BARRIERS TO HEALTH CARE ACCESS

The challenges the health care industry faced in responding to the COVID-19 pandemic exposed the most daunting impediments to the provision of health care to underserved populations.. The 2018 National Healthcare Quality and Disparities Report from the Agency for Healthcare Research and Quality (AHRQ), an HHS agency, predates the pandemic response but confirms that Black, indigenous, and people of color (BIPOC) communities receive worse health care than white people in approximately 40% of the quality measures.

These are among the most common barriers to health care access:

LACK OF HEALTH INSURANCE

The HHS found that uninsured adults across racial and ethnic groups are at least twice as likely as their white counterparts to avoid seeing a doctor. Patients who establish a strong personal connection with their health care provider are more likely to take better care of themselves. They’re also more likely to trust the health care profession.

• One in 10 adults report that they delayed or went without getting health care due to its high cost.

• The rate was 15% for Latinx and 13% for African Americans.

• Adults who most need medical care are twice as likely to delay or go without it than those who need care less.

• Among uninsured adults, 36.5% delay or go without medical care due to its high cost.

LACK OF FINANCIAL RESOURCES

The Centers for Medicare & Medicaid Services (CMS), an HHS agency, estimates that national health care expenditures grew by 4.6% in 2019 to $3.9 trillion, which represents 17% of the U.S. gross domestic product (GDP). The agency forecasts that by 2028, national health care expenditures will reach $6.2 trillion, representing 20% of GDP. These figures are much higher than the amount spent on health care by other developed countries.

• The Children’s Health Fund estimates that 20.3 million children in the U.S. (28% of all children) are unable to access the health care resources they need, due primarily to the high cost of care.

• Financial barriers include high copays, high deductibles, and unaffordable prescription drug prices.

• More than 13.1 million children are in families who are unable to pay their medical bills or are struggling to pay medical bills.

LACK OF A REGULAR HEALTH CARE SOURCE

Even when underserved populations are insured or are able to pay for their health care needs, they may be challenged to find a convenient provider. The Health Resources & Services Administration (HRSA), an HHS agency, identifies 7,359 health professional shortage areas in the U.S. where 85 million people reside. The HRSA estimates that 15,445 primary care professionals are needed to address these shortages.

• Research published in the CDC’s National Health Statistics Reports found that adults in the U.S. who lived outside a metropolitan statistical area had less access to health care and used health care services less often.

• More than half of all health professional shortage areas for primary care, dental care, and mental health care are in rural areas, yet the number of hospitals in these areas continues to decline.

LEGAL BARRIERS FACED BY IMMIGRANTS

The political and social response to the COVID-19 pandemic demonstrates clearly that a person’s immigration status serves as a social determinant of health. Several immigration-related factors influence a person’s health:

• Stressors that occur before and after migration

• Laws and policies that influence an immigrant’s access to health care services and benefits

• Health care services that vary based on the person’s legal classification of immigration status

Living environments, working conditions, and environmental factors also affect the ability of immigrants to access health care services. Legal barriers may be predicated on the person’s country of origin, race or ethnicity, age, socioeconomic status, and immigration status.

Also complicating health care for immigrants are the various state laws relating to who qualifies for health insurance coverage and inconsistent federal policies related to immigration. As of 2018, 23% of authorized immigrants and 45% of unauthorized immigrants lacked health insurance.

LACK OF TRANSPORT, LONG WAITS FOR APPOINTMENTS, AND OTHER STRUCTURAL BARRIERS

The American Hospital Association reports that each year, 3.6 million people in the U.S. are prevented from receiving the health care they need because they don’t have access to a vehicle, they’re too far away from their health care provider, or they face some other transportation obstacle. Physicians Practice notes that missing medical appointments due to transportation issues or other infrastructure-related matters has a cascading effect:

• Patients’ continuity of care is interrupted.

• Patients are challenged to maintain treatment regimens.

• Patients lack the support they need to make healthy decisions.

Patients who repeatedly miss medical appointments undergo fewer cancer screenings, have worse chronic disease control, and are more likely to require acute care and emergency services. In addition to compromising patient outcomes, the inability to make scheduled appointments increases the overall cost of medical care.

LACK OF HEALTH CARE PROVIDERS IN URBAN AND RURAL AREAS

The HRSA’s directory of health professional shortage areas includes both urban and rural areas of the U.S., yet the reasons for the shortage of health care providers in cities and lightly populated regions are similar. The National Rural Health Association highlights the unique challenges that health care providers in rural areas face:

• A high patient-to-primary care physician ratio

• A greater proportion of poor people

• Few transportation options

• Lack of high-speed internet access

However, residents in rural areas face unique challenges in accessing the health care services they need. For example, rural settings have a higher rate of fatal and injury-causing automobile crashes than urban areas, and fewer mental health services are available in rural settings despite the high rate of suicide among rural youth.

LANGUAGE BARRIERS

Twenty-five million people in the U.S. are estimated to have limited English proficiency (LEP) that compromises the quality of the health care they receive. The American Medical Association estimates that Hispanics with LEP have worse health care access, are less healthy, and receive fewer preventive services than English-speaking Hispanics.

While state and federal regulations require that health care providers offer patients with LEP trained interpreters during their care, a shortage of available interpreters and the shortcomings of audio and video equipment present barriers to communication for LEP patients.

• Only 13% of hospitals comply with all four National Standards for Culturally and Linguistically Appropriate Services (CLAS) in health care.

• Health insurance payers limit reimbursements for interpreter services because the payers question the cost-effectiveness of the services.

• Remote interpreter services rely on stable internet connectivity and are less effective than in-person translation, especially when patients are in emotional distress.

AGE

Older people are more likely to require access to health care services, yet they’re also more likely than younger adults to lack funds, have impaired mobility, and have less access to technology. Recommendations submitted as part of the National Academy of Medicine’s initiative to set health care priorities include six approaches to improving health care access for older people.

• Bolster the health care workforce through scholarships, loan forgiveness, clinical internships, and professional training.

• Invest in public health efforts to address the health care needs of older people.

• Fund efforts to eliminate social, structural, and economic barriers to health care access by people age 65 and over.

• Provide more telehealth services for older people and improve the quality of remote interactions.

• Offer more palliative and end-of-life care for treating serious illnesses and dementia.

• Develop new approaches to long-term care and support services for chronic illnesses.

RESOURCES ON BARRIERS TO HEALTH CARE ACCESS

• U.S. Department of Health & Human Services, Healthy People 2030 — The goals of the Healthy People 2030 government program can be browsed by health conditions, health behaviors, populations, settings and systems, and social determinants of health.

• The Commonwealth Fund, Advancing the Public Option in 2021: Leveraging Existing Federal Authority to Assist State Efforts — In the absence of action at the federal level to implement a public option for improved health care access, public-option initiatives implemented by state governments can be bolstered by executive authority.