Nearly every state showed health access declines in 2010

Highlighting the recent trend of fewer patients seeing their doctors for needed care, a Robert Wood Johnson Foundation report says the ability of individuals to obtain health care has declined in nearly every state during the last decade.

Unmet health care needs were most pronounced among those without insurance, yet the May 8 report also showed a drop in health access among the insured, who may be avoiding care for various other reasons.

Robert Wood Johnson funded the report as part of the Urban Institute’s ACA Implementation Monitoring and Tracking Series, which follows the enactment of the Patient Protection and Affordable Care Act in 2010. For adults 19-64, measures on having unmet medical needs due to cost, having routine checkups and having dental visits during the year worsened between 2000 and 2010.

Compared with insured Americans, adults without health insurance saw more substantial declines in their ability to obtain basic health care services, the report found. During the past decade, unmet medical needs due to cost rose by six percentage points, to 18.7%, affecting nearly one in five adults younger than 65. By 2010, almost half of uninsured adults had an unmet health need due to cost, compared with just over one in 10 insured adults.

American Medical Association President Peter W. Carmel, MD, said in a statement that it was “disappointing, but not surprising” that so many uninsured patients were deferring preventive care and necessary treatments, for which they would have had to pay out of pocket. “The AMA has long supported covering the uninsured in our nation, which is a key component of the health reform law and allows patients to get treatment earlier when care is more effective and less costly.”

The problems are significant for people with insurance as well, with the share of adults receiving routine checkups dropping in 37 states, and those receiving dental visits declining in 29 states, the report stated. “In all, 49 states experienced a significant decline on at least one of the three measures over the decade. Only West Virginia and the District of Columbia did not,” according to a RWJ Foundation statement.

A combination of factors is contributing to these declines in access, said Timothy Stoltzfus Jost, a professor at Washington and Lee University School of Law in Lexington, Va. “What’s been happening particularly in the last three to four years is an awful lot of people have lost their jobs in the recession, and in the United States, when you lose your job, you lose your health insurance,” Jost said. Also, employers increasingly have been passing nearly all the increased costs of insurance onto employees through both increased premiums and cost-sharing, he observed.

He said the rise of consumer-directed or high-deductible plans in particular has resulted in many employees saying, “Forget it, I’m not going to pay hundreds of dollars a month for a plan” for which the deductible’s too high or that will leave them with considerable costs due to co-pays and coinsurance. “And so, acceptance rates have been dropping very rapidly,” Jost said. He also cited a recent study in Health Affairs concluding that people who stay with their high-deductible plans obtain less preventive care and have more unmet medical needs.

The uninsured rate has been at about 25% for some time in Texas, which “places a terrific burden on physicians,” said C. Bruce Mallone, MD, an orthopedic surgeon and president of the Texas Medical Assn. Dr. Mallone, who like many other orthopedic surgeons does rotations in hospital emergency departments, said that up to about 40% of the people he treats “don’t pay me for the services I provide.”

Though the economy is recovering and Texas has created jobs, it’s still a very large state with rich urban areas and poor rural areas, “and we have lots of people who make their living in ranching, small businesses, construction work,” Dr. Mallone said. Those businesses usually don’t have access to group health insurance, or they believe they can’t afford it. “We’re also a right-to-work state, so the influence of labor unions is much smaller than it would be in, say, New York,” he said. As a result, there are fewer employment contracts that require businesses to provide a certain level of health insurance.

Downward trends in access are going to continue if coverage provisions in the national health system reform law are ruled unconstitutional, the report’s researchers concluded. “The ability for patients to access medical care is fundamental to the success of our health care system, since without timely health care access, the uninsured live sicker and die younger,” Dr. Carmel said.