The Nation's Health Care System

When asked to describe the U.S. health care system, most Americans would probably offer a description of just a single facet of a huge, complex interaction of people, institutions, and technology. Like snapshots, each account offers an image, frozen in time, of one of the many health care providers and the settings in which medical care is delivered. Examples of these include the following:

• Physician offices: For many Americans, health care may be described as the interaction between a primary care physician and patient to address minor and urgent medical problems, such as colds, flu, or back pain. A primary care physician (usually a general practitioner, family practitioner, internist, or pediatrician) is the frontline caregiver—the first practitioner to evaluate and treat the patient. Routine physical examinations, prevention such as immunization and health screening to detect disease, and treatment of acute and chronic diseases commonly take place in physicians' offices.
• Medical clinics: These settings provide primary care services comparable to those provided in physicians' offices and may be organized to deliver specialized support such as prenatal care for expectant mothers, well-baby care for infants, or treatment for specific medical conditions such as hypertension (high blood pressure), diabetes, or asthma.
• Hospitals: These institutions contain laboratories, imaging centers (also known as radiology departments, where x-rays and other imaging studies are performed), and other equipment for diagnosis and treatment, as well as emergency departments, operating rooms, and highly trained personnel.

Medical care is provided through many other venues, including outpatient surgical centers, school health programs, pharmacies, worksite clinics, and voluntary health agencies such as Planned Parenthood, the American Red Cross, and the American Lung Association.

IS THE U.S. HEALTH CARE SYSTEM AILING?

While medical care in the United States is often considered the best available, some observers feel the system that delivers it is fragmented and in serious disarray. In the report Crossing the Quality Chasm: A New Health System for the 21st Century (2001, http://www.nap.edu/books/0309072808/html/), the Institute of Medicine of the National Academies describes the nation's health care system as disjointed, inefficient, and in need of a major overhaul.

John P. Geyman, a retired physician and professor emeritus at the University of Washington in Seattle, believes that U.S. health care does not compare favorably with services provided in other industrialized Western nations. In Health Care in America: Can Our Ailing System Be Healed? (2001), Geyman contends that escalating costs and wide variations in access and quality are symptoms of our diseased health care delivery system.

Geyman cites the nearly forty-three million uninsured Americans (15% of the total 288 million people estimated by the U.S. Census Bureau to be living in the United States in 2002) and the fact that the United States has the highest health care expenditures of any of the world's other twenty-eight industrialized countries as indicators of serious systemic problems. (In 2006 the Census Bureau estimated the number of uninsured Americans was forty-six million.) Geyman notes that for eleven key indicators of health care quality (including measures of life expectancy at different ages), the United States earned tenth place or lower when ranked among thirteen industrialized nations. Geyman also observes that among comparable Western industrialized countries, the U.S. population is the only one without universal health insurance.

Geyman contends that the traditional approaches to solving health care delivery problems have been ineffective because they are incremental—shortsighted and piecemeal—rather than broad changes intended to provide optimal health care services to the greatest number of people. Global reform of health care financing is one solution Geyman offers to improve the system. He advocates a single-payer system, under which the government would pay for universal coverage but leave delivery under private control, intervening only as needed to improve access, affordability, and quality.

Other physicians, including Rudolph Mueller, a specialist in internal medicine, agree with Geyman's assessment. In As Sick as It Gets: The Shocking Reality of America's Healthcare, a Diagnosis and Treatment Plan (2001), Mueller cites statistics to support the premise that the U.S. health care system spends more money than other countries to deliver poorer results. Robert LeBow, a family practice physician who dedicated his career to serving indigent patients, offers still another scathing indictment of the health care system in Health Care Meltdown: Confronting the Myths and Fixing Our Failing System (2003). Like Geyman, LeBow calls for a single-payer system to correct inefficiencies and equitably distribute health care resources to uninsured and underinsured Americans.

In "Effective, Efficient Health Care for Everyone" (March 29, 2006, http://www.winonadailynews.com/articles/2006/03/29/opinion/29%20op%20imm%20column.txt), Ivan Imm, formerly the director of public health planning and programs for the state of Wisconsin, describes a national, universal single-payer health system as a way to effectively and efficiently provide care for all Americans. Imm asserts that a single-payer system such as Medicare, which covers older adults and people with disabilities, could be expanded to cover people of all ages and would act to strengthen business, local government, and schools by relieving them of the costs associated with providing health insurance.

THE COMPONENTS OF THE HEALTH CARE SYSTEM

The health care system consists of all personal medical care services—prevention, diagnosis, treatment, and rehabilitation (services to restore function and independence)—plus the institutions and personnel that provide these services and the government, public, and private organizations and agencies that finance service delivery.

The health care system may be viewed as a complex consisting of three interrelated components: health care consumers (people in need of health care services); health care providers (people who deliver health care services—the professionals and practitioners); and the institutions or organizations of the health care system (the public and private agencies that organize, plan, regulate, finance, and coordinate services), which provide the systematic arrangements for delivering health care. The institutional component includes hospitals, clinics, and home-health agencies; the insurance companies and programs that pay for services, such as Blue Cross/Blue Shield, managed-care plans such as health maintenance organizations, and preferred provider organizations; and entitlement programs such as Medicare and Medicaid (federal and state government public assistance programs). Other institutions are the professional schools that train students for careers in medical, public health, dental, and allied health professions, such as nursing and laboratory technology. Also included are agencies and associations that research and monitor the quality of health care services; license and accreditation providers and institutions; local, state, and national professional societies; and the companies that produce medical technology, equipment, and pharmaceuticals.

Much of the interaction among the three components of the health care system occurs directly between individual health care consumers and providers. Other interactions are indirect and impersonal such as immunization programs or screening to detect disease, which are performed by public health agencies for whole populations. Regardless, all health care delivery depends on interactions among all three components. The ability to benefit from health care depends on an individual's or group's ability to gain entry to the health care system. The process of gaining entry to the health care system is referred to as access, and many factors can affect access to health care. This chapter provides an overview of how Americans access the health care system.

ACCESS TO THE HEALTH CARE SYSTEM

Today, access to health care services is a key measure of the overall health and prosperity of a nation or a population, but access and availability were not always linked to health status. In fact, many medical historians assert that until the beginning of the twentieth century, a visit with a physician was as likely to be harmful as it was to help. Only since the early twentieth century has medical care been considered to have a positive influence on health and longevity.

There are three aspects of accessibility: consumer access, comprehensive availability of services, and supply of services adequate to meet community demand. Quality health care services must be accessible to health care consumers when and where they are needed. The health care provider must have access to a full range of facilities, equipment, drugs, and services provided by other practitioners. The institutional component of health care delivery—the hospitals, clinics, and payers—must have timely access to information to enable them to plan an adequate supply of appropriate services for their communities.

Consumer Access to Care

Access to health care services is influenced by a variety of factors. Characteristics of health care consumers strongly affect when, where, and how they access services. Differences in age, educational level achieved, economic status, race, ethnicity, cultural heritage, and geographic location determine when consumers seek health care services, where they go to receive them, their expectations of care and treatment, and the extent to which they wish to participate in decisions about their own medical care.

People have different reasons for seeking access to health care services. Their personal beliefs about health and illness, motivations to obtain care, expectations of the care they will receive, and knowledge about how and where to receive care vary. For an individual to have access to quality care, there must be appropriately defined points of entry into the health care system. For many consumers, a primary care physician is the portal to the health care system. Besides evaluating the patient's presenting problem (or immediate health care need), the primary care physician also directs the consumer to other providers of care such as physician specialists or mental health professionals.

Some consumers access the health care system by seeking care from a clinic or hospital outpatient department where teams of health professionals are available at one location. Others gain entry by way of a public health nurse, school nurse, social worker, pharmacist, or member of the clergy who can refer them to an appropriate source, site, or health care practitioner.

Comprehensive Availability of Health Care Services

Historically, the physician was the exclusive provider of all medical services. Until the twentieth century, the family doctor served as physician, surgeon, pharmacist, therapist, adviser, and dentist. He carried all the tools of his trade in a small bag and could easily offer state-of-the-art medical care in his patient's home, because hospitals had little more to offer in the way of equipment or facilities. Today, it is neither practical nor desirable to ask one practitioner to serve in all these roles. It would be impossible for one professional to perform the full range of health care services, from primary prevention of disease and diagnosis to treatment and rehabilitation. Modern physicians and other health care practitioners must have access to a comprehensive array of trained personnel, facilities, and equipment so that they can, in turn, make them accessible to their patients.

While many medical problems are effectively treated in a single office visit with a physician, even simple diagnosis and treatment relies on a variety of ancillary (supplementary) services and personnel. To make the diagnosis, the physician may order an imaging study such as an x-ray or ultrasound that is performed by a radiology technician and interpreted by a radiologist (physician specialist in imaging techniques). Laboratory tests may be performed by technicians and analyzed by pathologists (physicians who specialize in microscopic analysis and diagnosis). More complicated medical problems involve teams of surgeons and high-tech surgical suites equipped with robotic assistants and rehabilitation programs where highly trained physical and occupational therapists skillfully assist patients to regain function and independence.

Some health care services are more effectively, efficiently, and economically provided to groups rather than individuals. Immunization to prevent communicable diseases and screening to detect diseases in their earliest and most treatable stages are examples of preventive services best performed as cooperative efforts of voluntary health organizations, medical and other professional societies, hospitals, and public health departments.

Access Requires Enough Health Care Services to Meet Community Needs

For all members of a community to have access to the full range of health care services, careful planning is required to ensure both the adequate supply and distribution of needed services. To evaluate community needs and effectively allocate health care resources, communities must gather demographic data and information about social and economic characteristics of the population. They must also monitor the spread of disease and the frequency of specific medical conditions over time. All these population data must be considered in relation to available resources, including health care personnel, the distribution of facilities, equipment, and human resources (the available health care workforce), and advances in medicine and technology.

For example, a predicted shortage of nurses may prompt increased spending on nursing education; reviews of nurses' salary, benefits, and working conditions; and the cultivation of nonnursing personnel to perform specific responsibilities previously assigned to nurses. Similarly, when ongoing surveillance anticipates an especially virulent influenza (flu) season, public health officials, agencies, and practitioners intensify efforts to provide timely immunization to vulnerable populations such as older adults. Government agencies such as the Centers for Disease Control and Prevention (CDC), the National Institutes of Health, state and local health departments, professional societies, voluntary health agencies, and universities work together to research, analyze, and forecast health care needs. Their recommendations allow health care planners, policy makers, and legislators to allocate resources so that supply keeps pace with demand and to ensure that new services and strategies are developed to address existing and emerging health care concerns.

A REGULAR SOURCE OF HEALTH CARE IMPROVES ACCESS

According to the CDC, the determination of whether an individual has a regular source—a regular provider or site—of health care is a powerful predictor of access to health care services. Generally, people without regular sources have less access or access to fewer services, including key preventive medicine services such as prenatal care, routine immunization, and health screening. Many factors have been found to contribute to keeping individuals from having regular sources of medical care, with income level being the best predictor of unmet medical needs or problems gaining access to health care services.

The 2005 National Health Interview Survey (NHIS; an annual nationwide survey of about thirty-eight thousand households in the United States conducted by the National Center for Health Statistics, part of the CDC) finds that from 1997 through 2005 the percentage of people of all ages with a usual source of medical care did not substantially vary—ranging from a low of 86% in 1997 to a high of 88% in 2001. From January through September 2005, 87% of people had a usual place to go for medical care. (See Figure 1.1.)

Still, from 1998 through 2005 the percentage of people who needed medical care but did not obtain it because of financial barriers to access increased each year. The annual percentage of people who experienced this lack of access to medical care rose from 4.2% in 1998 to 5.5% in 2004 and did not change significantly in 2005. From January through September 2005, cost considerations prevented 5.4% of the population from obtaining needed medical care during the twelve months preceding the survey. (See Figure 1.2.)

The 2005 NHIS reveals that people ages eighteen to twenty-four were least likely to have a regular source of care, but the likelihood of having a regular source of medical care increased with age among people ages eighteen years and older. Children under age eighteen were more likely than adults ages eighteen to sixty-four to have a usual place to go for medical care. Among adults (ages eighteen to sixty-four), women were more likely than men to have a usual place to seek medical care. (See Figure 1.3.) The NHIS data indicate that not having a regular health care provider is a greater predictor of delay in seeking care than insurance status. Health care consumers with a regular physician or source of health care services are less likely to use the hospital emergency room to obtain routine nonemergency medical care and are less likely to be hospitalized for preventable illnesses.

The National Association of Community Health Centers (NACHC) is a nonprofit organization that represents the interests of federally supported and other federally qualified health centers and serves as an information source about health care for poor and medically underserved populations in the United States. In A Nation's Health at Risk Part III (March 2005, http://www.nachc.org/research/Files/poorcountiesSTIB9.pdf), Michelle Proser, Peter Shin, and Dan Hawkins of the NACHC report that thirty-six million Americans lacked access to basic health care in 2005 and that low-income families and minorities, populations traditionally characterized as medically underserved, were the hardest hit. Almost half of those without access to medical care—medically unserved—were from low-income families, and nearly two in five were members of minority groups. Hispanic adults had the highest concentration (28%) of medically unserved, followed by Asian Pacific Islander adults (16%) and African-American adults (12%).

Proser, Shin, and Hawkins assert that 12% of Americans with no access to health care had been overlooked, while the attention of policy makers was focused on the forty-five million Americans who lacked health insurance. Although uninsured Americans often faced barriers to access, nearly half of the thirty-six million Americans without access to basic medical care had health insurance but still encountered barriers in having their medical needs met. Some of these barriers to access included scarcity of health care resources, geographically inaccessible services, and health care that was not culturally sensitive or was otherwise unacceptable to health care consumers.

There Are Americans without Access to Medical Care in Every State

According to Proser, Shin, and Hawkins, there are medically unserved Americans in every state, with the highest concentrations in metropolitan areas with populations of less than one million. Figure 1.4 shows the medically underserved areas and population in each state in 2004. Health care access and wealth are closely related. Medically underserved areas are "poor counties"—counties with higher poverty rates than the national median (35.3% of the population living in poverty). Proser, Shin, and Hawkins report that in 2003, 1,570 counties and the District of Columbia were poor and one in four Americans—more than 73.4 million people—lived in these counties, which were spread across forty-five states. Excluding the District of Columbia, 75% of all counties in ten states—Alabama, Arkansas, Idaho, Louisiana, Mississippi, Montana, New Mexico, Oklahoma, Texas, and West Virginia—were among the poorest counties in the United States.

Proser, Shin, and Hawkins find that in 2003, 929 counties in nearly every state were poor and did not have health centers. Forty-two percent of residents of these counties were low income and three million had no health insurance. More than two-thirds (70%) of counties in Oklahoma and 50% of counties in Kentucky, Louisiana, Montana, and Texas were poor and unserved. Kentucky, Oklahoma, and Arkansas had the highest percentages of residents in poor counties with no access to a health center (33%, 40%, and 42%, respectively). More than one in five residents of Louisiana, Mississippi, Missouri, Montana, and South Dakota lived in poor unserved counties.

Race and Ethnicity Continue to Affect Access to Health Care

The 2005 NHIS finds that Hispanic adults and children continue to be less likely to have a regular source for medical care than white non-Hispanic and African-American non-Hispanic people. After adjusting for age and gender, 78.1% of Hispanics had a usual source of medical care, compared with 89.3% of non-Hispanic whites and 85.2% of non-Hispanic African-Americans. (See Figure 1.5.) Hispanics and non-Hispanic African-Americans were more likely than non-Hispanic whites to suffer financial barriers to access. After adjusting for age and gender, 6.1% of Hispanics and 6.6% of non-Hispanic African-Americans were unable to obtain needed medical care because of financial barriers, compared with 5.1% of non-Hispanic whites. (See Figure 1.6.) Health educators speculate that language barriers and lack of information about the availability of health care services may serve to widen this gap.

Women Face Additional Obstacles

Research conducted by the Henry J. Kaiser Family Foundation, a nonprofit, private operating foundation that focuses on the major health care issues facing the nation, documents significant racial and ethnic differences in access to care. Analyzing data from the 2004 Kaiser Women's Health Survey, the investigators find in Women and Health Care: A National Profile (July 2005, http://www.kff.org/womenshealth/upload/Women-and-Health-Care-A-National-Profile-Key-Findings-from-the-Kaiser-Women-s-Health-Survey.pdf) that overall, Hispanic and African-American women fared worse than white women in terms of access to health care services.

According to the Kaiser report, Hispanic women reported less access to care than their white counterparts. More than one-quarter of Hispanic women (29%) had not visited a health care provider in the year before the survey, compared with 16% of African-American women and 11% of white women. Uninsured women were the least likely to have had a provider visit (67%), compared with women covered by private insurance, Medicaid, or Medicare (90%, 88%, and 93%, respectively).

Financial barriers—the costs of obtaining care and lack of insurance—were women's most frequently cited reason for delaying care and were reported by about one-third of Hispanic women. Despite their poorer health status, low-income women had lower rates of provider visits than higher-income women.

The 2005 NHIS also documents gender-based disparities in access. Women ages eighteen to sixty-four and those ages sixty-five and older were more likely than men to have failed to obtain needed medical care because of financial barriers to access. (See Figure 1.7.)

Children Need Better Access to Health Care, Too

Data from the more than thirty-eight thousand households included in the NHIS were analyzed to look at selected health measures, including children's access to care, and compiled in the report Summary Health Statistics for U.S. Children: National Health Interview Survey, 2004 (February 2006, http://www.cdc.gov/nchs/data/series/sr_10/sr10_227.pdf). Among other factors, the analysis focused on the unmet health care needs of children under age eighteen, poverty status, insurance coverage, and usual place of medical care.

In 2004, 5% of children in the United States (3.5 million) did not have a regular source of medical care. Hispanic children (9.8%, 1,373) were least likely to have a regular source of care, compared with 4.7% (527) of non-Hispanic African-American children and 2.9% (1,280) of non-Hispanic white children. The NHIS data also reveal a relationship between not having a usual source of medical care and family structure, family income, poverty status, and health insurance coverage. The likelihood of lacking a regular source of care or having unmet needs was higher among poor and near poor families of all races and ethnic groups. (See Table 1.1.)

Having health insurance and the type of health insurance also predicted whether a child had a regular source of care. Children with no health insurance were much more likely to not have a usual place for health care as children with private health insurance (25.6%, or 1,674, and 2.3%, or 1,038, respectively). (See Table 1.1.)

The survey also finds that more than three times as many children with private health insurance (39,053) received health care in a physician's office than children with Medicaid or other public health insurance (11,532). Children without health insurance were more likely to receive routine health care in an emergency room than were children with private or public health insurance. (See Table 1.1.)

Slightly more than 9% of U.S. children (6.7 million) had no health insurance coverage in 2004. (See Table 1.2.) More than 13% of children in families with incomes of less than $20,000 per year and 16% of children in families with incomes ranging from $20,000 to $34,999 were uninsured, compared with a scant 2.8% of children in households with incomes of $75,000 or more. Children from poor and near poor families were more likely to be uninsured, have unmet medical needs, and delay seeking care because of financial barriers more frequently than children from families that were not poor. Health professionals are especially concerned about delayed or missed medical visits for children because well-child visits are not only opportunities for early detection of developmental problems and timely treatment of illnesses but also ensure that children receive the recommended schedule of immunizations.

According to the survey, there was significant geographic variation in insurance status, which was strongly linked to children's access to health care services. The percentage of children in the South (11.5%) and West (10.9%) that were uninsured was more than 40% higher than the percentage of uninsured children in the Midwest (6.8%) or the Northeast (5.3%). (See Table 1.2.)

All Americans Risk Problems Gaining Access to Health Care

Steven M. Asch et al., in "Who Is at Greatest Risk for Receiving Poor-Quality Health Care?" in the New England Journal of Medicine (March 2006, http://content.nejm.org/cgi/content/full/354/11/1147), find that practically every person in the United States is at risk of failing to receive needed health care regardless of race, gender, income, or insurance status. According to Asch et al., who surveyed more than sixty-seven hundred people between October 1988 and August 2000 to assess preventive services and health care for thirty acute and chronic conditions that are considered the leading causes of death and disability, survey respondents received about 55% of recommended care, and people in all sociodemographic groups lacked adequate access to needed health care.

Asch et al. did find that there were disparities in access based on age, gender, race, and ethnicity. For example, adults under age thirty-one were significantly more likely to receive preventive care than those older than thirty-one, while adults ages thirty-one to sixty-four received significantly better chronic (ongoing or continuing) care than those under thirty-one. Women received a higher proportion of recommended care than men (56.6% versus 52.3%), and younger and wealthier survey respondents were more likely to have received health care screening but less likely to receive follow-up care than older survey respondents. Hispanics were more likely to receive screening services than whites, and African-Americans were more likely than whites to have access to chronic care.

Possibly the most surprising finding was that insurance status was not directly related to access to quality services—having insurance was not sufficient to ensure access. One of the lead authors of the study opined that the study findings confirm that "the U.S. health care system is unreliable and cannot guarantee that patients—rich or poor, white or black, insured or uninsured—will receive the right care at the right time. We need to fundamentally redesign the health system to ensure that no matter who you are or where you go for care you will get what you need" (March 2006, http://rand.org/news/press.06/03.15b.html).

How to Reduce Disparities in Access to Care

Health services researchers think that many factors contribute to differences in access, including cultural perceptions and beliefs about health and illness, patient preferences, availability of services, and provider bias. They recommend special efforts to inform and educate minority health care consumers and increased understanding and sensitivity among practitioners and other providers of care. Besides factual information, minority consumers must overcome the belief that they are at a disadvantage because of their race or ethnicity. Along with action to dispel barriers to access, educating practitioners, policy makers, and consumers can help reduce the perception of disadvantage.

For decades, health care researchers have documented sharp differences in the ability of ethnic and racial groups to access medical services. The U.S. government has repeatedly called for an end to these disparities. Although some observers feel that universal health insurance coverage is an important first step in eliminating disparities, there is widespread concern that the challenge is more complicated and calls for additional analysis and action.

In "The Challenge of Eliminating Disparities in Health" in the Journal of General Internal Medicine (June 2002, http://www.blackwell-synergy.com/doi/full/10.1046/j.1525-1497.2002.20509.x), Judy Ann Bigby asserts that "eliminating racial disparities … requires an understanding of the ecology of health, the interconnectedness of biologic, behavioral, physical, and socioenvironmental factors that determine health." Bigby believes that a multifaceted approach must be used to address the many issues involved in access, including improving the physical environment, overcoming economic and social barriers, ensuring the availability of effective health services, and acting to reduce personal behavioral risk factors such as smoking, obesity, poor nutrition, substance abuse, and physical inactivity. Developing strategies to promote personal, institutional, and community change simultaneously may stimulate the sweeping reforms needed to reduce and ultimately eliminate disparities.

Managed care refers to a system of health payment or delivery in which the plan attempts to control or coordinate use of health services by its enrolled members to contain health expenditures, improve quality, or both. Research supported by the Agency for Healthcare Research and Quality (AHRQ; the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care) suggests that managed care, with its emphasis on preventive health services, may improve ethnic disparities in access for Hispanics and whites but not for African-Americans or Asians and Pacific Islanders. In "Effect of Managed Care Insurance on the Use of Preventive Care for Specific Ethnic Groups in the United States" (Medical Care, September 2002), Jennifer S. Haas et al. at the University of California in San Francisco analyzed data about preventive health care use by people enrolled in fee-for-service (FFS) and managed care plans from the AHRQ Medical Expenditure Panel Survey of noninstitutionalized U.S. civilians.

Haas et al. considered use of four preventive health screenings—mammography within the past two years for women ages fifty to seventy-five, breast examination within the past two years for women between ages forty and seventy-five, Pap smear (screening for cervical cancer) within the past two years for women between ages eighteen and sixty-five, and cholesterol screening within the past five years for men and women above age twenty. The analysis revealed that Hispanic and white women enrolled in managed care plans reported higher rates of mammography, breast exam, and Pap smear than Hispanic women with FFS insurance. There were no significant differences in access to preventive care for African-Americans or Asians and Pacific Islanders by type of insurance. The investigators theorize that managed care may improve access to a usual source of care for Hispanics, who are more likely to lack a usual source of care than whites.

AHRQ Report Documents Disparities in Access and Suggests Possible Solutions

In July 2003 the AHRQ released its first National Healthcare Disparities Report (http://www.ahrq.gov/qual/nhdr03/nhdrsum03.htm), a report requested by Congress that documented racial health disparities including access to care. Among other things, the report cited the finding that African-American and low-income Americans have higher mortality rates for cancer than the general population because they are less likely to receive screening tests for certain forms of the disease and other preventive services. Although the report asserted that differential access may lead to disparities in quality and observed that opportunities to provide preventive care are often missed, it conceded that knowledge about why disparities exist is limited.

Although the first AHRQ report generated fiery debate in the health care community and among legislators and painted a rather bleak view of disparities, it did offer some hopeful findings that suggest that targeted improvement efforts could significantly reduce health care disparities. For example, it observed that "black patients are more likely to receive blood pressure monitoring without any disparity in blood pressure management. A greater perceived risk for significant cardiovascular disease among blacks may result in appropriately increased screening rates and treatment for risk factors. Directed public education campaigns about cardiac risk factors and the importance of an activated patient may play an important role in the lower observed rate of cardiac disparities among blacks." The report called for detailed data to support quality improvement initiatives and observed that "community-based participatory research has many examples of communities working to improve quality overall, while reducing health care disparities for vulnerable populations."

Highlights from the 2005 National Healthcare Disparities Report

The 2005 National Healthcare Disparities Report (http://www.ahrq.gov/qual/nhdr05/nhdr05.pdf), the third AHRQ annual report, tracked the measures of access to care the original report identified. These measures included factors that facilitated access, such as having a primary care provider, and factors that were barriers to access, such as having no health insurance. The principal findings of the report were:

• Disparities in access persist. The 2005 AHRQ report finds that disparities related to race, ethnicity, and socioeconomic status still exist in terms of access to the health care system. Table 1.3 shows the factors that account for disparities in access among members of racial and ethnic minorities, and Table 1.4 shows how socioeconomic variables—income, education, and insurance status—serve to enable or deter access. For example, African-Americans, Native Americans, Hispanics, and Alaska Natives continued to experience worse access to care than whites, and poor people had worse access to care than those with high incomes in 2005. (See Figure 1.8.) For Hispanics, all disparities in access—except being uninsured all year—were found to have worsened.
• Some disparities are diminishing. For racial minorities, the disparities in access to care that were tracked by the 2005 AHRQ report were all found to have improved, or grown smaller; however, for Hispanics and poor people, just 17% and 20%, respectively, of disparities in access were improving, while 83% and 80%, respectably, had worsened in 2005. (See Figure 1.9.)
• There are still opportunities for improvement. Although some disparities are diminishing, many groups continue to face disparities in access. The single largest barrier to access in 2005 for all groups except Asians was lack of health insurance. Among Asians, lack of a primary care provider was cited as the biggest obstacle to access.
• Information about disparities is improving. The 2005 report contains more information about disparities than previous reports, because it examines many additional data sources as well as variables that may be related to disparities such as country of birth and language spoken at home—people for whom English is a second language may experience language as well as cultural barriers to accessing health care.

ACCESS DOES NOT NECESSARILY ENSURE QUALITY

Even insured Americans who live in metropolitan areas with an ample supply of available health care facilities and providers receive, on average, just half of the recommended screenings and other preventive health care services. An earlier Rand Corporation study found inadequate care in every one of the twelve metropolitan areas surveyed. In "Profiling the Quality of Care in Twelve Communities: Results from the CQI Study" (2004, http://www.rwjf.org/files/research/Profiling%20the%20Quality%20of%20Care-Kerr-HA.pdf), Eve A. Kerr et al. observe that "health care quality falls far short of its potential nationally."

Kerr et al. looked at interviews conducted between October 1998 and August 2000 and medical records of more than seventy-five hundred adults and analyzed them using 439 measures of quality for thirty medical conditions including asthma, diabetes, heart disease, and hypertension as well as preventive care. They found that just half of all heart attack patients receive timely treatment with two medications (aspirin and beta blockers) that have been proven to save lives. Of people with chronic diseases, those with diabetes fared worst by failing to receive adequate treatment and counseling to prevent or delay the serious consequences of the disease. Some preventive services, such as immunizations and blood pressure screenings, were performed much more often than others, such as counseling about and screening for sexually transmitted diseases and counseling about substance abuse.

Although access problems are much greater for people who are uninsured and for those who live in rural or otherwise underserved areas, this research confirms that the ability to pay for needed medical care and the availability of health services are necessary but not sufficient to guarantee access to quality care. The discrepancy between the health care that Americans should receive and the care that they actually receive is even more striking because the United States spends more on health care—an estimated $1.5 trillion each year—than any other nation in the world.

ACCESS TO MENTAL HEALTH CARE

Besides the range of barriers to access faced by all Americans trying to access the health care system, people seeking mental health care face unique challenges, not the least of which is that they are even less able than people in good mental health to successfully navigate the fragmented mental health service delivery system. Furthermore, because people with serious mental illness frequently suffer from unemployment and disability, they are likely to join the ranks of the impoverished, uninsured, and homeless, which only compounds access problems. Finally, the social stigmas, or deeply held negative attitudes, that promote discrimination against people with mental illness are a powerful deterrent to seeking care.

The social stigmas attached to being labeled "crazy," prevent some sufferers of mental illness from seeking and obtaining needed care. Myths about mental illness persist, especially the mistaken beliefs that mental illness is a sign of moral weakness or that an affected individual can simply choose to "wish or will away" the symptoms of mental illness. People with mental illness cannot just "pull themselves together" and will themselves well. Without treatment, symptoms can worsen and persist for months or even years.

Besides reluctance to seek care, social stigmas can have far-reaching consequences for people with mental illnesses. They may face discrimination in the workplace, in school, and in efforts to find housing. Thwarted in their efforts to maintain independence, people suffering from mental illness may become trapped in a cycle characterized by feelings of worthlessness and hopelessness and may be further isolated from the social and community supports and treatments most able to help them to recover.

The 2003 report from the President's New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America (http://www.mentalhealthcommission.gov/reports/Finalreport/FullReport.htm), describes problems in the delivery of mental health care and six overarching goals related to access to mental health services. (See Table 1.5.) For example, achievement of the first goal, to improve Americans' understanding that mental health is vital for overall health, would doubtless improve access by reducing the stigmas associated with seeking treatment for mental illness. The second goal, of delivering consumer- and family-driven care, would also act to improve access by offering care that is more acceptable to consumers and less likely to infringe on the rights of people with mental illnesses. Goals 3 and 6—eliminating disparities in mental health services and using technology to reach underserved populations—are clear moves to improve access. Goals 4 and 5 address the quality and effectiveness of mental health care; however, they, too, directly affect access by improving screening and detection of mental illness and expanding the workforce that provides mental health and support services.

Disparities in Access to Mental Health Care

The principal barriers to access mental health care are the cost of services, the fragmented organization of these services, and social stigmas toward mental illness. These obstacles may act as deterrents for all Americans, but for racial and ethnic minorities they are compounded by language barriers, ethnic and cultural compatibility of practitioners, and geographic availability of services.

The 2005 National Healthcare Disparities Report finds that when compared with whites, minorities have less access to care and are less likely to receive needed services. Figure 1.10 shows that the proportion of African-Americans, Hispanics, and Asians that received mental health care in 2003 was lower than whites; higher among the poor and near poor than the middle incomes; and increased with educational attainment. Some of these differences may, in part, be attributable to cultural attitudes toward mental health.

Education and income explain some but not all the racial and ethnic differences in access. Figure 1.11 and Figure 1.12 show that across all levels of income and education, Hispanics were less likely than non-Hispanic whites to have received mental health care in 2003. African-Americans with higher incomes and educational attainment were less likely than whites with comparable socioeconomic status, but the gap closes among the poor and people with less than a high school education.

IS ACCESS A RIGHT OR A PRIVILEGE?

The AHRQ and other health care researchers and policy makers observe that having health insurance does not necessarily ensure access to medical care. They contend that many other factors, including cost-containment measures put in place by private and public payers, have reduced access to care. Nonetheless, reduced access affects vulnerable populations—the poor, people with mental illness and other disabilities, and immigrants—more than others.

Health care is a resource that is rationed. In the United States and other countries without universal or national programs of health insurance, people with greater incomes and assets are more likely than low-income families to have health insurance and as a result have greater access to health care services. According to the NHIS, in 2004, of 293 million Americans, more than forty-two million people, including nearly seven million children, had no health insurance and either experienced sharply reduced access to the health care system or were excluded altogether.

A wide range of groups and organizations support the idea that health care is a fundamental human right, not a privilege. These organizations include Physicians for a National Health Program, the American Association of Retired Persons, National Health Care for the Homeless, Inc., and the Friends Committee on National Legislation, a Quaker public interest lobby. The American Medical Association's Patient Bill of Rights includes the "right to essential health care."

Americans Are Worried about Access to Care

The Health Coalition on Liability and Access (HCLA) is a national advocacy group representing physicians, hospitals, health care insurers, business, and health care consumers that advocates legal reform as the best way to ensure that affordable health care is accessible to all Americans. In "Poll Shows Americans Want Congress to Support Comprehensive Medical Liability Reform" (March 2005, www.hcla.org/polls.html), the HCLA reports that more than three-quarters (78%) of Americans surveyed felt that their access to affordable, quality health care was threatened because medical liability costs, such as malpractice insurance, have forced physicians out of the practice of medicine. Besides compromised access to care, more than two-thirds (68%) of the survey respondents pointed to medical malpractice lawsuits as a principal cause of escalating health care costs.