Background

Many factors contribute to an individual’s health. The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” [i] Optimal health can be defined as the best possible health for an individual that is free from inequities. In order to understand what “inequities” means it is helpful to review three other words commonly used when discussing underserved populations - health “disparities” or “inequalities” or “inequities.” Researchers and policy makers might use “health disparities” and “health inequalities” interchangeably. To them, the terms mean a difference in health between populations (eg countries) or between populations (e.g. by gender, race and ethnicity, socio-economic status). There is, however, a nuanced difference.

Disparities refer to differences between any two groups. This could be in access, process, outcomes, etc. A person can have access but still be in a group with disparate outcomes compared with another group. Women, for instance, have poorer outcomes from myocardial infarction than men and this is not a question of access, but may be a matter of different processes of care. African American women have higher rates of low birth weight babies than white women, independent of income and access.
Inequalities has an ethical component suggesting that resources and then health is not equally distributed.
Inequities of health implies that disparity and inequality are due to avoidable causes. Implicit in the word inequity is the idea that something lacks justice.

An example of a disparity that is not an inequity could be the disease burden of sickle cell disease in African Americans or cystic fibrosis in Caucasians. Different populations have different rates of these diseases due to higher prevalence of mutations in the beta hemoglobin and the CTFR genes respectively. These genetic changes likely stem from historical geographic factors, and are not due to social and economic factors. These disparities are NOT an indication of biological differences between races.

An example of a disease burden that is both a disparity and an inequity is the high rates of HIV seen in people of color in the US compared with the white majority.

This module seeks to introduce students to examples of vulnerable, underserved, and marginalized populations; this should not be seen as an exhaustive list.

Vulnerable Populations

The word vulnerable means susceptible to physical or emotional harm. When thinking about health, it can be used to describe people who are at risk for poor health outcomes. Almost everyone has some factor that makes one vulnerable to less than ideal health. A single vulnerability might not impact an individual’s health, or a single significant vulnerability, such has a genetic predisposition to a disease, could have a large impact on the health of an individual. Increasing vulnerabilities can together contribute to poor health.

Vulnerabilities can be multifactorial. A reminder below is the Socio-Ecological Model you have seen before. Vulnerabilities can stem from each or many of the tiers.

Below is a summary of some of the variables we explore in this module and each can be linked to the Social ecological model as you think about these.

People	Access	Resources
Gender	Transportation	Food
Age	Geography	Housing
Genetics	Income/Class/Poverty	Education
Race/Ethnicity	Employment	Health care
Country of Origin	Insurance	Physical Environment
Disability	Discrimination	Family Environment
Individual Habits		Social Environment
Disease States/Conditions		Political Environment
Culture		Community
Sexual Orientation/Gender Identity		Spiritual

Another way of thinking about vulnerabilities is the model below that thinks about what happens and exists “upstream” to the individual or community, the “midstream” (psychosocial and behaviors), and the “downstream,” or effects on health.ⁱⁱ

People have characteristics that by themselves can make them vulnerable to poor health. Individual attributes fall into two main categories – those intrinsic to the person and those that the person maintains some control over. All of the following characteristics are things people generally cannot change about themselves. These include:

age
genetics
race/ethnicity
country of origin
sexual orientation^*
gender identity^**
some disabilities
disease state or conditions

*Sexual orientation is made up of a person’s sexual attraction, identity, and behavior. Though these factors may change over time, a person’s rooted sense of sexual orientation is immutable.

**A person’s gender identity or expression may change over time, and this does not negate the immutability of their rooted sense of gender.

It is important to acknowledge that personal decision-making has a role in determining our disease states, but much depends on genetic factors and variables largely outside our personal control.

Individuals can exert control over some individual habits such as:

sexual practices
use of tobacco, alcohol and drugs
physical activity
diet

This control is however also influenced heavily by external factors. This is where thinking within the social ecological framework is helpful. For instance, while a person might theoretically have “control” over diet, if they live in a food desert with little access to fresh produce, their options and choices are limited. Individuals are also affected by their cultural and personal beliefs.

A variety of issues affect an individual’s ability to access resources. Some of these issues are concrete such as:

income
employment
insurance status
availability of transportation
geography of the environment in which an individual lives

Other variables include institutional policies and some that are more abstract such as the discrimination individuals may face due to the personal attributes previously described, or differences in social status as demarcated by class or poverty.

The resources needed for optimal health include tangible items such as food and housing. Possessing a resource is an asset, and the lack of a resource could be considered a deficit. The communities in which an individual lives are important on all levels-neighborhood, city, county, state, regional, national, and world.

physical environment (water and air quality, temperature, pollution, working conditions)
family environment (structure and level of supportiveness),
social environment (interaction with others, sense of empowerment and trust)
political environment (involvement, empowerment, justice)

Access to quality education and the ability to undertake spiritual pursuits are also important. Access to health care itself is a central resource concern.

Underserved Populations

“Underserved,” by its literal definition, implies a decreased level of service or access to health care. People who are underserved face systemic and institutional barriers which prevent them from accessing health care and/or receiving the same quality of health care as people not facing those barriers. Quality health care is safe, effective, patient- centered, timely, efficient and equitable.

Access to health care is just one aspect of what contributes to an individual’s health. Limitations in access to care extend beyond obvious causes, such as shortages of health care providers or lack of facilities. Access to health care can be limited by both personal and structural factors – many of these factors are similar to those that can cause an individual to be vulnerable.

Personal factors are those that cause an individual to decide not to seek care they need (such as cultural differences, distrust, language differences, not knowing what to do, or environmental challenges for people with disabilities).

Structural factors are those outside an individual’s personal decision making that act as barriers to obtaining the care they need (such as having no health insurance or lacking transportation)

All people who are underserved have a least one vulnerability; many people who are vulnerable are also underserved.

While access to care is fundamental to the idea of “underserved” populations, the term has also come to encompass a broader understanding of the limitations of the US health care system. Because underserved populations are so diverse, it is difficult to make broad generalizations about people who are underserved, or even to discuss the specific history or issues that apply to the underserved.

For example, it isn’t entirely clear where “underserved” overlaps with “racial and ethnic disparities.” While there are many common issues (e.g. Hispanic patients may have health insurance coverage issues and also experience language barriers), there are also situations when the two issues can be seen separately. For example, two insured patients with similar socioeconomic status – one black, one white –are likely to be treated differently and have different health outcomes.

The one common thread for people that are vulnerable or underserved is that despite a health care system that spends more than $3 trillion[iii]per year, tens of thousands of patients do not receive quality health care.

Examples of Underserved Communities

Uninsured and Underinsured Individuals and Families

Take a minute to complete this quiz from the Kaiser Foundation: http://kff.org/quiz/uninsured-quiz/ After the quiz, continue reading:

In the United States, many limits on access to care involve health insurance. Health care in the U.S. is market-based, with individuals most frequently obtaining insurance coverage through their employers. In 2009, the largest underserved population was made up of over 50 million uninsured Americans in 2009 – 22.5% of all adults under age 65 and 10.4% of all children.[iv] That rate dropped to 29 million or 9.1% of the population in 2015, because of the Affordable Care Act. For children it was down to 5.3% in 2015. [v]

While the majority of Americans obtain health insurance through their employers as a benefit, being employed does not guarantee that an individual or family will have insurance. Many uninsured individuals come from working families with low to moderate incomes, families for whom coverage is not available in the workplace or is unaffordable. Instability in the Insurance marketplace has led to increases in premium costs for consumers, particularly in states without expanded Medicaid.

Underinsurance occurs when people have health benefits that do not adequately cover their medical needs. This can occur through high deductible or catastrophic health plans or when coverage does not include needed benefits.

Those without adequate health insurance coverage face barriers to accessing to health care, which can ultimately lead to poor health outcomes. Furthermore, those lacking coverage are disproportionately low income and thus, more financially vulnerable. People without health insurance face higher out-of-pocket costs compared to the insured and those with low incomes face larger burdens with medical bills.

Medicare covers virtually all adults age sixty-five and older. Medicaid and the State Children’s Health Insurance Program (S-CHIP) help provide coverage for millions of low- income people. Under the Affordable Care Act in 2010, states were able to expand Medicaid coverage which contributed significantly to the drop in the numbers of uninsured individuals and families. [vi]

In 2015, health expenditures were 1.2 trillion for public (Medicare and Medicaid), 1.1 trillion for private, and 338.1 billion for out of pocket.[vii] This information could lead to the conclusion that public programs are wasteful compared to private companies but in fact the opposite has be shown to be true. Regression analyses show what variables account for this appearance.

Public programs spend more to cover fewer people because those people have a larger disease burden compared to individuals covered with private companies. When spending was adjusted for burden of disease, Medicaid actually spent less per person than private insurance. If all individuals on Medicaid were converted to private insurance, the total health expenditures per person would increase 26% for adults and 37% for children.[viii]

The Patient Protection and Affordable Care Act ("Obamacare") is a comprehensive health reform signed into law in March 2010. It aimed to increase the number of Americans with health insurance through an individual mandate (people are required to have health insurance or pay a penalty) while providing access to affordable coverage through a health insurance exchange, cost-sharing credits and subsidies, and the expansion of Medicaid.

Not all states are moving forward with Medicaid expansion. At this time Washington, Alaska, and Montana are the WWAMI states with expanded Medicaid.

The S-CHIP and ACA have resulted in a large decline in the proportion of uninsured children, covering 94% of them. Medicaid alone covers 36 million children and CHIP brings insurance to another 8 million whose parents are working with incomes too high to qualify for Medicaid. Many eligible children are not enrolled, whether because of knowledge, access, or immigration status.

Learn more about Medicare and Medicaid in the (linked) Underserved Pathway modules.

Rural Communities

In the United States, rural areas include 80% of the land but only 19% of the population. People living in rural areas face a variety of barriers to accessing health care. Although the rural population is almost one-fifth of the US population, only about one tenth of U.S. physicians work in rural areas. As an area becomes more remote, fewer physicians are available for the population living in that area. For example, in urban areas there are 209 physicians per 100,000 people compared to 113 physicians per 100,000 people in rural areas. Individuals living the most isolated areas have only 52 physicians per 100,000 people. Rural physicians are older than non-rural physicians and impending retirement will aggravate this rural physician shortage. As the number of physicians serving populations goes down, travel time to reach those physicians increases. Furthermore, those living in rural communities in America tend to be older with people age 65 and older make up 15% of rural populations compared with 12% of the total US population. [ix] People in rural areas have lower incomes than their urban counterparts and are less likely to be covered by private insurance. Minority populations are increasing in rural areas and now comprise 18.3% of the total rural population.[x]

Learn more about rural health in the (linked) Underserved Pathway modules Rural Health 1 and Rural Health 2.

Racial and Ethnic Minorities

Racial and ethnic minorities (link to related module) make up approximately 1/3 of the total population and experience many health disparities compared to white Americans in the United States. Some of these differences can be explained by discrepancy in income and insurance status. However, there robust evidence that racial and ethnic minorities suffer from worse health outcomes even after accounting for such factors suggesting that these disparities are actually inequities.

African Americans have the largest number of disparities with higher rates of infant mortality, heart disease, diabetes, and asthma compared to white Americans. Despite similar rates of cancer screening, they are more likely to die of breast, lung, and colon cancer. They are less likely to have received needed diabetes care and more likely to have diabetes related end state renal disease. They are less likely to be tested for HIV and more likely to be diagnosed with AIDS or to die of HIV. Asthma control is worse with more hospital admissions for exacerbations.
American Indian/Alaska Natives also have increased rates infant mortality compared to white They have lower rates of blood pressure and cholesterol screening and are more likely to be diagnosed with AIDS or die of HIV.

Compared to white Americans, Hispanics are screened less often for cervical and breast cancers and have lower rates of blood pressure and cholesterol Hispanics are more likely to have diabetes yet less likely to receive diabetes specific care. They suffer from higher rates of diabetes related end stage renal disease. Like African Americans and Native Americans, they are less likely to be tested for HIV and more likely to be diagnosed with AIDS, or die of HIV-related complications. Asthma control is worse for Hispanics reflected by increased rates of hospital admissions for exacerbation.
Historically, Asian Americans had lower screening rates for cancer. A number of factors were thought to be involved, including cultural ones. A 2014 study shows that access to primary care and insurance are key and that those who have been in this country for 20 years or more are far more likely to get screening than those who have been here fewer than ten years: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4143174/#:~:text=According%20to%20data%20from%20the,59.8%25%2C%2083.4%25%2C%20and

Compared to white Americans, all minorities have higher rates of self-reported fair or poor health. All minorities face decreased access to health care compared to white Americans and are more likely to report no usual source of medical care and less frequent dental care. Minority women are more likely to have late or no prenatal care for a pregnancy. [xi]

Specific Populations

Many smaller groups or communities exist that have some vulnerability making them less likely to receive quality health care. These groups include individuals with specific disease states that require specialized care such as those with HIV or substance use disorders. People with social issues such as homelessness, poverty, or intimate partner violence (IPV) often require care from multidisciplinary teams to overcome obstacles to improved health. Elders, immigrants, individuals who identify as LGBTQ+ and people with disabilities may require access to health care providers who have knowledge and skills to address their distinctive needs. Although these groups are heterogeneous in terms of specific characteristics, they share common problems related to access to and processes of care and they have unique needs that are best addressed in a sensitive manner with appropriate resources.

Improving the Health of Underserved Individuals and Communities

Many things can contribute to the improving the health of underserved populations and communities. Often this requires an in-depth look at the community or population in order to best determine its assets and what needs exist and to strategize on ways to meet them. A basic understanding of population health needs is vital to designing and implementing interventions aimed at improving health and reducing inequities. Advocacy for issues surrounding the underserved, be it on a personal, clinic or political level, is also paramount to affecting change that leads to social justice.

Physicians have a professional responsibility to examine their own potential biases and prejudices that may affect their care of patients, in particular underserved patients, and to address them to improve the care they deliver. One way to begin exploring this issue is to take Implicit Association Tests to determine hidden biases and assumptions about particular groups.

TASK: Please visit the Project Implicit website: https://implicit.harvard.edu/implicit/demo/takeatest.html

Select at least two tests to take. Each test takes 10-15 minutes to complete. In your reflection, please incorporate your thoughts on this. Do the results surprise you? Is the test a helpful tool for exploring implicit assumptions? Is it even accurate? Did the test make you feel uncomfortable? If so, why? If not, why?

Here is an article with seven suggestions for managing and minimizing your unconscious biases.

https://www.fastcompany.com/3044738/7-simple-methods-to-fight-against-your-unconscious-biases

Safety Net

Safety net programs are a critical part of health care in the U.S. and are increasingly essential to assuring access to health services for uninsured and other underserved populations. Federally Qualified Health Centers (FQHCs) are clinics governed by a board of directors that provide primary care for people of all ages, usually based on a sliding scale fee for uninsured patients. In addition to enhanced Medicare and Medicaid reimbursement, the FQHC designation gives these clinics federal grant support, malpractice coverage, and access to free vaccines and reduced cost medications.

FQHCs include Community Health Centers (CHCs), Migrant Health Centers, Health Care for the Homeless Programs (HCH), and Public Housing Primary Care Programs. Rural Health Clinics (RHCs) are another type of federally funded clinic that are located in a rural location and require incorporation of mid-level providers to meet primary care needs of a population.[xii]

There are many different types of safety net providers in addition to federally funded programs, including free clinics, county services and hospitals, and public health clinics. Various factors influence the extent to which access is actually increased these clinics or programs, including provider capacity and funding available to provide

care. Many physicians in private practice, especially those in rural areas working with underserved patients, informally provide charity care for patients who are otherwise unable to finance care.

Reducing Health Inequities to Lessen Disparities in Outcomes

Strategies to address health disparities include:

Access
- Insurance guarantees
- Health workforce
  - Increasing the number of minorities practicing health professions
  - Improving geographical distribution of professionals and facilities
  - Better distribution of specialties
Quality
- Design of health services
- Improving integration of public health and clinical medicine.
- Increasing patient education and outreach.
Clinical skills
- Improving clinician communication skills
- Improving skills of cultural humility, and working in cultural contexts
- Ensuring that health care services are provided in a culturally and linguistically sensitive manner.

Conclusion

Because many factors contribute to optimal health there are many ways that people can be vulnerable to poor health outcomes. When these vulnerabilities affect access to quality healthcare, an individual is considered underserved. The remaining modules focus on issues surrounding the underserved and also explore specific vulnerabilities a group or individual may possess. Almost 20% of the US population is uninsured, almost 20% of the population lives in rural areas and a third of the population is a racial or ethnic minority. This means that many people living in this country grapple with what it means to be underserved and therefore, most physicians and healthcare professionals will work with vulnerable and underserved patients. Adequate access to quality care is one crucial aspect in eliminating health inequities and increasing the quality and years of healthy life for all persons in the United States. Working towards social equity in other arenas is also needed if we are to improve the health of all and decrease health disparities.

Related resources for students who want to delve further:

Healthy People 2030 is the guiding document for the federal government’s efforts to improve quality of care and address health disparities. The documents address specific disease groups and populations and lay out the health goals of the nation: https://health.gov/healthypeople

The federal government’s Health Resources and Services Administration (HRSA) is the lead federal agency in providing resources and programs for underserved populations. Community Health Centers are administered through this agency: www.hrsa.gov

The Kaiser Family Foundation is an excellent source of information and data on the nation’s uninsured. www.kff.org

This article discusses the role of medical schools in eliminating health disparities:

Eliminating Racial and Ethnic Disparities in Health Care: What Is the Role of Academic Medicine?
Health Policy Academic Medicine. 81(9):788-792, September 2006. Betancourt, Joseph R. MD, MPH

References

[i] Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

[ii] Bay Area Regional Health Initiative. Framework. http://barhii.org/framework/

[iii] Young J. America Spent More Than $3 Trillion On Health Care Last Year. Huffpost July 2016. http://www.huffingtonpost.com/entry/america-spent-more-than-3-trillion-on-health-care-last-year_us_57868091e4b08608d332956a

[iv] US Census Bureau: Current Population Reports: Income, Poverty, and Health Insurance Coverage in the United States :2007. Table 149

[v] The US Census Bureau. Income, Poverty and Health Insurance Coverage in the United States: 2015. September 2016. https://www.census.gov/newsroom/press-releases/2018/income-poverty.html

[vi] HJ Kaiser Family Foundation. Current Status of State Medicaid Expansion Decisions. Jan 2017. http://www.kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/

^[vii]Center for Medicaid and Medicare Services. Highlights of National Medical Expenditure Data 2015. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/highlights.pdf

[viii] Health Affairs, 27, no. 4 (2008): w318-w327

[ix] Fordyce MA, Chen FM, Doescher MP, Hart LG. 2005 physician supply and distribution in rural areas of the United States. Final Report #116. Seattle, WA: WWAMI Rural Health Research Center, University of Washington; Nov 2007.

[x]USDA Rural America at a Glance, 2018. https://www.ers.usda.gov/publications/pub-details/?pubid=90555

[xi] HJ Kaiser Family Foundation. Key Facts: Race, Ethnicity and Medical Care, 2016 Update. http://www.kff.org/disparities-policy/report/key-facts-on-health-and-health-care-by-race-and-ethnicity.

[xii] Key Differences between FQHCs and RHCs. Chastity Werner, RHIT, June 13, 2013, Medical Billing & Collections, Practice Models, Physicians Practice. https://www.physicianspractice.com/blog/key-differences-between-fqhcs-and-rhcs