FIGURE 1.1
The National Health Interview Survey (NHIS is an annual nationwide survey of about thirty-six thousand households in the United States conducted by the National Center for Health Statistics, one of the Centers for Disease Control and Prevention) found that from 1997 through 2003 the percentage of persons of all ages with a usual source of medical care did not substantially vary—ranging from a low of 86.2% in 1997 to a high of 88% in 2001, where it remained through 2003. (See Figure 1.1.)
Still, from 1998 through 2003 the percentage of persons who needed medical care but did not obtain it because of financial barriers to access increased each year. The annual percentage of persons who experienced this lack of access to medical care rose from 4.2% in 1998 to 5.2% through September 2003. (See Figure 1.2.)
The 2003 NHIS revealed that people ages eighteen to twenty-four were least likely to have a regular source of care, but the likelihood of having a regular source of medical care increased with age among persons aged eighteen years and older. Children under age eighteen were more likely than adults aged eighteen to sixty-four to have a usual place to go for medical care. Among adults (aged eighteen to sixty-four), women were more likely than men to have a usual place to seek medical care. (See Figure 1.3.) The NHIS data indicate that not having a regular health care provider is a greater predictor of delay in seeking care than insurance status. Health care consumers with a regular physician or source of health care services
FIGURE 1.2
are less likely to use the hospital emergency room to obtain routine nonemergency medical care, and are less likely to be hospitalized for preventable illnesses.
The National Association of Community Health Centers (NACHC) is a nonprofit organization that represents the interests of federally supported and other federally qualified health centers and serves as an information source about health care for poor and medically underserved populations in the United States. A report from NACHC found that thirty-six million Americans lacked access to basic health care and described low-income families and minorities, populations traditionally characterized as "medically underserved," as the hardest hit (Dan Hawkins and Michelle Proser, A Nation's Health at Risk, Washington, DC: National Association of Community Health Centers, 2004). Almost half of those without access to medical care—"medically unserved"—are from low-income families, and nearly two in five are members of minority groups. Hispanic adults have the highest concentration (28%) of medically unserved, followed by Asian Pacific Islander adults (16%) and African-Americans adults (12%).
The NACHC report asserts that the one in eight Americans (12% of the U.S. population) with no access to health care—the medically unserved—have been overlooked while the attention of policymakers has been focused on the 43 million Americans who lack health insurance. Although uninsured Americans often face barriers to access, nearly half of the 36 million Americans
FIGURE 1.3
without access to basic medical care have health insurance but encounter barriers in having their medical needs met too. Some of these barriers to access include scarcity of health care resources, geographically inaccessible services, and health care that is not culturally sensitive or is otherwise unacceptable to health care consumers.
There Are Americans without Access to Medical Care in Every State
According to the NACHC, there are medically unserved Americans in every state, with the highest concentrations in metropolitan areas with populations of less than one million. Figure 1.4 shows the percentage of the population in each state that was medically unserved in 2003. The NACHC reported that in thirteen states—Alabama, California, Florida, Georgia, Louisiana, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania, Tennessee, and Texas—the medically unserved population exceeds one million persons, and these thirteen states account for about two-thirds (63%) of Americans who lack a regular source of health care.
In 2003 Texas was the state with the highest medically unserved population, followed by Florida, Georgia, Louisiana, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania, and Tennessee.
Race and Ethnicity Continue to Affect Access to Health Care
The 2003 NHIS found that Hispanic adults and children continued to be less likely to have a regular source for medical care than white non-Hispanic and African-American non-Hispanic persons. After adjusting for age and gender, 78.1% of Hispanic persons had a usual source of medical care, compared to 90.4% of non-Hispanic white persons and 86.4% of non-Hispanic African-American persons. Hispanic persons and non-Hispanic African-American persons were more likely than non-Hispanic white persons to suffer financial barriers to access. After adjusting for age and gender, 6.3% of Hispanic persons and 6.5% of non-Hispanic African-American persons were unable to obtain needed medical care due to financial barriers, compared to 4.8% of non-Hispanic white persons. (See Figure 1.5.) Health educators speculate that language barriers and lack of information about the availability of health care services may serve to widen this gap.
The U.S. Public Health Service's Agency for Healthcare Research and Quality (AHRQ) looks at ways to identify, address, and ultimately eliminate differences in access, availability, and the quality of health care services. Working with the National Institutes of Health (NIH) and national and local foundations, AHRQ seeks to develop plans and strategies to reduce and overcome disparities. One example of this collaborative effort is a program to improve access and quality of care for African-Americans suffering from chronic illnesses who primarily receive care from inner-city and rural health care providers. Another project aims to expand access to preventive medicine services among low-income, Medicaid-eligible populations. (Medicaid is a program run by state and federal governments to provide health insurance for persons younger than age sixty-five who cannot afford to pay for private health insurance.)
The AHRQ observes that income level and lack of health insurance are not the only barriers to access faced by members of racial or ethnic minority populations. The AHRQ asserts that having health insurance does not guarantee access and that even entering a health care provider's office does not ensure receipt of appropriate or quality health care services. AHRQ researchers described asthma care as an example of consistent variation in access to and use of medical care. Among children with asthma enrolled in Medicaid, African-American children were 70% more likely to visit an emergency department and 52% less likely to be cared for in an office visit with a health care practitioner. African-American children were similarly less likely to obtain routine well-child visits (check-ups) and prescriptions for medication.
Women Face Additional Obstacles
Research conducted by the Henry J. Kaiser Family Foundation, a nonprofit, private operating foundation
FIGURE 1.4
focusing on the major health care issues facing the nation, documented significant racial and ethnic differences in access to care. Analyzing data from the 2001 Kaiser Women's Health Survey, the investigators found that overall, Hispanic and African-American women fared worse than white women in terms of access to health care services (Racial and Ethnic Disparities in Women's Health Coverage and Access to Care Findings from the 2001 Kaiser Women's Health Survey, Menlo Park, CA, 2004).
According to the Kaiser survey, Hispanic women reported less access to care than their white counterparts. Almost one quarter of Hispanic women (24%) had not visited a physician in the year prior to the survey compared to 14% of African-American and 11% of white women. Just under one-third of Hispanic women and African-American women said they had delayed or simply chose not to seek needed care, compared to one-quarter of white women.
Financial barriers—the costs of obtaining care and lack of insurance—were women's most frequently cited reason for delaying care and were reported by about one-third of Hispanic women. According to the Kaiser survey, more than three times as many Hispanic women (18%) and twice as many African-American women (10%) cited transportation problems as a barrier to access, compared to 5% of white women.
The 2003 NHIS also documented gender-based disparities in access. Women aged eighteen to sixty-four and those aged sixty-five and older were more likely than men to have failed to obtain needed medical care because of financial barriers to access. (See Figure 1.6.)
FIGURE 1.5
Children Need Better Access to Health Care Too
Data from the more than 38,000 households included in the NHIS were analyzed to look at selected health measures, including children's access to care, and compiled in the report Summary Health Statistics for U.S. Children in 2003. Among other factors, the analysis focuses on the unmet health care needs of children seventeen years of age and under, poverty status, insurance coverage, usual place of medical care, and whether children's health needs were being met. The data from the NHIS reveal a relationship between family income and not having a usual source of medical care as well as having unmet medical needs. (See Table 1.1.) The likelihood of lacking a regular source of care or having unmet needs was higher among poor and near poor families of all races and ethnic groups. Having health insurance and the type of health insurance also predicted whether a child had a regular source of care and whether all of the child's medical needs were met. (See Table 1.2 and Table 1.1.)
In 2000, 6.4% of children in the United States (4.6 million) did not have a regular source of medical care. Hispanic children (12.7%) were least likely to have a regular source of care compared with 6.9% of non-Hispanic African-American children and 4.5% of non-Hispanic
FIGURE 1.6
white children. Twice as many Hispanic children (30%) as non-Hispanic white children (15%) received their usual health care in a clinic, and poor children were more than 2.5 times more likely to receive their usual care in a clinic than children who were not poor. (See Table 1.2.)
The survey also found that 25% more children with private health insurance (87%) received health care in a physician's office than children with public health insurance (62%). Children without health insurance were more likely to receive routine health care in an emergency room than were children with private or public health insurance.
Some 12% of U.S. children (8.8 million) had no health insurance coverage in 2000. More than one-fifth (21%) of children in families with incomes of less than $20,000 per year had no health insurance and the same proportion of children in families with incomes ranging from $20,000 to $34,999 were uninsured, compared with a scant 3% of children in households with incomes of $75,000 or more. Children from poor and near poor families were more likely to be uninsured, have unmet medical needs, delay seeking care because of financial barriers, have no usual place of health care, and visit hospital emergency rooms more frequently than children from families that were not poor. (See Table 1.1.) Health professionals
TABLE 1.1
| Selected measures of health care access for children under 18, by selected characteristics, 2000 | ||||||
| Selected measures of health care access1 | ||||||
| Selected characteristics | All children under 18 years | Uninsured for health care2 | Unmet medical need3 | Delayed health care due to cost4 | Had no usual place of health care5 | 2 or more visits to the emergency room in the past 12 months6 |
| Number in thousands7 | ||||||
| Total8 | 72,326 | 8,797 | 1,901 | 2,824 | 4,592 | 5,012 |
| Sex | ||||||
| Male | 36,995 | 4,504 | 1,011 | 1,420 | 2,246 | 2,669 |
| Female | 35,331 | 4,293 | 890 | 1,404 | 2,346 | 2,343 |
| Age | ||||||
| 0–4 years | 19,609 | 2,246 | 437 | 608 | 782 | 1,991 |
| 5–17 years | 52,717 | 6,551 | 1,464 | 2,216 | 3,810 | 3,021 |
| 5–11 years | 28,958 | 3,550 | 706 | 1,121 | 1,596 | 1,616 |
| 12–17 years | 23,759 | 3,001 | 758 | 1,095 | 2,215 | 1,405 |
| Race | ||||||
| 1 race9 | 70,564 | 8,551 | 1,840 | 2,690 | 4,509 | 4,862 |
| White | 53,640 | 5,969 | 1,306 | 1,969 | 3,179 | 3,430 |
| Black or African American | 10,709 | 1,262 | 366 | 530 | 739 | 1,101 |
| American Indian or Alaska Native | 643 | 217 | 42 | 37 | 26 | 70 |
| Asian | 2,491 | 292 | 21 | 28 | 232 | 77 |
| Native Hawaiian or other Pacific Islander | 133 | 19 | — | — | 6 | 5 |
| 2 or more races10 | 1,762 | 246 | 61 | 135 | 84 | 150 |
| Black or African American and white | 500 | 64 | 14 | 22 | 13 | 59 |
| American Indian or Alaska Native and white | 318 | 83 | 28 | 68 | 34 | 30 |
| Hispanic origin and race11 | ||||||
| Hispanic or Latino | 11,803 | 3,061 | 378 | 466 | 1,494 | 820 |
| Mexican or Mexican American | 8,160 | 2,438 | 291 | 342 | 1,169 | 533 |
| Not Hispanic or Latino | 60,523 | 5,736 | 1,523 | 2,358 | 3,098 | 4,192 |
| White, single race | 45,428 | 3,779 | 1,053 | 1,645 | 2,053 | 2,841 |
| Black or African American, single race | 10,428 | 1,237 | 358 | 527 | 719 | 1,087 |
| Family structure12 | ||||||
| Mother and father | 52,422 | 5,721 | 950 | 1,617 | 2,958 | 2,974 |
| Mother, no father | 15,789 | 2,342 | 824 | 1,048 | 1,217 | 1,760 |
| Father, no mother | 2,126 | 318 | 30 | 73 | 193 | 131 |
| Neither mother nor father | 1,988 | 416 | 97 | 86 | 224 | 147 |
| Parent's education13 | ||||||
| Less than high school diploma | 9,510 | 2,568 | 440 | 520 | 1,362 | 981 |
| High school diploma or GED14 | 16,788 | 2,592 | 592 | 845 | 1,222 | 1,432 |
| More than high school | 43,552 | 3,055 | 748 | 1,343 | 1,757 | 2,430 |
| Family income15 | ||||||
| Less than $20,000 | 13,169 | 2,752 | 719 | 908 | 1,328 | 1,636 |
| $20,000 or more | 55,885 | 5,403 | 1,054 | 1,744 | 2,934 | 3,188 |
| $20,000–$34,999 | 10,417 | 2,130 | 488 | 678 | 1,052 | 871 |
| $35,000–$54,999 | 12,352 | 1,404 | 274 | 475 | 662 | 802 |
| $55,000–$74,999 | 9,468 | 439 | 51 | 201 | 348 | 502 |
| $75,000 or more | 14,493 | 371 | 101 | 173 | 421 | 645 |
| Poverty status16 | ||||||
| Poor | 9,206 | 1,935 | 532 | 558 | 945 | 1,159 |
| Near poor | 12,528 | 2,620 | 546 | 844 | 1,227 | 1,059 |
| Not poor | 35,401 | 1,947 | 436 | 874 | 1,310 | 1,945 |
| Health insurance coverage17 | ||||||
| Private | 48,408 | … | 407 | 856 | 1,557 | 2,518 |
| Medicaid/other public | 13,288 | … | 385 | 549 | 512 | 1,734 |
| Other | 1,609 | … | — | 26 | 125 | 143 |
| Uninsured | 8,797 | 8,797 | 1,103 | 1,381 | 2,385 | 582 |
| Place of residence18 | ||||||
| Large MSA | 35,175 | 4,219 | 844 | 1,287 | 2,296 | 2,131 |
| Small MSA | 23,035 | 2,747 | 707 | 1,054 | 1,278 | 1,676 |
| Not in MSA | 14,116 | 1,831 | 350 | 483 | 1,019 | 1,205 |
are especially concerned about delayed or missed medical visits for children because well-child visits are not only opportunities for early detection of developmental problems and timely treatment of illnesses but also ensure that children receive the recommended schedule of immunizations.
According to the survey, there was significant geographic variation in insurance status, which was strongly linked to
| — Quantity zero. | ||||||
| 1In the 1997–1999 reports, this table was titled "Frequencies of selected health care risk factors, for children 17 years of age and under, by selected characteristics." | ||||||
| 2Uninsured for health care is based on the following question in the family core section of the survey: "[Are you/Is anyone] covered by health insurance or some other kind of health care plan?" | ||||||
| 3Unmet medical need is based on the following question in the family core section of the survey: "DURING THE PAST 12 MONTHS, was there any time when [you/someone in the family] needed medical care, but did not get it because [you/the family] couldn't affort it?" | ||||||
| 4Delayed health care due to cost is based on the following question in the family core section of the survey: "DURING THE PAST 12 MONTHS" [have/has] [you/anyone in the family] delayed seeking medical care because of worry about the cost?" | ||||||
| 5Had no usual place of health care is based on the following question in the sample child core section of the survey: "Is there aplace that [child's name] USUALLY goes when [he/she] is sick or you need advice about [his/her] health?" | ||||||
| 6Two or more visits to the emergency room in the past 12 months is based on the following question in the sample child core section of the survey: "DURING THE PAST 12 MONTHS, how many times has [child's name] gone to the hospital emergency room about [his/her] health? (This includes emergency room visits that resulted in a hospital admission.)" | ||||||
| 7Unknowns for the column variables are not included in the frequencies but they are included in the "All children under 18 years" column. | ||||||
| 8Total includes other races not shown separately and children with unknown family structure, parent's education, family income, poverty status, health insurance, or current health status. Additionally, numbers within selected characteristics may not add to totals because of rounding. | ||||||
| 9In accordance with the 1997 Standards for Federal data on race and Hispanic or Latino origin the category "1 race" refers to persons who indicated only a single race group. Persons who indicated a single race other than the groups shown are included in the total for "1 race" but are not shown separately due to small sample sizes. Therefore, the frequencies for the category "1 race" will be greater than the sum of the frequencies for the specific groups shown separately. Persons of Hispanic or Latino origin may be of any race or combination of races. | ||||||
| 10The category "2 or more races" refers to all persons who indicated more than one race group. Only two combinations of multiple race groups are shown due to small sample sizes for other combinations. Persons of Hispanic or Latino origin may be of any race or combination of races. | ||||||
| 11Persons of Hispanic or Latino origin may be of any race or combination of races. Similarly, the category "Not Hispanic or Latino" refers to all persons who are not of Hispanic or Latino origin, regardless of race. The tables in this report use the complete new OMB race and Hispanic origin terms, and the text uses shorter versions of these terms for conciseness. For example, the category "Not Hispanic or Latino black or African American, single race" in the tables is referred to as "non-Hispanic black" in the text. | ||||||
| 12Family structure refers to parents living in the household. "Mother and father" can include biological, adoptive, step, in-law, or foster relationships. Legal guardians are classified in "Neither mother nor father." | ||||||
| 13Parent's education is the education level of the parent with the higher level of education, regardless of that parent's age. | ||||||
| 14GED is General Educational Development high school equivalency diploma. | ||||||
| 15The categories "Less than $20,000" and "$20,000 or more" include both persons reporting dollar amounts and persons reporting only that their incomes were within one of these two categories. The indented categories include only those persons who reported dollar amounts. | ||||||
| 16Poverty status is based on family income and family size using the Census Bureau's poverty thresholds for the previous calendar year. "Poor" persons are defined as below the poverty threshold. "Near poor" persons have incomes of 100% to less than 200% of the poverty threshold. "Not poor" persons have incomes that are 200% of the poverty threshold or greater. | ||||||
| 17Classification of health insurance coverage is based on a hierarchy of mutually exclusive categories. Persons with more than one type of health insurance were assigned to the first appropriate category in the hierarchy. The category "Uninsured" includes persons who had no coverage as well as those who had only Indian Health Service coverage or had only a private plan that paid for one type of service such as accidents or dental care. | ||||||
| 18MSA is metropolitan statistical area. Large MSAs have a population size of 1,000,000 or more; small MSAs have a population size of less than 1,000,000. "Not in MSA" consists of persons not living in a metropolitan statistical area. | ||||||
| SOURCE: Debra L. Blackwell, Jackline L. Vickerie, and Ethiopia A. Wondimu, "Table 15. Frequencies of Selected Measures of Health Care Access, for Children under 18 Years of Age, by Selected Characteristics: United States, 2000," in Summary Health Statistics for U.S. Children: National Health Interview Survey, 2000, National Center for Health Statistics, Vital Health Statistics, vol. 10, no. 213, 2003, http://www.cdc.gov/nchs/data/series/sr_10/sr10_213.pdf (accessed June 1, 2004) | ||||||
| Region | Number in thousands7 | |||||
| Northeast | 13,448 | 897 | 237 | 370 | 320 | 837 |
| Midwest | 17,884 | 1,451 | 433 | 662 | 914 | 1,178 |
| South | 25,467 | 4,003 | 833 | 1,159 | 1,958 | 2,161 |
| West | 15,527 | 2,446 | 398 | 634 | 1,401 | 836 |
| Current health status | ||||||
| Excellent/very good/good | 70,975 | 8,621 | 1,762 | 2,641 | 4,502 | 4,623 |
| Fair/poor | 1,312 | 164 | 127 | 171 | 78 | 389 |
| Sex and age | ||||||
| Male: | ||||||
| 0–4 years | 10,021 | 1,143 | 225 | 287 | 357 | 1,011 |
| 5–17 years | 26,974 | 3,361 | 786 | 1,133 | 1,889 | 1,657 |
| 5–11 years | 14,805 | 1,831 | 414 | 615 | 819 | 919 |
| 12–17 years | 12,169 | 1,530 | 372 | 518 | 1,070 | 738 |
| Female: | ||||||
| 0–4 years | 9,588 | 1,103 | 213 | 321 | 425 | 979 |
| 5–17 years | 25,743 | 3,190 | 677 | 1,083 | 1,921 | 1,364 |
| 5–11 years | 14,153 | 1,718 | 292 | 505 | 776 | 697 |
| 12–17 years | 11,591 | 1,472 | 386 | 578 | 1,145 | 667 |
children's access to health care services. The percentage of children in the West and South (16% in each region) who were uninsured was twice the percentage of uninsured children in the Midwest (8%) or the Northeast (7%).
Do Americans Underestimate Access Problems?
A Kaiser Health Poll Survey from 2000–01 found Americans' knowledge about barriers to access was uneven. While almost three-quarters of survey respondents
TABLE 1.2
| Usual place of health care for children under 18 with a usual place of health care, by selected characteristics, 2000 | |||||||||
| Usual place of health care2 | |||||||||
| Selected characteristics | All children under 18 years | Has no usual place of health care1 | Has no usual place of health care1 | Clinic | Doctor's office | Emergency room | Hospital outpatient | Some other place | Does not go to 1 place most often |
| Number in thousands3 | |||||||||
| Total4 | 72,326 | 4,592 | 67,584 | 12,875 | 53,033 | 435 | 823 | 140 | 182 |
| Sex | |||||||||
| Male | 36,995 | 2,246 | 34,700 | 6,514 | 27,409 | 178 | 397 | 62 | 84 |
| Female | 35,331 | 2,346 | 32,884 | 6,361 | 25,624 | 258 | 426 | 78 | 98 |
| Age | |||||||||
| 0–4 years | 19,609 | 782 | 18,809 | 3,919 | 14,484 | 98 | 230 | 19 | 16 |
| 5–17 years | 52,717 | 3,810 | 48,775 | 8,956 | 38,549 | 337 | 594 | 121 | 166 |
| 5–11 years | 28,958 | 1,596 | 27,309 | 5,016 | 21,669 | 191 | 287 | 47 | 65 |
| 12–17 years | 23,759 | 2,215 | 21,466 | 3,941 | 16,880 | 147 | 307 | 74 | 101 |
| Race | |||||||||
| 1 race5 | 70,564 | 4,509 | 65,906 | 12,486 | 51,785 | 426 | 796 | 137 | 182 |
| White | 53,640 | 3,179 | 50,354 | 8,222 | 41,191 | 193 | 423 | 124 | 125 |
| Black or African American | 10,709 | 739 | 9,940 | 2,601 | 6,842 | 153 | 278 | 7 | 42 |
| American Indian or Alaska Native | 643 | 26 | 617 | 289 | 302 | 8 | 14 | 3 | — |
| Asian | 2,491 | 232 | 2,249 | 425 | 1,746 | 38 | 26 | 3 | 8 |
| Native Hawaiian or other Pacific Islander | 133 | 6 | 127 | 10 | 116 | — | — | — | — |
| 2 or more races6 | 1,762 | 84 | 1,678 | 390 | 1,248 | 10 | 28 | 3 | — |
| Black or African American and white | 500 | 13 | 487 | 91 | 391 | — | 5 | — | — |
| American Indian or Alaska Native and white | 318 | 34 | 284 | 82 | 198 | — | 5 | — | — |
| Hispanic origin and race7 | |||||||||
| Hispanic or Latino | 11,803 | 1,494 | 10,292 | 3,050 | 6,860 | 129 | 160 | 9 | 48 |
| Mexican or Mexican American | 8,160 | 1,169 | 6,980 | 2,114 | 4,609 | 90 | 84 | 9 | 39 |
| Not Hispanic or Latino | 60,523 | 3,098 | 57,293 | 9,825 | 46,174 | 307 | 663 | 131 | 134 |
| White, single race | 45,428 | 2,053 | 43,282 | 6,267 | 36,350 | 97 | 329 | 115 | 83 |
| Black or African American, single race | 10,428 | 719 | 9,680 | 2,537 | 6,655 | 153 | 270 | 7 | 42 |
| Family structure8 | |||||||||
| Mother and father | 52,422 | 2,958 | 49,420 | 8,277 | 40,140 | 233 | 472 | 117 | 115 |
| Mother, no father | 15,789 | 1,217 | 14,507 | 3,624 | 10,403 | 137 | 263 | 19 | 39 |
| Father, no mother | 2,126 | 193 | 1,906 | 433 | 1,349 | 45 | 47 | 4 | 25 |
| Neither mother nor father | 1,988 | 224 | 1,749 | 539 | 1,140 | 20 | 41 | — | 4 |
| Parent's education9 | |||||||||
| Less than high school diploma | 9,510 | 1,362 | 8,131 | 2,994 | 4,716 | 165 | 134 | 14 | 62 |
| High school diploma or GED10 | 16,788 | 1,222 | 15,536 | 3,343 | 11,799 | 133 | 204 | 20 | 30 |
| More than high school | 43,552 | 1,757 | 41,711 | 5,915 | 35,020 | 117 | 444 | 105 | 86 |
| Family income11 | |||||||||
| Less than $20,000 | 13,169 | 1,328 | 11,796 | 3,892 | 7,398 | 193 | 252 | 14 | 44 |
| $20,000 or more | 55,885 | 2,934 | 52,858 | 8,297 | 43,459 | 235 | 560 | 121 | 131 |
| $20,000–$34,999 | 10,417 | 1,052 | 9,336 | 2,401 | 6,584 | 109 | 156 | 26 | 46 |
| $35,000–$54,999 | 12,352 | 662 | 11,662 | 1,997 | 9,380 | 68 | 161 | 29 | 25 |
| $55,000–$74,999 | 9,468 | 348 | 9,119 | 1,175 | 7,826 | 9 | 77 | 6 | 25 |
| $75,000 or more | 14,493 | 421 | 14,069 | 1,522 | 12,352 | 36 | 95 | 55 | 10 |
| Poverty status12 | |||||||||
| Poor | 9,206 | 945 | 8,252 | 2,895 | 4,974 | 168 | 160 | 24 | 31 |
| Near poor | 12,528 | 1,227 | 11,259 | 2,832 | 8,044 | 146 | 171 | 18 | 46 |
| Not poor | 35,401 | 1,310 | 34,060 | 4,493 | 28,985 | 84 | 333 | 87 | 63 |
| Health insurance coverage13 | |||||||||
| Private | 48,408 | 1,557 | 46,774 | 5,616 | 40,649 | 87 | 187 | 83 | 104 |
| Medicaid/other public | 13,288 | 512 | 12,755 | 4,319 | 7,936 | 128 | 298 | 9 | 28 |
| Other | 1,609 | 125 | 1,483 | 638 | 618 | — | 198 | 24 | 5 |
| Uninsured | 8,797 | 2,385 | 6,369 | 2,273 | 3,686 | 218 | 125 | 22 | 37 |
| Place of residence14 | |||||||||
| Large MSA | 35,175 | 2,296 | 32,824 | 5,613 | 26,203 | 263 | 524 | 48 | 117 |
| Small MSA | 23,035 | 1,278 | 21,692 | 4,084 | 17,107 | 139 | 281 | 28 | 24 |
| Not in MSA | 14,116 | 1,019 | 13,068 | 3,179 | 9,724 | 33 | 19 | 64 | 41 |
knew that persons without insurance were less likely to have had a recent physician visit or a regular source of medical care, more than half (52%) were unaware that uninsured persons are more likely to have hospital and emergency room visits that could have been avoided if they had a regular source of medical care. (See Figure 1.7.)
The poll also revealed that about two-thirds of Americans (65%) acknowledged that the uninsured would be more likely to put off seeking needed medical care, and 62% thought the uninsured would be less likely to obtain preventive care. However, more than half (55%) said they thought that most uninsured persons
| — Quantity zero. | ||||||||||
| 1Having (or not having) a usual place of health care is based on the question, "Is there a place that [child's name] USUALLY goes when [he/she] is sick or you need advice about [his/her] health?" | ||||||||||
| 2Usual place of health care is based on the question, "What kind of place is it—clinic or health center, doctor's office or HMO, hospital emergency room, hospital emergency room, hospital outpatient department or some that place?" | ||||||||||
| 3Unknowns for the column variables are not included in the denominators when calculating percents. | ||||||||||
| 4Total includes other races not shown separately and children with unknown family structure, parent's education, family income, poverty status, health insurance, or current health status. Additionally, numbers within selected characteristics may not add to totals because of rounding. | ||||||||||
| 5In accordance with the 1997 Standards for Federal data on race and Hispanic or Latino origin the category "1 race" refers to persons who indicated only a single race group. Persons who indicated a single race other than the groups shown are included in the total for "1 race" but are not shown separately due to small sample sizes. Therefore, the frequencies for the category "1 race" will be greater than the sum of the frequencies for the specific groups shown separately. Persons of Hispanic or Latino origin may be of any race or combination of races. | ||||||||||
| 6The category "2 or more races" refers to all persons who indicated more than one race group. Only two combinations of multiple race groups are shown due to small sample sizes for other combinations. Persons of Hispanic or Latino origin may be of any race or combination of races. | ||||||||||
| 7Persons of Hispanic or Latino origin may be of any race or combination of races. Similarly, the category "Not Hispanic or Latino" refers to all persons who are not of Hispanic or Latino origin, regardless of race. | ||||||||||
| 8Family structure refers to parents living in the household. "Mother and father" can include biological, adoptive, step, in-law, or foster relationships. Legal guardians are classified in "Neither mother nor father." | ||||||||||
| 9Parent's education is the education level of the parent with the higher level of education, regardless of that parent's age. | ||||||||||
| 10GED is General Educational Development high school equivalency diploma. | ||||||||||
| 11The categories "Less than $20,000" and "$20,000 or more" include both persons reporting dollar amounts and persons reporting only that their incomes were within one of these two categories. The indented categories include only those persons who reported dollar amounts. | ||||||||||
| 12Poverty status is based on family income and family size using the Census Bureau's poverty thresholds for the previous calendar year. "Poor" persons are defined as below the poverty threshold. "Near poor" persons have incomes of 100% to less than 200% of the poverty threshold. "Not poor" persons have incomes that are 200% of the poverty threshold or greater. | ||||||||||
| 13Classification of health insurance coverage is based on a hierarchy of mutually exclusive categories. Persons with more than one type of health insurance were assigned to the first appropriate category in the hierarchy. The category "Uninsured" includes persons who had no coverage as well as those who had only Indian Health Service coverage or had only a private plan that paid for one type of service such as accidents or dental care. | ||||||||||
| 14MSA is metropolitan statistical area. Large MSAs have a population size of 1,000,000 or more; small MSAs have a population size of less than 1,000,000. "Not in MSA" consists of persons not living in a metropolitan statistical area. | ||||||||||
| SOURCE: Debra L. Blackwell, Jackline L. Vickerie, and Ethiopia A. Wondimu, "Table 11. Frequency Distributions of Having a Usual Place of Health Care, and Frequency Distributions of Usual Place of Health Care for Children with a Usual Place of Health Care, for Children under 18 Years of Age, by Selected Characteristics: United States, 2000," in Summary Health Statistics for U.S. Children: National Health Interview Survey, 2000, National Center for Health Statistics, Vital Health Statistics, vol. 10, no. 213, 2003, http://www.cdc.gov/nchs/data/series/sr_10/sr10_213.pdf (accessed June 1, 2004) | ||||||||||
| Number in thousands3 | ||||||||||
| Region | ||||||||||
| Northeast | 13,448 | 320 | 13,106 | 1,767 | 11,008 | 101 | 188 | 10 | 26 | |
| Midwest | 17,884 | 914 | 16,965 | 4,139 | 12,488 | 68 | 170 | 39 | 39 | |
| South | 25,467 | 1,958 | 23,436 | 3,895 | 18,996 | 190 | 211 | 44 | 86 | |
| West | 15,527 | 1,401 | 14,078 | 3,074 | 10,542 | 77 | 255 | 46 | 30 | |
| Current health status | ||||||||||
| Excellent/very good/good | 70,975 | 4,502 | 66,323 | 12,584 | 52,155 | 402 | 772 | 133 | 182 | |
| Fair/poor | 1,312 | 78 | 1,234 | 289 | 854 | 34 | 51 | 6 | — | |
| Sex and age | ||||||||||
| Male: | ||||||||||
| 0–4 years | 10,021 | 357 | 9,656 | 1,998 | 7,413 | 44 | 138 | 19 | 10 | |
| 5–17 years | 26,974 | 1,889 | 25,044 | 4,516 | 19,996 | 133 | 259 | 42 | 74 | |
| 5–11 years | 14,805 | 819 | 13,953 | 2,613 | 11,107 | 60 | 111 | 19 | 30 | |
| 12–17 years | 12,169 | 1,070 | 11,091 | 1,903 | 8,889 | 73 | 148 | 23 | 44 | |
| Female: | ||||||||||
| 0–4 years | 9,588 | 425 | 9,154 | 1,921 | 7,071 | 54 | 92 | — | 6 | |
| 5–17 years | 25,743 | 1,921 | 23,731 | 4,440 | 18,553 | 204 | 335 | 78 | 92 | |
| 5–11 years | 14,153 | 776 | 13,356 | 2,403 | 10,562 | 131 | 176 | 28 | 35 | |
| 12–17 years | 11,591 | 1,145 | 10,375 | 2,038 | 7,991 | 73 | 159 | 51 | 57 | |
were able to obtain needed medical care. (See Figure 1.7.)
How to Reduce Disparities in Access to Care
Health services researchers think that many factors contribute to differences in access, including cultural perceptions and beliefs about health and illness, patient preferences, availability of services, and provider bias. They recommend special efforts to inform and educate minority health care consumers and increased understanding and sensitivity among practitioners and other providers of care. In addition to factual information, minority consumers must overcome the belief that they are at a disadvantage because of their race or ethnicity. Along with action to dispel barriers to access, educating practitioners, policymakers, and consumers can help to reduce the perception of disadvantage.
For decades, health care researchers have documented sharp differences in the ability of ethnic and racial groups to access medical services. The U.S. government has repeatedly called for an end to these disparities. Although some observers feel that universal health insurance coverage is an important first step in eliminating disparities, there is widespread concern that the challenge is more complicated and calls for additional analysis and action.
In an article in the June 2002 issue of the Journal of General Internal Medicine (vol. 17, no. 6), Harvard Medical School physician Dr. Judy Ann Bigby asserts that "eliminating racial disparities … requires an understanding of the ecology of health, the interconnectedness of biologic, behavioral, physical, and socioenvironmental factors that determine health." Dr. Bigby believes that a multifaceted approach must be used to address the many issues involved in access, including improving the physical environment, overcoming economic and social barriers, ensuring the availability of effective health services, and acting to reduce personal behavioral risk factors such as smoking, obesity, poor nutrition, substance abuse, and physical inactivity. Developing strategies to promote personal, institutional, and community change simultaneously may stimulate the sweeping reforms needed to reduce and ultimately eliminate disparities.
Managed care refers to a system of health payment or delivery in which the plan attempts to control or coordinate use of health services by its enrolled members in order to contain health expenditures, improve quality, or both. Research supported by the AHQR suggests that managed care, with its emphasis on preventive health services, may improve ethnic disparities in access for Hispanics and whites but not for African-Americans or Asians/Pacific Islanders. Jennifer S. Haas and her colleagues at the University of California, San Francisco, analyzed data about preventive health care use by persons enrolled in fee-for-service (FFS) and managed care plans from the AHRQ Medical Expenditure Panel Survey (MEPS) of noninstitutionalized U.S. civilians ("Effect of Managed Care Insurance on the Use of Preventive Care for Specific Ethnic Groups in the United States," Medical Care vol. 40, no. 9, September 2002).
The investigators considered use of four preventive health screenings—mammography within the past two years for women aged fifty to seventy-five, breast examination within the past two years for women between forty and seventy-five, Pap smear (screening for cervical cancer) within the past two years for women between eighteen and sixty-five, and cholesterol screening within the past five years for men and women above age twenty. The analysis revealed that Hispanic and white women enrolled in managed care plans reported higher rates of mammography, breast exam, and Pap smear than Hispanic women with FFS insurance. There were no significant differences in access to preventive care for African-Americans or Asians/Pacific Islanders by type of insurance. The investigators theorize that managed care may improve access to a usual source of care for Hispanics, who are more likely to lack a usual source of care than whites.
REPORT DOCUMENTS DISPARITIES IN ACCESS AND SUGGESTS POSSIBLE SOLUTIONS. In July 2003 the AHRQ released a National Healthcare Disparities Report requested by Congress that documented racial health disparities including access to care. For example, the report cited the finding that African-American and low-income Americans have higher mortality rates for cancer than the general population because they are less likely to receive screening tests for certain forms of the disease and other preventive services. Although the report asserted that differential access may lead to disparities in quality and observed that opportunities to provide preventive care are often missed, it conceded that knowledge about why disparities exist is limited.
The report generated considerable controversy, and in January 2004 eight Democratic lawmakers wrote to Health and Human Services (HHS) Secretary Tommy Thompson, decrying its findings and conclusions as "watered down." The legislators wrote that the report, which had been released, edited, and re-released in December 2003, included revisions that "alter the original report's meaning, undermine efforts to address disparities and fit a pattern of the manipulation of science by the Bush administration." In response to this outcry, Thompson re-released the original report in February 2004.
The April 8, 2004, issue of the New England Journal of Medicine (vol. 350, no. 15) addressed the controversy surrounding the report, its re-release, and its findings. In "Disparities in Health Care—From Politics to Policy" Robert Steinbrook opined that "the controversy over the editing of the National Healthcare Disparities Report has focused attention yet again on problems with health care for racial and ethnic minorities in the United States. The dispute has also focused attention on the risks of either overstating or understating the real problems related to disparities. Both overstatement and understatement can undermine the credibility of the federal government. Downplaying the magnitude of disparities may also make it less likely that Congress will provide sufficient funding for research and policy initiatives." Steinbrook also asserted, "Inequities in health care did not originate during the Bush administration and are likely to pose daunting challenges for future administrations, both Democratic and Republican."
In the same issue of the New England Journal of Medicine M. Gregg Bloche wrote that "Department of Health and Human Services (DHHS) Secretary Tommy Thompson has said that health disparities are a national priority, and congressional Democrats and Republicans are advocating competing remedies." ("Health Care Disparities—Science, Politics, and Race"). Bloche stated, "When Congress asks a federal research agency to examine an issue and report on it impartially, peer review must not be confounded by political spin management. Self-restraint in the executive branch should be enough to ensure this. But given the bitterly partisan mood that prevails in Washington today, legislation ought to require it."
In an April 10, 2004, letter to the editor of the New Orleans Times-Picayune, Senate Majority Leader Bill Frist, a Republican from Tennessee who is also a physician, exhorted legislators to take a comprehensive approach to eliminating health care disparities, focusing not only on race or ethnicity, but also on geographic and socioeconmonic factors. Frist opined that legislative efforts to reduce disparities won unanimous bipartisan support in 2000 in the U.S. Senate. He expressed optimism that the Closing the Health Care Gap Act of 2004, which he introduced with Senator Mary Landrieu, a Democrat from Louisiana, would garner comparable support and expand upon existing legislation.
Although the AHRQ report generated fiery debate in the health care community and among legislators and painted a rather bleak view of disparities, it did offer some hopeful findings that suggest that targeted improvement efforts could significantly reduce health care disparities. For example, it observed that "black patients are more likely to receive blood pressure monitoring without any disparity in blood pressure management. A greater perceived risk for significant cardiovascular disease among blacks may result in appropriately increased screening rates and treatment for risk factors. Directed public education campaigns about cardiac risk factors and the importance of an activated patient may play an important role in the lower observed rate of cardiac disparities among blacks." The report called for detailed data to support quality improvement initiatives and observed that "community-based participatory research has numerous examples of communities working to improve quality overall, while reducing healthcare disparities for vulnerable populations."
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