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After insurance reform: an adequate safety net can bring us to universal coverage.

When, exactly, did the debate become about "INSURANCE?" I don't give a damn about that. I want HEALTH CARE.

--Comment posted on the New York Times blog Prescriptions, September 26, 2009

The overriding goal of health reform is to provide every American affordable access to adequate health care. Yet in every national effort to date, the focal means to this end has always been health insurance. Massachusetts is congratulated for having achieved nearly universal insurance coverage, and congressional Democrats are aiming for the same. But what if they don't succeed? Even in Massachusetts, 167,000 residents remain uninsured. Is it still possible to provide adequate access to medical care for those without insurance? If so, shouldn't we reframe social goals to achieve universal access through any means possible, whether or not insurance is involved?

The blog commenter and I agree that the answer to these questions is yes. This is not a technical or rhetorical point about a public option versus private plans. Instead, it is about insurance of any type as a funding mechanism versus direct government funding of providers to treat the uninsured. This contrast is essentially the same as that between "socialized insurance" and "socialized medicine." Even if we can't achieve "Medicare for all," perhaps we can achieve at least minimally accept able access--something along the lines of "veterans' health for all."

One way to characterize this alternative vision is as an adequate "safety net"--the accepted term for the conglomeration of hospitals, clinics, and doctors willing to accept patients regardless of ability to pay. Volumes of work document the inadequacies of safety net structure, funding, and access, (1) but I have found many examples of safety net systems that function well enough.

Much of the safety net is tattered and torn. Usually, it consists of a disconnected assortment of providers with limited funding and varied missions, willing to accept some patients in fairly dire straits as a last resort. Examples include underfunded public hospitals, thinly staffed free clinics, and overcrowded hospital emergency rooms. But in some places, the picture is quite different: state and local government agencies, charitable hospitals, physician organizations, or community groups have marshaled resources to organize well-structured systems of fairly comprehensive access for low-income, uninsured patients. Funding and motivation vary widely. Public and private hospitals seek to ease the burden on emergency rooms. Federal agencies and charitable foundations provide grants to build community networks and health facility infrastructures that will address disparities and lessen the greatest need. Local medical societies feel an ethical tug to facilitate physicians donating more indigent care.

A variety of funding and delivery structures has emerged in places as diverse as San Francisco and San Antonio; Exeter, New Hampshire, and Asheville, North Carolina; Denver and D.C.; Flint, Michigan, and Richmond, Virginia. (2) Some are completely free, and others charge substantial sliding-scale fees. Some are run by hospitals, others by physicians, and still others by community groups or local government. What these diverse safety net models have in common is simply affordable access to comprehensive health care. Covered services typically include a primary care medical home, essential medications, referrals to most specialists, and hospitalization. Recipients are screened for eligibility and given an enrollment identification that functions like (but is expressly not) an insurance card.

If well-woven safety nets look and feel like insurance, are they really that different? The answer is yes and no--but before harping on the differences, let's be clear about why they matter. The differences matter ethically because safety net care, even at its best, is still inferior to the best insurance. But, economically, safety net care is affordable. Even at its best, it's still substantially cheaper than comprehensive insurance--cheap enough that it might just be possible to fund everyone who lacks insurance. The Veterans Health Administration system, for instance, which functions in many ways like a government-funded safety net, delivers care at 20 percent less than what it would cost at Medicare rates, which themselves are a quarter to a third less than private insurance rates. (3)

Economy is achieved through both the conceptual and operational differences between insurance and safety net access. Conceptually, a safety net program does not provide a legal entitlement to a defined set of benefits. Care is mostly discretionary, not contractual. Safety net patients receive the leftovers, not the first course. Providers accept them for free, time and space permitting. Governments often finance them, but only to the extent of available funds. Operationally, to make do with fixed budgets, safety net systems give essentially no choice of providers. They insist on primary care case management. To see specialists, they impose prior authorization and sometimes substantial delays. And they restrict their formularies.

Are these restrictions acceptable? To those who receive the care, yes. Surveys of model safety net enrollees show levels of satisfaction and ease of access that resemble people covered by Medicaid or private insurance. Indeed, many recipients do not even realize they are uninsured, and safety net providers are often held out as paragons of the sought-after but elusive "medical home."

What objections are there, then, to efforts to expand these model systems? There are principally two, each relating to a distinct version of "crowding out." Better safety net care might encourage people to drop private insurance, forcing more financial burden onto government and charitable funders (economic crowd out). And better safety net care might subvert the social momentum for more comprehensive insurance reform (political crowd out).

To analyze the economic objection fully requires more space than I have here, but a literature review reassures that the problem can be minimized to manageable levels (for instance, through waiting periods and sliding fee scales). (4) The political objection deserves more attention here because of its strong ethical intonations. Should we settle for a distinctly second-best solution that would keep us from achieving single-tier universal coverage? Advocates (like me) shout that lack of insurance kills tens of thousands a year. (5) If this were no longer true (and even now it may not be (6)), the impetus to expand insurance might abate.

Lacking anything better, intuition substitutes for evidence, and slogans for rigor. But in my view, if there were ever an occasion to avoid the ideal becoming the enemy of the good, surely this is it. When Congress completes the sausage-making business of expanding comprehensive insurance as far as it can, why should we not fill the remaining gaps with any form of health care access that is available and affordable? To refuse this out of compunction over social equity is to hold the lives and welfare of the least advantaged among us hostage to the unachievable ransom demands of those who would prefer single-payer insurance for all. Certainly, safety net care rather than comprehensive insurance is an ethical compromise, but some form of two-tier access is inevitable in any realistic solution. Even single-payer insurance, were it ever enacted in the United States, would allow those with means to opt out, and up--as we do now with public education. Similarly, an adequate safety net might cause those with lesser means to opt down from private insurance. But that should not give us great ethical pause if it is the best that society can reasonably achieve in the present political and economic circumstances.

At least this much--insurance for most of us and a decent safety net for the rest--could allow the United States to hold its head higher among other industrialized nations. No longer would we be the only advanced economy that fails to provide some form of universal coverage. We may scoff at President Bush's "Mission Accomplished," but achieving universal access to decent care through an adequate safety net would be a remarkable accomplishment indeed.


My work on this column was supported by a grant from the Robert Wood Johnson Foundation, which does not necessarily endorse these views.

(1.) M.E. Lewin and S. Altman, Americas Health Care Safety Net: Intact but Endangered (Washington, D.C.: National Academy Press, 2000).

(2.) C. Moylan, "Managing Care for Uninsured Patients: Five Success Stories from America's Public Hospitals and Health Systems," National Association of Public Hospitals and Health Systems, July 2005, managingcareforuninsuredpatients.aspx; S.L. Eisert, P.S. Mehler, and P.A. Gabow, "Can America's Urban Safety Net Systems Be a Solution to Unequal Treatment?" Journal of Urban Health 85, no. 7 (2008): 766-78; S.M. Retchin, S.L. Garland, and E.A. Anum, "The Transfer of Uninsured Patients from Academic to Community Primary Care Settings," American Journal of Managed Care 15, no. 4 (2009): 245-52; L.A. Blewett, J. Ziegenfuss, and M.E. Davern, "Local Access to Care Programs (LACPs): New Developments in the Access to Care for the Uninsured," Milbank Quarterly 86 (2008): 459-79; J.T. Kullgren, E.F. Taylor, and C.G. McLaughlin, "Donated Care Programs: A Stopgap Measure or a Long-Run Alternative to Health Insurance?" Journal of Health Care for the Poor and Underserved 16 (2005): 421-30; S.L. Isaacs and P. Jellinek, "Is There a (Volunteer) Doctor in the House? Free Clinics and Volunteer Physician Referral Networks in the United States," Health Affairs 26 (2007): 87176.

(3.) G.N. Nugent, A. Hendricks, L. Nugent, and M.L. Render, "Value for Taxpayers' Dollars: What VA Care Would Cost at Medicare Prices," Medical Care Research and Review 61 (2004): 495-508.

(4.) G. Davidson, L.A. Blewett, and K.T. Call, "Public Program Crowd-Out of Private Coverage: What Are the Issues?" The Robert Wood Johnson Foundation, 2004, http: //

(5.) A.P. Wilper et al., "Health Insurance and Mortality in U.S. Adults," American Journal of Public Health, forthcoming.

(6.) R. Kronick, "Health Insurance Coverage and Mortality Revisited," Health Services and Research 44, no. 4 (2009): 1211-31.

This column appears by arrangement with the American Society for Bioethics and Humanities.
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Title Annotation:policy & politics
Author:Hall, Mark A.
Publication:The Hastings Center Report
Date:Nov 1, 2009
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