Access to Healthcare: The US Income Disparity

In the U.S. our method of rationing healthcare is that if you have good insurance or lots of money you have access to good healthcare otherwise you don’t have access to good healthcare. I believe this is far more reality than the widespread U.S. perception that health care is rationed in countries with government funded universal healthcare.  A recent NEJM Perspective article details the status of access to health care for citizens of high vs low income status and validates this opinion.  Here is a how the article begins:

“The United States has been unusual among industrialized countries in lacking universal health coverage. Financial barriers to care — particularly for uninsured and low-income people — have also been notably higher in the United States than in other high-income countries. …  According to a 2013 Commonwealth Fund survey of adults in 11 high-income countries, the United States ranks last on measures of financial access to care as well as of availability of care on nights and weekends.1 Uninsured people in the United States are particularly likely to report encountering barriers to care.”

In general, the survey reveals that such barriers are particularly striking for adults with incomes below or well below their countries’ median income

 

Other points made in the article include:

  • Low income U.S. citizens are 3 times as likely as citizens of the other 11 high income countries surveyed to not visit the doctor, not fill prescriptions, or skip medication doses because of financial barriers.
  • The perception of many in the U.S. is that countries with single payer systems “ration” care. This study shows that for lower income citizens obtaining primary timely care in the U.S. is more of a problem that in the other countries. Even high income individuals in the rest of the countries studied do not perceive they have a lower standard of care.
  • Evening and weekend care is more available in other countries than in the U.S. for low income persons.
  • In contrast higher income U.S. citizens do not report more difficulty with access to primary care, evening or weekend care, or that costs inhibit access to care, prescriptions, or their impression of the quality of their care. Note that I don’t say that U.S. high income persons feel their care is better than high income citizens of the other countries, just that it is not inferior.

The article ends with this summary:

“The inequity of the U.S. health care system is particularly troubling. The difference in health care experiences between people with below-average and above-average incomes will need to be monitored over time to determine whether further steps to improve coverage, especially for those at the lowest end of the income range, are needed. Although Americans at both ends of the income spectrum were more likely than their counterparts in other countries to report financial barriers to care, it is the substantially worse experience provided to people with below-average income that most seriously undermines the overall performance of the U.S. health care system.”

Whether by subsidized access to care via a system resembling the Affordable Care Act but expanded and enhanced, or through a single payer system like essentially all other first-world countries the US will continue to be a downside outlier in measurable health outcomes.

2 Responses to Access to Healthcare: The US Income Disparity

  1. Cheryl: Nearly all experts agree with you in principle. The devil is in the details. What is quality? What metrics to use to decide who is providing quality care, who is not. Every physician thinks their patient are sicker and so simple “health” of patients simply induces physicians to “cherry pick” well patients, and try to avoid sick ones. I personally believe it will take a single payer government paid healthcare system, with physicians responsible for a panel of patients, and then metrics could be applied in some way. Try to sell that to the American public. So far no one even dares to try. DrP.

  2. Access to affordable and effective primary care could be more easily achieved in part by overhauling how primary care is reimbursed. Because of perceived low reimbursements by payers, a transactional relationship, providers are forced to increase production. This yields a less than desire able product: only being able to treat the sick. If providers are compensated for truly managing their patients’ health through appropriate care at the right time in their life, outcomes are improved as well as patient engagement with their PCP. They become an active participant in their own health care. By focusing provider reimbursements on quality and not quantity, compensating behaviors that promote better patient outcomes and moving from a transactional payer/provider relationship, we begin to see healthcare costs decline in part due to supplying preventative services that keep patients healthy and out of the hospital. Population management is effective and can be profitable in the right context. Good medicine shouldn’t be measured by RVUs produced or total $ amount billed – it should be measured by the health of your patient panel. Are they receiving the appropriate care? Are you receiving appropriate funding based on the health status of your patient population? Are complex chronic diseases being managed or are they driving your work? Managing care and value based contracting will get us far in the journey of providing access to affordable care for all.

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