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Posts Tagged ‘healthcare access

How do healthcare and health outcomes in the US compare to those of other developed countries?

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By: Vanessa Gordon-Dseagu, PhD

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source: pixabay

For much of 2017, the Trump administration engaged in numerous attempts to repeal the Affordable Care Act – legislation that was considered by many to be the first step towards the introduction of universal healthcare within the US. As the debate continues over the role of the government in the provision of healthcare, comparisons with systems abroad may reveal important shortcomings within those found in the US. There are a number of methods to assess and compare the performance of a healthcare system; this essay focuses upon the key areas set out by the Peterson-Kaiser Health System Tracker – spending and health outcomes (those amenable to health-service provision) as well as the uninsured/access. By looking at the provision of healthcare internationally, we may learn key lessons in how to improve the US system.

Cost

In 2016 the US spent around 17% of its GDP on healthcare (around $3 trillion). This is almost double the amount spent by other industrialized nations, while the amount of healthcare used per capita is similar across countries. The key reason for this appears to be cost. Patients in the US pay far more for their healthcare to be provided than their international counterparts, with one study finding hospital prices in the US to be 60% more than those in Europe. One reason for this appears to be the high cost of insurance administration within the US system caused by, oftentimes, fractured and duplicative provision. Hospitals must employ large departments to properly bill insurance companies and verify insurance coverage, costs that are passed on to the patient. In comparison, nationally or regionally organized systems, free at the point of need, do away with the need for insurance administration. The Affordable Care Act (ACA) sought to address some of the administrative waste and duplication found within US healthcare provision by employing economies of scale and streamlining the insurance procedure.

The cost of prescription drugs in the US is also an issue for concern for patients and policy-makers alike. The US spends more per capita on prescription drugs than other countries within the Organization for Economic Cooperation and Development (OECD). A 2016 JAMA study found that per capita spending on prescription drugs was $858 a year within the US, compared with $400 for 19 other industrialized countries. One factor likely influencing this is the more rapid uptake of new and, thus, more expensive prescription drugs within the US compared with other OECD countries. While an equally important factor is the price at which the drugs are sold in the US compared to other countries – drug prices in the US are substantially increased compared with other markets. The experience internationally is that policies, such as centralized pricing and universal healthcare, as well as other price controlling strategies, are effective at reducing drug costs. While the majority of developed countries enact some form of price regulation, within the US, the federal government is legally prohibited from negotiating drug prices for its widely administered Medicare program. Further to this, for each new drug the US Food and Drug Administration approves, it upholds a market exclusivity period, ranging from six months to twelve years, in which it will not approve a generic form of the same drug, limiting access to cheaper generic drugs. This, combined with US patent law protections, means that, on average, a brand-name drug manufacturer can expect their product to be on the market between 12-16 years before  the introduction of generic competitors. In comparison, across Europe 13 countries have policies which make generic drug substitution mandatory, 13 have voluntary protocols, with only five forbidding the practice.

The uninsured and access to healthcare

The World Health Organization considers universal health coverage to be a system within which 1) individuals can use the health services they need; 2) the care is of a sufficient quality to be effective; 3) individuals are not exposed to financial hardship caused by accessing the services. Of the 35 countries within the OECD, 32 have healthcare legislation that is in keeping with the WHO definition of universal healthcare. The US is now the only high-income country not to offer universal health insurance coverage.

Although the introduction of the ACA reduced the number of uninsured in the US from 44 million in 2013 to a low of 28 million in 2016, by the end of 2017 the number of uninsured had again risen by 1.3%, an estimated 3.2 million individuals. The causes of this increase may relate to the uncertainty surrounding the potential repeal of the ACA under the current administration, the repeal of the individual mandate within the Trump tax bill, the exit of several insurers from the ACA market and increasing health insurance costs.

The benefits of healthcare coverage upon health outcomes are well documented and relate to access to preventive, ambulatory, primary and secondary healthcare. Further to this, access to healthcare is particularly important for those with complex or ongoing chronic conditions. A review of the evidence related to health insurance coverage and health concluded:

“There remain many unanswered questions about U.S. health insurance policy, including how to best structure coverage to maximize health and value and how much public spending we want to devote to subsidizing coverage for people who cannot afford it. But whether enrollees benefit from that coverage is not one of the unanswered questions. Insurance coverage increases access to care and improves a wide range of health outcomes. Arguing that health insurance coverage doesn’t improve health is simply inconsistent with the evidence.”

To overcome some of these issues, members of the House of Representatives (with a parallel bill introduced in the Senate in 2017) have been developing the Expanded & Improved Medicare for All Act, colloquially known as ‘Medicare for all’. The bill seeks to take the role of government in healthcare one step further than the ACA and introduce:

“A system in which a single public or quasi-public agency organizes health care financing, but the delivery of care remains largely in private hands. Under a single-payer system, all residents of the U.S. would be covered for all medically necessary services, including doctor, hospital, preventive, long-term care, mental health, reproductive health care, dental, vision, prescription drug and medical supply costs”.

Health outcomes

In relation to access, the US system has been found to fall short, particularly in the areas of primary care, prevention and management of chronic conditions. In its comparison of healthcare systems, the Commonwealth Fund concluded that the US ranked last on access. The insufficiencies of these areas of care contribute to the lower life expectancy found within the US compared with the majority of OECD countries – in their 2016 report, the US was found to rank 26 out of the 35 OECD countries. The same investigation found that the US also fell below the OECD average in several more nuanced indicators of health (for example maternal and infant mortality). In the same study undertaken by the Commonwealth Fund, the US ranked last out of 11 comparable countries for healthcare outcomes. The report also found that the US had the highest rate of mortality considered amenable to the provision of care. Compared with the other 10 countries under investigation, the US performed better in areas such as in-hospital mortality following a cardiovascular disease related event and five-year survival for some cancers. The lack of easily available preventative services may also contribute to the high, and increasing, rates of non-communicable diseases such as diabetes, as well as other conditions such as overweight and obesity, for which the US has the highest rates within the OECD.

Despite the substantially increased costs of healthcare in the US compared with international counterparts, the population is not experiencing a corresponding improvement in health outcomes. International comparisons suggest that tighter regulation of costs, particularly those related to insurance administration and prescription drugs, may go some way to addressing this issue. The introduction of universal coverage is also likely to allay some of the deficiencies inherent to healthcare provision within the US. How the issue of the provision of healthcare is broached by this, and future, administrations will have a substantial impact upon the health of the nation.

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Written by sciencepolicyforall

February 1, 2018 at 11:42 am

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

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By: Rachel F Smallwood, PhD

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         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