Financial access to healthcare services has declined over the past two decades, despite the implementation of Obamacare and other government insurance programs, according to a new study.

The analysis, published in JAMA Internal Medicine, traces the drop in access to the rise in premiums, deductibles, co-pays, and other costs, which have weighed against higher insurance coverage. It concludes that “over the past 20 years, the proportion of adults aged 18 to 64 years unable to see a physician owing to cost increased, mostly because of an increase among persons with insurance.”