Sindhu Kubendran
Senior Research Analyst, Health Economics Research
Sindhu Kubendran is a senior associate and research analyst at the Milken Institute who focuses on areas of public health that include prevention, wellness, chronic disease, and longevity. At the Institute, Kubendran is a co-author of the reports, “Healthy Savings: Medical Technology and the Economic Burden of Disease,” which examines...
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Curing health care a heavier lift than fixing a website
By: Sindhu Kubendran
November 12, 2013

The Patient Protection and Affordable Care Act (PPACA) aEUR" Obamacare aEUR" has dominated the news. On October 1, the health insurance exchanges, one of the most innovative aspects of the health care law, were launched in a process filled with mishaps. The exchange website,, has been criticized for technical difficulties.The site malfunctioned due to traffic overloads, potential enrollees experienced confusion over eligibility requirements, and there was a poorly developed transfer of information to crucial third parties such as insurers.

As I read these articles, I found the bewilderment among news reporters and the public over somewhat odd. To be sure, we should expect the high-profile and clinically significant exchange website to function properly. But I am not surprised about the current predicament. I used to work at a federally qualified health center and saw firsthand the struggles medically underserved patients routinely encounter in their attempts to obtain government-sponsored or low-cost health care. They, and I, had come to accept and even expect these difficulties as part of the process.

Enrollment requirements for programs such as Medi-Cal have always been confusing; patients in need of insurance or medical care had to come to the clinic several times to register. For many of these prospective patients, transportation would be a great obstacle. Too many patients needed services, so they would often wait a month or more for their first visit with a clinician. Coordination of care was an arduous process aggravated by the clinicaEUR(TM)s financial constraints. Administrative resources were insufficient, and the clinic was still in the process of rolling out and adjusting to its new, expensive health IT system. This made it hard for health professionals to relay clinical information in the seamless way more integrated clinics can.


Diagram by Gary Hirsch and Sherry Immediato from their Health Care Microworld simulation. See

These problems were not unique to the clinic where I worked. They are representative of the issues facing underserved or vulnerable patients across the United States. From my perspective, the access issues with seem like nothing more than a continuation of the status quo aEUR" which itself represents a problem not simply with access to insurance but the overall health care delivery system. The launch of Obamacare has brought these issues to light in front of the mainstream media, with reporters finally beginning to focus on the complications that have characterized the system of care for low-income patients for years.

While coverage of the poor functioning of reveals real issues, all this attention to the websiteaEUR(TM)s woes obscures the bigger problem with health care delivery. The system as a whole is overloaded, with the demand for care and levels of disease not matched by the geographic distribution of supply. In delivering care, providers too often must contend with conflicting needs, such as risk avoidance versus cost saving, contributing to both the underutilization of effective care and overutilization of unnecessary care. Coordination of care is poor, leading to inefficient transfer of information and further ineffective use of resources. In a broad sense, the system is too expensive for the mediocre outcomes it yields.

Obamacare was developed to address these problems. It requires health plans to provide coverage for cost-effective services and encourages the creation of quality-driven systems such as accountable care organizations. It is uncertain how these new delivery systems will play out, as relatively few have been active long enough to serve as reliable models. But these developments are important — delivery system reform is likely to affect all Americans, not merely the uninsured and underinsured.

While technical issues with are a barrier to accessing insurance, this is only one of the many barriers that prevent too many Americans from receiving high-quality health care.