Consider a patient who has been told to arrange a specialist visit. She calls the number in her plan’s directory, learns that the practice cannot see her, and starts again. Her referral remains open in the electronic record. To the sending office, a task may appear complete. To the patient, the work has barely begun.
This illustrative example captures the difference between a financial entitlement and a functioning care pathway. Coverage matters. But an insurance card cannot establish whether a clinician is available, whether the appointment is timely or whether the patient can reach it. The World Health Organization explicitly includes needed services, quality and protection from financial hardship in its account of universal health coverage.[1]
A useful reform question therefore goes beyond enrollment: what happens when the person tries to obtain care?
The gap between coverage and use
Financial barriers can remain after enrollment. In the Commonwealth Fund’s 2024 Biennial Health Insurance Survey, 23% of working-age adults were classified as underinsured despite having coverage throughout the year. Among underinsured respondents, 57% reported forgoing needed care because of cost.[2] These are survey estimates using the Fund’s specified income-related thresholds. They are not a count of every inadequate insurance arrangement, nor proof of the effect of any particular deductible.
Their practical message is still clear. A policy can provide coverage while leaving patients worried about using it. Affordability should be assessed against household resources, alongside the clinical importance of the service. The same charge can represent very different burdens to different families.
Distance creates another obstacle. The journey to a clinic includes transport, accessibility, work schedules and caregiving. A short trip on a map may be difficult in practice. In its 2022 report on rural obstetric care, the Government Accountability Office described declining availability and stakeholder concerns about financing and workforce recruitment.[3] Those findings identify a capacity problem that enrollment alone cannot solve.
Design around the whole journey
I propose that access be measured as a sequence. Can the patient secure an appropriate appointment, reach the service, understand the options, obtain the agreed treatment and complete necessary follow-up? Where that sequence breaks, someone should be responsible for investigating why.
For referrals, the sending and receiving teams should agree on responsibility for outstanding results, urgency and failed contact. A patient should know whom to call if the appointment cannot be arranged. A directory should be tested against actual availability. A system should distinguish a patient’s informed decision to decline care from an appointment that was never realistically obtainable.
These proposals require staff time and funding. Adding another tracking obligation to an overwhelmed practice without support can create more documentation without better access. Payment and staffing should recognize coordination as part of care.
Geographic planning also requires honest choices. Every community cannot safely provide every specialized service. When care must be centralized, travel, accommodation where necessary, communication and local follow-up should be included in the design. Technology can support some contacts; its suitability should be judged against the clinical task and the patient’s circumstances.
The goal is not to count more transactions. It is to establish whether the patient reached the next clinically appropriate step. A scheduled visit, a completed test and a clear explanation mean more than a referral that has simply left one office’s inbox.
References
[1] World Health Organization. Universal health coverage (UHC) [Internet]. Geneva: WHO; 2025 Dec 5 [cited 2026 Sep 8]. Available from: https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)
[2] Collins SR, Gupta A. The state of health insurance coverage in the U.S.: findings from the Commonwealth Fund 2024 Biennial Health Insurance Survey [Internet]. New York: Commonwealth Fund; 2024 Nov 21. Available from: https://www.commonwealthfund.org/publications/surveys/2024/nov/state-health-insurance-coverage-us-2024-biennial-survey
[3] U.S. Government Accountability Office. Maternal health: availability of hospital-based obstetric care in rural areas. Washington, DC: GAO; 2022. Report No.: GAO-23-105515. Available from: https://www.gao.gov/products/gao-23-105515