2012 National Healthcare Quality Report

Many Americans have good access to health care that enables them to benefit fully from the Nation's health care system. Others face barriers that make it difficult to obtain basic health care services. As shown by extensive research and confirmed in previous National Healthcare Disparities Reports (NHDRs), racial and ethnic minorities and people of low socioeconomic status (SES)ⁱ are disproportionately represented among those with access problems.

Previous findings from the National Healthcare Quality Report (NHQR) and NHDR showed that health insurance was the most significant contributing factor to poor quality of care for some of the core measures, and many measures are not improving. Uninsured people were less likely to get recommended care for disease prevention, such as cancer screening, dental care, counseling about diet and exercise, and flu vaccination. They also were less likely to get recommended care for disease management, such as diabetes care management.

Poor access to health care comes at both a personal and societal cost. For example, if people do not receive vaccinations, they may become ill and spread disease to others. This increases the burden of disease for society overall in addition to the burden borne individually.

According to the Centers for Disease Control and Prevention (CDC), the lack of access to health care that results from inadequate insurance coverage should be greatly reduced by the Affordable Care Act (ACA). The ACA is expected to extend insurance coverage to an additional 27 million people by 2019 (CBO, 2013).

Recent studies by the Office of the Assistant Secretary for Planning and Evaluation have demonstrated early evidence of greater rates of insurance coverage among young adults. Before ACA implementation, young adults with private insurance were more than twice as likely to lose insurance coverage as older adults (Schwartz & Sommers, 2012). New estimates, however, show that from September 2010 to December 2011, more than 3 million additional young adults had coverage (Sommers, 2012). This includes an estimated 913,000 Latino, 509,000 African American, and 121,000 Asian young adults (Sommers & Kronick, 2012). Overall, males have significantly benefited from the expanded coverage, and their rate of coverage has increased from 57.9% to 72.0% (Sommers, 2012).

The ACA also makes significant changes to the Medicaid program. All citizens and legal permanent residents with a household income up to 133% of the poverty level who do not have access to affordable health coverage through their employers and who reside in a State that chooses to participate in the expansion will be eligible for Medicaid. This change could improve the health of millions of Americans. Medicaid expansions have been shown to reduce mortality among adults, particularly those ages 35-64 years, minorities, and residents of low-income areas (Sommers, et al., 2012).

Components of Health Care Access

Access to health care means having "the timely use of personal health services to achieve the best health outcomes" (IOM, 1993). Attaining good access to care requires three discrete steps:

• Gaining entry into the health care system.
• Getting access to sites of care where patients can receive needed services.
• Finding providers who meet the needs of individual patients and with whom patients can develop a relationship based on mutual communication and trust.

Health care access is measured in several ways, including:

• Structural measures of the presence or absence of specific resources that facilitate health care, such as having health insurance or a usual source of care.
• Assessments by patients of how easily they can gain access to health care.
• Utilization measures of the ultimate outcome of good access to care (i.e., the successful receipt of needed services).

Facilitators and Barriers to Health Care

Facilitators and barriers to health care discussed in this chapter include health insurance, financial burden of health care costs. usual source of care (including having a specific source of ongoing care and a usual primary care provider), and patient perceptions of need.

Findings

Health Insurance

Health insurance facilitates entry into the health care system. Uninsured people are less likely to receive medical care and more likely to have poor health status. The cost of poor health among uninsured people was almost $125 billion in 2004 (Hadley & Holahan, 2004).

The financial burden of uninsurance is also high for uninsured individuals; almost 50% of personal bankruptcy filings are due to medical expenses (Jacoby, et al., 2000). Uninsured individuals report more problems getting care, are diagnosed at later disease stages, and get less therapeutic care. They are sicker when hospitalized and more likely to die during their stay (Hadley & Holahan, 2004).

  Figure 9.1. People under age 65 with health insurance, by age and gender, 2000-2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey (NHIS), 2000-2010.
Denominator: Civilian noninstitutionalized population under age 65.
Note: NHIS respondents are asked about health insurance coverage at the time of interview. Respondents are considered insured if they have private health insurance, Medicare, Medicaid, State Children's Health Insurance Program, a State-sponsored health plan, other government-sponsored health plan, or a military health plan. If their only coverage is through the Indian Health Service, they are not considered insured. Estimates are not age adjusted.

• Overall, there was no statistically significant change from 2000 to 2010. In 2010, 81.8% of people under age 65 had health insurance (data not shown).
• From 2000 to 2010, the percentage of children ages 0-17 who had health insurance increased (from 87.4% to 92.2%; Figure 9.1). However, for adults ages 18-44 and 45-64, the percentage decreased (for ages 18-44, from 77.6% to 72.9%; and for ages 45-64, from 87.4% to 84.3%).
• In all years, adults ages 18-44 were less likely than children ages 0-17 and adults ages 45-64 to have health insurance.
• From 2000 to 2010, there was no statistically significant change in the percentage of males and females who had health insurance.
• Females were more likely to have health insurance than males throughout this period (in 2010, 83.9% compared with 79.7%).

Also, in the NHDR:

• From 2000 to 2010, American Indians and Alaska Natives (AI/ANs) under age 65 were less likely than Whites to have health insurance in all years. Blacks under age 65 were less likely than Whites to have health insurance in 7 of 11 years..
• In all years, Hispanics under age 65 were less likely to have health insurance compared with non-Hispanic Whites.
• From 2000 to 2010, the percentage of people with health insurance was significantly lower for poor, low-income, and middle-income people than for high-income people in all years.
• In 2010, people with less than a high school education were about one-third less likely than people with any college education to have health insurance.

Uninsurance

Prolonged periods of uninsurance can have a particularly serious impact on a person's health and stability. Uninsured people often postpone seeking care, have difficulty obtaining care when they ultimately seek it, and may have to bear the full brunt of health care costs. Over time, the cumulative consequences of being uninsured compound, resulting in a population at particular risk for suboptimal health care and health status.

  Figure 9.2. People under age 65 who were uninsured all year, by age and gender, 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population under age 65.
Note: For this measure, lower rates are better.

• Overall, from 2002 to 2009, the percentage of people under age 65 who were uninsured all year increased from 13.4% to 15.5% (data not shown).
• From 2002 to 2009, children ages 0-17 were least likely to be uninsured all year, while adults ages 18-44 were most likely to be uninsured all year (in 2009, 6.3% for ages 0-17 and 21.8% for ages 18-44; Figure 9.2).
• From 2002 to 2009, females were less likely to be uninsured all year than males (in 2009, 13.5% compared with 17.5%).

Also, in the NHDR:

• In 2009, AI/ANs were more likely than Whites to be uninsured all year.
• In all years, Hispanics were much more likely than non-Hispanic Whites to be uninsured all year.
• In 2009, the percentage of poor and low-income people who were uninsured all year was more than four times as high as that for high-income people. The percentage of middle-income people uninsured all year was more than twice as high as that for high-income people.
• From 2002 to 2009, the percentage of people who were uninsured all year was nearly three times as high for people who spoke another language at home as that for people who spoke English at home.

  Figure 9.3. People under age 65 who were uninsured all year, California, by English proficiency and place of birth, 2001-2009

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Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey, 2001-2009.
Denominator: Civilian noninstitutionalized population ages 0-64 in California.
Note: For this measure, lower rates are better.

• In California, from 2001 to 2009, there was no statistically significant change in the percentage of people who were uninsured all year (12.4% compared with 12.2%; data not shown).
• During this period, people in California who spoke English well or very well were about twice as likely to be uninsured all year and people who did not speak English well or did not speak English at all were nearly five times as likely as those who spoke English only to be uninsured all year (Figure 9.3).
• During this period, people in California who were not born in the United States were more than three times as likely as people who were born in the United States to be uninsured all year.

Financial Burden of Health Care Costs

Health insurance is supposed to protect individuals from the burden of high health care costs. However, even with health insurance, the financial burden of health care can still be high and is increasing (Banthin & Bernard, 2006). High premiums and out-of-pocket payments can be a significant barrier to accessing needed medical treatment and preventive care (Alexander, et al., 2003).

According to one study, uninsured families can afford to pay for only 12% of hospitalizations that they experience (Chappel, et al., 2011). One way to assess the extent of financial burden is to determine the percentage of family income spent on a family's health insurance premium and out-of-pocket medical expenses.

  Figure 9.4. People under age 65 whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income, by insurance and activity limitation, 2006-2009

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Key: ESI = employer-sponsored insurance.
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006-2009.
Denominator: Civilian noninstitutionalized population under age 65.
Note: For this measure, lower rates are better. Total financial burden includes premiums and out-of-pocket costs for health care services.

• Overall, in 2009, 17.4% of people under age 65 had health insurance premium and out-of-pocket medical expenses that were more than 10% of total family income (data not shown).
• In all years from 2006 to 2009, the percentage of people under age 65 whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income was three times as high for individuals with private nongroup insurance as for individuals with private employer-sponsored insurance (Figure 9.4). During this same period, there was no statistically significant difference between publicly insured individuals and individuals with employer-sponsored insurance in 3 of 4 years.
• The gap narrowed between people with private employer-sponsored insurance and public insurance whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income. The gap also narrowed between people with neither basic nor complex activity limitations and people with activity limitations (both basic activity limitations and complex limitations).
• In all years, females were more likely than males to have family's health insurance premium and out-of-pocket medical expenses that were more than 10% of total family income (data not shown).
• In all years, people with activity limitations (both basic activity limitations and complex limitations) were significantly more likely than people with neither type of activity limitation to have family's health insurance premium and out-of-pocket medical expenses that were more than 10% of total family income.
• During this same period, there was a significant decrease in the percentage of people with basic activity limitations to have family's health insurance premium and out-of-pocket medical expenses that were more than 10% of total family income.

Also, in the NHDR:

• From 2006 to 2009, the percentage of people under age 65 whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income was lower for Blacks than for Whites and lower for Hispanics than for non-Hispanic Whites in all years.
• During this period, the percentage of people under age 65 whose family's health insurance premium and out-of-pocket medical expenses were more than 10% of total family income was more than four times as high for poor individuals, more than three times as high for low-income individuals, and more than twice as high for middle-income individuals compared with high-income individuals in all years.

Usual Source of Care

People with a usual source of care (a provider or facility where one regularly receives care) experience improved health outcomes and reduced disparities (smaller differences between groups) (Starfield & Shi, 2004) and costs (De Maeseneer, et al., 2003). Evidence suggests that the effect on quality of the combination of health insurance and a usual source of care is additive (Phillips, et al., 2004). In addition, people with a usual source of care are more likely to receive preventive health services (Ettner, 1996).

Specific Source of Ongoing Care

The term "specific source of ongoing care" accounts for patients who may have more than one source of care. For example, women of childbearing age and older people tend to have more than one doctor. A specific source of ongoing care can include an urgent care/walk-in clinic, doctor's office, clinic, health center facility, hospital outpatient clinic, health maintenance organization/preferred provider organization, military or other Veterans Affairs health care facility, or some other similar source of care (however, hospital emergency rooms are excluded).

  Figure 9.5. People with a specific source of ongoing care, by age, gender, insurance (under age 65), and residence location, 2010

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2010.
Denominator: Civilian noninstitutionalized population of all ages.
Note: Measure data are not age adjusted. A hospital emergency room is not included as a specific source of ongoing care.

• Overall, 85.5% of people had a specific source of ongoing care in 2010 (data not shown).
• In 2010, people age 65 and over were most likely to have a specific source of ongoing care (96.5%), while people ages 18-44 were least likely to have a specific source of ongoing care (73.8%; Figure 9.5).
• Females were more likely to have a specific source of ongoing care than males (88.9% compared with 81.9%).
• In 2010, people with private insurance were nearly twice as likely to have a specific source of ongoing care as uninsured people (91.2% compared with 48.0%).

Also, in the NHDR:

• In 2010, the percentage of people with a specific source of ongoing care was significantly lower for Hispanics than for non-Hispanic Whites.
• In 2010, the percentage of people with a specific source of ongoing care was significantly lower for poor and low-income people than for high-income people.
• In 2010, the percentage of people with a specific source of ongoing care was significantly lower for people with less than a high school education than for people with any college education.

Usual Primary Care Provider

Having a usual primary care provider (a doctor or nurse from whom one regularly receives care) is associated with patients' greater trust in their provider and with good provider-patient communication. These factors increase the likelihood that patients will receive appropriate care. By learning about patients' diverse health care needs over time, a usual primary care provider can coordinate care (e.g., visits to specialists) to better meet patients' needs. Having a usual primary care provider correlates with receipt of higher quality care (Parchman & Burge, 2002; Inkelas, et al., 2004).

A person is determined to have had a primary care provider if his or her usual source of care setting was either a physician's office or a hospital (other than an emergency room) and he or she reported going to this usual source of care for new health problems, preventive health services, and physician referrals.

  Figure 9.6. People with a usual primary care provider, by age and insurance (under age 65), 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population of all ages.
Note: A usual primary care provider is defined as the source of care that a person usually goes to for new health problems, preventive health care, and referrals to other health professionals.

• Overall, in 2009, about 76% of people had a usual primary care provider (Figure 9.6).
• In all years, people ages 18-44 were least likely to have a usual primary care provider, while people age 65 and over were most likely to have a usual primary care provider (in 2009, 61.1% and 89.5%, respectively).
• In all years, uninsured people ages 0-64 were much less likely to have a usual primary care provider than people with private or public insurance (in 2009, 41.5% compared with 79.6% and 80.6%, respectively). There were no statistically significant differences between people with public insurance and people with private insurance in the percentage with a usual primary care provider.
• In all years, there were no statistically significant differences between residents of nonmetropolitan areas and residents of large fringe metropolitan areas (data not shown).

Also, in the NHDR:

• From 2002 to 2009, Blacks were less likely than Whites to have a usual primary care provider in all years and Asians were less likely than Whites to have a usual primary care provider in 7 of 8 years.
• In all years, the percentage of people with a usual primary care provider was lower for Hispanics than for non-Hispanic Whites.
• In all years, poor, low-income, and middle-income people were significantly less likely than high-income people to have a usual primary care provider.

Patient Perceptions of Need

Patient perceptions of need include perceived difficulties or delays in obtaining care and problems getting care as soon as wanted. Although patients may not always be able to assess their need for care, problems getting care when patients perceive that they are ill or injured likely reflect significant barriers to care.

  Figure 9.7. People who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines in the last 12 months, by age and insurance (under age 65), 2002-2009

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2009.
Denominator: Civilian noninstitutionalized population of all ages.
Note: For this measure, lower rates are better.

• Overall, the percentage of people who were unable to receive or delayed in receiving needed medical care, dental care, or prescription medicines significantly increased between 2002 and 2009 (Figure 9.7).
• In all years, people ages 18-44 were more likely than people age 65 and over and, in 7 of 8 years, people ages 0-17 to be unable to get or delayed in getting needed medical care, dental care, or prescription medicines (Figure 9.7).
• In all years, uninsured people and people with public insurance were more likely than people with private insurance to be unable to get or delayed in getting needed medical care, dental care, or prescription medicines. In 2009, for people under age 65, the percentage of people who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines was more than twice as high for people with no health insurance as for people with private insurance (20.3% compared with 8.7%).

Also, in the NHDR:

• In 2009, Asians and Hispanics were less likely than Whites and non-Hispanic Whites to report that they were unable to get or delayed in getting needed medical care, dental care, or prescription medicines.
• In all years, the percentage of people who were unable to get or delayed in getting needed medical care, dental care, or prescription medicines was significantly higher for poor, low-income, and middle-income people than for high-income people.

References

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Banthin JS, Bernard DM. Changes in financial burdens for health care: national estimates for the population younger than 65 years, 1996 to 2003. JAMA 2006;296(22):2712-9.

Chappel A, Kronick R, Glied S. The value of health insurance: few of the uninsured have adequate resources to pay potential hospital bills. ASPE Research Brief. Washington, DC: U.S. Department of Health and Human Services; May 2011. Available at: http://aspe.hhs.gov/health/reports/2011/ValueofInsurance/rb.pdf [Plugin Software Help]. Accessed June 29, 2011.

Congressional Budget Office. Effects of the Affordable Care Act on health insurance coverage—February 2013 baseline. Washington, DC: CBO; February 2013. Available at: http://www.cbo.gov/publication/43900. Accessed March 14, 2013.

De Maeseneer J, De Prins L, Gosset C, et al. Provider continuity in family medicine: does it make a difference for total health care costs? Ann Fam Med 2003;1(3):144-8.

Ettner SL. The timing of preventive services for women and children: the effect of having a usual source of care. Am J Pub Health 1996;86(12):1748-54.

Hadley J, Holahan J. The cost of care for the uninsured: what do we spend, who pays, and what would full coverage add to medical spending? Kaiser Issue Update. Washington, DC: The Henry J. Kaiser Family Foundation; May 10, 2004.

Inkelas M, Schuster MA, Olson LM, et al. Continuity of primary care clinician in early childhood. Pediatrics 2004;113(6 Suppl):1917-25.

Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services. Access to health care in America. Washington, DC: National Academy Press; 1993.

Jacoby M, Sullivan T, Warren E. Medical problems and bankruptcy filings. Norton's Bankruptcy Law Advisor 2000 May;5:1-12.

Parchman ML, Burge SK. Continuity and quality of care in type 2 diabetes: a Residency Research Network of South Texas study. J Fam Pract 2002;51(7):619-24.

Phillips R, Proser M, Green L, et al. The importance of having health insurance and a usual source of care. Am Fam Physician 2004 Sep 15;70(6):1035.

Schwartz K, Sommers BD. Young adults are particularly likely to gain stable health insurance coverage as a result of the Affordable Care Act. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services; 2012. Available at: http://aspe.hhs.gov/health/reports/2012/UninsuredYoungAdults/rb.pdf [Plugin Software Help]. Accessed March 14, 2013.

Sommers B. Number of young adults gaining insurance due to the Affordable Care Act now tops 3 million. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services; 2012. Available at: http://aspe.hhs.gov/aspe/gaininginsurance/rb.shtml. Accessed March 14, 2013.

Sommers B, Kronick R. Report shows Affordable Care Act has expanded insurance coverage among young adults of all races and ethnicities. ASPE Issue Brief. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services; 2012. Available at: http://aspe.hhs.gov/health/reports/2012/YoungAdultsbyGroup/ib.shtml. Accessed March 14, 2013.

Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after State Medicaid expansions. N Engl J Med 2012;367:1025-34.

Starfield B, Shi L. The medical home, access to care, and insurance: a review of evidence. Pediatrics 2004;113(5 Suppl):1493-8.

^i. As described in Chapter 1, Introduction and Methods, income and educational attainment are used to measure SES in the NHDR. Unless specified, poor = below the Federal poverty level (FPL), low income = 100-199% of the FPL, middle income = 200-399% of the FPL, and high income = 400% or more of the FPL. The Measure Specifications and Data Sources appendixes provide more information on income groups by data source.