Treading Water: Americans' Access to Needed Medical Care, 1997-2001

Tracking Report No. 1, March 2002

Bradley C. Strunk, Peter J. Cunningham

The late 1990s brought sustained economic expansion, falling unemployment, and rising household incomes across the United States. Under such favorable conditions, one might have expected Americans to find it easier to obtain medical care when they needed it. Yet findings from the Center for Studying Health System Change (HSC) Community Tracking Study reveal a different picture: between 1997 and 2001, access to needed health care barely budged. Roughly one in seven Americans -- about 41 million people -- reported trouble getting the medical attention they needed in 2001, a figure that remained stubbornly close to levels recorded four years earlier. Economic prosperity, it turned out, was not enough to close the gap.

A Persistent Problem: Unmet Medical Need on the Rise

Drawing on a large-scale household survey of approximately 60,000 people conducted in multiple rounds, the HSC Community Tracking Study measured several dimensions of health care access across the nation. The core finding was not encouraging. The share of Americans who reported going without needed medical care -- whether they delayed treatment or never received it at all -- edged upward from 5.2 percent in 1997 to 5.8 percent by 2001. While that increase may appear modest in percentage terms, it translated into millions of additional people who could not get the care they believed they required.

This was not a problem confined to any single group. Americans across age ranges, income levels, and insurance categories reported difficulties. Still, certain populations bore a disproportionate share of the burden. People without health insurance were roughly three times as likely to go without needed care compared to those who had coverage. Similarly, individuals with lower incomes were nearly twice as likely to experience unmet need as those earning higher wages. These disparities persisted throughout the study period, suggesting that economic growth alone was insufficient to address the structural barriers many Americans faced in the health care system.

Cost: The Dominant Barrier to Care

When people did encounter obstacles to getting medical care, affordability stood out as the single biggest reason. Among those who reported problems accessing care, 62 percent pointed to cost-related concerns as the primary barrier. This included not being able to afford out-of-pocket expenses, not having insurance, or finding that their coverage did not adequately pay for the services they needed.

The dominance of cost as a barrier reflected the broader reality of health care financing in the United States during this period. Health care spending was accelerating, insurance premiums were climbing, and employers were beginning to shift more costs onto workers through higher deductibles and copayments. Even those who technically had insurance found that rising out-of-pocket costs could put certain services out of reach. For the uninsured, the math was even more stark: without any coverage to absorb a portion of medical bills, many simply went without.

Growing Frustrations with the Health Care System Itself

While cost remained the most frequently cited obstacle, the data revealed a troubling secondary trend: barriers related to the health care delivery system were getting worse. Between 1997 and 2001, the proportion of people reporting system-related access problems jumped from 45.2 percent to 53.8 percent. These were not financial complaints but rather frustrations with the mechanics of actually navigating the system to get an appointment, see a specialist, or receive timely attention.

Appointment wait times illustrated the problem clearly. In 1997, about 22.2 percent of people who sought care for an illness or injury reported waiting at least a week to be seen. By 2001, that figure had climbed to 28 percent. For patients dealing with acute symptoms or worsening conditions, a delay of a week or more could mean the difference between a manageable health issue and a more serious one.

Insurance-related complications also grew more common. Problems tied to health plan rules, referral requirements, and coverage disputes rose from 28.5 percent in 1997 to 33.4 percent by 2001. This increase coincided with the era of managed care, when many insurance plans imposed strict utilization controls such as mandatory referrals, prior authorization requirements, and limited provider networks. For many patients, these administrative hurdles created real barriers to receiving the care their doctors recommended.

The Insurance Divide: Coverage Remained the Key Factor

Perhaps the most consistent finding throughout the study period was the stark divide between the insured and uninsured. Americans who lacked health insurance were approximately three times more likely to report that they could not obtain needed medical care compared to those with coverage. This gap held steady from 1997 through 2001, neither widening nor narrowing significantly despite the period's strong economic conditions.

The persistence of this divide underscored a fundamental limitation of relying on economic growth as a path to better health care access. While strong labor markets did help some people gain employer-sponsored coverage, millions of workers remained in jobs that did not offer health benefits or that required employee contributions too expensive for lower-wage earners to afford. Self-employed individuals and part-time workers faced similar challenges. As a result, roughly 41 million Americans continued to lack insurance throughout this period, and their access to care reflected that vulnerability.

Income and Access: A Steep Gradient

Income level proved to be another powerful predictor of whether someone could get the medical care they needed. Low-income Americans were nearly twice as likely as their higher-income counterparts to report unmet medical needs. This pattern held even after accounting for insurance status, suggesting that factors beyond coverage -- such as transportation, time off from work, availability of nearby providers, and the ability to pay copayments and deductibles -- also played significant roles.

For low-income families, the burden of health care costs weighed especially heavily. Even those who qualified for Medicaid or other public insurance programs sometimes encountered difficulties finding providers willing to accept their coverage, given the relatively low reimbursement rates these programs offered. Those without any form of coverage faced even steeper obstacles, often relying on emergency rooms for care that would have been more appropriately -- and less expensively -- delivered in a primary care setting.

A Bright Spot: Improved Access for Children

Against the backdrop of stagnant or deteriorating access for adults, children's access to health care actually improved during the study period. The share of children whose families reported problems obtaining needed care declined from 6.3 percent in 1997 to 5.1 percent by 2001. This improvement stood in contrast to the trends observed among the adult population.

Researchers attributed much of this progress to the State Children's Health Insurance Program (SCHIP), which Congress established in 1997. SCHIP gave states federal funding to extend health coverage to children in families whose incomes were too high to qualify for Medicaid but too low to afford private insurance. By the early 2000s, millions of previously uninsured children had gained coverage through SCHIP and related Medicaid expansions. The program demonstrated that targeted policy interventions could make a measurable difference in access to care, even when broader trends were moving in the wrong direction.

What the Data Showed About the Health Care System

The Community Tracking Study Household Survey, which provided the foundation for this analysis, was one of the most comprehensive sources of data on health care access available at the time. Conducted by the Center for Studying Health System Change, each round of the survey gathered responses from roughly 60,000 people across the country, capturing a detailed picture of how Americans interacted with the health care system.

The survey tracked multiple measures of access, including whether respondents had a usual source of care, whether they had experienced delays in obtaining treatment, and whether they had gone without care they believed was necessary. By following these indicators over three survey rounds spanning 1997 to 2001, researchers could identify trends that a single snapshot would have missed.

The overall picture that emerged was one of a health care system struggling to keep pace with the needs of the population it served. While the economy was growing and many Americans were doing well financially, the health care system's structural problems -- high costs, gaps in insurance coverage, and growing administrative complexity -- continued to prevent millions of people from getting the care they needed.

Implications for Policy and Practice

The findings from this tracking report carried significant implications for health policy. First, they made clear that a strong economy alone would not solve the nation's access problems. The period from 1997 to 2001 represented one of the longest economic expansions in American history, yet access to care failed to improve for most adults. This suggested that structural reforms -- not just economic growth -- were necessary to make meaningful progress.

Second, the data highlighted the importance of insurance coverage as a determinant of access. The threefold difference in unmet need between insured and uninsured Americans pointed clearly to coverage expansion as one of the most direct levers for improving access. The success of SCHIP in reducing access barriers for children provided additional evidence that expanding coverage could yield tangible results.

Third, the growing role of health system barriers suggested that having insurance was necessary but not sufficient. Even insured Americans were encountering more difficulty navigating the system, dealing with longer waits, and contending with plan restrictions. Addressing these issues would require attention not just to who had coverage but to how care was organized and delivered.

Finally, the rise in cost-related barriers underscored the need to confront the underlying drivers of health care spending. As long as medical costs continued to outpace wage growth and inflation, many Americans would remain priced out of the care they needed, regardless of whether they carried an insurance card.

Data Source

This analysis was based on data from the HSC Community Tracking Study Household Survey, which interviewed approximately 60,000 people in each of three rounds conducted between 1997 and 2001. The survey was designed to provide nationally representative estimates of health care access, use, and insurance coverage among the civilian noninstitutionalized population. Funding for the Community Tracking Study was provided by the Robert Wood Johnson Foundation.

Additional Resources

AHRQ — National Healthcare Quality and Disparities Report: https://www.ahrq.gov/research/findings/nhqrdr/index.html

Kaiser Family Foundation — Uninsured: https://www.kff.org/uninsured/

Census Bureau — Health Insurance Coverage: https://www.census.gov/topics/health/health-insurance.html

CMS — SCHIP/CHIP: https://www.cms.gov/chip

Commonwealth Fund — Access to Care: https://www.commonwealthfund.org/