Adil Menon
Brookline, Massachusetts

Since the late 1940s when employer based private health insurance became increasingly prevalent in the United States, the expansion of public health insurance to a growing share of the population has been viewed as the best approach to helping people, particularly those on the lower end of the socioeconomic spectrum, obtain medical care.¹ This paper will seek to elucidate why the myopic emphasis on public insurance expansion is not enough to produce equitable and accessible care and address how a single payer system more effectively achieves this goal.

At the heart of the argument that insurance expansion is sufficient to achieve equity is the assumption that “if poor people have health insurance, physicians and other providers of medical care will” by necessity “provide the same services . . . they do to middle-class people.”² A brief review of the literature proves this supposition false, as glaring and well documented distinctions exist between not only the insured and the uninsured, but also between different types of insurance. Those with public insurance find themselves at the bottom of the coverage hierarchy and are burdened with enormous stigma, leading to interactions with the medical system that leave them feeling ignored, disrespected, and rushed. This discrimination is compounded further by the fact that groups who experience insurance-based discrimination are disproportionately likely to be individuals who enter the health care system as already stigmatized patients due to the overrepresentation of ethnic and racial minorities among recipients of public coverage. These myriad forms of prejudicial treatment lead many publicly insured patients to have low satisfaction with healthcare providers and staff and to perceive public insurance as providing substandard care. In one study of this patient population it was found that three quarters (77%) felt public insurance status played a significant role in how health care providers treat people, and more than half (65%) had either personally experienced such treatment or observed others receiving inferior care to those with private coverage.³ This differential treatment not only involves disproportionately long wait times and hostile or otherwise negative interpersonal interactions, but can also significantly compromise quality of care. As one patient recollects in the case of her son, “I told the doctor before he’s allergic to amoxicillin, penicillin, and he (the doctor) actually wrote him an amoxicillin script. . . . He didn’t even read through his file.”⁴ Providing health coverage does nothing to erase potentially centuries old biases nor the bias surrounding public insurance itself. Thus, expansion without understanding and confronting how stigma may contribute to historical patterns of late diagnoses, higher mortality, and poorer health outcomes for public insurance recipients will never offer a viable path to equity.

In addition to the discrimination they often face during their interactions with healthcare providers and institutions, those on public insurance additionally face enormous hurdles in accessing the system at all, challenging the premise of a social safety net and the fundamental value of insurance. In one study, it was determined that 16.3% of Medicaid beneficiaries confront one or more barriers when seeking primary care. These include not being able to reach a doctor by phone, not being able to get a timely appointment, and lack of transportation to the doctor’s office.⁵ It should be noted that these statistics remain true for “even those Medicaid patients who have primary care physicians.”⁶ This compares with 8.9% of people with private insurance who report facing such difficulties. As both Jennifer DeVoe and her colleagues and the National Center for Policy Analysis assert, these findings are especially troubling as an “additional 16 million people . . . will be added to the Medicaid rolls over the next decade” and the current system “puts both patients and providers into an impossible position that will only get worse as more people enroll in Medicaid.”⁷ The failure to properly perceive and address barriers to access, while continually pushing the rhetoric of expansion as a panacea, has ironically turned the provision of public insurance from a means of striving for evenhandedness within healthcare to yet another source of inequity for lower income patients.

Despite the problems of access and discrimination already addressed, it is almost certain that someone will attempt to raise the argument that something is better than nothing. It is therefore key in commenting on the myth of public insurance as leveling the playing field to elucidate just how legally tenuous that supposed something is. Medicaid is a federal entitlement with federal rights protected by the federal courts; however these defenses have never been overly robust ones. While recipients who fall into “mandatory” eligibility categories—including supplemental security income (SSI) recipients, poor children, and pregnant women—can claim eligibility as a right and have a right to services “with reasonable promptness,” the waters become far murkier when it comes time to plainly lay out what services these rights provide.⁸ Medicaid programs are only required to provide a short list of services, including hospital, physician, and skilled nursing facility care.⁹ Additionally, the Department of Health and Human Services holds the ability to waive many key statutes and program requirements. The 1997 Balanced Budget Act, along with the Bush administration’s Health Insurance Flexibility and Accountability policy, gave the states even freer rein to disregard basic program requirements for some eligibility groups.¹⁰ If one is unmoved by the ease with which Medicaid recipients can lose federal rights, it should also be noted that healthcare providers accepting Medicaid have even weaker grounds upon which to argue. Even though Wilder v. Virginia Hospital Association recognized the right of providers to sue state Medicaid programs in federal court, few statutes exist allowing care providers to receive restitution for unreasonably low payment levels or arbitrary budget cuts.¹¹ Given its inability to adequately guarantee services to recipients and compensation to providers, even when enshrined as a federal entitlement, and the discrimination and difficulties accessing the care it does nominally provide, public insurance as it stands in the status quo will never result in equal access to health resources nor the equal dignity implicit in its promise.

Considering all the problems engendered by the myopic focus on expanding public insurance as the primary route to equity within the healthcare system, a better path must exist. In the eyes of this author, the superior way forward rests not in rejecting public insurance and shifting more fully towards privatization, but instead expanding it to its limit and constructing a single-tiered system that covers all people equally regardless of age, income, employment, or diagnosis. Rather than preserving the overly idealistic hope that a certain type of insurance coverage will lead those with lower incomes to be treated with the same respect and dignity as their more affluent neighbors, a single tier system would simply erase any means of denoting divergent status.¹² This equity would be further bolstered by a unified system that fosters universally high quality that is acceptable to all citizens. Single-payer reform not only generates increased equality with regards to bias and quality of care, but also offers the financial resources to make health care affordable and accessible to all. Using estimates from current government run insurance programs, savings on administrative waste of over $350 billion annually could be utilized to fund coverage of the currently uninsured and to improve benefits to insured Americans.¹³ Given its potential to address the deleterious legacy of inequality in American healthcare as explored above, a single tier, single payer system far outclasses the current insurance-focused paradigm.

Expanding public insurance as it exists today does nothing to address the deleterious impacts of discrimination, compounds larger societal prejudices, places additional barriers to care for those it is meant to assist, and is an extraordinarily weak entitlement. A shift to a single payer system is not perfect or easy, but is a superior way forward. While discrimination in healthcare will always exist, a single tiered system shuts down avenues through which it can be exercised. While we have often failed to live up to it, all citizens of the United States have the right to equality. When we have taken steps towards this ideal, we leave indelible, positive marks on our society. A single tiered, single payer system holds the potential to be one such leap forward in our nation’s history and is therefore, despite the rigor and peril, a step worth taking.

Notes

1. Katherine Swartz. “Health care for the poor: For whom, what care, and whose responsibility?” Focus 26, no. 2, 69-75. Accessed January 6, 2017.
2. Swartz.
3. Anna C.Martinez-Hume, Allison M. Baker, Hannah S. Bell, Isabel Montemayor, Kristan Elwell, and Linda M. Hunt. ““They Treat you a Different Way:” Public Insurance, Stigma, and the Challenge to Quality Health Care.” Culture, Medicine, and Psychiatry, December 26, 2016, 1-20. Accessed January 6, 2017. doi:10.1007/s11013-016-9513-8.
4. Martinez-Hume.
5. ErikaMatich. “Primary care barriers for Medicaid patients.” CU Anschutz Today. November 18, 2016. Accessed January 06, 2017. http://www.cuanschutztoday.org/primary-care-barriers-for-medicaid-patient/.
6. Jennifer DeVoe,, Alia Baez, Heather Angier, Lisa Krois, Christine Edlund, and Patricia Carney. “Insurance plus Access Does not Equal Health Care: Typology of Barriers to Health Care Access for Low-Income Families.” Annals of Family Medicine 5, no. 6 (November 29, 2007): 511-18. Accessed January 5, 2017.
7. “Enrollees Have Difficulty Accessing Care under Medicaid.” Ncpa.org. December 11, 2014. Accessed January 09, 2017. http://www.ncpa.org/sub/dpd/index.php?Article_ID=25159.
8. T. S. Jost, “The Tenuous Nature Of The Medicaid Entitlement.” Health Affairs 22, no. 1 (January 01, 2003): 145-53. Accessed January 7, 2017. doi:10.1377/hlthaff.22.1.145.
9. Jost.
10. Jost.
11. Jost.
12. David U.Himmelstein, and Steffie Woolhandler. “National Health Insurance or Incremental Reform: Aim High, or at Our Feet?” American Journal of Public Health 98, no. Supplement_1 (September 2008). doi:10.2105/ajph.98.supplement_1.s65.
13. Himmelstein.

Bibliography

• DeVoe, Jennifer, Alia Baez, Heather Angier, Lisa Krois, Christine Edlund, and Patricia Carney. “Insurance plus Access Does not Equal Health Care: Typology of Barriers to Health Care Access for Low-Income Families.” Annals of Family Medicine 5, no. 6 (November 29, 2007): 511-18. Accessed January 5, 2017.
• “Enrollees Have Difficulty Accessing Care under Medicaid.” Ncpa.org. December 11, 2014. Accessed January 09, 2017. http://www.ncpa.org/sub/dpd/index.php?Article_ID=25159.
• Himmelstein, David U., and Steffie Woolhandler. “National Health Insurance or Incremental Reform: Aim High, or at Our Feet?” American Journal of Public Health 98, no. Supplement_1 (September 2008). doi:10.2105/ajph.98.supplement_1.s65.
• Jost, T. S. “The Tenuous Nature Of The Medicaid Entitlement.” Health Affairs 22, no. 1 (January 01, 2003): 145-53. Accessed January 7, 2017. doi:10.1377/hlthaff.22.1.145.
• Martinez-Hume, Anna C., Allison M. Baker, Hannah S. Bell, Isabel Montemayor, Kristan Elwell, and Linda M. Hunt. ““They Treat you a Different Way:” Public Insurance, Stigma, and the Challenge to Quality Health Care.” Culture, Medicine, and Psychiatry, December 26, 2016, 1-20. Accessed January 6, 2017. doi:10.1007/s11013-016-9513-8.
• Matich, Erika. “Primary care barriers for Medicaid patients.” CU Anschutz Today. November 18, 2016. Accessed January 06, 2017. http://www.cuanschutztoday.org/primary-care-barriers-for-medicaid-patient/.
• Patel, Kavita, Amy Boutwell, Josiah D. Rich, and Brad W. Brockmann. “Insurance is Not Enough: Addressing the Health and Social Needs of the Criminal Justice-Involved.” Brookings.edu. July 28, 2016. Accessed January 06, 2017. https://www.brookings.edu/blog/up-front/2014/03/04/insurance-is-not-enough-addressing-the-health-and-social-needs-of-the-criminal-justice-involved/.
• Resneck, Jack, Mark J. Pletcher, and Nia Lozano. “Medicare, medicaid, and access to dermatologists: The effect of patient insurance on appointment access and wait times.” Journal of the American Academy of Dermatology 50, no. 1 (January 2004): 85-92. Accessed January 6, 2017. doi:10.1016/s0190-9622(03)02463-0.
• Swartz, Katherine. “Health care for the poor: For whom, what care, and whose responsibility?” Focus 26, no. 2, 69-75. Accessed January 6, 2017.
• “The GOP Puts Obamacare on the Chopping Block.” Comedy Central.com. January 5, 2017. Accessed January 11, 2017. http://www.cc.com/video-clips/ln9vxj/the-daily-show-with-trevor-noah-the-gop-puts-obamacare-on-the-chopping-block.