Last Updated Aug 8, 2022
This guide is intended to help donors gain a deeper understanding of the issues related to the U.S. healthcare system and outlines opportunities to address the root causes of inequitable outcomes. See the entire series. By Lucy Brennan-Levine
The U.S. healthcare system consists of public health options and federal assistance options, including:
Other healthcare options include state subsidies for hospitals, private insurance, and employer-based insurance. Private and employer-based options, however, aren’t always accessible and can be very expensive.
The Affordable Care Act (ACA) made it possible for nearly 6 in 10 uninsured Americans to receive coverage for $100 or less per person, per month in 2014. When the ACA was signed into law, 50 million Americans were uninsured and could not afford healthcare. The ACA helped increase the number of people who qualified for insurance by expanding Medicaid programs and offering premium tax credits to families living under the federal poverty level, among others. The ACA definitively offered avenues for healthcare for individuals and families who did not qualify for public health programs like Medicaid but still needed insurance.
Despite policy efforts like the ACA, affordability, time, access to employer-based coverage, and social determinants of health affect equitable access to healthcare. For instance, if individuals are from a low-income background, they are less likely to have coverage which limits access to healthcare. Income can also determine factors like residence, education and employment status, and external settings (that can all impact health and healthcare access). Additionally, employment status and type can determine whether someone will receive high- or low-quality employer-based insurance and benefits.
The high cost of care is a burden for American families. People report cutting back on other household expenses such as food and utilities due to health costs.
“Health spending per person in the U.S. was $11,945 in 2020, which was over $4,000 more expensive than any other high-income nation. The average amount spent on health per person in comparable countries ($5,736) is roughly half that of the U.S.” -Peterson-KFF Health System Tracker
Expensive healthcare costs disproportionately impact the uninsured, Black and Hispanic adults, and low-income individuals.
The racial health and wealth gap highlights how healthcare costs can jeopardize health and financial outcomes for Black families. For instance, 1 in 3 Black adults have past due medical bills, which can contribute to sustained medical and financial hardship over time. Medical debt affects communities along race, ethnicity, education, and income lines leading to inherited debt, bankruptcy, and generational poverty.
Young, uninsured adults are twice as likely to have difficulty affording healthcare. And for transgender people seeking gender-affirming care, studies indicate that financial insecurities are the most commonly reported reason for not being able to access the healthcare treatment they need. Additionally, transgender adults of color are more likely to experience bias and discrimination in the medical system, on top of huge healthcare expenses.
Prescription affordability remains difficult for consumers, especially for those who take at least four medications and are from households earning less than $40,000. For many people living on the margins, healthcare affordability remains out of reach for both financial, social, and systemic reasons and can keep people trapped in cycles of poverty.
Donors can help improve healthcare access by supporting efforts that bolster telehealth efforts, address physician shortages, and advocate for Medicaid expansion in states. There is ample evidence and research to support the benefits of paid and medical leave for improved economic security. Donors can continue to advocate and fund research that informs policymakers on how equitable healthcare policies that take care of workers will help overall economic security.
Eighteen percent of U.S. adults, or an estimated forty-six million people, reported they could not afford quality healthcare services in the United States.
People earning less than $24,000 per year are more likely to report neglecting healthcare than high-income households. Additionally, nearly 70% of the uninsured population is poor or near-poor, making it more likely for them to avoid preventive care and have more serious conditions or wait until these conditions have worsened to the point that they would need to pay more for healthcare services. An unexpected trip to the emergency room could cost $1,000 or more, contributing to family medical debt and the cycle of poverty and health outcomes. Poorer families are also less likely to have assets to draw funds from if serious health conditions and high medical bills emerge. Additionally, rural communities also face higher rates of medical debt, 22.1% of households in the South reported having medical debt compared with 15.2% of households in the West, 15.6% in the Northeast, and 20.1% of households in the Midwest.
While the Affordable Care Act helped to narrow the gap between those who are insured and uninsured, racial and ethnic disparities in healthcare affordability remain. Non-elderly American Indian and Alaska Natives, Hispanic, Native Hawaiians and Other Pacific Islanders, and Black people were still more likely to be uninsured than their white peers.
While states that expanded Medicaid also saw gains in coverage among non-white racial groups, “but adults with income below 138% of the federal poverty level in the remaining non-expansion states are disproportionately Black and Latinx/Hispanic.”
In 2019, the Black unemployment rate was historically low at 6.4%, but was still twice that of white unemployed workers. In a country that relies heavily on employer-based healthcare, racial inequalities in employment ensure that employer-based healthcare remains less attainable for communities of color comparatively.
Racism drives many inequalities along the social determinants of health, making it more difficult for people of color to afford healthcare and have positive health outcomes. Racial minorities are more likely to live in places with exposure to unsafe water or air pollution, increasing their health risks and subsequent healthcare costs. There has been a history of employment and wage disparities between people of color and white individuals, especially for women of color experiencing both gender and racial wealth gaps.
Complex healthcare policies with eligibility laws and limited federal funding contribute to limited coverage for immigrant and Indigenous communities.
Language barriers and access to translation services also play a role in racial/ethnic healthcare disparities and costs. One study found that “patients who do not speak the local language will have less satisfaction with their healthcare and less access to usual sources of healthcare. Even when patients with language barriers have access to healthcare, they have decreased satisfaction with that healthcare, decreased understanding of their diagnoses, and increased medication complications.” Additionally, some providers that offer interpreters or translators end up increasing costs for patients, making affordability even more difficult. More research surveying patients that do not speak English as their first language reported feeling uncomfortable due to language barriers and experience discrimination, bias, and humiliation during medical visits.
Undocumented immigrants face various barriers to accessing or affording care largely due to limitations in eligibility from various insurance coverage policies, including employer-based coverage, Medicare, Medicaid, CHIP, and the ACA marketplaces. Additionally, this population can’t access preventative or prenatal care, resulting in poorer reproductive health outcomes for undocumented women, such as birth complications, neonatal morbidity, including fetal alcohol syndrome, respiratory distress syndrome, and seizures.
In 2011, 29% of undocumented immigrants had either employer-sponsored or private health insurance, whereas 71% reported no health insurance coverage. In the same year, 47% of undocumented immigrant children were uninsured.
Public assistance and healthcare program participation rates among immigrant adult and children have declined because many people face confusion about eligibility, are “intimidated by the application process, or feared being labeled a public charge (i.e., an individual who is likely to become reliant on public assistance and deemed ineligible to become an LPR or citizen of the United States).” This can lead to poorer health and food security outcomes for immigrant populations. State-funded welfare reform policy that is inclusive of both documented and undocumented immigrants could help support positive health outcomes and affordability.
Indigenous communities face extensive hardships due to a history of genocide, land displacement, and broken treaties which prompted forced poverty within Native nations. Assimilation policies dating back to the 1800s, such as boarding schools and prohibition of traditional healthcare systems, lead to “rampant infectious diseases, poor sanitation, malnutrition, poverty, overcrowding and inadequate ventilation in homes, poor education practices, and isolation.” While some policies are no longer in place, generational trauma and inadequate access to healthcare for many tribal nations exists today. In 2020, approximately 1 in 3 Indigenous peoples in the United States lived in poverty, earning a median income of $23,000.
IHS is one of the only departments dedicated to providing healthcare services for 574 federally recognized American Indian and Alaskan Native tribes in the country. More than 200 unrecognized federal tribes, equaling tens of thousands of Indigenous peoples, do not have access to IHS.
The IHS has been inadequately funded for years and federal funding only offers 54% of necessary services. Additionally, IHS facilities are not always located in close proximity to reservations, increasing difficulty in access. Only 2% of IHS funding serves urban communities with Indigenous peoples.
There are increasing rates of obesity due to introducing flour, sugar, lard, and butter when communities previously ate seasonally and grew familiar foods from the land. Indigenous communities have lower life expectancies, higher rates of suicide, and high rates of premature death due to diabetes, cardiovascular disease, cancer, and accidents. Having chronic conditions increases the need for consistent, high-quality healthcare to maintain wellbeing, which Indigenous communities living in poverty may not be able to afford and do not have access to.
Indigenous women specifically struggle with access to reproductive healthcare services and post-pregnancy coverage. While public health insurance policies help cover their services while pregnant, Medicaid and Medicare coverage ends a couple of months after the pregnancy in states without expansion. While 43.3% of Indigenous peoples rely on Medicaid, 15% are uninsured and currently over half of uninsured Native peoples live in states that haven’t agreed to expansion.
Chronic diseases and/or conditions are defined as lasting one year or more and “require ongoing medical attention or limit activities of daily living or both.” More than 11 million of the U.S. uninsured population are working-age adults experiencing at least one chronic condition. And racial and ethnic minorities are almost twice as likely to have most of the major chronic diseases than white individuals – often connected to environmental and external factors. Additionally, one study found that “14% of chronically ill U.S. adults reported they did not get the support they needed from healthcare providers to manage their conditions.”
A patient with chronic disease averages $6,032 in direct health care costs (prescriptions, procedures, other care), which is five times higher than someone with no chronic health conditions. Cardiovascular conditions, diabetes, Alzheimer’s Disease, arthritis, and obesity made up $1.1 trillion of direct healthcare costs in 2016. Forty-six percent of Americans carried medical debt in 2020 compared to 50% in 2021.
It is estimated that 7.5 million seniors are unable to pay for medicine prescribed to them due to high healthcare costs. About 1 in 6 older adults (over 65) skipped their dental appointments due to high costs in 2020. Public health policies are less likely to cover adult dental care and won’t be able to provide insurance for this population.
Fragmented systems contribute to duplication of care and low-quality coordination of services. One study found that chronically ill patients receiving fragmented care had increased medical costs and higher rates of preventable hospitalizations.
Despite the fact that 60% of Americans live with at least one chronic condition, many will forgo necessary healthcare services because of affordability issues.
By 2019, there were more than 250,000 medical campaigns conducted annually on the popular crowdfunding site, GoFundMe, signifying a huge burden of medical costs for Americans. And, 50% of U.S. adults fear medical bankruptcy due to a major health event or injury. Even insured Americans still spend more out-of-pocket costs than other adults in wealthy nations.
Community-based health insurance has limitations because they rely on volunteers and community-pooled funds. There is less funding and focus on community health centers in the U.S. and one-third of U.S. healthcare spending is aimed at hospital care, rather than affordable preventative and outpatient care. If community health centers can’t rely on enough federal funding, they may have to freeze hiring processes and cut staffing hours, making it more difficult to run a practice, especially community health centers located in states that haven’t expanded Medicaid.
While more than half of Americans have coverage through employer-based benefits, there are many who do not have those same protections because they may work multiple part-time jobs (which don’t offer insurance) and not all jobs offer the same benefits to all workers. Layoffs, firings, or low-paying jobs can impact individuals’ access to healthcare and its subsequent affordability.
Not everyone has access to the same employment opportunities due to racism and bias in hiring processes which can immediately impact who will obtain high-quality jobs with the best healthcare benefits. The gender wage gap is especially significant since “nearly half – 43 percent - -of the 29.6 million employed women in the United States were clustered in just 20 occupational categories, of which the average annual median earnings were $27,383.”
There is a coverage gap for adults that have too-high incomes for eligibility for Medicaid but are still considered below the poverty line. States that did not expand their coverage have limited eligibility for insurance.
While telehealth opportunities are now emerging since the beginning of the pandemic, home-based care has been able to thrive. In 2018, only 2% of insured adults participated in a telehealth visit with their provider. Healthcare policy that expands telehealth reimbursements or provides a variety of payment strategies could help the payment landscape become more equitable and inclusive, especially if telehealth is here to stay. The American Rescue Plan offers a financial incentive for states to expand Medicaid and Medicare coverage, which would increase program enrollment by 6.69 million in 2022.
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