Weekend Long Reads: The Evolution of Our Health Care System

by Kevin Schofield

This weekend's "long read" focuses on two medical research papers exploring how the U.S. health care system has changed over the past two decades: the money going into the system and the outcomes for individuals. And it's not a pretty picture.

Let's start with a paper from a group of researchers at the Institute for Health Metrics and Evaluation here in Seattle, looking at health care spending from 2002 through 2016 and broken out by race and ethnicity. Total spending has grown dramatically, from about $1.5 trillion annually in 2002 to over $2.4 trillion in 2016. The amount spent per person increases as they age, from a low of about $3,000 per year for children in 2016 to more than $15,000 per year for those over the age of 65. There are some significant differences in spending across racial and ethnic lines, with Asians, Native Hawaiians, Pacific Islanders, and Hispanics seeing some of the lowest levels of spending across all age groups and white and multiracial individuals seeing the highest spending.

But that doesn't tell the whole story: The researchers show that there are also significant differences in the kinds of health care that each of these groups accesses. White people spend more on ambulatory care (e.g., appointments to primary care physicians and specialists), whereas Black people spend more on inpatient care, nursing facilities, and emergency care and American Indian/Alaska Native individuals on emergency department visits and ambulatory care. Hispanics, on the other hand, have low spending across all categories of health care.

The researchers dove further into the data and concluded that the differences in spending are almost entirely attributed to levels of utilization of those services and not differences in prices. They also found that the differences in spending didn't relate to diagnoses of any specific health care condition: Spending related to a particular health care condition followed the same patterns.

The second paper looks at changes in how individuals self-rate their health as well as their pattern of access to health care services from 1999 through 2018. The self-ratings focus on three areas: how many people rate their own health as "fair" or "poor," how many report a functional limitation due to a health issue, and how many say that they suffer from severe psychological distress.

Despite the dramatic increase in health care spending in the United States, there has been no significant change in the number of people self-reporting "fair" or "poor" health across the major racial and ethnic groups. However, there have been measurable increases in both the number of people reporting a functional limitation and/or severe psychological distress.

That said, the data shows the clear impact of the Affordable Care Act on closing some of the racial and ethnic gaps in health care access — especially for Black and Hispanic Americans. The number of uninsured individuals plummeted starting in 2014, most notably for Hispanics. Some of the racial and ethnic disparities in health care access have narrowed — though disparities still exist. The one place where the researchers found substantial and consistent narrowing of the disparities was between low-income Black and white individuals, where the gaps have all but disappeared (except for self-reported functional limitations, where Black individuals report significantly lower rates).

These two studies align in some important ways, and perhaps the most important is the impact of "delayed health care seeking." The second study found that there are still a substantial number of people forgoing or delaying care because of the cost. It's not much of a stretch to tie that to the high numbers of people reporting their health as "fair" or "poor" and to disparate use of inpatient care and emergency departments.

It's been said many times before, but it's still astounding that with the vast amount of money we spend on health care in the United States we have such poor outcomes — and those outcomes largely aren't changing over time.

U.S. Health Care Spending by Race and Ethnicity, 2002—2016

Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999—2018

📸 Featured Image: Photo by Annie Spratt/Unsplash.com