Social Emergency Medicine Teaching Modules
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Healthcare Coverage and Access to Health Care
Dennis Hsieh, MD, JD
1. To learn what different types of healthcare coverage are available to patients
2. To learn the difference between healthcare coverage and access to care
3. To help patients figure out how to get the appropriate follow up.
A 68-year-old woman comes to the emergency department for a medication refill. She has a history of diabetes, hypertension, and hyperlipidemia. At triage, her glucose is 350 and her BP is 220/110 so the nurse rushes her back to see you.
She has been taking her medications everyday but cannot afford to refill them each month, so she carefully cuts each pill in half and takes half the recommended dose so that the prescriptions last twice as long. She worked for most of her life in the service industry and thus does not have much savings. She gets $885 from her supplemental security income (SSI) check each month and this goes towards food and housing. She assigned doctor through Medicaid is one hour away, so she comes to the emergency department to get her medications refilled.
The financial counselor educates her about the fact that she has both Medicare and Medicaid and that both are willing to change her assigned doctor if she calls the service center. She is given the phone number and is reassigned to a new primary care doctor who changes her medications to those that are on the $4 list at the local store.
1. What is the difference between healthcare coverage and access to healthcare?
2. What are the different types of healthcare coverage available to patients?
3. What should a patient do when the patient cannot find a doctor who takes their insurance?
1. Healthcare coverage doesn’t guarantee access to care.
2. Medicaid is for individuals with low income. The income level depends on the state. Depending on if the state has chosen to expand Medicaid coverage under the Affordable Care Act, there may be additional requirements linked to Medicaid eligibility, such as age, disability status, and pregnancy status. Medicare is for individuals who are 65 or older. There is no income limit or requirement. However, to be eligible for Medicare, one must have worked 40 quarters or more in one’s lifetime or be linked to someone who has worked at least 40 quarters.
3. Insurance companies will often assign a patient to a doctor if the patient does not select a doctor. One can change this assignment by calling the insurance company. Access to a medical home may decrease emergency department utilization.
4. All providers should inquire about the patient’s ability to obtain the prescriptions when prescribing new medications. Patients may not volunteer that they cannot afford the medications unless asked.
1. Where can patients go to sign up for insurance at your institution?
2. What are the wait times for primary care and specialty care at your institution?
3. Does insurance limit whom patients can follow up with at your institution?
Recommended Screening Question(s)
The LA County Health Agency SBDOH Workgroup has not developed any questions on access to care. For assessing healthcare coverage, the Workgroup recommends:
1. What type of health insurance do you have?
- No health insurance
- Medi-Cal (Medicaid)
- Medi-Cal (Medicaid) pending
- Employer provided
- State children’s health insurance
- Private health insurance
- VA medical services
- Indian health services
- Don’t know or unsure
- Decline to disclose
- Data not collected
Sommers BD, Biendon RJ, Orav EJ et al. “Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance.” JAMA Intern. Med. 2016. 176(10):1501-1509.
Discussion Points from the Reading
1. This paper compares 3 states: Arkansas, Kentucky, and Texas. They compared U.S. Citizens, age 19 to 64, in the three states. The populations had no differences in sex, income or marital status. The subjects in Texas, which did not expand Medicaid, was younger, more urban, and disproportionately Latino compared with the other two states. Kentucky expanded Medicaid. Arkansas used Medicaid funds to purchase private insurance for low- income adults.
2. Expansion of Medicaid coverage led to increased access to primary care, fewer skipped medications due to cost, reduced out-of-pocket spending, reduced likelihood of emergency department visits, and increased outpatient visits. Glucose testing among patients with diabetes, regular care for chronic conditions, quality of care ratings and the proportion of adults reporting excellent health all increased after Medicaid coverage expansion.
3. Increased healthcare coverage appeared to lead to improved health by improving access to care while decreasing emergency department utilization.
1. Kominski GF, Nonzee NJ, Sorensen A. “The Affordable Care Act’s Impacts on Access to Insurance and Health Care for Low-Income Populations.” Annu Reb Public Health. 2017 38:489-505.
2. Zallman L, Nardin, R, Malowney, M. “Affordability of health care under publicly subsidized insurance after Massachusetts health care reform: a qualitative study of safety net patients. In J Equity Health 2015;14:112
3. DoVoe JE, Marino M, Gold R. “Community Health Center Use After Oregon’s Randomized Medicaid Experiment.” Ann Fam Med 2015;13(4):312-20.