ORIGINAL RESEARCH
Usual Source of Care and Unmet Health Care Needs Interaction of Disability With Race and Ethnicity Willi Horner-Johnson, PhD and Konrad Dobbertin, MPH
Background: Having a usual source of care (USC) and having unmet health care needs have been found to vary in relation to sociodemographic differences in the US population, including race, ethnicity, and disability status. People in underserved racial and ethnic groups who also have a disability may experience a complex mix of health care advantages and disparities. However, little is known about this intersection. Objective: To determine how disability status, combined with membership in an underserved racial or ethnic group, is associated with having a USC and unmet health care needs. Methods: We conducted multivariate regression analyses of 2002–2010 data from the Medical Expenditure Panel Survey, focused on working age adults (18–64 y). Results: Although most racial and ethnic groups were less likely to have a USC than non-Hispanic whites, people with disabilities were more likely to have a USC; Hispanics with basic activity limitations were the only disability group with elevated odds of lacking a USC. Conversely, disability was strongly associated with unmet health care needs, but we did not find inflated impacts of both having a disability and belonging to an underserved racial or ethnic group. Conclusions: We found limited evidence of interaction or additive effects of disability and race/ethnicity but did confirm separate disparities for each. Ongoing research is needed to track both disability-related and racial/ethnic disparities, to determine whether increased insurance coverage, provider training, care coordination, and other efforts under the Affordable Care Act lead to reductions in disparities. Key Words: health care disparities, people with disabilities, race, ethnicity (Med Care 2014;52: S40–S50)
From the Institute on Development & Disability, Oregon Health & Science University, Portland, OR. Development of this journal article was funded by the Centers for Disease Control and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities (NCBDDD) under Cooperative Agreement U01DD000231 to the Association of University Centers on Disabilities (AUCD). The content of this material does not necessarily reflect the views and policies of CDC, NCBDDD, nor AUCD. The authors declare no conflict of interest. Reprints: Willi Horner-Johnson, PhD, Institute on Development & Disability, Oregon Health & Science University, 707 SW Gaines Street, Portland, OR 97239. E-mail: [email protected]. Copyright r 2014 by Lippincott Williams & Wilkins ISSN: 0025-7079/14/5210-0S40
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ccess to and receipt of health care in the United States is not distributed equally across population groups.1 There are significant variations in ability to obtain needed care in a timely manner. A substantial proportion of the population has no insurance, and these individuals encounter significant barriers to accessing health care.2–4 Medicaid expansion and implementation of health care exchanges under the Affordable Care Act (ACA) will help reduce uninsurance among people with disabilities and those in underserved racial and ethnic groups, at least in some states.5,6 However, current projections suggest that physician capacity will be inadequate to care for new Medicaid patients;7,8 hence, many of the newly insured may continue to lack a usual source of health care and remain at high risk of having unmet health care needs. In the Behavioral Model of Health Services Use, having a usual source of care (USC) is an important indicator of potential health care access.9,10 Having a USC is positively associated with regular health maintenance visits and receipt of preventive services.11–13 Individuals without a USC are more likely to have unmet health care needs.7 Failure to receive health care when needed may lead to exacerbation of health problems, requiring utilization of more extensive and expensive care in the future.14 Although the Behavioral Model categorizes USC as an enabling factor similar to health insurance,9,10 USC is logically “farther down the chain” in that people with health insurance are much more likely to have a USC,7 which in turn is associated with increased receipt of care. The Behavioral Model is designed to study utilization of health care (realized access), but greater utilization does not necessarily result in health care needs being better met. That concern suggests the importance of focusing instead on whether the health care received was adequate to meet perceived needs. Examining unmet need moves beyond realized access to address an aspect of patient satisfaction with care, which is a component of effective health care access.10 Both having a USC and unmet health care needs have been found to vary in relation to sociodemographic differences in the US population. For example, people in traditionally underserved racial and ethnic groups are less likely to have a USC, and less likely to receive regular checkups and other preventive care than non-Hispanic whites.7,12,15,16 People with disabilities (defined in this context as self-reported limitations in physical, sensory, cognitive, and/or emotional functioning) are more likely than those with no disabilities to have a USC, yet they are also Medical Care
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Volume 52, Number 10 Suppl 3, October 2014
much more likely to report unmet health care needs.17–21 Where there are disparities related to both disability and to race/ethnicity individually, one might anticipate that people in underserved racial and ethnic groups who also have a disability could experience magnified disparities. Further, people with disabilities in underserved racial and ethnic groups may experience a complex mix of advantages and disparities, particularly with regard to having a USC. However, very little is known about this intersection. Indeed, we were unable to locate any prior studies that have examined the interaction of disability status and race/ethnicity on access to health care and unmet health care needs. Similarly, there has been negligible attention in the literature to potential additive effects of race/ethnicity and disability. The purpose of the present study was to determine how disability status in combination with membership in an underserved racial or ethnic group is associated with having a USC and having unmet health care needs while controlling for important predisposing and enabling factors related to health care access and receipt. Because the health insurance landscape is currently shifting, we were interested in differences in USC and unmet health care needs that might remain after accounting for differences in insurance status. Similarly, even if access to a USC improves, disparities in unmet health care needs may well continue to exist. The ACA does include provisions pertaining to culturally competent care for both underserved racial and ethnic groups and people with disabilities, but it is likely to be several years before substantial widespread reductions in disparities are apparent. Thus, we focused on disparities in effective receipt of health care that may require targeted intervention regardless of improvements in potential access to health care. Because most people over the age of 64 are covered by Medicare, we limited our analyses to working-age adults 18–64 years old. Our key research questions were: (1) Are there interactions between race/ethnicity and disability such that disparities in USC and unmet health care needs are different for groups at the intersection than would be expected based solely on adding together the disparities associated with being in each group? (ie, are disability effects of consistent magnitude across racial and ethnic groups and vice versa?) (2) Regardless of whether interactions are present, what is the additive effect of disability status and membership in an underserved racial or ethnic group on USC and unmet health care needs? Are there significantly greater disparities associated with having both a disability and being in an underserved racial or ethnic group than are associated with being in either group alone?
METHODS Data Source Our sample was drawn from the Medical Expenditure Panel Survey (MEPS) Household Component, which is conducted by the Agency for Healthcare Research and Quality. The MEPS includes data regarding demographics, health care utilization and expenditures, sources of payment, health insurance, and quality of care. It has an overlapping r
2014 Lippincott Williams & Wilkins
USC and Unmet Needs
panel design with a new panel selected each year from the previous year’s National Health Interview Survey sample.22,23 Data are gathered via 5 in-person interviews over 2 years, and multistage stratified sampling is employed to provide a nationally representative sample of the US civilian noninstitutionalized population. Racial and ethnic minorities as well as low-income respondents are oversampled to increase precision of estimates for these groups.22 The Agency for Healthcare Research and Quality creates full-year consolidated files weighted to provide annualized US population estimates. We combined full-year files from 2002 to 2010 to provide adequate sample size for analyzing smaller racial and ethnic groups. Of the overall 294,513 MEPS respondents for 2002–2010, we identified 170,742 adults 18–64 years of age. After excluding 5714 observations with missing data on variables of interest, our final analytic sample included 165,028 respondents.
Measures Dependent Variables We assessed whether or not individuals reported having a USC (yes/no). A follow-up question asked those who answered yes what their source of care was. If the emergency department was the USC, we recoded respondents as having no USC. We analyzed 4 indicators of unmet health care needs in the past 12 months, each coded yes or no: (1) delay in receiving needed medical care; (2) unable to get needed medical care; (3) delay in getting prescription medication; (4) unable to get needed medication.
Primary Independent Variables We created a 3-level variable indicating presence and severity of disability, based on the categories of basic and complex activity limitations described by Altman and Bernstein.17 Basic activity limitations were identified by affirmative responses to one or more MEPS survey questions about limitations in physical functions such as walking, lifting, standing, bending, reaching, or grasping; cognitive limitations including confusion or memory loss or difficulty making decisions; and difficulty with vision (while wearing glasses, if used) or hearing (with hearing aid, if used). We also included individuals who used assistive devices such as wheelchairs or walkers. Complex activity limitations were determined by an affirmative response to one or more MEPS items about needing assistance with activities of daily living (eg, bathing, dressing) or instrumental activities of daily living (eg, paying bills, going shopping), or having limitations in work, housework, social, or recreational activities. We grouped respondents into the following 3 categories: (1) no basic or complex activity limitations (nondisabled reference group); (2) limitations in basic activities only; and (3) limitations in complex activities. Race and ethnicity were grouped into a single variable with the following mutually exclusive categories: non-Hispanic white, non-Hispanic black, non-Hispanic American Indian/Alaskan Native (AIAN), non-Hispanic Asian/Native Hawaiian/Pacific Islander (AHPI), non-Hispanic Multiple races; or Hispanic of any race. www.lww-medicalcare.com |
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Covariates We included the following sociodemographic variables in our analyses: age (18–29, 30–39, 40–49, 50–59, and 60–64 y), sex, family income as percent of the Federal Poverty Line (Z400%, 200% to
Usual Source of Care and Unmet Health Care Needs Interaction of Disability With Race and Ethnicity Willi Horner-Johnson, PhD and Konrad Dobbertin, MPH
Background: Having a usual source of care (USC) and having unmet health care needs have been found to vary in relation to sociodemographic differences in the US population, including race, ethnicity, and disability status. People in underserved racial and ethnic groups who also have a disability may experience a complex mix of health care advantages and disparities. However, little is known about this intersection. Objective: To determine how disability status, combined with membership in an underserved racial or ethnic group, is associated with having a USC and unmet health care needs. Methods: We conducted multivariate regression analyses of 2002–2010 data from the Medical Expenditure Panel Survey, focused on working age adults (18–64 y). Results: Although most racial and ethnic groups were less likely to have a USC than non-Hispanic whites, people with disabilities were more likely to have a USC; Hispanics with basic activity limitations were the only disability group with elevated odds of lacking a USC. Conversely, disability was strongly associated with unmet health care needs, but we did not find inflated impacts of both having a disability and belonging to an underserved racial or ethnic group. Conclusions: We found limited evidence of interaction or additive effects of disability and race/ethnicity but did confirm separate disparities for each. Ongoing research is needed to track both disability-related and racial/ethnic disparities, to determine whether increased insurance coverage, provider training, care coordination, and other efforts under the Affordable Care Act lead to reductions in disparities. Key Words: health care disparities, people with disabilities, race, ethnicity (Med Care 2014;52: S40–S50)
From the Institute on Development & Disability, Oregon Health & Science University, Portland, OR. Development of this journal article was funded by the Centers for Disease Control and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities (NCBDDD) under Cooperative Agreement U01DD000231 to the Association of University Centers on Disabilities (AUCD). The content of this material does not necessarily reflect the views and policies of CDC, NCBDDD, nor AUCD. The authors declare no conflict of interest. Reprints: Willi Horner-Johnson, PhD, Institute on Development & Disability, Oregon Health & Science University, 707 SW Gaines Street, Portland, OR 97239. E-mail: [email protected]. Copyright r 2014 by Lippincott Williams & Wilkins ISSN: 0025-7079/14/5210-0S40
S40 | www.lww-medicalcare.com
A
ccess to and receipt of health care in the United States is not distributed equally across population groups.1 There are significant variations in ability to obtain needed care in a timely manner. A substantial proportion of the population has no insurance, and these individuals encounter significant barriers to accessing health care.2–4 Medicaid expansion and implementation of health care exchanges under the Affordable Care Act (ACA) will help reduce uninsurance among people with disabilities and those in underserved racial and ethnic groups, at least in some states.5,6 However, current projections suggest that physician capacity will be inadequate to care for new Medicaid patients;7,8 hence, many of the newly insured may continue to lack a usual source of health care and remain at high risk of having unmet health care needs. In the Behavioral Model of Health Services Use, having a usual source of care (USC) is an important indicator of potential health care access.9,10 Having a USC is positively associated with regular health maintenance visits and receipt of preventive services.11–13 Individuals without a USC are more likely to have unmet health care needs.7 Failure to receive health care when needed may lead to exacerbation of health problems, requiring utilization of more extensive and expensive care in the future.14 Although the Behavioral Model categorizes USC as an enabling factor similar to health insurance,9,10 USC is logically “farther down the chain” in that people with health insurance are much more likely to have a USC,7 which in turn is associated with increased receipt of care. The Behavioral Model is designed to study utilization of health care (realized access), but greater utilization does not necessarily result in health care needs being better met. That concern suggests the importance of focusing instead on whether the health care received was adequate to meet perceived needs. Examining unmet need moves beyond realized access to address an aspect of patient satisfaction with care, which is a component of effective health care access.10 Both having a USC and unmet health care needs have been found to vary in relation to sociodemographic differences in the US population. For example, people in traditionally underserved racial and ethnic groups are less likely to have a USC, and less likely to receive regular checkups and other preventive care than non-Hispanic whites.7,12,15,16 People with disabilities (defined in this context as self-reported limitations in physical, sensory, cognitive, and/or emotional functioning) are more likely than those with no disabilities to have a USC, yet they are also Medical Care
Volume 52, Number 10 Suppl 3, October 2014
Medical Care
Volume 52, Number 10 Suppl 3, October 2014
much more likely to report unmet health care needs.17–21 Where there are disparities related to both disability and to race/ethnicity individually, one might anticipate that people in underserved racial and ethnic groups who also have a disability could experience magnified disparities. Further, people with disabilities in underserved racial and ethnic groups may experience a complex mix of advantages and disparities, particularly with regard to having a USC. However, very little is known about this intersection. Indeed, we were unable to locate any prior studies that have examined the interaction of disability status and race/ethnicity on access to health care and unmet health care needs. Similarly, there has been negligible attention in the literature to potential additive effects of race/ethnicity and disability. The purpose of the present study was to determine how disability status in combination with membership in an underserved racial or ethnic group is associated with having a USC and having unmet health care needs while controlling for important predisposing and enabling factors related to health care access and receipt. Because the health insurance landscape is currently shifting, we were interested in differences in USC and unmet health care needs that might remain after accounting for differences in insurance status. Similarly, even if access to a USC improves, disparities in unmet health care needs may well continue to exist. The ACA does include provisions pertaining to culturally competent care for both underserved racial and ethnic groups and people with disabilities, but it is likely to be several years before substantial widespread reductions in disparities are apparent. Thus, we focused on disparities in effective receipt of health care that may require targeted intervention regardless of improvements in potential access to health care. Because most people over the age of 64 are covered by Medicare, we limited our analyses to working-age adults 18–64 years old. Our key research questions were: (1) Are there interactions between race/ethnicity and disability such that disparities in USC and unmet health care needs are different for groups at the intersection than would be expected based solely on adding together the disparities associated with being in each group? (ie, are disability effects of consistent magnitude across racial and ethnic groups and vice versa?) (2) Regardless of whether interactions are present, what is the additive effect of disability status and membership in an underserved racial or ethnic group on USC and unmet health care needs? Are there significantly greater disparities associated with having both a disability and being in an underserved racial or ethnic group than are associated with being in either group alone?
METHODS Data Source Our sample was drawn from the Medical Expenditure Panel Survey (MEPS) Household Component, which is conducted by the Agency for Healthcare Research and Quality. The MEPS includes data regarding demographics, health care utilization and expenditures, sources of payment, health insurance, and quality of care. It has an overlapping r
2014 Lippincott Williams & Wilkins
USC and Unmet Needs
panel design with a new panel selected each year from the previous year’s National Health Interview Survey sample.22,23 Data are gathered via 5 in-person interviews over 2 years, and multistage stratified sampling is employed to provide a nationally representative sample of the US civilian noninstitutionalized population. Racial and ethnic minorities as well as low-income respondents are oversampled to increase precision of estimates for these groups.22 The Agency for Healthcare Research and Quality creates full-year consolidated files weighted to provide annualized US population estimates. We combined full-year files from 2002 to 2010 to provide adequate sample size for analyzing smaller racial and ethnic groups. Of the overall 294,513 MEPS respondents for 2002–2010, we identified 170,742 adults 18–64 years of age. After excluding 5714 observations with missing data on variables of interest, our final analytic sample included 165,028 respondents.
Measures Dependent Variables We assessed whether or not individuals reported having a USC (yes/no). A follow-up question asked those who answered yes what their source of care was. If the emergency department was the USC, we recoded respondents as having no USC. We analyzed 4 indicators of unmet health care needs in the past 12 months, each coded yes or no: (1) delay in receiving needed medical care; (2) unable to get needed medical care; (3) delay in getting prescription medication; (4) unable to get needed medication.
Primary Independent Variables We created a 3-level variable indicating presence and severity of disability, based on the categories of basic and complex activity limitations described by Altman and Bernstein.17 Basic activity limitations were identified by affirmative responses to one or more MEPS survey questions about limitations in physical functions such as walking, lifting, standing, bending, reaching, or grasping; cognitive limitations including confusion or memory loss or difficulty making decisions; and difficulty with vision (while wearing glasses, if used) or hearing (with hearing aid, if used). We also included individuals who used assistive devices such as wheelchairs or walkers. Complex activity limitations were determined by an affirmative response to one or more MEPS items about needing assistance with activities of daily living (eg, bathing, dressing) or instrumental activities of daily living (eg, paying bills, going shopping), or having limitations in work, housework, social, or recreational activities. We grouped respondents into the following 3 categories: (1) no basic or complex activity limitations (nondisabled reference group); (2) limitations in basic activities only; and (3) limitations in complex activities. Race and ethnicity were grouped into a single variable with the following mutually exclusive categories: non-Hispanic white, non-Hispanic black, non-Hispanic American Indian/Alaskan Native (AIAN), non-Hispanic Asian/Native Hawaiian/Pacific Islander (AHPI), non-Hispanic Multiple races; or Hispanic of any race. www.lww-medicalcare.com |
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Covariates We included the following sociodemographic variables in our analyses: age (18–29, 30–39, 40–49, 50–59, and 60–64 y), sex, family income as percent of the Federal Poverty Line (Z400%, 200% to
