Increases in Worry Over Health Care Costs and Skipping/ Postponing Treatment Due to Cost Over the Last Year
|PERCENTAGE WHO SAY THEY ARE VERY OR SOMEWHAT WORRIED ABOUT…|
Increases in Worry Over Health Care Costs and Skipping/ Postponing Treatment Due to Cost Over the Last Year
|PERCENTAGE WHO SAY THEY ARE VERY OR SOMEWHAT WORRIED ABOUT…|
Recently we’ve been working with one of our member health systems to build a comprehensive plan for ambulatory access. As we were brainstorming a list of success metrics, one physician leader made an interesting comment: “I’ll know we’re successful at improving access when people stop calling me asking to get their mom or husband or friend into a specialist.”
The other leaders in the room all nodded in agreement. While we’re all happy to assist friends and family with finding the best doctor for their problem, or getting in more quickly, these leaders recognized that these informal channels represent yet another level of inequality in our healthcare system: patients and families who can tap into “insider” provider connections have access to a “black market” of enhanced access and information that can expedite treatment, assuage worry, and potentially provide better outcomes.
Thinking about eliminating the need for the healthcare black market broadened our discussion of a successful access solution. Getting a quick appointment doesn’t fully solve the problem, patients want to be assured they’re seeing the “best” doctor for their problem—meaning the system needs to have a better process for matching new patients to the most appropriate provider.
One call to tap into the “black market” can eliminate a dozen frustrating calls and dead ends; any solution must also address the many friction points in finding the right care. A tall order for sure, but one that could address one large inequity in our healthcare system: the difference between people who know someone on the inside and those who don’t.
The Trump administration wants to drop an Obama-era rule designed to ensure that there are enough doctors to care for Medicaid patients.
State health officials say the rule, which requires states to monitor whether Medicaid reimbursement rates are high enough to keep doctors in the program, forces them to spend a lot of time collecting and analyzing data with little benefit. Health care advocates, though, fear that dropping the regulation would enable states to set those payments at a level that would cause some of the 72 million Americans who rely on Medicaid to scramble for health care. Research shows that when reimbursement rates drop, fewer providers agree to accept low-income Medicaid patients.
Although the Medicaid Access Rule, adopted in 2016, pertains to Medicaid fee-for-service plans, the Trump administration also is seeking to relax requirements on how states determine whether Medicaid managed care organizations have enough providers.
If reimbursement rates are too low, there’s a risk that health care providers would see fewer Medicaid patients or even refuse to treat Medicaid enrollees altogether. That, in turn, could lead to longer wait times to see providers still participating in Medicaid or force patients to travel longer distances to reach providers remaining in the program.
Medicaid, the government health plan for low-income U.S. residents, covers 1 in 5 citizens. It is jointly administered and financed by the federal government and the states.
The rule, the Centers for Medicare and Medicaid Services (CMS) said, “excessively constrains state freedom to administer the program in the manner that is best for the state and Medicaid beneficiaries in the state.”
According to Matt Salo, executive director of the National Association of Medicaid Directors, scrapping it would eliminate a bureaucratic headache for states that, in the end, hasn’t improved patients’ access to providers.
“Nobody is moving the goal of improved access,” Salo said.
Some health care advocates disagree, pointing out that the rule hasn’t been in place very long and that getting rid of it fits the Trump administration’s overall mission of giving states more freedom in operating Medicaid.
“The Trump administration’s approach to Medicaid has been state flexibility, giving states a lot more discretion to do what they want without a lot of attention to what beneficiaries need,” said Abbi Coursolle, a senior attorney with the National Health Law Program, a group based in Washington, D.C., that works to protect access to health care for low-income populations.
CMS last year called for a significant watering down of the Obama rule. Last month, the agency proposed to scrap it altogether. The comment period on elimination of the rule runs through next month, after which CMS will announce its decision.
The initial proposal to weaken the rule generated plenty of opposition. Among those objecting were hospital and physician organizations, groups that advocate for health care access for all, and organizations created to support those living with certain diseases and to raise funds for research into those conditions.
Among the latter was the Epilepsy Foundation, which warned in its public comment that weakening the rule would deprive CMS of information it needed to monitor and enforce Medicaid beneficiaries’ access to care. State reimbursement rates, the foundation said, are crucial to ensuring enough willing providers are available to treat Medicaid beneficiaries.
Shawn Martin, senior vice president of the Academy of Family Physicians, said scrapping the rule would make states more likely to set reimbursement rates too low, prompting practitioners to stop taking Medicaid patients or cut back. “A low reimbursement would affect how many beneficiaries providers are willing to see.”
Just as adamant on the other side, however, are many states that complain that the Obama rule is cumbersome and ineffective at ensuring access for Medicaid beneficiaries.
At the Maryland Department of Health, Tricia Roddy, a research director, said the rule doesn’t do much to help gauge the fees’ effects on access to care.
Similarly, at the Colorado Department of Health Care Policy and Financing, Marc Williams, a spokesman, said his state uses other strategies to ensure Medicaid beneficiaries’ access to the health services they need.
According to Salo of the Medicaid directors group, states of both political stripes, red and blue, are delighted that the Trump administration is moving to abolish the rule.
“It was creating many bureaucratic burdens without accomplishing anything concrete,” Salo said. The rule, he said, “is insanely micro-managed and overly bureaucratic.”
The 1965 law establishing Medicaid has been amended through the years to ensure that enough doctors, nurses and other providers are available to serve beneficiaries. Congress in 1989 passed an amendment making clear states’ obligation to pay providers enough to ensure Medicaid enrollees have access to care.
Medicaid pays doctors about three-fourths as much as Medicare, the government program for senior citizens, according to a 2017 analysis by the Urban Institute, a nonpartisan think tank in Washington, D.C. And Medicare pays much less than private insurers.
When Medicaid and Medicare payments, or reimbursement rates, go down, research shows that patients make fewer doctor’s visits and more trips to the emergency room.
According to a 2017 Kaiser Family Foundation report, only about 70% of office-based physicians accept new Medicaid patients. The results vary from 39% in New Jersey to 97% in Nebraska. By comparison, the study found, 85% of doctors accept new patients with private insurance.
The 2016 rule required states to tell the agency every three years how providers from various geographic regions and specialties were participating in Medicaid, and how reimbursement rates were affecting that participation.
As recent congressional hearings on Medicare for All proposals have illustrated, members of Congress and presidential candidates are looking outside the United States to find ways to achieve universal coverage. Some have suggested that other countries are able to provide universal coverage because they “ration” care — a term rife with negative connotations. This post examines the extent to which health care is rationed in Germany, the Netherlands, Sweden, Switzerland, and the United Kingdom — as compared to the U.S.
Examples of health care rationing tend to focus on long wait times for procedures —such as hip replacements, or MRIs — or limited access to the newest drugs. This happens in some (but not all) countries and can be a challenge for policymakers. But there are other ways in which health systems engage in rationing, by restricting access to insurance, through insurance benefit design, or by imposing high patient cost-sharing. While other countries may ration because of national budget constraints and supply-side factors, the United States’ lack of access to comprehensive insurance and affordable care represent a de facto form of rationing that leads people to delay getting care or going without it entirely.
In the five European countries we examined, all residents are entitled to health care through the national system. These range from tax-funded systems in Sweden or the U.K. to private insurance-based systems in Germany, the Netherlands, and Switzerland. In the latter, governments regulate premiums to be affordable and provide income-related subsidies to low-income families, which include 27 percent of Swiss and 30 percent of Dutch residents. Governments also mandate generous benefit packages that typically guarantee a minimum set of services: primary, specialty, and hospital care; prescription drugs; mental health; maternity; and palliative care.
In comparison, there are 30.4 million uninsured people in the U.S. Not having affordable, comprehensive insurance coverage often means that sick Americans do not even get in the door to see a doctor. For those who do have coverage, new rules that allow states to circumvent the Affordable Care Act’s mandated essential health benefits may mean skimpy coverage for some.
Patients in some countries face longer wait times for specialty care than in the U.S., where only 25 percent of Americans need to wait longer than one month for a specialist appointment. Patients in Germany and Switzerland get in just as fast (27% and 26%, respectively) as their U.S. counterparts, but those in Sweden and the U.K. do not (45% and 43%, respectively). Similarly, very few U.S., Dutch, and Swiss patients (4% to 7%) who need elective surgery face wait times longer than four months, while 12 percent of Swedish and British patients do. It should be noted that in Sweden and the U.K., where wait times for specialty care are longer, people can buy supplemental insurance to gain quicker access to private specialists.
While Americans overall enjoy shorter wait times for specialty care, wait times for same- or next-day appointments when sick are around average compared to other countries. U.S. adults are among the most frequent users of emergency departments. Nearly half who do report doing so because they couldn’t get an appointment with their regular doctor.
In a recent Commonwealth Fund survey, fewer than one of 10 patients in the U.K., Germany, the Netherlands, or Sweden reported skipping needed care or treatments because of cost. This contrasts sharply with the U.S., where one of three Americans reported the same. This is partly because of the rise in high deductibles, unpredictable and opaque copayments, and higher health care prices in the U.S. than in other countries. An estimated 44 million Americans who have insurance are effectively underinsured because their out-of-pocket costs and deductibles are very high relative to their incomes.
Other countries are more protective. In the U.K., Germany, and the Netherlands, patients have no out-of-pocket costs when they visit a primary care doctor, and Brits never pay for hospital care. In Germany, out-of-pocket costs are capped at 2 percent of annual household income and 1 percent for chronically ill people. In Sweden, out-of-pocket costs for physician visits and drugs are capped at $370 annually. No one in these five countries declares bankruptcy because of medical debt.
A commitment to providing universal coverage means that other countries have to make hard choices to ensure that each health care dollar is spent effectively.
Countries aim to give patients access to the most clinically meaningful and cost-effective drugs. In the U.K., only drugs that are deemed cost-effective are covered, while in Germany, manufacturers have to demonstrate that their new drug adds clinical benefit to negotiate a higher price than other existing drugs. This doesn’t mean that new technologies aren’t available; in fact, 79 percent of new cancer drugs are approved for routine use in the U.K.
These kind of controls, coupled with fixed copayments and annual caps on patient drug spending, translate into better access. While nearly one of five U.S. adults skip doses or do not fill a prescription because of costs, just 2 percent to 9 percent of patients do so in the other countries discussed here.
It would be a missed opportunity for America to ignore lessons about universal coverage from other countries out of a fear that they ration health care more than we do. In reality, more people in the U.S. forgo needed health care because access to care is rationed through lack of access to adequate insurance or unaffordable services and treatments.
We have an intuitive sense that things like what we eat, how much we exercise, the quality of our water and air, and getting appropriate health care when sick all help us stay healthy, but how much do each of these factors matter?
Studies have also shown that our incomes, education, even racial identity are associated with health — so-called “social determinants of health.”
How much do social determinants matter? How much does the health system improve our health?
In the 1970s the Centers for Disease Control and Prevention tried to answer these questions but had little rigorous science to guide it. Though we know a great deal more today, they still have not been fully answered. This is no mere curiosity — knowing what makes us healthy will help us direct investments into the right programs.
Over the years, many frameworks have been developed to illuminate what affects health. The relationships are so complex that no single framework captures everything. To get us started on this research project — and our broader conversation about what drives health — we created a model that allows us to explore some of the dimensions of these drivers, and their relationships to each other.
We developed our framework by reviewing research on factors that influence health and surveying similar projects and tools from prominent organizations . It is not meant to be complete, but a starting point that allows us to think about what drives health and how.
Indirect vs. Direct Factors
Many things affect health, some directly and others indirectly. Government/policy, income/wealth, education, and racial identity don’t necessarily affect health in an immediate way. They are indirect factors that tend to affect health through complex pathways. Those pathways usually involve other factors that more immediately affect health. These are the direct factors such as occupation, health care access, and health behaviors.
Why these Outcomes?
There are many possible health outcomes. The framework includes four examples—age-adjusted mortality, life expectancy, quality of life/well-being, and functional status. These outcomes are commonly studied, prevalent in the literature, and reflect the kinds of things people care most about.
A wide range of government policies can affect health. For example, in 2007, Australia became the first country to introduce a government-funded human papillomavirus (HPV) vaccination program. For years later, significantly lower levels of HPV were present in the population. As another example, studies show that Medicaid expansion in the US facilitates access to care and improves self-reported health outcomes. Policies outside the health system can affect health too. Those pertaining to deportation of undocumented immigrants and same-sex marriage have been linked to health outcomes, for example.
Income and wealth are associated with health, but through complex pathways. While income and wealth facilitate access to health care, food, and housing, it’s also true that good health facilitates labor force participation, potentially leading to higher income. Several studies suggest that income and resources have profound effects in early life and development, but a much smaller effect on adults.
Racial Identity is closely associated with health outcomes in the US. For example, African-American adults experience much higher levels of mortality than white adults, from all causes. Racial Identity also plays a role in the accumulated stress from discrimination and in the quality of health care received.
Evidence suggests that gender identity plays a role in health and health care. For example, one study found that women with angina pectoris and low socioeconomic status were referred to cardiologists less frequently than men.
Genetics play a role in the development of certain disease. For example, while cancer is not caused by genetics, most cancers have some genetic determinants. The BRCA1 and BRCA2 genes play a role in tumor suppression, and, when mutated, increase the risk of female breast, ovarian, and other cancers.
Environmental factors — natural and built — have profound effects on our health. Of course, factors like air quality affect our health, evidenced by a study that demonstrated an association between higher levels of air pollutants O3 and PM2.5 and pediatric pneumonia. Environmental conditions even before birth (present during fetal development) can affect health and well-being into adulthood.
Medical care is designed to facilitate good health, so both the quality of medical care and access to it influence our health outcomes. One study found that the medically uninsured receive 20% less care after auto accidents and have significantly higher mortality rates than people who are insured.
Health behaviors encompass a wide range of human behaviors that affect health including: physical activity; diet; sleep; and tobacco, alcohol, and other substance use. Just as one example, reducing exposure to tobacco has been identified as the single biggest way to prevent morbidity, disability, and early death.
Social relationships can affect mental and physical health as well as behaviors and mortality risk. The people we are surrounded by (at an early age, parents, and later in life, peers and romantic partners) strongly influence health through mechanisms of stress, social support, and pressure to engage in or avoid risky behaviors.
Occupation is linked to health outcomes, and may both cause health due to the conditions of the job, and be caused by health due to the limitations particular to certain conditions.
Historical vs. Current, Marginal Effects
When attempting to quantify the impact of direct health-related factors, it is important to make a distinction between how much of our current health is related to these factors versus how much of our current health can be improved by interventions that target particular factors. Grasping this distinction is critical so that we know where our dollars are best spent to maximize health improvement. In other words, how much have each of these factors affected our health in the past through today versus how much could they affect health in the future if policy was immediately changed? For example, a disease like smallpox has a huge direct effect on health outcomes, but it has essentially been eradicated, so an additional investment in eradicating smallpox has virtually no marginal gains, even though the disease is closely linked to health.
It is also relevant to consider the timespan on which we see certain effects taking place, especially when considering policy intervention. For example, with an environmental change such as improving the air quality, it would take a significant amount of time for all measurable changes in health outcomes to manifest; other interventions, such as dramatically increasing flu vaccination rates, could have significant health outcomes that would be observable on a much shorter timescale.
Correlations vs. Causation
Considering the available literature on social determinants of health and the links between these factors and measurable health outcomes, it is critical to clarify whether what we are observing or seeking is a correlation or causation. Correlations can guide hypothesis generation, but only causation is actionable in terms of policy.
Finally, it is worth considering how a framework like this relates to policy intervention. The specific interventions that might be effective within a category (e.g., health behaviors) could change over time. For example, promotion of wearing motor vehicle seat belts was an important area for policy interventions in the 1970s and 1980s, but is less so now because doing so has become commonplace. Though health behaviors remain relevant to health today, the class of interventions that would have the largest impact are different.