Understanding U.S. Health Insurance Access: It's Like an Airplane

Having a ticket is not the same as having a seat, and not all seats (or planes) are created equal.

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AdrisLateef/Reuters

The old axis of access ­in U.S. health care -- insured or uninsured -- is being replaced by the kind of gradations and complexity in determining who-gets-what-when-for-what-price for which the airline industry has become famous. Recent data and reactions to the provisions of the Affordable Care Act reinforce the trend.

While the number of Americans left standing at the gate because they can't afford a health insurance "ticket" is declining, the scheduled takeoff in insurance coverage has run into mechanical difficulties. The Census Bureau announced this month that the number of uninsured dropped slightly in 2011 to 48.6 million, or 15.7 percent of the population. That slide is partly due to a health law provision allowing parents to keep children on their insurance plans until age 26.

But prospects of adding another 30 million Americans starting in 2014 and going forward under the health law's various mandates and subsidies are now up in the air. The Supreme Court didn't ground the entire law, but it did invalidate the penalty designed to compel states to expand Medicaid to many above the federal poverty line. That decision could void tickets to health insurance for an estimated three million people, says the Congressional Budget Office and Joint Committee on Taxation, and possibly a lot more, according to a critical analysis by two liberal legal experts.

Tickets vs. seats 

As airline passengers have learned, having a ticket isn't the same as having a confirmed seat. In 2011, nearly one-third of physicians said they wouldn't accept new Medicaid patients because of payment issues; a smaller number of doctors have said the same thing about Medicare patients. Even with some private plans, you may be on permanent standby because the doctor of your choice does not accept your health plan.

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Private jets 

Of course, when money is no object, there are those who rate the equivalent of a private jet. That group would include individuals paying a reported $6,000 to $27,000 a month for "boutique" services like Guardian 24/7 (whose one-page public website simply says, "By Invitation Only"), World Clinic and PinnacleCare Private Health Advisory. The latter promises "medical research...at your fingertips," your complete health records instantly available online and "access to outstanding medical and emergency support anytime, anywhere."

First class, commercial flight

What's more interesting is what happens behind the curtain separating first class from other travelers on a commercial flight. Seated up front are the senior corporate managers who get "executive" physicals at places like the Mayo Clinic plus reimbursement checks for their out-of-pocket costs. One CEO with a total compensation package of about $9 million received another $23,000 to pay his medical bills, USA Today reported. These executive perks will be stopped by the health law in 2014 if loopholes can't be found.

Business class 

Unlike Medicaid "recipients," Medicare 'beneficiaries' start off with a generous benefit at a modest price and can easily upgrade. They can choose a Medicare Advantage plan in which the average enrollee received more than $70 in additional benefits and reduced cost-sharing, as one recent study found. In addition, Medigap plans provide wrap-around coverage to pay costs traditional Medicare doesn't. And even middle-class retirees may be able to upgrade to low-end concierge medicine, like MDVIP.

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Michael L. Millenson is a visiting scholar at the Northwestern Kellogg School of Management and the author of Demanding Medical Excellence: Doctors and Accountability in the Information Age

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