Survey Finds Crisis in Access to Health Care : Fewer Poor Are Able to Afford Medical Aid

Americans in general are seeing their doctors less often than they did in 1982, but the poor--Latinos in particular--have experienced such a deterioration in access to health care that the national foundation which sponsored a new survey says the situation has become a “crisis.”

President Reagan’s “safety net,” a guarantee of services to protect the health and welfare of the poor, “has holes in it,” said UCLA sociologist Howard Freeman, who headed the survey, “big holes.”

And health-care observers unaffiliated with the study say the trend represents an almost inevitable result of belt-tightening in the medical community and overall changes in the U.S. economy since 1980. “I’m afraid (the problem of access to health care) will get worse before it gets better,” said Columbia University medical economist Eli Ginzberg. “I see nothing on the horizon that assures me we are anywhere near coming to grips with this problem sensibly.”

Figures Double-Checked

The erosion in access to health services was so pronounced among the poor, that when the study was first shown to the sponsoring Robert Wood Johnson Foundation, executives ordered a reanalysis because they could not believe such radical worsening in just four years.

But the reanalysis confirmed the original conclusions. Results were released in Washington on Thursday. The survey, in which 10,130 persons were questioned nationwide, found that:

The proportion of Americans who had not visited a doctor’s office in the preceding 12 months increased from 19% in 1982 to 33% in 1986. They survey found 17.7% of Americans, or 43 million people, said they had no regular source of health care--no regular doctor, clinic or hospital--up from 11% four years before. Among Latinos, the proportion with no regular source of care tripled in four years, from 10% to 30%.

Hospital-use rates dropped in general, from 9% to 7%, but declined even more for the poor, who went from 10.4% to 7.9%, than the non-poor, whose hospital use fell from 8.8% to 6.2%. Among the poor, Latinos had the lowest hospital-use rates--just 4.5%, down from 6.3% in 1982. Rates of emergency room visits overall went up 12% in four years--implying, sur veyors said, that many people turned away from or unable to afford routine care ended up in emergency departments--often after their conditions deteriorated.

A total of 16%, or 38 million Americans, reported they had difficulty getting health care even though they needed it. Strictly economic reasons accounted for most of the disparity, with 6% of all respondents overall saying they were financially strapped when it came to health, but with 9% of blacks, 7% of Latinos and 13% of people not covered by health insurance saying they could not afford care.

About 1 million Americans--0.4% of the population--were turned away at doctors’ offices or hospitals because they could not pay. An additional 2 million people had to pay at least $1,500 of their own money in their last contact with the health system.

Children, pregnant women and the very sick either could not afford, find or get much of the care they needed. A total of 17% of people with a chronic illness had not seen a doctor in a year--the proportion was highest among blacks, at 25%. Nationally, 15% of pregnant women got no health care during their first trimesters, with rates double that for low-income women. Twenty percent of people with hypertension had not had their blood pressures checked in a year, with blacks and Latinos recording 30% each.

Headquartered in Princeton, N.J., the Robert Wood Johnson Foundation generally enjoys a reputation as a solid research center. In the last several years, it has collaborated with government agencies on programs and worked to resolve a wide range of problems, from housing and health care for the elderly to the treatment of AIDS patients. In that context, the report released Thursday was significant in part because of the element of urgency it conveyed.

“The most disturbing findings of the 1986 (survey) involve the deterioration in access and medical care among the nation’s poor, minority and uninsured citizens,” the report concluded. “A number of improvements noted in 1982 have been reversed. These changes are real . . . and have had a serious impact on the segments of the American population least able to take advantage of the various new forms of health-care delivery or to pay for the care they so evidently need.”

Few Surprises

While the deterioration in access to health-care services was striking in terms of its degree, many experts said, the new developments noted by the survey were hardly unexpected. Beginning with passage of the Medicare and Medicaid (Medi-Cal in California) programs in the mid-1960s, survey after survey had noted significantly improved access to health services among the poor.

While large disparities remained between the poor and non-poor in terms of health status, quality and amount of services available, the poor continued to make gains as recently as 1982, when a similar Robert Wood Johnson Foundation survey found the nearly 20-year trend continuing.

But since then, for a complex of reasons--not simply related to Reagan Administration cuts in federal health-care programs--gains of the last two decades in access to care and the quality of medical attention Americans receive have been significantly reversed, agreed Freeman and Robert Blendon, the foundation’s senior vice president.

“I don’t think that the (overall) result of the Robert Wood Johnson (survey) is surprising, but the magnitude is,” said Dr. James Todd, a vice president of the American Medical Assn. Todd and other experts said that, as early as 18 months ago, top health-policy observers in and out of the federal government feared a looming crisis in access to care.

While the new survey estimated that 9% of Americans--or 21.7 million people--do not have health insurance, Todd contended that if those with inadequate or unsatisfactory insurance were added, the total might reach 50 million Americans. Other observers have suggested the total of uninsured and inadequately insured may be a third of the nation’s 241 million people. The survey found also 10.1% of blacks had no insurance, and the proportion of Latinos was more than double that--21.7%.

At the same time, 11.8% of the respondents characterized themselves as in fair to poor health, with 15.3% of blacks, 19.4% of Latinos and 10.6% of Anglos describing themselves that way. UCLA’s Freeman said that, though the characterization might appear subjective and vague, it seems reliable because the self-assessments are consistent with other findings that lend themselves to verification. An article by Freeman further detailing the findings is to be published shortly in the journal Health Affairs.

Future Costs

Sen. David Durenberger (R-Minn.), chairman of the health subcommittee of the Senate Finance Committee, said that while he does believe the situation is a crisis, there are indications that future costs of caring for those now locked out of routine health care will be enormous. “Looking at it as a policy-maker and pulling all the compassion out of it,” he said, “if costs are a problem today, they’re going to be a more serious one in the future since so much health care is being foregone now.

“All of the benefit that we’re getting from reform of the system and causing upper- and middle-class people to adopt more healthy life styles is going to be overwhelmed by the more serious health problems of people who lack financial access.”

Blendon, Todd and other experts agreed that various economic factors have combined to bring unprecedented pressures on the health-care system. Now, what many experts saw as an inevitable result of such pressures has taken form. Spurred by Reagan, federal health programs were cut back starting in the early 1980s, with financially strapped state, county and city governments cutting back on health programs, as well.

Simultaneously, private insurers, employers and labor unions pressured physicians and hospitals to cut costs and many payers began to refuse to cover amounts greater than the bare-bones cost of care received by those in their plans. All of these steps disrupted the way the health system had historically worked--the traditional way that costs of those who could not pay were spread among those who could.

Further complicating the situation, new and more cost-sensitive health care institutions have taken root or vastly increased their market share. They include health maintenance organizations, which provide all care for a set fee but erect barriers to usage, and for-profit health centers.

This complex phenomenon has come under increasing scrutiny by economists. Columbia’s Ginzberg, for instance, called it the “destabilization of health care.” In an essay published in the New England Journal of Medicine last year, Ginzberg predicted economically induced pressures would soon have the effect of exiling millions of the poor and the near-poor from the health-care system.

“I’m not surprised at what the new data begin to show,” Ginzberg said last week from New York. “We have a really structural problem that’s developing in this country.” Ginzberg said the United States is unique among major industrialized nations in that it has no unified national policy guaranteeing access to health care--but instead a system of largely employer-paid private insurance and underfunded government programs for the elderly and very poor.

Jobs and Benefits

As American industry began a restructuring at the start of the decade to compete in global trade, hundreds of thousands of workers were displaced from core industries. Many eventually found themselves in different fields or working for companies whose health benefits were nonexistent or minimal. The result, Ginzberg said, has been a fundamental change in eligibility for health benefits--change that is starting to have pronounced effects.

Ginzberg said that, thus far, the Los Angeles and Chicago metropolitan areas and Texas appear to be among the hardest hit in the availability of health services.

“I don’t think we’ll let people get hit by a truck and lie in the street bleeding in the U.S.,” Ginzberg said. “But anything that’s less dramatic (could) slip through the cracks.”

Blendon said critics of the health-care system might argue that the number of physician visits is not necessarily a measure of the quality of health care. But he said that, for the poor, the new findings make it clear significant deterioration in quality has occurred.

“There’s no way to say what the effect of this is for the general population,” he said. “The disturbing issues are clear, however, about blacks, Hispanics, the poor and the uninsured.

“You absolutely have to be worried about how we have reversed the gains of at least a couple of decades. They (low-income groups) are clearly a sicker population. They should be in physicians’ offices and hospitals much more, by any objective measure.

“If something doesn’t happen, the lives of that group of people in our society look like they’re getting a lot worse.”

HEALTH CARE AVAILABILITY

Ethnicity Blacks Latinos Whites* U.S. population 12.4% 6.7% 80.9% Without regular source of health care 20.1% 30.1% 16.3% Did not have ambulatory visit within 1 year prior to the survey 37.4% 38.0% 31.6% Hospitalized at least once in the year prior to the survey 6.2% 4.5% 6.8% Without health insurance 10.1% 21.7% 7.7% In fair or poor health 15.3% 19.4% 10.6% With chronic or serious illness 21.1% 15.8% 20.4%

* Including non-Latino Caucasians, Asians, Alaskan Eskimos, Native Americans and others.

Source: Robert Wood Johnson Foundation