The effects of insurance coverage on access to care in Arizona provides a startling lesson of the problems with inconsistent coverage. People cycling on and off insurance tend to forgo care and necessary medication.
As the price tag of medical care grows, insurance providers and employers seek cost control strategies that decrease coverage and shift the financial burden of health care onto patients. The rise in healthcare out-of-pocket costs (co-pays, deductibles, coinsurance, coverage limits, etc.) contributes to a rise in individuals with medical debt in the United States.
The 2008 Arizona Health Survey (AHS) was a study of 4200 Arizona households designed to assess health insurance coverage, health status and behaviors, and social and environmental factors that affect population health. This study took a retrospective look at a subset of data on 2368 individuals aged 18-64. It examined the relationship between insurance status, medical debt, and the impact on access to care in Arizona.
Authors analyzed data surrounding insurance status (continuity of coverage, extent of coverage, type of insurance), medical debt (either having current medical bills or having problems paying medical bills), and assessed the impact on access to care (access to medications or medical treatment). Additionally, researchers examined variables including health status, patient income, age, ethnicity, gender, household status, and marital status to determine predictors of medical debt and access to care.
Insurance status alone, even when adjusted for the aforementioned variables, did not predict medical debt. However, individuals with inconsistent insurance coverage (i.e. loss of coverage at some point during the prior 12 months) were 2.5 times more likely to have problems paying medical bills compared to those with consistent coverage (AOR 2.48, 95 percent CI 1.61-3.82).
Those with problems paying bills were five times as likely to have delayed medical care (AOR 4.96, 95 percent CI 3.34-7.38) and over six times as likely to have a delay obtaining medications (AOR 6.16, 95 percent CI 3.87-9.81). Persons currently paying off medical bills were three times as likely to have delayed medical care (AOR 3.04, 95 percent CI 2.04-4.52) and over 3.5 times as likely to have a delay in obtaining medication (AOR 3.68, 95 percent CI 2.31-5.87).
Additional factors played a role. Poor health status and being insured by Medicare predicted problems with paying bills or currently having medical bills. Female gender predicted delays in access to needed medication and medical care.
This evidence inferred that insurance coverage alone did not lower the odds of having medical debt. Medical debt itself, however, remained a strong predictor of delayed or missed medical treatment and medication.
A newer term for “the patient” in discussions on health policy is “the consumer”. As such, consumers have been rudely awakened from an insurance system that previously shielded them from actual costs beyond modest co-pays and deductibles. The current reality of dwindling employer coverage forces consumers to instantly become savvy shoppers for products of which they have little knowledge and whose growing costs are only recently made more transparent.
The undertone of this research is that Americans are being forced to make tough, and possibly uninformed, choices when it comes to the cost of their own health care.
Adapting to a system of increased out-of-pocket costs has lead individuals to re-value their own health status. The danger in this trend is the downstream effect for individuals in true need of medical care – those with chronic conditions are at extreme risk for unnecessary exacerbations. As medical debt accumulates, individuals delay medical care and medication use leading to poorer health and the possible need for more expensive treatment – emergency and hospital care as opposed to office visits.
Further complicating matters is the deleterious nature of inconsistent coverage. Americans are particularly vulnerable in a system where medical insurance is tied so closely to employment. Medical bills are often incurred through illness or injury which also limits the ability to work. Many suffer the “double whammy” of losing income along with insurance coverage. An ideal health care system, as we profess, requires continuity of coverage.
Patrick Fitzgerald, MPH