Access to Care Is the Centerpiece in the Elimination of Socioeconomic Disparities in Health

The Institute of Medicine defines access to health care as the timely use of personal health services to achieve the best possible outcomes [1]. Achieving the objectives implied in this definition for socioeconomically disadvantaged populations has come to represent a serious, continual, and somewhat time-worn objective in the United States. Without a national health insurance program, society has tacitly accepted a piecemeal, incremental approach to improving the health care circumstances of these populations. Such an approach has shifted the focus of efforts to states, in which substantial variation in the percentage of persons without insurance for at least 12 months (the definition of long term) belies a concurrent variation in insurance policies; in 1995, this rate ranged from 2.9% in Hawaii to 17.1% in Louisiana [2]. At the same time, many continue to believe that if the financial barriers to health care could be lowered or eliminated, we could greatly reduce differences in the quality of health care as well as health care outcomes across socioeconomic groups. But would leveling the differences created by financial inequity really eliminate major disparities, or is this a shibboleth that masks more complex, deep-seated concerns that would continue to perpetuate great inequality in health care access and health status? This paper supports the contention that action that successfully decreases financial barriers across socioeconomic groups will go a long way toward the substantial reduction of socioeconomic disparities in health. In so doing, it draws on selected reports from the vast literature that lead to these conclusions and puts in context the great health care benefit that could be derived from a leveling of financial differences. Poverty, Lack of Insurance, and Health Adversity The literature is replete with studies linking problems with health care access, differences across socioeconomic groups, and health consequences. As we approach the 21st century, reports indicate that the consequences of such disparities are increasing. For example, a summary report on children who live in poverty, a population with large numbers of uninsured, profiled the familiar litany of adverse consequences, including greater likelihood of receiving lower-quality care and dying in infancy [3]. Moreover, as many as one in four children-the same proportion of children growing up in poverty in the United States-may face these and other adverse circumstances. Between 1979 and 1994, the number of children younger than 6 years living in poverty increased from 3.5 million to 6.1 million. A 1997 report from the Center for Studying Health Systems Change also shows that disparities remain large and that their adverse impact may be growing [4]. This survey-based study of almost 44 000 persons conducted in 1996 and 1997 found a familiar pattern: Families classified as low income were more likely than any other group to report decreased access to health care within the past 3 years. More than twice as many uninsured persons (43%) reported reduced access compared with persons who had private insurance (21%). In contrast, elderly persons, who are eligible for Medicare coverage, were the least likely to report reduced access. Investigations of avoidable hospitalizations and emergency department use among uninsured persons and across socioeconomic groups show how this situation plays out in our health care system. An examination of California hospital discharge data found that, among other factors, poverty was correlated with higher rates of preventable hospitalization. The report also concluded that uninsured persons are likely to have greater difficulty than privately insured patients in accessing inpatient care [5]. A 1997 report using National Hospital Discharge Survey data found that the number of potentially avoidable hospitalizations was far greater in middle-income and low-income populations than in the wealthiest populations; children were also affected by socioeconomic disparities in access. These findings led the authors to comment on the striking class and racial differences in rates of potentially avoidable hospitalization [6]. Using National Medical Care Utilization and Expenditure Survey data, Spillman [7] found that the rate of nonemergency care for uninsured children was only 70% of the rate for those who were insured and that much less money was being spent on the uninsured population for inpatient and ambulatory care. According to the National Center for Health Statistics, nonurgent cases accounted for more than 50% of the 90 000 000 visits to U.S. hospital emergency departments in 1992 [8]. Emergency departments are a well-established source of access to persons of lower socioeconomic status, who most often have no other recourse for care [9, 10]. This aspect of our health care system sets us apart from other countries as well, with the related consequences falling squarely on those who have difficulty meeting their health care costs. A survey-based comparison of perceived access to health care among residents in the United States, Canada, and Germany conducted in 1994 and 1995 found that persons in the United States were most likely to report difficulties in obtaining and paying for their health services [11]. In particular, the U.S. group reported greater likelihood of financially based access problems. In all, 20% of the U.S. group reported serious problems in paying medical bills in the past year. In addition, an estimated one third of the uninsured U.S. group reported financially based access problems, and almost two thirds reported delaying care because of such problems. Significant differences were found for access to specialists, diagnostic tests, and overall medical care. Breaking the Link between Poverty and Lack of Access To Improve Health Outcomes Obviously, many factors influence the health of individual persons, regardless of whether they are poor. Nonetheless, the ability to substantially improve access for low-income populations through elimination of financial barriers is probably a sine qua non when it comes to eliminating disparities in health status. The health care literature provides important evidence of the financial leveling effect-or the lack thereof-by two measures: health care utilization and health care outcomes. For example, in an international study of children and health care utilization, Casanova and Starfield [12] found that when access to primary care is leveled across income strata, no significant differences by income appeared for rates of ambulatory care-sensitive conditions, such as asthma. The implication drawn from this finding is that the ability to use a primary care practitioner may obviate worsening of a treatable condition that if left unaddressed, would probably require more urgent care. A survey-based examination of the link between access and insurance in the Seattle-King County area found that being insured was the strongest predictor for having a regular source of care and was strongly correlated with ease of access to care. Moreover, when uninsured persons became eligible for Medicaid, their health care access improved (although it never reached the levels seen with private insurance) [13]. An examination of patterns of inpatient, out-patient, and related health care status among 346 persons who were previously uninsured and became enrolled in a Kaiser managed care program found patterns of utilization similar to those seen in a commercially enrolled group [14]. In addition, the costs of care for this previously uninsured group were not substantially greater than those in the commercially enrolled group. A review of 1987 data from the National Medical Expenditures Survey and the Survey of Income and Program Participation from 1984 to 1988 found that persons receiving Aid to Families with Dependent Children who received Medicaid coverage were significantly more likely to use both inpatient and outpatient services than they would if they had been uninsured [15]. Other evidence of the value of access comes from research examining health-related quality-of-life outcomes for HIV-infected low-income and medically indigent persons [16]. Using interviews on access from 196 public hospital clinic patients participating in the HIV Outcomes Study, the authors found significantly better quality-of-life outcomes (such as freedom from pain and improved social and cognitive function) among persons who were in moderate physical and mental health and had greater access to services than those of similar health but with poorer access (access measures were based on Medical Outcomes Study responses). Several studies have documented the adverse effect of lack of health insurance on outcomes and quality of care. A 1991 report by Hadley and colleagues [17] comparing privately insured and uninsured hospital patients according to admission, use of resources, and discharge outcome found that with few exceptions, persons without insurance had a greater likelihood of dying in the hospital. A 1993 study by Franks and associates [18] found lack of health insurance to be more highly correlated with death among adults who were followed over several years. A report on birth outcomes in ethnic minority women suggests the positive outcome that can be derived from reducing financial access barriers [19]. For eligible Medicaid recipients, a New Jersey initiative increased the number of prenatal visits available; increased provider reimbursement; and enhanced other service support, including follow-up after pregnancy, case coordination, and health education. Program evaluation found an increase of almost 56 g in mean birth weight and a 3.7% reduction in the likelihood of having a low-birth-weight infant. Because low birth weight is associated with more problems in children, the ability to increase perinatal weight through improved access to health care implies healthier outcomes for a population of con