Who can't pay for health care?

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.

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.

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

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

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.

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.

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.