Health Law & Policy Institute

NONFINANCIAL BARRIERS TO HEALTH CARE EXECUTIVE SUMMARY

There are currently about 41 million people in the United States who lack private or public health insurance and at least 3.8 million of them are non-elderly Texans. One popular misconception is that providing increased health insurance coverage will automatically ensure increased access to health care. Based on a variety of studies as well as our national and state experience with Medicaid, this is unlikely to be true. Notwithstanding the cost-free provision of health insurance to a sizeable segment of the poor, access to health care continues to be difficult. Among public health experts there is a consensus that insurance alone will not ameliorate the problem. A wide range of nonfinancial barriers preclude many persons from receiving health care.

In 1993, the Legislature of the State of Texas funded the study, "Nonfinancial Barriers to Health Care." The study was conducted by the University of Houston Health Law & Policy Institute. In December 1994, 73 advisory board members gathered at the University of Houston for a half-day conference devoted to developing the broad parameters of the study. Advisory members included 11 members of the State Legislature and representatives of various state agencies, not-for-profit and for-profit institutions, professional organizations, advocacy groups, academics, public officials, and other health care experts. Intensive information gathering through work groups generated a number of significant issues and ideas which were incorporated into the project plan. Throughout the months, a limited number of technical contracts were granted to the Tomás Rivera Center, the Office of Client Transportation, and several individual health researchers. In an attempt to elicit consumer input, focus group interviews were conducted in four areas of Texas. In addition, the Tomás Rivera Center conducted focus groups concerning the effect of culture, language, and ethnicity on Latino populations within the state. The information provided by focus group participants is discussed throughout the text.

The major study objectives included:

            1. Analyzing and describing the major nonfinancial barriers to health care access in Texas;

The nonfinancial barriers to health care were divided into two broad categories -- structural and personal. Included within the structural category were barriers related to availability of providers and services, the organization of the health care system in Texas, and the transportation environment in the state. Personal barriers included the role of culture, language and ethnicity; provider attitudes; and lack of social support, knowledge, and awareness. It should be noted that many of these barriers are interconnected. For example, if there is no primary care physician in rural Texas, availability becomes the obvious barrier. However, transportation also may present difficulties. As a result, there may be some overlap of information within each chapter. In general, each category of barrier is contained in a separate chapter.

This report contains a review of the literature, results of contractual research and surveys, and an examination of innovative approaches that are successfully being used. The last chapter of the study provides policy options for the Texas Legislature to consider. The following narrative briefly highlights the cogent nonfinancial barriers and lists several policy options that were identified as possible remedies.

 Availability

Many experts agree that the most significant nonfinancial barrier to access is the lack of available health care providers and services. Availability encompasses several factors. First, the health care work force must be composed of an appropriate number and mix of physicians, other medical professionals, and facilities to provide medical services. Second, these services must be located reasonably close to the population needing care. Third, the hours of operation, paperwork required, and other "convenience" factors must not act as an impediment.

Texas faces an acute shortage of primary care physicians in rural counties and inner-city neighborhoods. Shortages lead to greatly decreased access to health care and contribute to a lack of continuity of care. To increase the number of primary care physicians practicing in underserved areas, the content, process, and financing of graduate medical education in the state must change. In addition, access to health care, particularly in those counties without any physicians, physician assistants (PAs), or advanced nurse-practitioners (ANPs), can be improved through increased numbers and scope of practice of ANPs and PAs.

Several policy options that address the availability of health services and providers may be considered. The Legislature could --

(a) Authorize the Texas Higher Education Coordinating Board to contract with the Baylor College of Medicine to disburse funds for residents who train at community health clinics under the sponsorship of the Baylor Division of Urban Family Medicine; encourage University of Texas Health Science Center in San Antonio and University of Texas Southwestern in Dallas to create divisions of Urban Family Medicine modeled after the Baylor program, to include specialized curricula, residency programs at inner-city clinics, faculty recruitment, and ongoing research.

(b) Subsidize development of a rural physician training program at Texas A & M (whose enrolled proportion of graduate medical students from rural areas is roughly one-third), modeled on the Minnesota Rural Physician Associate Program, which includes a nine-month, third-year preceptorship in disadvantaged rural sites and a specialized curriculum.

(c) Direct the Texas Department of Health to create a Center for Urban Health Initiatives to address inner-city shortages in the same manner as the Center for Rural Initiatives addresses rural shortages, including (1) an urban "HealthFind" program to offer advice, workshops, and job fairs for inner-city neighborhoods seeking physicians; (2) an Outstanding Urban Scholar Program, whereby inner-city neighborhoods recruit and sponsor community students who are obligated to return to practice in the sponsoring community and whose medical loans may be forgiven.

(d) Direct the Texas Department of Health to design and implement a network of public after-hours clinics, utilizing medical school residents and volunteers to supplement local efforts, which will accept walk-in patients; authorize emergency room staff to offer appointments to patients willing to accept these in lieu of being seen in the emergency room.

(e) Amend Continuing Medical Education standards to require two hours of annual ethics training, which can include such issues as treatment of HIV-positive patients, cross-cultural sensitivity training, avoiding patient stereotyping, and handling conflicts of interest.

(f) Grant advanced nurse practitioners (ANPs) prescriptive authority which is commensurate with the ANP's scope of practice.

(g) Increase funding for ANP and PA positions because many of the available positions are not filled. Increased educational funding also would increase ANP and PA production.

(h) Extend the co-signature requirement afforded to advanced nurse practitioners and physician assistants in underserved areas to all ANPs and PAs regardless of where they practice.

Organization 

Many Texans experience a very complicated and fragmented health care delivery system. Much of the difficulty and confusion is derived from the maze of services in many communities and their lack of coordination. Service delivery also has been complicated by a growing number of federal laws and regulations. The development of publicly supported human services agencies and departments, without an effective mechanism to ensure unduplicated continuity of service further complicated the growing meshwork of services.

The complexity of the health care system is one of the greatest difficulties potential clients encounter. There are multiple agencies in many different locations. These agencies usually have different application requirements, as they are at the federal, state, and local levels. Generally, the process for accessing health care varies greatly, and clients must sort through this confusion after traveling form one agency to another. To further compound the problem, agencies often do not communicate with each other and thus have no information about what the others provide.

While some improvements have been made in recent years to address the complexity and fragmentation of the health care system in Texas, the state continues to maintain a complicated and fragmented health care delivery system. Several legislative options which may be considered to address the fragmentation and complexity of the Texas health care system are as follows:

(a) Direct and fully fund the Health and Human Services Commission to enhance current Client Access Projects sites (which provide all basic services in one location and use one application form for all services) by developing and testing additional components, such as marketing strategies, additional consultation on the use of automation, and utilization of a uniform client release form for sharing data among agencies.

(b) Direct and fully fund the Health and Human Services Commission to implement the Client Access Projects and future enhancements in additional settings to further test its effectiveness, with particular emphasis on rural settings. Experience gained in current pilot programs should be used to develop criteria for site selection.

(c) Utilize the Texas Office of State/Federal Relations in Washington, D.C., to work with the federal government to streamline the eligibility process for Supplemental Security Income (SSI) for the elderly and persons with disabilities.

Transportation

State agencies, advocacy groups, and others have repeatedly cited a lack of adequate transportation as a barrier to health care in Texas. No system is in place to ensure unduplicated service provision, to target underserved areas, or to maximize available resources in the course of making funding decisions. Yet the cost of providing the necessary transportation for medical services may be exceeded by the cost of doing nothing because the preventive care and early intervention enabled by providing transportation are much more cost-effective than illness management.

Several options that address the inadequacy of the transportation system in Texas are for the Legislature to --

(a) Require the Office of Client Transportation Services, created by the Legislature and provided under contract with the Health and Human Services Commission, to determine and adopt a single set of public/client transportation service regions to be used by all state agencies in planning, funding, and providing public and client/patient transportation.

(b) Require the Office of Client Transportation Services, working with the Agency Transportation Coordinating Council, to develop and adopt a consolidated planning process for public and client/patient transportation funding and services delivery based on standard, statewide service regions.

(c) Require the Texas Department of Transportation to fund this new planning process, and the development thereof, with its federal transportation planning funds.

Culture, Language, and Ethnicity

Health behavior differs among people of various cultures. By learning about the different cultures in Texas, assessing their health beliefs and practices, and integrating these beliefs and practices into plans of care, intercultural communication with patients and their families and the provision of health services can be enhanced. While we have dealt with several cultural groups in this study, we focused on Latinos as an example of the way in which culture, language and ethnicity have an impact on health care access.

The diversity of the Latino population in reference to language, educational attainment, nativity, and other factors, means that individuals within the Latino community do not face the same barriers in the same way. The diversity in orientation of medical institutions creates the possibility for Latinos with similar backgrounds to experience different access problems depending on the particular orientation of the health care entity. Although providers, advocates, and researchers are in general agreement that Latinos face language and cultural barriers in accessing medical services, other than language barriers, the focus group members were not able to articulate specific examples of cultural practices that limit access.

Several options that address the barriers of culture, language, and ethnicity for the Legislature to consider are to --

(a) Direct the Texas Department of Health through its Cultural Competence and Minority Health programs, to implement a pilot program in cooperation with one of the state's hospital districts that would explore the use of incentives to reward existing Spanish-language skills on the part of medical providers.

(b) Mandate the state's hospital districts to incorporate a community advisory group that would provide feedback to the district regarding its efforts to address the needs of minority consumers. The members of the advisory group should represent a cross-section of consumer, advocacy, and community-based organizations involved in health care issues. Each hospital district would be required to submit a progress report approved by the respective advisory group.

Other Barriers

There are several other nonfinancial barriers to health care discussed in detail in Chapter 5. Fear of malpractice, fear of infection, fear of economic loss, cultural insensitivity, language barriers, and outright bias jeopardize the access of racial, ethnic, and other minority populations to health care services. Access to health care may be impeded by a lack of personal resources, the absence of a personal support system, or a lack of knowledge. Policy options for these barriers and more detailed options for all of the other barriers are contained in Chapter 6.