It would not be surprising to know that when the Great Recession hit the U.S. in 2008, one in three Americans delayed medical treatment due to costs.

Ten years later, as media headlines and the President boast an improved American economy, the same proportion of people are self-rationing healthcare due to cost. That percentage of people who delay medical cost based on the expense has remained stable since 2006: between 29 and 31 percent of Americans have self-rationed care due to cost for over a decade.

And, 19% of U.S. adults, roughly one-in-five people who are sick and dealing with serious conditions, also put off treatment due to costs, Gallup learned in its survey conducted the week of the U.S. mid-terms elections in the first week of November, 2018.

Underneath this statistic, it’s important to compare the payor mix of patients delaying care: nearly one-third of people with private, commercial insurance delayed care by 2018; 22% of people enrolled in Medicaid or Medicare put off care. So did 54% of people who had no insurance.

In another survey, conducted by NPR collaborating with IBM Watson Health, younger people had more trouble paying for care than older people, the survey found. One-third of people under 35 said that health care costs prevented them from getting care, compared with only 8% of people 65 and older.

Younger people identified the cost of prescription drugs as a problem: 38% of people under 35 said they had difficulty paying for medicines, versus 8% of people 65 and older.

Another survey from Earnin and the Harris Poll conducted in September 2018 found that over one-half of Americans delayed care in the past year because they couldn’t afford it. The analysis included the financial stress point that only 39% of Americans can cover an unexpected $1,000 expense with savings.

Health Populi’s Hot Points:  The average outpatient visit in the United States runs $500, and an inpatient stay, $22,000, a new study from the Institute for Health Metrics and Evaluation at the University of Washington on the global costs of medical services and how to fund universal health care.

The table shows that the U.S. has the highest inpatient admission costs, on average, about 50% greater than those in Switzerland, the highest-cost site for health care in this study which examined data from about 130 countries.

Switzerland’s outpatient visit ran about 5% higher than costs in the U.S. — $502 per visit compared with $478 in the U.S.

When considering how to fund universal health coverage, which this paper was addressing, identifying both quantity/utilization and cost/prices is key as total spending is a function of unit prices times volume.

The U.S. historically has had much higher prices for healthcare than other develop nations, prompting late health economist Uwe Reinhardt to tell us, “It’s the Prices, Stupid” when it comes to American health spending.

Any plan to move American health care toward universal coverage must get real about this phenomenon: that costs are part of the health economy in terms of healthcare workers’ wages and local economies. Lowering costs and prices means moving healthcare to less expensive sites of care (say, retail clinics, telehealth, and pharmacies providing primary care) and lowering utilization or allocating more self-care to patients at home.

Consider the 2020 Presidential elections and calls for universal health care. Any discussions about covering all Americans for healthcare must speak about the health economy, which is inextricably linked to the larger national macroeconomy for jobs, wages, and local economic development and health.