Chapter 3. Access to Health Care

Contents

Facilitators and Barriers to Health Care
Health Care Utilization
Summary Tables
References

Many Americans have good access to health care that enables them to benefit fully from the Nation's health care system. Others face barriers that make the acquisition of basic health care services difficult. As demonstrated by extensive research and confirmed in previous National Healthcare Disparities Reports (NHDRs), racial and ethnic minorities and people of low socioeconomic status (SES)ⁱ are disproportionately represented among those with access problems. Poor access to health care comes at both a personal and societal cost. For example, if people do not receive vaccinations, they may become ill and spread disease to others, increasing the burden of disease for society overall in addition to the burden borne individually.

Components of Health Care Access

Access to health care means having "the timely use of personal health services to achieve the best health outcomes."¹ Attaining good access to care requires three discrete steps:

• Gaining entry into the health care system.
• Getting access to sites of care where patients can receive needed services.
• Finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and trust.²

Health care access is measured in several ways, including:

• Structural measures of the presence or absence of specific resources that facilitate health care, such as having health insurance or a usual source of care.
• Assessments by patients of how easily they are able to gain access to health care.
• Utilization measures of the ultimate outcome of good access to care (i.e., the successful receipt of needed services).

Return to Contents

How This Chapter Is Organized

This chapter presents new information about disparities in access to health care in America. It is divided into two sections:

• Facilitators and barriers to health care, including measures of health insurance coverage, usual source of care and primary care provider, and patient perceptions of need.
• Health care utilization, including measures of dental care, emergency care, potentially avoidable admissions, mental health care, and substance abuse treatment.

---

ⁱ As described in Chapter 1, Introduction and Methods, income and educational attainment are used to measure SES in the NHDR. Unless specified, poor = below the Federal poverty level (FPL), near poor = 100-199% of the FPL, middle income = 200-399% of the FPL, and high income = 400% or more of the FPL. See measure specifications and data source descriptions for more information on income groups by data source.

---

Information about patient-provider communication is found in the section on patient centeredness in Chapter 2, Quality of Health Care. As in previous NHDRs, this chapter focuses on disparities in access to care related to race, ethnicity, and SES status in the general U.S. population. Disparities in access to care and patient-provider communication within specific priority populations are discussed in Chapter 4, Priority Populations. Analyses of changes over time and stratified analyses are also presented in this chapter.

Return to Contents

Facilitators and Barriers to Health Care

Facilitators and barriers to health care discussed in this section include health insurance, usual source of care (including having a usual source of ongoing care and a usual primary care provider), and patient perceptions of need. (Go to Tables 3.1a and 3.1b for a summary of findings related to all core measures on facilitators and barriers to health care.)

Health Insurance

Health insurance facilitates entry into the health care system. Uninsured people are less likely to receive medical care³ and are more likely to die early⁴ and have poor health status.⁵ The costs of early death and poor health among uninsured people total $65 billion to $130 billion.⁴ The financial burden of uninsurance is also great for uninsured individuals; almost 50% of personal bankruptcy filings are due to medical expenses.⁶ Uninsured individuals report more problems getting care, are diagnosed at later disease stages, and get less therapeutic care.^6,7 They are sicker when hospitalized and more likely to die during their stay. ⁷

Figure 3.1. Persons under age 65 with health insurance, by race (top left), ethnicity (top right), income (bottom left), and education (bottom right), 1999-2006

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

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey (NHIS), 19992006.

Reference population: Analyses by race, ethnicity, and income performed for civilian noninstitutionalized population under age 65. Analyses by education performed for civilian noninstitutionalized population ages 2564.

Note: NHIS respondents are asked about health insurance coverage at the time of interview; respondents are considered uninsured if they lack private health insurance, Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), a State-sponsored health plan, other government-sponsored health plan, or a military health plan, or if their only coverage is through the Indian Health Service. This measure reflects the percentage of survey respondents under age 65 who were covered by health insurance at the time of the interview.

• From 1999 to 2006, the gap between Blacks and Whites in insurance coverage decreased (Figure 3.1). In 2006, the percentage of people with insurance was lower for Blacks than for Whites (81.9% compared with 83.3%).
• From 1999 to 2006, the gap between Hispanics and non-Hispanic Whites in insurance coverage remained the same. In 2006, the percentage of people with insurance was lower for Hispanics than for non-Hispanic Whites (65.0% compared with 87.5%).
• The gap between poor people and high-income people decreased during this period. Still, in 2006, the percentage of people with insurance was significantly lower for poor people than for high-income people (69.8% compared with 93.5%).
• The gap between people with less than a high school education and people with some college increased. In 2006, the percentage of people with insurance was almost one-third lower for people with less than a high school education than for people with some college (60.3% compared with 89.1%).
• From 1999 to 2006, the rates of insurance worsened for Whites, high-income people, and people at every education level. There were no statistically significant changes in the rate of insurance for Blacks, Asians, American Indians and Alaska Natives (AI/ANs), non-Hispanic Whites, and Hispanics.

Racial and ethnic minorities are disproportionately of lower SES.⁸ To distinguish the effects of race, ethnicity, income, and education on health insurance coverage, this measure is stratified by income and education level.

Figure 3.2. People under age 65 with health insurance, by race (left) and ethnicity (right), stratified by income, 2006

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

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey (NHIS), 2006.

Reference population: Civilian noninstitutionalized population under age 65.

Note: NHIS respondents are asked about health insurance coverage at the time of interview; respondents are considered uninsured if they lack private health insurance, public assistance, Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), a State-sponsored health plan, other government-sponsored health plan, or a military health plan, or if their only coverage is through the Indian Health Service. This measure reflects the percentage of survey respondents under age 65 who were covered by health insurance at the time of the interview.

Figure 3.3. People under age 65 with health insurance, by race (left) and ethnicity (right), stratified by education, 2006

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

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey (NHIS), 2006.

Reference population: Civilian noninstitutionalized population ages 25-64.

Note: NHIS respondents are asked about health insurance coverage at the time of interview; respondents are considered uninsured if they lack private health insurance, public assistance, Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), a State-sponsored health plan, other government-sponsored health plan, or a military health plan, or if their only coverage is through the Indian Health Service. This measure reflects the percentage of survey respondents under age 65 who were covered by health insurance at the time of the interview.

• SES explains some but not all of the differences in the health insurance coverage of racial and ethnic groups in people under age 65 (Figures 3.2 and 3.3).
• Hispanics of every income and education level were significantly less likely than their non-Hispanic peers to have health insurance.
• Blacks who were poor and had less than a high school education (76.7% and 68.1%, respectively) were significantly more likely than their White counterparts (67.1% and 58.4%, respectively) to have health insurance.
• AI/ANs at every income level except poor and every education level except less than high school were significantly less likely to have health insurance than Whites.
• Among people with a high school education, Blacks (74.5%), Asians (69.2%), and AI/ANs (54.5%) were significantly less likely than Whites (79.4%) to have health insurance. Hispanics (65.7%) also were significantly less likely than non-Hispanic Whites (81.6%) to have health insurance.
• No group has yet achieved the Healthy People 2010 target of 100% of Americans with health insurance.

Prolonged periods of uninsurance can have a particularly serious impact on a person's health and stability. Uninsured people often postpone seeking care, have difficulty obtaining care when they ultimately seek it, and may have to bear the full brunt of health care costs. Over time, the cumulative consequences of being uninsured compound, resulting in a population at particular risk for suboptimal health care and health status.

Figure 3.4. People under age 65 who were uninsured all year, by race (top left), ethnicity (top right), income (bottom left), and education (bottom right), 2002-2005

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

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2005.

Reference population: Analyses by race, ethnicity, and income performed for civilian noninstitutionalized population under age 65. Analyses by education performed for civilian noninstitutionalized population ages 18-64.

Note: Beginning in 2002, survey respondents could report more than one race. Estimates for racial groups other than Whites and Blacks are significantly affected by this change. Data for these groups are not directly comparable with earlier years and are not shown here. Racial categories shown here exclude multiple-race individuals, who are shown as a separate group.

• From 2002 to 2005, the gap between Blacks and Whites in the percentage of uninsured people remained the same (Figure 3.4). The percentage of people uninsured all year was still higher for Blacks than for Whites in 2005 (15.6% compared with 13.8%).
• From 2002 to 2005, the gap between Hispanics and non-Hispanic Whites in the percentage of uninsured people remained the same. The percentage of people uninsured all year was still almost three times higher for Hispanics than for non-Hispanic Whites in 2005 (28.5% compared with 10.3%).
• From 2002 to 2005, the gap between poor people and high-income people in the percentage of uninsured people remained the same. In 2005, the percentage of people uninsured all year was still nearly four times higher for poor people than for high-income people (24.3% compared with 6.2%).
• From 2002 to 2005, the gap between people with less than a high school education and people with some college in the percentage of uninsured people increased. The percentage of people uninsured all year increased for people with less than a high school education (from 30.2% to 33.3%).

Each year, multivariate analyses are conducted in support of the NHDR to identify the independent effects of race, ethnicity, and SES on access to health care. Past reports have listed some of these findings. Figure 3.5 shows the results of a multivariate model for one additional access measure: people without insurance all year. Adjusted odds ratios are shown to quantify the relative magnitude of disparities after controlling for a number of confounding factors.

Figure 3.5. People ages 18-64 who were uninsured all year: Adjusted odds ratios, 2002-2005

Key: ■ = reference group.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2005.

Reference population: Civilian noninstitutionalized population ages 18-64.

Note: Adjusted odds ratios are calculated from logistic regression models controlling for race, ethnicity, income, education, age, gender, insurance, and residence location. White, non-Hispanic White, male, high income, some college, and metropolitan are reference groups with odds ratio = 1; odds ratios <1 indicate that a group is less likely to receive service than the reference group. For example, compared with non-Hispanic Whites, Hispanics had 2.5 times the odds of having no insurance after controlling for other factors. Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders and for American Indians and Alaska Natives.

From 2002 to 2005, in multivariate models controlling for race, ethnicity, gender, income, education, insurance, and residence location:

• Blacks had 0.9 times the odds and Asians had 1.1 times the odds of being uninsured all year compared with Whites (Figure 3.5).
• Hispanics had 2.5 times the odds of being uninsured all year compared with non-Hispanic Whites.
• Poor individuals had 5.8 times the odds of being uninsured all year compared with high-income individuals.
• Females had 0.6 times the odds of being uninsured all year compared with males.
• Individuals within nonmetropolitan areas had 1.1 times the odds of being uninsured all year compared with individuals within metropolitan areas.

Return to Contents

Usual Source of Care

People with a usual source of care (a facility where one regularly receives care) experience improved health outcomes and reduced disparities (smaller differences between groups) ⁹ and costs,¹⁰ yet more than 40 million Americans do not have a specific source of ongoing care.¹¹

Specific Source of Ongoing Care

Higher costs, poorer outcomes, and greater disparities (larger differences between groups) are observed among individuals without a usual source of care.¹²

Figure 3.6. People with a specific source of ongoing care, by race (top left), ethnicity (top right), income (bottom left), and education (bottom right), 1999-2006

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

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 1999-2006.

Reference population: Analyses by race, ethnicity, and income performed for civilian noninstitutionalized population of all ages. Analyses by education performed for civilian noninstitutionalized population ages 25-64.

Note: Measure is age adjusted. Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders.

• From 1999 to 2006, the gap in usual source of care between Hispanics and non-Hispanic Whites remained the same (Figure 3.6). In 2006, the percentage of people with a specific source of ongoing care was significantly lower for Hispanics than for non-Hispanic Whites (74.3% compared with 88.8%).
• During this period, the gap between poor people and high-income people remained the same. In 2006, the percentage of people with a specific source of ongoing care was significantly lower for poor people than for high-income people (77.8% compared with 91.7%).
• No group has yet achieved the Healthy People 2010 target of 96% of Americans with a specific source of ongoing care.

Usual Primary Care Provider

Having a usual primary care provider (a doctor or nurse from whom one regularly receives care) is associated with patients' greater trust in their provider¹³ and with good patient-provider communication. These factors increase the likelihood that patients will receive appropriate care.¹⁴ By learning about patients' diverse health care needs over time, a usual primary care provider can coordinate care (e.g., visits to specialists) to better meet patients' needs.¹⁵ Indeed, having a usual primary care provider correlates with receipt of higher quality care.^16,17

Figure 3.7. People with a usual primary care provider, by race (top left), ethnicity (top right), income (bottom left), and education (bottom right), 2002-2005

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

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2005.

Reference population: Analyses by race, ethnicity, and income performed for civilian noninstitutionalized population of all ages. Analyses by education performed for civilian noninstitutionalized population age 18 and over.

Note: A usual primary care provider is defined as the source of care that a person usually goes to for new health problems, preventive health care, and referrals to other health professionals. Data are age adjusted. Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders.

• From 2002 to 2005, the gap between Asians and Whites remained the same. In 2005, Asians were less likely than Whites to have a usual primary care provider (70.2% compared with 77.5%; Figure 3.7).
• The gap between Hispanics and non-Hispanic Whites remained the same. In 2005, the percentage of people with a usual primary care provider was significantly lower for Hispanics than for non-Hispanic Whites (64.6% compared with 80.4%).
• The gap between poor people and high-income people remained the same. In 2005, the proportion of people with a usual primary care provider was significantly lower for poor people than for high-income people (70.4% compared with 81.1%).
• The gap between people with less than a high school education and people with some college remained the same. In 2005, the proportion of people with a usual primary care provider was significantly lower for people with less than a high school education than for people with some college (66.5% compared with 74.9%).
• No group has yet achieved the Healthy People 2010 target of 85% of Americans with a usual primary care provider.

Each year, multivariate analyses are conducted in support of the NHDR to identify the independent effects of race, ethnicity, and SES on access to health care. Past reports have listed some of these findings. Figure 3.8 shows the results of a multivariate model for people who have a usual primary care provider. Adjusted odds ratios are shown to quantify the relative magnitude of disparities after controlling for a number of confounding factors.

Figure 3.8. People ages 18-64 with a usual primary care provider: Adjusted odds ratios, 2002-2005

Key: ■ = reference group.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2005.

Reference population: Civilian noninstitutionalized population ages 18-64.

Note: Adjusted odds ratios are calculated from logistic regression models controlling for race, ethnicity, income, education, age, gender, insurance, and residence location. White, male, non-Hispanic White, high income, some college, private insurance, and metropolitan are reference groups with odds ratio = 1; odds ratios <1 indicate that a group is less likely to receive service than the reference group. For example, compared with individuals with private insurance, individuals with no insurance had 0.3 times the odds of reporting a usual primary care provider after controlling for other factors. Data were insufficient for this analysis for Native Hawaiians and Other Pacific Islanders and for American Indians and Alaska Natives.

From 2002 to 2005, in multivariate models controlling for race, gender, ethnicity, income, education, insurance, and residence location:

• Blacks had 0.9 times the odds and Asians had 0.7 times the odds of having a usual primary care provider compared with Whites (Figure 3.8).
• Females had 1.7 times the odds of having a usual primary care provider compared with males.
• Hispanics had 0.6 times the odds of having a usual primary care provider compared with non-Hispanic Whites.
• Poor individuals had 0.7 times the odds of having a primary care provider compared with high-income individuals.
• Individuals with no health insurance had 0.3 times the odds of having a usual primary care provider compared with individuals with private insurance.
• Individuals within nonmetropolitan areas had 1.2 times the odds of having a usual primary care provider compared with individuals within metropolitan areas.

Return to Contents

Patient Perceptions of Need

Patient perceptions of need include perceived difficulties or delays in obtaining care and problems getting care as soon as it is wanted. Although patients may not always be able to assess their need for care, problems getting care when patients perceive that they are ill or injured likely reflect significant barriers to care.

Figure 3.9. People who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines in the last 12 months for financial or insurance reasons, by race, ethnicity, income, education, and insurance status, 2005

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005.

Denominator: Analyses by race, ethnicity, income, and insurance performed for civilian noninstitutionalized population, all ages. Analyses by education performed for civilian noninstitutionalized population age 18 and over.

• Among people who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines, the percentage who cited financial or insurance reasons was higher for Blacks and people of multiple race than for Whites (73.1% and 81.8% respectively, compared with 64.2%; Figure 3.9) and higher for Hispanics than for non-Hispanic Whites (83.3% compared with 61.2%).
• Among people who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines, the percentage who cited financial or insurance reasons was significantly higher for poor (78.0%), near-poor (79.6%), and middle-income (65.3%) people than for high-income people (44.2%).
• Among people who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines, the percentage who cited financial or insurance reasons was almost two times higher for people with no health insurance than for people with private insurance (91.1% compared with 57.2%).

Return to Contents