Virtually Every State Experienced Deteriorating Access to Care for Adults over the Past Decade

Virtually Every State ExperiencedDeteriorating Access to Care for Adults over the Past DecadeACA Implementation—Monitoring and TrackingGenevieve M. Kenney, Stephen Zuckerman, Dana Goin, Stacey McMorrow, Urban InstituteMay 2012 Virtually Every State Experienced Deteriorating Access to Care for Adults over the Past Decade2SUMMARYWe use the Behavioral Risk Factor Surveillance System (BRFSS) to examine state-level changes in three key access indicators over the past decade. Specifically, we explore changes in the likelihood of having unmet medical needs due to cost, receiving a routine checkup, and receiving a dental visit for all nonelderly adults and for the subgroup of uninsured adults. We also consider differentials in access between uninsured and insured adults within each state in 2010, and how these differences are reflected in the relationship between access to care and state-level uninsurance rates. We find that the deterioration in access to care observed in national trends during the past decade was evident in virtually every state in the country. Similarly, consistent with the national trends, the situation deteriorated more for the uninsured than for other adults in most states, which exacerbated the differentials in access and use between the insured and uninsured that had prevailed at the beginning of the previous decade. At the end of the decade, the uninsured in every state were at a dramatic disadvantage relative to the insured across the three access measures we examined. This analysis suggests that the potential benefits of the coverage expansion in the Affordable Care Act (ACA) are large and exist in every state. We also found that states with higher uninsurance rates have worse access to care for all three measures, which implies that these states have the most to gain from the ACA. In particular, the ACA coverage expansion has the potential to reduce unmet needs due to costs and other cost-related barriers, problems that are more severe in states with high uninsurance rates.INTRODUCTIONIn a recent analysis that used the National Health Interview Survey (NHIS) to assess changes in access to care among nonelderly adults, we found a marked deterioration in access between 2000 and 2010, with the most dramatic declines occurring among the uninsured.1 The national analysis showed that the access declines over the past decade were not driven solely by the most recent recession or changes in the distribution of insurance coverage. Access had already been declining before the start of the recession, and declines in access occurred for adults with all types of health insurance. Our analysis also found that, by 2010, access problems for uninsured adults were particularly pronounced compared with adults who had public and private coverage. This paper builds on the national analysis by examining state-level changes in access to care among nonelderly adults over the past decade, and comparing access to care between insured and uninsured adults in each state in 2010. Historically, states have been on the front lines of health policy, given the important choices they make that affect coverage and access to care. The Affordable Care Act (ACA) continues states’ prominent role by requiring them to implement a number of key provisions of the law. However, even if parts of the ACA are overturned in the courts or repealed, states will continue to make many decisions that can affect future health reforms. Therefore, it is useful to understand the extent to which the deterioration in access observed nationally is reflected widely across all states or is driven by a few states that had particularly large access declines. State-level analysis will also identify those places with the biggest access hurdles to overcome and therefore the largest potential gains from the ACA. This analysis will indicate whether access improvements under the ACA are likely to be widespread or more concentrated at the state level. We use the Behavioral Risk Factor Surveillance System (BRFSS) to examine state-level changes in three key access indicators over the past decade. Specifically, we explore changes in the likelihood of having unmet medical needs due to cost, receiving a routine checkup, and receiving a dental visit for all nonelderly adults and This research was funded by the Robert Wood Johnson Foundation. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. The authors appreciate the helpful suggestions and comments of Linda Blumberg, John Holahan, Sharon Long, and other members of the Urban Institute’s quantitative ACA evaluation team and the research assistance of Vicki Chen. We also greatly appreciate the assessment of the Behavioral Risk Factor Surveillance System (BRFSS) sample and weights, the development and testing of new BRFSS weights for the BRFSS, and related statistical analysis by Timothy Triplett and Doug Wissoker. Virtually Every State