Why are some individuals forgoing medical care due to cost?

Proper and timely medical care is a key part of preventing disease and maintaining a healthy lifestyle, yet for many Americans this part is often missing, as people forgo needed medical care due to cost. This can lead to increased risk of health problems, especially in vulnerable populations such as people with low incomes and racial and ethnic minorities. Previous research has found that individual-level factors, such as income, affect levels of forgone care. Larger scale area-level factors, such as state income levels, regional characteristics and state Medicaid policies, can also play a role.

In a new study published in the International Journal of Environmental Research and Public Health, Samuel D. Towne Jr, PhD, MPH, CPH, assistant professor at the Texas A&M School of Public Health, studied national health care data to clarify the individual socioeconomic, geographic and political factors affecting forgone care after the Great Recession, which ended in 2009.

Towne analyzed data from the Behavioral Risk Factor Surveillance System, an annual telephone survey of American adults, from 2011 to 2015. As the main outcome of interest, the study looked at whether a respondent did not go to a doctor when needed due to cost during the past year. To see how different factors affected this outcome, Towne analyzed income, sex, education, race, ethnicity and geospatial factors such as region and rurality (meaning whether the person lived in a rural or urban area). The study also examined state-level variables such as statewide median income and the status of a state’s Medicaid expansion as part of the Affordable Care Act.

“Nearly 20 percent of adults between the ages of 18 and 64 stated they had skipped medical care due to cost during the past 12-months. This figure had dropped to 15 percent in 2015,” Towne said. “People in this age group with annual incomes less than $15,000 and those without a high school diploma or GED had the highest levels of forgone care.”

Hispanic, black and American Indian or Alaska Native adults reported forgone care at up to nearly twice the rate of white or Asian respondents. Additionally, people living in rural areas and in the southern United States were more likely to have skipped medical care. For older adults—people over the age of 65—the rate of forgone care was around 5 percent throughout the study period, and the study found similar differences in forgone care with income, race or ethnicity, education and geographic region as in younger adults.

Towne also checked the levels of forgone care with respect to state Medicaid expansion. For working age adults, the study found similar results for income, education, race and other factors; however, differences in forgone care rates appeared in 2014 and 2015 when states began expanding Medicaid.

“The findings suggest that individuals aged 18–64 living in states that did not expand Medicaid were more likely to have skipped medical care at least once in the past 12 months because of cost than people in Medicaid expansion states,” said Towne.

This study confirms results from previous research on health disparities associated with race, income, education and other factors and aims to help inform public policy and research in the future. Filling in gaps in medical coverage requires a deep understanding of what factors are associated with forgone care. Additionally, as the U.S. population ages, managing chronic health conditions will become more important. Medicare may explain the lower rates of forgone care in older adults, but it may be beneficial to find policies to help older adults improve their financial situation, as income appears to have a strong association with missing medical care even among adults 65 and older.

The study cautions that its findings only show an association and not a causal relationship. In addition, because the study relied on self-reported data, there may be inaccuracies due to recall bias. The study also did not examine different approaches to expanding Medicaid or enrollment in insurance exchanges put in place by the Affordable Care Act.

“Future work should explore these more in depth and consider economic opportunities and other state-level factors that may play a role in forgone care,” Towne said. “Policy makers seeking to make data-driven decisions to improve access to needed medical care should consider individual as well as geographic and political factors affecting forgone medical care.”