Saturday was World Health Day. It’s been celebrated every year on April 7 since 1948, under the sponsorship of the World Health Organization (WHO).
Its purpose is to call attention to the need for “ensuring that all people get quality health services, where and when they need them, without suffering financial hardship.”
It got scant attention from our major TV networks and newspapers this weekend. Maybe it’s because producers and editors think the WHO is focused exclusively on healthcare in third world countries. Maybe it’s because we think the U.S. system doesn’t have the same access issues that undeveloped health systems face. Maybe the media gatekeepers decided healthcare is simply too complicated or no one’s interested. That’s regrettable.
Healthcare matters to people across our land. It’s newsworthy to the general population beyond the coverage it gets when egregious errors are exposed, big deals are announced, insurance premiums are raised, new drugs are approved or politicians rail for and against healthcare legislation they promise to change.
The story this weekend should have been about the state of our system’s health, particularly what we’re learning about how it is accessed. Here’s what we know: if you have health insurance, a reasonable income, live in a safe community and you’re fairly healthy, access to the system is probably not a major concern (Agency for Healthcare Research and Quality National Health Disparity Report). If you’re white and educated, access is easier than for a person of color or Native American. And if you’re lucky enough to be among those in groups that do not face access issues, you’ll might live up to 15 years longer (American Public Health Association).
Access to our system is a problem to one in four in our country and that number is increasing. Consider:
Access to insurance coverage: 9.0% of our population (28.6 million) have no health insurance of any kind including 3.8 million children under 18 ((NCHS, National Health Interview Survey, 1997–2016)). And those with insurance face access issues: 29% who have insurance report have problems paying their medical bills, 43% have trouble paying their deductible and 63% use all or most of their savings to pay their medical bills. (Kaiser Family Foundation). The correlation is clear: neighborhoods with low health insurance rates have fewer providers, hospital beds and emergency resources making access problematic. (Robert Wood Johnson Foundation)
Access to providers: 12% of our population have “no place to go for care”, down from 15% in 2010. One in four young adults 18—24 and 21%% of adults 25-44 have no place to go for care. 4.4% of the population failed to obtain needed medical care due to cost at some time during the past 12 months--down from 6.9% in 2010 (NCHS, National Health Interview Survey, 1997–2016)). There are 7,200 primary care, 5,000 mental health, and 5,900 dental federally designated “Health Professional Shortage Areas” in the U.S. (HRSA). Though 18% of the population has a mental health issue, 59% are untreated due to lack of access to mental health providers. (National Alliance on Mental Illness). And 159 hospitals closed last year, most in rural and underserved communities. (AHA). Access to providers is not an issue is you have insurance they accept; it’s difficult if you don’t.
Access to preventive health: 37.7% did not have their vaccination last year; 33.6% reported their health status was not good (up from 31.5% in 2016) including half over the age of 65. (CDC). Primary and preventive health services are in short supply and the safety net, the 1400 federally-funded community health centers, are struggling to keep up with burgeoning demand. (NACHC). And states are cutting public health funding to make ends meet.
Access to healthy environments: 24.6 million Americans live in substandard housing that’s associated with 1.6 million emergency room visits and increased incidence of asthma, diabetes, depression and other disorders (Robert Wood Johnson Foundation). At least 1.5 million are homeless in the U.S.: they’re 5 times more likely to be admitted to a hospital and their lengths of stay are four days longer (Root Cause Coalition, American Journal of Public Health). And 16.5% of US households are food insecure (USDA December 2016). For one in five American households, a safe, healthy home environment is not reality.
Lack of access to healthcare in the U.S. system is a menacing problem. We invest more than any other system in the world in technologies, facilities, therapies and programs to treat our sickest and injured. But we invest relatively nothing in preventive health, especially targeted to populations most at risk because they lack access. Hospitals are addressing social determinants of health with greater emphasis: according to the Deloitte Center for Health Solutions, 67% of hospitals now screen patients for food insecurity 70% screen for housing, and 81% for social support needs. Insurers are investing in social support programs, drug makers are increasing their benevolent use efforts and physicians are accommodating new patients whose ability to pay is not a consideration. But access is a tsunami that’s only getting worse.
At a federal level, access to care for the poorest and underserved is funded primarily through two federal programs: the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA). Both have seen their funding shrink while access issues grow:
The CDC responsibilities include emergency preparedness, chronic disease, tobacco and obesity epidemics; injury control and violence prevention; global health security; health promotion in schools and workplaces; the prevention of diabetes, heart disease, stroke, cancer, lung disease and other chronic diseases; nutrition and physical activity; immunization; environmental health; oral health; preventing infant mortality and birth defects; preventing antimicrobial resistance; preventing prescription drug overdose; and public health research and health statistics. It also serves as the federal government’s monitor and coordinator for infectious disease controls. It’s annual appropriation from Congress, $7B has been flat since 2010.
HRSA responsibilities include strengthening the health workforce via scholarship and loan repayment programs to secure a well-trained workforce in underserved populations and areas, funding for 10,400 community health centers that serve low income populations, maternal and child health programs, HIV/AIDS support programs; family planning for 4 million low-income women, men and adolescents and rural health programs. Since 2010, Congressional appropriations for HRSA have dropped from 7.4 billion annually to 6.2 billion.
The Affordable Care Act’s expansion of insurance coverage via Medicaid expansion and the state-run marketplaces alleviated some of the access pressures but many states are cutting back on their public health funding and limiting access where they can.
And employers who provide health benefits coverage are shifting their costs to the employees themselves through high deductible plans: today, 24% now offer a high deductible plan to their employees. Per the Health Care Cost Institute analysis, employee wage increases have been offset by surging out of pocket costs for healthcare, and more workers are opting for high deductible plans as a way to pay lower premiums. That leaves more exposed to higher out of pocket costs and potential financial disaster if they face a major health problem at home. Access to care for many working Americans covered by a high deductible insurance plan is simply out of reach due to the out of pocket costs they incur.
The access issue in the U.S. system is real. It hits home in every hospital emergency room in the country. It hits home in hospital waiting rooms where families subsist for days lacking means for accommodation elsewhere. It hits home as seniors choose to split their pills to make ends meet. It hits home as families face the choices between of food, shelter or healthcare.
I was in Tennessee for an extended period last month: the political races for Senate and Governor are underway. TV ads touting their respective positions on issues are airing and their fund raising appeals are hitting hard at the changes they’ll make when elected. But I haven’t seen anything about access to healthcare.
In Tennessee and every state, more and more of our families are struggling to access our health system. For many, it’s simply not affordable. Some have given up.
Maybe it’s time to take a fresh look at our health system. It’s not about bad people; it’s simply a flawed system. We need fresh solutions to issues like access, costs and quality. We need to mute voices on all sides that seek short-term gain over systemic reform. We need media to help by providing meaningful, fact-based information upon which civil discussion is based. And we need it now.
World Health Day draws attention to the fact that healthcare is important in each of the 195 countries that share our planet. In each, access to care is an issue, including the U.S.