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Non-financial barriers to care

[Journal Club] This guest post is the first in a series of Journal Club contributions by the Commonwealth Fund/Harvard University Fellows in Minority Health Policy

The Patient Protection and Affordable Care Act (PPACA) was developed to help reduce affordability barriers to accessing medical care. With PPACA, the increase in affordability of insurance and the number of individuals covered will eliminate some, if not all, financial barriers to accessing care.  The PPACA specifically addresses financial limitations that effect young adults, low-income families, and the chronically ill. However, other non-financial barriers to care exist. Many believe that true improvements in access to care may not be seen unless these non-financial barriers are concurrently addressed.

This study attempts to identify the prevalence of non-financial barriers to access to care for US adults. Survey data from the 2007 Health Tracking Household Survey was used to assess barriers to care using the Penchansky and Thomas model of access to care. This model categorizes barriers to access to care into 5 dimensions:

  • Affordability – Relationship between prices and ability to pay
  • Accommodation – Appropriateness of systems for accepting patient’s needs
  • Availability – Relationship between patient’s needs and volume of services
  • Accessibility – Relationship between locations of patients and services
  • Acceptability – Relationship between providers and patient preferences

The study showed that barriers in affordability were the most common reason for unmet need or delayed care (18.5 percent). Accommodation barriers represented a close second barrier to access to care (17.5 percent). However, non-financial barriers in aggregate were more frequent reasons for unmet need or delayed care than affordability barriers (21 versus 18.5 percent).  Also, many adults with affordability barriers also experience non-affordability barriers as large portions of the survey respondents were insured (66.8 percent).


This article demonstrates the fact that having insurance will not address or eliminate all barriers that prevent patients from receiving proper health care.  PPACA’s impact on improving health will be limited if non-financial barriers are not also addressed concurrently.  Accommodating patients’ needs by having more flexible scheduling, expanded hours, and easier to access clinics will help address some non-financial barriers to care.

There are a few limitations to the study. The Penchansky and Thomas model looks at barriers to care from a systems point of view and not a patient’s perspective.  Issues such as health literacy are not well incorporated in this model.  Response bias also limits this study’s interpretation. This survey does not adequately represent the US population as a whole: 68.5 percent of the respondents were white and many were insured. Minorities and the uninsured, however, are more likely to have both financial and non-financial barriers to care.

Accountable care organizations (ACO’s), patient-centered medical  homes, and insurance exchanges should be explored for their ability to reduce financial and non-financial barriers.

Kullgren, JT, et al. “Nonfinancial Barriers and Access to Care for U.S. Adults.” Health Serv Res. 2012 Feb;47(1 Pt 2):462-85.

review by

Denise De Las Nueces, MD and Alden Landry, MD, MPH

Alden Landry, MD, MPH

is a practicing Emergency Medicine Physician at Beth Israel Deaconess Medical Center, Boston, MA. In addition to his clinical roles, Dr Landry is also the Director of Outreach for the Office of Multicultural Affairs at the hospital.

Denise De Las Nueces, MD 

most recently completed  residency in Internal Medicine/Primary Care at Brigham and Women’s Hospital and currently is a Commonwealth Fund/Harvard University Fellow in Minority Health Policy.


“The Commonwealth Fund/Harvard University Fellowship in Minority Health Policy is designed to prepare physicians for leadership roles in formulating and promoting health policies and practices that improve the access to high-quality care at the national, state, and /or local levels for the minority, disadvantaged, and most vulnerable populations.”

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