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

Tracking Report No. 1
March 2002
Bradley C. Strunk, Peter J. Cunningham

espite unprecedented economic growth, low unemployment and fewer uninsured people, Americans’ ability to get needed medical care failed to improve significantly between 1997 and 2001, according to findings from the Center for Studying Health System Change’s (HSC) Community Tracking Study Household Survey. While most people get the care they believe they need, about one in seven Americans reported some difficulty obtaining needed care in 2001—about the same as in 1997. At the same time, health system-related problems—such as the ability to get timely appointments—increased, suggesting possible health system capacity constraints are emerging. On a brighter note, children’s ability to get needed care improved.


Trends in Americans’ Ability to Get Care

hile the majority of Americans believe they get the medical care they need, millions do not. In 2001, almost 16 million people in the United States reported they were unable to get needed medical care. Another 26 million people delayed needed care in the previous 12 months. Altogether, more than 15 percent of Americans, or about 41 million people, reported not getting or delaying needed care in 2001 (see Data Sources).

Despite a strong economy, fewer uninsured people and record low unemployment, overall rates of unmet need and delayed care—two important measures of access to care—failed to improve between 1997 and 2001 (see Figure 1 and Table 1). In fact, the frequency of unmet medical needs in the U.S. population, defined as the inability to get needed medical care at some point in the previous year, increased slightly, from 5.2 percent in 1997 to 5.8 percent in 2001. Reports of delayed care held steady between 1997 and 2001.

The lack of improvement in access to care during one of the most prosperous times in American history is not encouraging. Instead, Americans increasingly appear to be facing problems with aspects of health care not directly related to general economic trends. These include getting timely physician and clinic appointments, having medical providers accept their health insurance and getting their health insurer to pay for services. A weak economy could intensify problems with access to care by increasing unemployment and the number of people who are uninsured.


FIGURE 1: Access Gap Persists: Unmet Need for Insured vs. Uninsured People

FIGURE 1: Access Gap Persists: Unmet Need for Insured vs. Uninsured People

Note: See Table 1 for additional data on access to care.

# Change from 1997 to 2001 is statistically significant at p<.05.

Source: HSC Community Tracking Study Household Survey


TABLE 1: Indicators of Access to Care for the U. S. Population
 
1997
1999
2001
All People
Unmet Need
5.2%
5.6%*
5.8%#
Delayed Care
9.8
8.5*
9.5*
Either Type of Problem
15.0
14.1*
15.2*
Insured People
Unmet Need
3.9
4.3*
4.4#
Delayed Care
8.7
7.6*
8.6*
Either Type of Problem
12.5
11.9*
13.0*
Uninsured People
Unmet Need
13.5
14.2
15.0#
Delayed Care
17.1
14.1*
15.7
Either Type of Problem
30.6
28.2*
30.6*
Notes: If a person reported both an unmet need and delayed care, that person is counted as having an unmet need only. An unmet need means a person did not get needed medical care at some point during the previous 12 months. Delayed care means the person put off or postponed getting needed medical care at some point during the previous 12 months.

* Change from previous survey is statistically significant at p<.05.

# Change from 1997 to 2001 is statistically significant at p<.05.

Source: HSC Community Tracking Study Household Survey

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Insured vs. Uninsured: The Gap Persists

etting needed medical care continues to be a bigger problem for people without health insurance coverage. Trends are roughly similar for insured and uninsured people, so that the long-standing disparities in access hardly changed between 1997 and 2001. For example, 4.4 percent of insured people reported an unmet need in 2001, up from 3.9 percent in 1997. Likewise, 15 percent of uninsured people reported an unmet need in 2001, up from 13.5 percent in 1997.

Uninsured Americans in 2001, compared to 1997, were still about three times as likely not to get needed care as insured people. And, uninsured people in 2001 remained almost twice as likely to delay needed care as insured people—15.7 percent vs. 8.6 percent.

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Low-Income People Face More Problems Getting Care

oth low-income and high-income people experienced little or no increase in unmet need between 1997 and 2001. Despite small fluctuations, disparities in access to care by income remained about as high in 2001 as in 1997. And, low-income, uninsured people, whose incomes were below 200 percent of poverty, or about $35,000 a year for a family of four in 2001, continued to have the most trouble getting needed care, with 16.4 percent reporting an unmet need in 2001, which was not statistically different from 1997 (see Table 2).

Low-income people remained almost twice as likely to report an unmet need in 2001 as higher-income people—8.1 percent vs. 4.7 percent. Interestingly, the rate of unmet need for higher-income people increased from 3.9 percent in 1997 to 4.7 percent in 2001, a statistically significant change. The rate of unmet need also increased for low-income people, from 7.5 percent in 1997 to 8.1 percent in 2001, although this increase was not statistically significant. Overall, rates of delayed care did not differ substantially by income.

TABLE 2: Americans’ Likelihood of Having an Unmet Need, by Family Income and Health Status
 
1997
1999
2001
Family Income   
Below 200% of Poverty
7.5%
8.1%
8.1%
Insured
5.2
5.8
5.6
Uninsured
14.9
15.0
16.4
Above 200% of Poverty
3.9
4.3*
4.7*#
Insured
3.3
3.6*
4.0*#
Uninsured
11.0
12.7*
13.1#
Health Status
Fair or Poor Health
11.9
11.9
13.0
Insured
8.6
8.7
10.0*#
Uninsured
27.7
26.3
26.8
Good, Very Good or Excellent Health
4.2
4.7*
4.6#
Insured
3.2
3.7*
3.6#
Uninsured
10.7
11.7
12.2#
* Change from previous survey is statistically significant at p<.05.

# Change from 1997 to 2001 is statistically significant at p<.05.

Source: HSC Community Tracking Study Household Survey

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Health Status Matters

eople who reported fair or poor health remained almost three times as likely not to get needed care as people who reported their health was good or excellent—13 percent vs. 4.6 percent in 2001. Disparities in delayed care were not as great, but people with health problems were still more likely to delay care than healthier people, and these disparities remained fairly constant between 1997 and 2001. Greater difficulty getting medical care among people with health problems reflects in large part their greater need for care and, thus, more opportunities to experience problems with the health care system.

Uninsured people in poor or fair health continued to have the most trouble getting needed care, with 26.8 percent reporting an unmet need in 2001, down slightly from 27.7 percent in 1997, but the change was not statistically significant.

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Cost Remains Top Barrier to Care

ost remained the most frequently cited barrier to getting needed care (see Table 3), and trends were virtually flat from 1997 to 2001. Among people with an unmet need or who delayed care, about 62 percent in both 1997 and 2001 reported difficulty getting care because of worries about cost. Not surprisingly, cost was overwhelmingly the main barrier to care for the uninsured: 93.1 percent of the uninsured cited cost as the reason for difficulty getting care in 2001, almost unchanged from 1997. Nevertheless, more than half of people with insurance also cited cost as a barrier.

TABLE 3: Reasons for Access Problems
 
1997
1999
2001
All People
   Worried About the Cost
62.4%
61.2%
62.6%
   Health System-Related
45.2
50.7*
53.8*#
   Health Plan-Related
23.7
24.9
28.4*#
Insured People
   Worried About the Cost
51.2
49.6
52.3*
   Health System-Related
54.0
58.9*
62.4*#
   Health Plan-Related
28.5
29.4
33.4*#
Uninsured People
   Worried About the Cost
91.5
92.4
93.1
   Health System-Related
22.0
28.6*
28.5#
   Health Plan-Related
N/A
N/A
N/A
Notes: Percentages for a particular group do not add up to 100 percent because a person was permitted to cite more than one reason. See Table 4 for a detailed list of reasons for access problems.

* Change from previous survey is statistically significant at p<.05.

# Change from 1997 to 2001 is statistically significant at p<.05.

Source: HSC Community Tracking Study Household Survey

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Different Problems Emerging

hile trends in overall access changed little, there were greater changes in the types of problems people experienced with the health care system. Specifically, more people reported system—related problems and health insurance—related barriers.

More than half of people who had problems getting care cited health system-related barriers as a reason—up from 45.2 percent in 1997 to 53.8 percent in 2001. Specifically, people reported more problems getting appointments, getting through on the telephone to medical providers and getting to a doctor’s office or clinic when it was open (see Table 4). Similar trends were found for both insured and uninsured people, with 62.4 percent of insured people citing system problems in 2001, up from 54 percent in 1997, and 28.5 percent of the uninsured citing system problems in 2001, up from 22 percent in 1997.

Other survey data appear to confirm that more people are having problems scheduling appointments. The percentage of people who waited more than three weeks for an appointment for a checkup or general examination increased from 24.4 percent in 1997 to 27.4 percent in 2001 (see Figure 2).Waiting times also increased for people scheduling appointments for a specific illness or injury, with the percentage of people waiting more than a week for such visits increasing from 22.2 percent in 1997 to 28 percent in 2001.

Longer waiting times for appointments suggest growing physician capacity constraints, and some experts are predicting physician shortages.1 And, the prospect of crowded hospital emergency departments also might discourage people with nonurgent problems from seeking care there and increase the demand on office-based physicians.2

FIGURE 2: Appointment Waiting Times for Last Physician Visit

FIGURE 2: Appointment Waiting Times for Last Physician Visit

* Change from previous survey is statistically significant at p<.05.

# Change from 1997 to 2001 is statistically significant at p<.05.

Source: HSC Community Tracking Study Household Survey
 


TABLE 4: Detailed Reasons for Access Problems
 
1997
1999
2001
Worried About the Cost
62.4%
61.2%
62.6%
Health Plan-Related
Doctor or Hospital Would Not Accept Your Health Insurance
9.7
10.6
13.2*#
Health Plan Would Not Pay for Treatment
17.1
19.3*
22.2*#
Change in Health Insurance
0.6
0.5
0.6
Other Insurance-Related Problems
0.9
0.9
0.7
Health System-Related
Could Not Get an Appointment Soon Enough
22.9
29.7*
32.6*#
Could Not Get There When the Doctor’s Office or Clinic Was Open
19.5
21.3*
24.0*#
It Takes Too Long to Get to the Doctor’s Office or Clinic from Your House or Work
9.6
11.8*
12.2#
Could Not Get Through on the Telephone
6.9
9.7*
12.3*#
Had to Wait in Office or Clinic Too Long
1.1
1.0
0.8#
Do Not Know Where to Go/Cannot Find Doctor/Cannot Use Doctor of Choice
2.1
1.6*
1.5#
Cannot Get Referral from Doctor
1.5
1.1*
0.9#
Other Problems Related to the Health System
1.0
2.5*
2.1#
Notes: The universe for this table is all persons who reported an unmet need or delaying care. Percentages for a particular group do not add up to 100 percent because a person was permitted to cite more than one reason.

* Change from previous survey is statistically significant at p<.05.

# Change from 1997 to 2001 is statistically significant at p<.05.

Source: HSC Community Tracking Study Household Survey

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Insurance Troubles Increase

or insured people, the percentage reporting problems with their insurance increased from 28.5 percent in 1997 to 33.4 percent in 2001. In particular, more people reported their health plan would not pay for a service and their medical providers would not accept their insurance.

Increases in health plan-related problems may be related in part to growing instability in some health plan provider networks. Increasingly, some hospitals and physicians are testing greater bargaining clout with health plans, with some providers dropping out of health plan networks if they are unable to secure more favorable contracts.3, 4 This increased network instability could help to explain the increase in the percentage of people reporting problems getting care because their provider would not accept their insurance.

It is less clear why more people are reporting difficulty getting care because their plan refused to pay for the service—especially since plans’ restrictions on enrollee access to providers and services appear to have eased somewhat in recent years. However, there have been reports of health plans excessively delaying provider payments, which could result in some providers refusing services to patients who have delinquent accounts because of insurer delays.

Another factor that might contribute to consumers’ perception of more health plan-related barriers could be the continuing shift of insured workers from traditional indemnity insurance plans to some form of managed care. In 1996, 27 percent of workers were enrolled in indemnity plans, but by 2001, only 7 percent had indemnity coverage.5 For example, people moving from indemnity insurance into some form of managed care, even less restrictive preferred provider organizations, might have to choose between an in-network or out-of-network provider for the first time.

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Children’s Access to Care

ncreasingly, policy makers have focused on children’s health in recent years. Most notably in 1997, Congress passed the State Children’s Health Insurance Program (SCHIP), which may account for the decrease in the rate of uninsured children under age 18, from 12.1 percent in 1997 to 9.2 percent in 2001, according to the Community Tracking Study Household Survey. Generally, SCHIP allows states to expand coverage to children in families whose income is too high for Medicaid but too low to afford private insurance.

Contrary to the findings for the general population, children’s ability to get care improved. The percentage of children reporting any difficulty getting care decreased from 6.3 percent in 1997 to 5.1 percent in 2001 (see Table 5). Problems with unmet need and delayed care both decreased, although the decrease in unmet need among children was not statistically significant.

The ability to get care improved by about the same amount for both low-income and higher-income children, although changes for both groups were not statistically significant due to smaller samples. While SCHIP and other programs for low-income children may be contributing to these positive trends, the improvement in access to care among children does not appear to be limited just to low-income children.

Despite significant increases in access, almost 2 million children could not get needed care in 2001, while another 1.7 million children, or 2.4 percent, delayed needed care. As with the general population, uninsured and low-income children and children with health problems faced more difficulty getting care.

TABLE 5: Indicators of Access to Care for Children, by Insurance Status and Family Income
 
1997
1999
2001
All Children
   Unmet Need
3.2%
3.1%
2.7%
   Delayed Care
3.1
2.4*
2.4#
   Either Type of Problem
6.3
5.5
5.1#
Insurance Status
   Insured Children
     Unmet Need
2.4
2.5
2.3
     Delayed Care
2.7
2.1*
2.0#
     Either Type of Problem
5.1
4.6
4.3#
   Uninsured Children
     Unmet Need
9.7
7.7
7.1
     Delayed Care
5.6
5.4
6.6
     Either Type of Problem
15.2
13.1
13.6
Family Income
   Below 200% of Poverty
     Unmet Need
4.6
4.8
3.8
     Delayed Care
3.5
3.1
3.1
     Either Type of Problem
8.1
7.8
6.8
   Above 200% of Poverty
     Unmet Need
2.1
1.8
2.0
     Delayed Care
2.7
2.0*
2.1
     Either Type of Problem
4.8
3.8*
4.1
Note: If a child experienced both an unmet need and delayed care, that child is counted as having an unmet need only. Unmet need means a child did not get needed medical care at some point during the previous 12 months. Delayed care means the child put off or postponed getting needed medical care at some point during the previous 12 months.

* Change from previous survey is statistically significant at p<.05.

# Change from 1997 to 2001 is statistically significant at p<.05.

Source: HSC Community Tracking Study Household Survey

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Rough Waters Ahead

ince 2001, the US economy has weakened considerably, and unemployment has risen. If these economic trends continue, the number of uninsured is likely to rise, along with the number of Americans who face financial barriers to care. State budget shortfalls and other financial pressures on the health care safety net, along with a decrease in the proportion of physicians providing charity care,6 could lead to further deterioration in access to care for uninsured people.

And, problems are emerging that could affect people’s ability to get care, including rising health care costs that may prompt some employers either to drop health benefits or pass on more costs to workers, a severe nursing shortage, an undersupply of physicians in certain areas, providers dropping out of health plan networks and emergency department crowding.

Policy makers are discussing options to increase access to care. Insurance coverage expansions through tax credits or public coverage or extending coverage to families of unemployed persons could help offset losses in coverage because of the weak economy. In addition, expansions of federally supported community health centers could increase the availability of free or low-cost care for uninsured people even as market pressures reduce their access to private health care providers.

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Data Sources

his Tracking Report presents findings from the HSC Community Tracking Study Household Survey, a nationally representative telephone survey of the civilian, noninstitutionalized population conducted in 1996-97, 1998-99 and 2000-01. Each of the surveys was conducted over a roughly 12-month period that overlapped two calendar years (e.g., from September 2000 to September 2001). For ease of presentation and discussion, we refer only to a single calendar year for each of the surveys (1997, 1999 and 2001), although the results also reflect the latter part of the preceding year for each of the surveys. Data were supplemented by in-person interviews of households without telephones to ensure proper representation. Each round of the survey contains information on about 60,000 people, and response rates ranged from 60 percent to 65 percent.7

Estimates of unmet need and delayed care were based on 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 those reporting either unmet needs or delayed care, follow-up questions were asked to determine why. 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 had something to do with the health care system, and responses related only to personal reasons were not considered as unmet need or delayed care.

Insurance status reflects coverage on the day of the interview and includes coverage obtained through employer-sponsored private insurance, individually purchased private insurance, Medicare, Medicaid, other state programs, CHAMPUS and the Indian Health Service.

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Notes

1. Cooper, Richard A., et al., “Economic and Demographic Trends Signal an Impending Physician Shortage,”Health Affairs, Vol. 21, No. 1 (January/February 2002).
2. Brewster, Linda, Liza S. Rudell and Cara S. Lesser, Emergency Room Diversions: A Symptom of Hospitals Under Stress, Issue Brief No. 38, Center for Studying Health System Change, Washington, D.C. (May 2001).
3. Short, Ashley C., Glen P.Mays and Timothy K. Lake, Provider Network Instability: Implications for Choice, Costs and Continuity of Care, Issue Brief No. 39, Center for Studying Health System Change,Washington, DC (June 2001).
4. Strunk, Bradley C., Kelly J. Devers and Robert E. Hurley, Health Plan-Provider Showdowns on the Rise, Issue Brief No. 40, Center for Studying Health System Change,Washington, DC (June 2001).
5. Levitt, Larry, et al., Employer Health Benefits: 2001 Annual Survey. Kaiser Family Foundation,Menlo Park, Calif., and Health Research and Educational Trust, Chicago, Ill. (2001).
6. Reed, Marie C., Peter J. Cunningham and Jeffrey J. Stoddard, Physicians Pulling Back from Charity Care, Issue Brief No. 42, Center for Studying Health System Change,Washington, DC August 2001).
7. For a detailed description of the Household Survey methodology, see Community Tracking Study Household Survey Public Use File: User’s Guide (Round 2, Release1), Technical Publication No. 21, Center for Studying Health System Change,Washington, DC, www.hschange.org (June 2001).


Web-Exclusive Data Tables for Tracking Report 1


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

President: Paul B. Ginsburg
Director of Public Affairs: Richard Sorian
Editor: The Stein Group

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