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Strategies to Reduce Health Disparities
Access to Insurance
E. Richard Brown, Ph.D., Director, University of California, Los Angeles (UCLA), Center for Health Policy, Professor, UCLA School of Public Health, Los Angeles, CA
Mary Diane Ross, Assistant Director, Division of Member Services, Arizona Health Care Cost Containment System (AHCCCS), Phoenix, AZ
Disparities in health status are compounded by reduced access to health care, resulting primarily from higher rates of uninsurance. Racial and ethnic minorities are more likely to be uninsured than white persons. Uninsured rates are highest for Hispanic persons (37 percent) but also high for Asian/Pacific Islanders and black persons. All are well above the 14-percent rate for non-Hispanic white persons. Higher uninsured rates are driven by lower rates of employment-based health insurance. Hispanic persons are particularly likely to work in jobs that do not provide insurance.
Geographic areas of the country vary widely in residents' health insurance coverage. In a study of the 85 largest metropolitan statistical areas (MSAs), those with higher-than-average uninsured rates have:
- Lower proportions of residents living in families with at least one adult employed full-time, year-round.
- Lower rates of job-based insurance.
- Higher proportions of breadwinners working in firms with fewer than 10 employees.
- Higher unemployment rates.
- Higher poverty rates.
- Larger proportions living in households headed by single parents.
- Larger proportions of immigrants, including both non-citizens and naturalized citizens.
- Larger proportions of Hispanic persons and black persons.
Access to care for the uninsured is worse in cities with high rates of uninsured persons. Among moderate- and low-income (below 250 percent of the Federal poverty level (FPL)) residents, 52 percent of uninsured residents living in MSAs with higher-than-average uninsured rates had no usual source of care. This compares with 36 percent of uninsured residents in MSAs with low levels of uninsured persons. In MSAs with higher-than-average rates of uninsurance, 48 percent of uninsured residents had no physician visit in the past year (versus 41 percent in MSAs with low levels of uninsured persons).
For Hispanic persons, health insurance coverage reduces but does not eliminate differences in the number of physician visits. Adults and children with Medicaid or any private insurance have much better access than those who are uninsured. However, differences between Hispanic and non-Hispanic white persons are substantial at all ages. Such disparities in the minimum number of physician visits are not seen for black persons, possibly because safety net provider sources are better established and more accessible in black communities than in some other communities.
Asian/Pacific Islanders have many fewer physician visits than non-Hispanic white persons. For children and adults who are Asian or Pacific Islanders, however, coverage decreases disparities. Disparities between Asian/Pacific Islanders and non-Hispanic white persons are substantial among the uninsured but not among those with coverage.
Lack of insurance severely reduces the use of physician services for American Indians/Alaska Natives (AI/ANs). Twenty percent of AI/ANs are covered by the Indian Health Service (IHS), but IHS access alone does not constitute health insurance coverage. Persons with only IHS coverage are less likely to have seen a physician in the past year (of children or adults in fair or poor health) or 2 years (of adults in good or excellent health) than those with Medicaid or private insurance.
Arizona is trying a unique idea for expanding insurance coverage. In November 2000, Arizona voters approved Proposition 204 to expand health care coverage to all individuals and families with incomes below 100 percent of the FPL. There is no cap on enrollment. Verification is only required for citizenship or immigration status (if born outside the United States) and for income. There are no resource limits, except for the Medical Expense Deduction Program. The State estimates that between 137,000 and 185,000 eligible people will enroll by 2005. Funding would be provided from the tobacco settlement and the State's general fund.
The State will use a phased-in approach for enrollment. Different populations will become eligible following the expected schedule:
- April 1, 2001: Aged/blind/disabled individuals currently eligible only for Medicare premiums, co-insurance, and deductibles.
- July 1, 2001: Parents of poverty-level children and individuals participating in the State-funded
program for seriously mentally ill individuals.
- October 1, 2001: Parents of State Children’s Health Insurance Program (SCHIP) children with incomes at or below 100 percent of the FPL; recipients of family planning services only; food stamp beneficiaries, and single individuals or couples without dependent children whose income does not exceed 100 percent of the FPL or whose income, if greater than 100 percent of the FPL, is reduced to 40 percent of the FPL due to Medical Expense Deductions.
Measures taken to make the Proposition 204 expansion more accessible will include:
- Universal application, which can be mailed in or completed during an office visit.
- Simplified/streamlined eligibility process.
- $900,000 media campaign (including media outlets in Hispanic communities).
- $1 million in outreach grants to community-based organizations.
- Communication plan with stakeholders.
- Direct mailings to targeted groups.
- Earned income deductions.
Brown ER, Ojeda VD, Wyn R, et al. Racial and ethnic disparities in access to health insurance and health care. Los Angeles (CA): UCLA Center for Health Policy and Research and The Henry J. Kaiser Family Foundation; 2000 Apr.