More Americans Stuggle to See a Doctor Despite Gains in Coverage

A growing number of Americans cannot afford to see a doctor despite improvements in health insurance coverage, according to a study published in JAMA Internal Medicine. The research published in January, suggests that access remains an issue as both insured and uninsured US adults forego medical care due to the related costs. This trend could be tied to narrowing provider networks as well as rising co-payments and out-of-pocket expenses, according to the researchers who co-authored the study from Harvard Medical School, Cambridge Health Alliance, and Hunter College.

Back in 2000, John Z Ayanian, MD, MPP, and colleagues published a study that examined the unmet health needs of uninsured adults aged 18 to 64 years in the United States during 1997 and 1998. They found that uninsured adults in this age demographic were far more likely than the insured to have gone without seeing a doctor because of the expense. The uninsured were also more likely to skip recommended check-ups for long-term health conditions as well as preventive services, the director of the Institute for Healthcare Policy and Innovation at the University of Michigan pointed out in an accompanying commentary.

Like the study published two decades ago, the recent research relied on data from the Behavioral Risk Factor Surveillance System, a nationwide survey conducted by the Centers for Disease Control and Prevention and state health departments. The intent was to explore whether the unmet need for physician services has shifted between the years 1998 and 2017. 

According to the findings, short-term coverage gains associated with the implementation of the ACA have been outweighed by long-term trends headed in the direction of reduced affordability. Most measures of unmet need for physician services have not shown improvement, and access to physician services, from a cost standpoint, have worsened. 

The proportion of adults ages 18 to 64 years who reported that they were unable to see a doctor due to cost increased from 11.4% in 1998 to 15.7% in 2017. When broken down by insurance status, the share of uninsured who were unable to see a physician because of the expense increased from 32.9% to 39.6%. For those with coverage, meanwhile, that figure rose from 7.1% to 11.5%. In 2017, nearly 1 out of 5 with a chronic condition such as diabetes, obesity, or cardiovascular disease indicated they were unable to see a doctor due to cost. 

The main encouraging finding is the increase in the proportion of people—insured and not—who are getting flu shots and cholesterol checks. On the other hand, the proportion of women who did not receive breast cancer screening grew throughout the study period.

While some analyses have documented the short-term impact of the ACA on factors such as coverage and access to care, these examinations may miss out on trends taking place over the long haul. “We know a lot about how access to physician services improved in the years immediately surrounding the ACA—that national uninsurance rates dropped and access to care improved,” lead author Laura Hawks, MD, told First Report Managed Care. There has been less awareness, however, of the extent to which these outcomes have changed over the course of decades. 

“Certainly, the most surprising finding of the study was the rapid relative increase of unmet health needs among those who are insured,” she explained. This worsening among those with health insurance is likely due to the growing reliance on cost-sharing mechanisms utilized by private health insurance plans, such as high premiums, high-deductible health plans, and high co-pays. All of these create financial barriers and limit patient access to care. “This study suggests that too many people who are covered by insurance are going without basic health care in times of need. There are almost certainly clinical consequences of this forgone care.” 

Managed care leaders and decision-makers are held accountable to the underlying need to optimize the bottom line and maintain a fiduciary duty to shareholders, Dr Hawks acknowledged, but this research suggests that “the quality of the product has been substantially reduced over time.” Those who implement health insurance plans ought to assess how to minimize these financial barriers to care for their clients, she added.

Out-of-pocket spending among those ages 18 to 64 with incomes under 250% of the federal poverty level was significantly reduced after the ACA was implemented. Those with incomes over 400% of the federal poverty level saw little to no reduction in out-of-pocket spending, however, and a significant increase in health insurance premiums from 2012 to 2015. 

The result is that the ACA has had little or no impact on improving access or controlling costs for most nonelderly US adults who are covered by employer-sponsored insurance, Dr Ayanian noted in his commentary paper. In the future, he added, it will be important to reduce the number of Americans who do without care because of the expense by expanding coverage to those who remain uninsured and by slowing the growth of spending for those who do have health insurance.

Dr Hawks reported financial support from an Institutional National Research Service Award and the Cambridge Health Alliance. Several of her co-authors disclosed involvement in Physicians for a National Health Program, an organization that advocates for a single-payer national health insurance program.