Health Insurance Coverage Vs. Access To Care—The Gap Between Them

Executive Briefing | by | October 11, 2017


Monica E. Oss
Monica E. Oss

I was pleased to read that the uninsured rate for consumers with severe mental illness (SMI) is dropping. Between 2012 and 2015, the percentage of adults with severe mental illness (SMI) who were uninsured dropped by nearly 10 percentage points, from 28.6% to 18.6% as we reported recently in Uninsured Rate Among Adults With Severe Mental Illness Dropped From 28% In 2012 To 18% In 2015. (We’ve had continuous reporting on health insurance coverage, a key piece of market intelligence for organizations in the field—Insurance Rate Up 0.3 Points In 2016 To 91.2%, Uninsured Rate For U.S. Adults Rises To 11.3%, More Than 90% Of Uninsured Consumers With Behavioral Health Disorders Eligible For ACA Subsidies, and Medicaid Covers 45% Of Children In Small Towns & Rural Areas.)

But having health insurance doesn’t insure access to care. The Institute of Medicine defined access to care as “the timely use of personal health services to achieve the best health outcomes” (see National Healthcare Quality and Disparities Report). This requires gaining entry to the health care system, to sites of care, and to programs and clinical professionals meeting specific health needs. But we have seen the proportion of U.S. residents with an SMI with health insurance increase, that hasn’t corresponded with an equal increase in access. Access improved but not as much as the rate of increased coverage. Consider, during the same period, the share of adults with SMI who:

  1. Delayed any medical care due to cost dropped from 32.0% to 27.7%
  2. Skipped medical care due to cost dropped from 30.1% to 24.8%.
  3. Failed to fill prescriptions due to cost dropped from 38.5% to 29.8%
  4. Skipped mental health care due to cost dropped from 24.8% to 16.3%
  5. Saw a mental health professional dropped from 39.8% to 35.7% (see Uninsured Rate Among Adults With Severe Mental Illness Dropped From 28% In 2012 To 18% In 2015)

The reasons for the coverage-to-access gap are many. The recent 2016 State of Mental Health in America – Access to Care Data discussed the factors in addition to insurance coverage that create barriers to access –

  1. Lack of available treatment professionals
  2. Lack of available treatment types (inpatient treatment, individual therapy, intensive community services)
  3. Insufficient finances to cover costs—including copays, uncovered treatment types, or when providers do not take insurance

Lack Of Available Treatment Professionals: This is an issue that effects both mental health and physical health and although we all know there is a lack of available treatment professionals—the question remains to be answered how many clinical professionals is enough? While many have attempted to answer this question and estimated the shortage of professionals, we do not have a definite answer for how many is enough for each treatment professional type. For more on attempts to quantify the market see Nebraska’s Psychiatrist-To-Population Ratio At 8.8 Per 100,000 Is 41% Below National Average Of 12.4 Per 100,000, Up To 90,000 Physicians Needed In United States By 2025, and 44% Of U.S. Population Lives In An Area With Psychiatry Shortage.

Lack Of Available Treatment Types: While closely related to the lack of available treatment professionals, the lack of available treatment types is also a problem. A couple of months ago, we wrote about whether there was a need for more psychiatric treatment beds and we received a lot of responses. Many of the people we talked with argued that rather than needing more inpatient beds, we need a more robust crisis service system and alternative settings to care for individuals (see Will Value-Based Reimbursement Solve The Psych Bed Question? and How Many Psychiatric Beds Are Enough? Opinions Vary). This argument also extends beyond mental health and into most other health and human service fields, for example the availability of medication-assisted treatment or care designed to meet the needs of individuals with developmental disabilities (see Buprenorphine & Methadone – Do We Actually Need To Increase Treatment Capacity?  and  Health Care Disparities Common For Ohio Adults With Developmental Disabilities).

Increases In Consumer Out-of-Pocket Expenses: Finally there is the issue of the cost of care to consumers. While the cost of care has actually dropped for many consumers with public insurance, the cost of care has increased for consumers with private insurance between 2000 and 2014 (see Out-Of-Pocket Health Care Costs – Down For Most, Up For Some and The Challenges Of Rising Consumer Spending On Health Care). Additionally, many consumers are becoming much more budget conscious and looking to sites to compare the cost of health care services at different provider organizations (see The Next Wave Of Consumer Price Shopping For Health Care and New Maine Law Requires Health Plans To Pay The Difference To Members Who Find Better Prices On Certain Health Services).

There is not simple solution for this complex access to care situation, which has many contributing factors. Developing programmatic approaches—at the health plan level and the provider organization level—for helping consumers understand and navigate their out-of-pocket payment expectations is part of the issue. Strategies to use professional extenders and peers, as appropriate, are part of the solution. Use of new technologies such as telehealth and eCBT is another. This is a period of uncertainty in terms of overall health care policy—which creates the need for creative solutions to make the landscape work for the consumers with the greatest needs.


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