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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.