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In spite of ACA, affordability of care is being undermined for too many

January 29, 2020

Topics: Quote of the Day

By Laura Hawks, M.D.; David U. Himmelstein, M.D.; Steffie Woolhandler, M.D., M.P.H.; David H. Bor, M.D.; Adam Gaffney, M.D., M.P.H.; Danny McCormick, M.D., M.P.H.
JAMA Internal Medicine, January 27, 2020

Key Points

Question: Has unmet need for physician services shifted for US adults between 1998 and 2017?

Findings: Using data from US adults aged 18 to 64 years in 1998 (n = 117 392) and in 2017 (n = 282 378) who responded to the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System, this study found that from 1998 to 2017 the inability to see a physician because of cost increased 2.7 percentage points owing to worsening access to care among the insured. In contrast, the proportion of chronically ill adults receiving checkups did not change; results for receiving guideline-recommended preventive services were mixed.

Meaning: Many US adults face substantial and increasing barriers in access to care, despite a modest improvement in insurance coverage in the past 20 years.


Importance: Improvements in insurance coverage and access to care have resulted from the Affordable Care Act (ACA). However, a focus on short-term pre- to post-ACA changes may distract attention from longer-term trends in unmet health needs, and the problems that persist.

Objective: To identify changes from 1998 to 2017 in unmet need for physician services among insured and uninsured adults aged 18 to 64 years in the United States.

Design, Setting, and Participants: Survey study using 20 years of data, from January 1, 1998, to December 31, 2017, from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System to identify trends in unmet need for physician and preventive services.

Main Outcomes and Measures: The proportion of persons unable to see a physician when needed owing to cost (in the past year), having no routine checkup for those in whom a routine checkup was likely indicated (within 2 years), or failing to receive clinically indicated preventive services (in the recommended timeframe), overall and among subgroups defined by the presence of chronic illnesses and by self-reported health status. We estimated changes over time using logistic regression controlling for age, sex, race, Census region, employment status, and income.

Results: Among the adults aged 18 to 64 years in 1998 (n = 117 392) and in 2017 (n = 282 378) who responded to the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System (mean age was 39.2 [95% CI, 39.0-39.3]; 50.3% were female; 65.9% were white), uninsurance decreased by 2.1 (95% CI, 1.6-2.5) percentage points (from 16.9% to 14.8%). However, the adjusted proportion unable to see a physician owing to cost increased by 2.7 (95% CI, 2.2-3.8) percentage points overall (from 11.4% to 15.7%, unadjusted); by 5.9 (95% CI, 4.1-7.8) percentage points among the uninsured (32.9% to 39.6%, unadjusted) and 3.6 (95% CI, 3.2-4.0) percentage points among the insured (from 7.1% to 11.5%, unadjusted). The adjusted proportion of persons with chronic medical conditions who were unable to see a physician because of cost also increased for most conditions. For example, an increase in the inability to see a physician because of cost for patients with cardiovascular disease was 5.9% (95% CI, 1.7%-10.1%), for patients with elevated cholesterol was 3.5% (95% CI, 2.5%-4.5%), and for patients with binge drinking was 3.1% (95% CI, 2.3%-3.3%). The adjusted proportion of chronically ill adults receiving checkups did not change. While the adjusted share of people receiving guideline-recommended cholesterol tests (16.8% [95% CI, 16.1%-17.4%]) and flu shots (13.2% [95% CI, 12.7%-13.8%]) increased, the proportion of women receiving mammograms decreased (−6.7% [95% CI, −7.8 to −5.5]).

Conclusions and Relevance: Despite coverage gains since 1998, most measures of unmet need for physician services have shown no improvement, and financial access to physician services has decreased.


A widely cited study by Ayanian et al highlighted the high prevalence of unmet health needs in 1998, particularly among the uninsured. In the subsequent 2 decades, medical costs have grown exponentially, deductibles and copayments have escalated; Medicaid enrollment has risen sharply; accountable care organizations and pay-for-performance incentives have become commonplace; many private insurers have implemented new cost containment measures and narrowed their provider networks; and, in 2014, a landmark health reform, the Affordable Care Act (ACA), was implemented.

Many analyses have documented the salutary effects of the ACA on coverage, access to care, and disparities in access. However, such analyses may miss the longer-term trends that may affect access to care, eg, the growth of narrow networks, high-deductible plans and higher co-pays that obstruct access to physician services and may compromise health, especially for persons with low incomes. A longer view could help place the achievements of the ACA in the context of these longer-term changes and inform future reform efforts.

We used the same data source as in the 1998 study to explore changes in unmet health care needs among adults aged 18 to 64 years in the past 2 decades.

From the Discussion

Despite short-term gains owing to the ACA, over the past 20 years the proportion of adults aged 18 to 64 years unable to see a physician owing to cost increased, mostly because of an increase among persons with insurance. In 2017, nearly one-fifth of individuals with any chronic condition (diabetes, obesity, or cardiovascular disease) said they were unable to see a physician owing to cost. In contrast, we found improvements in the proportions receiving 2 clinically indicated preventive services, but worsening for another; little change was observed in the proportions who had received checkups in the prior 2 years.

Our finding that financial access to physician care worsened is concerning. Persons with conditions such as diabetes, hypertension, cardiovascular disease and poor health status risk substantial harms if they forego physician care. Financial barriers to care have been associated with increased hospitalizations and worse health outcomes in patients with cardiovascular disease and hypertension, and increased morbidity among patients with diabetes.

Our results provide important context for understanding the consequences of ACA. The implementation of the ACA’s major coverage provisions in 2014 was associated with a 10 percentage point increase in coverage, and improvements in measures of access to care. For example, between 2012 and 2014 the proportion of US individuals who reported skipping care because of costs decreased from 43% to 36%, and the number of persons reporting difficulty paying medical bills decreased by 11 million. Our findings suggest that these substantial short-term improvements were outweighed by longer-term trends toward reduced affordability. Coverage and access rates were decreasing prior to the ACA and improvements from the ACA mostly returned access to levels prevalent in 1998 or left them worse.

The long-term increase in the proportion of uninsured persons reporting they were unable to see a physician because of cost implicates factors unrelated to coverage, eg, decreasing affordability of physician visits relative to income or decreasing availability of safety-net health care. The increase among the insured suggests that increasing copayments and deductibles have decreased the affordability of physician visits for this group.

Our findings are consistent with evidence of growing underinsurance (and resulting problems in access), especially among persons with employer-based plans. Enrollment in a high-deductible health plan, which has become increasingly common in the last decade, a trend uninterrupted by the ACA, is associated with forgoing needed care, especially among those of lower socioeconomic status. Other changes in insurance benefit design, such as imposing tiered copayments and coinsurance obligations, eliminating coverage for some services (eg, eyeglasses), and narrowing provider networks (which can force some patients to go out of network for care) may also have undermined the affordability of care.

The increasing cost of health care creates an access barrier for the insured as well as the uninsured; the RAND Corporation estimated that total expenditures (including premiums, out-of-pocket costs, and taxes on health care) nearly doubled for US consumers between 1999 and 2009, far outpacing inflation. Although many insured adults reported access barriers, the situation remained worse for the uninsured, highlighting the importance of covering the 29 million US individuals who remain uninsured.

The current level of unmet health needs in the US that we found far exceed those of similar countries. Among nations in the Organisation for Economic Co-operation and Development, an average of 9.1% of persons reported skipping health care because of cost in 2017, compared to the 15.7% we found in the US. In Canada, only 1% of adults 45 years old or older with a chronic disease reported a cost-related unmet health need – compared with 18.7% of adults with a chronic medical condition in our US sample. A health care system that offers universal health coverage and eliminates out-of-pocket expenses for patients may be the most practical solution to improving unmet health needs in the US.


Voters’ dissatisfaction with the health care system has spawned a renewal of debate over health reform, suggesting that the ACA’s improvements were insufficient to fully address the health care needs of many US adults. Covering the 29 million who remain uninsured would ameliorate, but not resolve the access to care problems we identified. Additional measures should address the problems in affording care that face many insured US adults. Other nations have achieved universal coverage and substantially reduced cost barriers. Experience in those nations should inform discussion of the additional reforms required to address the unmet health needs of US adults.


An Invited Commentary by John Z. Ayanian, M.D., M.P.P., a co-author of the original article on unmet health needs of the uninsured in 1998, “Looking Back to Improve Access to Health Care Moving Forward”:

An audio interview of lead author Laura Hawks and original paper author John Ayanian (18 minutes):

Despite insurance gains, more people in the U.S. can’t afford doctors

By Lisa Rapaport
Reuters, January 27, 2020

A growing number of Americans find it too expensive to see doctors even though more people have health insurance, a U.S. study suggests.

Over the past two decades, the proportion of adults without insurance dropped to 14.8% from 16.9%, the study found. But during this same period, the proportion of adults unable to afford doctor visits climbed from 11.4% to 15.7%.

Out-of-pocket costs made doctors too expensive for the uninsured, but costs also kept people with coverage from seeing physicians even when they had chronic medical conditions requiring regular checkups.

“The quality of private health insurance is getting worse, and the cost of healthcare is rising significantly,” said lead study author Dr. Laura Hawks of the Cambridge Health Alliance and Harvard Medical School in Boston.

“We know that private health insurance plans increasing rely on high premiums, high-deductible health plans…high copays and other forms of cost-sharing,” Hawks said by email. “All these create financial barriers.”



By Don McCanne, M.D.

This study is of great importance because it shows how well health needs were met in the two decades before and after enactment of the Patient Protection and Affordable Care Act (ACA). Yes, the number of uninsured declined, but “financial access to physician services has decreased.” It is safe to say that the ACA did not do near enough to make health care affordable and accessible for everyone.

Considering the very high costs and the mediocre results of our health care financing system, it is obvious that major changes are required. Yet many politicians and members of the policy community are calling for more of the same – tweaking ACA and adding a Medicare-in-name-only option to the selection of private plans. This will not correct any of the fundamental structural flaws in our health care financing system. Health care will remain unaffordable and inaccessible for far too many, and the rest of us will pay ever higher costs for this highly flawed system.

The single payer model of an improved Medicare for All of course would fix these problems. More Americans are understanding this. Yet too many of our politicians have aligned themselves with the medical-industrial complex, especially the private insurers and pharmaceutical firms. Remember, we do have a democracy and that should allow us to trade in our stale politicians for new ones who understand that government is for all of the people and not just for the plutocrats who think they own Congress. But for us to be heard, our voice to Congress can be no less than a deafening roar.

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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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