Paying the Bills: Health Insurance in the U.S. PDF

Paying the Bills: Health Insurance in the U.S. Johnie Rose, MD, PhD Center for Community Health Integration Case Comprehensive Cancer Center 8-5-24 [email protected]  Disclosures...

Paying the Bills: Health Insurance in the U.S. Johnie Rose, MD, PhD Center for Community Health Integration Case Comprehensive Cancer Center 8-5-24 [email protected]  Disclosures “Interactions with industry are essential to bringing the researchers’ discoveries to the public, but can present the potential for conflicts of interest related to their research activities.” X I have no financial relationships with commercial entities that produce health- care related products. The commercial entities with which I have financial relationships do not produce health-care related products or services relevant to the content of this lecture. I disclose the following financial relationships with commercial entities that produce health-care related products or services relevant to the content of this lecture: e.g., -Consulting relationship with Company X on Topic Y, discussed in this talk. -Advisory board for Company A, that produces B device, used as treatment for Topic Y.  Goals To review basic principles of health insurance To describe the major payment mechanisms for healthcare in the US To discuss some of the ‘problems’ created by insurance and the solutions that have evolved to address them To provide the context necessary to understand issues around healthcare systems and reform Why do we need health insurance? Healthcare costs are not always predictable Distribution of healthcare costs highly skewed Why do we need health insurance? Patients – Ensure provision of care – Financial protection – Quality-of-life Spread the risk Ensure payment Healthy workforce  Paying for Healthcare How are services and supplies paid? Patient Provider $ Payer Generic Payment Model  Basic Health Insurance Concepts Regular premiums paid to insurer Traditionally, provider performs services they deem necessary then charge the insurance company (“fee-for-service”) Deductible – an annual threshold that must be met before insurer begins paying costs (e.g. once patient has paid $3000 out-of-pocket, coverage kicks in)  Basic Health Insurance Concepts Cost-sharing at point of care – Copayment – A flat charge per encounter (e.g. $20 to see your primary care provider / $40 to see a specialist) – Coinsurance – a percentage of the full cost that must be paid by the patient (e.g., 20% of billed services) after the deductible is met – Out-of-pocket maximum – threshold where cost sharing goes to 0 Lifetime maximums – Went away with ACA  Scenario Jack is a med student with insurance that has a $1000 annual deductible and 20% coinsurance. He presents to the ED after breaking his arm and incurs charges of $2000 for the care he receives before being discharged home. How much must he pay out-of-pocket if this is the first time he has sought care this year?  Sequel In a cruel twist of fate, Jack breaks his other arm 4 weeks later in the same year! He again incurs ED charges of $2000. How much must he pay out of pocket?  Problems with health Insurance? Each party has different financial incentives Patient – Minimize Patient premiums and out-of- pocket costs Provider $ Provider – Maximize revenue Payer Payer – Minimize fees per service; minimize volume  Problems with health Insurance? Doctors as economic agents Doctors originally set their own fees Provides an incentive to do more (Insurer’s “losses” are someone’s revenues) Some early solutions – Eventually, companies paid “usual and customary” fees only – Prior authorization of some expensive services – Utilization review  Adverse Selection Adverse selection – People who are more likely to need health insurance are more likely to want to buy health insurance – In the extreme, one could purchase insurance on the way to the hospital.  Moral hazard – People “spend” more when they have insurance. Moral Hazard and Demand Elasticity Moral Hazard and Demand Elasticity How elastic is the demand for health services? The solution(?) to problems with traditional “fee-for-service” health insurance  Managed Care Organizations Attempt to improve quality and/or control cost Key elements – Provider contracts Contracting with (groups of) doctors for reduced fees in exchange for guaranteed patient volume In the extreme: salaried providers – Bundling of payments A way of shifting financial risk to providers E.g. Capitation – per-member, per-month payment to manage patients – Gatekeeping PCP’s control access to specialists  Managed Care Spectrum Classic HMO* HMO’s based on provider HMO’s but patients can Vertical integration networks opt out of network Regionalized tertiary Non-employee In-network and out-of- care providers receive network options Salaried providers capitations or reduced Out-of-network options fees for service less rich Shifts more risk onto E.g. POS – Point-of- providers service plan E.g. PPO – Preferred provider organizations *HMO = Health Maintenance Organization  Problems with Managed Care Some early success in controlling costs – Cost curve bent (at least initially) But – Restrictive to doctors – Restrictive to patients – Patients without enough ‘skin in the game’ So…  Consumer-directed Health Plans Health savings account + Catastrophic insurance coverage – Health savings account Pre-tax employee contributions Often partially employer-funded Works like a checkings account Can roll over year to year – Catastrophic insurance coverage High deductible Less expensive – Patients still likely incentivized to stay in-network “Patients will make better purchasing decisions.”  Consumer-directed Health Plans Health savings account + Catastrophic insurance coverage – Health savings account Pre-tax employee contributions Often partially employer-funded Works like a checkings account Can roll over year to year – Catastrophic insurance coverage High deductible Less expensive – Patients still likely incentivized to stay in-network “Patients will make better purchasing decisions.” What is a major assumption behind this?  The Other Type of Cost Sharing ‘Balance Billing’ – Billing patient for balance not paid by the insurer for out-of-network services When in-network provider contracts with payer for negotiated rates, they waive right to bill the patient further. Several states have passed legislation to at least partially address. The Health Insurance Market  Group vs. Individual Health Insurance Group – 1930’s – Response to rising healthcare costs; a way to ensure revenue – Usually employment-based: Employer and Employees split premiums – Can only enroll during open enrollment periods – Experience rated usually - based on past claims of group Individual – Traditionally quite expensive - High administrative costs – Medically underwritten (until 2014) Decision to issue Could exclude pre-existing conditions Higher rates for higher risk – Now a growing portion of the market with ACA Marketplace insurance exchanges  Pop Quiz What economic problem with health insurance are open enrollment periods in group insurance and medical underwriting in individual insurance designed to address?  What economic problem with health insurance is cost sharing attempting to address? Public Insurance Plans  A Note on Government Funding Government funding of healthcare goes far beyond government-run healthcare programs. – Tax breaks for employee benefits = big subsidy – Numerous grants to fund safety net care – Billions in research funding over the years …And Pre-ACA  Federal Spending on Healthcare Around a quarter of U.S. federal spending Defense: ~15% Tax Policy Center (Brookings and Urban Institute): https://www.taxpolicycenter.org/briefing-book/how-does-federal-government- spend-its-money  Medicare 1965 – Lyndon Johnson Federally-funded Eligibility – 65 years of age – Younger people with certain disabilities – Those with end-stage renal disease (ESRD)  Medicare Part A Part A – Hospital payments and short-term skilled nursing – Free if individual or their spouse has 40+ quarters of employment – Funded by payroll tax (FICA) Hospital stays – $1,600 deductible – Days 1-60: $0 copayment/day – Days 61-90: $408 copayment/day – Days 91 and beyond: $816  Medicare Part B – Physician and outpatient payments – 20% coinsurance – $240/year deductible – Funded by Premiums: $174.70/mo for most General tax revenues – ~92% of those with A also elect B – Many purchase private ‘MediGap” policies “Part C” - Medicare Advantage (MA) – Private insurers running Medicare HMO’s – A & B + ‘extras’ (e.g., drugs) – Nearly half of those with Parts A & B access via Part C Part D – Drug benefit (Since 2003) – Opt-in (nearly 4/5 do via standalone Part D Plan or MA) – Private benefit managers – 2025 base premium: $36.78 - Designed to cover 25.5% of the cost of standard drug coverage Medicare Part D Coverage How Americans Are Insured (or not)  Medicaid Healthcare for the poor Run by states Funded by federal and state funds Means tested. Traditional eligibility: – Uninsured children: 200% of FPL through CHIP – Pregnant women: 200% of FPL – Parents: 90% of FPL – Childless: ? Does cover nursing homes Some states contract to private insurers (Medicaid HMO’s) – Most Medicaid recipients in Ohio  Medicaid Expansion The Patient Protection and Affordable Care Act (PPACA or ACA) originally mandated an expansion of Medicaid to adults up to 138% FPL More on this Wednesday… Summing Up  Paying for Healthcare Evolution has been driven by a mix of – Attempts to control costs – Attempts to balance the economic incentives to provide too much or too little care Though most Americans are privately insured, government is the predominant payer for healthcare. Questions?  Healthcare Systems Johnie Rose, MD, PhD Center for Community Health Integration Case Comprehensive Cancer Center 8/5/24  Goals To describe a framework for characterizing healthcare systems To describe and compare a few prototypical international health systems To describe the U.S. healthcare system within the health systems framework  Health System Defined Health System = “all organizations, people and actions whose primary intent is to promote, restore or maintain health.”* Health System = Public Health System + Healthcare System – We are focusing on the latter today. * Everybody's business. Strengthening health systems to improve health outcomes : WHO’s framework for action. WHO. 2007.  Systems Paradigm A change from past thinking that quality healthcare depended only on the diagnostic and treatment skills of doctors Outcomes are a result of system design. Our Framework for Understanding Healthcare Systems: Structure – Measures – Function Structure – What is the anatomy of the health system? How are services and supplies paid for? Who controls the infrastructure? How does the patient gain access to the system? Measures – What do the objective data show about health system performance? Cost Access Quality Our Framework for Understanding Healthcare Systems: Structure – Measures – Function Function – How does a health system balance these high-level aims as specified by the Institute of Medicine (IOM)/National Academy of Medicine (NAM)? Safety Timeliness Effectiveness Efficiency Equity Patient-centeredness Healthcare System Structure  Model Healthcare System Structures How are services and supplies paid for? Patient Provider $ Payer Generic Payment Model How are services and supplies paid for? 1. Out-of-pocket model Patient Provider Payer How are services and supplies paid for? Out-of-pocket model Simple Most lower income countries Patient ~26m million U.S. patients Provider – Medical bankruptcy – Somebody pays Payer How are services and supplies paid for? 2. Private Insurer (Bismarck) Model Patient Premiums Provider Private Insurers How are services and supplies paid for? Private Insurer (Bismarck) Model Multiple insurers Patients pay Insurers can be additional $ when – Not-for-profit they seek care. – For-profit (only 1 country) Insurers use $ from Patient premiums to pay private providers, administer Premiums Provider benefits (+/- pay shareholders) Private Germany, Japan, France Insurers How are services and supplies paid for? 3. National Health Insurance Model Patient Provider Taxes Government Insurer How are services and supplies paid for? National Health Insurance Model Single government entity acts as insurer Patient Private providers Easier to administer Provider Taxes with one insurer Government Canada is prototype Insurer How are services and supplies paid for? 4. Socialized (Beveridge) Model Patient Govt-employed Taxes Providers Government How are services and supplies paid for? Socialized (Beveridge) Model Single government Patient entity acts as insurer Providers work for the Govt-employed Taxes government Providers Patients pay little to access care Government U.K. is prototype  Who controls the infrastructure? Private or public ownership? – Private Most U.S. infrastructure controlled by private, not-for- profit and for-profit companies Same true in most industrialized countries, including Canada – Public In U.K., government controls most infrastructure U.S. Veterans Administration, military, Indian Health Services, prison healthcare facilities, etc. Public hospitals such as MertoHealth (owned by Cuyahoga County)  Who controls the infrastructure? Degree of vertical integration – To what extent are primary, secondary, tertiary care, pharmacies, diagnostics, etc. under same administrative roof? Organization – Regionalized – 3 distinct tiers: primary, secondary tertiary care – Dispersed – less clear boundaries; emphasis on access to tertiary services Summary: Financing and Infrastructure Payor(s) Predominant controller of infrastructure Bismarck Multiple private Private Natl Health Insurance Single public Private Socialized (Beveridge) Single public Public  How does the patient gain access to the system? Eligibility – Group membership (e.g. employee, veteran, senior citizen, American Indian)? – Financial need? – Citizenship or residence?  How does the patient gain access to the system? Gatekeeping – Does the patient have to see a primary care provider in order to access specialists? Cost sharing – Does the patient have to pay anything at the time they receive care? Deductibles Copayments Coinsurance Healthcare System Measures  Healthcare System Measures Cost – Per capita – % of Gross Domestic Product (GDP) – Growth rate – % healthcare costs paid out-of-pocket  Healthcare System Measures Access – % uninsured – Waiting times – PCP turnover  Healthcare System Measures Quality – Infant mortality – Immunization rates – Medical errors – Patient experience – Mortality amenable to healthcare – Life expectancy Healthcare System Function  Healthcare System Function How does a health system balance these high-level aims as specified by the Institute of Medicine (IOM)/National Academy of Medicine (NAM)? Safety Timeliness Effectiveness Efficiency Equity Patient-centeredness A Subjective assessment (and subject of your TBL…) Structure of Some International Healthcare Systems  France – Bismarck Model Financing care – Taxes + Patients/Employers pay premiums to one of 42 “sickness funds” – Sickness funds pay providers – Enrollment mandatory – Negotiated fee schedules – Government provides budgeted amounts by category to regional health agencies (‘global budgets’) – 95% of French have some form of private insurance (only covers 14% of expenses) – mostly to cover cost sharing Mix of privately and publicly owned infrastructure with significant Government role in planning  France – Bismarck Model Accessing services – Eligibility – All residents covered Employment-based groups Unemployed/retired: Government picks up tab – Comprehensive (Inpt, Outpt, LTC, RX) – No provider networks – No gatekeeper requirement – 20-30% coinsurance – Rx co-insurance inversely proportional to effectiveness – No paper charts  Canada – National Health Insurance Model Financing care – Federal and Provincial taxes – Provinces reimburse private providers mostly fee- for-service – ~70% have some form of private insurance; covers 12% of expenses, mostly for Rx – Cost control Global budgets Negotiated (between provinces and medical associations) fee schedules based on evidence of effectiveness  Canada – National Health Insurance Model Mix of privately and publicly owned infrastructure Accessing services – Eligibility – All legal residents covered – No out-of-pocket for publicly-insured services – Outpatient drug coverage variable across provinces – No universal gatekeeper requirement – >50% report waiting >4 weeks to see a specialist  U.K. – Socialized (Beveridge) Model Financing care – Taxes fund the National health Service (NHS) – Private insurance covers 12% of population and finances 1% of care – Providers paid by combination of salary, capitations, and FFS – Cost controls Global budgets Systematic appraisal of new technology  U.K. – Socialized (Beveridge) Model Mostly publicly owned infrastructure – Highly regionalized Accessing services – Eligibility – All those “ordinarily resident” – Comprehensive services including drugs and dental – Little out-of-pocket cost – Primary-care centered; Strong gatekeeper requirement The U.S. Healthcare System(s)  The Out-of-pocket model in the U.S. Financing care – No intermediary – If patients don’t have the means to pay, they Forego care Suffer diminished creditworthiness or bankruptcy – leaving providers/hospitals with the bill Use the “safety net” – Little power to negotiate fees The Bismarck Model in the U.S.  The Bismarck Model in the U.S. Financing care Patient – Patients/Employers pay premiums to mostly for- Premiums Provider profit insurers – Insurers pay providers Private Insurers – Balance billing can be a problem Privately owned, for-profit and not-for-profit infrastructure mostly used  The Bismarck Model in the U.S. Accessing services – Eligibility Employee groups Individuals – Usually involves provider networks – +/- gatekeeping – Usually involves substantial cost sharing – Recommended preventive services covered for many National Health Insurance in the U.S.  National Health Insurance in the U.S. AKA Medicare Financing – Funded through taxes and modest premiums – Providers paid by single entity – Significant cost sharing; many purchase “Medigap” policies or join MA plans – Cost controls CMS sets fees - subject to political pressure Alternative payment models (more Weds)  National Health Insurance in the U.S. Patients use mostly private infrastructure – Center for Medicare and Medicaid Services (CMS) plays a substantial role in determining supply by virtue of their fee setting activities Accessing services – Eligibility: age, disability The Socialized (Beveridge) Model in the U.S.  The Socialized (Beveridge) Model in the U.S. VA, Military, Indian Health Services, public hospitals Financing – Primarily by taxes – Providers usually salaried employees – Often little patient cost sharing – Cost controls Budgets Market power to negotiate supply prices  The Socialized (Beveridge) Model in the U.S. Government owns and plans infrastructure – High degree of regionalization Accessing services – Eligibility Special groups – Self-contained networks with vertical integration/regionalization – PCP gatekeeping prominent  The U.S. Safety Net Patchwork of public and charitable bodies providing care to those with no means to pay Safety net organizations provide ~60% of the care received by the full-year uninsured The non-government part of this system relies mostly on government funds to provide care  The U.S. Safety Net Components (not exhaustive) – Federally-qualified Health Centers (FQHC’s) – Rural Health Clinics – Public hospitals – Emergency Departments – Uncompensated care provided by physicians and hospitals – Free clinics – Pharmaceutical company assistance programs – Condition-specific clinics (e.g. Ryan White HIV/AIDS programs, Black Lung clinics) Health System Measures: Cost The U.S. is a world outlier when it comes to health care spending. Percent of GDP spent on health, 1980–2021* 2021 data (or latest 20.0 available year)*: AUS: 10.6%* 18.0 CAN: 11.7% 16.0 FRA: 12.4% GER: 12.8% 14.0 JPN: 11.1%* KOR: 8.8% 12.0 NETH: 11.2% NZ: 9.7%* 10.0 NOR: 10.1% SWE: 11.4% 8.0 SWIZ: 11.8%* 6.0 UK: 11.9% US: 17.8% 4.0 2.0 OECD average: 0.0 9.6% 1980 1985 1990 1995 2000 2005 2010 2015 2020 Notes: * 2020 data. Current expenditures on health for all functions by all providers for all financing schemes. Data points reflect share of gross domestic product. Based on System of Health Accounts methodology, with some differences between country methodologies. GDP = gross domestic product. OECD average reflects the average of 38 OECD member countries, including ones not shown here. Data: OECD Health Statistics 2022. Source: Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II, U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes (Commonwealth Fund, Jan. 2023). https://doi.org/10.26099/8ejy-yc74 The U.S. spends three to four times more on health care than South Korea, New Zealand, and Japan. Dollars (USD) per capita spend on health expenditures Government/compulsory + Voluntary Household out-of-pocket $1,225 $858 $625 $993 $1,577 $841 $744 $10,687 $663 $754 $489 $505 $621 $1,040 $6,524 $6,128 $6,072 $5,602 $4,980 $5,161 $5,421 $4,725 $4,709 $3,888 $4,045 $2,874 KOR NZ JPN UK AUS FRA CAN SWE NETH NOR SWIZ GER US Notes: Data reflects all financing schemes on all functions of current expenditures on health by all providers. The OECD considers the vast majority of ACA marketplace plans in US to be “government/compulsory spending” because of the individual mandate, despite its repeal in 2018. See here for more information: https://www.oecd.org/health/Spending-on-private-health-insurance- Brief-March-2022.pdf. Government/compulsory spending data: 2021 data for CAN, GER, KOR, NETH, NOR, SWE, and UK; 2020 data for AUS, FRA, JPN, NZ, SWIZ, and US. Voluntary spending data: 2021 data for CAN, GER, KOR, NETH, NOR, SWE, and UK. 2020 data for FRA, JPN, SWIZ, and US; 2019 data for AUS; 2018 data for NZ. Household out-of-pocket spending data: 2021 data for CAN, GER, KOR, NETH, NOR, SWE, UK, and US; 2020 data for FRA, JPN, and SWIZ; 2019 data for AUS; 2018 data for NZ. Data: OECD Health Statistics 2022. Source: Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II, U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes (Commonwealth Fund, Jan. 2023). https://doi.org/10.26099/8ejy-yc74 The U.S. is the only high-income country that does not guarantee health coverage. Percent of total population with health insurance coverage Government/compulsory health insurance Voluntary health insurance 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 99.9 99.9 99.9 96.1 83.2 72.2 68.0 62.0 54.3 38.1 28.5 28.1 25.8 10.3 UK GER NZ SWIZ AUS US CAN KOR NETH FRA JPN NOR SWE Notes: Government/compulsory health insurance data: 2021 data for AUS, CAN, FRA, NZ, and NOR; 2020 data for GER, KOR, NETH, SWE, SWIZ, UK, and US; 2019 data for JPN. Voluntary health insurance coverage data: 2021 data for AUS, CAN, and NZ; 2020 data for GER, KOR, NETH, and US; 2019 data for UK; 2017 data for FRA and SWIZ. Government health insurance refers to public benefit basket covering a minimum set of health services. Voluntary health insurance refers to payments for private insurance premiums, which grant coverage for services from private providers. See more information on definitions here: https://www.oecd.org/health/Spending-on-private-health-insurance-Brief-March-2022.pdf. Data: OECD Health Statistics 2022. Source: Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II, U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes (Commonwealth Fund, Jan. 2023). https://doi.org/10.26099/8ejy-yc74 How do we spend so much in the U.S.? Big drivers Higher payments to hospitals and providers Higher drug spending Higher administrative costs While spending less on long term care Keep in mind: Cost ~ Volume x Price The U.S. has among the lowest rates of physician visits and practicing physicians. Physician consultations in all settings per capita Practicing physicians per 1,000 population 14.7 12.4 9.5 8.4 OECD average: 5.7 6.6 5.2 6.1 4.3 4.5 4.5 5.0 OECD average: 3.7 4.3 3.8 3.9 4.0 3.8 3.9 3.5 3.2 3.2 2.5 2.6 2.6 2.8 2.2 Notes: Data for UK not available. 2021 data for AUS and NOR; 2020 data for FRA, GER, KOR, Notes: 2021 data for CAN, GER, NZ, NOR, SWIZ, and UK; 2020 data for AUS, FRA, JPN, KOR, NETH, and SWE; 2019 data for CAN and JPN; 2017 for NZ and SWIZ; 2011 data for US. OECD and NETH; 2019 data for SWE and US. OECD average reflects the average of 31 OECD average reflects the average of 37 OECD member countries, including ones not shown here. member countries, including ones not shown here. Data: OECD Health Statistics 2022. Data: OECD Health Statistics 2022. Source: Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II, U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes (Commonwealth Fund, Jan. 2023). https://doi.org/10.26099/8ejy-yc74 Hospital stays are shortest in the Netherlands and the U.S. The U.S. has among the lowest number of hospital beds. Average length of stay for inpatient care (days) Number of total hospital beds per 1,000 population 12.6 12.7 19.1 7.8 5.7 OECD average: 4.3 OECD average: 7.3 8.7 9.1 8.2 8.2 4.5 6.6 3.8 6.3 3.4 5.2 5.3 5.4 2.8 2.9 4.5 4.8 2.6 2.7 2.3 2.1 Notes: Data reflect average length of stay for inpatient care for all hospitals. 2021 data for NOR; 2020 data for CAN, FRA, GER, KOR, NETH, SWE, and SWIZ. 2019 data for AUS and NZ; 2018 Notes: 2021 data for NZ and UK; 2020 data for CAN, FRA, GER, JPN, KOR, NETH, NOR, SWE, data for UK; 2010 data for US. Data for JPN not available. OECD average reflects the average of and SWIZ; 2019 data for US; 2016 data for AUS. OECD average reflects the average of 38 36 OECD member countries, including ones not shown here, where data are available. OECD member countries, including ones not shown here, with available data. Data: OECD Health Statistics 2022. Data: OECD Health Statistics 2022. Source: Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II, U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes (Commonwealth Fund, Jan. 2023). https://doi.org/10.26099/8ejy-yc74 Hospital Discharge Rates – 2000 and 2017 Prices in the Healthcare Sector, 2017 OECD Average = 100 U.S. Prescription Drug Prices as a Percentage of Other Countries’ Prices, U.S. Net Price Adjustment Applied to All Drugs, 2022 Adjusted for manufacturer rebates/discounts  Healthcare Volume per capita and Health Expenditures, 2017 OECD average = 100 Actual Individual Consumption (AIC) Purchasing Power Parity (PPP) conversion factors are used to express amounts in a common currency which adjusts for differences in purchasing power for non-traded goods between currencies. MR, CT, and PET Scans Administrative Costs Inadequate Physical Activity Walking or biking to purposeful destination http://www.citylab.com/commute/2012/03/true-cost-unwalkable-streets/1616/ The U.S. obesity rate is nearly double the OECD average. Percent of total population that is obese 42.8 34.3 30.4 OECD average: 25.0 28.0 23.6 24.3 15.6 14.4 13.0 13.4 11.3 7.4 4.6 JPN KOR SWIZ NOR NETH SWE FRA GER CAN UK AUS NZ US Notes: Obese defined as body-mass index of 30 kg/m² or more. Data reflect rates based on measurements of height and weight, except NETH, NOR, SWE, SWIZ, for which data are self-reported. (Self-reported rates tend to be lower than measured rates.) 2021 data for NZ; 2020 data for KOR, NETH, and SWE; 2019 data for CAN, JPN, NOR, UK, and US; 2017 data for AUS, FRA, and SWIZ; 2012 data for GER. OECD average reflects the average of 23 OECD member countries, including ones not shown here, which provide data on obesity rates. Data: OECD Health Statistics 2022. Source: Munira Z. Gunja, Evan D. Gumas, and Reginald D. Williams II, U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes (Commonwealth Fund, Jan. 2023). https://doi.org/10.26099/8ejy-yc74 Diabetes in Adults, 2019 Adults in the U.S. are the most likely to have multiple chronic conditions. Percent of adults age 18 and older who have multiple chronic conditions 30.4 25.6 25.9 22.4 20.8 19.8 20.0 18.5 19.2 18.1 17.0 FRA* SWIZ* NETH* SWE* NZ* GER* NOR* UK* CAN* AUS* US Notes: Chronic disease burden defined as adults age 18 years and older who have ever been told by a doctor that they have two or more of the following chronic conditions: asthma or chronic lung disease; cancer; depression, anxiety or other mental health condition; diabetes; heart disease, including heart attack; or hypertension/high blood pressure. Data reflect 11 countries which take part in the Commonwealth Fund's International Health Policy Survey. * Statistically significant differences compared to US or comparator bar at p