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Health insurance 'coverage' is not the same as healthcare 'access'


(NaturalNews) Often lost in the debates over reform to the United States' broken healthcare system is a subtle but critical point: Providing people with health insurance coverage is not the same thing as providing them with access to healthcare.

This issue has come to the forefront in the debate over the merits of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which changes the way doctors receive Medicare reimbursements. Rather than being paid a flat fee for every service provided, doctors will now (in theory) be rewarded for providing higher quality care at lower costs, and paid less if they perform unnecessary tests or procedures, or provide poor quality care.

While some doctors' groups have welcomed the change, other doctors warn that the program will simply incentivize doctors to stop accepting Medicare, thus worsening the nation's primary care shortage. And this will create more and more situations where people have healthcare coverage – Medicare – but may be unable to find a doctor willing to provide such care.

Can U.S. health spending be cut?

Fundamentally, MACRA seeks to correct some of the problems caused by the United States' for-profit healthcare system, which rewards doctors for providing as many interventions as possible – from CT scans to surgeries to pharmaceutical drugs – regardless of the benefit to the patients themselves. Analysts have pointed to this system as part of the reason that the U.S. spends more on healthcare than any other wealthy nation (both per capita and as a percentage of GDP), but has the unhealthiest population and the highest rates of heart disease, diabetes and infant death.

According to a 2010 report by Thomson Reuters, one-third of this spending goes to inefficiency, mistakes and fraud. Of this wasted spending, 37 percent – as much as $300 billion yearly – is due to unnecessary tests, treatments and procedures, while medical errors account for another 11 percent.

Under MACRA, doctors may sign up for one of two performance-based reimbursement systems. The first, which will probably be the most widely used, is the Merit-Based Incentive Payment System (MIPS). MIPS sets a baseline reimbursement for each procedure, just like Medicare of old. But doctors can receive either more or less than the baseline, depending on how they score on a number of performance metrics relative to average performance nationwide. Under the second option, doctors can choose from a number of Alternative Payment Models (APMs) that also promote providing high-quality care at lower costs.

Widespread doctor shortage

Critics of MACRA have raise two primary concerns. Firstly, critics worry that cost savings from the program may be eaten up by increased paperwork and reporting load on doctors.

The 2010 review found that administrative costs are remarkably large in the U.S. healthcare system, accounting for 18 percent of wasted spending.

The deeper concern is that the combination of increased paperwork burden and potentially lowered reimbursement may cause doctors to stop accepting Medicare altogether. A similar problem already plagues Medicaid, which is notorious for a shortage of participating physicians. Even without a mass exodus from Medicare, the federal government already estimates that the United States will be short of 20,000 primary care doctors by 2020.

This shortage of primary care physicians is one of the major factors believed to be behind the rise of emergency room visits since the Affordable Care Act (ACA, popularly known as Obamacare) took effect in 2014. Large numbers of people were suddenly made able to have healthcare coverage, but were not necessarily able to find a primary care doctor to provide them with that care.

Other factors also affect access to care, regardless of coverage status. Low-income people are less likely to have access to paid sick days to be able to visit doctors during business hours, and primary care can be harder to come by at all in rural or low-income areas.

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