QuickTake: Access to Health Care Providers Improved between September 2013 and September 2014

 

Michael Karpman, Adam Weiss, and Sharon K. Long

February 4, 2015

 

The expansion of health insurance coverage under the Affordable Care Act (ACA) is likely to increase demand for health care as cost barriers are reduced for newly insured adults.1 For example, a recent study found that significantly fewer adults were going without needed care because of costs in 2014 (as the ACA’s coverage expansions were being implemented) than in 2012 (Collins et al. 2015). However, concerns about adequate provider supply2 and long-term barriers to care under Medicaid (Office of the Inspector General 2014) continue to raise questions about how easily coverage gains and the resulting improvements in affordability under the ACA will translate into improved access to health care providers.

 

The Urban Institute’s Health Reform Monitoring Survey (HRMS) has been measuring access to health care since the first quarter of 2013. This QuickTake reports on changes in health care provider access among nonelderly adults (ages 18 to 64) between September 2013, just before the first health insurance Marketplace open enrollment period, and September 2014, just before the second open enrollment period. We monitor changes in the share of nonelderly adults who report (1) a lack of a usual source of health care when sick or in need of health advice at the time of the survey, (2) trouble finding a doctor in the previous year,3 and (3) trouble getting an appointment as soon as one was needed in the previous year. We also examine trends over time in the share of adults reporting at least one of these problems. Though we find improvements in provider access, many adults still struggle to get the care they need and disparities persist in access by age, ethnicity, and income.

 

Fewer adults reported health care provider access problems in September 2014 than in September 2013. The share of nonelderly adults who reported that they do not have a usual source of care dropped from 29.8 percent in September 2013 to 26.0 percent in September 2014, a decrease of 3.8 percentage points (figure 1). There was also a statistically significant 1.5 percentage-point decline in the share of adults who had any difficulty finding a doctor or other provider in the previous year. Though fewer adults reported trouble getting a doctor’s appointment as soon as they thought one was needed in the previous year, this change was not statistically significant. Overall, the share of adults with any difficulty accessing a provider declined 3.9 percentage points. Nearly 40 percent of adults, however, still reported one or more of the provider access problems described.

 

 

Problems with provider access decreased across income groups. Both middle-income adults (those with family income between 139 and 399 percent of the federal poverty level) and higher-income adults (those with family income at or above 400 percent of the federal poverty level) experienced statistically significant reductions in problems with provider access. The share of adults in both the middle- and higher-income groups with any provider access difficulty decreased 4.4 percentage points (figure 2). Middle-income adults (those targeted by the ACA’s coverage subsidies through the health insurance Marketplaces) were 4.8 percentage points less likely to lack a usual source of care and 2.2 percentage points less likely to have had difficulty finding a doctor who would see them during the previous year. The share of higher-income adults without a usual source of care declined 2.8 percentage points. Fewer low-income adults (those with family income at or below 138 percent of the federal poverty level) reported provider access problems in September 2014 than in September 2013, but these changes were not statistically significant.

 

Low-income adults continue to have the most trouble with provider access, followed by middle-income adults; higher-income adults fare the best. In September 2014, more than half of low-income adults (54.6 percent) reported a provider access problem, compared with 38.1 percent of middle-income adults and 30.0 percent of higher-income adults (data not shown).

 

 

Adults with provider access difficulties are more likely to be young, Hispanic, and of lower socioeconomic status than adults without provider access problems. Among those with provider access difficulties, 44.6 percent were between the ages of 18 and 34; that age group represented just under one-third (31.6 percent) of adults who did not have any difficulties obtaining care from providers (table 1). There are also disparities in access by socioeconomic status and ethnicity. Adults with provider access problems were nearly 18 percentage points more likely to have family income at or below 138 percent of the federal poverty level than adults without provider access problems (39.1 percent compared with 21.4 percent), 4.6 percentage points more likely to have less than a high school education (14.2 percent compared with 9.6 percent), and 3.3 percentage points less likely to be employed (64.5 percent compared with 67.7 percent). Adults with provider access difficulties were also 6 percentage points more likely to be Hispanic than adults without any difficulty receiving care (20.3 percent compared with 14.2 percent).

 

Table 1
Characteristics of Adults Ages 18 to 64, by Reported Difficulty with Provider Access

 

Did not have difficulty with provider access

Had difficulty with provider access

Age

 

 

     18–34

31.6%

44.6%

**

     35–49

31.8%

28.9%

**

     50–64

36.5%

26.5%

**

Gender

 

     Male

48.6%

49.6%

 

     Female

51.4%

50.4%

 

Race or ethnicity

 

     White, non-Hispanic

66.5%

58.5%

**

     Black or other race, non-Hispanic

19.2%

21.2%

 

     Hispanic

14.2%

20.3%

**

Education

 

     Less than high school

9.6%

14.2%

*

     High school  or some college

58.6%

58.9%

 

     College

31.8%

26.8%

**

Marital status

 

     Married

57.2%

45.8%

**

     Not married

42.8%

54.2%

**

Employment status

 

     Employed

67.7%

64.5%

*

     Not working

32.3%

35.5%

*

Family income

 

     At or below 138% of FPL

21.4%

39.1%

**

     139–399% of FPL

37.3%

34.5%

*

     400% of FPL or greater

41.2%

26.4%

**

Homeownership status

 

     Owns home

71.8%

57.2%

**

     Does not own home

28.2%

42.8%

**

Region

 

     Northeast

18.0%

15.2%

*

     Midwest

24.5%

21.9%

*

     South

34.4%

36.3%

 

     West

23.1%

26.7%

 

State Medicaid expansion status as of September 2014

 

     Expansion state

55.1%

54.9%

 

     Nonexpansion state

44.9%

45.1%

 

Urban or rural status

 

     In metropolitan area

84.6%

85.7%

 

     Not in metropolitan area

15.4%

14.3%

 

Sample size

4732

2882

 

Source: Health Reform Monitoring Survey, quarter 3 2014.

Note: FPL is federal poverty level. “Had difficulty with provider access” includes those who lack a usual source of care, had trouble finding a doctor or other health care provider who would see them, were told by a doctor’s office or clinic they would not be accepted as a new patient, were told by a doctor’s office or clinic their health insurance coverage would not be accepted, or had trouble getting an appointment as soon as they thought one was needed. Estimates exclude respondents who did not report at least one provider access problem and refused to indicate whether they had difficulty accessing care on at least one measure.

*/** Estimate differs significantly from those who did not have difficulty with provider access at the 0.05/0.01 level, using two-tailed tests.

 

Gains in provider access reflect more than the coverage gains under the ACA. Though we find a decrease in the proportion of nonelderly adults with problems receiving health care, not all of these changes are necessarily a result of coverage expansions through the ACA. Access to providers improved not only among adults targeted by the ACA’s coverage provisions but also among higher-income adults, even though health insurance coverage among this group was stable between September 2013 and September 2014 (Long et al. 2014). However, given concerns that coverage gains under the ACA would exacerbate pressures on the existing supply of health care providers, it is notable that increased difficulties in provider access have not yet materialized for nonelderly adults as a whole or for adults in specific income groups. In addition, many adults who were newly insured in 2014 gained coverage in March or later. Given the 12-month reference period for two of our three provider access measures and the possibility that many newly insured adults had not had much time to use their new coverage by September, estimated improvements in provider access under full implementation of the ACA may be understated. We will continue to monitor changes in health care access as more newly insured adults use their coverage to obtain care.

 

Methods: Each round of the HRMS is weighted to be nationally representative. We use these weights and a regression adjustment to control for differences in the demographic and socioeconomic characteristics of the respondents across the different rounds of the survey. This allows us to remove any variation in health care access caused by changes in the types of people responding to the survey over time rather than by changes in the health care landscape. The basic patterns shown for the regression-adjusted measures are similar to those based solely on simple weighted estimates. In presenting the regression-adjusted estimates, we report estimates of health care access in each quarter for the same nationally representative population. For this analysis, we base the nationally representative sample on survey respondents from the most recent 12-month period from the HRMS (i.e., quarter 4 of 2013 and quarters 1?3 of 2014).

 

References

 

Collins, Sara R., Petra W. Rasmussen, and Michelle M. Doty. 2014. Gaining Ground: Americans’ Health Insurance Coverage and Access to Care After the Affordable Care Act’s First Open Enrollment Period. New York: Commonwealth Fund.

 

Collins, Sara R., Petra W. Rasmussen, Michelle M. Doty, and Sophie Beutel. 2015. The Rise in Health Care Coverage and Affordability Since Health Reform Took Effect. New York: Commonwealth Fund.

 

Coughlin, Teresa A., Sharon K. Long, Lisa Clemans-Cope, and Dean Resnick. 2013. What Difference Does Medicaid Make? Assessing Cost Effectiveness, Access, and Financial Protection under Medicaid for Low-Income Adults. Menlo Park, CA: Kaiser Family Foundation.

 

Long, Sharon K., Michael Karpman, Adele Shartzer, Douglas Wissoker, Genevieve M. Kenney, Stephen Zuckerman, Nathaniel Anderson, and Katherine Hempstead. 2014. Taking Stock: Health Insurance Coverage under the ACA as of September 2014.Washington, DC: Urban Institute.

 

Office of the Inspector General. 2014. Access to Care: Provider Availability in Medicaid Managed Care. Washington, DC: US Department of Health and Human Services.

 

About the Series

 

This QuickTake is part of a series drawing on the HRMS, a quarterly survey of the nonelderly population that is exploring the value of cutting-edge Internet-based survey methods to monitor the ACA before data from federal government surveys are available. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute, and this analysis was also supported by funding from the Ford Foundation.

 

For more information on the HRMS and for other QuickTakes in this series, visit www.urban.org/hrms.

 

Notes


1 One study shows that 60 percent of adults who were newly enrolled in Medicaid or private coverage had used their new coverage to go to a doctor or hospital or to fill a prescription, and three-quarters of the newly insured who used their new coverage to obtain care would not have been able to receive this care before obtaining their insurance (Collins et al. 2014). Earlier studies show Medicaid enrollees are significantly more likely to use health care services other than outpatient emergency departments and more likely to report a usual source of care than they would be if they had no health insurance coverage (Coughlin et al. 2013).

2 Kelli Kennedy, “Health Law Impacts Primary Care Doc Shortage,” Associated Press, December 8, 2014.

3 The category “adults who report trouble finding a doctor in the previous year” includes those who report having had trouble finding a doctor or other health care provider who would see them, having been told by a doctor’s office or clinic that they would not accept them as a new patient, or having been told by a doctor’s office or clinic that their health insurance coverage would not be accepted.

Urban Institute Robert Wood Johnson Foundation