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How Easy is it to Access Health Care in the US?

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By: Rachel F Smallwood, PhD

Source: pixabay

         Access to health care has been a concern as long as there has been health care, and it is one of the hot-button issues of health care policy debates. The recent repeal of the Affordable Care Act and passing of the American Health Care Act (AHCA) in the House of Representatives has again brought this debate front and center. The Congressional Budget Office’s analysis of the first iteration of the AHCA indicated that it would result in 24 million less people having health insurance by 2026. It would also place more of the financial burden on people making less than $50,000 per year. However, substantial changes were made to parts of the bill before it passed in the House, and there will likely be more if it is to be passed in the Senate. There is much debate and dissension on what level of access to health care should be provided by the government and whether health care is a right versus a privilege. In addition to that debate, there are other facets of the United States’ health care system that need examination and work to ensure access to health care.

There are many reasons a person may not have access to health care – not having health insurance is just one. To measure access to health care, one must first define it. Is there some quality standard that must be met for treatment to be considered health care? How do we determine whether one person’s health care is equivalent to another’s? With health care measures that range from necessary, recommended but not dire, to completely elective, even these differences can be difficult to quantify. Most institutions collecting data on health care use a working definition like that set by the Institute of Medicine in 1993: access to health care means a person is able to use health care services in a timely manner to achieve positive health outcomes. This implies that a person can enter the health care system, physically get to a place where they can receive health care, and find physicians whom they trust and who can provide the needed services.

Indeed, there are differing opinions on what constitutes “access”, and this heterogeneity is further compounded by the multiple barriers to access. For example, with the recent AHCA proposal, many representatives spoke about separating the concepts of health care coverage and health care access, while others believe that the two are not separable. There are at least four factors that limit a person’s access to healthcare. The first barrier is the availability of health services; if the necessary health care is not provided within reasonable traveling distance of a person seeking services, none of the other factors matter. The other three factors are personal barriers such as a person’s perceptions, attitudes, and beliefs about their own health and health care, organizational barriers such as referrals, waiting lists, and wait times, and financial barriers such as inability to afford insurance, copays, costs beyond deductibles, and lost wages.

The current policy in the United States is the Affordable Care Act, put into place under the Obama administration. One of the most contentious points of the law is its requirement that every person have health care coverage or pay a penalty. A 2015 survey released by the National Center for Health Statistics indicated a substantial drop in the percentage of the US population without insurance over the previous few years. There was a slight increase in the percentage of people with a usual place to go for health care (i.e. a primary care provider or clinic for regular check-ups), and a decrease in the number of people who failed to obtain needed health care due to cost, but simply requiring everyone to purchase health insurance did not induce a commensurate rise in people gaining access to health care, in accordance with the steps and measures discussed by the Agency for Healthcare Research and Quality. Additionally, there have been substantial increases in premiums, which means that those consumers still have a significant financial barrier to health care.

The numbers and policies referenced above address the country as a whole, but statistics vary widely across regions of the United States. US News ranked states on their access to health care using six metrics: child wellness and dental visits, adult wellness and dental visits, health insurance enrollment, and health care affordability. Some examples of the ranges seen between states in these measures are that 20% of adults do not have regular checkups in the highest ranked states, while around 40% do not have regular checkups in the lowest ranked states. In the highest ranked state for affordability, the fraction of people who needed to see a doctor but could not because of cost was around 7%, while in the lowest ranked state this percentage was just under 20%. While some of this is due to the differing demographics and living conditions from state to state, the discretion and freedom that states have in applying health care laws also factor in.

When comparing to other similar (high-income) nations, the United States falls short on access to health care. Although the Affordable Care Act improved access to health insurance, the US is still lagging when it comes to its residents receiving actual care. This is partially due to fewer physicians practicing general medicine in the US. In 2013, the US ranked below all other Organization for Economic Co-operation and Development countries, except for Greece, for the density of general practitioners per 1,000 people. A related measure showed that the US also had a lower percentage of physicians choosing general practitioner/primary care as their specialty than all other 35 countries. These countries are all World Bank-categorized high-income countries except for Mexico and Turkey, which are upper middle-income (and had better stats than the US). This disparity has been noted in the US and is driven by many factors including physician salaries, patient loads, and medical education emphasis (or lack thereof) on primary care. This shortage also disproportionately affects rural areas, likely contributing to some of the state-to-state variability noted above.

The United States is struggling when compared with similar nations to provide health care access to its citizens. The reasons for this struggle are multifaceted, including access to health insurance, financial barriers, and lack of primary care physicians. The political tensions and opposing principles held by individuals can also be barriers to working toward a more accessible health care system. We should be focused on developing a health care system where all can reasonably obtain health insurance, where health care costs are not prohibitively expensive, and medical education should emphasize the importance of primary care in our nation’s health and communicate the need for practitioners in under-served areas. Shedding light on these areas for improvement will allow people to work together to address our weaknesses and create a system that improves and sustains the health of our nation.

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Written by sciencepolicyforall

May 19, 2017 at 10:16 am