Patient Care Access News

Top Social Determinants of Health Barring Patient Care Access

Income, racial bias, geography, and transportation serve as key social determinants of health hampering patient care access.

social determinants of health affect patient care access

Source: Getty Images

By Sara Heath

- Convenient and comprehensive patient care access is the hallmark of good patient engagement and healthcare. But far too often, key roadblocks get in the way of that seamless access, including a number of key social determinants of health.

These social determinants of health, or the social factors that influence an individual’s ability to achieve health and wellness, can make it challenging for patients to simply set foot inside a provider office. Below, PatientEngagementHIT explores the leading social determinants of health adversely affecting patient care access. This list is certainly not exhaustive, but can represent some of the biggest barriers to care.

Income

Although access to care is instrumental to good outcomes, the reality is that healthcare is only freely accessible to those with higher incomes. Individuals earning lower incomes regularly encounter barriers to care in the United States, regardless of their employment and insurance status.

At the end of 2019, high out-of-pocket healthcare costs were pushing nearly a quarter of patients to forego healthcare that they needed. This was the highest proportion of cost-related care delays the Gallup Poll had recorded.

However, a separate poll a few months later conducted by NBC News and the Commonwealth Fund topped it; 31 percent of those ages 18 to 35 said they or a family member delayed care access because of the risk of a high medical bill, the survey showed. Thirty percent of them said they or their family’s health suffered due to that care avoidance, while 22 percent of the survey population overall said the same.

Delayed or forgone access to care carried into the coronavirus pandemic, when arguably access to key preventive measures like testing were deemed close to life or death. But even then, a sizeable portion of the public said concerns about out-of-pocket costs deterred them from accessing a COVID-19 test.

In an April 2020 survey conducted by Gallup Poll and West Healthcare, 14 percent of people said they skipped a COVID-19 test because they were concerned about the costs associated.

That is not to mention the number of people who skipped a test because they could not afford to quarantine while awaiting results.

This level of income-based health disparity is a fairly unique situation in the United States. In December 2020, the Commonwealth Fund found that income-based health disparities in the US far outpace disparities seen in other countries. Other countries face a smaller difference in the care access and overall wellness of the nation’s poorest and richest populations.

The study, which looked at income-based healthcare disparities—including access to care—in the US and 10 other similarly developed nations, found that more Americans skip care because of cost than in any other country.

In total, 38 percent of US adults have skipped a medical visit, test, treatment, follow-up, or prescription fill within the last year because of cost. Fifty percent of low-income adults skipped care because of cost and 27 percent of high-income earners said the same.

That is a wider health disparity than in any other nation included in the study.

What’s more, it’s a higher rate of skipped care than any other similarly developed nation in the study, regardless of income. For most nations, under 27 percent of the poorest patients are forced to skip care due to costs. In other words, healthcare is about as cost-prohibitive for the wealthiest Americans as it is for the poorest patients in other countries.

Race, racial bias

The healthcare industry also sees significant access disparities related to race, as well. Although very few healthcare organizations overtly turn patients away simply because of their race, factors such as racial bias and institutional racism have created care access barriers for Black, Latinx, and other traditionally marginalized racial groups in the US.

This racial bias and institutional racism have manifested themselves as two types of care access barriers. Foremost, racial bias has created an untenable environment for Black, Latinx, and other traditionally underserved populations.

Racial bias and a long history of more overt racism—the Tuskegee syphilis experiment or forced sterilization, just to name two­—have eroded patient trust, leaving many Black patients not to access healthcare at all.

According to a report from ESPN’s The Undefeated and the Kaiser Family Foundation, a total of 70 percent of Black people encounter discrimination in healthcare at least somewhat often, with 31 percent of those people saying discrimination is frequent.

That discrimination has led to perceptions of poor healthcare quality and poor trust between Black patients and the healthcare institution. Most recently, those negative consequences have resulted in higher COVID-19 vaccine hesitancy among Black and Latinx communities.

Racial bias can result in another form of care access barrier: lack of institutional access. In this case, a patient may actively want to visit a clinician office, but experience other barriers driven by institutional racism.

For example, Black patients are more likely to report the financial barriers to care discussed above. Racist policies like redlining have also kept Black people in underserved neighborhoods, keeping childhood wellness opportunity low and high-quality hospitals far away.

Geographic location

Geographic location demonstrates a tangible care access barrier. Getting into a clinic or hospital is more challenging when that facility is extremely far away, or when one doesn’t have a car or otherwise is unable to drive one.

In May 2019, the Robert Wood Johnson Foundation (RWJF) reported that about a quarter (23 percent) of individuals living in rural regions go without care because the travel distance to the nearest hospital is too much for them.

A few months later in February 2020, the University of Minnesota School of Public Health found that travel distances for individuals living in rural areas could reach up to 40 miles. The analysis looked specifically at travel distances for individuals undergoing breast cancer treatment, but separate studies have also revealed long travel distances for opioid use disorder treatment and even COVID-19 testing for those living in rural areas.

Rural hospital closures have proven to make this trend worse, resulting in poorer health outcomes.

Limited medical transportation

Finally, transportation to medical appointments, or lack thereof, is getting in the way of patient care access. In 2017, the American Hospital Association found that 3.6 million individuals did not have a ride to their clinician’s office, and that lack of transportation is the third leading cause of missed medical appointments.

This can have significant consequences; a patient managing a chronic illness but who misses a check-in appointment could miss out in key health coaching or even alarming health metrics, resulting in poor outcomes down the line.

The good news is the healthcare industry seems to have found a viable solution for this social determinant of health, and is continuing to deploy it nationwide. Non-emergency medical transportation (NEMT), including rideshare companies like Uber and Lyft, have become instrumental partners in healthcare. These platforms let patients get convenient rides to the hospital or clinician office, at little charge to the healthcare organization. The cost of these rides often offsets costs associated with poor outcomes.

It would be remiss not to mention that many of these social determinants of health compound, leading to complex patient care access issues. Individuals living in rural areas also tend to be low-income and carry greater disease burden. And as alluded, communities of color also face higher disease burden and can overlap with low-income populations, as well.

It’s because of that overlap that healthcare policymakers should consider interventions that can address multiple social determinants of health needs.