Let's face it: Even in relatively flush times a few years back, Americans were finding it harder to get medical care. Tens of millions were uninsured, and even some with coverage lacked a regular doctor.
Now, structural changes in health plans and a decline in the availability of primary-care physicians, coupled with recession and loss of employer-sponsored coverage, have all combined to make "going to the doctor" much more difficult.
One study published earlier this month by the University of Colorado analyzed surveys taken between 1999 and 2009 on adult access to health care. It found that the percentage of respondents reporting at least one barrier to primary care rose from 6.3 in 1999 to 12.5 percent a decade later.
The barriers included limited physician's-office hours, long wait times for appointments, difficulty in contacting a physician's office and problems with transportation.
Among people in the survey who reported making at least one emergency-room visit, the share that had at least one barrier to primary care rose from 12 percent in 1999 to nearly 19 percent in 2009.
"People come to the ER because it's the one place they are guaranteed to get the help they need," said Dr. Sandra Schneider, president of the American College of Emergency Physicians.
There were nearly 124 million ER visits in 2008, up from 100 million at the beginning of the decade, with estimates of the share of "non-urgent" care ranging from less than 10 percent to as much as 50 percent. The increased visits have come despite the fact that nearly a third of the nation's hospital-based emergency departments have closed in the past 20 years.
A survey released by the college in April showed that 97 percent of emergency doctors reported they treat patients every day who are referred to their ER by primary-care doctors.
Schedules and a lack of open appointments are partly to blame, but there's also reluctance among family docs to take on complicated cases. Many offices no longer have in-house diagnostic lab and imaging tools. Hospitals are limiting or eliminating the extent that community doctors can care for patients in-house, preferring to use salaried staff physicians.
The ACEP argues that emergency departments account for only 2 percent of the nation's health-care tab and that routine care from an already staffed and equipped ER really costs about the same as a trip to a doctor's office.
But a recent analysis by Rand Corp. health consultants concluded that shifting non-urgent patients from hospital emergency departments to retail clinics and urgent-care centers would cut as much as $4.4 billion a year in health costs.
Other studies have shown that people without insurance are no more likely to visit an ER than those with private insurance, but that people in poverty and those with public insurance, particularly Medicaid, do use emergency care more often than others.
A June report from the University of Michigan noted that children with public health insurance are 22 percent less likely to get comprehensive primary-care services than are youngsters with private insurance.
Surveys have found a steady decline in the share of doctors accepting new patients with both public and private health coverage since 2005. Only about 42 percent were willing to take on new Medicaid patients as of 2008, while 87 percent would add patients with traditional private insurance.
Federally subsidized community health centers, known to reduce pressure on emergency centers by filling the primary-care gap for 20 million mostly low-income and uninsured Americans, are seeing an era of expansion come to a sudden halt.
Congress recently cut $600 million from the program, which will eliminate care for 5 million new patients. State funding for the centers has been cut 42 percent in the past two years, according to the National Association for Community Health Centers. Proposed changes to Medicaid funding could push at least 1.7 million more patients from the program, the association says.
A recent survey of 300 all-volunteer-staffed free clinics around the country found that almost all have seen a sharp rise in patient visits in the past three years and that 56 percent have been forced to turn patients away due to inadequate staff and space, clinical support like lab tests and shortages of medications. The report, prepared for the medical relief group AmeriCares, noted that shortages of primary-care doctors and nurses were the biggest obstacles free clinics cited to expanding their services.