A Decade Of Health Care Access Declines For Adults Holds Implications For Changes In The Affordable Care Act

By Genevieve M. Kenney, Stacey McMorrow, Stephen Zuckerman and Dana E. Goin
Health Affairs, May 2012

Over the past decade, access to health care deteriorated among nonelderly adults. The likelihood of having a usual source of care, having seen a dentist, and having had an office visit all declined. In addition, the likelihood of having had an emergency department visit rose slightly.

Consistent with other sources, the National Health Interview Survey data pointed to significant increases in rates of Medicaid coverage and uninsurance and decreases in rates of private coverage for adults between 2000 and 2010.

The declines in access found among all adults are also reflected within each coverage category. Among the privately insured, significant declines occurred for half of the access measures. There was improvement in one measure — a 1.6-percentage-point increase in the likelihood of having an office visit. However, privately insured adults were more likely to have unmet medical and unmet dental needs in 2010 compared to 2000, and they were more likely to have delayed needed care because of cost and noncost reasons.

Similarly, adults with public coverage experienced reductions in receiving an office visit and increases in unmet medical needs from 2000 to 2010. Especially striking were the increases in unmet dental need and delayed care for noncost reasons (increases of 9.1 and 4.7 percentage points, respectively) among adults with public coverage.

We also found that people with public coverage were less likely to have a usual source of care, to have received an office visit, and to have received a dental visit in 2010 compared to 2000.

Although the above indicates that the deterioration in access was not limited to uninsured adults, it was particularly pronounced for this population. Access to care worsened for uninsured adults for all eight access measures.

From the Discussion

This analysis revealed a noticeable deterioration in access to care among nonelderly US adults during the first decade of the twenty-first century. Access declined for adults in every category, but the most dramatic declines occurred among the uninsured.

More fundamental systemic problems may be reflected in the increased likelihood of delays in care for noncost reasons that we observed among both children and adults. These increases were particularly large among publicly insured adults during the past decade — a time of substantial increases in Medicaid enrollment. This may have strained providers’ capacity or willingness to serve Medicaid patients in some areas of the country.

In addition, despite increased funding for community health centers and continued supplemental payments through Medicare and Medicaid, the safety net has not been able to fully meet the increased need for care among the nation’s growing uninsured and publicly insured population.

Experience also indicates that there is no guarantee providers could adapt quickly to meet the needs of an influx of a large number of newly insured adults. When reforms similar to the Affordable Care Act were implemented in Massachusetts, overall access to care improved; however, some measures of unmet need for care also increased as more people sought care.

The US health care system could respond similarly under the Affordable Care Act, meaning that both the newly insured and those who already have coverage could have problems getting timely appointments or could experience long waits at the doctor’s office. This could be especially true in areas that experience large increases in coverage relative to provider capacity. If these problems with access emerge, they could dampen the potential benefits of the Affordable Care Act.


This study from the Urban Institute provides further confirmation of what we already knew. Uninsured individuals have impaired access to health care. What should be particularly alarming to us about this report is that the two coverage expansions in the Affordable Care Act – private insurance and Medicaid – have also been associated with further impaired access over the past decade.

Medicaid’s problem is that it is chronically underfunded. As it expands, health care professionals and institutions are finding that they are less able to serve this population as their losses escalate.

Private insurance also has been associated with a decline in access resulting in greater unmet medical needs. This is most likely due to the unique nature of private insurers competing in the marketplace. To slow the increases in premiums, insurers have shifted more costs to patients, especially through high deductibles, which impairs access because of lack of affordability. They also have reduced access to providers through the use of network contracting. The actuarial values of their plans are declining, leaving greater financial exposure to patients in need of health care. The business model of private insurance works better for the insurers when barriers are erected to care.

This study is receiving wide coverage in the press today, with headlines to the effect that health care access will decline if the Affordable Care Act is overturned. What needs to be emphasized is that health care access has been declining under the two programs to be expanded by the Affordable Care Act – private insurance and Medicaid.

What should be covered in these articles is that if we want to improve access, we can do it by removing financial barriers for everyone, simply by adopting a single payer national health program – an improved Medicare for all.