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The signing of the Affordable Care Act in 2010 ushered in the largest expansion in the number of Americans covered by health insurance since the implementation of Medicare and Medicaid more than 50 years ago. The ACA provided health new coverage to 19 million previously uninsured working-age people, allowing many of them to afford the care they need.

In spite of that expansion of insurance coverage, though, Americans’ ability to afford care is no better now than it was two decades ago.


In a study we published last week in JAMA Internal Medicine, we and several colleagues showed that Americans actually have more unmet health care needs today than they had two decades ago. We defined unmet health care needs as a situation in which a person needed medical care for illness, injury, or preventive purposes, but did not receive it.

Our team analyzed data from the Behavioral Risk Factor Surveillance System, a national survey conducted between 1998 and 2017 to see how unmet needs for physician visits changed over the years. During that time, the percentage of adults who were unable to afford to see the doctor when needed increased by nearly one-third, from 11% to 16%.

In 2017, individuals who were uninsured were about three times more likely to say they couldn’t afford health care than those with coverage. No surprise there. But over the past 20 years, it was people with insurance who had the biggest relative increase in being unable to afford doctor visits. And it wasn’t just healthy people — between 1998 and 2017, more and more people with serious illnesses like diabetes and heart disease said they couldn’t afford doctor visits. By 2017, nearly one-fifth of all adults with at least one serious chronic disease said they couldn’t afford doctor visits.


If more people have health insurance, why is health care getting less affordable?

Much has changed in the health care industry since 1998. Insurers have raised deductibles and co-pays, and narrowed their networks of providers, saddling many patients with surprise medical bills for out-of-network care. And health care costs have increased exponentially, with more than $800 billion going each year to health care bureaucracy.

Our findings shine a light on the limitations of the ACA. While the law provided insurance coverage to many who had previously been uninsured, it did little to alter the financial barriers introduced by the insurance industry itself. The effects of the ACA weren’t enough to overcome longer-term trends of rising out-of-pocket expenses that prevent people from getting the care they need, trends driven by private insurance.

Other wealthy nations do much better than ours. In Canada’s single payer system, only 2% of adults with a chronic illness report that they can’t afford doctor visits, and similarly low numbers are reported in Germany, Spain, Sweden, the United Kingdom, Israel, and Italy.

Our findings reinforce what many Americans already know: health care is unaffordable. That’s why health insurance is a top issue for voters in the upcoming elections. The Trump administration wants to dismantle the ACA and impose even greater financial barriers to care. Several Democratic presidential candidates would merely layer a new public option on top of the current system which is dominated by private insurance.

Any solution that builds upon the insurance industry is likely to impose costs that make health care unaffordable, even to the insured. Tens of millions of Americans who currently have private coverage still can’t afford care.

Only a single-payer health plan can fix that problem.

Laura Hawks, M.D., is a primary care physician and research fellow at the Cambridge Health Alliance and Harvard Medical School. Danny McCormick, M.D., is a primary care physician at the Cambridge Health Alliance and an associate professor of medicine at Harvard Medical School. He is a volunteer member of Physicians for a National Healthcare Program, which supports single-payer health reform.

  • Hospitals can now screen patients before even admitting them, sending them elsewhere, when their insurance does not reimburse enough. The ACA was developed to protect the insurance industry, medical providers, and profiteers like the pharma industry, not Americans. The ACA only reinforced the two tiered healthcare system. Every other developed nation has universal healthcare, making a profit is not consistent with health.

  • While I agree with the author’s conclusions about health care affordability, to say that “only a single payer health plan can fix that problem” is a stretch (to put it mildly). Lots of pluralistic payment systems around the world have far fewer issues with affordability. We simply need to apply those lessons to our our domestic situation. Some form of all payer rate setting (as we see in Maryland) applied more broadly to health care products and services could go a long ways toward addressing the single biggest problem we face which is unit pricing. As for the overhead cost issue, administrative simplification focusing on standardizing insurance forms would take that number down considerably. It just requires the political will to learn from the experiences of other developed nations.

    Focusing our efforts on solutions that have no realistic chance of becoming US policy any time in the foreseeable future (e.g. “Medicare for All”) not only fails to help average Americans with the serious affordability issues we face, it damages the the credibility of the entire case for any substantive health care reform.

    • We wasted almost 2 decades on the ACA, as our corporate funded politicians, compromised with corrupt corporate interests. Getting rid of the insurance companies takes 20 percent of the costs off the top. We saw how the corrupt industry insiders, even corrupted data gathering. A lot of time has been wasted closing loopholes and other corporate gifts in the ACA. The mess we have now is a result of compromising with industry interests, and allowing misinformation and marketing to replace facts with industry talking points. Remember when the EHR, was supposed to “revolutionize medicine?” All we saw was an industry wide nightmare, because the health industry does not like accountability. Sites like this and the rest of mass media, rely on advertising, so positive reporting on Medicare For All, is going to be offset by a lot of industry talking points.

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