US trails other developed
countries in access to health care
By Esther Galen
12 January 2017
A major focus of political debate in the United
States as 2017 begins is what will happen to the Affordable Care Act, also
known as Obamacare, the legislation restructuring the US health care system
enacted in 2010, which took effect in 2014.
While Republicans denounce Obamacare as a total
failure, and Democrats defend it as a progressive, all be it limited, success,
the entire discussion revolves around an unstated assumption: that US health
care is the “best in the world,” requiring only minor adjustments in a system
based on the profit drive of privately owned corporations that sell health
insurance, drugs and medical equipment, and operate hospitals and other
facilities.
A recent survey shows that this consensus in
favor of the for-profit medical system in the United States is based on a lie.
The Commonwealth Fund questioned adults in 11 countries: Australia, Canada,
France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the
United Kingdom, and the United States. It found the US ranked at the bottom in
access to and affordability of health care.
Compared to the 10 other “high-income”
countries, the survey found: “Adults in the U.S. are more likely to go without
needed care because of costs and to struggle to afford basic necessities such
as housing and healthy food. U.S. adults are also more likely to report having
poor health and emotional distress.”
There are numerous indicators of the failure of
the U.S. for-profit healthcare system:
· One-third of US adults went without
recommended care, did not see a doctor when sick, or did not fill a
prescription because of costs.
· Fifteen percent said they worried about having
enough money for nutritious food and 16 percent struggled to afford their rent
or mortgage.
· Half of US adults struggled to get health care
on the weekends and evenings without going to an emergency department.
· Fourteen percent of chronically ill U.S.
adults said they did not get the support they needed from health care providers
to manage their conditions.
While the ten other countries outside the US
offer universal insurance coverage, their health care services have faced
cutbacks in recent years. In Britain, for example, dozens of hospitals,
Accident and Emergency units, maternity units, mental health units, children’s
heart units and GP surgeries have been downgraded or shut down, despite popular
opposition. However, even after cuts, the countries surveyed have better cost
protection and a larger safety net than the US, giving more people the ability
to get medical care.
The Affordable Care Act has increased the number
of people with private health insurance, but only by so redefining the meaning
of “insurance.” People are said to be “insured” when they are enrolled in
policies that require enormous out-of-pocket expenses and deductibles, which
means they cannot afford to use medical services and if they do, may go
bankrupt. In the jargon of the industry, they are “underinsured.” In fact, 31 million
Americans were underinsured in 2014 .
Obama and the Democrats based their health care
reform bill on the tendencies already prevailing in the private insurance
market. In the US, more and more employees getting group health insurance
through their employer and individuals buying insurance through a “marketplace”
or an “exchange” are only being offered high-deductible health plans (HDHP).
A health plan with a deductible means that other
than certain preventive services, the plan holder must pay for all medical care
until the deductible is met. So people with high-deductible plans are hit hard
paying for medical services before the health plan starts to pay. Even when the
health plan starts to pay, a person still must pay a copayment for health care
services that could be as much as 40 percent of the cost.
A Kaiser Family Foundation report found that the
average annual out-of-pocket costs per patient rose almost 230 percent between
2006 and 2015. A survey of employers found employee deductibles increased 67
percent from 2010 to 2015. In the last year for which figures are available,
for example, workers’ wages increased a mere 1.9 percent between April 2014 and
April 2015, whereas out-of-pocket medical expenses went up 9 percent.
Kaiser reported that 43 percent of insured
patients said they delayed or skipped physician-recommended tests or treatment
because of high associated costs. When patients put off medical care, they are
more likely to end up in a hospital Emergency Room. About 80 percent of
emergency physicians said they are treating insured patients who have
sacrificed or delayed medical care due to unaffordable out-of-pocket costs,
co-insurance or high deductibles. This represented a 10 percent increase during
the first six months of 2016.
The American College of Physicians noted:
“Evidence shows that cost sharing, particularly deductibles, may cause patients
to forgo or delay care, including medically necessary services. The effects are
particularly pronounced among those with low incomes and the very sick. In the
private insurance market, cost sharing typically is used as a blunt instrument,
without regard for an individual’s income or health status ... higher cost
sharing is associated with adverse health outcomes among vulnerable
populations, including individuals with a low income, poor health or chronic
illness, or those who are elderly.”
In the individual market, almost 90 percent of
enrollees in Affordable Care Act (ACA) Marketplaces are in a high deductible
health plan. A HDHP is one where the deductible is at least $1,300 for
self-only coverage or $2,600 for family coverage. So if your 2017 ACA plan has
a $1,500 deductible and you find out in January you need a CT scan that costs
$1,500, you would be responsible for paying the full amount. It’s easy to see
why someone would put off such a test.
The increasingly poor health of people in the US
is the result of a health care system based on increasing the profits of the
health care stakeholders. The health insurance companies have set up models of
patient treatment to maximize their profits and with lucrative benefits for
doctors and hospitals.
The modus operandi in health care, which
underlies patient treatment, is called value-based health care, in which the
business model and the care model become increasingly intertwined. The ACA
includes provisions that promote this trend in Medicare, the federally funding
health insurance system for the elderly and disabled.
The federal Centers for Medicare and Medicaid
Services (CMS) and private health insurance companies are moving from a purely
fee-for-service payment system to payment models that reward health care
providers based on the quality and cost of care provided. CMS and the
Department of Health and Human Services began implementing value-based programs
in 2001, billing them as “Quality Initiatives.”
Through these various doctor and hospital
programs, the insurance industry and CMS regulate patient care. They decide
what services health care providers will be paid for (and what they will not be
paid for), how much money providers have to save and how much they will be
reimbursed for patient care—and their “incentive” payment if they cut costs.
One of the tenets of this model is to declare
patients to be “health care consumers” who must be held responsible for the
financial management of their own care. They must shop around to find the least
expensive care or be able to afford the best care. One idea being floated by
large employers, for example, is to set a fixed dollar amount they will pay for
common but expensive procedures. For hip replacement, they could limit payment
to $5,000. Since the best doctors and hospitals charge more, only the wealthy
could get the best care.
The stakeholders involved with creating
Obamacare—health insurance companies, the Department of Health and Human
Services, hospitals, physician groups, drug companies and employers—all will be
involved in what comes next. The structures and systems are already in place to
make sure the stakeholders benefit and population suffers, unable to get good
quality, affordable care.
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