The U.S. Health Care System

The U.S. Health Care System

When asked to describe the U.S. health care system, most Americans would probably offer a description of just a single facet of a huge, complex interaction of people, institutions, and technology. Like snapshots, each account offers an image, frozen in time, of one of the many health care providers and the settings in which medical care is delivered. Examples of these include:

  • Physician offices: for many Americans, health care may be described as the interaction between a primary care physician and patient to address minor and urgent medical problems, such as colds, flu, or back pain. A primary care physician (usually a general practitioner, family practitioner, internist, or pediatrician) is the frontline caregiverthe first practitioner to evaluate and treat the patient. Routine physical examinations, prevention such as immunization and health screening to detect disease, and treatment of acute and chronic diseases commonly take place in physicians' offices.
  • Medical clinics: these settings provide primary care services comparable to those provided in physicians' offices and may be organized to deliver specialized support such as prenatal care for expectant mothers, well-baby care for infants, or treatment for specific medical conditions such as hypertension (high blood pressure), diabetes, or asthma.
  • Hospitals: these institutions contain laboratories, imaging centers (also known as radiology departments, where x-rays and other imaging studies are performed), and other equipment for diagnosis and treatment, as well as emergency departments, operating rooms, and highly trained personnel.

Medical care is provided through many other venues, including outpatient surgical centers, school health programs, pharmacies, worksite clinics, and voluntary health agencies such as Planned Parenthood, the American Red Cross, and the American Lung Association.

IS THE U.S. HEALTH CARE SYSTEM AILING?

Even though medical care in the United States is often considered the best available, some observers feel the system that delivers it is fragmented and in serious disarray. In Crossing the Quality Chasm: A New Health System for the 21st Century (2001, http://www.nap.edu/books/0309072808/html/), the Institute of Medicine (IOM) of the National Academies describes the nation's health care system as disjointed, inefficient, and in need of a major overhaul.

Regina E. Herzlinger of the Harvard Business School agrees with the IOM. In Who Killed Health Care?: America's $2 Trillion Medical Problemand the Consumer-Driven Cure (2007), she contends that the current U.S. health care system is in crisis because it is incorrectly organized around the motives, methods, and preferences of health care providers and payers rather than aimed at meeting the needs of health care consumers. Herzlinger argues that the present orientation of the U.S. health care system is dangerously eroding patient welfare and driving costs so high that for millions of Americans, medical care is inaccessible.

Herzlinger proposes streamlining the system by eliminating insurance companies, which she believes only serve as middlemen between physicians and patients. She also recommends:

  • Mandatory health insurance with subsidies provided for people who cannot afford to purchase it
  • Establishment of small medical facilities that provide comprehensive health care services
  • A national system of medical records that ensures confidentiality as well as provider access to medical information
  • Compulsory performance reviews of all hospitals and health care organizations

Herzlinger asserts that in a consumer-driven model of health care delivery, providers would compete on the basis of quality, services would be timely, coordinated, and cost-effective, and innovation would be encouraged and rewarded.

Albert Fuchs, a practicing physician, offers another scathing indictment of the health care system in Dollars to Doughnuts Diagnosis (Los Angeles Times, April 16, 2008). Like Hurzlinger, he blames insurance companies for creating high-volume medical practices and compromising the time physicians can spend with patients. By dropping all of his insurance plans and seeing patients on a fee-for-service basis, Fuchs claims he can devote more time to his patients. He also believes that eliminating insurance companies from the health care equation will cause prices to drop. Fuchs asserts, When doctors break free from the shackles of insurance companies, they can practice medicine the way they always hoped they could. And they can get back to the customer service model in which the paramount incentive is providing the best care.

In A Second Opinion: Rescuing America's Health Care (2007), Arnold S. Relman of Harvard Medical School explains how the commercialization of medicine harms both physicians and patients. Relman opines that the profit motive increases costs; it may also jeopardize quality or aggravate the system's inequity. He favors a single-payer insurance program supported by a progressive health care tax to finance a delivery system in which all hospitals would be not-for-profit and most physicians would be salaried employees.

THE COMPONENTS OF THE HEALTH CARE SYSTEM

The health care system consists of all personal medical care servicesprevention, diagnosis, treatment, and rehabilitation (services to restore function and independence)plus the institutions and personnel that provide these services and the government, public, and private organizations and agencies that finance service delivery.

The health care system may be viewed as a complex consisting of three interrelated components: health care consumers (people in need of health care services), health care providers (people who deliver health care servicesthe professionals and practitioners), and the institutions or organizations of the health care system (the public and private agencies that organize, plan, regulate, finance, and coordinate services), which provide the systematic arrangements for delivering health care. The institutional component includes hospitals, clinics, and home-health agencies; the insurance companies and programs that pay for services, such as Blue Cross/Blue Shield, managed care plans such as health maintenance organizations, and preferred provider organizations; and entitlement programs such as Medicare and Medicaid (federal and state government public assistance programs). Other institutions are the professional schools that train students for careers in medical, public health, dental, and allied health professions, such as nursing and laboratory technology. Also included are agencies and associations that research and monitor the quality of health care services; license and accreditation providers and institutions; local, state, and national professional societies; and the companies that produce medical technology, equipment, and pharmaceuticals.

Much of the interaction among the three components of the health care system occurs directly between individual health care consumers and providers. Other interactions are indirect and impersonal such as immunization programs or screening to detect disease, which are performed by public health agencies for whole populations. Regardless, all health care delivery depends on interactions among all three components. The ability to benefit from health care depends on an individual's or group's ability to gain entry to the health care system. The process of gaining entry to the health care system is referred to as access, and many factors can affect access to health care. This chapter provides an overview of how Americans access the health care system.

ACCESS TO THE HEALTH CARE SYSTEM

In the twenty-first century, access to health care services is a key measure of the overall health and prosperity of a nation or a population, but access and availability were not always linked to health status. In fact, many medical historians assert that until the beginning of the twentieth century, a visit with a physician was as likely to be harmful as it was helpful. Only since the early twentieth century has medical care been considered a positive influence on health and longevity.

There are three aspects of accessibility: consumer access, comprehensive availability of services, and supply of services adequate to meet community demand. Quality health care services must be accessible to health care consumers when and where they are needed. The health care provider must have access to a full range of facilities, equipment, drugs, and services provided by other practitioners. The institutional component of health care deliverythe hospitals, clinics, and payersmust have timely access to information toenablethemtoplan anadequatesupply of appropriate services for their communities.

Consumer Access to Care

Access to health care services is influenced by a variety of factors. Characteristics of health care consumers strongly affect when, where, and how they access services. Differences in age, educational attainment, economic status, race, ethnicity, cultural heritage, and geographic location determine when consumers seek health care services, where they go to receive them, their expectations of treatment, and the extent to which they wish to participate in decisions about their own medical care.

People have different reasons for seeking access to health care services. Their personal beliefs about health and illness, motivations to obtain care, expectations of the care they will receive, and knowledge about how and where to receive care vary. For an individual to have access to quality care, there must be appropriately defined points of entry into the health care system. For many consumers, a primary care physician is the portal to the health care system. Besides evaluating the patient's presenting problem (or immediate health care need), the primary care physician also directs the consumer to other providers of care such as physician specialists or mental health professionals.

Some consumers access the health care system by seeking care from a clinic or hospital outpatient department, where teams of health professionals are available at one location. Others gain entry by way of a public health nurse, school nurse, social worker, or pharmacist, who refers them to an appropriate source, site, or health care practitioner.

Comprehensive Availability of Health Care Services

Historically, the physician was the exclusive provider of all medical services. Until the twentieth century, the family doctor served as physician, surgeon, pharmacist, therapist, adviser, and dentist. He carried all the tools of his trade in a small bag and could easily offer state-of-the-art medical care in his patient's home, because hospitals had little more to offer in the way of equipment or facilities. In the twenty-first century, it is neither practical nor desirable to ask one practitioner to serve in all these roles. It would be impossible for one professional to perform the full range of health care services, from primary prevention of disease and diagnosis to treatment and rehabilitation. Modern physicians and other health care practitioners must have access to a comprehensive array of trained personnel, facilities, and equipment so that they can, in turn, make them accessible to their patients.

Even though many medical problems are effectively treated in a single office visit with a physician, even simple diagnosis and treatment relies on a variety of ancillary (supplementary) services and personnel. To make the diagnosis, the physician may order an imaging study such as an x-ray or ultrasound that is performed by a radiology technician and interpreted by a radiologist (physician specialist in imaging techniques). Laboratory tests may be performed by technicians and analyzed by pathologists (physicians who specialize in microscopic analysis and diagnosis). More complicated medical problems involve teams of surgeons and high-tech surgical suites equipped with robotic assistants and rehabilitation programs in which highly trained physical and occupational therapists skillfully assist patients to regain function and independence.

Some health care services are more effectively, efficiently, and economically provided to groups rather than to individuals. Immunization to prevent communicable diseases and screening to detect diseases in their earliest and most treatable stages are examples of preventive services best performed as cooperative efforts of voluntary health organizations, medical and other professional societies, hospitals, and public health departments.

Access Requires Enough Health Care Services to Meet Community Needs

For all members of a community to have access to the full range of health care services, careful planning is required to ensure both the adequate supply and distribution of needed services. To evaluate community needs and effectively allocate health care resources, communities must gather demographic data and information about the social and economic characteristics of the population. They must also monitor the spread of disease and the frequency of specific medical conditions over time. All this population data must be considered in relation to available resources, including health care personnel, the distribution of facilities, equipment, and human resources (the available health care workforce), and advances in medicine and technology.

For example, a predicted shortage of nurses may prompt increased spending on nursing education; reviews of nurses' salary, benefits, and working conditions; and the cultivation of nonnursing personnel to perform specific responsibilities previously assigned to nurses. Similarly, when ongoing surveillance anticipates an especially virulent influenza (flu) season, public health officials, agencies, and practitioners intensify efforts to provide timely immunization to vulnerable populations such as older adults. Government agencies such as the Centers for Disease Control and Prevention (CDC), the National Institutes of Health, state and local health departments, professional societies, voluntary health agencies, and universities work together to research, analyze, and forecast health care needs. Their recommendations allow health care planners, policy makers, and legislators to allocate resources so that supply keeps pace with demand and to ensure that new services and strategies are developed to address existing and emerging health care concerns.

A REGULAR SOURCE OF HEALTH CARE IMPROVES ACCESS

Accordingtothe CDC, thedetermination of whetheran individual has a regular sourcea regular provider or siteof health care is a powerful predictor of access to health care services. Generally, people without regular sources have less access or access to fewer services, including key preventive medicine services such as prenatal care, routine immunization, and health screening. Many factors have been found to contribute to keeping individuals from having regular sources of medical care, with income level being the best predictor of unmet medical needs or problems gaining access to health care services.

J. S. Schiller, K. M. Heyman, and P. Barnes of the National Center for Health Statistics (NCHS) analyze the 2007 National Health Interview Survey (NHIS), an annual nationwide survey of about thirty-eight thousand households in the United States, in Early Release of Selected Estimates Based on Data from the JanuarySeptember 2007 National Health Interview Survey (March 2008, http://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease200806.pdf). The researchers find that from 1997 to 2007 the percentage of people of all ages with a usual source of medical care did not substantially varyranging from a low of 86% in 1997 to a high of 88% in 2001. (See Figure 1.1.) From January to September 2007, 87% of people had a usual place to go for medical care.

Still, from 1998 through 2006 the percentage of people who needed medical care but did not obtain it because of financial barriers to access increased each year. The annual percentage of people who experienced this lack of access to medical care rose from 4.2% in 1998 to 5.8% in 2006 and did not change in 2007. (See Figure 1.2.)

Schiller, Heyman, and Barnes reveal that people aged eighteen to twenty-four were the least likely to have a regular source of care, but the likelihood of having a regular source of medical care increased with age among people aged eighteen years and older. (See Figure 1.3.) 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. Schiller, Heyman, and Barnes 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 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. In Access Denied: A Look at America's Medically Disenfranchised (2007, http://www.nachc.com/client/documents/research/Access_Denied42407.pdf), the NACHC reports that fifty-six million Americans of all income levels, race, and ethnicity were medically disenfranchised (at risk of inadequate access to basic medical services) in 2005 and that low-income families and minoritiespopulations traditionally characterized as medically underservedwere the hardest hit. The number of people considered medically disenfranchised was higher than the nearly forty-seven million Americans who lacked health insurance during the same year because the NACHC believes people lack access for a variety of additional reasons such as scarcity of health care resources, geographically inaccessible services, and health care that was not culturally sensitive or was otherwise unacceptable to health care consumers.

There Are Americans without Access to Medical Care in Every State

According to NACHC, in 2005 there were medically unserved Americans in every state, with the highest concentrations in Florida, Texas, and California. Together, these three states contained 29% of the fifty-six million. Twenty-one states were home to more than one million medically disenfranchised people and in nine states (Alabama, Alaska, Florida, Kansas, Mississippi, Missouri, Oregon, South Carolina, and Utah) two out of five residents had sharply limited or no access to the health care system. More than half (55.9%) of Alabama residents were medically disenfranchised.

In 2005 close to fifteen hundred counties in nearly every state had disenfranchised populations and did not have health centers. Health centers served fifteen million people in 2005, effectively reducing the number of medically disenfranchised people by 21%. In Hawaii, Maine, New Jersey, and Vermont, health centers reduced the number of disenfranchised by 50%; in ten other states (California, Colorado, Connecticut, Illinois, Maryland, Montana, New Mexico, New York, Pennsylvania, and South Dakota) and in the District of Columbia health centers reduced the ranks of the disenfranchised by 30%.

Race and Ethnicity Continue to Affect Access to Health Care

According to Schiller, Heyman, and Barnes, Hispanic adults continue to be less likely to have a regular source for medical care than white non-Hispanic and African-American non-Hispanic people. After adjusting for age and gender, 77% of Hispanics had a usual source of medical care, compared to 88.6% of non-Hispanic whites and 86.4% of non-Hispanic African-Americans. (See Figure 1.4.) Hispanics and non-Hispanic African-Americans Americans were more likely than non-Hispanic whites to suffer financial barriers to access. After adjusting for age and gender, 6.5% of Hispanics and 6.4% of non-Hispanic African-Americans were unable to obtain needed medical care because of financial barriers, compared to 5.5% of non-Hispanic whites. (See Figure 1.5.) Health educators speculate that language barriers and the lack of information about the availability of health care services may serve to widen this gap.

Women Face Additional Obstacles

In Women and Health Care: A National Profile (July 2005, http://www.kff.org/womenshealth/upload/Women-and-Health-Care-A-National-Profile-Key-Findings-from-the-Kaiser-Women-s-Health-Survey.pdf), Alina Salganicoff, Usha R. Ranji, and Roberta Wyn analyze data from the 2004 Kaiser Women's Health Survey. The researchers indicate that, overall, Hispanic and African-American women fared worse than white women in terms of access to health care services.

According to Salganicoff, Ranji, and Wyn, Hispanic women reported less access to care than their white counterparts. More than one-quarter (29%) of Hispanic women had not visited a health care provider in the year before the survey, compared to 16% of African-American women and 11% of white women. Uninsured women were the least likely to have had a provider visit (67%), compared to women covered by private insurance, Medicaid, or Medicare (90%, 88%, and 93%, respectively).

Schiller, Heyman, and Barnes also document 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.)

Children Need Better Access to Health Care, Too

Barbara Bloom and Robin A. Cohen of the NCHS analyzed data from the 2006 NHIS to look at selected health measures, including children's access to care, and compiled their findings in Summary Health Statistics for U.S. Children: National Health Interview Survey, 2006 (September 2007, http://www.cdc.gov/nchs/data/series/sr_10/sr10_234.pdf). Among other factors, Bloom and Cohen's analysis focused on the unmet health care needs of children under age eighteen, poverty status, insurance coverage, and usual place of medical care.

The researchers note that in 2006, 5% of children in the United States did not have a regular source of medical care. Non-Hispanic African-American children (97%) and

Usual place of health care b
Selected characteristic All children under 18 years Has usual place of health carea Clinic Doctor's office Emergency room Hospital outpatient Some other place Doesn't go to one place most often
Number in thousandsc
      Totald(crude) 73,493 69,626 15,137 52,879 419 673 233 202
Sex
Male 37,569 35,525 7,757 26,877 237 386 132 *96
Female 35,924 34,101 7,380 26,003 182 287 *101 106
Age
04 years 20,410 19,704 4,648 14,644 107 217 *43 *39
511 years 27,776 26,417 5,673 20,157 157 245 106 *61
1217 years 25,307 23,505 4,817 18,078 154 210 *84 *102
Race
1 racee 70,976 67,245 14,606 51,132 410 601 233 180
      White 55,881 52,891 11,007 40,958 260 279 169 151
      Black or African American 11,455 10,964 2,747 7,778 116 242 *47
      American Indian or Alaska Native 691 661 360 277
      Asian 2,835 2,615 458 2,048 *62
      Native Hawaiian or other Pacific Islander 114 *114 *72
2 or more racesf 2,518 2,382 531 1,747 *72
      Black or African American and white 935 868 167 680
      American Indian or Alaska Native and white 572 522 206 259
Hispanic origin and race g
Hispanic or Latino 14,815 13,175 4,987 7,649 158 222 92
      Mexican or Mexican American 10,186 8,919 3,709 4,875 76 148 *68
Not Hispanic or Latino 58,678 56,451 10,150 45,230 260 451 184 111
      White, single race 42,480 41,017 6,605 33,951 *131 *80 125 *76
      Black or African American, single race 10,899 10,483 2,509 7,570 100 227 *42
Family structureh
Mother and father 51,777 49,295 9,700 38,641 236 355 174 124
Mother, no father 17,083 16,215 4,326 11,358 148 268 *34 *71
Father, no mother 2,479 2,180 511 1,622
Neither mother nor father 2,154 1,936 600 1,258 *23 *33
Parent's educationi
Less than high school diploma 10,103 9,010 3,893 4,811 103 136 *35
High school diploma or GEDj 16,106 15,187 3,683 11,096 128 172 *46 *61
More than high school 44,356 42,812 6,762 35,310 161 316 146 83
Family incomek
Less than $20,000 12,865 11,940 4,343 7,148 123 242 *22 *59
$20,000 or more 56,887 54,207 9,883 43,345 273 386 145 119
      $20,000$34,999 10,320 9,461 2,824 6,348 93 109 *34
      $35,000$54,999 10,843 10,161 2,100 7,854 *77 *68 *31
      $55,000$74,999 8,071 7,756 1,384 6,229 *66
      $75,000 or more 17,425 17,148 2,043 14,984 *62 *17
Poverty statusl
Poor 11,139 10,233 3,789 6,118 79 183 *41
Near poor 13,098 12,082 3,332 8,364 132 170 *51
Not poor 32,175 31,253 4,531 26,364 *77 135 *72 *52
Number in thousandsc
Health insurance coveragem
Private 42,773 41,747 5,391 35,936 *60 122 131 *52
Medicaid or other public 21,407 20,670 6,991 13,128 144 326 *38 *29
Other 1,738 1,659 585 923 *104
Uninsured 7,251 5,269 2,050 2,760 190 121 *53 91
Place of residence
Large MSAn 37,482 35,507 7,257 27,274 184 396 177 146
Small MSAn 23,470 22,301 4,557 17,311 181 164 *52 34
Not in MSAn 12,542 11,819 3,324 8,294 *112

non-Hispanic white children (97%) were more likely to have a regular source of care, compared to Hispanic children (89%). Bloom and Cohen also reveal a relationship between not having a usual source of medical care and family structure, family income, poverty status, and health insurance coverage. 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. (See Table 1.1.)

Usual place of health care b
Selected characteristic All children under 18 years Has usual place of health carea Clinic Doctor's office Emergency room Hospital outpatient Some other place Doesn't go to one place most often
*Estimates preceded by an asterisk have a relative standard error of greater than 30% and less than or equal to 50% and should be used with caution as they do not meet the standards of reliability or precision.
Estimates with a relative standard error greater than 50% are indicated with a dagger, but data are not shown.
Quantity zero.
aHaving 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?
bUsual place of health care is based on the question, What kind of place is it/what kind of place does [child's name] go to most oftenclinic or health center, doctor's office or HMO, hospital emergency room, hospital outpatient department or some other place?
cUnknowns for the columns are not included in the frequencies, but they are included in the all children under 18 years column.
dTotal 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.
eIn 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 because of 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.
fThe 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 because of small sample sizes for other combinations. Therefore, the frequencies for the category 2 or more races will be greater than the sum of the frequencies for the specific combinations shown separately.
gPersons 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.
hFamily 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.
iParent's education is the education level of the parent with the higher level of education, regardless of that parent's age.
jGED is General Educational Development high school equivalency diploma.
kThe 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.
lPoverty 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.
mClassification 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. Persons under age 65 years and those aged 65 years and over were classified separately because of the prominence of Medicare coverage in the older population. The category private includes persons who had any type of private coverage either alone or in combination with other coverage. For example, for persons aged 65 years and over, private includes persons with only private or private in combination with Medicare. 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.
nMSA 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.
Number in thousandsc
Region
Northeast 13,574 13,319 2,015 10,966 88 147 *58
Midwest 16,708 16,080 4,252 11,616 *53 125
South 27,186 25,358 4,400 20,345 205 264 *66 *66
West 16,026 14,870 4,470 9,953 *73 *137 133 *78
Current health status
Excellent or very good 60,121 57,195 11,668 44,385 298 404 219 172
Good 11,933 11,085 3,048 7,642 105 230 *25
Fair or poor 1,398 1,306 416 818 *39

Having health insurance and the type of health insurance also predicted whether a child had a regular source of care. In 2006 children with no health insurance (5.3 million out of a total of 7.3 million children aged eighteen years and under, or 73%) were less likely to have a usual place for health care than children with private health insurance (41.7 million out of 42.8 million, or 98%). (See Table 1.1.)

BloomandCohenalsofindthatmorethantwiceasmany children with private health insurance (35.9 million) received health care in a physician's office than children with Medicaid or other public health insurance (13.1 million). (See Table 1.1.) 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.

In 2006, 9.5% of U.S. children had no health insurance coverage. (See Table 1.2.) Of those children who were uninsured, 13.3% lived in families with incomes of less than $20,000 per year and 16.5% lived in families with incomes ranging from $20,000 to $34,999, compared to 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, and delay seeking care because of financial barriers more frequently than children from families that were not poor. Health professionals 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.

Selected measures of health care access
Selected characteristic All children under 18 years Uninsured for health carea Unmet medical needb Delayed care due to costc Uninsured for health carea Unmet medical needb Delayed care due to costc
Number in thousandsd Percente
      Totalf(age-adjusted) 73,492 6,921 1,792 2,942 9.5 2.4 0.4
      Totalf(crude) 73,492 6,921 1,792 2,942 9.5 2.4 0.4
Sex
Male 37,568 3,628 963 1,511 9.7 2.6 0.4
Female 35,924 3,293 828 1,431 9.2 2.3 0.4
Ageg
04 years 20,386 1,516 455 758 7.5 2.2 3.7
511 years 27,830 2,624 634 1,016 9.5 2.3 3.7
1217 years 25,276 2,782 702 1,168 11.1 2.8 4.6
Race
1 raceh 71,043 6,634 1,739 2,832 9.4 2.4 4.0
      White 55,866 5,250 1,327 2,309 9.4 2.4 4.1
      Black or African American 11,496 949 363 458 8.4 3.2 4.0
      American Indian or Alaska Native 737 176 *18 23.7 *2.5
      Asian 2,850 242 *38 *47 8.8 *1.4 *1.7
      Native Hawaiian or other Pacific Islander 94 *20.6
2 or more racesi 2,449 288 *53 *110 12.1 *2.2 *4.6
      Black or African American and white 924 95 *40 9.5 *3.4 *4.0
      American Indian or Alaska Native and white 566 137 *59 24.4 *10.3
Hispanic origin and racej
Hispanic or Latino 14,815 2,850 472 704 19.9 3.2 4.8
      Mexican or Mexican American 10,125 2,251 329 510 23.1 3.3 5.2
Not Hispanic or Latino 58,677 4,071 1,319 2,238 7.0 2.2 3.8
      White, single race 42,454 2,633 895 1,686 6.2 2.1 3.9
      Black or African American, single race 10,914 836 346 412 7.8 3.2 3.8
Family structurek
Mother and father 51,768 4,664 972 1,769 9.1 1.9 3.4
Mother, no father 17,065 1,645 686 948 9.7 4.0 5.5
Father, no mother 2,469 311 *68 152 12.8 *3.5 6.7
Neither mother nor father 2,190 302 67 73 13.5 2.7 3.3
Parent's educationi
Less than high school diploma 9,762 2,074 337 479 21.4 3.5 4.9
High school diploma or GEDm 16,126 1,896 497 754 11.9 3.1 4.7
More than high school 43,531 2,502 853 1,611 5.8 2.0 3.7
Family incomen
Less than $20,000 12,417 1,593 461 545 13.3 3.8 4.5
$20,000 or more 55,513 4,829 1,192 2,247 8.7 2.1 4.0
      $20,000$34,999 9,747 1,590 429 746 16.5 4.4 7.7
      $35,000$54,999 10,253 1,261 321 622 12.4 3.1 6.0
      $55,000$74,999 7,762 518 120 247 6.6 1.5 3.1
      $75,000 or more 16,868 510 *129 360 3.0 *0.8 2.1
Poverty statuso
Poor 10,539 1,365 394 550 13.4 3.9 5.3
Near poor 12,379 2,052 537 920 16.8 4.4 7.5
Not poor 30,977 1,560 440 941 5.0 1.4 3.0
Health insurance coveragep
Private 43,283 548 1,021 1.3 2.3
Medicaid or other public 21,027 368 708 1.9 3.5
Other 1,673 *32 *1.9
Uninsured 6,921 6,921 862 1,169 100.0 12.4 16.9
Place of residence
Large MSAq 38,266 3,529 941 1,484 9.3 2.5 3.9
Small MSAq 22,965 2,094 539 887 9.2 2.4 3.9
Not in MSAq 12,261 1,299 312 572 10.6 2.5 4.6

According to Bloom and Cohen, there was significant geographic variation in insurance status, which was strongly linked to children's access to health care services. The percentage of children in the South (12.8%) and West (11.6%) who were uninsured in 2006 was nearly 50% higher than the percentage of uninsured children in the Midwest (6.3%) and the Northeast (4.3%). (See Table 1.2.)

Selected measures of health care access
Selected characteristic All children under 18 years Uninsured for health carea Unmet medical needb Delayed care due to costc Uninsured for health carea Unmet medical needb Delayed care due to costc
Estimates with a relative standard error greater than 50% are indicated with a dagger, but data are not shown.
*Estimates preceded by an asterisk have a relative standard error of greater than 30% and less than or equal to 50% and should be used with caution as they do not meet the standards of reliability or precision.
Quantity zero.
aUninsured 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?
bUnmet 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 afford it?
cDelayed 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?
dUnknowns for the columns are not included in the frequencies, but they are included in the all children under 18 years column.
eUnknowns for the column variables are not included in the denominators when calculating percentages.
fTotal 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.
gEstimates for age groups are not age adjusted.
hIn 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 because of small sample sizes. Therefore, the frequencies for the category I 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.
iThe 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 be cause of small sample sizes for other combinations. Therefore, the frequencies for the category 2 or more races will be greater than the sum of the frequencies for the specific combinations shown separately.
jPersons 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 Office of Management and Budget race and Hispanic origin terms.
kFamily 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.
lParent's education is the education level of the parent with the higher level of education, regardless of that parent's age.
mGED is General Educational Development high school equivalency diploma.
nThe 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.
oPoverty 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.
pClassification 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. Persons under age 65 years and those aged 65 years and over were classified separately because of the prominence of Medicare coverage in the older population. The category Private includes persons who had any type of private coverage either alone or in combination with other coverage. For example, for persons aged 65 years and over, Private includes persons with only private or private in combination with Medicare. 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.
qMSA 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.
Number in thousandsd Percente
Region
Northeast 13,208 568 170 276 4.3 1.3 2.1
Midwest 16,757 1,044 295 704 6.3 1.8 4.2
South 27,069 3,421 878 1,221 12.8 3.2 4.5
West 16,459 1,889 449 742 11.6 2.7 4.5
Current health status
Excellent or very good 59,370 5,172 1,199 2,079 8.8 2.0 3.5
Good 12,581 1,619 481 726 12.9 3.8 5.7
Fair or poor 1,407 125 107 133 8.8 7.6 9.5
Note: Data are based on household interviews of a sample of the civilian noninstitutionalized population.

How to Reduce Disparities in Access to Care

Health care researchers believe 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. Besides 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, policy makers, and consumers can help 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 federal government has repeatedly called for an end to these disparities. Even though some observers believe 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 The Challenge of Eliminating Disparities in Health (Journal of General Internal Medicine, vol. 17, no. 6, June 2002), 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. 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 to contain health expenditures, improve quality, or both. Research supported by the Agency for Healthcare Research and Quality (AHQR), the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care, 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 and Pacific Islanders. Jennifer S. Haas et al. analyze in 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) data about preventive health care use by people enrolled in fee-for-service and managed care plans from the AHRQ Medical Expenditure Panel Survey of noninstitutionalized U.S. civilians.

Haas et al. consider the use of four preventive health screenings: mammography within the past two years for women aged fifty to seventy-five, breast examination, Pap smear (screening for cervical cancer) within the past two years for women aged eighteen and sixty-five, and cholesterol screening within the past five years for men and women above age twenty. Their analysis reveals that Hispanicandwhitewomenenrolledinmanagedcare plans reported higher rates of mammography, breast exam, and Pap smear than Hispanic women with fee-for-service insurance. There were no significant differences in access to preventive care for African-Americans or Asians and Pacific Islanders by type of insurance. Haas et al. 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.

AHRQ Report Documents Disparities in Access

In July 2003 the AHRQ released its first National Healthcare Disparities Report (http://www.ahrq.gov/qual/nhdr03/nhdr2003.pdf), a report requested by Congress that documented racial health disparities including access to care. Among other things, the report cited the finding that African-Americans 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. Even though 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 AHRQ report generated fiery debate in the health care community and among legislators and painted a rather bleak view of disparities. 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.

Highlights from the National Healthcare Disparities Report 2007

In National Healthcare Disparities Report 2007 (February 2008, http://www.ahrq.gov/qual/nhdr07/nhdr07.pdf), the AHRQ tracks the measures of access to care that the first report, National Healthcare Disparities Report, identified. These measures include factors that facilitated access, such as having a primary care provider, and factors that were barriers to access, such as having no health insurance. The AHRQ's principal findings are:

  • Disparities in access persist. The AHRQ notes that disparities related to race, ethnicity, and socioeconomic status still exist in terms of access to the health care system. Table 1.3 shows the factors that account for disparities in access among members of racial and ethnic minorities, and Table 1.4 shows how socioeconomic variablesincome, education, and insurance statusserve to enable or deter access. For example, African-Americans, Native Americans, Hispanics, and Alaskan Natives continued to experience worse access to care than whites, and poor people and those without insurance had less access to care than those with higher incomes. (See Table 1.3 and Table 1.4.) For Hispanics, all disparities in accessexcept one that related to patients' own perceptions of difficulties or delays in obtaining health carewere found to have worsened.
    Racial differencea
    Core report measure Black Asian NHOPI AI/AN >1 Race Ethnic differenceb Hispanic
    aCompared with whites.
    bCompared with non-Hispanic whites.
    NHOPI = Native Hawaiian or other Pacific Islander; AI/AN American Indian or Alaska Native.
    Health insurance coverage
    Persons under 65 with health insurance = = =
    Persons uninsured all year = = = =
    Usual source of care
    Persons who have a specific source of ongoing care = = =
    Persons who have a usual primary care provider = = = =
    Patient perceptions of need
    People who experience difficulties or delays in obtaining health care or do not receive needed care = =
    People who experience difficulties or delays in obtaining health care due to financial or insurance reasons = =
    Key to symbols
    = Group and comparison group have about same access to health care.
    Group has better access to health care than the comparison group.
    Group has worse access to health care than the comparison group.
    Blank cell: Reliable estimate for group could not be made.
    Income differencea Educational differenceb Insurance differencec
    Core report measure <100% 100199% 200399% <HS HS grad Uninsured
    aCompared with persons with family incomes 400% of federal poverty thresholds or above.
    bCompared with persons with any college education.
    cCompared with persons under 65 with any private health insurance. HS High school.
    Health insurance coverage
    Persons under 65 with health insurance
    Persons uninsured all year
    Usual source of care
    Persons who have a specific source of ongoing care
    Persons who have a usual primary care provider
    Patient perceptions of need
    People who experience difficulties or delays in obtaining health care or do not receive needed care
    Key to Symbols
    = Group and comparison group have about same access to health care.
    Group has better access to health care than the comparison group.
    Group has worse access to health care than the comparison group.
    Blank cell: Reliable estimate for group could not be made.
  • Even though some disparities are diminishing, many groups continue to face disparities in access. Socioeconomic status accounts for some differences in health insurance coverage of racial and ethnic groups but not all. Hispanics of every income and educational level remained less likely than their non-Hispanic peers to have health insurance. African-Americans, Native Americans, and Alaskan Natives who had attended college were much less likely than whites who had attended college to have health insurance.
  • No group had attained the goal of 100% of Americans covered by health insurance set forth in Healthy People 2010 (2000, http://www.healthypeople.gov/document/tableofcontents.htm), the set of national health objectives that aim to identify and reduce the most significant preventable threats to health.

ACCESS TO MENTAL HEALTH CARE

Besides the range of barriers to access faced by all Americans trying to access the health care system, people seeking mental health care face unique challenges, not the least of which is that they are even less able than people in good mental health to successfully navigate the fragmented mental health service delivery system. Furthermore, because people with serious mental illness frequently suffer from unemployment and disability, they are likely to join the ranks of the impoverished, uninsured, and homeless, which only compounds access problems. Finally, the social stigmas (deeply held negative attitudes) that promote discrimination against people with mental illness are a powerful deterrent to seeking care.

The social stigmas attached to being labeled crazy prevent some sufferers of mental illness from seeking and obtaining needed care. Myths about mental illness persist, especially the mistaken beliefs that mental illness is a sign of moral weakness or that an affected individual can simply choose to wish or will away the symptoms of mental illness. People with mental illness cannot just pull themselves together and will themselves well. Without treatment, symptoms can worsen and persist for months or even years.

Besides reluctance to seek care, social stigmas can have far-reaching consequences for people with mental illnesses. They may face discrimination in the workplace, in school, and in efforts to find housing. Thwarted in their efforts to maintain independence, people suffering from mental illness may become trapped in a cycle characterized by feelings of worthlessness and hopelessness and may be further isolated from the social and community supports and treatments most able to help them recover.

The President's New Freedom Commission on Mental Health describes in Achieving the Promise: Transforming Mental Health Care in America (2003, http://www.mentalhealthcommission.gov/reports/Finalreport/FullReport.htm) problems in the delivery of mental health care and six overarching goals related to access to mental health services. (See Table 1.5.) For example, achievement of the first goal, to improve Americans' understanding that mental health is vital for overall health, would doubtless improve access by reducing the stigmas associated with seeking treatment for mental illness. The second goal, of delivering family and consumer-driven care, would also act to improve access by

Goal 1 Americans understand that mental health is essential to overall health.
Recommendations 1.1 Advance and implement a national campaign to reduce the stigma of seeking care and a national strategy for suicide prevention.
1.2 Address mental health with the same urgency as physical health.
Goal 2 Mental health care is consumer and family driven.
Recommendations 2.1 Develop an individualized plan of care for every adult with a serious mental illness and child with a serious emotional disturbance.
2.2 Involve consumers and families fully in orienting the mental health system toward recovery.
2.3 Align relevant federal programs to improve access and accountability for mental health services.
2.4 Create a comprehensive state mental health plan.
2.5 Protect and enhance the rights of people with mental illnesses.
Goal 3 Disparities in mental health services are eliminated.
Recommendations 3.1 Improve access to quality care that is culturally competent.
3.2 Improve access to quality care in rural and geographically remote areas.
Goal 4 Early mental health screening, assessment, and referral to services are common practice.
Recommendations 4.1 Promote the mental health of young children.
4.2 Improve and expand school mental health programs.
4.3 Screen for co-occurring mental and substance use disorders and link with integrated treatment strategies.
4.4 Screen for mental disorders in primary health care, across the life span, and connect to treatment and supports.
Goal 5 Excellent mental health care is delivered and research is accelerated.
Recommendations 5.1 Accelerate research to promote recovery and resilience, and ultimately to cure and prevent mental illnesses.
5.2 Advance evidence-based practices using dissemination and demonstration projects and create a public-private partnership to guide their implementation.
5.3 Improve and expand the workforce providing evidence-based mental health services and supports.
5.4 Develop the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care.

offering care that is more acceptable to consumers and less likely to infringe on the rights of people with mental illnesses. Goals 3 and 6eliminating disparities in mental health services and using technology to reach under-served populationsare clear moves to improve access. Goals 4 and 5 address the quality and effectiveness of mental health care; however, they, too, directly affect access by improving screening and detection of mental illness and by expanding the workforce that provides mental health and support services.

Goal 6 Technology is used to access mental health care and information.
Recommendations 6.1 Use health technology and telehealth to improve access and coordination of mental health care, especially for Americans in remote areas or in underserved populations.
6.2 Develop and implement integrated electronic health record and personal health information systems.

Disparities in Access to Mental Health Care

The principal barriers to access of mental health care are the cost of services, the fragmented organization of these services, and the social stigmas toward mental illness. These obstacles may act as deterrents for all Americans, but for racial and ethnic minorities they are compounded by language barriers, ethnic and cultural compatibility of practitioners, and geographic availability of services.

The AHRQ finds in National Healthcare Disparities Report 2007 that when compared to whites, minorities have less access to care and are less likely to receive needed services. The proportion of African-Americans, Hispanics, and Asian-Americans that received outpatient mental health care in 2005 was lower than whites; lower among the poor and near poor than the middle incomes; and increased with educational attainment. Some of these differences may be attributable to cultural attitudes toward mental health.

Education and income explain some but not all the racial and ethnic differences in access. According to the AHRQ, across all levels of income and education, Hispanics were less likely than non-Hispanic whites to have received mental health care in 2005, 7.8% compared to 15.1%. African-Americans with higher incomes and educational attainment were less likely to have received care than whites with comparable socioeconomic status, but the gap closes among the poor and people with less than a high school education.

IS ACCESS A RIGHT OR A PRIVILEGE?

The AHRQ and other health care researchers and policy makers observe that having health insurance does not necessarily ensure access to medical care. They contend that many other factors, including cost-containment measures put in place by private and public payers, have reduced access to care. Nonetheless, reduced access affects vulnerable populationsthe poor, people with mental illness and other disabilities, and immigrantsmore than others.

Health care is a resource that is rationed. In the United States and other countries without universal or national programs of health insurance, people with greater incomes and assets are more likely than low-income families to have health insurance and as a result have greater access to health care services.

A wide range of groups and organizations support the idea that health care is a fundamental human right, rather than a privilege. These organizations include Physicians for a National Health Program, the American Association of Retired Persons, National Health Care for the Homeless, Inc., and the Friends Committee on National Legislation, a Quaker public interest lobby.

Americans Are Worried about Access to Care

The Mayo Clinic Health Policy Center reports in Health Care Reform Survey: Costs Are Top Worry (March 10, 2008, http://www.mayoclinic.org/news2008-rst/4698.html) that in 2007 Americans were pessimistic about the likelihood that reforms to improve the health care system will occur in the coming decade. Less than half (43%) of the survey respondents said they were satisfied, very satisfied, or completely satisfied with the U.S. health care system, and the majority (80%) felt it was vitally important to improve health care quality and reduce health care costs.

According to the center, costs were the most pressing concern of health care consumers in 2007. Ninety-one percent of respondents felt that costs were excessively high. Access was identified as the second-most pressing concern by 24% of respondents. More than two-thirds of respondents called for improved access to health information and services. They want the freedom to choose their own physicians, hospitals, and insurance plans. Respondents without insurance were more likely to give failing ratings to the health care system's ability to ensure coordination of care, access, and value.

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