Health Insurance Is Not Health Care Mitchell H. Katz, MD

Thanks to the Affordable Care Act (ACA), low-income Americans (those earning less than 139% of the federal poverty level) living in 25 states and the District of Columbia gained eligibility to Medicaid on January 1, 2014. 1 The Congressional Budget Office estimates that Related articles pages 861, 920, and 988 by 2022 there will be 12 mill i o n n e w e n r o l l e e s i nt o Medicaid.2 Although this is an unprecedented leap forward in providing low-income Americans with health insurance, it is important to remember that health insurance is not health care. Health insurance is a financial mechanism for paying for health care. It is not the care itself, or even a guarantee of care.

What does the lack of deterioration in access under these state initiatives tell us about what will happen under the ACA? One reason to worry that access will be more constrained under the ACA is that the Medicaid expansion is just one part of the expansion of health insurance under the ACA. The Congressional Budget Office estimates that 26 million persons will enroll in one of the health insurance exchanges created through the ACA by 2022.2 When people gain insurance, their use of services increases, especially when they first gain insurance, a phenomenon referred to as pent-up demand. With more people seeking care, it may be particularly hard for those with Medicaid, a traditionally poor payer, to find a provider who will see them.

Gap Between Health Insurance and Health Care

Improving Access for Medicaid Patients

The gap between health insurance and health care can be particularly challenging for many Medicaid recipients to bridge. Studies have shown that a substantial proportion of physicians do not accept new Medicaid patients. Decker3 reported that 33% of primary care physicians were not taking new Medicaid patients in the 2011-2012 period; rates were as high as 54% in New Jersey, one of the 26 states that expanded Medicaid. Acceptance of Medicaid by some specialists was even lower than for primary care physicians. New Medicaid patients were not accepted by 56% of psychiatrists, 45% of dermatologists, and 40% of orthopedic surgeons. Therefore, amid the optimism that millions of previously uninsured persons will gain Medicaid coverage, there is a fear that the newly insured will not be able to find physicians who will care for them, or that the influx of new enrollees will make access harder for those persons who already have Medicaid. In this vein, the results of the study by Ndumele et al4 in this issue of JAMA Internal Medicine are reassuring. The investigators took advantage of a natural experiment: some states had expanded eligibility for Medicaid prior to the implementation of the ACA. The investigators used data from the National Health Interview Survey to compare 1764 adult Medicaid recipients from 11 states that had enacted substantial (>25%) changes in income eligibility for Medicaid with 5089 Medicaid recipients from states that had not changed eligibility criteria. In expansion states, the percentage of Medicaid recipients who reported poor access to care declined from 8.5% prior to the expansion to 7.3% after the expansion. For Medicaid recipients in states where there was no expansion, the percentage remained constant at 5.3%. There were also no differences between expansion and control states in terms of increase or decrease of emergency department use. It did not appear that adding new enrollees worsened the access of those persons who were already enrolled in the program.

To improve access for Medicaid patients, the ACA included a provision that requires that Medicaid reimburse primary care providers at Medicare rates during 2013 and 2014. 5 Although this is welcome news to physicians who provide services to Medicaid patients and have long received inadequate rates, it is unclear how effective this incentive will be to induce physicians to take on new Medicaid patients. Physicians will rightly be concerned that if they grow their Medicaid base too large, once the rates decrease, their practices will no longer be solvent. Moreover, focus groups of physicians have identified that low reimbursement rates are only one reason that physicians are reluctant to accept new Medicaid patients. Other prominent reasons are: cumbersome billing procedures, delays in reimbursement, perceptions that Medicaid patients are more challenging to care for (eg, less likely to show up for visits, more likely to need nonmedical support), and difficulty obtaining specialist referrals for patients when needed.6 States can minimize the administrative burden on physicians through simplified computerized billing and reimbursement methods. To ease the burden on physicians caring for Medicaid patients who have substantial needs for nonmedical services (eg, housing, food, transportation to physician visits), case management services are needed. Even if reimbursement were available, it would be difficult for small practices to provide these services, but they could be provided in a centralized way so that individual physicians could refer patients to an agency that receives Medicaid funding for providing these services. Although this would be an additional cost to the Medicaid program, homelessness, food insufficiency, and lack of transportation to regular medical appointments all can result in otherwise avoidable illness, expensive specialty care, and hospitalizations. For example, a review of California hospital admissions found that the risk for hypoglycemia


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Opinion Editorial

admission increased during the last week of the month compared with the first week in the low-income population but not in the high-income population, suggesting that patients with diabetes were running out of food.7

Meeting the Increased Need for Medical Services More broadly, the practice of American medicine will have to change to accommodate the increased demand for services. Because it is not possible to increase the supply of physicians in the short term (and in the long term, increasing the supply of physicians would likely increase costs), we need strategies for maintaining access in the face of increasing demand. The most promising strategies for providing more ambulatory care without increasing cost or diminishing quality are the following: 1. Empanel patients into longitudinal patient-centered primary care homes. Consistent care by the same physician or team of physicians and other health care providers will decrease duplication, increase receipt of recommended prevention services, 8 and increase patients’ sense of being cared for, which in and of itself is therapeutic. Patient-centered primary care may decrease avoidable hospitalizations9,10 and ambulatory sensitive emergency department visits.11 2. Create primary care teams12 in which each member of the team functions at the highest level of his or her license. For example, internists should diagnose illness and determine ARTICLE INFORMATION Author Affiliations: Los Angeles County Department of Health Services, Los Angeles, California; Deputy Editor, JAMA Internal Medicine. Corresponding Author: Mitchell H. Katz, MD, Los Angeles County Department of Health Services, 313 N Figueroa St, Room 912, Los Angeles, CA 90012 ([email protected]). Published Online: April 7, 2014. doi:10.1001/jamainternmed.2014.598. Conflict of Interest Disclosures: None reported. Disclaimer: The views expressed herein are those of Dr Katz and do not necessarily reflect the views of the Los Angeles County. REFERENCES


treatment plans; medical assistants can keep patients up to date on cancer screening such as mammogram appointments; pharmacists can review chronic medication regimens and renew prescriptions; and nurses can counsel new parents on well-child care. 3. Use alternatives to a single patient-physician visit when possible, such as group visits for patients with diabetes, electronic consultations for specialty care, retinal cameras in place of ophthalmologic examinations, and telemedicine consultations. 4. Encourage self-care12 through better education of patients about their illness. 5. Use alternatives to fee-for-service care (eg, per-member monthly capitation, bundled payments) to avoid paying for more care that does not lead to improvement of health status. 6. Eliminate unnecessary testing and overuse of medications as modeled by the Choose Wisely campaign of the American Board of Internal Medicine13 and Less is More feature of this journal. No one of these strategies will work alone, and it is healthy for our profession to debate the efficacy of each of them, especially given that existing studies have had mixed results.14 However, what we know for sure is that failure to evolve our system will result in insufficient access and long waits, especially for those who are uninsured or have Medicaid, and higher costs for all.

a baseline to measure future acceptance rates. Health Aff (Millwood). 2013;32(7):1183-1187. 4. Ndumele CD, Mor V, Allen S, Burgess JF, Trivedi AN. Effect of expansions in state Medicaid eligibility on access to care and the use of emergency department services for adult Medicaid enrollees [published online April 7, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2014.588. 5. McGinnis T, Bereson J, Highsmith N; Center for Health Care Strategies Inc. Increasing primary care rates, maximizing Medicaid access and quality: policy brief, January 2001. www.chcs.org/usr_doc /PCP_Rate_Increase_Issue_Brief_FINAL.pdf. Accessed January 7, 2014. 6. Long SK. Physicians may need more than higher reimbursements to expand Medicaid participation: findings from Washington State. Health Aff (Millwood). 2013;32(9):1560-1567.

1. Henry J. Kaiser Family Foundation. Status of state action on the Medicaid expansion: December 11, 2013. Kff.org/health-reform/state-indicator /state-activity-around-expanding-medicaid-under -the-affordable-care-act/. Accessed January 7, 2014 .

7. Seligman HK, Bolger AF, Guzman D, López A, Bibbins-Domingo K. Exhaustion of food budgets at month’s end and hospital admissions for hypoglycemia. Health Aff (Millwood). 2014;33(1): 116-123.

2. California Healthline. CBO updates spending projections for ACA, Medicare, Medicaid: February 6, 2013. www.californiahealthline.org/articles/2013 /2/6/cbo-updates-spending-projections-for-aca -medicare-medicaid. Accessed January 7, 2014.

8. O’Malley AS, Mandelblatt J, Gold K, Cagney KA, Kerner J. Continuity of care and the use of breast and cervical cancer screening services in a multiethnic community. Arch Intern Med. 1997;157 (13):1462-1470.

3. Decker SL. Two-thirds of primary care physicians accepted new Medicaid patients in 2011-12:

9. Cheng SH, Chen CC, Hou YF. A longitudinal examination of continuity of care and avoidable

hospitalization: evidence from a universal coverage health care system. Arch Intern Med. 2010;170(18): 1671-1677. 10. Nyweide DJ, Anthony DL, Bynum JP, et al. Continuity of care and the risk of preventable hospitalization in older adults. JAMA Intern Med. 2013;173(20):1879-1885. 11. Rosenthal MB, Friedberg MW, Singer SJ, Eastman D, Li Z, Schneider EC. Effect of a multipayer patient-centered medical home on health care utilization and quality: the Rhode Island chronic care sustainability initiative pilot program. JAMA Intern Med. 2013;173(20):1907-1913. 12. Bodenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff (Millwood). 2013;32(11):1881-1886. 13. American Board of Internal Medicine Foundation. Choosing Wisely Initiative. http://www .abimfoundation.org/Initiatives/Choosing-Wisely .aspx. Accessed January 11, 2014. 14. Grumbach K. The patient-centered medical home is not a pill: implications for evaluating primary care reforms. JAMA Intern Med. 2013;173 (20):1913-1914.

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Health insurance is not health care.

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