Access to Health Care

Discussion of fee‐for‐service or HMOs generally applies to middle‐class employed persons. But what about the working poor, the unemployed, or the disabled? What options exist for them? Unfortunately, in the United States, access to health care is still closely tied to the ability to pay for such care, either personally or through insurance. Therefore, people who are not covered by health plans, are unemployed, or are disabled qualify for only limited access to health care. The United States, as one of the few Western nations without a national health care plan, falls far behind most other industrialized nations in providing care for such people. This fact is ironic considering that the United States spends more per person on health care than any other industrialized nation.

Without a doubt, the need for health care is significant, especially among the poor. Sociologists point to substantial evidence that shows the poor are sicker, die younger, and have higher infant mortality rates than the non‐poor. Because minorities also tend to be poorer than non‐minorities, poor‐quality health care disproportionately affects them. Blacks have the highest death rate in the United States, followed by Hispanics. Whites have the lowest. Violence and accidents, both of whose rates are higher in the United States than in other industrialized nations, also contribute to high health costs.

The government tried to respond to the needs of the poor in the 1960s with Medicaid and Medicare. Medicaid is a federally funded program that provides medical insurance to the poor, disabled, and welfare recipients. Similarly, Medicare is a federally funded program that provides medical insurance for all people age 65 and older.

Although these programs have provided considerable benefits to many people, they have come under fire for a variety of reasons. Critics argue that the programs are too costly for the services provided, many are wasteful and inefficient, and, because of poor monitoring, these programs are often routinely abused by unscrupulous medical practitioners who defraud the system. To address billing fraud, the Office of the Inspector General (OIG) now aggressively investigates questionable billing to the Health Care and Finance Administration (HCFA), which oversees Medicare and Medicaid. The OIG expects all providers to implement and audit a compliance plan, that is, a comprehensive procedure and audit manual that demonstrates diligence in correct billing and avoidance of fraud. A new industry of consultants and legal advisors emerged during the 1990s and continue to assist practices with their compliance plans.

Recent political debates have sought to reform or abolish Medicare and Medicaid in their present forms or reduce the amounts paid for some procedures. Unfortunately, efforts to reduce Medicaid and Medicare costs may actually contribute to the overall rise in the cost of medical care. For example, many laboratory services are reimbursed at or below the cost to perform the test and produce the report. A laboratory processing a standard biopsy may break even or lose money depending on the complexity of the case. For every dollar lost on Medicare cases, the laboratory needs to make up that loss elsewhere. If Medicare or Medicaid were to pay less for these services, laboratories would be forced to charge more for tests to non‐Medicare and Medicaid patients, refuse to accept Medicare and Medicaid tests, or go out of business. Also, there is a gap between where Medicaid ends and private insurance picks up. Many of the working poor are not covered by Medicaid, their companies do not provide health insurance, and they can't afford private insurance, so they are among the 40 to 60 million uninsured. Medicare is also facing problems as Medicare HMOs go out of business and doctors limit or refuse to accept patients covered by Medicare and Medicaid because of low payments, late payments, and excessive paperwork.