never know what could happen to you or that loved one. When you need your doctor the most, you want to feel confident about the person whom you've entrusted with your health because it's scary to think of the things that some people go through - being misdiagnosed, told their making things up and nothing is wrong with them, and unnecessarily spending money on out-of-pocket fees and deductibles that could have been saved or used for other things. This process is so important, that I've decided to share some of the things I've learned and also other tips you should consider when looking for a doctor in the hopes that they can save someone else a bit of time and frustration and hopefully make things at the very least, a little easier.

Before you even start looking, there are a few things to figure out: 

1. Does your insurance policy restrict which doctors you can see with your insurance?

Insurance varies, some policies only offer "in-network" benefits where there are specific doctors they allow their policy holders to choose from. Others have both "in-network" and "out of network" benefits that offer the policy holder more choices in doctors by allowing them to be covered if they see a physician that is outside of their insurance network. Most of the time, the insurance company only covers a portion of the costs for seeing the "out of network" physician compared to the 100% they would cover if the policy holder saw an "in-network" physician.

2. If you need to see a specialist, do you need a referral?

Some insurance companies require that their policy holders get a referral from their primary care physician before seeing a specialist.

After you've sorted out issues 1 & 2 above, now it's time to actually look for your doctor. 

3. There are several ways you can search for a doctor these days:

• Your insurance company's website. Your health insurance website may have a search tool that helps you find doctors that meet your criteria (distance, location, and specialty, etc.).

• If they don't you can try other websites that are designed to help with searching for various things such as physicians like Yelp or physician search focused websites like ZocDoc

4. Once you've identified some doctors, look for reviews of them online.

Although my health insurance provider had a provider search tool, I found the information to be limiting (i.e., doctor's name, address, qualifications). Don't get me wrong, the information they provide is vital but I like to hear feedback from other people to get a more comprehensive picture of the doctor so, I like to do further research by looking at reviews.  Also of note, reviews are helpful but must be looked at objectively. Anyone can write a review and you don't always know the intention of the reviewer - if the review is honest or a lie to purposely ruin or beef up the doctors reputation so I try to look at reviews on more than one site.

5. If you're lucky, you can get a recommendation from family, friends, colleagues, and/or your previous or current practitioner (if you're looking for a specialist).

My loved one received a referral from a doctor to see a specific physician. My thoughts were "great, it can't get any easier than that, I'll make the appointment tomorrow" - until we realized that the referral was for an "out of network" physician. So, just be mindful of this when asking for recommendations. If you can, ask whoever is making the recommendation if the doctor they are recommending accepts your insurance. If they don't know, ask them if there are any additional doctors they can recommend just in case and/or try to get recommendations from multiple sources (e.g., a friend and a family member).

6. Things you'll want to know about the doctors you're researching before you try to schedule the appointment:

• Are they accepting new patients?
• If you're seeing a specialist, does that doctor's office have a screening process before they allow you to make an appointment? In my experience, some specialists will not consider even giving you an appointment unless you've had a "work up" (blood work and/or other screenings such as MRI's) that they feel shows them that there is a problem they should address (as opposed to a different kind of specialist).

In the end, this can be a lot of work and not everyone may have to go through this whole process depending on your situation. There is no doubt that knowing that yourself or a loved one is well makes all the time and stress worth it. But there's a part of me that knows that there has to be an easier way to find a doctor. Like I said, everyone's experience varies but for me this process was very time consuming. If others have had to go through what I did, I can't imagine how much time, work place productivity, and hence more good that could be done for the economy if this process was more efficient.   

How health care works in the U.S. (Part 2 - delivery through government programs)

The U.S. health care system 

In the U.S., health care is provided to individuals through services delivered by a mix of public and private entities, namely the government and not-for-profit and for-profit health insurance companies.

Government Programs 

The top government agency responsible for "protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves" is the U.S. Department of Health and Human Services (HHS) (ASPA, n.d.). HHS carries out its duties in a number of ways: 1) through various offices and agencies and 2) by working with state and local governments.  

The Centers for Medicare & Medicaid Services (CMS), is an example of one such agency. CMS was created to administer the Medicare, Medicaid, and Children's Health Insurance (CHIP) programs, among others. These programs were created to reduce the gaps in health insurance coverage for all Americans, but especially "those who are least able to help themselves." 

• CHIP - Designed for children whose families can't afford to provide them with private health insurance coverage but have incomes that disqualify them from being covered under Medicaid (Medicare.gov, n.d.)

• Medicare - Provides health coverage for older Americans (age 65 or older), people with certain disabilities, and those with End-Stage Renal Disease, regardless of age (Medicaid.gov, n.d.). 

• Medicaid - Provides health coverage for people with disabilities and those experiencing economic hardships (qualifying income level varies by state) (HealthCare.gov, n.d.). 

According to HHS, the Medicare program is the United States' largest health insurer (ASPA, n.d.). Together both programs, Medicare and Medicaid, provide health insurance for one in four Americans (ASPA, n.d. & HHS, n.d.). So how do they do it? HHS provides funding and guidelines to state and local government agencies and to private entities to provide these programs at the local level (ASPA, n.d. & HHS, n.d.).

References

1. ASPA. (n.d.). About HHS. Retrieved from http://www.hhs.gov/about/

2. HealthCare.gov. (n.d.). Medicaid. Retrieved from http://www.healthcare.gov/using-insurance/low-cost-care/medicaid/

3. HHS. (n.d.). HHS: What We Do. Retrieved from http://www.hhs.gov/about/whatwedo.html

4. Medicaid.gov. (n.d.). Children’s Health Insurance Program. Retrieved from http://www.medicaid.gov/CHIP/CHIP-Program-Information.html

5. Medicaid.gov. (2012). Medicare Program - General Information. Retrieved from http://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html

How health care works in the U.S. (Part 1 - delivery through health insurance companies)

As the U.S. prepared for its 2012 presidential election, there was a lot of talk about the Affordable Care Act (ACA), famously known as "Obamacare", President Obama's solution to improving health care in the country. Countless points were argued for and against this law that, despite having already been signed into law in March of 2010, is still hotly debated (The White House, n.d.). Those for the plan argued that it would help the millions of Americans that are uninsured, be able to secure insurance. While those opposed, argued that it would be bad for businesses and that health care should be handled on the state level, to name a few. To ordinary citizens, all of these arguments raise several questions. What impact will this law have on my life (i.e., my health, my budget)? What would it mean for me if health care was handled at the state level? etc. Before you can understand the impact of ACA or any major changes in health care for that matter, it's important to understand how health care works in the U.S. - how care is delivered, who delivers care, how its paid for, etc.

The U.S. health care system 

In the U.S., health care is provided to individuals through services delivered by a mix of public and private entities, namely the government and not-for-profit and for-profit health insurance companies.

Health Insurance Companies

Health insurance companies such as Kaiser Permanente and UnitedHealthcare offer "pre-payment" health plans or policies to employers and individuals or families. With these "pre-payment" plans, individuals pay monthly rates to their health insurance company, ensuring some level of coverage for a certain time period (Note: pricing, level of coverage, and length varies by company and health policy. Also, in addition to monthly rates, policy holders may also be responsible for paying co-pays and co-insurance fees and meeting yearly deductibles). Most people consider themselves to be fortunate if their employer offers health insurance as part of a benefits package because employers, unlike individuals, can take advantage of group rates that can reduce the cost of health plans for their employees and their families.  However, just because an employer offers health insurance it doesn't mean they will cover the cost of it. Some employers cover all, part, or none of the plan costs.

References:

1. The White House. (n.d.). About the new law. Retrieved from http://www.whitehouse.gov/healthreform/healthcare-overview