Even with ACA, access to care remains a pressing ethical concern

Even with ACA, access to care remains a pressing ethical concern

Enrollment "not the same thing as access"

One of the most important ethical reasons for enacting the Affordable Care Act (ACA) is justice, says Mark A. Rothstein, JD, founding director of the Institute for Bioethics, Health Policy and Law at the University of Louisville (KY) School of Medicine.

"The ACA is designed to expand access to health care for approximately 50 million Americans who lacked health coverage," he says. Health care access is being expanded in two ways: by increasing the number of people covered by Medicaid and by making individual health insurance policies affordable through health exchanges with income-based subsidies.

"One frequently overlooked problem is the big difference between eligibility and enrollment," says Rothstein. "Making individuals eligible for coverage is not the same thing as having people enrolled."

Even before the ACA, only two-thirds of eligible individuals enrolled in the Medicaid program; now, the Medicaid expansion has been limited for political reasons in several states. "Opposition to the ACA and the troubled website also have impeded enrollment for individual health insurance," he adds. "Even being enrolled is not enough; enrollment is not the same thing as access."

There are numerous nonfinancial barriers to health care, says Rothstein. These include the lack of health care providers in some parts of the country, and the reluctance of some providers to accept Medicaid patients because of low reimbursement.

Other factors limiting access include lack of transportation, translators, child care, convenient hours, and health literacy allowing patients to understand the importance of immunizations and other forms of preventive medicine.

"Expanding the financial aspect of health care is very important," says Rothstein. "But it is only the first step in implementing a just health care system for all."

Out-of-pocket costs increasing

Out-of-pocket costs have been increasing over the past decade, largely in the form of high-deductible health plans; patients might have to pay $1000 to $10,000 before more comprehensive coverage begins. The ACA likely will cause a major expansion in these high-deductible plans, even among some patients who previously had more generous coverage, predicts J. Frank Wharam, MB, BCh, BAO, MPH, assistant professor of medicine, department of population medicine, Harvard Medical School in Boston, MA.

"Unaffordable health care is, ironically, a real and growing concern, notwithstanding the substantial benefits of insurance to people who were previously uninsured and needed care," says Wharam.

Wharam says the primary ethical issue with health care affordability is equitable access to care. High out-of-pocket costs risk creating a system in which wealthier patients have better access to care.

Another less recognized issue is ethical resource use. "Very low out-of-pocket costs could lead to overconsumption of health care services, so that health care might take dollars away from other societal priorities like education, welfare, or defense," Wharam explains.

Physicians are busy, he acknowledges, but they should try to be aware of their patients' insurance type and general ability to pay out-of-pocket costs.

"Obviously, physicians should only recommend necessary and evidence-based testing and treatment," says Wharam. "Beyond that, they might consider less expensive but evidence-based approaches." Physicians or facilities could take these approaches:

• Ensure that patients receive generic medications instead of brand names;
• Offer installment payments in cases in which the only alternatives seem unaffordable for the patient;
• Have staff connect financially vulnerable patients to community resources;
• Waive charges for the poorest patients;
• Advocate for a more nuanced health insurance system that considers out-of-pocket costs, not just monthly premiums, to determine insurance affordability.

"Many hospitals and other health care professions, such as dentistry, have experience in these areas," notes Wharam.

The ACA caps yearly out-of-pocket costs at $12,700. "This is still a large amount for middle and lower income families, but better than the extreme expense of many medical procedures, and might be tolerable for some families if spread over two or three years," says Wharam.

More evidence is needed to determine what level of out-of-pocket costs causes adverse health outcomes and financial hardship. Then, says Wharam, "the next generation of insurance designs could tailor out-of-pocket costs to be lower for people who are expected to be harmed by high out-of-pocket costs, and higher for those who can afford them without adverse health effects."

SOURCES

• Mark A. Rothstein, JD, Founding Director, Institute for Bioethics, Health Policy, University of Louisville (KY) School of Medicine. Phone: (502) 852-4982. E-mail: [email protected].
• J. Frank Wharam, MB, BCh, BAO, MPH, Assistant Professor of Medicine, Department of Population Medicine, Harvard Medical School, Boston, MA. Phone: (617) 509-9921. E-mail: [email protected].