Health care vs. health care coverage: The difference matters

You’ve likely heard a lot about health care recently—reforming it, repealing it, and replacing it. But what is perhaps most confusing is how everyone from lawmakers to the media is talking about the subject. Often they use the term “health care” (preventative medicine, emergency room visits, and prescription drugs) interchangeably with “health care coverage,” an entirely different animal, and a pathway to health care itself.

This mix-up has made the latest attempts at a health care bill even more uncertain. Is “access” to health care—not health care coverage—really enough? Republicans seem to think so, but many argue that just as “access” to an expensive car doesn’t mean you actually have a way to pay for one, “access” to health care doesn’t mean people can afford it, leading to a poorer, sicker population in the long run.

So why does the difference between care and coverage matter? Well, it’s currently shaping the ACA reform making its way through the government—and lawmakers nowadays seem to be choosing health care “access” over health care coverage, which can affect the quality and price of care.

Here’s what you should know.

Coverage and care under the ACA

One of the most important pieces of the Affordable Care Act was the essential health benefits—10 services that all health insurance plans are required to cover. These services include:

  1. Ambulatory (outpatient) services
  2. Emergency services
  3. Hospitalization (inpatient care)
  4. Maternity and newborn care
  5. Mental health and addiction services
  6. Prescription drugs
  7. Rehabilitation services and devices
  8. Laboratory services
  9. Preventative, wellness, and chronic disease services
  10. Pediatric care, including dental and eye exams

This made health coverage—no matter what channel you got it through—one-size-fits-all. This blueprint was intended to lower the country’s health care costs by reducing visits to the emergency room and increasing visits to physicians, which are far less expensive.

Before these 10 essential health benefits, a physician could have turned you away if you didn’t have health insurance for the specific area of health care they covered. Emergency rooms could not. This meant that the overall cost spent on health care—often by those who didn’t have the money to pay—was becoming enormous. Back then, people still had “access” to health care—it was just likely to be the most expensive kind: emergency care. By introducing the 10 essential benefits and providing equal health care coverage to everyone, costs were supposed to go down across the board.

Health care coverage for you, not for everyone

Essential benefits sound good, right? The issue here is that many people believe that they shouldn’t be required to opt into types of care that they don’t need or want. Men, for example, could choose a cheaper plan without maternity care. Some don’t want preventative care and wellness visits; they simply want to cover their preexisting or emergency conditions. If people could pick and choose what they wanted on their health plans, they would ultimately pay less for those pieces.

These pick-and-choose plans provide that all-important “access” that Republicans are talking about. People have access to the care that they want—whether that is more coverage or less. Unfortunately, this only works on a rather immediate scale. As fewer people pay for any one service or plan, the more expensive that plan becomes.

So while the young and healthy may see their costs decrease as they drop parts of their health care coverage they don’t want, older and sicker people—those who rely on less popular coverage benefits—could see prices jump. This, in turn, makes their actual health care unaffordable, even if it’s technically “accessible.” You can’t be turned away, since you have health insurance, but you probably can’t afford the coverage or care you need.

In addition, the tricky part of health care is that people often don’t know what kind of care they need until they need it. You may not need prescription drug coverage now, but if diagnosed with a condition that requires prescription drugs, you could end up missing that essential part of your health care coverage. You can either skip the pills and potentially develop even more health issues, pay the full cost of the prescription up front, or get a new plan that covers your prescriptions—potentially with more difficulty and at a higher price than your original plan.

You have access, and you have choice, but whether you choose a prescription-friendly plan or to buy the drugs out of pocket, those drugs may be out of your price range.

What happens when “access” isn’t enough?

The ACA wanted to guarantee that all Americans had the same health care coverage. The health care reforms Republicans support have emphasized everyone having access to insurance—but not insurance with the same amount of coverage. It’s an important distinction to make. Emphasizing only health care “access” doesn’t mean that the sick would be turned away from care, but it could result in a sicker population and higher health care costs overall—most likely meaning higher long-term costs for businesses and individuals, even if they have the benefit of fewer regulations.

It’s no secret that health care is complicated—there are valid arguments for cutting coverage requirements, and valid arguments against cutting them, and both will have impacts on the plans employers can and should provide their employees. But mixing up access to care with affordable comprehensive coverage doesn’t make things any easier.