Editor`s Opinion: Access to Quality Healthcare — Beyond the Headlines

  For decades, access to quality healthcare for all people has been an often elusive goal of governments all over the world. More than 30 years have passed since ministers from 134 countries attended the 1978 Alma-Ata conference and, in association with the World Health Organization and UNICEF, called for “health for all” by the year 2000. One of the Alma-Ata declarations supported by all participating countries states, “Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life.”¹ The conference also recognized that inequalities in health status are both socially unacceptable and economically undesirable and that a strong primary healthcare system is needed to attain the health-for-all goal. Many countries simply have not had the required financial resources or stability to come close to attaining this goal. Some were successful but of late are struggling to maintain it; others, including the United States, simply keep trying.   Four years before (!) the Alma-Ata conference, President Nixon presented a plan to Congress with the goal of providing affordable health insurance for all, because “without adequate healthcare, no one can make full use of his or her talents and opportunities. It is thus just as important that economic, racial, and social barriers not stand in the way of good healthcare as it is to eliminate those barriers to a good education and a good job,” and “… the 25 million Americans who remain uninsured often need it the most and are most unlikely to obtain it. They include many who work in seasonal or transient occupations, high-risk cases, and those who are ineligible for Medicaid despite low incomes.”² Support for the proposal to essentially provide affordable health insurance for everyone was mixed, but liberals and unions were soundly opposed to his plan and only a few minor changes were signed into law.

  Thirty-six years later, the Patient Protection and Affordable Care Act was signed into law. In those intervening years, the number of persons without health insurance almost doubled to 49.9 million or 18% of persons <65 years of age.³ Meanwhile, as cost-shifting to the individual continues, a Commonwealth Fund study4 found that the number of persons who have insurance but very high medical bills as a percentage of their income (aka, underinsured) increased 80% between 2003 and 2010. This study also found that rates of forfeited care (eg, not filling a prescription or not following up on recommended tests or treatment) were twice as high among the underinsured and three times as high among the uninsured as rates reported by adults with more adequate insurance.

  In the world of wound care, that means people are walking around with untreated, nonhealing wounds that develop complications, canceling appointments, and not obtaining needed supplies. We also know what happens when these persons finally have to seek care and the “unadjusted by insurance agreement” bills remain unpaid. Clearly, this is not a sustainable trend, nor is this an environment conducive to providing optimal care. Obviously, everyone will benefit when the downward access and upward cost spiral is interrupted. Although the general belief is that the Patient Protection and Affordable Care Act, once fully implemented, will do just that⁴ (not unlike previous attempts to implement fundamental changes), confusion, concern, and political posturing continue.

  We need to be aware of some important changes that already have taken effect. First, persons not covered by an employer-based plan are now able to find health insurance rates and coverage information in consumer-friendly language all on one website (www.healthcare.gov/using-insurance/index.html). The easy-to-navigate website has been growing by leaps and bounds as more and more insurance companies submit information. Not only can patients learn if they qualify for subsidized insurance in their state, but they also can be apprised of some of the important insurance regulation changes that have been implemented. Among these changes: 1) the Medicare Part D coverage gap is slowly closing; 2) if desired/needed, young adults can remain in a family plan until age 26 years; 3) persons with a pre-existing health condition have options to obtain health insurance; 4) it is much more difficult for insurance companies to retroactively rescind a policy when the insured becomes ill; and 5) annual and lifetime limits on coverage are disappearing. Some changes apply to new insurance plans only — ie, if your plan existed before a certain date, it does not have to comply with the changes— and others apply to old and new insurance plans. For example, rate review is mandatory for premium increases >10% in individual and small group plans,⁵ another part of the 2010 act applicable to new insurance plans. Funding has been made available for patient-centered outcomes research (visit www.pcori.org/), and payments to insurance companies for administering Medicare Advantage programs have changed or are changing soon. The provisions designed to reward providers for good outcomes, encourage preventive care, and strengthen the primary care workforce seem to suggest that the countries’ commitment to the 1978 declaration has not been completely forgotten.

  With distracting headlines all around, it is crucial for front-line healthcare providers to understand what is really going on, for our own sanity as well as to help our patients. To that end, the Health Reform time line, available at www.healthcare.gov/law/timeline/index.html or the site maintained by the Henry J.Kaiser Foundation (available at https://healthreform.kff.org/timeline.aspx), may be the prescription we all need to help us understand what is happening and prevent health reform-related headaches!

 This article was not subject to the Ostomy Wound Management peer-review process.

Correction

  In the article, Schessel ES, Ger R, Oddsen R. The costs and outcomes of treating a deep pressure ulcer in a patient with quadriplegia (Ostomy Wound Manage. 2012;58[2]:41–46), Robert Oddsen’s credentials are incorrect. He is a mechanical engineer; his credentials should read ME. The Editors sincerely regret the error.

1. Declaration of Alma-Ata: international conference on primary health care, Alma-Ata, USSR, September 6–12, 1978. Available at: www.who.int/hpr/NPH/docs/declaration_almaata.pdf. Accessed February 11, 2012.

2. Nixon R. Special message to the Congress proposing a comprehensive health insurance plan. Available at: www.scribd.com/doc/19391844/President-Richard-Nixons-Special-Message-to-the-Congress-Proposing-a-Comprehensive-Health-Insurance-Plan. Accessed February 11, 2012.

3. US Department of Health and Human Services. Overview of the Uninsured in the United States: A Summary of the 2011 Current Population Survey. Available at: http://aspe.hhs.gov/health/reports/2011/CPSHealthIns2011/ib.shtml. Accessed February 11, 2012.

4. Schoen C, Doty MM. Robertson RH, Collins SR. Affordable Care Act reforms could reduce the number of underinsured US adults by 70 Percent. Health Aff. 2011;30(9):1762–1771.

5. Centers for Medicare and Medicaid Services. Health Insurance Rate Review: Lowering Costs for American Consumers and Businesses. Available at: http://cciio.cms.gov/resources/factsheets/rate_review_fact_sheet.html. Accessed February 11, 2012.