Health Care Access

Access to health care—both preventive care and treatment—is crucial for cardiovascular health. Research shows that by improving health care access, population-level cardiovascular disease (CVD) risk may be reduced.

For example, having health insurance is associated with earlier CVD detection and reduced risk of major cardiac events. 1 However, access to and use of health care services varies across population subgroups. Black/African American persons, Hispanic/Latino persons, American Indian/Alaska Native persons, people with lower incomes, and people who live in under-resourced neighborhoods are less likely to have access to quality health care.

Several factors influence health care access. In some communities, there is a shortage of primary care physicians, nurses, community health workers (CHWs), pharmacists, paramedics, and/or physical/occupational therapists; in others, health care clinics, pharmacies, and hospitals are inaccessible due to their location. Health care affordability also affects one’s ability to access health care.

Although the Affordable Care Act expanded insurance coverage to millions of Americans who have heart disease or risk factors for heart disease, nearly one-quarter of low-income Americans with CVD or cardiovascular risk factors remain uninsured. Similarly, approximately 13% of Black/African American adults, and 29% of Hispanic/Latino adults with CVD or CVD risk factors are uninsured. 2

Even where health care is accessible, widespread differences in the quality of care provided can lead to differential health outcomes. Moreover, factors such as health literacy—which is notably lower within non-White communities, older adults, and individuals with less education—affects patients’ ability to make recommended healthy lifestyle changes and adhere to prescribed medication. 3

Table of Contents

Indicators

This document provides guidance for measuring five indicators related to health care access that influence inequities in access to and use of health care services, leading to differential risks for developing CVD or complications from CVD. The five health care access indicators are measured at different levels of analysis, including block group, census tract, ZIP code, county, congressional district, metro division, metro area, and state.

Health Care Affordability

Why is this indicator relevant?

Health care affordability refers to the cost of health care services, health insurance premiums, deductibles, co-pays or co-insurance, and patients’ ability to pay for these. 4 According to the 2018 National Center for Health Statistics National Health Interview Study, 14.2% of individuals in the U.S. lived in families that experienced problems paying medical bills in the past 12 months 5 and more than 45% of adults between the ages of 18 to 64 with CVD reported financial hardship due to medical bills. 6

Health insurance coverage (public or private) may increase patients’ ability to afford health care costs; however, even among those with health insurance, many people with CVD experience financial hardship due to the high costs of insurance deductible, copay, and coinsurance. 7

The American Heart Association (AHA) reports that an estimated 7.3 million Americans with CVD are uninsured. 8 In 2018, among people younger than 65, those who were uninsured were more likely than those who had Medicaid or private coverage to be in families experiencing problems paying medical bills. 9 People who are uninsured also face challenges accessing preventive care, which is critical for early identification of cardiovascular risk factors. 10,11

Similarly, lack of insurance is associated with inadequate and untimely medical treatment access, resulting in greater risk of poor cardiovascular health outcomes. 12,13 Concerns with health care affordability result in patients avoiding or delaying seeking care. In a study of adults ages 50–64 years, 13.2% of respondents reported they did not get medical care in the past year; 11.9% avoided filling a prescription due to cost. 14

This indicator can be assessed by the following measures. Click on each measure to learn more:

Measure 1: Avoided Care Due to Cost

America’s Health Rankings (AHR)

The United Health Foundation’s AHR evaluates a comprehensive set of health, environmental, and socioeconomic data. The AHR website provides state-level analyses of CDC Behavioral Risk Factor Surveillance System (BRFSS) data on the percentage of adults who reported a time in the past 12 months when they needed to see a doctor but could not because of cost. Users can access this measure under Clinical Care > Access to Care – Annual > Avoided Care due to Cost. National and state-level estimates are provided by age, educational attainment, gender, income, and race/ethnicity for the most recent data. Current editions (2015–2021) can be explored online or downloaded in various formats including Excel, CSV, and ZIP. Past editions (1990–2014) are also available for download.

Kaiser Family Foundation

The Kaiser Family Foundation website provides state-level data on the proportion of adults who report not seeing a doctor in the past 12 months due to cost of care. Data for this measure are available annually for 2013–2020 and are sourced from the BRFSS. Data are available by race/ethnicity; however, some states do not have sufficient data for certain racial/ethnic groups. Data can be downloaded as a CSV file.

Example Survey Instrument

The following survey is available for assessing avoided care due to cost:

Healthcare Access & Utilization Survey

The Healthcare Access & Utilization Survey was developed for the National Institutes of Health’s All of Us Research Program, which is a national effort to build one of the most diverse health databases. This survey asks questions about a participant’s access to and use of health care and includes several questions related to health care costs. Questions on avoidance of care due to cost are provided below. The entire instrument is available from NIH’s All of Us Research Program.

There are many reasons people delay getting medical care. Have you delayed getting care for any of the following reasons in the PAST 12 MONTHS?

Survey questions
Yes No Don’t Know
Couldn’t afford the copay.
Your deductible was too high/or could not afford the deductible.
You had to pay out of pocket for some or all of the procedure.

DURING THE PAST 12 MONTHS, was there any time when you needed any of the following, but didn’t get it because you couldn’t afford it?

Survey questions
Yes No Don’t Know
Prescription medicines
Mental health care or counseling
Emergency care
Dental care (including checkups)
Eyeglasses
To see a regular doctor or general health provider (in primary care, general practice, internal medicine, family medicine)
To see a specialist
Follow-up care

DURING THE PAST 12 MONTHS, were any of the following true for you?

Survey questions
Yes No Don’t Know
You skipped medication doses to save money
You took less medicine to save money
You delayed filling a prescription to save money
You asked your doctor for a lower cost medication to save money
You bought prescription drugs from another country to save money
You used alternative therapies to save money
survey questions
Very worried Somewhat worried Not at all worried Don’t know
If you get sick or have an accident, how worried are you that you will be able to pay your medical bills?
Measure 2: High Medical Cost Burden Measure 3: Insurance Status and Coverage

Example Survey Instrument

The following survey questions are available for assessing insurance status:

American Community Survey (ACS)

The U.S. Census Bureau’s ACS asks questions about health insurance coverage to create statistics about the percentage of people covered by health insurance and the sources of health insurance. To view the ACS survey questions on health insurance coverage, visit the U.S. Census Bureau’s website below. Users can use the question on current health insurance or health coverage plans.

Health Care Availability

Why is this indicator relevant?

Health care availability is typically defined as the geographic proximity of providers and facilities in relation to an individual and reflects the capacity of medical service markets to adequately meet the needs of the local population. 15,16 Limited availability of health care resources, including the number of primary care physicians, nurse practitioners, and pharmacists per capita, presents a barrier that may reduce access to health services and increase the risk of poor health outcomes. 17

In the United States, nearly 84,000,000 people live in Primary Care Health Professional Shortage Areas. 18 Primary care serves as the usual and ongoing source of care that is associated with enhanced access to other health care services, including preventive services such as blood pressure screenings; better health outcomes; and a decrease in hospitalization and emergency department visits. Primary care can also help counteract the negative effect of poor economic conditions on health. 19

Safety net providers focus on providing care to uninsured, poor, Medicaid, or other vulnerable patients. Safety net providers typically rely on Medicaid, Medicare, or charitable funding and typically offer essential health services and enabling or “wraparound” services (e.g., language interpretation, transportation, childcare, nutrition and social support services) specifically targeted to the needs of the vulnerable populations. 20,21 The availability of safety net providers is linked to improved access of care among uninsured persons. 22 One critical component of the health care safety net are Federally Qualified Health Centers (FQHCs). FQHC service availability is positively associated with access to care for the uninsured and having a usual source of care for those with Medicaid. 23 Having access to care and a usual source of care may facilitate CVD screening and increase opportunities for patients to receive preventive care and information about CVD risk behaviors from a health care provider. 24

Health care availability is typically defined as the geographic proximity of providers and facilities in relation to an individual and reflects the capacity of medical service markets to adequately meet the needs of the local population. This indicator can be assessed by the following measures. Click on each measure to learn more:

Measure 1: Nurse Practitioner Ratio

To measure the magnitude of disparities in health care availability, users should calculate metrics for specific subgroups. This facilitates setting tailored targets, measuring baseline disparities, and tracking trends by population groups that matter for advancing health equity. Demographic categories to consider for data disaggregation are race/ethnicity as defined by the Office of Management and Budget (OMB), gender, socioeconomic status, sexual orientation, immigration status, ability status, and geography.

One method to consider for setting equity targets is the HOPE Initiative’s approach. This method consists of averaging the proportion of the top five geographic units within a jurisdiction for the highest-performing socioeconomic groups. This method helps set targets based on actual population performance using socioeconomic status, which is strongly associated with health outcomes. One limitation to this approach is the assumption that the highest-performing groups are in favorable health. More details on this methodological approach are provided in the Benchmark Development section.

As a piloted indicator in DHDSP’s HEI Pilot Study, sites found that county-level data were most useful to provide multiple data points for analysis. A large sample size and a broader set of counties are needed to enhance the utility of this indicator.

Measure 2: Number of Safety Net Providers

Safety net providers are “those providers that organize and deliver a significant level of health care and other related services to uninsured, Medicaid, and other vulnerable patients.” 25 Safety net providers include some hospitals (e.g., public, children’s, teaching, and community hospitals serving low-income individuals), community health centers, Federally Qualified Health Centers (FQHCs),* migrant health centers, health services programs for the homeless or public housing residents, school-based clinics, and some home health agencies. 26

* An FQHC is a community health center that qualifies for enhanced reimbursement, beyond standard Medicare and Medicaid, from the HRSA Health Center Program, due to its focus on health disparities and work to empower people who live in areas that are medically underserved with high-quality patient care.

*CAHs are located in rural areas more than 35 miles from another hospital (or more than 15 miles in areas with mountainous terrain or that have only secondary roads available, or they have been certified as a “necessary provider” by their state prior to January 1, 2006), provide 24-hour emergency services, have a maximum of 25 inpatient beds, and maintain an annual average length of stay of 96 hours or less for their acute care patients.

**The DSH index is a function of a hospital’s total inpatient days from patients on Supplemental Security Income (SSI) with Medicare and the total inpatient days from non-Medicare patients on Medicaid.

This indicator may require skills in pulling secondary data, setting up a database, and conducting descriptive statistical analysis and reporting.

To measure the magnitude of disparities in health care availability, users should calculate metrics for specific subgroups. This facilitates setting tailored targets, measuring baseline disparities, and tracking trends by population groups that matter for advancing health equity. Demographic categories to consider for data disaggregation are race/ethnicity as defined by the Office of Management and Budget (OMB), gender, socioeconomic status, sexual orientation, immigration status, ability status, and geography.

One method to consider for setting equity targets is the HOPE Initiative’s approach. This method consists of averaging the proportion of the top five geographic units within a jurisdiction for the highest-performing socioeconomic groups. This method helps set targets based on actual population performance using socioeconomic status, which is strongly associated with health outcomes. A limitation to this approach is the assumption that the highest-performing groups are in favorable health. More details on this methodological approach are provided in the Benchmark Development section.

As a piloted indicator in DHDSP’s HEI Pilot Study, sites found that county-level data were most useful to provide multiple data points for analysis. A large sample size and a broader set of counties are needed to enhance the utility of this indicator.

Identifying the number of safety net hospitals can be difficult due to the absence of a standard definition. 27,28,29,30 Safety net hospitals are generally recognized as hospitals that provide essential care to patients regardless of ability to pay, insurance status, or immigration status. These hospitals usually serve a substantial share of uninsured, Medicaid, and other vulnerable patients. 31,32 Common ways to identify safety net providers include payer mix (e.g., Medicaid, uninsured, private insurance), hospital characteristics (e.g., teaching status, public ownership, nonprofit status), patient case mix (e.g., socioeconomic status, health status), Medicaid disproportionate share hospital payment (DSH) status, Medicaid caseload (e.g., percentage of inpatient discharges that are Medicaid), and/or the level of uncompensated care. 33,34

Health care availability metrics should be interpreted alongside health care needs. It is important to consider the level of need in a community, because some areas with high rates of disease may have high health care availability due to high need for health services.

Measure 3: Primary Care Physician Ratio

To measure the magnitude of disparities in health care availability, users should calculate metrics for specific subgroups. This facilitates setting tailored targets, measuring baseline disparities, and tracking trends by population groups that matter for advancing health equity. Demographic categories to consider for data disaggregation are race/ethnicity as defined by the Office of Management and Budget (OMB), gender, socioeconomic status, sexual orientation, immigration status, ability status, and geography.

One method to consider for setting equity targets is the HOPE Initiative’s approach. This method consists of averaging the proportion of the top five geographic units within a jurisdiction for the highest-performing socioeconomic groups. This method helps set targets based on actual population performance using socioeconomic status, which is strongly associated with health outcomes. A limitation to this approach is the assumption that the highest-performing groups are in favorable health. More details on this methodological approach are provided in the Benchmark Development section.

As a piloted indicator in DHDSP’s HEI Pilot Study, sites found that county-level data were most useful to provide multiple data points for analysis. A large sample size and a broader set of counties are needed to enhance the utility of this indicator.

Health care availability metrics should be interpreted alongside health care needs. It is important to consider the level of need in a community, because some areas with high rates of disease may have high health care availability due to high need for health services.

Measure 4: Pharmacy Ratio

To measure the magnitude of disparities in health care availability, users should calculate metrics for specific subgroups. This facilitates setting tailored targets, measuring baseline disparities, and tracking trends by population groups that matter for advancing health equity. Demographic categories to consider for data disaggregation are race/ethnicity as defined by the Office of Management and Budget (OMB), gender, socioeconomic status, sexual orientation, immigration status, ability status, and geography.

One method to consider for setting equity targets is the HOPE Initiative’s approach. This method consists of averaging the proportion of the top five geographic units within a jurisdiction for the highest-performing socioeconomic groups. This method helps set targets based on actual population performance using socioeconomic status, which is strongly associated with health outcomes. A limitation to this approach is the assumption that the highest-performing groups are in favorable health. More details on this methodological approach are provided in the Benchmark Development section.

As a piloted indicator in DHDSP’s HEI Pilot Study, sites found that county-level data were most useful to provide multiple data points for analysis. A large sample size and a broader set of counties are needed to enhance the utility of this indicator.

Health care availability metrics should be interpreted alongside health care needs. It is important to consider the level of need in a community, because some areas with high rates of disease may have high health care availability due to high need for health services.

Measure 5: Pharmacist Ratio

To measure the magnitude of disparities in health care availability, users should calculate metrics for specific subgroups. This facilitates setting tailored targets, measuring baseline disparities, and tracking trends by population groups that matter for advancing health equity. Demographic categories to consider for data disaggregation are race/ethnicity as defined by the Office of Management and Budget (OMB), gender, socioeconomic status, sexual orientation, immigration status, ability status, and geography.

One method to consider for setting equity targets is the HOPE Initiative’s approach. This method consists of averaging the proportion of the top five geographic units within a jurisdiction for the highest-performing socioeconomic groups. This method helps set targets based on actual population performance using socioeconomic status, which is strongly associated with health outcomes. A limitation to this approach is the assumption that the highest-performing groups are in favorable health. More details on this methodological approach are provided in the Benchmark Development section.

As a piloted indicator in DHDSP’s HEI Pilot Study, sites found that county-level data were most useful to provide multiple data points for analysis. A large sample size and a broader set of counties are needed to enhance the utility of this indicator.

Health care availability metrics should be interpreted alongside health care needs. It is important to consider the level of need in a community, because some areas with high rates of disease may have high health care availability due to high need for health services.

Medically Underserved Areas

Why is this indicator relevant?

Medically Underserved Areas/Populations (MUA/Ps) are physician shortage designations that are sister programs to the Health Professional Shortage Area (HPSA), which provide similar benefits to communities in need. 35 MUA/Ps are designated by HRSA as having too few primary care providers, high infant mortality, high poverty, or a high older adult population. 36 Individuals living in medically underserved areas often face economic, cultural, or linguistic barriers to health services and preventive care, 37 which is associated with earlier identification of cardiovascular risk factors, 38,39 and inadequate and untimely access to medical treatment, resulting in greater risk of poor cardiovascular health outcomes. 40,41

If a population group does not meet the criteria for an MUA/P, but exceptional conditions exist as barriers to health services, they can be designated with a recommendation from the state’s governor. A list of Governor-Designated Secretary-Certified Shortage Areas for MUA/Ps for each state is available on the HRSA site. 42

Medically Underserved Areas/Populations (MUA/Ps) are physician shortage designations. MUA/Ps are designated by the Health Resources and Services Administration as having too few primary care providers, high infant mortality, high poverty, or a high older adult population. This indicator can be assessed by the following measure. Click on the measure to learn more:

Measure 1: Medically Underserved Areas

Health Care Effectiveness and Quality

Why is this indicator relevant?

Whether an individual has a primary care physician influences key aspects of the quality of care that individual receives (care coordination, person-centered care). According to an article in the Annals of Internal Medicine, data obtained from patients over the past 15 years show that most Americans have a primary care physician. Although having a primary care provider does not guarantee quality of care, it does support achieving improved health outcomes. 43,44

The 2021 National Healthcare Quality and Disparities Report found that Black/African American, Hispanic/Latino, and American Indian/Alaska Native communities experience significant disparities in all domains of health care quality compared with White persons. 45 People of color tend to receive lower-quality health care than White persons, even when insurance status, income, age, and severity of conditions are comparable. For example, Black/African American and Hispanic/Latino patients are less likely to be given appropriate cardiac medications, diagnostic tests, and treatments. 46 Lack of health insurance, poor routine health care access, low socioeconomic status, and language barriers contribute to racial/ethnic disparities in screening and treatment. 47,48 Statin prescribing and statin use for atherosclerotic cardiovascular disease (ASCVD) prevention varies by race. A study that analyzed data from 2013-2020 National Health and Nutrition Examination Survey found that and was much lower in Black/African American (20%) and Hispanic/Latino participants (15.4%) than White participants (27.9%). 49

Patients with access to a regular primary care physician receive more effective and higher-quality health care. They also report lower overall health care costs, improved health outcomes, fewer hospitalizations, less duplication in treatment, and lower prevalence of health care disparities. 50 A study in a California hospital asked patients about their access to care, chronic medical conditions, and propensity to seek health care. The study found that communities with perceived poor access to medical care had higher prevalence of hospitalizations for chronic disease and noted that “improving access to care is more likely than patients’ propensity to seek health care or eliminating variation in physician practice style to reduce hospitalizations for chronic conditions.” 51

Patients with access to a regular primary care physician receive more effective and higher quality health care. This indicator can be assessed by the following measures. Click on each measure to learn more:

Measure 1: Dedicated Health Care Provider Measure 2: Preventable Hospitalizations