Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality www.ahrq.gov
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to www.ahrq.gov for current information.

National Healthcare Quality Report, 2013

Chapter 10. Access to Health Care

Many Americans have good access to health care that enables them to benefit fully from the Nation's health care system. Others face barriers that make it difficult to obtain basic health care services. As shown by extensive research and confirmed in previous National Healthcare Disparities Reports (NHDRs), racial and ethnic minorities and people of low socioeconomic status (SES)i are disproportionately represented among those with access problems.

Previous findings from the National Healthcare Quality Report (NHQR) and NHDR showed that health insurance was the most significant contributing factor to poor quality of care for some of the core measures, and many measures were not improving. Uninsured people were less likely to get recommended care for disease prevention, such as cancer screening, dental care, counseling about diet and exercise, and flu vaccination. They also were less likely to get recommended care for disease management, such as diabetes care management.

Poor access to health care comes at both a personal and societal cost. For example, if people do not receive vaccinations, they may become ill and spread disease to others. This increases the burden of disease for society overall in addition to the burden borne individually.

According to the Centers for Disease Control and Prevention (CDC), the lack of access to health care that results from inadequate insurance coverage should be greatly reduced by the Affordable Care Act. The Affordable Care Act is expected to extend insurance coverage to an additional 25 million people by 2019 (CBO, 2013).

Recent studies by the Office of the Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services have demonstrated early evidence of greater rates of insurance coverage among young adults. Before Affordable Care Act implementation, young adults with private insurance were more than twice as likely to lose insurance coverage as older adults (Schwartz & Sommers, 2012). New estimates, however, show that from September 2010 to December 2011, more than 3 million additional young adults had coverage (Sommers, 2012). This includes an estimated 913,000 Latino, 509,000 African American, and 121,000 Asian young adults (Sommers & Kronick, 2012). Overall, males have significantly benefited from the expanded coverage, and their rate of coverage has increased from 57.9% to 72.0% (Sommers, 2012).

The Affordable Care Act also makes significant changes to the Medicaid program. All citizens and legal permanent residents with a household income up to 133% of the poverty level who reside in a State that chooses to participate in the expansion will be eligible for Medicaid. This change could improve the health of millions of Americans. Medicaid expansions have been shown to reduce mortality among adults, particularly those ages 35-64 years, minorities, and residents of low-income areas (Sommers, et al., 2012).

Components of Health Care Access

Access to health care means having "the timely use of personal health services to achieve the best health outcomes" (IOM, 1993). Attaining good access to care requires three discrete steps:

  • Gaining entry into the health care system.
  • Getting access to sites of care where patients can receive needed services.
  • Finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and trust.

Health care access is measured in several ways, including:

  • Structural measures of the presence or absence of specific resources that facilitate health care, such as having health insurance or a usual source of care.
  • Assessments by patients of how easily they can gain access to health care.
  • Utilization measures of the ultimate outcome of good access to care (i.e., the successful receipt of needed services).

Facilitators and Barriers to Health Care

Facilitators and barriers to health care discussed in this chapter include health insurance, financial burden of health care costs, usual source of care (including having a specific source of ongoing care and a usual primary care provider), and patient perceptions of need.

Findings

Health Insurance

Health insurance facilitates entry into the health care system. Uninsured people are less likely to receive medical care and more likely to have poor health status. In 2008, uninsured people received approximately $86 billion in medical care during the time they lacked insurance coverage for all or any part of the year (Hadley, et al., 2008).

The financial burden of uninsurance is also high for uninsured individuals; more than 60% of personal bankruptcy filings are due to medical expenses (Himmelstein, et al., 2009). Uninsured individuals are more likely to go without needed care than insured people. They are also more likely to visit the emergency department and be admitted to the hospital for ambulatory care-sensitive conditions. Chronically ill uninsured people are less likely to have a usual source of medical care and thus are less likely to receive preventive and primary care. A recent study showed that uninsured adults under age 65 are nearly twice as likely to die as adults under age 65 with insurance (Wilper, et al., 2009).

Figure 10.1. People under age 65 with health insurance, by age, 2000-2012, and activity limitations, 2006-2012

Text description is below image

Text description is below image

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey (NHIS), 2000-2012. Data for activity limitations were not analyzed or collected before 2006.
Denominator: Civilian noninstitutionalized population under age 65.
Note: NHIS respondents are asked about health insurance coverage at the time of interview. Respondents are considered insured if they have private health insurance, Medicare, Medicaid, State Children's Health Insurance Program, a State-sponsored health plan, other government-sponsored health plan, or a military health plan. If their only coverage is through the Indian Health Service, they are not considered insured. Estimates are not age adjusted. Basic activity limitations include problems with mobility, self-care, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life.

  • Overall, there was no statistically significant change from 2000 to 2010. From 2010 to 2012, health insurance for people under age 65 improved (81.8% in 2010, 82.8% in 2011, and 83.1% in 2012; Figure 10.1).
  • From 2000 to 2012, the percentage of children ages 0-17 who had health insurance increased (from 87.4% to 93.4%; Figure 10.1). However, for adults ages 18-44 and 45-64, the percentage decreased (for ages 18-44, from 77.6% to 75.2%; and for ages 45-64, from 87.4% to 84.4%).
  • In all years, adults ages 18-44 were less likely than children ages 0-17 and adults ages 45-64 to have health insurance.
  • In 2012, at least 80% of people with any type of activity limitation had health insurance.

Also, in the NHDR:

  • From 2000 to 2012, American Indians and Alaska Natives under age 65 were less likely than Whites to have health insurance in all years.

Uninsurance

Prolonged periods of uninsurance can have a particularly serious impact on a person's health and stability. Uninsured people often postpone seeking care, have difficulty obtaining care when they ultimately seek it, and may have to bear the full brunt of health care costs. Over time, the cumulative consequences of being uninsured compound, resulting in a population at particular risk for suboptimal health care and health status.

Figure 10.2. People under age 65 who were uninsured all year, by age and activity limitations (ages 18-64), 2002-2011

Text description is below image

Text description is below image

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2011.
Denominator: Civilian noninstitutionalized population under age 65 for insurance and ages 18-64 for activity limitations.
Note: For this measure, lower rates are better. Basic activity limitations include problems with mobility, self-care, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life.

  • Overall, from 2002 to 2010, the percentage of people under age 65 who were uninsured all year increased from 13.4% to 15.0%. The overall percentage in 2011 was 14.5% (Figure 10.2).
  • From 2002 to 2011, children ages 0-17 were least likely to be uninsured all year, while adults ages 18-44 were most likely to be uninsured all year (in 2011, 5.7% for ages 0-17 and 21% for ages 18-44.
  • In all years except 2004 for people with basic activity limitations and 2005 for people with complex activity limitations, adults ages 18-64 with basic or complex activity limitations were less likely to be uninsured all year than adults with neither basic nor complex activity limitations.

Also, in the NHDR:

  • In 2011, poor and low-income people were about four times as likely to be uninsured compared with high-income people, while middle-income people were more than twice as likely to be uninsured as high-income people.

Financial Burden of Health Care Costs

Health insurance is supposed to protect individuals from the burden of high health care costs. However, even with health insurance, the financial burden of health care can still be high and is increasing (Banthin & Bernard, 2006). High premiums and out-of-pocket payments can be a significant barrier to accessing needed medical treatment and preventive care (Alexander, et al., 2003).

According to one study, uninsured families can afford to pay for only 12% of hospitalizations that they experience (Chappel, et al., 2011). One way to assess the extent of financial burden is to determine the percentage of family income spent on a family's health insurance premium and out-of-pocket medical expenses.

Figure 10.3. People under age 65 whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income, by insurance and activity limitations (ages 18-64), 2006-2011

Text description is below image

Text description is below image

[D] Select for Text Description.

Key: ESI = employer-sponsored insurance.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006-2011.
Denominator: Civilian noninstitutionalized population under age 65 for insurance and ages 18-64 for activity limitations.
Note: For this measure, lower rates are better. Total financial burden includes premiums and out-of-pocket costs for health care services. Basic activity limitations include problems with mobility, self-care, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life.

  • Overall, in 2011, 17.5% of people under age 65 had health insurance premium and out-of-pocket medical expenses that were more than 10% of total family income (Figure 10.3).
  • In all years from 2006 to 2011, the percentage of people under age 65 whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income was about three times as high for individuals with private nongroup insurance as for individuals with private employer-sponsored insurance.
  • In all years, people ages 18-64 with basic or complex activity limitations were significantly more likely than people with neither type of activity limitation to have family health insurance premium and out-of-pocket medical expenses that were more than 10% of total family income.

Also, in the NHDR:

  • In all years, the percentage of people under age 65 whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income was more than four times as high for poor individuals, more than three times as high for low-income individuals, and more than twice as high for middle-income individuals compared with high-income individuals.

Usual Source of Care

People with a usual source of care (a provider or facility where one regularly receives care) experience improved health outcomes and reduced disparities (smaller differences between groups) (Starfield & Shi, 2004) and costs (De Maeseneer, et al., 2003). Evidence suggests that the effect on quality of the combination of health insurance and a usual source of care is additive (Phillips, et al., 2004). In addition, people with a usual source of care are more likely to receive preventive health services (Ettner, 1996).

Specific Source of Ongoing Care

The term "specific source of ongoing care" accounts for patients who may have more than one source of care. For example, women of childbearing age and older people tend to have more than one doctor. A specific source of ongoing care can include an urgent care/walk-in clinic, doctor's office, clinic, health center facility, hospital outpatient clinic, health maintenance organization preferred provider organization, military or other Veterans Affairs health care facility, or some other similar source of care (however, hospital emergency rooms are excluded).

Figure 10.4. People with a specific source of ongoing care, by insurance (under age 65), age, and activity limitations, 2012

Text description is below image

[D] Select for Text Description.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2012.
Denominator: Civilian noninstitutionalized population of all ages.
Note: Measure data are not age adjusted. A hospital emergency room is not included as a specific source of ongoing care. Basic activity limitations include problems with mobility, self-care, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life.

  • In 2012, overall, 85.9% of people had a specific source of ongoing care (Figure 10.4).
  • Regardless of age, more than 70% of people had a specific source of ongoing care. In 2012, people age 65 and over were most likely to have a specific source of ongoing care (96.3%), while people ages 18-44 were least likely to have a specific source of ongoing care (74.3%.
  • In 2012, people with private insurance were nearly twice as likely to have a specific source of ongoing care as uninsured people (91.3% compared with 47.7%).
  • More than 80% of people under age 65 regardless of activity limitation had a specific source of ongoing care. The percentage of people with a specific source of ongoing care was higher for people with basic and complex activity limitations than for those with neither basic nor complex activity limitations (87.8% and 90.0%, respectively, compared with 80.4%).

Also, in the NHDR:

  • The percentage of people with a specific source of ongoing care was significantly lower for poor and low-income people than for high-income people.

Usual Primary Care Provider

Having a usual primary care provider (a doctor or nurse from whom one regularly receives care) is associated with patients' greater trust in their provider and with good provider-patient communication. These factors increase the likelihood that patients will receive appropriate care. By learning about patients' diverse health care needs over time, a usual primary care provider can coordinate care (e.g., visits to specialists) to better meet patients' needs. Having a usual primary care provider correlates with receipt of higher quality care (Parchman & Burge, 2002; Inkelas, et al., 2004).

A person is determined to have had a primary care provider if his or her usual source of care setting was either a physician's office or a hospital (other than an emergency room) and he or she reported going to this usual source of care for new health problems, preventive health services, and physician referrals.

Figure 10.5. People under age 65 with a usual primary care provider, by insurance and activity limitations (ages 18-64), 2002-2011

Text description is below image

 

Text description is below image

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2011.
Denominator: Civilian noninstitutionalized population under age 65 for insurance and ages 18-64 for activity limitations.
Note: A usual primary care provider is defined as the source of care that a person usually goes to for new health problems, preventive health care, and referrals to other health professionals. Basic activity limitations include problems with mobility, self-care, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life.

  • Overall, in 2011, 77.3% of people had a usual primary care provider (Figure 10.5).
  • In all years, uninsured people were less likely to have a usual primary care provider than those with private or public insurance.
  • In all years, the percentage of people with a usual primary care provider was higher for people with basic activity limitations and complex activity limitations than for people with neither limitation.

Also, in the NHDR:

  • From 2002 to 2011, Blacks and Asians were less likely than Whites to have a usual primary care provider in all years except 2004.

Patient Perceptions of Need

Patient perceptions of need include perceived difficulties or delays in obtaining care and problems getting care as soon as wanted. Although patients may not always be able to assess their need for care, problems getting care when patients perceive that they are ill or injured likely reflect significant barriers to care.

Figure 10.6. People who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines in the last 12 months, by insurance (under age 65) and activity limitations (age 18 and over), 2002-2011

Text description is below image

Text description is below image

[D] Select for Text Description.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2011.
Denominator: Civilian noninstitutionalized population under age 65 for insurance and ages 18 and over for activity limitations.
Note: For this measure, lower rates are better. Basic activity limitations include problems with mobility, self-care, domestic life, or activities that depend on sensory functioning. Complex activity limitations include limitations experienced in work or in community, social, and civic life.

  • In 2011, 10.4% of people were unable to get or delayed in getting needed medical care, dental care, or prescription medicines (Figure 10.6).
  • In all years, for people under age 65, uninsured people and people with public insurance were more likely than people with private insurance to be unable to get or delayed in getting needed medical care, dental care, or prescription medicines. In 2011, the percentage of people who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines was higher for people with no health insurance than for people with private insurance (19.7% compared with 8.2%).
  • In 2011, people with basic or complex activity limitations were more likely to report delays in getting care than those with neither limitation.

Also, in the NHDR:

  • In 2011, Asians were less likely than Whites to report that they were unable to get or delayed in getting needed medical care, dental care, or prescription medicines.
  • In all years, adults ages 45-64 were more likely than adults age 65 and over, adults ages 18-44, and children ages 0-17 to be unable to get or delayed in getting needed medical care, dental care, or prescription medicines.

References

Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA 2003;290(7):953-8

Banthin JS, Bernard DM. Changes in financial burdens for health care: national estimates for the population younger than 65 years, 1996 to 2003. JAMA 2006;296(22):2712-9.

Chappel A, Kronick R, Glied S. The value of health insurance: few of the uninsured have adequate resources to pay potential hospital bills. ASPE Research Brief. Washington, DC: U.S. Department of Health and Human Services; May 2011. Available at: http://aspe.hhs.gov/health/reports/2011/ValueofInsurance/rb.pdf (PDF File, 125 KB). Accessed June 29, 2011.

Congressional Budget Office. Effects of the Affordable Care Act on health insurance coverage—February 2013 baseline. Washington, DC: CBO; February 2013. Available at: http://www.cbo.gov/publication/43900. Accessed March 14, 2013.

De Maeseneer J, De Prins L, Gosset C, et al. Provider continuity in family medicine: does it make a difference for total health care costs? Ann Fam Med 2003;1(3):144-8.

Ettner SL. The timing of preventive services for women and children: the effect of having a usual source of care. Am J Pub Health 1996;86(12):1748-54.

Hadley J, Holahan J, Coughlin T, et al. Covering the uninsured in 2008: current costs, sources of payment, and incremental costs. Health Aff 2008;27(5):w399-w415 (published online August 25, 2008).

Himmelstein DU, Thorne D, Warren E, et al. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med 2009 Aug;122(8):741-6. Epub 2009 Jun 6.

Inkelas M, Schuster MA, Olson LM, et al. Continuity of primary care clinician in early childhood. Pediatrics 2004;113(6 Suppl):1917-25.

Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Washington, DC: National Academy Press; 1993.

Parchman ML, Burge SK. Continuity and quality of care in type 2 diabetes: a Residency Research Network of South Texas study. J Fam Pract 2002;51(7):619-24.

Phillips R, Proser M, Green L, et al. The importance of having health insurance and a usual source of care. Am Fam Physician 2004 Sep 15;70(6):1035.

Schwartz K, Sommers BD. Young adults are particularly likely to gain stable health insurance coverage as a result of the Affordable Care Act. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services; 2012. Available at: http://aspe.hhs.gov/health/reports/2012/UninsuredYoungAdults/rb.pdf (PDF File, 86 KB). Accessed March 14, 2013.

Sommers B. Number of young adults gaining insurance due to the Affordable Care Act now tops 3 million. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services; 2012. Available at: http://aspe.hhs.gov/aspe/gaininginsurance/rb.shtml. Accessed March 14, 2013.

Sommers B, Kronick R. Report shows Affordable Care Act has expanded insurance coverage among young adults of all races and ethnicities. ASPE Issue Brief. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services; 2012. Available at: http://aspe.hhs.gov/health/reports/2012/YoungAdultsbyGroup/ib.shtml. Accessed March 14, 2013.

Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after State Medicaid expansions. N Engl J Med 2012;367:1025-34.

Starfield B, Shi L. The medical home, access to care, and insurance: a review of evidence. Pediatrics 2004;113(5 Suppl):1493-8.

Wilper AP, Woolhandler S, Lasser KE, et al. Health insurance and mortality in U.S. adults. Am J Public Health 2009 Dec;99(12):2289-95. Epub 2009 Sep 17.


i As described in Chapter 1, Introduction and Methods, income and educational attainment are used to measure SES in the NHDR. Unless specified, poor = below the Federal poverty level (FPL), low income = 100-199% of the FPL, middle income = 200-399% of the FPL, and high income = 400% or more of the FPL. The Measure Specifications and Data Sources appendixes provide more information on income groups by data source.


Return to Contents

Page last reviewed May 2014
Page originally created May 2014
Internet Citation: Chapter 10. Access to Health Care. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/nhqrdr/nhqr13/chap10.html

 

The information on this page is archived and provided for reference purposes only.

 

AHRQ Advancing Excellence in Health Care