Insurance + Access ≠ Health Care: Typology of Barriers to Health Care Access for Low-Income Families

Jennifer E. DeVoe; Alia Baez; Heather Angier; Lisa Krois; Christine Edlund; Patricia A. Carney

doi:10.1370/afm.748

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Table 1.

Comparison of Respondent Characteristics to Overall Sample Population

Demographic Characteristic	Overall Random Sample (n=10,175) No. (%)*	Eligible Survey Population (n=8,636) No. (%)*	Survey Respondents (n=2,681) No. (%)*	Respondents To Open-Ended Survey Question (n=722) %*
NA = not available; OMAP = Office for Medical Assistance Programs.
* All percentages are unweighted.
† Race and ethnicity are combined into 1 variable in this table because the administrative data available to us had only 1 combined variable.
‡ Insurance status was based on self-report and not included in the administrative data, so it was only known for respondents to the survey.
Race/ethnicity^†
White	7,528 (74.0)	6,369 (73.7)	2,026 (75.6)	76.7
Black	270 (2.7)	218 (2.5)	50 (1.9)	0.7
Hispanic	1,864 (18.3)	1,600 (18.5)	475 (17.7)	19.3
Asian	110 (1.1)	95 (1.1)	31 (1.2)	0.6
American Indian	324 (3.2)	286 (3.3)	74 (2.8)	2.4
Pacific Islander	13 (0.1)	12 (0.1)	6 (0.2)	0.3
Other/unknown	47 (0.7)	40 (0.7)	16 (0.7)	0.1
Sex, child
Female	4,983 (49.0)	4,227 (48.9)	1,295 (48.3)	44.5
Male	5,192 (51.0)	4,409 (51.1)	1,386 (51.7)	55.5
Age
1–4 years	2,728 (26.8)	2,259 (26.2)	687 (25.6)	24.5
5–9 years	2,943 (28.9)	2,495 (28.9)	811 (30.2)	27.6
10–14 years	2,520 (24.8)	2,192 (25.4)	707 (26.4)	27.8
≥15 years	1,984 (19.5)	1,690 (19.6)	476 (17.8)	20.1
Region
Northwest Coastal	1,685 (16.6)	1,459 (16.9)	504 (18.8)	19.3
Portland area	1,702 (16.7)	1,387 (16.1)	417 (15.6)	15.2
Central Western	1,701 (16.7)	1,448 (16.8)	427 (15.9)	16.3
Southwest Coastal	1,696 (16.7)	1,462 (16.9)	435 (16.2)	16.2
North Central, Columbia Gorge	1,695 (16.7)	1,422 (16.5)	409 (15.3)	14.7
Southern and Eastern	1,696 (16.7)	1,461 (16.9)	489 (18.2)	18.3
Monthly income
<$500	3,109 (30.6)	2,589 (30.0)	770 (28.7)	27.4
$501–$1,000	2,628 (25.8)	2,221 (25.7)	711 (26.5)	27.3
$1001–$1,500	1,976 (19.4)	1,666 (19.3)	487 (18.2)	17.6
$1501–$2,000	1,434 (14.1)	1,249 (14.5)	412 (15.4)	17.5
>$2000	1,028 (10.1)	911 (10.5)	301 (11.2)	10.2
Current enrollment in program sponsored by OMAP
At least 1 child enrolled in OMAP	5,087 (50.0)	4,346 (50.3)	1,471 (54.9)	54.0
No child enrolled in OMAP	5,088 (50.0)	4,290 (49.7)	1,210 (45.1)	46.0
Insurance status^‡
Child uninsured	NA	NA	16.8	19.0
Child had gap in insurance coverage in past 12 months	NA	NA	34.8	39.0
Parent uninsured	NA	NA	35.8	37.7

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Table 2.

Insurance Status and Child’s Utilization of Primary Care Services

	Child Has Usual Source of Care		Child Had Doctor Visit in Past Year
Insurance Status	Weighted %	*AOR (95% CI)**	Weighted %	*AOR (95% CI)**
AOR = adjusted odds ratio; CI = confidence interval.
*Adjusted for age, race/ethnicity, household income, region of residence, parental insurance status (for children)/children’s insurance status (for parents).
† P <.01 for the comparison with uninsured children.
‡ P <.01 for the comparison with uninsured parents.
Child’s insurance status
Private	96.8^†	10.72 (3.30–34.89)	90.2^†	5.04 (1.71–14.85)
Public	90.4^†	5.35 (2.21–12.97)	89.2^†	4.82 (1.98–11.76)
Uninsured	58.9	1.00	56.6	1.00
Parent’s insurance status
Private	92.8^‡	1.58 (0.57–4.40)	87.6^‡	1.50 (0.53–4.19)
Public	90.5^‡	1.06 (0.41–2.79)	90.1^‡	1.33 (0.57–3.11)
Uninsured	80.1	1.00	77.4	1.00

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Table 3.

Themes and Subthemes of Barriers to Care Among Low-Income Families

Themes and Subthemes	Examples
OHP = Oregon Health Plan (public insurance in Oregon for anyone eligible for Medicaid and children eligible for the Oregon children’s health insurance program).
Getting and keeping health insurance coverage
Insurance coverage for parents; keep parents healthy to keep kids healthy	“Yes. I would like to be on OHP with my 3 girls because if I get sick and can’t go to the doctor, who is going to take care of my girls?!!”
	“Yes! I want my OHP health insurance back.… My children have no one else to turn to if I get sick and die because of a lack of health care.”
	“I am terrified of losing my OHP coverage.… What good does it do to provide coverage for children without coverage for the parents that care for them? Not much.”
Unfairness of selective Medicaid coverage	“OHP sometimes does not accept adult applications unless they are pregnant. I think that is dumb and unfair. This is racist to men and to women who can’t have kids or have their tubes tied or already have kids and are done having kids. Because of this, it encourages women or teens to get pregnant.”
	“The only reason why I can get OHP right now is because I am pregnant. I do not know what I will do after I have the baby.”
	“The only reason I get health insurance is because I am currently pregnant. After I have the baby, I will get kicked off.”
System requirements and age limits	“Although we are thankful for OHP, they make it very hard to keep and complicated.”
	“I feel it’s not right that a family that is trying to make it in life gets knocked back and down. My 10-year-old son lost his health insurance because I got a 39-cent raise in pay.”
	“My 18-year-old daughter has been hospitalized for complications due to anorexia.… She is in desperate need of either a residential program or continuing coverage past her 19th birthday. My daughter was told that OHP is not accepting any new adults.… Is the state of Oregon going to let my daughter die?”
Access to health care services
Difficulty finding physicians; traveling long distances	“Everyone who takes OHP takes no more new patients.”
	“There’s never space for my children at the dentist.”
	“I’ve heard that it’s hard to find doctors who are accepting new OHP patients. We are generally healthy, so we are risking it.”
	“It is impossible to find a dentist that will take OHP. The only one I could find is 3 hours and at least 2 mountain passes away, making getting there almost impossible, especially in the winter.”
	“My daughter got a severe sore throat, and absolutely no doctors in Bend would accept OHP. We were referred to the local free clinic but weren’t accepted there because we had OHP. The nearest medical service was in Prineville (40 miles away). And I had no means of transportation.”
Costs associated with medical care
Unaffordable health care services; services not covered by insurance	“I can’t afford to pay co-pays or prescriptions when all I have is $200 child support for rent, gas, diapers, and anything else I need for my apartment like dish soap or toilet paper.”
	“We make sure our children get the medical care and medications they need, but sometimes this leaves us without money for other things.”
	“I have worked my way off welfare and OHP. I have become eligible for and elected to receive medical insurance through my employer.… I cannot afford to use the insurance.… That is not fair to my child and makes me feel I am failing him as a parent. I’m afraid to drop the coverage because of possible accident or emergency, but we sure could use the money.”
Unaffordable private insurance premiums	“I have to pay a lot out of pocket (for employer-sponsored insurance) and can’t afford it, so my son goes without.”
	“We have tried to get assistance but were told we make too much money, but we can’t afford it on our own! Please help us.”
	“I was actually relieved when my husband lost his job because it made my son eligible for coverage again. There is no feeling in the world worse than trying to figure out if you should really take an injured child to the doctor or not because of lack of money.”

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Table 4.

Frequency of Families Reporting Each Major Theme by Demographic Characteristics and Other Pertinent Factors

Demographic Characteristics and Other Factors	Getting and Keeping Health Insurance Coverage %	Access to Health Care Services %	Costs Associated With Medical Care %
Total subsample responding to open-ended survey question	56.9	23.1	19.9
Age
1–4 years	66.7	16.4	20.9
5–9 years	50.3	23.6	16.6
10–14 years	56.5	27.4	17.9
≥ 15 years	55.9	18.6	22.8
Ethnicity
Hispanic	51.8	20.1	13.4
Not Hispanic	59.5	22.6	20.5
Household income percentage of federal poverty level (FPL)
0%	32.5	23.4	13.0
1%–50% FPL	52.4	24.7	11.3
51%–100% FPL	68.3	20.2	23.6
101%–133% FPL	65.1	19.4	25.6
>133% FPL	54.9	22.5	26.8
Child’s current insurance status
Public only	55.1	25.9	15.2
Uninsured	72.6	13.3	14.8
Private or combination	50.0	19.9	32.4
Parent’s current insurance status
Public only	39.2	28.1	12.2
Uninsured	87.2	19.3	18.9
Private or combination	42.8	18.6	30.3
Did child have an insurance gap?
No gap, continuous 12-month coverage	54.1	22.5	18.9
Yes, gap in past 12 months	63.6	20.0	19.5
Does child have usual source of care?
No usual source of care identified	57.6	19.6	15.2
Yes, usual source of care identified	57.2	22.5	20.0
Did child have a physician visit in past year?
No physician visit in past 12 months	58.5	0.3	12.7
Yes, physician visit in past 12 months	57.0	22.3	20.5

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Table 5.

Barriers to Care Typology

Patient Circumstances	Why Patients Report They Do Not Get Care?	Who These Patients Are in Our Practices
No insurance and not getting care	Need coverage	Patients who fear the first question on the phone: “What’s your insurance?”
		Parents who get care at their children’s visits
Have insurance but not getting care	Need access	Patients who referring providers cannot get into specialists’ offices
		Patients traveling long distances to see clinicians
Have insurance and access but not getting care	Unafforable costs	Patients calling for advice to avoid visit co-payments
		Patients struggling to get their medications and asking for pharmaceutical samples

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The Article in Brief

Insurance + Access $!=$ Health Care: A Typology of Barriers to Healthcare Access for Low-Income Families

Jennifer E. DeVoe, MD, MPhil , and colleagues

Background Many Americans do not have access to basic medical care. This study identifies barriers faced by low-income parents seeking health care for their children.

What This Study Found Low-income families identify three major barriers to obtaining health care for themselves and their children: lack of insurance coverage, poor access to health care services, and unaffordable costs. Obtaining health insurance is most important to parents. If they obtain insurance, they face issues of access to care. Families that overcome insurance and access barriers struggle with costs such as co-pays for office visits, insurance deductibles, and prescription drug costs.

Implications

There are three successive barriers to obtaining health care: insurance, access, and cost. Insurance does not guarantee access, and having access to primary care does not guarantee receipt of all necessary care.
Policy makers must understand the barriers faced by low-income families who are trying to obtain necessary medical care.
Health insurance is an essential foundation for all families, but it does not solve all problems. Policy reforms need to address insurance, access, and cost.