U.S. Health Care Delivery:
Underserved Populations
Objectives
• Discuss and describe underserved populations
that are more vulnerable to poor health and
illness due to barriers to care
– Identify population groups that are vulnerable
– Understand the health needs of vulnerable
populations
– Learn about the major challenges faced by
vulnerable populations
We Have a Problem…
• “It is an understatement to say that health
care quality in the United States is nowhere
near as good as it could or should be. We
also have wide racial, socioeconomic, and
geographic inequities in how health care is
delivered in this country.”
– Carolyn M. Clancy, MD
Director, Agency for Health care Research and Quality
U.S. Department of Health & Human Services
What are Underserved Populations?
• Population groups in the United States that
face greater challenges than the general
population in accessing timely and needed
health care services
– Greater risk of poor physical, psychological, and/or
social health (Aday 1994)
Why Do Underserved Populations Exist?
• Experience greater barriers in…
Access to care
Financing of care
Racial or cultural acceptance
• Unequal social conditions
Unequal economic conditions
Unequal health conditions
Unequal geographic conditions
Who are Underserved Populations?
• Groups that are more vulnerable than the general
population
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Racial & ethnic minorities
Children
Women
Rural residents
Uninsured
Homeless
Mentally ill
Chronically ill
Disabled
Those with HIV/AIDS
Why Should We Care About Underserved
or Vulnerable Populations?
• It depends on your point of view…
– Market justice philosophy?
– Social justice philosophy?
Why Should We Care About Underserved
or Vulnerable Populations?
• Is vulnerability a personal problem?
• “Vulnerability does not represent a personal
deficiency of special populations but rather
the interaction effects of multiple factors, over
many of which individuals have little or no
control” (Aday, 1999)
• “…justifies the role of society as a whole to
address the concerns of vulnerable
populations”
How is Vulnerability Determined?
• Convergence of factors…
– (1) Predisposing characteristics
• Propensity to use services
– (2) Enabling characteristics
• Means individuals have available to them for the use of
services
– (3) Need characteristics
• Health status and risk
Vulnerability:
Predisposing Characteristics
• Demographic characteristics, belief systems,
social structures
• Difficult to change – individuals have relatively
little control over predisposing attributes
• Influence vulnerability because they are
associated with social position, status, access
to resources, health behaviors, and variations
in health status
Vulnerability:
Predisposing Characteristics
• Race and ethnicity
• Gender
• Age
• Geographic distribution
Vulnerability:
Predisposing Characteristics
• Compared to their white counterparts,
racial/ethnic minorities are shown to:
Have poorer ACCESS to care,
Receive poorer QUALITY care,
Experience greater HEALTH STATUS deficits
Vulnerability:
Predisposing Characteristics
• “Racial and ethnic disparities in the quality of
health care delivered in the United States are
well documented” (Thorlby et al., 2011)
– Blacks, American Indians, and Alaska Natives
received poorer quality of care than whites on
40% of core measures
– Hispanics received poorer quality of care than
non-Hispanic whites on 60% of core measures
– http://www.ahrq.gov/research/findings/nhqrdr/in
dex.html
Distribution of core quality
measures
Distribution of core access
measures
Overall Quality is Mostly Improving
But Relative Quality is Not Changing
Less Improvement in Access
Relative Access is Unchanged
Vulnerability:
Predisposing Characteristics
• Gender
– Women have a longer life expectancy than men in
the United States…
but they also suffer greater morbidity and
poorer health outcomes
– More acute and chronic illnesses…
Greater number of short- & long-term disabilities
– Pronounced differences between men and
women for heart disease, stroke, and mental
illness (e.g., anxiety disorders & depression)
Ambulatory care visits due to
adverse effects of care
Adults with major depressive
episode receiving depression
treatment (past 12 months)
Vulnerability:
Predisposing Characteristics
• Age
– Children’s health maintains unique aspects:
Developmental vulnerability
…how do changes affect a child’s development?
Dependency
…who does a child depend on for health care?
New morbidities
…what new conditions threaten a child’s health?
Vulnerability:
Predisposing Characteristics
• Geographic distribution
…RURAL AREAS
• How does geographic distribution affect
access to health?
BARRIERS:
Poverty
Long distances
Rural topography
Weather conditions
Availability of personal transportation
Shortage of health professionals
Vulnerability:
Predisposing Characteristics
• “We know that compared with their national
counterparts, rural residents are more likely to
be elderly, poor, in fair or poor health, and to
have chronic conditions. Rural residents are
less likely to receive recommended preventive
services and report, on average, fewer visits to
health care providers.”
– Carolyn M. Clancy, MD, AHRQ Director
• 20% of Americans live in rural areas
– 9% of American physicians practice in such areas
Vulnerability:
Predisposing Characteristics
• Measures to improve access to care in rural
areas
– National Health Service Corps
– Health Manpower/Professional Shortage Areas
– Medically Underserved Areas
– Community and Migrant Health Centers
– Rural Health Clinics Act
What are rural health clinics (RHCs)?
• A Rural Health Clinic is a federally qualified
health clinic (FQHC) certified to receive special
Medicare and Medicaid reimbursement.
• CMS provides advantageous reimbursement
as a strategy to increase rural Medicare and
Medicaid patients' access to primary care
services.
• Use of both physicians and mid-levels
Vulnerability:
Predisposing Characteristics
• Medically Underserved Areas (MUA)
– Based on the Index of Medical Underservice (IMU)
– Scale from 0 (completely underserved) to
100 (best served/least underserved)
– IMU of 62.0 or less qualifies as MUA
– Four variables
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Ratio of primary care physicians to 1,000 population
Infant mortality rate
Percentage of population below poverty level
Percentage of population aged 65 or older
Vulnerability:
Predisposing Characteristics
• Medically Underserved Populations (MUP)
– Also based on Index of Medical Underservice
– IMU of 62.0 or less qualifies as MUP
– Same process and data elements as for MUAs
except the population is now the population of
the requested group within the area rather than
the total resident civilian population of the area
• e.g., only the number of FTE primary care physicians
serving the requested population group
Vulnerability:
Predisposing Characteristics
• Health Professional Shortage Areas (HPSA)
– Designated as having shortage of primary care,
dental, or mental health providers
• Primary care: Ratio of population to FTE primary care
physicians greater than 3,500 to 1
• Dental: Ratio greater than 5,000 to 1
• Mental health: greater than 6,000 to 1
– May be urban or rural areas, population groups,
or medical or other public facilities
– http://www.hrsa.gov/shortage/
Vulnerability:
Predisposing Characteristics
• Health Professional Shortage Areas (HPSA)
– Nearly 6,500 Primary Care HPSAs
• Affecting 66.7 million, requiring 17,762 practitioners
• 373 in Texas, 6 in Bexar County
– Over 4,800 Dental HPSAs
• Affecting 52.2 million, requiring 10,169 practitioners
• 239 in Texas, 3 in Bexar County
– Over 3,900 Mental Health HPSAs
• Affecting 95 million, requiring 6,226 practitioners
• 332 in Texas, 4 in Bexar County
Vulnerability:
Enabling Characteristics
• Socioeconomic status
– Social position, access to resources, income,
education, employment status, occupation
• Individual assets
– Human capital, skills, wealth, inheritance
• Mediating factors
– Health insurance, access to health care, quality of
health care
Vulnerability:
Enabling Characteristics
• 36.5 million poor people in America
– 24% Blacks, 21% Hispanics, 10% Asians, 8% White
• Poor people received lower quality of care
than high-income people on about 80% of
core measures
• Poor people have worse access to care than
high-income people on all core measures
Vulnerability:
Enabling Characteristics
• Uninsured
– What characteristics describe many of the
uninsured?
Income? Education? Employment?
Age? Ethnicity?
• How do the uninsured affect those who have
insurance or can pay for care?
Vulnerability:
Enabling Characteristics
• Homeless
– What barriers are faced to appropriate care?
• Finance: paying for care or satisfying insurance
eligibility requirements
• Transportation: access to medical facilities
• Living conditions: proper sanitation, medication
storage, appropriate food for healthy diet
– Untreated acute and chronic medical, mental
health, and substance abuse problems
– Greater risk of assault, victimization, and
exposure to harmful environmental elements
Vulnerability:
Enabling Characteristics
• Measures to help eliminate socioeconomic
differences that jeopardize health
– Community Health Center Program
– National Health Service Corps
– Public Housing Primary Care Program
– Healthy Schools, Healthy Communities Program
– Health Care for the Homeless Program
Vulnerability:
Need Characteristics
• Self-perceived health status
– Self-perceived physical and mental health
• Professionally-evaluated health status
– Professional diagnoses of disease and illness
• Quality-of-life indicators
– Activities of daily living (ADL) performance
Social limitations
Cognitive limitations
Limitations in work, housework, and school
Vulnerability:
Need Characteristics
• Certain subpopulation groups are at higher
health risks to:
– Physical health
High-risk mothers & infants, Chronically ill and
disabled, Persons with HIV/AIDS
– Mental health
Mentally ill and disabled, Alcohol or substance
abusers, Suicide- or homicide-prone
– Social well-being
Abusive families, Homeless, Refugees, Immigrant
Vulnerability:
Need Characteristics
• Mental health
– Significant burden on health & productivity
– Phobias, substance abuse, affective disorders
– Mental illness is a risk factor for death from
suicide, cardiovascular disease, and cancer
– Most mental health services provided in the
general medicine sector:
the “de facto mental health service system”
• Specialty mental health services +
general counseling services
Vulnerability:
Need Characteristics
• Chronic illness and/or disability
– Every person is vulnerable during his/her lifetime
– Major chronic disease killers:
Cardiovascular disease, Cancer, Diabetes, COPD
– What is “chronic”?
…a disease or injury with long-term (3 months)
conditions or symptoms
– Unique challenges:
• Health care system’s orientation to treat acute illness
• Tobacco use, physical inactivity, poor nutrition,
lack of regular screening for certain cancers
Vulnerability:
Need Characteristics
• HIV/AIDS
– Acquired immunodeficiency syndrome (AIDS) is
caused by Human immunodeficiency virus (HIV)
– Causes immune system suppression
– Question: are AIDS cases still underreported?
• Poor reporting standards, Patients’ denial of risk
behaviors, Absence or decreased access to health care
preventing diagnosis of HIV
– Combination antiretroviral therapy
• Effective in delaying progression of HIV to AIDS
• Prohibitive costs: $12,000 per year
Some Examples of Efforts to Care
for Vulnerable Populations
• Integrated Health Outreach System & Promotoras
http://www.youtube.com/watch?v=zN5TcrOQ-hs&feature=relmfu
• Caring Across Communities
http://www.youtube.com/watch?v=Su2WRPUGf8&feature=BFa&list=PL980E23206527EC51&index=26
• First Place for Youth
http://www.youtube.com/watch?v=mhKcCMxk3E&feature=BFa&list=PL980E23206527EC51
• In SHAPE
http://www.youtube.com/watch?v=H4jvOm7yC0&feature=BFa&list=PL980E23206527EC51
• Community Advocacy Program
http://www.youtube.com/watch?v=egrm6csKERg&feature=BFa&list=PL98
0E23206527EC51
More examples
• Health Leads
– http://www.youtube.com/watch?v=pSo4ililQ58
&feature=BFa&list=PL980E23206527EC51
• Child First
– http://www.youtube.com/watch?v=EZ33vjcK3hk
&feature=BFa&list=PL980E23206527EC51
• St. Vincent de Paul Society
– http://www.youtube.com/watch?v=hdFH2InciEc
&feature=BFa&list=PL980E23206527EC51
What We’ve Learned
• Major characteristics of U.S. population
groups that face challenges and barriers in
accessing health care
– Organized along predisposing, enabling, and need
characteristics
• Importance of addressing unique health
concerns of U.S. subpopulation groups