Race/Ethnicity, insurance, income and access to care: the influence of health status

The Institute of Medicine (IOM) defined disparity as “a difference in access or treatment provided to members of different racial or ethnic groups that is not justified by the underlying health conditions or treatment p of patients [1].” Access to health care services has been one of the major topic areas for both Healthy People 2010 and Healthy People 2020. In Healthy People 2010, it was one of the goals to eliminate racial/ethnic disparities in access to health care [2]. In Healthy People 2020, relevant goals included increasing the proportion of persons with a usual primary care provider, increasing the proportion of persons who have a specific source of ongoing care, reducing the proportion of individuals who are unable to obtain or delay in obtaining necessary medical care, dental care, or prescription medicines, etc [3].

Andersen (1995) proposed a framework of access to health care in which access is determined by environment including health care system and external environment, population characteristics which include predisposing characteristics such as demographic factors, community and personal enabling resources such as income and health insurance, and health needs which consist of both perceived and evaluated health status including the presence of comorbidity and disability [4]. Empirical studies have demonstrated that race/ethnicity, health insurance status, income, and demographic characteristics including health status are important contributing factors to access disparities [5, 6].

The association between race/ethnicity and access to care has been studied for a long time. Although some studies reported no significant difference between non-Hispanic Whites and minority groups in access to certain preventive [7‐10], mental health [11], and specialist services [12], a larger body of literature concluded that racial/ethnic disparities in access to care persist or have even worsened during the past few years [6‐8, 13‐22]. In addition, the influence of insurance on access to care has been well established. Uninsured adults were less likely to get preventive care and physician care, and therefore, more likely to have unmet needs than insured individuals [23‐26], which ultimately result in fundamental differences in health outcomes and overall life experiences [27]. According to Kenny (2012), uninsured population on average received only 55 percent of medical services and slightly more than a quarter of dental care of those insured. Furthermore, more than half of uninsured adults did not visit a doctor in 2010 [23]. Lastly, low income is another barrier to access to care [25, 27‐29]. However, research has pointed out that even among high-income adults, those uninsured still have significantly lower use of recommended health care services than the insured [30].

However, most of the prior research had not adequately examined or controlled for the impact of the patients’ health status such as multimorbidity and functional limitations. As is well-known, people of racial/ethnic minorities and low-income typically also have worse health status than their counterparts [31, 32]. Without adjusting for health status, it is not clear whether observed racial and income-related disparities are stand-alone or a reflection of health disparities.

The purpose of this study is to examine health care access disparities with regard to health status and presence of functional limitations, a common measure of disability and multimorbidity, after controlling for individual’s race/ethnicity, insurance status and income in the U.S. using the latest survey data.

Health status and functional limitations are closely associated with access to care. The presence of functional limitations, a common measure of disability and multimorbidity, is associated with five of the six measures of access. People with poorer health experience more access barriers even after controlling for insurance and other measures. This finding indicates that interventions to enhance access should target those with greatest need, i.e., people with poorer health status.

Furthermore, although a large number of studies have established that racial/ethnic disparities persist in the United States, our study found that after controlling for insurance and health status, as well as other socioeconomic factors, differences between Whites and racial/ethnic groups in most measures of access were not significant. In fact, previous research has observed that disparities by race/ethnicity were more “nuanced” than was typically described in the literature [17]. Income was also found to be not significantly related to inadequate care. Alternatively, insurance was found to be an important factor that was associated with all six measures of access to care. Uninsured populations were significantly more likely to have no usual place of care and difficulties getting care. One of the main goals of the Affordable Care Act is to promote universal coverage by provisions such as expanding Medicaid and establishing State Health Insurance Exchanges. Based on our study, these measures to expand insurance coverage are expected to further improve access to care and reduce racial/ethnic disparities. However, among those insured, Medicaid beneficiaries were more likely to report having no usual place of care and inability to get dental care, while Medicare recipients more frequently reported inability to get medical care and delayed medical care, indicating that there are still gaps in benefits between public and private insurance. Further, the current health care system may not be able to quickly adapt to meet the increasing demands from the newly covered. Therefore, expansion in insurance should be accompanied with improvements in public insurance system and enhancement of the health care system [18, 23, 39].

Nevertheless, there are limitations in our study. First, due to the cross-sectional nature of the survey, we could not examine the causal relationships between access to care and potential predictors. Secondly, since data on income, health status, functional limitations, etc. were self-reported, bias may exist. Thirdly, because of data availability, other important factors such as health care system characteristics, external environment and language barriers were not taken into consideration. Lastly, by only including respondents who visited a health provider in the previous two weeks, the generalizability of the findings may be compromised. Future studies should also focus on quality of care received by different racial/ethnic and insurance groups and its ultimate effects on health outcomes.

In conclusion, using the latest data, this study found that disparities in access to care among racial/ethnic groups as well as income levels have been reduced significantly. Insurance and health status (in particular functional limitations) were found to be the most important factors that were associated with access to care. Therefore, interventions to expand insurance coverage and the Affordable Care Act are expected to contribute to reducing disparities in access to care. However, to further improve access to care, targeted interventions and assistance must be given to those who are of poorer health status.