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Original Investigation
Health Care Policy and Law
January 27, 2020

Trends in Unmet Need for Physician and Preventive Services in the United States, 1998-2017

Author Affiliations
  • 1Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
  • 2Harvard Medical School, Boston, Massachusetts
  • 3Hunter College, City University of New York, New York, New York
  • 4Division of Pulmonary and Critical Care, Cambridge Health Alliance, Cambridge, Massachusetts
JAMA Intern Med. Published online January 27, 2020. doi:10.1001/jamainternmed.2019.6538
Key Points

Question  Has unmet need for physician services shifted for US adults between 1998 and 2017?

Findings  Using data from US adults aged 18 to 64 years in 1998 (n = 117 392) and in 2017 (n = 282 378) who responded to the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System, this study found that from 1998 to 2017 the inability to see a physician because of cost increased 2.7 percentage points owing to worsening access to care among the insured. In contrast, the proportion of chronically ill adults receiving checkups did not change; results for receiving guideline-recommended preventive services were mixed.

Meaning  Many US adults face substantial and increasing barriers in access to care, despite a modest improvement in insurance coverage in the past 20 years.

Abstract

Importance  Improvements in insurance coverage and access to care have resulted from the Affordable Care Act (ACA). However, a focus on short-term pre- to post-ACA changes may distract attention from longer-term trends in unmet health needs, and the problems that persist.

Objective  To identify changes from 1998 to 2017 in unmet need for physician services among insured and uninsured adults aged 18 to 64 years in the United States.

Design, Setting, and Participants  Survey study using 20 years of data, from January 1, 1998, to December 31, 2017, from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System to identify trends in unmet need for physician and preventive services.

Main Outcomes and Measures  The proportion of persons unable to see a physician when needed owing to cost (in the past year), having no routine checkup for those in whom a routine checkup was likely indicated (within 2 years), or failing to receive clinically indicated preventive services (in the recommended timeframe), overall and among subgroups defined by the presence of chronic illnesses and by self-reported health status. We estimated changes over time using logistic regression controlling for age, sex, race, Census region, employment status, and income.

Results  Among the adults aged 18 to 64 years in 1998 (n = 117 392) and in 2017 (n = 282 378) who responded to the Centers for Disease Control and Prevention Behavioral Risk Factors Surveillance System (mean age was 39.2 [95% CI, 39.0-39.3]; 50.3% were female; 65.9% were white), uninsurance decreased by 2.1 (95% CI, 1.6-2.5) percentage points (from 16.9% to 14.8%). However, the adjusted proportion unable to see a physician owing to cost increased by 2.7 (95% CI, 2.2-3.8) percentage points overall (from 11.4% to 15.7%, unadjusted); by 5.9 (95% CI, 4.1-7.8) percentage points among the uninsured (32.9% to 39.6%, unadjusted) and 3.6 (95% CI, 3.2-4.0) percentage points among the insured (from 7.1% to 11.5%, unadjusted). The adjusted proportion of persons with chronic medical conditions who were unable to see a physician because of cost also increased for most conditions. For example, an increase in the inability to see a physician because of cost for patients with cardiovascular disease was 5.9% (95% CI, 1.7%-10.1%), for patients with elevated cholesterol was 3.5% (95% CI, 2.5%-4.5%), and for patients with binge drinking was 3.1% (95% CI, 2.3%-3.3%). The adjusted proportion of chronically ill adults receiving checkups did not change. While the adjusted share of people receiving guideline-recommended cholesterol tests (16.8% [95% CI, 16.1%-17.4%]) and flu shots (13.2% [95% CI, 12.7%-13.8%]) increased, the proportion of women receiving mammograms decreased (−6.7% [95% CI, −7.8 to −5.5]).

Conclusions and Relevance  Despite coverage gains since 1998, most measures of unmet need for physician services have shown no improvement, and financial access to physician services has decreased.

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    1 Comment for this article
    EXPAND ALL
    unmet need for physician services
    Karl Stecher, M.D. nsurgical residency | retired neurosurgeon
    Well, of course fewer people can afford to see a physician today.
    The offender is large part is the ACA (Obamacare), passed by Democrats without one Republican vote.
    Millions lost their doctors, lost their insurance plans.
    And, contrary to the false promise of Obama that premiums would decrease by $2,500, premiums immediately began to skyrocket.
    Insurance companies have raised policy deductibles, so that for many policies the deductible is so high that the insurance is essentially good for catastrophic events only.
    Hard to get accurate figures, but roughly 21 million may have been "underinsured" then. Now it is 30
    million.
    CONFLICT OF INTEREST: None Reported
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