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

Differences in Community and Individual Characteristics

Table 2 shows the difference in characteristics observed among white, African American, and Hispanic persons. Insurance coverage was higher among whites (88 percent) than either blacks (80 percent) or Hispanics (68 percent). Whites were more likely than either Hispanic or African Americans to have incomes above 400 percent of the FPL. Whites also reported higher levels of health status than minority persons.

African Americans and whites lived in communities where physicians provided more charity care for the uninsured than in communities where Hispanics lived. Both Hispanics and African Americans lived in communities with fewer emergency rooms per capita than whites. The supply of primary care physicians was similar among all three groups. African Americans were more likely than whites or Hispanics to live in communities with greater percentages of African Americans. Similarly, Hispanics were more likely than whites or African Americans to live in communities with a greater percentage of Hispanics.

Regression-Based Decomposition of Differences in Access to Care

Tables 3 and 4 show the results of the regression-based decomposition. The absolute total differences for all three measures of access to medical care are presented in the first row. For example, the percentage of Hispanics reporting unmet medical needs was 1.57 more than the percentage of whites. The next two rows in the tables separate the total differences in access measures to those attributed to means (i.e., difference in characteristics) or to coefficients obtained from regression models (i.e., returns to population characteristics). Almost the entire (97 percent) unmet medical needs difference between Hispanics and whites resulted from differences in measured characteristics. In other words, only a small portion of the differences in reports of unmet needs could not be explained by the different population characteristics between Hispanics and whites, such as health insurance coverage, income, and availability of safety net resources.

The bottom half of Table 3 breaks down each access measure into differences due to means for personal characteristics or community characteristics. Each of these two classes of population characteristics is further separated into unique components (e.g., insurance, income, safety net, etc.). For example, insurance and income differences between Hispanics and whites account for 1.43 or 91 percent of the reported unmet medical needs gap. Furthermore, the safety net of communities (i.e., physicians providing charity care and hospital emergency departments) also accounted for a modest proportion of the differences in reports of unmet medical care needs (0.49 or 31 percent).

Whites were significantly more likely to have a regular health care provider and to have seen a physician in the last year than Hispanics (see Table 1). More than 80 percent of these differences were related to the population characteristics of the two groups. Differences in the proportion of Hispanic and whites with health insurance explained the single largest portion of the differences in having a medical provider and having a doctor visit between the two groups. One-third of the differences between Hispanics and whites in having a regular provider and two-fifths of the differences in having a doctor visit were related to insurance coverage. Income differences that explained about 20 percent of the disparities in access and the availability of safety net providers accounted for about 15 percent of the Hispanic--white differences in having a regular provider and seeing a physician in the last year.