Impaired access to health care

Why the U.S. Still Trails Many Wealthy Nations in Access to Care

By Aaron E. Carroll
The New York Times, October 24, 2016

Many are still unhappy with Obamacare.

The main intent of the Affordable Care Act was to expand the safety net (Medicaid), regulate the non-employer-based private insurance market (the insurance exchanges) and help people buy that insurance (subsidies) in order to reduce the number of Americans who are uninsured.

On those metrics, it appears to be succeeding.

First and foremost, Obamacare was about improving access to health care. While it did improve access to insurance, in many, many other ways the United States is falling short. Things are likely to get worse before they get better.

Even with Obamacare, the United States still ranks poorly among comparable countries in insurance coverage. Even in 2016, when the rate of insured is the best it has ever been in the United States, Americans still have a greater percent of the population uninsured than pretty much any other industrialized nation in the world.

Access is about more than insurance, though. Every few years, the Commonwealth Fund conducts an international survey of patients. The last time the fund fielded the survey was in 2013, and it sampled patients in 11 different countries, all of them on the high end of the worldwide socioeconomic spectrum.

When asked if patients could get a same-day or next-day appointment with their provider when they were sick or needed care, 52 percent of Americans said no. This placed the United States next to last among these countries. Only Canada (59 percent) was worse.

When asked whether it was “somewhat” or “very easy” to get care after regular working hours, the United States placed eighth, beating France, Canada (again) and Sweden. Because of this, at least in part, Americans are more likely to use the emergency room for care.

Primary care physicians feel this pinch as well. When the Commonwealth Fund surveyed them in 10 countries, doctors in the United States ranked ninth (ahead of Canada) in being “well prepared” to manage the care of patients with complex needs. They ranked last in whether staff made home visits. They also ranked last, by far, in whether practices had arrangements so that patients could see a doctor or nurse after hours without going to the emergency department.

Why is this? One of the reasons is manpower. The United States, for all its spending, has fewer general practitioners per population than any of these other countries.

The biggest access problem in the United States is the expense of obtaining care. More than one third of Americans said they did not fill a prescription they were given, did not visit the doctor they should have or did not get the tests that were ordered because of the cost.

Perhaps most telling, when adults were asked about their views of the health care system in 2013, 75 percent of Americans said that it needed fundamental change, or that it needed to be completely rebuilt. This percentage was higher than for any other country surveyed, Canada included. Primary care physicians feel similarly. Yet years after the Affordable Care Act was passed, Americans are still litigating whether to return to the previous system.

Access was a problem before. Access is a problem now. Americans can’t seem to have a discussion on how to make that better. Without that, it’s hard to see how things will improve.



By Don McCanne, M.D.

The point here is that, although the Affordable Care Act (ACA) did expand the percentage of people with some form of health insurance, it still leaves us worse off than other nations in the percent of individuals remaining uninsured, and it didn’t fix other problems such as impaired access to health care.

Canada also scored poorly, near the United States, on some of these measures. This is partly due to our similar cultures, and both nations need to improve. In fact, Canada is making a concerted effort to address its problems with queues. But it is important to note that this does not mean that Canada’s single payer system has failed them. Not reported here are much more important measures in which Canada is clearly superior to the United States as a direct result of their single payer financing system: universality, equity, portability of coverage, elimination of financial barriers through first dollar coverage, reduction of administrative waste through public administration, and other efficiencies that have resulted in much lower per capita spending.

This month there is a campaign to tout the successes of ACA in order to reduce concerns about the announcement of the double digit increases in premiums for the ACA exchange plans. But when you objectively evaluate the successes, with the exception of the expansion of Medicaid, these improvements are almost negligible when compared to the improvements that Canada already has in place by virtue of the Canada Health Act that provides support for the single payer systems in their provinces.

As Aaron Carroll states, if we want improvement, we need to have a discussion on how to make the system better. Since ACA is falling so short, that discussion needs to center around truly effective reform, including a single payer national health program.