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RESEARCH ARTICLE |
a Institute for Health Services Research and Policy Studies, Northwestern University, Evanston, Illinois
b Multipurpose Arthritis and Musculoskeletal Disease Center, Northwestern University, Chicago, Illinois
c Division of Arthritis-Connective Tissue Diseases, Northwestern University Medical School, Chicago, Illinois
d Department of Preventive Medicine, Northwestern University Medical School, Chicago, Illinois
Dorothy D. Dunlop, Institute for Health Services Research and Policy Studies, Northwestern University, 629 Noyes Street, Evanston, IL 60208 E-mail: ddunlop{at}nwu.edu.
Decision Editor: Fredric D. Wolinsky, PhD
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Abstract |
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Methods. Data from the 1993–1995 study on the Asset of Health Dynamics Among the Oldest Old (AHEAD) were used to investigate differences in the 2-year use of health services by gender and among non-Hispanic White versus minority (Hispanic and African American) ethnic/racial groups. Analyses account for predisposing factors, health needs, and economic access.
Results. African American men had fewer physician contacts; minority and non-Hispanic White women used fewer hospital or outpatient surgery services; minority men used less outpatient surgery; and Hispanic women were less likely to use nursing home care, compared with non-Hispanic White men, controlling for predisposing factors and measures of need. Although economic access was related to some medical utilization, it had little effect on gender/ethnic disparities for services covered by Medicare. However, economic access accounted for minority disparities in dental care, which is not covered by Medicare.
Discussion. Medicare plays a significant role in providing older women and minorities access to medical services. Significant gender and ethnic/racial disparities in use of medical services covered by Medicare were not accounted for by economic access among older adults with similar levels of health needs. Other cultural and attitudinal factors merit investigation to explain these gender/ethnic disparities.
THE national consumption of medical services by older adults is an important public policy issue. Although adults older than 65 years represent approximately one-eighth of the United States population, they account for more than one-third of health care expenditures (U.S. Department of Health and Human Services [U.S. DHHS], 1990
). Medicare spending for health care among older adults rose dramatically from $7 billion in 1970 to $193 billion in 1996, representing a 13.5% average annual rate of change (U.S. DHHS 1998). In comparison, the personal health care expenditure average annual rate of change over the same period was only 10.7%.
Almost all older adults are insured, in contrast to younger age groups for whom lack of health insurance is an important factor in health services utilization inequities, particularly among ethnic/racial groups (Brown, Ojeda, Wyn, and Levan 2000; Krauss, Machlin, and Kass 1996; Powell-Griner, Bolen, and Bland 1999). More than 95% of all elderly persons (65 or older) are covered by Medicare, which is often supplemented by private insurance or Medicaid coverage. However, despite the benefit of health insurance, inequities in the use of health services among older adults persist (Hurd and McGarry 1997; Lum and Chang 1998).
Earlier studies that addressed disparities in the utilization of health services among older adults had several limitations. First, detailed data on income and wealth, which are important measures of health care access, have been deficient. Second, whereas a number of reports evaluated African American versus White utilization among older adults using national data sets (e.g., Physician Payment Review Commission 1992; Stump, Johnson, and Wolinsky 1995; Wolinsky, Callahan, Fitzgerald, and Johnson 1993; Wolinsky and Johnson 1991), to our knowledge there are no similar reports evaluating the health care utilization among Hispanics. Third, many reports are based on utilization before 1990 that do not reflect the current health care system. Finally, a number of studies used cross-sectional data rather than longitudinal data, which are needed to evaluate the impact of factors on future utilization.
This study uses data from the Asset and Health Dynamics Among the Oldest Old (AHEAD) survey, a longitudinal study of Americans aged 70 or older, to investigate the effect of economic access barriers on the 2-year health care utilization of men and women from Hispanic, African American, and White ethnic/racial groups. The AHEAD data offer several strengths for this purpose. First, AHEAD is a national sample of older adults, which permits inference to the U.S. population of older adults. Second, the survey oversampled African Americans and Hispanics at the rate of 2:1 relative to Whites, which provides a sufficiently large number of older adults to examine differential characteristics by ethnic/racial groups. Third, self-reported functional status, economic, health behavior, and health care utilization information documents the dynamic experiences of this cohort. Of particular value is the collection of detailed economic data using bracketing methods to minimize nonresponse for these data (Smith 1997). This approach addressed deficiencies from earlier studies that lacked adequate measures of both health and economic status (Myers, Juster, and Suzman 1997).
A widely used behavioral model of health services utilization proposed by Andersen 1968 describes predisposing, need, and enabling factors that predict health care utilization. Predisposing variables describe the propensity of individuals to use health services and include basic sociodemographic characteristics (e.g., age, sex, ethnicity, marital status). Need refers to health conditions or illness, the most immediate cause of health services use. Enabling variables describe the economic means and human capital people have to access medical services. Andersen 1995 concept defines potential access as a function of enabling factors, which in this study include financial (e.g., income, wealth, health insurance) and human capital (e.g., education), and geographic barriers to services.
Our aim is to examine the role of economic access in health service utilization disparities of older men and women from Hispanic, African American, and White racial/ethnic groups. People most likely to experience greatest socioeconomic status differences tend to be women and minorities (Kington and Smith 1997; Krauss et al. 1996). Economic and human capital barriers to health care, including lack of health insurance and low socioeconomic status factors (e.g., income, wealth, education), are well recognized (Gornick et al. 1996; Powell-Griner et al. 1999; Weissman, Stern, Fielding, and Epstein 1991). These barriers reflect a lack of financial or human capital. Potential access relates to the use of health care by factors ranging from knowledge of available health services to the ability to purchase medical care. Because women and minorities are most likely to have fewer economic resources and less education (Kington and Smith 1997), this study focuses on the influence of economic access on gender and ethnic/racial differences in the use of health care.
Economic barriers are different for older adults, compared with others. Some barriers are accentuated. Gender and ethnic/racial differences in education, income, and lifetime accumulation of wealth are greatest among older adults (Crystal and Shea 1990). Other barriers are modified. In the general U.S. population, a lack of health insurance is a major barrier to health care for the general U.S. population (Centers for Disease Control 1995; Krauss et al. 1996; Powell-Griner et al. 1999). But the vast majority of older adults have health insurance through Medicare. As a result, the relative contribution of these economic access factors for older adults to health care utilization disparities may differ from the general population.
This study uses 1993–1995 data from the AHEAD study to evaluate the relationship of gender and ethnicity/race with subsequent health care utilization among a national sample of older adults who lived in the community at the baseline interview. To address ethnic/racial differences among Whites and minorities (Hispanics and African Americans), the sample is divided into Hispanics and non-Hispanics; non-Hispanics are further divided into African Americans and Whites. For simplicity, we refer to these mutually exclusive groups as Hispanic, non-Hispanic White, and African American. The role of economic access barriers on health care utilization disparities among women and minorities, accounting for influence of other predisposing factors and health needs, is systematically evaluated by addressing the following three questions.
First, are there gender or ethnicity/race differences in health care utilization among the U.S. population of older adults, and do they persist after accounting for other predisposing sociodemographic differences? Because predisposing factors are not subject to intervention (e.g., age or marital status), utilization accounting for such factors provides a reference with which to compare the potential impact of modifiable factors. Demographic differences in the use of certain medical services are known. For instance, African American Medicare beneficiaries saw physicians less than Whites (Physician Payment Review Commission 1992). Hispanics and African Americans were less likely than non-Hispanic Whites with the same diagnosis to undergo invasive procedures (Carlisle, Leake, and Shapiro 1997). Women report fewer physician visits and are less likely to receive hospital care than men (Wolinsky and Johnson 1991). In addition, health care utilization increases with age (Liu, Wall, and Wissoker 1997), and some use of health services differ by marital status (Crystal, Johnson, Harman, Sambamoorthi, and Kumar 2000; Mutran and Ferraro 1988). Therefore, potential gender and ethnicity/race utilization differences, controlling for other predisposing factors, are investigated.
Second, to what extent do health needs impact gender or ethnicity/race utilization differences? This is an important question from a policy perspective, because it addresses inequities in health care utilization among people with similar burdens of health problems. Health needs, including functional limitations and chronic conditions, increase health care utilization (Liu et al. 1997). At the same time, health needs differ by gender and ethnicity. Functional limitations are more prevalent among Hispanics and African Americans than White older adults (Stump, Clark, Johnson, and Wolinsky 1997). Frequencies of chronic conditions differ among African Americans, Whites, and Hispanics (Kington and Smith 1997). These relationships motivate an investigation of gender and ethnic/racial utilization differences, controlling for the burden of chronic diseases and functional limitations in addition to predisposing factors.
Third, to what extent does economic access to health care services attenuate gender or ethnic/racial differences in utilization? Gender and ethnic/racial income inequalities have long been recognized (Danziger and Gottschalk 1993; Levy 1987). Wealth, income, and education inequalities are greatest among older adults, with unmarried women and minorities reporting the lowest resources (Crystal and Shea 1990; Shea, Miles, and Hayward 1996). These socioeconomic differences translate into reduced access to health services, which can impact utilization (Freeman and Corey 1993). Also, differences in medical insurance among older adults are associated with differences in health service utilization (Hurd and McGarry 1997; Newhouse and the Insurance Experiment Group 1993). Potential ethnic/racial inequities in health insurance among older adults are suggested by the greater proportion of Whites, compared with African Americans and Hispanics who hold insurance to supplement Medicare coverage (Crystal et al. 2000). Thus, we investigate the indirect effect of economic access (i.e., education, income, wealth, health insurance) on gender and ethnicity/race utilization differences, controlling for other predisposing factors and health needs.
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Methods |
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). The AHEAD is a probability sample of community-dwelling elderly persons in the United States sponsored by the National Institute on Aging and conducted by the University of Michigan. All analyses are based on the weighted sample to reflect this population. AHEAD monitored transitions in physical health, functional health, economic resources, and health care demand. African Americans and Hispanics were oversampled to provide sufficiently large numbers of participants to examine differential characteristics of these groups in elderly persons. Of those selected in the multistage sample, 7,447 people from the 1923 or earlier birth cohort participated in the 1993 interviews (an 80.0% response rate). This study focuses on 6,152 Hispanic, African American, or non-Hispanic White adults who provided health care utilization information in 1995. By the 1995 interview, 256 of these 6,152 respondents resided in a nursing home. An additional 781 people were deceased by 1995, and 409 were nonrespondents. Two-year mortality rates were somewhat higher for African Americans (13.1% vs 11.5% Hispanic, 10.1% non-Hispanic White), and men (12.5% vs 9.5% women). We restrict analyses to individuals who were alive at the 1995 interview because of dependence on self-reported utilization information.
Outcome Variables
AHEAD provides self-reported information on health care services that include physician visits, hospital stays, outpatient surgery, home health care, and nursing home stays. Respondents were asked in 1995 how many times in the last 2 years they saw or talked to a medical doctor, including emergency room and clinic visits, which was used to determine if they had any physician contacts; if they were an overnight hospital patient (any hospital admission); if they had outpatient surgery; if a medically trained person came to the home (among people not residing in a nursing home); and if they had been a nursing home patient.
The use of self-reported utilization data is common for large, nationally representative studies of older adults' health behavior, such as the National Health Interview Survey. However, when self-reported data are compared with administrative data, there is substantial evidence that self-reports significantly underestimate actual utilization (Cleary and Jette 1984; Roberts, Bergstralh, Schmidt, and Jacobsen 1996). Wallihan, Stump, and Callahan 1999 found that for elderly individuals in Indiana who self-reported utilization within the past year, there was significant underreporting for both physician use and hospitalizations. They found that numbers of visits were subject to the greatest underreporting, but found limited correlation of underreporting with specific predictor variables. To limit this problem, we emphasize measures of whether any utilization occurred and, for physician visits, we also look at median rather than mean number of visits.
Independent Variables
Predisposing variables.
AHEAD ethnicity/race information was used to classify people into three mutually exclusive groups: (non-Hispanic) African American, Hispanic, and non-Hispanic White. People from other racial/ethnic groups are excluded from analyses. AHEAD also provided information on age, gender, and marital status.
Health needs.
Health needs are represented by chronic conditions and functional health reported at the baseline (1993) interview. Baseline information was obtained on eight categories of chronic conditions: arthritis, diabetes, cancer, hypertension, heart disease, lung disease, stroke, and psychiatric problems. Arthritis was based on an affirmative response given to seeing a doctor within 12 months for arthritis or rheumatism or the report of a joint replacement that was not associated with a hip fracture. Participants were also asked whether a physician ever told them that they had cancer, diabetes, hypertension, lung disease (chronic bronchitis, emphysema), heart disease (heart attack, coronary artery disease, congestive heart failure, angina, other), or stroke. People were asked if they ever had or had ever been told by a physician that they had psychiatric problems (emotional, nervous, psychiatric).
Functional limitations were evaluated by task limitations in basic activities of daily living (ADLs) and in higher level function related to instrumental ADLs (IADLs) and lower and upper extremity use. Baseline basic functioning was evaluated using six ADL tasks: walking across a room, dressing, bathing, eating, using the toilet, and transferring from a bed. Higher level function is evaluated using five IADL tasks (preparing hot meals, shopping for groceries, making telephone calls, taking medications, and managing money); four tasks involving lower extremity use (walking several blocks, climbing one flight of stairs without resting, pulling or pushing large objects, lifting or carrying weights over 10 pounds); and one upper extremity task (picking up a dime from a table). Because upper extremity limitation based on only one task was a weak measure, it was not included in analyses. A limitation in a specific IADL task is ascertained from affirmative responses to having difficulty and receiving help with the task. Because questions about lower and upper extremity tasks did not solicit information about needing help with the task, the report of difficulty with, inability to perform, or avoidance of the task is coded as a limitation.
Economic access.
The term economic access is used to refer to Andersen 1995 concept of potential access. Economic access in this study is measured by an individual's level of human capital and the financial ability to pay for medical care.
AHEAD includes education as a measure of human capital and includes income, wealth, and health insurance as measures of financial ability to pay. Education was determined from completed years of education reported at the initial interview. Family income was aggregated across all income sources from the preceding year, reported by the respondent and spouse/partner. Respondents were asked about all income received the previous month from Social Security, Supplemental Security Income, private pensions, labor income, annuities, IRAs, stocks, bonds, veteran's benefits, food stamps, and other sources. For respondents who were unable or unwilling to provide exact amounts, the interviewer gave them the opportunity to provide an amount within a bracketed category, to minimize item nonresponse. Imputed estimates of income utilize bracketed responses (Smith 1997). Wealth was evaluated by household net worth, which summarizes the household's tangible wealth in terms of housing equity and nonhousing equity (e.g., savings). Similar procedures were used to minimize item nonresponse. Imputed values provided on the public use files were used for cases of missing income and wealth data.
Self-reported health insurance is categorized into five groups: Medicare only, Medicare plus Medicaid, Medicare plus other private or government health insurance, other, and no health insurance. Medicare Part A (with a 1-day copayment) covers hospital inpatient costs and short-term nursing home care. Part B covers 80% of physician and outpatient charges after a copayment. Additional private or Medicaid insurance tends to fill in gaps from Medicare coverage. "Medicare only" includes people holding Medicare Part A or Part A plus Part B who reported no other health insurance. Although AHEAD asked if Medicare holders had Part B coverage in addition to Part A, there were insufficient numbers holding Medicare Part A, but not reporting other coverage (69 non-Hispanic White, 53 African American, and 23 Hispanic), to separately analyze "Part A only" as a separate category.
Analysis
The research questions were addressed using multiple regression analyses that were developed in hierarchical stages entering (1) predisposing, (2) need factors, and (3) economic access. Health care services (physician, hospital, outpatient surgery, home health, nursing home) were dichotomized to indicate any 1993–1995 utilization (yes vs no). Because it is not known if ethnic differences are the same across gender, gender and ethnicity/race were initially entered as main effects in the first stage and then interaction terms were added to handle the possibility that some ethnic differences are not the same across gender. Linear contrasts were used to compare ethnic/racial differences within gender from interaction analyses.
Logistic regression was used to estimate the odds of using each type of health care service. Logistic regression models were estimated by applying Taylor series methods with between-cluster robust estimation to adjust for the complex sampling design using SUDAAN software (Shah, Barnwell, and Bieler 1997; Williams 2000). Among people reporting physician utilization, the number of physician visits is modeled using median quantile regression using Stata software (StataCorp 1997). Quantile regression, which models median utilization, is analogous to least-squares regression that models the mean outcome. Because quantile regression is robust to outliers and does not require assumptions regarding the underlining distribution of the outcome to obtain valid inference tests, the method is advantageous for modeling utilization outcomes that are not normally distributed (Buchinsky 1996). The variance of the median quantile regression coefficients is estimated using balanced repeated replication methods (Korn and Graubard 1999) applied to variance half-sample clusters identified in the public dataset to account for potential correlation among outcomes due to the complex sampling design.
Analyses are restricted to people who participated in both the 1993 and 1995 interviews. Of those alive, 94% participated in the 1995 interview. To make utilization statements about people alive in 1995, we adjusted for potential bias caused by nonresponse by handling respondents as an additional sampling stage to obtain sampling weights for 1995 respondents, using standard sampling methodology (U.S. Bureau of the Census 1963). Respondents were compared with nonrespondents to identify differential baseline characteristics, which included an incomplete baseline interview, hearing problems, withholding permission to obtain additional records, nonresponse to sensitive baseline questions, and geographic region. The sampling weight for 1995 respondents equaled the 1993 AHEAD sampling weight multiplied by the inverted probability of having a 1995 interview given these characteristics; that probability was estimated using logistic regression.
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Results |
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). There are no significant gender or ethnic/race main effect differences in physician contacts. However, adding interaction terms indicated notable gender/ethnic differences. Table 2 shows that African American men were significantly less likely than their non-Hispanic White male counterparts to see a physician, regardless of predisposing (Model 1, OR = 0.43), health needs (Model 2, OR = 0.32), or economic access factors (Model 3, OR = 0.49). ORs for Hispanic men are also less than one across the three models (although not significant), indicating they were less likely to see a physician, compared with non-Hispanic Whites. In contrast, women across ethnic groups had associated ORs near 1, indicating a similar propensity as the referent to see a physician for all three models. The complete behavior model (Model 3) for any physician contact is shown in Table 3 . There were no significant predisposing factors in addition to gender and ethnicity. Significant health needs are all chronic conditions (arthritis, cancer, diabetes, hypertension, lung disease), which increased the odds of seeing a physician. Economic access reference categories represent people with the greatest resources (higher education, income, assets, supplemental Medicare insurance). Compared with the reference group, less education (12 years or less), low income (<$7,500), low assets (<$10,000), and having only Medicare insurance decrease the odds of seeing a physician. The lower odds associated with only Medicare coverage is consistent with the higher out-of-pocket copayments for physician visits.
The volume of physician visits over 2 years among people with physician contacts (95% of the cohort) have no significant gender or ethnic/race main effect differences adjusted for other predisposing factors. However, adding interaction terms indicates notable gender/ethnic differences (Table 2 , Model 1). Minority men (African American = 8, Hispanic = 8 median visits) and African American women (7.5 median visits) report significantly more physician visits than their non-Hispanic White counterparts (men = 6, women = 6 median visits). These differences persist after controlling for health need (Model 2). When economic access variables (Model 3) are included, the excess visits among Hispanic men become marginally nonsignificant, but other differences remain significant. It should be noted that the observed differences between African American and non-Hispanic Whites may be underestimated because of a greater tendency among African Americans who contacted a physician to underreport the number of physician visits (Wallihan et al. 1999).
The complete behavioral model for the number of physician visits is shown in Table 3 . Among people who saw a physician (95% of the cohort), there are no significant predisposing factors in addition to gender and ethnicity. Regarding health needs, all chronic conditions except stroke and all functional limitations significantly predict more physician visits. Among economic access variables, Medicare plus Medicaid coverage is associated with more physician visits, which may reflect the Medicaid benefit covering physician visits.
These findings indicate that minority men, particularly African Americans, are less likely to see a physician than their non-Hispanic White counterparts. At the same time, minority men and African American women report more physician visits. These results suggest that minority men may delay seeking health care and thus require more medical management when care is ultimately obtained. Minority and non-Hispanic White women have similar likelihood of seeking physician care, but African American women with similar health needs report significantly more physician visits. The report of more physician visits by minorities suggests that these groups may experience greater severity of disease that is not captured by the health need factors in the model.
These physician service findings show that economic access factors influence the likelihood of seeking physician care. However, economic access has little impact on the gender or ethnic/racial disparities in seeking physician care or the number of visits among people who contacted a physician.
Use of Hospital Services
Hospitalizations are significantly less likely among women, but no main effect differences related to ethnicity/race are found, controlling for other predisposing factors. Referring to the gender/ethnic specific comparisons in Table 2 , it is evident that the odds of hospitalization are lower for wo-men in all ethnic/racial groups (significantly lower for non-Hispanic White women) after controlling for predisposing factors (Model 1). The indirect effect of health needs (Model 2) increases gender disparities, resulting in significantly lower ORs for all female ethnic/racial groups (non-Hispanic White, OR = 0.75; African American, OR = 0.69; Hispanic, OR = 0.54). Including economic factors (Model 3) does not reduce these gender disparities.
The complete behavioral model on the likelihood of a hospital stay is shown in Table 3 . There are no significant predisposing factors in addition to gender and ethnicity. All health needs increased the odds of hospitalization. None of the economic access factors were significant predictors of hospitalization.
These hospital findings indicate that women, regardless of ethnicity, were less likely to be hospitalized than men, particularly when health needs are considered. Economic access factors have no impact on the disparities related to hospital admissions.
Use of Outpatient Surgery
Outpatient surgery was significantly less likely among women, African Americans, and Hispanics, controlling for other predisposing factors. Referring to the gender/ethnic specific comparisons in Table 2 , it is evident that minority men (African American, OR = 0.54; Hispanic, OR = 0.57), as well as minority women (African American, OR = 0.61; Hispanic, OR = 0.43) and non-Hispanic White women (OR = 0.80), were significantly less likely than non-Hispanic White men to have outpatient surgery, after controlling for other predisposing factors (Model 1). In addition, Hispanic women reported outpatient surgery less frequently than non-Hispanic White women. The indirect effect of health needs did not change these differences (Model 2). However, adding economic access factors to the model attenuated some outpatient surgery differences. Whereas Model 3 outpatient surgery ORs remain less than one for all minorities and women, indicating less utilization among those groups, ORs for Hispanic men and African American women are no longer statistically significant.
The reason for these observed gender differences could relate to differential incidence of medical problems treated by outpatient surgery (e.g., hernia repair is more common among men), physician attitudes, or may be related to differential mortality risks by gender. Observed ethnic differences also may relate to a lack of referral networks in poor, minority areas. However, the reduction in these disparities after accounting for economic access may reflect a dependence on outside resources for elective outpatient surgery not covered by Medicare.
The complete behavior model for outpatient surgery is shown in Table 3 . There are no significant predisposing factors in addition to gender and ethnicity. Among health needs, selected chronic conditions (arthritis, cancer, hypertension) significantly increased outpatient surgery odds, but severe ADLs (3 or more) significantly decreased the odds. Because outpatient surgeries are generally minor elective procedures, lower odds related to severe ADL limitations may reflect a tendency not to subject these frail adults to optional surgeries; alternatively, such people may be handled on an inpatient basis, which is consistent with the high odds of hospitalization (3 ADLs, OR = 1.83 in Table 3 ) related to severe ADL limitations. Significant economic access factors indicate that people with low income ($7,500–$14,999) and few assets (<$1,000) were less likely to have outpatient surgery, compared with people with similar levels of need but greater financial resources.
These outpatient surgery findings indicate that women and minorities were less likely to have these procedures, even when health needs are considered. However, economic access variables reduced these disparities for minorities, rendering some of the differences insignificant.
Use of Home Health Care
Home health care is significantly more likely to be used by women, compared with men, and by minorities compared with non-Hispanic Whites, controlling for other predisposing factors. Table 2 shows notable gender-specific ethnic differences in the use of home health care. Controlling for predisposing factors (Model 1), African American men were more likely to use home health (OR = 1.55), compared with non-Hispanic White men. In addition, women, regardless of ethnicity (non-Hispanic White, OR = 1.38; African American, OR = 1.78; Hispanic, OR = 1.89), were significantly more likely to use home health than non-Hispanic White men. The indirect effect of health needs (Model 2) reduced gender and ethnic ORs, rendering all nonsignificant except non-Hispanic White women versus men. This finding suggests that the more frequent use of home health services among women and minorities is related to greater health needs in these gender/ethnic groups. Accounting for economic access eliminates the remaining difference (Model 3).
The complete behavioral model for home health care is shown in Table 3 . Older age significantly increases the odds of home health care. Health needs associated with greater use of home health includes cancer, diabetes, and all functional limitation measures (lower extremity limitations, IADL, and ADL limitations). However, the only significant economic access factor was holding only Medicare health insurance, which reduced the use of home health. Because Medicare pays for acute, but not chronic health care, in contrast to supplemental policies or Medicaid, which covers long-term health care, those who solely rely on Medicare have less coverage for home health.
These home health findings indicate that the greater use of home health services by women and minorities is largely explained by differences in health needs. Economic access factors have little indirect effect on gender/ethnic disparities after controlling for health needs.
Nursing Home Use
The initial analysis, which entered gender and ethnicity/race as main effects, did not show any significant differences, controlling for other predisposing factors. Table 2 shows that nursing home usage is reported with similar frequency among all but one gender/ethnic group, when interactions are entered. Hispanic women were significantly less likely to use nursing home care than non-Hispanic White men or women, after controlling for predisposing factors (Model 1, OR = 0.21), health needs (Model 2, OR = 0.15), or economic access (Model 3, OR = 0.13).
The complete behavioral model for nursing home use is shown in Table 3 . The likelihood of nursing home use significantly increased with older age, among those not married or functionally limited (IADL and ADL). Compared with those with greater economic access resources, the likelihood of nursing home care decreased with lower education, lower income, fewer assets, and those holding only Medicare or Medicare plus Medicaid. This finding may reflect that those with fewer resources have less access to higher quality nursing homes, which require private payments beyond that covered by Medicaid. Although health needs and economic access factors are related to nursing home use, these factors had little impact on the lower nursing home use by Hispanic women.
Health Service Not Covered by Medicare
In the health care outcomes examined previously, economic access variables did little to attenuate gender and ethnic differences in medical services. However, almost all older adults hold Medicare health insurance, which covers to some degree the health services considered. To explore the potential influence of Medicare health insurance on gender and ethnic utilization, we evaluate dental care utilization, because this service is not reimbursed by Medicare and people are less likely to hold dental insurance (Lillard, Rogowski, and Kington 1997).
Dental care is reported by almost twice as many non-Hispanic Whites, compared with African Americans or Hispanics for both men (57% vs 35%, 30%) and women (55% vs 31%, 38%). Table 4 shows gender-specific odds of dental care from stepwise logistic regressions, using the staged analyses. Model 1 analyses, which adjust for predisposing factors, show that minority men (African American, OR = 0.42; Hispanic, OR = 0.30) and women (African American, OR = 0.45; Hispanic, OR = 0.59) were significantly less likely than their non-Hispanic White counterparts to use dental care. In addition, non-Hispanic White women versus men had greater odds of using dental care. Adding chronic condition and functional limitations factors (Model 2) did not modify these differences. However, including economic access factors (Model 3) greatly reduces all minority disparities and shifted some gender disparities in the direction of greater use (i.e., Hispanic versus non-Hispanic White women).
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; Jones, Fedele, Bolden, and Bloom 1994; Manski and Magder 1998). It is recognized that factors motivating the use of dental care differ from medical care, particularly regarding dental health needs (U.S. General Accounting Office 2000). Many relevant dental health factors are not available from AHEAD data (e.g., dentate vs edentulous status). Despite these limitations, if dental care is viewed as a (limited) surrogate of health care utilization without the benefit of Medicare, it is evident that economic access factors have a strong indirect effect on utilization disparities among African Americans and Hispanics. In contrast, controlling for economic access had almost no effect in reducing gender/ethnic disparities for services covered by Medicare. These findings indicate that Medicare plays an important role in providing older women and minorities access to medical services, regardless of economic resources. |
Discussion |
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Specifically, there are gender and ethnic disparities in physician contacts (less likely among African American men), hospital admission (less use by non-Hispanic White women), outpatient surgery (less use by women and minorities), home health (more use by women and non-Hispanic African American men), and nursing home (less use by Hispanic women), after controlling for other predisposing factors. Controlling for health needs showed gender disparities in hospital admissions (less likely among minority and non-Hispanic White women), but explain almost all disparities in home health care. With the exception of outpatient surgery differences, further adjustment for economic access did little to reduce remaining gender/ethnic utilization disparities.
This study focused on the effects of economic access on the use of medical care. Among older adults, although the vast majority of older adults have health insurance through Medicare, potentially reducing one major economic barrier, disparities from other economic factors related to education, income, and lifetime accumulation of wealth are accentuated. AHEAD data are particularly valuable to explore the influence of economic access in health care disparities among older women and minorities, because this national probability sample of older community-dwelling adults includes detailed wealth and income information, providing important economic access measures. These findings document that economic access continues to influence the use of some health care (physician services, outpatient surgery, and nursing home care). However, with the exception of outpatient surgery, these factors do little to explain gender and ethnic disparities among older adults with similar burdens of health needs for services covered by Medicare. These findings also indirectly suggest that geographic barriers do not play a significant role in the observed utilization disparities, except perhaps in outpatient surgery. Geographic barriers to health care utilization (e.g., distance to medical facilities) would be similar for men and women within ethnic/racial groups. The fact that there were significant gender/ethnic interactions in medical care utilization suggests that geographic barriers are insufficient to explain differences found.
Economic access does appear to play a significant role in health services not covered by Medicare. Use of dental care was analyzed as a surrogate for health care utilization without the benefit of Medicare. Large disparities were found in the use of dental care between minorities and non-Hispanic Whites. The lower utilization of dental services among minority men and women was largely explained by differences in economic access. In contrast, economic access had little effect on services covered by Medicare, which indicates that the system works well for those services.
Economic access alone does not ensure that people will benefit from available health care. Other influential factors may include, but are not limited to, physician attitudes, patient beliefs about the medical system, care-seeking behaviors, patient views about physicians, and bias among health care providers (Ford and Cooper 1995). Medical literature is peppered with examples of ethnic and gender disparities related to clinical decision making (Finucane and Carrese 1990), use of medical procedures (Escarce, Epstein, Colby, and Schwartz 1993; McBean and Gornick 1994; Whittle, Conigliaro, Good, and Lofgren 1993), patient decisions to accept a recommended procedure (Maynard, Fisher, Passamani, and Pullum 1986), and patient delay in obtaining care (Weissman et al. 1991). There are also potential cultural barriers to medical care, including language, acculturation, and social isolation of ethnic groups (Abraido-Lanza, Guier, and Revenson 1996; Chesney, Chavira, Hall, and Gary 1982; Council on Scientific Affairs 1991). Because gender and ethnic differences in the use of Medicare-covered services persist after accounting for economic access, this suggests that future studies are needed to investigate the influence of other factors on disparities.
This study shows that older African American men are significantly less likely to seek physician care, compared with non-Hispanic White men, a difference not reported elsewhere. In contrast, Wolinsky and Johnson 1991 analysis of the Longitudinal Study of Aging (LSOA) found no gender or ethnic/racial differences in those who contacted a physician in the prior 12 months. However, the LSOA reports on utilization from the 1980s did not evaluate interactions between gender and ethnic/racial group. In addition, the AHEAD results show that minority men who sought physician care reported more visits than non-Hispanic Whites. Disparities in the use of physician services by minorities persisted after controlling for health needs and economic access factors. These findings suggest that minority men may delay seeking health care and thus require more medical management when care is ultimately obtained. Delayed care by older minorities is consistent with a Henry J. Kaiser Family Foundation report (1999) that shows African Americans and Hispanic Medicare beneficiaries are most likely to postpone seeking medical care.
Also, to our knowledge, this study is the first report on health care utilization among older Hispanics using a national probability sample. Hispanic gender-specific disparities are found in the use of physician, hospital, outpatient, and nursing home use, after controlling for predisposing factors and health needs. Compared with non-Hispanic White men, Hispanic men and women were less likely to use outpatient surgery; in addition, Hispanic women were less likely to use hospital or nursing home care. Lower use of hospital services by Hispanics is consistent with other reports (Guendelman and Wagner 2000). Findings on nursing home care are partially consistent with a study of older adults in rural Colorado (Hamman et al. 1999), which showed Hispanics were less likely to reside in nursing homes, compared with non-Hispanic Whites, adjusted for age and gender. In contrast, the current study, based on a national sample, shows less frequent nursing home utilization among Hispanic women, but not among Hispanic men, compared with non-Hispanic White adults. Although older Hispanics have more complex living situations, greater levels of functional limitations, and fewer economic resources than Whites (Waite and Hughes 1999), the lower use of nursing home care for Hispanic women persisted after accounting for predisposing, need, and access factors. The lower propensity of Hispanic women to use nursing home care may suggest a cultural commitment to keep older Hispanic women in the community or lack of access due to family structure, language, and cultural factors.
The AHEAD nursing home findings do not show strong African American versus White differences in the use of nursing home services, observed from some LSOA studies. An analysis of the LSOA found significantly less use of nursing home services over a four year period (1984–1988) among African Americans, compared with Whites, after controlling for predisposing, enabling, and need factors (Wolinsky, Callahan, Fitzgerald, and Johnson 1992). Similar analyses of 2-year LSOA survivors (Wolinsky et al. 1993) found no significant ethnic differences in 2-year (1986–1988) nursing home placement; but, when previous changes in functional status were included, significantly less usage by African Americans was found. Results from the current AHEAD study are consistent with lower (although nonsignificant) 2-year (1993–1995) nursing home use among African Americans versus non-Hispanic Whites for both older men and women. Differences between LSOA and AHEAD findings may reflect the decades monitored (1980s vs 1990s), nursing home use periods (4 vs 2 years), and variables included in analyses.
Several caveats should be noted regarding findings from this study. First, it is recognized that medical service outcomes are not independent (i.e., physicians are gatekeepers for use of other medical services). Also, there is potential for circularity between medical diagnoses and use of services. Detailed information regarding diagnoses and the sequence of medical events is needed to address such interrelationships, which is not available from AHEAD. Second, the nursing home analyses capture "late" rather than "early" nursing home placements. Because baseline characteristics of a community-dwelling cohort are used to model nursing home use over the subsequent 2-year period, all previous "early" nursing home placements are excluded from these analyses. Third, self-reported utilization data are adjusted for potential nonreporting bias, but are limited to those alive at 2-year follow-up. African Americans (13.1% vs 11.5% Hispanic, 10.1% non-Hispanic White) and males (12.5% vs 9.5% female) had somewhat higher mortality rates. Because those who died may be expected to have higher utilization rates, on average, but a shorter exposure period, the net effect on total utilization is unclear.
Finally, the reader is reminded that this study evaluates medical utilization before the Balanced Budget Act (BBA) of 1997. The BBA reduced support for indigent hospital care through reductions in Medicare disproportionate share hospital payments, outlier supplements, and indirect medical education payments. The BBA of 1997 also constrained the growth of state Medicaid disproportionate share hospitals and repealed the Boren Amendment, which may negatively affect state Medicaid payment formulas that traditionally favored providers with high indigent costs. However, a 1999 Balanced Budget Refinement Act of 1999 reduced many of these adverse payment effects. Although these changes were not in effect during the study period, they could increase ethnic and access-related effects beyond those observed in this study.
Despite these limitations, this study extends our understanding of the effect of economic access on gender and ethnic/racial disparities in health services utilization among older adults. Although economic access influenced the utilization of some services covered by Medicare, it did little to reduce the observed gender and ethnic/racial disparities. Other factors, such as cultural and attitudinal barriers, merit investigation. In contrast, economic access was strongly related to gender and ethnic disparities in dental care, a service not covered by Medicare. Further studies are needed to explore mechanisms contributing to gender and ethnic/racial health care utilization disparities to direct future policy making.
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Acknowledgments |
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We gratefully acknowledge the administrative help of Ms. Sandee Feldman, analytical advice of Dr. Bruce Spencer, and comments of Dr. Jane Holl, Dr. Linda Perloff, and Mr. Eric Ortland. The Asset of Health Dynamics Among the Oldest Old (AHEAD) is sponsored by the National Institute of Aging and conducted by the University of Michigan.
Received for publication April 9, 2001. Accepted for publication August 7, 2001.
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