The share of Americans who say they cannot afford to see a doctor has increased over the last two decades, even with some coverage gains stemming from the Affordable Care Act.
Working-age adults who reported being unable to see a physician due to cost increased from 11.4% in 1998 to 15.7% in 2017, according to a new analysis of nationwide survey data collected by the Centers for Disease Control and Prevention. The findings were published Monday in JAMA Internal Medicine.
The research suggests insured individuals were most impacted by cost-sharing on private insurance plans, while the uninsured felt the brunt of overall rising care costs, according to Dr. Laura Hawks, the study's lead author and a research fellow at Massachusetts-based health system Cambridge Health Alliance.
"The quality of private health insurance is getting worse, and the cost of healthcare is rising significantly," Hawks said. "We know that private health insurance plans increasingly rely on high premiums, high-deductible health plans, high copays and other forms of cost-sharing—these suggest that insurance generally is not doing what it is supposed to do—ensure people have access to healthcare when they need it."
Individuals earning $50,000 to $75,000 per year were most affected by the costs, going from 6.9% in 1998 who couldn't afford to see a doctor to 12.4% in 2017, according to the study. The lowest income groups reported having the least change in their ability to afford physician services.
Cost issues were a constant barrier to healthcare access for most health conditions. Nearly 1 out of 5 individuals with any chronic condition in 2017 said they were unable to see a physician because of their inability to pay for services.
While fewer individuals reported they weren't receiving preventive services, such as cholesterol checks and flu shots, the percentage of women who reported not receiving mammography screening increased from 12.5% in 1998 to 19% in 2017.
"Persons with conditions such as diabetes, hypertension, cardiovascular disease and poor health status risk substantial harms if they forgo physician care," study authors wrote.
Many have credited the ACA for increasing healthcare coverage and expanding access to care for millions. Since the health law was enacted in 2010, the uninsured rate fell from more than 46 million in 2010 to just below 27 million in 2016. A 2015 Commonwealth Fund report found the increase in coverage led to a rise in access. The share of adults who reported not getting healthcare because of cost declined from 43% in 2012 to 36% in 2014.
But the JAMA study found those gains were not enough to reverse long-term trends of rising healthcare costs. The proportion of people who said cost prevented them from seeing a physician increased from 33% in 1998 to 39% in 2017 among the uninsured and from 7% to 11% among those with coverage.
Lawmakers have acknowledged the importance of rising healthcare costs as they debate how to reform the healthcare system. An estimated 26% of U.S. adults have reported either they or a member of their household has had problem paying medical bill over the past year, according to data published by the Kaiser Family Foundation in June.
For those who are insured, changes in insurance costs over the past 20 years have shifted more of the economic burden onto individual patients. Families with employer-based insurance coverage paid 67% more for their health benefits and care in 2018 than the previous decade due to increases in premiums and cost-sharing, according to an August KFF analysis.
Such issues have increased calls from the public as well as several of the current Democratic candidates for president to propose creating a healthcare system that ensures universal coverage.
But Hawks cautioned that any proposed plan must cover everyone and reduce or eliminate cost-sharing to encourage more people to see their physician more often.
"Health coverage needs to be both universal, covering everyone, and comprehensive, paying in full for all medically necessary care," Hawks said. "Universal coverage that includes significant cost-sharing — high copays and deductibles — will improve but not minimize the high levels of unmet health needs we documented in our study."