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May 18, 1994

Money Isn't EverythingNonfinancial Barriers to Access

JAMA. 1994;271(19):1535-1538. doi:10.1001/jama.1994.03510430091042

WHETHER they take the form of managed competition, single-payer systems, regulated multipayer approaches, or expansion of Medicare and/or Medicaid, virtually all health care reform proposals share an underlying principle: that provision of coverage to the uninsured will ensure their access to care. (An exception is direct subsidy of hospital indigent care, which does not encourage structural change or make physician-based primary care available to the uninsured.)

Unfortunately, the track record of American health care, especially in recent times, does not support the belief that coverage is equivalent to access. In the first place, all coverage is not created equal. For some theoretically insured groups, especially the Medicaid population, the availability of physician care is constrained,1-3 and differences have been found in treatment patterns among patients with Medicare alone, Medicare and private supplemental coverage, and Medicare and Medicaid together.4

Physicians' concerns about their financial viability following the introduction of

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