ACA Leads to Insurance Gains, Affordable Access to Care Wanes

The US has seen coverage gains over the past two decades, due in large part to the ACA. However, access to care has dropped nearly three percentage points in that same time frame because of high healthcare costs, a recent JAMA Internal Medicine study found.

The study employed data from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. The researchers studied how many patients encountered a cost-related access to care barrier, failed to have a routine checkup within two years, or did not receive appropriate preventive services between January 1, 1998 to December 31, 2017. 

 “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,” the authors stated.

“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 study found that more uninsured individuals struggled to access care due to costs. Nearly six percent more did not visit a doctor because they could not afford it. Among the insured, the number of those unable to see a physician due to cost rose from 7.1 percent to 11.5 percent. 

Those who suffered chronic illnesses had an even harder time accessing the care they need at an affordable rate. Almost six percent more patients with cardiovascular disease were unable to see a provider due to cost in 2017 than in 1998. For those with high cholesterol, the number of people with cost-related care barriers rose by 3.5 percentage points. The rate of increase was similar among those with alcoholic substance abuse disorder.

The population with chronic diseases also saw no dent in the rate of checkups for patients with chronic illnesses.

The healthcare industry’s pursuit of preventive care saw mixed results. More people received cholesterol tests and flu shots. However, mammograms declined by around 6.7 percent. The researchers were unsure about the cause for this drop.

Access to care saw a decline for cost-related reasons across socioeconomic demographics, including racial and income categories.

Healthcare coverage significantly impacted whether a person experienced a severe cost-related access barrier, as may be expected.

For an uninsured low-income individual, almost 50 percent of individuals (48.6 percent) did not visit their provider due to affordability. Among low-income individuals with insurance, 21 percent said that cost prevented them from seeing a doctor.

Those at the bottom of the high-income group (income at $34,999 per year) saw the least impact of affordability on their physician visits.

However, those making over $75,000 annually with healthcare coverage had a slightly higher risk of avoiding doctor visits due to cost. Uninsured with high income were five percent more likely to avoid the doctor due to cost. Even those with employer-sponsored insurance were not safe from rising healthcare costs, the study confirmed.

The researchers said the slightly higher likelihood of a low-income individual seeing her provider was due to the rise in Medicaid enrollment starting at the beginning of the millennium.

Of the uninsured minorities studied, uninsured black individuals were most likely to avoid a doctor’s visits due to cost. Among insured minorities, Hispanics were most likely to avoid seeing their provider for affordability reasons.

According to the study’s authors, some of these impacts can be attributed to poor insurance benefit design. 

“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 researchers explained. “The increase among the insured suggests that increasing copayments and deductibles have decreased the affordability of physician visits for this group.”

As previous JAMA Internal Medicine studies have indicated, the ACA’s subsidized coverage significantly cut down the uninsured rate, but may be having a mixed impact on healthcare spending. The prior research stated that the ACA successfully decreased out-of-pocket spending, but that premiums were still a burden, especially for middle-income families. 

High premiums combined with an overall increase in healthcare spending due to expensive healthcare products and services continue to reduce access to care in the US. So the researchers suggested looking beyond US borders for solutions.

“Additional measures should address the problems in affording care that face many insured US adults,” the researchers concluded. “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.”