How affordable is health care in the United States and other countries?

Abstract

The Affordable Care Act (ACA) is bringing transformational change to the U.S. health care system. Numerous studies and cross-country comparisons show convincingly that the United States spends far more on health care than does any other country, yet by any measure of access, efficiency, satisfaction or health outcomes, the United States ranks below lower-spending countries. There are volumes of scholarly work that explain this apparent paradox, but some of the main contributing factors include higher prices for health care goods and services, higher administrative costs and inefficiency. One recent study estimates that at least one-third of health care spending in the United States is wasteful.1Lallemand NC Health Policy Briefs: Reducing waste in health care. Health Affairs.www.healthaffairs.org/health policybriefs/brief.php?brief_id=82Date: Dec. 13, 2012Google Scholar The ACA tries to simultaneously address the core issues by expanding health coverage—which is the focus in this early phase of reform—and changing the health care delivery and financing model to improve outcomes and manage costs. New data from the Commonwealth Fund, a top-notch independent think tank, sheds light on the importance of addressing financial barriers to both medical and dental care in the United States. The figure2The Commonwealth Fund 2013 Commonwealth Fund International Health Policy Survey.www.commonwealthfund.org/Surveys/2013/2013-Commonwealth-Fund-International-Health-Policy-Survey.aspxGoogle Scholar shows the percentage of adults who reported not being able to obtain medical or dental care they needed because of cost for 11 countries within the Organization for Economic Cooperation and Development (OECD). There are three things I think are worth highlighting in these data. First, the United States has the highest level of financial barriers for both medical and dental care. Whether the ACA will lower financial barriers to dental care for U.S. adults still is unclear, although any potential effect is likely to be focused among the Medicaid population.3Yarbrough C Vujicic M Nasseh K More than 8 million adults could gain dental benefits through Medicaid expansion. American Dental Association Health Policy Resources Center Research Brief.www.ada.org/sections/professionalResources/pdfs/HPRCBrief_0214_1.pdfGoogle Scholar Second, in most countries, the financial barriers to dental care are much higher than those for medical care. Third, the United Kingdom has the lowest level of financial barriers for both medical and dental care of any of the countries. These data are insightful in that they highlight important cross-country differences in one important aspect of access to care. There could be, and surely is, a plethora of factors that account for the variation in financial barriers to dental care. Within the OECD, there is considerable variation in how medical and dental care is financed and delivered. In Canada, for example, medical coverage is universal and care is paid for primarily through a single-payer system. But dental coverage for adults is not included in the essential benefits and is financed primarily through private (employer-provided) dental insurance and out-of-pocket payment. This is one factor that could explain the very different level of financial barriers to medical care compared with dental care in Canada.4Quinonez C Grootendorst P Equity in dental care among Canadian households.Int J Equity Health. 2011; 10 (Accessed April 1, 2014.): 14www.biomedcentral.com/content/pdf/1475-9276-10-14.pdfCrossref PubMed Scopus (25) Google Scholar Of all the 11 countries, the United Kingdom goes furthest in aiming to limit out-of-pocket spending and the financial burden of health care. There is little or no cost sharing for a comprehensive set of benefits in the National Health Service, including dental care.5Schoen C Osborn R Squires D Doty MM Pierson R Applebaum S How health insurance design affects access to care and costs, by income, in eleven countries.Health Aff (Millwood). 2010; 29: 2323-2334Crossref PubMed Scopus (192) Google Scholar In the Netherlands and Switzerland, medical coverage is provided mainly through private insurance that must cover core benefits through a tightly regulated marketplace. Dental care for adults is not included in core benefits, but in both countries most people purchase supplemental dental coverage. Interestingly, wait times to see health care providers are not correlated strongly with financial barriers to care.5Schoen C Osborn R Squires D Doty MM Pierson R Applebaum S How health insurance design affects access to care and costs, by income, in eleven countries.Health Aff (Millwood). 2010; 29: 2323-2334Crossref PubMed Scopus (192) Google Scholar Aside from financial barriers to care, there are important differences across OECD countries in dental coverage rates, dental care use and oral health outcomes. For example, a large study of 18 OECD countries showed that the United States has the lowest rate of dental care use among low-income adults and one of the lowest rates for high-income adults.6Devaux M Inequalities in health care utilisation in OECD countries. Organisation for Economic Co-operation and Development, Health Division. Paper presented at: EU Expert Group Meeting on Social Determinants and Health Inequalities; Jan. 21, 2013; Luxembourg.http://ec.europa.eu/health/social_determinants/docs/ev_20130121_co01_en.pdfGoogle Scholar There is a fivefold difference in rates of decayed, missing or filled teeth among children across OECD countries, with the rate for the United States slightly below the OECD average.7Organisation for Economic Co-operation and Development (OECD) iLibrary Health at a glance 2009: OECD indicators.www.oecd-ilibrary.org/sites/health_glance-2009-en/01/10/g1-10-01.html?contentType=&itemId=%2Fcontent%2Fchapter%2Fhealth_glance-2009-12-en&mimeType=text%2Fhtml&containerItemId=%2Fcontent%2Fserial%2F19991312&accessItemIds=%2Fcontent%2Fbook%2Fhealth_glance-2009-enGoogle Scholar There have been some attempts at comparative analysis of dental care systems in different countries.8Chen M Comparing Oral Health Care Systems: A Second International Collaborative Study. World Health Organization, Geneva1997Google Scholar But, in my view, the global evidence base needs to be strengthened considerably by focusing on a large set of countries (such as the OECD), focusing on more recent experiences and adopting an analytic approach that identifies how alternative dental care financing and delivery arrangements impact dental benefits coverage, affordability, access to care, dental care use and oral health. Such an analysis would be an enormous contribution to the global health policy knowledge base and would, ultimately, help advance oral health around the globe.