Sunday, December 10, 2006

Missing the Point: The Need for Public Health to Redefine Access to Healthcare – Rachel Heafield

There is a big debate in the field of public health of whether access to healthcare is the main cause for health disparities among different populations. While some public health specialists argue that in order to alleviate health disparities everyone must have access to healthcare (Andrulis, 1998) others advocate that access to health care is not the root cause of these health disparities (Ross & Mirowsky, 2000; Pincus, Ester, DeWalt, & Callahan, 1998). But what does access to health care mean? For many public health officials, access to health care means health insurance status. However as shown below, simply having health insurance does not guarantee a person has access to healthcare. There are many factors, such as discrimination and access to transportation, which can become barriers to gaining access to healthcare. Unfortunately, these factors are often not included in the public health’s definition of access to healthcare. If public health specialists wish to mitigate and resolve the health disparities in our healthcare system, it is imperative that specialists properly assess all aspects that factor into access to healthcare. In order to properly assess access to healthcare, public health practitioners must first broaden their definition of access to health care to include other factors besides insurance status. By not broadening this definition, the field of public health will truly fail to understand the barriers to access to health care and thus be ineffective in mitigating health disparities in healthcare.

It should be mentioned that not every public health specialist believes access to health care simply equates health insurance status. Some argue against this limited view and suggest that multiple factors besides health insurance are present (Guillford, Figueroa-Munoz, Morgan, Hughes, Gibson, Beech, & Hudson, 2002). So what are these factors? In this paper, we will review factors such as costs, transportation and location of health care facility, time, discrimination, and language barriers about the health care system. We will also look at health insurance status and how it is not static, but fluid. Finally, we will look at the quality of health care and how this might be improved using the model called concordance. As shown below, all these factors play a critical role in access to healthcare.

Even though people may have health insurance, they may not have access to health care due to cost concerns. Bodenheimer and Grumbach (2002) write that, “Health insurance does not guarantee financial access to care. Many people are underinsured, i.e., their health insurance coverage has limitations that restrict access to needed services.” Costs can range from costly treatments such as prescription drugs, transportation costs, and loss of work/income while at the health care facility. The costs can certainly add up if the health care is needed on a regular basis for chronic diseases such as diabetes, cancer, and HIV. Pregnancy is also condition that needs monitoring and support from a health care facility and thus can be costly due to all the visits recommended. Costs can also be higher if the person lives very far away from the health care facility (Guillford et al., 2002). Thus a person without a large income may not be able to go to his or her health care provider simply because it is too expensive. Thus even with health insurance, a person may not have access to healthcare.

As briefly mentioned, location of the health care provider and transportation are access to health care factors. If the desired health care facility is too far away, it may be impossible for certain populations to obtain access. It could be that the facility is not very far away, but there is no mode of transportation the person can realistically use. For example, if a person does not have a car, he or she can be greatly disadvantaged if there is no adequate form of public transportation around. However, it should be mentioned that simply having a health care facility near a person does not mean he or she is close to his or her health care provider. A health care facility may not accept a person’s form of insurance and even if they do, the provider may have too many patients for a person to be admitted in the near future. A health care facility provider may not specialize in the person’s condition thus forcing the patient to look elsewhere for care. For example, a person with cancer may need a health care facility that specifically deals with oncology care. However if the facility does not, the person may have to travel great lengths to find a place that does. Another major example is abortion. Obtaining an abortion can greatly be affected by location since many health care facilities do not perform abortions (Bodenheimer & Grumbach, 2005). Public health researchers thus should be aware of this especially when they are performing studies that look at geography and health care provider.

It should be mentioned that time it of itself is an important factor. While time away from work can be costly, it can also be problematic to leave young children alone if no one else is able to watch over them. Time at the health care facility can also be long and thus can be frustrating especially if a patient has waited a long time and still has not received any care. Gullford et al. (2002) thus advocate restructuring the health care system in order to reduce the amount of long waiting lines and waiting times that can be a barrier for patients.

Another factor that can bar people from health care is discrimination. Racism, sexism, homophobia, ageism, and perceptions about different cultures and groups can all contribute to hindering patients from obtaining proper health care. In a recent study, researchers found that doctors treated and diagnosed their patients with myocardial infarction different solely depending (type of insurance and social economic status were controlled) on their race and gender (Schulman, Berlin, Harless, Kerner, Sistrunk, Gersh, Dubé, Taleghani, Burke, Williams, Eisenberg, & Escarce, 1999). Bodenheimer and Grumbach (2002) explain that, “Medicine in the United States has not escaped the nation’s legacy of institutionalized racism toward many minority groups.” Thus for many minorities discrimination is faced everywhere, even in the medical world. For minorities are often unable to obtain proper care and even if they are, are often not given certain beneficial treatments. It should also be mentioned that different ethnic and racial groups have different views on disease and how to approach diseases. But even though for example Latinos have a more fatalistic view on cancer than non-Latino whites, “these differences in beliefs do not explain differences in the use of cancer-screening services among Latinos and non-Latinos (Bodenheimer & Grumbach, 2002).

With regards to sexism, women report more dissatisfaction and problems with their physician since many feel their physicians talk down or do not take their ailments serious (Bodenheimer & Grumbach, 2002). Women, like other minorities, often are not prescribed certain beneficial treatments and sometimes they can be given treatments such as hysterectomies and cesarean section deliveries that unnecessary (Bodenheimer & Grumbach, 2002). Women often are the primary childcare person in a family and thus may have trouble balancing taking care of their kids and seeing a health care provider for themselves and/or for their child.

The Gay, Lesbian, Bisexual, and Transgender (GLBT) community also faces discrimination. The GLBT Health Access Project found that many in GLBT community do not seek a healthcare provider for themselves or for their families due to fear of discrimination (Clark, Landers, Linde, & Sperber, 2001). Carroll (1999) found that there was a lack of information and awareness regarding lesbians’ health. For example, many physicians wrongly assume that lesbians have no risk for STD or contracting HPV. Lesbians may thus have more health complications such as HPV simply because their physicians did not think common prevention tests like Papanicolaou smears applied to lesbians (Carroll, 1999). As a result, many patients (lesbians as well as other minorities) are receiving inadequate healthcare simply due to discrimination.

Another factor that is somewhat tied into discrimination is language barriers. If a patient does not speak English very well (assuming he or she is in America), many problems can occur. And even though American Sign Language (ASL) is an American language, very few people in the healthcare field can actually communicate with ASL (Iezzoni, Davis, Soukup, & O’Day, 2002). Thus, a lack of people speaking ASL can be detrimental for a deaf person’s health. Like ASL, Spanish is a language spoken throughout the US, but it can be a barrier if the healthcare provider does not speak Spanish. In the study conducted by Flores, Abreu, Olivar, & Kastner (1998), the researchers found that many Latino parents cited that, “language problems were the single greatest barrier to getting health care for their child” (Flores, Abreu, Olivar, & Kastner, 1998). Meanwhile, O’Leary, Federico, and Hampers (2003) found that residents at a hospital where there was a major Hispanic population had varying trouble with patients who could not speak English. If the resident could speak fluent Spanish there was not as much trouble seen by the resident. However, if the resident did not speak Spanish very well, the resident found it hard and sometimes even avoided the Spanish speaking patients all together. If they did attempt to help the patient, they often used their own inadequate Spanish skills or employed fellow family members to translate rather than use the in-house or call a medical translator since the latter two were seen as more frustrating to use. Many problems can occur from this such as the resident does not understand and misdiagnoses or the patient does not understand and does not use their given treatment properly. Unfortunately, this translation problem can apply to any health care provider and patient when neither speaks the same language.

All the factors above demonstrate that they can be barriers to access to healthcare regardless of a person’s health insurance status. However, even though many public health studies place access to healthcare solely on insurance status, they do not mention that insurance status can and often changes. Studies such as Ross and Mirowsky (2000) and Pincus et al. (1998) did not take into account that insurance status is dynamic rather than a static phenomenon. For example, a person may have had employee based insurance, but the person was laid off and is now uninsured. Even if the person finds a new job, his or her new business may not be able to afford employee based insurance and thus the person remains uninsured. This example is quite common due to the recent changes in the US economy (Bodenheimer & Grumbach, 2002). Bodenheimer and Grumbach (2002) state that the US economy has shifted away from high paying full-time jobs with employee based insurance to low-wage part time jobs that do not offer employee based insurance. A person may also loose his or her insurance if the person’s spouse looses his or her job (Bodenheimer & Grumbach, 2002). A person could also divorce his or her spouse and thus loose insurance that was through the person’s spouse (Bodenheimer & Grumbach, 2002). These are just a few examples that demonstrate health insurance status can change a lot through the years. Public health practitioners must also take this into account if they are to fully understand and assess access to healthcare.

These factors are important since they show access to health care within a social context. Even if the people have a great desire to take care of their health and wish to visit their health care provider, they cannot for various reasons. Even if all these factors somehow are solved, there are still problems. One problem is the quality of healthcare. One model that wishes to help quality is concordance. Thambirajah (2005) explains that concordance should replace the model of patient compliance. Compliance refers to the patient’s motivation and action in completing the treatment the physician has prescribed. However this model has been heavily criticized since it often devalued the patient’s autonomy and dignity (Thambirajah, 2005). As already briefly noted, the feeling of being talked down to can lead to patient to have dissatisfaction with the physician and perhaps have dissatisfaction with the whole health care system itself. Instead, Thambirajah suggests that the concordance model should be used. He states that, “Concordance describes the process whereby patients and professionals exchange their views on treatment and come to an agreement about the need (or not) for a particular treatment” (Thambirajah, 2005). This model allows patients to discuss their beliefs and views of medicine and allows physicians to obtain a better treatment for the patient. Ironically, this could mean that the patient is more likely to take the treatment or be compliant if he or she had a sense of control and autonomy in the decision. While the model does not cover other parts of health care that could also be altered for higher quality, it is certainly a step in the right direction. A patient may be willing to travel long distances, spend money, and wait if their physician understands and treats the patient with respect and dignity.

In conclusion, health insurance status is not the only factor that can contribute to access to healthcare. Rather, access to healthcare has a number of factors and they should be assessed by public health specialists. If public health officials want to create solutions to mitigate the health disparities between different groups in America, they must first understand all the factors that play a role in access to healthcare. In order to do this, public health specialists must broaden their definition of access to healthcare. If they do not, public health may never be able to effectively intervene and resolve the health disparities in America.


Andrulis, D. P. (1998) Access to care is the centerpiece in the elimination of socioeconomic disparities in health. Annals of Internal Medicine, 129, 412-416.

Bodenheimer, T.S. & Grumbach, K. (2005). Understanding health policy: A clinical approach. Access to health care (3). New York, NY: Lange Medical Books/McGraw-Hill.

Carroll, N. M. (1999). Optimal gynecologic and obstetric care for lesbians. Obstetrics and Gynecology, 93, 611-613.

Clark, M.E., Launders, S., Linde, R., & Sperber, J. (2001). The GLBT health access project: A state-funded effort to improve access to care. American Journal of Public Health, 91, 895-896.

Flores, G., Abreu, M., Olivar, M.A., & Kastner, B. (1998). Access barriers to health care for latino children. Archives of Pediatrics Adolescent Medicine, 152, 1119-1125.

Gulliford, M., Figueroa-Munoz, J., Morgan, M., Hughes, D., Gibson, B., Beech, R., & Hudson, M. (2002) What does ‘access to health care’ mean? Journal of Health Services Research and Policy, 7, 186-188.

Iezzoni, L. I., Davis, R.B., Soukup, J., & O’Day, B. (2002). Satisfaction with quality and access to health care among people with disabling conditions. International Society for Quality in Health Care, 14, 369-381.

O’Leary, S. C. B., Federico, S. & Hampers, L. C. (2003). The truth about language barriers: One residency program’s experience. Pediatrics, 111, 569-573.

Pincus, T., Esther, R., DeWalt, D.A., & Callahan, L. F. (1998). Social conditions and self-management are more powerful determinants of health than access to care. Annals of Internal Medicine, 129, 406-410.

Ross, C.E. & Mirowsky, J. Does medical insurance contribute to socioeconomic differentials in health? The Milbank Quarterly, 78, 291-321.

Schulman K.A., Berlin, J.A., Harless, W., Kerner, J.F., Sistrunk, S. Gersh, B.J., Dubé, R., Taleghani, C.K., Burke, J.E., Williams, S., Eisenberg, J.M., & Escarce, J.J. (1999) The effect of race and sex on physicians’ recommendations for cardiac catheterization. The New England Journal of Medicine, 340, 618-626.

Thambiragah, M.S. (2005). Psychological Basis of Psychiatry. Treatment compliance, adherence and concordance (5). Edinburgh, UK: Elsevier Churchill Livingstone.


Anonymous Jessi H said...

Good paper Rachel! So many times, we simply toss out phrases like "access to healthcare" without really considering what such statements really mean. Your paper does a great job exploring the deeper meaning behind the terminology.

6:06 AM  

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