DISPARITIES IN ACCESS:Reality vs. Perception
Peter J. Cunningham
Jack Hadley
2008 AcademyHealth Annual Meeting
June 8, 2008, Washington D.C.
Survey Measures of Unmet Need
Used to examine disparities in access
“Need” is usually self-defined, not clinically-based
Can be influenced by differences in perceptions orexpectations
Low expectations, low perceived seriousness ofmedical problems may reflect “non-financial” barriersto care.
General Measures of Unmet Needs
Uninsured consistently report more unmet need theninsured
Lower access by blacks, Hispanics not alwaysreflected in general unmet need measure
•Speculate that lower perceived need for care among somegroups may account for lack of disparity
•Suggests general unmet need measures are inadequatefor assessing racial/ethnic disparities
Objectives
Examine unmet need as reported for specific medicalsymptoms
Compare general and symptom-specific measures ofunmet need in terms of insurance-related andracial/ethnic disparities
•Do differences in perceived need explain accessdisparities?
•Do coverage differences explain racial/ethnic disparities?
2003 CTS Household Survey
Included module for care-seeking in response to 15 symptoms
(Based on measure used by David Baker and colleagues)
Symptoms identified by panel of physicians who agreed that careshould be obtained
Module asked for subsample (all uninsured adults, all elderly, andrandom sample of insured)
3,299 persons reported to have at least 1 of 15 symptoms
Follow-up questions to determine whether care received, perceivedneed, activity limitation.
Sequence of unmet need questions
All adults(36,520)
Ask whether care wasperceived as needed
16,266 screened forsymptom module
Ask whether carereceived for symptom
3,299 reported symptomin last 3 months
Any unmet need inprior year
Unmet Need Measures
General unmet need measure (asked of all persons)
Symptom-specific – did not receive care for reportedsymptom
Perceived need for care in response to specificsymptom
Symptoms Reported
Serious Symptoms
%
Shortness of Breath
8.6
Chest Pain 1+ Minute
5.7
Loss ofConsciousness
2.7
Blurry Vision
6.3
Frequent SevereHeadaches
14.4
Sadness/Hopelessness
10.4
Lump or Mass inBreast
1.2
Morbid Symptoms
%
Back or Neck Pain
9.5
Cough with YellowSputum
12.4
Anxiety, Nervousness
3.2
Pain in Hip or Knee
8.9
Sprained Ankle
3.4
Fatigue, ExtremeTiredness
9.6
Difficulty urinating (males)
0.6
Difficulty Hearing
3.1
Sample Distribution (Weighted)
General AdultSample (n=36,520)
Persons with NewSymptom (n=3,299)
Insurance
Private
59.5
54.8
Medicare
16.2
13.5
Other
9.0
13.8
Uninsured
15.3
17.8
Race/Ethnicity
White
71.5
67.4
African-American
11.3
11.4
Hispanic
12.4
15.9
Comparisons of Unmet Need Measures(Based on symptom sample, n=3,299)
Symptom-Specific Measure
GeneralUnmet Need
Did NotGet Care
Thought CareWas Needed
Insurance Coverage
Privately Insured
10.3*
52.4*
57.5
Uninsured
23.3
79.6
55.8
Race/Ethnicity
White
14.6
49.7
60.8
African-American
12.3
57.7
61.7
Hispanic
12.7
66.5*
62.3
* Difference with uninsured, white statistically significant at .05 level
Control Variables for LogisticRegressions
Symptom Information
•Specific symptom
•When first occurred within past 3 months
•Severity (days of limited activity due to symptom)
•Associated with pregnancy
General Health Status, Age, Gender
Family Income, Education
Family Structure
General Care-Seeking Behavior
Odds Ratios for Racial/EthnicDisparities
Symptom-Specific Measure
GeneralUnmet Need
Did NotGet Care
Thought CareWas Needed
Unadjusted
Hispanic
0.85
2.01*
1.07
African-American
0.82
1.38
1.04
Fully adjusted
Hispanic
0.57
1.18
1.37
African-American
0.67
1.04
1.25
Coverage Excluded
Hispanic
0.61
1.44
1.36
African-American
0.68
1.03
1.25
Conclusions
Insurance-related disparities consistent acrossdifferent measures of unmet need
Racial/ethnic disparities in access extremely sensitiveto the measure used
Hispanics more likely to have unmet need in responseto specific symptoms, compared to more generalmeasure
Differences in perceived need for care do not explaindisparities in access
Coverage differences explain some, not all ofracial/ethnic disparities in unmet need
Policy Implications
Insurance coverage expansions will eliminateinsurance-related disparities, but not racial/ethnicdisparities
Suggests that “non-financial” barriers may play a rolein lower access among Hispanics.
•Study limited to acute symptoms, not chronic conditions
•Hispanics treated as homogeneous group
Nonfinancial barriers may be greater depending on country oforigin, citizenship, English-language proficiency, length of time incountry, etc . . .