2012 National Healthcare Disparities Report

Low-Income Groups

In this report, poor populations are defined as people living in families whose household income falls below specific poverty thresholds. These thresholds vary by family size and composition and are updated annually by the U.S. Bureau of the Census (U.S. Census Bureau, 2011b). After falling for a decade (1990-2000), the number of poor people in America rose from 31.6 million in 2000 to 42.9 million in 2009. In 2009, 14.3% of the U.S. population had incomes below their respective poverty thresholds (Bishaw & Macartney, 2010).

Poverty varies by race and ethnicity. In 2010, 14% of Whites, 36% of Blacks, 35% of Hispanics, and 23% of other races had incomes below the poverty level (Urban Institute and Kaiser Commission, 2010). People with low incomes often experience worse health and are more likely to die prematurely (Adler & Newman, 2002). In general, poor populations have reduced access to high-quality care. While people with low incomes are more likely to be uninsured, income-related differences in quality of care that are independent of health insurance coverage have also been demonstrated (Brown, et al., 2003).

Previous chapters of this report describe health care differences by income. Among all measures of health care quality and access that are tracked in the reports and support trends over time, poor^vii individuals had worse care than high-income^viii individuals in the most recent year for 69 measures. Most of these measures showed no significant change in disparities over time. These measures include measures for preventive care for children, diabetes care, asthma care, obesity prevention, patient safety, and access to care.

For 2 measures, the gap between poor and high-income individuals grew smaller, indicating improvement:

• Hospital admissions for congestive heart failure per 100,000 population.
• Children ages 2-17 who had a dental visit in the calendar year.

For 3 measures, the gap grew larger, indicating worsening disparities:

• Adults age 50 and over who ever received a colonoscopy, sigmoidoscopy, or proctoscopy.
• Hospital admissions for short-term complications of diabetes per 100,000 population age 18 and over.
• People without a usual source of care who indicated a financial or insurance reason for not having a source of care.

Residents of Rural Areas

About one in five Americans lives in a nonmetropolitan area (IOM, 2005). Compared with their urban counterparts, rural residents are more likely to be older, be poor (Ziller, et al., 2003), be in fair or poor health, and have chronic conditions (IOM, 2005). Rural residents are less likely than their urban counterparts to receive recommended preventive services and on average report fewer visits to health care providers (Larson & Fleishman, 2003).

Although about 19% of Americans live in rural areas, only 11% of physicians in America practice in those settings (Rosenblatt, et al., 2010). Other important providers of health care in those settings include nurse practitioners, nurse midwives, and physician assistants. A variety of programs deliver needed services in rural areas, such as the National Health Service Corps Scholarship Program, Indian Health Service, State offices of rural health, rural health clinics, and community health centers.

Many rural residents depend on small rural hospitals for their care. There are approximately 2,000 rural hospitals throughout the country (AHA, 2011). Most of these hospitals are critical access hospitals that have 25 or fewer beds. Rural hospitals face unique challenges due to their size and case mix. During the 1980s, many were forced to close due to financial losses (AHRQ, 1996). More recently, finances of small rural hospitals have improved and few closures have occurred since 2003.

Language barriers are often greater in rural areas. To support rural hospitals in their provision of language assistance services to individuals with limited English proficiency, the HHS Office for Civil Rights (OCR) has established a national initiative, "Advancing Effective Communication in Critical Access Hospitals." OCR initially piloted a 10-State, onsite examination of critical access hospitals to determine their compliance with Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq. Each hospital in the pilot developed a comprehensive language assistance services program, including:

1. A needs assessment of its service area;
2. Oral language assistance services;
3. Written translation services;
4. Written policies and procedures, including grievance and nondiscrimination policies;
5. Notification of the availability of language assistance at no cost;
6. Staff training;
7. An assessment of access and quality;
8. Stakeholder consultations;
9. Information management; and
10. Compliance with Title VI.

Under this ongoing Initiative, OCR will conduct language assistance compliance reviews in each of the 45 States served by the critical access hospital program.

Similarly, transportation needs are pronounced among rural residents, who must travel longer distances to reach health care delivery sites. Of the nearly 1,000 "frontier counties"^ix in the Nation, most have limited health care services and many do not have any (Frontier Education Center, 2000).

Geographic areas are classified in different ways depending on the data source. Chapter 1, Introduction and Methods, provides more information on the classifications used. In this chapter, we compare residents of noncore^x (rural) areas with residents of large fringe metropolitan (suburban) areas because residents of suburban areas tend to have higher quality health care and better outcomes.

Among all measures of health care quality and access that are tracked in the reports and support trends over time, residents of noncore areas had worse care than residents of large fringe metropolitan areas in the most recent year for 33 measures. Most of these measures showed no significant change in disparities over time. These include measures for cancer mortality, obesity prevention, patient-centered care, and access to care.

For one measure, the gap between residents of noncore and large fringe metropolitan areas grew smaller, indicating improvement:

• Hospital admissions for uncontrolled diabetes per 100,000 population age 18 and over.

For 4 measures, the gap grew larger, indicating worsening disparities:

• Cancer deaths per 100,000 population per year.
• Deaths per 1,000 adult hospital admissions with pneumonia.
• Adults with obesity who ever received advice from a health provider about eating fewer high-fat or high-cholesterol foods.
• Adult current smokers with a checkup in the last 12 months who received advice to quit smoking.

Individuals With Disabilities or Special Health Care Needs

The NHDR tracks many measures of relevance to individuals with disabilities or special health care needs. Data are often limited, and AHRQ has worked with Federal partners to improve reporting on health care quality for individuals with disabilities.

In 2007, AHRQ convened a disabilities subgroup of the NHQR/NHDR Interagency Work Group. This subgroup received assistance from the Interagency Subcommittee on Disability Statistics of the Interagency Committee on Disability Research. The charge to the disabilities subgroup was to advise AHRQ on measures of disabilities from existing data that could track disparities for disabled individuals in quality of and access to care and that would be comparable across national surveys. For this initial effort, the subgroup focused on measures for adults, a population for which the most survey data are available.

For the 2012 NHDR, AHRQ is again using a broad, inclusive measure of disability for adults. This definition is intended to be consistent with statutory definitions of disability, such as the first criterion of the 1990 Americans With Disabilities Act (ADA) (i.e., having a physical or mental impairment that substantially limits one or more major life activities [HHS, 2005; LaPlante, 1991]) and Federal program definitions of disability based on the ADA.

For the purpose of the NHDR, adults with disabilities are those with physical, sensory, and/or mental health conditions that can be associated with a decrease in functioning in such day-to-day activities as bathing, walking, doing everyday chores, and engaging in work or social activities. In displaying the data on disability, paired measures are shown to preserve the qualitative aspects of the data:

• Limitations in basic activities represent problems with mobility and other basic functioning at the person level.
• Limitations in complex activities represent limitations encountered when the person, in interaction with the environment, attempts to participate in community life.

Limitations in basic activities include problems with mobility, self-care (activities of daily living), domestic life (instrumental activities of daily living), and activities that depend on sensory functioning (limited to people who are blind or deaf). Limitations in complex activities include limitations experienced in work and in community, social, and civic life. The use of the subgroup's recommendation of these paired measures of basic and complex activity limitations is conceptually similar to the way others have divided disability and is consistent with the International Classification of Functioning, Disability, and Health separation of activities and participation domains (WHO, 2001).

These two categories are not mutually exclusive; people may have limitations in basic activities and complex activities. The residual category Neither includes adults with neither basic nor complex activity limitations.

In this year's reports, analyses by activity limitations for adults are presented for selected measures in the Effectiveness, Lifestyle Modification section and in the Access chapter of the NHQR and in the Effectiveness, Musculoskeletal Diseases and Respiratory Diseases sections of the NHDR. In addition, the Data Tables appendix includes activity limitations as a stub variable for all National Health Interview Survey and Medical Expenditure Panel Survey tables.

Among all measures of health care quality and access that are tracked in the reports and support trends over time, individuals with basic activity limitations had worse care than individuals with neither basic nor complex activity limitations in the most recent year for 18 measures. Most of these measures showed no significant change in disparities over time. Such measures included measures for patient-centered care and access to care.

For one measure, the gap between individuals with basic activity limitations and individuals with neither basic nor complex activity limitations narrowed, indicating improvement:

• People under age 65 whose family's health insurance premium and out-of-pocket medical expenditures were more than 10% of total family income.

Individuals with complex activity limitations had worse care than individuals with neither basic nor complex activity limitations in the most recent year for 18 measures. Most of these measures showed no significant change in disparities over time. Such measures included measures for patient-centered care and access to care.

For 2 measures, the gap between individuals with complex activity limitations and individuals with neither basic nor complex activity limitations narrowed, indicating improvement:

• People under age 65 whose family's health insurance premium and out-of-pocket medical expenditures were more than 10% of total family income.
• People under age 65 with private insurance whose family's out-of-pocket medical expenditures were more than 10% of total family income.

Lesbian, Gay, Bisexual, and Transgender Populations

LGBT individuals encompass all races and ethnicities, religions, and social classes. Sexual orientation and gender identity questions are not asked on most national or State surveys, making it difficult to estimate the number of LGBT individuals and their health needs. There is emerging evidence suggesting that LGBT people face a variety of personal and structural barriers to obtaining high-quality medical care.

Personal barriers may include disrespectful behavior from staff and providers, perceived threatening environment, and stigma associated with being a sexual minority (IOM, 2011). Discrimination against LGBT persons has been associated with high rates of psychiatric disorders (McLaughlin, et al., 2010), substance abuse (Ibanez, et al., 2005; Herek & Garnets, 2007), and suicidal behavior (Remafedi, et al., 1998; Haas, et al., 2011).

Structural barriers include difficulty obtaining health insurance, since many employer-sponsored insurance plans do not recognize same-sex unions, and the dearth of culturally competent providers (Ash & Badgett, 2006; Heck, et al., 2006). Improving the health, safety, and well-being of LGBT individuals is one of the goals of Healthy People 2020.

In looking at health care quality, a study shows that same-sex couples are more likely to face barriers to care and that individuals in same-sex couples have less positive perceptions of their provider's interactions with them (Clift & Kirby, 2012). The study used pooled data from the Medical Expenditure Panel Survey from 1996 to 2007 and is not necessarily representative of current differences between these types of couples but rather average differences over the 12 years.

The sample consisted of 696 individuals in same-sex couples and 136,676 individuals in different-sex married couples. While sexual orientation is not a question on the survey, researchers identified same-sex couples through the relationship of household members to a reference person. Individuals were identified as being in a same-sex couple if they reported being the spouse or partner of the reference person who was of the same sex. Also, MEPS data do not distinguish transgendered individuals, so they may or may not be included in the data. The following findings show comparisons between same-sex and different-sex couples from this study.

 Figure 10.3. Differences between individuals in same-sex couples and different-sex couples in access to care, 1996-2007

[D] Select for Text Description

Source: Clift JB, Kirby J. Health care access and perceptions of provider care among individuals in same-sex couples: findings from the Medical Expenditure Panel Survey (MEPS). J Homosexual 2012;59:839-50.
Note: Transgender data are not included in MEPS. Data represent couples and should not be used to infer differences between LGBT and heterosexual individuals.

• Individuals in same-sex couples were less likely than individuals in different-sex couples to report getting medical care when wanted for nonurgent care in the last 12 months (74.3% compared with 83.7%; Figure 10.3).
• Individuals in same-sex couples were less likely than individuals in different-sex couples to report that it was easy to see a specialist in the last 12 months (62.2% compared with 76.6%).

 Figure 10.4. Differences between individuals in same-sex couples and different-sex couples in difficulty getting access to care, 1996-2007

[D] Select for Text Description

Source: Clift JB, Kirby J. Health care access and perceptions of provider care among individuals in same-sex couples: findings from the Medical Expenditure Panel Survey (MEPS). J Homosexual 2012;59:839-50.

• Individuals in same-sex couples were more likely than individuals in different-sex couples to report a delay in getting necessary prescriptions (6.2% compared with 2.6%; Figure 10.4).

 Figure 10.5. Differences between individuals in same-sex couples and different-sex couples in patient-provider interaction, 1996-2007

[D] Select for Text Description

Source: Clift JB, Kirby J. Health care access and perceptions of provider care among individuals in same-sex couples: Findings from the Medical Expenditure Panel Survey (MEPS). J Homosexual 2012;59:839-50.

• Individuals in same-sex couples were less likely than individuals in different-sex couples to report that their doctor spent enough time with them (80.4% compared with 86.7%; Figure 10.5).

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^vii. Household income less than Federal poverty thresholds.
^viii. Household income 400% of Federal poverty thresholds and higher.
^ix. "Frontier counties" have a population density of less than 7 people per square mile; thus, residents may have to travel long distances for care.
^x. Noncore areas are outside of metropolitan or micropolitan statistical areas. Micropolitan and noncore areas are typically regarded as "rural."