By Andrew M. Seaman
Reuters

Americans made fewer trips to their doctors' offices during the Great Recession than they did earlier in the decade, according to new research. 

"These are not dramatic drops, but in our healthcare system we're used to our numbers going up... So just seeing a reverse in the trend is interesting," said Karoline Mortensen, the study's lead author from the University of Maryland in College Park.

Using a national database of medical expenses from about 54,000 people between the ages of 18 and 64 years old, Mortensen and her colleague compared how many times people of different races used health services during two-year periods before the recession (2005 and 2006) and during it (2008 and 2009).

On average, white patients went to the doctor's office 7.3 times in the two-year span before the recession, compared to 7 times each during the economic downturn.

Black patients went to the doctor about 5.8 times each before the recession, and 5.3 times during it. Hispanic patients made about 4.5 visits each to the doctors before the recession and 4.1 during it.

That downward trend was similar for the number of people admitted to hospitals, and the number of prescriptions they filled.

Previous studies and surveys have also suggested that people use fewer health services during tough economic times.

In 2009, the American Academy of Family Physicians (AAFP) found in a survey of its members that 58 percent were seeing an increased number of canceled appointments.

The AAFP also found that 60 percent of the doctors reported they had "seen more health problems caused by their patients forgoing needed preventive care." "The first thing that drops off is preventive medicine," said Dr. Jeffrey Cain, AAFP president and a family physician in Denver.

Cain, who was not involved with the new research, said that not getting preventive care can lead to real problems for people.

For example, he said a woman may forgo her mammogram and end up being diagnosed with breast cancer later, when it is advanced.

"When you have a recession, people think of it in terms of dollars in their pocket, but it also affects their health," said Cain. 

Mortensen, who published her findings in JAMA Internal Medicine, said she can't say whether or not the decreased usage in her study actually led to worse care or outcomes.

She also said that more research is needed to find out if other factors could have contributed to the decrease.

"There is something else out there that could be behind all of this," she said. 

Americans are far more unhealthy than people in 16 other developed countries, and it’s probably our own fault, experts reported on Wednesday. We die younger from diseases such as obesity and heart disease, and we are far more likely to be murdered and die in car accidents, the researchers at the National Academy of Sciences found.

U.S. culture has a lot to do with it and policymakers need to take action right away to reverse the trend, the experts who wrote the report advised.

"It's a tragedy. Our report found that an equally large, if not larger, disadvantage exists among younger Americans," said Dr. Steven Woolf, chair of the department of family medicine at Virginia Commonwealth University, who chaired the panel.

“I, personally, was stunned by how pervasive the disadvantage was across so many topic areas.”

Experts have complained for years that Americans spend far more on healthcare than people in other rich countries, yet have poorer health. The latest report from the federal government shows Americans spent more than $8,600 a year per person on healthcare – more than twice what countries such as Britain, France and Sweden spend, even with their universal healthcare systems.

Yet we don’t live any longer and we are not even healthier, the report by the National Research Council and Institute of Medicine finds. The NRC and IoM, both parts of the National Academies of Science, provide advice to U.S. policymakers. The National Institutes of Health asked them to compare  the health of Americans to people in Canada, Australia, Japan and 13 European countries including Britain, France, Portugal, Italy and Germany.

“The size of the health disadvantage was pretty stunning,” Woolf told reporters in a telephone briefing.

Americans did worse in nine areas: infant mortality; injury and homicide rates; teen pregnancy and sexually transmitted diseases; the AIDS virus; drug abuse; obesity and diabetes; heart disease; lung disease; and disabilities.

And many of these affect young people, not the elderly. Americans are seven times more likely to be murdered than people in the other countries, and 20 times more likely to be killed by a gun.

"I don't think most parents know that, on average, infants, children, and adolescents in the U.S. die younger and have greater rates of illness and injury than youth in other countries,” Woolf said.

“For many years, Americans have been dying at younger ages than people in almost all other high-income countries,” the expert panel wrote.

There were a few bright spots. Americans have lower death rates from cancer, the No. 2 cause of death, and do better at controlling blood pressure and cholesterol. “Americans who reach age 75 can expect to live longer than people in the peer countries,” the report reads.

No one reason accounts for the differences, the experts said. It’s likely a combination of factors, from a U.S. reliance on cars that keeps us from exercising enough, to a love of fast foods, to rejection of being told what to do.

“We have a culture in our country … that cherishes personal autonomy and wants to limit intrusion of government and other entities upon our personal lives,” Woolf said. “Some of those forces may act against the ability to achieve optimal health outcomes.”

It’s clearly not pollution or some other outside factor, said Ana Diez Roux, an epidemiologist at the University of Michigan, who served on the panel. “It seems to be a whole bunch of things acting together,” she said.

“Something fundamentally is going wrong to cause our country to lose ground against other high-income countries,” Woolf added.

Some of the report’s findings: The United States has a higher infant mortality rate than the other countries, with 32.7 deaths per 100,000. Other countries have infant mortality rates between 15 and 25 deaths per 100,000.

U.S. men live the shortest lives, 75.6 years compared to 79 for Swiss men, who topped the charts. Most of the difference comes in men who die before they reach age 50. U.S. women, who can expect to live on average to just under 81 years, ranked second-last. Japanese women can expect to live to be 86.  

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The recession kept U.S. health care spending low in 2011, according to a federal government report released on Monday. It finds that health spending grew just 3.9 percent -- the same historically low rate of growth as over the past three years.

But don’t credit the controversial 2010 health reform law. It has had little or no effect on spending just yet,  according  to the report, written by the Centers for Medicare and Medicaid Services (CMS).

“The Affordable Care Act had a minimal impact on overall healthcare spending,” Micah Hartman, a statistician at CMS who wrote the report, told reporters in a telephone briefing.

And  Americans still spend more per person than people in any other developed country on health care -- more than $8,600 a head, the report finds.

“In 2011 US health care spending grew 3.9 percent to reach $2.7 trillion,” the report reads.

“Although spending for retail prescription drugs and physician and clinical services grew at a quicker pace in 2011 than in 2010, growth slowed for hospital care services and certain categories of nonpersonal health care spending, including the net cost of health insurance,” the report says.

That’s even with more than a million new young people carrying health insurance under one of the most popular provisions of the health reform law: the requirement that health insurance companies let parents carry their children on their accounts until they are 26.

Hartman says the recession of 2007-2009 had a major effect on health spending. As tens of thousands of people lost their jobs, they also lost health insurance, and thus stopped spending money on health care, he said.

“During 2007–10, private health insurance enrollment declined by 11.2 million, while Medicaid enrollment increased by 7.5 million and the number of uninsured people increased by 7 million,” Hartman and colleagues write in the report, published in the journal Health Affairs.

"There is a well-documented correlation between insurance coverage and health care use: People tend to seek less medical care when they lack coverage,” they added. “In 2010 private health insurance coverage declined by another 3.4 million, and the number of uninsured people increased by 2.2 million.”

Over the same time, 2.7 million young adults under age 26 joined their parents’ health insurance plans – but they didn’t spend much money on healthcare because they were so young and generally healthy.

Ceci Connolly, managing director of the PwC Health Research Institute, agrees that the recession is still affecting health spending. “People are putting off care,” she told NBC News.

But there’s also evidence that Americans are figuring out when they are being advised to take unnecessarily expensive medications, and to have unneeded tests and procedures. “We know that consumers are starting to be more discerning,” Connolly said.

“There are a couple of dozen states with transparency laws on the books … and we think that is starting to have an impact,” she added. “Just the simple fact of putting that out there in the public domain causes people to think twice about prices they are (being charged).”

Employers, who provide health insurance for about 55 percent of U.S. adults, have been pushing to lower costs, Connolly points out. There’s also an effort by both the federal government and by insurers for doctors to prescribe cheaper, generic drugs instead of pricey brand names.

One area where spending did go up was in hospitals. Hospital spending rose more than 4 percent in 2011, to $850.6 billion. People also used doctors more, Hartman said, and spending for Medicare, the federal health insurance plan for people over 65, grew 6.3 percent in 2011.

And public health spending fell in 2011, for the first time since the government began keeping statistics in 1960, Hartman said. This is in part because the states and federal government ramped up spending in 2009 and 2010 because of the new pandemic of H1N1 swine flu, and then not nearly as much in 2011 when the new strain of flu did not turn out to be especially deadly.

Most experts agree the United States spends far too much for health care, and many reports show that Americans do not end up healthier or even living longer because of all this spending. One of the main goals of the 2010 health reform law is to reduce spending by cutting waste, reducing expensive mistakes such as infections patients get while in the hospital and encouraging doctors to choose the most cost-effective treatments.

Connolly says she sees some evidence this is happening already -- and she credits the Affordable Care Act in part .

“What is happening out there in the healthcare industry is they are taking their cues from that law and concluding that we have to be more efficient, that we have to actually deliver quality these days and that means reducing errors and waste,” she said. “You can see things starting to head in that direction.”

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• Americans pay more for health insurance
• Health care is officially a mess
• Who falls through the cracks if states don't expand Medicaid
• States decide future of health reform

Updated at 7:40 p.m. ET: UnitedHealth Group's plan to continue offering some elements of the Affordable Care Act regardless of the fate of the legislation is a political as well as a business decision.

While people — especially young adults and people suffering from expensive or chronic illnesses — will benefit from the insurance giant's initiative, the company reaps a public relations coup that will increase its costs by as little as one or two percent, one analyst said. 

"It makes UHG attractive among employees and, hence, employers," Uwe Reinhardt, professor of economics and public affairs at Princeton University, said via e-mail. 

In a statement Monday, UnitedHealth Group said its UnitedHealthcare company will preserve a few popular aspects of the new healthcare law that have already been put into place even if the Supreme Court strikes down all or part of the ACA. It will continue to let young adults stay on their parents' policies until they turn 26, not charge co-pays for some preventative health services and waive lifetime coverage dollar caps, along with provisions related to appeals and policy termination. 

"I think the company sees the opportunity to score some political points by standing behind these very popular aspects of the law," said Matthew Coffina, an analyst at Morningstar. Coffina pointed out that since the company is already offering these services as required by law, the costs of providing them has already been incorporated into premium prices. 

Later Monday, Humana said it would continue those same provisions, according to Kaiser Health News. Aetna, too, said it would retain the young adult provision, the preventive care benefits and a third-party appeals program. The  Aetna announcement did not include a reference to lifetime limits on coverage. 

"The protections we are voluntarily extending are good for people’s health, promote broader access to quality care and contribute to helping control rising health care costs," UnitedHealth Group president and CEO Stephen J. Hemsley said in a statement. "These provisions make sense for the people we serve."

It might seem strange that insurance companies — an industry known for aggressive cost-cutting tactics — only are now getting around to realizing the potential savings in services like free diabetes and blood pressure screenings. 

"Sheer inertia can explain it," Reinhardt said. "It would be a mistake to assume that private health insurers are particularly visionary or innovative in this regard." 

Insurance companies haven't traditionally been motivated to provide this kind of service because it hasn't been demanded by companies. A majority of Americans are still insured through their workplaces, although that number is falling. But since people rarely stay with one employer for their entire careers, there's little economic incentive for a company to make long-term investments in workers' health.

Coffina said the intense political debates about healthcare issues have prompted Americans and insurance companies alike to think more about long-term trends and ramifications. "Reform legislation frames what's expected of these companies and what a minimum level of service is," he said.

The provision allowing young adults to stay on their parents' insurance is particularly popular, and has been widely used. An April poll conducted by the Kaiser Family Foundation found that 71 percent of Americans support the provision, and nonprofit group the Commonwealth Fund calculated that 6.6 million people between the ages of 19 and 25 were able to obtain health insurance as a result.

Some Republican lawmakers — who are unified in their opposition to the health reform law — have conceded that this is a good idea, and it's politically popular enough that rejecting it could be political suicide. Bloomberg reported last week that Rep.Phil Gingrey, R-Ga., co-chair of the GOP Doctors Caucus, called the young-adult provision “a good policy," although the Caucus advocates a "complete repeal" of the Affordable Care Act on its website. 

If health insurers expect that lawmakers will require them to provide certain services even if the Supreme Court strikes down the law, preempting that by volunteering compliance is a shrewd maneuver. "It seems like they're trying to get ahead of their competitors," said Igor Volsky, deputy editor of left-leaning blog ThinkProgress.org. "I wouldn't be surprised to see others echo it."

Some other insurers have already weighed in. The CEOs of Aetna and Humana both acknowledged in recent interviews that popular provisions such as young adult coverage might be already too ingrained in the system to roll back, according to the Wall Street Journal. 

Even if legislation doesn't force their hand, taking away benefits is an unpalatable choice for insurance companies because it makes them look like the bad guys. "It's going to be very hard, regardless of what happens with the [Supreme Court] decision, for insurance companies to take away benefits," Volsky said. "I think once you grant people certain benefits, it's very difficult to move backwards."