ACCESS AND INEQUITIES IN
HEALTH CARE
Introduction to Health Policy
1/20/2023
2
1/20/2023
AC·CESS
noun
1. A means of approaching, entering, exiting,
communicating with, or making use of: a store with
easy access.
2. The act of approaching.
3. The ability or right to approach, enter, exit,
communicate with, or make use of: has access to the
restricted area; has access to classified material.
3
1/20/2023
IN·EQ·UI·TY
n. pl. in·eq·ui·ties
1. Injustice; unfairness.
2. An instance of injustice or unfairness: discerned some
inequities in the criminal justice system.
4
1/20/2023
ACCESS TO HEALTH
CARE
 Ability to obtain health services, when
needed
 Millions of US residents have
difficulty accessing healthcare
services.
5
1/20/2023
BARRIERS TO ACCESS
Financial
Non-Financial
- Lack of health care providers and facilities
- Public transportation
- Lack of Cultural Competency
- Language
- Poverty
- Education
- Lack of information about when and how to access the
system
6
THE INSURED…….
1/20/2023
1. See healthcare providers 70% more than uninsured
2. Utilize 90% more hospital services
3. Sick newborns with insurance receive more hospital
services than sick newborns w/o insurance
4. The quality of the coverage matters: if it fails to cover
a pre-existing condition or critical service, financial
barriers persist.
5. Coverage does not guarantee access
7
1/20/2023
THE UNDER-INSURED…
1. An estimated 25 million Americans between the ages of
19 and 64 were underinsured in 2007
2.
3.
4.
5.
6.
 60% increase since 2003
Face serious medical costs even though they have insurance.
Healthcare spending can comprises a large fraction of income
(e.g., greater than 10 percent).
Half of all bankruptcies in 2001 were caused, in part, by medical
debts
3/4 of those bankrupted by medical debt had health insurance
at the start of their illness or injury.
Should change with ACA
8
1/20/2023
THE UN-INSURED…….
1. Stigma
2. Receive less care
3. Worse health outcomes
4.
5.
6.
7.
Less likely to have a regular source of care
55% postpone care
More likely to receive care in the ER
Children 4 x more likely to go without medical &
dental care
9
1/20/2023
THE UN-INSURED….CHALLENGES ACROSS THE
COUNTRY
 People who live in rural areas are less likely to have job-based
insurance and more likely to have a low income resulting in
 higher rates of people without insurance
 Similar problems exist in certain urban areas.
 The increase in the uninsured has strained public hospitals
and clinics, and emergency departments.
 Between 1994 and 2004, emergency department visits rose by
26%.
10
RAND HEALTH INSURANCE STUDY
(1971-1986)
1/20/2023
1. Compared patients with no out-of-pocket costs to patients
with varying amounts of cost sharing
2. Patients who shared costs
a) Had less ambulatory care visits
b) Increased morbidity
c) HTN
d) DM
e) Asthma
f)
Less likely to buy prescription medications
11
1/20/2023
DIFFERENCES ACROSS
STATES
1. States with lower-than-average income have higher-thanaverage uninsured rates.
2. States with citizens who lack insurance are generally not those
with good health care outcomes.
3. Affected areas concentrated in the South and West.
4. More jobs in service, agriculture, and other industries that are
less likely to offer health benefits than manufacturing or
government jobs.
12
1/20/2023
HEALTHCARE PROVIDERS
& PATIENT INCOMPATIBILITIES
1. Census – By 2050
a. 1/3 of US citizens will identify themselves as a minority
b. Only 10% of minority healthcare providers
c. Lack of minority healthcare providers persistent factor in
healthcare disparities
2. Other incompatibilities:
a. Language
b. Gender
c. Race
d. Generational
e. Lack of cultural competency
13
1/20/2023
HEALTHCARE
PROVIDERS
1. Between 1997 and 2005 the number of medical
school graduates entering family practice
residencies dropped by 50%.
2. Designated underserved areasa. Nearest source of primary healthcare is >30 minutes away
b.
Nearest source of specialty care >40 minutes away
14
1/20/2023
U.S. PRACTICING PRIMARY CARE PHYSICIANS,
2010
Primary care physicians in
Type of practice
Percent estimated to be
Practicing primary care
practicing
physicians
Adjusting for retirement
direct patient care*
FP
87,650
84,033
95%
79,831
GER
3,260
3,157
95%
2,999
GP
11,883
9,557
100%
9,557
GIM
93,655
89,359
80%
71.487
PD
49,642
47,297
95%
44,933
Total
246,090
233,403
208,807
* From the AMA Physician Masterfile 2010.
Abbreviations: FP = Family Practice, GER = Geriatrics, GP =General Practice, GIM= General Internal Medicine,
PD = General Pediatrics.
15
1/20/2023
TRANSPORTATION
1. At least 3.6 million Americans miss medical care due to a
lack of transportation per year.
2. Disproportionately female, poorer, and older
3. Less educated
4. More likely to be minorities
5. Have physical and mental disabilities
6. Unable to drive
7. Rural Areas
- Greater distance to healthcare
- Less public transportation
- Inconvenient schedules
16
1/20/2023
LANGUAGE
1. <10 million US citizens speak little or no English
2. 1 out of 5 residents’ primary language spoken at
home is not English
3. Language barrier makes it difficult for patients
- Navigate the healthcare system and hospital culture
- Present symptoms,
- Understand diagnosis
4. Barrier can lead to misdiagnosis and increased
morbidity, and mortality
17
1/20/2023
LANGUAGE
1. Limited English Proficiency (LEP) limited ability of
speaking, understanding, reading or writing English
2. Hearing impaired and visually impaired
3. RSMI ( Remote Simultaneous Medical Interpreter)
18
1/20/2023
EDUCATION
1. Education of the head of the household contributes
to the frequency and utilization of healthcare.*
2. Americans with <12 years of education reported
- fair to health outcomes
- used more disability days off from work
- increased hospital days
(*National Center Of Labor Statistics )
19
1/20/2023
GENDER & ACCESS
 Olga is angry.
Her male MD had not listened to her
 He told her that her incontinence was from too many childbirths
She would have to live with it
 Olga also had questions about the hormone medication the MD was
prescribing
But the MD always seemed too busy
 so she didn’t ask
 Olga decides to see a female provider
Her HMO gave her the name of a MD and a nurse practitioner
Neither is accepting new patients
20
1/20/2023
GENDER & ACCESS
1. Women 50% more likely than men to report leaving a MD because:
- Dissatisfied with care
- Talked down to by MD
- Problems were “in their head”
2.
Women with comparable disease severity
-
Less likely to receive major procedures
-
CABG
-
Renal transplantation
-
Inappropriate care
21
1/20/2023
RACE & ACCESS
Jose is suffering
The pain from the fractured femur is excruciating
ER doc has not given him pain medication
In the next room, Joe has received 10mg of morphine
and is resting comfortably
22
1/20/2023
RACE & ACCESS
1. Study of California ER 1990-1991 found:
• 55% of Latino patients with fractures did
not get pain medication
• Nothing to do with insurance status
• Higher proportion of uninsured minorities
have….
•
Fewer MD visits
•
•
Less preventive services
Fewer surgical procedures
23
1/20/2023
“The Schulman Study”
 NEJM 1999:
 Documented racial and gender bias in clinical
decision-making (cardiac catheterizations)
 Patient’s race and sex
independently influence how physicians manage chest
pain
Congress mandated IOM to study disparities
24
1/20/2023
“From cancer, heart disease, and HIV/AIDS to diabetes
and mental health, African Americans, Hispanic
American, and Native American tend to receive less and
a lower quality healthcare than whites, resulting in higher
mortality rates.”
(The Sullivan Commission on Diversity in the Healthcare Workforce, (2004).
Missing persons: minorities in the health professions.)
25
26
1/20/2023
THE U.S. HEALTH CARE SYSTEM
Professional and biomedical paradigm
Responsible for many attractive characteristics of the U.S.
health care system:
Reduced medical quackery
Instilled respect for the scientific method
Professionalism directed physicians:
Act in the best interest of their patients
Patients have access
Wider array of specialists
27
1/20/2023
AMERICAN HEALTH SYSTEM BASICS
Health and Medicine Distinction
Overwhelming resources are spent on sickness
Small portion spent on keeping people healthy
Health Promotion
Public Health
Disease Prevention
There is a move towards spending more resources on the above
Still accurate to say— “American Health Care System”
Most significant determinants of good health
Income
Education
Dr. George Kaplan, University of Michigan, “We need to start thinking that
economic policy is the most powerful form of health policy. As we increase
people’s income, we increase the health of all.”
28
1/20/2023
TRADITIONAL STRUCTURE
 Most medical care
 Fee-for-service
 Most hospitals
 Not-for-profit
 Most physicians
 Practiced solo
 Small practice groups
 Physicians
 Dominant power in hospitals
 Admit patients
 Referral networks
 Often involved the physicians in the same hospital
29
MANAGED CARE
 New relationship between
 Purchasers, Insurers, Providers
 Traditionally,

Employers paid health care premium

Provider had total control
 Insurer paid the provider
 MCOs
- Cost
- Tests
-Treatment plans
 Manage patient care
 Strong likes and dislikes
1/20/2023
30
1/20/2023
FORCES DRIVING US HEALTHCARE SYSTEM
Biomedical model
Stricter State licensing laws
Flexner report (1906)
Consolidated medical training in academic oriented medical schools
Many medical school serving Blacks closed
Academic medical schools embraced the biomedical
paradigm
Departed from common healing practices
Mysticism
Empiricism
31
1/20/2023
BIOMEDICAL MODEL (CONT)

Emphasis on basic science and research
Scientific medicine
Professional specialties
Physicians trained to master
Pathophysiologic changes in a particular organ system
Led to specialization


Increased funding in medical research
Optimism that union of technologic innovation & expertise in science
Eradicate disease sources


Advocates for larger role of generalism
Integrated scientific approach to understand
Illness
Health
Incorporate individual’s psychosocial experiences

Family medicine emerged in 1970s
Attempt to define the scientific and clinical basis of generalizations
32
1/20/2023
PROFESSIONALISM
U.S. unique in its relative laxity
Public regulation of health care resources
Most industrialized countries & governments wield considerable control:
Health planning/hospital capacity & technology
Residency training positions:
Generalists
Specialists
•Coordination
•Public health
•Primary, secondary, & tertiary facilities
•U.S. provided financing
•But exercised little administrative control
1/20/2023
ACCESS PROBLEMS
33
34
1/20/2023
COST
US health care system most expensive (2006):
$7,026
OECD (Organization for Economic Cooperation and Development,
2004)
Canada: $3,165
Germany: $3,043
UK: $ 2,508
Japan: $2,249 (2003)
OECD: $2,552 (average)
Switzerland: :$4,077
France: $3,159
Australia: $3,120
Italy: $2,147
1/20/2023
HEALTH CARE EXPENDITURES
Source: OECD Factbook 2014
35
36
1/20/2023
WHERE DO HEALTH CARE DOLLARS COME FROM?
Taxes
 Federal
 State
 Local
Huge portion already financed by the government
Private Funds: 53%
Health Insurance: 61%
Out-of-Pocket: 31%
Other private funds: 8%
37
1/20/2023
FINANCING HEALTH CARE
Progressive
% of income as income rises
Example: income taxes - Why?
Income tax provides largest tax for money for government financed health care.
Regressive
Falling % of income as income rises
Example: Sales tax - Why?
Out-of-pocket expenses took 12% of income from lower income persons vs. 1.2% for wealthier families.
Lower income people tend to be sicker and have more out-of-pocket expenses
Experience rating is regressive
Proportional
ratio of payment to income is the same for all income classes
Example: Social security taxes - Why?
56% of health care is financed by out-of-pocket and 44% via government
revenues
Total sum of health care financing is regressive
38
1/20/2023
GOVERNMENT FINANCING INSURANCE
Employment based insurance grew in the 1950s.
Poor and elders without insurance
Elders hard hit with experience rating
Johnson’s Great Society enacted
Medicare (1965)
Part A: hospital insurance
Part B: physician services
Medicaid (1965)
Clinton enacted
• SCHIP (1997)
1/20/2023
NATIONAL HEALTH EXPENDITURES 2010
Total = $2.6 Trillion
39
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group.
40
1/20/2023
WHY SO COSTLY?
Intensity of services
Longer life spans
Chronic Illness
Long-term care services such as nursing homes
Prescription drugs
Accelerated in 2006
Medicare Part D
Technology
Generate consumer demand for more intense, costly services
Even if they are not necessarily cost-effective
Aging of the population
Baby boomers will begin qualifying for Medicare in 2011
Administrative Costs
25% vs. 7%
Excessive paperwork required for insurance companies
Medicare:2- 3% administrative costs
Medicaid: 6% administrative costs
1/20/2023
OUT –OF-POCKET-EXPENSES
41
1/20/2023
OUT-OF-POCKET EXPENSES
COMPARISON
42
43
1/20/2023
PUBLIC’S VIEW OF
HEALTH CARE SYSTEM
Highest quality
Most compassionate
Handles complex illnesses
Denies care to those without insurance
Preventive services
Inappropriate high-risk surgeries
Done on uninformed patients.
44
1/20/2023
U.S. HEALTH CARE SYSTEM TODAY
Least universal
Most costly system
Large inequities
In 1998
17% of Americans feel the system worked well
79% feel system needs real changes
18% of Americans had problems paying medical bills
5% of Canadians have problems
3% of people in U.K. have problems
45
1/20/2023
CONCLUSION
US model of excellence focuses on:
Medical specialization
Technology
Curative care
US model misses:
Basic primary care services
Attention to disease prevention and supportive care
US model places value on
Individualism
Autonomy
46
1/20/2023
WHY STUDY HEALTH POLICY?
UNDERSTANDING THE CRISIS
Must understand the system
Correct the weaknesses
Maintain the strengths
How is health care financed
Causes of complete/incomplete care
How are health professionals paid
Health care services organization
Illness prevention
Potential solutions
47
1/20/2023
WHO HEALTH SYSTEM GOALS
WORLD HEALTH REPORT 2000
Maximizing population health
Health Quality
Equity
Health of the population
Levels
Distribution
Responsiveness
Reflects expectations of the population
Delivery of health services
Fairness in financing
Discretionary expenditures less for lower income than higher income households
Protection against catastrophic costs r/t illness
Overall efficiency
Above indicators
48
1/20/2023
OVERALL HEALTH SYSTEM
PERFORMANCE
WHO results of the overall health system performance for 191
countries:
U.S.
France
Japan
Canada
Italy
Germany
United Kingdom
49
1/20/2023
WHO MEMBER STATES EFFICIENCY RANKS
France: 1
Italy: 2
Japan: 10
United Kingdom: 18
Canada: 30
Germany: 25
U.S. : 37
1/20/2023
50