Insurance Public Health Insurance Health Disparities Examples of a Population's Access to a Specific Type of Health Care References Access to health care is defined as the ability to get medical care when needed. It is an umbrella term that is affected by everything from location of health centers and availability of medical providers, to health insurance and the cost of health care. Access can be hindered by lack of transportation and cultural and linguistic barriers, among other things. Access to health care, or lack of access, has major consequences for morbidity and mortality. We will look in turn at three dimensions of access: insurance, population, and type of care. Insurance In the United States, one especially important determinant of access to care is health insurance(1) One division in the population is between those who have insurance and those who are uninsured. In 2005, there are 46 million uninsured people in the United States (about 16% of the population). (1) The uninsured rate and number of uninsured increased from 2002 to 2003 for non-Hispanic Whites (from 10.7 % and 20.8 million to 11.1 % and 21.6 million), but not for African Americans.(2) Although the number of uninsured increased for Hispanics (from 12.8 million to 13.2 million), their uninsured rate was unchanged at 32.7 %.(2) The number of people who are inadequately insured is much larger. There are 52 million people in the U.S. who are uninsured or underinsured (people are underinsured if they have experienced a recent lapse in health coverage in the past two years.)(3) Additionally, types of insurance in the U.S. vary widely. Private insurance, usually employer-sponsored, may cover all of a family’s medical, dental, and mental health care needs or only a small portion of them. The percentage and number of people covered by employment-based health insurance fell between 2002 and 2003, from 61.3 % and 175.3 million to 60.4 % and 174.0 million.(3) Back to Top Public Health Insurance Public insurance programs began in 1965 and include Medicare, Medicaid, CHAMPUS, and the Indian Health Service; these differ widely from one another. Medicare is the national health insurance program for people age 65 or older and some people under age 65 with disabilities. Medicare provides coverage to approximately 40 million individuals.(4) Medicaid is a program that assists individuals and families with low incomes and resources. It is the largest source of funding for medical and health-related services for people with limited income but its provisions differ from state to state.(4) CHAMPUS is a program that covers medical necessities only for military, ex-military, and their dependents.(5) The Indian Health Service is a federal health program that serves approximately 1.6 million of the nation's estimated 2.6 million American Indians and Alaska Natives.(6) Its annual appropriation is approximately $3.5 billion.(6) Finally, in 1996-7 the U.S. Congress created State Children’s Health Insurance Programs (SCHIP), special Medicaid programs designed for children whose parents may not qualify for public health care coverage. Under SCHIP, children who reside in a family with an income below 200% of the Federal Poverty Level (FPL) or whose family has an income no more than 50% higher than the state’s Medicaid eligibility threshold, are covered. Health Disparities Many factors other than insurance affect access to care. One way to these factors is in terms of two simple questions: Who? and What? That is, who needs health care and what kind of health care does he or she need? Not all populations in the U.S. have the same access to care and access to care also varies by the type of care needed. A particular population (be it children, women, members of racial or ethnic minority groups, or those with low-incomes) many times differ from the general population in their access to specific types of care (such as preventive care, primary care, long-term care, or mental health care.) Such disparities are what is often referred to as health disparities. Rather than listing every case of disparities in access, we are going to illustrate these ideas with specific examples. Below are five examples of a population’s access to a specific type of care, and the barriers that exist to receiving that care. To read more on each topic, follow the link or continue your search through PubMed or Google. Back to Top Population: Children Type of care: Primary Care Barrier: Managed care policy that limits choice of provider Stevens et al. found that minority children are affected by managed care policies that restrict patient freedom in choosing where to seek care. Minority children experience poorer patient-provider relationships when compared with white children, even when controlling for socioeconomic factors. Asian, African American, and Hispanic respondents had shorter duration relationships with their regular source of carethan did white respondents. On average, white children had been seeing their regular provider for between 1 and 2 years, while minority children, on average, had only been seeing their regular provider for 6 to 11 months. Managed care policies are strongly negatively associated with minority children’s interpersonal relationships with their physicians. According to both self-reported and validated data, Asians had the largest deficits in interpersonal relationships, with disparities ranging from about 13-15% difference from results for whites.(7) Population: Women Type of care: Preventive Care Barrier: No regular source of care The study conducted by Cornelius found that the most consistent predictor of seeking preventive care, regardless of race or ethnicity, was having a regular doctor. Women who had a doctor were at least twice as likely as those who did not to have received preventive care.(8)   Back to Top Population: Rural Type of care: Primary Care Barrier: Medicaid reimbursements The results of a study conducted by Sheikh suggest that the quality of inpatient care for acute myocardial infarctions (AMI), or heart attacks, provided to Medicare beneficiaries by acute care hospitals in Kansas was inferior in rural areas compared with urban areas. (9) Medicare pays rural hospitals and physicians less than urban hospitals and physicians for the same services, and is a larger source of the payer mix in rural areas than in urban settings. Medicare accounts for 35% of the health spending in rural areas, but pays 18% less annually per rural beneficiary than urban beneficiary. When all of the Medicare rate adjustments are applied, average rural hospital payments are 40% less than urban hospital payments. (10)   Population: Minorities Type of care: Primary Care Barrier: Inadequate pharmacies in minority neighborhoods Morrison found that more than 50% of a random sample of pharmacies in New York City did not have adequate medication in stock to treat a person in severe pain. Pharmacies in predominantly nonwhite neighborhoods were significantly less likely to stock opioids than were pharmacies in majority white neighborhoods. Two thirds of the pharmacies that did not carry any opioids were in neighborhoods where the majority of the residents were nonwhites. This finding, together with reports that nonwhite patients are significantly less likely than whites to receive prescriptions for analgesic agents recommended by AHCPR, suggests that members of ethnic and racial minority groups are at a substantial risk for undertreatment of pain.(11) Population: Minorities Type of care: Mental Health Barrier: Location of providers In a study on mental health service utilization by Mexican Americans, Vega found that more urban residents used mental health specialists for their mental health than rural residents. Rural residents were more likely to use general medical and informal care providers.(12)   Back to Top References 1. National Center for Health Statistics. Health, United States, 2004 With Chartbook on Trends in the Health of Americans. Hyattsville, Maryland: 2004. 2. DeNavas-Walt, Carmen, Bernadette D. Proctor, and Robert J. Mills, U.S. Census Bureau, Current Population Reports, P60-226, Income, Poverty, and Health Insurance Coverage in the United States: 2003, U.S. Government Printing Office, Washington, DC, 2004. 3. Hoffman C, Schoen C, Rowland D, Davis K. Gaps in health coverage among working-age Americans and the consequences. J Health Care Poor Underserved 2001;12(3):272-89 4. http://www.cms.hhs.gov/medicare     5. http://www.ndw.navy.mil/Newcomers/Medical/champus.html     6. http://www.ihs.gov/index.asp     7. Stevens GD, Shi L. Effect of managed care on children's relationships with their primary care physicians: differences by race. Arch Pediatr Adolesc Med 2002;156(4):369-77.   8. Cornelius LJ, Smith PL, Simpson GM. What factors hinder women of color from obtaining preventive health care? Am J Public Health 2002;92(4):535-    9. Sheikh K, Bullock C. Urban-rural differences in the quality of care for medicare patients with acute myocardial infarction. Arch Intern Med 2001;161(5):737-43.    10. Rosenthal TC, Fox C. Access to health care for the rural elderly. Jama 2000;284(16):2034-6.    11. Morrison RS, Wallenstein S, Natale DK, Senzel RS, Huang LL. "We don't carry that"--failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics. N Engl J Med 2000;342(14):1023-6. 12. Vega WA, Kolody B, Aguilar-Gaxiola S, Catalano R. Gaps in service utilization by Mexican Americans with mental health problems. Am J Psychiatry 1999;156(6):928-34. This research was supported by a National Library of Medicine (NLM) Publication Grant #5G08 LM07653-02 in support of the creation of a web site titled Factline: Tracking Health in Underserved Communities, www.factline.org. Saqi S. Maleque, MSPH, Researcher, Principal Investigator: Virginia Brennan, PhD.