For what we spend, do U.S. children see the doctor or dentist enough?

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(Michail Petrov/Shutterstock)

By now, most Americans know this dark and disturbing truth about our health care system: We spend more than any other industrialized country on health care, yet we have some of the worst health outcomes on a number of measures (including infant mortality, average lifespan, and death from preventable diseases).

Our current system focuses much more on treating illness than preventing it. So how does our usage, or the amount we spend on and utilize health care resources, relate to our outcomes, or how healthy we are overall? Better yet: What can we learn from comparing our country with one that has better health outcomes and a similar insurance system?

In the December 2015 issue of Health Affairs, a team of researchers based at Boston Children’s Hospital examined relationships between pediatric well-visit utilization and health outcomes in the U.S. and the Netherlands, which has a health insurance structure similar to that of the U.S. but superior health outcomes.

Lead author Dougal Hargreaves, MD, who hails from England and spent a year at Boston Children’s as a Commonwealth Fund Harkness Fellow, says he came to the U.S. believing what he’d heard about our health care system: The richest people in our country receive some of the best health care in the entire world.

He was surprised, to say the least, when the data painted a very different picture. It’s true the U.S. has some of the most innovative and high-quality treatments of anywhere in the world. But even among the rich, utilization of our top-notch pediatric primary care services is relatively low.

And the comparisons among the poor in both countries are even more disheartening.

“The most striking finding in our report,” says Hargreaves, “was that Dutch children see their doctor twice as often as American children, and their dentist more than twice as often.”

In the U.S., the poorest children in the worst health are not seeing their doctors enough. In the Netherlands, “it appears that health care pretty much matches need,” says Hargreaves.

Hard truths, big questions

The study’s findings suggest there is a significant unmet need in health care services among all income levels in the United States, but the need is greater among the poor.

Inadequate utilization of health services is particularly troubling in pediatrics, because clinical preventive services (i.e., primary care visits) for children and young people have been identified as a key determinant for both short and long-term health outcomes by the Centers for Disease Control and Prevention.

Recent work by the research team behind the Health Affairs article provides further evidence of this link. Their August 2015 article for Pediatrics showed that the odds of adverse health outcomes were 13 percent to 52 percent higher among people who reported unmet health care need as teenagers, compared with those who had similar adolescent health outcomes, insurance coverage and sociodemographic backgrounds but no unmet need.

Beyond insurance and income

The U.S. faces a dual problem: widespread under-utilization of pediatric primary care services and disproportionately worse health outcomes for our nation’s poor. What can be done?

Hargreaves says there are two related issues.

First, he notes that while it’s clear that universal health insurance for children is necessary, this alone is not sufficient to ensure children and young people get the care they need.

U.S. children in low-income households use health services less than their high-income counterparts, even when they have health insurance. So issues like the coverage and co-pays of an insurance policy are also important.

Second, Hargreaves adds, health care is not the only — or even the most important — determinant of health.

“The answer to improving health outcomes goes beyond health care and probably has a lot to do with the level of income inequality in the US,” he says. “We can do things to mitigate that, or we can just accept that these are the decisions we’ve made as a society.”

Further research on barriers to health care utilization in the U.S. — across all income levels — is needed to piece together the areas where we fall behind other industrialized nations and outline the roadmap to a better future.

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