Insurance + Access ≠ Health Care: Typology of Barriers to Health Care Access for Low-Income Families

Jennifer E. DeVoe; Alia Baez; Heather Angier; Lisa Krois; Christine Edlund; Patricia A. Carney

doi:10.1370/afm.748

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Nuggets of Truth
Joseph Schuchter

Published on: 11 December 2007
The Coverage Crux
Gerry Fairbrother

Published on: 11 December 2007
The Poor and The Health Professionals
Philip Pollner

Published on: 07 December 2007

Published on: (11 December 2007)
Page navigation anchor for Nuggets of Truth
Nuggets of Truth
Joseph Schuchter, Cincinnati, USA
Several things are striking about this study by DeVoe and colleagues:
The hierarchal but interrelated typology of barriers brings to mind several analogies as to how families deal with barriers to health care, both real and perceived. Like the Russian matryoshka doll, once past the biggest and first, in this case obtaining insurance coverage, additional dolls, such as access and cost, await inside. Families are...
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Several things are striking about this study by DeVoe and colleagues:
The hierarchal but interrelated typology of barriers brings to mind several analogies as to how families deal with barriers to health care, both real and perceived. Like the Russian matryoshka doll, once past the biggest and first, in this case obtaining insurance coverage, additional dolls, such as access and cost, await inside. Families are not naïve there are other “dolls” inside; they simply may not know how many, or what they look like. As well, barriers in the health care system may put families in a “crossing that bridge when I arrive” mentality. As DeVoe and colleagues suggest, the equation is not simple.
It is also intriguing that what some researchers may consider left- over data in a quantitative survey revealed such insights. This study smartly combines quantitative and qualitative findings and responsibly makes full use of survey data. Although qualitative approaches are ideal, few studies using focus groups or other ethnographic techniques have specifically addressed the issues of insurance and access. Dr. DeVoe’s study helps fill that void.
By “crystallizing” free text responses, the authors got a glimpse of the intricacies of families' struggles. However, we should not be too quick to assume that we as researchers have a crystal ball. Additional studies using ethnographic methods are called for. An in-depth understanding of barriers such as stigma, time away from work, cost of transportation. etc. will be needed to fully inform policy.
Even as these barriers are overcome and surmounted, we cannot expect vast improvements in the ability to obtain health care. We may continue to identify and knock down barriers, but provisions such as citizenship documentation requirements for insurance continue to create new barriers. Availability can never be guaranteed in such a fragmented system of entitlements, payers and providers.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (11 December 2007)
Page navigation anchor for The Coverage Crux
The Coverage Crux
Gerry Fairbrother, Cincinnati, USA
The paper by DeVoe and colleagues offers important new insights into problems low-income families face in obtaining health care for their children. As the authors point out, for these families receiving care is not one struggle, but three. The first and most formidable is the struggle to obtain and retain coverage; but problems do not end there. Children with public coverage have difficulties accessing care, while ch...
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The paper by DeVoe and colleagues offers important new insights into problems low-income families face in obtaining health care for their children. As the authors point out, for these families receiving care is not one struggle, but three. The first and most formidable is the struggle to obtain and retain coverage; but problems do not end there. Children with public coverage have difficulties accessing care, while children with private coverage have difficulties paying for it. Problems with insurance coverage and access among children have been described in the literature, (1-5) but the cost barriers for families with private coverage are less well understood. The authors bring this problem into sharp relief with statements from parents that they retain insurance in case of an accident or emergency, and often avoid taking their children to the doctor for other matters because they cannot afford co-payments and fees.
Still, the most important problem was coverage. Though the barriers are interrelated, insurance coverage must be obtained before families can cross additional bridges of access and cost. Furthermore, in that the sample consisted entirely of families using the food stamp program, all children in the study were certainly eligible for either Medicaid or the State Children’s Health Insurance Program (SCHIP). The authors’ finding that 35% of the currently insured children had a gap in coverage during the last year reinforces this point.
Oregon and other States can improve enrollment and retention through outreach, enrollment and renewal policies and are under increasing pressure to do so. Nationally, and in Oregon in particular, taking steps to retain eligible children would be one important action. In Oregon, over 40% of the Medicaid children drop off the rolls in a three-year period, only to return a short time later-- half were back on the program in 2 months and over 95% were back on in a year, strongly indicating that these children were eligible when they dropped off.(6) Further, the fact that 45% of low-income uninsured children in Oregon had been on public insurance the past year, a larger proportion than in most states, further highlights the problem of retention for Oregon children.(7)
States are under increasing pressure to enroll and retain eligible children; if they are to enroll 95% of eligible children, as CMS has recently proposed, retention will have to be improved dramatically. Policies that would help facilitate this include: simplifying the renewal process, requiring renewal every 12 months rather than 6 (44 states have 12 month renewal; only 6, including Oregon, set this at 6 months), monitoring churning at state and county levels and rewarding counties that retain more eligible children. The proposed SCHIP legislation includes some of these steps. However, States can take leadership and begin adopting policies to improve coverage for eligible children now.
1. Skinner AC, Mayer ML. Effects of insurance status on children's access to specialty care: a systematic review of the literature. BMC Health Serv Res. Nov 28 2007;7(1):194. 2. Feeg VD. Why SCHIP is such a good deal for children's access to care. Pediatr Nurs. Jul-Aug 2007;33(4):299, 312. 3. Guendelman S, Angulo V, Oman D. Access to health care for children and adolescents in working poor families: recent findings from California. Med Care. Jan 2005;43(1):68-78. 4. Mansour ME, Lanphear BP, DeWitt TG. Barriers to asthma care in urban children: parent perspectives. Pediatrics. Sep 2000;106(3):512-519. 5. Sochalski J, Villarruel AM. Improving access to health care for children. J Soc Pediatr Nurs. Oct-Dec 1999;4(4):147-154. 6. Fairbrother GL, Emerson HP, Partridge L. How stable is medicaid coverage for children? Health Aff (Millwood). Mar-Apr 2007;26(2):520-528. 7. Sommers BD. Why millions of children eligible for Medicaid and SCHIP are uninsured: poor retention versus poor take-up. Health Aff (Millwood). Sep-Oct 2007;26(5):w560-567.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (7 December 2007)
Page navigation anchor for The Poor and The Health Professionals
The Poor and The Health Professionals
Philip Pollner, Newark DE USA
Your excellent paper “Insurance + Access Does Not Equal Health Care” discusses the plight of poor American families struggling to achieve quality health care thought to be available to middle-higher income insured citizens. Although access barriers to care that were identified in the study differed for each low income group, many other serious barriers common to most poor families were unacknowledged yet play a major part...
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Your excellent paper “Insurance + Access Does Not Equal Health Care” discusses the plight of poor American families struggling to achieve quality health care thought to be available to middle-higher income insured citizens. Although access barriers to care that were identified in the study differed for each low income group, many other serious barriers common to most poor families were unacknowledged yet play a major part in a special human disaster – low-income plus poor health equals poor medical outcomes. A long-recognized poverty syndrome exists in which the poor are likelier to be sick, the sick are likelier to be poor, and without intervention the poor get sicker and the sick get poorer. This poverty-and -health disaster is revealed to us regularly by every classic index: total morbidity and mortality, maternal mortality, infant mortality. The poverty syndrome is represented by a cluster of associated risk factors…higher morbidity and mortality, low utilization of health services, unemployment and unemployability, low education and functional illiteracy, family disorganization, high rates of crime, delinquency, second and third generation dependency, powerlessness and doing things for rather than with poor people.
Although many of our health services for the poor are often of high technical quality and better organized – unsolved insuperable barriers to access continue to exist: the barrier of time and distance, the remoteness of certain health care facilities, the hours of travel and waiting time, fragmentation – well child care in one place, sick child care in another, adult care in yet another, in-hospitalization at another site, social work and specialized resources someplace else. All this for the working mother with many children – to hold a job, maintain the home and to be expected to be able to utilize preventative or therapeutic care.
The barriers of cost and insurance cited in the article, even if resolved, cannot be expected to impact the crisis that this population experiences. Confusing, complex and contradictory eligibility requirements even make available insurance unavailable for many.
These barriers are real and should be included. For without change, the system will remain inevitably episodic, symptomatic, piecemeal and uncoordinated – it is often not patient-centered, except for certain situations not family-centered, and in most cases not community-based.
To treat symptoms and send the patient back, unchanged in behavior, knowledge, and attitude to the same physical and social environment – also unchanged – that helped to produce their illnesses, and will do it again. The poor need better health services than the rest of the population. They carry a heavier burden of unmet need; they are at higher risk; they live in dangerous environments.
Health services and health insurance alone are not enough – change in the social and environment determinants of health are a requisite. That social task is the explicit business of all of us – including the health professions.
Competing interests: None declared
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Competing Interests: None declared.