2018 was a special year for the Commonwealth Fund. The foundation established by Anna Harkness a month before the close of World War I celebrated its centennial — one hundred years of advancing access to high-quality, affordable health care for all Americans, especially the most vulnerable. Following are some highlights from the work conducted by the Fund’s staff and grantees in service of this enduring mission.
The U.S. spends twice as much per person on prescriptions drugs dispensed in primary care settings compared to 10 other wealthy countries, according to Steven Morgan, a health care economist at the University of British Columbia and former Commonwealth Fund Harkness Fellow. Yet Americans don’t spend more because they use more (the U.S. actually consumes less of certain classes of prescription drugs). The answer lies in the prices Americans pay and the more expensive types of medications they use.
Health systems in these other countries achieve lower drug prices by aggregating their purchasing to gain negotiating leverage with drug companies, as Commonwealth Fund President David Blumenthal, M.D., and colleagues explained on the Fund’s To the Point blog. They also systematically assess the value of individual drugs, using the best available information on benefits and expenses, to assist purchasers in their negotiations.
Back in the U.S., analysts at Waxman Strategies have been tracking regulatory and legislative actions taken by the administration and Congress to lower drug prices, including the removal of barriers to cheaper generics and efforts to promote value-based drug purchasing. They and other Commonwealth Fund grantees continue to explore additional pragmatic steps policymakers could pursue to bring down prices.
Americans don’t pay higher prices just for pharmaceuticals. According to a Commonwealth Fund–supported study in JAMA, general practitioners in the U.S. earn nearly double what their counterparts do across other high-income countries. Medical devices also often cost substantially more in the U.S.: as another Fund-supported study in Health Affairs showed, the mean price of a dual-chamber pacemaker in 2014 was $1,400 in Germany, but $4,200 in the U.S. Meanwhile, outlays for health care administration are two-and-a-half times greater in the U.S. as a percentage of national health expenditures.
To reduce health care spending, experts say that U.S. policymakers need to focus on lowering prices and administrative costs, rather than simply reducing the use of health care.
The Commonwealth Fund’s latest Biennial Heath Insurance Survey, conducted between June and November 2018, found that the uninsured rate for working-age adults last year, 12.4 percent, was statistically unchanged from 2016, despite actions taken by the Trump administration to weaken the Affordable Care Act (ACA), including deep cuts in advertising and outreach during open enrollment for marketplace plans.
Since 2010, when the ACA was enacted, more people have health insurance, but a higher share of U.S. adults are "underinsured," meaning they have high health plan deductibles and out-of-pocket medical expenses relative to their income. The greatest growth in the underinsured rate, the Fund survey showed, has occurred among Americans in employer-based health plans, according to Fund researchers Sara Collins, Herman Bhupal, and Michelle Doty.
According to the Commonwealth Fund’s 2018 Scorecard on State Health System Performance, the combined death rate from suicide, alcohol, opioids, and other drugs increased by 50 percent nationwide between 2005 and 2016. Deaths rose across all states, with rates doubling or more in Delaware, Ohio, New Hampshire, New York, and West Virginia.
Writing on the Commonwealth Fund blog To the Point, Susan Hayes, David Radley, and Douglas McCarthy reported that drug overdose deaths more than doubled between 2005 — when the opioid crisis was under way but not yet making headlines — and 2016. The Fund researchers pointed to successful state strategies for expanding access to opioid addiction treatment, such as Vermont’s hub-and-spoke model, and called for greater cooperation and engagement among policymakers and across the health care, social service, and criminal justice sectors.
Even if it is eventually upheld by the Supreme Court, the Texas federal court decision in December 2018 invalidating the Affordable Care Act wouldn’t inhibit states’ role as primary regulators of health insurance. Legislatures across the country could still enact and enforce their own laws to prevent insurers from discriminating against people with preexisting health conditions — one of the many consumer protections enshrined in the ACA.
But while several states have incorporated some or all of the ACA’s protections into law, they are in the minority, wrote Commonwealth Fund–supported researchers with Georgetown University’s Center on Health Insurance Reforms in a post on To the Point. Many of the 29 states lacking any consumer protections were plaintiffs in the Texas court case.
Health law expert and Fund grantee Timothy S. Jost believes that even though the Texas decision is likely to be reversed, it will do “untold damage to the American health care system.” In his December 17 post, Jost explained the judge’s reasoning and predicted “untold confusion” for consumers seeking marketplace coverage during the ACA’s final open enrollment period of 2018.
So far, nine states have received federal approval to impose work requirements on Medicaid beneficiaries, and about as many states are seeking to do the same. Proponents say these rules will help people gain employment and reduce dependency.
But do work requirements help low-income adults improve their opportunities, or are they designed to sanction beneficiaries in a bid to lower Medicaid program caseloads?
In June 2017, Arkansas became the first state to implement a waiver program terminating Medicaid coverage for expansion enrollees who fail to report having worked at least 80 hours per month for three or more months. While more than 200,000 Arkansans have gained health insurance through the state’s Medicaid expansion, Commonwealth Fund grantees Erin Brantley and Leighton Ku of George Washington University estimated that 30,700 to 48,300 adults could end up losing their coverage over one year because of the new requirements. (Recently, a Fund-supported study by Benjamin Sommers, M.D., and colleagues found that 17,000 adults in Arkansas were removed from Medicaid between October and December 2018.)
Meanwhile, grantee Sherry Glied of New York University calculated that Arkansas will lose between $220 million and $340 million in federal Medicaid funds in 2020. The state’s own spending on medical assistance for those dropped from the program because of the work rules would fall by $25 million to $40 million.
Many rural health care providers and communities are struggling because the need for health services far outstrips the supply. According to the Centers for Disease Control and Prevention, there are 40 physicians per 100,000 people in rural America, compared with 53 per 100,000 in large U.S. cities. As part of our blog series Listening to Low-Income Patients and Their Physicians, Commonwealth Fund researchers interviewed primary care doctors in rural communities to learn about the distinct challenges they and their patients face, from geographic isolation and an absence of economic opportunity to limited access to specialty care.
Through the words of patients and their physicians, each episode in the series gives voice to the experiences of low-income people across the U.S. as they strive to overcome obstacles ranging from poverty, addiction, and mental health issues to trust in the health system itself.
Medicare covers a lot of health services, but it doesn’t include routine dental, vision, or hearing benefits. That helps explain why three-quarters of beneficiaries who need a hearing aid don’t have one, and why 70 percent of those who have trouble eating because of problems with their teeth haven’t gone to the dentist in the past year.
According to Commonwealth Fund–supported researchers Amber Willink, Cathy Schoen, and Karen Davis, Medicare could offer a voluntary, supplemental benefit that provides basic coverage of these important preventive services at a reasonable cost to seniors. Willink, who is based at Johns Hopkins University, leads a Commonwealth Fund grant to inform policymakers about options for revamping Medicare’s benefit package and its beneficiary cost‐sharing to better address the needs of America’s aging population.
The Dose, which premiered last October, gets you up to date on the latest research, personal stories about health care and the health system, and innovations that could make life easier for patients, family, and caregivers. Episodes in 2018 explored the truth about wait times for health care in Canada, what it means to be sick in America, and the status of U.S. women’s health and health care.
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