A recent study by Matthew Toth and Lauren Palmer from the Research Triangle Institute (RTI) evaluated the impact of the Center for Medicare and Medicaid Services (CMS) Financial Alignment Initiative (FAI) on access to primary care by those people who are eligible for both Medicare and Medicaid. These people are called “dual-eligibles” and represent about 13% of Medicare recipients. The FAI aimed to increase coordination of care, and the authors discovered that it did increase primary care access, to some degree, in 6 of the 9 states in which this demonstration project was implemented. In one state where it did not, Washington, eligibility for the program required people to have multiple morbidities (chronic diseases), and so the authors speculate that it increased access in other states for “healthier” dual eligibles.
There is nothing wrong with this study, or the program it
studies, insofar as they go. But it raises two major issues. The first is that the
program is yet another example of how the federal government continues to
tinker around the edges of a completely flawed healthcare system by
experimenting with one program after another that might possibly help, to
some degree, a small portion of our population. This is not to say that the
people who were studied, those eligible for both Medicare (by age or
disability) and Medicaid (by poverty) are not deserving of better access to
care and care coordination; certainly, they are. But we all are. Because we
have some people who are eligible for Medicare and some people who are eligible
for Medicaid and lots of people who are eligible for neither, and many people who
are uninsured, and many more are grossly underinsured, we have fragmented our
population and made financial access both unwieldy, far from comprehensive, and
incredibly expensive. If this study (maybe) shows that the improvement in
access was more for those “dual-eligibles” without multiple morbidities, is
this bad? Well, it’s bad that they weren’t getting coordinated care in the
Here I need to take a break, before going on to the second issue, to put in a word or two for our medical insurance companies and large hospital systems. They are not doing badly. Indeed, the outrageous excess cost of our health system, two to three times (or more) per capita than other OECD countries despite leaving large numbers of people uncovered, is due almost entirely to their profit-taking. They are doing well, thank you, along with the drug manufacturers, even while rural and inner-city safety net hospitals are going broke taking care of poor and uninsured (and sick) people, and millions of Americans go without care or receive inadequate care. The words – I’ll go with two – are rapacious thieves.
The second issue is that while financial access, being covered by adequate insurance, is very important, it is only part of the picture. The other part is having doctors (or other appropriate clinicians) who are available to see patients. This is the other area in which the US (and, in fairness, a few other countries including Canada) are failing. Have you tried to get an appointment to your primary care clinician lately? Maybe you can get in easily, but if so you are the exception. Most people have to wait weeks or months. If they go to the ER, they wait many hours, even for urgent or emergent problems. It would be good to be able to see a doctor who knows you, and knows your history, right? Instead of someone in an Urgent Care Center. I can answer all of these for people I know (or me) and the answers are not positive, and these are folks who are well insured and live in a major metropolitan area, not in a rural one or an inner-city health care desert! In Canada, there are suggestions that the way to fix the wait is to – wait – privatize health care! Hah! Come on down and see how that works here!
Why is it that people cannot get appointments to see primary care clinicians? Shouldn’t there be enough? Years ago on Saturday Night Live, Don Novello portrayed a character called Father Guido Sarducci who offered a “5-minute university”, where you were only taught what you would remember years later anyway. For Economics, it was “supply and demand”. So if there is so much demand for doctor visits, especially primary care visits, why is there not enough supply to meet it? This is, as you would guess, kind of complicated
Obviously, there are not enough primary care clinicians, either as a whole or as a percent of all physicians. If there were enough, you could call your doctor and get in today if you were sick or had a worsening problem. Like on TV (pick your favorite FP/GP show). So we don’t have enough. This is all about money. To some degree, it is about doctors wanting to make as much as they can. This results in far too small a proportion of graduates entering primary care, since they can make two or three times as much in some other specialties, which is enough to convince even many who liked the idea of primary care that, especially with their debt load, they liked anesthesiology more. We are at about half the percentage of primary care that we should be. For this I blame the system that pays other specialties so much more (or primary care so much less). In addition, the distribution is poor – not enough doctors in rural areas, or certainly poor urban areas, but all concentrated in more wealthy urban and suburban areas.
Ultimately this is all about the corporatization of health care, and the treatment of providers as widgets in a factory. Put this many in clinics, make sure that they are totally booked and have no room for anyone who needs to get in on short notice, put others in the hospital, put others in urgent care or ERs. Have no flexibility in the system because if you have the capacity to expand when needed, that means that at other times you have down time, and that is unacceptable for making maximum corporate profit. Of course, this is not good for your health, which is better when you can see a doctor who knows you, especially when you are sick and couldn’t plan two to eight weeks ahead of time (or more!) to make an appointment.
Creating doctors and other health professionals takes many years, and cannot change on a dime, but it will never change if that change doesn’t start. If we care about people’s health and healthcare, we need to dramatically decrease the difference between what primary care and other specialist income so it doesn’t discourage students from choosing primary care. We need to ban for-profit corporations (or ostensibly non-profit systems that act like for-profits) from being in our health system at all. All of health care and its components should be about ensuring better quality health for our people, not making money for businesses.
The usual pattern in the US is to have funding for public services cut by politicians who are receiving money from private corporations, to the point that they do not function well at meeting public needs. Then those same politicians say “privatize!” and they do and the cost goes way up and the public needs are still not met, because, well, that’s not what private enterprise is there for. (See this good video by Brittlestar on why privatization is not a good choice for Canadian healthcare.)
Jimi Hendrix said “Castles made of sand fall into the sea eventually”. But our health care system is not built on sand. It is built on rocks of intransigent corporate profit, and it is not going to change without a fight. You and your health don’t count as much as big business making money. So there. Pick up the gauntlet, and fight for yourself, your family, your community.
Spot on and well said!
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