Access to Care

Usual Source of Care

Higher costs, poorer outcomes, and greater disparities are observed among individuals without a usual source of care.⁴⁷ Women tend to have a usual source of care more often than men, but disparities are seen among women in different income groups.

Figure 4.34. People with a specific source of ongoing care, by race, ethnicity, and income, stratified by gender, 2007

         

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

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2007.

Denominator: Civilian noninstitutionalized population, all ages.

Note: Measure is age adjusted to the 2000 standard population.

• Overall, the percentage of people with a specific source of ongoing care was significantly higher for females than for males (89.8% compared with 82.8%; Figure 4.34).
• The percentage was also significantly higher for females than for males among all racial and ethnic groups: Whites (89.9% for females compared with 82.8% for males), Blacks (89.0% compared with 82.2%), Asians (89.6% compared with 85.5%), AI/ANs (90.5% compared with 73.1%), non-Hispanic Whites (91.5% compared with 85.3%), and Hispanics (82.9% compared with 72.1%).
• Among females, the percentage was significantly lower for poor (83.4%), near-poor (84.9%), and middle-income (90.1%) individuals than for high-income individuals (95.0%).
• There were no statistically significant differences by race or ethnicity among females.

Figure 4.35. People without a usual source of care who indicate a financial or insurance reason for not having a source of care, by race and ethnicity, stratified by gender, 2006

         

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006.

Note: Data for Native Hawaiians and Other Pacific Islanders, American Indians and Alaska Natives, and Asian males did not meet the criteria for statistical reliability, data quality, or confidentiality.

• Females were more likely than males to lack a usual source of care due to financial or insurance reasons (20.0% compared with 14.9%; Figure 4.35). However, there were no statistically significant differences by gender among any of the racial or ethnic groups.
• There were no statistically significant racial or ethnic differences among females.

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Patient Safety

Obstetric Trauma

Childbirth and reproductive care are the most common reasons for women of childbearing age to use health care. With more than 11,000 births each day in the United States, childbirth is the most common reason for hospital admission.⁴⁸ Obstetric trauma involving a severe tear (i.e., 3^rd or 4^th degree laceration) to the vagina or surrounding tissues during delivery is a common complication of childbirth.

The higher risk of severe perineal laceration may be related to the degree of fetal-maternal size disproportion. API women with the smallest body size experience most obstetric trauma.⁴⁹ In addition, although any delivery can result in trauma, existing evidence shows that severe perineal trauma can be reduced by restricted use of episiotomy and forceps.⁵⁰

This year, the NHDR presents a measure of obstetric trauma occurring in vaginal deliveries without instrument assistance.

Figure 4.36. Obstetric trauma with 3^rd or 4^th degree laceration per 1,000 vaginal deliveries without instrument assistance, by race/ethnicity, 2006

Key: API = Asian or Pacific Islander.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2006.

Note: White, Black, and API are non-Hispanic. Data were not available for American Indians and Alaska Natives. Data are adjusted for age, gender, and diagnosis-related group clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population.

• In 2006, the overall rate of obstetric trauma with 3^rd or 4^th degree laceration was lower for Black women and Hispanic women compared with White women (26.1 per 1,000 vaginal deliveries without instrument assistance and 30.1 per 1,000, respectively, compared with 39.1 per 1,000; Figure 4.36).
• The overall rate of obstetric trauma with 3^rd or 4^th degree laceration was higher for API women than for White women (57.4 per 1,000 vaginal deliveries without instrument assistance compared with 39.1 per 1,000).

Figure 4.37. Obstetric trauma with 3^rd or 4^th degree laceration per 1,000 vaginal deliveries without instrument assistance, by race/ethnicity, stratified by area income, 2006

Key: API = Asian or Pacific Islander.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2001-2006.

Note: White, Black, and API are non-Hispanic. Data were not available for American Indians and Alaska Natives. Data are adjusted for age, gender, and diagnosis-related group clusters. Quartile income categories are used instead of the NHDR's usual descriptive categories because that is how data are collected for this measure. Quartile 1 corresponds to the lowest income quartile, and Quartile 4 corresponds to the highest income quartile. 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 25 States that have 66% of the U.S. resident population.

• The rate of obstetric trauma with 3^rd or 4^th degree laceration was lower for all groups living in communities in the lower income quartile communities compared with patients who lived in communities in the highest income quartile (Quartile 4) (Figure 4.37).
• Within all income groups, the rate of obstetric trauma with 3rd or 4th degree laceration was lower for Black women and Hispanic women compared with White women. The rate was highest for API women.

Figure 4.38. Obstetric trauma with 3^rd or 4^th degree laceration per 1,000 vaginal deliveries without instrument assistance, by race/ethnicity, stratified by insurance, 2006

Key: API = Asian or Pacific Islander.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2006.

Note: White, Black, and API are non-Hispanic. Data were not available for American Indians and Alaska Natives and API women with Medicare. Data are adjusted for age, gender, and diagnosis-related group clusters. The HCUP SID disparities analysis file is designed to provide national estimates using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population.

• Overall, the rate of obstetric trauma with 3^rd or 4^th degree laceration was lower for Medicare^xiv (32.8 per 1,000), Medicaid (28.7 per 1,000), and uninsured or self-pay (33.0 per 1,000) patients compared with patients with private insurance (43.1 per 1,000) (Figure 4.38).
• Among women with private insurance, the rate of obstetric trauma with 3^rd or 4^th degree laceration was lower for Blacks and Hispanics than for Whites (30.4 per 1,000 and 33.1 per 1,000, respectively, compared with 44.6 per 1,000). The rate was highest for APIs (61.3 per 1,000).
• Among women with Medicare,^xiv the rate of obstetric trauma with 3rd or 4th degree laceration was lower for Blacks compared with Whites (14.1 per 1,000 compared with 37.8 per 1,000).
• Among women with Medicaid, the rate of obstetric trauma with 3^rd or 4^th degree laceration was lower for Blacks compared with Whites (23.9 per 1,000 compared with 29.2 per 1,000).
• Among uninsured women, the rate of obstetric trauma with 3^rd or 4^th degree laceration was higher for APIs and Hispanics compared with Whites (48.5 per 1,000 and 33.2 per 1,000, respectively, compared with 30.3 per 1,000).

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Children

Children (individuals less than 18 years old) made up 24.6% of the U.S. population, or 73.7 million people, in 2006.³² Almost 40% of all children were members of racial and ethnic minority groups,⁵¹ and 17.6% of children lived infamilies with incomes below the Federal poverty level.²⁸

Children who are members of racial and ethnic minority groups tend to face greater health risks. For example, in 2003, Black children and AI/AN children had death rates about one and one-half to two times as high as White children. In 2005, Black infants were more than twice as likely as White infants to die during their first year.³⁵ Life expectancy at birth was 78.3 years for White children and 73.2 years for Black children, a difference of about 5 years.³⁵

The NHDR tracks many measures relevant to children. Findings presented here highlight five quality measures and one access measure of particular importance to children (for ages 2 months to 19 years, depending on the measure):

Component of health care need	Measure
Prevention	Early childhood vaccinations, counseling about physical activity, vision screening
Patient safety	Accidental puncture or laceration
Timeliness	Admissions with perforated appendix
Access to care	Health insurance

Quality of Health Care

Prevention: Early Childhood Vaccinations

Childhood vaccinations protect recipients from illness and disability and protect others in the community. Vaccinations are important for reducing mortality and morbidity in populations.

Figure 4.39. Composite measure: Children ages 19-35 months who received all recommended vaccines, by race, ethnicity, and family income, 2000-2007

         

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

Source: Centers for Disease Control and Prevention, National Center for Health Statistics and National Center for Immunization and Respiratory Diseases, National Immunization Survey, 2000-2007.

Denominator: Civilian noninstitutionalized population ages 19-35 months.

Note: Recommended vaccines for children ages 19-35 months are based on the Healthy People 2010 objective and do not include varicella vaccine or vaccines added to the recommended schedule after 1998 for children up to 35 months of age. Racial categories changed in 2000 and may not be comparable with those used for previous years. More information can be found in the Measure Specifications appendix.

• From 2000 to 2007, the gap between Blacks and Whites who received all recommended vaccines decreased (Figure 4.39). However, in 2007, Black children were less likely than White children to receive all recommended vaccines (77.5% compared with 80.9%).
• The gap between Hispanics and non-Hispanic Whites in the percentage of children who received all recommended vaccines decreased during this time. In 2007, there were no statistically significant differences between Hispanics and non-Hispanic Whites.
• In 2007, the percentage of children who received all recommended vaccines was lower for children from poor (76.5%) and near-poor (77.8%) families than for children from high-income families (84.1%).
• Nationally, vaccination coverage levels achieved the Healthy People 2010 objective of 80% of children receiving all recommended vaccines for several groups: White (80.9%), AI/AN (83.5%), non-Hispanic White (81%), middle income (81.8%), and high income (84.1%).

Prevention: Counseling About Physical Activity

Unhealthy eating and lack of physical activity contribute to overweight children. Professional societies recommend routine promotion of healthy eating among children, which may help them form eating habits that will last into adulthood, contributing to better long-term health.

Figure 4.40. Children ages 2-17 whose parents/guardians reported advice from a doctor or other health provider about healthy eating, by race, ethnicity, and family income, 2002-2006

         

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.

Denominator: Civilian noninstitutionalized population ages 2-17.

Note: Data for American Indians and Alaska Natives and Native Hawaiians and Other Pacific Islanders did not meet criteria for statistical reliability.

• In 2006, the percentage of children whose parents or guardians reported advice from a health provider about healthy eating was significantly lower for children from poor (54.2%), near-poor (51.5%), and middle-income (55.0%) families than for children from high-income families (62.9%) (Figure 4.40).
• The percentage of children whose parents or guardians reported advice from a health provider about healthy eating was significantly lower for uninsured children (41.4%) and children with public insurance (53.6%) than for children with private insurance (59.1%; data not shown).
• There were no statistically significant differences by race and ethnicity.

Prevention: Dental Visits

Regular dental visits promote prevention, early diagnosis, and optimal treatment of craniofacial diseases and conditions.⁵² To improve overall oral health, Healthy People 2010 set a goal of increasing the annual percentage of people age 2 and over using the oral health system from 44% to 56%.

Figure 4.41. Children ages 2-17 with a dental visit in the past year, by race, ethnicity, and family income, 2004-2006

         

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2004-2006.

Denominator: Civilian noninstitutionalized population ages 2-17.

• From 2004 to 2006, no statistically significant changes were seen in the percentage of children with a dental visit in the past year in any group (Figure 4.41).
• In 2006, the percentage of children with a dental visit in the past year was lower for Blacks than for Whites (41.8% compared with 54.6%) and for Hispanics than for non-Hispanic Whites (38.6% compared with 59.7%).
• The percentage of children with a dental visit in the past year was lower for children from poor (37.1%), near-poor (41.6%), and middle-income (53.0%) families compared with children from high-income families (68.4%).
• The percentage of children with a dental visit in the past year was lower for children with public insurance (41.4%) and for uninsured children (27.9%) compared with children with private insurance (59.6%; data not shown).

Patient Safety: Accidental Puncture or Laceration

Adverse events occurring during surgical procedures include unintended cuts, punctures, perforations, and lacerations. Such events may be more likely in children, whose smaller anatomy may make avoiding such events more technically challenging. Prior analyses of Healthcare Cost and Utilization Project (HCUP) data from 2000 using earlier versions of the present indicator identified a cumulative incidence of 1 accidental puncture or laceration per 1,000 pediatric discharges. These incidents produced significant associated increases in length of stay, billed charges, and inpatient mortality.⁵³

To the degree that adverse events can be avoided by proper surgical technique, variations in their occurrence may be a marker of differences in the quality of pediatric surgical care. However, such rates are best interpreted in light of the risks associated with medical or surgical discharges of varying complexity.

Figure 4.42. Accidental puncture or laceration during procedure per 1,000 discharges, children under age 18, by race/ethnicity and income, 2006

         

Key: API = Asian or Pacific Islander.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2006.

Note: White, Black, and API are non-Hispanic. The HCUP SID disparities analysis file is designed to provide national estimates on disparities using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population. Income categories are based on the median income of the ZIP Code of the patient's residence. These data are adjusted for age, gender, diagnosis-related group, and comorbidities. Rates include medical or surgical discharges only.

• Black children (0.77 per 1,000 discharges) and Hispanic children (0.71 per 1,000 discharges) had lower rates of accidental puncture or laceration than White children (0.89 per 1,000 discharges). API children had higher rates than Whites (1.16 per 1,000 discharges compared with 0.89 per 1,000 discharges; Figure 4.42).
• There were no significant differences by income.

Timeliness: Admissions With Perforated Appendix

Appendiceal perforation or rupture may increase risks of internal organ damage, female infertility, and even death.⁵⁴ Research suggests that there is little time lag in the United States between the correct diagnosis of appendicitis and surgical intervention.⁵⁵ Therefore, perforated appendix in children may better reflect delayed symptom recognition by parents or providers. In addition, patients may face logistical, financial, racial, sociocultural, and other barriers to timely access to acute care for a time-dependent illness.⁵⁶ Prior studies based on data from HCUP and other sources have identified minority status, lower income, lack of private insurance, and admission from a non-emergency department source as risk factors for discharge with appendiceal rupture.⁵⁷

Figure 4.43. Perforated appendixes per 1,000 admissions with appendicitis, ages 1-17, by race/ethnicity and income, 2006

         

Key: API = Asian or Pacific Islander.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases (SID) disparities analysis file, 2006.

Note: White, Black, and API are non-Hispanic. Rates are adjusted for age and gender. The HCUP SID disparities analysis file is designed to provide national estimates on disparities using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population.

• Among children with appendicitis, hospitalizations involving perforations were higher for Blacks (365.3 per 1,000 admissions), APIs (329.3 per 1,000 admissions), and Hispanics (344.5 per 1,000 admissions) than for Whites (276.1 per 1,000 admissions) (Figure 4.43).
• Among children with appendicitis, hospitalizations involving perforations were higher for those living in poor communities (337.1 per 1,000 admissions), low-income communities (317.8 per 1,000 admissions), and middle-income communities (301.9 per 1,000 admissions) than for those living in high-income communities (268.5 per 1,000 admissions).

To distinguish between the effects of race/ethnicity and income on pediatric discharges with perforated appendix, this measure is stratified by income level.

Figure 4.44. Perforated appendixes per 1,000 admissions with appendicitis, ages 1-17, by race/ethnicity, stratified by income, 2006

Key: API = Asian or Pacific Islander.

Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) disparities analysis file, 2006.

Note: White, Black, and API are non-Hispanic. Quartile income categories are used instead of the NHDR's usual descriptive categories because that is how data are collected for this measure. Quartile 1 corresponds to the lowest income quartile, and Quartile 4 corresponds to the highest income quartile. 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 on disparities using weighted records from a sample of hospitals from 25 States that have 66% of the U.S. resident population. These data have been adjusted for age and gender.

• Hispanic children living in communities at every income level had higher rates of hospital discharges with perforated appendix than Whites (Figure 4.44).
• Black children living in communities at every income level had higher rates of hospital discharges with perforated appendix than Whites.
• API children living in communities in Quartile 1 had higher rates of hospital discharges with perforated appendix than Whites (410.3 per 1,000 compared with 287.7 per 1,000 admissions).

Access to Health Care

Health Insurance

Insurance coverage is among the most important factors in access to health care. Special efforts have been made to provide insurance coverage to children.⁵⁸

Figure 4.45. Children with health insurance, by race, ethnicity, and family income, 1999-2007

         

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

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 1999-2007.

Denominator: Civilian noninstitutionalized population under age 18.

Note: Insurance status is determined at the time of interview. Children are considered uninsured if they lack private health insurance, public assistance (including the State Children's Health Insurance Program), Medicare, Medicaid, a State-sponsored health plan, other government-sponsored program, or a military health plan, or if their only coverage is through the Indian Health Service. This measure reflects the percentage of children who were covered by health insurance at the time of interview.

• In 2007, the percentage of children with health insurance was higher for Blacks than for Whites (93.8% compared with 90.7%; Figure 4.45).
• In 2007, the percentage of children with health insurance was significantly lower for AI/AN children than for White children (71.4% compared with 90.7%).
• From 1999 to 2007, the gap between Hispanics and non-Hispanic Whites in the percentage of children with health insurance decreased.
• In 2007, the percentage of children with health insurance was significantly lower for Hispanic children than for non-Hispanic White children (84.7% compared with 92.9%).
• In 2007, the percentage of children with health insurance was significantly lower for children in poor (88.1%), near-poor (84.3%), and middle-income families (91.8%) than for children in high-income families (97.8%).

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Older Adults

In 2006, 37.3 million people age 65 and over lived in the United States.⁵⁹ Furthermore, the percentage of the population age 65 and over is swiftly increasing. People age 65 and over represented 12.4% of the population in 2006 but are expected to grow to about 20% of the population by 2030.⁶⁰ The past century has seen significant increases in life expectancy; in 2007, 65-year-olds could expect to live an additional 18.7 years.⁵⁹ Nonetheless, older adults face greater health care concerns than do younger populations. In 2006, 39.8% of noninstitutionalized older adults assessed their health as excellent or very good, compared with 65.1% of people ages 18-64⁶¹; most older adults have at least one chronic condition.

Older women outnumber older men by more than one-third.⁵⁹ In addition, members of minority groups are projected to represent more than 25% of the older population in 2030, up from about 16% in 2000.⁶⁰ About 3.4 million older people lived below the poverty level in 2006, corresponding to a poverty rate of 9.4%.⁵⁹ Another 2.2 million, or 6.2% of older people, were classified as near poor, with incomes between 100% and 125% of the Federal poverty level.⁵⁹

The Medicare program provides core health insurance to nearly all older Americans and reduces many financial barriers to acute and postacute care. The Medicare Prescription Drug Improvement and Modernization Act of 2003 has added prescription drug and preventive benefits to Medicare and provides extra financial help to older people with low incomes. Therefore, differences in access to and quality of health care tend to be smaller among Medicare beneficiaries than among younger populations.

Surveys of the general population often do not include enough older people to examine racial, ethnic, or socioeconomic differences in health care. The NHDR relies on data from the Medicare Current Beneficiary Survey to examine disparities in access to and quality of care. Findings presented here highlight two quality measures and one access measure of particular importance to the older population:

Component of health care need	Measure
Prevention	Influenza vaccination, vision screening
Access to care	Delayed care due to cost
Patient centeredness	Health literacy

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Quality of Health Care

Prevention: Influenza Vaccination

Influenza is responsible for significant morbidity and decreased productivity during outbreaks. Older adults are at increased risk for complications from influenza infections. Vaccination is an effective strategy to reduce illness and deaths due to influenza. The U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention recommend annual influenza vaccination of all older individuals.

Figure 4.46. Medicare beneficiaries age 65 and over who had an influenza vaccination in the last winter, by race, ethnicity, and income, 2002-2005

               

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander.

Source: Centers for Medicare & Medicaid Services, Medicare Current Beneficiary Survey, 2002-2005.

Denominator: Medicare beneficiaries age 65 and over living in the community.

• From 2002 to 2005, the percentage of Medicare beneficiaries age 65 and over with an influenza vaccination in the last winter decreased overall from 68.9% to 64.6% (Figure 4.46).
• From 2002 to 2005, the gap between Blacks and Whites remained the same. In 2005, the percentage was significantly lower for Blacks than for Whites (49.9% compared with 66.3%).
• During this period, the gap between Hispanics and non-Hispanic Whites remained the same. In 2005, the percentage was also significantly lower for Hispanics than for non-Hispanic Whites (52.3% compared with 67.1%).
• From 2002 to 2005, the gaps between poor, near-poor, and middle-income groups and high-income groups remained the same. In 2005, the percentage was significantly lower for poor, near-poor, and middle-income beneficiaries than for high-income beneficiaries (56.0%, 61.8%, and 65.5%, respectively, compared with 70.8%).
• In 2005, no population group achieved the Healthy People 2010 target of 90% of older Americans receiving influenza vaccination.

Prevention: Vision Screening

Visual impairment is a common and potentially serious problem among older people. Personal safety may be compromised as risks of falls and car accidents increase.

Figure 4.47. Medicare beneficiaries age 65 and over who had an eye examination in the last 12 months, by race, ethnicity, and income, 2002-2005

          

Key: AI/AN = American Indian or Alaska Native; API = Asian or Pacific Islander.

Source: Centers for Medicare & Medicaid Services, Medicare Current Beneficiary Survey, 2002-2005.

Denominator: Medicare beneficiaries age 65 and over living in the community.

• From 2002 to 2005, the gap decreased between Blacks and Whites in the percentage of Medicare beneficiaries age 65 and over with an eye exam in the past year. In 2005, there was no statistically significant difference between Blacks and Whites (Figure 4.47, 61.8% compared with 63.3%).
• During this period, there were no statistically significant changes or differences between Hispanics and non-Hispanic Whites.
• During this period, the gap between poor, near-poor, and middle-income individuals and high-income individuals remained the same. In 2005, poor, near-poor, and middle-income individuals were less likely than high-income individuals to have had an eye exam in the past year (55.9%, 60.8%, and 63.7%, respectively, compared with 67.1%).

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^xiv In most cases, this population would consist of women who qualified for Medicare due to disability.

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