Racial and ethnic differences in access to medical care in managed care plans

OBJECTIVE: To examine the extent to which access differences between racial/ethnic minorities and whites in managed care plans are greater than such differences in other types of health plans. DATA SOURCE: A nationally representative sample of 4,811 African American, 3,379 Hispanic, and 33,737 white nonelderly persons with public or private health insurance. STUDY DESIGN/DATA COLLECTION: A cross-sectional survey of households was conducted during 1996 and 1997. Commonly used measures of access to and utilization of medical care were constructed for individuals: (1) percentage of visits with a usual provider, (2) percentage with a regular provider, (3) visit with a physician in the past year, (4) hospital ER use, (5) last visit was to a specialist. PRINCIPAL FINDINGS: Fewer than 74 percent of Hispanics and African Americans had a regular provider compared to more than 78 percent of white Americans. Hispanics were least likely to have had their last doctor visit with a specialist (22 percent) compared to African Americans (26 percent) and whites (28 percent). Differences between ethnic/racial minorities and whites in managed care plans are similar to differences observed in non-managed care plans. Americans of all racial and ethnic backgrounds in managed care plans with gatekeeping are more likely to have a usual source of care, a regular provider, and lower use of specialists compared to persons in plans without gatekeeping. CONCLUSION: Although greater access to primary care was shown among African Americans and Hispanics in managed care plans, the extent of the disparities between racial/ethnic minorities and whites in managed care is similar to disparities in other types of health plans.     

Raising low 'patient activation' rates among Hispanic immigrants may equal expanded coverage in reducing access disparities

There is a growing consensus that activating consumers to become better managers of their health is an essential component of US health care reform. We measured how activated blacks, whites, and Hispanics are-that is, how confident, skillful, and knowledgeable they are about taking an active role in improving their health and health care. We found that patient activation among blacks and Hispanics was low, relative to that of whites. For example, 24.8 percent of Hispanics were at the highest level of patient activation, compared to 39.5 percent of blacks and 45.3 percent of whites. Among Hispanic immigrants, low acculturation and lack of familiarity with the US health care system contribute to low activation. The findings indicate that increasing activation levels among Hispanic immigrants may be as important as expanding insurance coverage in reducing disparities in unmet medical need.     

Massachusetts' health care reform increased access to care for Hispanics, but disparities remain

Hispanics are more likely than any other racial or ethnic group in the United States to lack health insurance. This paper draws on quantitative and qualitative research to evaluate the extent to which health reforms in Massachusetts, a model for the Affordable Care Act of 2010, have reduced disparities in insurance coverage and access to health care. We found that rates of coverage and the likelihood of having a usual provider increased dramatically for Massachusetts Hispanics after the state's reforms, but disparities remained. The increase in insurance coverage among Hispanics was more than double that experienced by non-Hispanic whites. Even so, in 2009, 78.9 percent of Hispanics had coverage, versus 96 percent of non-Hispanic whites. Language and other cultural factors remained significant barriers: Only 66.6 percent of Hispanics with limited proficiency in English were insured. One-third of Spanish-speaking Hispanics still did not have a personal provider in 2009, and 26.8 percent reported not seeing a doctor because of cost, up from 18.9 percent in 2005. We suggest ways to reduce such disparities through national health care reform, including simplified enrollment and reenrollment processes and assistance in finding a provider and navigating an unfamiliar care system.     

Racial and Ethnic Disparities in the Use of Mental Health Services

The authors used data from the 1998-1999 Community Tracking Study (CTS) household survey to examine variations in predictors of use of mental health services among different racial and ethnic groups (white, African American, Hispanic, and other). African Americans and Hispanics were less likely to have visited a mental health professional (MHP) in the prior year than were whites. Independent of health insurance and health status, low- to middle-income African Americans may be at particular risk for inadequate use of an MHP compared to higher-income African Americans. Similarly, upper-income Hispanics were more likely to have visited an MHP than Hispanics in the lowest income range. Adults aged 50 and older were less likely to visit an MHP than individuals aged 18-49. Depressed men were more likely to visit an MHP than depressed women. Efforts to reduce disparities should focus on lower-income racial and ethnic minorities.     

The insurance gap and minority health care, 1997-2001

Gaps in access to medical care among working-age white Americans, African Americans and Latinos failed to improve between 1997 and 2001, despite a booming economy and increased national attention to narrowing and eliminating minority health disparities. African Americans and Latinos continue to have less access to a regular health care provider, see a doctor less often and lag behind whites in seeing specialists, according to recent findings from the Center for Studying Health System Change (HSC). Ethnic and racial disparities in access among uninsured Americans are much greater than disparities among the insured. Uninsured whites' greater financial resources may explain why they have fewer problems accessing care. Eliminating disparities in minority health care will be difficult without first eliminating these gaps in minority health insurance.     

Awareness of racial and ethnic health disparities has improved only modestly over a decade

Documented disparities exist in the United States between the majority white population and various racial and ethnic minority populations on several health and health care indicators, including access to and quality of care, disease prevalence, infant mortality, and life expectancy. However, awareness of these disparities-a necessary first step toward changing behavior and compelling action-remains limited. Our survey of 3,159 adults age eighteen or older found that 59 percent of Americans in 2010 were aware of racial and ethnic disparities that disproportionately affect African Americans and Hispanics or Latinos. That number represents a modest increase over the 55 percent recorded in a 1999 survey. Meanwhile, in our survey, 89 percent of African American respondents were aware of African American and white disparities, versus 55 percent of whites. Yet the survey also revealed low levels of awareness among racial and ethnic minority groups about disparities that disproportionately affect their own communities. For example, only 54 percent of African Americans were aware of disparities in the rate of HIV/AIDS between African Americans and whites, and only 21 percent of Hispanics or Latinos were aware of those disparities between their group and whites. Policy makers must increase the availability and quality of data on racial and ethnic health disparities and create multisectoral partnerships to develop targeted educational campaigns to increase awareness of health disparities.     

Would safety-net expansions offset reduced access resulting from lost insurance coverage? Race/ethnicity differences

This study simulated whether increased community health center (CHC) funding under the Bush administration narrowed racial/ethnic gaps in access to care among low-income people. Expanded CHC funding resulted in small increases in access to care, more so for minorities than for whites. Spanish-speaking Hispanics had the largest improvements in access in the simulation. However, minorities experienced bigger drops in insurance coverage. The net result was no improvements in the access measures for Spanish-speaking Hispanics and slight decreases in access for whites, English-speaking Hispanics, and African Americans. Access gaps either remained the same or worsened slightly for English-speaking Hispanics and African Americans relative to whites.     

The role of health insurance coverage in reducing racial/ethnic disparities in health care

Research showing racial/ethnic disparities in medical care obtained by people with comparable insurance has raised questions about the extent to which health insurance improves opportunities for care. To assess whether insurance expansions could be expected to reduce racial/ethnic disparities in access to care, this paper reviews evidence from studies specifically designed to quantify the contribution of health insurance to racial/ethnic disparities in access. The studies provide evidence that a sizable share of the differences in whether a person has a regular source of care could be reduced if Hispanics and African Americans were insured at levels comparable to those of whites.     

The role of health insurance in explaining immigrant versus non-immigrant disparities in access to health care: Comparing the United States to Canada

Using a cross-national comparative approach, we examined the influence of health insurance on U.S. immigrant versus non-immigrant disparities in access to primary health care. With data from the 2002/2003 Joint Canada/United States Survey of Health, we gathered evidence using three approaches: 1) we compared health care access among insured and uninsured immigrants and non-immigrants within the U.S.; 2) we contrasted these results with health care access disparities between immigrants and non-immigrants in Canada, a country with universal health care; and 3) we conducted a novel direct comparison of health care access among insured and uninsured U.S. immigrants with Canadian immigrants (all of whom are insured). Outcomes investigated were self-reported unmet medical needs and lack of a regular doctor. Logistic regression models controlled for age, sex, nonwhite status, marital status, education, employment, and self-rated health. In the U.S., odds of unmet medical needs of insured immigrants were similar to those of insured non-immigrants but far greater for uninsured immigrants. The effect of health insurance was even more striking for lack of regular doctor. Within Canada, disparities between immigrants and non-immigrants were similar in magnitude to disparities seen among insured Americans. For both outcomes, direct comparisons of U.S. and Canada revealed significant differences between uninsured American immigrants and Canadian immigrants, but not between insured Americans and Canadians, stratified by nativity. Findings suggest health care insurance is a critical cause of differences between immigrants and non-immigrants in access to primary care, lending robust support for the expansion of health insurance coverage in the U.S. This study also highlights the usefulness of cross-national comparisons for establishing alternative counterfactuals in studies of disparities in health and health care.     

Racial and Geographic Disparities in the Use of Parenteral Nutrition Among Inflammatory Bowel Disease Inpatients Diagnosed With Malnutrition in the United States

Background: Racial disparities have been described in the use of a diverse spectrum of surgical procedures. The objectives of this study are to determine whether disparities also exist for the use of parenteral nutrition (PN) in inflammatory bowel disease (IBD). Methods: The U.S. Nationwide Inpatient Sample between 1998 and 2003 is analyzed to determine PN use among IBD inpatients diagnosed with protein‐calorie malnutrition and assess whether use patterns differ by race and geographical region. Results: The proportion of African American IBD admissions with protein‐calorie malnutrition who receive PN is significantly lower than that in whites (19.9% vs 28.1%, P = .001), whereas there is no difference between Hispanics and non‐Hispanic whites. After adjustment for gender, comorbidity, health insurance status, geographic region, and median neighborhood income, African Americans remain less likely than whites to receive PN (odds ratio [OR] 0.67; 95% confidence interval [CI], 0.50–0.89), whereas the difference between Hispanics and non‐Hispanic whites is marginally significant (OR 0.65; 95% CI, 0.41–1.04). PN use varies geographically, with highest rates in the Northeast (44.3%) and lowest in the Midwest (17.3%). Uninsured patients are less than half as likely to receive PN as those with insurance (OR 0.46; 95% CI, 0.31–0.69). Compared with whites, Hispanics experience a longer time interval between admission and initiation of PN (3.5 vs 4.8 days, P = .02) and have higher rates of catheter‐related complications (5.1% vs 12.2%, P = .04). Conclusions: Among IBD inpatients with clinically diagnosable malnutrition, PN use is lower among African Americans compared with whites. The underlying mechanisms of these racial variations merit further investigation.     

Disparities in access to care and satisfaction among U.S. children: the roles of race/ethnicity and poverty status

OBJECTIVES: The study assessed the progress made toward reducing racial and ethnic disparities in access to health care among U.S. children between 1996 and 2000. METHODS: Data are from the Household Component of the 1996 and 2000 Medical Expenditure Panel Survey. Bivariate associations of combinations of race/ethnicity and poverty status groups were examined with four measures of access to health care and a single measure of satisfaction. Logistic regression was used to examine the association of race/ethnicity with access, controlling for sociodemographic factors associated with access to care. To highlight the role of income, we present models with and without controlling for poverty status. RESULTS: Racial and ethnic minority children experience significant deficits in accessing medical care compared with whites. Asians, Hispanics, and blacks were less likely than whites to have a usual source of care, health professional or doctor visit, and dental visit in the past year. Asians were more likely than whites to be dissatisfied with the quality of medical care in 2000 (but not 1996), while blacks and Hispanics were more likely than whites to be dissatisfied with the quality of medical care in 1996 (but not in 2000). Both before and after controlling for health insurance coverage, poverty status, health status, and several other factors associated with access to care, these disparities in access to care persisted between 1996 and 2000. CONCLUSIONS: Continued monitoring of racial and ethnic differences is necessary in light of the persistence of racial/ethnic and socioeconomic disparities in access to care. Given national goals to achieve equity in health care and eliminate racial/ ethnic disparities in health, greater attention needs to be paid to the interplay of race/ethnicity factors and poverty status in influencing access.     

Racial and ethnic differences in parents' assessments of pediatric care in Medicaid managed care

OBJECTIVE: This study examines whether parents' reports and ratings of pediatric health care vary by race/ethnicity and language in Medicaid managed care. DATA SOURCES: The data analyzed are from the National Consumer Assessment of Health Plans (CAHPS) Benchmarking Database 1.0 and consist of 9,540 children enrolled in Medicaid managed care plans in Arkansas, Kansas, Minnesota, Oklahoma, Vermont, and Washington state from 1997 to 1998. DATA COLLECTION: The data were collected by telephone and mail, and surveys were administered in Spanish and English. The mean response rate for all plans was 42.1 percent. STUDY DESIGN: Data were analyzed using multiple regression models. The dependent variables are CAHPS 1.0 ratings (personal doctor, specialist, health care, health plan) and reports of care (getting needed care, timeliness of care, provider communication, staff helpfulness, plan service). The independent variables are race/ethnicity (white, African American, American Indian, Asian, and Hispanic), Hispanic language (English or Spanish), and Asian language (English or other), controlling for gender, age, education, and health status. PRINCIPAL FINDINGS: Racial/ethnic minorities had worse reports of care than whites. Among Hispanics and Asians language barriers had a larger negative effect on reports of care than race/ethnicity. For example, while Asian non-English-speakers had lower scores than whites for staff helpfulness (beta = -20.10), timeliness of care (beta = -18.65), provider communication (beta = -17.19), plan service (beta = -10.95), and getting needed care (beta = -8.11), Asian English speakers did not differ significantly from whites on any of the reports of care. However, lower reports of care for racial/ethnic groups did not translate necessarily into lower ratings of care. CONCLUSIONS: Health plans need to pay increased attention to racial/ethnic differences in assessments of care. This study's finding that language barriers are largely responsible for racial/ethnic disparities in care suggests that linguistically appropriate health care services are needed to address these gaps.     

Hispanic-Asian Immigrant Inequality in Perceived Medical Need and Access to Regular Physician Care

In the face of continuing large immigrant streams, Hispanic and Asian immigrants’ human and social capital inequalities will heighten U.S. race/ethnic health and health care disparities. Using data from the 2004 and 2008 panels of the Survey of Income and Program Participation, this study assessed Hispanic-Asian immigrant disparity in access to health care, measured by perceived medical need and regular access to a physician. Logistic regression results indicated that Hispanics had lower perceived met medical need and were less likely to see a doctor regularly. These disparities were significantly attenuated by education and health insurance. Assimilation-related characteristics were significantly associated with a regular doctor visit and were not fully mediated by socioeconomic variables. Findings indicate the importance of education above and beyond insurance coverage for access to health care and suggest the potential for public health efforts to improve preventive care among immigrants.     

Proximal and Distal Determinants of Access to Health Care among Hispanics in El Paso County, Texas

In the United States, having health insurance is an important determinant of health care access and individual health outcomes. Nationwide, a significant proportion of the population does not have health insurance. Hispanics, in particular, are less likely than non-Hispanics to have insurance. A framework was established to examine the relationships between the determinants of insurance coverage and health care affordability in El Paso County, Texas. Data from the 2005 Behavioral Risk Factor Surveillance System were used to examine the relationships described by this framework. The sample included 653 adults, of those 477 self-identified as Hispanic or Latino. In El Paso County, almost half of adult Hispanics lack any type of health insurance coverage, three times the rate of non-Hispanics. Among Hispanics, the lack of health insurance was strongly associated with reduced affordability of health care. Employment status, income, and age were found to have significant associations with insurance coverage and health care affordability. Sex and education level were relevant, yet distal determinants of these outcomes. Ongoing conversations about health care reform should take into account the patterns of coverage within the Hispanic population. Knowing how economic and social factors affect coverage is necessary to inform policy that can effectively alleviate disparities experienced by Hispanics.     

The impact of race,income, drug abuse and dependence on health insurance coverage among US adults

Little is known about the impact of drug abuse/dependence on health insurance coverage, especially by race groups and income levels. In this study, we examine the disparities in health insurance predictors and investigate the impact of drug use (alcohol abuse/dependence, nicotine dependence, and illicit drug abuse/dependence) on lack of insurance across different race and income groups. To perform the analysis, we used insurance data (8057 uninsured and 28,590 insured individual adults) from the National Surveys on Drug Use and Health (NSDUH 2011). To analyze the likelihood of being uninsured we performed weighted binomial logistic regression analyses. The results show that the overall prevalence of lacking insurance was 19.6 %. However, race differences in lack of insurance exist, especially for Hispanics who observe the highest probability of being uninsured (38.5 %). Furthermore, we observe that the lowest income level bracket (annual income <$20,000) is associated with the highest likelihood of being uninsured (37.3 %). As the result of this investigation, we observed the following relationship between drug use and lack of insurance: alcohol abuse/dependence and nicotine dependence tend to increase the risk of lack of insurance for African Americans and whites, respectively; illicit drug use increases such risk for whites; alcohol abuse/dependence increases the likelihood of lack of insurance for the group with incomes $20,000–$49,999, whereas nicotine dependence is associated with higher probability of lack of insurance for most income groups. These findings provide some useful insights for policy makers in making decisions regarding unmet health insurance coverage.     

Health Insurance Disparities in Traditional and Contingent/Alternative Employment

Relative to whites, Hispanics and blacks are less likely to have employer health insurance coverage. We examine whether ethnicity or race affects employment in traditional jobs or in contingent and alternative work arrangements, and whether ethnicity or race affects insurance offer, eligibility, and/or enrollment, conditional on employment sector. Health insurance disparities relative to whites are more pronounced for Hispanics, primarily due to disparities in employment by firms that offer coverage. Eliminating racial/ethnic disparities in offers, eligibility, and takeup would increase insurance coverage rates of Hispanics in traditional jobs and of both Hispanics and blacks in contingent and alternative jobs. JEL classification: I10, J32, J70     

Language and regional differences in evaluations of Medicare managed care by Hispanics

OBJECTIVES: This study uses the Consumer Assessments of Healthcare Providers and Systems (CAHPS((R))) survey to examine the experiences of Hispanics enrolled in Medicare managed care. Evaluations of care are examined in relationship to primary language (English or Spanish) and region of the country. DATA SOURCES: CAHPS 3.0 Medicare managed care survey data collected in 2002. STUDY DESIGN: The dependent variables consist of five CAHPS multi-item scales measuring timeliness of care, provider communication, office staff helpfulness, getting needed care, and health plan customer service. The main independent variables are Hispanic primary language (English or Spanish) and region (California, Florida, New York/New Jersey, and other states). Ordinary least squares regression is used to model the effect of Hispanic primary language and region on CAHPS scales, controlling for age, gender, education, and self-rated health. DATA COLLECTION/EXTRACTION METHODS: The analytic sample consists of 125,369 respondents (82 percent response rate) enrolled in 181 Medicare managed care plans across the U.S. Of the 125,369 respondents, 8,463 (7 percent) were self-identified as Hispanic. The survey was made available in English and Spanish, and 1,353 Hispanics completed one in Spanish. PRINCIPAL FINDINGS: Hispanic English speakers had less favorable reports of care than whites for all dimensions of care except provider communication. Hispanic Spanish speakers reported more negative experiences than whites with timeliness of care, provider communication, and office staff helpfulness, but better reports of care for getting needed care. Spanish speakers in all regions except Florida had less favorable scores than English-speaking Hispanics for provider communication and office staff helpfulness, but more positive assessments for getting needed care. There were greater regional variations in CAHPS scores among Hispanic Spanish speakers than among Hispanic English speakers. Spanish speakers in Florida had more positive experiences than Spanish speakers in other regions for most dimensions of care. CONCLUSIONS: Hispanics in Medicare managed care face barriers to care; however, their experiences with care vary by language and region. Spanish speakers (except FL) have less favorable experiences with provider communication and office staff helpfulness than their English-speaking counterparts, suggesting language barriers in the clinical encounter. On the other hand, Spanish speakers reported more favorable experiences than their English-speaking counterparts with the managed care aspects of their care (getting needed care and plan customer service). Medicare managed care plans need to address the observed disparities in patient experiences among Hispanics as part of their quality improvement efforts. Plans can work with their network providers to address issues related to timeliness of care and office staff helpfulness. In addition, plans can provide incentives for language services, which have the potential to improve communication with providers and staff among Spanish speakers. Finally, health plans can reduce the access barriers faced by Hispanics, especially among English speakers.     

The association between health insurance coverage and diabetes care; data from the 2000 Behavioral Risk Factor Surveillance System

OBJECTIVE: To describe the association between type of health insurance coverage and the quality of care provided to individuals with diabetes in the United States. DATA SOURCE: The 2000 Behavioral Risk Factor Surveillance System. STUDY DESIGN: Our study cohort included individuals who reported a diagnosis of diabetes (n=11,647). We performed bivariate and multivariate logistic regression analyses by age greater or less than 65 years to examine the association of health insurance coverage with diabetes-specific quality of care measures, controlling for the effects of race/ethnicity, annual income, gender, education, and insulin use. PRINCIPAL FINDINGS: Most individuals with diabetes are covered by private insurance (39 percent) or Medicare (44 percent). Among persons under the age of 65 years, 11 percent were uninsured. The uninsured were more likely to be African American or Hispanic and report low incomes. The uninsured were less likely to report annual dilated eye exams, foot examinations, or hemoglobin A1c (HbA1c) tests and less likely to perform daily blood glucose monitoring than those with private health insurance. We found few differences in quality indicators between Medicare, Medicaid, or the Department of Veterans Affairs (VA) as compared with private insurance coverage. Persons who received care through the VA were more likely to report taking a diabetes education class and HbA1c testing than those covered by private insurance. CONCLUSIONS: Uninsured adults with diabetes are predominantly minority and low income and receive fewer preventive services than individuals with health insurance. Among the insured, different types of health insurance coverage appear to provide similar levels of care, except for higher rates of diabetes education and HbA1c testing at the VA.     

Methods for using Medicare data to compare procedure rates among Asians, blacks, Hispanics, Native Americans, and whites

OBJECTIVE: Small sample sizes in Asian, Hispanic, and Native American groups and misreporting of race/ethnicity across all groups (including blacks and whites) limit the usefulness of racial/ethnic comparisons based on Medicare data. The objective of this paper is to compare procedure rates for these groups using Medicare data, to assess how small sample size and misreporting affect the validity of comparisons, and to compare rates after correcting for misreporting. DATA: We use 1997 physician claims data for a 5 percent sample of Medicare beneficiaries aged 65 and older to study cardiac procedures and tests. STUDY DESIGN: We calculate age and sex-adjusted rates and confidence intervals by race/ethnicity. Confidence intervals are compared among the groups. Out-of-sample data on misreporting of race/ethnicity are used to assess potential bias due to misreporting, and to correct for the bias. PRINCIPAL FINDINGS: Sample sizes are sufficient to find significant ethnic and racial differences for most procedures studied. Blacks' rates tend to be lower than whites. Asian and Hispanic rates also tend to be lower than whites', and about the same as blacks'. Sample sizes for Native Americans are very small (about .1 percent of the data); nonetheless, some significant differences from whites can still be identified. Biases in rates due to misreporting are small (less than 10 percent) for blacks, Hispanics, and whites. Biases in rates for Asians and Native Americans are greater, and exceed 20 percent for some procedures. CONCLUSIONS: Sample sizes for Asians, blacks, and Hispanics are generally adequate to permit meaningful comparisons with whites. Implementing a correction for misreporting makes Medicare data useful for all ethnic groups. Misreporting race/ethnicity and small sample sizes do not materially limit the usefulness of Medicare data for comparing rates among racial and ethnic groups.     

Access of Hispanics to health care and cuts in services: a state-of-the-art overview

The most current research literature on the access of Hispanics to medical care is reviewed, and data from a 1982 national survey by Louis Harris and Associates on access to health care are presented to document current levels of access to health care of the Hispanic population. Through telephone interviews, 4,800 families were contacted, yielding a total sample of 6,610 persons. According to the survey's data, the ability of Hispanics to obtain health services is hampered by relatively low incomes, lack of health insurance coverage, and ties to a particular physician. However, Hispanics do not differ significantly from whites in their use of hospitals, physicians, or outpatient departments and emergency rooms. Hispanics are less satisfied than whites on a host of measures describing the most recent medical visit. These levels of dissatisfaction with the visit are similar to those of blacks. The recession and public care service cutbacks did not appear to result in a substantial reduction in the volume of medical care received by Hispanics and blacks. Still, the services available to minorities are viewed by them as less effective in meeting their needs in comparison with how whites view the services they receive. Further, the 1982 survey reveals particular difficulties and barriers for Hispanics in obtaining needed medical services. More than one-fifth of the Hispanic families had one or more significant problems in obtaining needed services.