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How Discrimination in Health Care Affects Older Americans, and What Health Systems and Providers Can Do

April 21, 2022

Racial and ethnic discrimination has a significant impact on the health of people of color, affecting mental health and contributing to high blood pressure, negative health behaviors, and early aging. For Black older adults, the cumulative effects of race-related stress experienced over the course of a life can increase the risk for mental and physical health problems.In health care settings, experiences of discrimination can include providers dismissing a patient's symptoms or health concerns, offering different treatment based on a patient's type of insurance, or not providing care in a patient's preferred language.We analyzed findings from the Commonwealth Fund 2021 International Health Policy Survey of Older Adults to examine experiences of racial discrimination in health care settings among Latinx/Hispanic and Black older adults. (See "How We Conducted This Study" for more details.) To provide some cross-national context, we first detail the extent to which older adults in 11 high-income countries believe their national health system treats people unfairly because of race or ethnicity. We then look more in-depth at the United States and report on older Americans' experiences of discrimination and the consequences of health providers' unfair or dismissive treatment. Finally, we consider steps that U.S. health system leaders, health care educators, policymakers, and others can take to address discrimination and dismantle systemic racism in health care.

When Costs Are a Barrier to Getting Health Care: Reports from Older Adults in the United States and Other High-Income Countries: Findings from the 2021 International Health Policy Survey of Older Adults

October 1, 2021

Issue: Unlike older adults in other high-income countries, those in the United States face significant financial barriers to getting health care, despite Medicare's universal coverage. These barriers may affect use of health services as well as health outcomes.Goal: To compare the out-of-pocket spending and care-seeking experiences of older Americans with those of older adults in 10 other high-income countries.Methods: Analysis of findings from the Commonwealth Fund's 2021 International Health Policy Survey of Older Adults.Key Findings: One-fifth of older Americans spent more than $2,000 out of pocket on health care in the past year. Only a small share of older adults in most of the other surveyed countries had such high out-of-pocket health costs. Similarly, a higher share of older Americans reported forgoing health care because of costs. Rates of skipping dental care because of costs were similar for older adults in nations that do not offer coverage of such services, including the U.S.Conclusions: Older Americans pay more for health care and are more likely to not get care for cost-related reasons than people in other high-income countries. Affordability remains a concern and should continue to be a focus of research and policy.

Mirror, Mirror 2021: Reflecting Poorly - Health Care in the U.S. Compared to Other High-Income Countries

August 4, 2021

Issue: No two countries are alike when it comes to organizing and delivering health care for their people, creating an opportunity to learn about alternative approaches.Goal: To compare the performance of health care systems of 11 high-income countries.Methods: Analysis of 71 performance measures across five domains — access to care, care process, administrative efficiency, equity, and health care outcomes — drawn from Commonwealth Fund international surveys conducted in each country and administrative data from the Organisation for Economic Co-operation and Development and the World Health Organization.Key Findings: The top-performing countries overall are Norway, the Netherlands, and Australia. The United States ranks last overall, despite spending far more of its gross domestic product on health care. The U.S. ranks last on access to care, administrative efficiency, equity, and health care outcomes, but second on measures of care process.Conclusion: Four features distinguish top performing countries from the United States: 1) they provide for universal coverage and remove cost barriers; 2) they invest in primary care systems to ensure that high-value services are equitably available in all communities to all people; 3) they reduce administrative burdens that divert time, efforts, and spending from health improvement efforts; and 4) they invest in social services, especially for children and working-age adults.

Americans' Views on Health Insurance at the End of a Turbulent Year

March 1, 2018

The Affordable Care Act's 2018 open enrollment period came at the end of a turbulent year in health care. The Trump administration took several steps to weaken the ACA's insurance marketplaces. Meanwhile, congressional Republicans engaged in a nine-month effort to repeal and replace the law's coverage expansions and roll back Medicaid. Nevertheless, 11.8 million people had selected plans through the marketplaces by the end of January, about 3.7 percent fewer than the prior year. There was an overall increase in enrollment this year in states that run their own marketplaces and a decrease in those states that rely on the federal marketplace.To gauge the perspectives of Americans on the marketplaces, Medicaid, and other health insurance issues, the Commonwealth Fund Affordable Care Act Tracking Survey interviewed a random, nationally representative sample of 2,410 adults ages 19 to 64 between November 2 and December 27, 2017, including 541 people who have marketplace or Medicaid coverage.The findings are compared to prior ACA tracking surveys, the most recent of which was fielded between March and June 2017. The survey research firm SSRS conducted the survey, which has an overall margin of error is +/– 2.7 percentage points at the 95 percent confidence level.

Older Americans Were Sicker and Faced More Financial Barriers to Health Care Than Counterparts in Other Countries

November 15, 2017

An international survey of older adults finds that seniors in the United States are sicker than their counterparts in 10 other high-income countries and face greater financial barriers to health care, despite the universal coverage that Medicare provides. Across all the countries, few elderly adults discuss mental health concerns with their primary care providers. Moreover, nearly a quarter are considered "high need" — meaning they have three or more chronic conditions or require help with basic tasks of daily living.

Following the ACA Repeal-and-Replace Effort, Where Does the U.S. Stand on Insurance Coverage? Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, March–June 2017

September 7, 2017

Issue: After Congress's failure to repeal and replace the Affordable Care Act, some policy leaders are calling for bipartisan approaches to address weaknesses in the law's coverage expansions. To do this, policymakers will need data about trends in insurance coverage, reasons why people remain uninsured, and consumer perceptions of affordability.Goal: To examine U.S. trends in insurance coverage and the demographics of the remaining uninsured population, as well as affordability and satisfaction among adults with marketplace and Medicaid coverage.Methods: Analysis of the Commonwealth Fund Affordable Care Act Tracking Survey, March–June 2017.Findings and Conclusions: The uninsured rate among 19-to-64-year-old adults was 14 percent in 2017, or an estimated 27 million people, statistically unchanged from one year earlier. Uninsured rates ticked up significantly in three subgroups: 35-to-49-year-olds, adults with incomes of 400 percent of poverty or more (about $48,000 for an individual), and adults living in states that had not expanded Medicaid. Half of uninsured adults, or an estimated 13 million, are likely eligible for marketplace subsidies or the Medicaid expansion in their state. Four of 10 uninsured adults are unaware of the marketplaces. Adults in marketplace plans with incomes below 250 percent of poverty are much more likely to view their premiums as easy to afford compared with people with higher incomes. Policies to improve coverage include a federal commitment to supporting the marketplaces and the 2018 open enrollment period, expansion of Medicaid in 19 remaining states, and enhanced subsidies for people with incomes of 250 percent of poverty or more.

How the Affordable Care Act Has Helped Women Gain Insurance and Improved Their Ability to Get Health Care

August 10, 2017

Issue: Prior to the Affordable Care Act (ACA), one-third of women who tried to buy a health plan on their own were either turned down, charged a higher premium because of their health, or had specific health problems excluded from their plans. Beginning in 2010, ACA consumer protections, particularly coverage for preventive care screenings with no cost-sharing and a ban on plan benefit limits, improved the quality of health insurance for women. In 2014, the law's major insurance reforms helped millions of women who did not have employer insurance to gain coverage through the ACA's marketplaces or through Medicaid.Goals: To examine the effects of ACA health reforms on women's coverage and access to care.Method: Analysis of the Commonwealth Fund Biennial Health Insurance Surveys, 2001–2016.Findings and Conclusions: Women ages 19 to 64 who shopped for new coverage on their own found it significantly easier to find affordable plans in 2016 compared to 2010. The percentage of women who reported delaying or skipping needed care because of costs fell to an all-time low. Insured women were more likely than uninsured women to receive preventive screenings, including Pap tests and mammograms.

Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care

July 14, 2017

ABSTRACTIssue: The United States health care system spends far more than other high-income countries, yet has previously documented gaps in the quality of care.Goal: This report compares health care system performance in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.Methods: Seventy-two indicators were selected in five domains: Care Process, Access, Administrative Efficiency, Equity, and Health Care Outcomes. Data sources included Commonwealth Fund international surveys of patients and physicians and selected measures from OECD, WHO, and the European Observatory on Health Systems and Policies. We calculated performance scores for each domain, as well as an overall score for each country.Key findings: The U.S. ranked last on performance overall, and ranked last or near last on the Access, Administrative Efficiency, Equity, and Health Care Outcomes domains. The top-ranked countries overall were the U.K., Australia, and the Netherlands. Based on a broad range of indicators, the U.S. health system is an outlier, spending far more but falling short of the performance achieved by other high-income countries. The results suggest the U.S. health care system should look at other countries' approaches if it wants to achieve an affordable high-performing health care system that serves all Americans.

How Medicaid Enrollees Fare Compared with Privately Insured and Uninsured Adults: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016

April 27, 2017

Issue: The number of Americans insured by Medicaid has climbed to more than 70 million, with an estimated 12 million gaining coverage under the Affordable Care Act's Medicaid expansion. Still, some policymakers have questioned whether Medicaid coverage actually improves access to care, quality of care, or financial protection. Goals: To compare the experiences of working-age adults who were either: covered all year by private employer or individual insurance; covered by Medicaid for the full year; or uninsured for some time during the year. Method: Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016. Findings and Conclusions: The level of access to health care that Medicaid coverage provides is comparable to that afforded by private insurance. Adults with Medicaid coverage reported better care experiences than those who had been uninsured during the year. Medicaid enrollees have fewer problems paying medical bills than either the privately insured or the uninsured.

How High-Need Patients Experience Health Care in the United States: Findings from the 2016 Commonwealth Fund Survey of High-Need Patients

December 8, 2016

Health care costs are highly concentrated among people with multiple chronic conditions, behavioral health problems, and those with physical limitations or disabilities. With a better understanding of these patients' challenges, health care systems and providers can address patients' complex social, behavioral, and medical needs more effectively and efficiently. Goal: To investigate how the challenges faced by this population affect their experiences with the health care system and examine potential opportunities for improvement. Methods: Analysis of the 2016 Commonwealth Fund Survey of High-Need Patients, June–September 2016. Key findings and conclusions: The health care system is currently failing to meet the complex needs of these patients. High-need patients have greater unmet behavioral health and social issues than do other adults and require greater support to help manage their complex medical and nonmedical requirements. Results indicate that with better access to care and good patient–provider communication, high-need patients are less likely to delay essential care and less likely to go to the emergency department for nonurgent care, and thus less likely to accrue avoidable costs. For health systems to improve outcomes and lower costs, they must assess patients' comprehensive needs, increase access to care, and improve how they communicate with patients.

Who Are the Remaining Uninsured and Why Haven't They Signed Up for Coverage? Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, February–April 2016

August 18, 2016

The number of uninsured people in the United States has declined by an estimated 20 million since the Affordable Care Act went into effect in 2010. Yet, an estimated 24 million people still lack health insurance. Goal: To examine the characteristics of the remaining uninsured adults and their reasons for not enrolling in marketplace plans or Medicaid. Methods: Analysis of the Commonwealth Fund ACA Tracking Survey, February–April 2016. Key findings and conclusions: There have been notable shifts in the demographic composition of the uninsured since the law's major coverage expansions went into effect in 2014. Latinos have become a growing share of the uninsured, rising from 29 percent in 2013 to 40 percent in 2016. Whites have become a declining share, falling from half the uninsured in 2013 to 41 percent in 2016. The uninsured are very poor: 39 percent of uninsured adults have incomes below the federal poverty level, twice the rate of their overall representation in the adult population. Of uninsured adults who are aware of the marketplaces or who have tried to enroll for coverage, the majority point to affordability concerns as a reason for not signing up.

Does Medicaid Make a Difference? Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014

June 24, 2015

As millions of Americans gain Medicaid coverage under the Affordable Care Act, attention has focused on the access to care, quality of care, and financial protection that coverage provides. This analysis uses the Commonwealth Fund Biennial Health Insurance Survey, 2014, to explore these questions by comparing the experiences of working-age adults with private insurance who were insured all year, Medicaid beneficiaries with a full year of coverage, and those who were uninsured for some time during the year. The survey findings suggest that Medicaid coverage provides access to care that in most aspects is comparable to private insurance. Adults with Medicaid coverage reported better care experiences on most measures than those who had been uninsured during the year. Medicaid beneficiaries also seem better protected from the cost of illness than do uninsured adults, as well as those with private coverage.