Leiyu Shi, DrPH, MBA, MPA; Jenna Tsai, EdD; Patricia Collins Higgins, PhD, MPH; Lydie A. Lebrun, MPH

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1 J Ambulatory Care Manage Vol. 32,. 4, pp Copyright c 2009 Wolters Kluwer Health Lippincott Williams & Wilkins Racial/Ethnic and Socioeconomic Disparities in Access to Care and Quality of Care for US Health Center Patients Compared With n Health Center Patients Leiyu Shi, DrPH, MBA, MPA; Jenna Tsai, EdD; Patricia Collins Higgins, PhD, MPH; Lydie A. Lebrun, MPH Abstract: This study aims to compare racial/ethnic and socioeconomic disparities in access to care and quality of care for US health center patients and non health center patients. Data for the study came from the 2002 Community Health Center User Survey and the 2003 National Healthcare Disparities Report. Descriptive analysis was performed using nationally representative survey data pertaining to access to care and quality of care for people of different races, ethnicities, incomes, and education levels. Results of the study show that health center patients experience fewer racial/ethnic and socioeconomic disparities in access to care and quality of care, compared with non health center patients nationally. Racial/ethnic disparities favoring whites occur in non health center patients in every measure of quality and access included in this study. Conversely, there are few disparities favoring whites among health center users. Education and income-related disparities occur for several measures of access and quality in both health center and non health center patients; however, the magnitude of these disparities is usually greater among non health center patients compared with health center patients. In conclusion, health centers have been touted for cost-efficient, high-quality care. This study adds to growing evidence that health centers may also help eliminate racial/ethnic and socioeconomic disparities in access to care and quality of care. Key words: access, quality of care, primary care, racial/ethnic differences in health and healthcare, safety net providers THE UNITED STATES has by far the highest per capita healthcare spending of industrialized nations (Anderson et al., 2006), yet does not rank near the top of international comparisons of quality of care and health status (Hussey et al., 2004; Macinko et al., 2003; Reinhardt et al., 2002). One factor contribut- Author Affiliations: Johns Hopkins Bloomberg School of Public Health (Dr Shi and Ms Lebrun) and Johns Hopkins Primary Care Policy Center (Dr Shi), Baltimore, MD; Mathematica Policy Research, Washington, DC (Dr Collins Higgins); National Defense Medical University (Dr Shi) and Hungkuang University (Dr Tsai), Taiwan, Republic of China. Dr Collins Higgins was formerly with Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Corresponding Author: Leiyu Shi, DrPH, MBA, MPA, Bloomberg School of Public Health, Johns Hopkins University, 624 rth Broadway, Room 452, Baltimore, MD (lshi@jhsph.edu). 342 ing to this contradiction is the existence of widespread disparities in access to and quality of healthcare across racial/ethnic and socioeconomic groups (Institute of Medicine [IOM], 2003). Recognizing the inefficiencies and injustices created by health disparities, their elimination is a major goal of Healthy People 2010 (U.S. Department of Health and Human Services [U.S. DHHS], 2000), Crossing the Quality Chasm (IOM, 2001), and Unequal Treatment (IOM, 2003). Improving the nation s health will require improving equity: ensuring access to care and quality of care across all population groups. The community health center (CHC) model is a promising approach to improving equity. For more than 4 decades, CHCs have been a crucial component of the nation s safety-net system, providing primary and

2 Racial/Ethnic and Socioeconomic Disparities in Access to Care and Quality of Care 343 preventive care to predominantly lowincome, racial/ethnic minority patients in medically underserved urban and rural areas (Lefkowitz, 2007; Sardell, 1988). In addition to clinical care, CHCs provide enabling services, such as transportation, translation, and health education, to facilitate access to care for vulnerable populations. The Bureau of Primary Health Care (BPHC), within the Health Resources and Services Administration, U.S. DHHS, runs the health center program. In financial year 2002, the Bush administration launched the largest expansion of health centers in program history. The goal of the president s Health Center Growth Initiative was to provide an additional 6.1 million people in 1200 underserved communities with new health center access points and expanded services in existing health centers. By 2006, significant progress had been made toward this goal: BPHC was funding more than 1000 health centers, serving approximately 15 million people (BPHC, 2007). Numerous studies have concluded that CHCs improve access and deliver high-quality, cost-effective care (Falik et al., 2006; Hadley & Cunningham, 2004; Hicks et al., 2006; O Malley et al., 2005; Politzer et al., 2003; Proser, 2005; Shi et al., 2007; Shi & Stevens, 2007; Shin et al., 2006). Evidence further suggests that CHCs may help reduce health disparities. A study controlling for socioeconomic status, insurance, and other factors found racial/ethnic disparities in activity limitations and health status among the national population, but not among health center patients (Shi et al., 2001). Another study simulating the impact of the president s Health Center Growth Initiative found that expanding health center capacity could help narrow racial/ethnic disparities in access to care (Hadley et al., 2006). Moreover, CHCs have been cited by the IOM (2003) for their effectiveness in increasing access to care and improving health outcomes for vulnerable populations. Despite the wealth of evidence supporting health centers effectiveness, value, and potential to reduce health disparities, comparisons of health disparities experienced by health center patients and non health center patients have been limited. Using the nationally representative 2002 Community Health Center User Survey, this study examines disparities in measures of access to care and quality of care for health center users of different races, ethnicities, incomes, and education. These measures are compared with non health center patients nationally, using results from the Agency for Healthcare Research and Quality s 2003 National Healthcare Disparities Report (NHDR). METHODS Data Data used to analyze disparities in access to care and quality of care for health center patients were drawn from the 2002 Community Health Center User Survey. The CHC User Survey, conducted by the BPHC with the assistance of the National Center for Health Statistics, collects data from a random, representative sample of all CHCs that receive funding from the BPHC and provide primary care (N = 70 CHCs and 1115 CHC patients; Research Triangle Institute, 2002). The survey was designed to match the content and sampling strategy of the 2002 National Health Interview Survey as closely as possible. Temporary clinics, clinics open for less than 1 year, school-based health centers, and specialized clinics were excluded from the survey. Nine strata were formed on the basis of census region and urban/rural designation, and a 10th was formed for health centers with large proportions of managed care patients. Selection was carried out using probability-proportional-to-size methodology within a stratum. Of the 581 eligible health centers in 2002, 70 centers (or 12% of total eligible centers) were randomly selected for inclusion in the study, and all participated. National comparison data were drawn from the 2003 NHDR (U.S. DHHS, 2003). The Agency for Healthcare Research and Quality annually produces the NHDR, which focuses on measuring equity: the provision of healthcare of equal quality based solely on need and clinical factors (p. 3) (U.S. DHHS, 2003). The NHDR provides an overview of disparities in access to care and quality of

3 344 JOURNAL OF AMBULATORY CARE MANAGEMENT/OCTOBER DECEMBER 2009 care across racial/ethnic and socioeconomic groups. The 2003 NHDR obtains information from a variety of data sources. The NHDR data sources used for comparisons in this study include the National Health Interview Survey (1998, 2000), the Medical Expenditure Panel Survey (1999, 2000), the Commonwealth Fund Health Care Quality Survey (2001), and the substance abuse and mental health services administration (SAMHSA) National Household Survey on Drug Abuse (2001). Each source provides data by race, ethnicity, and/or socioeconomic status, is nationally representative, and includes a large sample size. The 2003 NHDR was chosen for comparison with the 2002 CHC User Survey due to proximity across the surveys in the years data were collected. Measures Measures included in the 2002 CHC User Survey match the 2002 National Health Interview Survey in content. Many of these measures are also included in the 2003 NHDR. For this study, we chose measures of quality of care and access to care that appeared in both the CHC User Survey and the NHDR. As defined by the NHDR, quality measures relate to whether persons receive the healthcare services they need. Access measures relate to whether persons can get healthcare or experience barriers to care. The following quality measures are included in this study: (1) percentage of women who received a Pap smear in the past 3 years; (2) percentage of adults with diabetes who received an eye examination in the past year; (3) percentage of persons 65 years and older with an influenza vaccination in the past year; (4) percentage of adults who reported difficulty understanding information from their doctor; and (5) percentage of adults who received outpatient mental health treatment in the past year. The following access measures are included in this study: (1) percentage of persons younger than 65 years with health insurance and (2) percentage of children with any period of uninsurance during the year. While this set of measures is far from comprehensive, it provides a snapshot of national disparities in quality and access. Moreover, because this set of measures appears in both the NHDR and the CHC User Survey, it allows for comparison between health center patients and non health center patients. The racial and ethnic categories used in the NHDR are congruent with Office of Management and Budget (OMB) standards for reporting federal statistics (U.S. DHHS, 2003). Racial categories include white, black, Asian, Native Hawaiian or other Pacific Islander, American Indian or Alaska Native, and more than 1 race. All racial categories can include persons of Hispanic and non-hispanic origin. Ethnic categories are Hispanic or Latino, non-hispanic white, and non-hispanic black. Racial and ethnic categories used in the CHC User Survey are the same, with 1 exception: the CHC User Survey groups Asians and Pacific Islanders together. We account for this difference by grouping Asians and Pacific Islanders together in our analyses. As in Healthy People 2010, family income is expressed as a percentage of the federal poverty level (FPL). Educational attainment is expressed as less than high school, high school completion, or any college attendance. Analysis Descriptive and comparative analyses of CHC User Survey data were performed with SAS and compared with NHDR data. For each measure, CHC User Survey data were analyzed by race, ethnicity, income, and education. Disparities in each of these categories were assessed and compared with corresponding disparities in the NHDR. Results of the national comparisons may be found in the 2003 NHDR. Results of health center comparisons are available from the corresponding author upon request. RESULTS Comparisons of CHC and national patients of all racial/ethnic and socioeconomic groups reveal that CHC patients experienced better access to care and quality of care for most measures included in this study. CHC adult patients with diabetes lagged behind non health center patients in their receipt of

4 Racial/Ethnic and Socioeconomic Disparities in Access to Care and Quality of Care 345 eye examinations in the past year (63% vs 67%, respectively). However, 85% of adult women who were CHC patients reported having a Pap smear in the past 3 years, compared with 81% of adult women nationally. In addition, 70% of adults 65 years and older who were CHC patients reported having an influenza vaccination in the past year, compared with 65% of national patients. Fewer CHC patients reported difficulty understanding information from their providers (15%), compared with non health center patients (43%). CHC patients were also more likely than non health center patients to receive outpatient mental health services in the past year (22% vs 11%, respectively). These results are remarkable, given that fewer CHC adult patients had health insurance (59%), compared with non health center patients (83%). Proportions of children with any period of uninsurance in the past year were similar in CHCs (20%) and nationally (21%). Racial/ethnic disparities As Table 1 displays, racial and ethnic disparities favoring whites occurred for non health center patients in every measure of quality and access included in this study. In only 1 case (percentage of women who had a Pap smear in the past 3 years) were blacks favored over whites. For every other measure, whites reported better access to care and quality of care compared with blacks, Asian/Pacific Islanders, American Indians/Alaska Natives, and people of more than 1 race. n-hispanic whites were favored in every measure, compared with Hispanics of any race. The range of magnitude of disparities (ie, the range in difference between percentage of whites and percentage of other races and Table 1. Comparison of racial/ethnic disparities in quality and access measures: Health center patients versus non health center patients. Are there racial/ethnic disparities favoring non-hispanic whites? a n-health center (range Health center (range in in difference between difference between whites whites and individual and individual racial/ethnic Indicators racial/ethnic groups) groups) Quality indicators Women with Pap smear in past 3 Yes (3% 16%) years, % Adults with diabetes with eye Yes (3% 10%) Yes (0% 8%) (result unreliable examination in past year, % because of small sample size) Persons 65 years and older with Yes (8% 18%) flu vaccine in past year, % Adults who report difficulty Yes (3% 17%) understanding information from MD, % Adults who received outpatient Yes (0 8%) Yes (1 11%) mental health treatment in past year, % Access indicators Persons younger than 65 years Yes (2% 23%) with health insurance, % Children with any period of Yes (2% 24%) Yes (0 12%) (result unreliable uninsurance during the year, % because of small sample size) a Race categories: Whites are compared to blacks, Asians/Pacific Islanders, American Indian/Alaska Natives; ethnicity categories: non-hispanic whites are compared to Hispanics of all races.

5 346 JOURNAL OF AMBULATORY CARE MANAGEMENT/OCTOBER DECEMBER 2009 ethnicities reporting yes to any given measure) varied by measure. For instance, the difference between whites and other races/ ethnicities in the percentage of adults with diabetes who had an eye examination in the past year ranged from 3% (the difference between whites and blacks) to 10% (the difference between non-hispanic whites and Hispanics). In contrast, the difference between whites and other races/ethnicities in percentage of children with any period of uninsurance during the year was much broader, ranging from 2% (the difference between whites and blacks) to 24% (the difference between non-hispanic whites and Hispanics). Conversely, there are few disparities favoring whites in the health center patient population. Compared with all racial/ethnic minorities, whites were not favored in the measure of the percentage of women who had a Pap smear in the past 3 years, nor in the measure of percentage of persons older than 65 years who had a flu vaccine in the past year. For measures of diabetic eye examinations, difficulty understanding information from a doctor, and insurance for adults and children, white health center patients were favored only compared to one other race/ethnic group (which differed by measure). The only measure in which white health center patients were favored over most other races/ethnicities was percentage of adults who received outpatient mental health treatment in the past year; however, 42% more American Indian/Alaska Native health center patients reported receiving outpatient mental health treatment, compared with whites. Income disparities Table 2 presents the results of the comparisons of two income groups: less than 100% Table 2. Comparison of income disparities in quality and access measures: Health center patients versus non health center patients. Are there income disparities favoring higher income groups (100%--199% of FPL)? a n--health center (difference between 2 Health center (difference Indicators income groups) between 2 income groups) Quality indicators Women with Pap smear in past 3 years, % Adults with diabetes with eye exam in past year, % Persons 65 years and older with flu vaccine in past year, % Adults who report difficulty understanding information from MD, % Adults who received outpatient mental health treatment in past year, % Access Indicators Persons younger than 65 with health insurance, % Children with any period of uninsurance during the year, % Yes (2%) Yes (1%) Yes (5%) Yes (12%) (result unreliable because of small sample size) Yes (5%) Yes (2%) NA Yes (2%) Yes (23%) (result unreliable because of small sample size) Abbreviation. FPL: Federal poverty level. a Those with incomes of 100% 199% FPL ( near poor ) are compared to those with incomes <100% FPL ( poor ).

6 Racial/Ethnic and Socioeconomic Disparities in Access to Care and Quality of Care 347 of the FPL ( poor ) versus 100% 199% of the FPL ( near poor ). Again, there were fewer disparities among health center patients of different incomes, compared with non health center patients. tably, there were no income disparities favoring the higher-income group for health center patients with regard to the following measures: percentage of women who received a Pap smear in the past 3 years, percentage of adults with diabetes who had an eye examination in the past year, and percentage of persons younger than 65 years with health insurance. In contrast, there were disparities favoring the higher-income group for these measures in non health center patients. There were some income disparities favoring the higher-income group in both the national data and the health center data. These included the percentage of persons 65 years and older who had had a flu vaccine in the past year and percentage of adults who re- ported difficulty understanding information from the doctor. There was no national data on income disparities for outpatient mental health treatment, but in health center patients, the higher-income group reported lower utilization of these services. Finally, while there was no national disparity favoring the higher-income group for percentage of children with any period of uninsurance during the year, there was a sizable disparity favoring the higher-income group among health center patients although the result was unreliable due to small sample size. Education-level disparities In education, health centers continued to display fewer disparities favoring higher education level, compared with national data (Table 3). In health centers, there were no disparities favoring those with high school or any college education (compared with those Table 3. Comparison of education level disparities in quality and access measures: Health center patients versus non health center patients. Are there education-based disparities favoring people with higher education ( high school/any college )? a n-health center Health center (difference (difference between 2 between 2 educational Indicators educational groups) groups) Quality indicators Women with Pap smear in past 3 years, % Adults with diabetes with eye examination in past year, % Persons 65 years and older with flu vaccine in past year, % Adults who report difficulty understanding information from MD, % Adults who received outpatient mental health treatment in past year, % Access indicators Persons younger than 65 years with health insurance, % Children with any period of uninsurance during the year, % Yes (12%) Yes (10%) Yes (5%) Yes (12%) Yes (11%) (result unreliable due to small sample size) Yes (24%) Yes (2%) Yes (1%) Yes (27%) NA Yes (8%) (result unreliable due to small sample size) NA a High school/any college is compared with less than high school graduate.

7 348 JOURNAL OF AMBULATORY CARE MANAGEMENT/OCTOBER DECEMBER 2009 with less than high school education) in the measures of Pap smear and insurance for persons younger than 65 years. Nationally, there were sizable disparities in both of these measures, particularly the insurance measure, in which those with high school or any college education differed from those with less than a high school diploma by 27%. However, both the national and the health center data revealed disparities favoring the higher education group for several measures, including the adult diabetic eye examination, persons older than 65 years with a flu vaccine, adults reporting difficulty understanding information from the doctor, and adult outpatient mental health treatment. The magnitude of these disparities was greater nationally for three of the four measures: by a factor of 2 for the diabetic eye examination and by a factor of 12 for difficulty understanding information from the doctor. DISCUSSION Compared with data from non health center patients nationally, our findings indicate that racial/ethnic disparities in access and quality measures are nonexistent among CHC patients (with the exception of outpatient mental health treatment). In addition, the overall proportions of CHC patients who reported positive results in measures of access and quality were often superior to their national counterparts. These results suggest that the CHC program may help reduce national racial/ethnic disparities in health. However, elimination of disparities in access and quality would depend on an even broader national adoption of the CHC model of care, which includes comprehensive and preventive primary care, a focus on vulnerable populations such as minorities and the uninsured, consumer participation, enabling services, cultural and linguistic sensitivity, community partnership, and continuous quality improvement. Reducing health disparities, a cornerstone of the nation s public health roadmap, Healthy People 2010, is important for several reasons. First, racial/ethnic and socioeconomic disparities in healthcare access and quality are troubling reminders of long-standing, unjust inequalities in the United States. The United States is nearly unique among developed nations in its lack of universal access to healthcare. Vulnerable populations, particularly minorities and the uninsured, are disproportionately and negatively affected by this policy failure. Second, health disparities are inefficient. They affect not only vulnerable populations but also the nation as a whole. Despite our status as the highest spenders on healthcare, the United States lags behind many developed countries on basic public health indicators such as life expectancy and infant mortality. Without improving access to care and quality of care for those populations who are worst off, the United States is unlikely to improve its standing relative to other nations. Finally, if the status quo is maintained, health disparities are poised to worsen rather than improve. Vulnerable population groups are rapidly growing in the United States. The proportion of individuals living in poverty has been steadily increasing, as has the proportion of individuals lacking health insurance coverage. Racial/ethnic minority groups, particularly Hispanics, are growing at a faster rate than nonminorities. The existence of health disparities indicates that the current healthcare system is ill-equipped to address these demographic realities. In addition to significantly reducing racial/ ethnic disparities in access and quality, our study also indicates that CHCs have narrowed education and income disparities on a number of access and quality indicators. This is likely due to CHCs program requirements that ensure that they are community focused and built around addressing all social determinants of health. Health centers remove common barriers to care by serving communities that otherwise confront financial, geographic, language, cultural, and other barriers, making them different from most private, office-based physicians (National Association of Community Health Centers, 2008). They are located in high-need areas identified by the federal government as having

8 Racial/Ethnic and Socioeconomic Disparities in Access to Care and Quality of Care 349 elevated poverty, higher than average infant mortality, and where few physicians practice; are open to all residents, regardless of insurance status, and provide free or reduced cost care based on ability to pay; offer enabling services that help their patients access healthcare, such as transportation, translation, case management, health education, and home visitation; and tailor their services as communitydriven providers to fit the special needs and priorities of their communities (eg, behavioral healthcare, dental services) and provide services in a linguistically and culturally appropriate setting. However, despite the efforts from health centers, the general economic situation is such that there are still outstanding barriers to care that drive poor outcomes income- and education-related barriers. CHCs are resourcepoor providers and are already stretched thin. An implication of this study is that future strategies to reduce disparities both within CHCs and in the nation as a whole should include a special focus on the challenges faced by patients with low socioeconomic status. This study has several potential limitations, including the limited number of access and quality measures available in both the CHC User Survey and the NHDR for comparison. Furthermore, the national data were obtained from published results, thus restricting us from performing further stratified analyses or multivariate analyses including covariates associated with access and quality measures. The study did not look at the provision of certain services on-site versus off-site, for example, mental healthcare, where some CHCs have this service on-site and others provide external referrals. Finally, this study demonstrates CHCs ability to overcome racial/ethnic and some socioeconomic disparities but does not show how this was accomplished. Future studies exploring the mechanisms through which these accomplishments were achieved will be important for the development of best practice models for national adoption. Despite these limitations, this study affirms the important role of CHCs in helping the United States reduce or eliminate health disparities related to race/ethnicity and socioeconomic status. As cost-effective providers of primary and preventive care services, CHCs have long been considered a crucial component of the safety net. This study demonstrates that compared with their national counterparts, CHC patients experience superior access to care and quality of care. These findings not only demonstrate that investing in CHCs could achieve better patient outcomes and lower disparities among patients but also suggest that CHCs may well serve as a model system of primary care provision in the United States. REFERENCES Anderson, G. F., Frogner, B. K., Johns, R. A., & Reinhardt, U. E. (2006). Health care spending and use of information technology in OECD countries. Health Affairs, 25(1), Bureau of Primary Health Care. (2007). What is a health center? Retrieved August 20, 2007, from hrsa.gov/. Falik, M., Needleman, J., Herbert, R., Wells, B., Politzer, R., & Benedict, M. B. (2006). Comparative effectiveness of health centers as regular source of care. Journal of Ambulatory Care Management, 29(1), Hadley, J., & Cunningham, P. (2004). Availability of safety net providers and access to care of uninsured persons. Health Services Research, 39(5), Hadley, J., Cunningham, P., & Hargraves, J. L. (2006). Would safety-net expansions offset reduced access resulting from lost insurance coverage? Race/ethnicity differences. Health Affairs, 25(6), Hicks, L. S., O Malley, J., Lieu, T., Keegan, T., Cook, N. L., & McNeil, B. J. (2006). The quality of chronic disease care in U.S. community health centers. Health Affairs, 25(6), Hussey, P. S., Anderson, G. F., Osborn, R., Feek, C., McLaughlin, V., & Millar, J. (2004). How does the quality of care compare in five countries? Health Affairs, 23(3), Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.

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