By Phil Galewitz

Having trouble finding a doctor?

You’re not alone. Tens of millions of adults under 65 — both those with insurance and those without — saw their access to health care dramatically worsen over the past decade, according to a study released Monday.

The findings suggest more privately insured Americans are delaying treatment due to rising out-of-pocket costs, while safety net programs for the poor and uninsured are failing to keep up with demand for care, say Urban Institute researchers who wrote the report.

Overall, the study published in the journal Health Affairs found one in five American adults under 65 had an “unmet medical need” because of costs in 2010, compared to one in eight in 2000.

They also had a harder time accessing dental care, according to the analysis based on data from annual federal surveys of adults.

“For decades, Americans have been facing costs rising well above wage levels,” said Lynn Quincy, senior policy analyst for Consumers Union, a nonpartisan group. “These are real families. … It’s very concerning.”

President Barack Obama’s health law, which will expand health coverage to 30 million people starting in 2014, won’t necessarily solve all those access problems, the study says.

While the law does increase payments temporarily to primary care doctors who see people covered by Medicaid, it will not force more doctors into the program, or require states to provide dental coverage to adults.

Quincy noted the law does offer several new strategies such as new payment methods to control rising costs—which could help improve access, but there’s no guarantee they will work.

The study underscores what’s at stake in the law’s coverage expansion: People with private or public health insurance have significantly better access to care than the uninsured. If the law is overturned or scaled back, “we would be likely to see further deterioration in access to care for all adults — uninsured and insured alike,” it concludes.

‘Unmet Needs’ Increase For Privately Insured

Genevieve Kenney, lead author and senior fellow at the Urban Institute, speculated that higher cost sharing and deductibles that shift more of the cost onto individuals could be driving those changes.

Several studies have found that privately insured Americans are spending a higher proportion of their income on health services, said Peter Cunningham, senior fellow at the nonpartisan Center for Studying Health System Change.

One analysis by the consulting firm Milliman showed health costs for an American family of four have more than doubled since 2002.

“As employers shift more costs onto workers, that is something we are going to continue to see,” Cunningham said.

For insured Americans, a shortage of doctors in some parts of the country was a factor, but not as important as cost, he said.

An increasing number of consumers are also facing delays finding a primary care doctor when they are sick because physicians leave less room on their schedules for walk-ins, said Arthur Kellermann, director of the research firm Rand Health.

To make more money, physicians prefer to fill their days with quick turnaround type patients, such as those with chronic illnesses that need regular monitoring, he said.

‘Stressed And Worried’

Poor and uninsured adults had greater difficulties not just with health care costs, but finding doctors who would see them.

About one third of 41 million uninsured adults delayed getting care due to costs in 2010, compared to 25 percent in 2000, the study found. Nearly half the uninsured said they had an unmet medical need in 2010, up from 33 percent in 2000.

Marla Madden, 54, of Boca Raton, Fl., has gone without a Pap test to check for cervical cancer for more than a decade. She’s also years overdue for an MRI to check on her epilepsy and scoliosis.

Uninsured since her divorce in 2002, Madden said she can’t afford the tests. “You do feel a little bit helpless,” she said, adding that she’s recently gotten care through Project Access, in which doctors volunteer their time to treat those without coverage.

The uninsured who had a “usual source of care,” such as a family doctor or community health center, fell to 38 percent in 2010 from 44 percent in 2000.

The finding was startling given the billions of additional federal funding to community health centers over the past decade, Cunningham said.

Toni Wolf, 45, of Roanoke, Va., says she’s put off going to the doctor for the past year, even though she has diabetes and suffers from a lung disorder that causes her to be short of breath.

“It makes me feel very stressed and worried,” said Wolfe, who works as a teacher at a day care center but can’t afford the employee coverage it offers. She also recently got care through Project Access.

The study found that among adults getting care through public programs (more than two-thirds were enrolled in Medicaid, the state-federal insurance program for the poor) 26 percent said they had an unmet medical need in 2010, up from 20 percent in 2000.

About 19 percent experienced delays getting care due to non-cost factors in 2010, up from 14 percent in 2000. Nearly one in four people in public programs in 2010 had an unmet dental need, up from 15 percent in 2000.

The problems indicate that too few providers are taking Medicaid and an increasing number of states are dropping dental coverage — which is an optional benefit, Kenney said.

The American Medical Association, which has backed Obama’s health law, said the study findings were not surprising. “The ability for patients to access medical care is fundamental to the success of our health care system, since without timely health care access the uninsured live sicker and die younger,” said Dr. Peter W. Carmel, association president.

Rand’s Kellermann noted that even as the nation’s total health care bill doubled in the past decade to $2.6 trillion, many Americans had difficulty getting treated.

“We’re paying more and more and getting less and less,” he said.

Asked if there was any good news in her report, Kenney said that in contrast to adults, millions more children gained access to care in the past decade, likely due to the availability of public coverage for children through Medicaid and CHIP.

The study found the percent of children who had been to a doctor in the past year rose to 92 percent in 2010, from 89 percent in 2000.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Huffington Post: Women’s Health Care Is Stronger Thanks To The Health Care Law

In many families, women are the health care decision makers. When children go for their checkups, we are often the ones who make the appointment and sit in the room holding their hand. When elderly parents see a new specialist, we are the ones carrying the folder with all their health information. … In the past, this also meant that many women would take care of their own health last. By the time they got around to it, women found a system stacked against them. But thanks to the health care law, that’s changed (Kathleen Sebelius, 3/20).

The New Yorker: Holding Court

Late last year, a three-judge panel of the D.C. Circuit [Court of Appeals] voted, two to one, to uphold President Obama’s health-care reform, known as the Affordable Care Act (ACA). [Brett M.] Kavanaugh dissented, primarily on the ground that the lawsuit was premature. … “Under the Constitution,” Kavanaugh wrote, “the President may decline to enforce a statute that regulates private individuals when the President deems the statute unconstitutional, even if a court has held or would hold the statute constitutional.” … In other words, according to Kavanaugh, even if the Supreme Court upholds the law this spring, a President Santorum, say, could refuse to enforce ACA because he “deems” the law unconstitutional. That, to put the matter plainly, is not how it works (Jeffrey Toobin, 3/26).

Governing: What Will The Supreme Court Ask About Health Reform?

If the court decides to rule on the lawsuit, a decision is expected by the end of June before the conclusion of the court’s current session. That decision has heavy implications for states. The ACA includes an extensive expansion of Medicaid (expected to add up to 20 million people to the program’s rolls) and asks states to create a health insurance exchange where individuals and small businesses can compare and purchase insurance plans. Market reforms, such as rules for the medical loss ratios that insurance companies must maintain, would also require cooperation from state governments (Dylan Scott, 3/15). Photo: Franz Jantzen

The Atlantic: The Most Scientific Birth Is Often The Least Technological Birth

When I ask my medical students to describe their image of a woman who elects to birth with a midwife rather than with an obstetrician, they generally describe a woman who wears long cotton skirts, braids her hair, eats only organic vegan food, does yoga, and maybe drives a VW microbus. … Many medical students, like most American patients, confuse science and technology. They think that what it means to be a scientific doctor is to bring to bear the maximum amount of technology on any given patient. And this makes them dangerous. In fact, if you look at scientific studies of birth, you find over and over again that many technological interventions increase risk to the mother and child rather than decreasing it (Alice Dreger, 3/20).

TIME: Inside America’s Drug Shortage

Lynn Divers thought she had heard the worst of it when doctors told her that her daughter Alyssa had cancer. … Then came the truly heartbreaking news. In late February, when Divers called the hospital to confirm Alyssa’s upcoming chemotherapy treatment, the nurse informed her that there was a drug shortage. The hospital couldn’t be sure that there would be enough methotrexate — the cornerstone of therapy for some childhood cancers, including leukemia and osteosarcoma — to treat Alyssa, now 10. … How did this happen? How could hundreds, perhaps thousands of cancer patients suddenly find themselves without the drug treatments that could save their lives? (Alice Park, 3/19).

American Medical News: The ABCs Of Health Literacy

One in three patients has “basic” or “below basic” health literacy, meaning he or she struggles with tasks such as completing a health insurance application or understanding a short set of instructions about what liquids to avoid drinking before a medical test. This literacy gap has medical consequences. A wide body of research has found that patients with poor literacy skills have much worse health outcomes than patients who can read well. They make more medication or treatment errors, are less compliant and are 50% likelier to be hospitalized, says the National Patient Safety Foundation. Low-literacy patients with chronic diseases … rack up four times more in annual medical costs than patients with higher reading ability (Kevin B. O’Reilly, 3/19)

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Mother Jones: Santorum In ’93: More Government Needed in Health Care

Rick Santorum (Photo: Gage Skidmore)

If elected president, Santorum vows, he will end the “tyranny” of President Obama’s Affordable Care Act. Yet as an up-and-coming congressman in the early 1990s, Santorum took a much different line. Then—like now—health care was one of the nation’s most divisive issues. In 1993, Republicans were up in arms about a health care reform bill spearheaded by Hillary Clinton and pushed by President Bill Clinton. … During that fiery debate, Santorum said it would be a mistake to allow the delivery of health care services to be determined only by the market. He asserted that Republicans were “wrong” to let the marketplace decide how health care works. He instead argued that government should play a “proactive” role in shaping the health care marketplace “to make it work better” (Andy Kroll and Tim Murphy, 3/5).

The Atlantic: Making The Best Of What Is Often The Very Worst Time Of Our Lives (Book Excerpt)

As difficult as things are now, these may turn out to be the good old days. How we die is already a public health crisis, and care for people through the end of life is poised to become a generation-long social catastrophe. … Very soon, for the first time in human history, older people will outnumber younger people on our planet. In the United States, one in five adults is 65 or older. … Those of us who are concerned about long-term care have good reasons to worry. The nursing homes of the future — our future! — may make today’s nursing homes look like luxury hotels. It doesn’t have to turn out that way (Ira Byock, 3/7).

American Medical News: Legal Risks Of Going Paperless

System breaches. Modification allegations. E-discovery demands. These issues are becoming common courtroom themes as physicians transition from paper to EMRs, legal experts say. Not only are EMRs becoming part of medical negligence lawsuits, they are creating additional liability. … Studies are mixed about how EMRs will impact liability for physicians. … Whatever the future holds for EMRs, it’s important that doctors reduce their liability risks during system implementation, legal experts say. Being aware of potential legal pitfalls prevents doctors from falling victim to technology intended to do good — not cause hardship (Alicia Gallegos, 3/5).

The Daily Beast: Talking About Sex Is the Only Way To Stop HIV

[The United States has] been stuck at about 50,000 new infections each year for more than a decade. Compared with the challenges facing places like sub-Saharan Africa, our failure is particularly galling: we have plenty of drugs that work, the money and systems to administer them, and effective, if not particularly popular, ways to interrupt the spread (condoms, clean needles, abstinence). So why aren’t we doing better? The answer is blindingly simple: sex. Almost all HIV in the U.S. is spread by sexual intercourse, yet when faced with this fact, we act like a bumbling junior-high-school kid hearing about the birds and the bees for the first time. As a result, we have before us an unabated 30-year epidemic of a sexually transmitted disease (Kent Sepkowitz, 3/5).

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

By Shefali S. Kulkarni

Americans who turn up in the emergency room to get dental care aren’t lost, they’re probably just running out of options.

According to a new report from the Pew Center on the States, more than 800,000 visits to the ER in 2009 were for toothaches and other avoidable dental ailments.

“People showing up at emergency rooms for dental is really your sign that your system is breaking down,” Shelly Gehshan, director for the Pew Center’s Children’s Dental Campaign says. “It’s just not serving enough people. This is your symptom of a system in crisis.”

During times of economic crisis, state Medicaid programs often target dental benefits as their first budgetary cut, pushing low-income patients from the dentist office to the emergency room.

A Washington state survey of 53 hospitals found that during an 18-month period in 2008-09, residents made more than 23,000 visits to ERs for toothaches or other dental problems. Among the uninsured, patients with dental disorders were the most frequent ER visitors. – Pew Report

But the shift from Medicaid reimbursements to hospitals is still costly to states. Dental groups have long since said that ERs only provide temporary relief for dental emergencies and lead to reoccurring hospital visits, which burden taxpayers. “We’re spending in the worst possible way,” Gehshan says.

For example the report shows that in 2002 Maryland had a 12 percent increase in the rate of ER dental visits once the state stopped Medicaid reimbursements for private practice dentists treating adult emergencies. Florida reported more than 115,000 dental-related ER visits in 2010, and in Oregon a 31 percent hike of ER cases among Medicaid enrollees over a three-year-period.

Access to dental care is also creating the surge in ER visits. Safety-net facilities like community health centers are losing federal dollars and are unable to provide comprehensive dental care.

The report suggests several steps to alleviate this problem. “States committed to serving more low-income people should ensure their Medicaid reimbursement rates are high enough to cover the cost of care,” the report notes.

Gehshan says that 90 percent of dental care in the U.S. is done by private practitioners and the majority of them don’t accept Medicaid.

Another strategy includes implementing ‘dental therapists’ or providers that are similar to nurse practitioners in the medical field.

According to the report, dental therapists would be supervised by dentists and “could perform some services offered by dentists, including both preventive and restorative (e.g., filling cavities) care.”

Minnesota and some Native American Alaskan tribes are already using these professionals.

But the American Dental Association, which released a statement on Tuesday agreeing with much of Pew’s report, opposes the idea of expanding dental therapists in the U.S. The dental association challenges Pew’s projections of a decreasing supply of trained dentists and notes that relegating patients to “so-called ‘midlevel dental providers’ is wrongheaded.”

The ADA cites the Journal of Dental Education’s 2009 report that “both the ratio of dentists to population and the net number of dentists will increase, not decrease, contrary to what the Pew report states.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

By Phil Galewitz

The Obama administration launched a $40 million effort Wednesday to reduce premature births, especially early elective deliveries, but it has no plans to stop Medicaid from paying for those deliveries.

About 10 percent of all deliveries are scheduled — either as induced or Cesarean-section –before 39 weeks and are not medically indicated, according to the Department of Health and Human Services.

Preterm babies, those born before 39 weeks, are at increased risk for death, low birth weight, lung disorders, feeding problems and blood infections, according to the American College of Obstetricians and Gynecologists.

Medicaid, the state-federal health insurance program for the poor, pays for about 40 percent of all deliveries in the United States each year. Medicaid last year stopped paying for several so called “never” events such as preventable complications or wrong site surgery.

But on Wednesday, Medicaid chief Cindy Mann said it has no plans to stop paying for elective deliveries before 39 weeks. “This is not a payment strategy,” Mann said when asked whether Medicaid would keep paying for elective preterm deliveries.

Under the four year initiative called Strong Start announced Wednesday, the federal Center for Medicare and Medicaid Innovation will seek to reduce preterm births by giving money to hospitals and other health providers and community coalitions to improve prenatal care and test new approaches such as group visits for pregnant women and offer case management services at birth centers.

Local Resources: Read LocalHealthGuide’s story about the Seattle-based Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), an initiative launched by Seattle Children’s in 2007.

“Preterm births are a growing public health problem that has significant consequences for families well into a child’s life,” said HHS Secretary Kathleen Sebelius said.

Medicaid spends $20,000 a year on babies born premature in their first year, almost 10 times that of infants born at full term.

More than 500,000 infants are born prematurely in the United States each year, an increase of 36 percent in the past two decades, Sebelius said.

A recent study by the Leapfrog Group, an employer health coalition, showed huge variation in hospitals performing elective preterm deliveries. Rates ranged from less than 5 percent at some hospitals to more than 40 percent, according to Leapfrog’s 2011 data.

Leapfrog CEO Leah Binder said Medicaid and employers should consider stopping coverage for elective preterm births. “We fully support changes in payment to disincentivize the practice,” she said.

Doctor groups often say early deliveries are done at the request of pregnant women. “Women ask for it,” said Dr. Hal Lawrence, executive vice president of the American College of Obstetricians and Gynecologists.

Scott Berns, senior vice president for the March of Dimes, said doctors also need to be educated about the risks of early deliveries.

“More education is needed for doctors and patients,” Berns said.

HHS is working with both ACOG and March of Dimes to reduce the incidence of early elective births.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.