Universal Health Insurance Coverage -- Really?

"Universal" vs. "Coverage"

Yesterday, CNN’s Tim Langmaid reported that Health and Human Services estimates that the percent of insured young people aged 19 to 25 rose from 64 percent to 73 percent. Based on census figures, that percentage change represents about 2.5 million young people. The increase is attributed by some to a provision of the health care reform legislation signed into law last year that allows young adults to remain on their parents’ insurance plans through age 26.

Today, however, Sara Rosenbaum writes in The New England Journal of Medicine about the Douglas cases for which the Supreme Court heard oral arguments in October. These consolidated cases are comprised of suits against California Medicaid for cutting reimbursement rates to the degree that, plaintiffs argued, beneficiaries’ access to care was seriously threatened.

The question before the Supreme Court is all about legal standing in the shadowy ground between federal legislative authority and the role of the states. Does the U.S. Constitution give private individuals the right to go to court to halt state actions that violate federal law and threaten immediate and irreparable harm? This will be a key issue in the years ahead as the federal government and the states get set to squabble over who gets the last legislative word in the realm of public health and safety.

The question for the rest of us is more pedestrian, but just as important. What is the value of universal health insurance if coverage is increasingly limited, in essence, a safety net full of holes?

Life in a leaky tent

An increasing number of physicians we speak to are telling us that patients -- even patients with private, employer-sponsored health insurance -- are not able to receive treatment because co-payment responsibilities exceed patients’ ability to pay.

An example? Our industry news in recent months has heralded the arrival of protease inhibitors against hepatitis C and their ability to increase sustained responses -- presumptive cures -- in more patients. But some patients -- employed, insured patients -- go untreated. Our therapeutic innovation is remarkable, but it is an option only for those with health insurance coverage. Increasingly that coverage is shot through with holes that threaten to make the concept of universal care illusive and theoretical.

Like many shared sacrifices of modern economic times, the burden associated with the paradox of more inclusive coverage that affords thinner protection will be felt by both the poor and the middle class. Over the next few months, we will be writing again about the clinical implications that tougher choices pose for patients and the providers who treat them.