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Closing the Health Care Gaps: "Insurance Doesn't Mean the Same Thing as Assurance"

(Ron Carlson) -- As the size of the health care uninsured problem continues to grow with little hope of seeing a solution any time soon, local jurisdictions are being pressed to come up with their own ways and means for meeting these "access-to-care" problems.  It’s heartening to see innovative plans being put in place such as the one here in Howard County as well as the initiatives underway or planned in other jurisdictions across the state.  Local leaders are taking on the job of learning more about their own unique "gaps" in healthcare coverage and coming up with some new ideas.  And it’s especially encouraging to see these approaches are not relying on health insurance solutions as the panacea.    

That said, an interesting phenomena is emerging. As state and national "policy makers" are working to come up with "politically and financially" acceptable answers to the tough insurance "entitlement" issues, i.e., Medicaid, Medicare and SCHIP (the State Children’s Health Insurance Program), communities are taking another path.  As many worry that some of the insurance reform solutions on the table carry the signs of  "breaking the bank", local governments and nonprofit organizations are working together to move in the opposite direction, i.e., doing what they can to minimize local tax burdens while increasing access to care and shoring up their ability to monitor the health of their communities. They are prioritizing their local health care needs and tapping into "previously untapped" resources to help them address some of the "access-to-health care" problems.  Their bottom-line: find answers that take the "assurance initiatives" road rather that relying on the more expensive "insurance option".

While "insurance" and "assurance" solutions indeed both require money, each comes with a substantially different price tag and looks for support from very different sources. Taking an "assurance" approach means spending less while relying more on the assets that are already available in the community.  It calls for targeting those issues that need attention locally and where the community can be most effective as well as accountable.

Those of us who spend time wrestling with the issues of "access to care" and "health disparities" know that insurance by itself doesn’t get you to where you want to be.   Karen Davis and Cathy Schoen, two highly regarded health care economists addressed this point in a paper recently published by the Commonwealth Fund, "A Roadmap to Health Insurance for All: Principles for Reform." They point out that the current health insurance system by itself falls short in meeting "access to care" objectives. Not only is the insurance driven approach to "access…unequal", that "poor access to care is linked to poor quality" but "care delivery" itself, influenced as it is by insurance, "is ineffective." Their position is that insurance reform, if its going to accomplish its objectives, has to be able to motivate the health care system itself through incentives that will actually "assure" access to care.  In other words, just relying on insurance reform without taking into account the other determinants of access, will not work!

Many good examples help clarify the point. Maryland has been proactive in expanding Medicaid and SCHIP coverage for children, but even with that, thousands of kids still can’t get the care they need. Hard to believe? Data from the U.S. Public Health Service’s Health Resources Administration show there are Medically Underserved (MUA) communities throughout the state from inner city Baltimore, to Anne Arundel, Prince Georges Counties, to the western parts of the state. Even in affluent Montgomery County and Howard County, access to care is an issue. The lack of available and affordable dental and mental health services remains at or near the top of their "community priority needs list".  Public school systems know only too well that insurance coverage is not the full answer to meeting the needs of their students, especially as demographics change and new diversity introduces other access barriers such as language and cultural differences. Disease prevention (immunizations, etc.) and health promotion (physical activity and good nutrition) programs are critical to reducing the incidence of chronic diseases such as diabetes and heart disease negatively impact on insurance premiums. Shortfalls in all of these areas are pervasive.   

 These "assurance" related shortfalls aren’t confined only to the "disadvantaged" parts of the states but also raise their ugly heads in the "more affluent" counties of Howard, Montgomery, Frederick and Harford. And these "access to care" barriers come in various forms and contribute to the creation of different kinds of problems.  For example, the shortage of health care workers such as registered nurses (now the case throughout Maryland) introduces serious quality of care problems for all.  Here again, insurance reform is not the sole answer. The absence of transportation services in the "harder to reach areas" of the state means thousands of children and families (even the insured), can’t get the help they need when they need it. Mobile health units are brought in under the "assurance" banner to help address the problem.

As state and national policy makers continue to work at the issues of health insurance reform, it is important that they come up with answers that make sense both in terms of their 1) "affordability" and 2) how well they encourage and blend with local solutions.  At the same time, local communities need to come up with their own set of complementary answers that contribute to closing their unique health care gaps.  And the "tool kit" to be drawn upon in these local jurisdictions should more and more take on the appearance of an "assurance kit," rather one that carries the usual "health insurance label".