Universal coverage is not universal access

By Sarah Kliff
The Washington Post, Ezra Klein's Wonkblog, July 27, 2012

It’s well known that the Massachusetts health law increased health insurance coverage. The picture on how it changed access to health care is a little bit less clear. Some research has suggested that access has increased – a 2011 study found a 6.6 percent increase in residents with primary care doctors. At the same time, other research has shown access gains eroding.

New research from a team of Harvard researchers sheds some light on what might be happening: While access to care has improved, those in public programs have more difficulty finding doctors and paying for care.

“Most of the narrative about Massachusetts has been that we solved the coverage problem and the access problem,” says Harvard’s Danny McCormick, the study’s lead author. “We show that people with Medicaid and CommonWealth Care face challenges confronting a wide range of cost-related barriers not faced by the privately insured.”

CommonWealth Care is Massachusetts’ publicly-subsidized health insurance program, which covers those with incomes below 300 percent of the federal poverty line. About three-quarters of those who gained insurance through the Massachusetts expansion did so through a public program – CommonwealthCare and Medicaid – while the other quarter purchased private, unsubsidized policies.

McCormick and his colleagues interviewed 431 Massachusetts residents at a safety-net hospital in Boston. Their results, published in the Journal of General Internal Medicine, showed everyone was using outpatient care, such as prevention and normal doctor visits, at about the same rates.

But there were other barriers that showed up primarily among those with public coverage. They report higher rates of delaying or not getting medications: This happened with 30 percent of Medicaid patients, compared to 7 percent of the privately insured. Dental care was also an issue, with 51 percent of CommonWealth Care subscribers delaying or forgoing care due to cost. That number stood at 27 percent for the privately insured.

“Even though the co-pays for medication in Medicaid are between $1 and $3, that can represent a substantial barrier,” says McCormick. “If you’re a person with several chronic conditions, and get six prescriptions, it adds up.”

McCormick says he sees this in his own work as a primary care physician in the Boston area. About two months ago, he prescribed two hypertension medications for a Medicaid patient with high blood pressure. The patient showed up in his office again last week; he had never filled the prescriptions.

“I asked him what happened, and he said he just couldn’t pay for them,” McCormick recalls. “He had no money coming in. I ended up having to admit him to the emergency room. It illustrates what happens when low income people can’t get medication. It ended up costing several thousands of dollars.”

McCormick stresses that his report isn’t meant to attack the value of public programs. He wholeheartedly agrees with the findings his colleagues published on Wednesday showing increased Medicaid coverage to correlate with lower mortality rates. Medicaid, he says, is still better than no coverage at all. His research showed that the small number of uninsured Massachusetts residents fared even worse than those on public programs.

“I think the two studies are consistent,” he says. “Public programs do provide substantial benefit. At the same time, there could be cost barriers that get in the way of access.”

J Gen Intern Med. 2012 Jul 24. (Epub ahead of print)
"Access to Care After Massachusetts' Health Care Reform: A Safety Net Hospital Patient Survey." McCormick D, Sayah A, Lokko H, Woolhandler S, Nardin R.