Shifting barriers to health care access: from affordability to coverage issues

Although the Affordable Care Act (ACA) significantly expanded health insurance coverage, it remains unclear whether increases in care affordability have been offset by other barriers. We use the Medical Expenditure Panel Survey (MEPS) to assess whether self-reported delays or inability to obtain necessary health care due to insurance coverage-related barriers have risen in the years following ACA implementation. We also assess whether these barriers fall more heavily on low-income respondents. Between 2010–2012 and 2015–2017, the probability of reporting affordability barriers declined by 1.29 percentage points (40% relative reduction; 95% CI, -1.53 to -1.05), while the probability of reporting coverage-related barriers increased by 0.50 percentage points (67% relative increase; 95% CI, 0.35 to 0.66). The overall rate of delayed or forgone care remained statistically unchanged (95% CI, -0.56 to 0.34). Affordability issues fell much more heavily on the poor than insurance coverage issues. Exposure to overall barriers to care decreased significantly among poor respondents (− 1.3 percentage points; 19% relative reduction; 95% CI -2.3 to -0.4) and rose among high-income respondents (0.9 percentage points; 21% relative increase; 95% CI 0.3 to 1.5). The income gradient in access to care has flattened since ACA implementation, reflecting a shift in the type of barriers respondents experience. Since the implementation of the ACA, there has been a substantial reduction in affordability-related barriers to care, particularly among low-income populations. At the same time, there has also been a rise in coverage-related barriers. This shift suggests a transition in US health care rationing from price-based toward non-price mechanisms, with important implications for equity and efficiency.