National Healthcare Disparities Report, 2007

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Chapter 3. Access to Health Care (continued)

Health Care Utilization

Measures of health care utilization complement patient reports of barriers to care and permit a fuller understanding of access to care. Barriers to care that are associated with differences in health care utilization may be more significant than barriers that do not affect utilization. Landmark reports on disparities have relied on measures of health care utilization,^{17, 18} and these data demonstrate some of the largest differences in care among diverse groups. More recent efforts to inform health care delivery continue to include measures of health care utilization.¹⁹

Interpreting health care utilization data is more complex than analyzing data on patient perceptions of access to care. Along with access to care, health care utilization is strongly affected by health care need and patient preferences and values. In addition, greater use of services does not necessarily indicate better care. In fact, high use of some inpatient services may reflect impaired access to outpatient services. Therefore, the key to symbols used in Tables 3.2a and 3.2b, which summarize findings on all core measures related to health care utilization, is different from that used for Tables 3.1a and 3.1b. Rather than indicating better or worse access compared with the comparison group, symbols on the utilization tables simply identify the amount of care received by racial or ethnic minority and socioeconomic groups relative to their comparison groups.

In 2004, the Nation's 14 million health services workers²⁰ provided about 910 million office visits²¹ and 662 million hospital outpatient visits²² and treated 37 million hospitalized patients²²and 1.4 million nursing home residents.²³ About 70% of the civilian noninstitutionalized population visit a medical provider's office or outpatient department, about 60% receive a prescription medicine, and about 40% visit a dental provider each year.²⁴

National health expenditures totaled about $2.0 trillion in fiscal year 2004, nearly doubling those of a decade earlier, in 1994.²⁵ Health expenditures among the civilian noninstitutionalized population in America are extremely concentrated, with 5% of the population accounting for 55% of outlays.²⁶ In addition, a study using earlier data estimated that as much as $420 billion a year—almost a third of all health care expenditures—are the result of poor quality care, including overuse, misuse, and waste.²⁷

Previous NHDRs reported that different racial, ethnic, and socioeconomic groups had different patterns of health care utilization. Asians and Hispanics tended to have lower use of most health care services, including routine care, emergency department visits, avoidable admissions, and mental health care. Blacks tended to have lower use of routine care, outpatient mental health care, and outpatient HIV care but higher use of emergency departments and hospitals, including higher rates of avoidable admissions, inpatient mental health care, and inpatient HIV care. Lower socioeconomic status individuals tended to have lower use of routine care and outpatient mental health care and higher use of emergency departments, hospitals, and home heath care. In this section, findings related to dental care, potentially avoidable admissions, and mental health care and substance abuse treatment are highlighted.

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Dental Visits

Regular dental visits promote prevention, early diagnosis, and optimal treatment of oral diseases and conditions. Failure to visit the dentist can result in delayed diagnosis, overall compromised health, and, occasionally, even death.²⁸

Figure 3.9. Persons with a dental visit in the past year, by race (top left), ethnicity (top right), and income (bottom left), 2002-2004

Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2004.

Reference population: Analyses by race, ethnicity, and income performed for civilian noninstitutionalized persons, all ages.

There were no significant changes in the proportion of persons with a dental visit in the past year from 2002 to 2004 across racial, ethnic, or income categories (Figure 3.9).
From 2002 to 2004, the gap between Blacks and Whites in the proportion of persons with a dental visit in the past year remained the same. In 2004, the proportion was significantly lower for Blacks than for Whites (30.5% compared with 45.9%).
During the same period, the gap between Hispanics and non-Hispanic Whites remained the same. In 2004, the proportion was significantly lower for Hispanics than for non-Hispanic Whites (28.9% compared with 49.4%).
In 2004, the gap between poor people and high income people remained the same. The proportion was significantly lower for poor (26.5%), near poor (29.9%), and middle income people (41.9%) than for high income people (57.9%).
Only high income persons met the Healthy People 2010 target of 56% of persons with a dental visit in the past year.

To distinguish the effects of race, ethnicity, and socioeconomic status on health care utilization and to identify populations at greatest risk for barriers to health care utilization, this measure is stratified by income.

Figure 3.10. Persons with a dental visit in the past year, by race (left) and ethnicity (right), stratified by income, 2004

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2004.

Reference population: Civilian noninstitutionalized population, all ages.

Note: Data were insufficient for this analysis for Native Hawaiians or Other Pacific Islanders and for American Indians and Alaska Natives.

SES explains some, but not all, of the racial and ethnic differences in rates of dental visits (Figure 3.10).
In all income categories except poor, Blacks were significantly less likely than Whites to have had a dental visit in the past year (near poor—26.7% for Blacks versus 30.5% for Whites, middle income—31.0% for Blacks versus 43.8% for Whites, and high income—42.9% for Blacks versus 59.5% for Whites).
Hispanics in every income level were significantly less likely than non-Hispanic Whites to have had a dental visit (poor—20.2% of Hispanics versus 30.9% of non-Hispanic Whites, near poor—21.1% of Hispanics versus 34.8% of non-Hispanic Whites, middle income—31.4% of Hispanics versus 46.2% of non-Hispanic Whites, high income—49.4% of Hispanics versus 60.4% of non-Hispanic Whites).

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Potentially Avoidable Admissions

Potentially avoidable admissions are hospitalizations that might have been averted by good quality outpatient care. They relate to conditions for which good outpatient care can prevent the need for hospitalization or for which early intervention can prevent complications or more severe disease. Though not all admissions for these conditions can be avoided, rates in populations tend to vary with access to primary care.²⁹ For example, better access to care should facilitate the diagnosis of appendicitis before rupture occurs.

Figure 3.11. Perforated appendix per 1,000 adult admissions with appendicitis, by race/ethnicity (left) and area income (median income of ZIP Code of residence) (right), 2001-2004

Key: API=Asian or Pacific Islander.

Source: Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2001-2004.

Denominator: Patients hospitalized with appendicitis age 18 and over.

Note: White, Black, and API are non-Hispanic groups. Numerical income categories are used instead of the NHDR's usual descriptive categories because that is how data are collected for this measure. Income categories are based on the median household income of the ZIP Code of the patient's residence. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 23 States that have 64% of the U.S. resident population. Data were not collected for American Indians and Alaska Natives.

From 2001 to 2004, the gap between Blacks and Whites in the proportion of hospital admissions for perforated appendix decreased (Figure 3.11). In 2004, the rates for Blacks and Whites were not statistically different.
During this period, the gap between Asians or Pacific Islanders (APIs) and Whites in the proportion of perforated appendix admissions changed. In 2001, the proportions for APIs and Whites were not statistically different. However, in 2004, the proportion was lower for APIs than Whites (266.8 per 1,000 compared with 287.8 per 1,000).
The gap between Hispanics and non-Hispanic Whites decreased. In 2004, the disparity between Hispanics and Whites was eliminated (291.8 per 1,000 compared with 287.8 per 1,000).
From 2001 to 2004, the gap between people living in poor communities and those living in high income communities in the proportion of hospital admissions for perforated appendix decreased. In 2004, the disparity was eliminated; there was no statistical difference between people living in poor communities and those living in high income communities.

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Mental Health Care and Substance Abuse Treatment

Mental Health Care

In 2004-2005, 7.6% of American adults, or about 16.4 million persons, reported having experienced at least one major depressive episode during the past year.³⁰ Although the prevalence of mental disorders for racial and ethnic minorities in the United States is similar to that for Whites,³¹ minorities have less access to mental health care and are less likely to receive needed services.³² These differences may reflect, in part, variation in preferences and cultural attitudes toward mental health.

Figure 3.12. Adults who received mental health treatment or counseling in the past year, by race (top left), ethnicity (top right), and education (bottom left), 2003-2005

Key: AI/AN=American Indian or Alaska Native.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2003-2005.

Reference population: U.S. population age 18 and over.

Note: Data were insufficient for this analysis for Native Hawaiians or Other Pacific Islanders.

From 2003 to 2005, the gap between Blacks and Whites in the proportion of persons who received mental health treatment or counseling remained the same (Figure 3.12). In 2005, there was no statistically significant difference between Blacks and Whites.
The gap between AI/ANs and Whites remained the same. (There was no statistical change for either group from 2003 to 2005.) In 2005, the proportion was lower for AI/ANs than Whites (12.7% compared with 14.0%).
The gap between Asians and Whites in the proportion of persons who received mental health treatment or counseling remained the same. In 2005, the proportion for Asians was less than a third that of Whites (4.0% compared with 14.0%).
The gap between Hispanics and non-Hispanic Whites remained the same. In 2005, the proportion for Hispanics was just over half that of non-Hispanic Whites (7.8% compared with 15.1%).
The gap in mental health services use between people with less than a high school education and people with some college education remained the same. In 2005, the proportion was lower for people with less than a high school education than for people with some college education (10.9% compared with 14.4%).

Substance Abuse Treatment

In 2005, about 16 million Americans age 12 and over acknowledged being heavy alcohol drinkers, and about 55 million acknowledged having had a recent binge drinking episode.³³ About 19.7 million persons age 12 and over were illicit drug users, and about 71.5 million reported recent use of a tobacco product.³³ In 2001, an estimated $18 billion was devoted to treatment of substance use disorders. This amount constituted 1.3% of all health care spending.³⁴

Racial, ethnic, and socioeconomic differences in substance abuse treatment³² may, in part, reflect variation in preferences and cultural attitudes toward mental health and substance abuse.

Figure 3.13. Persons age 12 and over who received any illicit drug or alcohol abuse treatment in the past year, by race (top left), ethnicity (top right), and education (bottom left), 2003-2005

Trend line graphs show percentage of persons age 12 and over who received any illicit drug or alcohol abuse treatment in the past year. By Education: Less than High School: 2003, 2.3; 2004, 2.8; 2005, 2.7. High School Grad: 2003, 1.6; 2004, 1.8; 2005, 1.8. Some College: 2003, 1; 2004, 1; 2005, 1.2.

Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2003-2005.

Reference population: U.S. population age 12 and over.

Note: The figure reflects both prevalence and treatment; prevalence likely has an effect on racial/ethnic differences in treatment.

From 2003 to 2005, the gap between AI/ANs and Whites in the proportion of persons age 12 and over who received any illicit drug or alcohol abuse treatment remained the same (Figure 3.13). In 2005, the proportion was two times higher for AI/ANs than for Whites (3.0% compared with 1.5%).
During this period, the gap between Asians and Whites in the proportion of persons age 12 and over who received drug or alcohol abuse treatment remained the same. In 2005, the proportion of persons age 12 and over who received any illicit drug or alcohol abuse treatment was lower for Asians than for Whites (0.4% compared with 1.5%).
During this period, there were no significant differences for Hispanics and non-Hispanic Whites.
The gap between people with less than a high school education and people with some college education remained the same. In 2005, the proportion was more than two times higher for people with less than a high school education than for people with some college education (2.7% compared with 1.2%).

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Summary Tables

Table 3.1a. Racial and Ethnic Differences in Facilitators and Barriers to Health Care

Core Report Measure	Racial Differenceⁱ					Ethnic Differenceⁱⁱ
	Black	Asian	NHOPI	AI/AN	>1 Race	Hispanic
Health Insurance Coverage
Persons under 65 with health insuranceⁱⁱⁱ	↓	=	=	↓	=	↓
Persons uninsured all year^iv	=	=	=	↓	=	↓
Usual Source of Care
Persons who have a specific source of ongoing careⁱⁱⁱ	↓	=	↓	=	=	↓
Persons who have a usual primary care provider^iv	↓	=	=	=	=	↓
Patient Perceptions of Need
People who experience difficulties or delays in obtaining health care or do not receive needed care^iv	=	↑		=	↓	↑
People who experience difficulties or delays in obtaining health care due to financial or insurance reasons^iv	=	=			↓	↓

ⁱ Compared with Whites.

ⁱⁱ Compared with non-Hispanic Whites.

ⁱⁱⁱ Source: National Health Interview Survey, 2005.

^iv Source: Medical Expenditure Panel Survey, 2004.

Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

Key to Symbols Used in Access to Health Care Tables:
= Group and comparison group have about same access to health care.
↑ Group has better access to health care than the comparison group.
↓ Group has worse access to health care than the comparison group.
Blank cell: Reliable estimate for group could not be made.

Table 3.1b. Socioeconomic Differences in Facilitators and Barriers to Health Care

Core Report Measure	Income Differenceⁱ			Educational Differenceⁱⁱ		Insurance Differenceⁱⁱⁱ
	<100%	100-199%	200-399%	<HS	HS Grad	Uninsured
Health Insurance Coverage
Persons under 65 with health insurance^iv	↓	↓	↑	↓	↓
Persons uninsured all year^v	↓	↓	↑	↓	↓
Usual Source of Care
Persons who have a specific source of ongoing care^iv	↓	↓	↑	↓	↓	↓
Persons who have a usual primary care provider^v	↓	↓	↑	↓	↓	↓
Patient Perceptions of Need
People who experience difficulties or delays in obtaining health care or do not receive needed care^v	↓	↓	↑	↓	↓	↓

ⁱ Compared with persons with family incomes 400% of Federal poverty thresholds or above.

ⁱⁱ Compared with persons with any college education.

ⁱⁱⁱ Compared with persons under 65 with any private health insurance.

^iv Source: National Health Interview Survey, 2005.

^v Source: Medical Expenditure Panel Survey, 2004.

Key: HS=High school.

Table 3.2a. Racial and Ethnic Differences in Health Care Utilization

Core Report Measure	Racial Differenceⁱ					Ethnic Differenceⁱⁱ
	Black	Asian	NHOPI	AI/AN	>1 Race	Hispanic
General Medical Care
Persons with a dental visit in the past yearⁱⁱⁱ	↓	=	=	↓	=	↓
Avoidable Admissions
Admissions for perforated appendix per 1,000 admissions with appendicitis^v	=	↑				=
Mental Health Care and Substance Abuse Treatment
Adults who received mental health treatment or counseling in the past year^v	=	↓		=	=	=
People age 12 and older who received illicit drug or alcohol abuse treatment in the past year^v	↑	↓		↑	=	=

ⁱ Compared with Whites.

ⁱⁱ Compared with non-Hispanic Whites.

ⁱⁱⁱ Source: Medical Expenditure Panel Survey, 2004.

^iv Source: HCUP SID disparities analysis file, 2004. This source categorizes race/ethnicity very differently from other sources. Race/ethnicity information is categorized as a single item: Non-Hispanic White, Non-Hispanic Black, Hispanic, Asian or Pacific Islander. These contrasts compare each group with non-Hispanic Whites.

^v Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2005.

Key: NHOPI=Native Hawaiian or Other Pacific Islander; AI/AN=American Indian or Alaska Native.

Key to Symbols Used in Health Care Utilization Tables:
= Group and comparison group receive about same amount of health care.
↑ Group receives more health care than the comparison group.
↓ Group receives less health care than the comparison group.
Blank cell: Reliable estimate for group could not be made.

Table 3.2b.Socioeconomic Differences in Health Care Utilization

Core Report Measure	Income Differenceⁱ			Educational Differenceⁱⁱ		Insurance Differenceⁱⁱⁱ
	<100%	100-199%	200-399%	<HS	HS Grad	Uninsured
General Medical Care
Persons with a dental visit in the past year^iv	↓	↓	↑	↓	↓	↓
Mental Health Care and Substance Abuse Treatment
Adults who received mental health treatment or counseling in the past year^v	=	=	=	=	=
Persons age 12 and older who received illicit drug or alcohol abuse treatment in the past year^v	↓	↓	=	↓	↓

ⁱ Compared with persons with family incomes 400% of Federal poverty threshold or above.

ⁱⁱ Compared with persons with any college education.

ⁱⁱⁱ Compared with persons under 65 with any private health insurance.

^iv Source: Medical Expenditure Panel Survey, 2004.

^v Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2005. Insurance disparities were not analyzed.

Key: HS=high school.

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