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Trends in Americans' Access to Needed Medical Care, 2001-2003

Tracking Report No. 10
August 2004
Bradley C. Strunk, Peter J. Cunningham

Despite sluggish economic growth and rapidly rising health care costs, Americans’ access to needed medical care improved between 2001 and 2003, especially among low-income children and adults, according to findings from the Center for Studying Health System Change’s (HSC) nationally representative Community Tracking Study Household Survey. In particular, the proportion of low-income, uninsured Americans who reported going without needed medical care fell by 3.2 percentage points to 13.2 percent in 2003, and unmet medical needs for low-income children decreased to the point where income-related differences in access to care for children have disappeared. Nonetheless, about one in seven Americans reported difficulty obtaining needed care in 2003, and people reporting access problems increasingly cited cost as a barrier to care.


Access to Needed Medical Care Improves

espite a weak economy and rapidly rising health care costs, the proportion of Americans that reported an unmet medical need between 2001 and 2003 declined by 0.5 percentage points, the equivalent of about 1 million fewer people going without needed care (see Table 1). At the same time, the proportion of Americans delaying needed care declined by 1.1 percentage points, or about 2 million people. Taken together, these declines reversed a trend of increasing access problems between 1997 and 2001. Also, the improved access was not the result of changes in income, insurance coverage and other key characteristics of individuals that are related to access, suggesting that health system-related factors played a role.1

Despite the decline in access problems, 14 percent of the U.S. population, or about 39 million people, reported not getting or delaying needed medical care in 2003, according to findings from the nationally representative Community Tracking Study Household Survey (see Data Sources). About 5 percent of the U.S. population-or almost 15 million Americans-reported an unmet medical need at some point in the previous 12 months, and another 24 million Americans delayed care.

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

 
1997
1999
2001
2003
All People
Unmet Need
5.2%
5.6%*
5.7%
5.2*
Delayed Care
9.8
8.5*
9.5*
8.4*#
Insured People
Unmet Need
3.9
4.3*
4.4
3.9
Delayed Care
8.7
7.6*
8.6*
7.2*#
Uninsured People
Unmet Need
13.5
14.2
15.0
13.2*
Delayed Care
17.1
14.1*
15.7*
16.1
Note: If a person reported both an unmet need and delayed care, that person is counted as having an unmet need only.
* Change from previous round is statistically significant at p <.05.
# Change from 1997-2003 is statistically significant at p <.05.
Source: HSC Community Tracking Study Household Survey

Vulnerable People Gain...

ninsured and low-income Americans traditionally have had much more difficulty getting medical care than people with insurance and higher incomes, and these gaps persisted in 2003. For example, uninsured people were more than three times as likely to report going without care as insured people—13.2 percent vs. 3.9 percent. Nevertheless, decreases in unmet need between 2001 and 2003 were concentrated among vulnerable groups. Among uninsured people with low incomes—less than 200 percent of poverty, or $36,800 for a family of four in 2003—the proportion with an unmet need decreased by 3.2 percentage points to 13.2 percent in 2003 (see Table 2).

The decline in people delaying care was concentrated among both low-income and other insured individuals. Among low-income insured people, the proportion delaying care declined from 9 percent in 2001 to 7.6 percent in 2003. Among insured people with family incomes above 200 percent of poverty, the proportion delaying care declined from 8.4 percent to 7.1 percent.

Initiatives at the federal, state and local levels targeting the health care safety net—an important source of care for low-income and uninsured people—may have contributed to the improvements for low-income people. Increased federal aid to communities through the Community Access Program and Community Health Center (CHC) expansion grants have encouraged improved coordination among safety net providers and allowed many CHCs to create new facilities and expand services.2

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Table 2
Americans’ Likelihood of Having an Unmet Need,
by Family Income and Health Status

 
1997
1999
2001
2003
Family Income
Below 200% of poverty level
7.5%
8.1%
8.1%
6.9%*
   Insured
5.2
5.8
5.6
5.0
   Uninsured
14.9
15.0
16.4
13.2*
Above 200% of poverty level
3.9
4.3*
4.7*
4.3
   Insured
3.3
3.6*
4.0*
3.5
   Uninsured
11.0
12.7*
13.1
13.3
Health Status
Fair of Poor Health
11.9
11.9
13.0
11.9
   Insured
8.6
8.7
10.0*
9.0
   Uninsured
27.7
26.3
26.9
24.5
Good, Very Good or Excellent Health
4.2
4.7*
4.6
4.1*
   Insured
3.2
3.7
3.6
3.2
   Uninsured
10.7
11.7
12.2
10.5
Note: No changes from 1997-2003 were statistically significant at p <.05.
* Change from previous round is statistically significant at p <.05.
Source: HSC Community Tracking Study Household Survey

...Except Those in Poor Health

eople who reported fair or poor health remained almost three times as likely to go without needed care as people who reported their health was good or excellent—11.9 percent vs. 4.1 percent in 2003.

Uninsured people in fair or poor health reported the greatest problems getting needed care in 2003, with one in four (24.5%) reporting they went without needed care. This is in part due to the fact that people in fair and poor health use more health care services and, therefore, have more opportunities to experience an access problem. Between 1997 and 2003, the proportion of uninsured people in fair or poor health reporting an unmet need changed little.

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Children’s Income-Related Disparities Eliminated

hile access to care fluctuated for the overall U.S. population between 1997 and 2003, children’s access to care improved steadily during this time, particularly for low-income children. In 2003, only 2.2 percent of all children did not get the medical care they needed, and another 2 percent delayed care (see Table 3).

The most notable improvements in access to medical care occurred for low-income children, likely reflecting the growth in Medicaid and State Children’s Health Insurance Program (SCHIP) coverage and concurrent reductions in uninsurance rates for low-income kids. The percentage of low-income children with unmet medical needs declined by more than half between 1997 and 2003—from 4.6 percent to 2.2 percent. More importantly, this improvement in access for low-income children eliminated long-standing income-related disparities in access to care. In 1997, low-income children were about twice as likely as children in higher-income families to experience an unmet need. But by 2003 that gap had closed, with 2.2 percent of both groups reporting an unmet need.

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Table 3
Indicators of Access to Care for Children,
by Insurance Status and Family Income

 
1997
1999
2001
2003
All Children
   Unmet Need
3.2%
3.1%
2.7%
2.2%#
   Delayed Care
3.1
2.4*
2.4
2.0#
Insurance Status
Insured Children
   Unmet Need
2.4
2.5
2.2
1.7#
   Delayed Care
2.7
2.1*
2.0
1.8#
Uninsured Children
   Unmet Need
9.7
7.7
7.0
7.1
   Delayed Care
5.6
5.4
6.7
4.4
Family Income
Below 200% of Poverty
   Unmet Need
4.6
4.8
3.8
2.2*#
   Delayed Care
3.5
3.1
3.1
2.5
Above 200% of Poverty
   Unmet Need
2.1
1.8
2.0
2.2
   Uninsured
2.7
2.0*
2.1
1.6#
Note: If a child experienced both an unmet need and delayed care, that child is counted as having an unmet need only
* Change from previous round is statistically significant at p <.05.
# Change from 1997-2003 is statistically significant at p <.05.
Source: HSC Community Tracking Study Household Survey

Cost Concerns Increase

or people reporting an access problem, cost was the most frequently cited—and a growing—barrier to care. In 2003, 65.2 percent of people who went without or delayed needed care cited worries about cost, a 2.8 percentage point increase from 1997 (see Table 4). Most of this change occurred between 2001 and 2003.

The increase in cost concerns occurred mostly among higher-income people—those with family incomes above 200 percent of poverty—although a higher percentage of low-income and uninsured people cited cost as barrier to care. Significant increases in patient cost sharing in recent years may be driving growing cost concerns among higher-income people—most of whom are covered by private insurance. By contrast, the effects of rising health care costs on low-income people may have been offset to some extent by increased enrollment in public coverage and declines in uninsurance rates for children, as well as a strengthening safety net that often provides free or reduced-cost care.

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Table 4
Reasons for Access Problems

 
1997
1999
2001
2003
All People
Worried about the cost
62.4%
61.2%
62.6%
65.2%#
Health plan-related1
23.7
24.9
28.4*
24.8*
Health system-related2
45.2
50.7*
53.8*
49.6*#
Insured People
Worried about the cost
51.2
49.6
52.3*
53.7
Health plan-related
28.5
29.4
33.4*
30.5*
Health system-related
54.0
58.9*
62.4*
58.8*#
Uninsured People
Worried about the cost
91.5
92.4
93.1
93.6
Health plan-related
N/A
N/A
N/A
N/A
Health system-related
22.0
28.6*
28.4
26.7#

Note: Percentages for a particular group do not add up to 100 percent because a respondent was permitted to cite more than one reason.
1 Includes: Doctor or hospital would not accept insurance; health plan would not pay for treatment; health insurance changed; and other reason related to a health plan.
2 Includes: Inability to get an appointment soon enough; get to the doctor’s office or clinic when it is open; get through on the telephone; find a doctor or get a referral; long wait time in office or clinic; office or clinic is too far away; and other system-related reasons.
* Change from previous round is statistically significant at p <.05.
# Change from 1997-2003 is statistically significant at p <.05.
Source: HSC Community Tracking Study Household Survey


Health Plan-Related and System-Related Concerns Wane

etween 2001 and 2003, health plan-related barriers to care such as a plan payment denial and health system-related barriers such as being able to get a timely appointment became less of a concern for people who had difficulty getting care. The frequency with which insured people cited a health plan-related reason for going without or delaying care declined by 2.9 percentage points to 30.5 percent in 2003. This decline specifically reflected people having fewer problems getting their health plan to pay for treatment.

Insured people who encountered access problems also were less likely to cite health system-related reasons. The frequency with which this group reported a health system-related reason for their access difficulty declined from 62.4 percent to 58.8 percent. Specifically, insured people reported fewer problems getting to a doctor’s office or clinic when it was open and getting through on the telephone. While declines in plan-related barriers were concentrated among low-income people, declines in system-related barriers were concentrated among people with higher incomes.

The trend for health system-related barriers since 2001 represents a reversal of the trend between 1997 and 2001, when a steady increase in system-related barriers was reported. While capacity constraints in the health care system may have led to the earlier increase in system-related barriers, the more recent decline in system-related barriers could mean that these constraints have eased somewhat, particularly since growth in utilization of hospital services slowed significantly in 2003.3 Nevertheless, system-related barriers were still cited more frequently in 2003 than in 1997.

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Implications

he economic recession of 2001 and the subsequent slow recovery in employment, as well as rapidly rising health care costs, could have worsened access to care significantly during the past few years. This did not come to pass, however, for a variety of reasons. While many predicted the number of uninsured Americans—who are much more likely to report access problems—would increase as a result of the recession, overall insurance coverage held fairly steady between 2001 and 2003.4 Employer coverage did decline significantly, but growing enrollment in public insurance programs largely offset this decline. Concurrently, many local communities across the country, with the aid of federal grant programs, strengthened their health care safety nets—an important source of care for vulnerable people who experienced the greatest improvements in access to care. Indeed, the recent improvements in access likely are the result of both care and coverage expansions.

It is unclear, however, if these recent gains are temporary or can be sustained over time. Further increases in health insurance premiums and patient cost sharing could lead to decreases in private insurance coverage and higher out-of-pocket costs among those who retain private coverage. If higher out-of-pocket costs increase the level of medical debt incurred by families, then cost barriers to medical care could increase substantially.5 And although state budgets have improved somewhat from a few years ago, continued increases in the costs of public programs could still lead to cuts in eligibility and coverage, which could spill over to affect many providers of care to the uninsured as well. Finally, although income-related disparities in unmet medical needs among children have been eliminated, other vulnerable Americans—such as uninsured people in fair or poor health—are still considerably more likely to report an access problem than the rest of the population.

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Notes

1. After using regression analyses to control for changes in key population characteristics, including age, family income, health insurance status, race, health status and work status of the family (i.e., whether or not at least one member of the family is employed), we still observed a similar level of change in access to care between 2001 and 2003.
2. Hoadley, John F., Laurie E. Felland, and Andrea B. Staiti, Federal Aid Strengthens Health Care Safety Net: The Strong Get Stronger, Issue Brief No. 80, Center for Studying Health System Change, Washington, D.C. (April 2004).
3. Strunk, Bradley C., and Paul B. Ginsburg, "Tracking Health Care Costs: Trends Turn Downward in 2003," Health Affairs, Web exclusive, June 9, 2004.
4. Strunk, Bradley C., and Jim Reschovsky, Trends in Health Insurance Coverage, 2001-2003, Tracking Report No. 9, Center for Studying Health System Change, Washington, D.C. (August 2004).
5. 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).
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Data Source

This 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, 2000-01 and 2003. For discussion and presentation, we refer to a single calendar year of the first three surveys (1997, 1999 and 2001). Data were supplemented by in-person interviews of households without telephones to ensure proper representation. The first three rounds of the survey contain information on about 60,000 people, while the 2003 survey contains responses from about 47,000 people. Response rates ranged from 60 percent to 65 percent for the first three rounds and 57 percent in 2003.

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; responses related to personal reasons only 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 and individually purchased private insurance, Medicare, Medicaid, SCHIP, other state programs, TRICARE and other military insurance programs and the Indian Health Service.

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ISSUE BRIEFS are published by the Center for Studying Health System Change.

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Washington, DC 20024-2512
Tel: (202) 484-5261
Fax: (202) 484-9258
www.hschange.org

President: Paul B. Ginsburg
Vice President: Len M. Nichols

 

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