1. DISPARITIES IN ACCESS: Reality vs. Perception Peter J. Cunningham Jack Hadley 2008 AcademyHealth Annual Meeting June 8, 2008, Washington D.C.

2. Survey Measures of Unmet Need Used to examine disparities in access “Need” is usually self-defined, not clinically-based Can be influenced by differences in perceptions or expectations Low expectations, low perceived seriousness of medical problems may reflect “non-financial” barriers to care.

3. General Measures of Unmet Needs Uninsured consistently report more unmet need then insured Lower access by blacks, Hispanics not always reflected in general unmet need measure Speculate that lower perceived need for care among some groups may account for lack of disparity Suggests general unmet need measures are inadequate for assessing racial/ethnic disparities

4. Objectives Examine unmet need as reported for specific medical symptoms Compare general and symptom-specific measures of unmet need in terms of insurance-related and racial/ethnic disparities Do differences in perceived need explain access disparities? Do coverage differences explain racial/ethnic disparities?

5. 2003 CTS Household Survey Included module for care-seeking in response to 15 symptoms (Based on measure used by David Baker and colleagues) Symptoms identified by panel of physicians who agreed that care should be obtained Module asked for subsample (all uninsured adults, all elderly, and random sample of insured) 3,299 persons reported to have at least 1 of 15 symptoms Follow-up questions to determine whether care received, perceived need, activity limitation.

6. Sequence of unmet need questions All adults (36,520) Ask whether care was perceived as needed 16,266 screened for symptom module Ask whether care received for symptom 3,299 reported symptom in last 3 months Any unmet need in prior year

7. Unmet Need Measures General unmet need measure (asked of all persons) Symptom-specific – did not receive care for reported symptom Perceived need for care in response to specific symptom

8. Symptoms Reported Serious Symptoms% Shortness of Breath8.6 Chest Pain 1+ Minute5.7 Loss of Consciousness 2.7 Blurry Vision6.3 Frequent Severe Headaches 14.4 Sadness/ Hopelessness 10.4 Lump or Mass in Breast 1.2 Morbid Symptoms% Back or Neck Pain9.5 Cough with Yellow Sputum 12.4 Anxiety, Nervousness3.2 Pain in Hip or Knee8.9 Sprained Ankle3.4 Fatigue, Extreme Tiredness 9.6 Difficulty urinating (males)0.6 Difficulty Hearing3.1

9. Sample Distribution (Weighted) General Adult Sample (n=36,520) Persons with New Symptom (n=3,299) Insurance Private59.554.8 Medicare16.213.5 Other9.013.8 Uninsured15.317.8 Race/Ethnicity White71.567.4 African-American11.311.4 Hispanic12.415.9

10. Comparisons of Unmet Need Measures (Based on symptom sample, n=3,299) Symptom-Specific Measure General Unmet Need Did Not Get Care Thought Care Was Needed Insurance Coverage Privately Insured10.3*52.4*57.5 Uninsured23.379.655.8 Race/Ethnicity White14.649.760.8 African-American12.357.761.7 Hispanic12.766.5*62.3 * Difference with uninsured, white statistically significant at.05 level

11. Control Variables for Logistic Regressions  Symptom Information Specific symptom When first occurred within past 3 months Severity (days of limited activity due to symptom) Associated with pregnancy  General Health Status, Age, Gender  Family Income, Education  Family Structure  General Care-Seeking Behavior

12. Odds Ratios for Racial/Ethnic Disparities Symptom-Specific Measure General Unmet Need Did Not Get Care Thought Care Was Needed Unadjusted Hispanic0.852.01*1.07 African-American0.821.381.04 Fully adjusted Hispanic0.571.181.37 African-American0.671.041.25 Coverage Excluded Hispanic0.611.441.36 African-American0.681.031.25

13. Conclusions Insurance-related disparities consistent across different measures of unmet need Racial/ethnic disparities in access extremely sensitive to the measure used Hispanics more likely to have unmet need in response to specific symptoms, compared to more general measure Differences in perceived need for care do not explain disparities in access Coverage differences explain some, not all of racial/ethnic disparities in unmet need

14. Policy Implications Insurance coverage expansions will eliminate insurance-related disparities, but not racial/ethnic disparities Suggests that “non-financial” barriers may play a role in lower access among Hispanics. Study limited to acute symptoms, not chronic conditions Hispanics treated as homogeneous group  Nonfinancial barriers may be greater depending on country of origin, citizenship, English-language proficiency, length of time in country, etc...