Using data from a nationally representative survey of American adults, we find that approximately 1 in every 6 adults reports avoiding needed health care due to cost. Some of our findings are encouraging. For example, Medicare enrollees have levels of these problems no greater than the privately insured. Also, while it is problematic that many cannot afford health care, the issue does not appear to be compounded by racial and ethnic disparities. Other findings, however, are cause for concern. Substantial proportions of low-income and functionally impaired individuals with private or public insurance report avoiding needed care due to cost. Such problems among those with functional impairments are particularly alarming, given their potentially greater need for health care; the problems encountered by these individuals may demonstrate the inadequacy of existing benefit structures in the face of significant illness.
We may underestimate the true extent to which American adults avoid needed health care due to cost for several reasons. First, the Commonwealth Fund 2001 Health Care Quality Survey excludes information on children and was administered via telephone, which is likely to disproportionately exclude the poorest households in which individuals may have the most difficulties with the cost of health care. Second, respondents may underreport financial barriers if they perceive a stigma. Third, the survey does not address the issue of providers not suggesting treatment options because they know that the patient cannot afford them. Fourth, low-income persons are more likely to be unaware of chronic conditions such as hypertension, diabetes, or elevated cholesterol and therefore not perceive the need for care.22
Fifth, we were unable to examine differences among subgroups of Medicare beneficiaries associated with supplemental insurance or managed care enrollment.
There are two additional limitations to this study. First, the questions on problems related to paying for health care refer to time periods 1 to 2 years preceding the interview, while the questions on health insurance refer only to the individual's current status at the time of the interview, which may result in some misclassification bias. Second, there is a high rate of missing income data. However, this would only be problematic for the analysis if the distribution of income for those who are missing data is substantially different from those for whom income is known. This issue is further mitigated by the inclusion in the multivariate model of education, race, and insurance status, which are known correlates of income, and of a dummy variable for missing income.
Avoiding needed care is only one potential response to health-related financial difficulties, and there are a number of additional mechanisms not addressed in the survey that individuals may use to compensate when they cannot afford care. For example, individuals or families may choose to not buy food,23
may forgo paying other bills, or may deviate from prescribed treatments. One study found that 22% of poor or near-poor persons ages 65 and over report not filling a prescription, skipping doses, splitting pills, or not taking the medication as directed because of cost.24
Others describe the ways in which Medicare managed care beneficiaries decreased their use of essential medications during gaps in prescription coverage and how chronically ill adults cut back on medications due to cost concerns.25,26
In addition, many individuals facing financial difficulties obtain care but incur substantial amounts of medical debt. For example, nearly half of all uninsured individuals receiving ambulatory care at a safety net facility report being in debt to that facility, and one quarter of these individuals felt that their debts would deter them from seeking care there again.27
As a result, the true extent of Americans' problems paying for medical care will be considerably higher than our estimates of the proportion of adults who avoid needed care due to cost.
Though the health consequences of uninsurance for adults have been well documented,15
much less is known about the health consequences of financial barriers to care among the privately and publicly insured. Advances in prevention, management of chronic illness, treatment of disabling conditions, and pharmacotherapy can result in improved health and functional status and reduce costly catastrophic events, but may increase the mismatch between existing benefit structures and needed care. This mismatch disproportionately impacts low-income and disabled Americans' ability to afford care.
Currently, there are renewed calls for universal health insurance.17
Our findings underscore that insurance alone will not be enough to ensure that people can afford needed care. Even among those with private insurance, more than 1 in every 4 adults with low family incomes and approximately 1 in every 5 adults with functional limitations experiences difficulty obtaining needed care due to cost. Similarly, 1 in every 5 low-income adults with public insurance coverage reports having problems paying for care. Considering the design of coverage benefits and issues of underinsurance for primary, preventive, and chronic care—not just for catastrophic illness—is crucial in the attempt to alleviate Americans' difficulties paying for needed health care.
With the expected high costs of health care resulting from preventable illnesses, such as heart failure from uncontrolled hypertension, these issues take on increased urgency. In addition, as new technology and medications contribute to rising health care costs, they may also contribute to increasing socioeconomic disparities in health care, as there is evidence that the uninsured have less access to these technologies.28
As a nation, we are generally reluctant to engage in health care rationing based on explicit criteria and instead do so implicitly through financial barriers.29
This disproportionately affects both the uninsured and individuals from low-income families with public or private coverage, who are more likely to face substantial health challenges.15,30
Economic equity in access to needed services will be difficult to achieve without both strategies to promote system efficiency and a process for explicit needs-based allocation of services. Making health care affordable for all is a considerable national challenge, but one that must be addressed in order to eliminate socioeconomic disparities in health and ensure that all Americans have access to high-quality medical care when needed.