Health Insurance is not Healthcare
The vast majority of Americans have health insurance, by a 2022 Census report, the percentage of persons with health insurance was as high as 92.1 percent, a reflection of decades of work towards full coverage and increased access to healthcare systems in this country. There exists a common misconception that being insured equates to healthcare, but this is far from the truth, and invites further exploration. The concept of insurance in itself is relatively straightforward and ancient as civilization itself, with insurance regulations chiseled into our oldest system of law, Hammurabi’s Code, some 3,700 years ago. A set amount of money is paid at a regular interval to an insurer, known as a premium, in exchange for a guarantee of financial protection against potential losses or risks. When functioning as intended, insurance acts as a safety net, offering compensation for certain eventualities, in this case those being health issues. Health insurance is critically important, offering some financial protection from costly medical attention, such as car accident injuries, heart attacks, and hospitalizations. There is still much room for improvement, as demonstrated by the rising $220 billion worth of medical debt owed in this country, but for these kinds of catastrophic events, health insurance is playing its role and remains essential. Unfortunately, the same health insurance model is employed for the coverage of much more readily anticipated and common medical costs, and in this respect the model falls far short, contributing to ballooning health costs and poorer health outcomes relative to the dollars spent.
When most of us think of “healthcare,” we are often envisioning a traditional patient-physician relationship, the primary care model that remains the cornerstone of any well functioning health system. It has been estimated that a primary care doctor can provide up to 90% of health care services needed during a person’s lifetime, but we are nowhere near that goal. Insurance was never designed for the coverage of primary care and preventative services, and insurers have never willingly invested in the lower cost primary care model, instead continuously choosing to incentivize high cost, high tech, fragmented, and impersonal health services that have proven to be continuously and increasingly profitable. As a nation, we are spending close to $13 thousand per person on health expenditures, nearly double that of other comparable developed nations. Despite the high cost we pay, we continue to lag far behind our international colleagues in regards to observable health metrics, including life expectancy, infant mortality, diabetes management, and childbirth. This represents a threat not just to the physical and financial health of the individual, but writ large, poses a threat to the greater economy and workforce. This is not what most of us would think of as healthcare, and it calls us to remind ourselves of what modern healthcare in a wealthy nation should look like.
The immense value of a relationship with a good primary care physician is not hard to sell, but there remain major barriers. For patients, access remains an often insurmountable barrier, by a 2022 survey the average wait time for a new patient appointment was on the order of 26 days, and a wait time on average of six days for sick patients who already have an established relationship with their physician.
Major surveys last conducted in 2021 confirmed that despite the insurance coverage rate as high as 92.1%, only about 28.7% of adults report having a “usual source of care.” The benefits of primary care can not be overstated, a major literature review in 2005 helped highlight and quantify some of these improved health outcomes, with observable benefits in reduction of heart disease, cancer, stroke, infant mortality, to name just a few, and a prolonged lifespan. These findings were comparable to similar studies done internationally. Later research in 2021 reaffirmed these findings, and further examined both financial and health impacts, citing that US adults who regularly see a primary care physician have 33% lower healthcare costs and benefit from 19% lower odds of premature death compared to those who do not see a primary care physician. At a macroeconomic level, even conservative analyses have found that for every $1 allocated towards primary care services, there are about $13 worth of savings generated. On the physician’s end, compensation for primary care services under the insurance based model necessitates a high volume practice, and despite playing a critical role in the health system, compensation relative to our specialist colleagues remains on the order of $150 thousand less per year. The average medical school debt for a graduating student in 2024 is on the order of $200 thousand, and in light of this burden it is easy to understand why medical students who may have otherwise taken interest in primary care are pushed more towards specialist care, with a resultant shortage in the supply and access to primary care physicians, expected by conservative measurements to widen to a 50 thousand physician shortage in the next decade.
The data and studies conducted so far paint a somewhat bleak picture–while the benefits of primary care have been thoroughly demonstrated and most patients find these truths easy to digest and comprehend, the access remains an often insurmountable barrier. I do not propose that the Direct Primary Care model I have chosen will serve as a panacea for the many national and even global issues preventing broad primary care access, however, I have not yet found a model that offers a better solution to these issues on the patient or the physician’s end. In the field of medicine, much has been written about “The Triple Aim,” as a guiding ethos for improvement in the health system: the simultaneous pursuit of 1.) enhanced patient experience, 2.) improved population health and 3.) a reduction in costs. In recognition of the increasing issue of burnt out healthcare providers, this was expanded to the “Quadruple Aim” in a publication from 2014, adding the 4th objective: improving the work life for those who provide care. Dr. Mechley, a researcher in the Direct Primary Care sector, has accurately surmised that DPC is so far the only healthcare delivery model in primary care that manages to meet all four of the stated aims, benefiting both patients and providers alike.
Patients who have a DPC doctor benefit most directly in the quality of the care that they are receiving. Appointments tend to be on the order of an hour for introductions and annual physicals, and at least a half hour if needed for other needs, creating a strong foundation in the relationship and allowing the time to work together in development of a concrete plan for health improvement, maintenance, and prevention. The access is also far greater, with a doctor who responds to your messages and concerns in a much timelier and personal manner, and is available for telemedicine, same day, or next day appointments if needed. Pricing is transparent, and direct, and when considering the lack of copayments for office visits, advantages in pricing on lab services and generic medications, most patients find they do not pay any more for this higher quality care than they otherwise would, many studies finding that for many patients the overall annual healthcare costs are lower in this model. Consider the cost savings of a single prevented emergency room or urgent care visit with prompt care from a DPC doctor who knows you well. This high quality of care is foundational to the model, a 2024 survey conducted by the American Academy of Family Physicians found that 97% of DPC doctors cited the potential to provide better care as the primary driver for opening their practice. The advantages to the physician are also very significant, with the same survey finding 94% of respondents indicating overall satisfaction with their practice, and far lower rates of reported burnout when compared to their peers. The topic of insurance and its rocky relationship with healthcare is a hearty one, and I have only scratched the surface, with open enrollment season around the corner, I am drafting a follow up post on the coverage options available in the marketplace. I recognize the shortcomings of the present insurance based system, and I look forward to demonstrating to my patients at Sana Sana that there is a better way.
References
American Academy of Family Physicians. Direct Primary Care 2024 Data Brief. American Academy of Family Physicians, 2024. Available at: https://www.aafp.org/dam/AAFP/documents/practice_management/direct-primary-care-2024-data-brief.pdf
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