More Americans today say they have skipped a needed trip to the doctor due to costs compared with two decades ago. Image by Thomas Breher from Pixabay

Even though the Affordable Care Act expanded access to health insurance, the number of Americans who can't afford to see a doctor keeps increasing, a new study shows.

The researchers found that compared with two decades ago, more Americans today say they have skipped a needed trip to the doctor due to costs, despite a roughly 60 percent increase in people with health insurance.


The trend, researchers said, is likely related to a years-long decline in the quality of private health insurance. Americans today face higher deductibles and co-payments, along with ever narrowing networks of providers covered by their plan.

So, while the Affordable Care Act -- widely known as Obamacare -- reduced the ranks of the uninsured, it has left fundamental problems with private insurance unaddressed.

The study is not an indictment of Obamacare, stressed lead researcher Dr. Laura Hawks.

"Our opinion is things would be much worse without it," said Hawks, a research fellow at the Cambridge Health Alliance, an affiliate of Harvard Medical School.

That's because Americans without health insurance still have the hardest time affording care. Of people who remained uninsured in 2017, the study found, almost 40 percent said they'd been unable to see a doctor in the past year because of costs; that compared with roughly 12 percent of Americans with health insurance.

Dr. John Ayanian directs the Institute for Healthcare Policy and Innovation at the University of Michigan.

Twenty years ago, he co-authored a study showing that many Americans were forgoing doctor visits due to money, and the uninsured were clearly hardest-hit.


The new study, using the same government dataset, shows that the problem has only gotten worse.

"Lack of health insurance is still the biggest barrier," said Ayanian, who wrote an editorial published with the study in the Jan. 27 online edition of JAMA Internal Medicine.

But, he added, it's not the only one. Over the years, Americans with insurance have faced ever more "cost-sharing" -- including a rise in high-deductible plans, Ayanian said.

Employers have been turning to those plans to help keep monthly premium costs down. The problem is that when employees need health care, they have to pay for a large chunk of it before their coverage kicks in.

In addition, insurance plans have been narrowing their lists of in-network providers. So people often end up seeing a doctor out-of-network -- sometimes unknowingly, Ayanian noted -- and get hit with a big bill.

It all amounts to one thing, Hawks said: "Private health insurance is not doing what it's supposed to -- making health care affordable when you need it."

For the study, her team used data from a long-running federal health survey. They compared over 117,000 Americans aged 18 to 64 who responded in 1998 with over 280,000 who responded in 2017.

Over those two decades, there was a significant increase in the percentage of people saying they skipped seeing a doctor in the past year because of costs -- from just over 11 percent to almost 16 percent.

That figure increased from 33 percent to almost 40 percent among people without insurance. Among the insured, meanwhile, the numbers were smaller -- rising from about 7 percent to 11.5 percent -- but the relative increase was bigger, at 60 percent.


Of particular concern, Hawks said, was the fact that people with serious chronic illnesses were commonly skipping care due to money. Among Americans with heart disease, for example, over one-quarter said they were unable to afford a doctor visit in 2017.

Ayanian agreed that the benefits of Obamacare, which rolled out in 2014, are clear. The law expanded Medicaid in many states, and offered subsidies to help middle-income individuals buy private insurance through Obamacare "exchanges."

By 2017, just under 26 million Americans were uninsured -- down from 50 million in 2010. And based on other research, Ayanian said, the law did lower out-of-pocket health care spending for many lower-income Americans.

But for those with incomes above 400 percent of the federal poverty line, there was no such benefit, he noted.

To truly make health care affordable, Hawks said, the cost-sharing pervasive in private insurance "needs to be eliminated."

A universal health care system would do that, according to study co-author Dr. David Himmelstein, of Harvard and Hunter College, in New York City.

"A single-payer reform, like Medicare-for-All, that eliminates financial barriers to care is what patients need," he said.

More information

The American Academy of Family Physicians has more on understanding health insurance.

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