Access to Care:

Close to one-quarter of American families -- 24 percent -- reported that obtaining medical care had become harder for them compared with three years earlier. In a survey conducted by the Center for Studying Health System Change, 12 percent of families said access had actually improved, while 64 percent reported no change. These findings established an important baseline for understanding how Americans experienced shifts in the health care system during the late 1990s.

Access Perceptions Differ by Income, Race, and Age

Low-income families were more likely to perceive worsening access to care. Among families with incomes below the poverty line, 30 percent said getting care had become harder -- six percentage points above the national average. Yet this was not solely a problem for the poor. Roughly one in five families with incomes at or above 400 percent of the federal poverty level also reported increased difficulty in obtaining care.

Hispanic families stood out as particularly likely to report deteriorating access, with 30 percent saying care had become harder to get. This matched the rate seen among the poorest families, highlighting the compounding effects of income, language barriers, and cultural factors on health care access.

The elderly were a notable exception. Only 11 percent of older Americans perceived increased difficulty in getting care, while 81 percent reported no change. The near-universal coverage provided by Medicare likely contributed to this sense of stability, offering older adults greater continuity and consistency in their health coverage compared with the working-age population.

Insurance status appeared to play a particularly powerful role in shaping perceptions. Forty-three percent of families that were uninsured at the time of the survey reported worsening access -- more than double the 21 percent reported by families with private insurance coverage.

Variation Across Communities

Comparing 12 randomly selected communities showed meaningful variation in how families perceived changes in their access to care. Families in Boston (21 percent), Lansing (19 percent, significantly different), and Syracuse (20 percent, significantly different) were less likely to report that getting care had become harder. Miami stood out at the other end, with 33 percent of families reporting worsening access (significantly different from the metropolitan average).

The remaining communities fell closer to the national average: Cleveland (24 percent), Greenville, S.C. (23 percent), Indianapolis (23 percent), Little Rock (25 percent), Newark (27 percent), Orange County (25 percent), Phoenix (26 percent), and Seattle (21 percent). The average for metropolitan areas with populations over 200,000 was 24 percent, matching the national figure.

Understanding the Drivers of These Perceptions

Identifying and quantifying the factors behind these perceptions required further study. Differences in local insurance markets, provider availability, out-of-pocket costs, and the pace of managed care adoption could all have contributed to variations in how families experienced access to care. The Center's ongoing research program was designed to analyze these factors alongside more objective measures of access changes.

Future iterations of the household survey would allow the Center to track shifts in these perceptions over time, measuring whether the early warning signs of declining access identified in this survey translated into sustained trends or proved to be temporary responses to market upheaval.

Sources and Further Reading

This Data Bulletin presents findings from the Community Tracking Study Household Survey, a nationally representative telephone survey of the civilian, non-institutionalized population conducted in 1996 and 1997. The survey included 12 randomly selected metropolitan communities. Statistical significance is noted where site values differ from the mean for metropolitan areas with populations over 200,000.