Call, Kathleen Thiede

Background: Although the Affordable Care Act has been successful in expanding Medicaid to >17 million people, insurance alone may not translate into access to health care. Even among the insured, substantial barriers to accessing services inhibit health care utilization. Objectives: We examined the effect of selected barriers to health care access and the magnitude of those barriers on health care utilization. Research Design: Data come from a 2008 survey of adult enrollees in Minnesota’s public health care programs. We used multivariate logistic regression to estimate the effects of perceived patient, provider, and system-level barriers on past year delayed, foregone, and lack of preventive care. Subjects: A total of 2194 adults enrolled in Minnesota Health Care Programs who were mostly female (66%), high school graduates (76%), unemployed (62%), and living in metro areas (67%) were included in the analysis. Results: Reporting problems across all barriers increased the odds of delayed care from 2 times for provider-related barriers (OR=2.0; 95% CI, 1.2–3.3) to >6 times for access barriers (OR=6.2; 95% CI, 3.8–10.2) and foregone care from 2.6 times for family/work barriers (OR=2.6; 95% CI, 1.3–5.1) to >7 times for access barriers (OR=7.1; 95% CI, 3.9–13.1). Perceived discrimination was the only barrier consistently associated with all 3 utilization outcomes. Conclusions: Multiple types of barriers are associated with delayed and foregone care. System-level barriers and discrimination have the greatest effect on health care seeking behavior.

Studies have examined how individual risk factors affect unmet health needs, but few have assessed how factors combine to create compounded risk. Using administrative and survey data from 1,897 publicly insured individuals in Minnesota, this study examines how diagnosed depression—a condition with established functional morbidity—moderates the association between seven common access barriers (e.g., transportation problems, lack of child care, clinic hours) and self-reported unmet health needs. Depression and access barriers were independently, positively associated with unmet need. Depression moderated barriers’ effects: Number of barriers reported had a stronger association with unmet need for individuals with depression. Depressed individuals reporting all barriers had a 70 percent chance of unmet need. Subgroup differences for individual barriers suggest that depressed individuals’ utilization patterns and functional limitations may shape their reactions to access barriers. Findings may inform improvements in public benefit designs and target the unique vulnerabilities associated with depression.