Inequalities In Access To Health Care Research Articles

Risk Prediction and Machine Learning: A Case-Based Overview.

Risk Prediction and Machine Learning: A Case-Based Overview.

Differences in Health Care Access and Use by Gender, Race, Income, Age and Employment among Residents of the Rural South.

Understanding how disparities are experienced by subpopulations within rural areas may inform efforts to mitigate persistent inequities in access to health care. Among 2,545 randomly sampled adults who completed a mailed survey in ten rural counties in Georgia as part of a health equity initiative, 50.8% of respondents were aged 35-64, 65.9% were women, 16.6% identified as Black, 36.0% worked full-time, and 39% had a high school degree or less. Significant disparities were observed in health care access, use and financial burden by age, employment status, race, and annual household income. In an examination of intersectionality of race and income, all sub-groups except for higher income Black respondents were more likely to report no health insurance and not seeing a doctor in the past 12 months due to cost relative to higher income White respondents. The findings shed insight into inequities in health care access within rural communities.

Secret shopper studies: an unorthodox design that measures inequities in healthcare access

Secret shopper studies are particularly potent study designs that allow for the gathering of objective data for a variety of research hypotheses, including but not limited to, healthcare delivery, equity of healthcare, and potential barriers to care. Of particular interest during the COVID-19 pandemic, secret shopper study designs allow for the gathering of data over the phone. However, there is a dearth of literature available on appropriate methodological practices for these types of studies. To make these study designs more widely accessible, here we outline the case for using the secret shopper methodology and detail best practices for designing and implementing them.

Factors associated with the perception that eHealth facilitates access to healthcare

Abstract Background The provision of eHealth has increased in the COVID-19 era with the aim of improving access to care without the risk of infection. Perceiving eHealth beneficial may affect the use. This study examined which patient-related factors are associated with the perception that eHealth facilitates access to care. Methods A nationwide survey was sent to 61,600 Finnish residents during the COVID-19 pandemic (September 2020-February 2021). Binary logistic regression analysis was used to examine whether the service needs (self-rated health, met service needs, challenges accessing traditional care) and eHealth experience (e-visits, need for guidance, data security concerns) were associated with perceiving that eHealth facilitates access to care. The model was adjusted for age, gender and education. Results The study included 21,409 respondents who had used healthcare services in the past 12 months (55.0% female, mean age 52.88, SE .18). The majority (63.8%) agreed with the benefit that eHealth facilitates access to care. Patients in good health (OR 1.24, 95% CI 1.13-1.37), whose service needs were met (OR 1.34, 95% CI 1.19-1.52) and who had no challenges in accessing traditional care (OR 1.18, 95% CI 1.02-1.36) had greater odds of perceiving the benefit compared to their counterparts. Patients with experience of e-visits (OR 2.60, 95% CI 2.28-2.96) and without need for guidance (OR 1.71, 95% CI 1.52-1.91) had greater odds of perceiving the benefit compared to their counterparts. Conclusions Patients in good health, with met service needs and with easy access to traditional care appear to perceive eHealth more beneficial than their counterparts, which might exacerbate the already existing inequalities in healthcare access and health outcomes. Promotion of eHealth skills might increase equitable opportunities to benefit from eHealth for those patients whose service needs could be met without traditional face-to-face encounter. Key messages • Patients in good health, with met service needs and without difficulties accessing traditional healthcare appear to find eHealth more beneficial than their underprivileged counterparts. • Promotion of eHealth skills might increase equitable opportunities to benefit from eHealth for those patients whose service needs could be met without traditional face-to-face encounter.

The burden of chronic diseases and patients' preference for healthcare services among adult patients suffering from chronic diseases in Bangladesh.

Low- and middle-income countries (LMICs) have a disproportionately high burden of chronic diseases, with inequalities in health care access and quality services. This study aimed to assess patients' preferences for healthcare services for chronic disease management among adult patients in Bangladesh. The present analysis was conducted among 10,385 patients suffering from chronic diseases, drawn from the latest Household Income and Expenditure Survey 2016-2017. We used the multinomial logistic regression to investigate the association of chronic comorbid conditions and healthcare service-related factors with patients' preferences for healthcare services. The top four dimensions of patient preference for healthcare services in order of magnitude were quality of treatment (30.3%), short distance to health facility (27.6%), affordability of health care (21.7%)and availability of doctors (11.0%). Patients with heart disease had a 29% significantly lower preference for healthcare affordability than the quality of healthcare services (relative risk ratio[RRR] = 0.71; 0.56-0.90). Patients who received healthcare services from pharmacies or dispensaries were more likely to prefer a short distance to a health facility (RRR = 6.99; 4.80-9.86) or affordability of healthcare services (RRR = 3.13; 2.25-4.36). Patients with comorbid conditions were more likely to prefer healthcare affordability (RRR = 1.39; 1.15-1.68). In addition, patients who received health care from a public facility had 2.93 times higher preference for the availability of medical doctors (RRR = 2.93; 1.70-5.04) than the quality of treatment in the health facility, when compared with private service providers. Patient preferences for healthcare services in chronic disease management were significantly associated with the type of disease and its magnitude and characteristics of healthcare providers. Therefore, to enhance service provision and equitable distribution and uptake of health services, policymakers and public health practitioners should consider patient preferences in designing national strategic frameworks for chronic disease management. Our research team includes four researchers (co-authors) with chronic diseases who have experience of living or working with people suffering from chronic conditions or diseases.

'I Didn't Know Where to Go': A Mixed-Methods Approach to Explore Migrants' Perspectives of Access and Use of Health Services during the COVID-19 Pandemic.

The COVID-19 pandemic put pressure on health systems, affecting populations’ use of health services, especially those experiencing increased difficulties in healthcare access, as some migrant groups. This study aimed to investigate access and use of health services during the COVID-19 pandemic among migrants in Portugal. A mixed-methods approach was used. A community-based cross-sectional survey was conducted involving migrant communities residing in the Lisbon Metropolitan Area. Analyses of a subsample of participants (n = 929) examined factors associated with perceived worsening of access to health services during the pandemic. Semi-structured interviews with 14 migrants were conducted and thematically analyzed to further understand experiences and difficulties in health services’ use. Around 44% of surveyed participants reported worsening of access to health services since the pandemic, more frequently women, those with lower income, and those who perceived being at moderate or high risk for COVID-19 infection. Digital change in services and lack of formal and informal support during lockdowns were highlighted by interviewers as main barriers in access to healthcare for migrants. The pandemic renewed concerns about inequalities in healthcare access among migrants. It is key that in following years health systems are able to address the potential accumulated burden of disease.

Quantifying inequities in COVID-19 vaccine distribution over time by social vulnerability, race and ethnicity, and location: A population-level analysis in St. Louis and Kansas City, Missouri.

Equity in vaccination coverage is a cornerstone for a successful public health response to COVID-19. To deepen understanding of the extent to which vaccination coverage compares with initial strategies for equitable vaccination, we explore primary vaccine series and booster rollout over time and by race/ethnicity, social vulnerability, and geography. We analyzed data from the Missouri Department of Health and Senior Services on all COVID-19 vaccinations administered across 7 counties in the St. Louis region and 4 counties in the Kansas City region. We compared rates of receiving the primary COVID-19 vaccine series and boosters relative to time, race/ethnicity, zip-code-level Social Vulnerability Index (SVI), vaccine location type, and COVID-19 disease burden. We adapted a well-established tool for measuring inequity-the Lorenz curve-to quantify inequities in COVID-19 vaccination relative to these key metrics. Between 15 December 2020 and 15 February 2022, 1,763,036 individuals completed the primary series and 872,324 received a booster. During early phases of the primary series rollout, Black and Hispanic individuals from high SVI zip codes were vaccinated at less than half the rate of White individuals from low SVI zip codes, but rates increased over time until they were higher than rates in White individuals after June 2021; Asian individuals maintained high levels of vaccination throughout. Increasing vaccination rates in Black and Hispanic communities corresponded with periods when more vaccinations were offered at small community-based sites such as pharmacies rather than larger health systems and mass vaccination sites. Using Lorenz curves, zip codes in the quartile with the lowest rates of primary series completion accounted for 19.3%, 18.1%, 10.8%, and 8.8% of vaccinations while representing 25% of the total population, cases, deaths, or population-level SVI, respectively. When tracking Gini coefficients, these disparities were greatest earlier during rollout, but improvements were slow and modest and vaccine disparities remained across all metrics even after 1 year. Patterns of disparities for boosters were similar but often of much greater magnitude during rollout in fall 2021. Study limitations include inherent limitations in the vaccine registry dataset such as missing and misclassified race/ethnicity and zip code variables and potential changes in zip code population sizes since census enumeration. Inequities in the initial COVID-19 vaccination and booster rollout in 2 large US metropolitan areas were apparent across racial/ethnic communities, across levels of social vulnerability, over time, and across types of vaccination administration sites. Disparities in receipt of the primary vaccine series attenuated over time during a period in which sites of vaccination administration diversified, but were recapitulated during booster rollout. These findings highlight how public health strategies from the outset must directly target these deeply embedded structural and systemic determinants of disparities and track equity metrics over time to avoid perpetuating inequities in healthcare access.

The impact of Medicaid funding structures on inequities in health care access for Latinos in New York, Florida, and Puerto Rico.

To study the impact of Medicaid funding structures before and after the implementation of the Affordable Care Act (ACA) on health care access for Latinos in New York (Medicaid expansion), Florida (Medicaid non-expansion), and Puerto Rico (Medicaid block grant). Pooled state-level data for New York, Florida, and Puerto Rico from the 2011-2019 Behavioral Risk Factor Surveillance System and data from the 2011-2019 American Community Survey and Puerto Rico Community Survey. Cross-sectional study using probit with predicted margins to separately compare four health care access measures among Latinos in New York, Florida, and Puerto Rico (having health insurance coverage, having a personal doctor, delayed care due to cost, and having a routine checkup). We also used difference-in-differences to measure the probability percent change of having any health insurance and any public health insurance before (2011-2013) and after (2014-2019) the ACA implementation among citizen Latinos in low-income households. The sample consisted of Latinos aged 18-64 residing in New York, Florida, and Puerto Rico from 2011 to 2019. Latinos in Florida had the lowest probability of having health care access across all four measures and all time periods compared with those in New York and Puerto Rico. While Latinos in Puerto Rico had greater overall health care access compared with Latinos in both states, health care access in Puerto Rico did not change over time. Among citizen Latinos in low-income households, New York had the greatest post-ACA probability of having any health insurance and any public health insurance, with a growing disparity with Puerto Rico (9.7% any [1.6 SE], 5.2% public [1.8 SE]). Limited Medicaid eligibility (non-expansion of Florida's Medicaid program) and capped Medicaid funds (Puerto Rico's Medicaid block grant) contributed to reduced health care access over time, particularly for citizen Latinos in low-income households.

The Effect of Social Determinants of Health on Telemedicine Access During the COVID-19 Pandemic.

Social determinants of health contribute to inequalities in access to care and inferior outcomes in pediatric populations. Before the coronavirus disease 2019 (COVID-19) pandemic, telemedicine was shown to be an effective tool to bridge the gap between health care providers and rural or underserved populations. The pandemic has rapidly changed the current landscape of health care. Telemedicine has played a critical role in health care delivery between providers and patients because of the need for social distancing. That being said, it has become apparent that SDOH have affected access to telemedicine for communities that already suffer from inequities in health care access. Solutions directed toward addressing issues such as lack of broadband access, digital literacy and language barriers, and obstacles within the health care system are crucial to ensure telemedicine access is equitable for all patients and does not contribute toward worsening health care disparities. [Pediatr Ann. 2022;51(8):e311-e315.].

CLIMATE CHANGE AND COVID-19 IN THE KRUGER TO CANYONS BIOSPHERE REGION, SOUTH AFRICA AND AMAZONAS, BRAZIL

Climate change is predicted to exert further stress on already exploited ecologies and healthcare systems, added to this, the coronavirus SARS-CoV-2 (Covid-19) has signified a stimulus to revolutionize existing models of sustainable development in broad, and sustainable supply chains in the healthcare sector in particular. The Kruger to Canyons Biosphere Region in South Africa and the Amazonas state in Brazil serve as geographic case studies for this paper. The impact of economic globalization, natural catastrophes such as droughts, economic and geopolitical stresses, deforestation, economic and healthcare access inequalities in these two biomes converge with issues of climate change, and undercut coping mechanisms that are customarily used to oversee extreme events such as pandemics. The Covid-19 pandemic has deepened many of the economic and social difficulties which South Africa and Brazil are already facing. In comparison to Brazil, South Africa’s overall response to the pandemic can be regarded as a standout. By borrowing from best practices from prior public health responses to heath emergencies in South Africa, such as the tuberculosis and the HIV/AIDS crisis, South Africa has demonstrated its comparatively successful means of dealing with Covid-19.

Facility or Transport Inequality? Decomposing Healthcare Accessibility Inequality in Shenzhen, China.

Accessibility to healthcare services is crucial for residents’ wellbeing. Numerous studies have revealed significant spatial inequality in healthcare accessibility across various contexts. However, it still remains unclear whether the inequality is caused by the unbalanced spatial distribution of healthcare facilities or by unequal transport access to them. This study decomposes inequality in healthcare accessibility into facility- and transport-driven inequality by comparing scenarios of healthcare accessibility, which consider various combinations of multidimensional components of accessibility using different distance measures. Using a case study in Shenzhen, this study reveals that both facility distribution and transport access substantially contribute to spatial inequality in healthcare accessibility. Facility distribution accounts for 61.3% and 50.8% of the overall accessibility inequality for driving and transit modes, respectively. The remaining inequality is induced by imbalanced mobility provided by transport networks. Furthermore, the impact of transport component on healthcare accessibility is unevenly distributed. This study highlights that both facility- and transport-related countermeasures should be considered to improve the accessibility and equality of healthcare services. It provides transferable methods for quantitatively decomposing facility- and transport-driven inequality in accessibility to healthcare or other facilities.

Race and ethnicity define disparate clinical outcomes in chronic rhinosinusitis

BackgroundChronic rhinosinusitis (CRS) is a common upper airways inflammatory disease requiring multidisciplinary care. ObjectiveTo evaluate if African Americans (AA), Latinxs, and nonLatinx White (White) patients have different chronic rhinosinusitis outcomes and to identify associated factors impacting these outcomes. MethodsWe conducted a large prospective cohort study of CRS patients who were evaluated and followed for several clinical variables at the initial encounter and after continuous management of CRS for a mean of 40 months. The Sinonasal Outcome Test (SNOT-22) and Lund-MacKay scores were measured on initial visits, and SNOT-22 was repeated at the end of follow-up. Logistic regression was used to compare outcomes between the different groups adjusted for comorbidities and demographics. ResultsAmong the 977 enrolled CRS cases, 615 (63.0%), 235 (24.1%) and 138 (13.0%) were White, AA and Latinx respectively. There was no difference in severity of CRS based on Lund-MacKay scores and SNOT-22 scores, and frequency of other comorbidities at presentation among the 3 groups. During the follow-up period, compared with Whites, AA and Latinx were less frequently evaluated by an allergist. AAs had less frequent CRS related visits and lower final SNOT-22 score compared with Whites. ConclusionAlthough our enrolled patients from the 3 ethnic groups had similar clinical characteristics and disease burden at baseline, AAs had less frequent follow-up visits and worse final SNOT-22 after 40 months of follow-up. The observed poorer outcomes in AAs are likely owing to inequity in healthcare access evidenced by differences in insurance and suboptimal management of CRS.

Public Health surveillance from emergency call center data: visualization dashboard and NLP of call reports

By focusing on symptoms and not diagnoses, the socalled syndromic surveillance system gains in immediacy what it loses in specificity with respect to other more traditional options for public health surveillance. Reports of calls to emergency medical communication centers (EMCC) supplemented by the data collected by the rescue workers who arrived on the scene constitute a cost-effective and rich source of information. Unfortunately, EMCC data are infrequently used and their utility has not been demonstrated.The aim of this study was to explore the usefulness for public health surveillance of EMCC data when analyzed using text mining and visualization tools. Transformer-based deep learning architectures were used to classify call reports according to the reason for the call. We also extracted indicators that could serve as proxy measures using a keyword-search algorithm. We then developed a dashboard visualization tool to enable dynamic and spatial exploratory analyses. Finally, we explored the potential of this tool for two applications. While the tool proved unable to detect Covid-19 outbreaks, it appeared to be promising for a better understanding of territorial inequalities in healthcare access.

Socioeconomic Status and Prognosis of Patients With ST-Elevation Myocardial Infarction Managed by the Emergency-Intervention "Codi IAM" Network.

BackgroundDespite the spread of ST-elevation myocardial infarction (STEMI) emergency intervention networks, inequalities in healthcare access still have a negative impact on cardiovascular prognosis. The Family Income Ratio of Barcelona (FIRB) is a socioeconomic status (SES) indicator that is annually calculated. Our aim was to evaluate whether SES had an effect on mortality and complications in patients managed by the “Codi IAM” network in Barcelona.MethodsThis is a cohort study with 3,322 consecutive patients with STEMI treated in Barcelona from 2010 to 2016. Collected data include treatment delays, clinical and risk factor characteristics, and SES. The patients were assigned to three SES groups according to FIRB score. A logistic regression analysis was conducted to estimate the adjusted effect of SES on 30-day mortality, 30-day composite cardiovascular end point, and 1-year mortality.ResultsThe mean age of the patients was 65 ± 13% years, 25% were women, and 21% had diabetes mellitus. Patients with low SES were younger, more often hypertensive, diabetic, dyslipidemic (p < 0.003), had longer reperfusion delays (p < 0.03) compared to participants with higher SES. Low SES was not independently associated with 30-day mortality (OR: 0.95;9 5% CI: 0.7–1.3), 30-day cardiovascular composite end point (OR: 1.03; 95% CI: 0.84–1.26), or 1-year all-cause mortality (HR: 1.09; 95% CI: 0.76–1.56).ConclusionAlthough the low-SES patients with STEMI in Barcelona city were younger, had worse clinical profiles, and had longer revascularization delays, their 30-day and 1-year outcomes were comparable to those of the higher-SES patients.

The Factors Associated With Nonuse of and Dissatisfaction With the National Patient Portal in Finland in the Era of COVID-19: Population-Based Cross-sectional Survey.

BackgroundIn the abnormal circumstances caused by the COVID-19 pandemic, patient portals have supported patient empowerment and engagement by providing patients with access to their health care documents and medical information. However, the potential benefits of patient portals cannot be utilized unless the patients accept and use the services. Disparities in the use of patient portals may exacerbate the already existing inequalities in health care access and health outcomes, possibly increasing the digital inequality in societies.ObjectiveThe aim of this study is to examine the factors associated with nonuse of and dissatisfaction with the Finnish nationwide patient portal My Kanta Pages among the users of health care services during the COVID-19 outbreak. Several factors related to sociodemographic characteristics, health, and the use of health care services; experiences of guidance concerning electronic services; and digital skills and attitudes were evaluated.MethodsA national population survey was sent using stratified sampling to 13,200 Finnish residents who had reached the age of 20 years. Data were collected from September 2020 to February 2021 during the COVID-19 pandemic. Respondents who had used health care services and the internet for transactions or for searching for information in the past 12 months were included in the analyses. Bivariate logistic regression analyses were used to examine the adjusted associations of respondent characteristics with the nonuse of My Kanta Pages and dissatisfaction with the service. The inverse probability weighting (IPW) method was applied in all statistical analyses to correct for bias.ResultsIn total, 3919 (64.9%) of 6034 respondents were included in the study. Most respondents (3330/3919, 85.0%) used My Kanta Pages, and 2841 (85.3%) of them were satisfied. Nonusers (589/3919, 15%) were a minority among all respondents, and only 489 (14.7%) of the 3330 users were dissatisfied with the service. Especially patients without a long-term illness (odds ratio [OR] 2.14, 95% CI 1.48-3.10), those who were not referred to electronic health care services by a professional (OR 2.51, 95% CI 1.70-3.71), and those in need of guidance using online social and health care services (OR 2.26, 95% CI 1.41-3.65) were more likely nonusers of the patient portal. Perceptions of poor health (OR 2.10, 95% CI 1.51-2.93) and security concerns (OR 1.87, 95% CI 1.33-2.62) were associated with dissatisfaction with the service.ConclusionsPatients without long-term illnesses, those not referred to electronic health care services, and those in need of guidance on the use of online social and health care services seemed to be more likely nonusers of the Finnish nationwide patient portal. Moreover, poor health and security concerns appeared to be associated with dissatisfaction with the service. Interventions to promote referral to electronic health care services by professionals are needed. Attention should be targeted to information security of the service and promotion of the public’s confidence in the protection of their confidential data.

ATA2022 Annual Conference &amp; Expo May 1–3, 2022Boston, Massachusetts

ATA2022 Annual Conference &amp; Expo May 1–3, 2022Boston, Massachusetts

Trends in Health Care Access/Experiences: Differential Gains across Sexuality and Sex Intersections before and after Marriage Equality.

Background: Sexual minority adults experience several health care access inequities compared to their heterosexual peers; such inequities may be affected by LGBTQ+ legislation, such as the 2015 national marriage equality ruling. Methods: Using population-based data (n = 28,463) from the Association of American Medical Colleges biannual Consumer Survey of Health Care Access, we calculated trend ratios (TR) for indicators of health care access (e.g., insurance coverage, delaying or forgoing care due to cost) and satisfaction (e.g., general satisfaction, being mistreated due to sexual orientation) from 2013 to 2018 across sexuality and sex. We also tested for changes in trends related to the 2015 marriage equality ruling using interrupted time series trend interactions (TRInt). Results: The largest increases in access were observed in gay men (TR = 2.42, 95% CI 1.28, 4.57). Bisexual men had decreases in access over this period (TR = 0.47, 95% CI 0.22, 0.99). Only gay men had a significant increase in the health care access trend after U.S. national marriage equality (TRInt = 5.59, 95% CI 2.00, 9.18), while other sexual minority groups did not. Conclusions: We found that trends in health care access and satisfaction varied significantly across sexualities and sex. Our findings highlight important disparities in how federal marriage equality has benefited sexual minority groups.

\u201cMany people have no idea\u201d: a qualitative analysis of healthcare barriers among Yazidi refugees in the Midwestern United States

BackgroundThe COVID-19 pandemic has shed new light on inequities in healthcare access faced by immigrant and refugee communities. To address ongoing disparities, there is an urgent need for ecological approaches to better understand the barriers that hinder and resources that facilitate access to healthcare. This study investigates barriers to healthcare system access faced by Yazidi refugees in the Midwestern United States.MethodsInformed by the Interpretative Phenomenological Approach, three focus group meetings with a community advisory board were conducted between September 2019 and January 2020. The nine-member focus group included social workers, healthcare providers, and members of the Yazidi community. Meeting recordings were transcribed into English, coded for themes, and validated.ResultsWe describe themes related to specific barriers to healthcare access; analyze the influence of relational dynamics in the focus group; explore experiential themes related to healthcare access in the Yazidi community, and finally interpret our findings through a social-ecological lens.ConclusionCommunity agencies, healthcare organizations, policymakers, and other stakeholders must work together to develop strategies to reduce systemic barriers to equitable care. Community representation in priority-setting and decision-making is essential to ensure relevance, acceptability, and utilization of developed strategies.

Individual and community experiences and the use of language in understanding diabetes and depression in rural Kenya

ABSTRACT As the prevalence of long-term conditions continues to rise it becomes increasingly important to identify ways to mitigate their effects, including the psychological impact. In rural Kenya identifying people with diabetes or mental health problems is challenging due to the stigma and negative experiences within community settings. Four broad themes were identified; (1) misconceptions and stigma: the use of language, (2) treatment and medications, (3) community beliefs and alternative treatment pathways, (4) the role of informal and formal care. Our study demonstrated the detrimental effect of the use of stigmatising language and misconceptions surrounding diabetes and depression at both the individual and community levels. Inequalities in health care access were observed and a lack of resources in rural communities was evident. Improvements in support for health care workers at the community level as well as acknowledging the importance of informal care could help improve the psychological and emotional impact of diabetes and depression.

Causes and Consequences of Not Having a Personal Healthcare Provider Among American Indian Elders: A Mixed-Method Study.

Having a regular relationship with a healthcare provider contributes to better health outcomes and greater satisfaction with care for older adults. Although members of federally recognized American Indian tribes have a legal right to healthcare, American Indian Elders experience inequities in healthcare access that may compromise their ability to establish a relationship with a healthcare provider. This multi-year, community-driven, mixed-method study examines the potential causes and consequences of not having a personal healthcare provider among American Indian Elders. Quantitative surveys and qualitative interviews were conducted with 96 American Indian Elders (age 55 and over) in two states in the Southwestern United States. Quantitative and qualitative data were analyzed separately and then triangulated to identify convergences and divergences in data. Findings confirmed that having a consistent healthcare provider correlated significantly with self-rated measures of health, confidence in getting needed care, access to overall healthcare, and satisfaction with care. Lack of a regular healthcare provider was related to interconnected experiences of self-reliance, bureaucratic and contextual barriers to care, and sentiments of fear and mistrust based in previous interactions with medical care. Increasing health equity for American Indian Elders will thus require tailored outreach and system change efforts to increase continuity of care and provider longevity within health systems and build Elders' trust and confidence in healthcare providers.