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National Healthcare Disparities Report, 2009 |
Chapter 3. Access to Health CareContentsFacilitators and Barriers to Health Care 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 it difficult to obtain basic health care services. As shown 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 AccessAccess 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:
Health care access is measured in several ways, including:
How This Chapter Is OrganizedThis chapter presents new information about disparities in access to health care in America. It is divided into two sections:
This chapter presents new information about disparities in access to health care in America since the last NHDR. It is divided into two sections:
Information about provider-patient 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 in the general U.S. population. This chapter also presents analyses of changes over time and stratified analyses. Disparities in access to care and provider-patient communication within specific priority populations are discussed in Chapter 4, Priority Populations. Facilitators and Barriers to Health CareFacilitators 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 InsuranceHealth 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. People under age 65 with health insurance, by race, ethnicity, income, and education, 1999-2007
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), 1999-2007. Denominator: Analyses by race, ethnicity, and income performed for civilian noninstitutionalized population under age 65. Analyses by education performed for 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, 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.
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 and ethnicity, stratified by income, 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 (NHIS), 2007. Denominator: 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 and ethnicity, 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), 2007. Denominator: 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.
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, ethnicity, income, and education, 2002-2006
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, 2002-2006. Denominator: 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.
Each year, multivariate analyses are conducted in support of the NHDR to identify the independent effects of race, ethnicity, income, and education on quality of health care. Past reports have listed some of these findings as odds ratios. This year, the NHDR presents the results of a multivariate model as adjusted percentages for this measure: people under age 65 who were uninsured all year. Adjusted percentages show the expected percentage for a given subpopulation after controlling for a number of factors, which include race/ethnicity, family income, education, health insurance status, and geographic location. Figure 3.5. Adjusted percentages of people under age 65 who were uninsured all year, by race/ethnicity, family income, education, and residence location, 2002-2006. Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, pooled 2002-2006 fiscal year files. Note: Adjusted percentages are predicted marginals from a statistical model that includes the covariates race/ethnicity, family income, education, health insurance, and residence location. Refer to Chapter 1, Introduction and Methods, for more information.
Financial Burden of Health Care CostsHealth insurance is supposed to protect individuals from the burden of high health care costs. However, even with health insurance, the financial burden for health care can still be high and is increasing.9 High premiums and out-of-pocket payments can be a significant barrier to accessing necessary medical treatment and preventive care.10 One way to assess the extent of financial burden is by determining the percentage of family income spent on a family's health insurance premium and out-of-pocket medical expenses. 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; ESI = employer-sponsored insurance; NHOPI = Native Hawaiian or Other Pacific Islander. Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006. Note: Total financial burden includes premiums and out-of-pocket costs for health care services.
Usual Source of CarePeople with a usual source of care (a provider or facility where one regularly receives care) experience improved health outcomes and reduced disparities (smaller differences between groups)11 and costs.12 More than 40 million Americans do not have a specific source of ongoing care.13 Specific Source of Ongoing CareEvidence suggests that the effect on quality of the combination of health insurance and a usual source of care is additive.14 In addition, people with a usual source of care are more likely to receive preventive health services.* *Refer, for example, to Ettner SL. The timing of preventive services for women and children: the effect of having a usual source of care. Am J Pub Hlth 1996;86:1748-54. Figure 3.7. People with a specific source of ongoing care, by race, ethnicity, income, education, and insurance status, 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: 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.
Each year, multivariate analyses are conducted in support of the NHDR to identify the independent effects of race and SES on quality of health care. Past reports have listed some of these findings as odds ratios. This year, the NHDR presents the results of a multivariate model as adjusted percentages for this measure: people under age 65 with a specific source of ongoing care. Adjusted percentages show the expected percentage for a given subpopulation after controlling for a number of factors, which include race/ethnicity, family income, education, health insurance status, and geographic location. Figure 3.8. Adjusted percentages of people under age 65 with a specific source of ongoing care, by race/ethnicity, family income, insurance status, and residence location, 2005 Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2005. Note: Adjusted percentages are predicted marginals from a statistical model that includes the covariates race/ethnicity, family income, education, health insurance, and residence location. Refer to Chapter 1, Introduction and Methods, for more information.
Usual Primary Care ProviderHaving a usual primary care provider (a doctor or nurse from whom one regularly receives care) is associated with patients' greater trust in their provider15 and with good provider-patient communication. These factors increase the likelihood that patients will receive appropriate care.16 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.17 Having a usual primary care provider correlates with receipt of higher quality care.18,19 Figure 3.9. People with a usual primary care provider, by race, ethnicity, family income, education, and insurance status, 2002-2006
Key: AI/AN = American Indian or Alaska Native. Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006. Denominator: 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.
Patient Perceptions of NeedPatient 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 3.10. People who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines in the last 12 months, by race, ethnicity, income, education, and insurance status, 2006
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006. 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.
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. Return to Contents
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