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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.

Health and Health Care for Women of Reproductive Age: How the United States Compares with Other High-Income Countries

April 5, 2022

The maternal mortality crisis in the United States has been well documented: U.S. women have the highest rate of maternal deaths among high-income countries, while Black women are nearly three times more likely to die from pregnancy-related complications than white women are. But maternal deaths and complications may be a bellwether for the U.S.'s wider failures with respect to women's health and health care.Using data from the Commonwealth Fund's 2020 International Health Policy Survey and the Organisation for Economic Co-operation and Development (OECD), this brief compares selected measures of health care access and outcomes for women of reproductive age (18 to 49) in 11 high-income countries. After identifying gaps in U.S. health system performance for women in this age group, we explore some of the policies other nations have put in place to ensure more equitable access and better health outcomes. We also suggest policy options for the United States.

Achieving Racial and Ethnic Equity in U.S. Health Care: A Scorecard of State Performance

November 17, 2021

In this report, we evaluate health equity across race and ethnicity, both within and between states, to illuminate how state health systems perform for Black, white, Latinx/Hispanic, AIAN, and Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations. Our hope is that policymakers and health system leaders will use this tool to investigate the impact of past policies on health across racial and ethnic groups, and that they will begin to take steps to ensure an equitable, antiracist health care system for the future.

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.

As the Pandemic Eases, What Is the State of Health Care Coverage and Affordability in the U.S.? Findings from the Commonwealth Fund Health Care Coverage and COVID-19 Survey, March–June 2021

July 16, 2021

To shore up an economy and health system battered during the COVID-19-induced recession, the U.S. Congress passed four major relief bills in 2020 and 2021. The Biden administration also made a number of administrative changes, including some aimed at helping people enroll in health insurance coverage.After a year of severe job market disruption combined with a massive federal pandemic relief effort, what is the state of health care coverage and affordability in the United States?To answer these and related questions, the survey research firm SSRS interviewed a random, nationally representative sample of 5,450 adults ages 19 to 64 from March 9 through June 8, 2021. This brief reports on the survey's findings about current uninsured rates, pandemic-related coverage loss, and Americans' ongoing struggles to pay their medical bills.

American COVID-19 Vaccine Poll

June 16, 2021

The American COVID-19 Vaccine Poll is a partnership between the African American Research Collaborative and The Commonwealth Fund. The Robert Wood Johnson Foundation supported an expansion of the poll in the Native American community and the W.K. Kellogg Foundation supported expansion in New Mexico.We surveyed over 12,000 Americans to better understand their access to and opinions about the vaccines, as well as messages and messengers that encourage different groups to get vaccinated.

How Auto-Enrollment Can Achieve Near-Universal Coverage: Policy and Implementation Issues

June 10, 2021

Issue: Automatic enrollment is receiving increased policy attention as a means of achieving universal coverage. Auto-enrollment also could have eliminated insurance gaps that occurred during the COVID-19 pandemic. However, it could face resistance from some Americans who would newly be expected to pay premiums. The approach also raises difficult design and implementation issues.Goal: Explore how two auto-enrollment strategies, one affecting all legal residents and another affecting a narrower low-income population, might work.Methods: Based on lessons learned from the Affordable Care Act and understanding of subsidized insurance programs, we explore design and implementation issues, such as how to deem enrollment, how to collect premiums, and which exemptions to permit. We also use the Urban Institute's Health Insurance Policy Simulation Model (HIPSM) to estimate coverage and cost implications of each approach.Key Findings and Conclusions: Both the comprehensive and limited approach to auto-enrollment would require the development of new administrative systems and enhanced marketplace subsidies to improve coverage affordability. Each approach would operate more simply if accompanied by a public insurance option. We conclude that the administrative and financing challenges related to auto-enrollment can be addressed and that a balance between public costs and sufficient political support could be identified.

Racial and Ethnic Inequities in Health Care Coverage and Access, 2013–2019

June 9, 2021

In this brief, we update our 2020 report on coverage and access inequities using 2013–2019 data from the American Community Survey Public Use Microdata Sample (ACS PUMS) and the Behavioral Risk Factor Surveillance System (BRFSS). We examine trends in Black and Latinx/Hispanic disparities across the following measures, with a particular focus on the effects of Medicaid expansion on equity at the state level:adults ages 19 to 64 who are uninsuredadults ages 18 to 64 who went without care in the past 12 months because of costadults ages 18 to 64 who report having a usual health care provider.

Inequities in Health and Health Care in Black and Latinx/Hispanic Communities: 23 Charts

June 3, 2021

COVID-19 has devastated Black and Latinx/Hispanic communities in the United States during the past year, erasing recent life expectancy gains and reinforcing racism as a potent, structural driver of health and human inequity.The health disparities contributing to this burden are long-standing. They reach well beyond the pandemic and have left many communities of color with historically worse outcomes. This chartbook details inequities between white, Black, and Latinx/Hispanic communities across a range of health indicators in four main areas:insurance coverage and access to carereceipt of health serviceshealth statusmortality.

How Would State-Based Individual Mandates Affect Health Insurance Coverage and Premium Costs?

July 20, 2018

Issue: The Tax Cuts and Jobs Act of 2017 eliminated the financial penalty of the Affordable Care Act's individual mandate. States could reinstate a similar penalty to encourage health insurance enrollment, ensuring broad sharing of health care costs across healthy and sick populations to stabilize the marketplaces.Goal: To provide state-by-state estimates of the impact on insurance coverage, premiums, and mandate penalty revenues if the state were to adopt an individual mandate.Methods: Urban Institute's Health Insurance Policy Simulation Model (HIPSM) is used to estimate the coverage and cost impacts of state-specific individual mandates. We assume each state adopts an individual mandate similar to the ACA's.Findings and Conclusion: If all states implemented individual mandates, the number of uninsured would be lower by 3.9 million in 2019 and 7.5 million in 2022. On average, marketplace premiums would be 11.8 percent lower in 2019. State mandate penalty revenues would amount to $7.4 billion and demand for uncompensated care would be $11.4 billion lower. The impact on coverage and on premiums varies in significant ways across states. For example, in 2019, the number of people uninsured would be 19 percent lower in Colorado and 10 percent lower in California if they implemented their own mandates. With mandates in place, average premiums would be 4 percent lower in Alaska and 15 percent lower in Washington.

Getting Ready for Health Reform 2020: What Past Presidential Campaigns Can Teach Us

June 26, 2018

The candidates for the 2020 presidential election are likely to emerge within a year, along with their campaign plans. Such plans will include, if not feature, health policy proposals, given this issue's general significance as well as the ongoing debate over the Affordable Care Act.