Underinsurance is bad for your heart
Financial Barriers to Health Care and Outcomes After Acute Myocardial Infarction
Ali R. Rahimi, MD, MPH; John A. Spertus, MD, MPH; Kimberly J. Reid, MS; Susannah M. Bernheim, MD, MHS; Harlan M. Krumholz, MD, SM
JAMA
March 14, 2007
Objective: To measure the baseline prevalence of self-reported financial barriers to health care services or medication (as defined by avoidance due to cost) among individuals following AMI (acute myocardial infarction) and their association with subsequent health care outcomes.
Results: The prevalence of self-reported financial barriers to health care services or medication was 18.1% and 12.9%, respectively. Among individuals who reported financial barriers to health care services or medication, 68.9% and 68.5%, respectively, were insured. At 1-year follow-up, individuals with financial barriers to health care services were more likely to have lower SAQ (Seattle Angina Questionnaire) quality-of-life score (77.9 vs 86.2), and increased rates of all-cause rehospitalization (49.3% vs 38.1%) and cardiac rehospitalization (25.7% vs 17.7%). At 1-year follow-up, individuals with financial barriers to medication were more likely to have angina (34.9% vs 17.9%), lower SAQ quality-of-life score (74.0 vs 86.1), and increased rates of all-cause rehospitalization (57.0% vs 37.8%) and cardiac rehospitalization (33.7% vs 17.3%).
Conclusion: Financial barriers to health care services and medications are associated with worse recovery after AMI, manifested as more angina, poorer quality of life, and higher risk of rehospitalization.
http://jama.ama-assn.org/cgi/content/abstract/297/10/1063
Comment:
By Don McCanne
Many in the policy community insist that we must build on our existing system of private health plans and public programs. They do not perceive the elimination of private plans and substitution of a single public program to be a politically viable option.
The problem with these multi-payer models is that the private insurance industry has been unable to offer products with affordable premiums that are effective in eliminating financial barriers to beneficial health care services. Since the reform proposals require affordable premiums, the insurance industry has responded with products that deliberately erect greater financial barriers for the purpose of reducing health care utilization.
Do these barriers make a difference? Emphatically, yes. As an example, this study confirms that victims of heart attacks have worse outcomes when they have financial barriers to followup care and medications.
The policy community should be particularly concerned about the fact that two-thirds of the individuals with financial barriers and impaired outcomes were insured! At a time when efforts should be made to remove financial barriers that impair outcomes, the policy community is supporting measures that will increase those barriers.
Private plans that would remove financial barriers to beneficial services cannot serve as the vehicle for coverage for average-income individuals. The reason is that the health care that they must fund through a guaranteed-issue program and the administrative excesses that they require are so great that the premiums they must charge could never be affordable. Since the private plans are no longer able to function as equitable insurance risk pools, why would we want to design reform that merely perpetuates their administrative excesses?
There is another very important policy lesson from this study. Of those reporting financial barriers to health services and medications, 47.6 percent had Medicare coverage and 42.4 percent were on Medicaid. We can only speculate that Medicare patients had inadequate access to affordable drugs and that Medicaid patients had inadequate access because of a lack of willing providers. Regardless, it is important that reform efforts be directed toward taking down these financial barriers that prevent patients from getting the care they need.
For the “but we can’t afford it” crowd, there are many other mechanisms in the single payer model that would reduce waste to a level that would allow us to provide comprehensive care for everyone without spending more than we already do.