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

This study uses individual-level data for nonelderly persons of Hispanic, African American, and white racial or ethnic background (n= 96,414). Members of the U.S. military and people older than age 65 were excluded. All estimates are weighted to account for nonresponse to the survey and to represent the civilian noninstitutionalized population of the continental United States.

Conceptual Model

We use the behavioral model developed by Andersen (1968, 1975) to guide the selection of independent variables for the analysis. The model's conceptual domains include enabling, predisposing, and need factors that include demographics, personal preferences, individual health status, and economic and market characteristics, especially individuals' health insurance coverage and income, and the availability of medical care resources (Weinick, Zuvekas, and Cohen 2000). The dependent variables are measures of access and utilization.

Dependent Variables: Measures of Access and Utilization

We compare whites to African Americans and Hispanics along three commonly used dimensions of lower access to primary care: reporting unmet needs, having no regular health care provider, and the probability of no physician visits in the last year. These measures provide information about perceived needs, continuity and access with a regular provider, and actual use of health care.

Unmet Medical Needs. Individual reports of unmet medical needs are a commonly used measure of access problems. For this study, we created a measure that indicates that individuals had no report of unmet needs. Respondents were asked, "During the past 12 months, was there any time when you didn't get the medical care you needed?" Each person who replied "no" was classified as having "unmet needs." "Yes" responses were checked using follow-up questions and recoded if they reflected personal preferences rather than an access problem related to the health care system. For example, if the only reason a person gave for having an unmet need was "laziness," the response was not classified as an unmet need. This refined measure of unmet medical needs provides a more accurate indication of access problems resulting from health care organization, financing, or delivery.

No Regular Health Provider. This variable measures whether the individual sees the same health care provider (i.e., physician, nurse practitioner, or physician's assistant) at each visit to his or her regular source of care. Persons with a regular health provider are less likely to report delays in getting medical care, more likely to visit their provider, and less likely to use emergency rooms for ambulatory care (Lambrew et al. 1996). Problems with access to care associated with lack of a regular physician persist even among those with insurance (Sox et al. 1998).

No Doctor Visit in the Past Year. The proportion of a population that has contact with a physician is a commonly used measure of access to care. Although it is possible that lower levels of use may reflect more efficient use of care (rather than lower access), and higher levels of use may reflect overutilization of services (rather than greater access), discrepancies in health services use among racial/ethnic minorities are consistent with known disparities in access among racial/ethnic minorities.