Racial and Socioeconomic Disparities in Health Care Among the Insured

Grant Description: What is the effect of managed care market penetration on socioeconomic and racial/ethnic disparities in health care? Researchers at the University of Rochester hypothesized that, given managed care’s assumption of responsibility for the health care of populations (rather than specific individuals), managed care penetration may help alleviate disparities in health care access and quality between different socioeconomic and racial/ethnic populations. Among their hypotheses was that enrollment in an HMO will result in lower access, utilization and satisfaction, but higher overall disease prevention compliance. In addition to the CTS Household Survey, the researchers used market data from the Area Resource File in their analyses. The study had three specific objectives: 1) to examine racial/ethnic and socioeconomic disparities in health care access, utilization, preventative care, and satisfaction among insured populations; 2) to compare disparities in health care by socioeconomic and racial/ethnic status among persons enrolled in HMOs with similar individuals covered through indemnity insurance; and 3) to examine disparities in health care access, quality, and satisfaction among HMO enrollees of different racial/ethnic groups based on HMO market penetration, patient choice, and duration of enrollment.

Policy Summary: Among insured non-elderly adults, there are appreciable disparities in health care utilization by race, ethnicity, and language that are not fully explained by differences in household income, education, or conventional access measures (usual source of care, telephone access, lag time to appointment, travel time, office waiting time, delayed seeking needed care because of various access barriers). The finding that these disparities differ by race/ethnicity suggests that beliefs, attitudes and norms related to culture may contribute to disparities. For example, African Americans, but not members of other minority groups had lower rates of influenza vaccination and members of “other” (presumably comprised primarily of Asian Americans) racial/ethnic minority had lower rates of mammography. African Americans, Spanish speaking Hispanics, and members of other racial/ethnic minority groups were less likely to have had a mental health visit in the past year. These findings suggest the possibility that culturally appropriate educational campaigns might reduce these disparities. Among insured non-elderly adults, patient education is a powerful independent predictor of lower health care utilization. Persons with less than a high school education had fewer physician visits, and lower likelihood of having seen a specialist at their last visit, of having had a mental health visit in the past year, of having had surgery in the past year, of having had a mammogram in the past 2 years (women greater than or equal to the age 40), or of having had an influenza vaccination in the past year. These effects are not explained by differences in age, sex, race/ethnicity, family size, income, education, insurance type, rural residence, HMO status, smoking, health status, or access barriers. These results highlight the salience of patient-level factors in health care utilization and underscore the need for interventions specifically targeted toward a low literacy group. Compared to fee-for-service (FFS), HMO membership was associated with reduced disparities in health care utilization by education, but not race/ethnicity. Educational disparities were narrowed by boosting utilization among the less educated for some services while reducing utilization for other services among the more educated. Thus, HMOs appear to be a more equitable provider according to education, but not race/ethnicity. However, compared to FFS, HMOs are better equipped, i.e. using HEDIS measures and quality improvement, to monitor and improve the quality of care provided to members of racial and ethnic minority groups.