Although policymakers sometimes portray increasing access and reducing cost as separate objectives for health care reform, the two are closely related. When North Carolinians lack immediate access to primary care or mental health services, they bear the cost either of waiting for an appointment or of traveling long distances to get the care they need.
According to the state’s Department of Health and Human Services, 82 of North Carolina’s 100 counties rate poorly in access in primary care. Most are exactly where you’d expect them to be, in our state’s most rural eastern and western areas.
Thinking about a lack of health care access as an additional cost helps clarify what might otherwise be muddy issues. For example, advocates of Medicaid expansion, Medicare for All, and other expansive approaches to government finance of health care tend to conflate price and cost.
It certainly matters who pays the bills — patients, taxpayers, or some combination thereof. But shifting the price from (relatively) shallow pockets to (apparently) deep pockets doesn’t necessarily change the cost. Indeed, in some cases it may increase the true expense of delivering the service by making patients less cost-conscious or by imposing regulatory burdens that exclude some providers from the market, thus reducing competition.
In large swaths of North Carolina, access to medical care is a big problem. Let’s tackle it, in ways that don’t shift costs but actually reduce them.
One idea is to make it easier for advanced-practice nurses to set up shop in rural areas. For example, North Carolina is one of only 12 states requiring that nurse practitioners, certified nurse midwives, clinical nurse specialists, and certified registered nurse anesthetists agree to be “supervised” by a physician. I put that term in quotes because, in reality, the supervision is minimal — sometimes the docs and the nurses are separated by hundreds of miles and rarely see each other — but the latter must pay the former for the privilege.
A bill making its way through the General Assembly this year, the SAVE Act (which stands for Safe, Accessible, Value-directed and Excellent care), would address this and other unwarranted obstacles to providing affordable primary care in rural areas.
Another solution in some circumstances will be to expand the use of technology. While ill-suited for some services and patients, telemedicine is already used routinely and effectively to diagnose conditions, prescribe or supervise treatment, and provide counseling services. It could do more to expand access under the right regulatory framework.
To be more specific, North Carolina should not let its licensing laws block rural residents from accessing out-of-state specialists as long as those physicians are in good standing with their home states’ medical boards.
On the other hand, state lawmakers shouldn’t try to “help” the field expand by dictating to health plans how they must pay for telemedicine services. “If insurers are forced to pay for virtual services at the same rate as in-person services,” explains John Locke Foundation health-policy analyst Jordan Roberts, “there is no incentive for the utilization of technology that has the potential for cost savings and a more patient-centered form of care.”
No matter what policymakers do, there will still be local differences across North Carolina in access to medical services. People choose where to live based on a host of considerations. Some prioritize urban amenities. Others place a higher value on housing prices, family roots, rural lifestyles, and wide-open spaces. Given economies of scale, some health-care institutions and options are only going to be available in metropolitan areas.
But the gaps don’t have to be as wide as they are now. Better access to primary care, in particular, will help keep rural North Carolinians healthier while saving time and money. That will, in turn, strengthen rural communities. We don’t need to break the bank or vastly expand government to accomplish the goal. We simply have to reduce regulatory barriers so that health providers and patients can make mutually beneficial arrangements. We have to target cost, not just price.