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Care Access Affected by Income, Not Just Coverage, Commonwealth Fund Survey Finds

By Nellie Bristol, CQ HealthBeat Associate Editor

February 7, 2012 -- While expanded coverage under the health care overhaul will increase health care access, primary care improvements will still be necessary to make sure people can see a medical provider in a timely way instead of relying on a hospital emergency room, findings from a recent Commonwealth Fund survey indicate.

The survey showed that 44 percent of adults with incomes under 133 percent of the federal poverty line, with or without insurance, said they went to an emergency room during the evening or on weekends, compared with 23 percent of adults with incomes above 400 percent of poverty. In addition, 35 percent of insured adults with incomes under 250 percent of poverty indicated using an emergency room to get a prescription, compared with 17 percent of insured adults with incomes of 250 percent of poverty or above. People who needed after-hours care were most likely to go an emergency room or urgent care provider, the study said.

The findings indicate that income-related differences in people's ability to access care may continue even after insurance enrollment is increased through the health overhaul (PL 111-148, PL 111-152), researchers concluded. The overhaul's goals include ensuring consistent services for as many people as possible both to improve quality of care and reduce costs associated with avoidable hospital admissions and high levels of emergency room use for routine care.

"The survey findings suggest that more low- and moderate-income adults with health insurance resort to emergency rooms for non urgent care than do higher income insured adults," researchers said. Further, they said, findings indicate that increased coverage "is a necessary, though not sufficient, condition for ensuring equal access to timely health care across income levels. People will need both health insurance and timely access to physicians and clinics who know them and their medical histories."

In an effort to improve care, the health law temporarily increases Medicaid payment rates for primary care physicians. It also allows states to provide extra compensation to providers who develop health homes for Medicaid recipients with chronic health problems. The project is designed to provide patients with more timely and comprehensive care. The act also includes $11 billion over five years in increased funding for community health centers, although expected funding for the program was reduced by $600 million for fiscal year 2011 during budget deficit negotiations.

The survey, according to lead researcher Sara Collins, vice president of Affordable Health Insurance at the Fund, "really does point to the need for the other provisions in the law that are aimed at bolstering the primary health care system, in particular, the large expansion and resources for community health centers."

Strong supporters of the health overhaul, the Commonwealth Fund, says coverage and health delivery system changes enacted under the act will reduce disparities in access to care, including preventive services. The survey found that uninsured adults were much less likely to be up to date on recommended preventive services like cancer screenings and cholesterol testing. Among adults with incomes under 250 percent of poverty, ten percent without insurance had received a recommended colonoscopy compared to 50 percent of those with insurance.

The Commonwealth Fund surveyed 2,134 adults aged 19-64 between June 24 and July 5, 2011. The survey has a margin of error of plus or minus three percentage points.

The report is the first in a series the group is planning to track changes in coverage resulting from the health law. Overall, the survey found that 57 percent of adults in families earning less than 133 percent of poverty were uninsured at some point in 2011 and 41 percent were uninsured for one or more years. Among adults in households with moderate incomes (between 133 and 249 percent of poverty), 36 percent lacked insurance during 2011 and 23 percent had been uninsured for one or more years. Researchers note that while the economy has been improving, unemployment is still high and new jobs being created may not have the same level of benefits.

"Many jobs lost during the recession have been solidly middle-class positions in large firms and state and local governments, with health care and retirement benefits," they say. "Much of the new job growth, in contrast, has been in the retail and food services industries, typically positions with low wages and no benefits."

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