Annals Articles Tackle Health Care Coverage, Other Issues

Two articles in the September/October issue of Annals of Family Medicine analyze the effect of patients' insurance status on their health care or lack of care. One article gives a glimpse into what happens when patients lose Medicaid coverage. Another article shows how physicians’ clinical decisions take into account patients’ insurance status.

“Short-Term Impacts of Coverage Loss in a Medicaid Population: Early Results From a Prospective Cohort Study of the Oregon Health Plan” notes that all 50 states implemented Medicaid cost-containment strategies that affected millions of beneficiaries during the recent economic downturn. In Oregon, which was the focus of the study, the Oregon Health Plan changed coverage under its OHP Standard Medicaid benefits package for low-income single adults and couples with no children. Changes included higher premiums and copays and elimination of some benefits, according to the article.

Within 10 months after the changes to the OHP Standard package, some beneficiaries, who responded to a mailed survey, said they lost coverage, some had coverage disrupted and some maintained coverage. Sixty-seven percent of those who lost coverage reported having unmet health care needs, compared with 40 percent of those with disrupted coverage and 28 percent of those with stable coverage. Only 45 percent of those who lost coverage had had a primary care visit in the previous six months, compared with 74 percent of those with disrupted coverage and 82 percent of those with stable coverage.

“Primary Care Physicians’ Perceptions of the Effect of Insurance Status on Clinical Decision-Making” tracks the role of insurance status in physicians’ decisions during the course of patients’ visits. The article’s authors include current and former staff members from the AAFP’s Robert Graham Center in Washington.

In this pilot study, 23 family physicians and two pediatricians submitted 409 post-visit surveys, and 22 of the 25 physicians said they made a change away from their preferred clinical management because of patients’ insurance status at least once during the visits. The physicians changed their preferred clinical course with 44 percent of uninsured patients, 30 percent of publicly insured patients and 19 percent of privately insured patients. Examples of the affected clinical decisions included not prescribing medicine to help a patient stop smoking and not referring a patient with a family history of colon cancer for colonoscopy.

An editorial in the same issue, “Reliving History and Renewing the Health Care Reform Debate,” builds on the two articles described above. The editorial authors note, “Deciding not to order tests and treatment should be based on necessity and standards for high-quality care rather than because there is no one to pay the bill.” They add, “Cutbacks in Medicaid in response to skyrocketing costs, like those seen in Oregon, are becoming commonplace, as are decisions of employers and individuals to go without health insurance because it is so costly.”

The authors continue, “The challenges before us are enormous. … the situation around the country is in many ways worse than 20 years ago." Referring to the need to renew the health care reform debate, the authors insist, "Debate alone is not enough; this time we must emerge from the debate with actual solutions.”

Titles of other articles in this issue of Annals, as well as the title of its supplement, include