One of the most common questions I get asked about the new health care law concerns how expanding health insurance coverage to millions of low-income families through Medicaid will affect those who already have insurance. "What will all of those new people with access to health care do to the rest of us? Will it make it harder to get access to our doctors? Will they clog up our emergency rooms and hospitals?"
As someone whose profession takes a strong position in favor of universal access to health care, I have a hard time saying anything but, "What a great problem to have!" It turns out to not even be a problem.
Massachusetts did this many years ago, as we are being frequently reminded, and the results are in. Use of emergency rooms is down, waiting times to see a primary care doctor are essentially unchanged and there has been a vast expansion in the use of preventive services: mammograms, colon cancer screens and prenatal care, for instance. Doctors and the people of Massachusetts overwhelmingly favor continuation of their program, and they are now proceeding to the really hard part: getting costs under control. Stay tuned!
An even more interesting experiment is being conducted in Oregon via an unhappy accident. Due to a shortage of funds, Medicaid eligibility was determined by lottery, creating a natural experiment of haves and have-nots. In the first year, those who were enrolled were 70 percent more likely to have a usual source of care, were 55 percent more likely to see the same doctor over time, received 30 percent more hospital care and received 35 percent more outpatient care, and much more.
Every doctor you know can tell you stories about how the lack of access to health insurance and health care has injured a patient's health, life, limbs, finances or all of the above. I've had patients who work full time in jobs that fall far short of the American dream. They get by, but they can't afford health insurance.
There's the cabbie who recognizes his diabetes and determines to work harder and longer so he can buy insurance before he is stricken with the label even worse than diabetes: preexisting condition! He doesn't make it and ends up in the ICU with diabetic ketoacidosis.
There's the construction worker who has a controllable seizure disorder that goes uncontrolled. He ends up in the ICU multiple times.
There's the woman who stays home to care for her dying mother and loses her insurance along with her job. When she finally gets to a doctor for herself, her cancer is far advanced.
So, for me and my profession, the most expansion for the most people is a best-case scenario. But others see expanding health insurance only through a short-term budgetary lens and consider covering nearly everyone a worst case.
For one thing, this view ignores the incredible deal states get when they accept Medicaid expansion. According to the Kaiser Foundation, by 2019 Pennsylvania would add about 482,000 new enrollees; another 282,000 who are eligible but don't know it would come into the program. That's more than three-quarters of a million people with access to care.
Critics point to the potential cost to the state of more than a billion dollars over six years. That's a lot of money, but the federal government would pay more than $17 billion -- over 94 percent of the cost. Furthermore, the additional billion would be only 1.4 percent more than Pennsylvania's currently scheduled spending over that period. Even in a best-case scenario, with insurance for an additional 1.1 million Pennsylvanians, this figure would rise to only 2.7 percent.
One can choose to focus on the costs to the state and federal governments, but we spend many of those dollars already on the wrong end of the care continuum. Our governments already pay for patients who cannot pay for themselves, largely by cutting big checks to hospitals.
You can take care of a lot of diabetic cabbies for a lot of years for the cost of a stay in the ICU. Just because the costs don't show up as a line item in a government budget -- it could be labeled "Exorbitant Amounts of Money for Preventable Complications and Deaths" -- doesn't mean we don't pay them.
A frequent talking point against expanding access to health care, "You can always go to an emergency room," is actually dead on. Literally.
The law requires emergency rooms to treat and stabilize patients even if they have no means to pay. But no emergency room does cancer screening. Or prenatal care. No emergency room manages diabetes. Or congestive heart failure. As a result, many people don't seek treatment until they are nearly dead.
Patients forgoing care or medicines because they can't afford them simply shifts the costs from keeping people healthy to our extremely expensive system of "rescue care." And remember, Massachusetts' early experience and Oregon's current experiment are showing the benefits to the entire system of getting people taken care of before they need an ER or ICU.
Not long ago, expanding access to health care was a nonpartisan goal. As recently as 2007, a bipartisan group of U.S. senators, including Republicans Jim DeMint and Trent Lott, wrote a letter to then-President George W. Bush pointing out that our health care system was in urgent need of repair. "Further delay is unacceptable as costs continue to skyrocket, our population ages and chronic illness increases. In addition, our businesses are at a severe disadvantage when their competitors in the global market get health care for 'free.' "
Their No. 1 priority? "Ensure that all Americans would have affordable, quality, private health coverage, while protecting current government programs. We believe the health care system cannot be fixed without providing solutions for everyone. Otherwise, the costs of those without insurance will continue to be shifted to those who do have coverage."
Medicaid expansion, as well of the rest of the new health care law, represents our best effort so far in reaching these once-bipartisan goals. Pennsylvanians deserve an expansion of health insurance and health care, a healthier state, a healthier workforce and to continue the journey toward my profession's goal: excellent, affordable health care for all.
Christopher M. Hughes practices intensive care and hospice medicine in Pittsburgh and is the Pennsylvania director of Doctors for America (www.drsfor america.org).