Health Insurance Doesn’t Equal Health Access

A sliver of cross-partisan agreement on healthcare: It’s not fair to have to pay for something you can’t access.

It has been observed by many people that red states, and in particular red rural counties, have had the largest increases in insurance coverage through Obamacare. So why would they be against it? Why would they be adamantly convinced they had to pay their money to help somebody ELSE?

In some cases, it’s probably straight partisanship, or a globalized sense of persecution, or just not knowing the score. But in other cases, they’re right, for a simple reason: Health insurance is meaningless if you can’t use it to access medical care.

That’s one of the reasons we created Obamacare in the first place – to get rid of insurance that doesn’t actually insure you, that drops you the second you make a claim. However, bad insurance wasn’t exclusively the problem, because the existence of insurance doesn’t magically create doctors where you need them.

If you are not in or near a sufficiently large population center, medical care is hard to come by. Doctors just aren’t there. Don’t want to be. Don’t want to move out to the middle of nowhere to make less money; don’t want to have to start their own one-room practice rather than join a medical community they can consult with, and refer to, and commission tests from.

If you want to see this expressed in a jokey fictionalized way, watch Northern Exposure. The struggle is real. My best friend lives in New Mexico, and has expensive “good” work-based insurance, and had to wait something like two years to get registered with a primary doctor even though she was willing to drive anywhere within 120 miles of her house. There aren’t doctors out there. Patient rolls are full. Even now, she has to assume she’ll spend $100 a month on urgent care, even though all she usually needs is for a nurse to shine a flashlight in a kid’s ear and, say “yep, ear infection” and prescribe a course of antibiotics – because there’s no chance she’s going to get a timely appointment with a pediatrician.

This isn’t a market failure; it’s the way markets work. Doctors don’t want to move to that area. You move to a small town because you have roots in the small town, and basically for no other reason. Meanwhile, the kinds of people from small towns that have big medical school dreams often have big other kinds of dreams that don’t involve the small town.

Freeing up the insurance market further, by allowing people to buy insurance across state lines, is not going to fix that, because it’s not an insurance problem. It’s the kind of thing that is best handled by creating a National Health System, which requires doctors to put in time out there, pays them some kind of bonus for that tour of duty, and sets aside large grants to create community health centers in geographically isolated areas. Obamacare didn’t do that. Republican Obamacare 2.0 doesn’t do that either. I’m not super optimistic that U.S. legislators are ready for that particular grand bargain, considering we weren’t even able to get rural broadband access going.

But absent such access: Yes, it is unfair to force people to buy insurance they cannot apply to their own medical care, whether because copays make those visits unaffordable or because there are not doctors to take the insurance. That is an absolutely fair critique. That is a way of making people with fewer resources subsidize people with more resources. And since the individual mandate is one of the three legs of Obamacare and the whole stool falls over without it, we’re kind of stuck.

Just a reminder that the fight, long term, isn’t really over Obamacare, or shouldn’t be. It’s a fight to get affordable healthcare to everyone. A lightly-regulated free market system doesn’t do that: my evidence is that it hasn’t. But Obamacare hasn’t either. It makes sense that some people are mad they have to spend money they can’t really spare on something they can’t really use. On that much, we can agree.