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New College report shows access problems are growing

From the February ACP-ASIM Observer, copyright 2003 by the American College of Physicians-American Society of Internal Medicine.

By Robert B. Doherty

Physicians often wonder why politicians in Washington don't view problems in the health care system with the same degree of urgency that they do.

A major reason is that in today's post-Sept. 11 political climate, terrorism prevention and homeland defense trump all other issues. Compared to the risk of nuclear, chemical, biological or even conventional attacks on American citizens, other problems just don't seem to measure up.

For those of us in Washington, the challenge is to show lawmakers that problems in the health care system are putting the health and lives of millions of Americans at risk. We must do so, however, without using the type of hyperbole that could undermine the College's credibility.

To demonstrate how problems in the health care system are reaching crisis proportions, the College released a new report, "The Growing Crisis in Access to Medical Care, Causes and Remedies," at a Jan. 21 briefing for Washington reporters. The paper provides solid data to show that access—particularly access to physician services—is declining nationwide.

(The report is available online.)

Here are some details from the College's new report that point out the magnitude of some of America's access problems:

  • Fewer Americans have health insurance and fewer uninsured persons have a regular source of medical care. Between 2000 and 2001, the number of Americans without health insurance rose by 1.4 million to more than 41 million people, representing almost 15% of the population. ("Health Insurance Coverage 2001," U.S. Department of Commerce, Sept. 30, 2002.)

    In addition, fewer uninsured patients had a regular source of care or saw a physician in 2001. ("Mounting Pressures: Physicians Serving Medicaid Patients and the Uninsured, 1997-2001," Center for Studying Health System Change, December 2002.)

  • Millions of poor Americans will soon be dropped from Medicaid. The drop in Medicaid coverage can be attributed to the worst state fiscal crisis in half a century. States are facing cumulative budget deficits of $60 to $85 billion in 2004. (Center on Budget and Policy Priorities, Jan. 6, 2003.)

  • Employees are paying more for their medical care. Small employers are passing on higher costs to their employees and cutting back on benefits and eligibility. In one particularly troubling trend, many small employers stopped helping employees pay for dependent or family coverage. ("Cutting Back But Not Cutting Out. Small Employers Respond to Premium Increases," Issue Brief No. 56, Center for Studying Health System Change, October 2002.)

  • Declining Medicare reimbursements mean that patients are having a harder time finding physicians. The number of physicians who said they accept all new Medicare fee-for-service patients dropped 7.2% between 1999 and 2002. (Preliminary MedPAC survey of access to physician services, September 2002.)

    According to Paul Ginsburg, PhD, director of the Center for Studying Health System Change, "Additional Medicare cuts of the magnitude expected over the next few years are likely to increase beneficiaries' access problems, especially in markets where private insurers pay significantly more than Medicare for physician services." ("Declining Access to Physician Services Not Just a Medicare Problem," Center for Studying Health System Change, Sept. 5, 2002.)

  • Medicare paperwork and administrative requirements are leading many physicians to limit services for Medicare patients. According to a recent survey of physicians, almost 75% were concerned about "hassle factors." As a result, 16% said that they had limited their acceptance of Medicare patients. (Preliminary MedPAC survey of access to physician services, September 2002.)

  • Rising medical liability insurance premiums are forcing many doctors to limit services, relocate their practices or retire early. According to a recent article in the Washington Post, "Americans are beginning to feel the effects of double-digit increases in medical malpractice insurance premiums, which are prompting doctors to flee states with the highest rates, refuse to perform high-risk procedures, retire early out of frustration or stage protests such as one underway in West Virginia." ("Increase in Physicians' Insurance Hurts Care. Services are Being Pared, and Clinics are Closing," Washington Post, Jan. 5, 2003.)

  • Fewer physicians are providing uncompensated care to the uninsured and fewer are seeing Medicaid patients. The proportion of doctors providing any charity care dropped from 76.3% in 1997 to 71.5% in 2001. Not only is the proportion of physicians who provide any charity care decreasing, those who provide such care are spending less time doing so.

    The proportion of physicians serving Medicaid patients decreased from 87.1% in 1997 to 85.4% in 2001. ("Mounting Pressures: Physicians Serving Medicaid Patients and the Uninsured, 1997-2001," Center for Studying Health System Change, December 2002.)

ACP-ASIM's agenda for reform

Taken in isolation, any one of the above trends would be a cause for concern. But the combined impact threatens to elevate the access problem to a crisis.

Simply put, access is declining nationwide because fewer people have health insurance coverage, and those who have it are paying more for their medical care. At the same time, physicians' ability to treat Medicare, Medicaid and uninsured patients is being limited due to declining reimbursements, skyrocketing medical liability costs and the rising costs of complying with government regulations.

Our latest report on access concludes with an ambitious agenda for reform. It calls on Congress and President Bush to do the following:

  • Maintain Medicaid coverage for millions of the poor by providing emergency fiscal relief to the states.

  • Expand health insurance coverage in steps based on the College's seven-year plan to provide all Americans with affordable coverage by the end of the decade. (The seven-year plan is available online.)

  • Give physicians adequate reimbursement under Medicare and Medicaid.

  • Ease increases in physicians' costs of delivering care by reforming liability laws and reducing regulatory hassles.

The College acknowledges that the costs of implementing our agenda will be substantial. But we also believe that the costs of doing nothing will be even greater. Inaction will not only mean lost economic productivity, but also suffering and even premature death for millions of Americans who are denied access to essential medical care.

Robert B. Doherty is ACP-ASIM's Senior Vice President for Governmental Affairs and Public Policy.

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