Study sees 'significant' reduction in access to care
One in five U.S. residents reported not getting or delaying needed medical care in the previous 12 months, up significantly from one in seven people in 2003. Documentation of deterioration in access to medical care in the United States is part of a national study released by the Center for Studying Health System Change (HSC).
In 2007, HSC says, more than 23 million people reported going without needed care and some 36 million people delayed care, for a total of 59 million people citing access problems. Information comes from HSC's 2007 Health Tracking Household Survey. HSC has conducted the survey five times since 1997 as part of its Community Tracking Study. Officials say the 2007 survey shows the sharpest increase in access problems in a decade, particularly among insured Americans.
"We were really struck by the size of the change," lead researcher Peter Cunningham, an HSC senior fellow, tells State Health Watch. "Certainly, a majority of Americans are still getting the care they need, but we were really struck by the size of the increase in people reporting they did not get or delayed care. It was a pretty substantial increase over a four-year period. We also were surprised that the increase was even higher for insured people than for uninsured people."
Mr. Cunningham's tracking report says the dramatic decline in access between 2003 and 2007 "signals a sharp change in Americans' access to care, which was relatively stable between 1997 and 2003, including some gains. Increased health care costs, along with health insurance-related and health system-related problems, appear to be the major contributors to Americans' declining access to care."
The survey finds that uninsured people continue to have much higher levels of unmet medical need and delayed care compared with insured people, and access for the uninsured decreased between 2003 and 2007, both for those with incomes below 200% of the federal poverty level and above it.
But insured people experienced a greater percentage increase in unmet medical needs compared with uninsured peoplea 62% increase for the insured vs. a 33% increase for the uninsured. As a result, Mr. Cunningham says, the access gap between insured and uninsured people narrowed slightly.
Unmet medical needs are greater for people in poor or fair health compared with people in good, very good, or excellent health. Sicker people use more health care and thus have more chances to encounter obstacles in getting care, the report says. Access to care worsened the most for people in poor or fair health, and Mr. Cunningham says this is a particular concern because sicker people are in greater need of care.
Despite many efforts to bring health care coverage and services at least to children, they are not exempt from the trend toward reduced access. Low-income children encountered the greatest increase in unmet needs among all children, reversing the gains they experienced between 1997 and 2003. While income differences in unmet needs for children were eliminated by 2003, those disparities returned by 2007.
For the 59 million people reporting an access problem, cost was the most frequently citedand a growingobstacle to care. In 2007, 69% of people who went without or delayed needed care cited worries about cost, a 3.8% increase from 2003.
While more than 90% of uninsured people reported cost as a barrier across three surveys, the increase in cost barriers occurred mostly among insured people. Higher patient cost-sharing likely is driving growing cost concerns among insured people, the report says. As the underlying cost of medical services and insurance premiums has increased, many employers have reduced benefits and increased patient cost-sharing through so-called benefit buy-downs as a way to moderate large premium increases and pass along more of the cost increases to employees.
Health system and plan problems
After concerns about costs, health system-related concerns were the next most frequently cited reason for access problems, followed by health plan-related issues. Increased provider capacity constraints may have contributed to the rise in health system barriers, Mr. Cunningham says. A shortage of some types of doctors in different markets, particularly primary care physicians, could affect people's ability to get a timely appointment. Also, some physicians are taking a more entrepreneurial response to constraints on their incomes, with responses including reducing the amount of charity care they provide and limiting their availability outside of normal business hours and over the telephone. Also, he says, capacity constraints among safety net providers such as community health centers may contribute to access problems. Also creating barriers are increased difficulties in finding transportation, obtaining leave from work, and arranging for child care.
Health plan-related barriers that people cited included that their health plan would not pay for treatment, followed by the doctor or hospital not accepting their insurance. A return of health plan prior authorization requirements for certain services also may be a contributing factor. And rising insurance deductibles or coinsurance that cause people to be responsible for much or all of a medical bill may contribute to some people reporting that their health plan would not pay for treatment.
Mr. Cunningham says the sharp increase in access problems for insured people "strongly suggests that the access to medical care that insurance coverage previously guaranteed is declining. Insured people are facing growing cost pressures, including higher out-of-pocket spending for care, more difficulties finding providers who will accept their insurance and renewed limits on what their insurance will cover. An alternative interpretation of these results is that as individuals are exposed to more of the costs of care, they are becoming more efficient by delaying or forgoing care that may be of low marginal value, which is the key rationale for consumer-directed health care."
He also says while the measure of unmet need used in the study does not allow for a determination of the clinical need for care or the potential health consequences of delayed or forgone care, the fact that unmet need increased the most for the sickest people should cause concern, as they are the most likely to experience adverse health consequences as a result of disruptions in their medical care use.
Mr. Cunningham tells State Health Watch he believes the cause for the deterioration in access is the fact that health care costs are increasing incrementally more than wages or family income. Also, he says, the deterioration in the general economy is playing into the problem.
"The problems of cost and access are inextricably linked," he says. "Without cost containment, expanded government support for insurance coverage will have to keep pace with the trend in medical care spending to maintain affordability for individuals and families. Such increases in health care costs will be difficult for governments to sustain, especially during periods of slow or negative economic growth. To the extent that cost increases are passed on to individuals, continued declines in access to care are inevitable."
Commenting on the findings, Robert Wood Johnson Foundation Vice President for research and evaluation David Colby said the deteriorating access to care, particularly for vulnerable groups, is especially disturbing. "The findings send a clear message that we are heading down the wrong path," he said. "The American health care system is broken, and with each passing year more Americans are falling behind when it comes to getting the medical care they need. This is a national problem that demands national attention."
Download the HSC report at http://www.hschange.org/CONTENT/993/. Contact Mr. Cunningham at (202) 484-4242.
One in five U.S. residents reported not getting or delaying needed medical care in the previous 12 months, up significantly from one in seven people in 2003.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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