Health Care Inequality Grows

| Tue Dec. 6, 2005 10:39 PM EST

A new Health Affairs report out today. Good and bad news. Here 'tis. Good: those Americans living in relatively well-off communities, along with retirees on Medicare, are enjoying better access to health care than ever before. Cardiac and orthopedic surgery is in particular making great strides. High fives all around.

Oh, right, the bad: both the uninsured and Medicaid recipients are receiving increasingly worse access to basic care, especially after the last recession, as states face budget crunches. For instance:

Adhering to commitments to not give up hard-won gains in eligibility, most state Medicaid agencies have used other techniques, including reducing or freezing provider payments, eliminating certain benefits, instituting copayments, setting service limits such as total inpatient days or prescriptions covered, shrinking periods of guaranteed eligibility, and narrowing the time window for reapplying for coverage renewal.

Medicaid payment reductions and freezes have exacerbated problems with access to key services such as mental health and dental care, as well as many types of specialty care. Applying copayments, eliminating benefits, and setting arbitrary limits on services is seen by some observers as "cost shirking," which leaves providers caring for these patients in the position of either dropping them or absorbing the cost of their uncompensated care. More commonly, providers avoid undertaking care for these patients to evade such discomforting situations.The reduced access to dental care is a critical one. Malcolm Gladwell touched on this awhile back in his New Yorker article on health insurance, but the bad effects of tooth decay, common among those who can't afford to see a dentist, start to multiply very quickly. First your teeth start turning brown and rotting, then you're pulling them out with pliers to stop the pain ("They'll break off after a while, and then you just grab a hold of them, and they work their way out"), then you can't eat fruits and vegetables, which invariably leads to further health problems, and then you can't ever land a job that requires you to be seen by other human beings—such as a bank teller, or a receptionist—since no employer will hire a receptionist with brown stumps in his or her mouth.

Dentures are sometimes an option, but many state Medicaid programs won't cover dentures unless all your teeth have been yanked out with pliers, and if the dentures are made incorrectly and don't fit quite right, an adjustment can cost hundreds of dollars—it's usually cheaper just to toss the ill-fitting dentures in a drawer than shell out $200. So "problems with access to… dental care" are a big deal.

The Health Affairs study also notes that public mental health services have been cut in recent years. In Orange County, pop. 3,000,000, the county mental health agency has a crisis inpatient unit of exactly 10 beds. For instance. I'm guessing it's obvious how and why these cuts can be devastating, but it's worth adding that in the absence of a decent public mental health system, throwing a person in jail often becomes the primary way to treat the mentally ill—after all, state health budgets may have an upper bound, but the sky's the limit for the correctional system, even during a downturn. Needless to say, prison mental health services are often only slightly less humane than kicking a homeless guy in the stomach.

At any rate, Medicaid access is getting marginally better of late thanks to the recovery, as state deficits start to shrink, but the program is still in a shaky state, especially since more and more Americans are losing their private insurance and signing up for the program. (Well that, and Republicans are wetting themselves over cutting billions from the program to show how "bold" they are about reining in spending.) Inequality in both access to and quality from care is widening all across the country. The only real question is whether the Health Affairs authors are right to be so cynical when they say that they believe "U.S. society is prepared to tolerate trading off pursuing excellence for some, at the expense of deteriorating care for others."