The contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access to care - Impact of Health Care Context

Health Services Research, June, 2003 by J. Lee Hargraves, Jack Hadley

Well-documented disparities in health exist among members of racial and ethnic groups (Brown et al. 2000). For example, death associated with heart disease, stroke, and cancer remain higher for African Americans than whites (Keppel, Pearcy, and Wagener 2002). Compared to non-Hispanic whites, diabetes-related death rates were 2.5 times higher for black persons and 1.7 times higher for Hispanics (National Center for Health Statistics 1998). Particularly troubling to policymakers are the problems with access to medical care that appear among minority groups. Two possible explanations for these problems are that (1) differences in the measured characteristics of whites and minority persons (e.g., income, insurance coverage, and need for care) lead to differences in access and/or (2) unobserved factors, such as culture, attitudes, or discrimination, differentially influence members of racial and ethnic minority groups to seek medical care. To develop policies to reduce disparities in access, it is important to asc ertain the relative importance of these two sets of explanations, and to identify the characteristics most strongly associated with differences in access.

This paper extends previous efforts examining racial and ethnic disparities in health, focusing on the roles that insurance coverage, income, and community medical care resources related to the safety net play in reducing disparities in access to medical care. Proposals to expand health insurance are motivated in large part by the expectation that insurance coverage improves access to medical care. Knowing the extent to which insurance coverage reduces racial and ethnic disparities may provide additional information salient to policy making. Conversely, it is sometimes argued (Butler, Jameson, and Sullivan 2000) that the availability of safety net resources in communities compensates for the lack of insurance and reduces the likelihood that uninsured persons go without needed medical care services. Some policymakers have argued that uninsured persons do not have access problems related solely to lack of insurance coverage, rather they have access to care through community safety net resources. Empirical evide nce concerning the extent to which the safety net either reduces or does not reduce the need for insurance coverage may serve to inform this "coverage versus care" debate.

We look separately at differences between whites, and Hispanic and African Americans. Our analysis uses a regression-based decomposition methodology (Qaxaca 1973; Acs 1995) to address four related questions. First, how much does insurance explain racial and ethnic disparities in access to care? Second, what roles do income and other characteristics play in influencing racial disparities in health? Third, to what extent does availability of community-level safety-net resources contribute to reducing racial disparities? Finally, how much of the difference in access can be attributed to "unobservable" factors, such as differences in culture, discrimination, or attitudes?

BACKGROUND

Racial and ethnic disparities in access to medical care are well known among health services researchers. Empirical studies typically include a set of dummy variables representing ethnicity in a regression model that pools whites with racial and ethnic minorities. Differential access to medical care can be examined in relation to personal characteristics (e.g., race, ethnicity, socioeconomic, or health status) as well as community characteristics (e.g., poverty areas, physician supply, or availability of hospital beds). A few studies suggest that ethnic disparities in access to medical procedures differ substantially depending on the type of insurance coverage. However, most studies focus on access differences related to either race/ethnicity or insurance.

Racial and ethnic disparities in access to primary care are not fully explained by differences in sociodemographic and health status (Shi 1999). Most studies conclude that members of minority ethnic groups are more likely to have access problems than whites. These problems persist among those covered by insurance, but are even more pronounced among those persons who lack insurance or live in areas with high levels of poverty.

Racial and ethnic differences appear among patients with varied medical conditions. For example, racial differences that persist after controlling for insurance coverage and socioeconomic status have been observed for early detection of cancer (Baker, Stevens, and Brook 1996) and for surgical management of cancer (Velanovich et al. 1999). In some areas of medical care, for example the use of emergency departments, racial and ethnic differences have been reported to disappear upon controlling for socioeconomic status and health insurance coverage (Baker, Stevens, and Brook 1996).

The disparate use of cardiovascular procedures among racial and ethnic groups is perhaps the most widely examined topic in the growing literature on differences in medical care access and utilization, suggesting that members of ethnic minority groups are less likely than white Americans to receive interventional therapies, controlling for income and insurance status (Ford and Cooper 1995). Health insurance, either the lack of coverage or type of insurance, has an essential role in obtaining medical care for heart disease. The publicly insured have been reported to be less likely than privately insured persons to receive cardiovascular procedures (Wenneker, Weissman, and Epstein 1990; Carlisle, Leake, and Shapiro 1997). Furthermore, racial differences in use of cardiovascular procedures have been reported among publicly insured persons, but not among those with private insurance (Carlisle, Leake, and Shapiro 1997). Finally, differences between ethnic groups in terms of care for cardiac disease have been obser ved to narrow when persons obtain adequate insurance coverage, such as eligibility for Medicare or development of end stage renal disease (Daumit et al. 1999).