2012 National Healthcare Disparities Report

Chapter 9. Access to Health Care

Many Americans have good access to health care that enables them to benefit fully from the Nation's health care system. Others face barriers that make it difficult to obtain basic health care services. As shown by extensive research and confirmed in previous National Healthcare Disparities Reports (NHDRs), racial and ethnic minorities and people of low socioeconomic status (SES)i are disproportionately represented among those with access problems.

Previous findings from the National Healthcare Quality Report (NHQR) and NHDR showed that health insurance was the most significant contributing factor to poor quality of care for some of the core measures, and many measures are not improving. Uninsured people were less likely to get recommended care for disease prevention, such as cancer screening, dental care, counseling about diet and exercise, and flu vaccination. They also were less likely to get recommended care for disease management, such as diabetes care management.

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. This increases the burden of disease for society overall in addition to the burden borne individually.

According to the Centers for Disease Control and Prevention (CDC), the lack of access to health care that results from inadequate insurance coverage should be greatly reduced by the Affordable Care Act (ACA). The ACA is expected to extend insurance coverage to an additional 27 million people by 2019 (CBO, 2013).

Recent studies by the Office of the Assistant Secretary for Planning and Evaluation have demonstrated early evidence of greater rates of insurance coverage among young adults. Before ACA implementation, young adults with private insurance were more than twice as likely to lose insurance coverage as older adults (Schwartz & Sommers, 2012). New estimates, however, show that from September 2010 to December 2011, more than 3 million additional young adults had coverage (Sommers, 2012). This includes an estimated 913,000 Latino, 509,000 African American, and 121,000 Asian young adults (Sommers & Kronick, 2012). Overall, males have significantly benefited from the expanded coverage, and their rate of coverage has increased from 57.9% to 72.0% (Sommers, 2012).

The ACA also makes significant changes to the Medicaid program. All citizens and legal permanent residents with a household income up to 133% of the poverty level who do not have access to affordable health coverage through their employers and who reside in a State that chooses to participate in the expansion will be eligible for Medicaid. This change could improve the health of millions of Americans. Medicaid expansions have been shown to reduce mortality among adults, particularly those ages 35-64 years, minorities, and residents of low-income areas (Sommers, et al., 2012).

Components of Health Care Access

Access to health care means having "the timely use of personal health services to achieve the best health outcomes" (IOM, 1993). 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.

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 can gain access to health care.
  • Utilization measures of the ultimate outcome of good access to care (i.e., the successful receipt of needed services).

Facilitators and Barriers to Health Care

Facilitators and barriers to health care discussed in this chapter include health insurance, financial burden of health care costs, usual source of care (including having a specific source of ongoing care and a usual primary care provider), and patient perceptions of need.

Findings

Health Insurance

Health insurance facilitates entry into the health care system. Uninsured people are less likely to receive medical care and more likely to have poor health status. The cost of poor health among uninsured people was almost $125 billion in 2004 (Hadley & Holahan, 2004).

The financial burden of uninsurance is also high for uninsured individuals; almost 50% of personal bankruptcy filings are due to medical expenses (Jacoby, et al., 2000). Uninsured individuals report more problems getting care, are diagnosed at later disease stages, and get less therapeutic care. They are sicker when hospitalized and more likely to die during their stay (Hadley & Holahan, 2004).

  Figure 9.1. People under age 65 with health insurance, by race and income, 2000-2010

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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), 2000-2010.
Denominator: Civilian noninstitutionalized population under age 65.
Note: NHIS respondents are asked about health insurance coverage at the time of interview. Respondents are considered insured if they have private health insurance, Medicare, Medicaid, State Children's Health Insurance Program, a State-sponsored health plan, other government-sponsored health plan, or a military health plan. If their only coverage is through the Indian Health Service, they are not considered insured. Estimates are not age adjusted.

  • Overall, there was no statistically significant change from 2000 to 2010 in the percentage of people under age 65 with health insurance. In 2010, 81.8% of people under age 65 had health insurance (data not shown).
  • From 2000 to 2010, American Indians and Alaska Natives (AI/ANs) under age 65 were less likely than Whites to have health insurance in all years (in 2010, 56.0% compared with 82.4%). Blacks under age 65 were also less likely than Whites to have health insurance in 7 of 11 years (Figure 9.1).
  • In all years, Hispanics under age 65 were less likely to have health insurance compared with non-Hispanic Whites (data not shown).
  • The percentage of people with health insurance was significantly lower for poor, low-income, and middle-income people than for high-income people in all years (in 2010, 69.8%, 67.6%, and 82.6%, respectively, compared with 94.4%).
  • Between 2000 and 2010, the percentage of people with less than a high school education who had health insurance decreased from 63.1% to 54.4%. In 2010, people with less than a high school education were about one-third less likely than people with any college education to have health insurance (54.4% compared with 86.9%; data not shown).

Also, in the NHQR:

  • From 2000 to 2010, the percentage of children ages 0-17 who had health insurance increased. However, for adults ages 18-44 and 45-64, the percentage decreased.
  • In all years, adults ages 18-44 were less likely than children ages 0-17 and adults ages 45-64 to have health insurance.
  • Females were more likely to have health insurance than males throughout this period.

Uninsurance

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 9.2. People under age 65 who were uninsured all year, by ethnicity and income, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population under age 65.
Note: For this measure, lower rates are better.

  • From 2002 to 2009, the percentage of people under age 65 who were uninsured all year increased from 13.4% to 15.5% (data not shown).
  • In 2009, AI/ANs were more likely than Whites to be uninsured all year (24.1% compared with 15.6%). There was no statistically significant difference between Blacks and Whites or between Asians and Whites (data not shown).
  • In all years, Hispanics were much more likely than non-Hispanic Whites to be uninsured all year (in 2009, 29.0% compared with 11.9%; Figure 9.2).
  • In 2009, the percentage of poor and low-income people who were uninsured all year was more than four times as high as that for high-income people (26.5% and 26.1%, respectively, compared with 6.2%). The percentage of middle-income people uninsured all year was more than twice as high as that for high-income people (15.1% compared with 6.2%).
  • From 2002 to 2009, the percentage of people who were uninsured all year was nearly three times as high for people who spoke another language at home as that for people who spoke English at home (in 2009, 34.2% compared with 12.5%; data not shown).

Also, in the NHQR:

  • From 2002 to 2009, children ages 0-17 were least likely to be uninsured all year, while adults ages 18-44 were most likely to be uninsured all year.
  • Females were less likely to be uninsured all year than males.

  Figure 9.3. Predicted percentages of adults ages 18-64 who were uninsured all year, by race, age, gender, family income, and education, 2002-2009

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Key: NHOPI = Native Hawaiian or Other Pacific Islander; AI/AN = American Indian or Alaska Native.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, pooled 2002-2009 Full Year files.
Note: For this measure, lower rates are better. Predicted percentages are predicted marginals from a logistic regression model that includes the covariates race, age, gender, family income, and education. Predicted percentages for multiple races did not meet criteria for data reliability and are not reported.

  • In the multivariate model used, after adjustment, 15.8% of Blacks, 17.7% of Asians, and 8.9% of Native Hawaiians and Other Pacific Islanders would have been uninsured all year compared with 17.6% of Whites (Figure 9.3). AI/ANs would have been more likely than Whites to be uninsured all year (21.5% compared with 17.6%).
  • After adjustment, people ages 18-44 would have been more likely than people ages 45-64 to be uninsured all year (18.6% compared with 15.0%).
  • After adjustment, 32.5% of poor, 30.1% of low-income, and 16.7% of middle-income individuals would have been uninsured all year compared with 7.4% of those with high income.
  • After adjustment, 24.3% of people with less than a high school education and 18.5% of high school graduates would have been uninsured all year compared with 12.8% of those with any college education.

Hispanic and Asian Subgroups

The Hispanic population in the United States is highly heterogeneous. Almost 65% of all Hispanics in the country are of Mexican descent, making this group the largest subpopulation. People originating from Puerto Rico, Central America, and South America are the next largest subgroups. Variation is seen in access to care among Hispanics related to country of origin. Findings are presented below on differences among Hispanic subpopulations on health insurance.

In 2012, California's Hispanic population was more than twice the percentage in the United States overall (38.1% in California compared with 16.7% of the U.S. population; U.S. Census Bureau, 2012). Almost 30% of the Hispanic population in the United States lives in California (U.S. Census Bureau, 2012).

California Health Interview Survey (CHIS) data show disparities among Hispanics in California, not only compared with non-Hispanic Whites but also within Hispanic subgroups (Mexican, Puerto Rican, Central American, and South American). The data also show disparities across Hispanic subgroups by income. This section shows only some of the significant disparities for these groups in California from CHIS data.

To show differences within racial groups, this year's NHDR also includes information from the CHIS on Asians in California. The geographic distribution of Asian subpopulations allows such comparisons in California using CHIS data.

In 2010, an estimated 5.6 million Asian people, or about 32% of the Asian population in the United States, lived in California (U.S. Census Bureau, 2011). The proportion of many Asian subpopulations in California is also greater than the proportion in the overall U.S. population. For example, in 2010, the Vietnamese population was 1.6% of California's population compared with only 0.4% of the U.S. population, and the Filipino population was 3.2% of California's population compared with only 0.7% of the U.S. population (U.S. Census Bureau, 2010). This finding is especially important when examining data for these relatively smaller groups, as most national data sources do not have sufficient data to report estimates for these groups.

  Figure 9.4. People under age 65 who were uninsured all year, Hispanics and Asians, California, 2001-2009

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Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2001-2009.
Denominator: Hispanic and Asian civilian noninstitutionalized population ages 0-64 in California.
Note: For this measure, lower rates are better. Data for Filipinos, South Asians, and South Americans did not meet criteria for statistical reliability in 2009.

  • In all years from 2001 to 2009, Mexicans and Central Americans in California were more likely than non-Hispanic Whites to be uninsured all year (Figure 9.4).
  • In all years from 2001 to 2009, Koreans in California were more likely than all other Asian ethnic groups to be uninsured all year.
  • In all years during this time, among Hispanics in California, people who were not born in the United States were more than three times as likely as Hispanics born in the United States to be uninsured all year. Similarly, in all years, Asians not born in the United States were approximately three times as likely as Asians born in the United States to be uninsured all year (data not shown).

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 of health care can still be high and is increasing (Banthin & Bernard, 2006). High premiums and out-of-pocket payments can be a significant barrier to accessing needed medical treatment and preventive care (Alexander, et al., 2003).

According to one study, uninsured families can afford to pay for only 12% of hospitalizations that they experience (Chappel, et al., 2011). One way to assess the extent of financial burden is to determine the percentage of family income spent on a family's health insurance premium and out-of-pocket medical expenses.

  Figure 9.5. People under age 65 whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income, by race and family income, 2006-2009

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Key:AI/AN = American Indian or Alaska Native.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006-2009.
Denominator: Civilian noninstitutionalized population under age 65.
Note: For this measure, lower rates are better. Total financial burden includes premiums and out-of-pocket costs for health care services.

  • Overall, in 2009, 17.4% of people under age 65 had health insurance premium and out-of-pocket medical expenses that were more than 10% of total family income (data not shown).
  • From 2006 to 2009, 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 than for Whites in all years (in 2009, 14.7% compared with 17.9%; Figure 9.5).
  • In all years, the percentage was also lower for Hispanics than for non-Hispanic Whites (data not shown).
  • In all years, 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 at least four times as high for poor individuals, about three times as high for low-income individuals, and more than twice as high for middle-income individuals compared with high-income individuals.

Also, in the NHQR:

  • In all years from 2006 to 2009, 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 three times as high for individuals with private nongroup insurance as for individuals with private employer-sponsored insurance.
  • In all years, people with activity limitations (both basic activity limitations and complex limitations) were significantly more likely than people with neither type of activity limitation to have family's health insurance premium and out-of-pocket medical expenses that were 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) (Starfield & Shi, 2004) and costs (De Maeseneer, et al., 2003). Evidence suggests that the effect on quality of the combination of health insurance and a usual source of care is additive (Phillips, et al., 2004). In addition, people with a usual source of care are more likely to receive preventive health services (Ettner, 1996).

Specific Source of Ongoing Care

The term "specific source of ongoing care" accounts for patients who may have more than one source of care. For example, women of childbearing age and older people tend to have more than one doctor. A specific source of ongoing care can include an urgent care/walk-in clinic, doctor's office, clinic, health center facility, hospital outpatient clinic, health maintenance organization/preferred provider organization, military or other Veterans Affairs health care facility, or some other similar source of care (however, hospital emergency rooms are excluded).

  Figure 9.6. People with a specific source of ongoing care, by ethnicity and income, 2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2010.
Denominator: Civilian noninstitutionalized population of all ages.
Note: A hospital emergency room is not included as a specific source of ongoing care.

  • In 2010, 85.5% of people had a specific source of ongoing care (data not shown).
  • Whites were more likely than all other racial groups to have a specific source of ongoing care, but these differences were not statistically significant (data not shown).
  • The percentage of people with a specific source of ongoing care was significantly lower for Hispanics than for non-Hispanic Whites (76.2% compared with 88.2%; Figure 9.6).
  • The percentage of people with a specific source of ongoing care was significantly lower for poor and low-income people than for high-income people (77.3% and 79.7%, respectively, compared with 91.9%).
  • The percentage of people with a specific source of ongoing care was significantly lower for people with less than a high school education than for people with any college education (75.1% compared with 87.4%; data not shown).

Also, in the NHQR:

  • In 2010, people age 65 and over were most likely to have a specific source of ongoing care, while people ages 18-44 were least likely to have a specific source of ongoing care.
  • In 2010, people with private insurance were nearly twice as likely to have a specific source of ongoing care as uninsured people.

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 provider and with good provider-patient communication. These factors increase the likelihood that patients will receive appropriate care. 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. Having a usual primary care provider correlates with receipt of higher quality care (Parchman & Burge, 2002; Inkelas, et al., 2004).

A person is determined to have had a primary care provider if his or her usual source of care setting was either a physician's office or a hospital (other than an emergency room) and he or she reported going to this usual source of care for new health problems, preventive health services, and physician referrals.

  Figure 9.7. People with a usual primary care provider, by race and family income, 2002-2009

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Key: AI/AN = American Indian or Alaska Native.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population of all ages.
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.

  • In 2009, about 76% of people had a usual primary care provider (Figure 9.7).
  • From 2002 to 2009, Blacks were less likely than Whites to have a usual primary care provider in all years and Asians were less likely than Whites to have a usual primary care provider in 7 of 8 years (in 2009, 68.4% compared with 76.7%).
  • In all years, the percentage of people with a usual primary care provider was lower for Hispanics than for non-Hispanic Whites (data not shown).
  • In all years, the percentage of people with a usual primary care provider was significantly lower for poor, low-income, and middle-income people than for high-income people.
  • In all years, people with less than a high school education were less likely than people with any college education to have a usual primary care provider (data not shown).

Also, in the NHQR:

  • From 2002 to 2009, people ages 18-44 were least likely to have a usual primary care provider.
  • In all years, uninsured people ages 0-64 were much less likely to have a usual primary care provider than people with private or public insurance.

Patient Perceptions of Need

Patient perceptions of 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 care, problems getting care when patients perceive that they are ill or injured likely reflect significant barriers to care.

  Figure 9.8. 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 and income, 2002-2009

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Key: AI/AN = American Indian or Alaska Native.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population of all ages.
Note: For this measure, lower rates are better.

  • In 2009, 11.1% of people were unable to get or delayed in getting needed medical care, dental care, or prescription medicines (data not shown).
  • In 2009, Asians (6.5%) and AI/ANs (8.1%) were less likely than Whites (11.6%) to report that they were unable to get or delayed in getting medical care, dental care, or prescription medicines (Figure 9.8).
  • In all years, Hispanics were less likely than non-Hispanic Whites to report that they were unable to get or delayed in getting medical care, dental care, or prescription medicines (data not shown).
  • In all years, 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, low-income, and middle-income people than for high-income people.
  • In all years, people with less than a high school education and people with a high school education were more likely than those with any college education to report they were unable to get or delayed in getting needed care (data not shown).

Also, in the NHQR:

  • In all years, people ages 18-44 were more likely than people age 65 and over and, in 7 of 8 years, people ages 0-17 to be unable to get or delayed in getting needed medical care, dental care, or prescription medicines.
  • Uninsured people and people with public insurance were more likely than people with private insurance to be unable to get or delayed in getting needed medical care, dental care, or prescription medicines.

References

Alexander GC, Casalino LP, Meltzer DO. Patient-physician communication about out-of-pocket costs. JAMA 2003;290(7):953-8.

Banthin JS, Bernard DM. Changes in financial burdens for health care: national estimates for the population younger than 65 years, 1996 to 2003. JAMA 2006;296(22):2712-9.

Chappel A, Kronick R, Glied S. The value of health insurance: few of the uninsured have adequate resources to pay potential hospital bills. ASPE Research Brief. Washington, DC: U.S. Department of Health and Human Services; May 2011. Available at: http://aspe.hhs.gov/health/reports/2011/ValueofInsurance/rb.pdf [Plugin Software Help]. Accessed June 29, 2011.

Congressional Budget Office. Effects of the Affordable Care Act on health insurance coverage—February 2013 baseline. Washington, DC: CBO; February 2013. Available at http://www.cbo.gov/publication/43900. Accessed March 14, 2013.

De Maeseneer J, De Prins L, Gosset C, et al. Provider continuity in family medicine: does it make a difference for total health care costs? Ann Fam Med 2003;(1):144-8.

Ettner SL. The timing of preventive services for women and children: the effect of having a usual source of care. Am J Pub Health 1996;86(12):1748-54.

Hadley J, Holahan J. The cost of care for the uninsured: what do we spend, who pays, and what would full coverage add to medical spending? Kaiser Issue Update. Washington, DC: The Henry J. Kaiser Family Foundation; May 10, 2004.

Inkelas M, Schuster MA, Olson LM, et al. Continuity of primary care clinician in early childhood. Pediatrics 2004;113(6 Suppl):1917-25.

Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Washington, DC: National Academy Press; 1993.

Jacoby M, Sullivan T, Warren E. Medical problems and bankruptcy filings. Norton's Bankruptcy Law Advisor 2000 May;5:1-12.

Parchman ML, Burge SK. Continuity and quality of care in type 2 diabetes: a Residency Research Network of South Texas study. J Fam Pract 2002;51(7):619-24.

Phillips R, Proser M, Green L, et al. The importance of having health insurance and a usual source of care. Am Fam Physician 2004 Sep 15;70(6):1035.

Schwartz K, Sommers BD. Young adults are particularly likely to gain stable health insurance coverage as a result of the Affordable Care Act. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services; 2012. Available at: http://aspe.hhs.gov/health/reports/2012/UninsuredYoungAdults/rb.pdf [Plugin Software Help]. Accessed March 14, 2013.

Sommers B. Number of young adults gaining insurance due to the Affordable Care Act now tops 3 million. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services: 2012. Available at: http://aspe.hhs.gov/aspe/gaininginsurance/rb.shtml. Accessed March 14, 2013.

Sommers B, Kronick R. Report shows Affordable Care Act has expanded insurance coverage among young adults of all races and ethnicities. ASPE Issue Brief. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services; 2012. Available at: http://aspe.hhs.gov/health/reports/2012/YoungAdultsbyGroup/ib.shtml. Accessed March 14, 2013.

Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after State Medicaid expansions. N Engl J Med 2012;367:1025-34.

Starfield B, Shi L. The medical home, access to care, and insurance: a review of evidence. Pediatrics 2004;113(5 Suppl):1493-8.

U.S. Census Bureau. Facts for Features, Asian/Pacific American Heritage Month: May 2011. Available at: http://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb11-ff06.html. Accessed August 24, 2011.

U.S. Census. Bureau.American Fact Finder, 2010. Available at http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml. Accessed March 14, 2013.

U.S. Census Bureau. State & County QuickFacts; 2012. Available at: http://quickfacts.census.gov/qfd/states/06000.html. Accessed March 13, 2013.


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), low income = 100-199% of the FPL, middle income = 200-399% of the FPL, and high income = 400% or more of the FPL. The Measure Specifications and Data Sources appendixes provide more information on income groups by data source.

Page last reviewed May 2013
Internet Citation: 2012 National Healthcare Disparities Report: Chapter 9. Access to Health Care. May 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/nhdr12/chap9.html