There’s been debate in political and healthcare circles about the President’s decision to not open a Special Enrollment Period for ACA markets in the midst of the 2020 global coronavirus pandemic. While some claim calamity for the uninsured, others liken it to opening the option to buy insurance right as a disaster approaches, thereby negating the purpose of holding insurance in the first place. I’m not interested in taking sides in the debate over the decision. But something stuck out to me in the arguments and that was the conflating of access to healthcare with access to health insurance. When facing a pandemic buying health insurance might seem like a critical need, but would buying health insurance guarantee access to the actual care required?
Access to Healthcare
We like to think of access to healthcare as the ability to seek health services when needed. But as we’re experiencing during the coronavirus pandemic there can be interruptions in access even for those with the best of coverage. If interruptions to access to healthcare can occur for those in the most privileged of positions what happens during a pandemic for the uninsured? How do the unemployed access necessary healthcare in the best of times? Even for the insured, there can be barriers to accessing health care. Cost is the leading barrier to healthcare with nearly 1 in 10 adults delaying care because of cost. This is in part due to high deductible health plans that make the out-of-pocket expense overwhelming for segments of the population. Another key barrier is the ability to find a doctor. This can be due to geographic restrictions or the scope of the health plan’s network.
“Cost is the leading barrier to healthcare with nearly 1 in 10 adults delaying care because of cost.”
One area where health plans are looking to improve health and reduce health gaps is in expanding care management to include Social Determinants of Health (SDOH). Axene Health Partners’ President and Consulting Actuary David Axene recently wrote about this issue and noted “SDOH include availability of resources to meet health care needs and the access to them.”
A positive move in removing barriers to access we can take from the pandemic is it has led to widespread implementation of telehealth services which improves access to healthcare in two ways. Directly by having care available on your nearest screen and by lowering costs associated with delivering care via video conference rather than a traditional office setting.
Access to Health Insurance
One of the primary keys to gaining entry to the health system to receive care is health insurance. Access to health insurance in the U.S. is primarily tied to employment. For those who lose their employer-sponsored coverage due to coronavirus-related layoffs, there are few options for maintaining some degree of coverage. One option is for Medicaid if income thresholds are met and one happens to live in a state that expanded under ACA. Another option is exchange enrollment again depending on the state. COBRA is an option, but this is if one can afford the full brunt of the premium that was paid by the employer (hundreds per month, minimum). All options are either expensive or typically viewed as low-quality. These limits on choice are a barrier when accessing health insurance and highlight that we need to rethink employer-based healthcare.
Making a Positive Impact on the Health System
In our efforts to work with various parts of the health system to define risk and improve efficiencies, we can often find ourselves deep in spreadsheets filled with billing codes, premiums and actuarial models. And in so doing we risk losing sight of the more granular impact of our work in affecting these issues. Sometimes it’s necessary to step away from the data and put yourself in the shoes of the group you’re trying to help. Ask yourself questions like:
- What would you do if you didn’t have health insurance?
- What if you lost your job and can’t afford insurance?
- What if you are not a native English speaker?
- What if you do not have a college or high school education?
- How do you find a doctor or the nearest clinic?
- What if you do not have internet access, how do you find care?
- What paperwork is needed to apply for insurance?
- What options are available to you?
The answers to the questions above can add perspective to dealing with issues we might not necessarily face in our own circumstances. In working to make a positive impact on the health system, it’s important our efforts include making it easier to access healthcare and to access health insurance. When we prioritize accessibility, everyone benefits.
A lesson we can take from the coronavirus pandemic is: Our population is only as healthy as the least healthy among us. The gap between health insurance and healthcare is an opportunity to improve health outcomes for vulnerable segments of the population. These improvements to access to care can help protect the health of the entire population. While debates will continue about Special Enrollment Periods and shortcomings of the ACA, access to health insurance isn’t worth much if we do not have access to healthcare when we need it. As members of the health system, this is an important area where we can make a difference.
 David Axene, FSA, FCA, CERA, MAAA: https://axenehp.com/care-management-expanded-include-impacting-social-determinants-health/