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Treading Water: Americans' Access to Needed Medical Care, 1997-2001
Tracking Report No. 1
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 Changes (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, childrens 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 caretwo important measures of access to carefailed 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.
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 people15.7 percent vs. 8.6 percent.
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 people8.1 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.
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 excellent13 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.
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.
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 systemrelated problems and health insurancerelated barriers.
More than half of people who had problems getting care cited health system-related barriers as a reasonup 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 doctors 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
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 serviceespecially 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.
Childrens Access to Care
ncreasingly, policy makers have focused on childrens health in recent years. Most notably in 1997, Congress passed the State Childrens 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, childrens 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.
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 peoples 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.
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 didnt 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.
TRACKING REPORTS are published by the Center for Studying Health System