Contact: Dr. Laura Hawks, primary care physician and research fellow at Harvard Medical School and Cambridge Health Alliance, lhawks@challiance.org
Jan., 27, 2020 — More Americans have unmet health needs today than two decades ago, according to a new study from Harvard Medical School and the City University of New York at Hunter College. The study, published today in JAMA Internal Medicine, found that despite an increase in insurance coverage from the Affordable Care Act (ACA), the percentage of people who are unable to afford to see a doctor when needed has risen. This was especially true of people with serious medical conditions like heart disease, for whom physician care is essential. The largest relative increases in unmet health needs occurred among people who had had insurance, suggesting that deterioration in quality of private health insurance, not lack of insurance, caused most of the increase in unmet health needs over the last 20 years.
Using survey data from over 400,000 working age adults, the researchers compared responses in 1998 to responses to the same questions in 2017. Over the two decades, the share of non-elderly adults who were unable to afford to see a doctor has increased by nearly a third – from 11% to 16%. However, among those with health insurance coverage, the study found a 60% increase — from 7% to 12%. Overall, adults with a chronic disease had nearly a 20% chance of skipping a doctor visit due to cost in 2017 — 63% worse than 1998. The study also found no improvements in the likelihood of having a routine check-up among high-risk patients in 2017 as compared to 1998.
The study’s authors noted that private insurance has become less comprehensive as insurers have increased deductibles, coinsurance and copays. Meanwhile, many private insurers’ provider networks have narrowed, leading to the recently publicized phenomenon of “surprise medical bills” which may deter patients from seeking future care. While the study could not separate private insurance from public insurance programs such as Medicaid, Medicaid typically does not require cost sharing.
“Our findings call into question the value of private health insurance today,” said the study’s lead author, Dr. Laura Hawks, a Harvard research fellow and primary care physician. “When so many people can’t get the care they need even when they have insurance coverage, it says that insurance is not doing what it is supposed to do: ensure that health care is affordable when you need it.”
The new study also provides new insights into both the achievements and limitations of the ACA’s coverage expansions. Previous studies have established that these expansions improved both insurance coverage and the affordability of care for previously uninsured Americans. The new Harvard/Hunter College study suggests, however, that these gains didn’t counterbalance the long-term trend toward deteriorating access to needed medical care.
“The ACA was crucial for expanding coverage to low-income Americans, particularly the Medicaid expansion in states that allowed it,” said senior study author Dr. Danny McCormick, an associate professor of medicine at Harvard Medical School and primary care physician at the Cambridge Health Alliance. “However, because it did little to fix the biggest problems with private insurance — such as high copays and deductibles and narrow networks — the ACA didn’t reverse the long-term downward trend towards decreasing health care affordability.”
“Health coverage needs to be both universal and comprehensive, meaning that it covers everyone and that it pays in full for all medically necessary care,” commented study co-author, Dr. Steffie Woolhandler, a distinguished professor of public health at CUNY’s Hunter College and lecturer in medicine at Harvard Medical School. “Our private insurance-based system simply isn’t doing that.”
The study found improvement in a few types of preventive care since 1998; more Americans are receiving cholesterol checks and flu shots. However, fewer women are now receiving mammograms.
“Some aspects of health care are improving, but death rates are rising and we are mostly moving backwards on the health and health care of working-age adults, ” said study co-author Dr. David Himmelstein, a distinguished professor of public health at CUNY’s Hunter College and lecturer in medicine at Harvard Medical School. “A single-payer reform like Medicare-for-All that eliminates financial barriers to care is what patients need.”
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“Trends in Unmet Need for Physician and Preventive Services in the United States, 1998 to 2017,” Laura Hawks, MD; David U. Himmelstein, MD; Steffie Woolhandler, MD, MPH; David H. Bor, MD; Adam Gaffney, MD, MPH; and Danny McCormick, M.D., M.P.H. JAMA Internal Medicine. Published online first, January 27th, 2020. doi:10.1001/jamainternmed.2019.6538