[Updated after passage of the healthcare reform law, March 2010.]
Should all Americans be guaranteed access to basic health and medical care? Prior to the passage of the healthcare reform law in 2010, these were the questions that were asked:
Is healthcare a right, like police protection, fire protection, education or even libraries? Or is healthcare a responsibility or obligation, meaning an individual must purchase it for herself and her family like we do for food or shelter?
Should the child of an unskilled hourly worker have access to the same care options as the CEO of a large corporation, or a U.S. Congress member or a retired union member? Should the child of a corporate CEO have access to better quality care than the child of a laborer?
Should there be differences in the care available from state to state?
Should health insurers be allowed to deny care or reimbursement to some individuals?
Should patients be told which doctors they may, or may not, see for their care?
What about prevention? Should patients be allowed to seek assistance for problems like quitting smoking or losing weight? Should a healthcare payer be expected to pay for those services?
These are some of the questions that were asked as Americans considered the ways they believed healthcare should be reformed. While many of them were eventually part of the law passed in March 2010, some were omitted.
According to the Institute of Medicine, one of the National Academies Sciences of the United States government, the United States is the only wealthy, industrialized nation that does not ensure all citizens access to healthcare as part of a universal healthcare system. By the end of 2009, 47 million Americans did not have health insurance, meaning, they could not access medical care without having to pay for it out of their pockets. The new law will make it possible for 32 million of them to get healthcare services by 2014, but do the math - there will still be 15 or 16 million who will still not have access to care.
There are a number of reasons people don't have health payment coverage, all related to the cost of that coverage. Among those reasons:
- Not all employers offer health insurance as a benefit. Therefore, even among those who work and should have access, not everyone does. The new law provides for incentives and fines to be sure more employers do offer healthcare coverage.
- Some people worked for employers that offered health insurance coverage, then lost their jobs through layoffs. That makes them eligible for COBRA (a program that allows them to keep their insurance) but they are then required to pay the full amount of the premiums, which are no longer subsidized by their employer. That addition to their premiums, plus the fact that they no longer receive a paycheck, may make insurance too expensive.
- Prior to passage of the healthcare reform law, there was no requirement, law or regulation that forced a health insurance company to sell a policy to anyone. That meant that an individual who wanted to purchase a health insurance policy could be denied that coverage due to a pre-existing condition, a health problem she already has, for which a health insurance company doesn't want to be responsible for payment. As of passage of the law in 2010, children may no longer be denied insurance based on pre-existing conditions; however, it will be 2014 before insurers are required to provide policies to adults.
- Health payers deny care for some tests and treatments. Denial of coverage is a form of rationing, and and takes place when the insurer thinks the test or treatment will not provide enough of a benefit for the cost. These denials of care will not only continue with passage of the healthcare reform law; it is expected there will be more denials than ever before.
- Some people can afford insurance, but don't think they need it. This is an attitude most prevalent among younger workers who are too old to be included on a parent's health insurance policy, and are healthy enough that they don't consider health insurance to be a priority. Ironically, when these younger, healthier individuals participate in health insurance, it reduces the cost for others. Passage of healthcare reform in 2010 will change this dynamic over time. By 2014, even these young people will have to purchase insurance, or they will be fined by the government through their taxes if they don't.
- Not all types of healthcare are covered by insurance or government programs. Mental health needs often lack coverage. Dental insurance, vision coverage and other necessary types of healthcare are often excluded from coverage.
Not all coverage and access is inhibited by money or payment directly. In some cases, coverage and ability to see the doctor one needs to see for care is related to a shortage of some kinds of doctors, or their location. The cost is still part of the conversation, however. Shortages of primary care providers are problematic across the country because fewer and fewer medical students are choosing to go into primary care. They don't choose primary care because once they are in practice, they are not reimbursed by payers at the same higher rates as other specialists are. Further, finding good medical providers in rural areas is becoming more difficult.
The results of a study undertaken by the journal Health Affairs in late 2007, demonstrated that this lack of payment coverage also affects mortality. It was estimated that as many as 101,000 people die each year because they did not have insurance.
