On Medical Domination.

Gay, bisexual, and other men who have sex with men (GBM) are more likely to be diagnosed with HIV and other sexually transmitted infections (STIs) compared with the general population. Although newcomers generally experience a health advantage in Canada compared with non‐immigrants and more established immigrants (i.e., healthy immigrant effect), they also experience disparities in access to healthcare services. These disparities, in turn, may lead to unique vulnerabilities for the sexual health of GBM immigrants. We examined disparities in healthcare access, STI testing, and HIV pre‐exposure prophylaxis (PrEP) use among immigrant and non‐immigrant GBM. Using baseline data (collected between February 2017 and August 2019) from a multisite cohort study of GBM in Toronto, Vancouver, and Montreal (n = 2449), we found that newcomer GBM (migrated ≤ 5 years prior) were less likely to report having a primary healthcare provider than non‐immigrants. This had a weak indirect effect in mediating both access to STI testing and the use of HIV PrEP. These disparities dissipated after controlling for migration precarity (e.g., refugees and those without permanent residency), suggesting that disparities in newcomer GBM healthcare access may, in part, be driven by the large number of newcomers with precarious migration statuses.Public Significance Statement: New immigrants tend to be less likely to have a primary healthcare provider or use other sexual health clinics, which can have adverse consequences for sexual health. This disparity appears to be largely concentrated among temporary foreign workers, international students, and refugees. Interventions should target policies that increase the number of primary healthcare providers, and address immigration policies that lead to fear of deportation due to one's health.

Racial and ethnic disparities in health care quality are indicative of relatively poorer quality of care for racial/ethnic minority groups. They represent critical injustices when provisions of health care are unexplained by the patient's clinical needs and other determinants of health care delivery, and the benefits of health care services are not equitably realized. While health care remains suboptimal in the United States, improvement in health care quality is observed for all population subgroups. Yet, racial and ethnic disparities in health care access and quality have not shown any significant improvement. Health care disparities have discernible patterns and different putative explanatory pathways. Extricating these patterns and pathways will help to better understand why race/ethnic disparities are observed for some measures of health care quality (e.g., invasive cardiac care), but not others (e.g., cancer screening); and why health care access and quality are suboptimal for all Americans. Evidence‐based health care quality improvement, which integrates the elimination of defined racial/ethnic disparities, is the paradigm for achieving equitable best care.

Purpose: This article provides a conceptual framework for understanding healthcare disparities experienced by individuals with disabilities. While health disparities are the result of factors deeply rooted in culture, life style, socioeconomic status, and accessibility of resources, healthcare disparities are a subset of health disparities that reflect differences in access to and quality of healthcare and can be viewed as the inability of the healthcare system to adequately address the needs of specific population groups. Methods: This article uses a narrative method to identify and critique the main conceptual frameworks that have been used in analyzing disparities in healthcare access and quality, and evaluating those frameworks in the context of healthcare for individuals with disabilities. Specific models that are examined include the Aday and Anderson Model, the Grossman Utility Model, the Institute of Medicine (IOM)’s models of Access to Healthcare Services and Healthcare Disparities, and the Cultural Competency model. Results: While existing frameworks advance understandings of disparities in healthcare access and quality, they fall short when applied to individuals with disabilities. Specific deficits include a lack of attention to cultural and contextual factors (Aday and Andersen framework), unrealistic assumptions regarding equal access to resources (Grossman’s utility model), lack of recognition or inclusion of concepts of structural accessibility (IOM model of Healthcare Disparities) and exclusive emphasis on supply side of the healthcare equation to improve healthcare disparities (Cultural Competency model). In response to identified gaps in the literature and short-comings of current conceptualizations, an integrated model of disability and healthcare disparities is put forth. Conclusion: We analyzed models of access to care and disparities in healthcare to be able to have an integrated and cohesive conceptual framework that could potentially address issues related to access to healthcare among individuals with disabilities. The Model of Healthcare Disparities and Disability (MHDD) provides a framework for conceptualizing how healthcare disparities impact disability and specifically, how a mismatch between personal and environmental factors may result in reduced healthcare access and quality, which in turn may lead to reduced functioning, activity and participation among individuals with impairments and chronic health conditions. Researchers, health providers, policy makers and community advocate groups who are engaged in devising interventions aimed at reducing healthcare disparities would benefit from the discussions.Implications for RehabilitationEvaluates the main models of healthcare disparity and disability to create an integrated framework.Provides a comprehensive conceptual model of healthcare disparity that specifically targets issues related to individuals with disabilities.Conceptualizes how personal and environmental factors interact to produce disparities in access to healthcare and healthcare quality.Recognizes and targets modifiable factors to reduce disparities between and within individuals with disabilities.

Research ObjectiveRacial disparities in health care experiences and access are well‐documented. Yet, little is known regarding racial variations in the confluence of multiple health care access (HCA) experiences among cancer patients. We identified cancer patient subgroups with similar, co‐occurring HCA experiences, and evaluated racial differences in HCA subgroup membership.Study DesignWe used data from the University of North Carolina Health Registry/Cancer Survivorship Cohort. Participants completed a baseline questionnaire assessing demographics, health history, health‐related quality of life, and health care experiences. HCA was assessed along five domains (ie, doctor interpersonal manner, doctor communication, financial burden, time spent with doctor, and accessibility/convenience) using the RAND Patient Satisfaction Questionnaire. We used latent profile analysis to identify subgroups of patients with similar HCA experiences. Modified Poisson regressions were estimated to assess racial differences in HCA subgroup membership, adjusting for patient clinical and demographic characteristics.Population StudiedBlack and white breast, gastrointestinal, genitourinary, and head/neck cancer patients aged 18 or older and enrolled in the University of North Carolina Health Registry/Cancer Survivorship Cohort during 2010 to 2016.Principal FindingsOur analysis included 393 black (14.8%) and 2265 white (85.2%) participants. The latent profile analysis resulted in an optimal solution of 5 HCA profiles/subgroups, ranging from Low HCA to High HCA. Members of profile 1 (6.0% of sample) reported “Low” HCA along all HCA domains. Profile 2 (10.8%) consisted of individuals reporting low scores on every HCA domain except “financial burden,” where scores were moderate. Profile 3 (49.9%) members exhibited moderate scores on each HCA domain, while members of profile 4 (11.7%%) reported moderate HCA scores on most HCA domains, with the exception of low scores on “financial burden.” Profile 5 (21.7%) was comprised of patients reporting “High” HCA along every HCA domain. In unadjusted chi‐square comparisons, black patients were more likely to be in the “Low” HCA group (Profile 1) than whites (11.11% vs 5.3%, P < .001), but less likely to be in the “High” HCA group (13.2% vs 22.8%, P < .001). In adjusted regressions predicting subgroup membership, black race was associated with a 34% lower likelihood of membership in the “High” HCA subgroup (adjusted risk ratio [ARR] = 0.66; CI: 0.51‐0.87]. Other patient characteristics associated with the “High HCA” subgroup membership included holding a postgraduate degree (ARR = 1.33; CI: 1.06‐1.68) and being married (ARR = 1.22; CI: 1.03‐1.44).ConclusionsDistinct patterns of co‐occurring HCA experiences exist among cancer patients, with black patients reporting worse care experiences relative to whites across multiple HCA domains.Implications for Policy or PracticeOur findings point to potential opportunities for identifying patient subgroups especially vulnerable to worse outcomes due to their collective HCA experiences. Routinely collecting HCA data alongside health care outcomes data in diverse cancer patients may be helpful in addressing disparities in HCA and outcomes.Primary Funding SourceNational Institutes of Health.

English proficiency may be important in explaining disparities in health and health care access among older adults. Population-based representative sample (N=18,659) of adults age 55 and older from the 2001 California Health Interview Survey. We examined whether health care access and health status vary among older adults who have limited English proficiency (LEP), who are proficient in English but also speak another language at home (EP), and who speak English only (EO). Weighted bivariate and multivariate survey logit analyses were conducted to examine the role of language ability on 2 aspects of access to care (not having a usual source of care, delays in getting care) and 2 indicators of health status (self-rated general health and emotional health). Limited-English proficient adults were significantly worse off (1.68 to 2.49 times higher risk) than EO older adults in 3 of our 4 measures of access to care and health status. Limited-English proficient older adults had significantly worse access to care and health status than EP older adults except delays in care. English proficient adults had 52% increased risk of reporting poorer emotional health compared with EO speakers. Provision of language assistance services to patients and training of providers in cultural competence are 2 means by which health care systems could reduce linguistic barriers, improve access to care, and ultimately improve health status for these vulnerable populations.

Disparities in access to and quality of health care along racial and ethnic lines are an important national problem. Health care purchasers and payers have a potentially important role to play in alleviating this problem. Using national surveys of 609 employers and 252 health plans with HMO products in 41 U.S. markets, we examined awareness of racial and ethnic disparities in health care access and quality, perceptions of employer and health plan role in addressing disparities, and reported efforts to measure and reduce disparities. Our findings suggest that most health plans and many employers are aware of the existence of substantial disparities and that health plans, but not employers, have taken steps to examine and influence patterns of care by race and ethnicity among their members.

State policies provide variable health insurance coverage for the 3 million immigrant children in the US, with limited understanding of associations with health care access. To (1) examine disparities in health insurance and health care access between immigrant and US-born children and (2) analyze associations of state insurance policies with health care access outcomes for immigrant children. This population-based, retrospective cross-sectional study sampled from the National Survey of Children's Health (2016 to 2022) to facilitate national estimates. Caregivers of children aged 0 to 17 years completed the survey. Data were analyzed from May to December 2024. Child immigration status and state-level health insurance policies for immigrant children, categorized as least inclusive (5-year waiting period and eligibility restricted by immigration status), moderately inclusive (waived 5-year waiting period), and most inclusive (waived 5-year waiting period and all immigrant children eligible). Primary outcomes were (1) uninterrupted health insurance in the past 12 months, (2) usual place for primary care, (3) usual place for sick care, (4) having foregone medical care, and (5) having difficulty with referrals. For each outcome, multivariable logistic regression models examined the association with immigration status, adjusting for state-level policies and individual variables, reporting adjusted odds ratios (aORs) and 95% CIs. There were 277 386 children included (population estimate, 72 473 052 children) with 8835 immigrant children (population estimate, 3 097 329 children [4.3%]; 1 513 509 [48.9%] aged 12-17 years; 1 542 412 female [49.8%]) and 268 551 US-born children (population estimate, 69 375 723 children [95.7%]; 23 450 439 [33.8%] aged 12-17 years; 33 876 023 female [48.8%]). In multivariable analyses, immigrant compared with US-born children had lower odds of uninterrupted health insurance (aOR, 0.48; 95% CI, 0.41-0.56), usual place for primary care (aOR, 0.44; 95% CI, 0.38-0.52), and usual place for sick care (aOR, 0.62; 95% CI, 0.55-0.70), and increased odds of having foregone medical care (aOR, 1.61; 95% CI, 1.22-2.14) and difficulty with subspecialty referral (aOR, 1.54; 95% CI, 1.16-2.04). Immigrant children in the most compared with least inclusive policy states had increased odds of uninterrupted health insurance (aOR, 3.01; 95% CI, 1.89-4.79) and usual place for primary care (aOR, 1.61; 95% CI, 1.07-2.41). In this cross-sectional study of US children, immigrant compared with US-born children had disparities in health care access, which were attenuated in states with the most inclusive state insurance policies, suggesting that inclusive state insurance eligibility policies for immigrant children may improve health care access outcomes for this population.

Objective:To examine racial and ethnic disparities in health care access and utilization after the Affordable Care Act (ACA) health insurance mandate was fully implemented in 2014.Research Design:Using the 2011–2014 National Health Interview Survey, we examine changes in health care access and utilization for the nonelderly US adult population. Multivariate linear probability models are estimated to adjust for demographic and sociodemographic factors.Results:The implementation of the ACA (year indicator 2014) is associated with significant reductions in the probabilities of being uninsured (coef=−0.03, P<0.001), delaying any necessary care (coef=−0.03, P<0.001), forgoing any necessary care (coef=−0.02, P<0.001), and a significant increase in the probability of having any physician visits (coef=0.02, P<0.001), compared with the reference year 2011. Interaction terms between the 2014 year indicator and race/ethnicity demonstrate that uninsured rates decreased more substantially among non-Latino African Americans (African Americans) (coef=−0.04, P<0.001) and Latinos (coef=−0.03, P<0.001) compared with non-Latino whites (whites). Latinos were less likely than whites to delay (coef=−0.02, P<0.001) or forgo (coef=−0.02, P<0.001) any necessary care and were more likely to have physician visits (coef=0.03, P<0.005) in 2014. The association between year indicator of 2014 and the probability of having any emergency department visits is not significant.Conclusions:Health care access and insurance coverage are major factors that contributed to racial and ethnic disparities before the ACA implementation. Our results demonstrate that racial and ethnic disparities in access have been reduced significantly during the initial years of the ACA implementation that expanded access and mandated that individuals obtain health insurance.

Healthcare disparities disproportionately affect underserved and marginalized communities due to social determinants of health (SDoH), contributing to significant differences in health outcomes and life expectancy within different communities in Florida. This observational study aimed to understand the impact of SDoH, such as race/ethnicity, income level, and education attainment on healthcare access in Florida. Methods Self-reported data from the 2020 Behavioral Risk Factor Surveillance System were pooled to evaluate disparities in healthcare access by race/ethnicity, income, and education level in Florida. Results Health status and healthcare access vary based on characteristics related to SDoH, including race/ethnicity, income level, and educational attainment. Health status and healthcare access increased with income and education attainment. There were no significant disparities in health status and healthcare access among racial and ethnic groups. Conclusion While race and ethnicity were not significant predictors of health status nor healthcare access, income level and education were positively correlated which may be related to policy including Florida's lack of Medicaid expansion or population characteristics such as health-seeking behaviors. Understanding the prevalence of healthcare disparities based on SDoH can inform and support the implementation of evidence-based strategies for improving the accessibility and affordability of culturally competent care for underserved populations.

This study investigates the influence of the household registration system on rural–urban disparity in healthcare access (including healthcare quality, blood pressure check, blood test, vision test, dental examination, and breast exam), using data from a large-scale nationwide life history survey that covered 150 counties across 28 provinces and municipalities in China. In contrast to the findings of many previous studies that emphasize the disparity in the residence place as the cause of rural–urban disparity in healthcare access, this study finds that the residence place just has a very limited influence on healthcare access in China, and what really matters is the household registration type. Our empirical results show that people with a non-rural household registration type generally have better healthcare access than those with a rural one. For rural residents, changing the registration type of their household (from rural to non-rural) can improve their healthcare access, whereas changing the residence place or migrating from rural to urban areas have no effect. Therefore, mere rural-to-urban migration may not be a valid measure to eliminate the rural–urban disparity in healthcare access, unless the institution of healthcare resource allocation is reformed.

Persons with disabilities face greater barriers to health care than do those without disabilities (1). To identify characteristics of noninstitutionalized adults with six specific disability types (hearing, vision, cognition, mobility, self-care, and independent living),* and to assess disability-specific disparities in health care access, CDC analyzed 2016 Behavioral Risk Factor Surveillance System (BRFSS) data. The prevalences of disability overall and by disability type, and access to health care by disability type, were estimated. Analyses were stratified by three age groups: 18–44 years (young adults), 45–64 years (middle-aged adults), and ≥65 years (older adults). Among young adults, cognitive disability (10.6%) was the most prevalent type. Mobility disability was most prevalent among middle-aged (18.1%) and older adults (26.9%). Generally, disability prevalences were higher among women, American Indians/Alaska Natives (AI/AN), adults with income below the federal poverty level (FPL), and persons in the South U.S. Census region. Disability-specific disparities in health care access were prevalent, particularly among young and middle-aged adults. These data might inform public health programs of the sociodemographic characteristics and disparities in health care access associated with age and specific disability types and guide efforts to improve access to care for persons with disabilities.

Health care access and quality for persons with disability: Patient and provider recommendations

Health-care needs change throughout the life course. It is thus crucial to assess whether health systems provide access to quality health care for all ages. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019), we measured the Healthcare Access and Quality (HAQ) Index overall and for select age groups in 204 locations from 1990 to 2019. We distinguished the overall HAQ Index (ages 0-74 years) from scores for select age groups: the young (ages 0-14 years), working (ages 15-64 years), and post-working (ages 65-74 years) groups. For GBD 2019, HAQ Index construction methods were updated to use the arithmetic mean of scaled mortality-to-incidence ratios (MIRs) and risk-standardised death rates (RSDRs) for 32 causes of death that should not occur in the presence of timely, quality health care. Across locations and years, MIRs and RSDRs were scaled from 0 (worst) to 100 (best) separately, putting the HAQ Index on a different relative scale for each age group. We estimated absolute convergence for each group on the basis of whether the HAQ Index grew faster in absolute terms between 1990 and 2019 in countries with lower 1990 HAQ Index scores than countries with higher 1990 HAQ Index scores and by Socio-demographic Index (SDI) quintile. SDI is a summary metric of overall development. Between 1990 and 2019, the HAQ Index increased overall (by 19·6 points, 95% uncertainty interval 17·9-21·3), as well as among the young (22·5, 19·9-24·7), working (17·2, 15·2-19·1), and post-working (15·1, 13·2-17·0) age groups. Large differences in HAQ Index scores were present across SDI levels in 2019, with the overall index ranging from 30·7 (28·6-33·0) on average in low-SDI countries to 83·4 (82·4-84·3) on average in high-SDI countries. Similarly large ranges between low-SDI and high-SDI countries, respectively, were estimated in the HAQ Index for the young (40·4-89·0), working (33·8-82·8), and post-working (30·4-79·1) groups. Absolute convergence in HAQ Index was estimated in the young group only. In contrast, divergence was estimated among the working and post-working groups, driven by slow progress in low-SDI countries. Although major gaps remain across levels of social and economic development, convergence in the young group is an encouraging sign of reduced disparities in health-care access and quality. However, divergence in the working and post-working groups indicates that health-care access and quality is lagging at lower levels of social and economic development. To meet the needs of ageing populations, health systems need to improve health-care access and quality for working-age adults and older populations while continuing to realise gains among the young. Bill & Melinda Gates Foundation.

Changes in the health insurance system in Indonesia continue to evolve, one of which is implementing the Standard Inpatient Class (KRIS) policy as a replacement for the BPJS Health class system based on Presidential Regulation (Perpres) Number 59 of 2024. This policy is designed to unify healthcare classes to reduce disparities in healthcare access and quality in Indonesia. However, its implementation is faced with key challenges, including hospital infrastructure readiness, limited human resources, and criticism from various parties, including patients and healthcare providers. This study uses a qualitative approach with descriptive methods to review various policy documents, relevant literature, and legal and social perspectives related to policy implementation. The results show that although KRIS has the potential to reduce disparities in access to health services, its implementation requires more attention to the readiness of health facilities, strengthening management systems, and budget adjustments to support optimal operations. Furthermore, this policy requires the active involvement of the community and health workers in the evaluation and decision-making process so that the policy is more responsive to the real needs in the field. The theoretical approaches used, such as public policy theory and progressive law, highlight the importance of cooperation between the government, healthcare providers, and communities to ensure effective and equitable implementation of KRIS. This research suggests improving hospital infrastructure, continuous training for health workers, and strengthening a transparent monitoring system to ensure the success of this policy. This research is expected to make a positive contribution to the formulation of health policies that are more inclusive and sustainable and can serve as a reference in efforts to realize a more equitable and fair health service system for all Indonesians.

Sinusitis can significantly decrease quality of life, is costly in both health care expenditure and lost productivity, and can lead to complications if treatment is delayed. Our objective was to explore disparities in health care access among adults with sinusitis based on sociodemographic factors. A total of 32,994 participants (representing 244,838,261 US adults) who completed the 2016 National Health Interview Survey (NHIS) were analyzed, of whom 12.17% were diagnosed with sinusitis at least once in the prior 12 months. Multivariate regression analyses were performed. In regression analyses, female sex (odds ratio [OR],2.00 [95% confidence interval (CI), 1.79-2.24]; p<0.001) and older age groups were associated with increased odds of having sinusitis. Within the sinusitis cohort, Asian race (OR,5.97 [95% CI, 1.61-22.12]; p=0.008) and Hispanic ethnicity (OR,6.97 [95% CI, 3.22-15.06]; p<0.001) were associated with increased odds of obtaining foreign medications. Individuals with Medicaid had decreased odds of delaying care (OR,0.37 [95% CI, 0.25-0.56]; p<0.001) or not receiving care due to cost (OR,0.40 [95% CI, 0.24-0.65]; p<0.001), but increased odds of delaying care due to transportation barriers (OR,4.64 [95% CI, 2.52-8.55]; p<0.001). Uninsured individuals had higher odds for delaying care (OR,4.97 [95% CI, 3.35-7.38]; p<0.001) and not receiving care (OR,5.46 [95% CI, 3.56-8.38]; p<0.001) due to cost. Income >$100,000 was associated with a nearly 90% reduction in inability to obtain care due to cost (OR,0.11 [95% CI, 0.05-0.21]; p<0.001) and an over 99% reduction in inability to obtain care due to transportation issues compared with income<$35,000 (OR,0.01 [95% CI, 0.00-0.04]; p<0.001). Significant disparities in health care access based on race, health insurance status, and income exist among adults with sinusitis in the United States.