There are so many problems in our health care delivery system and its financing structure that even families who have health insurance are having problems getting care as well as paying for it, according to a recent study by an Oregon Health & Science University family physician. The study, "Insurance Plus Access Does Not Equal Health Care: Typology of Barriers to Health Care Access for Low Income Families," recently was published in the journal Annals of Family Medicine.

"Incremental health insurance reforms alone are not going to solve these problems. A more comprehensive approach is desperately needed," said Jennifer DeVoe, M.D., D.Phil., research assistant professor of family medicine, OHSU School of Medicine.

The study was designed to the identify barriers low-income parents face when accessing health care for their children and how insurance status affects their reporting of these barriers. DeVoe found three major barriers: lack of insurance coverage, poor access to services and unaffordable costs. Even families with health insurance had trouble affording the co-pays as well as needed medications. Families with public health insurance had trouble getting access to a health care provider. When they did gain access, they reported feeling unwelcome and having to travel long distances to get to these providers. Those without any insurance struggled to obtain publicly-financed or any affordable insurance.

The study population included all Oregon families enrolled in the federal food stamp program at the end of January 2005 with children who were also presumed eligible for publicly funded health insurance. Both programs require a household income of less than 185 percent of the federal poverty level and proof of a child's U.S. citizenship. Of the 8,636 questionnaires sent, 2,681 were returned. About 25 percent of those responding reported gaps in coverage during the previous year, suggesting difficulties getting and keeping continuous insurance coverage.

According to DeVoe, the motto for the first group could be: "We have insurance and we have a family physician, but we can't afford to get health care." The second group's could be: "We have health insurance, but we can't always find the care that we need." And for the third group: "Because we have no health insurance, we can't get care."

The study includes comments from many of the respondents. For example, one mother wrote, "Yes, I want my OHP (Oregon Health Plan) health insurance back... My children have no one else to turn to if I get sick and die because of a lack of health care."

And this was from a parent who is on the Oregon Health Plan: "It is impossible to find a dentist that will take OHP. The only one I could find is three hours and at least two mountain passes away, making getting there almost impossible, especially in the winter."

A parent who has health insurance wrote this: "I have to pay a lot out of pocket (for employer-sponsored insurance) and can't afford it, so my son goes without."

DeVoe tells a story from her experience: "One of the motivating stories from my own practice was the young mother with asthma who recently came to see me with bronchitis. On her way out, she apologetically asked me to examine her son's lungs. When I asked if her son had a regular doctor, her scared eyes told me - even before she said the words - that he had lost his insurance. Recently, her employer had announced that she must pay the total cost of her family's insurance. One major problem - the cost of her monthly family premium was more than her net earnings."

This study shows that there is no single struggle in obtaining health care, but rather three: insurance, access and cost.

"The current system of health insurance for some coupled with a fragile safety net for others is not working for many families," DeVoe said.

Other researchers on this study include: Alia Baez,OHSU School of Medicine; Heather Angier, formerly of the OHSU Oregon Rural Practice-based Research Network, now with OHSU's Oregon Clinical and Translation Research Institute; Lisa Krois, M.P.H., and Christine Edlund, M.Sc., Office of Oregon Health Policy and Research; and Patricia Carney, Ph.D., OHSU Department of Family Medicine, OHSU School of Medicine.

The data used for this analysis was collected under the auspices of the Office for Oregon Health Policy and Research with U.S. Health Resources and Services Administration.