Four Factors Impacting Access to Healthcare and Your Insurance

Injuries and specific illnesses can result in the need for healthcare services from a specialist physician. Besides cost, three other factors described by the federal DHHS that can prevent your acquiring healthcare services are inadequate health insurance (or no insurance), lack of availability of needed healthcare services, and lack of care that is culturally-competent.

Preventing the inability to acquire healthcare services when needed requires consideration of these factors in advance of sudden need for them. Considerations to avoid an inability to acquire healthcare services when needed are described below, as well as why reaching the goals of HealthyPeople 2030 matters for overall public health.

Cost of Healthcare Services as a Factor

The fee charged to insurance companies for medical care differs between hospitals and outpatient physician practices. Since many insurance plans (including Medicare) require that a deductible be met by you before insurance payment commences, understanding the cost of services provided to you is important.

If you are paying out-of-pocket for a service not covered by your health insurance, it makes sense to compare costs between providers before scheduling your appointment. Home healthcare services for personal care are often not covered (or are strictly limited) by insurance plans. If you break your wrist or undergo spinal surgery, you may need help bathing, dressing, and cooking for quite awhile.

Since Medicare restricts such coverage to specific circumstances, even someone who is Medicare-enrolled may need to pay for home healthcare services provided by a home health aide. According to an AARP article in 2019, the typical sources for payment to home healthcare agencies of prolonged care by a home health aide are:

• Annuities;
• Investments and/or savings accounts;
• Life insurance policies;
• Borrowing (such as by utilizing a reverse mortgage)

Inadequate Health Insurance as a Factor

Private insurance can differ markedly in the deductibles and co-pays required for specific healthcare services. One arena where coverage can differ markedly is for diagnostic tests (such as MRI or PET scans). This is also the case for Medicare Advantage plans. Although the federal government has ensured that diagnostic testing for Covid-19 is covered by insurance (along with the uninsured), coverage for treatment can vary (as described in a research article in Health Affairs).

Lack of Availability of Healthcare Services as a Factor

People with thyroid disorders, heart disorders, or cancer need to visit a specialist physician periodically for their care. However, some geographic regions of the US have few specialist physicians available for the population that needs their services (and especially in rural areas). Meanwhile, some health insurance plans require the use of “in-network” physicians.

If there is no “in-network” specialist physician meeting your needs – and you have to seek care out of the plan’s network – you may be faced with a high out-of-pocket expense. The best way to avoid this situation is to consider your personal health circumstances before enrolling in a specific PPO health plan. If you have Type 2 diabetes and the only covered endocrinologist is someone you do not like, you may prefer enrolling in a different health plan.

Culturally-Competent Healthcare as a Factor

Sensitivity to your cultural (and other) unique aspects about you is important for developing a trustful relationship with your physician and other health providers. If English is not your first language, it may make sense for you to receive care from a physician – and other clinicians such as nutritionists – who understand your native language. This is especially vital for people with Type 2 diabetes in the development of weekly meal plans to ensure good diabetic control.

Dietary preferences are often culturally-based, so you will be more likely to adhere to your prescribed diabetic diet if it includes food items familiar to you. Of all of these four factors, culturally-competent care has historically received the least attention by hospitals and ambulatory care practices.

Barriers to Care for People with Inadequate Health Insurance or No Insurance

The following are four barriers to healthcare specifically affecting people with inadequate (or no) health insurance (per the US Office of Disease Prevention and Health Promotion (ODPHP):

1. More likely to have poor overall health status;
2. More likely to be diagnosed later in the disease progression (such as at a later cancer stage);
3. Less likely to receive medical care;
4. More likely to die prematurely (and/or from a preventable condition)

If you are considering switching your health insurance plan or seeking insurance, you can schedule a consultation with a UrHealth Benefits agent to discuss your options.