Being Uninsured Is Bad for Your Health: Can Medical Homes Play a Role in Treating the Uninsurance Ailment?

IMPORTANCE OF HEALTH INSURANCE

In the United States, health insurance coverage is associated with better access to services and improved health outcomes.^1–4 Patients unable to obtain or maintain health insurance coverage report higher rates of unmet need than those with stable coverage.^5–9 Compared with insured patients, uninsured patients are at higher risk for dying prematurely from preventable causes.^10–12 Although primary care clinicians are often in a position to see how lack of insurance negatively affects health, most ambulatory care clinics do not have systems in place to help patients obtain health insurance, retain their coverage, or make important health insurance coverage decisions. Historically, health care financing has been separate from the delivery of health care services. Decisions about health insurance uptake and maintenance of coverage are made by employers, individuals, and/or family members. Federal and state governments also play a role in organizing and providing coverage to the elderly, disabled, poor, and other vulnerable populations.

The growing number of uninsured patients in the United States and the negative consequences of being uninsured motivated the passage of the 2009 Patient Protection and Affordable Care Act (PPACA) to enact reforms that would expand health insurance coverage options for the uninsured. For example, by 2014, the PPACA calls for expanding Medicaid to cover all Americans making less than 133% of the federal poverty level, creating state health insurance exchanges to allow individuals without employer-sponsored insurance the option to buy coverage directly, and implementing tax credits to help middle class families afford to buy insurance.^13,14 The magnitude and complexity of the “uninsurance” problem in the United States and the recent events surrounding the passage and implementation of the PPACA led me to ponder the question: Can medical homes play a more active role in helping patients find and keep insurance coverage?

THE ROLE OF A MEDICAL HOME

If uninsured patients die sooner, and medical homes are to aid patients in providing and coordinating care that improves health and reduces preventable morbidity and mortality, then helping individual patients find and keep health insurance should be within a medical home’s purview. Building upon the ethical foundation of beneficence, which outlines a moral obligation for clinicians to act for the good of patients, it could be argued that playing a central role in helping patients obtain and maintain insurance coverage is as important as helping a patient maintain a normal blood pressure or an optimal glycosylated (A_1c) hemoglobin level.^15–18 (Or, maybe help with coverage is even more important, as it is often not possible to receive these types of medical services without insurance.) At the population level, if we consider lack of insurance to be an epidemic sweeping the country, clinicians should advocate for protecting the public’s health, and health care systems should play a more active role in advocating for affordable coverage options for everyone. Although some medical organizations have a long tradition of political activity, medical professionals have not always lobbied for expanding coverage to patients.^19,20 More recently, however, health care professionals have been vocal about the need for health insurance reform, and many health care systems supported the PPACA or similar legislation.²¹

Although the PPACA may not be implemented in its entirety (due to the US Supreme Court ruling that state participation in public insurance expansions is optional), some provisions from the PPACA will likely expand coverage options.^22–24 These reforms create another unique opportunity at the individual level for clinicians and health care systems to play a more direct role in ensuring that patients find and keep health insurance coverage. For example, what can medical homes do to help patients successfully navigate health insurance exchanges to gain coverage and stay enrolled? Can medical home personnel with expertise in coordinating care and managing chronic disease also be better equipped to advise patients about important insurance options and decisions? Much of what health care systems currently do to provide health insurance support for patients is done by health care systems to provide health insurance support for patients is done once a patient gets sick and needs services. Hospitals make efforts to enroll eligible inpatients in publicly available coverage programs retroactively or as soon as they become hospitalized. Medical homes can be proactive and reach these patients before they get sick.

BEING PROACTIVE: DEVELOPING SYSTEMS

Primary care medical homes can partner with patients to reduce preventable mortality by assisting them in acquiring and maintaining health insurance coverage. This partnership can be supported by systems that are based on tenets of the chronic care model: a patient-centered, proactive, planned, and population-based approach.^25,26 If we can develop systems to know when a patient is due for his or her next hemoglobin A_1c test or antihypertensive medication refill, then we can develop systems to know when a patient is due to re-enroll in a health insurance program. As when transforming systems to provide better chronic disease care, a program to partner with patients to find and keep health insurance would require multicomponent practice changes in 4 categories: (1) increasing the expertise and skills of clinicians and other team members; (2) educating and supporting patients; (3) utilizing a team-based approach with more emphasis on prior planning; and (4) making better use of registry-based information systems.²⁷ Powerful catalysts for implementing these changes are a robust electronic health record (EHR) and the maximal use of the best health information technology (HIT) tools available.

ATTENDING TO THE FIDELITY OF HEALTH INSURANCE COVERAGE

As medical homes develop better systems for managing chronic disease and keeping patients healthy, clinicians will continue to hear from patients that a lack of insurance coverage has prevented them from taking essential medications, getting preventative screenings, and completing early diagnostic tests. Thus, it seems that helping a patient find and keep health insurance is a role that should be played by his or her medical home. Gains in population health from this approach would be analogous to those achieved by ensuring the delivery of evidence-based care to all patients (ie, optimizing the fidelity of health care delivery).^28,29 In fact, partnering with patients to improve the fidelity of our population’s health insurance coverage, that is, ensuring that all patients have the best and most continuous coverage available to them under existing and newly expanded programs, may be as (or more) important than ensuring that all patients have optimal blood pressure control, diabetes control, or timely cancer screenings. By adopting uninsurance and underinsurance as a chronic illness and applying tenets and tools of the chronic care model to treat it, medical homes have the opportunity to improve population health and make a positive difference in the lives of patients.