tag:theconversation.com,2011:/id/topics/health-care-spending-37345/articlesHealth care spending – The Conversation2024-03-08T13:38:33Ztag:theconversation.com,2011:article/2228582024-03-08T13:38:33Z2024-03-08T13:38:33ZAsthma meds have become shockingly unaffordable − but relief may be on the way<figure><img src="https://images.theconversation.com/files/579691/original/file-20240304-18-r33cu5.jpg?ixlib=rb-1.1.0&rect=25%2C51%2C8538%2C5469&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Its price will take your breath away.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/man-using-blue-asthma-inhaler-medication-royalty-free-image/1179346207?">Brian Jackson/Getty Images</a></span></figcaption></figure><p>The <a href="https://www.businessinsider.com/cost-asthma-medication-doubled-unjust-2023-7">price of asthma medication has soared</a> in the U.S. over the past decade and a half. </p>
<p>The jump – in some cases from around <a href="https://doi.org/10.1001/jamainternmed.2015.1665">a little over US$10</a> <a href="https://www.singlecare.com/blog/albuterol-sulfate-hfa-proventil-hfa-without-insurance/">to almost $100</a> for an inhaler – has meant that patients in need of asthma-related products <a href="https://www.businessinsider.com/cost-asthma-medication-doubled-unjust-2023-7">often struggle</a> to buy them. Others simply <a href="https://asthma.net/living/cannot-afford-inhalers">can’t afford</a> them. </p>
<p>To make matters worse, asthma <a href="https://www.fda.gov/drugs/buying-using-medicine-safely/generic-drugs">disproportionately affects</a> lower-income patients. Black, Hispanic and Indigenous communities have the <a href="https://aafa.org/asthma-allergy-research/our-research/asthma-disparities-burden-on-minorities/">highest asthma rates</a>. They also shoulder <a href="https://aafa.org/asthma-allergy-research/our-research/asthma-disparities-burden-on-minorities/">the heaviest burden</a> of asthma-related deaths and hospitalizations. Climate change will likely <a href="https://www.hsph.harvard.edu/c-change/subtopics/climate-change-and-asthma/">worsen asthma rates</a> and, consequently, these disparities.</p>
<p>I’m a health law professor at <a href="https://www1.villanova.edu/university/law/faculty-scholarship/faculty-directory/profiles/AnaSantosRutschman.html">Villanova University</a>, <a href="https://papers.ssrn.com/sol3/cf_dev/AbsByAuth.cfm?per_id=2667484">where I study</a> whether patients can get the medicines they need. And I’ve been watching this affordability crisis closely.</p>
<p>In many ways, it shows what happens when law and policy decisions aren’t aligned with public health needs. The good news, however, is that there finally seems to be some political will to rein in the price of asthma meds.</p>
<h2>Why inhaler prices are skyrocketing</h2>
<p>In 2008, the U.S. Food and Drug Administration <a href="https://www.fda.gov/drugs/frequently-asked-questions-popular-topics/transition-cfc-propelled-albuterol-inhalers-hfa-propelled-albuterol-inhalers-questions-and-answers">banned inhalers</a> that use chlorofluorocarbons, or CFCs – which were once widely used as propellants – because they can damage the ozone layer. The FDA was following a timeline set by an environmental treaty, the <a href="https://www.unep.org/ozonaction/who-we-are/about-montreal-protocol">Montreal Protocol</a>, which the U.S. ratified in the late 1980s. </p>
<p>From 2009 onward, CFC inhalers were phased out and replaced with hydrofluoroalkane, or HFA, ones, which are more environmentally friendly. They’re also a lot pricier. For patients with insurance, the average out-of-pocket cost of an inhaler rose from $13.60 per prescription in 2004 to $25 immediately after the 2008 ban, <a href="https://doi.org/10.1001/jamainternmed.2015.1665">a 2015 study found</a>.</p>
<p>Today, the <a href="https://www.singlecare.com/blog/albuterol-sulfate-hfa-proventil-hfa-without-insurance/">average retail price</a> of an albuterol inhaler is $98. Unlike CFC inhalers, which have <a href="https://www.fda.gov/drugs/buying-using-medicine-safely/generic-drugs">generic versions</a>, HFA inhalers are <a href="https://www.scientificamerican.com/article/unlikely-victims-of-banning-cfcs/">covered by patents</a>. While <a href="http://doi.org/10.1089/jamp.2016.1297">the drug itself</a> hasn’t changed, the switch to a different device allowed companies to increase their prices.</p>
<p>In 2020, the FDA finally approved the <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-generic-commonly-used-albuterol-inhaler-treat-and-prevent-bronchospasm">first generic version</a> of an albuterol inhaler. But generic competition still isn’t robust enough to lower prices meaningfully.</p>
<p>Patients with good insurance <a href="https://allergyasthmanetwork.org/advocacy-updates/united-healthcare-albuterol-epinephrine-cost/">may pay very little</a> or even nothing. But uninsured patients face steep market prices, and as of 2023, there were <a href="https://aspe.hhs.gov/sites/default/files/documents/e06a66dfc6f62afc8bb809038dfaebe4/Uninsured-Record-Low-Q12023.pdf">over 25 million</a> uninsured Americans. <a href="https://www.cdc.gov/asthma/asthma_stats/insurance_coverage.htm">Even insured patients may have trouble</a> affording their asthma meds, the CDC has found. </p>
<p>The same asthma medication for which U.S. patients pay top dollar is available elsewhere at much cheaper prices. Consider the following case for inhalers. The pharmaceutical company Teva sells <a href="https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ccd3aaec-4892-40d0-ad60-3e570178fbe1">QVAR RediHaler</a>, a corticosteroid inhaler, <a href="https://doi.org/10.1016/S2213-2600(24)00012-2">for $286</a> in the U.S.</p>
<p>In Germany, Teva sells that same inhaler for $9.</p>
<h2>Seeking meds from Mexico and Canada</h2>
<p>Some U.S. patients have traveled abroad to obtain cheaper asthma medication. After the 2008 ban on CFCs, it became common for patients to <a href="https://doi.org/10.1177/8755122515595052">visit border towns in Mexico</a> to purchase albuterol inhalers. They were sold for <a href="https://doi.org/10.1177/8755122515595052">as little as $3 to $5</a>. </p>
<p>A study of inhalers available to U.S. patients in Nogales, Mexico – about an hour south of Tucson, Arizona – found that Mexican products were <a href="http://doi.org/10.1177/8755122515595052">generally comparable to U.S. inhalers</a>. But researchers found some differences in performance, suggesting that American patients who use them could be getting a slightly different dose than their usual.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Asthma medication is seen on the shelves of a Mexican pharmacy." src="https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580250/original/file-20240306-24-xrc96u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Asthma meds are considerably more affordable south of the border.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-interior-of-farmacia-san-pablo-news-photo/1041982048">Jeffrey Greenberg/Universal Images Group via Getty Images</a></span>
</figcaption>
</figure>
<p>There have also been reports of Americans turning to Canadian pharmacies to purchase asthma inhalers at much cheaper prices. In one case, a U.S. pharmacy would have charged $857 for a three-month supply. A patient obtained it for <a href="https://www.seattletimes.com/life/wellness/canadian-pharmacy-provided-inhaler-at-a-fraction-of-us-cost/">$134 from a pharmacy in Canada</a>.</p>
<h2>One potential fix: Importing cheaper meds</h2>
<p>U.S. law has long <a href="https://www.fda.gov/about-fda/center-drug-evaluation-and-research-cder/frequently-asked-questions-about-drugs">prohibited</a> personal importation of pharmaceutical drugs. However, a recent development could <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/us-fda-allow-florida-import-cheaper-drugs-canada-2024-01-05">pave the way for states</a> to import cheaper asthma drugs.</p>
<p>In January 2024, the <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/us-fda-allow-florida-import-cheaper-drugs-canada-2024-01-05/">FDA authorized</a> the importation of certain prescription drugs from Canada for the first time. <a href="https://www.kff.org/policy-watch/what-to-know-about-the-fdas-recent-decision-to-allow-florida-to-import-prescription-drugs-from-canada/">For now</a>, this authorization is limited to Florida, and it covers only drugs for HIV/AIDS, prostate cancer and certain mental health conditions.</p>
<p>Should it prove successful, the program could serve as a blueprint for other states.</p>
<h2>Another possible solution: Price-capping</h2>
<p>Policymakers could also try borrowing a page from the insulin playbook. Insulin prices <a href="https://doi.org/10.1001/jamanetworkopen.2023.18074">climbed for almost two decades</a> before Congress acted, capping the cost of insulin for Medicare patients. The 2022 <a href="https://www.congress.gov/bill/117th-congress/house-bill/5376/text">Inflation Reduction Act</a> established an out-of-pocket ceiling of $35 per month for prescription-covered insulin products. </p>
<p>If this cap had been in effect two years earlier, it would have saved 1.5 million Medicare patients about $500 annually, <a href="https://www.hhs.gov/about/news/2023/08/16/first-anniversary-inflation-reduction-act-millions-medicare-enrollees-savings-health-care-costs.html">a recent study estimated</a>. It also would have saved Medicare <a href="https://www.hhs.gov/about/news/2023/08/16/first-anniversary-inflation-reduction-act-millions-medicare-enrollees-savings-health-care-costs.html">$761 million</a>.</p>
<p>A similar approach could be taken for asthma meds.</p>
<p>Congress could create an asthma-specific rule similar to the insulin case. Or it could place provisions for asthma-med prices into a larger piece of legislation.</p>
<p>While this approach depends on the political environment, there are signs the government is becoming more willing to act. In January 2024, the U.S. Department of Health and Human Services <a href="https://www.hhs.gov/about/news/2024/01/29/readout-hhs-officials-meeting-private-sector-patient-advocacy-leaders-improve-national-access-important-asthma-medications.html">hosted a meeting</a> to discuss the problem with manufacturers and other stakeholders.</p>
<p>It’s a start. And – together with other measures – it brings some hope that asthma meds might soon become more affordable to those in need.</p><img src="https://counter.theconversation.com/content/222858/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ana Santos Rutschman does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An inhaler that costs nearly $300 in the US goes for just $9 in Germany. What gives?Ana Santos Rutschman, Professor of Law, Villanova School of LawLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2013602023-03-16T12:37:05Z2023-03-16T12:37:05ZWhy it’s hard for the US to cut or even control Medicare spending<figure><img src="https://images.theconversation.com/files/515188/original/file-20230314-3582-48y9sf.jpg?ixlib=rb-1.1.0&rect=77%2C94%2C5673%2C2862&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The number of Americans covered by Medicare is growing.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-friends-walking-with-nordic-walking-poles-in-royalty-free-image/1339068107">OR Images/DigitalVision via Getty Images</a></span></figcaption></figure><p>President Joe Biden’s 2024 proposed budget includes plans to <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/03/07/fact-sheet-the-presidents-budget-extending-medicare-solvency-by-25-years-or-more-strengthening-medicare-and-lowering-health-care-costs/">shore up the finances of Medicare</a>, the <a href="https://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo">federal health insurance program</a> that covers Americans who are 65 and up and some younger people with disabilities.</p>
<p>His administration aims to increase <a href="https://crsreports.congress.gov/product/pdf/IF/IF11820">from 3.8% to 5%</a> an existing Medicare tax that’s collected on the labor and investment earnings of <a href="https://www.cnbc.com/2023/03/08/what-to-know-about-proposed-biden-tax-on-the-wealthy-to-fund-medicare.html">Americans who make more than US$400,000 annually</a>. It also aims to reap some savings from having the government <a href="https://www.politico.com/newsletters/politico-pulse/2023/03/10/the-white-houses-health-care-wish-list-00086344">negotiate prices on more prescription drugs</a>.</p>
<p>The White House projects that these changes would generate an additional <a href="https://www.whitehouse.gov/wp-content/uploads/2023/03/budget_fy2024.pdf">$650 billion</a> in revenue over a decade. <a href="https://budgetmodel.wharton.upenn.edu/issues/2023/3/10/president-bidens-proposal-to-extend-medicare-trust-fund">Some independent experts</a> concur.</p>
<p><a href="https://scholar.google.com/citations?hl=en&user=CwMgD5QAAAAJ">As economists</a> who have long <a href="https://scholar.google.com/citations?user=y0lrTOoAAAAJ&hl=en&oi=ao">researched</a> the <a href="https://scholar.google.com/citations?user=y0lrTOoAAAAJ&hl=en">Medicare and Social Security programs</a>, we believe the president’s proposal is an important first step in opening the necessary debate on strengthening Medicare’s finances.</p>
<h2>Part A’s precarious funding</h2>
<p>Medicare consumes more than <a href="https://www.cbo.gov/publication/58848">15% of the federal budget</a>. The program cost $975 billion in 2022, out of the government’s <a href="https://usafacts.org/state-of-the-union/budget/">$6.5 trillion in total federal spending</a>.</p>
<p>As anyone who has enrolled in it can tell you, the program itself is rather complicated. It’s divided into three parts, known as A, B and D, each of which relies on revenue from a different mix of sources.</p>
<p>Medicare Part A covers care delivered at hospitals and nursing homes, as well as home health care. Part B pays for doctor’s visits and outpatient procedures, and Part D pays for prescription drugs. There’s also Part C, a private insurance option, known as Medicare Advantage. However, its costs are included in the accounting for Parts A and B. </p>
<p>Part A is primarily funded by a <a href="https://www.irs.gov/publications/p80">1.45% Medicare payroll tax</a> on both employees and employers. When that tax and the program’s other tax revenues don’t raise enough money to cover Part A’s costs, the program dips into the <a href="https://www.crfb.org/our-work/projects/medicare-hospital-insurance-trust-fund">Medicare Hospital Insurance trust fund</a> to make up the difference. The trust fund, amassed from past surplus payroll taxes, currently stands at around <a href="https://www.ssa.gov/oact/TRSUM/tr22summary.pdf">$143 billion</a>.</p>
<p>Without spending cuts, funding increases or a combination of the two, the Medicare program’s trustees have predicted in their annual report that the <a href="https://www.cms.gov/files/document/2022-medicare-trustees-report.pdf">Medicare trust fund</a> will be exhausted by 2028. The <a href="https://home.treasury.gov/system/files/136/TR-2022-Fact-Sheet.pdf">trustees are the secretaries</a> of the Treasury, Labor and Health and Human Services departments, plus the Social Security commissioner. There can be up to two additional trustees, but those seats are vacant.</p>
<p>Medicare’s expenses are rising rapidly with the <a href="https://www.investopedia.com/articles/personal-finance/032216/are-we-baby-boomer-retirement-crisis.asp">retirement of baby boomers</a>, the large generation of Americans born between 1946 and 1964, and <a href="https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nationalhealthaccountshistorical">rising health care costs</a>. </p>
<p>Should the trust fund be emptied out, the trustees predict that hospital benefits would have to be cut by 10%. But those cuts are widely considered to be politically unacceptable, as illustrated by <a href="https://www.whitehouse.gov/state-of-the-union-2023/">statements from Biden</a> and his predecessor, former President <a href="https://www.pbs.org/newshour/politics/read-the-full-text-of-trumps-2020-state-of-the-union">Donald Trump</a>.</p>
<p>In addition to proposing an increase in the tax levied on the <a href="https://www.irs.gov/newsroom/questions-and-answers-on-the-net-investment-income-tax">investment earnings of high-income Americans</a>, Biden also proposes that these revenues be fully dedicated to the trust fund. Currently the <a href="https://www.cms.gov/files/document/2022-medicare-trustees-report.pdf">government treats that money as general revenue</a> that can be used for <a href="https://www.thebalancemoney.com/net-investment-income-tax-3192936">any government program</a>.</p>
<h2>2 very different scenarios</h2>
<p>Unlike Medicare Part A, Parts B and D are funded largely by general federal revenue and by premiums paid by retirees.</p>
<p>Because the government is allowed to use general revenue to pay for them, the funding of Parts B and D isn’t jeopardized by the depletion of their trust fund – no matter how fast those costs rise.</p>
<p>Even without Biden’s proposed changes, official Medicare spending projections rise rapidly through the mid-2030s and then plateau as a percentage of gross domestic product.</p>
<p>However, those projections are based on a presumption that payments to <a href="https://www.cms.gov/files/document/2022-medicare-trustees-report.pdf">hospitals are constrained as specified in the Affordable Care Act</a> and that other spending constraints on <a href="https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs">physician payments</a> are realized.</p>
<p>Unfortunately, <a href="https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2015/02/02/a-primer-on-medicare-physician-payment-reform-and-the-sgr/">history provides little assurance</a> that lawmakers will maintain all of these requirements to restrain future payments to health care providers. </p>
<p>We say this because of what happened after 1997, when Congress approved the sustainable growth rate system, which was intended to limit the annual increase in cost per Medicare beneficiary to the rate of economic growth. Starting in 2002, Congress passed legislation year after year to override it – and only stopped doing that once it <a href="http://doi.org/10.1001/journalofethics.2015.17.11.pfor1-1511">did away with the system altogether in 2015</a>.</p>
<p>Reflecting this uncertainty, the annual <a href="https://www.cms.gov/files/document/2022-medicare-trustees-report.pdf">trustees report</a> features an alternative projection that is arguably more credible and more scary. It indicates that Medicare costs will grow much faster than the economy starting in 2036.</p>
<p><iframe id="OcsqK" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/OcsqK/3/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Competing demands</h2>
<p>The Social Security program, a national pension program that primarily supports older Americans, faces similar funding shortfalls.</p>
<p>Its trustees anticipate that the <a href="https://www.ssa.gov/OACT/tr/2022/tr2022.pdf">Social Security trust fund will be depleted</a> by 2035 without changes in funding, promised benefits – or both. In that event, Social Security benefits <a href="https://www.cnn.com/2023/03/08/politics/social-security-benefit-cut/index.html">may have to fall by about 20%</a> from anticipated levels. </p>
<p>Medicare and Social Security are the nation’s largest <a href="https://www.aarp.org/politics-society/government-elections/national-debt-guide/glossary/entitlements-definition.html">entitlement programs</a>. Almost all Americans, if they live long enough, will eventually be eligible to obtain these benefits – regardless of their income or wealth. </p>
<p>While Americans do not yet agree on how to put these programs on a steadier fiscal footing, the math is clear.</p>
<p>Our elected representatives cannot avoid making hard decisions that involve increasing taxes, reducing benefits or both.</p><img src="https://counter.theconversation.com/content/201360/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dennis W. Jansen does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p><p class="fine-print"><em><span>Andrew Rettenmaier does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond his academic appointment.</span></em></p>The program’s expenses are rising rapidly as baby boomers retire and health care costs grow.Dennis W. Jansen, Professor of Economics and Director of the Private Enterprise Research Center, Texas A&M UniversityAndrew Rettenmaier, Executive Associate Director of the Private Enterprise Research Center, Texas A&M UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1490832020-10-29T20:34:53Z2020-10-29T20:34:53ZFact check US: Is Obamacare ‘dysfunctional and too expensive’, as Trump claims?<figure><img src="https://images.theconversation.com/files/366373/original/file-20201029-13-4tmzx8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">file j gerk</span> </figcaption></figure><p>During the first debate of the 2020 presidential campaign, Donald Trump attacked his challenger, Joe Biden, asserting that “Obamacare is too expensive; it doesn’t work”. The attack was unsurprising given Trump’s obsession with this major health care reform, formally known as the <a href="https://www.congress.gov/bill/111th-congress/house-bill/3590/text">Affordable Care Act</a> (ACA).</p>
<p>Work on the law that would become the ACA was initiated in 2009 by the Obama administration with the goal of extending health insurance to more than 20 million Americans out of the 45 million who didn’t have coverage. It was <a href="https://www.youtube.com/watch?v=nIwM0gkLF0s&ab_channel=TheObamaWhiteHouse">signed into law</a> on March 23, 2010. While the law did not succeed in reining in the cost of the US health care system – in 2010, the reform was estimated to cost $940 billion over 10 years, revised to $1.76 trillion just two years later – it has reduced the percentage of Americans without health insurance substantially. In 2013, 20.3% of US citizens had no health insurance. Today, that figure has fallen to slightly above 10%.</p>
<h2>Obama’s political legacy</h2>
<p>The criticism of the Affordable Care Act is part of Donald Trump’s persistent attempts to erase Obama’s political legacy, which is in some ways that of Joe Biden as well. After taking office, Trump quickly launched an effort to <a href="https://ballotpedia.org/Timeline_of_ACA_repeal_and_replace_efforts">“repeal and replace”</a> the ACA. While the Republicans controlled both the House and Senate at the time, the strategy failed. The proposed law passed the House by only a slim majority on May 4, 2017, and was rejected in the Senate on July 28. The <a href="https://www.nytimes.com/2017/07/27/us/politics/obamacare-partial-repeal-senate-republicans-revolt.html">deciding “no” vote was cast by John McCain</a>, the former Republican presidential candidate who has since passed on.</p>
<p>Despite his failure to repeal the ACA, <a href="https://ballotpedia.org/Federal_policy_on_healthcare,_2017-2020">Trump kept attacking</a>. He cut federal taxes aimed at financing the development of the new health insurance system, encouraged Republican governors not to implement the reform in their states, and challenged the act in Federal court on numerous occasions. The Supreme court will have its say on the subject on November 10, when it rules on <a href="https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2020/10/13/a-supreme-court-decision-to-strike-down-the-aca-would-create-chaos-in-the-health-care-system/"><em>California v. Texas</em></a>. The case concerns a suit bought by the Trump administration and a group of attorney generals challenging the law’s constitutionality. </p>
<p>Given the conservative majority on the Supreme Court, there is a real risk that the ACA will be overturned. However, the Covid-19 pandemic and the lack of any plausible alternative by Republicans weigh against such a ruling.</p>
<h2>A broad consensus</h2>
<p>Trump’s difficulties in overturning the ACA have their roots in the reform’s long development process, built on the political consensus of both Democrat and Republican health care policy experts. The law was developed by <a href="http://www.pressesdesciencespo.fr/fr/book/?gcoi=27246100830610">health insurance policy experts</a> both within government and outside (including think tanks and foundations), rather than career civil servants, worked for years to develop the program. In practice, the act is a subtle blend of extending the existing public programs of Medicare (targeting over-65s) and Medicaid (for isolated women and children), and drafting help from private insurers and employers. While certainly complex, the reform allowed for a gradual coverage extension of the health care safety net to a far greater number of US citizens and residents.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/nIwM0gkLF0s?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">President Barack Obama signs the Affordable Care Act on March 23, 2010.</span></figcaption>
</figure>
<p>Prior to the ACA, 20.3% of American citizens had no health insurance. Today, that figure has been cut in half, to just over 10%. Overall, around 25 million Americans have access the health system thanks to the Affordable Care Act. </p>
<p>On the other hand, expense of the reform has exceeded initial previsions: anticipated to cost $940 billion in 2010, in 2012, the bipartisan Congressional Budget Office revised the estimate to $1.76 trillion. And it has not succeeded in reducing health care spending in the United States, which still has by far the world’s most expensive health care system, spending more than <a href="https://data.oecd.org/healthres/health-spending.htm">$11,000 per capita annually</a>, 160% more than the OECD average. In all, 17% of the country’s GDP is spent on health care, yet 1 out of 10 Americans has no health coverage – and this is with the ACA in force. By comparison, France only spends 11% of its GDP for its health care system, which is universal.</p>
<h2>A hybrid system</h2>
<p>Part of the challenge of the ACA is its hybrid nature, a mix of public programs and private insurance. This is the basis for Trump’s claim that it “doesn’t work” and his demand that it be repealed and private insurance returned to the center of the system. This would take America back to the pre-reform status quo, when 20 million US citizens – seen as unprofitable or too risky by private insurers – were unable to obtain health coverage.</p>
<p>The Covid-19 pandemic has highlighted some of the limitations of the ACA and the US health care system – those who have lost their jobs lose access to employer-provided insurance. This has reopened the debate around <a href="https://www.nytimes.com/2020/02/25/upshot/medicare-for-all-basics-bernie-sanders.html">“Medicare for All”</a>, promoted by then-candidate Bernie Sanders during the primaries and supported by the progressive wing of the Democratic party.</p>
<p>Politically astute, Biden has been reaching out to Democrats who could support a gradual broadening of Medicare eligibility (Medicare-like, which lowers the threshold from 65 to 60 years of age) while retaining the structure of the consensus-based ACA. At a <a href="https://www.nbcnews.com/politics/meet-the-press/blog/meet-press-blog-latest-news-analysis-data-driving-political-discussion-n988541/ncrd1029811">October 13 meeting in Des Moines</a>, Biden said, “I think one of the most significant things we’ve done is pass the Affordable Care Act”. Should Biden win the presidential election, it is therefore likely the ACA will live on.</p>
<p>While the Affordable Care Act has not been able to rein in US health care spending, it has reached its objectives in terms of increasing the number and percentage of Americans with access to health care.</p>
<hr>
<p><em>This Fact Check was written with the help of Manon Bernard from the Tours Public School of Journalism (EPJT). It was translated from the French by Alice Heathwood for <a href="http://www.fastforword.fr/en">Fast ForWord</a>.</em></p>
<p><em>Fact check US is supported by <a href="https://craignewmarkphilanthropies.org/">Craig Newmark Philanthropies</a>, an American foundation fighting disinformation.</em></p><img src="https://counter.theconversation.com/content/149083/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William Genieys ne travaille pas, ne conseille pas, ne possède pas de parts, ne reçoit pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'a déclaré aucune autre affiliation que son organisme de recherche.</span></em></p>The US president has relentlessly attacked the ACA since taking office. While more costly than hoped, the law has cut the number of Americans without insurance in half, more than meeting its goals.William Genieys, Directeur de recherche CNRS au CEE à Sciences Po, Sciences Po Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1103522019-01-30T11:50:13Z2019-01-30T11:50:13ZWhat would happen if hospitals openly shared their prices?<figure><img src="https://images.theconversation.com/files/255724/original/file-20190127-108364-d6vrqm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many patients are surprised to learn what their health care procedures cost. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-treatmant-billing-statement-stethoscope-calculator-660981820?src=iMv-bEdpAFbg-pVtUTsjfg-1-5">9dream studio/shutterstock.com</a></span></figcaption></figure><p>Imagine there was a store where there were no prices on items, and you never knew what you’d pay until you’d picked out your purchases and were leaving the shop. You might be skeptical that the store would have any incentive to offer reasonable prices.</p>
<p>This exact situation has become the norm in U.S. health care, at least for those people who lack publicly provided health insurance. Meanwhile, American health care prices are, by many measures, the <a href="https://doi.org/10.1001/jama.2018.1150">highest in the world</a>. </p>
<p>Hospitals have resisted disclosing prices, leading policymakers to consider laws requiring price transparency. This issue has taken on increasing urgency, as patients face increasing out-of-pocket costs. In addition, prices vary widely across hospitals. The same lower limb MRI can cost <a href="https://doi.org/10.1093/qje/qjy020">US$700 at one hospital and $2,100 at another</a>. This means that there are large potential savings if patients switched to less expensive options.</p>
<p>There was a tiny step in this direction on Jan. 1, when all hospitals in the U.S. were required to post their charge prices. However, the list of over 15,000 procedures is notoriously incomprehensible, even for medical professionals. What exactly is a “<a href="https://nyti.ms/2RNDzkz">HC PTC CLOS PAT DUCT ART</a>,” a procedure listed by one Tennessee hospital? Perhaps more importantly, patients’ out-of-pocket costs often depend on the specifics of their insurance plan and the prices that are negotiated by their insurer, meaning the listed prices do not reflect what they actually pay. </p>
<p>For these reasons, <a href="https://khn.org/morning-breakout/fanciful-inflated-difficult-to-decode-and-inconsistent-experts-blast-rules-requiring-hospitals-to-post-prices/">many researchers and commentators</a>, including myself, believe that this approach is unlikely to have a meaningful effect on health care costs.</p>
<h2>Tools that patients can use</h2>
<p>That does not mean that price transparency is hopeless. Recent research shows that price transparency tools that actually have useful, easy-to-use information can benefit patients and reduce health care costs. </p>
<p>Individual employers worried about increasing health care costs have started offering tools with personalized information, helping employees compare out-of-pocket prices. A study by Ethan Lieber at University of Notre Dame found that patients who use Compass, one of these price transparency tools, <a href="https://doi.org/10.1257/pol.20150124">save 10 to 17 percent on medical care</a>. A separate study of a similar tool, Castlight, also found evidence that <a href="https://doi.org/10.1001/jama.2014.13373">using the tool led to sizable savings</a>. </p>
<p>Given the limited availability of these tools, a few states have tried to forge ahead on price transparency available to all. New Hampshire provides <a href="https://nhhealthcost.nh.gov/">a particularly well-designed website</a> that gives all insured patients in the state personalized information about prices, letting them easily determine which are the low-cost options. </p>
<p><a href="https://doi.org/10.1162/rest_a_00765">In an upcoming study</a>, I analyzed the effect of this website using detailed claims data from the state. I found that the website not only helped some patients choose lower-cost options, but it led to lower prices that benefited all patients, including those who did not use the website. </p>
<p>Even though individual patients can save hundreds of dollars by comparing prices, these tools are not yet widely used. In addition, prices are often only available for a small number of procedures. Therefore, overall cost savings are currently quite modest. When I looked at medical imaging procedures in New Hampshire, I found overall savings for patients and insurers of about 3 percent. However, the savings appear to be growing as more people use the website over time and hospitals lower their prices in response.</p>
<p><iframe id="v3qQ9" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/v3qQ9/2/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Imagining a transparent system</h2>
<p>Employer tools and state price transparency websites are a first step, but one could imagine going much further. Hospitals and insurers could be required to publicly disclose the rates negotiated with insurers, making it easy for governments or individuals to design innovative websites and apps using accurate data on prices and insurance policies. Currently, states such as New Hampshire use prices of medical claims in previous years to predict current prices.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/255968/original/file-20190128-108351-u3c5id.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/255968/original/file-20190128-108351-u3c5id.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/255968/original/file-20190128-108351-u3c5id.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/255968/original/file-20190128-108351-u3c5id.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/255968/original/file-20190128-108351-u3c5id.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/255968/original/file-20190128-108351-u3c5id.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/255968/original/file-20190128-108351-u3c5id.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/255968/original/file-20190128-108351-u3c5id.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Even though individual patients can save hundreds of dollars by comparing prices, these tools are not yet widely used by patients.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/old-woman-adult-man-sit-on-1109768135?src=yyaQWTEURN4TAe3TG4fWdg-1-4">toodtuphoto/shutterstock.com</a></span>
</figcaption>
</figure>
<p>Hospitals could also be required to provide a detailed price quote – with a single number summarizing what patient will actually pay – before scheduling any appointment. With the exception of a few medical procedures, such as emergency services, I see no practical reason why billing cannot be determined before a procedure rather than after. </p>
<p>Finally, it is important to note that even the best-designed price transparency initiatives are unlikely to reduce health care costs if there is not <a href="https://www.ftc.gov/news-events/blogs/competition-matters/2014/09/reference-pricing-not-substitute-competition-health">sufficient competition among hospitals</a>. What good is knowing the price if a patient has no other options? Hospital mergers have been continuing at a <a href="https://doi.org/10.1001/jama.2017.1173">rapid pace</a>, and there is growing consensus among researchers that these mergers often <a href="https://www.jstor.org/stable/24433982">increase prices</a> by reducing competition.</p>
<p>If health care is to be left to market forces, then I believe that those markets should be transparent and competitive. Reining in health care costs will require bold solutions that lift the veil on prices.</p><img src="https://counter.theconversation.com/content/110352/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zach Y. Brown has received funding from the National Science Foundation and National Institute of Health. </span></em></p>Hospitals are now required to post their prices online. This approach is unlikely to change US health care – but better price transparency tools could actually reduce costs.Zach Y. Brown, Assistant Professor of Economics, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/805932017-07-27T01:58:29Z2017-07-27T01:58:29ZThe US health economy is big, but is it better?<figure><img src="https://images.theconversation.com/files/178871/original/file-20170719-13593-bqtjik.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health care makes up a sizable portion of U.S. GDP.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/customer-paying-by-credit-card-drug-623126345">gpoiintstudio/Shutterstock.com</a></span></figcaption></figure><p>The U.S. health care system is the most expensive in the world. So why does it underperform relative to many peer countries by most measures? </p>
<p>While the <a href="https://theconversation.com/us/topics/obamacare-3321">Affordable Care Act</a> increased access and coverage, its reforms are years away from full implementation <a href="https://theconversation.com/what-happens-when-the-federal-government-eliminates-health-coverage-lessons-from-the-past-79989">and are now in danger of repeal</a>.</p>
<p>And changes to our health care system could have a powerful and meaningful impact on our economy. In 2015, health care made up US$2.9 trillion of the <a href="http://fortune.com/2015/01/21/americas-new-healthcare-economy-3-trends-to-watch/">$18 trillion U.S. GDP</a> and accounted for <a href="http://www.kff.org/other/state-indicator/total-health-care-employment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">more than 12 million jobs</a>. </p>
<p>My research, described in my book, “<a href="http://www.worldcat.org/title/essentials-of-health-economics/oclc/907391587?referer=di&ht=edition">The Essentials of Health Economics</a>,” as well as that of others, shows how the size of the health care economy continues to grow, without corresponding improvements in treatment outcomes. Looking at the evidence on health care costs, it is not surprising that the U.S. falls behind on access, quality and efficiency. </p>
<h1>The size of our health economy</h1>
<p>In 2014, <a href="http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS">the U.S. spent 17.1 percent of GDP</a> on health care. Meanwhile, France spent 11.5 percent, Germany spent 11.3 percent and the United Kingdom spent just 9.1 percent. </p>
<p><iframe id="Cn4k7" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/Cn4k7/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>What’s more, the health economy is quickly becoming <a href="https://healthcarousel.com/2016/01/19/healthcare-jobs-become-largest-employment-sector-of-the-u-s-economy/">the largest employment sector</a> of the U.S. economy. This is largely due to the rapidly expanding health care economy, a result of the Affordable Care Act. </p>
<p>According to the <a href="https://www.bls.gov/opub/mlr/2015/article/occupational-employment-projections-to-2024.htm">Bureau of Labor Statistics</a>, employment in this industry is expected to grow 21 percent between 2014 and 2024. The areas that have the most opportunities for growth in this sector are home health care services, outpatient care centers, health practitioner offices and ambulatory health care centers. Much of the growth is due to added emphasis on primary and preventive care services for an increasingly sick population with numerous chronic conditions presenting at earlier ages. </p>
<h1>Money versus results</h1>
<p>The large size of the U.S. health economy might make it seem like Americans are more likely to visit their doctor. However, <a href="http://www.commonwealthfund.org/%7E/media/Files/Publications/Fund%20Report/2013/Nov/1717_Thomson_intl_profiles_hlt_care_sys_2013_v2.pdf">studies of how consumers use medical services</a> suggest that <a href="http://www.commonwealthfund.org/%7E/media/Files/Publications/Fund%20Report/2012/Nov/1645_Squires_intl_profiles_hlt_care_systems_2012.pdf">the opposite is true</a>. Americans make fewer inpatient visits than people in other countries, but their visits are more expensive. </p>
<p>For example, in 2013, the U.S. had only 125 hospital discharges per <a href="http://www.commonwealthfund.org/%7E/media/files/publications/fund-report/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf">1,000 population</a>, compared to 252 in Germany and 166 in France. </p>
<p>A similar profile is seen for physician visits. That year, the average American visited only four doctors. Meanwhile, Canadians saw 7.7 and the Japanese saw more than a dozen. </p>
<p><iframe id="DKU4O" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/DKU4O/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>The comparatively high spending on health care in the U.S., coupled with lower rates of using health care services, can lead us to believe that medical prices in the United States must be significantly higher than in other countries due to more technologically advanced care or higher-quality care. </p>
<p>Although anecdotal evidence suggests that waiting times are lower in the U.S. than in other countries, true quality indicators are difficult to derive due to measurement errors. So it’s difficult to say definitively that U.S. consumers get better-quality care than people in other industrialized countries, but their care is definitely the most expensive.</p>
<h1>Is growth good or bad?</h1>
<p>The debate continues as to whether the growth of the health economy in the U.S. is beneficial or neutral to the economy as a whole, given that the health outcomes of the nation are not as good as in other countries.</p>
<p><iframe id="KLEZ3" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/KLEZ3/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>According to <a href="http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror">the Commonwealth Fund</a>, a private foundation that studies health care, the U.S. needs to improve in a variety of ways, including safety, costs, efficiency and equity. </p>
<p>As of 2014, approximately 13 percent of the U.S. population <a href="http://www.gallup.com/poll/171680/americans-remain-satisfied-healthcare-system.aspx">did not have health insurance coverage</a> throughout the year. In contrast, universal coverage exists in the other industrialized countries. I believe that our country would have similar statistics as other countries if we had universal coverage and greater government involvement.</p>
<p>Though health care spending makes up a larger fraction of our overall GDP, the U.S. ranks last among industrialized countries in terms of mortality, infant mortality and healthy life expectancy at age 60. </p>
<p>The growth of the health economy relative to other sectors of the nation’s economy implies that a greater share of resources is devoted to health care relative to other goods. This can result in the public sector putting more scrutiny on health care spending. That may cause the private sector to cut other business expenses – perhaps by reducing wages and health benefits and requiring employees to provide a greater share of the costs of health care. </p>
<p>Therefore, health costs will be shifted more toward consumers of care with increased co-payments and insurance premiums as the share of business benefits decrease over time. If the ACA is successfully repealed and/or replaced, there will be a cut in government spending, which will also contribute to an increased share of health care expenses paid by consumers.</p>
<p>The ultimate impact may be that rapidly rising health care spending lowers GDP and overall employment, while raising inflation. </p>
<p>The question for the nation is whether we are willing to give up growth in the overall economy in order to continue on our current path of ever ballooning health spending, regardless of health outcomes.</p><img src="https://counter.theconversation.com/content/80593/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Diane Dewar receives funding from NYS Department of Health. for system level evaluations of Medicaid waiver programs</span></em></p>Nearly one-fifth of US GDP is spent on health care. Where does all of that money go?Diane Dewar, Associate Professor of Health Policy, Management and Behavior, University at Albany, State University of New YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/780012017-07-26T01:45:22Z2017-07-26T01:45:22ZThe hidden extra costs of living with a disability<figure><img src="https://images.theconversation.com/files/177584/original/file-20170710-5928-xbqobi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Costs of transportation and accessibility are just two factors that increase cost of living for persons with disabilities. </span> <span class="attribution"><span class="source">Corepics VOF/shutterstock.com</span></span></figcaption></figure><p>Disability is often incorrectly assumed to be rare. However, <a href="http://www.who.int/disabilities/world_report/2011/report.pdf">global estimates</a> suggest than one in seven adults has <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2329676">some form of disability</a>. </p>
<p>The term “disability” covers a number of functional limitations – physical, sensory, mental and intellectual. These can range from mild to severe and might affect someone at any time across the lifespan, from an infant born with an intellectual impairment to an older adult who becomes unable to walk or see.</p>
<p>What is perhaps less well-known is that studies consistently show that people with disabilities are disproportionately poor. They are more likely to become poor and, when poor, are more likely to stay that way, because of barriers to getting an education, finding decent work and participating in civic life. Taken together, <a href="http://www.who.int/disabilities/world_report/2011/report.pdf">these barriers</a> significantly and adversely impact their standard of living. </p>
<p>However, a new body of research reveals another major barrier, previously missing from most studies: People living with disabilities also face extra costs of living. Our team’s recent review of the evidence suggests that living with a disability may cost an additional several thousand dollars per year, adding up over time to be a significant financial burden on households.</p>
<h1>Calculating the cost</h1>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/178874/original/file-20170719-13593-1a9eskd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/178874/original/file-20170719-13593-1a9eskd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/178874/original/file-20170719-13593-1a9eskd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/178874/original/file-20170719-13593-1a9eskd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/178874/original/file-20170719-13593-1a9eskd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/178874/original/file-20170719-13593-1a9eskd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/178874/original/file-20170719-13593-1a9eskd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People with disabilities may have more basic necessities than people without.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pretty-aged-granny-using-blue-cane-628135925?src=kI-X2eUyNwk5Y3w9dH5ZGg-3-64">Antonio Diaz/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Governments draw poverty lines at a level of income that they believe is sufficient to meet a minimum standard of living. Someone at the poverty line presumably has just enough resources to house, clothe and feed themselves at an acceptable level, and participate in the basic activities of being a citizen. Increasingly, countries provide <a href="http://www.ilo.org/wcmsp5/groups/public/---dgreports/---dcomm/documents/publication/wcms_245201.pdf">cash benefits or food transfers</a> to people below this poverty line so they are able to reach this minimum standard for basic resources. </p>
<p>The problem is that people with disabilities have extra costs of living that people without disabilities do not have. They have higher medical expenses and may need personal assistance or assistive devices, such as wheelchairs or hearing aids. They may need to spend more on transportation or modified housing, or be restricted in what neighborhoods they can live in to be closer to work or accessible services.</p>
<p>When this is the case, then some people with disabilities might appear “on paper” to live above the poverty line. But in reality, they don’t have enough money to meet the minimum standard of living captured in that poverty line.</p>
<p>In <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2967775">our recent review of the literature</a>, we found that people with disabilities in 10 countries face large extra costs of living. These costs can range widely, from an estimated US$1,170 to $6,952 per year. In a developing country such as Vietnam, for example, the estimate stands at $595 for additional health costs alone.</p>
<p>We used a method called the standard of living approach, which estimates extra costs based on the gap in assets owned by households with and without disabilities. Extra costs accounted for a large share of income, from a low of 12 percent in Vietnam to 40 percent for elderly households in Ireland. </p>
<p>Comparing the costs of disabilities across countries is challenging. Recent studies measure what is actually spent, not what needs to be spent. Estimated costs might be less in developing countries not because it is less expensive to accommodate the needs of people with disabilities in those countries, but because the goods and services needed are not available. If wheelchairs or hearing aids are nowhere to be found, then a person cannot spend money on them. </p>
<p>This could lead to the paradoxical finding that, as a country starts becoming more inclusive, the measured costs of living with a disability could increase. But hopefully, at the same time, the ability of people with disabilities to work and go to school will also increase.</p>
<h1>Unanswered questions</h1>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/177577/original/file-20170710-5952-1ohs79m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/177577/original/file-20170710-5952-1ohs79m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/177577/original/file-20170710-5952-1ohs79m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/177577/original/file-20170710-5952-1ohs79m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/177577/original/file-20170710-5952-1ohs79m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/177577/original/file-20170710-5952-1ohs79m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/177577/original/file-20170710-5952-1ohs79m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A woman is escorted from protest opposing cuts to Medicaid in front of Senator Mitch McConnell’s office on Capitol Hill on June 22, 2017.</span>
<span class="attribution"><span class="source">AP Photo/Jacquelyn Martin</span></span>
</figcaption>
</figure>
<p>There is much we still don’t know about what it costs to live with a disability. In our comprehensive review of the literature, we found only 20 studies that estimated increased costs of living with a disability. The vast majority were from developed countries. </p>
<p>We need better information on how these extra costs may vary by type of disability, and how they may be affected by efforts to remove barriers to participation. For example, how would building a fully accessible public transportation system impact the extra transportation costs that people with disabilities face?</p>
<p>Our work also suggests we may need different income tests for people with disabilities when it comes to social protection programs. For example, should the income limit for receiving cash transfers or subsidized housing be higher for families with disabilities because they face these extra costs? Some countries, such as Denmark and the United Kingdom, provide benefits to support families with disabilities who bear these costs. </p>
<p>Another important question is whether these benefits are adequate. Do they allow people with disability and their families to reach at least a minimum threshold for standard of living? To what extent does this improve their participation in society or the economy?</p>
<h1>Supporting people with disabilities</h1>
<p>To address these questions, we need to monitor these issues over time. For that, we need more and better data on disability in different countries linked to good data on income, assets and expenditures. We recommend adding well-formulated disability questions to the standard household surveys currently used by most countries to chart their citizen’s wellbeing. The best example of such questions was developed under the aegis of the U.N. Statistical Commission via <a href="http://www.washingtongroup-disability.com">the Washington Group on Disability Statistics</a>. </p>
<p>It’s also important to undertake qualitative research. For instance, focus groups and in-depth interviews would help researchers better understand the needs of people with disabilities in their own terms.</p>
<p>Policymakers also need to make social programs sensitive to the issue of extra costs associated with disability – for instance, in income tests and benefit amounts or through social health insurance programs. Our review has led us to believe that even well intended anti-poverty efforts and social protection schemes that do not take into consideration the additional costs of living with a disability will leave millions of people who have disabilities, and their families, in poverty.</p><img src="https://counter.theconversation.com/content/78001/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nothing to disclose.</span></em></p><p class="fine-print"><em><span>Daniel Mont, Hoolda Kim, Michael Palmer, and Sophie Mitra do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Depending on where you live, having a disability can cost thousands of additional dollars per year. Government programs often don’t account for that.Sophie Mitra, Associate Professor of Economics, Fordham UniversityDaniel Mont, Principal Research Associate in Epidemiology and Public Health, UCLHoolda Kim, Graduate Student in Economics, Fordham UniversityMichael Palmer, Senior Lecturer in Economics, RMIT University VietnamNora Groce, Chair of Disability and Inclusive Development, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/752062017-04-03T19:22:49Z2017-04-03T19:22:49ZHealth-care spending has only a modest effect on lifespan and premature death<figure><img src="https://images.theconversation.com/files/163260/original/image-20170330-15595-y9p3he.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new analysis found spending on health doesn't have a big effect on whether people die prematurely. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p><a href="http://www.sciencedirect.com/science/article/pii/S0277953617301132">A new analysis has found</a> spending more on health care has little impact on improving key health outcomes. It found that a 10% increase in health-care spending reduces the number of deaths by only 1.3%, and increases life expectancy by only 0.4%. </p>
<p>Our new meta-analysis, which pooled results from 65 studies, looked at health-care spending by both the private and public sectors including preventive and curative care.</p>
<p>Health-care spending as a share of GDP has nearly doubled in <a href="http://www.oecd.org/els/health-systems/health-data.htm">OECD countries</a> since 1970. Death rates fell in OECD countries by 86% during this period. While this is a great achievement, given our study found health spending improves death rates by only a small amount, the doubling of spending explains only a small fraction of this large improvement in health. This is because health-care spending is only one of many factors that affect health. </p>
<p>Our analysis looked at two measures of health: life expectancy and death rates, which are major health status indicators. These are two of the most important measures of health status, but health care treats a large number of diseases and conditions not investigated by our study.</p>
<p>Our analysis also showed public health-care spending is more effective in reducing death than private spending, contrary to <a href="http://www.tandfonline.com/doi/abs/10.1080/00036840210135665?journalCode=raec20">some earlier studies</a>. We found no real difference between the effect of spending on health in developed and developing countries, or between genders.</p>
<h2>Wealthier countries spend more on health</h2>
<p>Health-care spending per person has risen throughout the world. In 2014, the high-income OECD countries spent, on average, the equivalent of <a href="http://api.worldbank.org/v2/en/indicator/SH.XPD.PCAP.PP.KD?downloadformat=excel">US$4,698</a> per person on health. In Australia we spent US$4,357 per person. These amounts are significantly higher than the global average of US$1,276 per person. </p>
<p>Over time, spending on health has been diverging between high-income countries and the rest of the world, with spending in high-income countries growing faster than in other countries. This raises the issue of value for money, especially in the USA where spending is US$9,403 per person. This is despite having pretty <a href="https://ourworldindata.org/the-link-between-life-expectancy-and-health-spending-us-focus">poor outcomes</a> compared to money spent.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=436&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=436&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=436&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=548&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=548&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163570/original/image-20170403-19445-1y6tfpc.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=548&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Richer countries spend more on health care. Data here are in international dollars, adjusted for inflation and purchasing power price differences.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Even though spending is diverging among countries, some health outcomes are becoming similar over time between developed and developing countries. For example, child mortality has fallen throughout the world but the fall has been greater in non-OECD countries.</p>
<p>In 1960, <a href="http://api.worldbank.org/v2/en/indicator/SH.DYN.MORT?downloadformat=excel">child mortality</a> in OECD countries was 63 deaths per 1,000, compared to 183 in the world as a whole. This is a difference of 120 deaths. By 2015, mortality in the OECD countries fell to seven deaths per 1,000 and in the world as whole mortality fell to 43.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=436&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=436&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=436&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=548&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=548&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163571/original/image-20170403-19417-8577zq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=548&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The gap in child mortality between the OECD and all nations is narrowing.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>And while <a href="http://api.worldbank.org/v2/en/indicator/SP.DYN.LE00.IN?downloadformat=excel">life expectancy</a> has increased globally, the gap between OECD countries and all countries has remained largely unchanged.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=436&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=436&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=436&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=548&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=548&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163572/original/image-20170403-19452-8lfw16.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=548&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Life expectancy has increased globally but a large gap remains between nations.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>So where should the money go?</h2>
<p>So it follows from our study that household income, education, wealth inequality, demographics and lifestyle choices play a collectively more important role in improving health. Lifestyle choices include nutrition, physical activity, and the consumption of alcohol and tobacco. </p>
<p>Some health-care spending is <a href="http://www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/tackling-wasteful-spending-on-health_9789264266414-en#page1">wasted</a> on <a href="https://theconversation.com/why-were-wasting-money-on-medical-tests-and-how-behavioural-insights-can-help-72801">unnecessary procedures</a>, <a href="https://theconversation.com/how-to-slash-half-a-billion-dollars-a-year-from-australias-drugs-bill-73050">slow uptake of generic drugs</a> and administrative inefficiencies. Some of this is possibly due to the influence of powerful interest groups such as the pharmaceutical industry and medical bureaucracies.</p>
<p>The finding that public funding of health care results in a slightly larger reduction in premature death than private funding highlights the importance of directing funding to government hospitals and other public health measures. Progress in medical technology – for example, in fighting cancer and heart disease – is especially important and warrants additional funding.</p><img src="https://counter.theconversation.com/content/75206/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Doucouliagos does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Our new meta-analysis, which pooled results from 65 studies, looked at health-care spending by both the private and public sectors including preventive and curative care.Chris Doucouliagos, Professor of Economics, Department of Economics, Deakin Business School and Alfred Deakin Institute for Citizenship and Globalisation, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.