Health Care Affordability in 2014 : Failing Grade for U.S., But the ACA Could Turn It Around

By Jame OBrien

SUMMARY: The U.S. ranked last among 11 countries in a recent report on the state of health care. A key reason, in the study: high costs are blocking access to services. But the report also suggests that the ACA can change that scenario for the better. We look at the numbers, and the prognosis going forward. When it comes to the health care system in the United States, we might be closer to the end of dark days for affordability  and the barriers to access that unaffordable care creates but we're not out yet. A new report by The Commonwealth Fund, which has been assessing and ranking health care around the world for years in its Mirror Mirror on the Wall series, paints a grim picture for the U.S. As measured across the board, in areas of quality, effectiveness, access, efficiency, and equity, the rankings were as follows: Australia; Canada; France; Germany; the Netherlands; New Zealand; Norway; Sweden; Switzerland; United Kingdom; United States. Last place for the U.S., and one of the key ways we're not making the grade, according to the report, is in the area of affordable care that all individuals can access. We've the most expensive system in the world  the U.S. spent $8,508 in a year, per person, on health care (some 50% more than the report's second highest-spending country, Norway)but individuals using that system are still describing a troubling situation. " For many, insurance isn't buffering expenditures. Approximately 40% of U.S. respondents, both insured and uninsured, paid at least $1,000 out of pocket for medical care, in 2013. " 59% of the U.S. doctors surveyed told the Fund, in 2013, that affordability is a problem for people in need of medical attention. The numbers are hard to ignore. But so is the notion that we have a brighter future on the horizon, if the Affordable Care Act does what it's supposed to do for all Americans. And so, let's take a closer look at the findings, and at the potential for an emerging U.S. system that better addresses the costs associated with good health for all. The High Price of Equity: Paying for Health Care Getting ranked last is a hard pill to swallow. In the Fund's report, the numbers tell us that people in need of care are often not getting it because of the price tag attached. " 37% of the Americans polled said they did not follow through on recommended care, fill a prescription, or visit a medical professional because of cost. The next highest percentage was the Netherlands at 22%. " 28% said their insurance companies either denied them payment for medical care or they did not pay as much as the individual expected. (Followed by France: 17%.) " 23% of Americans said they had serious problems paying their medical bills, or they could not pay them. (Followed by France: 13%.) In all 11 surveyed countries, individuals reporting below-average incomes also more often reported having chronic health problems. " 39% of Americans with below-average income and medical problems, in the span of 201213, did not see a doctor because of cost. By comparison, only 17% of U.S. individuals with above-average incomes described that scenario. " 30% of below-average income answerers said they skipped prescriptions because of cost. Above-average income earners saying the same: 12%. Some good news, then? A remedy might already be in place. The Fund hasn't ignored the impact, and the the potential, of the Affordable Care Act as it approaches its first anniversary since implementation. The ACA and the Future of U.S. Health Care Equity Last year, 2013, was a particularly interesting year for the Fund to conduct its study the first year the ACA became operative. After a slow ramp-up, and with certain state-by-state challenges still ongoing, there are positive signals emerging from the reform. More than 8 million people entered the new system by the end of March 2014  far exceeding the predictions of even its federal proponents. And the New England Journal of Medicine estimates that some 20 million people gained coverage by May 2014. If we set aside for the moment all other ways of evaluating U.S. health care  from efficiency to effectiveness of care  and consider only the cost of care and its consequences for the individual patient, the ACA is, of course, designed to drive improvements along this very front. Among its numerous features, the following trio cut to the core of that idea. " Americans with incomes between 100% and 400% of the federal poverty level are eligible for subsidies to help them purchase health insurance. " For those who earn to much to get Medicaid, but too little to buy a state-exchange plan, the ACA provides the Basic Health Program  giving participating states a pool of money with which to leverage lower-price insurance. " When it comes to co-payments and deductibles, buying plans at the Silver level or higher mean further reductions to costs for the individual. And data in recent years from states that precede the ACA in health care reform tell us that the effects of more affordable care  from a financial perspective, at least  can be measurably positive. For example, Massachusetts has had its own reformed system in place since 2006. In that state, the number of bankruptcies attributed to medical bills dropped to 52.9% , down from 59.3%. Indeed, the Fund sees the future influence of the ACA as an important context for considering this year's report. It says so in the first pages of the study. "The U.S. has made significant strides adopting health information technology and undertaking payment and delivery system reforms spurred by the Affordable Care Act," wrote the authors of the 2014 report."Continued implementation of the law could further encourage more affordable access and more efficient organization and delivery of health care, and allow investment in preventive and population health measures that could improve the performance of the U.S. health care system." The prognosis might well be looking up. If the ACA works in the ways it's supposed to, state by state and nationwide, we can look forward to a follow-up report from The Commonwealth Fund that can't be summarized by pairing the words "U.S." and "last".