AHRQ: 2009 National Healthcare Disparities and Quality Reports: Chapter 4 (continued)

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National Healthcare Quality Report, 2009

Individuals With Disabilities or Special Health Care Needs

Individuals with disabilities or special health care needs include individuals who use nursing home and home health care or end-of-life health care and children with special heath care needs (CSHCN). The NHDR tracks many measures of relevance to individuals with special health care needs.

This year, the data on quality, access, and health care utilization are presented for adults with disabilities. This is the third year in which the Adults With Disabilities section has been expanded to include more analyses and additional data sources using a comparable measure of disability. In this year's report, the Adults With Disabilities section uses MEPS data. In last year's report, this section used data from the National Health Interview Survey (NHIS).

The appendix tables in this year's report, as in last year's report, present data categorized by activity limitation for all NHIS and MEPS tables. Activity limitations was included as a stub variable starting in the 2007 report, where it was included in the MEPS appendix tables. The goal for future reports is to use NHIS, MEPS, and additional data sources to include more information about individuals with disabilities.

Component of health care need	Measure
Access to care	Delayed dental care^xix
Health care utilization	Dental visits
Access to care	Underinsurance, financial burden of health care costs

In addition, findings for people who use nursing home care are presented in the section on Supportive and Palliative Care in Chapter 2, Quality of Health Care.

Adults With Disabilities

This is the third year in which the NHDR aims to include more information about individuals with disabilities. To reach this goal, AHRQ convened a disabilities subgroup of the National Healthcare Quality Report/National Healthcare Disparities Report Interagency Work Group. This subgroup received assistance from the Interagency Subcommittee on Disability Statistics of the Interagency Committee on Disability Research.

The charge to the disabilities subgroup was to advise AHRQ on measures of disabilities from existing data that could be used in the NHDR to track disparities in health care quality and access among individuals with disabilities. The disability measures would need to be comparable across national surveys. For this initial effort, the subgroup focused on measures for the adult population, a population for whom the most disability survey data were available.

Several ways of defining and measuring disability exist. Among the more common approaches are to identify individuals who:

Have problems with everyday functions, such as vision, hearing, communication, self-care, mobility, learning, and behavior.
Have difficulty with complex activities, such as working.
Meet the eligibility criteria for important income maintenance or training programs (e.g., Social Security Disability Income or vocational rehabilitation).

However, a particular challenge in reporting on racial, ethnic, and socioeconomic differences related to disability is that many data sources do not capture disability and, when they do collect such data, do not collect the data in the same way.

The International Classification of Functioning, Disability, and Health (ICF)⁷⁴ was adopted by the disabilities subgroup as a model to guide the deliberations. The subgroup reviewed questions and response categories for three national surveys—NHIS, MEPS, and the Medicare Current Beneficiary Survey—to identify inconsistencies and discrepancies in measurement of the major domains of disability in the ICF.

For the 2009 NHDR, AHRQ is again using a broad, inclusive measure of disability. This definition is intended to be consistent with statutory definitions of disability, such as the first criterion of the 1990 Americans With Disabilities Act (ADA) (i.e., having a physical or mental impairment that substantially limits one or more major life activities^75,76) and Federal program definitions of disability based on the ADA. For the purpose of the NHDR, people with disabilities are those with physical, sensory, and/or mental health conditions that can be associated with a decrease in functioning in such day-to-day activities as bathing, walking, doing everyday chores, and engaging in work or social activities. In displaying the data on disability, paired measures are shown to preserve the qualitative aspects of the data:

Limitations in basic activities represent problems with mobility and other basic functioning at the person level.
Limitations in complex activities represent limitations encountered when the person, in interaction with the environment, attempts to participate in community life.

Limitations in basic activities include problems with mobility, self-care (activities of daily living, or ADLs), domestic life (instrumental activities of daily living, or IADLs), and activities that depend on sensory functioning (limited to people who are blind or deaf). Limitations in complex activities include limitations experienced in work and in community, social, and civic life. The use of the subgroup's recommendation of these paired measures of basic and complex activity limitations is conceptually similar to the way others have divided disability⁷⁷ and is consistent with the ICF separation of activities and participation domains.⁷⁴ These two categories are not mutually exclusive; people may have limitations in basic activities and complex activities.

Access to Care: Adults Unable To Get or Delayed in Getting Needed Dental Care

As with other health care, patient perceptions of dental care need include perceived difficulties or delays in obtaining care and problems getting care as soon as wanted. Although patients may not always be able to assess their need for dental care, problems getting care when patients perceive that they need it likely reflect significant barriers to services. Dental care, unlike most other health care, is often not covered by health insurance.

Figure 4.53. Adults age 18 and over who were unable to get or delayed in getting needed dental care by race/ethnicity, family income, and education, stratified by activity limitation, 2006

Key: Basic = basic activity limitation (i.e., limitation in mobility or other basic person-level functioning); complex = complex activity limitation (i.e., limitation in ability to participate in community life); neither = neither basic nor complex activity limitation; NH = non-Hispanic; HS = high school.

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

Denominator: Civilian noninstitutionalized population age 18 and over.

Overall, adults with complex activity limitations were significantly more likely than adults with basic activity limitations to report being unable to get or delayed in getting needed dental care (14.8% compared with 11.3%; Figure 4.53). Those with basic activity limitations were significantly more likely than those with neither limitation to report being unable to get or delayed in getting needed dental care (11.3% compared with 6.4%).
The same pattern holds for non-Hispanic Whites and those with at least some college education. Among adults with at least some college education, those with complex activity limitations were about three times as likely as those with neither limitation to report being unable to get or delayed in getting needed dental care (16.4% compared with 5.2%).
Among non-Hispanic Black and Hispanic adults, those with basic and complex activity limitations were significantly more likely to report being unable to get or delayed in getting needed dental care than those with neither limitation. This pattern also held for all income groups, as well as for those with less than a high school education and high school graduates.
Among adults with neither basic nor complex activity limitations, non-Hispanic Blacks (7.7%) were significantly more likely than non-Hispanic Whites (6.1%) to report being unable to get or delayed in getting needed dental care.
Within each of the three activity limitation groups (basic, complex, neither), poor, low-income, and middle-income adults were significantly more likely than high-income adults to report being unable to get or delayed in getting needed dental care.
Among adults with neither basic nor complex activity limitations, those with less than a high school education (8.6%) and high school graduates (7.3%) were significantly more likely than those with at least some college education (5.2%) to report being unable to get or delayed in getting needed dental care.

Health Care Utilization: Dental Visits

Regular dental visits promote prevention, early diagnosis, and optimal treatment of oral diseases and conditions. Failure to visit the dentist can result in delayed diagnosis, compromised health overall, and, occasionally, even death.⁷⁸

Figure 4.54. Adults age 18 and over who had a dental visit in the calendar year, by race, ethnicity, family income, and education, stratified by activity limitation, 2006

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

Denominator: Civilian noninstitutionalized population age 18 and over.

Overall, adults with complex activity limitations were significantly less likely than those with basic activity limitations to have had a dental visit in the calendar year (34.5% compared with 38.4%; Figure 4.54). Those with basic activity limitations were significantly less likely than those with neither limitation to have had a dental visit in the calendar year (38.4% compared with 43.3%). The same pattern holds for Whites.
Among Black, non-Hispanic White, and non-Hispanic Black adults, those with basic and complex activity limitations were significantly less likely than those with neither limitation to have had a dental visit in the calendar year.
Differences in dental visits by activity limitation status were not statistically significant within any of the income groups (poor, low, middle, and high).
Among adults with at least some college education, those with complex activity limitations were significantly less likely than those with neither limitation to have had a dental visit in the calendar year (48.2% compared with 53.5%).
Within each of the three activity limitation groups, Black adults were significantly less likely than White adults to have had a dental visit. Non-Hispanic Black adults and Hispanic adults were significantly less likely than non-Hispanic Whites to have had a dental visit.
Within each of the three activity limitation groups, poor, low-income, and middle-income adults were significantly less likely to have had a dental visit than high-income adults. Similarly, within each activity limitation group, those with less than a high school education and high school graduates were significantly less likely than those with at least some college education to have had a dental visit.

Access to Health Care: Underinsurance

Private health insurance does not always protect individuals from the high cost of medical care. Even with private health insurance, a person may be underinsured. For example, a family's out-of-pocket medical expenses excluding premiums may be greater than 10% of total family income. Having high out-of-pocket medical expenses may directly affect access to needed medical and preventive care.^15,16

Figure 4.55. Adults ages 18-64 with private insurance whose family's out-of-pocket medical expenses excluding premiums were more than 10% of total family income, by race, ethnicity, family income, and education, stratified by activity limitation, 2006

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

Denominator: Civilian noninstitutionalized population ages 18-64.

Note: Estimates for Blacks, non-Hispanic Blacks, low-income people, and people with less than a high school education with complex activity limitations, Hispanics and poor people with basic or complex activity limitations, and high-income people with basic activity limitations did not meet criteria for statistical reliability.

Of adults ages 18-64 with private health insurance, people with complex activity limitations were more likely to be underinsured than those with basic activity limitations (21.2% compared with 12.4%; Figure 4.55). People with basic activity limitations (12.4%) were more likely to be underinsured than those with neither limitation (4.4%).
This same pattern holds for Whites, non-Hispanic Whites, and people with at least some college education.
Among Black, non-Hispanic Black, and low-income people and people with less than a high school education, those with basic activity limitations were significantly more likely to be underinsured than those with neither basic nor complex activity limitations. Among middle-income people and high school graduates, those with basic or complex activity limitations were significantly more likely to be underinsured than those with neither limitation.
Among people with neither basic nor complex activity limitations, Whites were significantly more likely than Blacks (4.6% compared with 2.9%) and non-Hispanic Whites were significantly more likely than non-Hispanic Blacks (4.7% compared with 2.9%) to be underinsured.
Among people with neither basic nor complex activity limitations, those living in poor (42.8%), low-income (9.4%), and middle-income (4.7%) families were more likely to be underinsured than those living in high-income families (1.6%). The percentage of underinsured people among those with no activity limitations who live in poor families was 27 times that of the percentage in high-income families (42.8% compared with 1.6%).
Among people with basic activity limitations, those with less than a high school education were more likely to be underinsured than those with at least some college education (20.0% compared with 9.2%). This finding also was observed for people with neither basic nor complex activity limitations (less than high school, 7.9%; at least some college education, 3.9%)

Access to Health Care: Financial Burden of Health Care Costs

High medical financial burden is defined as family out-of-pocket medical expenditures, including premiums, exceeding 10% of total family income. This is a comprehensive and policy-relevant measure. Having high medical financial burden may directly affect access to care.¹⁶

Figure 4.56. Adults ages 18-64 whose family out-of-pocket medical expenses, including premiums, exceeded 10% of total family income, by race, ethnicity, family income, and education, stratified by activity limitation, 2006

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

Denominator: Civilian noninstitutionalized population ages 18-64.

Overall, among adults ages 18-64, those with complex activity limitations were significantly more likely to be living in families with high medical financial burden than those with basic activity limitations (40.2% compared with 34.1%; Figure 4.56). Those with basic activity limitations were significantly more likely to be living in families with high medical financial burden than those with neither limitation (34.1% compared with 15.5%).
This same pattern holds for Whites, non-Hispanic Whites, and people with at least some college education.
Among Black, non-Hispanic Black, Hispanic, poor, low-income, middle-income, and high-income people, people with less than a high school education, and high school graduates, those with basic and complex activity limitations were significantly more likely to be living in families with high medical financial burden than those with neither limitation.
Among people with neither basic nor complex activity limitations, Whites were significantly more likely than Blacks (16.1% compared with 12.8%) and non-Hispanic Whites were significantly more likely than non-Hispanic Blacks and Hispanics (16.7% compared with 12.8% and 13.5%, respectively) to be living in families with high medical financial burden.
Within each of the three activity limitation groups (basic, complex, neither), adults ages 18-64 living in poor, low-income, or middle-income families were significantly more likely than those living in high-income families to be in families with high medical financial burden. For example, among those with basic activity limitations, people living in poor families (49.0%) were about three times as likely to be in families with high financial medical burden as those living in high-income families (16.4%).
Among people with basic activity limitations, those with less than a high school education and high school graduates were more likely to be living in families with high medical financial burden than those with at least some college education (38.7% and 38.7%, respectively, compared with 27.1%). This finding also was observed among people with neither basic nor complex activity limitations (less than a high school education, 17.3%; high school graduates, 17.6%; at least some college education, 13.9%).

^xixThis is a supplemental measure of the NHDR measure set.

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