More coverage doesn't mean more care, since the cost of care is still beyond the reach of many despite more people having insurance coverage since the passage of the Affordable Care Act.

That's among the findings of a new report published in JAMA Internal Medicine, which also points out that the uninsured "felt the brunt of overall rising care costs."

Dr. Laura Hawks, the study's lead author and a research fellow at Massachusetts-based health system Cambridge Health Alliance, told Modern Healthcare, "The quality of private health insurance is getting worse, and the cost of healthcare is rising significantly. We know that private health insurance plans increasingly rely on high premiums, high-deductible health plans, high copays and other forms of cost-sharing—these suggest that insurance generally is not doing what it is supposed to do—ensure people have access to health care when they need it."

Individuals in the $50,000 to $75,000 annual income bracket were hardest hit by the costs, the report says, with the percentage of those who couldn't afford the cost of going to the doctor increasing from 6.9 percent in 1998 to 12.4 percent in 2017. Groups making the lowest income reported the least change in their ability to afford a doctor's care.

Those with chronic health conditions have also been hit hard by costs, with the price of care erecting a barrier to necessary access. Nearly 20 percent of individuals with any chronic condition in 2017 said they couldn't afford to pay for a doctor's care and thus did not get it.

More people got preventive care like flu shots and cholesterol checks, but for other preventive services—such as mammograms—that's not the case, with the 12.5 of women not receiving mammography screenings in 1998 rising to 19 percent in 2017. Study authors wrote, "Persons with conditions such as diabetes, hypertension, cardiovascular disease and poor health status risk substantial harms if they forgo physician care."

All this is despite the increase in people covered by health insurance. Since the ACA's inception in 2010, the uninsured rate fell from more than 46 million to just below 27 million in 2016. And while a Commonwealth Fund report in 2015 said that the rise in coverage brought a rise in access—and a decline from 43 percent in 2012 among those not getting health care because of cost to 36 percent in 2014—that doesn't mean the problem has gone away.

Instead, the JAMA study says that the 33 percent of uninsured people who said they couldn't afford to go to a doctor in 1998 has risen to 39 percent in 2017, and even among the insured it rose from 7 percent in 1998 to 11 in 2017.

People with insurance coverage have seen a shift in insurance costs onto them over the past 20 years, According to an analysis from Kaiser Family Foundation, those with employer-sponsored health insurance pay 67 percent more than they did a decade ago due to increasing costs and premiums.

The study's conclusion is bleak: "Despite coverage gains since 1998, most measures of unmet need for physician services have shown no improvement, and financial access to physician services has decreased."

Says Hawks, "Health coverage needs to be both universal, covering everyone, and comprehensive, paying in full for all medically necessary care. Universal coverage that includes significant cost-sharing—high copays and deductibles—will improve but not minimize the high levels of unmet health needs we documented in our study."

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Despite increase in ACA coverage, more people can't afford care

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