Top social determinants of health barring patient care access

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 2023, high out-of-pocket healthcare costs were pushing more than a third of patients to forego healthcare that they needed, The Commonwealth Fund reported. This was, naturally, most common among those without insurance coverage (64 percent), but it wasn’t uncommon among folks with insurance.

Of those with employer-sponsored coverage, 29 percent said they skipped care due to costs, while 37 percent of those with marketplace plans, 39 percent with Medicaid, and 42 percent with Medicare said the same.

Separate data shows patients are foregoing care even when they seriously need it. A December 2022 assessment in the American Journal of Managed Care showed that 22 percent of older adults didn’t access emergency department (ED) care when they felt they needed it, mostly because of the threat of a high medical bill.

All of this has a negative impact on overall patient health. A 2023 report from the Federal Reserve showed that 28 percent of adults went without some kind of medical care because of cost in 2022. Dental care was the first type of care to go, followed by doctor’s visits, medication adherence, follow-up care, and mental healthcare access.

Ultimately, that impacts overall patient well-being, the data furthered. People with higher incomes—and who are less likely to skip medical care—are more likely to say they are in good health compared to those with lower incomes (91 percent and 75 percent, respectively).

Insurance coverage

Insurance coverage has a clear influence over patient access to care. When patients do not have comprehensive health insurance coverage, they are at higher risk of incurring a high medical bill and are therefore less likely to visit a healthcare provider.

As of 2022, the US has an 8 percent uninsurance rate, per KFF figures. Most people get their health insurance through their employer (48 percent), while 21.2 percent get it via Medicaid, and 14.6 percent are enrolled in Medicare. Depending on how comprehensive the coverage is, patients may be more or less inclined to access healthcare services.

Even still, data is showing that insurance coverage is less and less of a determinant of healthcare access. Indeed, folks without any insurance are still the least likely to access any kind of care, as noted in the above-mentioned Commonwealth Fund report. But even individuals with employer-sponsored plans skip healthcare access due to cost; this is most common among low-income people with employer-sponsored health plans.

These findings indicate many paths forward to ensuring healthcare affordability and access, the researchers said. Policy changes to protect consumers from being financially ruined by medical debt and to stem healthcare cost growth would be effective in helping patients with all insurance types, the Commonwealth Fund researchers recommended.

Racial bias & discrimination

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. A 2024 poll from KFF showed that a third of Americans think racism in medicine is a major problem, with Black and Hispanic folks being more likely to agree racism is a healthcare problem.

That latent specter of racism and discrimination had led to lower levels of trust among racial/ethnic minorities, according to the KFF poll. And without trust, patients may feel reticent to visit their healthcare providers.

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.

Discrimination is not limited to racial discrimination. Other populations, like members of the LGBTQ+ community, have also reported forms of implicit or explicit discrimination that keep them from accessing care.

Some patients have reported poor patient-provider relationships erode trust, dissuading patients from accessing care, while others have reported that healthcare providers do not always know how to deliver care, particularly gender-affirming care.

Furthermore, individuals with disabilities have faced discrimination that can both dissuade care access and make healthcare access very difficult. A 2022 Health Affairs study showed that few healthcare providers are prepared to make accommodations for individuals with disabilities.

Patient focus groups showed unanimous physical barriers to healthcare access, while provider focus groups showed they were not prepared to weigh individuals who use wheelchairs or to provide written materials in Braille.

Language barriers

In addition to racial or ethnic discrimination, language barriers can keep limited English proficiency (LEP) patients from getting into the hospital or clinic. When patients can’t read or communicate with providers and administrators, it can be hard for them to book an appointment. Eventually, LEP patients may become frustrated and give up.

According to 2023 surveying from KFF and the LA Times, 17 percent of LEP immigrants said interpreter services were not available to them or not provided in a timely manner. Some patients said they skipped care because they could not meet with a clinician who spoke their language.

This comes as all healthcare providers are required to provide interpreter services.

Even when LEP patients want to make an appointment, some assessments show this is out of reach. A 2023 RAND report in Health Affairs Scholar detailed a secret shopper survey in which individuals posing as English- and Spanish-speaking patients sought an appointment to get medication for depression.

The experiment showed that a fifth of Spanish-speaking LEP patients were hung up on by clinic staff. Only 41 percent of Spanish speakers were able to go through the scheduling process in their preferred language.

The appointment scheduling process was likely a challenge due to limited resources on the part of the clinics. When clinics are not able to hire a diverse, multicultural, and multilingual staff, patients who do not speak English may not be able to communicate effectively or even get a foot in the door of the clinic.

Immigration status

Immigration status can affect healthcare access due to both cultural barriers, as well as regulatory and legal barriers affecting access to health insurance.

In terms of cultural barriers, factors like limited racial and language concordance can harm the patient-provider relationship. Notably, 29 percent of immigrants told KFF and the LA Times that it’s hard to obtain respectful and culturally competent care.

Around a fifth (17 percent) said their provider did not take the time to listen to their concerns or ignored the concerns, 15 percent said doctors did not explain things in an understandable manner, and 12 percent said they’d been disrespected by front office staff.

Some immigrant respondents stated that discrimination was related to race/ethnicity while others posited it was due to perceived insurance status/ability to pay and their accent or ability to speak English.

Some immigrants may forego care to avoid these poor healthcare experiences, but for others, a murky legal and regulatory landscape impedes the ability to obtain health insurance, which has a direct tie to healthcare access.

According to a Robert Wood Johnson Foundation (RWJF) report, nonelderly noncitizens—including lawfully present and undocumented immigrants—make up only 8 percent of the US population but account for 31 percent of the nation’s uninsured population. Around 40 percent of the 22 million noncitizens in the US are uninsured, the May 2023 report showed.

Only around 16.5 percent of uninsured noncitizens are eligible for coverage through a state or federal health insurance marketplace or public payer. Immigration status is the top barrier to healthcare coverage for most US noncitizens.

Noncitizens experience a number of legal hurdles to obtaining insurance coverage, and while Medicaid expansion and some state policies providing insurance coverage to undocumented immigrants can close the gap, the RWJF researchers said there’s still simply lower utilization among immigrants.

This could be due to social stigma, as well as regulatory issues like Trump Administration’s public charge rule.

The public charge rule allows the US to deny admission or citizenship to immigrants who were likely to utilize public programs like Medicaid or SNAP. A 2022 report in JAMA Network Open showed that the public charge rule in California was linked to lower Medicaid and SNAP utilization.

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.