Health Insurance

Increased health insurance coverage is associated with statistically significant and clinically relevant improvements for low-income adults, including access to care, use of preventive services, and self-reported health. Among those with chronic conditions, increased coverage is linked to improved medication adherence, more regular communication with physicians, and improved perceived health status.⁴ In addition, emerging evidence indicates that improving health insurance coverage may promote equity and reduce disparities in access to care.⁵

Improving Measures

The two measures of health insurance that improved were:

• People under age 65 who were uninsured all year.
• People under age 65 with any period of uninsurance during the year.

Figure 1

People under age 65 who were uninsured all year, 2002–2018 (lower rates are better).

• From 2002 to 2018, overall, the percentage of people under age 65 who were uninsured all year decreased from 13.4% to 7.8% (Figure 1).

Figure 2

People under age 65 with any period of uninsurance during the year, 2002–2018 (lower rates are better).

• From 2002 to 2018, overall, the percentage of people under age 65 with any period of uninsurance during the year decreased from 25.5% to 17.1% (Figure 2).

Dental Insurance

Dental caries, or tooth decay, is a common chronic disease that can cause pain, suffering, and diminished quality of life throughout one’s lifespan. Left untreated, tooth decay can progress and lead to infection, more complex and expensive treatments, and, ultimately, tooth loss.⁶ Untreated tooth decay can affect essential aspects of daily living, including eating, speaking, and performing at home, school, or work.⁷

Oral health issues and lack of access to care can be associated with other aspects of one’s health. For example, people without dental insurance are more likely to have heart disease, diabetes, and osteoporosis.⁸ People with dental insurance are more likely to visit a dental professional, take their children to a dental professional, receive recommended preventive screenings and treatments, and have better overall health.⁹

Figure 3

People under age 65 with any period of private dental insurance during the year, 2006–2018. Note: In past years, this measure was referred to as “People under age 65 with any period of dental insurance during the year.” Period (more...)

• From 2006 to 2018, overall, there was no statistically significant change in the percentage of people with any period of private dental insurance (Figure 3).
• From 2006 to 2018, for people with high income, the percentage of people with any period of private dental insurance increased significantly, from 74.6% to 81.1% (data not shown).

No measures related to Health Insurance showed a worsening trend, but disparities related to Health Insurance still exist in subgroup categories such as age, race, and ethnicity. These are discussed in the Disparities portion of this Access section.

Timely Access to Care

A patient’s inability to obtain a timely healthcare appointment may result in various outcomes:

• The patient eventually sees the desired healthcare providers,
• The patient obtains healthcare elsewhere,
• The patient seeks an alternative form of care, or
• The patient does not obtain healthcare for the condition that led to the request for an appointment.

In any of these cases, the condition may worsen, improve (with or without treatment elsewhere), or continue until treated. Thus, long wait times may be associated with poorer health outcomes and financial burden from seeking nonnetwork care and possibly more distant healthcare.¹⁰

Figure 4

Adults who reported getting the help or advice they needed the same day they contacted their home health care providers, 2012–2019.

• From 2012 to 2019, there was no statistically significant change in the percentage of adults who reported getting the help or advice they needed the same day they contacted their home health care provider (Figure 4).

No measures related to Timely Access to Care showed a statistically significant worsening trend, but disparities related to Timely Access to Care still exist in subgroup categories such as race, ethnicity, geographic location, and insurance status. These are discussed in the Disparities portion of this Access section.

Perception of Need

The challenges patients encounter in accessing providers and managing their care reflect an important aspect of medical care. Examining how these challenges form barriers to care is essential for a complete understanding of healthcare access. This analysis involves quantifying impediments to full engagement in care in a way that is more comprehensive than traditional ratings of patient satisfaction.¹¹

The measure of perception of need that improved was:

• People with a usual source of care who is somewhat to very difficult to contact during regular business hours over the telephone.

Figure 5

People with a usual source of care who is somewhat to very difficult to contact during regular business hours over the telephone, 2002–2018 (lower rates are better).

• From 2002 to 2018, the percentage of people with a usual source of care who is somewhat to very difficult to contact during regular business hours over the telephone decreased from 19.1% to 15.5% (Figure 5).

Another perception of need measure did not show a statistically significant change over time:

• People with a usual source of care, excluding hospital emergency rooms, who has office hours at night or on weekends.

Figure 6

People with a usual source of care, excluding hospital emergency rooms, who has office hours at night or on weekends, 2002–2018.

• From 2002 to 2018, there was no statistically significant change in the percentage of people with a usual source of care, excluding hospital emergency rooms, who has office hours at night or on weekends (Figure 6).

One perception of need measure showed significant worsening over time:

• Children who needed to see a specialist in the last 12 months who sometimes or never found it easy to see a specialist, 2008–2017.

Figure 7

Children who needed to see a specialist in the last 12 months who sometimes or never found it easy to see a specialist, 2008–2017 (lower rates are better).

• From 2008 to 2017, the percentage of children who needed to see a specialist in the last 12 months who sometimes or never found it easy to see a specialist increased from 13.9% to 17.2% (Figure 7).

Snapshot of Disparities in Access to Care

Figure 8

Number and percentage of access measures for which members of selected ethnic and racial groups experienced better, same, or worse access to care compared with non-Hispanic White or White people, 2017, 2018, or 2019. Key: AI/AN = American Indian or Alaska (more...)

• For the most recent year, Hispanic people had worse access to care than non-Hispanic White people for 79% of access measures (Figure 8).
• American Indian and Alaska Native (AI/AN) people had worse access to care than White people for 50% of access measures.
• Asian people had worse access to care than White people for 29% of access measures and better access to care for 14% of access measures.
• Black people had worse access to care than White people for 53% of access measures.
• Native Hawaiian/Pacific Islander (NPHI) people had similar access to care as White people for all access measures.
• Multiracial (>1 race)^x people had worse access to care than White people for 21% of access measures.

Figure 9

Number and percentage of access measures for which members of selected age groups and with selected insurance status experienced better, same, or worse access to care compared with adults ages 18–44 years or individuals with private insurance, (more...)

• For the most recent year, children ages 0–17 years had worse access to care than adults ages 18–44 years for 13% of access measures and better access to care for 87% of access measures (Figure 9).
• Adults ages 45–64 years had worse access to care than adults ages 18–44 years for 8% of access measures and better access to care for 75% of access measures.
• Adults age 65 years and over had worse access to care than adults ages 18–44 years for 25% of access measures and better access to care for 63% of access measures.
• People with only public insurance had worse access to care than people with private insurance for 44% of access measures.
• People with no insurance had worse access to care than people with private insurance for 71% of access measures.

Figure 10

Number and percentage of access measures for which members of selected gender, income, and disability status groups experienced better, same, or worse access to care compared with males, people in high-income households, or people without disabilities, (more...)

• For the most recent year, females had better access to care than males for 43% of access measures (Figure 10).
• People in poor households^xi had worse access to care than people in high-income households for 79% of access measures.
• People in low-income households had worse access to care than people in high-income households for 71% of access measures.
• People in middle-income households had worse access to care than people in high-income households for 50% of access measures.
• People with disabilities had worse access to care than people without disabilities for 42% of access measures and better access to care for another 42% of access measures.

Figure 11

Number and percentage of access measures for which members of selected geographic locations experienced better, same, or worse access to care compared with people in large fringe metro areas, 2017, 2018, or 2019. Key: n = number of measures. Note: The (more...)

• For the most recent year, people in large central metro areas had worse access to care than people in large fringe metro areas for 71% of access measures (Figure 11).
• People in medium metro areas had worse access to care than people in large fringe metro areas for 29% of access measures.
• People in small metro areas had worse access to care than people in large fringe metro areas for 36% of access measures.
• People in micropolitan areas had worse access to care than people in large fringe metro areas for 50% of access measures.
• People in noncore areas had worse access to care than people in large fringe metro areas for 33% of access measures.

Disparities in Health Insurance

Evidence indicates that health insurance expansions significantly increase patients’ access to care and use of preventive care, primary care, chronic illness treatment, medications, and surgery. Indicators of increased insurance coverage include earlier detection of disease, better medication adherence and management of chronic conditions, and psychological well-being in knowing one can afford care when one gets sick.¹²

Healthcare access and insurance coverage are major factors that contribute to racial and ethnic disparities. Racial and ethnic disparities in access have been reduced significantly by expanded access to health insurance.¹³

Figure 12

People under age 65 with any private health insurance, by income, 2019.

• In 2019, people under age 65 from poor (18.4%), low-income (35.8%), and middle-income (70.4%) households were less likely to have private insurance compared with people under age 65 from high-income households (90.8%) (Figure 12).

Figure 13

People under age 65 with any private health insurance, by income and ethnicity, 2019.

• In 2019, among all income groups, Hispanic people and non-Hispanic Black people were less likely to have any private insurance compared with non-Hispanic White people (Figure 13).

Figure 14

People under age 65 with any private health insurance, by income and age, 2019.

• In 2019, children ages 0–17 years in poor and low-income families were less likely to have any private insurance compared with adults ages 18–44 years from poor and low-income families. (Figure 14).
• In 2019, adults ages 45–64 years from poor families were less likely to have any private insurance compared with adults ages 18–44 years from poor families.

Health Insurance Coverage: Early Release Program

The Early Release Program of the National Health Interview Survey (NHIS) provides timely data on health insurance coverage in the United States. These estimates are published prior to final data editing and final weighting to provide access to the most recent information from NHIS.

Estimates presented in Figures 15–18 are from the first 6 months of 2021, January–June. These data are not included in the summary analyses conducted for this report. However, it is important to present the status of health insurance coverage with the most recent data available because health insurance is a key factor in assessing the current state of access to care. These data are particularly relevant during a pandemic when health insurance status has changed for many people.

Below are findings from Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–June 2021. Because NHIS was redesigned for 2019, trends over time are not provided. More information about the estimates is available on the NHIS website (https://www.cdc.gov/nchs/nhis.htm).

Figure 15

Adults ages 18–64 who had private or public coverage or were uninsured at the time of interview, January–June 2021. Note: People were defined as uninsured if they did not have any private health insurance, Medicare, Medicaid, Children’s (more...)

• In the first 6 months of 2021, among adults ages 18–64, 66.3 % had private health insurance coverage, 21.6% had public coverage, and 14.0% were uninsured at the time of interview (Figure 15).

Figure 16

Children ages 0–17 who had private or public coverage or were uninsured at the time of interview, January–June 2021. Note: People were defined as uninsured if they did not have any private health insurance, Medicare, Medicaid, Children’s (more...)

• In in the first 6 months of 2021, among children ages 0–17, 53.1% had private health insurance coverage, 44.7% had public coverage, and 4.4% were uninsured at the time of interview (Figure 16).

Figure 17

Adults ages 18–64 who were uninsured at the time of interview, by income, January–June 2021 (lower rates are better). Key: FPL = federal poverty level. Note: People were defined as uninsured if they did not have any private health insurance, (more...)

• In the first 6 months of 2021, among adults ages 18–64, 26.9% of those from households with incomes below 100% FPL were uninsured, 23.8% of those from households with incomes 100% to below 200% FPL were uninsured, and 8.6% of those from households with 200% FPL and greater were uninsured (Figure 17).

Figure 18

Children ages 0–17 who were uninsured at the time of the interview, by income, January–June 2021 (lower rates are better). Note: People were defined as uninsured if they did not have any private health insurance, Medicare, Medicaid, Children’s (more...)

• In the first 6 months of 2021, among children ages 0–17 years, 6.9% of those from households with incomes below 100% FPL were uninsured, 6.2% of those from households with incomes 100% to below 200% FPL were uninsured, and 2.9% of those from households with incomes 200% FPL or greater were uninsured (Figure 18).

Disparities in Dental Insurance

Having private dental insurance is associated with receiving more dental care. Public insurance plans, such as Medicare and Medicaid, are only federally required to provide limited dental coverage (e.g., for children, dental emergencies). When Medicaid does provide dental coverage, some providers do not accept it because the reimbursement rates are typically lower than for private dental insurance.

For rural communities, which generally have lower rates of private dental insurance, insurance coverage is a barrier to dental care, along with dental care provider shortages, poor oral health education, and lack of transportation.¹⁴ Lower utilization of dental care in rural populations occurs despite higher risks for tooth decay and dental problems, due to factors such as higher rates of tobacco use and limited access to fluoridated water systems.¹⁵

Figure 19

People under age 65 with any period of private dental insurance during the year, by geographic location, 2018. Note: In past years, this measure was referred to as “People under age 65 with any period of dental insurance during the year.” (more...)

• In 2018, people in large central metro (57.6%), medium metro (58.6%), small metro (56.7%), micropolitan (49.2%), and noncore (48.2%) areas were less likely than people in large fringe metro areas (66.6%) to report having any period of private dental insurance (Figure 19).

Medicare Advantage Insurance

The CMS Medicare Advantage (MA) program allows Medicare beneficiaries enrolled in both Part A and Part B to receive benefits from private plans rather than from the traditional fee-for-service (FFS) program. MA enrollees appear to be somewhat healthier than beneficiaries in traditional Medicare, according to measures of self-assessed health, functional status, and cognitive status.¹⁶

MA enrollees have less education than beneficiaries in traditional Medicare, on average, and are more likely to have low to middle income (per capita incomes between $20,000 and $40,000). They are less likely to have per capita incomes greater than $40,000, perhaps because higher income beneficiaries are more likely to have Medigap and retiree health benefits that supplement traditional Medicare.¹⁶

Hispanic beneficiaries are more likely to be in MA than traditional Medicare, partly due to relatively high MA enrollment in parts of the country with large Hispanic populations, such as southern Florida. In contrast, beneficiaries living in rural areas, where MA has a smaller footprint, are more likely to have traditional Medicare.¹⁶

Figure 20

Adults age 65 and over with any Medicare Advantage health insurance, by geographic location, 2019.

• In 2019, people age 65 years and over in small metro (21.0%), micropolitan (17.3%), and noncore areas (19.0%) were less likely than people in large fringe metro areas (28.2%) to have an MA plan (Figure 20).
• In 2019, people age 65 years and over in large central metro areas (37.2%) were more likely than people in large fringe metro areas (28.2%) to have an MA plan.

Dual-Eligible Beneficiaries

Dual-eligible beneficiaries are enrolled in Medicare Part A and/or B and getting full Medicaid benefits and/or assistance with Medicare premiums or cost sharing through the Medicare Savings Program based on age, disability, or low income. Medicare is the primary payer for dual-eligible beneficiaries. Dual-eligible beneficiaries receive full Medicare coverage, including coverage of physician services, inpatient and outpatient acute care, and post-acute skill-leveled care. Medicaid may cover additional services not covered under Medicare, as well as help with costs for Medicare premiums, deductibles, coinsurance, and copayments.

Dual-eligible beneficiaries have low incomes that make it difficult to afford the premiums and cost sharing required by Medicare, as well as the cost of services not covered by the Medicare program.¹⁷

More than half (56%) of individuals dually eligible for Medicare and Medicaid benefits in 2013 had at least one limitation in activities of daily living. A plurality (43%) did not graduate from high school. Compared with non-dual Medicare beneficiaries, more dual-eligible beneficiaries reported being in poor health (18% vs. 6%). Dual-eligible beneficiaries were also more likely than non-dual Medicare beneficiaries to live in an institution.¹⁷

Figure 21

Adults age 65 years and over with dual-eligible insurance, by disability and income, 2019.

• In 2019, people with a disability (15.5%) were more likely than people without a disability (5.8%) to have dual-eligible insurance (Figure 21).
• In 2019, people from poor (34.7%) and low-income (11.9%) households were more likely than people from high-income households (1.5%) to have dual-eligible insurance.

Figure 22

Adults age 65 years and over with dual-eligible insurance, by ethnicity and race, 2019. Note: Data for American Indian and Alaska Native people and Native Hawaiian/Pacific Islander people do not meet the criteria for statistical reliability, data quality, (more...)

• In 2019, Hispanic adults age 65 years and over (22.0%) were more likely than non-Hispanic White adults age 65 years and over (3.9%) to have dual-eligible insurance (Figure 22).
• In 2019, Asian (22.7%), Black (15.9%), and multiracial (14.6%) adults age 65 years and over were more likely than White adults age 65 years and over (4.9%) to have dual-eligible insurance.

Usual Source of Care

Patients who have a usual source of care report greater trust and satisfaction with their providers, are more likely to receive treatment for chronic health conditions, and report fewer unmet service needs. Having a usual place and usual provider are associated with an increased likelihood of receiving preventive services and recommended screenings compared with having no usual source of care.^{18, 19} However, people without insurance are less likely to have a usual source of care, often due to out-of-pocket costs related to receiving care.

Figure 23

People under age 65 years with a specific source of ongoing care, by insurance status, 2019.

• In 2019, people under age 65 years with no health insurance (61.9%) were less likely than people under age 65 years with private insurance (92.3%) to have a specific source of ongoing care (Figure 23).

Figure 24

People with a specific source of ongoing care, by income, 2019.

• In 2019, people from poor (84.7%), low-income (86.1%), and middle-income (90.2%) households were less likely than people from high-income households (93.3%) to have a specific source of ongoing care (Figure 24).

Figure 25

People with a specific source of ongoing care, by ethnicity and race, 2019. Key: AI/AN = American Indian or Alaska Native; NHPI = Native Hawaiian/Pacific Islander.

• In 2019, Hispanic people (85.6%) were less likely than non-Hispanic White people (91.4%) to have a specific source of ongoing care (Figure 25).
• In 2019, Black people (88.3%) were less likely than White people (90.5%) to have a specific source of ongoing care.

Disparities in Timely Access to Care

Timely access to care is important for ensuring desirable health outcomes, reducing financial burden from seeking nonnetwork care and possibly more distant healthcare, and improving patients’ perception of need and experience with the healthcare system. Having health insurance coverage is strongly associated with receiving timely and continuous care, and lack of it has been consistently found to be one of the main contributors to disparities in access to health services.²⁰

Figure 26

Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as needed, by ethnicity and race, 2017 (lower rates are better). Note: Data for American Indian and Alaska Native people (more...)

• In 2017, Hispanic adults (18.3%) were more likely than non-Hispanic White adults(11.1%) to sometimes or never get care right away for an illness, injury, or condition as soon as needed (Figure 26).
• In 2017, Black adults(18.2%) were more likely than White adults(12.1%) to sometimes or never get care right away for an illness, injury, or condition as soon as needed.

Figure 27

Adults ages 18–64 years who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as needed, by insurance status, 2017 (lower rates are better).

• In 2017, uninsured adults (33.3%) and adults with only public insurance (19.0%) were more likely than adults with private insurance (12.0%) to sometimes or never get care right away for an illness, injury, or condition as soon as needed (Figure 27).

Figure 28

Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as needed, by geographic location, 2017 (lower rates are better).

• In 2017, adults living in micropolitan areas (16.4%) were more likely than adults living in large fringe metro areas (11.7%) to sometimes or never get care for an illness, injury, or condition as soon as needed (Figure 28).

Figure 29

Adults who had any appointments for routine healthcare in the last 12 months who sometimes or never got an appointment for routine care as soon as needed, by ethnicity and race, 2017 (lower rates are better). Note: Data for American Indian and Alaska (more...)

• In 2017, Hispanic (19.0%) adults were more likely than non-Hispanic White adults (14.4%) to sometimes or never get an appointment for routine care as soon as needed (Figure 29).
• In 2017, Asian (26.3%) and Black (20.7%) adults were more likely than White adults (15.0%) to sometimes or never get an appointment for routine care as soon as needed.

Figure 30

Adults ages 18–64 years who had any appointments for routine healthcare in the last 12 months who sometimes or never got an appointment for routine care as soon as needed, by insurance status, 2017 (lower rates are better).

• In 2017, adults without insurance (29.6%) were more likely than adults with private insurance (18.3%) to sometimes or never get an appointment for routine care as soon as needed (Figure 30).

Figure 31

Adults who had any appointments for routine healthcare in the last 12 months who sometimes or never got an appointment for routine care as soon as needed, by geographic location, 2017 (lower rates are better).

• In 2017, adults living in large central metro (19.2%), medium metro (16.7%), or small metro (17.0%) areas were more likely than adults living in large fringe metro (13.5%) areas to sometimes or never get an appointment for routine care as soon as needed (Figure 31).

Figure 32

Children who had any appointments for routine healthcare in the last 12 months who sometimes or never got an appointment for routine care as soon as needed, by ethnicity and race, 2017 (lower rates are better). Note: Data for American Indian and Alaska (more...)

• In 2017, Hispanic children (6.6%) were more likely than non-Hispanic White children (4.5%) to sometimes or never get an appointment for routine care as soon as needed (Figure 32).
• In 2017, Asian (11.4%) and Black (8.7%) children were more likely than White children (4.9%) to sometimes or never get an appointment for routine care as soon as needed.

Perception of Need

Access to healthcare can be seen as a continuum. Even if care is available, many factors can affect ease of access to it. Along with financial and locational aspects, navigational factors, such as ease in making an appointment with providers, are important determinants of access.²¹

Figure 33

Adults who tried to make an appointment to see a specialist in the last 12 months who sometimes or never found it easy to get the appointment, by age, 2017 (lower rates are better).

• In 2017, adults ages 45–64 years (16.0%) and age 65 years and over (9.3%) were less likely than adults ages 18–44 years (21.6%) to sometimes or never find it easy to get an appointment with a specialist (Figure 33).

Figure 34

People with a usual source of care who is somewhat to very difficult to contact during regular business hours over the telephone, by geographic location, 2018 (lower rates are better).

• In 2018, people in noncore areas (20.9%) were more likely than people in large fringe metro areas (15.0%) to have a usual source of care who was somewhat to very difficult to contact during regular business hours over the telephone (Figure 34).

Figure 35

People age 18 years and over with a usual source of care who is somewhat to very difficult to contact during regular business hours over the telephone, by disability, 2018 (lower rates are better).

• In 2018, people age 18 years and over with a disability (21.3%) were more likely than people age 18 years and over without a disability (15.8%) to report that their usual source of care was somewhat to very difficult to contact during regular business hours over the telephone (Figure 35).

Figure 36

People under age 65 years with a usual source of care who is somewhat to very difficult to contact during regular business hours over the telephone, by insurance status, 2018 (lower rates are better).

• In 2018, people under age 65 years without insurance (18.1%) and people with only public insurance (16.9%) were more likely than people with private insurance (13.8%) to report that their usual source of care was somewhat to very difficult to contact during regular business hours over the telephone (Figure 36).

Figure 37

People with a usual source of care, excluding hospital emergency rooms, who has office hours at night or on weekends, by geographic location, 2018.

• In 2018, people in large central metro (39.6%), medium metro (34.1%), small metro (33.1%), micropolitan (29.7%), and noncore areas (34.3%) were less likely than people in large fringe metro areas (46.2%) to report their usual source of care, excluding hospital emergency rooms, has office hours at night or on weekends (Figure 37).

Resources

HHS and other government agencies are committed to improving access to healthcare for all individuals. The following are examples of resources available:

• In 2016, AHRQ published the Chartbook on Access to Health Care. The chartbook presents national trends in access to care measures for the overall population, as well as trends by characteristics such as age, race, ethnicity, and income. Topics include rates of health insurance, demographics of providers, and demographics of various healthcare utilization groups (e.g., users of trauma centers).
• Healthy People 2030 identified Health Care Access and Quality as one of its key social determinants of health, with the goal to increase access to comprehensive, high-quality healthcare services. Healthy People 2030 sets and measures objectives, including assessment of health information technology, appointment wait times, ability to get prescription medications and medical care when needed, and having a usual primary care provider. Health systems and providers can use the objectives to set targets for improving access and reducing disparities.
• AHRQ’s Data Tools and CDC’s National Center for Health Statistics provide statistics and data related to healthcare access that researchers, policymakers, providers, consumers, and other stakeholders can use for purposes such as identifying areas of need, assessing the status of specific populations, and tracking progress over time. Data include topics such as health insurance rates, usual sources of care, and ability to obtain needed and timely care.
• The first goal for the Health Resources and Services Administration (HRSA) Strategic Plan FY2019–2022 is to improve access to quality health services. The goal is aimed at improving equity in access to quality care, particularly for people who are economically or medically vulnerable or geographically isolated. HRSA aims to meet the goal by increasing and improving the capacity of healthcare services, systems, and infrastructure; improving the quality and effectiveness of healthcare services and systems; and connecting patient populations to primary care and preventive services.