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How affordable is health care in the United States and other countries?
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How affordable is health care in the United States and other countries? Marko Vujicic JADA 2014;145(5):482-483 10.14219/jada.2014.33 The following resources related to this article are available online at jada.ada.org (this information is current as of June 30, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/5/482
This article cites 2 articles, 1 of which can be accessed free: http://jada.ada.org/content/145/5/482/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
Downloaded from jada.ada.org on June 30, 2014
Features
HEALTH POLICY PERSPECTIVES
How affordable is health care in the United States and other countries? Marko Vujicic, PhD
T
he 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.1 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 den-
tal care in the United States. The figure2 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.3 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 crosscountry 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.4 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.5 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.5 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
482 JADA 145(5) http://jada.ada.org May 2014 Copyright © 2014 American Dental Association. All Rights Reserved.
Downloaded from jada.ada.org on June 30, 2014
35 30 25 20 15 10 5
Dental Care
United Kingdom
Germany
Switzerland
Sweden
Netherlands
France
Canada
Norway
Australia
New Zealand
0 United States
PERCENTAGE OF ADULTS WITH FINANCIAL BARRIERS TO CARE
Features
Medical Care
Figure. Percentage of adults with financial barriers to care. Data are based on the percentage of respondents who indicated that they did not see a physician when they were sick or that they did not get recommended care because of cost in the past year. The figure also shows the percentage of respondents who indicated that they skipped dental care or checkups because of cost in the past year. Source: The Commonwealth Fund.2
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.6 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.7 There have been some attempts at comparative analysis of dental care systems in different countries.8 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. n
doi:10.14219/jada.2014.33
Dr. Vujicic is the managing vice president, ADA Health Policy Resources Center, American Dental Association, 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail [email protected]. Address correspondence to Dr. Vujicic. Disclosure. Dr. Vujicic did not report any disclosures. 1. Lallemand NC. Health Policy Briefs: Reducing waste in health care. Health Affairs. Dec. 13, 2012. www.healthaffairs.org/health policybriefs/brief.php?brief_id=82. Accessed April 1, 2014. 2. The Commonwealth Fund. 2013 Commonwealth Fund International Health Policy Survey. www.commonwealthfund.org/Surveys/ 2013/2013-Commonwealth-Fund-InternationalHealth-Policy-Survey.aspx. Accessed April 2, 2014. 3. Yarbrough 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.pdf. Accessed April 1, 2014.
4. Quinonez C, Grootendorst P. Equity in dental care among Canadian households. Int J Equity Health 2011;10(1):14. www.biomed central.com/content/pdf/1475-9276-10-14.pdf. Accessed April 1, 2014. 5. Schoen 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(12):2323-2334. 6. Devaux 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.pdf. Accessed April 1, 2014. 7. Organisation for Economic Co-operation and Development (OECD) iLibrary. Health at a glance 2009: OECD indicators. www.oecdilibrary.org/sites/health_glance-2009-en/01/10/ g1-10-01.html?contentType=&itemId=%2Fcont ent%2Fchapter%2Fhealth_glance-2009-12-en& mimeType=text%2Fhtml&containerItemId=%2 Fcontent%2Fserial%2F19991312&accessItemIds =%2Fcontent%2Fbook%2Fhealth_glance-2009en. Accessed April 1, 2014. 8. Chen M. Comparing Oral Health Care Systems: A Second International Collaborative Study. Geneva: World Health Organization; 1997.
JADA 145(5) http://jada.ada.org May 2014 483 Copyright © 2014 American Dental Association. All Rights Reserved.
How affordable is health care in the United States and other countries? Marko Vujicic JADA 2014;145(5):482-483 10.14219/jada.2014.33 The following resources related to this article are available online at jada.ada.org (this information is current as of June 30, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/145/5/482
This article cites 2 articles, 1 of which can be accessed free: http://jada.ada.org/content/145/5/482/#BIBL Information about obtaining reprints of this article or about permission to reproduce this article in whole or in part can be found at: http://www.ada.org/990.aspx
Copyright © 2014 American Dental Association. All rights reserved. Reproduction or republication strictly prohibited without prior written permission of the American Dental Association.
Downloaded from jada.ada.org on June 30, 2014
Features
HEALTH POLICY PERSPECTIVES
How affordable is health care in the United States and other countries? Marko Vujicic, PhD
T
he 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.1 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 den-
tal care in the United States. The figure2 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.3 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 crosscountry 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.4 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.5 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.5 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
482 JADA 145(5) http://jada.ada.org May 2014 Copyright © 2014 American Dental Association. All Rights Reserved.
Downloaded from jada.ada.org on June 30, 2014
35 30 25 20 15 10 5
Dental Care
United Kingdom
Germany
Switzerland
Sweden
Netherlands
France
Canada
Norway
Australia
New Zealand
0 United States
PERCENTAGE OF ADULTS WITH FINANCIAL BARRIERS TO CARE
Features
Medical Care
Figure. Percentage of adults with financial barriers to care. Data are based on the percentage of respondents who indicated that they did not see a physician when they were sick or that they did not get recommended care because of cost in the past year. The figure also shows the percentage of respondents who indicated that they skipped dental care or checkups because of cost in the past year. Source: The Commonwealth Fund.2
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.6 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.7 There have been some attempts at comparative analysis of dental care systems in different countries.8 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. n
doi:10.14219/jada.2014.33
Dr. Vujicic is the managing vice president, ADA Health Policy Resources Center, American Dental Association, 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail [email protected]. Address correspondence to Dr. Vujicic. Disclosure. Dr. Vujicic did not report any disclosures. 1. Lallemand NC. Health Policy Briefs: Reducing waste in health care. Health Affairs. Dec. 13, 2012. www.healthaffairs.org/health policybriefs/brief.php?brief_id=82. Accessed April 1, 2014. 2. The Commonwealth Fund. 2013 Commonwealth Fund International Health Policy Survey. www.commonwealthfund.org/Surveys/ 2013/2013-Commonwealth-Fund-InternationalHealth-Policy-Survey.aspx. Accessed April 2, 2014. 3. Yarbrough 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.pdf. Accessed April 1, 2014.
4. Quinonez C, Grootendorst P. Equity in dental care among Canadian households. Int J Equity Health 2011;10(1):14. www.biomed central.com/content/pdf/1475-9276-10-14.pdf. Accessed April 1, 2014. 5. Schoen 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(12):2323-2334. 6. Devaux 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.pdf. Accessed April 1, 2014. 7. Organisation for Economic Co-operation and Development (OECD) iLibrary. Health at a glance 2009: OECD indicators. www.oecdilibrary.org/sites/health_glance-2009-en/01/10/ g1-10-01.html?contentType=&itemId=%2Fcont ent%2Fchapter%2Fhealth_glance-2009-12-en& mimeType=text%2Fhtml&containerItemId=%2 Fcontent%2Fserial%2F19991312&accessItemIds =%2Fcontent%2Fbook%2Fhealth_glance-2009en. Accessed April 1, 2014. 8. Chen M. Comparing Oral Health Care Systems: A Second International Collaborative Study. Geneva: World Health Organization; 1997.
JADA 145(5) http://jada.ada.org May 2014 483 Copyright © 2014 American Dental Association. All Rights Reserved.