4.2 Access to Care
4.2.1 Access to Health Services
Many people face barriers that prevent or limit access to needed healthcare services, which may increase the risk of poor health outcomes and health disparities (Institute of Medicine, 2003). Barriers that prevent or limit access include lack of health insurance and other barriers such as poor access to transportation and limited healthcare resources.
I. Lack of Health Insurance
About 1 in 10 people in the United States don’t have health insurance (Berchick et al., 2018). Inadequate health insurance coverage is one of the largest barriers to healthcare access, and the unequal distribution of coverage contributes to disparities in health (Call et al., 2014; Institute of Medicine, 2003). Out-of-pocket medical care costs may lead individuals to delay or forgo needed care (such as doctor visits, dental care, and medications). In fact, medical debt is common among both insured and uninsured individuals (Herman et al., 2011; Pryor & Gurewich, 2004). People with lower incomes are often uninsured, and minority groups account for over half of the uninsured population (DeNavas-Walt, 2010; Franks et al., 1993; Hadley, 2003; Majerol et al., 2015; Zhu et al., 2010).
Lack of health insurance coverage may negatively affect health (Institute of Medicine, 2009; Majerol et al., 2015). Uninsured adults are less likely to receive preventive services for chronic conditions such as diabetes, cancer, and cardiovascular disease (Ayanian et al., 2000; Institute of Medicine, 2009). Similarly, children without health insurance coverage are less likely to receive appropriate treatment for conditions like asthma or critical preventive services such as dental care, immunizations, and well-child visits that track developmental milestones (Institute of Medicine, 2009).
In contrast, studies show that having health insurance is associated with improved access to health services and better health monitoring (Baicker et al., 2013; Buchmueller et al., 2005; McWilliams et al., 2003). For example, one study demonstrated that when previously uninsured adults ages 60 to 64 became eligible for Medicare at age 65, their use of basic clinical services increased (McWilliams et al., 2003). Similarly, providing Medicaid coverage to previously uninsured adults increased their chances of receiving a diabetes diagnosis and using diabetic medications (Myerson & Laiteerapong, 2016). Medicaid coverage is also critical for enabling children with special health needs or chronic illnesses to access health services. The Children’s Health Insurance Program (CHIP) is the only source of coverage for 41% of children with special healthcare needs (Musumeci, 2018). Many healthcare resources are more prevalent in communities where residents are well-insured, but the type of insurance individuals have may also matter (Institute of Medicine, 2009). Medicaid patients, for instance, experience access issues when living in areas where few physicians accept Medicaid due to its reduced reimbursement rate (Bodenheimer & Pham, 2010; Buchmueller et al., 2005; Decker, 2012).
II. Other Barriers
Health insurance alone cannot remove every barrier to care (Call et al., 2014). Limited availability of healthcare resources is another barrier that may reduce access to health services and increase the risk of poor health outcomes (Douthit et al., 2015; National Association of Community Health Centers and the Robert Graham Center, 2007). For example, physician shortages may mean that patients experience longer wait times and delayed care (Bodenheimer & Pham, 2010).
Inconvenient or unreliable transportation can interfere with consistent access to healthcare, potentially contributing to negative health outcomes (Syed et al., 2013). For example, research has shown that individuals from racial/ethnic minority groups with an increased risk for severe illness from COVID-19 were more likely to lack transportation to healthcare services (Clay et al., 2021). Transportation barriers and residential segregation are also associated with the late-stage presentation of certain medical conditions, such as breast cancer (Dai, 2010; Tarlov et al., 2009; Wang et al., 2008).
Expanding access to health services is an important step toward reducing health disparities. Affordable health insurance is part of the solution. However, factors like economic, social, cultural, and geographic barriers to healthcare must also be considered, as must new strategies to increase the efficiency of healthcare delivery (Bodenheimer & Pham, 2010; Call et al., 2014; Douthit et al., 2015; Green et al., 2013; Rieselbach et al., 2010). Further research is needed to better understand barriers to healthcare. This additional evidence will facilitate public health efforts to address access to health services as a social determinant of health.
Source for 4.2.1: (U.S. Department of Health and Human Services, n.d.-a)
4.2.2 Access to Primary Care
A primary care provider is usually an internist, family physician, pediatrician, or non-physician provider such as a family nurse practitioner or physician assistant (Friedberg et al., 2010; Shi, 2012). Research shows that access to primary care is associated with positive health outcomes (Shi, 2012; Starfield et al., 2005).
Primary care providers offer a usual source of care, early detection and treatment of disease, chronic disease management, and preventive care (Friedberg et al., 2010; Shi, 2012; Starfield et al., 2005). Patients with a usual source of care are more likely to receive recommended preventive services such as flu shots, blood pressure screenings, and cancer screenings (Blewett et al., 2008; Friedberg et al., 2010; Xu, 2002). However, disparities in access to primary care exist, and many people face barriers that decrease access to services and increase the risk of poor health outcomes (American College of Physicians, 1999). Some of these obstacles include lack of health insurance, language-related barriers, disabilities, inability to take time off work to attend appointments, geographic and transportation-related barriers, and a shortage of primary care providers (American College of Physicians, 1999; Avila & Bramlett, 2013; Ayanian et al., 2000; Bodenheimer & Pham, 2010; Douthit et al., 2015; Gleason & Kneipp, 2004; Krahn et al., 2006; Tolbert et al., 2022). These barriers may intersect to further reduce access to primary care.
Lack of health insurance decreases the use of preventive and primary care services and is associated with poor health outcomes (American College of Physicians, 1999; Ayanian et al., 2000; Brown et al., 2000; Tolbert et al., 2022; Zuvekas & Taliaferro, 2003). Individuals without health insurance may delay seeking care when they are ill or injured and are more likely to be hospitalized for chronic illness. Children who do not primarily speak English and immigrant Hispanic children are more likely to lack a usual source of care compared to non-immigrant Hispanic individuals in English-speaking households (Avila & Bramlett, 2013). Similarly, a study examining health quality of life outcomes in older populations discovered that older immigrants with limited English proficiency had less access to healthcare than older adults who speak English fluently (Nguyen & Reardon, 2013).
Limited provider office hours and availability can be barriers to accessing primary care (O’Malley et al., 2012; Schoen et al., 2009). Many primary care providers do not offer services during off-work hours, posing barriers to workers without sick leave benefits (Gleason & Kneipp, 2004). One study found that even when workers were provided with sick leave, some did not take time off to receive primary care because they feared losing wages (Gleason & Kneipp, 2004). Additionally, primary care provider shortages and extreme demand often make it challenging for patients to get an appointment (Douthit et al., 2015).
Factors such as access to transportation, travel distance, and the supply of primary care providers can also limit people’s ability to get primary care (Douthit et al., 2015). For example, rural residents may need to travel long distances to get primary care and thus may be less likely to seek preventive care such as vaccinations (Douthit et al., 2015). In addition, rural communities tend to have fewer providers than urban communities; this relative shortage of providers may make it harder for rural residents to access primary care (Douthit et al., 2015; Institute of Medicine, 1996).
Primary care is critical for improving population health and reducing health disparities (Starfield et al., 2005). Therefore, addressing barriers to accessing primary care may help reduce disparities and the risk of poor health outcomes. For example, the National Health Service Corps supports the work of primary healthcare clinicians in areas of the United States with limited access to care, also called health professional shortage areas (National Health Service Corps, 2021). Digital solutions like telehealth can also improve access to primary care by reducing barriers related to transportation and expanding the ability to offer services in languages other than English (Rural Health Information Hub, 2022).
Further research is needed to better understand barriers to primary care, offer support to primary care providers, and develop interventions that expand primary care access. This additional evidence will facilitate public health efforts to address access to primary care as a social determinant of health.
Source for 4.2.2: (U.S. Department of Health and Human Services, n.d.-b)
4.2.3 Health Literacy
Healthy People 2030 has elevated the importance of health literacy by declaring it a foundational principle and overarching goal. The following two definitions together constitute health literacy (National Library of Medicine, 2021):
- Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Examples of personal health literacy include understanding prescription drug instructions, understanding doctor’s directions and consent forms, and the ability to navigate the complex healthcare system.
- Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. Examples of organizational health literacy include simplifying the process to schedule appointments, using the Teach-Back method to ensure patient comprehension, and providing communications in the appropriate language, reading level and format.
Healthy People and the U.S. Department of Health and Human Services have long recognized that health literacy is not just the result of individual capacities but also the health-literacy-related demands and complexities of the healthcare system (U.S. Department of Health and Human Services, 2003, 2010). This official recognition of the two dimensions of health literacy clarifies the different routes to health literacy improvement and encourages stakeholders to engage on both levels. In addition, Healthy People’s new definitions of health literacy also underscore the differences between social risks and social determinants of health.
I. Personal Health Literacy
Personal health literacy is a social risk associated with worse healthcare and health outcomes (Berkman et al., 2011). When individuals have limited personal health literacy, they are at higher risk of misunderstanding information important to achieving and maintaining health or losing their way in the fragmented healthcare system.
Most measures of personal health literacy assess people’s ability to understand written health information and numbers. Using such an assessment in English, the only national health literacy measure found that over a third of adults in the U.S. have limited personal health literacy (U. S. Department of Health and Human Services, 2008). Assessing personal health literacy at a given point in time to target interventions to individuals has limitations; measurement tools can lack precision, and personal health literacy skills can fluctuate, declining at times of illness or stress (Pleasant et al., 2016). However, assessment at the aggregate level allows support and resources to be targeted to communities and populations in greatest need. Currently, there is no national measure of personal health literacy.
II. Organizational Health Literacy
Living in communities served by healthcare organizations that lack organizational health literacy can affect the quality of healthcare delivered and, consequently, health outcomes. People who reside near the catchment areas of organizations with limited health literacy may be more likely to suffer from miscommunication and have difficulty accessing services. Even people with high personal health literacy can suffer ill effects from low organizational health literacy. Healthy People 2030 organizational health literacy objectives focus on provider-patient communication and shared decision-making.
The concept of organizational health literacy is still evolving. Attributes of a health-literate organization and strategies for becoming a health-literate organization have been articulated (Abrams et al., 2014; Brach, 2017; Brach et al., 2012; Brega et al., 2015; Farmanova et al., 2018; Koh et al., 2013). Many measures of organizational health literacy have been developed, but currently, there is no measure of the extent of organizational health literacy in the nation (Brega et al., 2019; Kripalani et al., 2014). In addition, studies of organizational health literacy have largely been descriptive, with few impacts reported (Adsul et al., 2017; Brach, 2017; Institute of Medicine, 2013; Isibel, 2020; Kaphingst et al., 2014; Weaver et al., 2012). Additional research on the effect of organizational health literacy is needed (Agency for Healthcare Research and Quality, 2020a).
III. Health Literacy and Health Equity
Personal health literacy is associated with racial/ethnic minority status, age, poverty, health insurance coverage, educational attainment, language spoken before starting school, and self-reported health (Kutner et al., 2006). Strategies to increase personal health literacy disproportionately benefit populations that have been marginalized and therefore have the potential to decrease health disparities.
Similarly, improving organizational health literacy may reduce disparities. For example, one aspect of being a health-literate organization is meeting the needs of populations with a range of health literacy levels. Health-literate organizations advance health equity by ensuring that everyone, regardless of their abilities, can make use of health information and services.
The National Action Plan to Improve Health Literacy called for interventions that increase both organizational and personal health literacy (U.S. Department of Health and Human Services, 2010). On the organizational health literacy front, its goals include promoting changes in the healthcare system that improve communication, informed decision-making, and access to culturally and linguistically appropriate health information and services. On the personal health literacy front, it promotes accurate, standards-based, and developmentally appropriate health and science information and curricula in child care and education through the university level, and expands adult education and English language instruction.
Source for 4.2.3: (U.S. Department of Health and Human Services, n.d.-c)
