Health care access problems surge among insured Americans

One report finds that millions more insured patients are delaying or not getting care, while another shows a spike in "underinsured" Americans.

By — Posted July 21, 2008

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Middle-income insured Americans are increasingly experiencing health care access difficulties that are more commonly associated with their lower-income counterparts and the uninsured, according to two recent reports. These troubles include delayed or unmet needs for medical care, high insurance deductibles and difficulty getting in to see physicians.

One in five Americans -- 59 million people -- reported delaying or not getting needed health care in 2007, up from one in seven in 2003, found a June 26 Center for Studying Health System Change report. "We've been tracking access to care for 10 years, and this is by far the biggest change that we've seen in those 10 years," said Peter Cunningham, PhD, study co-author and senior fellow at the center. Of those reporting an access problem last year, 43.5 million had insurance, compared with 25.9 million in 2003.

In a similar vein, the number of underinsured -- steadily insured people who paid significant out-of-pocket costs for health care -- reached 25.2 million people in 2007, up from 15.6 million in 2003, according to an analysis by the Commonwealth Fund published online June 10 in the journal Health Affairs.

Many of the newly underinsured earned 200% or more of the federal poverty level. Their numbers increased by 7.2 million, hitting 11.4 million in 2007. The poverty level is $17,600 for a family of three.

Several factors are fueling these growing problems for the insured, but rising health care costs are a key culprit, the reports state. Specifically, insurance plans are trying to limit premium increases by implementing larger deductibles, more cost sharing and tighter spending limits, said Cathy Schoen, co-author of the survey by the Commonwealth Fund, a health policy research organization.

Both reports point out that the uninsured still face the most serious problems accessing and paying for health care. For example, 17.5% of the uninsured said they had an unmet need for health care in 2007, compared with 6.3% of the insured, according to the Center for Studying Health System Change, a policy research organization.

The center's findings reinforce the urgent need for health system reform, said American Medical Association Board of Trustees Chair Joseph M. Heyman, MD. "Our nation's uninsured live sicker and die younger, and according to the study, they are almost three times more likely to go without needed care as the insured."

The AMA plan to cover the uninsured calls for a system of tax credits inversely related to income to help people buy health insurance. It also includes expansion of health plan choices, more consistent insurance regulation, guaranteed policy renewals, an individual insurance mandate for those earning more than 500% of the federal poverty level, and subsidies for medically high-risk people.

Problems defy income, age

Access difficulties increased across income levels for people with insurance, the Center for Studying Health System Change report found. Of those earning 200% or more of the federal poverty level in 2007, 5.6% reported an unmet health care need, up 2.1 percentage points from 2003. For the insured earning less than 200% of poverty, 8.3% identified an unmet need, 3.3 points more than in 2003.

"What this study really shows is that we can't think about the problem as just about the uninsured and the insured," said Gail Shearer, director of health policy analysis at Consumers Union, publisher of Consumer Reports.

The center's report found growing access problems for children. Among all children, 3.9% had an unmet health care need in 2007, up from 2.2% in 2003 and 3.2% in 1996-97. Cunningham said children's access likely is being affected by the higher insurance costs their parents are facing.

Some people with access problems had trouble making or getting to medical appointments, the center reported. Fifty-eight percent of adults with access problems said the health system was a reason. Of those, 28.6% said they could not get to a doctor's office or clinic when it was open.

"This report is really a warning about seismic change in our health care system," said David Colby, PhD, vice president for research and evaluation at the Robert Wood Johnson Foundation, which funded the center's study. "With each passing year, more Americans are really falling behind when it comes to getting the medical care they need."

The American health care system needs to re-embrace the physician-patient relationship through medical homes and by paying physicians for delivering high-value care and communicating with patients in new ways, such as e-mail, said Rick Kellerman, MD, board chair of the American Academy of Family Physicians. "We're just throwing people into a system that doesn't work, whether they have insurance or not."

However, most Americans are not upset about their health costs, according to the latest annual health care survey by Gallup, conducted in November 2007. Fifty-seven percent of respondents said they were satisfied with the total cost of their health care, while 39% were dissatisfied with it.

Similarly, if 8% of Americans overall reported an unmet health care need in 2007, 92% did not, Cunningham said. "It's valid to say that for most people, they're still getting the medical care that they need." However, that 8% represents a striking increase from the 5.2% of Americans who reported an unmet need in 2003, he said.

Not insured enough

The Commonwealth Fund report found that the number of underinsured adults between 19 and 64 years old jumped 62% from 2003 to 2007.

The report defines the underinsured as individuals who had deductibles equal to or exceeding 5% of their income, spent 10% or more of their wages on out-of-pocket medical expenses, or spent 5% or more of their wages on these expenses if they earned less than 200% of poverty.

The underinsured were less likely to have employer-based coverage. Sixty-five percent of them had such insurance, while 80% of the adequately insured did. In contrast, 12% of the underinsured had individual market health plans, compared with 7% for the adequately insured.

The study might have overestimated the number of underinsured people by using deductibles as a measuring stick, said John Goodman, PhD, president of the National Center for Policy Analysis, a think tank that promotes private-sector approaches to policy questions. The study does not account for people with high-deductible health plans with savings options to which their employers contribute, he explained.

Schoen said that only a small minority of the insured population has high-deductible plans with employer contributions. In 2007, 3.8 million people were enrolled in high-deductible plans, but only a third to a half of those workers received an employer contribution.

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More Americans underinsured

The overall number of non-elderly adults who were underinsured grew 62% between 2003 and 2007, according to a Commonwealth Fund report. Low-income people constitute the largest portion of those lacking adequate insurance, but the population of underinsured middle-income individuals is approaching the same level.

Income below 200% of poverty 2003 2007 Change
Insured all year, not underinsured 18.8 million 16.3 million -13.3%
Underinsured 11.4 million 13.8 million 21.1%
Uninsured during year 29.2 million 28.0 million -4.1%
Income at 200% of poverty or more
Insured all year, not underinsured 82.2 million 73.9 million -10.1%
Underinsured 4.2 million 11.4 million 171.4%
Uninsured during year 12.5 million 16.6 million 32.8%

Source: "How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007," Health Affairs, June 10

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Health care access troubles

Fifty-nine million Americans reported that they delayed or didn't get needed health care in 2007, up from 36 million in 2003. Here is the percentage of the population experiencing these access problems.

2003 2007
All people
Unmet need 5.2% 8.0%
Delayed care 8.4% 12.3%
Insured people
Unmet need 3.9% 6.3%
Delayed care 7.2% 11.0%
Uninsured people
Unmet need 13.2% 17.5%
Delayed care 16.1% 20.0%

Source: "Falling Behind: Americans' Access to Medical Care Deteriorates, 2003-2007," Center for Studying Health System Change, June

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Access barriers

Cost was by far the biggest reason people went without or delayed care, found a recent report based on public surveys. Other causes included problems accessing a physician -- troubles the study attributed in part to doctor shortages in some areas and physicians' reactions to the financial difficulties they face. Here are the reasons for access problems among people with unmet medical needs, by percentage.

2003 2007
Worried about costs 65.2% 69.0%
Could not get timely appointment 30.1% 34.6%
Could not get to doctor's office/clinic when open 18.4% 28.6%
Health plan would not pay for treatment 18.9% 28.1%
Takes too long to get to doctor's office/clinic 12.0% 17.8%
Doctor or hospital doesn't accept insurance 11.9% 16.4%
Could not get through on the telephone 9.8% 16.0%
Do not know where to go/can't find a doctor 1.7% 1.1%
Had to wait in doctor's office/clinic too long 1.1% 1.1%
Could not get a referral 0.9% 0.4%
Change in health insurance 0.5% 0.4%

Source: "Falling Behind: Americans' Access to Medical Care Deteriorates, 2003-2007," Center for Studying Health System Change, June

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External links

"How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007," Commonwealth Fund, June 10 (link)

"Falling Behind: Americans' Access to Medical Care Deteriorates, 2003-2007," Center for Studying Health System Change, June (link)

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