Strategies to Reduce Health Disparities

"Voltage Drops" in Care

Presenter: Carolyn M. Clancy, M.D., Director, Center for Outcomes and Effectiveness Research, Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services, Rockville, MD

Although the American health care system is believed by many to be the best in the world, disparities exist in the quality of care that people receive around the country and across different institutions. The availability of health care does not necessarily mean that Americans are receiving the best possible care. Between the availability of insurance and the delivery of quality care, there are many "voltage drops" that interfere with the system's ability to meet people's needs.

Points at which the high quality of care can be lost include:

• Access to insurance coverage.
• Enrollment in available insurance plans.
• Access to covered services, clinicians, and health care institutions.
• Choice of plans, clinicians, and health care institutions.
• Access to a consistent source of primary care.
• Access to referral services.
• Delivery of high-quality health care services.

Access to insurance coverage

Even though the United States has taken steps to increase access to health care, the numbers of uninsured continue to grow. Approximately 17 percent of the U.S. population is uninsured (roughly one in six Americans). The 1997 AHRQ Medical Expenditure Panel Survey (MEPS) shows that more than 20 percent of black Americans and more than 33 percent of Hispanic Americans lack health insurance, compared with 12 percent of white people.

Enrollment in available insurance plans

Even when health insurance is available, people who are eligible do not always enroll because of barriers such as:

• Cost.
• Affordability.
• Differences in eligibility policies from State to State.
• The stigma of applying for publicly funded "welfare" programs.
• Literacy.
• Language and cultural barriers.

For example, the majority of the uninsured that have access to employer-based insurance do not enroll because of cost.

Access to covered services, clinicians, and health care institutions

Being insured does not guarantee access to all services, clinicians, and institutional providers.

• Certain services may not be covered.
• Certain physicians or hospitals may not participate in a plan.
• Cost-sharing policies may deter patients from seeking care.

Choice of plans, clinicians, and health care institutions

In a market-driven health system, the consumer should have the ability to choose plans and providers based on:

• Location.
• Price.
• Covered services.
• Quality.

In the United States, the consumer does not always have the ability to make an educated choice because of a lack of information and because employers may limit plan choices for their employees based on cost.

Access to a consistent source of primary care

Regularity of treatment is essential to improving health outcomes, especially for those with chronic illnesses. Patients can choose a plan that covers a service, but finding a provider that offers that service regularly can be difficult because of geographic issues, need for a particular doctor not covered by the plan, or other factors.

Access to referral services

Even though insurance and a usual source of care are available, individuals may still lack access to referral services that are essential to receiving high-quality care. For example, black persons undergo fewer coronary revascularization procedures than white people and are less likely than white persons to undergo surgery for specific conditions, even though these services may be needed.

Delivery of high-quality health care services

Even when all other voltage drops are addressed, there is evidence that the quality of care is not as good as it should be. Many examples can be found of quality gaps that fall into categories of underuse, overuse, and misuse. Performing the right service in the correct fashion at the right time is very important, but health care quality must also address the patient's needs. Failure to do this is another way in which a voltage drop can occur in the delivery of high-quality care.

Additional Resources

Eisenberg JM, Power EJ. Transforming insurance coverage into quality health care: Voltage drops from potential to delivered quality. JAMA 2000;284(16):2100-07.

White E. Public health lawmakers, agencies move to reduce racial and ethnic disparities in health. BNA Health Care Daily Report 6(38). Washington (DC): The Bureau of National Affairs, Inc.; 2001 Feb.

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