How Well Do Communities Perform on Access to Care for the Uninsured

Introduction

A substantial number of Americans -- 41 million people at the time of this study -- lacked health insurance, representing a 16 percent increase since 1990. Numerous studies have documented that uninsured individuals face significantly greater difficulty obtaining needed care compared to their insured counterparts. This Research Report presents findings from HSC's Community Tracking Study showing that the ability of uninsured people to access necessary medical care varies considerably depending on which community they live in. Moreover, the personal characteristics of the uninsured explain very little of this geographic variation. These findings represent an important first step in helping decision makers understand how the dynamics of communities and their safety nets affect the medically indigent population's ability to obtain needed care.

The data for this report come from the Community Tracking Study's Household Survey, a nationally representative telephone survey of the civilian, non-institutionalized population across 60 randomly selected communities. In-person interviews supplemented the telephone data for households without telephones. Interviews were conducted between July 1996 and July 1997. The survey contains observations on nearly 33,000 families and 60,000 individuals, of whom 7,200 were uninsured. The overall family response rate was 65 percent.

Wide Community Variations in Access

Because health care delivery is organized locally, it is not surprising that differences exist across communities in the ability of uninsured individuals to obtain medical care. What is striking, however, is the magnitude of these differences. For uninsured people, where they live turns out to be an important factor in determining how much difficulty they face in getting care.

Nationally, about 31 percent of uninsured individuals reported that they did not receive needed medical care in the previous year or had to delay getting it. This rate is more than double that of the privately insured population. At the community level, there was more than a twofold difference in the rate of these access difficulties, ranging from more than 40 percent in Lansing and Cleveland -- the communities with the highest rates -- to less than 20 percent in Orange County, the community with the lowest rate.

Roughly 15 percent of the variation in access to necessary care across communities could be explained by differences in the characteristics of the uninsured themselves -- factors such as health status, age, gender, family income, and race or ethnicity. The remaining variation was likely driven by particular characteristics of the communities that affect access for uninsured persons, though these were not directly assessed in the study. Such community-level factors may include the number and capacity of safety net providers, state policies that subsidize charity and uncompensated care, and the prevalence of managed care.

Additional variation may be attributable to factors unrelated to the health system itself, such as people's perceptions about their ability to get medical care and the wealth and size of the community. For example, the uninsured in both the greater Newark area and Orange County reported low rates of difficulty getting care. Both are relatively affluent areas (albeit with pockets of high poverty) and have a higher-than-average supply of physicians, suggesting greater health care resources. This may help explain why physicians in Newark provided more charity care -- about 10 hours per month on average -- than physicians in any other study site, according to HSC's Physician Survey.

Newark and Orange County are also part of the two largest metropolitan areas in the country -- New York and Los Angeles. Larger metropolitan areas may expand options for uninsured individuals by allowing them to use safety net facilities in contiguous areas. Some medically indigent patients in Orange County, for example, used the more extensive public facilities of nearby Los Angeles County, potentially improving their access to care.

While "reported difficulty in obtaining medical care" is the most direct measure of access available in the HSC survey, it is based on patients' own assessments rather than a clinical evaluation of need. In a separate analysis, HSC examined other less direct measures of access, such as the percentage of uninsured without a usual source of care, the number of ambulatory care visits, and distance from home or work to the physician's office. While these measures also showed substantial cross-community variation, the patterns did not generally align with the percentage reporting difficulty getting care. This led HSC researchers to conclude that considerably more work was needed to understand how safety net structures, local market characteristics, and idiosyncratic community attributes affect access for uninsured populations.

Comparisons With the Insured Population

Consistent with prior research, the HSC study found that people with health insurance reported less difficulty obtaining care than the uninsured at the national level. Only 15 percent of privately insured individuals reported difficulty getting care. While access for the insured also varied across communities -- from 12 percent in Lansing to 18 percent in Phoenix -- the range of variation was narrower than for their uninsured counterparts.

Notably, the patterns of variation in access for the uninsured and the privately insured did not correlate. Communities with relatively high levels of access problems among the uninsured did not necessarily have the highest levels of access problems for the privately insured. Orange County illustrates this disconnect: the uninsured there had less difficulty getting care than in most other sites, while the privately insured had greater difficulty than privately insured persons elsewhere.

This finding suggests that the factors driving access for uninsured populations are distinct from those affecting the insured. Uninsured individuals overwhelmingly cited cost concerns (90 percent) as the reason for their difficulty in getting care. While privately insured persons also cited cost concerns (48 percent), they additionally pointed to problems with health insurance and obtaining referrals (28 percent) and the ease and convenience of navigating the system (33 percent).

Policy Implications

Public and private decision makers concerned about the nation's health had to grapple with the implications of access to needed medical care varying so substantially across communities. While this report did not specifically address why these differences existed, the reasons were likely complex, and simple, effective policy responses would be difficult to design.

The health care safety net that many policy makers looked to for improvements in access was not a coordinated, well-integrated system of care in most communities. Rather, it consisted of a patchwork of providers -- public hospitals, community health clinics, local health departments, and other entities -- delivering care to the medically indigent on an ad hoc basis. This made designing effective interventions to strengthen the safety net a considerable challenge.

There was also limited information about how specific aspects of the safety net -- such as access to preventive and primary care through clinics and physician offices -- affected care for the uninsured. Planned HSC research aimed to help decision makers better understand what health system factors, including managed care penetration and the size of the uninsured population, influenced the uninsured population's ability to obtain charity care.

Communities also differed in how much priority they assigned to indigent care and in how they responded to the problem of the uninsured. Some of these differences were rooted in cultural attitudes and highly localized voluntary efforts -- factors that may fall beyond the reach of public policy.

Extending health coverage to those without it would address many of the difficulties the uninsured faced in getting needed care and would produce greater uniformity in access across communities. An HSC simulation showed that the percentage of uninsured persons experiencing difficulty getting care would decrease from 30 percent to about 21 percent if they were given Medicaid or other public coverage, and to 17 percent if they received private insurance. This improvement would be relatively consistent across the study sites, regardless of whether the uninsured in a given community currently experienced more or less difficulty in getting needed care.

The cross-community variation in difficulty obtaining care for the uninsured was expected to persist or grow larger in an environment of intensifying competition and shrinking public subsidies. The already limited federal role in providing care to the medically indigent was likely to contract further due to decreases in Medicaid and Medicare Disproportionate Share Hospital Payments. As a result, policies to support care for the uninsured would continue to be driven largely at the state and local level. Understanding how local market conditions affect the uninsured population's ability to get needed care -- including the role of managed care and local innovations -- was considered critical to designing policies that could enhance care for the uninsured.

Conclusion

This research demonstrated that the ability of uninsured Americans to obtain necessary medical care was far from uniform across the country. Where an uninsured person lived mattered a great deal, with more than a twofold difference in access difficulty rates between the best- and worst-performing communities. Personal characteristics of the uninsured -- health status, income, demographics -- accounted for only a small share of this variation. The remaining differences were likely rooted in community-level factors such as the strength and structure of the local safety net, the supply of providers willing to deliver charity care, and broader market dynamics.

These findings underscored the importance of understanding local health care markets when developing policies to improve access for the uninsured. National-level statistics can mask the wide variation in experiences across communities, and policy solutions that work in one market may not be effective in another. The research also highlighted the fundamental distinction between access barriers facing the uninsured versus the insured -- with cost being the dominant barrier for those without coverage -- suggesting that different policy approaches are needed for each population.

Sources and Further Reading

AHRQ -- National Healthcare Quality and Disparities Report -- Federal data on health care access and quality.

Kaiser Family Foundation -- Uninsured -- Data on uninsured populations and access barriers.

Census Bureau -- Health Insurance Coverage -- Population-level insurance coverage statistics.

Robert Wood Johnson Foundation -- Health policy research and programs.

Commonwealth Fund -- Research on health care access and equity.