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Barriers to Care and Health Care Utilization Among the Publicly Insured

Allen, Elizabeth M., PhD, MPH; Call, Kathleen T., PhD; Beebe, Timothy J., PhD; McAlpine, Donna D., PhD; Johnson, Pamela Jo, PhD

doi: 10.1097/MLR.0000000000000644
Original Article

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.

*Department of Family Medicine & Community Health

Division of Health Policy & Management, University of Minnesota

Department of Health Sciences Research, Mayo Clinic, Rochester

§Division of Health Policy & Management

Center for Spirituality & Healing, University of Minnesota, Minneapolis, MN

E.M.A. was supported by the National Cancer Institute of the National Institutes of Health under award number R25CA163184.

The authors declare no conflict of interest.

Reprints: Elizabeth M. Allen, PhD, MPH, Department of Family Medicine & Community Health, University of Minnesota, 717 Delaware Street SE, Suite 166, Minneapolis, MN 55414. E-mail:

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