More coverage but more cost: Are we better off now than 20 years ago?
The dawning of a new decade always sparks reflection. As we ponder how the 2020s will be different from previous decades, we also look back to see how far we’ve come. Or, in the case of health care affordability, how little has changed.
In a recent study in JAMA Internal Medicine, Harvard Medical School colleagues Laura Hawks, David U. Himmelstein, Steffie Woolhandler, David H. Bor (also a member of the Lown Institute Board of Directors), Adam Gaffney, and Danny McCormick examine trends in access to health care over the past 20 years.
They find that despite more Americans having insurance coverage now than at the turn of the century, the high cost of care for insured and uninsured alike keeps many people from being able to access preventive health services. In fact, more people in 2017 reported not being able to see a physician because of the cost than in 1998.
Hawks et al. used the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System to assess differences in access to physicians and preventive care for adults under 65. They found that the rate of uninsurance decreased from from 16.9% in 1998 to 14.8% in 2017–great news! However, the rate at which respondents said they were unable to see a physician because of the cost grew from 11.4% to 15.7% over the same time period.
This study points to two trends affecting health care affordability in the US: Rapidly rising costs, and increasing gaps in health insurance. The price of an office visit grew by $100 on average from 2003-2016. Prices for benchmark health care services such as knee replacement or appendectomy have also increased, especially for those with private insurance. At the same time, health insurance premiums have increased, and high-deductible plans with coinsurance fees have become much more prevalent.
The result is that many more insured people in 2017 are unable to see a doctor due to cost, compared to in 1998. In 2017, 1 in 9 insured people unable to see physician because of cost, compared to 1 in 14 in 1998.
Still, uninsured people face even greater challenges affording care; in the survey, far more uninsured people reported not being able to access care due to cost than insured people (39.6% vs 11.5%). Further, 20-30% of uninsured adults with a chronic medical condition (diabetes, heart disease, or hypertension) reported not having a check-up within the prior two years, a disturbingly high percentage which has not improved since 1998.
Are we better off now than 20 years ago? In some ways yes, because increased coverage from the Affordable Care Act has helped many people access care– specifically adults age 18-26 who can be covered under their parents’ plan and those now covered under the Medicaid expansion. However, for those with private or employer-sponsored insurance, the Affordable Care Act has done little to reduce the cost of care. And as the cost of care has grown, employers and insurers have increasingly pushed more and more of the burden onto patients, in the form of higher premiums, deductibles, and co-pays.
Ensuring that all Americans have insurance coverage is essential, but it’s only the first step. The insurance we provide has to be meaningful (what good is insurance if you are still stuck with thousands of dollars in co-payments?) and we need to control costs so that health care is accessible and affordable for everyone.