Barriers to Care and Comorbidities Along the U.S.-Mexico Border

Objective

While limited access to care is associated with adverse health conditions, little research has investigated the association between barriers to care and having multiple health conditions (comorbidities). We compared the financial, structural, and cognitive barriers to care between Mexican-American border residents with and without comorbidities.

Methods

We conducted a stratified, two-stage, randomized, cross-sectional health survey in 2009–2010 among 1,002 Mexican-American households. Measures included demographic characteristics; financial, structural, and cognitive barriers to health care; and prevalence of health conditions.

Results

Comorbidities, most frequently cardiovascular and metabolic conditions, were reported by 37.7% of participants. Controlling for demographics, income, and health insurance, six financial barriers, including direct measures of inability to pay for medical costs, were associated with having comorbidities (odds ratios [ORs] ranged from 1.7 to 4.1, p<0.05). The structural barrier of transportation (OR=3.65, 95% confidence interval [CI] 1.91, 6.97, p<0.001) was also associated with higher odds of comorbidities, as were cognitive barriers of difficulty understanding medical information (OR=1.71, 95% CI 1.10, 2.66, p=0.017), being confused about arrangements (OR=1.82, 95% CI 1.04, 3.21, p=0.037), and not being treated with respect in medical settings (OR=1.63, 95% CI 1.05, 2.53, p=0.028). When restricting analyses to participants with at least one health condition (comparing one condition vs. having ≥2 comorbid conditions), associations were maintained for financial and transportation barriers but not for cognitive barriers.

Conclusion

A substantial proportion of adults reported comorbidities. Given the greater burden of barriers to medical care among people with comorbidities, interventions addressing these barriers present an important avenue for research and practice among Mexican-American border residents.Limited access to health care has been associated with a wide range of adverse health consequences including premature mortality^1,2 and increased risk for many common chronic conditions.^3–5 Despite prior research documenting associations between sustained lack of access and many health conditions independently,^6,7 very little research has described whether people with more than one health condition (i.e., comorbidities) experience greater barriers to obtaining health care.Prior research based on information from the Medical Expenditure Panel Survey has further indicated that people with multiple chronic conditions incur far greater health-care costs (up to seven times as many) as patients with only one chronic condition.⁸ It is essential, therefore, to understand the barriers to care that are disproportionately faced by people with comorbidities who need ongoing care, particularly among populations at high risk for developing comorbidities.Populations at high risk for having multiple health conditions include most minority populations in the U.S. and, in particular, Hispanic people, the largest and most rapidly growing minority group in the U.S.⁹ For example, the largest subgroup of Hispanic people, Mexican-Americans, has been found to have the highest incidence (an estimated 33.2%) of metabolic syndrome,¹⁰ a cluster of risk factors placing people at higher risk for heart disease, type 2 diabetes, and stroke.¹¹ Although there is substantial variability among Hispanic subgroups, based on information from the National Health Interview Survey, Mexican-American populations have the poorest access to care and the lowest use of health services of all Hispanic subgroups.^12,13 An estimated 32% of Hispanic people in the U.S. do not have health insurance compared with 15% of non-Hispanic white people.¹⁴ Besides economic limitations, Hispanic populations often face additional barriers to accessing health services. Factors that have been reported to impede Hispanic populations from obtaining medical care include, but are not limited to, language and literacy barriers,^15–17 lack of transportation and geographic inaccessibility,^15,17 the perception of being treated without respect in medical settings, and the perception that they would have received better quality care if they belonged to a difference racial/ethnic group.¹⁸A valuable guiding framework for the current study that provides a comprehensive overview of modifiable factors associated with access to health care is the recently developed Health Care Access Barriers model, an evidence-based analytical framework developed by Carillo and colleagues.¹⁹ This model describes the assessment of three categories of barriers to health care (financial, structural, and cognitive) that have been shown to be associated with poor health outcomes.Given the limited access to health care and high risk for comorbidities, gaining insight into which financial, structural, and cognitive barriers to care are associated with comorbidities among Mexican-Americans can provide valuable information for preventive efforts. Therefore, based on information from a randomized household survey conducted in a large city along the U.S.-Mexico border, the primary aim of the current study was to compare barriers to health care of participants with and without comorbidities. We hypothesized that people reporting comorbidities would be disproportionately affected by financial, cognitive, and structural barriers to care.