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Who can’t pay for health care?


BACKGROUND: In an era of rising health care costs, many Americans experience difficulty paying for needed health care services. With costs expected to continue rising, changes to private insurance plans and public programs aimed at containing costs may have a negative impact on Americans’ ability to afford care.

OBJECTIVES: To provide estimates of the number of adults who avoid health care due to cost, and to assess the association of income, functional status, and type of insurance with the extent to which people with health insurance report financial barriers.

RESEARCH DESIGN: Cross-sectional observational study using data from the Commonwealth Fund 2001 Health Care Quality Survey, a nationally representative telephone survey.

PARTICIPANTS: U.S. adults age 18 and older (N=6,722).

MEASURES: Six measures of avoiding health care due to cost, including delaying or not seeking care; not filling prescription medicines; and not following recommended treatment plan.

RESULTS: The proportion of Americans with difficulty affording health care varies by income and health insurance coverage. Overall, 16.9% of Americans report at least 1 financial barrier. Among those with private insurance, the poor (28.4%), near poor (24.3%), and those with functional impairments (22.9%) were more likely to report avoiding care due to cost. In multivariate models, the uninsured are more likely (OR, 2.3; 95% CI, 1.7 to 3.0) to have trouble paying for care. Independent of insurance coverage and other demographic characteristics, the poor (OR, 3.6; 95% CI, 2.1 to 4.6), near poor (OR, 2.1; 95% CI, 1.9 to 3.7), and middle-income (OR, 1.8; 95% CI, 1.3 to 2.5) respondents as well as those with functional impairments (OR, 1.6; 95% CI, 1.3 to 2.0) are significantly more likely to avoid care due to cost.

CONCLUSIONS: Privately and publicly insured individuals who have low incomes or functional impairments encounter significant financial barriers to care despite having health insurance. Proposals to expand health insurance will need to address these barriers in order to be effective.

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  1. 1.

    Felt-Lisk S, McHugh M, Howell E. Study of Safety Net Provider Capacity to Care for Low-income Uninsured Patients. Final Report submitted to Health Resources and Services Administration; 2001.

  2. 2.

    Ku L, Nimalendran S. Losing Out: States Are Cutting 1.2 to 1.6 Million Low-income People from Medicaid, SCHIP and Other State Health Insurance Programs. Washington, DC: Center on Budget and Policy Priorities; 2003:Available at: http://www.cbpp.org/12-22-03health.pdf. Accessed December 22, 2003.

  3. 3.

    Gross DJ, Schondelmeyer SW, Raetzman SO. Trends in Manufacturer Prices of Brand Name Prescription Drugs Used by Older Americans—First Quarter 2004 Update. Issue Brief 69. Washington, DC: AARP Public Policy Institute; 2004 Available at: http://research.aarp.org/health/ib69_drugprices.pdf. Accessed August 23, 2004.

  4. 4.

    DeNavas-Walt C, Proctor BD, Mills RJ. Income, Poverty, and Health Insurance Coverage in the United States: 2003, Current Population Reports P60-226. Washington, DC: U.S. Census Bureau; 2004. Available at: http://www.census.gov/prod/2004pubs/p60-226.pdf. Accessed August 26, 2004.

  5. 5.

    Mills RJ, Bhandari S. Health Insurance Coverage in the United States: 2002, Current Population Reports P60-223. Washington, DC: U.S. Census Bureau; 2003. Available at: http://www.census.gov/prod/2003pubs/p60-223.pdf. Accessed December 23, 2003.

  6. 6.

    The Mercer Report. Surprise slow-down in health benefit cost increase. Issue 133, March 22, 2004. Mercer Human Resource Consulting. Available at: http://wrg.wmmercer.com. Accessed April 4, 2005.

  7. 7.

    Centers for Medicare and Medicaid Services. National Health Care Expenditures Projections Tables. Table 1. National Health Expenditures and Selected Economic Indicators, Levels and Average Annual Percent Change: Selected Calendar Years 1980–2012. Available at: http://www.cms.gov/statistics/nhe/projections-2002/tl.asp. Accessed December 24, 2003.

  8. 8.

    Centers for Medicare and Medicaid Services. Program Benefit Payments, Selected Fiscal Years. Available at: http://www.cms.hhs.gov/researchers/pubs/datacompendium/2003/03pg3.pdf. Accessed August 31, 2004.

  9. 9.

    Strengthening Medicare: A Framework to Modernize and Improve Medicare. Available at: http://www.whitehouse.gov/infocus/medicare/. Accessed December 23, 2003.

  10. 10.

    Achman L, Gold M. Medicare+Choice Plans Continue to Shift More Costs to Enrollees. New York, NY: The Commonwealth Fund; 2003 Available at: http://www.cmwf.org. Accessed December 23, 2003.

  11. 11.

    Schneider A, Elias R, Garfield R, Rousseau D, Wachino V. The Medicaid Resource Book. Washington, DC: The Kaiser Commission on Medicaid and the Uninsured; 2002.

  12. 12.

    Holahan J, Pohl MB. Changes in insurance coverage: 1994–2000 and beyond. Health Aff (Millwood). 2002; Web Exclusive: W162–W171.

  13. 13.

    The Kaiser Commission on Medicaid and the Uninsured. Health Insurance Coverage in America: 2002 Update. Washington, DC: The Kaiser Commission on Medicaid and the Uninsured; 2003:Available at: http://www.kff.org/uninsured/trends.cfm. Accessed December 29, 2003.

  14. 14.

    Authors’ tabulation of total health care charges, 1996–2000 using data from the Medical Expenditure Panel Survey.

  15. 15.

    Institute of Medicine. Care Without Coverage: Too Little, Too Late. Washington, DC: National Academy Press; 2002.

  16. 16.

    Institute of Medicine. Health Insurance Is a Family Matter. Washington, DC: National Academy Press; 2002.

  17. 17.

    Shiels J, Haught R. Cost and Coverage Analysis of Ten Proposals to Expand Health Insurance Coverage. Falls Church, VA: The Lewin Group; October 2003.

  18. 18.

    Age- and state-specific prevalence estimates of insured and uninsured persons—United States, 1995–1996. MMWR: Morb Mortal Wkly Rep. 1998;47:529–32.

  19. 19.

    Princeton Survey Research Associates. Methodology: Survey on Disparities in Health Care Quality: Spring 2001. Princeton, NJ: Princeton Survey Research Associates; February 28, 2002.

  20. 20.

    The Commonwealth Fund. 2001 Health Care Quality Survey. Available at: http://www.cmwf.org/surveys/surveys_show.htm?doc_id=228171. Accessed October 7, 2004.

  21. 21.

    Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA. 1998;290:1690–1.

  22. 22.

    Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988–2000. JAMA. 2003;290:199–206.

  23. 23.

    Kersey MA, Beran MS, McGovern PG, Biros MH, Lurie N. The prevalence and effects of hunger in an emergency department patient population. Acad Emerg Med. 1999;6:1109–14.

  24. 24.

    The Henry J. Kaiser Family Foundation. D.C. Health Care Access Survey, 2003: Highlights and Chartpack. October 2003. Available at: http://www.kff.org/minorityhealth/loader.cfm?url=/commonspot/ security/getfile.cfm&PageID=23624. Accessed December 30, 2003.

  25. 25.

    Tseng CW, Brook RH, Keeler E, Steers WN, Mangione CM. Cost-lowering strategies used by Medicare beneficiaries who exceed drug benefit caps and have a gap in drug coverage. JAMA. 2004;292:952–60.

  26. 26.

    Piette JD, Heisler M, Wagner TH. Cost-related medication underuse among chronically ill adults: the treatments people forgo, how often, and who is at risk. Am J Public Health. 2004;94:1782–7.

  27. 27.

    Andrulis D, Duchon L, Pryor C, Goodman N. Paying for Health Care When You’re Uninsured: How Much Support Does the Safety Net Offer? Boston, MA: The Access Project; January 2003. Available at: http://www.accessproject.org/downloads/d_finreport.pdf. Accessed December 30, 2003.

  28. 28.

    Glied S, Little SE. The uninsured and the benefits of medical progress. Health Aff. 2003;22:210–9.

  29. 29.

    Reinhardt UE. Rationing health care: what it is, what it is not, and why we cannot avoid it. Baxter Health Policy Rev. 1996;2:63–99.

  30. 30.

    Pamuck E, Makuc D, Heck K, Reuben C, Lochner K. Health, United States, 1998: Socioeconomic Status and Health Chartbook. Hyattsville, MD: National Center for Health Statistics; 1998:PHS 98-1232-1.

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Correspondence to Ms. Sepheen C. Byron MHS.

Additional information

The views in this article are the authors’. No official endorsement by the Agency for Healthcare Research and Quality or the Department of Health and Human Services is intended or should be inferred. The authors wish to thank David Meyers, William Lawrence, and the anonymous reviewers for their helpful comments.

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Weinick, R.M., Byron, S.C. & Bierman, A.S. Who can’t pay for health care?. J GEN INTERN MED 20, 504–509 (2005). https://doi.org/10.1111/j.1525-1497.2005.0087.x

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Key Words

  • health care affordability
  • insurance coverage
  • low-income populations
  • functional impairment