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We are all in this Together

By Dr. Cathleen London, MD

We are a month away from hearing the Supreme Court decision regarding the Affordable Care Act, and this week 2 studies highlight the need for the ACA.


We know that being uninsured is detrimental to one’s health, resulting in worse health outcomes, but a new study by a healthcare economist shows that high rates of uninsured mean worse outcomes even for those with coverage.  From 1999 to 2006, California had a 19% reduction in mortality from heart attacks. Across the state there was a large variation: San Francisco and Los Angeles had decreases between 26 percent and 30 percent, while in Sacramento, the drop was just 13 percent.


The author compared outcomes for insured heart attack patients in these cities, controlling for basic demographic information, as well as preexisting conditions.  He found that in cities where more uninsured patients are treated there were worse outcomes for insured patients.

The author estimates that, if a lack of insurance were eliminated, there would be 3 to 5 percent fewer deaths among those who already had coverage.


He describes this phenomenon as “negative spillover”.  Hospitals that treat more uninsured patients have a higher rate of uncompensated care which takes away resources that could be used to upgrade medical equipment, improve staffing or other investments that improve health outcomes. This results in worse care for ALL patients treated at the facility.  Conversely, increasing insurance coverage might have “positive spillover” effects – improving the quality of care for the already insured.  The author concludes that policies aimed at addressing the uninsured may have additional benefits to insured patients in the same communities.



The other study, by the Urban Institute, shows that access to care is eroding for millions – even those with insurance. The findings suggest that more privately insured Americans are delaying treatment because of rising out-of-pocket costs, while safety-net programs for the poor and uninsured are failing to keep up with demand for care. Overall one in five American adults under 65 had an "unmet medical need" because of costs in 2010, compared with one in eight in 2000.


People with private or public health insurance have significantly better access to care than the uninsured. If the ACA is overturned or scaled back, "we would be likely to see further deterioration in access to care for all adults -- uninsured and insured alike," it concludes.


While the Affordable Care Act does not solve the US healthcare paradox of both overtreatment and undertreatment it is certainly a first step in the right direction.  Quality healthcare for all Americans starts by covering all Americans.

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