Chapter 4. Priority Populations (continued, 2)

National Healthcare Disparities Report, 2008


Hispanics or Latinos

Previous NHDRs showed that Hispanics had poorer quality of care and worse access to care than non-Hispanic Whites for many measures the reports track. Findings based on core report measures of quality and access to health care that support estimates for Hispanics are shown below.

Figure 4.14. Hispanics compared with non-Hispanic Whites on measures of quality and access

Stacked column chart shows Hispanics compared with non-Hispanic Whites on measures of quality and access. Quality (34 CRM): Worse, 19; Same, 10; Better, 5. Access (6 CRM): Worse, 6; Same, 0; Better, 0.

Better = Hispanics receive better quality of care or have better access to care than non-Hispanic Whites.
Same = Hispanics and non-Hispanic Whites receive about the same quality of care or access to care.
Worse = Hispanics receive poorer quality of care or have worse access to care than non-Hispanic Whites.
CRM = core report measures (Table 1.2).
Note: Data presented are the most recent available.

Table 4.9. Hispanics compared with non-Hispanic Whites on measures of quality and access: Specific measures


TopicBetter than WhitesWorse than WhitesSame as Whites
CancerColorectal cancer diagnosed at advanced stageAdults age 50 and over who report they ever received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test 
Colorectal cancer deaths per 100,000 population per year  
Diabetes Adults age 40 and over with diagnosed diabetes who received all three recommended services 
End stage renal diseaseAdult hemodialysis patients with adequate dialysis (urea renal reduction ratio 65% or greater)Dialysis patients who were registered on a waiting list for transplantation 
Heart disease Recommended hospital care for heart attackAdult current smokers who received advice to quit smoking
 Adults with obesity who ever received advice to exercise moreRecommended hospital care for heart failure
  Deaths per 1,000 adult hospital admissions with acute myocardial infarction (AMI)
HIV and AIDS New AIDS cases per 100,000 population age 13 and over 
Maternal and child health Pregnant women who first received prenatal care in the first trimesterChildren ages 3-6 who ever had their vision checked
  Children for whom a health provider ever gave advice about physical activity
  Children ages 19-35 months who received all recommended vaccines
Mental health and substance abuseSuicide deaths per 100,000 populationAdults with a major depressive episode who received treatment for depressionPeople age 12 and over who needed treatment for illicit drug use and who received such treatment at a specialty facility in the last 12 months
  People age 12 and over treated for substance abuse who completed treatment course
Respiratory diseases Adults age 65 and over who ever received pneumococcal vaccination 
 Recommended hospital care for pneumonia 
 Patients with tuberculosis who completed a curative course treatment within 12 months of initiation of treatment 
Nursing home, home health, and hospice care Long-stay nursing home residents with physical restraintsAdult home health care patients whose ability to walk or move around improved
 High-risk, long-stay nursing home residents with pressure sores 
 Short-stay nursing home residents with pressure sores 
 Adult home health care patients who were admitted to the hospital 
Patient safetyAdults age 65 and over who received potentially inappropriate prescription medicinesAdult surgery patients who received appropriate timing of antibioticsFailure to rescue
Timeliness Adults who can sometimes or never get care for illness or injury as soon as wanted 
Patient centeredness Adults with poor provider-patient communication 
 Children with poor provider-patient communication 
Access to care People under age 65 with health insurance 
 People under age 65 who were uninsured all year 
 People with a specific source of ongoing care 
 People with a usual primary care provider 
 People unable to get or delayed in getting needed medical care, dental care, or prescription medicines 
 People without a usual source of care who indicated a financial or insurance reason 
  • For 19 of the 34 core report measures of quality, Hispanics had poorer quality of care than non-Hispanic Whites (Figure 4.14). For example, Hispanics were less likely to receive recommended care for heart attack and obese Hispanics were less likely to receive advice about exercise than Whites. For 5 measures, Hispanics had better quality care than Whites. These include older adults not receiving inappropriate medications and hemodialysis patients with adequate dialysis. For 10 measures of quality of care, Hispanics were not significantly different from Whites. For example, Hispanic children were as likely as White children to receive vaccinations and vision screening
  • For 6 of the 6 core report measures of access, Hispanics had worse access to care than non-Hispanic Whites. These include people under age 65 with health insurance, people with a usual primary care provider, and people who were unable to get care or who delayed care.

Figure 4.15. Change in Hispanic-non-Hispanic White disparities over time

Stacked column chart shows change in Hispanic-non-Hispanic White disparities over time. Quality (30 CRM): Worsening greater than 5%, 2; Worsening 1-5%, 6; Same, 12; Improving 1-5%, 6; Improving greater than 5%, 4. Access (4 CRM): Worsening greater than 5%, 0; Worsening 1-5%, 0; Same, 2; Improving 1-5%, 1; Improving greater than 5%, 1.

Improving >5% = Hispanic-non-Hispanic White difference becoming smaller at rate greater than 5% per year.
Improving 1-5% = Hispanic-non-Hispanic White difference becoming smaller at rate between 1% and 5% per year.
Same = Hispanic-non-Hispanic White difference not changing.
Worsening 1-5% = Hispanic-non-Hispanic White difference becoming larger at rate between 1% and 5% per year.
Worsening >5% = Hispanic-non-Hispanic White difference becoming larger at rate greater than 5% per year.
CRM = core report measures (Table 1.2).
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 34 core report measures could be tracked over time for Hispanics and non-Hispanic Whites.

Table 4.10. Change in Hispanic-non--Hispanic White disparities over time: Specific measures


TopicImprovingWorseningSame
Cancer Adults age 50 and over who report they ever received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood testColorectal cancer diagnosed at advanced stage
  Colorectal cancer deaths per 100,000 population per year
DiabetesAdults age 40 and over with diagnosed diabetes who received all three recommended services  
End stage renal disease Adult hemodialysis patients with adequate dialysis (urea renal reduction ratio 65% or greater)Dialysis patients who were registered on a waiting list for transplantation
Heart diseaseAdult current smokers who received advice to quit smokingAdults with obesity who were ever given advice to exercise moreDeaths per 1,000 adult hospital admissions with acute myocardial infarction (AMI)
HIV and AIDSNew AIDS cases per 100,000 population age 13 and over  
Maternal and child healthChildren ages 19-35 months who received all recommended vaccines Children ages 2-17 for whom a health provider ever gave advice about physical activity
Children ages 3-6 who ever had their vision checked  
Mental health and substance abuse Adults with a major depressive episode who received treatment for depressionSuicide deaths per 100,000 population
  People age 12 and over who needed treatment for illicit drug use and who received such treatment at a specialty facility in the last 12 months
  People age 12 and over discharged for substance abuse treatment who completed treatment
Respiratory diseases Adults age 65 and over who ever received pneumococcal vaccination. 
 Patients with tuberculosis who completed a curative course treatment within 12 months of initiation of treatment. 
Nursing home, home health, and hospice careLong-stay nursing home residents with physical restraints  
Adult home health care patients whose ability to walk or move around improved High-risk, long-stay nursing home residents with pressure sores
  Short-stay nursing home residents with pressure sores
  Adult home health care patients who were admitted to the hospital
Patient safety Adult surgery patients who received appropriate timing of antibioticsFailure to rescue
 Adults age 65 and over who received potentially inappropriate prescription medicines 
TimelinessAdults who can sometimes or never get care for illness or injury as soon as wanted  
Patient centerednessAdults with poor provider-patient communication  
Children with poor provider-patient communication  
AccessPeople under age 65 who were uninsured all year People under age 65 with health insurance
People with a usual primary care provider People with a specific source of ongoing care
  • Of core report measures of quality that could be tracked over time for Hispanics and non-Hispanic Whites, Hispanic-non-Hispanic White differences became smaller for 10 measures (Figure 4.15). For example, Hispanic-non-Hispanic White differences in timeliness of care and appropriate timing of antibiotics improved over time. Hispanic-non-Hispanic White differences became larger for 8 measures. These include differences in colorectal cancer screening and pneumococcal vaccination for older adults, which worsened over time. For 12 measures, Hispanic-non-Hispanic White differences did not change over time. For example, the differences in the percentage of patients who received substance abuse treatment remained the same.
  • Of core report measures of access that could be tracked over time for Hispanics and non-Hispanic Whites, Hispanic-non-Hispanic White differences became smaller for 2 measures (people under age 65 who were uninsured all year and people who had a usual primary care provider). For 2 measures, Hispanic-non-Hispanic White differences did not change over time (people under age 65 who had health insurance and people who had a specific source of ongoing care).

Recent Immigrants and Limited-English-Proficient Populations

Recent Immigrants and Language Barriers

Immigrants often encounter barriers to high quality health care. In 2003, about 33.5 million persons living in the United States were born outside the United States13, up from 20 million in 1990.14 Asians and Hispanics are much more likely to be foreign born. About 70% of Asians and 40% of Hispanics in the United States are foreign born, compared with about 4% of Whites and 6% of Blacks.14

Certain diseases are concentrated among Americans born in other countries. For example, 56.6% of tuberculosis cases in the Nation were among foreign-born individuals.15 In addition, the case rate among foreign-born individuals is more than 10 times higher than among individuals born in the United States.15 However, the case rates for tuberculosis among U.S.-born and foreign-born individuals are both decreasing.15

Quality health care requires that patients and providers communicate effectively. People who speak a language other than English at home may have less access to resources, such as health insurance, that facilitate getting needed health care. Providers and patients' ability to communicate clearly with one another can be compromised if they do not speak the same language. Quality may suffer if patients with limited English proficiency cannot express their care needs to providers who speak English only and do not have an interpreter's assistance. Communication problems between the patient and provider can lead to lower patient adherence to medications and decreased participation in medical decisionmaking, as well as exacerbate cultural differences that impair the delivery of quality health care. Moreover, Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, prohibits discrimination against patients based on their national origin by providers receiving Federal financial assistance.16 Such providers are required to take reasonable steps to provide people with limited English proficiency with a meaningful opportunity to participate in programs the U.S. Department of Health and Human Services funds.

Limited English proficiency is a barrier to quality health care for many Americans. About 52 million Americans, or 19.4% of the population, spoke a language other than English at home in 2000, up from 32 million in 1990. Of the 52 million, 32 million (about 12% of the population) spoke Spanish, 10 million (about 4% of the population) spoke another Indo-European language, and 7.8 million (about 3% of the population) spoke an Asian or Pacific Islander language, and 2 million spoke other languages at home. Almost half of the people who spoke a foreign language at home reported not speaking English very well.17 A study of health plan members and use of interpreters showed that the use of interpreters reduced disparities for Hispanic and Asian and Pacific Islander members (28% and 21%, respectively).18

As in previous NHDRs, findings are presented below for several quality and access measures based on data from the National Tuberculosis Surveillance System and the Medical Expenditure Panel Survey (MEPS). These sources are supplemented with data from the California Health Interview Survey. Information on disparities in health care quality and access for Americans born outside the United States and for Americans with limited English-speaking skills are presented for tuberculosis therapy, poor communication with health providers, and uninsurance.

Figure 4.16. Completion of therapy for tuberculosis within 12 months of being diagnosed among persons born outside the United States, by race (top) and ethnicity (bottom), 1999-2004

Line graph shows completion of therapy for tuberculosis within 12 months of being diagnosed among persons born outside the United States, by race. White: 1999, 79.3%; 2000, 79.3%; 2001, 78.9%; 2002, 80.0%; 2003, 80.5%; 2004: 79.5%. Black: 1999, 78.1%; 2000, 79.4%; 2001, 82.3%; 2002, 82.0%; 2003, 83.6%; 2004: 83.6%. API: 1999, 79.0%; 2000, 78.8%; 2001, 80.3%; 2002, 81.4%; 2003, 81.6%; 2004: 82.4%.

Line graph shows completion of therapy for tuberculosis within 12 months of being diagnosed among persons born outside the United States, by ethnicity. Non-Hispanic White: 1999, 82.9%; 2000, 81.5%; 2001, 81.6%; 2002, 85.8%; 2003, 84.8%; 2004: 82.7%. Hispanic: 1999, 78.5%; 2000, 79.0%; 2001, 78.6%; 2002, 79.2%; 2003, 79.8%; 2004: 79.1%.

Key: API = Asian or Pacific Islander.
Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 1999-2004.
Reference population: Foreign-born U.S. resident population with verified tuberculosis, all ages.

  • From 1999 to 2004, the proportion of people who completed therapy for tuberculosis within 12 months of being diagnosed improved for foreign-born APIs (from 79.0% to 82.4%) and foreign-born Hispanics (from 78.5% to 79.1%; Figure 4.16).
  • In 2004, the proportion of people who completed therapy for tuberculosis within 12 months of being diagnosed was significantly higher for foreign-born Blacks (83.6%) and APIs (82.4%) than for foreign-born Whites (79.5%) but lower for Hispanics compared with non-Hispanic Whites (79.1% compared with 82.7%).

Figure 4.17. Composite measure: Adult ambulatory patients who reported poor communication with health providers, by race and ethnicity, stratified by language spoken at home, 2005

Bar chart shows percent adult ambulatory patients age 18 and over who reported poor communication with health providers, by race and ethnicity, stratified by language spoken at home, 2005. Total: English, 9.5%; Other language, 13.5%. White: English, 8.9%; Other language, 10.9%. Asian: English. 10.2%; Other language, 18.5%. Non-Hispanic White: English, 8.9%; Other language, 7.5%. Hispanic: English, 12.4%; Other language, 12.6%.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005.
Denominator: Civilian noninstitutionalized population age 18 and over.
Note: Average percentage of adults age 18 and over who had a doctor's office or clinic visit in the last 12 months and were reported to have had poor communication with health providers (i.e., their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them). Data were insufficient for this analysis for Black non-English speakers.

  • The overall percentage of adults who had a doctor's office or clinic visit in the last 12 months who reported poor communication with their health provider was significantly higher for individuals who speak a foreign language at home than for individuals who speak English at home (Figure 4.17).
  • The percentage of adults who reported poor communication with their health provider was significantly higher for Whites who speak some other language at home (10.9%) than for Whites who speak English at home (8.9%). There were no statistically significant differences for other racial or ethnic groups due to small sample sizes.

Figure 4.18. Adults under age 65 who were uninsured all year, by race and ethnicity, stratified by language spoken at home, 2005

Bar chart shows percent adults under age 65 who were uninsured all year, by race and ethnicity, stratified by language spoken at home, 2005. Total: English, 11.4%; Other language, 33.0%. White: English, 10.8%; Other language, 35.8%. Black: English, 14.7%; Other language, 38.5%. Asian: English, 9.9%; Other language, 18.8%. Non-Hispanic White: English, 9.8%; Other language, 28.2%. Hispanic: English, 16.6%; Other language, 36.9%.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005.
Reference population: Civilian noninstitutionalized population ages 18-64.

  • The overall percentage of adults under age 65 uninsured all year was significantly higher for individuals who speak a foreign language at home than for individuals who speak English at home (Figure 4.18).
  • The percentage of people uninsured all year was significantly higher for Whites, Blacks, and Asians who speak some other language at home than for their counterparts who speak English at home (35.8% compared with 10.4% for Whites, 38.5% compared with 14.7% for Blacks, and 18.8% compared with 9.9% for Asians).
  • The percentage of people uninsured all year was more than twice as high for Hispanics who speak some other language at home than for Hispanics who speak English at home (36.9% compared with 16.6%).

Language Assistance

Clear communication is an important component of effective health care delivery. It is vital for providers to understand patients' health care needs and for patients to understand providers' diagnoses and treatment recommendations. Communication barriers can relate to language, culture, and health literacy.

For persons with limited English proficiency, having language assistance is of particular importance. Persons with limited English proficiency may choose a usual source of care in part based on language concordance. Not having a language-concordant provider may limit or discourage some patients from establishing a usual source of care.

The NHDR includes a noncore measure of access: provision of language assistance by the usual source of care. Language assistance includes bilingual clinicians, trained medical interpreters, and bilingual receptionists and other informal interpreters.

Figure 4.19. Adults with limited English proficiency, by whether they had a usual source of care with or without language assistance, 2003-2005

Stacked column chart shows adults with limited English proficiency, by whether they had a usual source of care with or without language assistance, 2003-2005. 2003: No USC, 51%; USC with language assistance, 42%; USC without language assistance, 7%; 2004: No USC, 47%; USC with language assistance, 46%; USC without language assistance, 7%; 2005: No USC, 52%; USC with language assistance, 44%; USC without language assistance, 4%.

Key: USC = usual source of care.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2005.
Reference population: Civilian noninstitutionalized population age 18 and over.
Note: Language assistance includes bilingual clinicians, trained medical interpreters, and informal interpreters (e.g., bilingual receptionists).

  • Approximately half (52%) of individuals with limited English proficiency did not have a usual source of care in 2005 (Figure 4.19).
  • In 2005, less than half (44%) of individuals with limited English proficiency had a usual source of care who offered language assistance.
  • Only 4% of individuals with limited English proficiency had a usual source of care who did not offer language assistance.

Low-Income Groups

In this report, poor populations are defined as people living in families whose household income falls below specific poverty thresholds. These thresholds vary by family size and composition and are updated annually by the U.S. Bureau of the Census.19, x After falling for nearly a decade (1990-2000), the number of poor people in America rose from 31.6 million in 2000 to 36.5 million in 2006, and the rate of poverty increased from 11.3% to 12.3% during the same period.20

Poverty varies by race and ethnicity. In 2006, 24% of Blacks, 21% of Hispanics, 10% of Asians, and 8% of Whites were poor.20 People with low incomes often experience worse health and are more likely to die prematurely.21 In general, poor populations have reduced access to high-quality care. While people with low incomes are more likely to be uninsured, income-related differences in quality of care that are independent of health insurance coverage have also been demonstrated.22

Previous chapters of this report described health care differences by income. This section summarizes disparities in quality of and access to health care for poorxi individuals compared with high-incomexii individuals. For each core report measure, poorer people can have health care that is worse than, about the same as, or better than health care received by high-income people. Only relative differences of at least 10% that are statistically significant with alpha = 0.05 are discussed in this report. Access measures focus on facilitators and barriers to health care and exclude health care utilization measures.

In addition, changes in differences related to income are examined over time. For each core report measure, racial, ethnic, and socioeconomic groups are compared with a designated comparison group at different points in time. Consistent with Healthy People 2010, disparities are measured in relative terms as the percentage difference between each group and a comparison group. Changes in disparity are measured by subtracting the percentage difference from the comparison group at the baseline year from the percentage difference from the comparison group at the most recent year. The change in each disparity is then divided by the number of years between the baseline and most recent estimate to calculate change in disparity per year.

Core report measures (Table 1.2) for which the relative differences are changing less than 1% per year are identified as staying the same. Core report measures for which the relative differences are becoming smaller at a rate of more than 1% per year are identified as improving. Core report measures for which the relative differences are becoming larger at a rate of more than 1% per year are identified as worsening. Changes of greater than 5% per year are also differentiated from changes of between 1% and 5% per year in some figures.

Figure 4.20. Poor compared with high-income individuals on measures of quality and access

Stacked column chart shows poor compared with high income individuals on measures of quality and access. Quality (17 CRM): Worse, 11; Same, 5; Better, 1. Access (6 CRM): Worse, 6; Same, 0; Better, 0.

Better = Poor receive better quality of care or have better access to care than high-income individuals.
Same = Poor and high-income individuals receive about the same quality of care or access to care.
Worse = Poor receive poorer quality of care or have worse access to care than high-income individuals.
CRM = core report measures (Table 1.2).
Note: Data presented are for the most recent data year available.

Table 4.11. Poor compared with high-income on measures of quality and access: Specific measures


TopicBetter than high incomeWorse than high incomeSame as high income
Cancer Adults age 50 and over who report they ever received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test 
Diabetes Adults age 40 and over with diagnosed diabetes who received all three recommended services 
Heart disease  Adult current smokers who received advice to quit smoking
 Deaths per 1,000 adult hospital admissions with acute myocardial infarction (AMI) 
 Adults with obesity who ever received advice to exercise more 
Maternal and child health Children ages 2-17 for whom a health provider ever gave advice about physical activityChildren ages 3-6 who ever had their vision checked
 Children ages 19-35 months who received all recommended vaccines 
Mental health and substance abusePeople age 12 and over who needed treatment for illicit drug use and who received such treatment at a specialty facility in the last 12 months Adults with a major depressive episode who received treatment for depression
Respiratory diseases Adults age 65 and over who ever received pneumococcal vaccination. 
Patient safety  Failure to rescue
  Adults age 65 and over who received potentially inappropriate prescription medicines
Timeliness Emergency department visits in which patients left without being seen 
 Adults who can sometimes or never get care for illness or injury as soon as wanted 
Patient centeredness Adults with poor provider-patient communication 
 Children with poor provider-patient communication 
Access to care People under age 65 with health insurance 
 People under age 65 who were uninsured all year 
 People with a specific source of ongoing care 
 People with a usual primary care provider 
 People unable to get or delayed in getting needed medical care, dental care, or prescription medicines 
 People without a usual source of care who indicated a financial or insurance reason for not having usual source of care 
  • Fewer than half of the core report measures supported estimates of quality for poor populations.
  • For 11 of the 17 core report measures of quality with income data, poor individuals had significantly poorer quality of care than high-income individuals (Figure 4.20). Only one measure (receipt of drug or alcohol treatment) was better for poor individuals than for high-income individuals.
  • For all 6 core report measures of access, poor individuals had significantly worse access to care than high-income individuals.

Figure 4.21. Change in poor-high-income disparities over time

Stacked column chart shows change in poor-high income disparities over time. Quality (15 CRM): Worsening greater than 5%, 4; Worsening 1-5%, 3; Same, 5; Improving 1-5%, 1; Improving greater than 5%, 2. Access (5 CRM): Worsening greater than 5%, 1; Worsening 1-5%, 0; Same, 1; Improving 1-5%, 2; Improving greater than 5%, 1.

Improving >5% = Poor-high-income difference becoming smaller at rate greater than 5% per year.
Improving 1-5% = Poor-high-income difference becoming smaller at rate between 1% and 5% per year.
Same = Poor-high-income difference not changing.
Worsening 1-5% = Poor-high-income difference becoming larger at rate between 1% and 5% per year.
Worsening >5% = Poor-high-income difference becoming larger at rate greater than 5% per year.
CRM = core report measures (Table 1.2).
Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 20 core report measures of quality and access could be tracked over time for poor and high-income individuals.

Table 4.12. Change in poor-high-income disparities over time: Specific measures


TopicImprovingWorseningSame
Cancer Adults age 50 and over who report they ever received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test 
Diabetes Adults age 40 and over with diagnosed diabetes who received all three recommended services 
Heart diseaseAdult current smokers who received advice to quit smoking Deaths per 1,000 adult hospital admissions with acute myocardial infarction (AMI)
  Adults with obesity who ever received advice to exercise more
Maternal and child healthChildren ages 3-6 who ever had their vision checkedChildren ages 19-35 months who received all recommended vaccinesChildren ages 2-17 for whom a health provider ever gave advice about physical activity
Mental health and substance abuse People age 12 and over who needed treatment for illicit drug use and who received such treatment at a specialty facility in the last 12 months 
Respiratory diseases Adults age 65 and over who ever received pneumococcal vaccination.Adults age 65 and over who ever received pneumococcal vaccination
Patient safetyAdults age 65 and over who received potentially inappropriate prescription medicines Failure to rescue
Timeliness Adults who can sometimes or never get care for illness or injury as soon as wanted 
Patient centeredness Adults with poor provider-patient communication 
 Children with poor provider-patient communication 
Access to carePeople under age 65 with health insurancePeople without a usual source of care who indicated a financial or insurance reasonPeople with a specific source of ongoing care
People under age 65 who were uninsured all year  
People with a usual primary care provider  
  • Only about half of the core report measures for quality allow comparisons between poor and high-income individuals over time.
  • Of core report measures of quality that could be tracked over time for poor and high-income individuals, poor-high-income differences became smaller for 3 measures (Figure 4.21). For example, the gap between poor people and high-income people in current smokers receiving advice to quite smoking and children with a vision exam became smaller. For 7 measures, the gap increased, including children who received all recommended vaccines and timeliness of care for illness or injury. For 5 measures, the poor-high-income difference did not change. For example, the gap between poor people and high-income people in pneumococcal vaccination and advice about exercise remained the same.
  • Of core report measures of access that could be tracked over time for poor and high-income individuals, poor-high-income differences became smaller for 3 measures (people under age 65 with health insurance, people under age 65 who were uninsured all year, and people who have a usual primary care provider), became larger for 1 measure (people without a usual source of care due to financial or insurance reason), and remained the same for 1 measure (people with a specific source of ongoing care).

x For example, in 2006 the Federal poverty threshold for a family of 2 adults and 2 children was $20,444.
xi Household income less than Federal poverty thresholds.
xii Household income 400% of Federal poverty thresholds and higher.


Focus on Uninsurance

Because low-paying jobs are less likely to offer health insurance as a benefit and the cost of health insurance leaves poorer individuals less likely to be able to afford it, this year's NHDR again focuses on uninsurance. Compared with insured people, uninsured people report more problems getting care and are diagnosed at later disease stages.23-24 They report poorer health status,25 are sicker when hospitalized, and are more likely to die during their hospital stay.24 Uninsured persons often avoid non-urgent care such as preventive screenings; have difficulty obtaining care for illness or injury; and must bear the full cost of health care. In addition, prolonged periods of uninsurance can have a particularly serious influence on health and stability.

Findings presented here highlight two quality measures related to prevention (screening for colorectal cancer and counseling parents about physical activity in children) and one access measure (dental care) of special relevance to uninsured people. Two of these measures include bivariate analyses to show data by income and insurance status.

Quality of Health Care

Prevention: Screening for Colorectal Cancer

Screening for colorectal cancer is an effective way to reduce new cases of late-stage disease and mortality caused by this cancer.

Figure 4.22. Composite measure: Adults age 50 and over who received colorectal cancer screening (colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test), by income, stratified by insurance status, 2005

Bar chart shows adults age 50 and over who received colorectal cancer screening (colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test), by income, stratified by insurance status, 2005. Total: Any private, 53.4; Public only, 48.8; Uninsured, 24.1. Poor: Any private, 35.6; Public only, 42; Uninsured, 23.5. Near Poor: Any private, 44.9; Public only, 50.5; Uninsured, 25.2. Middle Income: Any private, 50.5; Public only, 48; Uninsured, 19.0. High Income: Any private, 56.5; Public only, 62; Uninsured, 34.5.

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2005.
Reference population: Civilian noninstitutionalized men and women age 50 and over who reported they received a colonoscopy, sigmoidoscopy, proctoscopy, or fecal occult blood test in the last 2 years.

  • Overall, adults age 50 and over without insurance were less than half as likely as adults with private insurance to report they had colorectal cancer screening in the last 2 years (24.1% compared with 53.4%; Figure 4.22). Publicly insured adults were also less likely than adults with private insurance to report they had colorectal cancer screening in the last 2 years (48.8% compared with 53.4%).
  • Among poor adults, there was no statistically significant difference by insurance status.
  • Among near-poor adults, the percentage was significantly lower for uninsured adults (25.2%) than for privately insured adults (44.9%).
  • Among middle-income adults, the percentage was significantly lower for uninsured adults than for privately insured adults (19.0% compared with 50.5%).
  • Among high-income adults, the percentage was significantly lower for uninsured adults than for privately insured adults (34.5% compared with 56.5%).

Prevention: Counseling Parents About Physical Activity in Children

Counseling about physical activity can play an important role in helping children to lose excess weight and establish healthy lifestyle behaviors.

Figure 4.23. Children ages 2-17 with ambulatory visits for whom a health provider ever gave advice about the amount and kind of exercise, sports, or physically active hobbies they should have, by insurance status, 2002-2005

Line graph shows children ages 2-17 with ambulatory visits for whom a health provider ever gave advice about the amount and kind of exercise, sports, or physically active hobbies they should have, by insurance status, 2002-2005. The ranges are as follows: Total: 31.5-35%; Any private: 34-36.5%; Public only: 30.0-32.3%; and Uninsured: 25.0%-28.5%.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2005.
Reference population: Civilian noninstitutionalized population ages 2-17.
Note: Estimates were for children whose parents or guardians reported ever receiving advice from a health care provider about their children's physical activity. More data by race and ethnicity can be found in the Children section.

  • From 2002 to 2005, the gap between uninsured children and privately insured children whose parents or guardians reported receiving advice about physical activity remained the same. In 2005, the percentage was significantly less for uninsured children than for privately insured children (28.5% compared with 36.1%; Figure 4.23).
  • During this period, there was no significant difference between publicly insured and privately insured children whose parents or guardians reported receiving advice about physical activity.

Access to Health Care

Dental Care

Regular dental visits promote prevention, early diagnosis, and optimal treatment of oral diseases and conditions.

Figure 4.24. People who had a dental visit in the calendar year, by income, stratified by insurance status, 2005

Bar chart shows percent of people who had a dental visit in the past year, by income, stratified by insurance status, 2005. Healthy People 2010 target: 56%. Total: Any private, 50.9; Public only, 30.7; Uninsured, 17.3. Poor: Any private, 34.1; Public only, 29.6; Uninsured, 12.9. Near Poor--Any private, 37.2; Public only, 30.9; Uninsured, 14.2. Middle Income--Any private, 46.2; Public only, 31.4; Uninsured, 18.1. High Income--Any private, 58.6; Public only, 41.2; Uninsured, 27.1.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005.
Reference population: Civilian noninstitutionalized population, all ages.

  • Overall, the percentage of people with a dental visit in the past year was significantly lower for publicly insured and uninsured people than for privately insured people (30.7% and 17.3%, respectively, compared with 50.9%; Figure 4.24).
  • Among poor people, the percentage did not differ significantly between publicly insured and privately insured people (29.6% compared with 34.1%) but was significantly lower for uninsured people than for privately insured people (12.9% compared with 34.1%).
  • Among near-poor, middle-income, and high-income people, uninsured people were less than half as likely as privately insured people to have had a dental visit in the past year.
  • Only high-income people with private health insurance met the Healthy People 2010 target of 56% of people with a dental visit in the past year (58.6%).
Current as of March 2009
Internet Citation: Chapter 4. Priority Populations (continued, 2): National Healthcare Disparities Report, 2008. March 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr08/Chap4b.html