Falling Behind: Americans' Access to Medical Care Deteriorates, 2003-2007

Tracking Report No. 19

June 2008

Peter J. Cunningham, Laurie E. Felland

The number and share of Americans who reported going without or postponing necessary medical care rose sharply between 2003 and 2007, based on results from the Center for Studying Health System Change's (HSC) nationally representative 2007 Health Tracking Household Survey. Roughly one in five Americans — 59 million individuals — indicated they did not receive or delayed essential medical care in 2007, a significant jump from one in seven — 36 million individuals — in 2003. Although access worsened for both insured and uninsured populations, those with insurance experienced a proportionally greater rise in access difficulties compared to their uninsured counterparts. Furthermore, access eroded more substantially for individuals in fair or poor health than for healthier Americans. Unmet medical needs also grew among low-income children, reversing previous trends and expanding the access divide with higher-income children. Those who reported access difficulties increasingly pointed to cost as a barrier to obtaining needed care, alongside growing rates of health plan and health system obstacles.

Access to Needed Medical Care Declines

In 2007, roughly 20 percent of the U.S. population — one in every five individuals — indicated they had not received or had postponed necessary medical care at some point during the preceding 12 months, a significant rise from 14 percent — one in seven — in 2003. This dramatic erosion of access between 2003 and 2007 marks a stark departure from the period between 1997 and 2003, when Americans' ability to obtain needed care remained relatively steady and even showed some improvement. Escalating health care expenses, along with insurance-related and health system-related difficulties, appear to be the primary drivers behind Americans' declining access to medical services.

In 2007, over 23 million individuals reported forgoing needed care entirely, and approximately 36 million people put off seeking care, yielding a combined total of 59 million Americans experiencing access difficulties, according to HSC's nationally representative 2007 Health Tracking Household Survey (see Data Source). The share of Americans with unmet needs grew by 2.8 percentage points between 2003 and 2007 (from 5.2% to 8%), equivalent to roughly 9.5 million additional people going without medical care (see Figure 1 and Supplementary Table 1). The proportion who delayed necessary care climbed by 3.9 percentage points over the same period (from 8.4% to 12.3%), representing an estimated 13.5 million more people.

Access Deteriorates for Insured and Uninsured

Uninsured Americans continued to report significantly higher rates of unmet medical needs and care delays relative to insured individuals, and access for the uninsured worsened between 2003 and 2007 for both those with incomes below 200 percent of poverty — $41,300 for a family of four in 2007 — and those above that threshold (see Table 1). These results are consistent with additional HSC research documenting reductions in physician charity care and increasing strain on safety net capacity to serve uninsured patients, driven by financial and competitive pressures in health care markets.

Nevertheless, insured individuals also confronted substantial increases in unmet need over this period. In fact, those with insurance coverage saw a larger proportional rise in unmet medical needs than the uninsured — a 62 percent increase for insured persons compared with a 33 percent increase for those without coverage. Consequently, and somewhat ironically, the access gap separating insured and uninsured populations narrowed slightly. In 2003, uninsured people were 3.4 times more likely to report forgoing care than insured people; by 2007, that ratio dropped to 2.8 times. Additionally, the growth in unmet need was relatively uniform across both low- and high-income insured groups. Escalating out-of-pocket expenses — including higher deductibles, coinsurance, and copayments — likely account for much of the increased unmet need among those with insurance. Other HSC research confirms that insured individuals who bear greater out-of-pocket medical costs are more prone to delaying or forgoing necessary care.

Sickest Face More Access Problems

Unmet medical needs are more prevalent among individuals in poor or fair health compared with those in good, very good, or excellent health. Because sicker individuals utilize more health care services, they encounter more opportunities to face obstacles in obtaining care. However, access to medical care deteriorated most severely for those in poor or fair health — a particularly troubling development given that these individuals have the greatest need for medical attention. Overall, the share of people in poor or fair health with an unmet need rose by 5.1 percentage points between 2003 and 2007 (from 11.9% to 17.0%), in contrast to an increase of 2.1 percentage points for those in good, very good, or excellent health (from 4.1% to 6.2%).

Insured individuals in poor or fair health saw more than a 5 percentage point increase in unmet need (from 9.0% in 2003 to 14.2% in 2007), while insured persons in good, very good, or excellent health experienced a somewhat smaller rise of 1.8 percentage points (from 3.2% in 2003 to 5.0% in 2007). Uninsured individuals in poor or fair health faced the most severe access challenges among all people reporting fair or poor health, with one in four indicating in 2007 that they went without necessary medical care.

Children's Access Declines

As the broader U.S. population experienced increases in unmet need and delayed care between 2003 and 2007, children were not spared from these trends (see Table 2). Low-income children experienced the steepest growth in unmet needs among all children, reversing the progress they had made between 1997 and 2003. As a result, income-based differences in unmet need for children had largely disappeared by 2003, but these disparities reemerged by 2007.

The access improvements among low-income children between 1997 and 2003 likely reflected expansions in Medicaid and the State Children's Health Insurance Program (SCHIP) that reduced the ranks of uninsured children. However, enrollment of low-income children in Medicaid and SCHIP has remained essentially flat since 2003. Eligibility restrictions and enrollment policy changes implemented by some states, along with new federal requirements for Medicaid applicants to provide proof of citizenship, may have contributed to the stagnation in Medicaid and SCHIP enrollment since 2003. Simultaneously, continued declines in employer-sponsored coverage have driven up the proportion of low-income children who lack insurance (findings not shown). Moreover, the same factors affecting the general population's access to care — cost concerns, health plan barriers, and health system obstacles — likely played a role in the growing access problems experienced by children.

Cost Concerns Intensify

Among the 59 million Americans who reported an access problem, cost was the most commonly cited — and an increasingly prevalent — barrier to care. In 2007, 69 percent of individuals who went without or postponed needed care identified cost worries as the reason, reflecting a 3.8 percentage point increase from 2003 (see Supplementary Table 2).

While cost remained the predominant concern among uninsured individuals (more than 90% of uninsured people identified cost as a barrier across all three survey waves), the growth in cost-related barriers was concentrated primarily among insured people. As discussed above, greater patient cost sharing — with individuals facing higher deductibles and other increased out-of-pocket expenses for medical services — is likely fueling the growing cost concerns among those with insurance. As the underlying cost of medical services and insurance premiums have climbed, many employers have scaled back benefits and increased patient cost sharing through so-called benefit buy-downs as a strategy to moderate large premium increases and shift more of the cost burden onto employees.

More Health System and Plan Barriers

After cost-related concerns, health system-related issues were the next most commonly reported reason for access problems, followed by health plan-related barriers. Both health system and health plan obstacles to care surged by approximately 9 percentage points between 2003 and 2007.

Although insured individuals remained more likely than uninsured individuals to cite health system issues as reasons for access problems, uninsured people encountered particularly sharp increases in health system-related access difficulties between 2003 and 2007, which accounted for the bulk of their overall rise in access problems. Among all individuals reporting a health-system barrier to care (see Supplementary Table 3), the largest increases were observed in the following areas: inability to reach the provider when the office was open (10.2 percentage point increase); inability to get through on the telephone (6.2 percentage point increase); excessive travel time to the provider (5.8 percentage point increase); and inability to secure an appointment soon enough (4.5 percentage point increase).

Growing provider capacity constraints may have contributed to the increase in health system barriers. Shortages of certain physician specialties in various markets, particularly in primary care, could affect patients' ability to schedule timely appointments. In addition, some physicians are adopting more entrepreneurial approaches in response to income constraints, including cutting back on charity care and limiting their availability outside of regular business hours and over the telephone (a non-billable service). Furthermore, capacity limitations among safety net providers that serve low-income and uninsured populations, such as community health centers, may be exacerbating access problems. Increased difficulties with transportation, taking time off from work, and arranging childcare also represent potential explanations for growing challenges in reaching providers, particularly for uninsured individuals.

The health plan-related barriers that people increasingly identified were that their health plan would not cover treatment (9.2 percentage point increase), followed by the doctor or hospital refusing to accept their insurance (4.5 percentage point increase). The resurgence of health plan prior-authorization requirements for certain services may be a contributing factor. Additionally, rising insurance deductibles or coinsurance that leave people responsible for much or all of a medical bill may lead some individuals to perceive that their health plan would not pay for treatment. The increase in people reporting that their doctor would not accept their insurance may suggest that more physicians are opting out of private insurance networks or declining to take on new Medicare or Medicaid patients.

Implications

After a period of relative stability in access to medical care between 1997 and 2003, many Americans saw their access to care deteriorate between 2003 and 2007, including low-income children and those with the most substantial health care needs. Particularly noteworthy is that access eroded most for individuals with insurance coverage — likely because of the mounting financial burden associated with out-of-pocket medical costs. Other developments that began straining family budgets during 2007, such as escalating energy and fuel prices, the home foreclosure crisis, and an anticipated economic downturn, likely compounded growing economic anxiety that led families to cut back on spending, including for medical care.

The dramatic rise in access problems among insured individuals strongly implies that the access to medical care that insurance coverage once guaranteed is eroding. Insured Americans are confronting escalating cost pressures, including higher out-of-pocket expenditures for care, greater difficulty locating providers who will accept their insurance, and renewed restrictions on what their coverage will pay for. An alternative reading of these findings is that as individuals bear more of the direct costs of care, they may be becoming more selective consumers by forgoing or deferring care of limited marginal value — the central premise behind consumer-directed health care.

The unmet need measure employed in this analysis does not permit a determination of the clinical necessity for care or the potential health consequences of delayed or forgone services. Nonetheless, the fact that unmet need grew most sharply among the sickest individuals should be a source of concern, as they are the most likely to experience negative health outcomes when their medical care is disrupted.

Numerous state and national health reform proposals call for subsidizing the purchase of private insurance coverage, with caps on the total out-of-pocket spending required of individuals and families. Determining the appropriate out-of-pocket spending threshold will be critical to the effectiveness of these policies, because setting these limits too high may impose financial burdens that compel people to postpone or forgo needed care.

At the same time, the growth in cost-related access problems is a direct consequence of health care costs rising more rapidly than incomes over the preceding decade. Employment-based private insurance premiums climbed 114 percent from 1999 to 2007, while average hourly earnings rose only 27 percent, creating a gap of 6.7 percentage points per year. These escalating costs are passed on to individuals and families in the form of higher premiums, deductibles, coinsurance, and copayments for services.

The challenges of cost and access are fundamentally intertwined. Without effective cost containment, expanded government subsidies for insurance coverage will need to keep pace with the trajectory of medical care spending to preserve affordability for individuals and families. Such increases in health care expenditures will be difficult for governments to sustain, particularly during periods of sluggish or negative economic growth. To the degree that cost increases are passed along to individuals, continued deterioration in access to care is unavoidable.

Although escalating costs remain the primary obstacle to accessing needed care, Americans face growing barriers tied to health care system capacity and provider availability. This aligns with a widespread perception of mounting medical workforce shortages, especially among primary care practitioners, which will be challenging for policy makers to address in the near term. When such barriers cause delays in necessary care, patients may ultimately seek treatment in more expensive hospital emergency departments with potentially more advanced conditions. Uninsured individuals face especially acute health system barriers, as the expanding uninsured population strains the capacity of safety net providers. Without adequate resources for safety net providers to keep up with rising demand for services, unmet needs and delayed care will in all likelihood continue to climb.

Notes

1. Strunk, Bradley C., and Peter J. Cunningham, Trends in Americans' Access to Needed Medical Care, 2001-2003, Tracking Report No. 10, Center for Studying Health System Change, Washington, D.C. (August 2004).

2. Cunningham, Peter J., and Jessica H. May, A Growing Hole in the Safety Net: Physician Charity Care Declines Again, Tracking Report No. 13, Center for Studying Health System Change, Washington, D.C. (March 2006); Hurley, Robert E., Laurie E. Felland and Johanna Lauer, Community Health Centers Tackle Rising Demands and Expectations, Issue Brief No. 116, Center for Studying Health System Change, Washington, D.C. (December 2007).

3. Banthin, Jessica, Peter J. Cunningham and Didem Bernard, "Financial Burden of Health Care, 2001-2004," Health Affairs, Vol. 27, No. 1 (January/February 2008).

4. May, Jessica H., and Peter J. Cunningham, Tough Trade-offs: Medical Bills, Family Finances and Access to Care, Issue Brief No. 85, Center for Studying Health System Change, Washington, D.C. (June 2004).

5. Cohen Ross, Donna, Aleya Horn and Caryn Marks, Health Coverage for Children and Families in Medicaid and SCHIP: State Efforts Face New Hurdles, The Kaiser Commission on Medicaid and the Uninsured, Henry J. Kaiser Family Foundation (January 2008).

6. Strunk, Bradley C., Paul B. Ginsburg and John P. Cookson, "Tracking Health Care Costs: Declining Growth Trend Pauses in 2004," Health Affairs, Web exclusive (June 21, 2005).

7. Pham, Hoangmai H., and Paul B. Ginsburg, "Unhealthy Trends: The Future of Physician Services," Health Affairs, Vol. 26, No. 6 (November/December 2007).

8. Hurley, Felland and Lauer (December 2007).

9. Draper, Debra A., and Paul B. Ginsburg, Health Care Cost and Access Challenges Persist: Initial Findings from HSC's 2007 Site Visits, Issue Brief No. 114, Center for Studying Health System Change, Washington, D.C. (October 2007).

10. Ginsburg, Paul B., U.S. Senate Finance Committee Testimony on Health Care Costs (June 3, 2008).

11. Colwill, Jack M., James M. Coltice and Robin L. Kruse, "Will Generalist Physician Supply Meet Demand of an Increasing and Aging Population," Health Affairs, Web exclusive (April 29, 2008).

Data Source

This Tracking Report presents findings from the HSC 2007 Health Tracking Household Survey and the Community Tracking Study Household Surveys from 1996-97 and 2003. All three telephone surveys utilized nationally representative samples of the civilian, noninstitutionalized population. Sample sizes included approximately 60,000 people for the 1996-97 survey, about 47,000 people for the 2003 survey, and roughly 18,000 people for the 2007 survey. Response rates were 65 percent in 1996-97, 57 percent in 2003, and 43 percent in 2007. Population weights were applied to adjust for probability of selection and differences in nonresponse based on age, sex, race or ethnicity, and education. Although all three surveys are nationally representative, the samples for the 1996-97 and 2003 surveys were largely clustered in 60 representative communities, while the 2007 survey was based on a stratified random sample of the nation. Standard errors account for the complex sample design of the surveys. Questionnaire design, survey administration, and the question wording of all measures in this study were consistent across the three surveys.

Estimates of unmet need and delayed care were derived from the following two questions: (1) "During the past 12 months, was there any time when you didn't get the medical care you needed?" and (2) "Was there any time during the past 12 months when you put off or postponed getting medical care that you thought you needed?" For respondents who reported either an unmet need or delayed care, follow-up questions were posed to determine the reasons. Responses included worry about cost, problems with health insurance, problems with availability of medical providers, and personal reasons such as lack of time or procrastination. This Tracking Report includes only responses where at least one of the reasons was related to the health care system; responses attributed solely to personal reasons were not classified as unmet need or delayed care. Insurance status reflects coverage on the day of the interview and encompasses coverage obtained through employer-sponsored and individually purchased private insurance, Medicare, Medicaid, the State Children's Health Insurance Program (SCHIP), other state programs, TRICARE and other military insurance programs, and the Indian Health Service.

Supplementary Tables

Supplementary Table 1: Indicators of Access to Care for the U.S. Population

Supplementary Table 2: Reasons for Access Problems, Among People Reporting Delaying or Going Without Needed Care

Supplementary Table 3: Detailed Reasons for Access Problems, Among People Reporting Delaying or Going Without Needed Care

TRACKING REPORTS are published by the Center for Studying Health System Change.

600 Maryland Avenue, SW, Suite 550, Washington, DC 20024-2512. Tel: (202) 484-5261. Fax: (202) 484-9258. www.hschange.org

President: Paul B. Ginsburg

Sources and Further Reading

AHRQ: Access to Health Care — Agency for Healthcare Research and Quality resources on health care access trends, barriers, and disparities across the U.S. population.

KFF: The Uninsured and Coverage — Kaiser Family Foundation data and analysis on uninsured populations and coverage gaps that affect access to medical care.

Commonwealth Fund: Health Care Coverage Research — Research on insurance coverage and underinsurance affecting Americans' ability to obtain timely medical care.

Health Affairs: Financial Burden of Health Care — Peer-reviewed study on rising out-of-pocket costs and financial barriers to care, cited in this report.

Medical Expenditure Panel Survey (MEPS) — National survey data on health care access, utilization, and expenditures for the U.S. civilian population.