Could the Affordable Care Act Improve the U.S.' Failing Health-Care Grade?

When it comes to the health care system in the United States, we might be closer to the end of unaffordable services and the barriers to access they create. But we're not out yet.

A new report (link opens PDF) by the Commonwealth Fund, which has been assessing and ranking health care around the world for years in its Mirror Mirror on the Wall series, paints a grim picture for the U.S. Based on quality, effectiveness, access, efficiency, and equity, the rankings were as follows:

Australia; Canada; France; Germany; the Netherlands; New Zealand; Norway; Sweden; Switzerland; United Kingdom; United States.

The U.S. took dead last, and one of the biggest reasons we're not making the grade, according to the report, is the unavailability of affordable health care for all citizens. We have the most expensive system in the world: The U.S. spent $8,508 per person on health care in 2010 -- that's 50% more than the second-highest-spending country, Norway -- and yet individuals using that system still describe problems:

• For many, insurance isn't buffering expenditures. About 41% of U.S. respondents, both insured and uninsured, paid at least $1,000 out of pocket for medical care in 2013.
• 59% of the U.S. doctors surveyed told the Fund in 2013 that affordability is a problem for people in need of medical attention.

The numbers are hard to ignore. But so is the notion that we have a brighter future on the horizon if the Affordable Care Act does what it's supposed to do for all Americans. So let's take a closer look at the findings and the potential for an emerging U.S. system that better addresses the costs associated with good health for all.

The high price of equity

Getting ranked last is a hard pill to swallow. In the Fund's report, the numbers tell us that Americans in need of care are often not getting it because of the price tag attached.

• 37% of Americans polled said they did not follow through on recommended care, fill a prescription, or visit a medical professional because of cost. The next-highest percentage was in the Netherlands, at 22%.
• 28% said their insurance companies either denied them payment for medical care or did not pay as much as they had expected (followed by France at 17%).
• 23% of Americans said they had serious problems paying their medical bills or could not pay them at all (followed by France at 13%).

In all 11 surveyed countries, individuals reporting below-average incomes more often reported having chronic health problems.

• In 2013, a list-topping 39% of Americans with below-average income and medical problems did not see a doctor because of cost. By comparison, only 17% of U.S. individuals with above-average incomes described that scenario.
• 30% of below-average income respondents in the U.S. said they skipped prescription refills or doses because of cost. Above-average income earners saying the same: 12%. These percentages are the highest and second-highest, respectively, among countries surveyed.

How about some good news, then? A remedy might already be in place. The Fund hasn't ignored the impact, or the potential, of the Affordable Care Act as it approaches its first anniversary since implementation.

The ACA and the future of U.S. health care

2013 was a particularly interesting year for the Fund to conduct its study, as the ACA first became operative. After a slow ramp-up, and with state-by-state challenges still ongoing, there are positive signals emerging from the reform.

More than 8 million people entered the new system by the end of March 2014, far exceeding the predictions of even its federal proponents. And the New England Journal of Medicine estimates that some 20 million people gained coverage by May 2014.

If we set aside for the moment all other ways of evaluating U.S. health care, from efficiency to effectiveness of care, and consider only the cost of care and its consequences for the individual patient, the ACA is designed to drive improvements along this very front. Among the Act's many provisions, the following cut to the core of that idea:

• Americans with incomes between 133% and 400% of the federal poverty level are eligible for subsidies to help them purchase health insurance.
• For those who earn too much to get Medicaid but too little to buy a state-exchange plan, the ACA provides the Basic Health Program , giving participating states a pool of money with which to leverage lower-price insurance.
• When it comes to co-payments and deductibles, buying plans at the Silver level or higher means further reductions in costs for the individual.

And data from states that pioneered health care reform tells us that the effects of more affordable care -- from a financial perspective, at least -- can be measurably positive. For example, Massachusetts has had its own reformed system in place since 2006. In that state, the number of bankruptcies attributable to medical bills dropped to 52.9% in 2009 from 59.3% in 2007.

Indeed, the Fund sees the future influence of the ACA as an important context for considering this year's report -- it says so in the first pages of the study:

The U.S. has made significant strides adopting health information technology and undertaking payment and delivery system reforms spurred by the Affordable Care Act. Continued implementation of the law could further encourage more affordable access and more efficient organization and delivery of health care, and allow investment in preventive and population health measures that could improve the performance of the U.S. health care system.

The prognosis might well be looking up.

If the ACA works in the ways it's supposed to, state by state and nationwide, we can look forward to a follow-up report from The Commonwealth Fund that can't be summarized by pairing the words "U.S." and "last."