8.6: Healthcare Access and Quality

When people can get preventative care and screenings, diagnoses, and treatment for health conditions in a timely manner, their health outcomes are substantially better. Access to healthcare includes health insurance, affordability of care, location of doctor’s offices, urgent care facilities, and hospitals, along with access to transportation to get there, and even the availability of appointments with physicians and specialists. Costs and supplies of medical devices and medicines are also an important part of this access. Many barriers to getting healthcare are undeniably intertwined with the American healthcare system itself.

The U.S. outspends other similarly wealthy nations on per-person healthcare costs, and yet has the lowest life expectancy compared to these other countries (Reich, 2022). On average, U.S. life expectancy is 3.9 years below the average of other countries in the OECD (Organisation for Economic Co-operation and Development) such as Japan, Australia, Germany, Finland, Costa Rica and several others. The United States spent over $12,500 per person on healthcare in 2022; over twice the OECD average of other countries (in U.S. dollars) which was around $5000 per person (Sabine, 2023). Part of the reason for this is because America has a greater range of diagnostic tools and specialized procedures, however, it is unlikely that greater quality is the primary driver of higher healthcare spending. The highest excess expenditures of healthcare are from administrative costs (about 30%) and prescription drug costs (10%). Although American doctors and nurses get paid more on average than other OECD countries, this accounts for only about 15% (combined) of the excess expenditure on healthcare. The U.S. also tends to spend less on public health and more on medical care than other comparable countries, which could further explain why spending more doesn’t necessarily correlate with a healthier, longer-living population (Turner et al., 2023).

Health insurance policies are often offered as part of the compensation paid to employees along with their wages by large companies. Pursuant to the Employees who work part-time, are self-employed, or contract-based often have to purchase their own health insurance. Government funded health insurance like Medicare (for those 65+) Medicaid (for those in poverty, pregnant or with disabilities), and CHIP (Children’s Health Insurance Program - for children of low-income families), provide coverage for those people who might otherwise not be able to get health insurance through an employer. Additionally, through the ACA, government subsidies help reduce the cost of health insurance for those individuals who don’t qualify for other programs but for whom health insurance premiums would be cost prohibitive.

Just having health insurance alone does not necessarily make it affordable. Even if the healthcare plan is offered by an employer, it may still cost a monthly premium for the employee, especially if the plan covers other family members. Additionally, many health insurance plans have deductibles or annual out-of-pocket maximums that must be met before the insurance company begins to pay, or even co-insurance - which requires that the individual and the insurance company split the costs of doctors visits, prescriptions or procedures (see also chapter 14). Healthcare premiums and deductibles have continued to rise over the past 3 decades, often at a rate faster than inflation and employee wages (KFF, 2023). Perhaps as a result of this, employer-provided health insurance is declining (Reich, 2022). Employers can opt for cheaper plans with higher deductibles and out of pocket limits, deduct premiums out of employee paychecks, or even opt for creating more part-time and contract positions instead of full-time positions. A recent Kaiser Family Foundation (KFF) survey found that medical debt reached $220 billion by the end of 2021 - even though 90% of Americans were covered by health insurance. Within that total, the majority of people with medical debt owed more than $10,000. This debt can come from co-insurance, deductibles, or from being denied insurance coverage for certain procedures or getting care from out-of-network providers. Medical debt can discourage people from seeking further healthcare - thus contributing to worsening health over time (Rakshit et al., 2024). See Fig. \(\PageIndex{1}\) below.

Figure \(\PageIndex{1}\): Cumulative Premium Increases, Inflation, and Earnings for Covered Workers with Family Coverage, 2003-2023. KFF. (2023, October 18). Section 1: Cost of health insurance - 10240. 2023 Employer Health Benefits Survey; KFF

Health insurance coverage is only one barrier to getting timely healthcare. Another barrier is physically getting to the doctor. While there are shortages of primary care physicians in both urban and rural areas of the U.S., rural areas tend to have the highest rates of healthcare worker shortages (Rural Health Information Hub, 2024). Additionally, many hospitals in rural America have closed down altogether (Rural Hospital Closures, 2020), which means that residents will have to travel even further for some types of care. Conversely, long wait times for urgent care facilities and overcrowding of emergency rooms can decrease access to healthcare in more populated areas. A lack of transportation can be a barrier to accessing care, especially for those with disabilities or limited mobility. All of these barriers can lead to delayed care and diagnoses, which means that many people may not know they have a disease or get treatment for it until it has progressed to a worsened state (Access to Health Services - Healthy People 2030, n.d.). See Fig. \(\PageIndex{2}\) below.

Figure \(\PageIndex{2}\): Access to Health Services Infographic from Healthy People 2030.