Health care gap widens between rich and poor

An explosion of new drugs, medical apps and an ever-expanding array of ways to get treatment are reinventing how people consume health care. Yet those who would most benefit from the latest technology simply can’t afford it.

And, across Tennessee and the country, the gap between these two groups has only widened in recent years, experts said. 

“What that tells me, and the overall gist of our findings, is health care is becoming more and more of a regular commodity. If I can’t afford a fancy steak then I’m not going to buy a fancy steak — but I can get by without that,” said Dr. Samuel Dickman, lead author of a recent study. “Do we as a society want to treat health care like a fancy steak? I don’t know. I don’t know but that’s the direction we’re going.”

Income correlates to health care spending and is associated with longevity, according to two recent studies that looked at long-term expenditures across income brackets and tax and death records.

The amount spent by people in the highest income brackets — people who are generally among the healthiest — increased from 2004 to 2012, a period when care costs were beginning to be shifted to consumers in restructured health plans.

But, spending in lower income brackets over the same period began to decrease — leading to a gap in money spent on health care, according to a study published in the journal Health Affairs that looked at data from 1963 to 2012.

Then the gap began to widen, signaling to the authors that a "redistribution of care toward wealthier Americans" is happening.

"What we can say for sure, it’s not because rich people are sicker — that is the opposite of what’s true," said Dickman.

Dickman said the widening gap in spending surprised him, even though he knew there had been substantial changes in insurance structure and cost-sharing.

While the study doesn't include data under the Affordable Care Act, more and more insurance plans are shifting higher costs to patients through higher deductibles and other cost-sharing mechanisms. But for people who haven’t seen real wage growth, higher bills are competing with food, fuel, utility and internet bills and rent.

In 2014, the median income in Tennessee was $44,621 — it was $53,482 nationally — and the average family in the U.S. spent $4,290 on health care costs including insurance premiums, according to the U.S. Census Bureau and Bureau of Labor Statistics.

But the latter figure is quickly rising. In-patient care costs rose 197 percent between 1997 and 2015 while out-patient costs rose 200 percent in the same period, according to the BLS.

The disparity in who can afford health care shows up in various ways. People die earlier. Work productivity suffers when people are unwell. Hospitals get stuck with uncompensated care bills when people show up to the emergency room with out-of-control conditions and can’t pay.

Health care bills account for the greatest amount of debt Americans owe.

“As health care costs and prices have risen year after year, people (in the top income bracket that saw growth) have been able to keep up with that, but a lot of Americans haven’t,” said Dickman.

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The health care system is moving toward an emphasis on prevention and wellness. Attending to health problems before they become a crisis may mean appointments, medicines and lifestyle changes. In Tennessee, 26.8 percent of adults were not physically active in a 30-day span.

For many, though, trying to be healthy takes extra money. Gym memberships cost money or finding a place to safely be active is hard.

Even getting to the doctor’s office takes money.

Relatient, a Nashville-based tech company, teamed up with Uber to add a ride-scheduling feature to its messaging with patients. The companies started with a promotion wherein first-time Uber riders get a free ride up to $15.

But a trip to the doctor or the pharmacy requires a way home, so a round trip without a discount could reasonably be $30 — a hefty extra cost for many people who are trying to juggle bills.

The income disparity is also evident in health insurance.

People with higher incomes are more likely to have employer-sponsored plans that have lower deductibles and copays, industry officials said. Those stand in contrast to high-deductible plans where people pay more before the insurance coverage kicks in.

The theory behind shifting more costs to the patient is that people would be more diligent in the care they get. People are cutting back — but they are doing so indiscriminately, so they aren’t getting the care clinicians may think they need, said John Graves, assistant professor at the Vanderbilt School of Medicine.

Dr. Manish Sethi, an orthopedic trauma surgeon, travels around the state holding health fairs under his nonprofit Healthy Tennessee to talk to people about prevention and how to be healthier.

He thinks it’s time to challenge the notion of preventative care and access to reflect what he sees on the ground. If people aren’t going or can’t afford a trip to a primary care doctor, then the system needs to create a new venue for care.

“Over time, I’ve really evolved in my thinking about this. We have to think about prevention and access in a whole new way,” said Sethi. “We have to loop in the community. This is where I’m at.”

Tackling the income gap, and the factors behind it, means changing the way leaders from health care, business and all levels of government think about health care, experts said.

Policies need to connect the social determinants —  wages, education, access to healthy food and safe places — and human services with health care.

Right now health care reform, on both sides of the political aisle, is more focused on the delivery system and operates in a parallel universe from the policies addressing what impacts people’s health and well-being, said industry expert Paul Keckley, editor of the Keckley Report.

“This is going to be about how communities rationalize paying for care. The state is going to have to play a role. The business community is going to have to play a role,” said Keckley.

Reach Holly Fletcher at 615-259-8287 or on Twitter @hollyfletcher.