Back in July, New York Times columnist Aaron Carroll wrote a great piece for the newspaper’s Upshot blog titled “Why Improving Access to Health Care Does Not Save Money.” It’s a great piece, and one that even the most ardent of Affordable Care Act supporters should read.
As Carroll points out, one of the ACA’s biggest arguments is that it will reduce people’s need for more intensive care by promoting preventive care, most of which it makes free. The bottom line is that people will flock to primary care doctors instead of visiting expensive emergency departments for routine care.
There are so many flaws in that argument that it’s hard to know where to begin. For one, increased preventative care doesn’t necessarily save the health care system money in the long run. But as Carroll points out, and was often drilled into my head during my MPH years, all changes in the health care system involve trade-offs between cost, quality, and access. An improvement in any part of this triad almost always results in some other aspect getting worse. And improving access almost universally leads to higher costs – and may have disastrous effects on quality as well. But let’s stick to access and cost.
The emergency department is an expensive place. Unfortunately for those without insurance, it is often the only place to achieve care. But even for those of us with insurance, the emergency department is often the most convenient place to receive care, especially on nights and weekends. Having a larger proportion of insured patients isnt going to change the fact that visiting a primary care physician is still inconvenient, and unless that inconvenience changes, people will still go to the ER.
But lastly, there are a pool of people – including the uninsured, the underinsured, and some of the insured – who avoiding receiving care or didnt fully participate in their care because they couldn’t afford it. With increasing access, these people will likely obtain the care they didnt get before – whether it be physician visits, visits to the ER, or obtaining medications. In Massachusetts, which pioneered universal health insurance in 2007, expanded coverage was associated with a more than 9% increase in discretionary operations and a 4.5% increase in nondiscretionary ones. If the Massachusetts experience provides any insight, a similar trend should be expected for the Affordable Care Act.
The bottom line is this. Costs = units of service x price. If you increase the units of service by making access easier, the overall costs will increase. The real question though is whether this is a bad thing or not. To quote Aaron Carroll, sometimes good things cost money. If the increase in cost is also commensurate with an increase in quality, health, or well-being, it might just be worth it in the long run.