By William J. Cromie

Gazette Staff

One out of every four adults in the U.S. has problems getting access to and paying for health care, according to a study led by Harvard researchers.

Although poor and uninsured Americans have the biggest problem, some 28 million people with insurance do not get the care they think they need, or have problems paying medical bills.

"Four years ago, health-system reform was a hot issue in the presidential campaign; this year the subject is conspicuous by its absence," says Karen Donelan of the School of Public Health (SPH). "We undertook this study to determine what has happened in the interim."

Donelan and her colleagues surveyed a random selection of nearly 4,000 people and found about one out of three were uninsured or had problems getting or paying for medical care. According to the researchers, this sample represents about 60 million adults, 37 million of whom did not have health insurance at some time during the year preceding the study. Of the total, 34 million uninsured and insured people have serious problems getting and paying for health care.

"Health care providers insist that when you're really sick, you can get care," Donelan notes. "But the people we talked with tell a different story. Their voices give life to the statistics and tell of millions of individual crises."

The report by Donelan and colleagues, published in the latest Journal of the American Medical Association, quotes one women who needed surgery for cataracts. "My doctor couldn't do the surgery because I didn't have insurance," she said.

"Medicare doesn't pay the full cost of hospital or medicine," another person complained. "I don't take [my] prescriptions -- it costs $100."

Who Fares the Worst?

As you might expect, uninsured people in the worst health have the biggest problem getting care. Three out of four uninsured people told of such difficulties.

"If you're poor and uninsured, the sicker you get the more problems you're likely to have," Donelan points out. "Even if they have insurance, those with major medical problems run into financial troubles paying their bills."

Donelan and her colleagues calculate that 17 million people fall into the latter category. "They get overwhelmed by costs that insurance does not cover," she says. "Many of them tell us that they become afraid to go to the doctor."

"One problem I have is depression," said one insured woman. "I'm supposed to go to the doctor every three months, [but] I can't afford it. You get very stressful. It makes the problem worse, and you just don't go."

Much of the public thinks that uninsured people get medical care free or at reduced cost. One of the most startling findings of the study is that this turns out not to be true.

"Uninsured people who have trouble paying their bills are more likely to be referred to a collection agency than to get free care," Donelan notes. "We suspect that many people don't even ask for free care because they are too embarrassed or ashamed."

Some states, like Massachusetts, fund free care through a hospital tax on insured patients. In such cases, emergency rooms and hospitals can expect to be reimbursed. But many other states do not make such provisions, in which case it is up to doctors and hospitals to provide charity care.

"We found that many people don't feel entitled to charity, and they are afraid to ask for it," Donelan says. "It's not that a lot of people show up and get turned away; it's that they don't show up."

What can be done?

"One thing is to ask providers to take care of these patients, regardless of their ability to pay," Donelan answers. "A lot of them say they are willing to do this, but the cost pressures of managed care are making it harder and harder for them to do so."

The best solution apparently involves good health coverage. "Not just any insurance will do," Donelan comments. "The coverage must match a person's ability to pay premiums and out-of-pocket costs. That's expensive to do, and so far we haven't had the political will to do it."

The study was paid for by the Henry J. Kaiser Family Foundation. Robert Blendon, Roger Irving Lee Professor of Health Policy and Management at SPH, participated, along with researchers from the Foundation, the National Opinion Research Center at the University of Chicago, and Baruch College, City University of New York.