After Insurance Reform: An Adequate Safety Net Can Bring Us to Universal Coverage

When, exactly, did the debate become about "INSURANCE?" I don't give a damn about that. I want HEALTH CARE. --Comment posted on the New York Times blog Prescriptions, September 26, 2009 The overriding goal of health reform is to provide every American affordable access to adequate health care. Yet in every national effort to date, the focal means to this end has always been health insurance. Massachusetts is congratulated for having achieved nearly universal insurance coverage, and congressional Democrats are aiming for the same. But what if they don't succeed? Even in Massachusetts, 167,000 residents remain uninsured. Is it still possible to provide adequate access to medical care for those without insurance? If so, shouldn't we reframe social goals to achieve universal access through any means possible, whether or not insurance is involved? The blog commenter and I agree that the answer to these questions is yes. This is not a technical or rhetorical point about a public option versus private plans. Instead, it is about insurance of any type as a funding mechanism versus direct government funding of providers to treat the uninsured. This contrast is essentially the same as that between "socialized insurance" and "socialized medicine." Even if we can't achieve "Medicare for all," perhaps we can achieve at least minimally accept able access--something along the lines of "veterans' health for all." One way to characterize this alternative vision is as an adequate "safety net"--the accepted term for the conglomeration of hospitals, clinics, and doctors willing to accept patients regardless of ability to pay. Volumes of work document the inadequacies of safety net structure, funding, and access, (1) but I have found many examples of safety net systems that function well enough. Much of the safety net is tattered and torn. Usually, it consists of a disconnected assortment of providers with limited funding and varied missions, willing to accept some patients in fairly dire straits as a last resort. Examples include underfunded public hospitals, thinly staffed free clinics, and overcrowded hospital emergency rooms. But in some places, the picture is quite different: state and local government agencies, charitable hospitals, physician organizations, or community groups have marshaled resources to organize well-structured systems of fairly comprehensive access for low-income, uninsured patients. Funding and motivation vary widely. Public and private hospitals seek to ease the burden on emergency rooms. Federal agencies and charitable foundations provide grants to build community networks and health facility infrastructures that will address disparities and lessen the greatest need. Local medical societies feel an ethical tug to facilitate physicians donating more indigent care. A variety of funding and delivery structures has emerged in places as diverse as San Francisco and San Antonio; Exeter, New Hampshire, and Asheville, North Carolina; Denver and D.C.; Flint, Michigan, and Richmond, Virginia. (2) Some are completely free, and others charge substantial sliding-scale fees. Some are run by hospitals, others by physicians, and still others by community groups or local government. What these diverse safety net models have in common is simply affordable access to comprehensive health care. Covered services typically include a primary care medical home, essential medications, referrals to most specialists, and hospitalization. Recipients are screened for eligibility and given an enrollment identification that functions like (but is expressly not) an insurance card. If well-woven safety nets look and feel like insurance, are they really that different? The answer is yes and no--but before harping on the differences, let's be clear about why they matter. The differences matter ethically because safety net care, even at its best, is still inferior to the best insurance. …