Michael L. Millenson is a Highland Park, Illinois-based consultant, a visiting scholar at the Kellogg School of Management and the author of Demanding Medical Excellence: Doctors and Accountability in the Information Age.
The old axis of access in U.S. health care – insured or uninsured – is being replaced by the kind of gradations and complexity in determining who-gets-what-when-for-what-price for which the airline industry has become famous.
Some recent data and reactions to the provisions of the Affordable Care Act reinforce the trend. Here's an overview:
Being able to afford any kind of seat. While the number of Americans left standing at the gate because they can't afford a health insurance "ticket" is declining, the scheduled takeoff in insurance coverage has run into mechanical difficulties. The Census Bureau announced this month that the number of uninsured dropped slightly in 2011 to 48.6 million, or 15.7 percent of the population. That slide is partly due to a health law provision allowing parents to keep children on their insurance plans until age 26.
But prospects of adding another 30 million Americans starting in 2014 and going forward under the health law's various mandates and subsidies are now up in the air. The Supreme Court did not ground the entire law, but it did invalidate the penalty designed to compel states to expand Medicaid to many above the federal poverty line. That decision could void tickets to health insurance for an estimated three million people, says the Congressional Budget Office and Joint Committee on Taxation, and possibly a lot more, according to a critical analysis by two liberal legal experts.
A ticket isn't the same as a seat. As airline passengers have learned, having a ticket isn't the same as having a confirmed seat. In 2011, nearly one-third of physicians said they wouldn't accept new Medicaid patients because of payment issues; a smaller number of doctors have said the same thing about Medicare patients. Even with some private plans, you may be on permanent standby because the doctor of your choice does not accept your health plan.
Your private jet is ready. Of course, when money is no object, there are those who rate the equivalent of a private jet. That group would include individuals paying a reported $6,000 to $27,000 a month for "boutique" services like Guardian 24/7 (whose one-page public website simply says, "By Invitation Only"), World Clinic and PinnacleCare Private Health Advisory. The latter promises "medical research…at your fingertips," your complete health records instantly available online and "access to outstanding medical and emergency support anytime, anywhere."
First class, commercial flight. What's more interesting is what happens behind the curtain separating first class from other travelers on a commercial flight. Seated up front are the senior corporate managers who get "executive" physicals at places like the Mayo Clinic plus reimbursement checks for their out-of-pocket costs. One CEO with a total compensation package of about $9 million received another $23,000 to pay his medical bills, USA Today reported. These executive perks will be stopped by the health law in 2014 if loopholes can't be found.
Business class. Unlike Medicaid "recipients," Medicare 'beneficiaries' start off with a generous benefit at a modest price and can easily upgrade. They can choose a Medicare Advantage plan in which the average enrollee received more than $70 in additional benefits and reduced cost-sharing, as one recent study found. In addition, Medigap plans provide wrap-around coverage to pay costs traditional Medicare doesn't. And even middle-class retirees may be able to upgrade to low-end concierge medicine, like MDVIP.
Also traveling business class are those participants in the fast-dwindling number of health plans provided by unions, municipal employers or private companies where the worker contribution is minimal and benefits are generous.
Coach, but some people get better seats and prices. Patients with traditional Medicare coverage, a recent study found, are more likely than those with private health insurance to get needed care, to avoid access problems due to cost, to avoid medical bill problems and to be satisfied with their coverage. Medicare even reduces racial and ethnic disparities in access and drug expenditures.
But being a high-wage worker with a good employer-sponsored plan also is a great way to get a good ticket. A new Kaiser Family Foundation survey found that workers at businesses with more low-wage employees paid an average of nearly $1,000 more for their share of premiums than workers in a high-wage environment. That may not quite equal a free "executive" physical at the Mayo Clinic, but it's not bad. (KHN is an editorially independent program of the foundation.)
Overall, workers at small firms face higher cost sharing, including higher copayments and higher deductibles, and may face a greater premium contribution, the KFF survey found. Think of it as a high-cost ticket and maybe a middle seat, to boot. In that same vein, the health overhaul's ban on insurers using pre-existing condition information to refuse coverage or raise prices doesn't take effect until 2014, which affects today's self-employed workers who are older and have families. Those workers can find themselves paying much more than the $15,745 average premium cost for family coverage under an employer plan. State plans for high-risk individuals who are otherwise uninsurable typically are high priced and full of restrictions.
Sorry, your flight has been delayed. Of course, even sitting in first class doesn't mean your flight won't have mechanical problems or weather delays or a rough landing. Similarly, the most comprehensive insurance is no guarantee of high-quality, safe and appropriate care.
A new ticketing system? For all the inconveniences of the current health insurance system, it is at least familiar. However, both the public and private sectors have plans to shake up the shopping process as has happened in the era of deregulated airlines. It may come through easy-to-compare online shopping for basic health plans when the health law's coverage mandate takes effect in 2014. It may be the use of vouchers and comparative shopping among insurers for Medicare beneficiaries, as in the Republican Medicare plan proposed by Rep. Paul Ryan, R-Wis., the GOP vice presidential nominee. Or it may be in the increased use of high-deductible health plans by the private sector that put the onus on employees to choose the best care value.
Unlike with airline tickets, however, consumer choices in health care can lead to consequences that truly are non-changeable and non-refundable. Whether the industry turmoil leads to more Americans getting a better "seat" at a better price remains to be seen.