HLTH 6510 Week 5 Health Care Access Barriers Example

Covered but Not Seen: Why Insured Adults in the Rural County Still Go Without Care, Sorted by a Published Access Framework

Student Name

Walden University

HLTH 6510: Essentials of the U.S. Healthcare Delivery System and Population Health

Instructor Name

Month Day, Year

Covered but Not Seen: Why Insured Adults in the Rural County Still Go Without Care, Sorted by a Published Access Framework

The Gap

Most adults in the rural half of the course's invented region have some form of coverage: employer plans, Medicaid or Medicare. Yet community health center staff report that insured patients regularly delay or skip care, and the county's emergency department sees conditions that would usually be managed in a clinic. This paper explains why insured people still go without care. Rather than list whatever barriers come to mind, it sorts them with Levesque and colleagues' patient-centered model, which pairs each of five qualities a service can have with an ability a person needs in order to use it (Levesque et al., 2013). The five pairs give the paper its sections. Sorting barriers this way shows which ones coverage addresses and which it leaves untouched.

Approachability: Knowing a Service Exists

Approachability concerns whether people know a service exists and that it is for them. In the rural county, many Medicaid enrollees do not know that their coverage includes nonemergency transportation, adult behavioral health care or dental extractions, and some employer-insured workers do not know the community health center accepts their plan. Coverage that people do not know they have does not produce visits. On the people side, noticing that symptoms such as rising thirst and fatigue call for a visit depends on health literacy, which coverage does not change.

Acceptability: Whether Care Fits

Acceptability concerns whether services fit people's cultural and social expectations. Farmworkers in the county, many of whom speak Spanish, report that the regional medical center's specialty clinics rarely have interpreters on site, and some avoid referrals for that reason. Men in particular describe reluctance to seek care until symptoms are severe. The ability to seek care is shaped by these values and by past experiences, such as being turned away. Coverage leaves both largely in place.

Availability: Distance, Waits and Willing Providers

Availability and accommodation concern whether services exist within reach and fit people's schedules. This is the county's largest barrier. Specialists are 50 miles away, new-patient waits run several weeks and the community health center's evening hours end at 7:00 p.m. Medicaid coverage does not guarantee a willing provider: a national survey found that in 2011 nearly one-third of physicians were not accepting new Medicaid patients, with acceptance lower where Medicaid fees were lower (Decker, 2012). In the county, two of the three urban endocrinology practices limit new Medicaid patients. The ability to reach care depends on transportation, and while Medicaid covers rides, employer-insured and Medicare patients without cars do not have that benefit.

Affordability: Costs Beyond the Premium

Affordability concerns direct and indirect costs. Medicaid enrollees face minimal copayments, so direct cost is rarely the barrier for them. Employer-insured workers in the county are a different case: many small employers offer plans with deductibles of several thousand dollars, so a worker may pay the full allowed amount for a visit and lab work until the deductible is met. Indirect costs matter for everyone: a day's lost wages for an hourly worker driving to the urban specialist, fuel and child care. An early framework for access treated affordability as only one of several dimensions (Penchansky & Thomas, 1981), and the county shows why: removing direct costs for Medicaid enrollees did not remove the indirect ones.

Appropriateness: Care That Fits a Chronic Condition

Appropriateness concerns whether the care provided fits the person's needs, including timeliness and continuity. A patient with diabetes who sees a different clinician at each urgent care visit, with no shared record, receives care that may be technically correct but not appropriate for a chronic condition. The ability to engage, to follow a treatment plan and take part in decisions, depends on literacy, language, time and trust, all of which vary across the county's insured population.

How the Barriers Compound

The barriers rarely arrive alone. Consider a 58-year-old farmworker with diabetes, insured through a small employer with a $3,000 deductible. He does not know the community health center accepts his plan, so he waits until a foot sore will not heal. When he does go, the clinician refers him to a wound specialist in the urban county, where the next new-patient opening is four weeks away and no interpreter is scheduled. He would lose two days of wages for the trip, and the visit would count against his deductible. Each barrier on its own might be overcome; together, they explain why he returns to the emergency department instead. Sorting the barriers by dimension shows that his coverage solved none of them.

That is the practical value of a framework: it turns a list of complaints into a map of where a patient's path to care breaks and which part of the system owns each break.

What Coverage Addresses and What It Does Not

Table 1 summarizes the barriers by dimension and notes whether coverage, as currently designed, addresses each.

Table 1

Access Barriers for Insured Adults in the Rural County, by Dimension (Composite)

Conclusion

Sorted by a published framework, the barriers fall mostly outside what coverage, as designed, addresses. Coverage lowers direct costs, especially for Medicaid enrollees, and adds a transportation benefit for them. It leaves distance, provider acceptance, language, deductibles for employer plans, indirect costs and fragmentation in place. The finding explains why the county's insured residents still go without care and points the later weeks on delivery, workforce and payment toward the barriers coverage cannot reach.

References

Decker, S. L. (2012). In 2011 nearly one-third of physicians said they would not accept new Medicaid patients, but rising fees may help. Health Affairs, 31(8), 1673-1679. https://doi.org/10.1377/hlthaff.2012.0294

Levesque, J.-F., Harris, M. F., & Russell, G. (2013). Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. International Journal for Equity in Health, 12, Article 18. https://doi.org/10.1186/1475-9276-12-18

Penchansky, R., & Thomas, J. W. (1981). The concept of access: Definition and relationship to consumer satisfaction. Medical Care, 19(2), 127-140. https://doi.org/10.1097/00005650-198102000-00001