The Access to Care Report (#18) / Managing access when there are program failures

November 7, 2013

health-care-lawThis is installment #18 in a continuing series of Access to Care Reports.

The larger objective of the Affordable Care Act (ACA) has been to improve access by the public at large to health care services, by extending insurance coverage to those without any coverage or without adequate coverage.

All of the program successes and failures to date may be evaluated from this larger perspective.

Impact on “access to care” due to the ACA is resulting from both the direct and indirect ways in which the Act is affecting individuals and organizations.

Improved availability of health insurance may be seen as a planned direct outcome.

The organizational reactions by insurance companies, employers and providers may be seen as indirect outcomes.

Implementation of the ACA has experienced some early failures with respect to the direct activities intended to improve access.

It is not yet clear how well the ACA is going to be able to solve the “availability of insurance” problem. Many people still do not know much about the Exchanges and do not want to get involved, if any out-of-pocket expenses are likely to result. Resentment is also rising about cancellation of previous insurance policies.

And the expanded Medicaid program is being set up only in some states, limiting access  in other states. Many lower-income residents of nonparticipating states are being denied the opportunity to sign up for care.

Access to insurance coverage may also be restricted if applications through Exchanges are dominated by those with medical needs, while (usually healthy) young adults stay away.

In the best case, perhaps all of the publicity about implementation of the ACA will result in Exchange applications that are widespread and balanced across age and need groups. And perhaps political pressures will eventually result in more-widespread acceptance of the expanded Medicaid program by states that are not participating.

In addition to these direct threats to the availability of health insurance under the ACA, many potential indirect outcomes remain unresolved. Access may be limited by insurance company refusals to participate in the Exchange offerings on a widespread basis; by employers acting to avoid participation; and by providers unable or unwilling to increase access to accommodate increased patient volume and needs.

At this time, there does not seem to be a concerted plan in effect to deal with the possibility of program failures related to these indirect linkages. Perhaps there should be a high-level “access czar” appointed, with a team of “access experts” to assist to bringing fundamental attention to these issues.

Each of these potential failures should be a cause of concern for program managers. There should be an “insurance company leader” who helps represent company interests, encourages participation, and engages in widespread communications with the public and all affected organizations through multimedia efforts.

There should also be an “employer leader” and a “provider leader” with similar assignments.

Access through the ACA will only be obtained if these organizations are provided with skilled and visible leadership to “get the job done”. These leaders could assess the reasons for implementation failures to date, and shift to new strategies to support the overriding objective of improved access to care.

Attorneys can provide needed assistance to clients in helping them recognize the possible areas for direct and indirect program failures, and in advising how preventive efforts may help protect client interests.

More on  related ACA and access to care topics may be found in a recent book by the authors that describes implementation of the ACA, and in a new Practice Guide by the authors that addresses funding and access issues in health care.