The best of times?

Eco­nomic woes and prices de­press health­care ac­cess in our era

Modern Healthcare - - OPINIONS EDITORIALS - NEIL MCLAUGH­LIN Man­ag­ing Ed­i­tor

Notes on the news: Last week marked the 200th birth­day of Charles Dick­ens. If there is any writer from the past who can speak to the eco­nom­i­cally trou­bled present, it’s Dick­ens. While much has im­proved since the fi­nan­cially volatile and of­ten-op­pres­sive 19th cen­tury, Dick­ens would surely rec­og­nize some of his world in to­day’s so­ci­ety. Whereas his un­for­tu­nate char­ac­ters scrounged for food or shel­ter, con­tem­po­rary cit­i­zens down on their luck some­times strug­gle for health­care.

A re­minder of that par­al­lel sur­faced last week. A Com­mon­wealth Fund sur­vey showed that the Great Re­ces­sion has taken a toll on med­i­cal care. The poll of more than 2,000 adults found that house­holds liv­ing closer to poverty were less likely to be in­sured. Not sur­pris­ingly, the lack of in­sur­ance—some­times caused by job loss—made a dif­fer­ence in whether the re­spon­dents re­ceived ba­sic pre­ven­tive ser­vices such as blood pres­sure checks and colon can­cer screen­ing. (You can read the re­port on on­line at

In ad­di­tion, unin­sured lower-in­come adults were more likely to re­port vis­it­ing emer­gency rooms for rea­sons other than true emer­gen­cies, ac­cord­ing to the Com­mon­wealth re­port. Those rea­sons in­cluded need­ing a pre­scrip­tion drug, not hav­ing a reg­u­lar doc­tor or find­ing that other care sources were to ex­pen­sive.

The re­port’s au­thors con­cluded that the Pa­tient Pro­tec­tion and Af­ford­able Care Act will rem­edy many of these in­equities. That re­mains to be seen. It also as­sumes the law will sur­vive the Supreme Court chal­lenge and the many state-level at­tempts to nib­ble it to death.

To grasp the mag­ni­tude of to­day’s eco­nomic woes, please see a chart on Mod­ern Health­care’s Feb. 8 “Of In­ter­est” fi­nance blog by re­porter Me­lanie Evans ( The graphic shows the change to me­dian U.S. house­hold in­come in the first year af­ter a re­ces­sion since 1971. The fig­ure for the lat­est down­turn from 2010 is -2.3%, the deep­est drop of the past 40 years. It’s no won­der that a lot of Amer­i­cans are short of cash and short on med­i­cal care.

The sick econ­omy isn’t the only rea­son for di­min­ished ac­cess to care. An­other is in­flated treat­ment costs. As we have noted on this page many times, the U.S. posts the world’s high­est prices for most pro­ce­dures and goods yet falls far be­hind coun­ter­parts on mea­sures of public health.

More ev­i­dence of skewed costs came last week from Univer­sity of Pitts­burgh health re­searchers. They re­ported in the Feb. 9 New Eng­land Jour­nal of Medicine that drug prices and not the amount of drugs pre­scribed ac­count for re­gional dif­fer­ences in Medi­care Part D spend­ing. The Pitts­burgh team ex­am­ined 2008 data for 4.7 mil­lion ben­e­fi­cia­ries, look­ing at three widely pre­scribed cat­e­gories of drugs—blood-pres­sure med­i­ca­tions, statins and an­tide­pres­sants. Re­searchers found that more than 75% of the dif­fer­ence be­tween high-cost and low-cost regions was due to the cost per pre­scrip­tion.

They con­cluded that greater use of lower-cost generic drugs could sub­stan­tially re­duce spend­ing and out-of­pocket costs for ben­e­fi­cia­ries.

Drugs ac­count for about 10% of na­tional health ex­pen­di­tures, ac­cord­ing to gov­ern­ment fig­ures, so they shouldn’t be sin­gled out as the pri­mary cause of soar­ing spend­ing. But the phe­nom­e­non de­scribed by the Pitts­burgh re­searchers is em­blem­atic of a health­care sys­tem with ex­traor­di­nar­ily high markups.

The health­care sys­tem in to­tal presents a di­chotomy Dick­ens could ap­pre­ci­ate: high prices and overuse of ser­vices in some quar­ters and un­der­use (with all the dele­te­ri­ous con­se­quences) in oth­ers. Un­til we straighten out that sys­tem, there will be more Hard Times.

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