Not long after the first anniversary of the health-care reform law, I got an earful from a medical doctor who had just completed his residency and was moving out of state. All the emphasis reformists and people like me were putting on expanding “access” was fine, but it missed a crucial point, he told me: Access, or health coverage, does not translate automatically into better health. Disparities in health persist for more reasons than access.
What he had seen working in one of our local hospitals was not so much an issue of lack of access as misuse — or abuse — of access, he said. Emergency rooms and the law that forbids emergency departments from turning away patients ensure access — expensive, to be sure, but access all the same. Part of the difficulty in keeping people healthy at a reasonable cost, he said, is that we don’t do a good enough job of reducing misuse. He proceeded to illustrate: the Medicaid client who calls an ambulance for an office visit when she doesn’t have a ride; the patient who shows up in an ER once or twice a month because it is quicker than waiting for a doctor’s appointment; a patient who is hospitalized repeatedly for respiratory ailments but has no desire to quit smoking. …
In other words, from his perspective working with patients, the problem that should not escape attention is the inefficient use of access. Open up the system, as the law does, and it becomes all the more important to build in a capacity for patients to be efficient consumers.
It is no secret that socioeconomic status, geography and race contribute to broad disparities in health conditions and outcomes across the country. There are well-documented differences in rates of illnesses, for example, between African-American and white populations in obesity, infant mortality, cardiovascular diseases and HIV/AIDS infections.
If the Affordable Care Act develops as designed, the provisions for expanded coverage will narrow one kind of the disparity: the disparity of access (of course, all that hangs on the November elections and whether the Republican leadership follows through on the promise to repeal the law if the party wins the White House and majorities in the House and Senate).
But it seems to me the young physician was pointing to another type of disparity even when people gain access to health care: a disparity in know-how — in how to plug into the system in ways that improve health outcomes and are cost-effective. The widespread misuse of ERs is one manifestation of this gap. A recent study found there isn’t much difference in ER use between Medicaid clients and the uninsured. An article in the New York Times on Sunday reiterated the projections of serious shortages in the next few years of doctors in all specialties except plastic surgery and dermatology. With the health system set to absorb an estimated 30 million to 33 million more individuals, it doesn’t take a genius to anticipate the traffic through emergency rooms.
Along with celebrating (justified in my opinion) the expanded access to the health-care system, we would do well to find avenues that help individuals connect to the system more efficiently.
It is an article of faith in some quarters that we have the best health care in the world and don’t need any #*@&! “Obamacare” messing with it. But how good is the best health care in the world if it is breaking the bank and leaving millions of its citizens no healthier than they would be if they lived in places where health care was decidedly not the best in the world?
The Times magazine this weekend carried a cover story that I think amplifies the conversation we should be engaging now about building capacity that enables people to connect more efficiently with the health-care system.
The focus of the article is Mississippi, which boasts some of the most depressing health statictics in the country. The story, “Hope in the Wreckage,” discusses efforts by a team of doctors to adapt in rural Mississippi a model of health-care delivery developed and implemented with remarkable success in Iran. Iranian “health houses” are built to serve about 1,500 villagers who live within one hour walking distance. They are staffed by villagers who have been given basic training in preventive care, from immunization to nutrition advice, and are responsible for the well-being of their patients. The sick are moved through a network of care from the health house, to a rural health center to a district hospital. Thus villagers can receive care according to their health condition.
The “health house” concept appears not far removed from the familiar model of the community health center. But the intriguing aspect of the “health house” is the way the health workers are trained to be all-in-all, the first line of access to care for the people in the unit for which they are accountable. The Affordable Care Act has made of point of encouraging and funding innovative approaches to cost-effective care delivery. It will be interesting to see whether Mississippi health houses are in the nation’s future.
Ofobike is the Beacon Journal chief editorial writer. She can be reached at 330-996-3513 or by email at firstname.lastname@example.org.