May 29, 2005

Beyond Uninsurance

Er, so first we were treated to the strange spectacle specter of Newt Gingrich and Hillary Clinton holding hands and collaborating on health care issues, and now I see the AFL-CIO and the Heritage Foundation are butting heads and thinking up ways to expand health care for the uninsured. Well, okay. I also heard some very liberal thoughts from the mouths of some otherwise staunch conservatives this weekend, on immigration and pharmaceuticals, so perhaps the big progressive coalition's coming sooner than we think.

At any rate, if Jonathan Gruber's right about this, the most cost effective method of extending health coverage to the currently uninsured is simply to expand Medicaid. But instead of wonking out, let's do a bit of fretting that the debate about health care for the poor has become much too narrow. "Cover the uninsured and all will be well." Well, no. Many low-income mothers and children are already eligible for Medicaid, and don't take full advantage of it. Partly that's because the eligibility rules are often stiflingly complex—acting as a deterrent more than anything else—and partly because state workers often simply deny people care, to keep costs down. I doubt this is a problem somehow intrinsic to Medicaid—private insurance companies are just as good at weaseling out of coverage if it redounds to their benefits. So long as we have a patchwork system of coverage, the poor and the sick are always going to be booted around.

But there are all sorts of other reasons why insurance doesn't guarantee good health care for the poor. As these researchers showed, it's very often difficult for people in poor areas to get access to good primary care. People don't have all the time in the world; if care isn't convenient and accessible, then a person's far more likely to shrug off a nasty cough or limp than spend hours going to see a doctor. That goes triple for someone with two retail jobs, a one hour commute each way, and kids to take care of. Plus, as economists Dana Goldman and Dana Lakdawalla argue here, the poor tend to be less adept at taking care of themselves and using care efficiently, largely for reasons of education. (If you're interested, take a look at that paper—it implies that universal coverage alone could well worsen health inequality.)

To a large extent, then, who cares about the uninsured as such? That's overstating it, since a lot of people obviously do need affordable coverage, but it's certainly not the case that if everyone received decent coverage, everyone would start receiving drastically better health care. For many low-income families, that's potentially way off the mark. So perhaps it's time to start toying around with paternalistic solutions like better education about health, more public screenings (especially in school), more public health clinics, or the like. Newt? Heritage? Robert Fogel does a lot of good work along these lines, while reminding everyone to keep their eyes on the ball—the focus here should be on inequalities and inadequacies in health care, of which insurance plays only one part. Important, but still just one part.
-- Brad Plumer 10:54 PM || ||