This study demonstrates that vulnerability can be operationalized as a profile of multiple enabling risk factors to present a more comprehensive view of unmet health care needs due to cost. Regardless of race/ethnicity, having low income, lacking insurance coverage, and not having a regular source of care combine to create substantial barriers to accessing needed health services. This study further demonstrates that a substantial proportion of U.S. adults (about 1 in 5) has multiple risk factors for unmet health care needs, and that these risk factors create up to 5-fold differences in rates of unmet needs (e.g., delayed medical care) between the highest and lowest profiles, regardless of race/ethnicity. This view of vulnerability in the United States is even more striking when we consider that individuals with poor health status are among the most likely to report delayed or missed care.
Interestingly, our study shows that both before and after adjusting for the study covariates, whites were actually more likely than other racial and ethnic groups studied to report delayed or missed care due to cost for each type of health service. After controlling for each other vulnerability factor, minorities had 0.40 to 0.80 lower odds of reporting delayed or missed care than whites. Because minorities have lower income, are more likely to be uninsured, are less likely to have a regular source of care, and have poorer health status than whites, it is difficult to believe that whites are more likely to have delayed or missed needed care.
One possible explanation for this finding is that whites may have different ideas or perceptions of health needs, or a greater belief in their ability to access care than other racial and ethnic groups. This may contribute to greater reporting of delayed or missed care because whites may feel more empowered to obtain care and speak up when their health care needs are not being met. It is also possible that minorities may have lower expectations than whites for health care (owing to a long history of difficult interactions with the health care system) and consequently are less likely to report an unmet need when a health need is not addressed.36
Lower health literacy (including where to go to obtain needed health services) among some racial/ethnic minority groups may also contribute to lower reported rates of unmet needs.37,38
Lacking a sense of empowerment to address health care needs may stem from several sources. Minorities are less likely to have health insurance, and more likely to have public coverage (for which there is little cost sharing), both of which may discourage a sense of an entitlement to care. Similarly, racial/ethnic minorities may be more likely to believe that the health system is unable to meet their health needs (resulting in lower expectations for care) due to discrimination, distrust, negative prior interpersonal experiences in care, or poorer quality of care.39–45
Adding to the interpretation of the data, several sociodemographic factors were also strongly associated with unmet needs due to cost (data not shown). In particular, poor health status was associated with a higher likelihood of an unmet need (odds ratios ranging from 2.43 to 4.06; all P <.001), suggesting that those with the greatest health care needs are not having them adequately met. Younger age, female gender, not being married, and having lower education were all independently associated with a higher odds of having an unmet need for most types of care. These relationships may suggest that differing perceptions of health needs may contribute to differences in reports of unmet needs across groups.
Low income, no health insurance coverage, and lacking a regular source of care are closely related risk factors that build upon each other to influence the likelihood of having an unmet health need due to cost. From both the logistic regression and the comparison of all the different combinations of risk factors, lacking health insurance appears to have the strongest association with unmet health needs, followed by family income and having a regular source of care. There may be several different mechanisms underlying the effects of these factors on obtaining needed care. For example, health insurance and income influence the ability to purchase health care services and are essential factors in assuring access to a range of primary and specialty care services. Having a regular source of care means that, above and beyond the financial ability to obtain care, a person identifies with a health care provider or place of care from which they have been able to readily obtain health services.
Overall, our study suggests that the potential determinants of delayed or missed care are multifactorial. Reducing disparities in obtaining needed health care services for vulnerable populations will, therefore, likely require multiple clinical or policy strategies. To ensure that racial/ethnic minorities obtain needed health care services, health systems may need to address language difficulties, cultural beliefs, and practices, and ensure that all adults feel empowered to obtain care. Reducing disparities associated with SES will require attention to assuring health insurance coverage, but may also require attention to factors not assessed in this study such as the level of education (which is related to income, health behaviors, and health care seeking) and occupation (which may limit the flexibility in where and when health care services are sought).
Furthermore, providing insurance coverage to the uninsured continues to be an important enabling factor in obtaining care, but is an incomplete solution to assuring that needed health care services are obtained.21,28
Efforts to propagate the concept of primary care and encourage the linkage of adults with a regular source of care or “medical home” build upon health insurance to improve potential access to care,46
though there remains debate about what type of regular source of care is the most effective (e.g., the setting of care, and linkage with a specific provider vs team care).23,29,47
There are several limitations to this study. First, the risk factors included in the vulnerability profiles were meant to be illustrative and not exhaustive. The risk factors reflect primarily (though not entirely) financial risks for not obtaining needed care. Other risk factors that could be taken into account including demographics such as language, educational level, and marital status; provider factors such as availability, accessibility, and continuity; and health plan factors such as cost sharing and reimbursement for delivery of primary care services. We selected 4 key risk factors based on demonstrated associations with access to care in the literature. Other studies might consider combining additional or different risk factors to examine the robustness of these findings.
Second, the measures of unmet needs assess delayed or missed care due to costs but do not assess delayed or missed care for other potential reasons such as a lack of transportation, availability of providers, or discrimination. The data are also reported by respondents and may not accurately represent the presence of unmet health care needs. Because the unmet need questions in the NHIS did not provide guidance on what constitutes a health need, the unmet need measures may be less likely to capture conditions that are less easily recognized by patients as requiring medical care (e.g., obesity, hypertension). Perceived health needs may be susceptible to different personal conceptualizations of health needs and beliefs regarding what services should be received. On the other hand, health care should always meet the needs of individuals, and because individual perceptions of health needs are the strongest drivers of care seeking, it is important to assess how these patient-perceived needs are being met.
Third, due to the limitations of secondary data analysis, the study was not able to account for managed care insurance type. Managed care plans are constantly studied for their influence on access to care, particularly for vulnerable populations.48–52
Because most Medicaid plans have switched to managed care, racial/ethnic minorities and lower-income adults are more frequently enrolled in managed care plans, and thus may be most strongly affected by managed care in analyses of unmet needs. Fourth, we did not account for more complex subgroupings of race/ethnicity or SES (i.e., through education and employment) that may reveal more complex findings than are presented here.53–56
In conclusion, this study demonstrates that vulnerability may be operationalized to account for multiple risk factors through the use of profiles. These profiles revealed a distinct dose-response relationship between the number of enabling risks and unmet health care needs due to cost. Because of these interactive risks, strategies to reduce disparities for vulnerable populations should simultaneously address these co-occurring risks, rather than continue fragmented approaches of targeting single risk factors. More integrative approaches will likely require greater partnerships between medical and social sectors in designing interventions for vulnerable populations. Barring these integrated approaches, it is unlikely that substantial gains will be made in improving access to needed health and dental services among vulnerable populations.