Thinking About Health: Rural people most affected by negative health care trends

Recent studies about health care in America show troubling trends, especially in states with large rural and relatively low-income populations.

While the United States continues to spend far more than any other developed country on health care on a per capita basis and as a percentage of gross domestic product (GDP), many states, especially in the South and Midwest, are losing ground in key areas that pertain to life expectancy.

The Commonwealth Fund’s just-released 2018 Scorecard on State Health System Performance confirmed what other recent studies have shown: Life expectancy in the United States is going down while it continues to go up in other developed countries. And rural areas seem to be disproportionately affected.

Some researchers have used one word to explain the sudden reversal in life expectancy trends in the United States: despair. That’s because of the rapidly rising number of suicides and deaths associated with alcohol and drug use in this country. The Commonwealth Fund reported deaths from suicide, alcohol and drug use have increased 50 percent since 2005.

The Scorecard, which assessed every state and the District of Columbia on 43 measures in five broad categories – access to health care, quality of care, efficiency in care delivery, health outcomes, and income-based health care disparities – wasn’t all bad news by any means. In fact, most states made improvements between 2013 and 2016 in some or all of the categories. But several others, Nebraska in particular, saw a worsening in all five.

The states scoring the highest overall were Hawaii (No. 1), Massachusetts, Minnesota, Vermont, and Utah, while those scoring the lowest were Arkansas, Florida, Louisiana, Oklahoma, and Mississippi (No. 51).

But three of those bottom-ranking states – Arkansas, Louisiana, and Oklahoma – were among the five states making the most improvements. At the other end of the spectrum, the five making the fewest improvements were New Hampshire, Utah, Maine, Wyoming, and Nebraska (No. 51).

The Commonwealth Fund’s researchers noted progress in all categories is certainly possible in coming years but added unless significant steps are taken, improvements in many states aren’t likely anytime soon.

“If every state achieved the performance of the top-ranked state on each Scorecard indicator, the gains in health care access, quality, efficiency, and outcomes would be dramatic,” the researchers wrote. “At the current rates of improvement, however, it may take many years or decades for states and the nation to see such progress.”

That may portend a continuing decline in life expectancy in the United States.

The Centers for Disease Control and Prevention reported in December life expectancy in the United States declined for the second year in a row in 2016. U.S. life expectancy peaked at 78.9 years in 2014. It fell to 78.7 in 2015 and to 78.6 in 2016.

As the British Medical Journal pointed out earlier this year, this decline is the culmination of a decades-long trend. In 1960, the United States had the highest life expectancy of any country in the 35-member Organization for Economic Cooperation and Development (OECD), which comprises the world’s richest countries. Back then, Americans on average lived 2.4 years longer than residents of the other OECD countries. We started losing ground, though, in the 1980s. Our life expectancy first fell below the OECD average in 1998. Now it’s 1.5 years lower than the average of the 35 countries.

Steven H. Woolf, the author of the British Medical Journal article, attributed the decline to “life conditions” that seem to be more challenging to Americans, rural Americans in particular, than they are to residents of other developed countries. He cited the rising number of deaths from opioid overdoses in particular as a symptom of those greater life challenges.

But, he added, “the opioid epidemic is the tip of an iceberg, part of an even larger public health crisis in the U.S.: Death rates from alcohol abuse and suicides have also been rising … These ‘deaths of despair,’ as some have called them, are disproportionately affecting white Americans, especially adults aged 25-59 years, those with limited education, and women. The sharpest increases are occurring in rural counties, often in regions with longstanding social and economic challenges.”

Meanwhile, the United States spends far more on health care than any other country: $10,348 per capita annually, which is more than twice as much as the $5,169 average spent by OECD countries. We spend 31 percent more per capita than the next highest country, Switzerland.

And as noted above, we also spend more on health care – 17.3 percent of GDP, more than twice the 7.9 percent average of comparably developed countries. And the difference is widening every year.

That percentage is expected to keep going up because of constantly rising health care costs and health insurance premiums, although the rate of increase of both has slowed somewhat in recent years. But as the Kaiser Family Foundation reported last September, the average annual premium for employer-sponsored family coverage reached $18,764 in 2017. That’s a 55 percent increase over 10 years.

So although we’re spending more on health care every year and far more than any other developed country, we’re getting an increasingly smaller return on that money as measured by most health care outcomes, most notably life expectancy. And residents of many rural communities are especially disadvantaged.

Wendell Potter is a former health insurance executive, author and founder of the journalism nonprofit


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