As we once again begin to debate the limits of personal responsibility, and how much one of us needs to care for another, it’s worth thinking about the following. There’s little question that people without health insurance may not have optimal access to the health care system. But some have theorized that higher rates of uninsurance in an area may have a “spillover” effect that impacts even those with insurance:
A high community uninsurance rate may generate adverse spillover effects on access to and quality of care among the insured through several mechanisms. One possibility is that physicians practicing in a community with a high uninsurance rate curtail their provision of unprofitable services and shorten hours of service, which could affect access and quality for the insured and uninsured alike. Another potential mechanism results from the fact that mainstream providers—particularly private physicians—often both treat insured patients and provide charity (free or discounted) care to the uninsured. Physicians may find it difficult to provide very different levels of care to their insured and uninsured patients, and instead may tend to provide a similar level of care to all patients. Thus physicians may treat all patients in accordance with the average or modal insurance coverage in an area (or in their practice). Because the uninsured can afford—and hence demand—a lower quantity and quality of care than the insured, physicians who practice in communities with a high uninsurance rate, and who treat numerous uninsured patients as a result, may provide a lower level of care to all their patients than physicians who practice in communities with a low uninsurance rate.
A recent study in Medical Care looked at just this:
Background: Previous research suggests, but does not definitively establish, that a high level of uninsurance in a community may negatively affect access to and quality of health care for insured persons.
Objective: To assess the effect of the level of uninsurance in a community on access to and satisfaction with care—an important dimension of quality—among insured persons.
Research Design: The 1996 to 2006 Medical Expenditure Panel Survey Household Component data linked to data from the Current Population Survey, Area Resource File, and the InterStudy Competitive Edge. Analyses include 86,928 insured adult respondents living in approximately 200 large metropolitan areas.
Main Outcome Measures: Measures of whether an individual had a usual source of care, had any delay/difficulty obtaining needed care, used office-based services, used prescription drug services, and used any medical services, and measures of satisfaction with care.
What did they find?
For every 10% increase in the level of uninsurance in a community:
- the chance that a person with private insurance had a usual source of care went down by 6.2%
- the chance that an person with private insurance had difficulty receiving needed care went up by 7.7%
- the chance that an person with private insurance reported being satisfied with their usual source of care went down 1.9%
- the chance that a Medicare enrollee had problems receiving care, or didn’t get it at all, went up 1.7%
- the chance that a Medicare enrollee rated health care quality as high went down 6.8%