Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

Healthcare for All Won’t Solve It All: Access to insurance in Massachusetts does not overcome social and environmental barriers-Allison Peluso

In recent years, residents of the United States have noticed a change in the healthcare system(1). Many people have felt the impact of these changes in terms of access to healthcare and the quality of care they receive. Similarly, over the same time period there have been changes in health insurance. Over the past decade, healthcare costs in the United States have risen just as well as the premiums for health insurance while at the same time these insurance plans have reduced coverage and shifted the cost-sharing. Today in the United States approximately 1 out of 7, or 47 million people are without health insurance(2), and this figure does not include those who are underinsured(3). Some health service analysts believe that one major reason for the increase in healthcare expenditures is due to the burden the uninsured and underinsured place on the entire system. Their solution to the problem is to have all people adequately insured.
Many of the countries that boast healthier populations and better healthcare have a national healthcare system. The difference between these European countries and the United States is the political set-up and the political agenda at the time those systems were initiated. The last time the United States tried to insure all Americans was during the Clinton administration, of which the proposal failed to make it through Congress. The Commonwealth of Massachusetts enacted a law in 2006 requiring that all residents have health insurance coverage (14). People that lobbied for a health insurance mandate in Massachusetts imply that healthcare expenditure would be decreased by reducing chronic illness and reducing the number of people seeking care in emergency departments(15); however, this is unlikely to occur because insurance does not promote self-efficacy, stretches current resources, and does not remove social and environmental barriers.
Health Behavior
The Massachusetts law claims that the mandate will help people take personal responsibility for their health(15), yet does not account for the fact that the person is not the one making the decision under this law to take the step to buy health insurance coverage. A mandated health insurance law does nothing to promote self-efficacy. The healthcare for all reform does not provide a way to change people’s belief of being able to change their behavior. Self-efficacy is considered a person’s ability to believe they are able to change or take charge of their behavior(6).
Insurance coverage alone does not provide specific resources to help individuals overcome their beliefs that they can change their behavior(14). The health insurance being offered by the state (the commonwealth connector) does not have any allowances for health promoting behaviors. It simply provides basic level of insurance for people currently uninsured. For example, self-efficacy has been shown to be a predictor of exercise initiation and maintenance among diabetic patients (4). Furthermore, among patients with coronary heart disease, they need more than self-efficacy to decrease risk factors (smoking and low exercise), such as implantation strategies (5). If the baseline characteristic needed to change behavior is self-efficacy, and some behaviors related to chronic diseases require additional modification strategies then health insurance alone will not be an appropriate solution to elicit behavior change.
Resources to Improve Health Behavior
A mandated state-wide health insurance system would stretch currently available resources. At this point, with more people insured and a shortage of providers, including doctors and nurses, the quality of resource counseling provided will be diminished. The rationale policy makers used to help get this mandate passed was that if more people are insured then chronic diseases should be better managed and eventually decrease, yet they did not consider the current shortage of providers that normally work with patients with chronic illnesses as well as the current difficulties in obtaining appointments.
While having health insurance is a step towards getting healthcare, it does not ensure that you will be able to see a healthcare provider. For example, numerous primary care groups in Boston are not accepting new patients as well as some specialties that care for diabetic and arthritic patients. In 2005, the average wait time for a primary care appointment was six weeks, 32 days for cardiology, 44 days for GI , 24 days for a dermatology skin check(7, 8), and a wait of greater than 14 days is considered to show the system is experiencing a strain. Less than 50% of adults 18 and older feel that during an office the provider spent enough time with them (1). Physicians generally schedule appointments to last no more than 15 minutes, but the average face-to-face contact is 10-11 minutes (10), and many patients can tell you that they wait longer than they believe they should have to wait in the waiting room. Thus, in order for physicians to see more people in one day the visit time will be shortened and waiting times for appointments will increase. Moreover, if less than 50% of patients feel the physician spends enough time with them this percentage will drop dramatically, and likely with the decrease in visit time will be less counseling on resources to help patients improve their health.
Social and Environmental Barriers
Aside from the previously listed barriers related to obtaining an appointment for a healthcare provider, there are other potential social and/or environmental barriers to accessing important resources that may affect behavior change. These factors involve finances, accessibility to healthcare, accessibility of the resources, and cultural issues.
Financial barriers have a major influence on the ability to receive care and utilize resources (13). For example, reasons people do not seek medical care or the needed resources to change behavior is that the insurance premiums are so expensive that they are not able to afford co-pays or are simply not able to pay co-pays. Other issues related to finances are the costs of missing time at work to make it to an appointment.
Another important factor is the accessibility to the healthcare facility. The Massachusetts health insurance mandate does not provide the same insurance coverage for all consumers. Thus, the closet physicians office may not accept the health insurance that one patient may have. This means that a particular patient may have to travel further than others to receive any care. This will be a problem because Medicaid and Medicare are still types of coverage in Massachusetts and those people covered by government will continue to face the current problems with finding physicians in certain specialties. The differences in reimbursements are the major cause of the disparity. A related issue with the theme of ability to get to the healthcare facility is that physician’s office hours are not flexible with work schedules. Furthermore, it is difficult for parents to seek their own care with a child that needs parental attention. (11, 12,13)
Once a person is able to receive resource counseling, they may not be able to access those resources or follow directives. For example, people living in an urban area will have more difficulty exercising due to the environment they live in, such as the lack of sidewalks or increased potential for violence after dark, and fitness centers are not generally found in these areas(12). Additionally, people in the lower socioeconomic areas do not easily access many of the grocery stores that provide fresh produce; furthermore, if stores are located in these areas the price for fresh produce is not affordable.
Lastly are the remaining social and cultural reasons people do not see a physician or use the given resources to improve their health. Other obstacles to receiving needed care or accessing resources are language barriers if translators are not available or if there is a lack in cultural competence(11). Medical mistrust is still an issue for cultural groups, especially male African-Americans. The health insurance mandate does not include any initiatives to address any of these social and environmental problems.
There is no doubt that everyone should have health insurance; however a law designed to save money but promoted to reduce illness will not address the other external issues that also explain the current rate of uninsured and underinsured. The single step approach that the Commonwealth of Massachusetts has taken to insure all residents and improve their health will fail due to lack of consideration of other factors that need to be addressed to increase the health of the population. Had the required insurance mandate passed had additional clauses to help alleviate the other social and behavioral factors involved. This idea is exemplified by recent research estimating that 10% of health is due to health insurance while 40% of health problem are related to behavioral factors(9).
1. Agency for Healthcare Research and Quality, National Healthcare Quality Report, 2006, Rockville, MD.
2. Center on Budget and Policy Priorities. The number of uninsured Americans is at an all--time high. Released 8/29/2006.
3. Consumers Union. Consumer Reports health insurance survey reveals 1 in 4 people insured but not adequately covered. Washington, DC 2007.
4. Allen NA. Social cognitive theory in diabetes exercise research: an integrative literature review. Diabetes Educator. 30(5):805-19, 2004 Sep-Oct.
5. Johnston DW. Johnston M. Pollard B. Kinmonth AL. Mant D. Motivation is not enough: prediction of risk behavior following diagnosis of coronary heart disease from the theory of planned behavior. Health Psychology. 23(5):533-8, 2004 Sep.
6. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
7. Raja Mishra. State’s Patients Endure Long Wait. Boston Globe, 7 June 2005.
8. Lisa Girion. A Doctor Shortage Threatens to Set Off Healthcare Crisis. Los Angeles Times, 5 June 2006.
9. Schroeder SA, We can do better-improving the health of the American people. NEJM 2007;357:1221-8.
10. Tabenkin H, Goodwin MA, Zyzanski SJ, Stange KC, MedalieJH. Journal of Women's Health. 2004, 13(3): 341-349.
11. Institute of Medicine, National Academy of Sciences. Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C., 2002.
12. Frank L, Engelke PO, Schmid TL. Health and community design: The Impact Of The Built Environment On Physical Activity. Washington, D.C.:Island Press, 2003.
13. The Central Virginia Health Planning Agency’s Financial Access to care Committee. Breaking down financial barriers to healthcare: Synopsis of issues and a call to action. September 2005.
14. Commonwealth of Massachusetts. Chapter 58 of the Acts of 2006 (An Act Providing Access to Affordable, Quality, Accountable Health Care).
15. Commonwealth Connector. Health Care Reform. Summary.

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