Understanding and measuring health care insecurity.

Despite efforts to improve access and quality of care under the Affordable Care Act,1,2 significant numbers of Americans will continue to lack health insurance coverage. The Congressional Budget Office estimates that approximately 30 million nonelderly people in the U.S. will lack health insurance coverage in 2016, and the same number will be uninsured in 2022.3,4 There has been a recent slowing of the rate of increase in health care expenditures nationally; however, overall health care costs and insurance premiums continue to increase.5–7 Despite the subsidies available through programs under the Affordable Care Act, health insurance continues to be unaffordable for many.8,9 Much like food insecurity10 and job insecurity,11 health care insecurity can denote uncertainty and anxiety about the ability to access and sustain needed health services. Although theories of access have evolved to acknowledge the importance of factors beyond the affordability and availability of health services (in particular, previous system interaction and health outcomes) and so-called cognitive barriers (or personal beliefs, knowledge, or awareness of disease, prevention, treatment, and health resources)12–14 studies have and seem to remain focused on use and non-use of services (typically due to cost) as indicators of access and unmet health care needs.15–21 Measuring health care insecurity may illuminate a more subtle vulnerability highlighted within the progressing understanding of access that permeates a broad, often transient segment of society. We define health care insecurity as feeling uncertain, anxious, and vulnerable about the ability to obtain or sustain adequate health care services. This concept goes beyond traditional measures of health care access by assessing an individual’s subjective sense of vulnerability, lack of control, and worry about getting the health care they need when they need it. A measure of health care insecurity is necessary to supplement current measures of access and patient experience of health care. Such a measure can focus energy on reducing this under-recognized source of suffering among the underserved, and can serve as an outcome measure for health care improvement efforts. As a source of care that appears to offer benefits in preventive service delivery and decreased emergency room use among uninsured patients,22–25 free clinics are a useful setting in which to define and examine health care insecurity. We undertook this study to develop and evaluate a self-report measure of health care insecurity and assess if beginning care at a free clinic affects uninsured new patients’ health care insecurity.