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Expanding Access to Health Care: It Takes More than Money

Recent efforts to expand access to health care for nearly 50 million uninsured Americans have focused on expanding access to Medicaid and private health insurance. Extending coverage to uninsured individuals is obviously necessary, but it is not sufficient because access to health insurance does not necessarily mean access to health care.

As our political leaders meet at Blair House for a health care summit, it is important to consider the numerous nonfinancial barriers that prevent the timely and appropriate use of available health services. Among the barriers – and some possible solutions – are the following.

Lack of transportation. Individuals in rural areas often lack transportation to travel long distances for treatment. New technology, such as telemedicine, can help with diagnoses and specialist consultation. In urban areas, some individuals forego or delay health care visits because public transportation is either unavailable or inconvenient. Mobile clinics and paratransit systems are extremely cost-effective.

Lack of translators. Individuals who do not speak English well frequently have problems communicating with health care providers unless translation services are available. The lack of sign language interpreters also can complicate treatment for patients who are deaf. Remote technologies may help provide these services.

Lack of child care. For some people, accessing health care for themselves or their children is problematic because of a lack of available or affordable child care.

Lack of convenient hours. Many working people with chronic health conditions or in need of preventive services cannot leave work for a health care appointment. Evening or weekend hours are essential to make health care more available.

Lack of accessible facilities. Although the Americans with Disabilities Act requires hospitals, physician offices, and other structures to be accessible, many health care providers lack accessible examination tables, dental chairs, or other equipment to provide care for individuals who use a wheelchair or have various disabilities.

Lack of providers. There is a serious shortage of physicians in many low population areas; other locations have an imbalance of specialist and generalist physicians. Besides training more physicians and expanding the use of nurse practitioners, communications technology can help mitigate a shortage of providers.

Lack of willing providers. Low (and declining) reimbursement rates for Medicaid often make it difficult to find health care providers who accept Medicaid. For various nonfinancial reasons, some physicians simply prefer not to treat Medicaid or indigent patients. No law currently requires that they do so. In addition, individuals with particular conditions, such as HIV and Down syndrome, may have a difficult time finding health care providers willing to treat them.

Lack of cultural sensitivity. Some immigrant or ethnic minority populations have distinct health care customs or follow a mixture of traditional and Western medicine. A lack of cultural sensitivity can deter these patients from seeking health care.

Lack of outreach for vulnerable populations. Some individuals with stigmatizing conditions (e.g., substance abuse, domestic violence) are reluctant to seek care. Other vulnerable individuals (e.g., homeless people) often do not use available services unless outreach efforts locate and encourage them to get care.

Lack of health literacy. Many people do not get care for themselves or their children because they are not aware that it is vital. This is often true for prenatal or well baby care, immunizations, and periodic visits. Some elderly or cognitively impaired patients are unable to comply with physicians’ instructions for taking medications or getting follow-up care. Better health education and social services are essential.

Nonfinancial barriers mostly affect individuals who already are medically at risk because of their age, socio-economic position, medical history, or other factors. These people often face both financial and nonfinancial obstacles to health care. With policymakers concentrating on financial issues, it is important not to overlook the nonfinancial barriers to health care.

Addressing nonfinancial barriers is not a substitute for extending health insurance coverage to tens of millions of uninsured Americans, but nonfinancial issues need to be considered regardless of the progress of health finance reform. All levels of government, not-for-profit organizations, and health care providers can implement valuable measures to ensure that health care services are accessible and responsive to the needs of diverse patients. For some barriers, additional research and development is necessary to perfect technologies to assist both patients and providers.

Measures to remove nonfinancial barriers to health care are not free, but they are far less costly than various proposals to expand access to health insurance. Eliminating nonfinancial barriers also more efficiently utilizes existing programs and promotes the dignity of patients with special needs throughout the country. Politically, addressing nonfinancial barriers affords an opportunity to achieve bipartisan support for an initial series of vital health reform measures.

Mark A. Rothstein is the Herbert F. Boehl Chair of Law and Medicine and Director of the Institute for Bioethics, Health Policy and Law at the University of Louisville School of Medicine.


Published on: February 23, 2010
Published in: Health Care Reform & Policy

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