Learning Objectives
By the end of this section, you will be able to:
- Explain how lack of access to health care impacts one’s health goals
- Identify how cost can be a barrier to obtaining healthcare needs
- Describe how disparities in treatment are a disadvantage to the delivery of health care
Healthcare access is a patient’s ability to get healthcare services such as primary, secondary, and tertiary care when and where they are needed. Although a wide range and variety of healthcare systems and facilities are available in the United States, barriers to care may prevent large groups of people from receiving the types of care they need (Agency for Healthcare Research and Quality [AHRQ], 2018a; Center for Health Ethics, n.d.). Recent changes to laws and the creation of new systems, such as the Patient Protection and Affordable Care Act (ACA), have increased access. The goal of the ACA was to improve access to health insurance for Americans, offer subsidies to help pay for health insurance, and make health insurance more affordable. However, millions of Americans still lack necessary health care.
Barriers to health care may develop in a variety of ways. Some patients are unable to access healthcare services, some cannot afford them, and others experience lower quality treatment options. As you read, consider additional barriers to health care—ones that you can imagine or already know about.
Barriers to Using Healthcare Delivery Systems
Barriers to using healthcare delivery systems are often related to lack of access, or the ability to obtain healthcare services when and where patients need them (Huot et al., 2019). These types of barriers include geographical (where people live versus where providers are), timing (when providers are available versus when patients need them), and availability (having enough providers available and in practice for the patients who need them). Even the ability to access transportation can be a substantial barrier to using healthcare delivery systems. Other barriers include sociocultural issues, such as language, religion, and race or ethnicity. Together, these barriers can be as problematic for accessing health care as cost or lack of insurance (Rural Health Information, 2022).
Rural Areas
Individuals who live in rural areas may experience a variety of barriers to accessing the healthcare delivery system. People who live in rural areas are
- more likely to experience provider shortages;
- less likely to have insurance;
- more likely to have to travel long distances to receive care;
- more likely to work in jobs without paid time off work;
- less likely to trust healthcare professionals to give them quality care or to keep their issues private; and
- more likely to have limited health literacy (a patient’s ability to understand instructions and education from their providers and be able to actively participate in their care) than other populations (see Chapter 4 Health, Wellness, and Community-Based Health Care) (Rural Health Information Hub, 2022).
These barriers may be experienced in all locations, but they are often magnified for those living in rural areas. Residents in rural communities may also experience difficulties in unique ways. For instance, recruiting medical personnel is more difficult in rural communities because these areas are far from popular community resources and attractions. In addition, the rate of closure for rural hospitals is higher than for urban hospitals, particularly in the South. This results in a disproportionate impact on people who are socioeconomically disadvantaged and people of color. People who live in these communities then must travel farther than before for care. Lack of public transportation in rural areas can make the problem even more significant (Rural Health Information Hub, 2022).
Patient Conversations
Assessing Health Literacy
The following is an example of a patient conversation related to health literacy. Note: newspapers are written at an average 8th- to 10th-grade reading level, and news magazines at a 12th-grade level.
Scenario: The nurse is trying to quickly assess Mr. Smith’s health literacy and asks him questions about reading, education, and learning habits to know what types of education Mr. Smith will respond to best, and how information should be provided.
Nurse: Mr. Smith, can you please read me the information off your prescription bottle?
Patient: Diclofenac. It was ordered by my last doctor. It says take for pain twice daily.
Nurse: Do you like to read? What kinds of things do you read?
Patient: I don’t read much, but I do like the Sunday paper.
Nurse: What was the highest level of school that you completed?
Patient: I got my GED and then finished a two-year college program in accounting.
Nurse: How do you like to learn? By reading about things, discussing them with someone, trying things out, or listening to someone talk to you?
Patient: If I am really interested, I’ll look it up on Google or watch a video on YouTube.
Scenario follow-up: Identifying a patient’s health literacy is a crucial part of patient assessment and is always the responsibility of the nurse prior to educating. If patients are not provided health information and education in a way that they understand, they will not be able to make informed decisions about their own care. While there are some complicated assessments, there are also some simple techniques such as those the nurse used in this conversation to establish a baseline.
Healthcare providers are more likely to work in urban areas than rural areas. This is most true for specialist providers, such as mental health professionals, surgeons, and/or tertiary care providers, but it is even the case for primary care provider (PCP) (AHRQ, 2018c). Table 3.8 offers a snapshot of the differences between percentages of the U.S. population by location as compared to the percentages of primary care providers. For all areas other than urban centers, there is a lower number of PCPs for areas with smaller populations.
| Geography | Percentage of Practicing Primary Care Physicians (%) | Percentage of U.S. Population (%) |
|---|---|---|
| Urban (population >50,000) | 89 | 80 |
| Large rural (population 10,000–50,000) | 7.1 | 10 |
| Small rural (population 2,500–9,999) | 2.6 | 5 |
| Remote rural (population <2,500) | 1.3 | 5 |
The problem of supplying access to health care in rural areas is not just a challenge in the United States; it is a worldwide problem. Several reasons account for physicians choosing urban or large rural locations. Access to good school systems, art and cultural activities, and proximity to modern hospital systems are among the many reasons that physicians seem to prefer urban positions. Last, rural areas do not have as many sites for physician residency in the same way that urban areas do (McGrail et al., 2020; Szafran et al., 2020).
Restricted Daytime Hours
The restricted hours (e.g., Monday through Friday, daytime only) at physician offices and clinics are frequently named as a barrier by patients who need to seek care or those who have to have regular treatment visits (Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health [OASH], 2022). Most working adults are at work or children are at school during the same times that physician offices are open. While restricted hours remain a problem, particularly with the ability to receive secondary or tertiary care and in rural areas, the larger medical community is responding with a variety of strategies:
- extended hours (seeing patients after 5 p.m. and/or before 8 a.m.) at doctors’ offices, clinics, mental health centers, and providers, such as physical therapy;
- convenience care clinics with weekend or extended hours affiliated with large group practices;
- urgent care clinics unaffiliated with large group practices with extended hours and the ability to provide some primary care as well as acute management of mild to moderate illness and injury; and
- virtual visits where patients can use their smartphones, tablets, or computers to meet with a healthcare provider online.
Transportation Issues
Lack of transportation or limited transportation is one of the primary reasons (other than cost) that patients miss scheduled appointments or do not seek care until they are very sick (OASH, 2022). Some areas, generally urban ones, have transportation services that assist patients in getting to appointments; however, they may not be able to afford to use them as there can be a substantial cost involved. Additionally, public transportation for patients with disabilities can be quite complicated, particularly when they must walk to a train or bus stop or when they need assistance entering and exiting vehicles. During the COVID-19 pandemic, the regular concerns of patients with disabilities who have to use public transportation were exacerbated by shelter-in-place orders, and they had additional difficulties gaining assistance with getting into and out of transport vehicles, if they could obtain transportation at all (Cochran, 2020). For patients in rural areas, transportation issues can be even more difficult to overcome because public transportation is often unavailable, and they must rely on their own vehicles (if they have them) or the availability of family or friends to assist in getting them to appointments. Also, their appointments may be at a great distance from their home, particularly if they are seeing specialty or tertiary care providers.
Provider Shortages
Not having enough providers for a given population, or provider shortage, is a severe problem throughout the United States. In response to these shortages, the federal government has designated certain “Health Professional Shortage Areas” (HPSA) (Health Resources and Services Administration [HRSA], 2022) based on geographic areas, specific populations (such as people who are migrant workers or who are without homes), or facilities (such as mental health or public hospitals). In 2021, nationwide there were 8,160 federally designated HPSAs needing primary care practitioners; 7,192 HPSAs needing dental health providers; and 6,464 HPSAs needing mental health providers (HRSA, 2022). Figure 3.12 provides a graphic representation of the numbers of HPSAs in the nation and the severity of their need.
Link to Learning
The HRSA has several tools to find shortage areas and details about them. Check out your own address to see if shortages exist in your area.
Barriers Due to Healthcare Costs
Healthcare costs impact both Americans who have health insurance as well as those who do not (Montero et al., 2022). Regardless of their insurance status, almost half of adult Americans report difficulties affording their healthcare costs, and almost 40 percent have either delayed or not gotten needed medical care (Montero et al., 2022). Further, approximately a quarter of adults report not filling prescriptions, taking less than full doses, or skipping doses due to the costs of medications.
Congress enacted the Patient Protection and ACA in 2010 with several goals (Assistant Secretary for Public Affairs [ASPA], 2022):
- Make insurance more affordable for individuals who fall between 100 and 400 percent of the federal poverty level (an income measure determined annually by the government).
- Expand Medicaid insurance to cover all adults below 138 percent of federal poverty level.
- Support overall changes to healthcare delivery which would lower costs while maintaining or improving care.
By 2023, almost 16 million people were using ACA plans nationwide, and as Figure 3.13 shows, there has been a clear decrease in overall healthcare costs (Centers for Medicare and Medicaid Services [CMS], 2023).
Despite the introduction of the ACA, over 40 percent of people still admit to having healthcare debt, in one of several forms:
- past due or unable to pay;
- paying off over time to a provider;
- paying to a bank or collection agency (when the provider has sold old debt);
- paying to a credit card or revolving credit account (with interest, so paying more); or
- paying to a friend or family member from whom the money was borrowed.
Such medical/dental debts can be a financially harmful issue after a critical health event, even for those with insurance, and almost 60 percent of people worry about the effects of unexpected medical bills (Montero et al., 2022).
Link to Learning
Dental care is the most common type of medical care for patients to delay due to cost (Montero et al., 2022). However, many patients do not realize how important dental health is to overall health. Explore the Mayo Clinic’s web page on oral health to see the importance of dental health to overall health and consider why it is concerning that so many people cut costs with their dental health.
Having Insurance
Simply having insurance is not enough to prevent financial concerns and difficulties accessing health care related to costs. Between one-third and one-half of Americans with insurance worry about whether they can pay for their premium (the amount of money they pay each period to subscribe to their insurance) or afford their deductible (the amount of money someone with insurance must pay a provider before the insurance begins paying) (Montero et al., 2022). Also, dental and vision insurance are often not provided as part of the medical insurance package, so individuals have to either buy separate plans for dental and/or vision or pay out of pocket for these services.
Lack of Income for Public Health Insurance
In 2021, 21.7 percent of Americans were on some type of public health plan such as Medicaid, Medicare, military plans, or the Children’s Health Insurance Program (Adjaye-Gbewonyo & Boersma, 2022). Unfortunately, these programs may not cover all types of services. For example, Medicare does not cover hearing, dental, or prescription drugs (Montero et al., 2022). Patients are required to either pay out of pocket for supplementary plans that cover what the public health insurance does not cover or pay for the services themselves. For patients who are on fixed incomes (such as those who are retired or on disability), such services may be impossible to afford.
Uninsured
Since the ACA marketplace for subsidized insurance went into effect in 2013, the uninsured rate has decreased significantly for all age groups and ethnicities in the United States (AHRQ, 2018a). However, in 2021, 13.5 percent (approximately 30 million people) of adults over 18 years old in the United States still did not have health insurance (Adjaye-Gbewonyo & Boersma, 2022). These individuals are less likely than any other group to receive medical care and are more likely to be sicker and die younger (Adjaye-Gbewonyo & Boersma, 2022).
Barriers Related to Disparities in Treatment
There are also barriers to care that cause disparities (differences that negatively impact one group over another) in treatment between groups. Disparities can be caused by factors intrinsic (related to personal thoughts, values, and beliefs) to patients and providers or extrinsic (related to conditions outside of the individual, systemic issues) to the system as a whole. Intrinsic factors can include patient distrust in healthcare providers, so-called white-coat syndrome, and lack of education about the importance of primary care. Extrinsic factors can include systemic racism and infrastructure.
Distrust in Healthcare Providers
Distrust in healthcare providers, an intrinsic factor, can arise for many reasons, including previous negative interactions; anxiety about working with a provider of a different race, ethnicity, or gender; and poor health literacy (OASH, 2022). When a person’s previous experiences have been poor, it can be difficult to believe that another provider will be any different. Race, ethnicity, and gender concerns may be related to cultural norms, language barriers, or lack of similar life experiences. Poor health literacy can compound all these issues. Individuals with poor health literacy may feel that the provider is being untruthful because they do not understand what the provider is saying.
Link to Learning
Medical mistrust is a significant barrier to effective healthcare delivery and equitable health outcomes. Among Black Americans, historical and ongoing experiences with systemic racism, unethical medical practices, and inadequate healthcare contribute to a heightened level of mistrust in the medical system. Explore a comprehensive analysis of medical mistrust among Black Americans and strategies for addressing it in this article. Addressing this mistrust is crucial for improving healthcare access, adherence, and overall health outcomes in this community.
White-coat syndrome is another example of an intrinsic barrier to effective treatment. White-coat syndrome is when a patient experiences elevated anxiety and mistrust related to working with a healthcare provider. When interacting with a provider, particularly a new one, a patient’s vital signs may be altered, such as elevated blood pressure. White-coat syndrome can happen even to healthcare professionals themselves. It speaks to an internalized anxiety or mistrust related to health care of which patients may be unaware.
Lack of Education
Moving in tandem with issues of health literacy is lack of education regarding the importance of primary care, preventive screenings, and even acute care needs (OASH, 2022). Once they no longer have annual well-child physicals for immunizations, many individuals (particularly those in their 20s to 40s) do not see a physician unless they are ill or injured. The segment of the population who is in generally good health and/or those with poor health literacy frequently do not recognize the value of seeing a primary care physician. These individuals are often the ones who enter the healthcare system at the secondary or tertiary level when they are struck by an emergency. Additionally, many people are unaware of treatments and services available to them, so they do not seek care (OASH, 2022).
Racial Disparities
Despite many initiatives to decrease racial disparities in health care throughout the nation, they remain. These extrinsic disparities are deeply embedded in the culture and healthcare system of the nation. For example, in 2013, 14.6 percent of Americans were unable to get care when they needed it because it was unavailable; however, there were significant differences among races (19.8, 19.2, and 13.2 percent of Black, Hispanic, and White persons, respectively) (AHRQ, 2018a). While the rates of uninsured Americans are decreasing among all three groups due to the ACA, Black and Hispanic persons remain significantly less likely to be insured than White persons (Baumgartner et al., 2023). Also, while over 80 percent of White and Black adults report having a PCP, only 65.7 percent of Hispanic adults have a PCP (Baumgartner et al., 2023). Despite efforts of the Indian Health Service and tribal organizations, American Indian and Alaskan Native people have higher rates of many common conditions (such as diabetes and rheumatoid arthritis) and are more likely to die from them than other Americans (AHRQ, 2018b).