Americans underuse health care

By Jessica Schorr Saxe, M.D.
The Charlotte (N.C.) Observer, Jan. 17, 2014

Are we a nation of people waiting to have medical insurance so that we can spend our time seeking unnecessary medical care? Really?

The true problem is that many of us don’t get needed care.

Yet the myth of overuse reverberates throughout health care discussions. The myth is applied across socioeconomic classes – though differently. For the poor, it is argued that Medicaid will lead to unnecessary utilization and increased cost. For the privately insured, the myth suggests that people need high deductible health plans (HDHPs) to deter them from using medical care frivolously.

A recent study showed increased emergency department (ED) use for non-urgent conditions in Oregon patients who had recently gotten Medicaid through a lottery. It looked at short-term results of a largely white urban population. Much discussed in the media, it has been used as a warning against Medicaid expansion. It was not suggested that the care was unnecessary – just that much of it could have been provided in an outpatient setting.

Not as publicized was the recent national study of thousands of patients, examining their ED use by health insurance type. It found that Medicaid and privately insured patients used EDs similarly for acute problems, but Medicaid patients were more likely to use the ED for less serious conditions because they lacked other sources of health care. One might infer that the solution is to ensure that Medicaid patients have access to primary care, which is better and more cost-effective for non-urgent conditions.

For the privately insured, it is argued that, with HDHPs, consumers will be more conscious of their expenditures, use less care, and thus save money – largely for employers and insurers. If people have lower premiums and aren’t sick, they may also save money. But those who actually need health care may find themselves with large out-of-pocket expenses. According to the nonpartisan Kaiser Family Foundation, about one third of non-elderly adults had difficulty paying medical bills in 2012. Of people with medical debt, 70 percent are insured, mostly with employer-sponsored insurance – and more likely to have HDHPs.

And what about health, which health insurance is supposed to promote? The nonpartisan Robert Wood Johnson Foundation notes that cost-sharing (deductibles, co-pays and co-insurance) indeed cuts down on use of services, but that patients are as likely to forgo necessary as unnecessary care. Increases in cost-sharing have the worst impact on vulnerable populations, such as the poor, elderly and chronically ill.

Why isn’t anyone talking about the real American epidemic: the underuse of necessary care? A 2012 survey showed that 58 percent of Americans deferred medical care due to cost.

As a family physician, I live with this reality. I think of a patient who had rectal bleeding and one with life-threatening high blood pressure, who avoided the ED because of expense. I see patients who “stretch” their medications to make them last or miss needed visits for lack of co-pays.

Here’s another clue to possible underuse. Though we spend more per person than other countries, we actually use less health care. For example, Americans average 4 doctor visits a year compared to 7 in France and Canada, countries with better health outcomes than ours.

Whether others have health care matters to all of us. We all benefit when our colleagues aren’t working with chronic untreated conditions and our food servers don’t have coughs they can’t afford to have evaluated.

While many of us might have a story about someone who goes to the doctor more than necessary, the evidence asserts that lack of care is a much bigger problem. Even when insured, Americans have better things to do than wait in doctor’s offices when they don’t need to. But many who need health care don’t get it.

We should expand Medicaid, increase availability of primary care, and give access to our disproportionately sick population. Then we should move beyond Obamacare to improved health care for everyone. Other industrialized countries provide access to all, with lower costs and better health outcomes. Like them, we should eliminate insurance companies and for-profit medicine and expand health care to all.

Dr. Jessica Schorr Saxe is a family physician in Charlotte and chair of Health Care Justice – NC.