In all the talk about health care reform, controlling costs, and regulating the market, the actual reason we want people to get insurance can be lost. Health care is expensive. Without insurance, it is prohibitively expensive. Because of that, people who need care often go without it because of cost. As we’ve discussed many times, about half of uninsured Americans are expected to buy private insurance through the exchanges next year. The other half are expected to get insurance through the Medicaid expansion. These people, the poorest among us, are the ones most likely to delay care because of cost. Previously, the Commonwealth Fund reported that about one in five Americans had serious problems paying or were unable to pay their medical bills. About one in three Americans avoided needed care or medications because of cost. But those are national numbers. They don’t tell us how individuals in states differ in their actions or need. In a very recent letter to the NEJM, a group of researchers examined the relationship between Medicaid eligibility and such delays through the 2010 Behavioral Risk Factor Surveillance System survey. They found that there was a great deal of variability in the prevalence of delayed care because of cost, all the way from a low of 7% of people in Norfolk, MA to a high of 41% in Hidalgo, TX. The concerning part, though, was that the harder it was to get Medicaid, the more delayed care there appeared to be. If eligibility was set at 67-127% of the poverty line (FPL) instead of 133% of FPL or higher, the odds of delaying care were 16% higher. If eligibility was between 46% and 64% of FPL, the odds increased by 39%. If eligibility was below 44% of the FPL, then the odds of delaying care were 42% higher. Complicating the matter, counties that had the highest rates of delayed care were often those with the lowest incomes, the highest rates of chronic diseases, and governments which had delayed expanding the Medicaid program. Of particular note, however, was the fact that the concentration of primary care physicians was also related to the odds of delaying care because of cost. Those counties with the highest concentration of such doctors had the lowest levels of delayed care. Areas with more delayed care had fewer primary care physicians. This is going to be of great concern as Medicaid expands. We already have shortage of general practitioners in the United States. As we add 30 million uninsured to the ranks of the insured, this problem will be exacerbated. Given that the counties with the greatest need also appear to be those with the highest deficiencies, it’s not likely that this issue will resolve in the near future. The Affordable Care Act was an excellent start on this issue. But it’s unlikely to get everyone who needs Medicaid insurance, given some states’ reluctance to expand the program. Even when it does, it’s not going to fully compensate for the lack of primary care physicians in the areas of the country that need it more. There’s still a lot of work to do to improve the U.S. health care system.