Introduction. Over the past four decades, U.S. health expenditure as a shar eof GDP has widened and increased substantially. In 1970, only about 7 percent of GDP was spent on health and this was a comparable percentage with other countries. The U.S. stayed relatively balanced until 1980s, when health spending began to skyrock in growth rates relative to GDP. By 2012, the U.S. was spending 7 percent of its GDP on health. . (“Health at a Glance”) This paper considers the reasons and implications for health care expenditure in the United States as well as the outlook for the Affordable Care Act to control costs as well as to increase access.
I.
The Organization for Economic Co-operation and Development (OECD) is a collection of 34 member states coordinated to promote economic and social well being across the world. Member states are generally advanced or emerging economies. The OECD provides a global data set that tracks health care spending internationally called Health Statistics. Compared to other member countries in the OECD, health spending in the United States as a percentage of GDP is the highest in the world. In 2013, health spending (not including investment) was 16.4%, compared to an average of 8.9% in the OECD. The second and third highest spenders were the Netherlands, with 11.1% and Sweden, with 11.0%. (“Health at a Glance”) Government spending in the United States as a portion of total spending on health has also increased from 2000, when it was 44% to 48% in 2013. This period notably saw the expansion of Medicare Part D Insurance coverage has increased in the United States and this has led to a decrease in households spending to 12%.. (“Health at a Glance”) Household out-of-pocket spending on health care remains comparable to other G7 countries such as Germany (14%), France (7%) and the United Kingdom (10%). . (“Health at a Glance”) Rising health care costs are a problem for United States citizens. The main reason many American citizens cite as what prevents them from accessing health care is cost. Persons whose incomes are below average or who are uninsured are the most likely to report not complying with treatment directions, not seeking follow up care or receiving recommended tests, not filling needed medications. Fifty-eight percent of physicians in the U.S. acknowledge their patients have difficulty paying for care. In 2012, 32 percent of uninsured adults reported not getting or delaying medical care because of cost, compared to five percent of privately insured adults and 27 percent of those on public insurance, including Medicaid/CHIP and Medicare.(Zuckerman) There is not a single agreement about a single cause of rising health care costs and expenditures in the United States. Many analysts site just the basic fact that there is more health care all around in the United States. More surgeries are performed, there is more medication, more diagnostic tests. There is good evidence to suggest that prices are high and some quantities of provided services are high as well. An OECD study in 2010 found that US price level of services in hospitals were approximately 60 percent higher than comparable OECD member state nations' hospitals. . (“Health at a Glance”) For a normal birth delivery, for example, the price in the United States would be about 50 percent higher than in France or Canada. For a caesarean section, the pirce was 30 percent higher and more than 50 percent high in Canada To have a hip replacement completed in the United States will require 45 percent cost increase over comparable OECD nations, as well. . (“Health at a Glance”)
Experts have analyzed other reasons for this drive in price increase as well.. First is technologies and prescription drug innovation. The increasing presence of new, state-of-the-art technologies and drug innovations pumps money into greater spending on health care development due to increased demand for new and costly services, even if they do not prove effective. In 2011, the United States average was $985 per capital on non-durable medical care and pharmaceuticals, which was nearly more than 50 percent higher than the OECD average of $485.00 Chronic disease such as obesity are also cited as a reason for the increase in costs. Chronic diseases such as obesity are some of the biggest consumers of health care costs by proportion, in particular during hospice and other end of life care functions. Approximately 32 percent of total spending of Medicare goes to patients receiving end of life care in their last two years of life. (National Center for Health Statistics) Much of this percentage goes towards physician fees and related hospital care costs that result from frequent and repeated hospitalizations. Another explanation for increased costs is the rise of chronic diseases, including obesity. According to the National Academy of Sciences, the United States has a higher rate of chronic illness per capita and a lower overall life expectancy compared with other advanced industrial economies in the world. Today, experts are pushing greater focus on developing preventative care measures in order to improve overall health but also to reduce chronic diseases' financial burdens. Administrative costs are a third and final factor contributing to U.S. health care inflation costs. Compared to all other OECD nations, the United States leads in portion of national health care costs allocated to insurance administration. Admittedly, it is difficult to tell what are the specific differences between public and private administrative costs because the definition of "administrative" varies. What is clear, however, is that the largest firms spend a smaller portion of total expenditure on administration.
While I agree that the cost of health care is a huge problem in the United States system today, I think that lack of access to care and other health disparities are equally if not more so worrisome. Health care's expansion under the Affordable Care Act is thought to significantly reduce costs of obtaining health care for millions of United States adults currently uninsured. Yet, the reality is that that many adults, even with newly implemented coverage, continue to face barriers (financial, nonfinancial) that limit or exclude their access to health care.(Kullgren et al.). Barriers such as these include services not covered by insurance plans which lead to high out-of-pock health care costs and which are associated with failures to meet full needs for adequate care in patients (Collins et al.). Some examples of nonfinancial barriers include getting an appointment within a reasonable time as well as getting transportation to visit a doctors' office. There is an uneven distribution across subgroups facing challenges obtaining health care. According to federal survey data, prior to full ACA implementation, adults living with disability were much more likely to cope with access problems compared to adults without disabilities (Agency for Healthcare Research and Quality). Persons living with disabilities also were more likely to face work restrictions or limitations and have enrollment in either Medicare or Medicaid (Brault). They were also more likely to be poor, limited in the kind or amount of work they can do, and enrolled in Medicare or Medicaid (Brault). The potential for improved access to care because of increased coverage will be lessened if other barriers to care, particularly those that affect adults with disabilities, are not addressed. A recent study by Zuckerman of the Urban Institutes' Health Policy Center considered data on a national sample of adults ages 1964 from the Marc 2015 release of the Health Monitoring Survey the Urban Institute releases each year. (Zuckerman) The author selected from adults who had reported being insured for a minimum of 12 months prior to the survey (in other words, having been insured a full year) in order to analyze what, if any, access barriers exist that are not a result of difference in status of coverage. The focus of this study was to consider the access barriers among the population of full year long insurance holding adults as well as by disability status which was self-reported as of March 2015. (Zuckerman) From the sample of insured adults, approximately 3.8 percent reprted finding difficulty in obtaining a doctor or provider within the past 12 months.(Zuckerman) Nearly 11 percent reported having trouble getting an appointment as a doctor's office at a time when one was required. Persons who reported a disability were found to be 7.5 percent more likely to report having trouble finding a doctor and getting an appointment when was needed by 20.5 percent.(Zuckerman)
A further issue underscoring disparities in access to care was the fact that adults living with disabilities were nearly 30 percent more likely to report having unmet medical care needs due to a doctor's office or hospital denything their health insurance. Compared with individuals without disabilities, persons with disabilities were found to be 10.1 percent more likely to have this predicament. One explanation for this difference, however, is that the differences may correspond to the high proportion of adults with disabilities also living with public medical coverage (4.8 percent versus 15 percent of adults who do not self-report as have a disability). Disabled adults were also found to be double as likely compared with other results to report needs not met because their doctor's office or medical clinic was not fully accessible. They reported difficulty in finding transportation to a doctors office or clinic. Adults with disabilities were also nearly twice as likely as other adults to report unmet needs because of problems with the accessibility of a doctor’s office or clinic (16.8 percent versus 9.2 percent), Adults with disabilities were also more likely to report not having met some medical needs because they were not able to get timely appointments.(Zuckerman) This study suggests, then, disparities with respect to access to care continue to be a pressing and expansive problem in the United States and in particular with respect to the communities of persons living with disabilities. This situation will require novel and sensitive ways to look at issues include supply of providers, how adequate is the network. In addition, adults with disabilities were more likely to report an unmet need because they could not get an appointment soon enough.
II. These results suggest that lowering barriers to health care access among insured adults, including those with disabilities, will require multifaceted efforts to address issues such as provider supply, network adequacy, coverage of needed services, and transportation options. These findings also point to the fact that increasing access to health care according to status of disability should require more attention to the barriers to service provision. These findings also suggest that disparities and reducing disparities will require attention above and beyond issues of mere afford ability. A huge proportion of individuals on disability are enrolled on Medicaid. Therefore, policies should target other areas of the health care system as well, such as Medicare reimbursement levels, networks of providers, and what benefits are covered. Adjustments in these areas may be crucial for fully reducing disparities in this area. (National Center for Health Statistics Several other criticisms have been lodged against the Affordable Care Act since its implementation starting in 2012. Some allege the Act fails to do anything about the problem of health care cost growth. These critics say that although Americans see the problems of access and cost as the two dual and primary issues with respect to health care, that the ACA ignores the problem of cost growth and instead focuses the majority of its attention on providing coverage for those uninsured. (Zuckerman) This criticism begs the question of what is the primary cost driver. Many critics in this domain believe that medical malpractice is one of the biggest and most significant cost drivers and that the legislation failed to pay attention to medical malpractice for the most part, perhaps for political reasons. Despite this criticism, there is strong evidence pointing to the fact that the Affordable Care Act is designed with clear attention to controlling at least some costs in the industry. And, as time unfolds in the coming years, some of these specific provisions are expected to the growth rate in health care spending and particularly in the area of Medicare. There are other provisions which analysts argue are admittedly more on the experimental side but which are geared towards improving health care delivery in a fundamental way, resulting in not only improved quality but improved efficiency as well. (National Center for Health Statistics) On the upside, two federal agencies as of 2015 including the Centers for Medicare and Medicaid Services as well as the Congressional Budget Office which declare that future projections in health care growth rates has already slowed. This may be in part just from the economy, but there is good reason to believe that this is also to the Affordable Care Act. (Zuckerman) Several measures in the Affordable Care Act have been specifically designed to implement slowed cost growth. In addition, there are payment cuts for Medicare providers, taxes on high cost insurance plans and many other proposals. The actuaries working for The Centers for Medicaid and Medicare recently projected that health expenditure would increase only by one percentage point over GDP growth. They cited the shift to the development of fewer designer drugs and the shift to higher deductibles in private health care plans, as well as widespread use of generic drugs. Actuaries also cited the mandated reductions on Medcare payments, as well the excise tax on higher cost plans as two examples. (Zuckerman)
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