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National Healthcare Quality Report, 2009

Access to Care

Delayed Care Due to Cost

Timely delivery of appropriate health care has been shown to improve health care outcomes and reduce health care costs. Timely receipt of care is especially important for the older population due to their often increased medical needs. Delayed health care can lead to diagnosis at a more advanced disease stage and can reduce opportunities for optimal treatment.xv

Figure 4.48. Medicare beneficiaries age 65 and over with delayed care due to cost, by race, ethnicity, and income, 2002-2006

trend line chart. In Percentages. Total; 2002, 5; 2003, no data; 2004, 4.4; 2005, 5; 2006, 5.8; White; 2002, 4.7; 2003, 4.2; 2004, 4.2; 2005, 4.7; 2006, 5.5; Black; 2002, 5.4; 2003, 5.9; 2004, 5.9; 2005, 7.0; 2006, 7.4; AI/AN; 2002, no data; 2003, no data; 2004, no data; 2005, 6.9; 2006, 6.4; More than 1 Race; 2002, 11.5; 2003, 11.5; 2004, 7.8; 2005, 9.4; 2006, 9.2.

Non-Hispanic white; 2002, 4.7; 2003, 4.3; 2004, 4.3; 2005, 4.4; 2006, 5.4; Hispanic; 2002, 5.8; 2003, 3.9; 2004, 3.9; 2005, 7.8; 2006, 7.3.         Poor; 2002, 7.0; 2003, 6.7; 2004, 6.7; 2005, 9.5; 2006, 8.8; Near Poor; 2002, 7.0; 2003, 6.8; 2004, 6.8; 2005, 6.9; 2006, 7.6; Middle income; 2002, 4.3; 2003, 3.0; 2004, 3.0; 2005, 3.6; 2006, 5.4; High income; 2002, 2.0; 2003, 2.0; 2004, 2.0; 2005, 2.0; 2006, 2.0.

Source: Centers for Medicare & Medicaid Services, Medicare Current Beneficiary Survey, 2002-2006.

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

Note: Total was unavailable for 2003. Data for Asians and AI/ANs were statistically unreliable for 2002-2004.

  • In 2006, Black older adults and older adults of multiple race were more likely than White older adults to delay care due to cost (7.4% and 9.2%, respectively, compared with 5.5%; Figure 4.48).
  • In 2006, the percentage delaying care was significantly higher for poor (8.8%), near-poor (7.6%), and middle-income (5.4%) beneficiaries than for high-income beneficiaries (2.0%).

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Residents of Rural Areas

About one in five Americans lives in a nonmetropolitan area.62 Compared with their urban counterparts, rural residents are more likely to be older, poor,63 and in fair or poor health and to have chronic conditions.62 Rural residents are less likely than their urban counterparts to receive recommended preventive services and on average report fewer visits to health care providers.64

Although 20% of Americans live in rural areasxvi, only 9% of physicians in America practice in those settings.65 Other important providers of health care in those settings include nurse practitioners, nurse midwives, and physician assistants. A variety of programs deliver needed services in rural areas, such as the National Health Service Corps Scholarship Program, IHS, State offices of rural health, rural health clinics, and community health centers. Cost-based Medicare reimbursement incentives are also available for rural health clinics, critical access hospitals, sole community hospitals, and Medicare-dependent hospitals and physicians in health professional shortage areas.

Many rural residents depend on small rural hospitals for their care. There are approximately 2,000 rural hospitals throughout the country,66 1,500 of which have 50 or fewer beds. Most of these hospitals are critical access hospitals that have 25 or fewer beds. They face unique challenges due to their size and case mix. During the 1980s, many were forced to close because of financial losses.67 Yet, more recently, finances of small rural hospitals have improved and few closures have occurred since 2003.

Transportation needs are pronounced among rural residents, who must travel longer distances to reach health care delivery sites. Of the nearly 1,000 "frontier counties"xvii in the Nation, most have limited health care services and many do not have any.68

The NHDR tracks many measures of relevance to residents of rural areas. Findings presented here highlight three quality measures and one access measure of particular importance to residents of rural areas, with additional geographic data from metropolitan areas:

Component of health care need Measure
Outcome Heart attack mortality
Management Recommended services for diabetes
Timeliness Care for illness or injury as soon as wanted
Access to care Health insurance

In previous NHDRs, detailed geographic typologies were applied to two AHRQ databases-MEPS and HCUP-to define variations in health care quality and access for a range of rural and urban locations. This year, data from MEPS and HCUP are again presented. Federal definitions of micropolitan and noncore statistical areas (not metropolitan or micropolitan areas) published in June 2003 are used.69 In addition, Urban Influence Codes use a methodology developed by the National Center for Health Statistics to subdivide metropolitan areas into large central and large fringe metropolitan areas.70 Thus, categories used in this section of the NHDR may be defined as follows:

  • Metropolitan (total): all metropolitan areas.
  • Large central metropolitan statistical area: central counties in metropolitan area of 1 million or more inhabitants.
  • Large fringe metropolitan statistical area: outlying (suburban) counties in metropolitan area of 1 million or more inhabitants.
  • Medium metropolitan statistical area: counties in metropolitan area of 250,000 to fewer than 1,000,000 inhabitants.
  • Small metropolitan statistical area: metropolitan area of 50,000 to fewer than 250,000 inhabitants.
  • Nonmetropolitan (total): all nonmetropolitan areas.
  • Micropolitan statistical area: counties with an urban cluster of at least 10,000 but fewer than 50,000 inhabitants.
  • Noncore statistical area (rural): not metropolitan or micropolitan.

Urban-rural contrasts for measures from MEPS and HCUP compare residents of rural statistical areas (including both micropolitan and noncore statistical areas) with residents of urban statistical areas (including large central, large fringe, medium, and small metropolitan statistical areas). Sample sizes are often too small to provide reliable estimates for noncore statistical areas, limiting the ability to assess disparities among residents of these areas.

Quality of Health Care

Outcome: Heart Attack Mortality

Heart disease is the leading cause of death for both men and women in the United States, responsible for nearly 632,000 deaths in 2006.71 About 1.2 million heart attacks occur each year.72 Data on inpatient hospital deaths for patients who are admitted for a heart attack (AMI) are presented. To distinguish the effects of race/ethnicity on the AMI in-hospital mortality rate within urban and rural areas, race/ethnicity data are stratified by urban and rural location of patient residence.

Figure 4.49. Deaths per 1,000 adult admissions with acute myocardial infarction as principal diagnosis, by race/ethnicity and geographic location, 2006

Bar chart. rate. Large Central Metropolitan, Total, 69.6; White, 70.6; Black, 58.8; API, 81.7; Hispanic, 72.2; Large Fringe Metropolitan, Total, 66.6; White, 67.3; Black, 53.2; API, 91.7; Hispanic, 74.3; Medium Metropolitan, Total, 71.4; White, 70.8; Black, 66.1; API, 99.3; Hispanic, 74.0; Small Metropolitan, Total, 78.6; White, 77.9; Black, 77.1; API, no data; Hispanic, 97.2; Micropolitan, Total, 85.8; White, 86.5; Black, 86.3; API, 88.4; Hispanic, 73.8; Noncore, Total, 82.0; White, 83.6; Black, 68.6; API, 102.9; Hispanic, 62.0.

Large Central Metropolitan = central counties in metropolitan areas ≥ 1 million inhabitants.

Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥ 1 million inhabitants.

Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants.

Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants.

Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants.

Noncore = < 10,000 inhabitants.

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.

Denominator: Adults age 18 and over hospitalized for heart attack in community hospitals.

Note: White, Black, and API are non-Hispanic groups. These data are adjusted for age, gender, and all patient refined-diagnosis related group. Data for APIs in small metropolitan areas did not meet criteria for statistical reliability, data quality, or confidentiality. 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 overall heart attack death rate was significantly higher for people admitted to hospitals in noncore areas (82.0 per 1,000 AMI admissions) than for people living in large central metropolitan areas or small metropolitan areas (69.6 per 1,000 admissions and 78.6 per 1,000 admissions, respectively; Figure 4.49).
  • The overall rate was also significantly higher for people admitted to hospitals in micropolitan areas than for people living in large central metropolitan areas (85.8 per 1,000 admissions compared with 69.6 per 1,000 admissions).
  • In large central metropolitan areas and large fringe metropolitan areas, the heart attack death rate was lower for Blacks than for Whites (58.8 per 1,000 admissions compared with 70.6 per 1,000 admissions in large central metropolitan areas and 53.2 per 1,000 admissions compared with 67.3 per 1,000 admissions in large fringe metropolitan areas). The rate was higher for APIs than for Whites (81.7 per 1,000 admissions compared with 70.6 per 1,000 admissions in large central metropolitan areas and 91.7 per 1,000 admissions compared with 67.3 per 1,000 admissions in large fringe metropolitan areas).
  • In medium metropolitan areas, the heart attack death rate was higher for APIs than for Whites (99.3 per 1,000 admissions compared with 70.8 per 1,000 admissions).
  • In small metropolitan areas, the heart attack death rate was higher for Hispanics than for Whites (97.2 per 1,000 admissions compared with 77.9 per 1,000 admissions).
  • There were no statistically significant differences by race or ethnicity in micropolitan areas.
  • In noncore areas, the heart attack death rate was lower for Blacks (68.6 per 1,000 admissions) and Hispanics (62.0 per 1,000 admissions) than for Whites (83.6 per 1,000 admissions).

Management: Recommended Services for Diabetes

The NHDR presents a composite measurexviii that tracks receipt of three recommended services for effective management of diabetes: hemoglobin A1c testing, eye examination, and foot examination in the past year.

Figure 4.50. Composite measure: Adults age 40 and over with diagnosed diabetes who received three recommended services for diabetes in the calendar year (hemoglobin A1c measurement, eye examination, and foot examination), by geographic location, stratified by race, ethnicity, income, and education, 2006

Bar chart. Percentages. Race. Metropolitan, Total, 43.5; White, 44.8; Black, 39.3; Large Central Metropolitan, Total, 41.0; White, 37.7; Black, 48.0; Large Fringe Metropolitan, Total, 46.0; White, 49.6; Black, data statistically unreliable (DSU); Medium Metropolitan, Total, 42.9; White, 45.0; Black, DSU; Small Metropolitan, Total, 47.8; White, 51.1; Black, DSU; Nonmetropolitan, Total, 32.0; White, 32.8; Black, DSU; Micropolitan, Total, 38.6; White, 40.9; Black, DSU; Noncore, Total, 20.5; White, 20.2; Black, DSU.  Ethnicity. Metropolitan, Non Hispanic White, 48.4; Hispanic, 32.2; Large Central Metropolitan, Non Hispanic White, 38.2; Hispanic, 37.5; Large Fringe Metropolitan, Non Hispanic White, 54.4; Hispanic, DSU; Medium Metropolitan, Non Hispanic White, 46.7; Hispanic, DSU; Nonmetropolitan, Non Hispanic White, 33.5; Hispanic, DSU; Micropolitan, Non Hispanic White, 42; Hispanic, DSU.

Income. Metropolitan, Poor, 36.4; Near Poor, 32.7; Middle Income, 47.7; High Income, 47.7; Large Central Metropolitan, Poor, 36.2; Near Poor, 34.3; Middle Income, 44.9; High Income, 44.0; Large Fringe Metropolitan, Poor, DSU; Near Poor, DSU; Middle Income, DSU; High Income, 46.5; Nonmetropolitan (Total), Poor, DSU; Near Poor, 29.6; Middle Income, DSU; High Income, DSU.  Education. Metropolitan (Total), Less than high school, 35.2; High School Grad, 45.7; Some College, 47.2; Large Central Metropolitan, Less than high school, 38.5; High School Grad, 43.4; Some College, 41.6; Large Fringe Metropolitan, Less than high school, DSU; High School Grad, DSU; Some College, 52.2; Medium Metropolitan, Less than high school, 35.4; High School Grad, DSU; Some College, 45.9; Nonmetropolitan (Total), Less than high school, 18.6; High School Grad, 33.3; Some College, DSU; Micropolitan, Less than high school, 23.5; High School Grad, DSU; Some College, DSU.

Large Central Metropolitan = central counties in metropolitan areas ≥ 1 million inhabitants.

Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥ 1 million inhabitants.

Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants.

Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants.

Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants.

Noncore = < 10,000 inhabitants.

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

Denominator: Civilian noninstitutionalized population age 40 and over.

Note: Recommended services for diabetes are (1) hemoglobin A1c testing, (2) dilated eye examination, and (3) foot examination. Due to small sample sizes, estimates by race, ethnicity, income, or education could not be provided in all areas; these data were only available for metropolitan (total) and large central metropolitan.

  • In 2006, the percentage of diabetes patients who received all three recommended services for diabetes was lower for patients in nonmetropolitan areas than in metropolitan areas (32.0% compared with 43.5%; Figure 4.50).
  • In metropolitan areas (total), there were significant ethnic, income, and educational disparities. Hispanics were less likely than non-Hispanic Whites to receive recommended care for diabetes (32.2% compared with 48.4%). Poor (36.4%) and near-poor (32.7%) individuals were less likely than high-income individuals (47.7%) to receive recommended care for diabetes. Individuals with less than a high school education were less likely than individuals with some college education to receive recommended care for diabetes (35.2% compared with 47.2%).

Timeliness: Care for Illness or Injury as Soon as Wanted

Timely delivery of appropriate care has been shown to improve health care outcomes and reduce health care costs. In addition, when patients need or want care, having access to that care improves their health care experience, which may further promote health.

Figure 4.51. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by geographic location, stratified by income and education, 2006

Bar chart. Percentage. Metropolitan, Total, 15.3; Poor, 22.7; Near Poor, 20.4; Middle income, 16.2; High income, 10.4; Large Central Metropolitan, Total, 16.8; Poor, 22.3; Near Poor, 20.2; Middle income, 18.3; High income, 12.3; Large Fringe Metropolitan, Total, 15; Poor, 21.0; Near Poor, 23.0; Middle income, 17.2; High income, 10.6; Medium Metropolitan, Total, 14.5; Poor, 22.3; Near Poor, 18.7; Middle income, 15.0; High income, 9.4; Small Metropolitan, Total, 13.2; Poor, no data; Near Poor, 20.3; Middle income, no data; High income, no data; Nonmetropolitan, Total, 15.1; Poor, 24.4; Near Poor, 20.0; Middle income, 11.6; High income, 10.8; Micropolitan, Total, 14.2; Poor, 19.7; Near Poor, 21.8; Middle income, 12.1; High income, data statistically unreliable; Noncore, Total, 17; Poor, no data; Near Poor, 17.4; Middle income, no data; High income, no data.  Metropolitan, Less Than High School, 17.8; High School Grad, 15.3; Some College, 14.2; Large Central Metropolitan, Less Than High School, 20.0; High School Grad, 17.6; Some College, 15.1; Large Fringe Metropolitan, Less Than High School, 18.6; High School Grad, 15.1; Some College, 13.8; Medium Metropolitan, Less Than High School, 14.6; High School Grad, 14.2; Some College, 14.5; Small Metropolitan, Less Than High School, 17.8; High School Grad, 12.1; Some College, 11.5; Nonmetropolitan, Less Than High School, 22.0; High School Grad, 12.8; Some College, 12.5; Micropolitan, Less Than High School, 19.8; High School Grad, 11.7; Some College, 12.8; Noncore, Less Than High School, 26.2; High School Grad, 15.1; Some College, 12.1.

Large Central Metropolitan = central counties in metropolitan areas ≥ 1 million inhabitants.

Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥ 1 million inhabitants.

Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants.

Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants.

Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants.

Noncore = < 10,000 inhabitants.

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

Denominator: Civilian noninstitutionalized population age 18 and over.

Note: Data are not available for poor, middle-, and high-income groups in noncore areas or in small metropolitan areas. Data are not available for the high-income group in micropolitan areas.

  • There were no statistically significant differences between geographic areas in the overall percentage of adults who sometimes or never got care for illness or injury as soon as wanted (Figure 4.51).
  • In nonmetropolitan areas, poor (24.4%) and near-poor (20.0%) individuals were more likely than high-income individuals (10.8%) to report problems getting care for illness or injury as soon as wanted.
  • Differences by education also were observed in nonmetropolitan areas. Individuals with less than a high school education (22%) were more likely than individuals with some college education (12.5%) to report problems getting care for illness or injury as soon as wanted.
  • There were significant differences by income in metropolitan areas. Poor (22.7%), near-poor (20.4%), and middle-income (16.2%) individuals were more likely than high-income (10.4%) individuals to report problems getting care for illness or injury as soon as wanted. When further stratified into large fringe, large central, medium, and small metropolitan areas, there were no statistically significant differences between poor and near-poor groups and high-income groups.
  • In small metropolitan areas, individuals with less than a high school education were more likely than individuals with some college education to report problems getting care for illness or injury as soon as wanted (17.8% for less than high school compared with 11.5%).

Access to Health Care

Health Insurance

Access to health care services is a prerequisite to receipt of care, yet many Americans still face barriers to care. It has been observed that compared with urban residents, residents of rural areas are more likely to be uninsured, and those who are insured are more likely to be individually insured.73 Furthermore, rural residents with group insurance are more likely to have fewer benefits and higher out-of-pocket expenses, suggesting a higher rate of underinsurance. Data for prolonged periods of uninsurance (no insurance coverage for a full year) are presented.

Figure 4.52. Adults under age 65 who were uninsured all year, by geographic location, stratified by race, ethnicity, income, and education, 2006

Bar charts; in Percentages. Race. Metropolitan, Total, 14.1; White, 14.3; Black, 14.1; Asian, 12.7; Large Central Metropolitan, Total, 17.4; White, 18.6; Black, 14.4; Asian, 16.4; Large Fringe Metropolitan, Total, 11.6; White, 11.7; Black, 13.0; Asian, 7.0; Medium Metropolitan, Total, 12.7; White, 12.4; Black, 14.0; Asian, no data; Small Metropolitan, Total, 13.2; White, 13.0; Black, 15.8; Asian, no data; Nonmetropolitan, Total, 15.4; White, 14.9; Black, 19.0; Asian, no data; Micropolitan, Total, 14.7; White, 14.4; Black, 20.0; Asian, no data; Noncore, Total, 16.9; White, 16.1; Black, 17.3; Asian, no data.  Ethnicity. Metropolitan (Total), Non-Hispanic white, 10.1; Hispanic, 28.5; Large Central Metropolitan, Non-Hispanic white, 11.4; Hispanic, 29.7; Large Fringe Metropolitan, Non-Hispanic white, 8.2; Hispanic, 30.3; Medium Metropolitan, Non-Hispanic white, 10.5; Hispanic, 24.7; Small Metropolitan, Non-Hispanic white, 11.6; Hispanic, 21.2; Nonmetropolitan (Total), Non-Hispanic white, 13.6; Hispanic, 29.9; Micropolitan, Non-Hispanic white, 13.0; Hispanic, 28.2; Noncore, Non-Hispanic white, 14.8; Hispanic, 35.7.

Income. Metropolitan (Total), Poor, 24.0; Near Poor, 24.9; Middle Income, 15.4; High Income, 5.8; Large Central Metropolitan, 26.8; Near Poor, 25.6; Middle Income, 19.0; High Income, 8.2; Large Fringe Metropolitan, 24.0; Near Poor, 27.3; Middle Income, 14.3; High Income, 4.2; Medium Metropolitan, 21.4; Near Poor, 21.8; Middle Income, 13.0; High Income, 5.1; Small Metropolitan, 19.6; Near Poor, 24.3; Middle Income, 12.2; High Income, 5.2; Nonmetropolitan (Total), 22.0; Near Poor, 23.0; Middle Income, 15.8; High Income, 5.6; Micropolitan, 22.3; Near Poor, 24.2; Middle Income, 14.5; High Income, 5.7; Noncore, 21.6; Near Poor, 21.1; Middle Income, 18.0; High Income, 5.4.  Education. Metropolitan (Total), less than High School, 33.0; High School Grad, 21.1; Some College, 9.7; Large Central Metropolitan, less than High School, 38.0; High School Grad, 25.4; Some College, 12.5; Large Fringe Metropolitan, less than High School, 27.4; High School Grad, 19.0; Some College, 7.3; Medium Metropolitan, less than High School, 31.7; High School Grad, 18.6; Some College, 8.4; Small Metropolitan, less than High School, 28.9; High School Grad, 19.7; Some College, 10.0; Nonmetropolitan (Total), less than High School, 34.6; High School Grad, 20.1; Some College, 12.2; Micropolitan, less than High School, 34.0; High School Grad, 18.6; Some College, 11.0; Noncore, less than High School, 35.7; High School Grad, 23.0; Some College, 14.8.

Large Central Metropolitan = central counties in metropolitan areas ≥ 1 million inhabitants.

Large Fringe Metropolitan = outlying (suburban) counties in metropolitan areas ≥ 1 million inhabitants.

Medium Metropolitan = counties in metropolitan areas of 250,000-999,999 inhabitants.

Small Metropolitan = counties in metropolitan areas of 50,000-249,999 inhabitants.

Micropolitan = counties in an area with an urban cluster of 10,000-49,999 inhabitants.

Noncore = < 10,000 inhabitants.

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

Denominator: Civilian noninstitutionalized population age 18 and over.

Note: Estimates for Asians in medium metropolitan, small metropolitan, nonmetropolitan, micropolitan, and noncore areas did not meet criteria for statistical reliability and are not reported here.

Nonmetropolitan Areas
  • Noncore areas had a higher percentage of adults who were uninsured than large fringe metropolitan areas (16.9% compared with 11.6%; Figure 4.52).
  • In noncore areas, there were significant ethnic, income, and education disparities. Hispanics were more than twice as likely as non-Hispanic Whites to be uninsured all year (35.7% compared with 14.8%). Poor, near-poor, and middle-income individuals (21.6%, 21.1%, and 18.0%, respectively) were more likely than high-income individuals (5.4%) to be uninsured all year. In addition, individuals with less than a high school education (35.7%) and high school graduates (23%) were more likely than individuals with some college education (14.8%) to be uninsured all year.
  • In micropolitan areas, there were significant racial, ethnic, income, and education disparities. Blacks were more likely than Whites to be uninsured all year (20.0% compared with 14.4%). Hispanics were more than twice as likely as non-Hispanic Whites to be uninsured all year (28.2% compared with 13%). Poor (22.3%), near-poor (24.2%), and middle-income individuals (14.5%) were more likely than high-income individuals (5.7%) to be uninsured all year. Individuals with less than a high school education (34.0%) and high school graduates (18.6%) were more likely than individuals with some college education (11.0%) to be uninsured all year.
Metropolitan Areas
  • There were statistically significant differences within metropolitan areas in the percentage of adults under age 65 who were uninsured all year. Among metropolitan areas, the lowest percentage of uninsured overall was in large fringe metropolitan areas (11.6%; Figure 4.52); the highest percentage was in large central metropolitan areas (17.4%).
  • Large central metropolitan areas had significant racial, ethnic, income, and education disparities. In these areas, Blacks were less likely than Whites to be uninsured all year (14.4% compared with 18.6%). However, Hispanics were almost three times as likely as non-Hispanic Whites to be uninsured all year (29.7% compared with 11.4%). Poor (26.8%), near-poor (25.6%), and middle-income individuals (19%) were more likely than high-income individuals (8.2%) to be uninsured all year. Individuals with less than a high school education (38%) and high school graduates (25.4%) were more likely than individuals with some college education (12.5%) to be uninsured all year.
  • Large fringe metropolitan areas also had significant ethnic, income, and education disparities. In these areas, Hispanics were almost four times as likely as non-Hispanic Whites to be uninsured all year (30.3% compared with 8.2%). Poor (24%), near-poor (27.3%), and middle-income individuals (14.3%) were more likely than high-income individuals (4.2%) to be uninsured all year. Individuals with less than a high school education (27.4%) and high school graduates (19%) were more likely than individuals with some college education (7.3%) to be uninsured all year.
  • Medium metropolitan areas had significant ethnic, income, and education disparities as well. In these areas, Hispanics were more than twice as likely as non-Hispanic Whites to be uninsured all year (24.7% compared with 10.5%). Poor (21.4%), near-poor (21.8%), and middle-income individuals (13%) were more likely than high-income individuals (5.1%) to be uninsured all year. Individuals with less than a high school education (31.7%) and high school graduates (18.6%) were more likely than individuals with some college education (8.4%) to be uninsured all year.
  • Small metropolitan areas also had significant ethnic, income, and education disparities. In these areas, Hispanics were almost twice as likely as non-Hispanic Whites to be uninsured all year (21.2% compared with 11.6%). Poor (19.6%), near-poor (24.3%), and middle-income individuals (12.2%) were more likely than high-income individuals (5.2%) to be uninsured all year. Individuals with less than a high school education (28.9%) and high school graduates (19.7%) were more likely than individuals with some college education (10%) to be uninsured all year.

xv In this measure, delayed care due to cost is self-reported by patients.
xvi Many terms are used to refer to the continuum of geographic areas. For the 2000 census, the U.S. Census Bureau's classification of "rural" consists of all territory, population, and housing units located outside urban areas and urban clusters. The Census Bureau classified as "urban" all territory, population, and housing units located within (1) core census block groups or blocks that have a population density of at least 1,000 people per square mile and (2) surrounding census blocks that have an overall density of at least 500 people per square mile.
xvii "Frontier counties" have a population density of less than 7 people per square mile; thus, residents may have to travel long distances for care.
xviii For more information on composite measures, refer to Chapter 1, Introduction and Methods.

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