One of the overarching goals of the Affordable Care Act of 2010 (ACA) is to reduce financial burdens associated with obtaining health care services and ultimately improve access to care and health outcomes for all Americans. The ACA seeks to achieve these goals primarily through the expansion of adequate and affordable health insurance coverage. The ACA expands coverage through Medicaid for individuals with incomes below 138 percent of federal poverty level (FPL) and includes federal subsidies to those with incomes between 138 and 400 percent of the FPL to purchase coverage through newly established health insurance exchanges. As individuals gain coverage through Medicaid and the health insurance exchanges, they could have access to more affordable health services and ultimately experience better health.

This analysis examines key indicators of access and use from the National Health Interview Survey (NHIS) and assesses trends in these outcomes in the decade before the passage of the ACA (2000-2010). Our goal is to establish baseline trends that can serve as benchmarks against which access and use under the ACA can be evaluated. We focus on access for the non-elderly adult population and consider access trends for privately and publicly insured as well as uninsured adults. We estimate multivariate models on each measure to understand the drivers of changes in access and use including a variety of demographic, health and socioeconomic characteristics. In addition to describing the role of individual characteristics in explaining access to care, we will also explore how access varies across geographic areas using NHIS data at the Research Data Center. We will consider access trends for individuals in urban and rural areas as well as health professional shortage areas and consider the role of physician supply and the presence of federally qualified health centers in affecting access to care.

This analysis will build on earlier work which found a noticeable deterioration in access to care among non-elderly adults over the last decade.  For example, adults were 8.3 percentage points more likely to have unmet medical needs and 7.7 percentage points more likely to have unmet dental needs in 2010 compared to 2000. Increasing uninsured rates among adults were a contributing factor, but access declined significantly for adults in every insurance category and across a variety of measures. Our forthcoming work will establish the role of market characteristics in driving access to and use of health services with special attention paid to areas expecting large coverage gains under the ACA. This analysis will provide a strong foundation for assessing changes in access to care following the implementation of the ACA coverage expansion in 2014. It may also identify individuals or areas that may face particular access challenges under reform, and allow policymakers to target such areas in an effort to maximize the benefits of the ACA.

NOTE: This work was funded by the Robert Wood Johnson Foundation