What’s wrong with the U.S. health care system? One popular answer to the perennial question is that the system does not insure enough people. The Washington Post profiles Americans who slip through all the cracks of the our patchwork insurance system:
Nearly 4 million Americans and 800,000 Floridians live in this limbo of patchwork health care: They are not eligible for Medicaid; they don’t make enough money to afford ACA coverage. Florida, like many states that recently elected (or reelected) Republican governors, has decided not to expand Medicaid eligibility under the Affordable Care Act.As a result, many low-income Americans with chronic illnesses are bracing to make it work for the next four years — or simply through the day. They swap prescriptions for CVS bargains. They rely on family remedies: whiskey for a sore throat, tea leaves for asthma. They tumble into debt when an ailment demands medical attention.
The Post is of course right to bring attention to Americans who incur medical debt or risk their health because they cannot afford health insurance. But framing the health care conversation primarily around who has and doesn’t have coverage misses the prior point that even people who “have coverage” face serious difficulties in seeing a doctor or paying for health care. The real “coverage gap” in America isn’t so much the uninsured as the insured who still have poor health care options—because U.S. health care is so expensive. Witness, as just one example, the ongoing court battles over Medicaid, suits brought because low reimbursement rates prevent many Medicaid patients from getting timely care.This distinction is important, because if you see America’s health care problem as essentially a coverage problem, you will think the ACA was basically a good law that just needs to be extended more—with more state-level Medicaid expansions being the first place to start. But if you see America’s health care problem as essentially a cost problem that hurts everyone, insured and uninsured alike, that generates a whole different set of priorities. If you fix cost, coverage will follow; but if you expand coverage without fixing cost, that coverage will become increasingly less useful.