Why the Phrase “Access to Health Care” Should Always Pin Your Bullsh*t Detector (and You’re Not Alone)

Why the Phrase “Access to Health Care” Should Always Pin Your Bullsh*t Detector (and You’re Not Alone) 1

Readers, you know that word “access” pins my bullsh*t detector when used in the phrase “access to health care,” and many of you have picked up that same hypersensivity from me. Well, “access to health care” — the phrase, not the reality — is still ubiquitous, as I will first show. Next, I’ll give a quick look at what professionals mean when they say “access” (and raise a paradox, as well). Then I’ll look at an important new study from Health Affairs that raises the bare possibility that access to care means barriers to care and therefore, for many, no care. Finally, I (or rather Yves) will suggest that these barriers are not merely bureaucratic, or even financial, but part of the built environment itself. I will also do a little wandering through the sources in the notes, which you should not skip. But first, for the record, let me incriminate the guilty, something at which The Twitter is genuinely great:

Here is Democrat House Speaker Nancy Pelosi:

You will notice that in Pelosi’s tweet, and in every tweet below, the words “access to” can be deleted from “access to health care” without loss of meaning (at least to a dull normal. People don’t want access to health care; they want health care!). So what is “access” doing? Hold that thought.

Of course, Democrat Party leader Obama:

Vice-Presidential candidate Kamala Harris:

Presidential candidate Joe Biden:

(In an enormous act of chutzpah, Democrats bait-and-switched the public option, itself a bait-and-switch!) And from the other side of the aisle, Kellyanne Conway:

Note that Conway is the only one to indicate that there might be a class angle (“lives comfortably”) to any of this.

So what do health care professionals mean when they say “access to health care”? It’s complicated. It would take an intellectual historian with a grant to track down the history of “access to health care,” but here are a few hints derived from search. From “What does ‘access to health care’ mean?“, Journal of Health Services Research & Policy, 2002 (!):

Access is a complex concept and at least four aspects require evaluation. If services are available and there is an adequate supply of services, then the opportunity to obtain health care exists, and a population may ‘have access’ to services. The extent to which a population ‘gains access’ also depends on financial, organisational and social or cultural barriers that limit the utilisation of services. Thus access measured in terms of utilisation is dependent on the affordability, physical accessibility and acceptability of services and not merely adequacy of supply. Services available must be relevant and effective if the population is to ‘gain access to satisfactory health outcomes’. The availability of services, and barriers to access, have to be considered in the context of the differing perspectives, health needs and material and cultural settings of diverse groups in society. Equity of access may be measured in terms of the availability, utilisation or outcomes of services.

I tried to find out how the United States goverment operationalized “differing perspectives, health needs and material and cultural settings of diverse groups” in providing “access” to health care by searching U.S. Department of Health and Human Services and HealthCare.gov[1], but the best I could come up with was from HHS’s Office of Disease Prevention and Health Promotion (ODPHP), “Access to Health Services.”

Why Is Access to Health Services Important?

Access to health services means “the timely use of personal health services to achieve the best health outcomes.”1[2]

It requires 3 distinct steps:

  1. Gaining entry into the health care system (usually through insurance coverage)
  2. Accessing a location where needed health care services are provided (geographic availability)
  3. Finding a health care provider whom the patient trusts and can communicate with (personal relationship)2

And now the barriers:

Barriers to health services include:

  • High cost of care
  • Inadequate or no insurance coverage
  • Lack of availability of services
  • Lack of culturally competent care

And the ill effects, which amount to suffering and death, although this is America, so everybody is too polite to say that:

These barriers to accessing health services lead to:

  • Unmet health needs
  • Delays in receiving appropriate care
  • Inability to get preventive services
  • Financial burdens
  • Preventable hospitalizations

Now let us return to our question: What is “access” doing? Again, people don’t want access to health care; they want health care! Look again at the list of barriers: You will see that “gaining entry” and “finding a health care provider” are not considered barriers at all! “Access” is conceived of as a frictionless, seamless process that connects patient and provider, and not — paradoxically — itself a barrier! So, this response to Speaker Pelosi:

Why the Phrase “Access to Health Care” Should Always Pin Your Bullsh*t Detector (and You’re Not Alone) 2

“Access” erases the remaining financial barriers to health care after payment. A mere subsidy, even when achieved with the assistance of navigators does not eliminate co-pays, deductibles, network issues. “Access” also erases the enormous “tax on time” (as Yves calls it) of mastering complex eligibility requirements[3], finding the right policy, finding the right providers, handling the bills, and fighting with the insurance companies (generally while ill, or while caring for the ill). And of course the calls from collection agencies. Indeed, there’s an entire Twitter genre devoted to all the horror stories that “access” erases, and a fundraising site whose most numerous clientele didn’t get health care, even though they had “access” to it. “Access” to care paradoxically erases the enormous social cost determining who deserves “access” to health care, and if so, what kind and how much.

And so we come to the study I want to draw your attention to, from Health Affairs: “How Administrative Burdens Can Harm Health.” Imagine that! From the abstract:

In this brief, we detail how administrative burdens in our largest targeted social welfare policies may undermine health. First, we document the role of these social welfare policies in protecting health. We then define and conceptualize administrative burdens and detail how they limit access to these health-protective social welfare supports, all of which are critical in a major recession. Finally, we propose a research agenda to address the health implications of social welfare policy administration, especially the psychological and stress-related health impacts that may result from cumulative exposure to multiple administrative burdens.

I near spit coffee all over my keyboard at “research agenda”; see again footnote [2] at “generating theories”; it seems our system is Bourbon-like in its ability to “learn nothing.” That said, I’m happy to have everything that “access” erases made visible, so perhaps, under the lash and spur of the pandemic, we shall do better than we have heretofore. I’ll look only at the “administrative burdens” section, which begins:

The health benefits of social policies, however, are dependent on people accessing….


…. them. The coronavirus-induced economic turmoil highlighted how hard it can be to access our largest social welfare programs. We provide a conceptual framework to understand people’s experience of this kind of onerous policy administration. Administrative burdens emerge in three subcategories: the learning costs of finding out about a program’s existence and benefits, determining whether one is eligible for the program and what benefits one might receive, and understanding how to apply for and stay on programs; the compliance costs of filling out forms, documenting one’s status, or responding to bureaucratic directives; and the psychological costs, including stress, frustrations, anxiety, loss of autonomy, or sense of stigma, that arise from interacting with these programs.

This is progress! Processes that the ODPHP (and before them, the Journal of Health Services Research & Policy, and before them, the Committee on Monitoring Access to Personal Health Care Services) treated as frictionless and seamless are now being treated as having real costs to real people. Here is a handy chart:

Why the Phrase “Access to Health Care” Should Always Pin Your Bullsh*t Detector (and You’re Not Alone) 3

(Note that the chart applies to all social services, not just health care, which is also progress.) And — hold onto your hats, folks! — “onerous policy administration” is (dread word) political:

Burdens often have political origins and significant distributional impacts. Many are deployed as “policy by other means” to achieve aims that politicians otherwise struggle to acknowledge or enact, including rationing of benefits and services.

And profit for health insurance companies. More:

Although most people are familiar with cumbersome bureaucratic processes, it is easy to miss the scale, systemic nature, and intensity of the effects these processes can have. Moreover, they are often targeted at certain groups, including female, Black, poor, and disabled Americans.

Indeed, the working class generally. And it’s not easy to miss the “scale, systemic nature, and intensity” of these effects if you’ve had to deal with our health care system:

These burdens become magnified during major economic downturns, such as the COVID-19 pandemic-induced recession. Here, we detail health-harming burdens in our largest targeted social welfare programs, which also constitute crucial protections for those hit hardest by a recession.

The rest of the article covers unemployment insurance, the Earned Income Tax Credit, SNAP, and Medicaid, and is worth reading, but I don’t think adds anything on health care that readers don’t already know. The study concludes:

The previous section outlines how burdens may undermine health indirectly by reducing access to health protective programs. This section speculates about direct ways that burdens may influence health… pointing to a potential research agenda. Finally, although learning and compliance costs may affect psychological and physiological outcomes, how people are treated while they try to receive and keep benefits also likely matters. Psychological costs from stigma and discriminatory or belittling treatment may have long-term health consequences. Given evidence directly linking the experience of racial discrimination to poor health, it seems plausible that people who experience patterns of discrimination and negative bureaucratic encounters might also have worse downstream health. There is a need for more work examining the health implications of negative encounters with bureaucracies, many of which are patterned by race.

More study needed[4]. At least for health care, we don’t need a “research agenda.” We do not need to do “more work.” Canada, in what I have elsewhere called the largest natural experiment in the history of the world, has done the research and done the work. Canada — at least by the horrific and lethal example we have set — has made access a non-issue. We should follow their example. In my view, we should make health care free at the point of delivery for everyone. No co-pays, no deductibles, no in-network requirement, no eligibility determination, no billing. That entire bureaucracy of gatekeepers should be blown away[5]. How to do that is where the research and the work should be done.

Finally, there is one aspect not considered in any of the sources examined so far. It’s not enough to “find a health care provider” and “gain entry” to the system. The built environment in which care is deliverered matters too. Yves writes:

I happen to be spoiled by having insurance that does not limit me to an HMO or a PPO. I am getting a taste of what normal people go through via my mother.

She is in the HMO associated with the University of Alabama’s med school. Her doctor is part of the Kirklin Clinic, “one of the busiest outpatient centers in America.”

The place is a horrorshow for anyone with mobility issues. Whoever designed the space was fond of cavernous open areas. The parking is horrific and the parking lot is a huge walk (at least 1/5 mile) from the downstairs checkin. They claim they offer wheelchair assistance at the front entrance, but I wouldn’t trust it since even at airports (where everyone understands the passengers can’t be kept waiting too long) you can have waits for chairs. When you get upstairs to the floor where most of the MDs are, it’s another huge walk from the elevators to the exam rooms on the periphery. It’s a lot to ask a home health care aide to do as much pushing is required for a visit. And I can’t go with her, since the distances are so large, I need a wheelchair too.

And it’s a Covid nightmare. A line to check in. Elevators to get to the MDs. Oh, and touch-screens to check in!

And it’s also managed on a Stalinist model. You can’t reach an administrator. You can’t even see a particular specialist even with a referral from your MD. The adminisphere determines which specialist you see if you need one.

We haven’t been since Covid and I don’t plan on her ever going there again. I am switching doctors because this setup is too patient hostile.

We have here concerns about “accessibilty”, but concerns that serve as a lens to focus light on the entire structure. It seems that problems for those who have mobility issues is a happy accident, the pleasing consequence of a fortress mentality designed with “defense in depth” against patients in mind. For all patients, the walks are long. Check-in is hard to do (and in the days of Covid, dangerous). You must wait for an MD (or an unknown specialist). And the administrators are behind the highest walls of all. One wonders at what point there will be armed guards at their doors. It would seem that the architecture of the building mirrors the power structure of the hospital. Have readers had these experiences and perceptions?


[1] It wasn’t an easy search, because “accessibility” drowned out everything else on the HHS site; there may indeed by a definition of access at HHS and I just don’t know where to look. I did find this one manual for ObamaCare Navigators that has multiple uses of generic access (i.e., not for accessibility) but the term is not in the glossary. At HealthCare.gov, access is not in its glossary; a search on “access” yields 562 results, displayed 10 at a time. So, no. A search on “access definition” yields 10 hits, none obviously useful.

[2] Footnote 1 cites to the Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to Health Care in America. Millman M, editor. Washington, DC: National Academies Press; 1993 (!). The National Institutes of health has a copy online. From the Introduction:

Access is a shorthand term for a broad set of concerns that center on the degree to which individuals and groups are able to obtain needed services from the medical care system…. For the purposes of its work the committee defined access as follows: the timely use of personal health services to achieve the best possible health outcomes…. The access monitoring indicators recommended by the committee are intended to detect when and where access problems occur in the personal health care system. They do not explain the exact causes of these problems, but they can provide a better basis for generating theories about why differences in access exist among populations.”

From a contemporaneous review:

This useful volume defines a set of national objectives and identifies indicators–measures of utilization and outcome–that can ‘sense; when and where problems occur in accessing specific health care services… The committee offers recommendations to federal, state, and local agencies for improving data collection and monitoring. This highly readable and well-organized volume will be essential for policymakers, public health officials, insurance companies, hospitals, physicians and nurses, and interested individuals.

Canadian Medicare was passed in 1966. 1993 – 1966 = 27 years. Summarizing with this handy chart:

Why the Phrase “Access to Health Care” Should Always Pin Your Bullsh*t Detector (and You’re Not Alone) 4

As the chart shows, even if all one cares about is “bending the cost curve,” Canada and the United States, had already diverged in per capita costs by at least three thousand dollars when Access to Health Care in America was published. One might have thought that “generating theories” and “improving data collection and monitoring” would not have been the order of the day, even in 1993. 2020 – 1993 is neatly symmetrical: Another 27 years! The rot in our health care system — our system generally — is very, very deep.

[3] In “The History of ObamaCare, 2013-2016,” I have an entire section (twelve posts) on “ObamaCare’s relentless creation of second-class citizens,” which details the many bureaucratic atrocities intrinsic to ObamaCare’s program design.

[4]. And more grants.

[5] From back in 2013. I don’t think I was far wrong:

Can’t quantify any of this, of course; but when ObamaCare apologists talk about how ObamaCare is going to become harder to repeal, I don’t think they mean that a grateful populace will get dramatically better access to health care; I think they mean that ObamaCare is going to develop constituencies based on a distribution of rents; and that many of those rents will flow to political class and “creative class” Democratic constituencies; people much like themselves. Not that there’s anything wrong with that. The opportunity costs, alas, will be dramatically better access to health care for everyone, besides immense waste of time and energy by well-meaning civil society groups of all kinds, as well as software engineers, project managers, architects, designers, etc. All of these people really do have better things to do….

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