Chapter 3. Access to Health Care

Contents

Facilitators and Barriers to Health Care
Health Care Utilization
Summary Tables
References

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 Access

Access 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:

• Gaining entry into the health care system.
• Getting access to sites of care where patients can receive needed services.
• Finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and trust.²

Health care access is measured in several ways, including:

• Structural measures of the presence or absence of specific resources that facilitate health care, such as having health insurance or a usual source of care.
• Assessments by patients of how easily they are able to gain access to health care.
• Utilization measures of the ultimate outcome of good access to care (i.e., the successful receipt of needed services).

How This Chapter Is Organized

This chapter presents new information about disparities in access to health care in America. It is divided into two sections:

• Facilitators and barriers to health care, including measures of health insurance coverage, usual source of care and primary care provider, and patient perceptions of need.
• Health care utilization, including measures of dental care, emergency care, potentially avoidable admissions, mental health care, and substance abuse treatment.

This chapter presents new information about disparities in access to health care in America since the last NHDR. It is divided into two sections:

• Facilitators and barriers to health care, including measures of health insurance coverage, usual source of care and primary care provider, and patient perceptions of need.
• Health care utilization, including measures of dental care, emergency care, potentially avoidable admissions, mental health care, and substance abuse treatment.

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 Care

Facilitators 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 Insurance

Health 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.

• From 1999 to 2007, the gap between Blacks and Whites in insurance coverage decreased (Figure 3.1). In 2007, there was no statistically significant difference between Blacks and Whites in the percentage of people with insurance (83.0% compared with 83.7%).
• From 1999 to 2007, the gap between Hispanics and non-Hispanic Whites in insurance coverage remained the same. In 2007, the percentage of people with insurance was lower for Hispanics than for non-Hispanic Whites (68.2% compared with 87.4%).
• The gap between poor people and high-income people decreased during this period. Still, in 2007, the percentage of people with insurance was significantly lower for poor people than for high-income people (71.6% compared with 94.4%).
• The gap between people with less than a high school education and people with at least some college education increased. In 2007, the percentage of people with insurance was one-third lower for people with less than a high school education than for people with at least some college education (59.2% compared with 89.0%).
• From 1999 to 2007, the rates of insurance worsened for Whites and middle-income people. There were no statistically significant changes in the rate of insurance for Blacks, Asians, Native Hawaiians and Other Pacific Islanders (NHOPIs), American Indians and Alaska Natives (AI/ANs), non-Hispanic Whites, and Hispanics.
• During this period, the rates also worsened for adults ages 25-64 at every education level.

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.

• SES explains some but not all of the differences in the health insurance coverage of racial and ethnic groups in people under age 65 (Figures 3.2 and 3.3).
• Hispanics of every income and education level were significantly less likely than their non-Hispanic peers to have health insurance.
• Blacks who were poor were significantly more likely than their White counterparts to have health insurance (80.3% compared with 68.3%), as were Blacks with less than a high school education (67.7% compared with 58.2%).
• AI/ANs at every income level except poor and every education level except less than high school were significantly less likely to have health insurance than Whites.
• Among people with a high school education, AI/ANs (58.7%) were significantly less likely than Whites (78.7%) to have health insurance. Hispanics (62.8%) also were significantly less likely than non-Hispanic Whites (81.5%) to have health insurance.
• No group has yet achieved the Healthy People 2010 target of 100% of people in the United States having health insurance.

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.

• From 2002 to 2006, the gap between Blacks and Whites in the percentage of uninsured people remained the same (Figure 3.4).
• In 2006, Asians were less likely than Whites to be uninsured (12.9% compared with 14.4%), and AI/ANs were more likely than Whites to be uninsured (20.5% compared with 14.4%).
• From 2002 to 2006, the gap between Hispanics and non-Hispanic Whites in the percentage of uninsured people remained the same. In 2006, the percentage of people uninsured all year was still almost three times as high for Hispanics as for non-Hispanic Whites (28.6% compared with 10.8%).
• From 2002 to 2006, the gap between poor people and high-income people in the percentage of uninsured people remained the same. In 2006, the percentage of people uninsured all year was still about four times as high for poor people as for high-income people (23.7% compared with 5.7%).
• From 2002 to 2006, the gap between people with less than a high school education and people with at least some college education in the percentage of uninsured people increased. The percentage of people uninsured all year increased for people with less than a high school education (from 30.2% to 33.3%).

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.

• In the multivariate model used, after adjustment, 15% of non-Hispanic Blacks and 27% of Hispanics would have been uninsured all year compared with 14% of non-Hispanic Whites (Figure 3.5).
• After adjustment, 30% of poor, 28% of low-income, and 16% of middle-income individuals would have been uninsured all year compared with only 8% of those with high income.
• After adjustment, 21% of people with less than a high school education and 18% of high school graduates would have been uninsured all year compared with 13% of those with some college education.
• After adjustment, 18% of people living in nonmetropolitan areas would have been uninsured all year compared with 16% of those living in metropolitan areas.

Financial Burden of Health Care Costs

Health 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.

• In 2006, the percentage of people under age 65 whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income was lower for Blacks and Asians than for Whites (15.7% and 12.7%, respectively, compared with 18.0%), and lower for Hispanics than for non-Hispanic Whites (14.9% compared with 18.9%; Figure 3.6).
• The percentage of people under age 65 whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income was about four times as high for poor individuals (33.9%), almost three times as high for low-income individuals (23.6%), and more than twice as high for middle-income individuals (18.8%) compared with high-income individuals (8.2%).
• The percentage of people under age 65 whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income was more than three times as high for individuals with private nongroup insurance as for individuals with private employer-sponsored insurance (51.5% compared with 16.9%). There was no significant difference between publicly insured individuals and individuals with employer-sponsored insurance.
• The percentage of people under age 65 whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income was higher for individuals living in nonmetropolitan areas than for those in metropolitan areas (22.9% compared with 16.5%).
• Among individuals living in metropolitan areas, individuals in medium metropolitan areas (20.0%) and individuals in small metropolitan areas (18.5%) were more likely than individuals living in large central metropolitan areas (14.3%) to have health insurance premium and out-of-pocket medical expenses of more than 10% of total family income.

Usual Source of Care

People 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 Care

Evidence 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.

• From 1999 to 2007, the gap in usual source of care between Hispanics and non-Hispanic Whites remained the same (Figure 3.7). In 2007, the percentage of people with a specific source of ongoing care was significantly lower for Hispanics than for non-Hispanic Whites (77.4% compared with 88.5%).
• During this period, the gap between poor people and high-income people remained the same. In 2007, the percentage of people with a specific source of ongoing care was significantly lower for poor people than for high-income people (79.5% compared with 92.3%).
• Also during this period, for people under age 65, the gap between uninsured people and people with private insurance increased. In 2007, the percentage of people with a specific source of ongoing care was much lower for uninsured people than for people with private insurance (55.3% compared with 91.9%).
• Other than people age 65 and over with Medicare and private insurance, no other group has achieved the Healthy People 2010 target of 96% of people in the United States having a specific source of ongoing care.

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.

• In the multivariate model used, after adjustment, 83% of Hispanics would have had a specific source of ongoing care compared with 87% of non-Hispanic Whites (Figure 3.8).
• After adjustment, compared with the high-income group (88%), all other income groups would have had a lower percentage with a specific source of ongoing care (poor, 83%; low income, 85%; and middle income, 86%).
• After adjustment, only 60% of those who were uninsured all year would have had a specific source of ongoing care compared with 92% of those with private insurance.
• After adjustment, 88% of those living in noncore areas would have had a specific source of ongoing care compared with 87% of those living in large fringe metropolitan areas.

Usual Primary Care Provider

Having 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.

• From 2002 to 2006, the gap between Blacks and Whites remained the same. In 2006, Blacks were less likely than Whites to have a usual primary care provider (75.4% compared with 78.7%; Figure 3.9).
• In 2006, Asians were less likely than Whites to have a usual primary care provider (64.7% compared with 78.7%).
• The gap between Hispanics and non-Hispanic Whites remained the same. In 2006, the percentage of people with a usual primary care provider was significantly lower for Hispanics than for non-Hispanic Whites (65.6% compared with 81.7%).
• The gap between poor people and high-income people remained the same. In 2006, the percentage of people with a usual primary care provider was significantly lower for poor people than for high-income people (72.3% compared with 82.2%).
• The gap between people with less than a high school education and people with at least some college education remained the same. In 2006, the percentage of people with a usual primary care provider was significantly lower for people with less than a high school education than for people with some college education (67.4% compared with 75.9%).
• From 2002 to 2006, for people under age 65, the gap between uninsured people and people with private insurance remained the same. In 2006, uninsured people were almost half as likely as people with private insurance to have a usual primary care provider (45.4% compared with 80.6%).
• During this period, for people age 65 and over, the gap between people with Medicare only and people with Medicare and private insurance remained the same. In 2006, people with Medicare only were less likely than people with Medicare and private insurance to have a usual primary care provider (89.3% compared with 92.7%).
• With the exception of people age 65 and over with Medicare insurance coverage, no group has achieved the Healthy People 2010 target of 85% of Americans with a usual primary care provider.

Patient Perceptions of Need

Patient 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.

• The percentage of people who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines was lower for Asians than for Whites (6.4% compared with 11.7%; Figure 3.10) and higher for people of multiple race than for Whites (17.2% compared with 11.7%).
• The percentage of people who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines was lower for Hispanics than for non-Hispanic Whites (9.3% compared with 12.3%).
• The percentage of people who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines was significantly higher for poor (15.4%), near-poor (14.6%), and middle-income (12.8%) people than for high-income people (8.2%).
• For people under age 65, the percentage of people who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines was almost two times as high for people with no health insurance as for people with private insurance (19.5% compared with 10%). The percentage was about 1� times that of people with public insurance (19.5% compared with 13.1%).
• For people age 65 and over, the percentage of people who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines was higher for people with Medicare only (13.1%) and people with Medicare and public insurance (14.1%) than for people with Medicare and private insurance (8.9%; data not shown).

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.

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