While there is no single, universally accepted definition of the underserved, for the purpose of this paper, we characterize this population simply as those living in the United States who do not have adequate access to health care services. They share one or more of these characteristics: they may be poor; uninsured; have limited English language proficiency and/or lack familiarity with the health care delivery system; or live in locations where providers are not readily available to meet their needs. Members of ethnic and racial minority groups are not by definition “underserved”, but are disproportionately found among their numbers. Disparities in health status and access to health care that leave these populations worse off relative to others have been well documented by HHS over the last fifteen years.
Of the diverse set of groups represented among the underserved, perhaps disparities in health and health care of racial and ethnic minorities have been most thoroughly documented. Recently the Commonwealth Fund released a chart book analyzing data on the status of racial and ethnic minorities in the United States (available at http://www.commonwealthfund.org/publications). This effort compliments the primary federal government publication on health disparities, the “National Healthcare Disparities Report”, released annually by AHRQ with the last release for 2007 occurring in February of this year (available at http://www.ahrq.gov/qual/qrdr07.htm).1 Findings from both publications demonstrate persistent disparities in health status, access to health insurance, access to critical health care services such as a primary care, home and specialty care, and in the quality of care received by disadvantaged groups.2 The Commonwealth summary shows that as of 2006, data from surveys conducted by federal agencies including AHRQ, the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) demonstrate higher rates of self-reported poor health status, chronic disease and disability, life expectancy at birth, obesity, cancer (especially breast and colorectal), heart disease, diabetes, HIV/AIDS and other chronic illnesses among blacks compared to non-Hispanic whites in the United States. The chartbook also demonstrates specific types of behavioral and health status disparities for other racial and ethnic groups such as higher smoking prevalence and mental distress among American Indian and Alaska Native populations, and higher incidence of some infection-related cancers among Hispanics.
In terms of access to health care, the Commonwealth chart book shows greater percentages of Hispanic adults and adults of other racial and ethnic minorities reporting they have no doctor compared to whites, with the Hispanic average for this question being 2.5 times that of whites. They also show that blacks and Hispanics are less likely to report private physicians as their usual source of care relative to whites and are more likely to report going to community health centers and emergency rooms as their usual source of care or having no usual source of care. Hispanics also are much more likely than whites to report being uninsured during a given year. Some of these disparities are heavily mediated by income and are reduced or eliminated by controlling for this characteristic, suggesting the importance of viewing the low income population broadly as part of the underserved. However, many of these disparities, particularly as they relate to health status among blacks and access and insurance disparities issues among Hispanics persist even after adjusting for income.
Finally, the data on racial and ethnic disparities also demonstrates important differences in the quality of care delivered to ethnic and racial minorities. Primary care physicians who treat predominantly black patients report being unable to provide high quality care to all of their patients at a higher rate than similar physicians who treat a predominantly white population. Hispanics and Asians, on average, report wait times longer than others to get a doctor’s appointment. Hispanics also report being less likely to have received recommended screenings such as blood cholesterol and cancer screenings (colorectal and cervical) relative to others. Racial and ethnic minorities in general are less likely to have received a pneumococcal vaccination, a dental visit in the past year (for children), and first trimester prenatal care (women) than the equivalent non minority populations.3
Racial and ethnic minorities aside, evidence from research shows that low-income populations generally experience more disjointed care, being twice as likely to lack a regular source of care.4 Those with low socioeconomic status (SES) have limited access to quality health care as it relates to primary, specialty, dental and behavioral care relative to others.5 Additionally, lower SES patients experience lower rates of preventive care and chronic disease management.6 7 We found no definitive evidence that rural residents, as a group, experience lower quality care; however, low population density in rural areas makes care less convenient and more costly. Additionally, rural populations are more likely to be uninsured and of low income, making these areas more susceptible to the barriers faced by low-income populations.8
The AHRQ National Healthcare Disparities report cited above focuses heavily on disparities in measures that address quality of care. AHRQ and the Inter-Agency HHS work group that contributes to this report provide data on 211 measures including 41 core measures on quality and access. Comparisons are produced across various demographic groups including blacks compared to whites, Asians compared to whites, Hispanics compared to non-Hispanics, poor compared to high income and American Indian and Alaskan Native compared to whites. Findings from the latest version of this report for 2007 show some reduction in previously identified disparities facing segments of the underserved for measures such as adequacy of hemodialysis treatment and childhood vaccination rates for blacks versus whites. However, the findings also demonstrate the persistence of disparities and little or no improvement over time in the disparities associated with many measures since the start of this initiative.9
Given findings from the research and analysis presented above, as well as a wealth of additional evidence suggesting similar trends of poor health and access to quality health care among groups comprising the underserved, improving care to this group represents an important challenge for policy makers and program leaders in federal and State government. Some have speculated that increased automation in health care and use of advanced IT could exacerbate rather than address these disparities if a “digital divide” threatens to leave underserved populations behind, resulting in a situation where only those who have historically enjoyed steady health insurance and access to private medical providers would benefit from these advances. At the same time, many of the most promising potential improvements in care due to health IT adoption including clinical decision support to alert providers to the need for increasing use of screenings, preventive care, and behavioral counseling and patient registries that facilitate active management of chronic illness, could be of disproportionate benefit to the underserved. Finally, as the use of technologies such as PHRs serve to empower patients to take a more active role in their health care and overall well-being, it is increasingly important to recognize and address barriers to making the benefits of these technologies readily available to underserved populations who stand to benefit the most.