Nearly 1 in 5 Americans skipped care due to cost last year

Emergency department visits are still down around 30% at Providence's St. Joseph Hospital, and those who are coming in are sicker.

Fewer people have gone to the Orange, Calif.-based hospital over the past year for endoscopies, colonoscopies and other preventative gastrointestinal procedures that can catch early signs of cancer. Symptom severity has increased by about 10% even as ED volumes have dropped, said Glenn Raup, executive director of behavioral health, emergency and observational health at St. Joseph, noting that is a conservative estimate.

More people are coming in with GI bleeding and other serious conditions, which pose grave long-term consequences for both patients and the healthcare system, he said.

"Fear is still continuing to keep people away from their routine or, I would argue, urgent care," Raup said, emphasizing that hospitals and clinics are safe. "You also can't deny the impact COVID has had on employment and the economy."

About 1 in 5 U.S. adults have skipped healthcare over the past year because they couldn't afford it, a new West Health and Gallup survey of 3,753 Americans conducted in mid-February found. Low-income earners were hit the hardest, with 35% relaying that they couldn't pay for care.

"COVID is not the only pandemic—cost is a pandemic," said Tim Lash, chief strategy officer for West Health. "We talk about the toxicity of drugs and side effects of certain interventions, but we rarely talk about the financial toxicity that travels with this expensive system."

The COVID-19 pandemic has exacerbated underlying healthcare inequity and affordability issues.

People of color, who have been disproportionately impacted by COVID-19, have less access to healthcare. While many have had to forgo care prior to the pandemic due to a lack of coverage or high costs, the recession raised those hurdles.

Black adults were almost twice as likely to not be able to afford care compared to white adults, with 29% and 16% reporting cost barriers, respectively. More than 20% of Hispanics wouldn't be able to afford care, according to the survey.

Households that made less than $24,000 per year were five-times more likely to skip care than high-income households.

"Those same communities are more likely to be impacted by unemployment and COVID; our health system isn't equipped to deal with that," Lash said. "We're at a crossroads. Unless we drive substantial reforms on how we pay for care, this toxicity and associated mortality will perpetuate."

If people had gotten care, many cut back on both essential and discretionary expenses.

About 1 in 8 adults said they cut back on food (12%) and over-the-counter drugs (11%) to pay for healthcare or medicine. Unsurprisingly, that proportion increases significantly for those in lower-income brackets, 21% of which reported reducing spending on utilities due to the cost of care.

Across all income brackets, 35% limited spending on recreational activities to afford care. Although those cutbacks are more manageable, they could manifest in depression, anxiety and other behavioral health issues. Many behavioral health issues have gone unchecked during the pandemic, particularly for children and young adults, which is expected to dent healthcare outcomes.

"We are making people make tradeoffs that they shouldn't have to make," Lash said. "These are very difficult decisions that shouldn't have to be made in a modern industrialized society."

Elective procedures like mammograms, colonoscopies and joint replacements are rebounding at Methodist Health System. But unfunded care has increased as people lost their jobs and associated coverage, said Dr. Brian Jones, chief medical officer of the Methodist Patient Centered ACO. Dallas-based Methodist has a "generous foundation" that funds care for those with limited or no insurance, he said.

"Addressing inequities of healthcare needs to happen at the national level so that there are fewer gaps for those who need medical care," he wrote in an email to Modern Healthcare.

St. Joseph Health plans to shift more of its community benefit dollars to charity care to mitigate cost concerns, Raup said. It is also expanding its marketing efforts urging people not to delay care.

"If your symptoms are not normal, please don't let cost stop you—hospitals are willing to work with you in some way, shape or form because we don't want to see your conditions get worse," he said.

The Elijah E. Cummings Lower Drug Costs Now Act could help ease the healthcare financial burden, Lash said. The bill, which the House of Representatives passed in late 2019, would require HHS to negotiate prices for drugs that have little competition and account for substantial spending. Expanding Medicaid has also shown promising cost and outcome results, he said.

Overall, more should be done to incentivize the transition from fee-for-service to value-based care, said Lash, noting that providers that rely more heavily on payment arrangements that are linked to outcomes have fared better during the pandemic.

Fee-for-service medicine continues to drive the profit-oriented cycle, Lash said. Providers are rewarded for full hospitals and performing the highest number of costly procedures rather than building facilities that can adjust to demand or extending care to underserved areas, he said.

The move has been slow, with only a fraction of total healthcare expenditures tied to capitation and similar payment models.

"Patients' lives and livelihoods are at the expense of profit-motivating behavior," Lash said.