Sunday, July 9, 2017

Does health insurance save lives? No: primary care does.

Two recent review articles in the New England Journal of Medicine and the Annals of Internal Medicine discussed the relationship between having health insurance and improving health outcomes (including mortality, i.e., "saving lives"). In my latest Medscape commentary, I analyzed these two articles in the context of the debate over the U.S. Senate's Better Care Reconciliation Act (BCRA), which the Congressional Budget Office has estimated would lead to 22 million more uninsured persons if passed, compared to current law. I concluded that arguments about the effects of gaining or losing health insurance largely miss the point, since any positive effects of insurance are most likely mediated through providing primary care:

It is plausible that the positive effect of insurance on health is real. The next question is, why? It's not because insured people receive more or better care for acute, life-threatening illnesses. Instead, people who gain insurance generally increase their use of preventive services and are more likely to report having a usual source of primary care, which other studies have found is strongly associated with lower mortality. In fact, I would argue that health insurance's positive effects on health are mediated largely through prepaid primary care services.

The American Academy of Family Physicians has joined several other major physician groups in opposing BCRA because absent modifications, it will certainly decrease access to primary care by making insurance unaffordable for low-income and other vulnerable populations who don't qualify for Medicaid or Medicare. But paying for a barely affordable bronze marketplace plan with a $6000 deductible hardly makes primary care affordable, either, outside of a limited list of preventive services. The solution? Make it possible for more people to buy inexpensive primary care without having to go through expensive health insurance.

Health reform proposals should build on the knowledge that primary care saves lives for a fraction of the cost of a health insurance premium. In the long run, Democrats and Republicans could find common ground between their "Medicare for all" and "covering everyone costs too much" positions by removing primary care from the inefficient insurance system entirely. Instead, Congress should guarantee everyone a family doctor through a community health center or direct-pay primary care, as physician and financial planner Carolyn McClanahan has proposed.

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