But that immediate access to world-class care also gave me pause, particularly as I remembered some of the patients I’ve seen over the years. Patients who are uninsured, those covered by government programs such as Medicare and Medicaid, and those who are underinsured frequently have difficulty accessing any care, let alone the sophisticated treatments and technology I enjoyed. The stark contrast between my situation and theirs presented a moral conundrum.


Published 4/1/2012
John R. Tongue, MD

The Access-to-Care Conundrum

In my address to the fellowship at the AAOS Annual Meeting in February, I raised three issues that I believe are the major challenges facing our specialty—access to health care, the quality and value of orthopaedic surgery, and improving patient safety. In this and upcoming columns, I want to explore these issues in a little more depth.

During the past 2 years, both my wife and I faced life-threatening illnesses. We both survived, thanks to the unrivaled quality of health care in this country. I felt privileged to be receiving care from some of the best physicians in the world.

John R. Tongue, MD

The uninsured
Access to health care—or the lack of access—has significant repercussions for all of society. Already, healthcare costs consume more than 17 percent of the country’s gross domestic product (GDP) and are expected to reach 20 percent of the GDP within the decade. Such spending is patently unaffordable, so how can we afford to expand access to care?

I don’t have the answer, but the statistics concern me.

  • According to the U.S. Census Bureau, more than 50 million Americans are uninsured (Fig. 1).
  • More than one in five adults younger than age 65 (22 percent) were uninsured in 2010, which puts their health and financial security at risk.
  • As many as 45,000 Americans die prematurely each year because they don’t have health insurance coverage and thus are less likely to undergo screening tests, seek care for chronic conditions, or have access to effective treatments.
  • Illness or medical bills are contributing factors in more than half of all bankruptcies.

Indeed, there are those who would rephrase the question and ask, “How can we not afford to expand access to health care?”

A study conducted by econo-mist José A. Pagán, PhD, a Robert Wood Johnson Foundation Health & Society Scholar, found a relationship between rates of uninsured individuals in a community and unmet medical needs. In communities with high rates of uninsured individuals, even people with insurance report higher rates of unmet medical needs.

The uninsured are far more likely to use hospital emergency departments or urgent care centers for routine primary care, and far less likely to seek medical care through a doctor’s office, than those with insurance. The costs of caring for the uninsured are passed along to insurers, employers, and individuals in the form of higher healthcare costs.

The recent economic downturn has had a significant impact on access to health care. An increase in unemployment, a decline in employer-sponsored insurance plans, and rising costs for an employee’s share of employer-provided coverage have also contributed to the increasing numbers of uninsured Americans.

As I asked in San Francisco: Why is the United States the only developed country in the world without access to basic health care for all of its citizens?

Medicare beneficiaries
It is not only the uninsured who face access problems. More than 76 million baby boomers have begun joining the ranks of those covered by Medicare—one every 8 seconds since December 2010. Each year, the number of Medicare beneficiaries will increase by about 3 percent, while the number of workers rises by less than 1 percent. As a result, the number of workers per beneficiary is projected to drop from 3.4 today to 2.3 in 2030.

With fewer workers paying into the system, and more beneficiaries demanding more intensive and expensive care, current estimates are that the Medicare trust fund reserves will be exhausted by 2024.

Neither reducing fee payments to physicians nor shifting payments between primary care and specialist physicians will be sufficient to reduce the spiraling increase in costs of care with our present healthcare system. We must increase our country’s investment in our physician workforce, and attracting the best people into medicine will require competitive compensation.

Although few orthopaedic surgeons I know plan to retire completely at age 65, many wish to reduce the hours they spend in surgery.

Is the answer coming?
Some states have already begun to address the issue of access in a variety of ways—from the “universal coverage” of Massachusetts to the “rationing” of benefits in my home state of Oregon. By the time you read this column, the U.S. Supreme Court will have heard arguments on the constitutionality of the Patient Protection and Affordable Care Act (PPACA)—both favoring and opposing the law. (See
“States Take PPACA to the Supreme Court.”) The Court’s decision will obviously have a major impact on access to care.

Under PPACA, an “individual mandate” would go into effect in 2014, requiring all Americans to have health insurance. Those who cannot afford individual coverage would be able to take advantage of health exchanges or an expanded Medicaid program. These provisions were designed to enable more Americans to have better access to health care. But many believe the requirements are an overstepping of authority by Congress, in violation of the Constitution and an impingement on states’ rights.

Whatever the Court’s decision, the moral dilemma remains. As physicians, we are confronted with issues of access to care on a daily basis. How do we decide whether and to whom we provide care? I don’t have the answers, but I realize that we, as physicians, must consider the issue, get involved, and be part of the solution.

Additional Resources

  1. http://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp; Accessed 3/5/12
  2. http://www.census.gov/newsroom/releases/archives/income_wealth/cb11-157.html; Accessed 3/5/12
  3. www.kff.org/uninsured/upload/1420-13.pdf; Accessed 3/5/12
  4. http://pnhp.org/excessdeaths/health-insurance-and-mortality-in-US-adults.pdf accessed 3/27/2012
  5. http://www.washingtonpost.com/wp-srv/politics/documents/american_journal_of_medicine_09.pdf; Accessed 3/5/12
  6. http://www.rwjf.org/healthpolicy/product.jsp?id=24775; Accessed 3/5/12
  7. http://www.chrt.org/news/press-releases/announcing-cover-michigan-survey-2011/; Accessed 3/5/12
  8. http://www.usatoday.com/news/washington/2010-12-30-medicare30_ST_N.htm; Accessed 3/5/12
  9. http://www.ssa.gov/oact/TRSUM/index.html