Among middle-age and older adults in South Los Angeles, we observed higher levels of reported delays and variation in these outcomes by age, race and insurance status. Independent of insurance status, persons 50–64 years of age reported more delays in care and problems receiving needed medical care compared to those over age 65 years. The differences in delays and receipt of preventive care were even larger among those who were younger and uninsured.
An important feature of this work for our community stakeholders was the ability to benchmark study results with established national targets for delays in care and preventive service use. Compared with Healthy People 2010 (HP2010) national targets for delays in access to care (< 7%), the rates in our study were more than double for insured adults ages 50–64 years, and more than six-fold greater uninsured adults ages 50–64 years.,25
The rates reported by both insured and uninsured adults in the younger group fall far short of the HP2010 national objectives and far below the expectations of community stakeholders.
As in prior studies, we found those who are middle-aged without insurance are a high risk-group for delays in care and problems receiving needed medical care.8,26
However, our findings underscore that adults ages ≥65 years and older reported problems getting needed medical care that were greater than expected for this population. This is consistent with studies that suggest that Medicare coverage decreases but does not eliminate racial, ethnic, and socioeconomic health disparities in this age group.9,27–31
Older minorities who are uninsured and subsequently enroll in Medicare may have greater morbidity, greater health decline and, therefore, require more intensive and costly care after enrollment in the program.32,33
Our findings reinforce the importance of insurance in our urban African American and Latino study sample, but identify potentially remediable gaps in preventive service use when compared to Healthy People 2010.
HP 2010 objectives have also identified target rates for vaccination and preventive care that can be used for community program and intervention planning.25
For South Los Angeles residents, the adjusted rate of influenza vaccination was not above 60% for any group, compared to the HP2010 goal of 90%; for those who reported having a pneumococcal vaccine, the vaccination rate was less than 50% for all groups compared to the HP2010 goal of 90%. We observed rates of influenza vaccination higher than CDC reported national rates of 30% for non-Latino African Americans and Latinos for those ages 50–64 years, but still far from the goal set in HP2010. Additionally, the rates for both influenza and pneumococcal vaccination among those who are insured and age 65 years and older were still far from the targeted goals.
Future community based participatory research studies should examine the reasons for delays in care and lower use of preventive services. Our community partners suggested several reasons for our findings, and identified areas for future investigation. Our partners thought that delays in care may be due to lack of transportation, competing demands for time and money, and difficulty with accessing specialty services in our older population. To address these delays in care, community partners wanted to examine the capacity of the healthcare system to deal with older patients with chronic diseases in this community. Community partners thought that decreased preventive service use was linked to service availability, but additional issues remain in understanding the importance of certain services and overcoming distrust for immunizations. Our partners proposed the creation of a community action plan that would be dual-pronged to: 1) improve health education and outreach and 2) examine the capacity of the healthcare system for appointments, care coordination and education. Some specific suggestions included providing immunizations and colon cancer screening in a mobile van setting to build on the success of mobile mammography. Other partners wanted to have older residents educate other older persons about the important of getting timely care and preventive screening. This work is one example of how communities can address healthcare needs and share their voice in research agendas. Other communities can use this study as a model for approaching joint problem solving through identifying needs and vulnerabilities for older populations.
Despite low vaccination rates, this South Los Angeles cohort has generally high mammogram and colon cancer screening rates that are approaching or exceeding HP2010 goals. The HP2010 goals are set at 75% for mammography compared to impressively high rates in our study at over 90%. Ongoing breast cancer screening efforts should continue to focus on uninsured populations. For colonoscopy, our study demonstrates rates of screening at almost 70%, where national rates are often less than 40 % and HP 2010 sets goals of 50%.34,35
We distinguished different patterns in vaccination and cancer screening between both the late middle aged and elderly.
The success in cancer screening may potentially shed light on important local interventions. Future efforts should be directed at exploring the differences in community perception between vaccination and mammography to develop targeted outreach interventions. Effective community based breast cancer screening targets uninsured and low-income women through mammogram mobile clinics and media campaigns. These results could inform future combined interventions for vaccination or other cancer screening promotion efforts.
Our study has three key limitations. First, participants were recruited from one area of Los Angeles County, South Los Angeles, a community that recently faced the closure of a major urban public hospital. Our survey was performed after hospital closure and may represent a vulnerable and transient period in time. Thus, these findings may not generalize to other low income areas nor can we make inferences about the role of hospital closure from this cross-sectional design. Through our community based research methodology, we focused on measures important to community stakeholders. Second, by using a random sample of households with listed phone numbers, we may have oversampled those age 65 years and older who are retired, or younger persons who are unemployed or disabled. Finally, delays and the use of preventive services were obtained by self-report and not by chart review, which could have introduced recall. To mitigate these biases, however, we used previously tested measures that have been developed to limit these methodological challenges.24
As the numbers of uninsured decline after health reform implementation, focusing on those uninsured in middle age may be an important population for insurance expansion. These findings underscore the potential for future reductions in delays in care and increases in receipt of preventive services that may result from expansions of insurance coverage. As insurance coverage expands, visit and prescription co-pays may increase and cause further strain on older populations. Future opportunities for cost savings may also be captured through improved screening and disease prevention.36
Ongoing efforts to develop a community-based integrated care network37
may be able to address these concerns as community stakeholder plan to re-open the closed Martin Luther King Hospital.