NCHS Data Brief ■ No. 245 ■ May 2016

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics

State Variation in Health Care Service Utilization:

United States, 2014

Lindsey I. Black, M.P.H., Jeannine S. Schiller, M.P.H.

Key findings

Data from the National 

Health Interview Survey, 

2014

● The percentage of adults 

without a usual place of 

medical care ranged from 

2.8% in Vermont to 26.7% in 

Nevada.

● The percentage of adults 

who did not have a general 

doctor visit in the past 12 

months ranged from 15.9% in 

Vermont to 48.1% in Montana.

● The percentage of adults 

without a usual place of 

medical care was lower in 

states that expanded Medicaid 

compared with nonexpansion 

states.

● The percentage of adults 

without a usual place of 

medical care or who did not 

see a general doctor in the past 

12 months was lower in states 

with partnership marketplaces 

compared with Federally 

Facilitated Marketplace states.

State-level differences in the percentage of uninsured Americans, along with 

other factors, may affect health care access and utilization (1–4). This report 

examines the prevalence of two health care utilization measures among 

adults aged 18–64 by state. Additionally, differences by Medicaid expansion 

status and state Health Insurance Marketplace type are examined. Estimates 

are based on the 2014 National Health Interview Survey, a nationally 

representative sample of the noninstitutionalized U.S. population. 

Keywords: health services • Medicaid expansion • Health Insurance 

Marketplace • National Health Interview Survey

Did the percentage of adults without a usual place of 

medical care vary by state?

In 2014, 17.3% of adults aged 18–64 did not have a usual place of medical care. 

The percentage ranged from 2.8% in Vermont to 26.7% in Nevada (Figure 1).

*Significantly different from the national average (p < 0.05).

NOTE: Access data table for Figure 1 at: http://www.cdc.gov/nchs/data/databriefs/db245_table.pdf#1.

SOURCE: NCHS, National Health Interview Survey, 2014.

Figure 1. Percentage of adults aged 18–64 without a usual place of medical care, by state: 

United States, 2014

 
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Nine states (Nevada, Idaho, Texas, Oregon, Wyoming, Kentucky, Arizona, Alaska, and Florida) 

had a higher percentage of adults without a usual place of medical care compared with the 

national average (17.3%). 

Vermont, Delaware, Massachusetts, Wisconsin, Hawaii, Connecticut, Rhode Island, New 

Hampshire, North Dakota, South Dakota, New York, Alabama, Iowa, Maine, and Pennsylvania 

had a lower percentage of adults without a usual place of medical care compared with the national 

average. 

Did the percentage of adults who had not seen or talked to a general doctor 

in the past 12 months vary by state?

In 2014, 34.0% of adults aged 18–64 had not seen or talked to a general doctor in the past 12 

months. The percentage ranged from 15.9% in Vermont to 48.1% in Montana (Figure 2).

Eleven states (Montana, South Dakota, Alaska, Nevada, New Mexico, South Carolina, Idaho, 

Nebraska, Texas, Florida, and California) had a higher percentage of adults who had not seen or 

talked to a general doctor in the past 12 months compared with the national average (34.0%). 

*Significantly different from the national average (p < 0.05).

NOTE: Access data table for Figure 2 at: http://www.cdc.gov/nchs/data/databriefs/db245_table.pdf#2.

SOURCE: NCHS, National Health Interview Survey, 2014.

Figure 2. Percentage of adults aged 18–64 who have not seen or talked to a general doctor in the past 12 months, 

by state: United States, 2014

 
NCHS Data Brief ■ No. 245 ■ May 2016

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Vermont, Delaware, Virginia, Pennsylvania, Michigan, Wisconsin, New Hampshire, Oklahoma, 

and Ohio had a lower percentage of adults who had not seen or talked to a general doctor in the 

past 12 months compared with the national average. 

Did the percentage of adults without a usual place of medical care or who 

had not seen or talked to a general doctor in the past 12 months vary by 

state Medicaid expansion status?

In 2014, the percentage of adults aged 18–64 who did not have a usual place of medical care was 

lower in states with Medicaid expansion (16.6%) than in nonexpansion states (18.2%) (Figure 3).

In states without Medicaid expansion, nearly 35% of adults aged 18–64 did not see or talk to a 

general doctor in the past 12 months. This was not significantly different than the percentage in 

states with Medicaid expansion (33.3%).

 

1

Significantly different from states without Medicaid expansion (p < 0.05).

NOTE: Access data table for Figure 3 at: http://www.cdc.gov/nchs/data/databriefs/db245_table.pdf#3.

SOURCE: NCHS, National Health Interview Survey, 2014.

Figure 3. Percentage of adults aged 18–64 without a usual place of medical care or who had not seen or talked to a 

general doctor in the past 12 months, by state Medicaid expansion status: United States, 2014
NCHS Data Brief ■ No. 245 ■ May 2016

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Did the percentage of adults without a usual place of medical care or who 

had not seen or talked to a general doctor in the past 12 months vary by 

type of state Health Insurance Marketplace?

In 2014, the percentage of adults aged 18–64 who did not have a usual place of medical care was 

lower in states with a partnership Marketplace (15.4%) than in states with a Federally Facilitated 

Marketplace (18.0%) (Figure 4).

The percentage of adults aged 18–64 who had not seen or talked to a general doctor in the past 12 

months was similar in states with state-based and Federally Facilitated Marketplaces (34.3% and 

34.5%, respectively). The percentage was lower in states with partnership Marketplaces (30.4%) 

than in states with Federally Facilitated Marketplaces. 

 

1

Significantly different from states with a Federally Facilitated Marketplace (p < 0.05). 2

Significantly different from states with a partnership Marketplace (p < 0.05).

NOTE: Access data table for Figure 4 at: http://www.cdc.gov/nchs/data/databriefs/db245_table.pdf#4.

SOURCE: NCHS, National Health Interview Survey, 2014.

Figure 4. Percentage of adults aged 18–64 without a usual place of medical care or who had not seen or talked to a 

general doctor in the past 12 months, by type of Marketplace: United States, 2014 
NCHS Data Brief ■ No. 245 ■ May 2016

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Summary 

In 2014, state estimates of health insurance coverage for all 50 states and the District of Columbia 

could be reported from the National Health Interview Survey (NHIS) for the first time (5). The 

findings from this report highlight that just as there was state variation in the implementation of 

the Affordable Care Act (ACA), there was also variation in health care utilization based on place 

of residence. Several western states had rates of adults aged 18–64 who did not have a usual 

place of medical care or who had not seen or talked to a general doctor in the past 12 months that 

were in the highest quartile and were higher than the national average. Several northeastern states 

had rates of not having a usual place of medical care that were in the lowest quartile and were 

also lower than the national average. Adults in Medicaid expansion states were less likely to not 

have a usual place of medical care compared with nonexpansion states. The percentage of adults 

without a usual place of medical care or who did not see a general doctor in the past 12 months 

was lower in states with partnership Marketplaces compared with states with Federally Facilitated 

Marketplaces. Many factors likely influence rates of health care utilization, and rates may change 

as the length of time since ACA implementation increases. Although it is difficult to determine the 

complex reasons for differences in state health care utilization rates, these estimates can serve as a 

baseline for these measures. Continued state-specific monitoring will be helpful in identifying and 

tracking state and regional disparities in health care utilization over time.

Definitions

No usual place of medical care: Based on the survey question, “Is there a place that you usually 

go to when you are sick or need advice about your health?” If there was at least one such place, 

a follow-up question was asked, “What kind of place [is it/do you go to most often]—a clinic, 

doctor’s office, emergency room, or some other place?” Adults who indicated that the emergency 

room was their usual place for care were considered not to have a usual place for medical care.

Had not seen or talked to general doctor in the past 12 months: Based on the survey question, 

“During the past 12 months, have you seen or talked to any of the following health care providers 

about your own health? ... A general doctor who treats a variety of illnesses (a doctor in general 

practice, family medicine, or internal medicine).”

Medicaid expansion status: As of October 31, 2013, the following states expanded Medicaid: 

Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Hawaii, 

Illinois, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, 

New Mexico, New York, North Dakota, Ohio, Oregon, Rhode Island, Vermont, Washington, and 

West Virginia. The following states did not expand Medicaid: Alabama, Alaska, Florida, Georgia, 

Idaho, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, New 

Hampshire, North Carolina, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, 

Texas, Utah, Virginia, Wisconsin, and Wyoming.

Martketplace type: States are categorized as one of three types of health insurance marketplaces 

where individuals, families, and small businesses can enroll in health coverage: (a) a state-based 

Marketplace set up and operated solely by the state (California, Colorado, Connecticut, District 

of Columbia, Hawaii, Idaho, Kentucky, Maryland, Massachusetts, Minnesota, Nevada, New 

Mexico, New York, Oregon, Rhode Island, Vermont, and Washington); (b) a hybrid Partnership 

Marketplace in which the state runs certain functions and makes key decisions and may tailor 
NCHS Data Brief ■ No. 245 ■ May 2016

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the marketplace to local needs and market conditions but is operated by the federal government 

(Arkansas, Delaware, Illinois, Iowa, Michigan, New Hampshire, and West Virginia); and (c) the 

Federally Facilitated Marketplace operated solely by the federal government (Alabama, Alaska, 

Arizona, Florida, Georgia, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Montana, 

Nebraska, New Jersey, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South 

Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming).

Data source and methods

NHIS is a multipurpose health survey conducted continuously throughout the year by the 

National Center for Health Statistics (NCHS). Interviews are conducted in person in respondents’ 

homes, but follow-ups to complete interviews may be conducted over the telephone. In the 2014 

NHIS, supplemental funding provided the opportunity for augmentation of the NHIS sample in 

less populous states. As a result, for the first time, there was a large enough sample of completed 

interviews to produce state-level estimates. Questions about health care utilization are from the 

Sample Adult component. The Sample Adult component collects detailed health information 

from one randomly selected adult in the family. For more information about NHIS, including the 

questionnaire, visit the NHIS website at: http://www.cdc.gov/nchs/nhis.htm. 

Point estimates and their variances were calculated using sampling weights and SUDAAN 

software to account for the complex sample design of NHIS. The Taylor series linearization 

method was used for estimation of variance for the 10 states with the largest populations of 

adults aged 18–64 (California, Texas, Florida, New York, Illinois, Pennsylvania, Ohio, Michigan, 

Georgia, and North Carolina). For the 40 smaller states and the District of Columbia, the standard 

error was calculated by multiplying the square root of the average design effect based on the 

10 states with the largest populations with the standard error of the estimated percentage under 

a simple random sample. All estimates are based on a state sample size of 250 or more. All 

differences were evaluated using two-tailed significance tests that were adjusted to account for 

dependent samples where necessary.
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About the authors

Lindsey I. Black and Jeannine S. Schiller are with the National Center for Health Statistics, 

Division of Health Interview Statistics.

References

1. Martinez ME, Ward BW, Adams PF. Health care access and utilization among adults 

aged 18–64, by race and Hispanic origin: United States, 2013 and 2014. NCHS data brief, 

no 208. Hyattsville, MD: National Center for Health Statistics. 2015.

2. Hing E, Decker SL, Jamoom E. Acceptance of new patients with public and private 

insurance by office-based physicians: United States, 2013. NCHS data brief, no 195. 

Hyattsville, MD: National Center for Health Statistics. 2015.

3. Ashman JJ, Hing E, Talwalkar A. Variation in physician office visit rates by patient 

characteristics and state, 2012. NCHS data brief, no 212. Hyattsville, MD: National 

Center for Health Statistics. 2015.

4. Chen J, Vargas-Bustamante A, Mortensen K, Ortega AN. Racial and ethnic disparities 

in health care access and utilization under the affordable care act. Med Care 54(2):140–6. 

2016.

5. Cohen RA, Martinez ME. Health insurance coverage: Early release of estimates from 

the National Health Interview Survey, 2014. National Center for Health Statistics. June 

2015. Available from: http://www.cdc.gov/nchs/nhis/releases.htm.
NCHS Data Brief ■ No. 245 ■ May 2016

Suggested citation

Black LI, Schiller JS. State variation in 

health care service utilization: United States, 

2014. NCHS data brief, no 245. Hyattsville, 

MD: National Center for Health Statistics. 

2016. 

Copyright information

All material appearing in this report is in 

the public domain and may be reproduced 

or copied without permission; citation as to 

source, however, is appreciated.

National Center for Health 

Statistics

Charles J. Rothwell, M.S., M.B.A., Director

Nathaniel Schenker, Ph.D., Deputy Director

Jennifer H. Madans, Ph.D., Associate 

Director for Science

Division of Health Interview Statistics

Marcie L. Cynamon, Director

Stephen J. Blumberg, Ph.D., Associate 

Director for Science

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